HomeMy WebLinkAboutWILK LT 2B
.~t~tic Wa~e~ Level 35 feet
Drmw Down_ N~.~, feet
Lee
Gallons Per Minute
Tota~ Feet of t~asing
Type Material DrLlledg
0 feet to ? ?,~,
Y fee,*
20
%O
tO _
Hefty Drilling.
S.R.A. Box 1553 H
AmChorage,Al~skm
?~ ki~-~ I C I PAL I T~r' OF A~-~C:HL~'~"AG E'
DEPARTMENT OF HEALTH 8ND ENVIRONHEHTAL PROTECTION
~ L STREET., 8NCHORAGE~ ~K ._. I
PERMIT NO: 840]~40
DATE ISSUED: 05./i4/84
RPPL I ~.RNT:
RDDRESS:
CONTACT PHONE:
LEE D GARCIA
P 0 BOX
ANCHORAGE, AK
2?2-6654
99509
LEGAL DE~~.RIP. SUBDIVISION~ WILK LOT: 2B
SECTION~ 2 TOWNSHIP~ 12N RANGE~ 4W
LOT SIZE: i5'~M- ~'~J-
~._~ ~_i FT. OR ACRES)
BLDCK ' NA
C:ERTIF~' THAT
· . I AM FAMILIAR WITH
THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS 8S SET
FORTH BY THE MLINICIPALIT~ OF ANCHORAGE (MOA) 8ND THE STATE OF ALASKA.
I WILL INSTALL THE SVSTEbl IN ACCORDANCE WITH ALL MO8 CODES 8ND REGULATIONS,
AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT.
I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK
DISTANCES FROM ANY E~ISTING WELL~ WASTEWATER DISPOSAL SYSTEM OR PUBLIC
SEWERAGE SYSTE~ ON THIS OR ANY ADJACENT OR NEARBY LOT.
SIGNED
RF'PL I CANT:
ISSUED
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environrnentar Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA #
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Day phone
Day phone
Day phone
Properly OV~/~e~-1'' ,~,~ ~. ..~
M iling addre~s '~ '. "'
Lending agency -.' ,~/~
M~i!~ng. add~ess. ' , ~.
....
Address "'-,.x,....~,/~
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: "~ %
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev, 1/91) Front MOA #21
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'9
(~ Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: '~,~,U\~. ~-~,J~ ) [LoT ~.~ Parcel I.D.
A. WELL DATA
Well type
Log present (Y/N) \~ ~---*~
Total depth
Sanitary seal (Y/N) "'~. ~-~ ~
If A, B, or C, attach ADEC letter. ADEC water system number ~/A Date completed _,~"//,~'/l~ 4- Driller ~1' ~-~--'T~
Cased to IO~ ~ Casing height
Wires properly protected (Y/N) '"¢ ~--
FROM WELL LOG
Date of test ~'//~//~ ~-
Static water level ~.~z~"* r---~'~-
Well fl0w
Pump level
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~/'~.
Absorption field on lot
Public sewer main ~7~'/
opi,o ¢~s~F_,
Sewer service line
; On adjacent lots
Public sewer manhole/cleanout
; On adjacent lots
Fr'. Petroleum tank
WATER SAMPLE RESULTS:
Coliform ¢ Nitrate ~k[ ~ [~
Date of sample: ~ ~ ~Z/ c~/~l/~_ Collected by:
Other bacteria
B. S~DING TANK DATA pUBI_I'C~., ~I?__~,U~-'~_~.,
Date installe~_ Tank size ~ ~ Compartments
Cleanouts (WN) ~"~ ',Foundation cleanout (Y/N)
Depression
High water alar~ (Y/N) ' ''j '~ Alarm tested (Y/N) ~
Date°f'.pU~pi~g. ~ : .', './ mF~
Well(s) on Io~' '. 2'/On adjacem ~s ~ation
~a~r/dra,na~e
72-026 (Rev. 7/91 ) Front
CONTINUED ON BACK PAGE
C. LIFT STATION
~ed Manufacturer
Size ingallon~m--~ Manhole/Access (Y/N) ~
Vent (Y/N) ~ at ~ ~"--'~'~"Pump off" level at
level
High water alarm ~ Cycles tested
Meets~MOA electrical~codes (~~~ ~
S~ LIFT STATION TO:
ANCE FROM
Well on lot On adjacent lots Surface water
D. iORPTION FIELD DATA ~[~L]~L-i ~ ~'F--"J,J~-'~
Date Soil rating
Lengl Width Gravel thickness . 2th
Total absorption
Cleanout8
Depression over field (Y/N)
, test
Results (pass/fail) for
bedrooms
Peroxide treatment (past 12 months) (Y/N) __
If yes, give date
SEPARATION DISTANCE FROM ABSORP1
Well on lot__
To building foundation
On adj
E. ENGINEER'S CERTIFICATION
acent lots %. Property line
existing or aban~d system on
To
lot
Cutbank__ Water maih~rvice line
Driveway, parking/vehicle storage are'~__
/
I certify that I have checke¢, verified, or c~fdormed to all MOA and HAA guidelines in effecJ on t,h~C_ate of this inspection.
l '""'"'""
~nglneers ~ame ~ , ~ I ~ ~[~.~
HAAFee$ (~Z~, ~
Date of Payment ~:~'"" 2~ ~'-~"~ ~:~~--
ReceiptNumber--~f-2~,~"7 / .Z'f/./~)~.,,~/'~
72-026 (Rev, 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
--'l/A~ '::)¥ ,,9
i3AV qt ~9/~
ig
Alaska Water & Wastewater Services
"Preserving the Last Frontier"
DATE:
TO:
COMPANY:
SUBJECT:
MESSAGE:
-'FAX MEMO
NUMBER OF PAGES:
(Including Cover)
FROM:
8471 Brookrlcige Drive · Anchorage, Alaska 99504 · Telephone: (907)337.6179
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518
TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS RESULTS £o~ INVOICE ~ 57629
Chemlab Ref.# 92,4528 Sample # 1 ~atrix: WATER
Client Sample ID
PWSID
Collected
Received
Presexvad with
WILT $/D LOT 2E Client Name :AN WATER & WASTEWATEB SERVICES
UA Client Acct :AKWTRW$
AUG 28 92 ~ 09:30 hrs. EPOt : POt :NONE RECEIVED
AUG 25 92 § 09:35 h~s. ReqE :
AS REQUIRED Ozdered By :
Analysis Completed : AUG 31 92
Send Reports to:
i)AK WATER & WASTEWAYER SERVICES
2)
Paramat ez Results gnit~ ~ethod Allowable Limits
NITRATE-N ND(0.L0) mN/1 EPA 353.~ 10
Sample ROUTINE SAMPLE COLLZCYED BY: UA.
Remarks:
i Tests Pe~formed See Special Irmt~uctions Above UA-Unavailable
ND= None Detected "See Sample Remarks Above
NAm Not Analyzed LT-Less Than, GT=greater Than
~SGS Mernber of the SGS Group (Soci~t~ G~n~rale de Surveillance)
MU NICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
0/2
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (irlclude lot. block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner /4; EX/' ~ lq fi~) ~- Telephone: Home
Mailing Address "~, 0 T~, |LDO L~ 7....0 I'~tL)C[4
(c) Lending nstitution /'¢~ /~-'__~.) -~) '~' ~ [~' Telephone
Mailing Address (2/° "~'E)C4/I ~ ~:;~ f. LJ
(d)
(e)
Business --~---~'
9 /5-/o-
Real Estate Company anu Agent ~.~-~,. L.,~"Q/'~ 5~,~ (~'1-~¢ / ~~
Telephone ~?~ -- ~? ~ {
Mail the HAA to the followino address: or: Check here~, if hold for pick up.
List contact person and day phone number below.
2. TYPE OF RESIDENCE
Single-Family'~
Number of Bedrooms' ~r
WATER SUPPLY
Individual Well~[' Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status. '
SEWAGE DISPOSAL
Onsite [] P u blic.~.. Community[] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page I of 2 72-025 fRev 8/86~ Front
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MUNICIPALITY OF ANCHORAOE
ENVIRONMENTAL SERVICES DIVISION
RECEIVED
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-472O
L- ~-~ Lc)ILl/L-
Legal
Description:
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth ~--~--~ O Cased to
/'
If A, B, C, D.E.C. Approved (Y/N)
Date Completed Yield
Depth of Grouting ----
Pump Set At ~'~ ,~ / -/-
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
Static Water Level '~ ~' b-
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
/~J '~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole -/- /
Water Sample Collected by
Water Sample Test Results ,.~/~
Comments ~ .'~7-~.1~- /~'J
~0,~ 7'~/2-- c:Z. ~-,,,~/~.E~ ~ / 7-//
AY ~ ; On Adjoining Lots /~'"//~
~ To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ~L
; Date ~ - / ~- --
B. SEPTIC/HOLDING TANK DATA
Date Installed.
Standpipes (Y/N) Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septiq/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Size No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
72-026(~ 1/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments '~) O ~ L- { ~,
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify thsJ~ h. sc/e,c,becked, w;rified, or conformed to all M~.._OA and HAA guidelines in effect on the date of this inspection.
Signed ~¢¢/,~..2¢,~ ,¢¢,._. Date ~ Z ~ -- ~ ~ '
Com.an No, ¢¢ d
Date of Payment ~
Amount: $ /~, ~
Page 2 of 2
72-026 (11/84)
NO~THE~N TESTING LABORATO~iES, INC.
Constructing Engineers Inc.
9601 Buddy Werner Brive
Anchorage, Alaska 99516
Date Arrived: 08/15/88
Time Arrived: 1145
Date Sampled: 08/15/88
Time Sampled: 0700
Date Completed: 08/24/88
Source: Hose Bib
Sample ID#: A081588-2
Parameter Unit Result ADEC MCC*
Nitrate-N mg/1 <0.1 10
Reported By: ~ __~ ' Date: 08/24/88
Francois Rodigari, Anchorage Operations Manager
* MCC = Maximum Contaminant Concentration
NOflTHEfi N TESTING LAE 0flAT0 E8, INC.
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907-479-3115
2505 EAIREIANKS STREET ANOHORAGE, ALASKA 99503 907-277-8378
Quality Control Report
Client:
ID#:
Constructing Engineers Inc.
A081588-2
Listed below are quality control assurance reference samples with a known
concentration prior to analysis. The acceptable limits represent
a 95% confidence interval established by the Environmental Protection
Agency or by our laboratory through repetitive analyses of the
reference sample. The reference samples indicated below were analyzed
at the same time as your sample, ensuring the accuracy of your results.
Sample # Parameter Unit Result Acceptable Limit
EPA WP284 Nitrate-N mg/1 0.12 0.10 - 0.18
Reported By: f~ ~ ' Date: 08/24/88
Francois Rodigari, Anchorage Operation Manager