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Home My WebLink AboutZODIAK MANOR ALASKA BLK 13 LT 16t `j* MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) �1 t {b) Applicant Name ' s Telephone: Home Business 76 4.33 a 10 Applicant Address (c) Applicant is (check one): Lending Institution 0 ; Owner/builder; Buyer 0 ; Other[] (explain); (d) Lending Institution A 840 k Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: It A° 0,// 2. TYPE OF RESIDENCE Single -Family IU Multi -Family 0 Other Number of Bedrooms 3 3. WATER SUPPLY Individual Well El Community 0 Public D Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite 0 Public Community 0 Holding Tank 0 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/64) 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, l verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm a) i_k e y-pl -e Telephone Address Date 7 42 WATER WELL NOTE: This Health Authority Approval inspection merely certifies that the subject water well produced 150 gallons per bedroom per day and that certified laboratory tests showed no�`� presence of coliform bacteria in a sample of that water. No warantee`� ter® or certification is expressed or implied concerning the long term Zl�. adequacy or safety of the water supply. ON-SITE S' AGE DIS OSAL S TEM N07E: This -H alth Authority Approval f5. *°°°° .- inspectf n merely certif' s that th subjec on-site wage dispos e En 111% system accepte at le t 150 ga ons of ater per edr per ay tr°° �:�t�F 'T�°`'t �' Lary„7 -0 P' as termine by me ods appr ed by a Munici lits of Anc Drage f � `=` "�'g °° ''$`r �,. De rtment of H lth an Human Services N wara ee ori, certifi tion is express --d or i lied co cervi the ong term 14/�Zl adequ y of th on sewage isposal ystem Const ction data reported on uried stem mponents is fro MOA files and was not verified wring t'is in ection. 6. DHEP APPROVAL 43 Approved fors _ bedrooms by Date Approved\ Disapproved Conditional Terms of Conditional Approval The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 Ell M iivlClrALIT'! OF ANGH0.�AG1= DEPT. OF HES 17j-1 & l TNVIP,O,NMENTAI- PROTECTIO; a MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) `! I0 i9 CHECKLIST - FEBRUARY 1984 264-4720 A - J D Legal Description: .�/U�idiGs /l X-1, d1�iAX A. WELL DATA 5� t0 T! 2 /v le 3 cJ Well Classification If A, B, C, D.E.C. Approved (Y/N) fr A Well Log Present (Y/N) _ Date Completed Yield > IS 7 Total Depth '��'' 'lased to Depth of Grouting i Static Water Level Pump Set At Casing Height Above Ground lF Sanitary Seal on Casing (Y/N) Y&S Electrical Wiring in Conduit (Y/N) ��ra Depression Around Wellhead (Y/N) ZVO Separation Distances from Well: To Septic/Holding Tank on Lot/i901 ; On Adjoining Lots A',,k To Nearest Edge of Absorption Field on LotIle; On Adjoining Lots f To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole i .low To Nearest Sewer Service Line on Lot Water Sample Collected by /� AK'" ; Date 7 -e23 -g4'--- Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA /V %A Date Installed Standpipes (Y/N) Depression over Tank (Y/N) Size Air -tight Caps (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High -Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well To Property Line No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped ;for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA A/j Q 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 �6C/G Jc�za e Re ---- D. LIFT STATION /V 1A Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at . Tested for Electrical Codes (Y/N) Comments 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) Dimensions Manhole/Access (Y/N) — "Pump Off' Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA *' Check Permitted Bedroom Rating Against HAA Request ** I certify tha Ve v ied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed �/ Date 7 12 5� Company McLkl a–r ��, MOA No. Receipt No. _'_i 00 k' V 0a`7 Date of Payment 1–BO o Amount: $ te 6"m �c> Page 2 of 2 72-026 (11/84) A a •° •NEIL HAWTHORNc C_ - 4369 64 *4CNOAAC•L fF 4 �r o 0 u i GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3�O "C" Street, Anchorage, Alaska 99503 274-4561 Date Received E� Time of Inspection Date of Inspection" 5 J� REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR 1. Approval requested by: /,f"W/ll sij,��,r -6Z Mailing Address: Phone: 2. Property Owner: A-r:"Phone: r Mailing Address: 3. Legal Description: 77 / � A4 % 4. Location: 5. Type of facility to be inspected y No. of bedrooms 6. Well Data:,- A. ata:A. Type ��C-B. Depth C. Construction ` -v-e-e'J D. Bacterial Analysis 7. Sewage Disposal System: A. Installed C. Septic Tank: 1. Size B. Installer D. Seepage Pit: 1. Absorption Area E. Disposal Field: Total length of lines 8. Distances: 2. Manufacturer 2. Material A. Well to: Septic tank , Absorption area Nearest lot line Other contamination B. Foundation to septic tank Absorption area C. Absorption area to nearest lot line EQ -034 (1/74) , Sewer Lines , Page 1 of two pages F F F Rage 2 of two pagE Legal Description Comments Approved Disapproved Date 11c,l' j►a �®-�� ApprovaQJValid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this reauest for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date IEQ -034 (1/74)