HomeMy WebLinkAboutSCIMITAR #1 BLK 2 LT 15P,4 s
& Na. a
406\1-0 \?Ialw az
AMunicipality ®f Anchorage � i
1 9C •r i.��
Department of Health and Human Services Cjl"lha
825 "L" Street
Tom Fink,
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
January 8, 1990
Housing & Urban Development
235 West 8th Avenue
Anchorage, Alaska 99501
Subject: Lot 15 Block 2 Scimitar S/D #1
Permit #890199, PID #051-132-23
The subject permit, issued by this office for a single family
well and/or on-site wastewater system has expired as of December
31, 1989.
Permits are issued on a calendar year basis by authority of the
Municipal Code of Regulations. A new permit must be obtained
from this office for an well and/or on-site wastewater system
not installed by the expiration date.
If you have drilled the well, a well log needs to be sent to
this office for documentation of the installation and to close
the permit.
If a private engineer inspected the installation of the on-site
wastewater system, the original as -built inspection report
(three-part form) must be sent to this office for review,
approval and documentation.
When applying for a new permit, the fees are: $90.00 for an
on-site wastewater permit; $50.00 for a well permit; $140.00 for
a combined on --site wastewater and well permit.
If you have any questions, please call this office at 343-4744.
Sincerely,
John Smith, P.E.
Program Manager
On-site Services
JW/1jm:200
enc: Copy of Permit
"Kids Are Our ,Future"
M�NlClPALl7Y OF ANCHORAGI:
Department o� �ealth & Human Services
825 L Street, Anchorage, Alaska 99501 343~
Permit Number; 89O199 Upgrade
Date Issued: 09/07/89
Owner Name: H^U"D.
Owner Address: 605 W. 4 AVE.
ANCHORAGE, AK 969501
Parcel Id: 051~132-23
Lot Legal: Subdivision:
Section: 10
Lot Size 39489 (sq^{t,
Ila x Bedrooms: This Permit:
WELL PERMIT
S1NA{JM/Oq
SClMITAR #1 Lot: 15 Block: 2
Township: 15N Range: 1W
or acres)
3 Total Capacity: 3
Oay Phone:
694 979
WELL: Log must be submitted Lo Municipality of Anchorage Department of Health
and Human Services witkin 30 days o[ well completion.
YERIFY SEPARATION TO SEPTIC SYSTEM ON LOT 7 111 , 3 SCIMITAR #1.
[HIS PERMIT EXPIRES ON 12/31/89.
I LERTIFY
�pacity
�
THAT:
[amiliar
wiLh
1e requirements [or on~site
sewers and
wells
as set
forth
by the
11unicipa1ity
of Anchorage (MOA)
and the State
of Alaska.
2, I will
install
the
system in accordance with
all MOA codes
and
regulations,
and in
compliance
with Lhe design criteria o
his permit^
3. I will
adhere
to all
MOA and State o{ Alaska
requirements
for the
set back
distances {rom
any
existing well, wastewater
disposal system or
public
sewerage
system
on
this or any adjacent or nearby
lot^
4. l understand
that
Lhis permit is valid for a
maximum of 3
bedrooms.
1
also
understand
that
the caq (3f the total
System is
3 bedrooms
and
any enlargement wil1 require an additional permit.
Signed: r DATE: *�.—^�� ,-C�«�
_ �---�'�'_�-�-�`�-�-���-�-�
lssued 8y: DATE:
1ep7c:, /
SCALE
s--
Lc,T lS
To
a y^
RD
ROBERT A. 811AFER
CIVIL. ENUINFER
6947.979
HEALTH AUTHORITY
APPROVALS
ASSOCIATED 60OKERS
ATA; SAND'r
640 Weft Ath Avvnae
$EWER WATER
Sucte d 1
MAIN EXTENSIONS
Anchorage, Kaska 9959'
REFERENCE: lot 15, Sock i, Sciuni.tar I{1
srwEH a wnreR
NHN Tufvm IJlci ve, Peters Creek
INSPECTION
H.!l.D. '{034961
Dear Sandy,
ENGINEERING STUDIES
ANDRRT
EPOS
Ayou, � uqu_ebt we haVL' peklf o med an adequacy test On the septic
system serll4_ng the
p
ACAKenced propulty on June 2o, 1769. Ater
was added to the
-System white water icve?_ measurements wn,_lce taken.
in the move tolu.ny tube located within
.the Tvachajeld. Froom this
test it was concMded the septic system is
WELL INSPECTION
cuAvent?y Junctioning
adequately 6o4 a th4ve. ( ibednoom house.
aPLowTEST
However, the system
not gualanMeeragainst scbsegwent
-6cuTure-.
The septic tank- wn-_a pumped on JLuje 20, 1989 by JR's C W00t lumping.
STE PLANS
Also at youlc requ.en a 4100 test was pe.r60ON& on the weef serv.tng
the 4e6e4eneed
property. The static watvc-eeve2 was measured at
178 Q. be.1'ow the
top 06 th.e wee? cas.tn;g• A 6aucet was plumbed
into the. eyStem and a
ROAD DEMON
meter connected. The NOW was trutned on 6�
and the water r'.evv_.e >'as drawn down the
.to pump,(866 e,e4) , !o
to the pltoperty 4 .Mmes overt. .the next th4ee 6 e cee.)t .d
i
P.evet down to the pump each. time. On .the thilnd day,
Am the wactvt
Must
once. the
was drawn down to the pump the
solLTEST
pump :vas tuned oll and the
water wa.5 alYcwed to recover loll 40 minutes. The 6tow was then
tulr.ned
on and .rhe amount 04 "00 ams metered. This process was
repeated three time, with
e�,r��st��n-t resu ts. From this test it
was determined the- we" cur"fv c50dree 5
PERCOLATION
s GPH. This 6.eow hate
in not gualcanteed t0 remain co nstan.t�, subsequent valuations
TEST
Occult. can
Plater camp?es were taker. on June 20, 1989 and .tested lac e0Prl0lcm
rtua and r-tra�014000.Tale 'ceooltd were
6acte,5utr.s�act0l u.
STRUCTURALS
MECHANICAL 1 regret to inKoom you the 'Low vale 06 5 GPH is nod, 646icLen.t
IIJSPF.(ITION9 Ort a s,(,{�, n
6 g.c lamIfy home 06 any size. Even a one bedroom home .tis
rcegtuked t0 Love 6.25 GPQ to Obtain a MCA Authority App4ova.e
(MAA) 640m The 4un,ic pati -v nl Anchorage. (MOA). The. ,three (3
It idence eova ed on .she lrr . ) bedlcoam
ON Sol: a mi.n2mam c! 1s,75 Gp 1. ! - °_'r..%y rc_qu.�. It es a weP,Q which w.%2.2 prc0du,ee
WASTE WATER-
DISPOSALSYSTEM
DEMON
1:034 EAGI-F_ FVVE A LOOP, SWTE 201 CAGLE_ PNIFF1. ALASKA 99577
IJP
page. two
"Lot 15, Mock Z, SGilr-iW 111
NHN TO-tvait Vkive, Petm He.ek
H.U.D. # 034961
Juty 3,, 1989
Since the exi6tin;g welt -i6 900 feet deep the onQ way to obtain enough wate;t
on b.i.te i6 to Kitt a new well. 11 the new well pn.oducu moae than 13.75
GPH, but W6 that 18.75 GPH the two wells can be tied toge.thek to obtain
a AQieien;i amount o6 waten Jok a thkee (5) hedmoom home.
A6 a micning, the aqua mound tHs pkopenty is known 6ok how p4oducing wetty
A new wet may os may not encoantea a. 6uJ3'i_cient amount o6 watek boa the
pita pe pct y.
Wo to in4m you, a. feasibility 6tudy civ, wade by out Jim in 1988 6o&
pukpow o6 developing a pubtie warm zvotem Jon the Se.imitak Subdivibion.
At: that time it: = dete mined a wa.tRk Lytton could be. deveCoped Jo& appuxima.tsty
$300,000. whAch- would sevue 51 ON.
16 we may be 06 6uOr'1e.n sevvine, p0abe contant o6.
••,•,...DEPT Or-
FNVI (`)N.\46N1 ru P: !_,:'ii :f
MUNICIPALITY OF ANCHORAGE c q
SEP 8 1984
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION �"
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 R EC E IV ED
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME 7 T��-/ PHONE
Up GFADE
MAI LI NG ADIVIESScs
Ems' �v
LEGAL SC/RIPTI OCyN �- J cif'+'
LOCATION NO. OF BEDROOMS e�'7
Well Absorptio ea / Dwelling / PE O -
DISTANCE TO: �j ,� /'s
U Y __
I-- z Manufacturer No. of cofiripartments
N Liq. r fjirygpllons Inside length Width Liquid depth__
C�GG %'CC,,• IF HOMEMADE:
Q 7 DISTANCE TO: Well /Nellin9 PERMIT NO.
�/
Manufacturer Material Ligu�d capacity in gallons
E'
Wel v
Foui ion Nearest
�+p,
line PERel T.f�IO, r x TO: (�t'Z1�� �G, C� Lf -
DISTANCE
w u.
P' rc
No. of lines Length of a line/
�_
rY
Total Ig th f lir>,es Trench f (r
inches
Distance et Iii ks
q F-
[t:
- -- - - -
l op of tile to (]a
Material beneath the ti
Total eff9�jtiv al sorpti r ea
�Sl inches
;r '�.)
w
Length
Width
Depth
PERMIT NO.
c�_
_
a M
WP
Type of crib
Ci ib diameter
Crib d
Total effective absorption area
WWell
on
DISTANCE TO:
Building foundation
Nearest lot line
W
Class �—�
epth _
Dril r
Distance to lot line
PERMIT NO.
DISTANCE TO:
�-`
Building fou dation
Sewer line
Septic tank
Absorption areas)
OTHER
PIPE MATERIALS
/� T c,
SOI L T ST RATING
�
^�—��
reg
j
�
INSTAL,
REMARKS
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0
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LNbsA A. ShaMf
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TIT__
APPROVED ,F; �' r;•d'.sst1»•'fy S�-' DATE
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U RVII X CT,: X IF""' IL.- 3- * IF*�
DEPARTMENT OF HEALTH ANDENVIRONMENTAL PROTECTION
v
264-4720
PERMIT NO:
DATE IGSUED:
APPLICANT:
ADDRESS:
CONTACT PHONE:
840784
09/17/84
DENNIS WILLIAMS
% S&S ENGINEERING
EAGLE RIVERv AK 99577
694-2979
LEGAL DESCRIP: SUBDIVISION:
SCMITER 141
LOT: 15
BLOCK` 2
SECTION: 10
TOWNSHIP: 15N
RANGE: 1W
LOT SIZE: 39489 (SQ.FT^
OR ACRES)
MAX BEDDOONS: 3
Listed below are the options
available to you
in designing
your septic
system" Choose the option that best fits your
site.
-..... ... �~~�--~~~_.~~.~-_~.��~
13 RE 1:4
tyl~ K) FRAPT X I&I
DEPTH TO PIPE BOTTOM (FT' )
~�r�� `
��
0
4.0
GRAVEL DEPTH (FT.)
0.15
3.5
TOTAL DETTH (FT,)
GRAVEL WIDTH (FT")
2.5
0
5"0
GRAVEL LENGTH (FT.)
.0
28.0
GRAVEL VOLUME (CU"YDS")
13.5 ����~
14.6
20"8
TANK SIZE(GALS)
1,0000 ** ~^\
1,000^0 **
1,000"0 m. if
SOIL RATIN8 (SQ"FT./)-,R>
85
85
85
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
I certi{y that:
1" I am familiar with the requirements or on- site sewers and wells as set
�orth by the Municipalitf Anchorae (MOA) and the Stat� of Alaska"
2. I will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit"
3. I will adhere to all MOA and State of Alaska requirements [or the set back
distances [rom any existing well, wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot"
4" I understand that this permit is valid for at maximum obedrooms and
any enlargement will require an additional permit"
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS~BUILTS
WILL NOT B ELECTRICAL INSP�CTION REPORT; AND <3) THE
ELECTRICAL RA LICENSED ELECTRICIAN,
SIGNED DATE:
_w�-~��~------... .... ........ ..... ~~..... ..... -... ..... ~
APPLICANT: ILLIAMS
ISSUED BY
DATE:
/*�7 SOILS LOG
MUNICIPALITY OF ANCHORAGE
a . DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ❑ PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264.4720
SOILS LOG — PERCOLATION TEST
/moi f Cl i/�� f %f
PERFORMED FOR:^ i DATE PERFORMED: _
LEGAL DESCRIPTION:
,DEPTH SLO E
( FEET)
1 S/ &
�
f
(j
2
3 C7
V
4 0
5 V
6
p
7 ` cwt% /J �G C
9
d( �
10
U
WAS GROUND WATER 'tt S
11
,� a ENCOUNTERED? ' V L
O
V P
12 IF YES, AT WHAT E
DEPTH?
13 C/
14 / nti4 $�
•a} .I
15 ae •r . ra�s• �..
ify•. 40�•• �+.••e •ye r•
16�. ke6►r1 A. Shefa k;,
I U)•• No. 1d37•Ew
O q�
17 �4$F1► PRQFESS1t1N�,��AMav
18-
19
8 19
20
COMMENTS
PERFORMED BY:
72-008 (6/79)
-"-Reading
Date
Gross
Time
Net
Mime
Depth to
Water
Net
Drop
G
PERCOLATION RATE
TEST RUN BETWEEN
CERTIFIED
(minutes/inch)
FT AND FT
DATE:11, 4
MUNICIPALITY OF ANCHORAGE:
DEPARTMENT OF HEALTH.AND ENVIRONMENTAL PROTECTION ;.
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision,section, township, range)
Lot 15 Block 2 Scimitar Subdivision _
Location (address or directions) V
IL
(b) Applicant Name _Dennis Williams _;Telephone:'Home 688-4076 Business 688-3199
Applicant Address P.O. Box 670646, Chugiak, .; Alaska 99567
(c) Applicant is (check one): Lending Institution ; Owner/builder ®x Buyer ®; Other []:'(explain);
_
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent
Address
5. ENGINEERING FIRM PROVIDIh._ INSPECTIONS, TESTS, FILE SEARCH, DA,jA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I 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, ordinance§, and regulations in effect on
the date of this inspection.
Name of Firm Telephone
Address
Date -
This department has received written confirmation from the
the Conditional Approval of March 21,,.1986. ,.This property
requirements and is fully approved.
6. DHEP APPROVAL
Approved for three(3) bedrooms by to
Approved xxxxxxxxxx Disapproved - Conditional
.Engineer's Seal
engineer regarding
now meets MOA
(®p
EMCEE _ yFP
��V F R. Al
•AEALTH AUTHORITY
APPROVALS
'.EWER& WATER
%VAIN EXTENSIONS
.EWER & WATER
IISPECTION
NGINEERING STUDIES
tNDREPORTS
WELL INSPECTION
;, FLOW TEST
JLLne 3, 1986
Murnici.pa ity o6 Anchorage.
Pepwitmen.t 06 Hea th and HLunan Sn_nv,ice.6
825 L Street
Anchorage, A2a6ka 99.501
REFERENCt r Lot 15; stock 2; Sc.%m-i ta)L Subdivij i.on
ROBERTA.SHAFER
A7C/AqFjIVIL ENGINEER
41 )Fpr Ty OF 6942979
I �O�MF'VT�4 PROCT lc QRgjo
wl
RF o 11986 T%N
104 eb
A eonditionai Heat-th Authority Approval. wa6 iAAued on the ne6e,Leoce.d
pnoper-ty in Manch, 1986. rhe condition. o6 -tkiA appnovat n.equired the
we E w.i)Le6 to be ptaeed in con.dui,t and buried between the were c.a6.ing
and ,the house.
A vi6uaf in6pecti.on was per6unmed on June .3, 1986 and it was bound that
at2� wonh lcequi.ced by the conditionat appnovat had been compCeted.
Reque-st you i66ue a 6.i.na� HAA bon thiA pltoperLty.
16 weja-y-br. o6 6unther se)Lvice, peea_6e_ contact us.
eP_ y
31 IF PIANS / ��///
ZT A, Sha6en, V.E.
RAS/6s
ROAD DESIGN
ccr venn,i.6 (u.i.�.P.i.arn6
SOILTEST
PERCOLATION
LEST
1 �
STRUCTURAL&.
MECHANICAL
INSPECTIONS
ON SITE
WAS] E WATER
DISPOSAL SYSTEM
"'II SRO 196X EAGLE RIVER, ALASKA 99577
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
1. GENERAL. INFORMATION
(a) Legal /Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name 1S/�Gf/(�r!L«,Telephone: Home ��l ��d� %' Business
Applicant Address �� �O_ �69
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution
Address
(e) Real Estate Company and Agent
Address
Telephone
14!0ed
(f) MaWthe HAA to the following address:
C'_tr Z10_ ,
2. TYPE OF RESIDENCE
Single -Family Multi -Family ❑ Other
Number of Bedrooms
3. WATER SUPPLY
Telephone
u
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.
4. SEWAGE DISPOSAL
Onsite Public ❑ 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 1 of 2 72-025(11/84)
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, I 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 ' x Erginverinq Telephone
SRR 196x
Address f�ai er-dfasks qg?+
Date
e> ) 2—z,7z—
,d ° l�Enain�rl < eat ••:.' . v
+
� Z
"A 04
941
6. DHEP APPROVAL
Approved for 1tac� bedrooms by Date
Approved Disapproved Conditional
Ter f Cyjiditional Approval azs-�Lx,„��C�,c..s����.
(AZ
,ULT"
CAUTION
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
72-025 111/841
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE (MOm) DEPT. OF HEALTH &
HEALTH AUTHORITY APPROVAL (HAA) ENVIRONMENTAL PROTECTION
CHECKLIST - FEBRUARY 1984 MAR 1
264-4720
Legal Description: 4"r �i�n�nNlLE En
I 1
A. WELL DATA cS�-/fj?G 7L'
Well Classification f2tyfh' e If A, B, C, D.E.C. Approved (Y/N) µ N
Well Log Presennt &Wr Date Completed _ 11Z_8 Y Yield —t_ -
Total Depth /06! Cased to GG / Depth of Grouting
Static Water Level 9a ! Pump Set At — uk
/! t
Casing Height Above Ground /Z Sanitary Seal on Casing6to
Electrical Wiring in ConduitOA-Q •P Depression Around Wellhead.( -Y-49
Separation Distances from Well:
To Septic/Holding Tank on Lot —zoo / On Adjoining Lots
To Nearest Edge of Absorption Field on Lot /Uv 1 _ ; On Adjoining Lots —
To Nearest Public Sewer Line �' To Nearest Public Sewer
Cleanout/Manhole _ To Nearest Sewer Service Line on Lot
/vim tf
b I#,
,:5Z 1 p
Water Sample Collected by 54 S (;5P-4(.& ?,to: eAernitB Date — 3
Water Sample Test Results 5AOrfs fdfl=��G
Comments Vufr: LL- 1/,11oco:x 1Z /3rrF
"A> (4 A3 6-6" 4
B. SEPTIC/HOLDING TANK DATA
Date Installed ''ZU- D y Size !Uy A No. of Compartments _ Z�
Standpipes/W-- Air -tight Caps4 G* Foundation Cleanoutoklm�
Depression over Tank 0'0 Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) !jl/_ ; for
Holding Tank High -Water Alarm (Y/N)/�" _ Temporary Holding Tank Permit (Y/N)
Separation Distances Distances from Septic/Holding Tank:
To Water -Supply Well _yam I'*- To Building Foundation
To Property Line _ ?!a ° r To Disposal Field --
To Water Main/Service Line
Course
Comments
Page 1 of 2
72-026(11/84)
I r -
Ad
"rI
To Stream, Pond, Lake, or Major Drainage
C. ABSORPTION FIELD DATA
S15 /(�K. Type of System Design . _752_4 �i
Soils Rating in Absorption Strata /
-- Zg �
Date Installed , S( Length of Field � H
Depth of Field
Width of Field J'
Gravel Bed Thickness
7 coo � Standpipes Present ���
Square Feet of Absorption 1Area Date of Last Adequacy Test _
Depression over Field
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well
14)a r t__ To Property Line
To Building Foundation
; On Adjoining Lots
j/6
To Existing or Abandoned System on
.1. c+-
f__0
.4/0 / %- To Cutbank (if present)
Tk+--
o Water Line
To Stream/Pond/Lake/or Major Drainage Course ----
To Driveway, Parking Area, or Vehicle Storage Area -----
Comments
D. LIFT STATION
Dimensions
Date Installed
Manhole/Access (Y/N)
Size in Gallons
"Pump Off' Level al
"Pump On" Level at ,r
Vent (Y/N)
WAlarm Level at
Pumping Cycles during Adequacy Test. Meets MO
High ater
Tested for —
Electrical Codes (Y/N) —
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA hand 8 uidelines in effect on the date of this inspection.
Rin tri�aeat^ice_ Date P
Signed4_ gS'� 017 3
MOA No.
Company
Receipt No.
Date of Payment -- --
,—'ao
Amount: $
Page 2 of 2
72-026 (11184)
'�"y��ny` 3iei,
M1q d
it fi
say>y*
• ^�' ����'�, titl4ftr4 rl ,:t�
MUNICIPA.TaIT`Z OF ANCHORAGE
DIVISION OF ENVIRO; DMINTAL HEA14TH
DEPARMENT OF tff'ALTII AND ENV!"RONIME iTM, PROTECTION
APPLICATION ICOR IirAL 11 AUTHORITTY iTFR,OVAC, UERTUICATE
1. Grrnera!_ Information Application mate
(a) regal, Desc9:ipt:i,oat (include lot, block, subdivision, section, township, ,^anse)
,
(address or diroctaons)
(b) Applicants Name tt ', ai , e.bn hobre= Horse/ , `!Giilua:_ness
Applicants Address
(c) Applicant I (check one) "Lending 1vstl.tuti.on Owner/builder
Buyer Other(explain);!� 9
(d) Lending Institution
AddressC e. n:� tf.r•
(e) Real Estate Co. & Agent
Address
Telephone
(f) ?,r i1 the HAA. to the following add ostia
2. Tyne of Residence
Single—Family Multi—Family '� Other (describe)
Number of Bedrooms -:-a
C. Water S�l7
Individual Well. �Q. Community F_( PublAc. � my
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 Public � Community � m Iloldl.ng Tank
Note: If community well system, must have �-rr.itten confirmation from the State
Department: of Environnaenta.l. Con:3e,7at_i.on ai:to,t?_nen, to the legality and status.
[Pago I, of 2]
EnRiszce inQ Fizz Providiz� lnTlayr,i.iont,, 'I'csia� File �Search , Data OKftl tiTon
As certified by my seed offixed hereto and as of the validation &I belou, I
verify that my investigation of thi:; Healta Authority Approval. stz°;:: ;i. the ox°'i,Ite
water supply sand/or wastewater disposal 3;-5t:em is safe, funcL•_tonas
xiequnte for
the number of bedz°oom,, and type of structure indicated he;a: ern o z : - , . ,
based on the iDfo>:mat ion obtained from Gaze Munic.i.pali ty of Anchor ,,' ' 1 09' -1 -1 fz :vs. r,
i,revest:i ,ation enn inspection, the oa--wit€' nate s�app .y and/or zra %.,^:::,z `;a _ (1J;al)o ,a"!
system 3.ts in Compliance with. all Municipal and ,ytgte codes, ordinx.'- t%— and 5'cf,uL,a
tions in effect ou the date of th+s iuspection.
Name of Pixrii
Add,; e j
12a-L=
l
Date
I
e'
{ 5 fa NM1�l"d!
fs DIIIU.,]? Approval
� v
� �
�
Approved fez
bedrooms
3y rY�ila[:
T�
,
Approved �
Disapproved oved
Conditional
Terms of Gorditl.onal
Appr'oasl_
CAUTION
THE MUNICIPALITY OF ANCHORAGE DIaP ART, ENT OF HEALTH AND ENVIIIUNPtI?IJ'1 1I. PR0'PPC'1.`TUCi
(DHEP) ISSITRS UEALTH A.UTPHORIT.Y APPROVAL CERTI-FICATES BASED SOLELY U1'i)N Y'IFF REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENTeN-T PROF E SSf KT ., kNI;'l'NEER REGTS T RUD
IN THE STATIC OF ATASK&. THE DHEP DOES THIS AS A COURTESY TO PUT.Ri iiA;il?R ,i OF 1IOMEaS AND
THEIR LENDING INSTITUTITONS 1N ORDER TO SA` 1,SFY CERTAIN FEDERAL AND :.TAT), Rr,QUIRF=-
MENTS. FMPLOYLES OF DHEP 70 NOT CONDUCT INSPECTIONS OR AANALY' X I'A'.t'A BEFORE A
CERTIFICATE IS ISSUED. TML'. MUNICIPIUITY OF ANCHORAGE IS NOT RESPONSUBLE FOR L;RRORS
OR OMISSIONS -N THE PROFESSIONAL ENGINEER'S WORK.
(DIIEP SEAL)
RR4/ej/Dl8
[Page 2 of 21 7•-19--84
A. WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:vl
If A B or C D E.0 roved(Y/N)�
Well Classificati „��1J�1� B. C. �P
Well Log Present Date Completed J �- Yie1d�
Total Depth C Cased to ^� 0 Depth of Grouting
Static Water Level _!At)' Pump Set At G
Casing Height Above Ground /f Sanitary Seal on Casin (Yk)
Electrical Wiring in Conduit (Y Depression Around Wellhead (Y )
Separation Distances from Well:
To Septic/Holding Tank of Lot /6b r On Adjoining Lots ®'
To Nearest Edge of Absorption Field on Lot ea) On Adjoining Lots lU�
To Nearest Public Sewer Line __LZ_19 To Nearest Public Sewer �I
Cleancut/Manhole_ ba To Nearest Sewer Service Line on Lot
Water Sample Collected Bye -1 1 24,)&eIlIqq; Date O ?
Water Sample Test Results
Comm rents
B. SEPTIC/HOLDING TANK ARTA
Date Installed ` Size O 0 6�. No. of Compartments
Standpipes )N) _ Air -tight Caps tea) Foundation CleanoutYi/N)
Depression over Tank (Y ) Date Last PyrVed
Pumping/Maintenance Contract on File (Y/'w — for
Holding Tank High -Water Alarm (Y/N)/v / - Temporary Holding Tank Permit (Y/
Separation Distances from Septic/Holding Tank:
To Water -Supply Well zoo ° � _ To Building Foundation
`
To Property Line � /0 To Disposal �� Po Field To Water Main/Service Line iO f To Stream, Pond, Lake, or Major Drainage
Course L9 0\l P7 ---
Comments N LQ d.J E7 -_ -
Receipt # L�L_,
Date Paid:i I <r
Amount: c� ^
[Page 1 of 21 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata tP,5, 72! /l Type of System Design c -h
Date Installed Zo Length of Field _ 6
Width of Field _ _ Depth of Field
Gravel Bed Thickness _6 o ll
Square Feet of Absorption Area Standpipes Present (Y ) _
Date of Last Adequacy -._
Depression over.Field (Y qu y Test
Results of Last Adequacy 'lest � ,) _
A
Separation Distance from Absorption Field:
r
To Water -Supply Wall l�J To Property Line - /D
To Building Foundation To Existing or Abandoned System cn
Lot ill I_0 IOC On Adjoining Lots /69D
To Water Main/Service Line /�_ To Cutbank(if resent)
To Stream/Pond/Lake/or Major Drainage Course /U o /-JE
To Driveway, Parking Area, or Vehicle Storage Area
Comments ti f)r� il r
D. LIFT STATION
Date Installed Dimensions
Size in Gallons _ nhole/Access (Y 7)
"Pump On" Level at ' Off" Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy 'lest. Meets MOA
Electrical Codes(Y/N)�
Comments
Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all. MOA H �� �roes in effect
!9 r)£
on the date of this inspection.""
Signed :, t� t ,rri E ri�fdt; Date
%,
pD y MOA No s' }"
Company ,::>:",.= �'ijl�Vj'�,`��tjnP,(cA ^.~.1;r_ •
Relhart A.
KB1/d5/s tdo. 1457-t a
c
i�M1 l 1�RE.re nn a'..i�..4.
F S�fl='
(Page 2 of 21
2-15-84