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HomeMy WebLinkAboutSEA TURN BLK 1 LT 10��n- I OA ---- q 0. D ivwnnr.rr�tr-I I r UV AIVC;IiVITA(if; W DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO TELT ION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Teirphone 2.64-4720 _ - ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR VVEI.I_ INSPECTION REPORT NAME PHONE - .n�a 1-- MAILINGADDRESS t LEGAL /DESCRIPTION Alt. - LOCATION --- DISTANCE TO: W �t�f r Absorption area e Dwelling -_ NO. OF BEDROOMS PERMIT NO v2 E- "/-�C�� F- z Manufactur Materia N F• �c— <����,� � No. of compartl�pts Uri. capacity in gallons Inside length Width IF HOMEMADE: Liquid depth L z DISTANCE TO: Well Dwelling PERMIT NO. _ Manufacturer Material Liyuid capacity in gallons t] L = u. ti Well Foundation -- ' DISTANCE -FO: �''[} /��t �C1. Nearest lot va. T No. of lines Length of e�� i I�ne G! Lim /n PERfl91T NO��/� `) C% ,wj F z y Total length of s Trench r (�� _ �� _ --inches Top of tile to finish Distance be `,���tttt fines cc grad/ Material beneath tile inches Total of n I bsorption area Wid Depth "'�T PERMIT NO.(7aN ]Length e of crib Crib diameterCribdepth Total effective absorption area ISTANCE TO: Nell Building foundationNearest lotlineass UJ Depth Driller Distance to lot line -- P E R P4IT NO. UJ DISTANCE TO: Building foundation Sewer line Septic tank Absorptions ama(s) OTHER - PIPE MAT IALS ro_® SOIL TEST RIN� INSTALL RC,l/— �9 REMARKS �� DATE_ VED 72-0'13 'TYPE'.., OF ABSORPTICit-4 SY,_::JEM 1:5,: TRUIC'l-I Yl A:; -.,'I Il U M NUMBER OF BEDROC'IMS "- 4 SOIL RATING f.SC,! FT,,•BR":,= 190 'HE' REQUIRFE) SIZE OF THE SOIL AB,_;,ORf­`Tior,i sys'n:3.1 r " L -5 "D L.- EE tr-.§ IC"N" 7, V-1 == "c". E. C EE -"F- - U':x I Po �5 THE LENGTH DIPlEI`-J_SIOI`-,j is THE I-E."NGTH FEET) OF THE TRENCH OR DP.,AINFIELE'l. THE DEPTH OF A TF?EhICH OR PIT 1,5� THE DISTANCE BETI.K.-l-"N THE Sl lF..'PACE OF 11-1E j3RC"IUND FINE) THE BOTTOM OF THE Mf*:,'C*,A%*i"I'ION (IN FEET). 'THER.E IS NO SET kIJ.D"I"H FOR TREr--ICFIE*.--.-.;. THE GRAVEL C,EF,TFI IS THU' PlIkIINUM C.lEPTH OF GF?AVE`L 13ETWEEN THE OUITFALl. PIPE:' AND THE BC)TTOM OF THE Ee....'GAI.MTION (161 FEET,-. E--- F-0 -V :1 C- "T, F-011-41 1 �,:. L" I -=-': n _J_ 2�". �5-o CER F`o L.. L_ C-1.6 P-47'.Et. PERMIT Fif"PLIGANT HA'_5 THE RESPONS IBI L ITY "1 -Ci 11,IFFIRM DEPARTMEhIT DUR.P.,113 Ti -JE, INS"I"ALLA"FION IN:SPECTION:51 OF ANY IIELLS ADJAC:ENT TO TFIP:5 PRiDPERTY AND THE NUMBE-31 OF r-.lESIr.,,EhICE.,..­,; THAI" THE WELL WILL. SERVE. 71-1 C� of �2, > 3. P,JF---- C: 'T- -1P--0 #E5 F- I E � 7-- F?. E,=-* ff-,:Y L-0 IE IF-�! FE EMCKFILLPIG OF ANY SYSTEM WITHO(JT FINAL INSPEC:TION AND APPRO%.lAL E:lil Tlll- E)EPARTMEPIT I. -III -L E SUBJECT TO PFIC)SECA)TION. I- I`,'IIhIIPlUPl ClISTANCE BETWEEN A I.-IELL AND ANY ON-S.T'f*E SEWFiflE IS FOR F "I FEr -1- U I .I.C.10 FEE] .. -1 PRIVATE WELL OR, 1�1150 TO 20C -.:T Ff,",Orl A F- I _1C. 4ELL ClEFIENCING UPOP-1 THE T',-'F'EE OF' PUBLIC: WELL. MI N I Pil 11-1 FROM A PRI.I./ATEE kIELL TO A F,RI%.lATE SEWER LINE IS 2`5 FF.*:.ET ArID TO Fl C"Ol"ll"IUNITY '�;EWFR LINE I "P5 FEET. 1 -JELL LOIKS ARE REC.-:!I_IlRED ANC) BE RETURNED T() THE C,,EPARTMENT 1,111"HIN _Z*0 DAll-'s CIF" THE WELL COMPLETIC.1N. OTHIER RE(.-.'!lJIREPlENT,:_7 MAI-rl APPLY. SPECIFICATICINS AND DIAGI"--*.,AMS i7iP,E' A%.' IlLA13,L E To INSUF�:E PROPER 119STALLATIOP.J. P" r "1'°11 I" -V C,-" EFE, C�l F__ 11-11 L".. E -E I CEF,TIFY FOR .REMPIT.,55 01`+­.�55I TE: SEWES F,.AND [,JELLS A-'---.; 'SET .1..: 1 AN F-"AMILIAR WITH THE REi- "WI FORTH 13Y 'THE MUNI'CIPALITY OF ANCHC)RAGE. I WILL INSTALI.... 'THE SYSTEM Ir..I ACCORDANCE wiTi- THE CODES. .1 F 31' 1EN* T --S' TE SEWER, SYSTEM MAY REC ,,E EkILAR.0 3 T HE .1 LINEERsTAND THAT THE ON I RESIDENCE REPICIDELED Tili INFI-I-IDE" MORE: THF11 4 BECIROONS. Cj rz� T (IPPI.... I CANT K A 4Rr, r, , o, L P YR.1 ', 4l'_'1Z J 1. 1: PJ SSUEE'l 'Y "-0 R-1 m F;" Fo IN 1 -1 P"i 2p -l" IRTYlEkIT IlEf:It...'TH AND ROTECTI OPI '"i"TREET.- 26d-4720 00 a -t, V-4 E. -E, P.- I.- H.:_l P-4 CN CH r -A 1 -TJ 1 11 FE" F=" F_-_ F" M 1 1- P1 No. E,1.0110 Al -11L I CAN'T KARI.- PRP,'OZNIK 3770 COVD-4TRY D R. ANC H LC'ICAT I ON I RCON ST. I- E CiAl... LT. :10 1 '_::,EATURN S/D LOT ZE SQUAF:.E FEET 'TYPE'.., OF ABSORPTICit-4 SY,_::JEM 1:5,: TRUIC'l-I Yl A:; -.,'I Il U M NUMBER OF BEDROC'IMS "- 4 SOIL RATING f.SC,! FT,,•BR":,= 190 'HE' REQUIRFE) SIZE OF THE SOIL AB,_;,ORf­`Tior,i sys'n:3.1 r " L -5 "D L.- EE tr-.§ IC"N" 7, V-1 == "c". E. C EE -"F- - U':x I Po �5 THE LENGTH DIPlEI`-J_SIOI`-,j is THE I-E."NGTH FEET) OF THE TRENCH OR DP.,AINFIELE'l. THE DEPTH OF A TF?EhICH OR PIT 1,5� THE DISTANCE BETI.K.-l-"N THE Sl lF..'PACE OF 11-1E j3RC"IUND FINE) THE BOTTOM OF THE Mf*:,'C*,A%*i"I'ION (IN FEET). 'THER.E IS NO SET kIJ.D"I"H FOR TREr--ICFIE*.--.-.;. THE GRAVEL C,EF,TFI IS THU' PlIkIINUM C.lEPTH OF GF?AVE`L 13ETWEEN THE OUITFALl. PIPE:' AND THE BC)TTOM OF THE Ee....'GAI.MTION (161 FEET,-. E--- F-0 -V :1 C- "T, F-011-41 1 �,:. L" I -=-': n _J_ 2�". �5-o CER F`o L.. L_ C-1.6 P-47'.Et. PERMIT Fif"PLIGANT HA'_5 THE RESPONS IBI L ITY "1 -Ci 11,IFFIRM DEPARTMEhIT DUR.P.,113 Ti -JE, INS"I"ALLA"FION IN:SPECTION:51 OF ANY IIELLS ADJAC:ENT TO TFIP:5 PRiDPERTY AND THE NUMBE-31 OF r-.lESIr.,,EhICE.,..­,; THAI" THE WELL WILL. SERVE. 71-1 C� of �2, > 3. P,JF---- C: 'T- -1P--0 #E5 F- I E � 7-- F?. E,=-* ff-,:Y L-0 IE IF-�! FE EMCKFILLPIG OF ANY SYSTEM WITHO(JT FINAL INSPEC:TION AND APPRO%.lAL E:lil Tlll- E)EPARTMEPIT I. -III -L E SUBJECT TO PFIC)SECA)TION. I- I`,'IIhIIPlUPl ClISTANCE BETWEEN A I.-IELL AND ANY ON-S.T'f*E SEWFiflE IS FOR F "I FEr -1- U I .I.C.10 FEE] .. -1 PRIVATE WELL OR, 1�1150 TO 20C -.:T Ff,",Orl A F- I _1C. 4ELL ClEFIENCING UPOP-1 THE T',-'F'EE OF' PUBLIC: WELL. MI N I Pil 11-1 FROM A PRI.I./ATEE kIELL TO A F,RI%.lATE SEWER LINE IS 2`5 FF.*:.ET ArID TO Fl C"Ol"ll"IUNITY '�;EWFR LINE I "P5 FEET. 1 -JELL LOIKS ARE REC.-:!I_IlRED ANC) BE RETURNED T() THE C,,EPARTMENT 1,111"HIN _Z*0 DAll-'s CIF" THE WELL COMPLETIC.1N. OTHIER RE(.-.'!lJIREPlENT,:_7 MAI-rl APPLY. SPECIFICATICINS AND DIAGI"--*.,AMS i7iP,E' A%.' IlLA13,L E To INSUF�:E PROPER 119STALLATIOP.J. P" r "1'°11 I" -V C,-" EFE, C�l F__ 11-11 L".. E -E I CEF,TIFY FOR .REMPIT.,55 01`+­.�55I TE: SEWES F,.AND [,JELLS A-'---.; 'SET .1..: 1 AN F-"AMILIAR WITH THE REi- "WI FORTH 13Y 'THE MUNI'CIPALITY OF ANCHC)RAGE. I WILL INSTALI.... 'THE SYSTEM Ir..I ACCORDANCE wiTi- THE CODES. .1 F 31' 1EN* T --S' TE SEWER, SYSTEM MAY REC ,,E EkILAR.0 3 T HE .1 LINEERsTAND THAT THE ON I RESIDENCE REPICIDELED Tili INFI-I-IDE" MORE: THF11 4 BECIROONS. Cj rz� T (IPPI.... I CANT K A 4Rr, r, , o, L P YR.1 ', 4l'_'1Z J 1. 1: PJ SSUEE'l C.i I SOILS LOG MUNICIPALITY OF ANCHORAGE 60�97,2,PERCOLATION i� DEP TMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST �F'+� J✓ r Pouch 6.650, Anchorage, Alaska 99502 276-2221 '�/ '! SOILS LOG - PERCOLATION TEST PERFORMED FOR: � I ._ -DATE PERFORMED:__`"� LEGAL DESCRIPTIOI ------- SLOPE SITE PLAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1a 19 20 COMMENTS PERFORMED 72-008 (7/76) Garth O. 'rulbot a w No. 4069 • E a Reading Date Gross Time Net Time Depth to Water Net - Drop (~d iIY2 i _ 3 I � ,7 _ I Reading Date Gross Time Net Time Depth to Water Net - Drop iIY2 PERCOLATION RATE__ (minutes/inch) TEST RUN BETWEEN FT AND FT CERTIFIED BY: DATE: tF e7�lO lmoX 8309, SirAr I?Lcbuwm A ANCHORA"ov AX.AsHA 99502 344m7714 SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF 780 deet. DRILLED AT THE RATE OF _ $27.00 PER FOOT. PROPERTY OWNER hilt. XaAt PAtvopi•k 349-2057 _ LOCATION OF WELL SITE Lt. 10 Bip, 1 Sub. Sea Tunri Soule Ciouz of- P.amp &t alrZU tact' bJci k j, DRILLER - - — WELL LOG: 0----23S.U, )tp wet f:.ine gAgve.L. 23__-48' Cou ue czAave.L 3046 c.Ca.AA. 48---113' ki R Cemented q;mve.L. _ 773--759' Small bou.Ldyw, gzave,L w.i th 15% c, aq. btnde2. - 159--780' R wet ctac k and 4ma.U• bou.Ldeu. At 780 deet uya to t yeoduc t t oa o.- 8 to 70glli tn• a fine ghaveL. 80 deet o� water 4taruUng. og bottom., _ 3/4 Ho&4e SubmeuttiLe Pump 4hou-Ld be .inw-taUed Ove •deet oj;" bottom. MUNICIPALITY OF ANCHORAGE Coot o� 321.00 X 780 7eet: 93780.00 ENVIRONMENTALEALTH PROTECTION Coot. o-� Oe t Seat: 922.00 'JUL lo 198c) RECEIVED COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF U802.00 THANK YOU VERY MUCH. BERNIE CLAUS OF RAMPART DRILLING WORKS Rare, 28th, 7981 -7 DATE `4.� 0 ---- SERVICE CHARGE O F 1 %s% PER MONTH WILL BE ASSESSED ON PAST DUE ACCOUNTS. MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services tt On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # til VI - 1'Q � - 1-11 1. GENERAL INFORMATION HAA # Q Gi ?SLI aJ _ Complete legal description Lot 10 ' Bzoc 1 S"nn Subci%v.ia,ion Location (site address or directions) 14831 Z.LKeon CLn.c2e, Anchon.age, Aea3ha Property owner Kana P&ivoznih Day phone 345-6057 Mailing address 14831 Zincon C.incee,, Anchorage„ Atahha 99516 Lending agency Mailing address Agent _ Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 4 v XXX N Day phone Day phone 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 XXX ti 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 MOAN21 5. STATEMENT OF INSPECTION BY ENGINEER 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 application 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 S & S ENGINEERING Phone 7034 Eagle Rlv 1'1Lo P Road 204 Address aeale REvar °' Engineer's signature Date �^ 9 � : r,• f. it t. �t r; 1p.✓. In; • Sfl oherl fru - NO 6. DHHS SIGNATURE Approved for �� bedrooms. ` Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: RC1- (fir -c u-� Date i1I1TIr, The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS 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. 72-025 (Rev. 1/91) Back MOA k21 u Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LOT 10 13W ( -5MR)V&SJ SZO Parcel I.D. d / � A. WELL DATA Well type P!LZ1(1 7-6 If A, B, or C, attach ADEC letter. ADEC water system number /'Y% Log presentCY)N) yCs Date completed Driller I�rMFp✓zT [a2/LUNG WKS, Total depth PC) Jr Cased to.— ts Casing height 2Z Sanitary seal OYN) Y65 Wires properly protected ON) L�_S WATER SAMPLE RESULTS: Coliform 0/106'""L Nitrate 0 • lolywlxOther bacteria Date of sample: CJ Z �- �� 3 Collected by:�N B. SEPTIC/HOLDING TANK DATA Date installed 5`Tank size `Z `�U Compartments (Y z Cleanouts N) S Foundation cleanout jY/N)L< . Depression (Y/ lD NL3 High water alarm (Y6N))' /Uy Alarm tested, (YM)�/,,v A Date of pumping U S Z Pumper 1 5AA C 5 �U.�/NCS SEl2•0G&S SEPARATION DISTANCES FROM SEPTIC/ TANK TO: Wells) on lot /00 (f On ad'Iacent lots CSU (fi Foundation �- To property line _ Absorption field 17 Water main/service line Surface water/drainage /t/�N� Klyo /til e S'-/- -)� PES- iNS��G�700 ,CEpOZ:7- 72-026(Rev+7191)Front CONTINUED ON BACK PAGE FROM LOG AT INSPECTION Date of test WELL �?/Z�/ 3 �a L -T Static water level r TUU � Well flow /� � g.p.m. � 9 -p.m. � -. q •> �r KNuO �X161` ����/��� r Pump level _ SEPARATION DISTANCES FROM WELL TO: °� C) f n Septic/holding tank on lot Jac) ; On adjacent lots _/0L� Absorption field on lot /Uy'f _; On adjacent lots -1 OU rr -bra © rn Public sewer main A)aAJ6 r'2ESENT Public sewer manhole/cleanout N0106- Sewer service line ^/40 / Petroleum tank /CPOw0—) WATER SAMPLE RESULTS: Coliform 0/106'""L Nitrate 0 • lolywlxOther bacteria Date of sample: CJ Z �- �� 3 Collected by:�N B. SEPTIC/HOLDING TANK DATA Date installed 5`Tank size `Z `�U Compartments (Y z Cleanouts N) S Foundation cleanout jY/N)L< . Depression (Y/ lD NL3 High water alarm (Y6N))' /Uy Alarm tested, (YM)�/,,v A Date of pumping U S Z Pumper 1 5AA C 5 �U.�/NCS SEl2•0G&S SEPARATION DISTANCES FROM SEPTIC/ TANK TO: Wells) on lot /00 (f On ad'Iacent lots CSU (fi Foundation �- To property line _ Absorption field 17 Water main/service line Surface water/drainage /t/�N� Klyo /til e S'-/- -)� PES- iNS��G�700 ,CEpOZ:7- 72-026(Rev+7191)Front CONTINUED ON BACK PAGE C. LIFT STATION A)d 1,1E /'04C-_58IU/____ Date Size in gallons Vent(Y/N) High water alarm level Meets MOA electrical "Pum` a:' level at Manufacturer Manhole/Access (Y, SEPARATIIjaWDISTANCE FROM LIFT STATION TO: on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Surface water _ Date installed - . —_Z / & Soil rating /10 System type 'Fet l� Length gU Width 3 Gravel thickness / Total depth Total absorption area / �d d Cleanouts present Y/ ) �L S Depression over field (Y& /VD Date of adequacy test 3 Z3 Results/fail) 11ASS for __ q CFw�i bedrooms Peroxide treatment (past 12 months) (Y/N) A%61U6 �OU0tJ/J If yes, give date �/A SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot //(-�U r-7— On adjacent lots Z UD It Property line /0 /7e- 4 i To building foundation 2 � To existing or abandoned system on lot �ih+NE On adjacent lots r� Cutbank IlUdAJ6 /"���"r water main/service line��U Surface water UM.)C y�y6�l?� Driveway, parking/vehicle storage area S � Curtain drain A,�d'`-'L_ 1KA-20111L) E. ENGINEER'S CERTIFICATION -;k )06YLINS��c� i��/ k6)1, x27— I certify that i have checked, verified, or conformed to all MOA and HAA guidelines in effect on S & S ENGINEERING Signature 17034 Eagle River Loop Rnnd No 704 Eagle River, Alaska 99577 Engineer's Name Date z�, & HAA Fee $ /` Waiver Fee: $ Date of Payment—� Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Date of Payment Receipt Number l ,o inspection. �E � $F �J HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION 8 FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 7 ROBERT SHAFER, RE_ ROGER SHAFER. P.E. CIVILENGINEERS WELL FLOW TEST DATA (907) 694-2979 FAX 6941211 CLIENT: 642.L 2KWO-EIJ(K DATE OF TESTS '51 23 y3 LOCATION OF WELL (Legal Description):4-0'J`- ////\\L OT (O ISU< I 5-(SA2Lr 5�p WELL DEPTH: _2i2 CASINO DEPTH: `7y `J`' TESTED BY: _ DATE DRILLING COMPLETED: DRILLER:LUU7g wCM Ki TE&T nATA: CLOCK TIME DEPTH TO WATER DRAWDOWN PUMPING RATE(GPM) REMARKS swl FLOW v,u Fug-& 2 x / S / C9. S , 2ln(G MUMP zz PUMP /&)(y/ J/N(, Cc�,V T)NuvvS� MISC. DATA: CASING HEIGHT: ZZ Ir SANITARY SEAL? t WIRES.IN CONDUIT?: GRADING O.K.?t BACTERIA & NITRATE S LES COLLECTED: COLLECTED: 3 - RESULTS: WELL CURRENTLY PRODUCES 6, to GPM WITCH A _ LL7 DRAWDOWN FLOW RATS NOT GUARANTEED --SUBSEQUENT VARIATIONS CAN OCCURI 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) /—/� // �L�GIC / �f T�%er✓ SC/�3 5EG 35 7_/ 0 N ,2 3 S MAK Location (address or directions) (b) Applicant Namw�% l 12A1V0Z/V/1<_ _ Telephone: Home 1�46'6�7_ Business 2't56 '741" Applicant Address (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder [HKBuyer Cl ; Other ❑ (explain); (dSA*, Lending Institution s /'VE� TDh�e -Telephone _— �r Address®� . cS�1�.5 �/VC�D r� Al (e) Real Estate Company and Agent lir .— Address Telephone (f) Mail the HAA to the following address: P1r.'! k_j' 1 2. TYPE OF RESIDENCE Single -Family M Multi-Fa�mily ❑ Other J Number of Bedrooms -- 3. WATER SUPPLY Individual Well W' 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 MDIPublic ❑ 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 (11/04) t 5. ENGINEERING FIRM PROVIDINu INSPECTIONS, TESTS, FILE SEARCH, DA.A AND INFORMATION M 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 _19, d1af1 Telephone _21c� Address Ya s611rE 99 3 E�i�/cf/�2if4'� 995x3 Date E e DHEP APPROVAL jj Approved for_6oa2 `/)bedrooms by _ Approved X - Disapproved Conditional = Date J 9-P& 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 2 025 '{: ' MUNICIPALITY OF ANCI-IORAGE DEPT. OF HEALTH & MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTION. HEALTH AUTHORITY APPROVAL (HAA) '!,!L G `r' 1. CHECKLIST - FEBRUARY 1984 264-4720 / Legal Description: �07`_LL�.� ��V TU�i✓ 14 A. WELL DATA Well Classification _iq�wlxrE7/&&O" l— If A, ES, C, D..E.CC.QAp/proved (Y/N) —_ -&0 Well Log Present (Y/N) _ . Date Completed — Yield 9PEOi-0 �i phi Total Depth Cased to Depth of Grouting fyom� Static Water Level 00 r D�� ;007lDM Pump Set At �{- / Casing Height Above Ground Sanitary Seal on Casing (Y/N) _X/ Electrical Wiring in Conduit (Y/N) _y_Depression Around Wellhead (Y/N) �Separation Distances from Well: ' / #-4�- f * u- To Septic/Holding Tank on Lot �On Adjoining Lots :t t To Nearest Edge of Absorption Field on Lot _ ; On Adjoining Lots a O = To Nearest Public Sewer Line /rA To Nearest Public Sewer,1 Cleanout/ManholeTo Nearest Sewer Service Line on Lot Water Sample Collected by ���frLr/ ; Date��� Water Sample Test Results Comments PDX VZCW "rCSi '7/.11* - - ALG OrNe 9,*rA Rer cued -PG-c-6�- ' B. SEPTIC/HOLDING TANK DATA Date Installed 61/0/0 1 Size k06001- 1- No. of Compartments ;� y Standpipes (Y/N) --Y—/Air-tight Caps (Y/N) _L Foundation Cleanout (Y/N) —�_— Depression over Tank (Y/N) Date Last Pumped Pumping/Maintenance Contract on File (Y/N) � Holding Tank High -Water Alarm (Y/N) lk Temporary Holding Tank Permit (Y/N) —� Separation Distances from Septic/Holding Tank: To Water -Supply Well ,/ / 7/ I;_ To Building Foundation �✓r� / To Property Line Y_To Disposal Field �� To Water,Main/Service Line To To Stream; Pond, Lake, or Major Drainage Course . Comments -1E %7er McAScer(fMCW� 'T.4K-&A) A u_ 07-Hi5y rA Mr moA enc is Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata % 7 0 Type of System Design l�ftzT�—tom Date Installed 5mlol – Length of Field ?'� Width of Field Depth of Field Gravel Bed Thickness Square Feet of Absorption Area Standpipes Present (Y/N) Depression over Field (Y/N) /YDate of Last Adequacy Test .��! Results of Last Adequacy Test 2ES!lGT6 O� TIcS 70r5T Separation Distance from Absorption Field: To Water -Supply Well /I/ To Property Line To Building Foundation 4-77 To Existing or Abandoned System on Lot A/A ; On Adjoining Lots A/A To Water Main/Service Line &Z4 To Cutbank (if present) NA To Stream/Pond/Lake/or Major Drainage Course /Y,LSf To Driveway, Parking Area, or Vehicle Storage Area 'p Comments 4 Pe IV06 WC- ecydS ALL QTt464 Own -rAVC1J -1131K- 1 D. 1131K- D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check P mitte edrooki atin Against HAA Request ** I certify that I e ch cked, „or formed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Date 7.14 l KP Company �4 r'(PPmAJ&le MOA No. Receipt No. 37 Date of Payment Amount: $ max•.. �rs?•.�*��syf.. . � •. W pomN oob Page 2 of 2 a �E -580 ••` �w` •p*�.r' ••v e••�A 72-026 (11184) 5. LEGAL DESCRIPTION DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME 6. TYPE OF RESIDENCE (a. to ACs DATE DATE DATE 0— Two ❑ Five Cl MULTIPLE FAMILY ❑ Three ❑ Six INSPECTOR INSPECTOR INSPECTOR ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY ,.enl � 1d'� ❑ PUBLIC UTILITY MUNICIPALITY OF ANCHORAGE LL D[PT. OF I - ''•' I:CTIUN DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO��I�Ui�rwtPvl 825 L Street - Anchorage, Alaska 99501 _ INDIVIDUAL/ON-SITE** ENVIRONMENTAL SANITATION DIVISION Telephone 264.4720 RECEIVE REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTYOWNER - PHONE Lori r "pr- Va--2--v- \r—, 3 a% MAI LI NGADDRESS - -7-TO COu rz>o PROPERTY RESIDENT (If different from above) - - PHONE 2. BUYER - - - PHONE MAI LI NGADDRESS - - - - 3. LENDING INSTITUTION PHONE .Ir -,-INSV^M(Z- � MAILING ADDRESS \e 4. REALTOR/AGE T - - PHONE. - MAI LING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION ,Z),, L_ p�_ CT;� 6. TYPE OF RESIDENCE - NUMBER OF,BEDROOMS - - SINGLE FAMILY ❑ One 'K Four ❑ Other 0— Two ❑ Five Cl MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975, For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM - - INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) ��Iyu THIS SIDE FOR OFFICIAL USE ONLY�1 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑''MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO C:!r FOUR ❑ SIX 2. WATER SUPPLY IfT INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER J7 ✓ ,t. ❑Septic Tank pr ❑ Holding Tank Size: / �-- ? If Tank is homemade give dimensions:! SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/HoldingJank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line - 5. COMMENTS APPROVED FOR (Z BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY 72-010 (Rev. 6/79)