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HomeMy WebLinkAboutSCIMITAR #3 BLK 3 LT 2gc)L rruAa, `i3 MUNICIPALITY OF ANCHORAGE.-• Q , DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264.4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE NEW 6, J; ;?5 ❑UPGRADE 'fix 'V47- MAILING ADDRES LEG MLDESCRIPTION� J,� `' ? O� LOCATION NO. OF BEDROOMS S� -r /?:/v � / 1.�v Well Absorption area Dwelling / PERMIT NO. DISTANCE TO: % Uy P Q Material ` Manufacturer No. of compartments -v.2 = ` J7`%riL_ v y ~ Liq. capacity in gallons Inside length Width IF HOMEMADE: Liquid depth Well Dwelling PERMIT NO. j z DISTANCE TO: u 02< Manufacturer Material Liquid capacity in gallons Well Foundati Nearest lot line PERMIT NO. y�:,Z v�' = DISTANCE TO: L) � Z No. of lines Length of each line , y© Total length of lines Trench width a�p ' ?C1 inches Distance between lines � /¢ F- F Top of the to finish grade s _ Material beneath tile ej Total effective absor 'on aJ �ea lJ `r"'�� J� inches. Length Width Depth PERMIT NO. W C7 F a Type of crib Crib diameter Crib depth Total effective absorption area W a Well Building foupdation Nearest lot line N DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. w Building foundation Sewer line Septic tank Absorption area(s) DISTANCE TO: OTHER PIPE MATERIALS /r ` Sol LTESTRATING14 i INSTALLER REMARKS Le ;:s r N E - I f s + i . fir _? .•AHea o i s i 0 r 4' 7. �' f a No. 1 N� ssee • • r; .CF •IE.O ka1d• EGAL. APPROVED --DATE APPROVED, -- } r 1�X',i-1. AL.r%k 72-013 (Rev. 3/78) ' 264~4720 �E F_ ri 11 _T � PERMIT NO� 840246 . DHTE ISSUED� 04/25/84 HPPLICRNT� MYERS CONST HDDRESS� % S&S ENGINEERING EHGLE RIVER/ HK 99577 64�2979 CONTHCT PHONE9 � LEGHLDESCRIP� SUBDIYI�ION� �CIMITHR LOT� 2 BLOCK~�� SECTION� i0 TOWNSHIP. 15N RHNGE� 1W LOT SIZE� 42572 (SQFT OR HCRES) MHX BEDROOMS� ] ' LISTED BELOW HRE THE OPTIONS HVHILHBLE TO YOU IN DESIGNING YOUR SEPTIC SYSTEM� CHOOSE THE OPTION THHT BEST FITS YO&R SITE . .�~~��.�~~��~-�^~���~-��^�- �-F�" E_ i. -A' C_- �� � ������ ��. �»����][IN DEPTH TO PIPE BOTT1M�(FT) 40 � 5.0 40 GRRVEL DEPTH (�T) 5 0 05 I5 TO -1 DEPTH (FT ) 9�0 55 T7. F4; GRHVEL WIDTH (FT ) 25 140 50 GRHYEL LENGTH (FT. ) ' 260 280 28.0 GRHYEL VOLUME (CU.YDS 20.7 THNK SIZE1.000. 0 :q q.. SQIL RHTING 85 85 ** THNK MUST HHVE HT LERST ... ..... .... ... .... .... �.... .... TWO COMPHRTMENTS ����������� ..... �������������� I CERTIFY THHT J I HM FHMILIHR WITH THE REQUIREMENTS FOROr ITE SEWERS AND WELLS HS SET FORTH BY THE MUNICIPHLITY OF HNCHORHGE (MOH) HND THE STHTE OF HLHSKH 2. I WILL INS�HLL THE SYSTEM IN HCCORDHNCE WITH HLL MOH C DES HND REGULHTIONS/ HND IN CQMPLIHNCE WITH THE DESIGN CRITERIH OF THIS PERMI`[ I I WILL HDHERE TO HLL MOH HND ST�TE OF HLHSKH REQUIREMENTS FOR THE SET BHI DISTHNCES FROM HNY EXISTING WELL/ WHSTEWHTER DISPOSHL SYSTEM QR PUBLIC SEWERHGE SvSTEM ON THIS OR HNY HDJHCENT'OR NEHRBY LOT 4. I UNDERSTHND THHT THIS PERMIT IS VHLID FOR H MHXIMUM OF ] BEDROOMS HND HNY ENLHRGEMENT WILL REQUIRE HN HDDITIONHL PERMIT. IF H LIFT STHTION IS INSTQLLED IN HN HREH COVERED BY MOH BUILDINGCODES, THEN (1) AN ELECTRICAL. PERMIT HND INSPECTION MUST BE OBTHINED/ (2) HS~BUILTS WILL NOT BE HPPROYED WITHOUT HN ELECTRICHL INSPECTION REPORT/ HND (]) THE EL�CTRICHL WORK MUST BE DONE BY H LICENSED ELECTRICI�N SIGNED �~ DHTE� HPPLICn,NT� MYERS ST' / ISSUED BY DHTE� __ G PERFORMED FOR: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST tiS LEGAL DESCRIPTION: ` `LE`�" 02 Ic 2 3 4 U c 5 '� t G 6 t' 7 7 b G �r 8 r �— 9 L . � b 10 t 11 p 12 v rV J 13-- 14- 15- 16- 17 314151617 18- 19- 8 19 ti 20 COMMENTS PERFORMED BY:,. )w L G BS%'S//y /? of A er.�a :•o£ 6h,6wl A. 3hjfar 4 wr r X SOILS LOG ❑ PERCOLATION TEST DATE PERFORMED: o9/ 7/'g 2 WAS GROUND WATER S ENCOUNTERED? /vo L O P E IF YES, AT WHAT DEPTH? SITE PLAN Reading Data Gross Time Net Time Depth to Water Net Drop �.SrA �'^a„�. ,�•�'5•K*� -, PERCOLATIONRATE (minutes/inch) TEST RUN BETWEEN FT AND FT 72-008 (6/79) _ \\MI LII \YELL 1\GV VIYV STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological a Geophysical Surveys LOCATION OF WELL (Please complete either to, Ib or ICA la. Borough Subdivision L� Block Fb I/4gtrs. Borough Cimita f—of—of— Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS Street Address and Area of Well Location Drilling Permit No. A.D.L. No. 7 Section No. Township No Range E ❑ Merl Bion SO W� 3. OWNER OF WELL: Mr. Gene Skyles Address: Chugiak, Ak. Feet Delow 2. WELL LOG Surface 2. - Material Type Top Bottom 4, WELL DEPTH: (final) 266 ft. 5. DATE OF COMPLETION J J B. Cable fool YM ofory (]Driven C] Dug ❑ Auger Jotted Bored ❑ Other: rave , ou ers, si 9 9 7.UA omastic O Public Supply E] Industry 0 Irrigation Q Recharge ❑ Commerical ❑ Test Well ❑ other: Sand, gravel, .silt 4 60 Rockit green st one, wa e B. CASIV: E] Thr,OaAedXM Welded 1r7 diam. C3 In. to 1. ft. Depth Weight 1 Ibs.1ft. diam. in. to ft. Depth Stickup ft. 9. FINISH OF WELL: Type: Diameter Slot/Mesh Size: Length!_1 Set between ft. and ft.II Backfilling _ Gravel pack � - I - I ITY tire�(c�r - G 10. STATIC WATER LEVEL: 35 f4. 5Y5-1-84 � Above or n8elow land surface Dote E]y` Equipment usod: GEPT. Cc 1-1EA I. � �b�---- EivV1(2G;-din-1� ,- — 11 . PUMPING LEVEL below land surface and YIELD it. after hrs, pumping g.p.m. ft. after hrs. pumping _ q.p.m. 12.GROUTING Well Grouted: O Yes [ NO Material: C] Neat Cement C] Other: 13. PUMP: (if available) HP Length of Drop Pipe ft. capacity Q-P-m- Ej Sub,. Jot contrill oto Other 14. REMARKS: Productio of 2 GPM Perforations at 40®45 16. WATER WELL CONTRACTORS CERTIFICATION: I5. Wator Temperature _a C] F El C This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Magnuson Drilling AA 5385 P,ayaster°oxausl /bol Eagle River, Ake rCp{if.rpS�Llcense Number Address: t5 J77 i Dale: May 15, 19 84 ! Signed�!_-- Authorized Repress alive Form 02-WWR (11/81) Copy Distribution: WHITE -State DGGSI PINK-Orillor, CANARY-Cuslomer MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services Mi DIVISION OF ENVIRONMENTAL SERVICES -� 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel 1. D. # n�) � - .12_IQ - HAA # 0 M clu Y�) 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 2; Mock 3; Scimitar Subdivizion #3 Location (address or directions) 20066 So22enet Drive (b) Property owner Romab S,& Telephone: (home) Business Mailing Address 8013 Pioneer Diti.ve, Anchohage Ak. 99504 (c) Lending Institution NORTHLAND MORTGAGE CORPORATIONTelephone (d) Real Estate Company and Agent Centu&y 21 /New Ho i.zons Attn: Danne22 Johnson Address 2213 Ea4t Tudo& Road Anchokage, Atazka 99507 Telephone 562-6233 (e) Mail the HAA to the following address: (or check here EXXf hold for pick up.) List contact person and day phone number below: S & S ENGINEERING — -17034 EagIg River I einp Road No. 904 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single -Family IXX Number of bedrooms 4" 3. WATER SUPPLY Individual Well i%Ic Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site RX Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 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 Telephone 1,6 & S EiJGINEEq!NG Address - ,1 00P Raac� My saa!e River, Aiask9357: Date /15) _ 6. DHHS APPROVAL Approved for _bedrooms by Approved_ Disapproved Terms of Conditional Approval . Ck4N S✓1. m—I Conditional a '•. 7 i� nee slSeal —Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 oranalyze 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 7+88) Back Page 2 of 2 G `~ 0A P� MUNICIPALITY OF ANCHORAGE (MOA) \Qp���� • Health Authority Approval (HAA) a G �� CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: A. WELL DATA Well Classification �(� �`'— If A, B, C, D.E.C. Approved (Y/N) Well Log Present(ytN)_Date Completed Yield r y 1 r� _Z R,—q 0 ✓ Total Depth L� Cased to Depth of Grouting Static Water Level _7� 7 r Pump Set At Casing Height Above Ground Sanitary Seal on Casing QPN) y Electrical Wiring in ConduiVOD/N) Depression Around Wellhead (Y/& SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot (P, ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot \ 1e r ; On Adjoining Lots �t`k To Nearest Public Sewer Line N o To Nearest Public Sewer Cleanout/Manhole I To Nearest Sewer Service Line on Lot Water Sample Collected by S � S C—' -?_4g6 ;Z ; Date } C> - Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed �� Size No. of Compartments Z- Standpipes4VN) .__ 4 Air -tight Capsp/N) Foundation Cleanout") Depression over Tank (Y49 rate Last Pumped , �' — t `� `� L> Pumping/Maintenance Contact on File (Y/N)� ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) /4/,4 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well I I (.VtL To Building Foundation To Property Line i a To Disposal Field t To Water Main/Service Line 1 4- tf To Strea�ny Pond, Lake or Major Drainage Course 1 'rt Comments 72-026 (Rev. 7/88) Front Page i .of 2 f C. ABSORPTION FIELD DATA Soils Rating in Absorption Str to �'— Type of System Design ti Date Installed gA- Length of Field mo1l Width of Field eAlc> Depth of Field -:�ro0 Gravel Bed Thickness Square Feet of Absortion Area '� Statndpipes PresentQRN) Depression over Field (Y/&J / S Date of Last Adequacy Test o lei c., Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well ` �� To Property Line old ( To Building Foundation To Existing or Abandoned System on Lot ; On Adjoining Lots '!.o 1,4- To Water Main/Service Line -21-5 '}' To Cutback (if present) r, A I To Stream, Pond, Lake, or Major Drainage Course 'i - To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Dateailed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Check Permitted Bedroom Rating Against HAA Request" "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on, the date of this inspection. Signed t'cNC31iltiialtJ 17034si;ivcl' 1 Com an u' ©®p Road No. 204 p Y r 'r Date / v�z, S X! MOA No. 3 Receipt No. `2ac�" ( � C� �,- Date of Payment l `� 6 Amount: $ �� 6 Receipt No. _ Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 pd°� (7 tC. it 0 0. CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. «BORArOAMS 5633 B STREET B ANCHORAGE, ALASKA 99518 • TELEPHONE (907) 562-2343 FEDERAL TAX I.D. #92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order # 29485 Date Report Printed: OCT 22 90 @ 19:08 Client Sample ID:L2,B3, SCIMITAR #3 PWSID :UA Collected OCT 1B 90 @ 12:50 hrs. Received OCT 19 90 @ 16:15 hrs. Preserved with :AS REQUIRED Analysis Completed :OCT 22 90 Laboratory Supe visor : TEPHEN C. EDE Released By G Special Instruct: Chemlab Ref #: 904389 Lab Smpl ID: 7 Matrix: WATER Client Name S & S ENGINEERING Client Acct SNSENGP P.O.# NONE RECEIVED Req # Ordered By : R. SHAFER Send Reports to: 1)3 & S ENGINEERING 2)ADEC (FORMAT) Parameter Tested Result Units Method ---------------------------------------------------------------------------------------- NITRATE-N 0.28 mg/l EPA 353.2 Sample Remarks: SAMPLE COLLECTED BY; RAY 1 Tests Performed ND= None Detected NA= Not Analyzed ' See Special Instructions Above UA=Unavailable " See Sample Remarks Above LT=Less Than, GT=Greater Than Allowable Limits ----------------- 10 AtnNDF ofHpFhJ. O n v > MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES / I CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include loth, jblock, subdivision, section, township, range) Location (address or directions) (b) Property Owner -%q 6L.e Telephone: Home Mailing Address (c) Lending Institution Telephone Mailing Address (d) Real Estat Address Business Telephone (e) Mail the HAA to the following address: or: Check here, if hold for pick up. List contact person and day phone number below. S & S ENGINEERING 17034 Eagle rver LIGOP X0aCI No. 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single -Family Number of Bedrooms 7 3. WATER SUPPLY Individual Well P< 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 (Rev 8186) Front 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION r] 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 Address S & S ENGINEERING Date 99577 Telephone X16 �), s• `gip+ a92 � `� �4 ePea1- t t. DHHS APPROVAL Approved for "fes"' Date bedrooms by Date 6 -`7-g3 Approved t'� Disapproved Conditional Terms of Conditional Approval cihhs CAUTION 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. Page 2 of 2 72-025 fRev 8/861 Back �J MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) il�n� �9$7 CHECKLIST - FEBRUARY 1984 264-4744 Legal Description: �'T- A. A. WELL DATA S. f _ A/ Well Classification If A, B, C, D.E.C. Approved (Y/N) Well Log Present N) Date Completed Yield Total Depth Cased to ls/ Depth of Grouting Static Water Level 3 Pump Set At U Casing Height Above Ground /y Sanitary Seal on Casing�WN) Electrical Wiring in Conduit �/N) Depression Around Wellhead (Y(� 1 Separation Distances from Well: Cleanout/Manhole/ To Septic/Holding Tank on Lot On Adjoining Lots ic�f To Nearest Edge of Absorption Field on Lot // U� ; On Adjoining Lots To Nearest Public Sewer Line � To Nearest Public Sewer 2 S Cleanout/Manhole/ To Nearest Sewer Service Line on Lot Water Sample Collected by Date �;J= Water Sample Test Results i-7/5 /'-tcl� F,,P.e (or /A. ­ i /L x_,� Commentsc=�/��z B. SEPTIC/HOLDING TANK DATA Date Installed S lb Size /ZSZ-1 No. of Compartments Z Standpipeso/N) Air -tight Caps/N) Foundation Cleanout (DN) Depression over Tank (Y/6) Date Last Pumped * (-Lr & i Pumping/Maintenance Contract on File 'Y/N1 ; for OSA Holding Tank High -Water Alarm (Y/N) VIA Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well / To Property Line /o r -k To Water Main/Service Line Z- S 14 To Building Foundation To Disposal Field 7 7 &/A To Stream, Pond, Lake, or Major Drainage Course Comments }�: Page 1 of 2 72-026 lRev_ 81861 Front A CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 LABORATORIES FEDERAL TAX ID # 92-0040440 A�N 1 Jo, J'. r . -j4l 4 ic-rill CAI) 170, i j;j. �' .1 -.0 )��O dater Y 0 1 MPO bee, f 2i:1=tl 1151. 1' 1.10, r, I "T'S 600-V C "°ftk CkS f4 , r, MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIMONMENTAL HEALTH CJS DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date /6 V`� (a) Legal Description include lot, block, subdivision, section, township, range) G'.> Location (address or directions) (b) Applicants Name Applicants Address Telephone - Home Business (c) Applicant is (check one) Lending Institution Owner/builder ; Buyer � ; Other. F:- (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single -Family Multi -Family Other (describe Number of Bedrooms 3. (dater 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. 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 l of 2] 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 regula- tions in effect on the date of this inspection. Name of Firm 3i Address Date (ENGINEER SEAL) / • fl/ 6. DHEP Approval. Approved for �su/._'.Q/ bedrooms By Approved Disapproved Conditional Terms of Conditional Approval CAUTION Telephone .� nF �1 6 1 .� "Ih o A. Shsh:r Pd Lb.n ;T. Date lu-.•�<l THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 PROTECTION REPRESENT - REGISTERED HOMES AND REQUIRE - BEFORE A FOR ERRORS [Page 2 of 21 7-19-84 MUNICIPALITY OF ANCHOWv H uP *r. OF HEALTH ENviRc ENITA P OTaCTI is MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) J� CHECKLIST - FEBRUARY 1984 Legal Description: A. WELL DATA Well Classification U A �(C_ If A, B. or C. D.E.C. Approved(Y/N) Well Log Presen(Y Date Completed 7 Yield r Total Depth ( Cased to 6/ Depth of Grouting Static Water Level1 Pump Set At u GI Casing Height Above Ground Sanitary Seal on Casing (Y Electrical Wiring in Conduit (Y/ Impression Around Wellhead Separation Distances from Vb11: r To Septic/'Tank on Lot G On Adjoining Lots /00 To Nearest Edge of Absorption Field on Lot; On Adjoining Lots /cam To Nearest Public Sewer LLine To Nearest Public Sewer A/ Cleancut/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected By S' ��2t %!� �2��Gi ; Date -7 - V Water Sample Test Results Comments B. SEPTIC/TANK DATA Date Install � C1 Size '1No. of Ccmpartments 2 Standpipes ( /F) Air -tight Cap (Y 'Ed) Foundation Cleanou (Y ) Depression over Tank ( ) Date Las Pumped G`J Pumping/Maintenance Contract on File (YIN) for AliHolding Tank High -Water Alarm (Y/Ny Temporary Holding Tank Permit (Y/N) /-//44 Separation Distances from septic/Holding Tank: To Water -Supply 4\bll 116 f To Building Foundation, To Property Line /0 74- To Disposal Field r To Water Main/Service Line c0 To/ Stream, Pond, Lake, or Major Drainage Course vJ Comments Receipt Date Paid: Amount: cIS.OU [Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorpt'on Strata�Type of System Design Date Installed _ Length of FieldU Width of Field 'Vo _ Depth of Field f Gravel Bed Thickness 6 Square Feet of Absorption Area Z/0 Standpipes Present Depression over Field4 Date of Last Adequacy Results of Last Adequacy Test "-e- L -(J Separation.Distance from Absorption. Field: To Water-Supply.Vbll G To Property Lire To Building Foundation Z To Existing or Abandoned System cn Lot T r On Adjoining Lots To Water, d-n/Service Line To Cutbanl;(if present) / To Strearh/Pord/Lake/or Major Drainage Course /V To Driveway, Parking Area, or Vehicle Storage Area J� Comments D. LIFT STATION Date Installed Dimensions Size in Gallons Ma ole/Access (Y/N) _ "Pump On" Level at p ff'el at High Water Alarm Level at Ven� (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MoA Electrical Codes(Y/N) Comments ** Check Permitted Bedroom Rating Against 11AA Request ** I certify that I have checked, verified, or conforms d to all MOA HAA Guidelines in effect on the date of this inspection. Signed 'dix"�rDate ��� ' MOA No. Company f .. 'nal Rni� Ate_ 00 - KBI/d.5/s [Page 2 of 21 2-15-84 a' s - '�, J, No. tb57-E 2-15-84