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Home My WebLink AboutEAGLE RIVER HEIGHTS BLK 3 LT 10C�� '� W � 3 iac � os� a�� 58 r `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 .2G �- 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, s w ¢rf tow ship, range) I' 1 Location (address or directions) J (b) Applicant Name Telephone: Home Business ! Applicant Address (c) Applicant is (check one):LendingInstitution ❑ ; Owner/builder ❑ ; Buyer ❑ ; Otherexplain); i �- (d) Lending Institution �I +�1�J %i t14 <_" Telephone L Address (e) Real Estate Company and Agent �..•—r Address % iz yys y7 ��e (f) t�H AA t e following address: 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms—,3 3. WATER SUPPLY Individual Well d 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)d Community ❑ Holding Tank ❑ Note: If community well system, must havewritten confirmation from the State Department of Environmental Conservatior attesting to the legality and status. Page 1 of 2 72-025 fi. Ve"EERING FIRM PROVIDING .PECTIONS. TESTS, FILE SEARCH, DATk ND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Healthl ly and/or wastewaterdisposalsystemissafe,functionalandadequate Authority Approval shows that the on-site water supp_ for the number of bedrooms and type of structure indicated herein. I further verify that based on the Information obtained 1.. 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 Date DHEP APPROVA,L Approved for M�dA--c— bedrooms Approved Disappr Terms of Conditional Approval Telephone Conditional CAUTION fi !.bort A. Shofar �.,• No. 1{571 f Ike pROFCS11111',A 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 th, professional engineers work. Page 2 of 2 72{25 411,&4. ' 1 "IOPAUTy OF ANCHORAGE MUNICIPALITY OF ANCHORAGE (MOA/ DEPT. OF HI:AI,TH g HEALTH AUTHORITY APPROVAL (HAA) ENVIRONMENTAL PROTEC71Opy , Q CHECKLIST�FEBRUARY 1fl84 vLP p5 Legal Description: b-rCE" 3 A. WELL DATA Well Classification 'S'r If A, B. C, D.E.C. Approved ( /A -sY/N) o Well Log Present (Y/J Date Completed t &76 Yield s 6-hM-I- Total Depth 132r i Cased to 132/ Depth of Grouting Static Water Level 1 3 Z r Pump Set At 1 1, V� r Casing Height Above Ground Sanitary Seal on Casing ON) Electrical Wiring in Conduit C/N) Separation Distances from Well Depression Around Wellhead (Ylq To Septic/Holding Tank on Lot .'5r' ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot w ; On Adjoining Lots To Nearest Public Sewer Line ( oo r + To Nearest Public Sewer Cleanout/Manhole r oa r t To Nearest Sewer Service Line on Lot ZS 1+ Water Sample Collected by ;Date 'g'AI- gS Water Sample Test Results Xr�2- Comments n" WOV145— -rr-v 'fl✓ti- X46% -c- -M 1 al G=c 0Gd B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Size Air -tight Caps (Y/N) No. of Compartments Foundation Cleanout (Y/N) Depression over Tank (Y/N) Date Last Pumped Pumping/Maintenance Contract on File (Y/N) —;for Holding Tank High -Water Alarm (Y/N) / v Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well To Property Line To Water Main/Service Line Course To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage CommentsTo f LI13-tL 00ripnhf, -t-o 'AnW% J U Page 1 of 2 72-026(11/84) 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 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) To Driveway, Parking Area, or Vehicle Storage Area Comments-m�r..rtR- 2I-kp!t a Mr lW U S -so - 9S D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at I "Pump Off' Level at High Water Alarm Level at Vent(Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments •' Check Permitted Bedroom Rating Against HAA Request •• Icertify that Ihave checked. verified, orconformedtoall MOA an HAA guidelines ineffect onthe date ofthis inspection. Signed Date e f�C $RB 'ICompany'. - MOA No. X J Oo3 PH'1944079 '�� v4, Receipt No. - 2,55a Date of Payment 17'5` �,tQ�� "�� "••.qS� 11 Amount:$ 454�— Page 2 of 2 72-026 n usa) Girl.•: "' ' Reb.rt A. Shafli •. ' ; No. 1457•1 " s CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562.2343 ANCHORAGE INDUSTRIAL CENTER 5633 B Street Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: (•) See h on back I.D. NO. Water syawm Nanta Phots No. gu,t3 Mailing Addraa f2�ir ` it t �ny�� ML• 'en C5- 7 rL ph, slow zip Coda SAMPLE DATE FEE Mo. Day Yew SAMPLE TYPE: 6-Routfne -- ❑ Check Sample (for routine sample with lab ref. rto. ❑ Treated Water O Special Purpose 15'Untreated Water SAMPLE Time Collected No. - LOCATION 3 Collected By I i L_.� to .e- &-y IZ`. SP - N s 3 I 4 5 I I TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ,EKSatisfactory ❑ Unsatisfactory ❑ Sample too long In transit; sample should not be over 30 hours old at examination to Indicate reliable results. Please send new sample via special delivery mail. Date Received � njf_ Time Received /6 %Obc N Analytical Method: ❑ Fermentation Tube .Membrane Filter Lab Ret. No. Result' Analyst I yldo•.?a�l C I I m I I m I m I m •w el caarcrl0o au o• Mo W ►o'ro.• eo••en ae1220 4111 BACTERIOLOGICAL WATER ANALYSIS RECORD n«. lou READ INSTRUCTIONS Membrane Filter. Direct Count Verification: LTB BGB Final Membrane Filter Results BEFORE �- Reported By ✓Y 1 _ Data_a / Time: COLLECTING SAMPLE TNTC= Too Numerous To Count Collform/1DOmf Collforml100ml a.m. P.M.