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Home My WebLink AboutDEBORA BLK B LT 15t ii )),tLL �f 1� * 19,50 035 1(� 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) L~�f /5— /�// /� G'�: 6a.o f. h„!v % /y/t/le - tcJ 1'ec Z7 Location (address or directions) p ' i•/!-reY fieri .^G L4f� /`iK� (b) Applicant Name Telephone: Home %✓�� Business 6_1:1— ? sog Applicant Address S5' -2o Loire OTis f'il't✓y fine��,�r�Sa ilk 5'�J'o2 (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ❑ ; Buyer; Other ❑ (explain); (d) Lending Institution Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: /Gist. .4e * I /icy...0-• 2. TYPE OF RESIDENCE Single -Family ❑ Multi -Family Other Number of Bedrooms IV 3. WATER SUPPLY Telephone Individual Well Community Public �./�,rf fir'✓vts� we// Note: If community well systern, must have \`ten gniAnalign from the State Department of Environmental Conservation attesting to the legality and status. sj I(I�11111111 / 4. SEWAGE DISPOSAL ) I I 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. r \ Page 1 of 2 r2-025411 841^� 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 verity 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. l 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 EAGLE RIVER ENGINEERING SERVICES Telephone EAGLE ITIVER. An 99577 Address p n PnX jZg294 Date y��6AFf 694.5195 6. DHEP APPR70 AD Approved to �il� Approved 0. r1 f��• •• ",7 u it e: -S) I N . tr Engineer's Seal Louis A. Butwo CE -6776 Aarbeoo y Date/b'�— _ cV Disapprove — Conditional Terms of Conditional Approval i CAUTION �• 1tttll' The Muncipality of Anchorage Department of Healthtand Environmiental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations b Len 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. / PAne 2 of 2 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH d MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 APR 16 '5 264-4720 Legal Description: f.Jw sec A. WELL DATA Well Classification G /FSJ C s If A, B, C, D.E.C. Approved (YIN) -i Well Log Present (YIN) Date Completed Yield Total Depth Cased to Depth of Grouting Static Water Level Pump Set At Casing Height Above Ground Electrical Wiring in Conduit (YIN) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments — Sanitary Seal on Casing (YIN) _ — Depression Around Wellhead (YIN) On Adjoining Lots — On Adjoining Lots — To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date B. SEPTIC/HOLDING TANK DATA /QN G /, Se a✓PJ1 Date Installed Size Standpipes (YIN) Air -tight Caps (YIN) Depression over Tank (YIN) Pumping/Maintenance Contract on File (YIN) Holding Tank High -Water Alarm (YIN) Separation Distances from Septic/Holding Tank: To Water -Supply Well _ To Property Line To Water Main/Service Line Course Comments Page 1 of 2 72-026(M84) No. of Compartments Foundation Cleanout (YIN) Date Last Pumped ;for Temporary Holding Tank Permit (YIN) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field p" 6 /, � Sr .cn 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 D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at — High Water Alarm Levet 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 that 1 �hhavve/e checked. verified. or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed_,/fit ' i+ Date 4/4, S" Company AY4- ,P,4xn E1v - s'e.vMOA No. 15 7- 6 S Receipt No. 33(°(n f `� �►�� OF ,Q4 Date of Payment �%- I b- 85 �� •Cp;.•• tiS� �` Amount: $ U� rZ �/•, x 494' is S�j, Page 2 of 2 72-026 (11,84) V'c ;• Laun A. avlwa �e � %_ CE -6736 r f STATE OF ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION CONSTRUCTION AND OPERATION CERTIFICATE A. APPROVAL TO CONSTRUCT for PUBLIC WATER SYSTEMS Plans for the construction or modification of L /S n Q[,� A - C-�Gs es ) e_bum S�D�"�`SI°'� RS; / A Z i' — - �c Z public water system located In za c �y�t- Alaska, submitted in accordance with 18 AAC 80.100 been reviewed and are ❑ approved. ❑ conditionally approved (see attached conditions). BY TITLE DATE If construction has not started within two years of the approval date, this certificate Is void and new plans and specifications must be submitted for review and approval before construction. B. APPROVED CHANGE ORDERS Change (=,Iracl adv ". W deecdpilw mlerence) Approved by Date C. APPROVAL TO OPERATE The "APPROVAL TO OPERATE" section must be completed and signed by the Department before any water Is made available to the public. The construction of the nbo 1/1L- public water system was completed on (date). The system is hereby granted Interim approval to operate for 90 days following the completion date. BY TITLE DATE As -built plans submitted during the Interim approval period, or an inspection by the Department, has confirmed the system was constructed according to the approved plans. The system is hereby granted final approval to operate. BY TITLE DATE 180107 (Rev. 11IBJ) DISTRIBUTION: 1. WHITE - ENGINEER (Complete Section C) 2 YELLOW - WATER SYSTEM FILE (Cpnplete Secllon C) l PINI( . ENGINEERIMUNI BOROUGH (Complete Section C) • GOLDENROD - MUNI -BOROUGH (complete Secllon A)