The URL can be used to link to this page

Home My WebLink AboutDEBORA BLK E LT 5ImEwSOZA gC.K ��50 031 z3 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 1. GENERAL INFORMATION (a) Legal De,Scription (include lot, block, (address or directions) (b) ApbGcant Name Applicant Address — (c) Applicant is (check one): Application Date��4 5 range) F/a.Telephone: Home ��-�/O y�v Business to !Z:Y-- !F441- ._. _. /_ - iJ4 Institution ❑ ; Owner/builder O ; Buyer 0 ; Other (explain); (d) Lending Institution ro� Tell eph-0na Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single -Family ;� Multi -Family O Other Number of Bedrooms 3. WATER SUPPLY Individual Well Community ❑ Public[3 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 O Public W community(3 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 Telephone Address 11- 1. , . 1' ; • f. r Date - ed, 6. DHEP Approved for Approved — Terms q( Conditional Approval I CAUTION tF Or y ••. • t, it P, •��'••••••'�� 'f� ....s."n' r,� ttob�n•)t, Shafer ..•t.C./ c'pP ...•••,��, 10 fESJt.�' a 4 Date `14— 6 �J JI 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 engineers work. Page 2 of 2 72-025 411,04) +uuNrav, y CW MUNICIPALITY OF ANCHORAGE (MOA) SMI ICER OF ►ALG` HEALTH AUTHORITY APPROVAL (HAA) �NtNVTAL PF*rLCT" CHECKLIST - FEBRUARY 1984 NOVO 5 284-4720 owi Legal Description: Lcyr S 13L-IC1Co CE1J/ R r>emo � s I A. WELL DATA Well Classification S.F. If A. B. C, O.E.C. Approved (Y/N) Well Log Present (YtP Date Completed Ate. 199.0 Yield Total Depth Cased to 4or+ ^ Depth of Grouting Static Water Level 2-1 r Pump Set Aty • 1(—, Casing Height Above Ground �� N Sanitary Seal on Casing (9d) Electrical Wiring in Conduit¢AN) Separation Distances from Well to, IS C -QPM-}- ✓ Depression Around Wellhead (Y p>&jj To Septic/Holding Tank on Lot '%/,A ; On Adjoining Lots N �` To Nearest Edge of Absorption Field on Lot ;On Adjoining Lots r To Nearest Public Sewer Line pis;+ To Nearest Public Sewer Cleanout/Manhole I ornt-I" v To Nearest Sewer Service Line on Lot LSr� Water Sample Collected by I nT�1111 ; Date 152 -3', Water Sample Test Results Comments S1-:o�.�.� T—iFE. �.�i✓__So �._X� � iJ 'l��F�cS .sib (o a � C'i1�1 V•J'G-t_•L. �.a�l/+ iat'L.�s.... �kuJS� A.K.., racrr fb'ILICr'-� lk MGA o u.o s'E, B. SEPTICAHOLDING TANK DATA Date Installed Size No. of Compartments Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (Y/N)AA Date Last Pumped Pumping/Maintenance Contract on File (YAN ; for Holding Tank High -Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well To Property Line To Water Main/Service Line Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72.026(11/64) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata r.. Type of System Design Date Installed Length of Field Width of Field I Depth of Field ri Gravel Bed Thickness Square Feet of Absorption Area Standpipes Present (Y/N) 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 Date of Last Adequacy Test To Property Line To Existing or Abandoned System on On Adjoining Lots To Cutbank (if present) Comments C -2f' -%0e T'To c. SV55, D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at '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 •• I certify that I have checked_, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed SLE Date f;;v H. ALA :r'�;57r yS' o 3 Company PH CCM_1'79 MOA No. Receipt No. Date of Payment �� h�g5 C:; • 41 Amount: $ �J "� :,; •' Page 2 of 2 72.026 (11,64) U11 shores •r- �•. No. 1451•E Z. r lFaF.,•�• •• �1 1\� F,"•Or•ESS��4 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage. Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER II TO BE COMPLETED BY LABORATORY ❑ PUBLIC WATER SYSTEM I.D.M PRIVATE WATER SYSTEM 4 Name Phone No. .5112-f Mailing Address City state 21p Code SAMPLE DATE: Mo. Day Year SAMPLE TYPE: Routine ❑ Check Sample (for routine sample wits, I: b ref. no. t ❑ Treated Water C F- Purpose tX Untreated Water Time Collected LOCATION Collected By i LOTS I1C. 'r—' I 2 I 4 I s L READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Analysis shows this Water SAMPLE to be: -WNI rtla isfactory ✓ ❑ 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 Time Received Analytical Method: Membrane Filter No. of colonies/100 ml. Lab bR' Ref. No. Result' Analyst ®— U m U i m U m U m BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter. Direct Count Verification: LTB Final Membrane Filter Result Reported By-� TNTC = Too Numberous To Count OB = Other Bacteria - Collform/100ml / /JCollform/100ml Date- Time: _ a.m. p.m. aLE RIVER AREA ' GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 u 0� Date Received May 12, 1976 1Qnlp: n Time of Inspection amt Date of Inspectionn- A-�� _s REQUEST FOR APPROVAL OF jenh INDIVIDUAL SEWER & WATER FACILITIES FOR 1. Approval requested by: Mailing Address: Phone: 2. Property Owner: Joseph C. Laesar Phone: Mailing Address: General Delivery, Eagle River 99577 3. Legal Description: Lot 5 Block E Debora Subdivision 694-9751 4. Location: Juanita Loop Road, 1st house on right, white & gold trailer 5. Type of facility to be inspected Single Family 6. Well Data: Individual A. Type C. Construction 7. Sewage Disposal System: on—site system A. Installed C. Septic Tank: 1. Size No. of bedrooms 2 B. Depth 50' D. Bacterial Analysis B. Installer D. Seepage Pit: 1. Absorption Area E. Disposal Field: Total length of lines 8. Distances: 2. Manufacturer 2. Material A. Well to: Septic tank , Absorption area Sewer Lines , Nearest lot line Other contamination B. Foundation to septic tank Absorption area C. Absorption area to nearest lot line EQ -034 (1/74) Page 1 of two pages I Page 2 of two pages - Rem "st for Approval of Individual er & Water Facilities Cegal Description Lot 5 Block E Debora Subdivision Approved Disapproved Approval.Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmen DIAGRAM OF SYSTEM Date Quality I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED EQ -034 (1/74) Date 5. Name of Realtor or Agent: Mailing Address: Phone: 6. Legal Description: Z- O �� 1'LOC,f L= vd BO49 '.4 Svh. Location: rVAt ioU LnZe Al" 7. Type of Facility to be Inspected: M IV 14e+ oz/',E No. Bdrms. -�Z-- 8. Water Supply Type of Supply: Public Utility Individual If Individual, number of dwellings presently served If Individual, depth of well re 9. Sewage Disposal System Type of System: Public Utility Individual (onsite) t/ If Individual, date of installation A/ /r Tv A-Ao, o w i s o � . ,d Cs o ,� �^? S .o C� "/Vc Le, - 72 72 003(3/76) 1 s; -j 1.0 •� 3 c o ..' '1" C.WMP- ,,, 3old -1 re,'. le �V r r` Y Cf Dip htcNi_Et MUNICIPALITY OF ANCHORAGE 11-,dIINC D[N r. Citi C _ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTIONNYROe�+WT.'•,� PfCTCCTiO^l N L 2510 East Tudor Road, Anchorage, Alaska 99504 276.2221 12 19/6 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES RECEIVED. 1. Type of Inspection: CMRO VA FHA CONY 2. Property Owner: 2—as ee 1 C,d,& Q41 Mailing Address: -GA -Al 12E/ "y'/P1/% 41 /may Phone: ` K* 9 y q%i2 3. Name of Buyer: Mailing Address: Day Phone: 4. Name of Lending Institution: Mailing Address: Phone: 5. Name of Realtor or Agent: Mailing Address: Phone: 6. Legal Description: Z- O �� 1'LOC,f L= vd BO49 '.4 Svh. Location: rVAt ioU LnZe Al" 7. Type of Facility to be Inspected: M IV 14e+ oz/',E No. Bdrms. -�Z-- 8. Water Supply Type of Supply: Public Utility Individual If Individual, number of dwellings presently served If Individual, depth of well re 9. Sewage Disposal System Type of System: Public Utility Individual (onsite) t/ If Individual, date of installation A/ /r Tv A-Ao, o w i s o � . ,d Cs o ,� �^? S .o C� "/Vc Le, - 72 72 003(3/76) 1 s; -j 1.0 •� 3 c o ..' '1" C.WMP- ,,, 3old -1 re,'. le ls� �'crtcA` on P -1z —A �j?2i4 fur L)5 ,�. Lu - �SIGIL /S LbY �LAv)- MoA.�X.t LO�Lt>%cJ�a TLu -. � `� Q ,' � ��-� , i :�- � � l,, ��-I'