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Home My WebLink AboutEAGLE RIVER VALLEY RANCHETTES LT 17BEagle River Valley Ranchettes Lot 17B #050-222-17 MUNICIPALITY OF ANCHORAGE ~/~'~) ~ ,,~ ~ 2 ~ //7 DEPARTMENT OF HEALTH AND HUMAN SERVICES ' Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT DISTANCES SEPTIC ABSORPTION ~,ddress /FROM~ TANK FIELD WELL PhOne(s} Permit "o. JNo. of B~m. WELL LEGAL DESCRIPTION ~ ~ ~ ~? ;r~'~W~a~lr~(~t~how ocat on o, well. septic system, prope.y lines, foundation. TANKS ~- N Manufacturer ~pacity in gallons ~ Material ' No. o[ Compa.ments ~ ~ ~ ~ ~ TYPE OF SYSTEM A 0 TRENCH ~BED ~ W. DRAIN ~ OTHER ~. ~ ~ odginaigrade~ptht°pipeb°tt°mfr°m ~ FT Tot.ldepthfromoegin~grede~. ~ FT H!~ 11 Gravel lenglh I ~ravel width Number Of lines ~il ,ating Pipe material ~ Installer ~:~ Date I.,,alled ;~ l WELLS ~ PRIVATE THER (Identify) Installer Date I.aalled: ~ '~l ' / REMARKS: ~ ~ Date: 72~313 (3/85) M U N t C I P A L I T Y 0 F A N C H 0 R A G E Department DC Health & Humap Service~ 825 L Street, Anchorages. Alaska 9950~ ~4~--47~0.~ ~' Date Issued: 07/i4/89 Engineer Designed Owner Name: HUD F'ROF'. ~ISP08. Llwner Address: 6'5 W. 4TH ANCHORAGE, AK 9950 Day Phone: 27 J.-2792 Parcel Id: 050-'222-17 Lot Legal: Subdivision: Section: 7 ~e: I._c]t 8ize 17955 (sq. ~t. or' acr'es) Ma>.' Bedr. ooms: Fhls Permit: 3 Teta] Capacity: SEPTIC f'ANK: VJinimum tc~ta], septic: tank capaci'Ly: 1.000 gallc:)ns, Each se~)t, ic tank mus'c have at least. 2 compartments. Depth to top cJ~ septic tank (s) < 4.() feet requires insulation ow~p tank (s). PERMIT EXF'IRES DECEMBER 5~ :[989. REPOR'T INSPECTIONS DATES/TIMES AT 543-4744 OR 543'-468] ENGINEER MUST VERIFY INTEC~RITY OF EXISTINO SEPTIC TANK. MENT MAY BE REQUIRED. REPI_ACI:" CEF.~T I F'Y ]'HA]": L. ~ am familiar w~th the r'ecluipements {er (~n-slte sewers and weiis as set ¢orth by the Municil3al~ty. of Anchorage (MOA) and the Sta'Le a~ Alaska,, 2.. I wiI1 install the system in ac:c:apdance with ali MOA c. odms and ~egulations:, and in cc~mplianc:e with the desi(jn criteria of this permit. · ::,. I wi] ]. adhere t.o ali MOA and State al' Alaska requipement, s ~o~ the set back distances ~pom any existing well, wast, ewatep disposal svstem op public: sewerage system~°n this or any adjacent or nearby lat. 4. I understand 'Lha~pepmit is valid {or a maximum c)~ 3 bedrc~ams. I alsc~ uncier"'"sta~th~t ~e capac:ity o~' the to{al system i~ 3 bedrooms and any enlam~ w~e~uire an additional per. mit. .......................................... B-'-l''r SCALE O~O ~ PERFORMED FOR: Municipality of Anchorage ~%, DEPARTMENT OF HEALTH & HUMAN SERVICES ~./¢ 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST ,~,., DA~'E PERF~ LEGAL DESCRIPTION* ~-- I'~r~ ~=~ wnship, Range, Section' 4 7 9- 10 - WAS GROUND WATER ENCOUNTERED? 11 ,F ES. ATWHAT 12 DEPTH? 13 O,~ Depth to W~r After ~ t MonitoriflO? / Reading Date Gross Net Depth to Net Time Time Water Drop 14 15 16- 17- 18- 19- 20- PERCOLATION RATE I ~ (minutes/inch} PERC HOLE DIAMETER TEST RUN 8ETWEE~.-~ AND ~"~ FT COMMENTS' $ & S ENGINEERINi~ He MICIPALITY OF ANCHORAGE [nd Environmental Prot¢ Fourth Floor West 825 L Street Anchorage, Alaska 99501 264-4720 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYST~'/"A SEPTIC TANK: ~J ~,/,'I, /~ "" """ ' DISTANCE NUMBER OF INSIDE LENGTN INSIDE WID1H ...... LIQUID DEPTH __ LIQUID CAPACITY /~GALLONS. TILE DRAIN FIELD: . . rOTAL LENGTH O,S','ANCE ,:BOM ,','E,-L ..... FOUNDATION_ ~ .E^R~..~T .O, L NE /'::4 .... OF L,NE / ~o ABSORPTION AREA __~__.~_ ~_. ..... SQ. FT. LENGTH OF EACH LINE DEPTlt OF FILTER SEEPAGE PIT: Log Crib Rings BUILDING FOUNDATION__ DIAMETER __OR WIDTH LENGTH DEPTH Crib ~J_~e: DIAMETE~ .... DEPTH.____ DISTANCE FROM: WELL TOTAL EFFECTIVE NEAREST LOT LINE__ ABSORPTION AREA IWALL AREA)_ SQ. Fr. Well Class: Depth: Well D'istance To: Lot Line Bldg: Sewer Line: Pipe Materials: # of Bedrooms: Installer: Remarks: PERMi1 ~O DEPARTMENt' OF HE~LI'H AND ENViRONMEN1HL PROTECTION ( Y'/~55 ) HPPLIUANT P & G HUME BUILDERS PO BOX 1886 ERGLE R1VER DDS~ 6~4-~114 LUUHIION WA1RLHWAY LEGAL Li?B EAGLE RIVER VALLEY RANCAE LU1 SiZE ~0000 SQUARE FEE[ ['YPE OF SOIL ~BSORB]'ION SYSTEM IS: TRENuH MAXIMUM NUMBER OF 8EDRUUMS = ~ bUlL RATING (hQ FT/BR)= Z50 1HE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: L) E F' 1- H -- -1 5' L E I'-.I f:~ -F H = 5 4 [iR F! ~,/E L B~ E P' i- H -- 1HE LENGI'H DIMENSION IS THE LENGTH (IN FEEl') OF THE I'RENCH OR DRAINF'iELD. THE DEPTH OF R TRENCH OR PI] IS THE DISTANCE 8EI'LqEEN THE SURFACE uH tHE GROUND AND FHE 8UTIOM OF 'THE EXCAVATION (iN FEET). [HERE iS NO SET NIDi'H FOR FRENCHES. FHE GRAVEL DEPTH IS 1HE MINIMUM DEPlH OF GRAVEL BEIWEEN ]'HE UUiFALL PIPk fiND IHE BOll'OM OF I'HE E~CAVR'TION (IN FEET). ~:E~l~-~.~ff_ll T R~---]~ SEPIL- I C TFlbtK S T -;dE= iEiE~O PFliSk(RISE F'LF~4'I-' O F"T I Of-I A PACKAGE PLANT MAY 8E INSTALLED A't- THE PERMI'I-IEE¢~ OPTION SUBJECT t"0 THE FOLLOWING CONDITIONS: · . EITHER ~ CLASS I OR ii NSF' APPROVED PLANT MAY BE INSI'RLLED. 2. ~ CONT'INUOUS MAINIENANCE RGREEMENT IS REQUIRED. IF A MAINTENANCE AGREEMENT IS NOT KEPT CURRENT YOU MAY BE REQUIRED -FO ENLARGE iHE SOIL ABSORPTION SYSTEM AND?OR YOU MA9 8E SUBJECT TO PROSECUTION~ 1'"i413 (2) L NSPE[:I [ [~t~S F~RE E:EE-.,ffJ IRE[:, BRCKFILLIN~ OF RNY SYSTEM WITHOUT FtNRL INSPECTION RND RPPROVRL BY 1HIS DEPAR[MEN'[ ~ILL BE SUBJECI TO PROSECUTION. MINIMUM DISTANCE 8El'WEEN fl WELL AND ANY ON-SIIE SEWAGE DIbPOSHL SYSIEM IS i00 FEE1 FOR 8 PRIVATE WELL OR ~00 FEET FOR fl PUBLIC WELL. 01'HER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVH1L~BLE FO INSURE PROPER INSTALLATION. PEi-;d"I ! F EXF' 'r F-."ES [)ECEt'-IlBEF,:: gl.. 1SaT"F I -i: FOR'IH BY THE MUNICIPALITY OF' ANCHORAGE. ~: I WiLL INSTALL ]"NE SYSTEM IN ACCORDANCE WIIH THE CODES. -<: I UNDERST8ND THA1 t'HE ON-SII'E SEWER SYSTEM MAY REQUIRE ENLARGEMENi RESIDENCE IS REMODELED I'O INCLUDE MORE THAN ~ BEDROOMS. ~ I~NED: __~____~__~ "" ............. F RIITI [)FRq HPPLICBN-~ P ~ t~ HLME EUILDER~ CERTIFY THAT I AM FAMILIHR WITH THE REQUIREMENTS FOR ON-SI'KE SEWERS; 8ND WELLS AS SET IF' V.~. 0 o0 ~" E GEO~HNICAL ~' DEVEI~/IENT CO, Box 90 [Davis St.. Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster Earl Ellis 694-2774 SOIL LO~ 688-2280 Soils ~ Foundations Land Development Perfomed for: Name: ~'~ C~ '~,~.,.~,...,..~'z,Y> Tel. No. ~4°~-,"A Hailing Address: ~ q~o~ \~%~ ~r~.~'~t~- ~s~!~c~°t~?7 Legal Description: ~.--~-~ \-~ ~¢~r~.~--~_~./~_+~,. ~e~*,~r~ Depth (feet) So~1 CharacterJsMcs 0 1 2 3 5 6 7 8 9. 10 11 14 Ground ~at~r Encountered: Yes NO ~f ~es, ~het depth Proposed Installation: Seepage Pit Drain Field / . 77 Performed by: ~ Date: c~ ~ ~-- DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA ggs01 BILL SHEFFIELD, GOVERNOR Telephone: Address: 274-2533 To Whom it May Concern: According to records on file in this office the ~~z~'- y~/~ Water System is in compliance with the State Drinking Water Regulations Sincerely, MUNICIPALITY OF ANCHORAGE Department of Health & Human Services 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 I.D. # 1. GENERAL INFORMATION (Must be completed prior to submittal) ' (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 17B; Eaglz River Valley Ran~hettes Location (address or directions) 18548 Whi~laway~ EaRle River, Alaska (b) Property owner H.U.D.#053192-203 Mailing Address 605 W~_~t 4th Aven~e~ (c) Lending Institution Telephone:(home) anchoraqe~ Alaska 99501 Telephone Business Marling Address (d) Real Estate Company and Agent Associated Brokers ATTN: Sand~ Address 640 W~St 36th Avenue, S~te #I, Anchoraqe, Alaska 99503 ,9 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 Ri~er Leor~ Road No. 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single-Family[~G( Number of bedrooms .~ ~ 3. WATER SUPPLY Individual Well [] Community [] Public [~( Note: If commuqity well system, must haye written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ~X 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 flies 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 S & $ ENGINEERING Address 17034 Eaole River Loop Road Date Eagle River, Alaska 99577 6. DHHs APPROVAL Approved for '-~ _bedrooms by _ _ . Date Approved ~ Disapproved Conditional Terms of Conditional Approval 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 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. 7/88)Back Page 2 of 2 A. WELL DATA Well Classification Well Log Present (Y/N) Total Depth Cased to Stati9 Water LeveJ Casing.Height Above Grqund MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST -~FEBRUARY 1984 343-4744 Legal~Descr, pt,on,, /~"~ Date Completed Dept. h of Grouting If A, B, C, D.E.C. Approved (Y/N) Yield Pump Set At Electrical Wiring. n Conduit (YZN) SEPARATION DISTANCES FROM WELL: · Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) To Septic/Holding Tank on Lot To Naa'rest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample C01!ec~ed by ; Date Water Sample'Test Results ',r Comments _~. OMl."~.!it')~ ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole E~., SEPTIC/HOLDING TANK DATA Date Installed / / ?~Size ./C~O NO. of Compartments' Standpipes (Y/N) - . ~ Air-tight'Caps (Y/N) ' ~/ Foundation Cleanout (Y/N) Depression over Tank (Y/N)' AJ Date Last Pumped ~' - Pumping/Maintenance Contact on ,File (Y/N) , . ' for Holdi'ng Tank High-Water'A'l~ rm ( N) Temporary Holding Tank Permit (Y/N) SEP,~RATION DISTANCES FROM SEPTIC/HOLDING TANK: To W~t~e~-~upply Well .~-.-~/~ · : ,~ To Building Foundatibn ..... ! r~' .To Property Lir~e. ' . -,,-. t/O //" ' To DisposalField ...... ~.~ T.o Water Main/Serv ce L_ne. ~' ~ ~ To Strearq, Pond, Lake or Major Drainage Course ,/~ 7~ '.,. , ! Page1 of 2: C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ~ t'}O z~'/~ r~' Type of System Design Date Installed c~ _ ! ~ - ~ Length of Field '~,'.'/ Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test ~..O/ Depth of Field Gravel Bed Thickness ~. Statndpipes Present [Y/N) Date 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 To Property Line / O To Existing or Abandoned System on ; On Adjoining Lots ,'~O' ~ To Cutback (if present) /'J/~ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments ~ ~/b - ~<~ Dimensions 5,~' '~ ~ N / Lo/U,~ ~'C:O ,~-/ Manhole/Access(Y/N) c~ ,, "Pump Off" Level at -~. ~ ~" Vent (Y/N) ~ ~ ~,~C~J Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conforr~ed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Company Date 17034 Eagle River Leap Road No. 204 MOA No. Receipt No. ~' Date of Payment Amount: $ 72-026 (Rev. 7/88) Back /'70. Receipt Waiver Fee: $ Date of Payment Page 2 of 2 MUNICIF~ALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be cQmpleted prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Lot 17B~ Eagle River Valley Ranchettes Location (address or directions) 18548 (~hirlawa~;, Eagl-e.,Riv~er, Ak. (b) Property ~Jwner ,: H~.U.~),-' ,',";- .... Telephone: (home) Business Mailin~Address- ~05. West 4t~. , Avenue Anchoraq¢._ Alaska 99501 (c) Lending.,In~t'itutib~., -.~ '" '~ Telephone Mailing Add)es~' " (d) Real Estate Company and Agent Address 640 West 36th Avenue suite #I; Anchorage, Alaska 99503 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 River Loop Road No. 204 Eagle River, Alaska ~577 2. TYPE OF RESIDENCE Single-FamilyJ[3~ Number of bedrooms 3. WATER SUPPLY Individual Well [] Community [] Public~x 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 J~ 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. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATIO~ . 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 suppry 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 Date 17034 Eag!e RLve~ Loop Road No. 204 Telephone 6. DHHS APPROVAL Approved foF.~ -~ bed rooms by~O~g~'/~~,'' Approved '// Disapproved Conditional Terms of Conditional Approval 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 $ 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. 7/88) Back Page 2 of 2 ,..~¢~,~.5 ' ~ MUNICIPALITY OF ANCHORAGE (MOA) ~ Health Authority APproVal (HAA) ~ A. WELL DATA ' ~ Well Classification ~ IfA, B, C, D.E.C. Approved (Y/N) Well L~msent (Y/N) "- -bathe Compl;~ed '~' Yield Total Dept~_ Cased to Dept~of Grouting ........ Static Wate~Le~ Pump Set At Casing Height Above Gro~,~ Sanitary Seal on Casing(Y/N) Electrical W~n~g'in Conduit (Y/N) ~ ,, ~ . ~presslon A[ound Wellhead (Y/N) , SEPARATION DISTANCES FRoM'WELL: ~ ' ~ To Septic/Holding Tank on Lot _ __ --; On ~Lots ' To Nearest Edge of Absorption Field on Lot _. ; ~ Ad~s To Nearest Public Sewer Line _ __ To N~r~t P~I~ S~er ~u~ To Nearest Sewe~ Service Line on Lot ~ Water Sample Collecte~ ~y. ~ ;.Date , ~ Water Sample Test Results ~ B. SEPTIC/HOLDINGTANK DATA Date Installed /'~ Size ~_ 4:3C::)4;' No. of Compartments ~ St~ndpi¢~s~N) y Air-ti aps~N) Foundation Cleanout {~N) y Depression over Tank (Y~) gf~C ~ ~j Date Last Pumped ~ -"~J~" E~J PumPing./M¢ir~!er~a.r~ce c(~n~act on File (YZ~Nk/.. ' ~/'~: ;for ~ 1'~ ~ Hold. ing.~e,wk High-Water Alarm (YIN) ~ Temporary Holding Tank Permit (Y/N) :SEPARA~t(3N~p~,NCES FROM SEPTIC/HOLDING TANK: ..... '--,-; ~ 0 Water~$up.p, ly~Well, ~ ~' To Building Foundation: \ '~ ,r - To, Prope?t~/Ejne :_ . · '~,o W~r ~am/$;rv,~ ~.ine ~'~o'Stream, Pon~, Lake or Major Drainage Course To Disposal Field 72-026 fRev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ~ ';~'~_~____ Type of System Design Date Installed cl,- [~='-' ~ Length of Field ~ Width of Field ~ravel Bed Thickness ¢, ~ ~ ~ Statndp~pes Presen~N) S..ar of* o.,on*r. T.t Depression over Field (Y~) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FI ELD: 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 VehicleStorage Area '1 To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~ ~ To Cutback (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at ' High Water Alarm Lev. e/I Tested for //.,"r"'-- Meets MOA Electrical Codesd~N) Comments Y Dimensions Manhole/Access ON) ' ~'Pump Off" Le~el at ' ~-~ Vent ~/N) y Pumping Cycles during AdeQuacy Test. **Check Permitted Bedroom Rating Against HAA R~quest** I certify.,that I have checked, verified, or conformed to alt MOA and HAA guidelines in effect on the date of this inspection. Signed Company Date MOA No. 17034 Eagle River Loop Road No. 2o~ Receipt No. ~ Date of Payment Receipt No Waiver Fee: $ Date of Payment Page 2 of 2 (a) 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 264-4~'20 GENERAL INFORMATION Application Date ~'~///-//~ ~' /, , / Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) , (b, Applicant~Name Applicant Address ~'~/~ .*~- '~-~~' '/~.,.~ ~ (c) Applicant is (check one): Lending Institution []; Owner/builder,l~; Buyer []; Other [] (explain); (d) Lending Institu'~ion · ,._ . ~ · Telephone Address (e) Real Estate Companyand Agent Address Telephone (f) Mail the HAA to the following address: SRB 196x Ea~le ~,iver, a, las~a TYPE OF RESIDENCE Single-Family ~ Multi-Family[] Number of Bedrooms Other WATER SUPPLY Individual W~ll [] Community/~ Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite[~' Publicl'-I 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 (11/84) 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 Heatth 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 $ & $ Engineering Address Sp.~ Date Eagle Approved for ~ bedrooms by ~./L~/~),J~~ Approved '"',/ Disapproved . Conditional~-~ /\ Terms of Conditional Approval Date CAUTION 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 MUNICIPALITY OF ANCHORAGE ,(MO'~I~ HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: ,/~ · ,,,~c PROtECtION RECEIvEO WELL DATA Well Classification --~t~'P~L. t ~_~ I~ B, C, DEC. Approved~'~' Well Log Present (Y/N) Total Depth Static Water Level Date Completed Cased to Depth ~Gtouting ' 'P/J~p Set At Yield Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot Zcx~l 4- Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments ~i~ V%/~, ~,t- ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes ~N') Air-tight Caps ~/,N'~ Depression over Tank ~,"¢'~ Pumping/Maintenance Contract on File (Y/N} f,d/~.~ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: Size \ b/O (D No. of Compartments Foundation Cleanout~lT Date Last Pumped ;for Temporary Holding Tank Permit (Y/N) i-~ To Water-Supply Well To Property Line To Water Main/4~e~e Line Course ~,.~ ~' '~.~44L. To Building Foundation \~ ~C)~ '~' To Disposal Field ~;4- To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed I /-~'~-r-/I-I Width of Field \~ Square Feet of Absorption Area Depression over Field Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot Length of Field '~'O~ Depth of Field .~ Gravel Bed Thickness I ~ Standpipes Present (~ Date of Last Adequacy Test To Water Main/Cc;-vlc; Line *~ ~ 4-- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design To Property Line To Existing or Abandoned System on ; On Adjoining Lots -~ ~ 4-- To Cutbank (if present) ~"J' Comments 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 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 SRB ~9~x Gompany Receipt No. Date of Payment Amount: $ MOA NO. o~"~- OO~ Page 2 of 2 72-026 (11/84) #1: Time Date Insp ANCHORA~ C ~c=~ ~I~UNICIPALITYOF ~ '~ DEPARTM~,~ OF HEALTH AND ENVIRONMEN~t--PROTECTION 825 L Street, Anchorage. Alaska 99501 264-4720 Date Received: January 6, 1978 Time #3: Time Date Date Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES Lending Institution Request: Peoples Bank and Trust Mailing Address: Pouch 7-007 99510 Phone: 279-7511 Property Owner: Gary T./Marita A. Deardorff Mailing Address: Box 1086 99577 Phone: 694~2114/w 694-9450/h Legal Description: Lot 17B Eagle River Valley Ranchettes Subdivision Single Family Residence: Multiple Family Residence: ( ) Number of Bedrooms: Three Number of Bedrooms: 5. Well System: Individual well ( ) Community/Public System (~ Permit # Depth of Well Well Log on File ( ) Construction ~P~Lbm~/ Bacterial Analysis ~%~£/~ ~LQ~ 6. Sewage Disposal System: On-site System (x) Public Utility ( ) Permit # ~ Installed 1977 Installe~ Absorption Area 7L~)~£~~ Soils Rate ~ Material Distances: Well to Septic Tank to Absorption Area to Sewer Line Nearest Lot line Absorption Area to Nearest Lot Line DEPARTMENT OF FtEALrH AND ENVIRONMENTAL PROTECTION 825 L Street, Anchorage, Alaska 99501 279.-2511, ex't. REQUEST FOR APPROVAL OF INDiV~DUAL SEWER m~d WATER FACiLiTiES 1. Type of Inspection: VA .......... FHA ........... {_',ONV. XX 2, Property Owner' Gary T. and Marita A. Deardorff --~- ~ Box 1086, gagle River, Ak. r~ p ..... o. 694-9450 (Home) Mai!ing Aoores~: .......................................... 3. Name of Buyer:___ Duncan, Kirk W. and Jennifer A. ~-- , 313 E. 15th Terr. ~2, Anch. Ak. to, . 277-6177 Ma~lb~9 z..~ress: ................................ 4. Name of t_endin9 InsCtutkm:_~.}?JlS_~l.J__l!u_~_~2_: ~,. Pouch 7-007, Anch. Ak. p~., { 279-7511 MaU~nfl Aedress: .......................................... ~ , . Listing-Smiley's (Gary Deardorf) Selling-Dyn~ic (Valda Drake) 5. Name of Rea~tor o~ ,'~g~ mi: S~11eyts ............................................ Eo~ 1086, g.A., Ak. Address Mailing · : . 301 ~. ~o=t~e=~ %igbts, ~c~. A~. ;hone~F~mlc 279-7611 ~ r " ' Lot 17-B, Eagle River Valley Ranchettes L ~ NHN ~irlaway, Eagle River, Alaska 7~ Type of FacUity to be Inspects:d: ................ _S.~ 8. Water Supply "T Community Type of Supply: PubI[c ut~ fly .......... If Individual, mimbef of dwellings presently ~,rw~d If ladJvidual, depth of well 9. Sewage D~sposa~ System type of System: Public Utility unkno~ ~[ Individual date o[ 72 003(3/76) Rage ~wo Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 17B Eagle River Valley Ranchettes Subdivision Comments: Affadavit Attached: ( ) Letter Attached: ( Date: Department Worksheet: