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Home My WebLink AboutMOUNTAIN PARK ESTATES #2 BLK 8 LT 9 I ~'~ " Municipality of Anchorage I~)E-P~ARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION POUCH 6-650 ANCHORAGE, ALASKA 99501 INSPECTION REPORT ON ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL NAME ~'"tO~S ~;:)~ ~P,..~.~I'~, LOCATION ~--O~'~'"'~{:Z.,. ~P ~~ PER~IT NUMBER ADDRESS ~0~ ~O~B ~,~ ~ LEGAL DESCRIPTION ,~ ~ PHONE(S) ~~%~ ~-~ ~ ~ ~ ~ ~%~ ~OF BEDROOMS MANUFACTURER MATERIAL SEPTIC TANK CAPACITY IN GALS. #OF COMPARTMENTS INSIDE DIMENSIONI LENGTH tWIDTH r DEPTH SEEPAGE SYSTEM [] TILE DRAINFIELD NUMBER OF LINES LENGTH EACHI TOTAL LENGTH DISTANCE BETWEEN LINES TRENCH WIDTH DEPTHS: (~! (.C~ ~, ~t TILE TO GRADE FILL BELOW TILE FILL ABOVE TILE J~SEEPAGETRENCH OR [] PIT WIDTH ,~(~ LENGTH ?:j \Z~_ ~ [ [] LOG CRIB [] RINGS- DIA. FILL MATERIAL BEPTH DEPT TOTAL EFFECTIVE ABSORPTION AREA; CLASSIFICATION INSTALLER (,0~_~ SQ, FT, wELL ~ PIPE DEPTH MATERIAL REMARKS 72-012 (9/72) ', DISTANCES SEPTIC SEEPAGE SEWER TANK SYSTEM LINE CESSPOOL WELL WELL ~ t.~o~__<~D ~ LiNE ~r' "~,0 ~ SYSTEM DIAGRAM WELL CONSTRUCTION LOG Or ,,.g Co. /) DA D ~, 74 ~,,, ,S,S ,o. Depth of wall .~ '7 ~ ft. Casin,: depth ~"~ ft. diam. / / in. Static water level ~ '~ ft. (above, below) land surface. Date /¢ "/~' ~ Finish of well: (open-and, screen, perforated, ~n~;~ other) Describe intervals and size: Well yield tested by (pumping, bailing. Z) at--gal/min. for ~/ hours with ~ ft. of drawdown fram static level. DRILLER'S MATERIAL LOG Location sketch or remarks Depth below land Give description of strata penetrated surface in feet (size of material, color, hardness of drilling, and water content) be I~ land .fl'ica in feat %~i Give description of strsta penetrated -..', (size ef ~atarial, color, hardness of drilling, and water content)- ?' '?~'~' t o MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. 'Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# (¢')\'-~ - Li'%~ - HAA # GENERAL INFORMATION Complete legal description Location (site address or directions) 1~ ~' E ! /~'o_c/-dr Re,( Property owner D¢c<¢ Mailing address left ~/ ~'o.rf-¢,- R~,(." Lending agency ~c~/~ t~r~ - Po~* Day phone Mailing address ~o~' P e~a~; ~;, ~,~ Agent ~yn~ ~r~ - ~rnba~ Real~y Day phone Address 7~00 /<;~ ~'~ ~C~a¢~ Unless othe~ise reguested, HAA will be held for pickup. ~1~ NUMBER OF BEDROOMS: Day phone TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: NOTE: If community well system, provide written confirmation from State ADEC attest- Individual on-site Holding tank Community on-site Public sewer MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION RECEIVED If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER 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 application 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. NameofFirm F' I,~/-~/~ TFc~,, ; ¢~/ Ze¢~; ¢ ~ Address /'/5-3 0 ~cA~ _C/-:., ,4-,~c~or-~¢,¢., Engineer's signature '~~ ,~. ~ Phone DHHS SIGNATURE ~-- Approved for LC bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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. 72-025 (Rev. 1/91) Back MOA Municipality of Anchorage ~ DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 · MUNICIPALITy OF ANCHORAG~ ENVIRONMENTAL SERVICES DIVISION Legal Description: fro{- 9. A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Y Health Authority Approval Checklist ~/k-, ~ p-/~ ?,~rk E_cf fi2 Parcel I.D. : ~xL~,CIV~L~ IfA, B, or C, attach ADEC letter. ADEC water system number Date completed I o{ t-7 / 7 7 Cased to 5-~ ~ eff~e~3 Casing height (above ground) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Dateoftest 162 / ta° / 72 5-/ '~c' /9~' Static water level ~ 2' 5' ~ ~ Well production WATER SAMPLE RESULTS: Coliform 0 col /(oo ~. Date of sample: 5-/Id'/~ f B. SEPTIC/HOLDING TANKDATA Date installed t a / 77 Tank size Foundation cleanout (Y/N) Y Date of Pumping q/~/~' C. ABSORPTION FIELD DATA I. ~ g.p.m. [, 7 Nitrate /, ~ ,0,5, t/-~ Other bacteria no,~e Collected by: F/cfl-¢o/o 7-~'ch 5-uc g.p.m. Depression (Y/lq) Pumper ~,~a cj Number of Compartments ~ Cleanouts (Y/N) '( (O N High water alarm (Y/N) M. A, Date installed /O / '7 7 Soil rating (g.p.d./lt2 or ft2/bdrm) t ES' ~ ~/a:tr~System type -7-r'¢t~ tO' Length 3- ~ .Width 3' Gravel thickness below pipe ~' Total depth t~' ?e~ /~f£. rep. Effective absorption area fie ~ Momtoring Tube present(Y/N) V Depression over field (Y/N) Date of adequacy test 3'-/2 0 / 96~ Results (Pass/Fail) V~,sf For ¥ bedrooms Fluid depth in absorption field before test (in.); E 7" Immediately at, er 77algal. water added (in.): g-o ~-/,v Fluid depth 5'0 '/~6' (ins.) Minutes later: ~ 9 Absorption rate = ~c9 g.p.d. Peroxide treatment (past 12 months) (Y/N) k:.*,oa,~ If yes, give date /-c¢ole d' ~r'enct, reton.,re~( D, LIFt STATION ~ o a e~ Date installed Manhole/Access (Y/N) High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line Size in gallons "Pump on" level at* ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Lift station "Pump ofF' level at* SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building fomidafion ~,' Property line I B ' Absorption field Water main/service line ~ z~-' Surface water/drainage ;> too ' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation ~ q t Surface water > ~oo, Cunalndraln ~vo~ e ;ee~ Wells on adjacent lots ENGINEER'S CERTIlilCATION I certify that I have determined thru field inspections and review of Municipal re3br(~thaF'thb~b(ipe in conformance with MOA HAA guidelines in effect on this date. /; ' ~ Signature Engineer's Name 7-h ec, ct'o e'~' ,~. /'qoca re. Date tqeqy ~, /¢'96" Property Line Icv ' Water main/service line > ~)-" Driveway, parking/vehicle storage area / 05-r ~ix "~ EfigineeringSeal3t~re ': C,: - ':: ~ , HAA Fee $ Receipt Number Waiver Fee $ Date of Payment Receipt Number Rev. 8/95 OSS: haa.wk.doc MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Day phone Day phone = Agent Address Unless otherwise requested, HAA will be held for pickup.. Day phone NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: IndividuaFon-site Holding tank Community on-site Public sewer NOTE: If community wastewatecr system, provide written confirmation from State A~C attesting to the legality 'and status of system. 72-025 (Rev. 1/91) Front MOA¢21 '~tJo~ s~eeu!Bue i~uo!ssejoJd eq~ u! SUO!SS!LUO ~O s~o~Je ~oJ elq!suodseJ ~ou s! e§8~oqou¥ jo ~,!l~dp!UnlAI eq/ 'penss! s! e~3!J!~Jeo ~ e~ojeq ~3~p eZ~l~U~ Jo suop, oedsu! ~onpuoo lou op SHHQ jo seeZ, oldUU~ 'm, uetu9J!nbeJ e~E3s pu~ I~JepeJ u!81~eo XysBes o3~epJo u! suoBn~p, su! I~u!puel J!eq3 pue SeLUOq JO sJ@sEqoJnd o3 ~sel~noo E sE s!q~ seop SH HQ eq/'mlSel¥ jo e~m,S eq3 u! peJe~s!§e~ Jesu!~ue iEuo!ssejoJd 3uepuedepu! uB/~q e^oqB g qd8Jl~l~jl~d u! UeA!I~ suop, e3uese~deJ eq3 uodn ~lUO pes~q sm,~olJ!~JeO I~^oJdd~ ~!JOLI~nV q31eeH senss! (SHHQ) s@opueS ueLunH pue q~,leeH jo 3ueuJl~edeQ eB~Joqou¥ jo ~!l~d!o!unlAl eqJ. :suop,~lndp, s I~U!MOIIOJ eqi q3!M 'SUJOOJpaq JO~ I~^o~dde leUOp,!puoo 'pe^o~ddes!Q · suuoo~peq ~ ~oj. pe^o~dd¥ '9 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ ''~ TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: I ndivid ual' on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADc;EC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 Se STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigatiop of this Health Authority Approval application shows that the on-site water supply · and/or wastewater disposal system is safe, functional an'd 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 /'~'~'~b ¢_---/d ~]~ ¢ ~,' ~ toc~? ~- L~- Phone Address f4~) ~ ~ ] ~¢.~ /~/ ~ Engineer's signature ~ ~ D/~-4S SIGNATURE Ap p roved, fo r %_~'~ L/'!~..) Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments 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 DHH$ does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal an.d state requirements. Employees of DHH$ 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 IRev. 1/91) Back MOA Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~ °o ~"~'~ J~- ~ ~ Parcel I.D. A. Well Data Well type Log present (Y/N) Total depth Sanitary seal Date of test Static water level Well flow Pump level1 If A, B, or C, attach ADEC letter. ADEC water system number I'",7/,/~- Date completed /(~.~-7'-'] Driller ,Z~,.~/~ "~r,'J[l'~.. Cased to ,.~ ~ Casing height Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION 77 cZ. ?3 o ,.~ g.p.m. 1. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main h~//~ Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank r'/[o WATER SAMPLE RESULTS: Coliform /~ Date of sample: ~/o¢/'~ Nitrate (~, ~ ~' Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Tank size 1~--~ Compartments Foundation cleanout (Y/N) T Depression (Y/N) N ~//A Alarm tested (Y/N) ["~/-'~. ,.~/~. 2_// ~ --.~, Pumper "~ ~-e~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface water/drainage On adjacent lots ~' /O---'-'-'~ Foundation Absorption field l, 0 Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lets Surface water D. ABSORPTION FIELD DATA Date installed /~ - 2-¢ - 7 '~ Length .f~ ~... Width Soil rating (GPD/Ft2) / ¢¢¢'--.f~ Gravel thickness Total depth Total absorption area ~. r'~ F Cleanout present (Y/N) Date of adequacy test ¢/<¢/¢~-~ Results (pass/fail) Water level in absorption field before test 5 --~ Peroxide treatment (past 12 months) (Y/N) Depression over field (Y/N) for y Bedrooms After test ~'/7/' If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot %///L~ On adjacent lots ~' ,//~:> Property line To building foundation ? / O To existing or abandoned system on lot On adjacent lots ?' ~ g) Cutbank /~, ~) 1,/~_~ Water main/service line Surface water h-~ / C~ Driveway, parking/vehicle storage area Curtain drain ~ )~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidefines in effect oq.the date of, this inspection. Signature "~~ Engineer,s Name '- I~]/~ ~ >I Date C~// ¢/q.~ HAA Fee $ ~ ¢ ~ Date of Payment Receipt Number 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number ~. MUNICI'I~ALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. O? HEALTH & 825 L Street - Anchorage, ENVIRONMENTAL PROT~IO~ Alaska 99501 ) ENVIRONMENTAL ENGINEERING DIVISION 'JUL 6 1979J Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed. Please allow ten (10) days foF processing, 1. PROPERTY OWNER ~) ~ '-~) ,. PHONE I PROPERTY RESIDENT (If different from above) 2. BUYER ~ '' PHONE MAILING ADDRESS - ' ' 4. REALTOR/AGENT ' ' I PHONE I MAILING ADDRESS is. 'EGALDESC.,PT,ON ~ ~-/- ~ ~ /W, ~ N:,,,I-,,,-,.., ?~. ~,'r. 1--~~ ~ IsTREETL°c^*'°N 6. TYPE OF RESIDENCE [~3~'"~NG L E FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS [] One [] Four [] Two [] Five [~'"~r ee [] Six [] Other 7. WATER SUPPLY E~'"~NDIVI DUAL* * ATTACH WE LL LOG. A well log is required for all wells drilled ~ COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach log if available.) [~'~"~DIVI DUAL/ON-SITE** **If individual/on-site, give installation date If system is over two (2) years old an adequacy testJs required [] PUBLIC UTILITY by this Department, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED ~ INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE I NSPECTO R INSPECTOR INSPECTOR DIRECTIONS: 1, TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED \ 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] IN DI VI DUAL/ON -SITE DATE INSTALLED E~] PUBLIC UTI LITY Connection Verified INSTALLER []Septic Tank or []Holding Tank Size: /r~ If Tank is homemade SOILS RATING give dimensions', TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank · Absorption Area Sewer Line ] Neerest Lot Line WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS ~ APPROVED FOR ,Z~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION 72-010 (Rev, 3/78)