HomeMy WebLinkAboutROBIN HILL #3 BLK 3 LT 8 NAME MAI LING ADDRESS LEGAL DESCRIPTION LOCATION I Well DISTANCE TO: Manufacturer kiq. caoaciW in ~allons DISTANCE TO: Manufacturer DISTANCE TO: No, of~.~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PHONE Top of tile to finish gra~e (~ Well ~ / Length of~each line Length I Width Type of crib N/&Cj wri~ diameter DISTANCE TO: J cia. DISTANCE TO: IBuilding foundation NO, OF BEDROOMS Abs ° r Pt ~°~,~r ea/ W dth Inside length~,~/~ Dwelling Material Foundation i Nearest I~t~ Ii ne Total len~4 li~es Trench width ~'~' ~ inches Material beneath tile Depth PERMIT NO. No, of compartments Liquid depth Crib depth Building foundation Driller Sewer line [~NEW E~]UPGRADE PERMIT NO. Liquid capacity in gallons PERMIT NO. Distance berne?lines Total effective absorption area PERMIT NO. ! · Total effective absorption area Nearest lot line Distance to lot line Septic tank PERMIT NO. Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS ENVtP~,ONME NTAL APPROVED ,JUl! ,~ '~.'~.!; MLNI,_.IFHLITT OF FtNCHC,..~GE - DEPRRTMENT OF HEFtLTH FIN[:, ENVIRONMENTFIL PROTECTION 825 L STREET., FINCHORRGE.. BK 99501 264-4728 PERMIT NO: DRTE ISSUED: 840050 0S/t5784 FIPPLICRNT: RDDRESS: CONTRCT PHONE: FILMOND INC P.O. BOX li-2247 RNCHORFIGE, FIK ~951± .;45-382i LEGRL DESCRIP: LOT SIZE: MRX BEDROOMS: SUBDIVISION: ROBIN HILLS SECTION: 26 TOWNSHIP: ±2N i. 25R (SQ. FT. OR, RCRES) LOT: RRNGE: BLOCK: LISTED BELOW RRE THE OPTIONS FIVRILRBLE ~0 YOU IN DESIGNING YOLIR SEPTIC SYSTEM. CHOOSE THE OPTION THFIT BEST EITS YOUR SITE. TRE[4C:H BED ~4_ C, RKII~-I DEPTH TO PIPE BOTTOM (FT.) 4.5 4.5 4.5 GRRVEL DEPTH (FT.) 4.5 0.5 S. 5 TOTRL DEPTH (FT.) 9.0 5.0 8.0 GRFIVEL WIDTH (FT.) 2.5 19.0 5.0 GRFIVEL LENGTH (FT.) 50.0 ~6.0 49.0 GRRVEL VOLUME (CU. YDS. ) 2~.± 25. S S6.2 TRNK SIZE (GRLS) 1,000.0 ** 1,000.0 ** t, 000.0 ** SOIL RRTING (SQ. FT./BR) t50 150 150 ** TFINK MUST HRVE RT LERST TWO COMPRRTMENTS I CERTIFY THFIT: ±; I FIM FFIHILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS FIND WELLS FIS SET FORTH BY THE MUNICIPFILITY OF RNCHORRGE (MOFI) RND THE STRTE OF RLRSKFI. 2. I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH RLL MOFI CODES RND REGULRTIONS, RND IN COMPLIRNCE WITH THE DESIGN CRITERIR OF THIS PERMIT. ~. I WILL RDHERE TO FILL MOFI FIND STFITE OF BLFISKR REQUIREMENTS FOR THE SET BRCK DISTFINCES FROM RNY EXISTING WELL, WFISTEWRTER DISPOSRL SYSTEM OR PUBLIC SEWERRGE SYSTEM ON THIS OR RNY FIDJFICENT OR NEFIRBY LOT. 4. I UNDERSTRND THRT THIS PERMIT IS VFILID FOR FI MRXIMUM OF ~ BEDROOMS FIND RNY ENLRRGEMENT WILL REQUIRE RN RDDITIONRL PERMIT. IF R LIFT STFITION IS INSTRLLED THEN (1) RN ELECTRICRL PERMIT RND INSPECTION MUST BE OBTFIINED.~ WILL NOT BE RPPROVED WITHOUT RN ELECTRICRL INSPECTIF~N REPORT; ELECTRICFIL WORK MUST BE DONE BY FI LICENSED ELECTRICIRN. ' SIGNED DFITE: FIF'F'L 12.RNT: RLf"I;~;,~C ' ' - .... ....... IN RN RRER COVERED BY MOR BUILDING CODES, (2) RS-BUILTS RND (~) THE F:IL.HOIq!i:, iNC P.O. E:O::':;' i=I NIi: H 0 i:;:~I=I G ['!!:., I':iK 995::L;:L 3 ,::l. 5 -- 382 ::L LEGI::iL E,ES i 1;: I Fl' I ET S]:,7'.E: i'll:Ii:.:; SUE',[:, i ',,,' ! S i ON: ROD i N H ! LLS I...OT: SECT ]: ON: 26 TOi.,.ll'.ti~;H I F'; ::L;;L'N D.F!NGE: 314 :I.. 251:::I (S~;ZL F'T. 0!:;?. FiCFNES ) BLOCK E:,EF'"FH 'T'O P i F'E E~O'i"'TOi"i ( F"i". GRF:IVEI.... DEI::'TH ':: F:'T. T©TF!L DEFq","'i (FT. (:iRf::l'v'E!. !,.i i D'TH ,:1FT. GRF!VE!.. &.ENGTH ,::F'T. i3F:.'I::I,'v'EL. 'v'OL.L.ti"!P_:: (CU. '.r'DS. ']"FiNi.( S I ZE: (!3FiL,,S SO ~ L. F:FFi"! NG ,:: S(i:!. F'T. ,..'E:R) CEF.:T i' F:'V THF!T ' ..,"* .... 'r,~ FiI'"I FI:::P ................ 'rL T :1i:;' Ui"i?.i THF: ~:':'1"..._...'r*'..' .u,r'r,=. ~. ,, ., .FOP.. OH.....SiTE SEI4EFE5 8hlr,. HELLS 'FIS SET FORTH P' ., "I'FiE i,iLii-.,iiE;ZF:'Fii....]:T'?' OF' Fii;-,!CHOi:;2=!EiE (i'iEiF!) Fii",ID T~'i!E S"FSTE OF F:tLFtSKFI. ;:2.' :!: HILL. ':i'-,i'STFiI. L. ']i..iE: S'fSTEI"i J:H F:iE:COF:DFiNCE H:i:TH FiLL i"tOR 'i:or':,ES RNE:, REGULFYi"ZONS., F:Ii',iE:, i !,ii..i.. I:ff)HEf;:E: TO FILl.. ,%;::' FIND STFITE OF F!LFISK!::I REQUiREHENTS FOR THE SET E',FtCK !3,]:STF!I'4CES F:F:Oi','I FIhI'¢ EHZSTIN(3 HELl ..... I,.F'~:'"E'I, FTE'F? [:,ZSF'OSFIL :P¢'.STEH OR F'UE:LZC ................ ~ ...... :~ '" :"' LOT. .: ~ .!..!,:.,~.,?.: ~. S;'?'STEH '"' ....... .,., iS ',,'l=H iD F:'QI;? FI I"18H]iHIJH OF 3 E',EE:,F;:E~OI"tS F~t'.,iD ,::i..)l I...INE:,EF:STFIND 'T'HFfT' TFI 1[~ ~ ~:.1~.~ ~'~' -r' . ............ FII'-,i'./ EI"4LI:::!I:;;:GE!'!Ei"4T H ! Li. F:E~:!L.! i F'E; FIR F~!:' E' 111T ]1 (:)h!F!L. F'EiF:H ]: T. T.: .e L ! FT STRT ! Ed'.,i 11: S Z h~:EiR CO',/EF;:ED E','¢ HOF! E:Lt/[I.._[:, Z NG COE:,ES., THEN ,::!) RN EI.~:;T~~'iEd'-4' '~ HUST E',E OBTRZNE[:U ,::2::, RS-BUZLTS ELEcTRHiM"" NOT i CF::fL. i.,.!O1~~ N2t=IL ]:I'.,!:~:;F'ECT I ON REF'ORI".; FII'-,I[:, ,:: 31:, THE .~'~ WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological ~ GeophysicolSurveys C)rilling Permit No. LOCATION OF WELL (Please complete either ia, lb or lc.) A,D.L. NO. /~ {~;~ ,~) . ~';':~ ~; --of--of--of-- S~ W~ c~D STANCE AND D RECT ON FROM ROAD NT'ERSECT O~S 3. OWNER OF WELL: Street Address and Area of Well Location 4. WELL ~EPTH: (final) ~ 5. Below 2. WELL LOG Surface .,~,~//~ ft. Materiel Type Top Bottom ~' ..... ~ Auger ~detted ~Bored ~Other: , ~. '?' ,~ J /)] --t /' ~ / ' ~ .... ~' "? 7. USE:~ Domestic ~ Public Supply ~ Industry .... :,~ ..... <~ %'.x,%gh..,. ,::{ ..... '~ ~?~-,y" ~.2 / ~ ;~"~. ~ Irrigation ~ Recharge ~ Commericol r.~?~>?- A..~-.~ -~:~ ~!' ~:~?,~ ...... f_t' //~'~} 8. CASIN~: ~ Threaded / '~ '~ '/ /z~ ~ / *" /' ~/ ~.~?~? diam. (/~ i.. to.~ ~ ~ lt. ~pfh W~i~ht -" a~ A~c~~ -- ,. t~C~L~ Slot/M~sh Size: Length: . - ~ = E~t~O~ , '2 '-i .," .. ?.:... .~ t~ fh after ..... hrs. pumpi.~ . ~ , ~.p.m. Mof~ri~l: ~Neaf Cement ~ Other: /~ Subm. ~ ~et ~ Centrifical ~ Other 15. Wafer Temperofure ~o ~ F ~ C Address; ~'"~ ~'?..". - :"' / ,:' ('~ ,': / ...... :-.--.'~?.: ,-~ '"' >'. PERFORMED FOR: LEGAL DESCRIPTION: 1 4 6 7 8 9 10 11 12' 13 14 15- 16- 17- 18- 19- 20- COMMENTS MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ~ SOtLS LOG [] PERCOLATION TEST ~ ~W/~D~n%~TEPERFORMED: I,Z- Iz-~ I 'tl Io~ ~ .~Lot :? SITE PLAN WAS GROU.O WAFER ENCOUNTERED? P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) PERFORMED BY: '~/~r"/ G J"'~,~--__~ ~'~ CERTIFIED BY: DATE: 72-008 (6/'79) TRIP SUBJECT NIESSAIZE // / RETURN TO ~ SIGNED I::l~l~l=y DATE : SIGNED .. ............. ::~..:.~:~:~-:~:~.~ :~ .' · ? PART 3WILL ~ ~TURN~D:WiTH REPLy_ :carbonle~s POLY PAK (50 SETS) 4P472 SEND PARTS I AND 3 INTACT - ~~,. 45 472 PART 3 WiLL BE RETURNED WiTH REPLY. c~rbanM~ ~OLY PAK (50 SETS) 4P472 DETACH AND FILE FOR FOLLOW-UP Scot~ 7664 "POst-il" Routin,-, Re .,easo ROUTING.~__. REQUEST APPROvE and FORWARD RETURN 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 017-394-10 "v HAA # ' ~ ..~O~c~ 1, GENERAL INFORMATION Complete legal description Lot 8, Block 3, Robin Hills Location (si.te address or directions) 13021 Mountain Place Property owner Mailing address Mark McDermott Day phone 265-6394 13021 Mountain Place, Anchorage, AK 99516 Lending agency Mailing address Day phone 229-1275 Agent Clair & Anita Dalton/Dynamic Day phone Address3111 c Street, ~ 100, Anchorage, AK 99503 Unless otherwise requested, HAA will be held for pickup. 3~ NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual wel ××× Community well Public water NOTE: if community well system, provide written confirmation ~rom State ADEC attest- ' lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Com munity-on~site- Public sewer NOTE: XXX If community wastewater system, provide wriiten confirmation from State ADEC attesting to the legality and status of system. 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. Name of Firm Address Engineer's signature S & S ENGINEERING Eagle River, ~laska 9~577 Phone DHHS SIGNATURE '"/// Approved for 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 A'p-prd~,al--Ce'ftific~ft~'b~s~d 6rily-'o'iSOh'th-e-r~presentations gi,)-en ii~ pb;~;a~faph"5 ,~bbve by ~fn-in~epehde'nt professional engi~e'~r 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 If'21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division MUN~C~P^Ur~ OF 825 L Street, Room 502 · Anchorage, Alaska 99501 · (90~V;~-~4E'~S~VtC~S OIWS~ON Health Authority Approval Checklist LegalDescription: ~-0~- ?) i~-~c~: ~ /~0~,,~ Ht~'W3Parceli.D.: 017 - ~,~'z/ ~/ o A. WELL DATA Well type p~. ~ v,~-T ~ Log present (~/N) '¥ ~ ~ Total depth ~ ~( b Sanitary seal ~/N) ~/Ye- J' IfA, B, or C, attach ADEC letter. ADEC water system number Date completed 5'- / ~ / ¢ ~ Cased to ~. ~/ G Casing height (above ground) Wires properly protected (~'N) FROM WELL LOG AT INSPECTION Date of test t Static water level Well production / 0 g,p.m. WATER SAMPLE RESULTS: Coliform O Nitrate Date of sample: } / / ~ / ''& ~1 Collected by: B, SEPTIC/HOLDING TANK DATA Date installed ~'/! // ,~ ~ Tank size ) ~-5-O Foundation cleanout (~N) ¥~-J- Depression (Y~) ,~ _o Date of Pumping ~1 g/ ~i¥ Pumper Other bacteria O $ & $ ENGINEERING Eagle River, Alaska 99577 Number of Compartments :Z_ Cleanouts(~N) High water alarm (Y/~) ,,v o C, ABSORPTION FIELD DATA Date installed ~0 //~ / ~/ Length (~ c~l Width Effective absorption area ~ Soil rating (g.p.d./fF or~ I -~ ? System type y ~-t~, ~-~-, S~' Gravel thickness below pipe ;"~ Total depth ~r Monitoring Tube present(~N) ¥~J Depression over field (Y/~ Date of adequacy test ~/' ~t/~ ~ Results~/Fail) ~/)-~J For 3 Fluid depth in absorption field before test (in.); p ~.'/ Immediately after ~/~ Y gal. water added (in.): Fluid depth ~//~ (ins) Minutes later: /~///'~ Absorption rate = ~/3"0 ~ g.p.d. Peroxide treatment (past 12 months) (Y/N) ~ ~ ,~/~ /¢ ,v~,,.~/ If yes, give date bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tes__t~.df--~ - SEPARATION DISTANCES Size in gallons .._~-----~- *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: / Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation S' 7'- Property line S-o Water main/service line /o /-/~ · . Surface water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line !O ¢- Building foundation ~, o Surface water / 0 0 Curtain drain Absorption field Wells on adjacent lots /0 ¢~ ! /dO / /o -f Water main/service line Driveway, parking/vehicle storage area / Wells on adjacent lots ) O0 ENGINEER'S CERTIFICATION ,certify that,have determined ,hru ,,e,d inspections and review of Municipal in conformance with MO4 HAAsuideli~es in effect on this date. Signature Engineer's Name i~b/J/~,'~p % .. ~ 'a~N Date , HAA Fee $ L._'¢¢ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number CT&E Environmental Services CT&E Reft# Client Name Project Name/# · Client Sample ID Matrix· Ordered By PWSID. Sample Remarks 990215001 -. S & S Engineerin'g Lo[ 8 Bl.k 3 Robin Hills No. 3 Lot 8 BII~ 3 Robin Hills No. 3 Drinking Water Cl|ent PO# Printed Date/Time · 01/1'8/99:10:53 CollectedDate/Time 01112/99 10:45 Received Date/Time 01/12/99 11:15 Technical Director: Stephen C. Ede Total Coliform. Nf~ra~e-N 0 2,15 PQL Units col/lO0mL mg/L Method AllowabLe Prep. Analysis Limits Date Date . Init SMqB g222~ " EPA 300.0 10 max · 01/12/~9 KAP :0!/12/99 01/12/99 SCL RECEIVED JAN 1'8 1999 Mun c pality.of Anchorage t~ept. Heal..t.h .& Human Services 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 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ~4.C'~' ~c.,~E~:~l./--r Telephone: Home Business ApplicantAddress I .~O~.l A4OOM/-A, iM F::,/.A,' E~ A ~ Cl-l O ,e,4 ~ ~ ~ ,,4/c (c) Applicant is (check one): Lending Institution []; Owner/builder'l~; Buyer []; Other [] (explain); (d) Lending Institution Address Telephone (e) Real Estate Compaqy and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family i~ Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Well '1~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. SEWAGE DISPOSAL 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. Paee 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 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 OV/~/?.-~ ~.~&J~IE~'1=-7Z'/AI~ Telephone ~7~' "27'7d Address ~'['/! ~ /c~/f,,,~ (,,0 EE'/) ~4/¢8,//O 4.,/1b~ Date DHEP APPROVAL Approved for Approved bedrooms by .... te ,/~'~-~. Disapproved Conditional Terms of Conditional Approval 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. Pac~e 2 of 2 NOIJ.D31Oad ~g HL'W~H 40 '.1.,:1~(] ~©V"dOHDNV =lO )d.I'WdlDINnY,/ WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: £o7- Well Classification ,~',~z v',~'7-,¢'~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) ,!/ Date Completed ~//~,/~ f/ Yield Total Depth Z ~6x Cased to ~4/~/ Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot Depth of Grouting Pump Set At ~'~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /Z~ ' To Nearest Public Sewer Line NoT//,7 ¢¢,'~,¢ To Nearest Public Sewer Cleanout/Manhole A///¢ To Nearest Sewer Service Line on Lot Water Sample Collected by /A~C,A b~E;~V' ; Date ~!~-' Water Sample Test Results ~'~Tt~ ~.,-'I, CT~ ,V Comments B. SEPTIC/HOLDING TANK DATA Date installed Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well 1~ To Property Line ~ To Water Main/Service Line Course N~,dE iN Comments ~,~ ~ p'Y't~- Size /~'$-O No. of Compartments Air-tight Caps (Y/N) y Foundation Cleanout (Y/N) Date Last Pumped ~V ;for /.~, Temporary Holding Tank Permit (Y/N) ~/,~ -- To Building Foundation /~¢ To Disposal Field /¢/ To Stream, Pond, Lake. or Major Drainage Page 1 of 2 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 To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field Depth of Field E'- '5' 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) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA 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 .'~~ ~'"~' Date "~/* ~/~ ~' Company ~'~ ~ Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) MOA No. Engineer's Seal SHEET NO. / OF CHECKED BY .DATE F R O M SUBJECT DATE SIGNED REPLY ~._._r~___.. 4S 472 SIGNED SEND PARTS 1 AND 3 INTACT - PART 3 WiLL BE RETURNED WiTH REPLY. DETACH AND FILE FOR FOLLOW-UP carbonless POLY PAK ~50 SETS1 4P472 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF ffEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR ~r~ALTH AUTHORITY APPROVAL CERTIFICATE 1o General Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicants Name ~ /two. ~f ~?OC_ Telephone - Home Business ~qf~~82/ Applicants Address P'O' 60~ ti- ZZ q 7 '~C/40<~&C= ~- 9~// (c) Applicant ~is (check one) Lending Institution ~ ; 0wner/builder~,; Buyer ~ ; Other~ (explain); (d) Lending Institution ~,'~O ~K ~ ~(~S~Z~ Telephone Z?~--/~// (e) Real Estate Co. & Agent AP o~ Address Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single-Family~ Number of Bedrooms 3. Water Supply~ Individual Well~ Multi-Family~--~ Other (d'escribe) Community~--~ Public~--~ Note: If community well system, must have v~itten confirmation from the State Department of Environmental Conservation attesting to the legality and status. Sewage Disposal 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] 5. Engineering Firm Providin~ 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 regula- tions in effect on the date of this inspection. Name of Firm ~C~ Telephone Approved for ~ bedrooms By ~~~;~:~7;~?::::5~ Approved Disapprove4 ~ Condition~ __ Te~s of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. 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. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 Drinkin~ Wat~r Analysis Eeport for Total Coliform Eacteria TO BE COMPLETED BY,, WATER SUPPLIER  (*) See h on back .WATER SYSTEM: LD. NO. --i Phone No. Mailing ~dre~ ~ State Zip C~ Ciw Mo. Day SAMPLE '~PE: ~ Routine ~z .~-. Q Chack Sample (for routine sample; ~'Tredied Water with lab mr. no ~ ,~ntrea~ed Water G Special Purpose ~ · ~ Time Collectad SAMPLE ~ ~CATION 7' ,, i~ ~ Collected By NO. ~'"~ ~ ~' ....... ~:~EAD INSTI'gUG-i'ION S TO BE C'0MPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: [] Unsa~Jsfactory [] SamPe too long in transit; sample should not b~over 30 hours old at examination to md cate rehable results. Please send new samp~le via special delivery mail. Time ~ecelved /.g 0 Analytical Method: , ~ Fermentation Tube Membrane Filter Lab Ref. No. L L L J L -J b6422o (~) BACTERIOLOGICAL WATER AN^'LYSI$ RECORD Re~. Membrane Filler: Direct Count .......... Verification: .LTB__ Final'Membrane Filter Resulfs ---[,~ Reported By _ ---- TNTC= An,~.lyst Too Numerous To Count ~ G GOLLEGTIN SAMPLE Coilform/lOOml ~9~_ ' CoilformllOOml Well Classification ~ D Well Log P~esent Q/N) q~ 5 Total Depth 4~ ~(~' Cased to w~¥~ ' Static Water Level ~2 ~ g ! Pump Set At Casing Height ,Above Ground Electrical Wiring in Conduit ~N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line MUNICIPALITY OF ANCHORAGE (MOA) ~4UNiC~PALIIY OF HEALTH AUTHORITY APPROVAL (HAA) ENviRONMENTAL pROTECTION CHECKLIST - FEBRUARY 1984 [J~l ~ 7 Legal De.s, cription: If A, B, c~ C, D.E.C. Approved(Y/N) Date Completed ~- $ - ~ Yield /O~f~ Depth of G~outing ~] }% Sanitary Seal on Casing Depression Around R%llhead (Y .~ ; On Adjoining Lots 2~-o' iZ.~~ ; On Adjoining Lots To Nearest Public Sewer C!eanout/Ma~Ole ~/C///~ To Nearest Sewer Service Line on Lot /~//~. Water Sample Collected By ~--~C) ~- ; Date Water Sample Test Results ~~ B. SEPTIC/HOLDING T_~ DATA Date installed ~//6/~ g~ Size t Z gO No. of Compartments Standpipes ~) / / - Air-tight Caps ~) Foundation Cleanout Ta~ (Y~ Date ~st P~d ~pression o~r P~ing~intenan~ ~n~a~ ~ File (Y~) ~ ; for Holding Ta~ High-Wate~ ~a~ (Y~) ~/~ ~ra~ Holdi~ Tank Pe~t (Y~)~2~, ~p~ation Distance ~ ~ptic~olding Ta~: To Water-Supply Well~ I~ TO Property Line ~ To Water Main/Service Line Course A//~ ." To Building Foundation ~ I, ,5~ ~ To Disposal Field I~' To' Stream, Pond, Lake, c~ Major Drainage [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~'-;'0 Width of Field Square Feet of Absorption A~ea Depression over Field (Y~ Results of Last Adequacy Test Date of Last Adequacy Test. Separation Distance from Absorption Field: To Weter-Supply Well ~- /Z~~ To P~operty Line Type of System Design Length of Field ~ ~ ~ Depth of Field ,~ ~. ,-~ i Gravel Bed Thickness ~'~ Standpipes P~esent ~/N) To Building Foundation ~ '-~'~ '~ ~ o~ ,~ To Existing or Abandoned System cn Lot ,A3//~ ; On Adjoining Lots ~ ~ 5-o ' To Water Main/Service Line ,¢4~//~ To Cutbank(if present) ./%3/~ To Stream/Pond/Lake/c~ Major D~ainage Co~n~se ~/~ _ To D~iveway, Parking A~ea, o~ Vehicle Storage A~ea 4~ ~O ! Conlrents ~- f~ov~ ~-6~{~ D. LIFT STATION Date Installed ~/~f~ Size in Gallons "Pump On" Level at /M//% High Water Alarm Level at/ ~/~L Tested for /t)///~ f Electrical Codes (Y/N) Comments Dimensions y~ Manhole/Access ( "Pump Off" Level at ,, Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA ** Check Pe=mitted Bed~com Rating Against BAA Request ** I certify that I have checked, verified, o~ conformed to all MOA HAA Guidelines in effect on the date of this inspection. Date Company A6c~ MOA No. ~ ¢ C [Page 2 of 2] ~'~'°°" --'~"°-~ .... 2-15-84