HomeMy WebLinkAboutTURPIN #1 BLK 5 LT 3ATurpin I
Block 5
Lot 3A
#006�096�21
/L v r 3 A ) /,714-'
BIG -/
DIPPER
�U A[ ITWnMITV APPPOVAI
/� /-/ /V 4� 61
DRILLING W�*
7529 E. 6th Avenue e
July 21, 1984
Celia
%Century 21 --Sleeper
8050 old Seward Hwy.
Anchorage, Alaska 99502
Dear Celia, 0
Anchorage, Alaska 99504 0 (907) 333-6435
The following information is your copy
located at Lot 3, W1/2, & Lot 2, Block
of Anch. This should be retained
improvements to your peropety.
IM ct:
pa
:5 K
To 6 Feet
Silty
Gravel
>
rn
z 0:�
13
Sand
<
Co
Gravel
r7l
20
Silty
sand,
gravel
23
Gravel
28
Silty
0
6
10
13
14
20
23
28
30
34
35
47
50
53
61
73
77
83
88
90
91
115
132
148
156 Feet drilled
of the well log for the property
5, Ist Addn to �urpin Sub, Muni
as your permanent record of
WELL LOG
To 6 Feet
Silty
Gravel
10
Gravel
13
Sand
14
Gravel
20
Silty
sand,
gravel
23
Gravel
28
Silty
sand,
gravel
30
Sandy
silt
34
Silty
sand,
gravel
35
Silt
47
Silty
sand,
gravel
50
Gravel
53
Sandy
silt,
gravel
61
Sand,
gravel
73
Silty
sand,
gravel
77
Gravel
83
Silty
gravel
88
Sandy
silt
90
Sand
91
Silty
sand,
gravel
115
Sandy
silt
132
Sandy
water
148
156.
Silt,
Sand,
gravel
gravel(nTER)
15 LONS RYJL-MJXUNX�
Sfatic -water level
89 feet
STATEMENT
and cased @ $20.00
per foot
$3,120.00
Thank you for specifying BIG DIPPER DRILLING for your water well needs.
This will entitle you to one chance in the drawing for two round trip
airline tickets to Iiawaii. The drawing will be in December.
Sincerely,
ei 'Ie 7��
C. R. KRON
Owner Licensed* Bonded Insured
Anchorage
POU ~.,~1 6-650
ANCHORAGE, ALASKA 99502-0650
(907) 264-4111
TONY KNOWLES,
MA YOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Permit 9: Handwritten Permit
January 31, 1985
TO: Permit Applicant
SUBJECT: Lot 3, W½ Lot 2 Block 5 Turpin Subdivision #1
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1984o
Permits are issued on a calendar year basis by authority
of Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system not
installed by the expiration date.
If you have drilled the well, a well log needs to be sent
to this Department for documentation of the installation
and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, the original as-built inspection report
and the yellow copy must be sent to this office for review
and approval, and for documentation.
If there are any further questions, please call this office
at 264-4720.
Sincere ly,
Keith E. Bandt, SupeYvisor
Environmental Engineering Program
KEB/ljw
enc: Copy of Permit
SWP/057
MUNICIPALITY OF ANCHORAGE
Department,/~ Health and Environmenta]~rotection
825 Street, Anchorage, AK. '_2501
264'4720
* * * HANDWRITTEN PERMIT * * *
Permit ~
WELL ~~- .-~£~ PERMIT
Location: Z~,~ ~/~ ~3 ~/~ Phone Number:
Lega~ Description: . ~ Lot Size:
Type of Soil Absorpti'on System Is:
Trench: dfD Drainfield: ~ _ Seepage Bed: ~ Holding Tank:
~aximum Number of Bedrooms: ~ Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is:
~ ~ WIDTH r--........
DEPTH ~ LENGTH GRAVEL DEPTH '"' '
The length dimension is the length(in feet) of the trench or drainfieldo The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = ~,,/,/2~ GALLONS
Permit applicant has the responsibility to inform th~'s department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection.and approval by this department
. will be subject to prosecution.
~inimum distance between a well and any on-site sewage disposal system is 100 feet
~or a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 * *
I certify that:
(!) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes. .
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more th~t/~bedrooms.
Signe~: . Issued by
Date:.
SWP/024(1/81)
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
Certificate of On -Site Systems Approval
Parcel I. D%�'621'k4' Expiration Date:
1. GENERAL INFORMATION
Completedegal description Turpin #1 Block 5 Lot 3A
Ldqation (site addres o(3331 E 6th Ave
Current Rr6perty owner(§i,,. clayton afterburn
'PO Box 1036 Willow, AK
..M.alling address
"iReal Estate Agent
2. TYPt,OF DWELLING:
Fx Single Family (w/wo ADU)
F] Duplex
[I Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 04
Day phone 360-1149
Day
0 9 2 0 1'^
IV
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual
El
Individual Water Storage
Holding Tank
1-1
Community Class Well
Community
F-1
Public Water System
Public Sewer
nX
COSA Fee S 5 -;Lt, -
Date of Payment LL,
Receipt Number -7 vp
COSA #. lqoq
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
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,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) 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 in�pectign, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and.State codes.
ordinances, and regulations in effect at the time of installation.
Name of Firm C&M Engineering
Address 30840 Prudhoe Bay ave
Engineer's Printed Name Charles Balzarini
6. DSD SIGNATURE
_7K_ System #1 Approved for bedrooms
System #2 Approved for bedrooms
114"Proved
Phone 854-5558
Date 9/9_QQ16
�CQF A4- III##
io
40 0 �ie a ffaktrei�ni:
�� 10KE,
0 CE - IARM
0 Wo
- WOW
.4 Ni�'"
I
. .* "O'w
Conditional approval for _ bedrooms, with the following
Original Certificate Date:9
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the ropresontations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
COSA bl.� hoeLf � C
Nitrate Advisory''
Arsenic Advisory
Other
Jlf more than I septic system is on the lot:
COSA Checklist #
Structure served by this system
Certificate of On -Site Systems Approval Checklist
L,(q T 3/1 0V& -016q -Li
Legal Description: )-c-/iZZTA/ t/ ( 3 (; - - Parcel ID: AOEP� -
A. WELL DATA
Well type If A, B, or C provide PWSID Well Log(qN) A'-5
Date completed 71-' V1 4W Sanitary seal ON) Wii res.properly protected&) Yes
Total dipp!�L�-ft. Cased to L% -ft- Casin g height (above ground) in.
FROM WELL LOG
Date of test.
Static wat e r level.
Well production 9 -p -m -
WATER SAMPLE RESULTS:
AT INSPECTION
9 -P.M.
Coliform AIC�- colonies/100 mL Nitrate mg/L
Arsenic ug/L. Date of sample: Collected by: 6iM
.- B. SEPTICIHOLDING TANk DATA W14) Pr,/)3 1,7-c- 3 EC�R X -
Tank Type/Material
Tank size gal.- Number of Compartments
Date installed
Cleanouts (Y/N)
Foundation cleanout (YIN) — Depression over tank (Y/N) High water alarm (Y/N)
Date.of pumping', Pumper
A
C.' ABSORP-f[dW FIELD -DATA
Date installed
Length ft.
Soil rating (g. p.d./fe or ft2/bdrrn)
Width
System type
ft. Gravel below pipe ft.
Total depth. — ft. Eff. absorption area fe Monitoring tube — Depression over field
Date of adOqacy test Results (Pass/Fail) For bedrooms
Fluid depth�in�:db;s6.rption field before test— in., Wateraddled gal. New. depth_ in.
Elapsed Tin*? - min., Final fluid depth — in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
1), LIFT STATION /t-/)4 (-'TC
Date installed
"Pump on" level at
Datum
Size in gallons
in. "Pump ofr'level at
E. SEPARATION DISTANCES
WELL ON LOT TO:
Cycles tested
— Manhole/Access (Y/N)
in. High water alarm level at — in.
Meets alarm & circuit requirements?
Septic tank/lift station on lot A& On adjacent lots
Absorption field on lot All A On adjacent lots f
Public sewer main +7Y Public sewer manhole/cleanout (00
Sewer /septic service line Holding tank z
Animal containment areas go Manure/animal e xqrete storage areas
SEPTICIHOLDING TANK ON LOT TO: A1,14 -
Building foundation
Water main
Property line
Absorption
Water service line Surface water
Wells on ?djacent,lots
ABSORPTION FIELD ON LOT TO:'
Property line Building foundation,_ Water main
Water Service line
Curtain drain
Surface water
Wells on adjacent lots
Driveway, parking/vehicle storage
F. COMMENTS
.tv LA/Et-C -t
75 t40501-12 ZA-' A (lAvL-r
1IZ,q FIC7 S 94 DR*0 Lro, VAcl I -r D t -,A5 - VE A 2 r- re g) r* er72%P-1
G. ENGINEER!S CERTIFICATION
i certify that / have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effi)ct on this date.
Engineer's Printed Name CH4(UZ5 OAL2-11'z2�,OT-
Date 1.6
COSA yellow sheet-2-6-15.doc
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Arsenic Adviso
Certificate of On -Site Systems Approval 4 osc161409
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 5, Lot 3A
of Turpin #1 Subdivision. This inspection revealed an arsenic concentration
of 11. 1 micrograms per liter (ug/L) for the property's well water sample.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (NICL) of 10.0 ug/L for public drinking water systems.
While private wells are not subject to this regulation, EPA standards are
based on existing health inforrnation and can therefore be used to gauge the
relative quality of water from private wells. information on arsenic is
available from the On -Site Water and Wastewater Program website
(www.muni.or&onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
8443J
Tract D
N89055'06"E 102.36
15' Utility, T & E, Gas &
San. Sewer Easement
- — — — — — — — -- — — — — —
hed she;7�_
r — — — — — — — -- C)
to 10.1 � I deck FUL
38.0
1 1/2 Story UU
4 Frame House 4
04
N E 1/2
Lot 4 ..;;T Lot 2
10�0 38.0
00
Lo Grave
zo C)
driveway
0
0 oWell
Lot 3A C 4. _J
Plastic fence/
N89*53'26"W 102.26
C�
E. 6th Avenue
..... A4
49th
00 ....... 00
00 00
00 00
00 %Fred Walatka.*ff 00
3255 S
'Mo
Frsslota"-
SCALE: V= 30'
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED
PLAT ARE NOT SHOWN HEREON. FB 16-8, pg 23 BE
AS -BUILT NO CORNERS SET THIS DATE
I hereby certify that I have performed a
of the followino described DrODertv: L(
Anchorage Recording Precinct, Alaska, and that the
improvements situated thereon are within the property lines
and do not overlap or encroach on the property lying
adjacent thereto, that no improvements on the property lying
adjacent thereto encroach on the premises in question and
that there are no roadways, transmission lines or other
visible easements on said property except as indicated
hereon.
Dated at Anchorage, Alaska
this - 25th day of August .2016
FRED WALATKA & ASSOCIATES
(907-248-1666) Engineers and Surveyors
Municipality of An��g�
Development Services Department
Building Safety Division all . - 0
On -Site Water and Wastewater Program
4700 South Bragaw St. 5 A 9TT
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.enchorage.ek.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
" i
FOR A SINGLE'FAMILY DWELLING
Parcel I.D.- 00 HAA # A 0100 (o :7
–of
Expiration Date:
1. GENERAL INFORMATION,,
Complete legal descdp�jon B —1 0 Eat N #
Location (site address or directions) A ve
Current Property owner(s) Celcej 11 e ir- Day phone
Mailing address I;:: L, it, AA4_�-
Lending agency r�s-L A kyiericoL4 Day phone
Mailing address
Real Estate Agent tj r 0. It-- 2 Lk V, Day phone ;L5 7 – o 14
Mailing Address e le '911,00 '-do vo
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Individual On-site El
Individual Water Storage El Individual Holding tank El
Community Class Well El Community On-site El
Public Water System n Public Sewer 19
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an Independent professional civil
engineer registered in the State of Naska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not respons'ble for errors or omissions in the professional
engineer's work.
4. 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,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system ls(are) 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 frorn my Investigation and inspection, the on-site water supply and/or
wastewater disposal system Is(are) In compliance with all applicable Municipal and State codes. ordinances,
and regulations In effect at the time of installation.
Name of Firm 4D b 11),e,;,t P F_
, t I
Address zlos Awe-& A-14
Engineer's Printed Name lks V�
�\JY OF
ON-SITE
WATERAND
WASTEWATER
5. DSD SIGNATURE PROGRAM
Approved for bedrooms. '�,,'�o
Phone �7q-Bqlb,
qJ50 /
Date
EN'GINEERS
n:z
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
Original Certificate Date:
By:
(Pw. 12 0)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Sfte Water & Wastewater Program
47W South Bragaw St.
P.O. Box 196650 Anchorage, AK 9951M650
www.dznchorage.ek.us
(907) 343-79N .
HEALTH AUTHORITY APPROVAL CHECKLIST
LegaiDescription: 1-6-1 3A 15V.15 'T%)Q1PII�A0j Parcel ID: 00 6 - 6%*
A. WELL DATA:
well type R— if A, B, or C provide PWSID # Well Log (Y/N)
Date completed Sanitary seat (Y/N) Wires property protected (YIN)
Total depth iE&—ft- Cased to L.IELIL Casing height (above ground) in.
FROM WELL LOG
Dat a of test 7/v A- q -
Static water level 91? — ft.
Well production 15' — g.p.m.
WATER SAMPLE RESULTS:
Coldorm —0— colonies/1 00 rrJ. Nitrate mgA.
Dateofsample: 4115-14C�11 Collected by:
B. SEPTICIHOLDING TANK DATA
Tank Type/Material _
Tank size _ gal .
Number Of CompaV/ents
Foundation cleanout (YIN) _ Depress' er tank (Y/N) _
AT INSPECTION
sq
g -p -m -
Date of pumping
C. ABSORPTION FIELD DATA
Date Installed
I
Other bacteria -nhj colonies/1 00 mi.
Date Installed
Cleanouts (YIN)
High water alarm (Y/N)
Soil rating (g.p.dJft2,4r ft2A)drm) _ System type
Length ft. Wfidth ft. Gravel below pipe ft.
V'
Total depth ft. Eff. abso;rpbon 2 ft' Monitoring tube Depression over field
Date of adequacy test Results (PassJFail)
7 Wate For bedrooms
Fluid depth in absorption field befo test _ in. Water added_ gal. New depth— In.
Elapsed Time: _ min.
Final fluid depth _ In. Absorption rate >=_g.p.d.
Any rejuvenation treatment (Oast 12 mo.) (Y/N & type) — If yes, give date
'I
D. LIFT STATION
Date installed Size in gallons — i Manhole/Access (Y/N)
"Pump on' level at _ in. 'Pump off" level at High water alarm level at — In.
.1 8�:
Datum Cycles tested Meets alarm & ckcuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAtft station on lot
Absorption field on lot I`41A
Public sewer main SO
Sewer /septic service line —x>�,>�
N
On adjacent lots - I /
'oo
on adjacent lots — "A
Public sewer manholeldeanout JC0+
Holding tank NlAr
SEPARATION DISTANCES FROM SEPTICIHOLDING K ON LOT TO:
I
Building foundation Property line Absorption field
Water main WatWu se line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSOF
Property line Building
Water Service line Surface
Curtain drain
FIELD ON LOT TO:
adjacent lots
Water main
Drivoway, parking/vehicle sWrage
F. COMMENTS
G. ENGINEEITS CERTIFICATION so C;1
ge %
I certify that I have determined through field kMP8e0n3 and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect an this date
12^
Engineer's Printed Name
ig-
Date al, EO
HAA Fee $ C) Waiver Fee $
Date of Payment Date of Payment
Receipt Number. Receipt Number
(Rev. 12100)
011-22-01 15:34 FROM -CTE ENVIRONLENTAL
A ME Environmental services Inc.
56153GI
T-068 P.02/03 F-533
Waters laspartment
Nitritc-N 0.500 u 0.5()o trigil, EPA 300.0
Microbiology Laboratory
Cclifo", 0 ccllj(�)rnl. SM1892223
10 max 02, 1 SAI I SCL
02,151ul SKV,
1010759001
Client PO;; Pre -Paid Colisf.NO3
CT&F. Ref.0
'robben Spiukland P.E.
printed Daleffline 0212212001 9:10
client Name
Collected Datel'I'line 02/1512001 13;15
Project Narnef#
Turpin 41
Received VatetTime 0115/2001 16:30
client Sample ID
Lot 3 A Block 5
Technical Director Stephen C. Ede
Matrix
Ordered By
Drinking Water
01
Released By
PWSID
Sam,& Remarks;
Resells
PQI� ulits Method lainits Date Date
Waters laspartment
Nitritc-N 0.500 u 0.5()o trigil, EPA 300.0
Microbiology Laboratory
Cclifo", 0 ccllj(�)rnl. SM1892223
10 max 02, 1 SAI I SCL
02,151ul SKV,
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
2.
ApplicationDate Aarch 12,1986
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 3A, Block 5, Turpin Subdivision, First Addition
Location (address or directions) 1
6331 East 6th Avenue, Anchorage, Alaska
(b) Applicant NameCal!.4_j__St4) �,,. Telephone: Home337--7453 Business
Applicant Address (�'Jjj T��.qf- 6tli A17pnuo. Anch=arre, Ak q_95 0 A
(c) Applicant is (check one): Lending Institution El Owner/builder Buyer El ; Other 11 (explain);
(d) Lending Institution
Address
(e) Real Estate Company and Agent
Address
Telephone
Mail the HAA to the following address:
6331 East 6th Avenue, Ancho
Telephone
e. Ak 99504
TYPE OF RESIDENCE
Single-FamilyEJ Multi-FamilyE] Other
Number of Bedrooms
I
3. WATER SUPPLY
individual Well 12 Community 11 Public El
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 11 Public 0 Community 11 Holding Tank El
Note: if communitywell s . ystem, musthavewritten confirmation from the State Departmentof Environmental Conservation
attesting to the legality and status.
72-025 (11/84)
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 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 Barnard Engineering Telephone 274-5235
Address 203 West 15th.Ave. , Anchorage, Ak 99501
Date March 12, 1986
6. DHEP APPROVAL
Approved for bedrooms by
Approved A I
Terms of Conditional Approval
Q 1
14
N10el-01
CAUTION
Engineer's
. 'Vv
U
R. Bmnard
754-E
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 6 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
79-W� 111 IR41
MUNiciPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA�
HEALTH AUTHORITY APPROVAL (HAA) MAR 14
CHECKLIST - FEBRUARY 1984
264-4720 RECEIYED,
Legal Description: n
Subdi,Tisic4n, F11-st Addif:inn
A. WELL DATA
Well Classification Ind i vi dual If A, B, C, D.E.C. Approved (Y/N) —
Well Log Present (Y/N) YeS Date Completed Julv 21 F 19 8 6 Yield
Total Depth 1-56' Cased to 15 6 Depth of Grouting nnnc--
Static Water Level 89' — Pump Set At 140'
Casing Height Above Ground 31 — Sanitary Seal on Casing (Y/N) Yes
Electrical Wiring in Conduit (Y/N) Yes - Depression Around Wellhead (Y/N) No
Separation Distances from Well:
To Septic/Holding Tank on Lot NA On Adjoining Lots
To Nearest Edge of Absorption Field on Lot NA
, On Adjoining Lots Nj
To Nearest Public Sewer Line 80' — To Nearest Public Sewer
Cleanout/Man hole 150' To Nearest Sewer Service Line on Lot 60'+
e�
Water Sample Collected fA� �wner j Date Ael-Ae, z!r 91 /a
lvl�
Water Sample Test Results 5�4 7_-J A -,C. T_,9 A!�
Comments
B. SEPTIC/HOLDING TANK DATA NOT APPLICABLE
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Size
— Air -tight Caps (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
To Property Line
To Water Main/Service Line
Course
Comments
No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field —
To Stream, Pond, Lake, or Major Drainage
x fl-� L
Page 1 of 2
L
MIT
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
NOT APPLICABLE
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 -
NOT APPLICABLE
Size in Gallons —
"Pump On" Level at
High Water Alarm Level 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 I have checked, ified or con rmed to all MOA and HAA guidelines in effect on the date of this inspection.
D
Sigi . l2c= ate M_arjah_J_2_,__19_3_6_
CompanyBarnard EnqJnP(-rin(YOANo. Not: Appl J nahl P.
Receipt No. 7 7 7
%
Date of Payment C)F
Amount: $ Engineer's Seal
Page 2 of 2
72-026 (11/84)
F011 R. Barnord