The URL can be used to link to this page

Home My WebLink AboutMOUNTAIN PARK ESTATES #2 BLK 8 LT 8 I ~ '~ MuniciPality of Anchorage D~PARTI~IENT OF HEALTH & ENVIRONMENTAL PROTECTION POUCH 6-650 ANCHORAGE, ALASKA 99501 INSPECTION REPORT ON ONSITE SEWAGE DISPOSAL SYSTEM AND/OR wELL NAME ~'~O~ ~)r~:~.~'~,~,.~_~{~5~ LOCATION ~--O~%rr~.-~.. ~..~ '-~'~'~_.",~ ADDRESS ~ ~'-)O~ ~,.:~ ~ PERMIT NUMBER LEGAL DESCRIPTION PHONE(S) .--~q. z¥'~O'-~ ~_. ~ ~ ~;~ ~'tr~ ~R~[~. ~'T~ ~OF BEDROOMS SEPTIC TANK MANUFACTURER ~_~p..~-~.~--{~ CAPAC TY IN GALS. MATERIAL ~-~-C~-L.- #0F COMPARTMENTS INSIDE DIMENSIONl LENGTH ~WIDTH DEPTH SEEPAGE SYSTEM [] TILE DRAINFIELD NUMBER OF LINES DISTANCE BETWEEN LINES DEPTHS: TILE TO GRADE I FILL BELOW TILE ~SEEPAGETRENCH OR [] PIT LENGTH EACH TOTAL LENGTH ITRENCH WIDTH FILL ABOVE TILE NINTH '~(.¢-~ LENGTH "-[(~ DEPT" ~z~ FILL MATERIAL DEPTH [] LOG CRIB [] RINGS- DIA. TOTAL EFFECT VE ABSORPTION AREA: ~ { "~. SQ. FT. CLASSIFICATION wELL · DEPTH [ PIPE MATERIAL INSTALLER REMARKS DATE ~0 ~ APPROVED BY, DISTANCES SEPTIC SEEPAGE SEWER TANK SYSTEM LINE CESSPOOL WELL WELL LINE SYSTEM DIAGRAM ' his Aia~ka ::,.9950.7}. ;~ ,Afl:iON ' .... ~ '; ~. ' WELL CONSTRUCTION LOG Well owner ~"7~ .~¢ Z/¢~d/~'>~ '~ ~ Nearest community . . ~ Well location: (address & legal description) /fi~ -~'c~/ ~ Oepth of well ¢/¢ ft. Casing: depth 5~¢ ft. diam. ~ H in. Static water level ~ ft. (above. below) land surface. Date /¢'-27-2'2 Finish of well: (open-end, screen, pertorated, ~' other) OescrJbe intervals and size: Well yield tested by (pumping. bailing, air) at ~ for ,,~' hours with ft. of drawdown from static level. gal/min. DRILLER'S MATERIAL LOG /o -- 2 - ? ? 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) Parcel I.D. # .,. MuNjCiPALiTYOFANCHORA~E .... . - DEPARTMENT OF HEALTH & HUMAN SERVICES_ Division of Environmental Services On-Site Services Section P.O. Box196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE 0 PHEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING OI7- L/~2 - / ~ HAA# L~.~l~-~O~'-~c~ 1. .GENERAL INFORMATION Completelegal description ~',e~ /. o Location (site address or directions) ' 'i~.0 cji ~'¢$ ~,,. ~.. %0 MaiJi'ng':a'dd're'ss"'"; l~gl ' 'F'o.5~v-~ '~--- ~_ Lending agency Day phone Mailina address ' ' ' Agent ~v'~. L~t~/'-~¢'''' '-':-'1t~'cc'J~'° ~I.~-:..-'Day phone Address '.';:;'";'iii- - Un/ess otherwise requested, HAA.~viil ~e.heId for Pickup. . ' ' 3.' TYPE OFWATER SUPPLY:' ' '"' ' - " NOTE: If community weli'~y~b~;; P'~O~e :~rit~b'n b~firm~tion, from state ADEC 4: "' TYpE OF WAsTEWATE" d;'s~O'sA~: ~ ' '" ' · ' '!,~'~.?'~:'??;,'? ~i,.:,: ]..' NOTE: "'~j~i'"t."'i : 72-025(Rev. 1/91) Front MOAIf21 n:Site · .. ,,~::, ...,:. .... - ndiv dua o - " '"' ¢-: :..(..,... _,..... Holding tank '" ' ' Community on,site If community'wa'stew~t ~ Sj/stem;'Pr°vide Written confirmation from ~tate 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 nvestigation of this Health Authority Approval application shows ~hat 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 Anchoragef._es and:f.[om~my investigation and inspection, the on-site water supply and/or wastewater d sposa system is n compliance .with all Municipa and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ! ~ Address . ~ Engine,s signature DHHS SIGNATURE Approved for _ .~ Disapproved. Conditional approval for bedrooms. Phone 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 ' '.'., prefessional en~in~er'iegistered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes, : ':.:~i' ah~tth0¥r iending ihstitutions in order to satisfy certain federal and state requirements. Employoes of DHHS do not "-,. · ~onduct inspections or analYZe· data before a certificate is.issued..The. Municipality of Anchorage is not . responsible for errors or omi~ions inthe professional engineer's work. ;' 72-025(Rev. 1/91) Back MOA#21 . · Municipality of Anchorage ,~ Department of Health and Human Services ,' HEALTH AUTHORITY APPROVAL CHECKLIST A. Well Data Well type ~ Log present (Y/N) Total depth Sanitary seal (Y/N) Y Date of test Static water level Well flow Pump level1 Y FROM WELL LOG IO. 2-,'N~ 7'7 ' If A, B, or C, attach ADEC letter. ADEC water system number '~[/Ar- Date completed I0 .z ~. 77 Driller Cased to .~/-/ Casing height Wires properly protected (Y/N) "// ' AT INSPECTION SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform ~ Date of sample: ~,. ~, ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank '/',/,~ ~ .~. Nitrate ~. ~, ~5 Other bacteria Collected by: ~ ~, B. SEPTIC/HOLDING TANK DATA Date installed I0 .,2.~. 77' Tank size Compartments Cleanouts (Y/N) "/ Foundation cleanout (Y/N) High water alarm (Y/N) ~///,,N Date of pumping ~.~ ~ 7- ~ ~I ;,/ Depression (Y/N) Alarm tested (Y/N) I'Y/A, Pumpe[ -~ ~Lo J~.~_ ~' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I/0 ~ On adjacent lots ~, ~ Foundation To property line ~ ~ 0 Absorption field Water main/service line Surface Water/drainage 72-026 (3/93). Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level ... ,Pump On''` level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) ."Pqmp ofl":Lev¢ at Cycles tested SEPARATION, DISTANCE FROM L FT S, TATION TO~. Well on lot On adjacent lots Sudace Water D. ABSORPTION FIELD DATA Date installed 10 -~.o. 77 Length '7 ~' Width Soil rating (GPD/FF) /~C> Gravel thickness System type '7',P__.~- ~ cH Total depth I t Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Total absorption area c~/,Z. Cleanout present (Y/N) Date of adequacy test .~, ~, ~ tl/ Results (pass/fail) SEPARATION DISTANCE FROM'ABSORPTION FIELD TO: Depression over field (Y/N) for y After test ~ ~ If yes, give date Bedrooms Well on lot ! O ,~; '/' To building foundation / On adjacent lots ,,~ Sudace water ~/0 Curtain drain ' ~'"~/~ E. ENGINEER'S CERTIFICATION On adjacent lots ,~ / ~ Property line To existing or abandoned system on lot Cutbank I"'~o ~ <. Water main/service line Driveway. parking/vehicle storage area ~. I I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspect/on. HAA Fee $ ' Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back ~' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. OWNER ~,~:~,,/~t [ PHONE MAILING ADDR ESS~ PROP ERTY R ESI D EN~ (I f different ~rom above) [ PHONE 2, BUYER PHONE MAILING ADDRESS 3'. LENDING INSTITUTION ~¢~/~ ~ ~ I PHONE MAILING ADDRESS 4. REALTOR/AGENT ~ PHONE I MAILING ADDRESS 5. LEGAL DESCRIPTION STREET.OOAT,ON 6, TYPE OF RESIDENCE NUMBER OF BEDROOMS [] One [] Four ~ [~] Two [] Five SINGLE FAMILY [] MULTIPLE FAMILY [~ Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY *ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY **If individual/on-site, give installation date /~--~ '~ ~ If system is over two (2) years old an adequacy test is required 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 ONL~ DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE NSPECTOR 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 [] INDIVI DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [~Holding Tank Size: 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 I Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS I~'~APP ROV ED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE (~ BY~ 72-010 (Rev. 3/78)