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Home My WebLink AboutPURINGTON LT 12 :V[ar~K ~eql'Ch ,~nchor~g~, A J( 995!9-66~0 (907] Pump l stallation Log Drilling Permit D~te of Issue: __ p~rcel Identification Number: L. Pump I. nstnllnr/on D~te: ~p S~e ~ hp ~i~esa ~dap~r Bu~ Dep~: ~ feet Pi~ess :&daptar tnst~er: ~/all p~sinfected Upon Comp[ed,on'~fes ~Iethod of ~' infectiog: feet Pump In~t~ller A~endon: Th~ pun~p insmLI~r zhz2 prcvid~ a pump in~t~iI,~ti~n log t~ th~ DS3D ~tI-d~ 30 dsys of pump 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.# 1. GENERAL INFORMATION Complete legai description HAA# Location (site address or directions) Property owner Mailing address Lending agency tq .//~ /~//~ Mail;~g address ¢q'//~ Agent -,. 't~/A: .~/,.~- __ Add ress ~/~ ..... Unless othe~ise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ ~mEo~ Day phone .Day phone TYPE OF WATER SUPPLY: Individual well Community well Public water 72-025 (Rev. 1/91) Front MOA~21 NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legahty and status of system. .- ,, ,.'¢ . ~ ],')11.. TYPE OF WASTEWATER DISPOSAL: ,,,' ~,;',,,', ! ,, .>, ,: -~, Ind v dua on-site ~ ? L'.-; i ~ "! i '~' . . . .: .! ~ ~. ~ ?-;'~ . ~ . Holding tank ' . ' Commumty on-s~te ........ , Pubhc sewer - /~ ' " ,,,, '~/ NOTE: : If community wasteWater system, provide written Csnfirmation from State AD'EO : attesting to the legahty and status of system.' '. '. ': · . '.: . : . . ,, . : ': ,:';~,;; :, :',.:! ':, ' .::', ',';" t~? . .' . 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 ~ .... 7f ' Phone -~ Address ~¢:::~r~/I ~~~ ~~~/. ,~. Engineer's signature (/_ ./~/~'"] (//: ~ .-__ Date DHHS SIGNATURE /X~ ,, ~Approved for ~ Disapproved. conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments ,,".' ,-- '- '-r.','(/' Date //--/~- ~he,. Munmi~ali~ o.,AQehbrage... . Depa~ment of Health and Human Se~ices (DHHS) i~ues Health Authori~ ~p[oval Ce~ificat~based only upon the representations g ven in paragraph 5 above b an inde end nt '. ~ ~.. ,..,,~,,., ,,. . . Y p e pr,~o{o~o~al.~ ,'t, en~r. ~ : reg, ~stered m the State of Alaska The DHHS does th s as a cou~esy to purchasem of homes and thg~lend~ng msbtutlons ~n order to ~tts~ casein f~eral and state requirements. Employes of DHHS do not conduct inspect ons or anal~e-data before a ce~ificate ~s i~ued. The Municipali~ of Anchorage is not r~p0nsiblo for errom or oral.ions in th~ profe~ional onCn~e~ work. : ~,1~1) ~k MOA~ Municipality of Anchorage Department of Health and Human Services Legal Description: A. Well Data Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 HEALTH AUTHORITY APPROVAL CHECKLIST ~u ¢,4~ ~/¢ Parcel I.D. oo ~ - o ~ If A, B, or C,~attach ADEC letter. ADEC water ~ystem number ~ ~te completed ~//?/~J Driller ~ / Cased to ~0 ~ Casing height Wires properly protected (Y/N) '~% FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: g.p.m. AT INSPECTION Septic/holding tank on lot ~_.,~/ J Ac, ~- + g.p.m.,~.- Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform (:~ Nitrate . / ~/¢... Other bacteria ¢-~ Date of sample: /" ~/2-'}'/~,~ . Collected by: ('~.~z~->"-~--%~ ~PTIC/HOLDING TANK DATA ~'~ % ~J~ ~ Da~ .Tank size ~ .Compadments ~ ~ Cleanouts (Y/N) ~~, _Foundation cleanout (Y/N) _ ~Y/N) ~ TO: Well(s) on tot ,¢~ On adjacent tots Foun¢~~~ ~ - ' lin ~ Absorption field Water main/service line~ CONTINUED ON BACK PAGE 72-026 (~)* Front LIFT STATIO~ nstalled Size ons Manufacturer Manhole/Access (Y/N) Vent ~ High Meets MOA electric~ SEPARATION DISTANCE FR( Well on lot D. ABSORPTION FIELD DATA "Pump on" level at (Y/N) I LIFT STATION TO: ~n adjacent lots "Pump off" Level a~ Cycles tested /// Surface water Date installed Length Width Total absorption area To building ~,~ d~ation On ad~..erfrt lots ¢ade water ////Curtain drain E. ENGINEER'S CERTIFICATION @SS System type Total depth Depression over field (Y/N) Date of adequacy test Results (pass/fail for Water level in absorption field before,..te'/sst After test Peroxide treatment (past 12 mo/~t~) (Y/N) give date SEPARATION DIS OM ABSORPTION FIELD TO: Well on lot On adjacent lots To existing or abandoned system on lot '% Cutbank Water main/service line Driveway, parking/vehicle storage area Bedrooms Waiver Fee $ Date of Payment Receipt Number HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back I certify that I have checked,, verified, or conformed to ali MOA and HAA guidelines in effect on the date of this Jhspection. Signature ~~~~ 0 o3: ~ o CT&E Ret'.# Client Sample ID Matrix Commercial Testing & Engineering Co. Environmental Laboratorv Services ~?/~××~j/~l~/~×~.~~~£~z~ LABORATORY ANALYSIS REPORT 94.5012-1 TAP WATER/4105 B RANTLEY ST WATER Client Name AK WATER & WA STEWATER SERVICES WORK Order 82670 Ordered By JEFF GARNESS Printed Date 10/07/94 (~08:57 N's. Project Name Collected Date 09/29/94 @ 19:30 lu's. Project# Received Date 09/30/94 ~ 11:45 tuts. PWSID UA Technical Director STEPHEN 12. EDE Released By'~ ..... .~e %~-p ~ , ~_ Sample Re~narks: ROUTINE SAMPLE COLLECTED BY: J.G. QC Allowable Ext. Anal Pm'ameter Results Qual Units Method Limits Date Date hilt Nih'ate-N 0.10 U mg/L EPA 353.2/300.0 10 10/03/94 CMR * See Special Instructions Above ** See Sample Remarks Above U- l.h~detected, Repoded value is the practical quantification limit. D = Secondary dilution. UA = Unavailable NA = Not Analyzed LT= Less Than GT = Greater ~!han 5633 B Street, Anchorage, Al( 99518-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA DEPARTM 825 MUNICIPALITY OF ANCHORAG~ OF HEALTH AND ENVIRONME~ ~L PROTECTION L Street, Anchorage. Alaska 99501 264-4720 Date Received: February .8, 1978 ~2: Time #B: Time Date Date Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 4: Lending Institution Request: Mailing Address: Property Owner: Mailing Address: Coast Mortgage Company Post Office Box 1200 99510 Phone: La Verne L~wood Phone: 4106 Brantley, %Cloyd Moser, 274-3556 Legal Description: Lot 12 Block 10 Purington Subdivision 4106 Brantly Single Family Residence: (x) Multiple Family Residence: ( ) Well System: Permit ~ Construction 279-0665 Number of Bedrooms: Two Number of Bedrooms: Individual well (x) Depth of Well 6. Sewage Disposal System: Permit # Septic Tank Size Absorption Area Co~nunity/Public System ( ) 90' Well Log on File Bacterial Analysis On-site System ( ) Public Utility (x) Installed Installer Manufacturer Soils Rate Material Distances: Well to Septic Tank to Sewer Line Nearest Lot line to Nearest Lot Line to Absorption Area Absorption Area MUNICIPALIV~ OF ANCHORAG. Department of Health and Environmental Protection 825 L Street, Anchorage, Alaska 99501. 2 6 4-4 7 2 0 %%~'a~R~quest for Approval of Individual Sewer and Water Facilities Property Owner: Mailing Address: Name of Buyer: biailing Address: LaVerne Lakwood 4106 Brantley~_Ancorage Phone: unknown James E. Talley 3831 W. 72nd Court Phone: 279-5522 o Lending Institution: Coast MOrtgage Co. Mailing Address: PO Box 1200~ Anchorage Phone: 279-0665 o Realtor/Agent: Cloyd Moser (Please call agent for access) Mailing Address: 4467 Business Park Blvd~ Anchorage Phone: 274-3556 Legal Description: Lot 12~ Block 1O~ Purengton Subdivision .Street Location: 4106 Brantley Singie Family Residence: (x) Number of Bedrooms: 2 Multiple Family Residence: ( ) Number of Bedrooms: Water Supply: *Individual Well (x) If Individual. Well, well depth 90' If Con~nunity System, name of system Public/Conununity System ( ) Sewage Disposal System: *~On-site System ( ) Public System (x) If On-site System, date of installation: *NOTE: A well log is required on ALL wells drilled since 6/75. ** If on-site sewer system is over two(2) years old, an adequacy Zest is required by this department. A fee of $25.00 must accompany each request before processing can be initiated. 3/77 Page Two Department Of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 12 Block 10 Purington Subdivision Comments: Affadavit Attached: ~ ) f /, Approved: _q ¢. Disapproved: Letter Attached: ( ) Date: Date: Department Worksheet: g~/,-Og.b Z[O g/,6I: O,ID ~:- 'j~JJ~[ 1VNOIIVNtt]INI tlOt lot! OOg£ Iz6I '~dV (op!* ~oqlo oos) -illlllAOIJtt ][IV}IIAOD ]:)NVJlflSJ~II Oil tu~o.4 Sd GREATER ANCHORAGE AREA BOROUGH Department of Environmental Qualfty 3500 Tudor Road, Anchorage, Alaska 99507 279.-,9686 Time of ~[nspectlon /'~', L_~ .~ REQUEST FOR APPROVAL OF INDIVIDUAL SEt~ER & WATER FACILITIES FOR Address ~ Phone .' Number of Bedrooms 7. C. Septic Tank: 1. Size 2, Manufacturer D. Seepage Pit~ 1. Size 2. Material E. Disposal Field: Total Length of Lines Distances: A. t%].l, To: Septic Tank , Nearest Lot Line L% Foundation to Septic Tonic , Absorption Area , Sower Lines ., Other Contamination ",, Absorption Area o Co A,..,.~.pt.~on Area to Nearest Lot Line Rec~est for Approval c" ~ndividual Sewer & Water Faeil~''~s Page Tee Aporove v~.' fsapproved Date Approval Valid for One Year From Date Signed Greater Anchorage Area Borough, Department of Environmental Quality DTAGP, AM OF SYSTE~ that' the information contained in this request for approval to be a true ¢Jcc,Jra~,e represe¥~ta;tion of the sub.iect' sewer and water facilities located at: Signed Date GREATER ANCHORAG5 ARFA BOROUGH Department of 5nvt~ommentml Qumltty 3500 Tudo~ Road, An~ho~mge, Alaska g9~07 279-B6~6 Time of ~nsoectton.. ~' ~ Date of ~n,~ectio~ ~/,~_~ ~ ~ REQUEST FOR ^P~ROVAL OF INDIVIDUAL S£~ER & WATER FACILITIES ~OR Phone: Address ~ ' ' - -- Bacteria! Analy~is~-S'7~ ' B, ~nstal]er .... , ..... - .... A. ~natalled ......... C. Septic Tank~ 1, Size_...__ 2. ~anufacturer .. D. Seepage Ptt~ l. Size ...... 2, Material ................... ~. Disposal Field: Total Length of L~ne~ ............. -- A. , Absorption Area......_...___, Sewer Linea , Oth~,r Contamination _ ~. · ~, A~orption A~a ___, BEI~)T. OF ENVII]~ION~IENTAL CONSEI~[~V.~TIO~ / / SOUTHCENTRAL REGIONAL OFF/CE / 338 VENAL/STREET ~st 6, 1973. I MAC~YBUILDING-RoOM850 ANCHORAGE99501 Mr. John Clark Hewitt Lounsbury & Associates 723 Sixth Avenue P~chorage, Alaska 99501 SUBJECT: Brantley Place -Sanitary Sewer Extension, Purington Subdivision Dear ~. Clark: With the understanding that a drop connection will be provided at the existing manhole in the line on East 4nd Avenue, the plans and specifi- cations are approved for the features with which this department is concerned. Yours truly, Engineer cc: GAAB-DEQv/