Loading...
HomeMy WebLinkAboutPROSPECT HEIGHTS #1 BLK 6 LT 1 GP~ATER ANCHORAGE AREA BORO/:~H HEALTH DEPARTMENT 4 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-251 i INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM .N.°45 SEPTIC TANK: DISTANCE FROM WELL~/~,~J'/~)/~;''~) LIQUID CAPACITY <'~/,~--"' GALLONS. MATERIAL ~()/~/t'~'~-'- ~,~//~_~- NUMBER OF COMPARTMENTS J INSIDE LENGTH ,~ INSIDE WIDTH,-~''/~' LIQUID DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS LINING MATERIAL NEAREST LOT LINE /~/ /~? / OUTSIDE DIAMETER. OR WIDTH. , LENGTH ~.r~ !. DEPTH ~'~,'~' DISTANCE FROM WELI. C/'~¢~/'~/ ~<~z~/~//'~-~c~) , BUILDING FOUNDATION TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ~*'~L/_~ SQ. FT. TILE DRAIN FIELD: ~ ,, / ~ ///~OTAL LENGTH _ \ · ~-~ ~-~ ~ DISTANCE FROM / WATER ~ WELL: TYPE ~-~,42/~_~c:~ , DEPTH .,BUILDING FOUNDATION.__SAMPLE , NEAREST NEAREST ~ / SEPTIC SEEPAGE ~ / OTHER LOT LINE ~, SEWER LINE ~ ., TANK ~ , SYSTEM. , CESSPOOL , SOURCES DISTANCES: DIAGRAM OF SYSTEM GAAB-HD-2 GREATEI;~'ANCHORAGE AREA HEALTH DEPARTMENT 327 Eagle St. Anchorage, Alaska 99501 : '~)ROUGH c.~es0. /27~9~.5_!J_~ SEWAGE DISPOSAL SY,~STEM ' APPLICATION & PERA~IT NAME 0F APPL,CANT RESIDENCE ADDRESS LEGAL DESCRIPTION APPLICATION TO INSTALL: SEPTIC TANK TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH PERCOLATION TEST RESULTS MAILING ADDRESS~'~ ~-~'~/ , PHONE NO. LOCATION OF INSTALLATION ,OTHER ANTICIPATED DATE OF COMPLETION BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT THIS IS TO SERVE AS SEPTIC TANK SIZE DISTANCES: ~( ~'~-~" , PERMIT TO INSTALL A ~¢~ ,~~ , AS DESCRIBED BELOW. SIZE OF UNITTO DESERVED: ~ ~'~ TYPE~P~ ~ I ce~tJ£y that ~ am farnJlJa~ with the ~¢quJrcmcnts o£ G~cate~ A~cho~a~c A~ea Borough O~d~ance No, 28-68 ~d that thc above described system is in accordance with said code. ,~ nbT~ I~A~IT~ ~I~IATIIRF ~ ~ TYPE ,..,z~-c~ SEEPAGE AREA ., DIAGRAM;OF SYSTEM d..7 ~ Sidney p, Self 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 1. GENERAL INFORMATION Complete legal description Location (site address or directions) ~'~OO /,~,~(::// ~_.2~',~e. ~-' Dr- prOperty owner ~M r- ~-o,-1 ,.~--~ ~1 1.5 Day phone Mailingaddress IZOO ~ tvpor.Jl- i~Jc$ .---~¢. ~j~L~. '?..lO Lending agency Day phone Mailing address Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ ~l u~J ~N TYPE OF WATER SUPPLY: NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest~ lng to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer if community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~O25 (Rev. 1/91) Fronl MOA ff21  Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist LegalDescription: 6o41 ~Io=K ~ ParcelI.D.: A. ~LLDATA ~gOAf~°4 g~5 ~D Well type ~ Log present (Y/N) / Total depth I Z, O Sauitary seal (Y/N) IfA, B, or C, attach ADEC letter. ADEC water system number Date completed c) M I<,M O oo tx] Cased to I Z 0 Casing height (above ground) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level ? 5,2_ Well production lO g.p.m. g.p.m WATER SAMPLE RESULTS: Coliform O Nitrate Other bacteria Date of sample: I- 7~ 5f-c~ Collected by: 1'4, tO, B. SEPTIC/HOLDING TANK DATA Date installed Foundation cleanout (Y/N) ~ Date of Pumping f- - 7_. 0 - ~ ~ C. ABSORPTION FIELD DATA Tank size ~' 17_. Number of Compartments [ Cleanouts (Y/N) Depression (Y/N) /%/ High water alarm (Y/N) Pumper ~$~cb~ Ott..,~,,,~t,4..~ Date installed ~' 70 Soilrating (g.p.d./ftZorft2/bdrm) U,~/<., Systemtype 5~&p°-~o~ Length Z'~/~ g ' ' Width / Gravel thickness below pipe G Total depth Effective absorption area 5 gOAl Monitoring Tube present(Y/N)__)/Depression over field (Y/N) Date of adequacy test &'l'/:~.lS~ ~1~ Results(Pass/Fail) ~,$~ For 7_, bedrooms Fluid depth in absorption field before test (in.); L ? Immediately after 63OOgal. water added (iu.): h/ ~ Fluiddepth ~J,q~ (ius.)Minutes later: 6J,4/(', Absorption rate = 4- ~oo g.p.d. Peroxide treatment (past t2 xnonths) (Y/N) tx/ If yes, give date 39/4 NORTHERN TESTINI LABORATORIES, INC. 3330 INDUSTRIAL AVENUE 2505 FAIRBANKS STREET FAIRBANKS, ALASKA 99701 ANCHORAGE, ALASKA 99503 (907) 455-3116, FAX 456-3125 {907) 277-8378 · FAX 274-9645 Constructing Engineers 9601 Buddy Werner Dr. Anchorage, AK 99516 Report Date: 01/31/96 Date Arrived: 01/29/96 Date Sampled: 01/28/96 Time Sampled: 1900 Collected By: HS Attn: Henry Wilson Our Lab #: Location/Project: Your Sample ID: Sample Matrix: Comments: Lab Number Method A142951 L 1 Bk 6 Prospect Heights Hose Bib Water Parameter Units ** Definitions ** B = Present in Blank H = Above Regulatory Max. E = Estimated Value M = Matrix Interference D'= Lost to Dilution MDL = Method Detection Limit Date Date Result * MDL Prepared Analyzed A142951 EPA 353.3 Nitrate-N mg/L 6.12 0.50 01/29/96 ~~'o J. Lange Rep ny Chemistry Supervisor 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 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address I~O0 Lending agency Mailing address /LiL~...j. Day phone Day phone Agent ~-/~¢tk,-~ H/~/.¢o,~ Day phone Address ~2~'Of ~ ,~¢t,v t,c' ~,~¢'~ Pr'~ue. A~c Ao~-~ ~ 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: Individual on-site Holding tank Community on-site Public sewer NOTE: 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 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LoT / , ~L,~' (~ ?l~OSPecT ~(TS. Parcel I.D. If A, B, or C. attach ADEC letter. ADEC water system number Date completed O ~K'~owN Driller Cased to J:2o ' Casing height Wires properly protected (Y/N) y' A. Well Data .g.p.m. Well type [~' ~ v'/~'rE Log present (Y/N) '7' Total depth I '2_ o Sanitary seal (Y/N) \/ FROM WELL LOG Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot ~ Public sewer main ~ Sewer service line ¢~ 2;o AT INSPECTION :>/13 ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout ~ (OO¢ Petroleum tank WATER SAMPLE RESULTS: Coliform 0 Date of sample: Nitrate ~ r~ ? / Z.~ Other bacteria ,,/ Collected by: PL,~T'roP 'T~c 3/ B. SEPTIC/HOLDING TANK DATA Date installed ~/'70 Cleanouts (Y/N) ~ High water alarm (Y/N) ~./I. Date of pumping Tank size~ ~/2 Foundation cleanout (Y/N) G,9 c Compartments N Depression (Y/N) Alarm tested (Y/N) I,(./~. Ii / ~1' ~.~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot Io_~ Feo, ¢.o, On adjacent lots To property line 12. o~ Absorption field iS" Sudace water/drainage ~ Ioo 72-026 (3/93)' Front Foundation Water main/service line ~ ~o' CONTINUED ON BACK PAGE ..... ~= m~VI~UNMEN~AL LAB SERVICES * 3451355 N0.424 ~03 I COMMERCIAL TESTING 8/. ENGINE.;:RING CO. .%ro m h SA),~LE T.'-'PE: Routine meFe~ S~vle (for routine snm~le Special Pu~o~e S.&iM~LE LOCATION Collected Year Tretred War~v rjn~reated W.',te r Collected By TO BE CON~LE~D B~' r ,-.;,c_:? ~._- $.-.ow$ n S=-nv!: ~oc icr. i' in ...... ;" san. via $~o~d r~O{ bc over 4.~ g'"~" :,4 . ~.,.--:... · -~nai:'shSega= lOON a 9 [994 ....... .,,,-- Xfechod: /M'e~br~,-le Fihe.- ,,~;O-M~.~- ' ~N~u~':~7 0-~ .-.¢ --;.. ~ ..... o,.:..:./. JO Lab ~'" q~e,, No. S~:~:ro.-x.'~.Z,C. ~ ?~,k~ j~ 1_~." Fa '.-: c-J Ciieut -~etified of' unsari_%~cro~' r¢.~u!rs: Phoned '"- Coif __ Colo'-.io~/lO0 ml c o ..... Co!ifor-~,~/' l O0 ~1 . Tim: ~_, 5ri ~_~C:.'!R.C..?.fM~..,jT~.Z ..... . . - ..... SINCE 1908 CT&E Re£.# Client Sample Matrix Commercial Testing & Engineering Co. Environmental Laboratory Services wJJJ~'~'JJ~'J~'~'~'~-j~J~f~-jfjjj~j~jj~~ LABORATORY ANALYSIS REPORT 94.2938-3 L1 BLK6 PROSPECT HT8 HOSE BIB WATER Client Name FLATTOP TECHNICAL SRV WORK Order 7944 l Ordered By TED MOORE Printed Date 06/17/94 ~ 11:33 hrs. ProjectName CollectedDate 06/14/94 @ 14:30 hrs. Project# Received Date 06/14/94 @ 15:45 hrs. PWSID UA TeclmicalDirector STEPHEN C. EDE Sample Remarks: ROUTINE SAMPLE COLLECTED BY: CHRIS. Parameter QC Allowable Ext. Anal Results Qual Units Method Limits Date Date Init Nitrate-N 6.2 mg/L EPA 353.2/300.0 10 06/15/94 DJS * See Special Instructions Above ** See Sample Remarks Ab ov e U = Undetected, Reported value is the practical quantification limit. D = Secondary dilution. UA=Unav~l~le NA=NotAnalyzed LT=LessThan GT=C~ealer~tan 5633 B Street, Anchorage, AK 99518-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO. UTAH. WEST VIRGINIA D. _= RECEIVED ~':1M E TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECT~ MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHO,AGE  PROTE -I-.DEPT. OF HEALTH & DEPARTMENT OF HEALTH & ENVIRONMENTAL~,~v,~ ~~'~'ME~'TAL PROTECTION 825 L Street - Anchorage. Alaska 99501 ENVIRONMENTAL SANITATION DIVISION 1981 Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND 8E PlRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE MAILING ADDRESS PROPERTY RESIDENT (If different from above) PHONE 2. BUYER PHONE MAI~I~GADD~[SS 3. LENDING INSTITUTION PHONE MAILING ADDRESS 4. REALTOR/AGENT PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION / ¢ p o7 STREET LOCATION 6. TYPE OF RESIDENCE '~ SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS [] One [] Four ~ Two [] Five [] Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach Icg if available.) 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE~ [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72 010 (Rev. 6/79) · .. ~ CHEMICAL & Gk~,/LOGICAL LABORATORIES ,~£ ALASKA, INc.~ ~;' TELEPHONE (907)-279-4014 ANCHORAGE INDUSTRIAL CENTER /~~ 274-3364 §633 B Street ~ ......... -,~ Drinking Water Analysis RePort for Total ColifOrm Bacteria TO BE COMPLETED BY WATER SUPPLI'ER WATER SYSTEM: I.D. NO. ,,i ,. ~, ', '~ !' i :~ ,,~ ~ ' ~ · / ='" " Water System Name Phone N~. Mailing Address ,,, Zip Code City SAMPLE DATE: ~ MO. Day SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref. no. ) [] Special Purpose State Year [] Treated Water [] Untreated Water SAMPLE NO. I LOCATION Time COllected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: i~lSatisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results, Please send new sample. Date Received Time Received Analytical Method: [] Fermentation Tube .,1~' Membrane Filter Lab Ref. No. Result* Analyst I [-~ I *No. of coJonies/lO0 mi. or No of Positive portions· READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 (b) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Collected = Source Date Received Time ReCelveCl __ }.m. Lab. No. 24 Hours 48 Hours 24 Hours 48 Hours Multiple TUOe RePort; Membrane Filter: Direct ColJnt Verification: LTB Final Membrane Filter Results ; ''~'' Reportm:t By ' ~ '; . Date Broth 48 hours: 10mi Tubes Positive/Total 10mi Portlooe Coliform/100ml BGB Collform/1OOml ALASKA EnUIROFImeFITAL COI1TROL SERUICE$, IllC. ~n(lineerin(I 8- ~nuironmental Studies MUNICIPALITY OF ANCHORAGE DEPT. OF I~EALTH & ENVIRONMENTAL PF, OTECTION AL./8 1 i RECEIVED 8/lo/81 1ST NATIOINAL BANK BOX 4-2090 ANCHORAGE AK 99509 SELLER - ALEX HILLS SUBDIVISION-PROSPECT HEIGHTS BLOCK-6 LOT-1 ADEQUACY TEST FOR SEWER SYSTEM THE TYPE OF ABSORPTION SYSTEM IS A PIT WITH AN AREA OF 540 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 2 BEDROOM HOME. THE SEPT] WAS PUMPED ON 8/10/81 . · MUN C PALITY OF MUNICIPALITY OF ANCHORAGE / -I  825 L Street - Anchorage, Alaska 99501 ~ ...... ..>:, ENVIRONMENTAL ENGINEERING DIVISION AUG ? 1979 .... RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FAGILITIES ]1RE~TIONS: Oomplete all parts on page 1. Incomplete req~es~ will .or be processed. Please allow ten (10) days for processing. 1, PROPERTY OWNER PHONE M~ILING ADDRESS PROPERTY RES~ENT~l~different from ~bove) ~ ' ~ ~-' 2. BUYER ~ PHONE MA~ING ADDRES~ ' / / ~ 3. LENDING INSTITUTION / / ~ PHONE ~ILING ADDRESS ., / 4, REALTOR/AGENT - - - - PHONE 5. LEGAL DESCRIPTION ,~.-,,.,,~ ._/~ <~_~...,~ ~?.~-~ ,//~.,~-,X~ . ~.,.~_ ;TR EET LOCA~ON ~ / / /~ ~;~- /~ ~ ~ ,/?~ >~ ~PE OF R~ENCE ~ ' NUMBER OF BEDROOMS ~ One ~ Four ~INGLE FAMILY ~wo ~ Five ~ MULTIPLE FAMILY '~'" Three ~ Six [] Other 7. WATER SUPPLY [;~;;]---'IN D I V I D U A L* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. Awell 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 ," - '? * If individual/on-site, give installation date~ Iq"-~ ~ [~]~'~IVI DUAL/ON-SITE** If system is over two (2} years old an adequacy test is required [] PUBLIC UTI LITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) & e 'OLOalGAL. LABORATORIF.8 OF AI.A KA, INC.. P.O. BOX 4-1276 ~ ANCHORAGE,~ALASKA 99509 4649 BUSINESS PARK BLVD. Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER I.D. NO. Public:Water System Name Malll~ City State Zip Code Mo. Day Year TELEPHONE .... (907) 279-4014 TO BE COMPLETED BY LABORATORY LABORATORY: NAME Date Received Time Received CITY SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref, no. [] Special Purpose [] Treated Water [] Untreated Water Analytical Method: [] Fermentation Tube -~J~Mem brane Filter SAMPLE NO. LOCATION Time i Collected Lab Ref. No. Collected i!, By I Result* Analyst * No. of coloniel 1100 mi, or No. of Pollllve porllonl, READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Form No. 18-310 (3-78) 06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1978 Date Collected Source Presumptive 10mi 3.0mi /0mi 10mi 10mi 1.0mi 0.1mi 24 Hours 48 Hours Confirmatory 24 Hours 48 Hours EMB Broth 24 hours:_ Broth 48 hours: Multiple Tube Report: 10mi Tubes Positive/Total 10mi Portions Membrane Filter: Direct Count Collform/100ml verification: LTD ~7 ~'~' ) BGB Report~ By ":-~ / '~-: ~ Date / ~//~ JACK BENNY'S AND ANC~AGE CESSPOOL PUMPING Star Route A Box 144 ANCHORAGE, ALASKA 99502 344-2632 or 349.1131 I I J TAX All claims and returned goods MUST be 493 ..... ~an,e. b. th,sb,,,. ~,~, SERIES 609 et Anchorage, Alaska, 99503 907-279-8056 NEW PHONE N~BER 276-4113 !ION SYST~ TEST TELEPHONE:~'~'-~,'~ DATE OF TESTS:~__~.___ )S ON FILE: I~,~, ["~'l~'o~']'--p OTHER ~ITH JML STANDARD PROCEDURE ACCEPTED BY ~T. OF ENVIRO~ENTAL QUALITY ON )NS: SURGE CAPACITY: SOIL ABSORPTION SYST~4 SEPTIC TA[~ PLUS SAS ABSORPTION RATE AVERAGE 24 hfs ~_~ ,~,g STEADY STATE q RISE OBSERVATIONS: NOTES: SUPERVISED BY: - _ ' . TEST DATA AT~ JML SHEET ' _OF John M. Lambe, P.E. 4303 North Star Street Anchorage, Alaska, 99503 907.279-8056 DEPTH Bm.OW METER READING GALLONS PUMPED '1 TIME ~-~ ~olO 330_ JML S~S'ST "7' O~ · John M. Lambe, P.E. 4303 No,~.-, Star Street Anchorage, Alaska, 99503 907.279-8056 DATE ~'?/7~ PE~FO LEGAL'DESCRIPTION: DEPTH BELOW EETER READING GALLONS pUMPED '1 TI~E ~EFERENCE ~ ~~ ~ '7 '- ~" 6' I/0 /~ ~ " z ~/ 7 ~4~' 02/0 -- ' '7z~YF ~ ' ~ /o:o~~ ! 7.- ~ p:~..75~', _ THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR I NSP ECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [~] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX 2. WATER SUPPLY PERMIT NUMBER [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED E~]PUBLIC UTILITY (~ ~'~ Cd Connection Verified INSTALLER []Septic Tank or [] Holding Tank Size:. Co/i'5--- If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL , WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS [~;~"~PPR OV E D FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must acco~certificate) [] DISAPPROVED LEGAL DESCRIPTION 72-010 IRev. 3/7R) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE [] 'SINGLE FAMILY [] MULTIPLE FAMILY WATER SUPPLY INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SE~FAGE DISPOSAL'SYSTEM ~I~NDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified [~septiqT, ank or F-lHolding Tank Size: ( ':,"~ If Tank is homemade give dimensions: TYPE OF TANK TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line NUMBER OFBEDROOMS [] ONE [] THREE [] FIVE ,'~i TWO [~] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING MANUFACTURER MATERIAL [] OTHER 5. COMMENTS ~ .~ .. .~ ~-,i ~' [] CONDITIONAL APPROVAL (letter must accompany certificate) [] D~SAPPROVED DATE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level "Puml~ on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at .Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA Date installed c~/7o Length 2 '7 Width Total absorption area 5~o FL'~ Date of adequacy test ~,//z//?,~, ~_ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Surface water Wellonlot ~-/3o F~ ¢o, To building foundation On adjacent lots '~ Surface water ;>/o~ Curtain drain ~o~ E. ENGINEER'S CERTIFICATION Soil rating (GPD/FF) ~,~/.~ System type 5~E ~//GE Gravel thickness (~ Total depth c~ Cleanout present (Y/N) "/ Depression over field (Y/N) Results (pass/fail) ?~-~.r for ~ 2:/'~ After test '-/~t" If yes. give date Iq,A, On adjacent lots ~/oo~ Property line ~ .o, To existing or abandoned system on lot Cutbank ~, f~. Water main/service line Driveway, parking/vehicle storage area ~ Io0 pLT' N I ce~'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on .~.~.this inspect/on. Signature ~~ . ~ ~ ....~~~~~'~ :~: .~. ~ .~, · Engineers Name - H~ Fee $ ~ OO ~ Waiver Fee $ Date of Payme~ 7 - J -- ¢ ~/ Date of Payment Receipt Number ~ ~ ~¢D ~RecoiptNumber Bedrooms o 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 ~/~-/'o/v -'/'eo4~,e~/ _.~ero.;c~,. Phone Address )¥~"~2 ~c,~o ._C/~ ~r~chor~., Engineer's signature DHHS SIGNATURE ~, Approved for / Disapproved. bedrooms. Date 8TA! 1 P Conditional approval for bedrooms, with the following stipulations: Additional Comments Date 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 D. LIFt STATION Date iustalled ~ Size in gallons Manhole/Access (Y/N) -- "Pump on" level at* -- High water alarm level at* -- *Datum ~ Cycles tested -- '?ump oft" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot i 0 5 42 o C. O, Absorption field on lot ~ t 30 ' Public sewer main Sewer/septic service line ~ gO t : On adjacent lots 4- / O 0 : On adjacent lots 4- / o O Public sewer manhole/cleanout 4- I 00 Lift station ~+ [00 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Z '5 4-0 GO Property line ~ 2. © t Absorption field t' ~- Water main/service line % ff ot Surface water/drainage ~ I O D Wells on adjacent lots SEPARA~ON DIST~CE ~OM ABSOR~ON FIELD ON LOT TO: Building foundation ~ 8 ~ ~o ~ C, O · Water mai~se~ice line -~ 60 ' Surface water · too Driveway, parkinffvehicle storage area + Cu~ain drain + 50 ~ Wells on adjacent lots + I O O Prope~ line F. ENG~ER'S CERTI~CATION I certify that I have determined thrufield ins~ ections and review of Municipal reco~ ~:~ m conformance w~th MOA ~ guidelines in effect on this date .~/?~- Engineer's Name fi, ~4. ~ t { 5' o ~ ~o~ 5~ (~ma :~:~-~, . ~[3~ HAA Fee $ ~ Date of Payment Receipt Number Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number 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 Co~1 3-~v,~c.J¢, v~ ~ I vl~"~ ¥ 3 Phone ~G- ~ oo0 Address ~0~ ~O~ ~¢'i ~~ ~lQI ~1~ Engineer's signature ~¢ ~~ Date '&-~5-~G o DHHS SIGNATURE Approved for ~, Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: By: __ AddtonalComme-ts Note: The well for this property meets existing U . State and Municipal Codes. There are nitrates present. It is suggested that a )eriodic testing be performed to insure the wells continued suital 'itrate concentration is 6.lI-mg/1. EPA · 07 mg~.!. __Date. ~/g/Tg The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approv.a.I-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 #21