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HomeMy WebLinkAboutPTARMIGAN ROOST BLK 2 LT 7 Municipality of AnchoragePage / of 2-- DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~/ cl,~OIC~:).- PID Number: Name: ~ '~ ~ IE~~ Wastewater System: ~ New ~pgrade Addre,s: J~O ~p~ ~ABSORPTION FIELD.~ JNo. o, droo :  ~ Deep Trench ~ Shallow Trench ~ Bed ~und ~ Other LEGAL DESCRIPTION so~, ,~n~: ~th ~ o~n~ ~r~d~: GPD/S~. Ft. Township: Range: Section: Fill added above orig~e: Ft. Gravel Jength: Ft. WELL: D New ~ Upgrade GraveJdepth~ Number of lines: Distance belween lines: Ft. Ft. Classifi~on (Private, A,B,C): Total Depth: i Cased To: Total a~tion area: Pipe material: Driller: ' Date Drilled: StaticWater Level: In~aller: Date installed: Ft. Yield: ~ Pump Set at: Casing Height Above Ground: ~M ~. ~.TANK SEPARATION DISTANCES ~s~pt,c ~ Ho~d,n~ ~ s.~.~.~. TO Septic Absorption Lift Holding ~ublic/Private M~ufacturer: ~ Capacity in gallons: From Tank Field Station Tan~ S .... Lines ~~ ~ ~ Number of Compa~ments: Surface Water 1~ LIFT STATION LineL°t ~t~ Size in gallons: Manufacturer: Foundation ~0 ~ "Pump on" level at: ~ "Pump off" level at: ;'~-~ High water alarm at: CurtainDrain ~E Pump Make & Modal Electrical Inspections pedormed by: Remarks: ~ ~00 ~ ~c~ BENCH MARK L~cation and Description: I J Assumed Elevation: ENG~,BEAL Department of Health a~d Huma~ervices approval ~;~',, Reviewed and approved / ate . Page ~-~ of ~- Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report LegalDescription: ~-OT "~,~ .~(..l~..~,, ~/:t~VtlC~f+r~ ~--C~'/' % PIONo.: O~OOc/-~?m[ '\ 72-013A(2/91)MOA25 No. I PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW920152 DESIGN ENGINEER:~ILF=ILL~N-~N~iNEERSw~INC? OWNER NAME:DIFRANCESCO LAWRENCE J OWNER ADDRESS:16160 SANDPIPER DR Anchorage ak 99516 DATE ISSUED: 6/24/92 EXPIRATION DATE: 6/24/93 PARCEL ID:02004275 LEGAL DESCRIPTION: PTARMIGAN ROOST BLK 2 LT 7 LOT SIZE: 60653 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: PERMIT IS ISSUED FOR INSTALLATION OF ADDITIONAL 500 GALLON SEPTIC TANK. THE NEW TANK IS REQUIRED TO MEET REQUIREMENTS FOR A FOUR BEDROOM SYSTEM. RECEIVED BY: ~ Q,L~. ISSUED BY: .~O~bd ~5[~t,T~ DATE: ~,//~/~ ~-~ DATE: June 18, 1992 ROBERT SHAFER, P.E. ROGER SHAFER, P.E. CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN Muni~pality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Lot 7; Block 2; Ptarmigan Roost Subdivision~ Request to issue a p~rmit to upgrade the septic system s~rvin9 the referenced property for a 4 be~oom capacity. The existing septic tank and leachfi~ld were installed in 1984. The existing tank i~ 1000 gallon wherea~ the l~achfi~ld was adequately sized for a 4 bedroom capacity. An adequacy test was p~formed on the l~achfi~ld on June 4, 1992 and the absorption capacity was found to be in excess of 600 gallons per day. We propose the installation of a 500 gallon septic tank to make the total system capacity acceptable for 4 be~ooms. If you have any questions or require additional information for your review, please contact us. Sincerely, RJS/gm 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 ' I I i~: 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 MAILING ADDRESS LEGAL DESORIPTION LOCATION ~NO. OF BEDBO0~S We,, AbsorStiz~rea Dwelling PERMIT NO. ~ ~ Manufacturer Material No. of ~ ~ DISTANCE TO: Well~ Dwelling PERMIT NO. ~ ~ ~ Manufacturer ~' Material Liquid capacity in gallons '-. DISTANCE TO: ~~ N~' : , Total ~[[i~ NO. of lines ~ Length ~ linelen~f lines ~Trench~width~ I / dnz.h~ Distanc~,~,~. lines :~ Top of tile to finish grade ~ ~ ~ ~r~al 6e6eath tile I ~"~ ZY~Il W~ 6~ -- I O~nches Total~~beffec.~~area Length Width Depth : ~--< ~ Type of crib C Crib depth Total effective absorption ~ Well Buildin~ foundation Nearest lot line ~ DISTANCE TO: ~ ~ Class Depth Driller Distance to lot line ~ DISTANCE TO: Buff ndation Sewer line Septic tank PIPE MATERIALS ¢~ /~¢~ . ~ SOIL TE~ RATING / --' INSTALLER ~ ~ ~ ~ 'A~'OVED DATE .g 6EiVED 0 0 J:::,J:-Z.,:':'F:Ii::::Ti"IENT OF' HEF:II....TH F:Ii"~D EhIV:I:REth!!"tEhiTRL PRO'FE:CTION S;:!::!:~ L. :E;TF::EE:T., Fli'.,IC,"..IOF.:FIGE., F~.I<: .'.-T.'~:.a. 50:l. E~OE:: F'O E:OX ::L::i..2:'LT'7" I:::ii",JE:i...i O~:::'. R G E:., R i<:: :::i: 45 -. 7' d; :L 2 Y:;LIE',D ]: ',,,' l !:~ :[ ON: F:'TFIRI"I l GRN F..'002':'t' LOT: 7' '.'::;l::c"r'z ON: 2 'T'OI4N::.:;H :r. F>: :;L ::L i'.,II:;::FltqGE: 2:1.4 Z: 2.:.5 7.5 5.0 4:.1... 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E:'::.:; T '::;3" T l'.,t :'3 i.,.iELL., I.,.iF:I?I"E!.,.ff:ITEF:: [:.:, ]: E.';F'EJ~.;F:IL ?.¢L-TTEI'"I [31:'. F:'UE',L :[ C ::::::::::::::::::::::::::::::::::: :E;"¢'.::;,'i"EH 07',! "I" H :[ :.::; i:)F:: Elf',ih" f:ID..:rFiC:t!:-:I'.,!T ,4.. :[ LiN.(::,E.fi:::::TFi.h,ii::, 'T'HF:F'F TI'"i:i::E'; .f:'EF.':i"i :[ 'T T.'.E; ',/k-.iL. _T E:, F'i'_'F? t::l I'"II::I;:<;ZHUi"t ]::iF:' :: E:I-:::":E:,F::OCII'"IE; F'IN[:, ~::~?',i'.~" E:i'.4LF:ff;::(::iE:HEi:hiT i.,.! :[ L.L. F'E' '3 . :i: i:;'F-" l:::ff-,i F:I[::,D: 7':[ Ed'.,iRL.. i::'EF..:t"J ]: T. L.:i:F"F :::;,7'F:!'i":i:C:i'.~ :i:::1; :i:i'.,!'.::"['l:::lLi..£:'l.::, ii",! Fi[",i F:ff;::E!::i ::'.:',,,'EF:ED E',",.' t"tL-~FI E~I. IL.I::,iNG COS, E:::';., *:':t.::: I::!['.,i :' ~ ..... '-:'""'::" _. ........ l .... IL F:'I.:-::F::H'r"F F:J?.,E:, 'i.:['.,i':_:F'F..:CT'['.:'JFJ i-'!U:::T E~E OF:F['R:I:I',IE:[::,.: ,:;:'::, FIE;-...E:LI]:t...T:; i",[.:OT E'i;:: F:fi:'F'J:.:::C¢,¢'E[::, i.,.~.["i'i-..]Cii...iT FIN i:.::.:L :2 ': 'i'.:;' :i: L-.FJL. :[,N:;F'ECT:[ON F'::["_"F'OF.:T.~ F'-IiqE:, ,::.-.'::::, THE . ENGINEERS, INC. 7125 OLD SEWARD HIGHWAY ANCHORAGE, ALASKA 99502 (907) 349-6561 SOIL LOG PERCOLATION TEST 8 2O DEPTH (FEET) ,,/~ SOIL LOG ,/~ PERCOLATION TEST Co i~ :B I_Z.5~ 0 P E BEDROOMS ':.L. I I I I I I~ W E Gross Net Depth to Net Reading Date Time Time Water Drop COMMENTS L. O '7- /~,~ . _~_~.~_ PERCOL^T,ON RATE xJJ S L)~ L-. (mineteslinch) TEST RUN BETWEEN_ ~=~__ FT AND (~.. 5--- FT 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. # (L~'~,~-'~ - C"~\,-q -~-~ 1. GENERAL INFORMATION Complete legal description ': ;: :'! ';'~.~ h~'.~ ~-i ~ .:~ ~' Lot 7; Block 2; Ptarmigan Roost Location (site address or directions) Property owner Mailing address Larry DiFranc~sco Day phone 349-5 207 16160 Sandpiper Drive Anchorage, Alaska 99516 Lending agency Mailing address. Day phOne Agent Address Day phone '. Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: XX If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: X× 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. 72-025 (Rev, 1/91) Front MOA #21 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 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 [ ~ L=NGINEERING 17034 Eagle River Loop Road Ne, 204 Phone Date DHHS SIGNATURE //~ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: 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~)25(Rev. 1/91) Back MOA#21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Well type Log present (Y/! . Total depth Sanitary seal (¢N) If A, B, or C, attach ADEC letter. ADEC water system number ~J/'~' Date completed °/~/~'8~'1 Driller ~'~--. Cased to ~tSl~ ~c ~' ~.l' Casing height Wires properly protected (Q/N) FROM WELL LOG AT INSPECTION Date of test Static water level ~{,K, Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/~ tank on lot Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank uo /Od WATER SAMPLE RESULTS: Coliform C) Nitrate Date of sample: ~ -~.~_c~ ~. Collected by: Other bacteria B. SEPTIC/I~ TANK DATA Date installed ~.~.~1_3 H 'f~_).~l_c/3_ Tank sizer.~ /00o G p~ /r_~jo O,~t Compartments ,,2' Cleanouts (~N) ~- / / Foundation cleanout (~YN) Ot~ b~-¢..~¢ Depression (Y/~) High water alarm (Y/I~ /,,5//'~ Alarm tested (Y/l~ Date of pumping ~//d'/'~ ~ / /(,/zS~ 7',~f~c Pumper -~ NEW .~oo SEPARATION DISTANCES FROM SEPTIC/H~[;~i TANK TO: Well(s) on lot I(~(~' t- To property line ~O ~- Surface water/drainage On adjacent lots [(~0r ~- Foundation Absorption field ~/-k Water main/service line foe 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed :: ~ ~//~ Manufacturer.., - Size in gallons '"'~_ Manhole/Access (Y/N) ;:;~ (wY~e)r ~lar_m~-~ve-~"Pump~ Cyc:~i te'~l~;mP o,__._~f level a~" : Meets MOA electrical codes (Y/N) __ ~. SEPARATION DISTANCE FROM LiFT STATION TO: "-"'--~ Well on lot : On adjacent lots" Surface- - water ~---.....~. D. ABSORPTION FIELD DATA Date installed ~ ~.~.c~-~l Soil rating /(~ ~ ~///~ System type ~P Length '~c~ ~ Width ,~,~,l ~ Gravelthickness /O'~ . Total depth /-//~ ~ / Total absorption area Depression over field (Y/~ r Results (a~/fail) ~Fc~' ~.F Cleanouts present ((~N) Date of adequacy test for ~' Peroxide treatment (past 12 months) (Y/I~ /~O .~J~cu~ If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /00 To building foundation On adjacent lots Surface water adjacent lots (0© '~' Property line To existing or abandoned system on lot _Cutbank /'-',~-t Water main/service line Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date Of this inspection. OF Signature 17034 Ea,le Ri.or Loop Eoaa Ne, 2~ ¢%~,:' ~ ~(~ Eagle River, Alaska 99577 ~~J~ ~ ~ ~ ng.nee s Name ~~ , ~. ~ ~ · Date · . ~ ~ ~ ~ ~ ,. ~~":';;,AFER ~ ~ Date of Payment 7~~ Date of Payment Receipt Number Z ~7.~/ ~~ Receipt Number Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES OF ON-SITE SEWER AND WATER FACILITY 264-4744 Location (address Or dJr,e~!ions) (b). ~ 'i M¢iJing Address .... ., -~,,¢~, ' (c) :.Lend)ng Institution. ?~,,'~]¢'~,¢~ Mailirig ,~ddress -~ x Telephone' Home ~ Telephone (d) (e) Real Estate Corn~n~;~nd // Address Agent, Te,ephone Mail the HAA to the followina address: or; Check here d for pick up. List contact person and day ,pho,n~/p,/~mber b~elo~. TYPE OF RESIDENCE Single-Family~ Number of Bedrooms' WATER SUPPLY Individual Well"~ Community [] Public [] Note: If comm unity well system, must have written confirmation from the State Department of Environmental 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. Page 1 of 2 72-025 fRev 8/86~ Front ENGINEERING FI~ PNOVIDING INSPECTIONS, TESTS, FILE SEA~CH, DATA AND INFOrmATION As ce~Jfied by my sea~ ~ffixed hereto and as of the validation da~e shown below, I verify that my investigation of ~hJs Health Authority Approval shows tha~ ~he on-BJte w~ter supply and/or was~ewa~er dJBposa~ system is sa~e, func~JonBI and ade~uam ~or ~he number o~ bedrooms and ~ype of structure indicated herein. I fu~her veri~y 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 Date Approved for 7-~ bedrooms b ~~~~ DHHS APPROVAL . Y ~ . _ Approved /"~ Disapproved Conditional Terms of Conditional Approval CAUTION 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. Page 2 of 2 : 72-025 (Rev 8/86) Back vt .......... MUNICIPALITY OF ANCHORAGE (MO~i Ur~UHALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DiViI~I~LTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 AUG 2 ]988 264-4720 WELL DATA RECEIVED Legal Description: ~7"- '7 ~'Z-~£~ ~ ~>'2-,4~/¢/~,4~J ~¢~-- -?~///,/' ~)~U $~_~ ~ Well Classification If A, B, C, D.E.C. Ap/proved (Y/N) Well Log Present(~(N). / Date Completed ~-/~-~¢'¢' Yield Total Depth -~¢~' Cased to ~'/ ~ Depth of Grouting /'//"~- Static Water Level ~ /~7 · Pump Set At 4/`4 Sanitary Seal on Casing~N) Depression Around Wellhead (YN~ Casing Height Above Ground Wiring in Conduit(~N) Electrical Separation Distances from Well: To Septic/Holding Tank oh Lot / To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by /¢~'~-/~ ,,~. Water Sample Test Results ~/~- ~' Comments ~ A-/~~z:- ~ ; On Adjoining Lots /¢,z~ ¢' ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ;Date SEPTIC/HOLDING TANK DATA Date Installed Standpipes~_~_2~N) Depression over Tank (Y(~ Size /~¢/-r.) No. of Compartments Air-tight Caps~N) Foundation Cleanout~N) Date Last Pumped 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 /(2 To Water Main/Service'Line Cours9 , /~ /~/,"~' ; for ,'~/~' Temporary Holding Tank Permit (Y/N) "~/'~ To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026~11/84) Soils Rating in Absorption Strata Date Installed Width of Field ,~'"/ Square Feet of Absorption Area ~¢~' Depression over Field (YO Results of Last Adequacy Test /'~'~¢t~/-~r-~¢' Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present{~N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots /¢ To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION _ Man (Y/N) On" Level at ~'"~~ "Pump Off" Level at High Water Alarm Level at -~,~~ Vent (Y/N) . Tested for ~% duriPumping Cycles ng Adequacy Test. Meets MOA Electrical Codes (Y/N) ~ Comments ** Check Permitted Bedroom Rating Against HAA Request ** ~.._ I certify that I ~//~h~l~e~vCrif. ied, or c~nformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~'~--'~ ~"~/'~"- Date ~/~r~ Company ,~'~'~-~ MOA No. E¢~'F Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) ' MUNICIPALITY OF ANCHORAGE : DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVA'L OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date /¢"¢'~-~ 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) ' "T /lz,t t%> J Location (address or directions) . /~12~,~.1%, ~lephone: Home (b) Applicant Name ~CO i'~ ' ~ *' ~' Applicant Address ~ ! -] ! ~ A tV DN, ~ k~ (c) Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other D (explain); (e) Real Estate Company and Agent ' -~-'~/~,~, Address Telephone (f) Mail the HAA to the following address:/ TYPE OF RESIDENCE Single-Family~ MultFFamily Number of Bedrooms Other WATER SUPPLY Individual Well~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL OnsiteJ~ 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. Page 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 /~ ~ ~---.Lc'~ I/~f~,, Telephone DHEP APPROVAL Approved for t~-/z~ bedrooms by - Approved ~ 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. Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITY OF ANCHORAOE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION f,,,'iAY 0 ? $988 264-4720 WELL DATA Casing Height Above Ground Electrical Wiring in Conduit (~/N) Separation Distances from Well: To Septic/Holding Tank on Lot Well Classification ,! ~J I'.~j i/.?'"~f~'/.4/-- If A, B, C, D.E.C. Approved (Y/N) Well Log Present 0/N) Date Completed c//j ~/¢ ~/ Yield Total Depth ~ c/.~' / I ' v, /id// _ Cased to ~- J / Depth of Grouting Static Water Level J~J OT O IV II, IELL LO ~ Pump Set At ~L~3,o~'' ~ ! Sanitary Seal on Casing ~/N) Depression Around Wellhead (Y~ I 00 / J/- ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot I CO ~7/-; On Adjoining Lots To Nearest Public Sewer Line JV/J~ To Nearest Public Sewer Cleanout/Manhole Jk/'/~! To Nearest Sewer Service Line on Water Sample Collected by -¢~ ~(rOfl (f-~H~/(~i"~ ; Date Water Sample Test Results ~.~/°['"/'l.~ F/'J/(_~'C0 I/~. Y / Comments B. SEPTIC/HOLDING TANK DATA Date Installed ~- ~ ,~'~ ~/'/Size i 0di~ No, of Compartments Standpipes ~N) Air-tight Caps (~N) Depression over Tank (Y(~) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) /V//~ Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line ~")--~) / To Water Main/Service Line Course / Foundation Cleanout ~)N) Date Last Pumped Temporary Holding Tank Permit (Y/N) /~///1~ To Building Foundation '~l['K.!~"/ J~'~' / To Disposal Field j~- / To Stream, Pond, Lake, or Major Drainage Comments PaBe 1 of 2 72-026(11/84) ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 2 ~ I~10'¥ Width of Field ~ / Square Feet of Absorption Area "7 ? ~;~ Depression over Field (Y~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot TO Water Main/Service Line L./.~-* .~- To Stream/Pond/Lake/or Major Drainage Course _ To Driveway, Parking Area, or Vehicle Storage Area _ Type of System Design Length of Field Depth of Field i¢' I0" Gravel Bed Thickness Standpipes Present (~N) Date of Last Adequacy Test N / To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~ O To Cutbank (if present) ~//~ io0/¢-- Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at _ High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/AcceSS~ "~f" Level at / Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I haV¢l qj-j.e~k, ed~¥er~fied, 9r conformed to all MO, A ar)d~AA guidelines in effect on the date of this inspection. Signed_ Q ~; ,~'~/~ Date_ -~/L,~/~ g / Company O~4pC-L-?~ [/¥'~- MOA NO. ~ - OZV Receipt No. ~ ~ ~D '~ Date of Payment ~-~ ~ O~ ~ ~ ~ ,,~ Engineer's Seal Amount: $ ~'~ ~ ~'..' /~ Page 2 of 2 ~.~-*,~E- 2251 72-026 (11;84) ~ 2~.¢.~-;:,~.." ALASKA ENVIRONMENTAL CONTROL SERVI!'-";, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 JOB L/ SHEET NO. CALCULATEDSY d T~-% CHECKED BY SCALE DATE DATE. cio \ 5c/' . [ ; i ............. :