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Home My WebLink AboutDORA #2 LT 8 PERMIT NO. DEPFIR'T'ME:NT .. H[:'FILTH FIN[:, ENVIROIqMEN]"FIL. 5:0TEC'T' ]Z ON ',_=:25 '"L'" STREET., FtNCHORRGE., RK. 9950::L b,.l E-.T L L_ F" E ~." ~"1 [ T < 81:Z049 > F:IPF'L I CRNT LOCRT I ON LEGRL. T. S'f'EI4FIRT CON$'rRUC:TION L. 8 DORR 2 8420 HIL. LIHR C:IRCLE L. OT S:[ZE 20[300 SQURRE FEE'T MINIMUM DI$"r'RNCE BETHEEN R HELL RND RN'T' or,t-SITE SEP.IRGE DISPOSRL. S¥S'FEM ::L00 FEET FOR R PRIVRTE HELL OR i58 TO 208 FEET FROM R F'IJBLIC HELL DEPENDING UPON THE TYPE OF PUBLIC: HELL. MININUM [:,ISTRNCE FROM R PR!VRTE HELL TO R PRI'v'RTE SEI.4ER LINE IS 25 FEE"F RN[:, TO R COMMUNIT"¢ SEHER LINE IS 75 FEET. HELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DE;F'RRTPtENT OF THE HELL COMPLETZON. OTHER REQUZREP1ENTS MR"r' RPPL¥. SPECIFZCRTZONS RND CONSTRUCTION DZRGRRNS RRE FI'v'RZLRBLE TO ZNSI..IRE PROPER ZNSTR[_LRT~ON. I C:ERT I F'T' "['HFI'T' ±: I Rtl FRMIL. IRR NITH THE REQUIREMENTS FOR ON-SITE SEHERS RND HELLS FI"_""'; SET FORTH B? THE MUNICIPRLIT¥ OF RNC~R'.RGE. 2: ! I.,.IZLL.. ~NST'RkL THE S¥S;TEM I~R¢:CORDRNCE H!TH THE CODES. S :[ GNED: "-'RF'F'L.~C~NT T. STEHRRT OCINSTRUI2:T I ON Y4, O .... . ~-;: 'HEALTH MA,:N SERVICES. ~.:, '":'~. ,.,-;:?~. ...... . I,*,JII~',I;i;::'~EPARTMENT oF &HU '. '" ~'~"~ ~; .... :""-~'~;~'-,': On~ite ~e~ic~ Se~iO~:;~. ~;~ :- - .~.-, ...... ; Division of EnvirOnmentalSe~iC~ ..... ."~' '.'~ ,?:--: ':' , ~:: .... P.( Box 1~850 -: Anchorage, Al~ka~'9951~650 .... ' ~-~:,~-.., ~ . .- ~.~:. - ~ ;~ ~;;~.~ ~ - .~:~ ~.;?~, .~ .... ...... agency : IMBER OF BEDROOMS: . .~'~!i,;' .... J~ ',:: ~:~ lf c°mm~i~:~ell syst~ d~, Wri~en c~nfi~a~on from Sta~ ADEC a~eSt ~ ~:, lng to the legah~ and status of system. .... ...:. ..... , ...... .,~,~ .~ .,, . ~.~,)]~ NOTE. I~ communl~astewater ~y~tem, p~g~ wn~en confimation from State 5.~ STATEMENT OF INSPECTION BY ENGINEER · '~ AS certified by my seal affixe~d hereto and aS ~o~ th~ ~va'iidation'~te shoWn below, i verify that my investigation of this Health Authority,Appi;oval 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, lfurther verify that based o.n the information obtained from the Municipality of Anchoragefiles and from mY* inves.ti_,qationand inspection, the On-site water supply and/or wastewater disp~l syst~m'.is in'cOmpliance ~it~i~ all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Address ,,--, .......... COnditional :.'' ,% ', ' ?;~?;i'," : " ...... '"':'?" ' ~.~. :" ~''''...;~.~';;~ .... ' ,~ The ~" "O~'~irtmenCOf Health and Human Services (DHHS) issues Health Authority .~; I~ased only upon "the representations given in paragraph 5 above by a~'indePendent istered in theState of Alaska. The DHHS does this as a courtesy to purch~i;s'of homes order to ~tis~¢ertain federal'and state requirements. Employes Of DHH$ do not : con~t~t"ifi~l~cti°ns or analyze data before a certificate is issued. The Municipality of A~h0r~geis not · - .. - . ~ ·. . ...,. ~. ,~ ~ ~;-', . . .;.. ~:.- responsible for e~rors or omissions in the professional engineer's work. "' ', '- -"-~"-' ,,~..- Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /~<~. A. Well Data Wel~ type Log present(:~N) Total depth ~'"~ ~/~ Parcel I.D. Sanitary seal {~/N) If A, B, or ¢, attach ADEC letter. ADEC water system number ~.g Date completed ~/~//~/ Driller P~::::~'~ Cased to / ! / Casing height I Wires properly protected ~) FROI~ WFTLL LOG Date of test /-'7//,~'/ Static water level /7/~ Well flow Pump level1 (J{/9 AT INSPECTION g.p.m. ~,,C~ g.p.m. ~ .;7'~ SEPARATION DISTANCES FROM WELL TO: SepticJholdingtank on lot 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 ~ Date of sample: ~ _ Nitrate Collected by: Other bacteria ',PTIC/HOLDING Date Cleanouts (Y/N) High water alarm (Y/N) Date of pumping DATA~__ ~/~ F~~_ Tank size Foundation cleanout (Y/N) Compartments De¸ Alarm SEPARATION DISTANCES FROM SEPTI( Well(s) on lot To property lin, Su~ adjacent lots Absorption field Water m 72-026 (3/93)* Front CONTINUED ON BACK Date installed '""--~----... Size in gallons ~ Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) ~ SEPA~E FROM LIFT STATION TO: · W~l'0n lot On adjacent lots Manufacturer Manhole/Access (W~) "Pump on" level at ~~mp~ off" Level at ~Cycles te~ed ~-~_ Surface water Bedrooms N FIELD DATA ~/~ ~-~O~J p~//~/~-~ Soil rating (GPD/Ft~) .Sy~em ty~ Leah , ~ Wi~h Gravel thinness Total Total ab~tion area ~ Cleanout present (Y/N) Oepres~r field (Y/N) Date of adequaw te~ ~ Resume (pas~fail) ~ _ ~ Water level in ab~tion field before test~ ~er test ~__ Peroxide treatment (pa~ 12 months) (Y/N) . ~ / If yes, g~e date .~ Well on lot ~adjace~ lots ~ Prope~ line To or abandon~~o~ To bui~ing foundation / existing Water mai~sewic~~ On adjace~ lots . / Cutbank Suda~ D~veway, ~in~ehicle storage area n 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 inspect/on. Signature Engineer's Name Date HM Fee $ ~ Date of Payment Receipt Number '1,~...h', ' ,~l'i~l ..?i" Waiver Fee $ Date of Payment Receipt Number 72-026 (3/g3)* Back 17:04 COMMERCIAL TESTING ~ 90?6941211 NO.?l? Q02 CT&E Environmental Services Inc. Laboratory Division ........... ,5.0577-1 Laboratory Analysis Report L$ DOi~, ~/D Client Name 8 & 8 ENGINEERZNG WORK Order 12584 Ordered By KAY S. Printed Dat~ 02/13/9~ ~ i7:47 hrs. Pro~ect# Received Date 02/10/9S ~ 10:00 h~. PWSID UA Sample Remarks: ROUTINE S~PbE COLLECTED BY: J.W. Tech~1l~al Director STEPH~.N C. EDE QT Allowable Ext. Anal Parameter Results Qual Units Method Limit~ Date Da~e I~it Nitrato-N 0.10 U m~/L EPA 353.2 10_ 02/10/9~ CMR see $~ecial Instructions Above UA - U~available 8es 8ample Remarks Above NA - Not Analyzed Undetected, Reported value is the practical quaz~i~ication limit. LT = Le~m Than Seconder}, dilution. GT ~ Gmeater Yhan 200 W. Potter Drive, Aflohorage, AK 99518-1605 -- Tel: (907) 562-2343 Fax: (907) 561.5~0~ ENVIRONMENTAL FACILITIES IN ALASKA. CALIFORNIA, FLORIDA, ILLINOIS. MARYLAND, MICHIGAN. MISSOURI, NEW JERSEY. OHIO. WEST VIRGINIA MUNICIPALITY OF ANCHORAGE ~i~ 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~-~.51-~).-5 HAA# 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Day phone Mailing address Lending agency Mailing address Day phone Agent /~ c_ Address ~C>I /:3~-r-c.--~,c- ~l~,o~. ,z~,)~__. /~c.~. /~--- Unless otberwise requested, HAA will be beld ~or pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well NOTE: Community well Public water Day phone 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 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 inves_ti_gation 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 Phone ~,, Date DHHS SIGNATURE Approved for ~,~c~/~) Disapproved. Conditional approval for bed roe ms. 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. 72-025(Rev. 1/91) Back MOA#21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. Well Data Well type "~r', u,~,-+ ~ Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~ j ~-I j ~, ! Driller 1~, Cased to ~'+' Casing height "7/ Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG AT INSPECTION SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line J C)~)''k' g.p.m. J. 5/'-f/ ; On adjacent lots ; On adjacent lots /,v,~, Public sewer manhole/cleanout H(~ -I- Petroleum tank WATER SAMPLE RESULTS: Coliform (~ Nitrate Other bacteria d'~ 1 Date of sample: ~7- ~ c~- cj~ Collected by: /~.~ r~ ~,~.~ Date installe'b'-.... Tank size Co Cleanouts (Y/N) ~ Foundation cleanout (Y/N) /...--~Depression (Y/N) High water alarm (Y/N) ~~A~'rl~sted (Y/N) Date of pumping '"'""--~""~ Pumper SEPARATION DISTANCES FR~NG~ Well(s) on lot / On adjacent lots Foi3~la.tion To pro~ Absorption field Water main/se~ice-'"~'~ S~ water/drainage ~ 72-026 (3/93)' Front CONTINUED ON BACK PAGE C~ LIFT STATION Manufacturer Size in gallons "~ Manhole/Access (Y/N) Vent (Y/N) vel at el at High water alarm level -"'----..~~sted Meets MOA electrical codes (Y/N) ~ ~ SEPARATION DI~N TO: . Surface water Well on~.~l~lot ~ On adjacent ots D. ABSORPTION FIELD DATA led Width Total absorptio are'"~--.~a. Date of adequacy test ~ Soil rating (GPD/FF) System type Gravel thickness Total depth Cleanout present (Y/N) Results (pass/fail) Depression ~N'~''~ .~,~'~ Bedrooms Aft~'~t , .I.~f yes, give date Water level in absorption field before test '"-,,,. Peroxide treatment (past 12 months) (Y/N) '"""-... SEPARATION DISTANCE FROM ABSORPTIO Well on lot On adj~,efit lots '"---.~Property line ~- - To building foundation ~ To existing or abandoned sys~ On adjacent lots _..../,J Cutbank Water main/service line~"""~_.......,.....~ Sudac~ Driveway, parking/vehicle storage area C.tj~taTn drain E, ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect qn..tl~j~¢~f this inspection. Signature ~:~:::~{ EngineeFs Name HAA Fee $ / 7 Date of Payment ~ ~- g//-- ~'-~,~ Receipt Number ~-~ Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back LOCATION: ARCTIC SLOPE CONSULTING GROUP, INC. Subdivision: Lot: Block: Client's Name: DATE: Initial Reading on Meter: } ~:~ ~ DRAW TIME GPM GALLONS GALLONS FIELD MONITOR METER DOWN VOLUME TOTAL LEVEL READING '-t5 q: ~ .qq . ~.o ,4go t5-7 55 5:,'00 Production Rate: l' 5~ GPM 24-HourCapacity -%/al7 Gallons DOWN VOL,Leal " TOTA~ I..;eV~.. I~,,~OINO _J AUG 03'93 ' D ANCHORAGE RECORDING DISTRICT ~P~,~ mw DOWLING a ,.14~6 HYDER STRE£T " , ~ANOHORAGE, AEASKA' 9 95'01 It Is the ~espons4b~l~t.y of the owner to dete~mt 'the existence of any easements, covenanta,'or ~ dtvtsto~ ~lat.~U~de, no ct,c~sta'nces should a~V , '~OTE , ' data h'eeeon be used fo, construction or for estab- lishing boundary or fence l tnes~ The surveyor ta~e~ J zas~NTS O~etco~o. orH~ TH4~.~O~I r~po~S1~_~.lt.ty ~or th~_ tntttal transaction only.' s~ow~ ~zo~.. INK I 6 /ZI5 . Lot Bl~ck Subdivision or Addi ti on Property Owner Address Water Sewer ~ CiZe i~o. rnlit ~..~ t]r> 22 21 11 Indicate North 0 Z NORTHERN TESTING LABORATORIES, INC. 3330 INDUSTRIAL AVENUE 2505 FAIRBANKS STREET FAIRBANKS, ALASKA 99701 ANCHORAGE, ALASKA 99503 (907) 456-3116 · FAX 456-3125 (907) 277-8378 · FAX 274-9645 Arctic Slope Consulting Group 301 Danner Avenue, Suite 200 Anchorage AK 99518 Attn: Kevin Liebner Our Lab #: A125050 Location/Project: 2~9-00i/Dora Subdivision~ Your Sample ID: ~Lot 8 Sample Matrix: Water Comments: Lab Number Method Parameter Units Report Date= 08/05/93 Date Arrived: 07/30/93 Date Sampled: 07/30/93 Time Sampled: 1030 Collected By: KL * Definitions * B = Below Regulatory Min. H = Above Regulatory Max. E = Estimated Value M = Matrix Interference D = Lost to Dilution MDL = Method Detection Limit Date Date Result * MDL Prepared Analyzed A125050 EPA 353.3 Nitrate-N mg/1 <MDL 0.1 08/04/93 Reported By: Susan C. Tifental Microbiology Supervisor .... DATE RECEIVED INSPECTION APPOINTMENTS TheE 'TiME ' TIME DATE DATE ~ ~W {~) DATE ' MUNICIPALITY OF ANCHORAGE ~UNIOIPALITY OF ANOHOHAGE DE:[ OF HEA~ [ & DEPAHT~NT OF HEALTH ~ ~NVI HON~ENTAL PHOT~MDNTAL P. u~ [ECTION ~ ~ ENVIRONMENTAL SANITATION DIVISION ~ Telephone 264~720 , I DIRECTIONS: Complete all parts on page 1. Incomplete reque=~ will not be preceded. Please allow ten (10) days for processing. 1. ~ROPEHTY~WNER ' ' ' PHONE ' PROPERTY RESIDENT (If different from above~ PHONE '2 BUYER ' ' ~ "' . PHONE MAILING ADDRESS 4J R~ALTOR/AGENT -- _ ' ' ' I PHONE' ' MAILING ADDRESS E. LEG~,L DES~'RIPTION .......... 6. TYPE OF RESIDENCE ' ' NUMBER OF~BE~'ROOMS ' ' ' ' [] One [] Four [] Other S INGLE FAMILY [] MULTIPLE FAMILY WAT ,. UPPL¥ ' INDIVIDUAL* '[] COMMUNITY [] PUBLIC UTILITY S,' SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** . g .P, UBLICUTILITY , [] Two [] Five [] Three [] Six * ATTACI~ 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 Iog. ifavaila~ble.) ~ ,~ O~ .YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev, 6/79) 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY I [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or [] Holding Tank Size: , If Tank is homemade give dimensions: TYPE OF TANK TOTAL ABSORPTION AREA 4, DISTANCES WELL TO: Absorption Area to nearest Lot Line THIS SIDE FOR OFFICIAL USE ONLY NUMBER OF BEDROOMS ~ [] ONE [] THREE [] FIVE [] OTHER [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOl LS RATING MANUFACTURER MATERIAL Septic/Holding Tank IAbsorption Area ISewlr Line INearest Lot Line 5. COMMENTS DATE ~'~PPROVED FOR '-'L.-- BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev. 6/79)