HomeMy WebLinkAboutEAGLEWOOD Block 13 Lot 42
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENV RONMENTAL HEALTH ~
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date Nov_~mber b, !987
1. GENERAL INFORMATION
(a) Legal Description (include lot. block, subdivision, section, township, range)
LOT 4A, BLOCK 13, EAPJ.~W00D SUBDMSION PHASE 4, SEC. 18, T14N, R1W
. _ Location (address or directions)
~,--~9B26 West KANAGE LOOP E.AG]',F, RIVER
NameVAL'L'F;5r ~7_.A~ Telephone: Home N/A Business 746-6504,
)licantAddress P.O.' BOX SRO PALMER, AK 99645
I is (check one): Lending Institution []; Owner/builder []; Buyer []; Other I'~ (explain); 'RECTOR
3ho
Institution NOR'i~-~LAN-D MOF~GAGE Telephone 694-1798
- P.O-" POX 530 pAUV[ER: AK 99645 ."'L
~d Agent ~P~,~CA~
the followin~ ~d'res~!.,
IESI[
MUlti,Famil
and status.
::
PubliC' ~
confirmatic
.: OnSite Community[] Holding Tanl~ [] ::A.W.W.u. c°~cT #067023850002 ~, : ,-
Note:If Community well system, must have written confirmation from the State Department of EnvirOnmental Conservation
attesting to the legality and status~
72-025 (1 ~/84)
Page 1 of 2
ENGINEERING FIRM PROVIDING .$PECTIONS, TESTS, FILE SEARCH, DA'I...4ND 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 EA(LE RIVER ENGINF~,RING SERVICES Telephone 694-5195
Address P.O. BOX 77q294 EAGLE RIVER. AK 99577
Date NOV]~VJBER 4: 1087
6. DHEpAPPROVAL ':-¢'/~, t~//-~./."/ //
?~A:~pr°ved'for ~_~' bedrooms by ~_~/%~/J~_~/'/~-- Date
r~Approved .... ~ ' Disapproved Conditional
;::Terms of Conditional Approval
; ·~-:,5 ,¢
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 respcnsible for errors or omismons in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
~uN~CIPALI'(¥ OF ANCHORAGE
ENvt~ON~ENTAL sERVICES DiViSION
NOV 0 19B?
A. W,L, DAT EC£1V£D
MUNICIPALITY OF'AN~;HORAGE (MO~-,/
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description:
If A, B, C, D.E.C. Approved (Y/N) / .-~'~-~
Date Completed Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
Well Classification
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring ~n Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sam pie Collected by
Water Sam pie Test Results
Comments
: On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) Air-tight Caps (Y/N)
Depression over Tank (Y/N)
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
To Water Main/Service Line
Course
Size No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
: for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026(11/84)
ABSORPTION FIELD DATA ~/,~
Soils Rating in Absorption Strata
Date Installed
Width of Field
Type of System Design
Length of Field
Depth of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicte Storage Area
Comments
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
LIFT STATION ~
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I~~_*/_ ~onformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~//--~ ~J~ Date
Company .~/~',~J" MOA No. ~'~.~'
Receipt No. c:~'~ 0 (~ /-- ~-~ O/~
Date of Pay m e nt _,~? / ~Z~'./,~ 7
Amount: $ ,// ~ (~)
Page 2 of 2
72-026 (11/84)
DEPT. OF ENVIRONMENTAL CONSERVATION /
/
ANCHORAGE/UESTERN DISTRICT OFFICE /
3601 "C" STREET, SUITE 133A
ANCHORAGE. ALASKA 99503
STEVE COWPER, GOVERNOR
563-6775
DATE: 11-03-87
PWSlD #: 210875
To Whom It May Concern:
According to the records on ¢ile in this o?¢ice, the NORFOLK
UTILITIES Water System is in compliance with the
State o? Alaska Drinking Water Regulations.
Sincerely.
,.Ronald S. Klein
Environmental Field O??icer
