HomeMy WebLinkAboutELDON BLK 3 LT 1
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lOt, block, subdivision, section, township, range)
Location (address or directions)
J :2. 3o~ bJu'l $~ ST,
(b) Property owner J~C)B ~INK
Mailing Address ~o"~ E. NORTSERN
(c) Lending Institution
Mailing Address
(d) Real Estate Company and Agent ~R U YNE
Address 3o"/ E, No, LT$.
Telephone 2 'TCJ ' /~"(;, /
(e)
Mail the HAA to the following address: (or check herein, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family 1~i' Number of bedrooms
3. WATER SUPPLY
Individual Well ~ Community [] Public []
~ Note: If community.well system, must have written confirmati0r~ from the State Depm'tment of Environmental
' Cbn~ervation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site [] 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,
72-025 (Rev. 7/85) Page 1 of 2
5. 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 ~/./~ TTO? "~'E'C N 5'[/6. $ Telephone ~' ~ ~'~
Address 11~530 E. EH~, S-F, ~C~. ~/<
6. DHHS APPROVAL
Approved for ¢
Approved X~
Seal
bedroomsby. ~a/~~.'~/ /~Date /-~--¢/
Disapproved Conditional
Terms of Conditional Approval
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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. 7/88) Back Page 2 of 2
· ~. :~:;'~vl~ICIPALITY OF ANCHORAGE (MOA)
DWISIor
,~,~.~ ^~.~ Health Authority Approval (HAA)
L~,~_M4~. CHECKLIST - FEBRUARY 1984
jA '4 0 3-4;44
Legal Description:
A. WELL DATA
Well Classification /'~'~ ~ ~ If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) /~ Date Qompleted ~ ~o"? Yield ~' ~'~.,5'~'/~/,~
__ . ~¢'0" AIp,~ 0,-;#,~,¢ r'~'°,~,* -, ~H~.~.F,'~.) ~J'
Total Depth ~# ' Cased to ~ Depth of Grouting ~/hi,
Static Water Level '~ 7 ~ Pump Set At ~ 'fO '
Casing Height Above Ground~ ~ o Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) ~ Depression Around Wellhead (Y/N) N
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot N,~. ; On Adjoining Lots N0~I.
To Nearest Edge of Absorption Field on Lot /V./}. , ; On Adjoining Lots N.
To Nearest Public Sewer Line ~0' ~.~l $ . o~,~f. ~f f'~e o~
~o Nearest Public Sewer Cleanout/Ma'nhole /03' '
To Nearest Sewer Service Line on Lot ~2' (
Water Sample Collected by FIc'f/'~F
Water Sample Test Results .,.~z~a',~.¢./-of/v -
Comments~
B. SEPTIC/HOLDING TANK DATA (H,
Date Installed Size
No. of Compartments
Standpipes (Y/N) Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Foundation Cleanout (Y/N)
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well To Building Foundation
To Property Line To Disposal Field ' '
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion 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 Vehicle Storage Area
Comments ~¢~', ~' 4'o,~//~/'~o,~ ~/~
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if present)
D. LIFT STATION (..1'~'/~",)
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed
Company
Date ~'~
MOA No.
Receipt NO. o,~o~ ~'~-.~
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee:
Engineer's Seal
Date of Payment
Page 2 of 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET · ANCHORAGE ALASKA 99518 · TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
ANALYSIS REPORT BY SAMPLE fox Work O~dez ~ 31022 Date Rapo~t Printed: DEC 31 90 @ 09:12
Client Sample ID:L1 B3 ELDON S/D
PWSID
Collected DEC 27 90
ReeeiYed DEC 27 90
PraserYad with :AS REQUIRED
WASHER HOSE
Client Name FLATTOP TECHNICAL SRV
Chen~ A¢ct: FLATTOT
P.O.~ NONE RECEIVED
Req ~
Ozdexed By TED MOO~E
Analyszs Completed :DEC 28 90 Send Reports ~o:
I)FLATTOP TECHNICAL SRV
Labozatoxy SUDe~Vzspr~:ST~FHE~ C ~D5
Relaaeed . 2)
Special
Instruct;
Chemlab Raf $: 905376 Lab Smpl ID: 1 Matrix: WATER
Allowable
Parameter Tested Result Units Method Limits
NITBATE-N ND(O.iO) mR/1 EPA 353,2
Sample 50UTINE SAMPLE.
Remake: SAMPLE COLLECTED BY CHMS.
1 Tents P~zlo~med ' See Speoial Instructions Abo~e UA-Unavailable
ND~ None Detected *' See Sample Remarks Above
NA- Net Analyzed LT-Less Than, GT-Greatez Than
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name /'/'~/~q //'Z,~f,,f~'~ Telephone: Home ~¥)" ~¥~ Business
Applicant Address 5~/~ ~ ~-~ ~ ~
Applicant is (check one): Lending Institutio~; Owner/builder ~; Buyer ~; Other~ (explain);
(b)
(c)
(d) Address 4/,~-- ~/ d, ~'.~ /
(e) Real Estate ComPany and Agent __ -,~?~//',//~
Address
Telephone
(f)
Mail the HAA to the following address:
A-,~,:.~, /FI~ ~ ? ~-¢
TYPE OF RESIDENCE
Si ngle- Fa mily'~/~'--~Mu Itl- Family
Number of Bedrooms
Other
WATER SUPPLY
Individual Well ~-.._..Com munity [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. 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
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 ,'~ ~- ~' .~ Telephone ~-~' I ¥'b ~ 0
Address / 'Z O~' ~'' .'~ ':5 ~ ~c~ ~ .~ 7~ ~
Date ~'-I E ~' ~
Approved for ~ bedrooms b e
Approved ~ Disapprov~-~'- ' ' Conditiona ~
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
264-4720
Legal Description:
NIUNICIPALIT~ OF ANCHORAG~
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
WELL DATA
Well Classification P~ IfA, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/~. Date Completed ~--'¢'¢~ Yield
Total Depth ~ ~ Cased to, ~ Depth of Grouting ~
Static Water Level ~,~ ~ ~ Pump Set At ~~
Casing Height Above Ground
Electrical Wiring in Conduit~N)
Separation Distances from Well:
To Septic/Holding Tank on Lot /t)~C-
To Nearest Edge of Absorption Field on Lot /L)//~.
To Nearest Public Sewer Line ~ !
Sanitary Seal on Casing~N)
Depression Around Wellhead (Y/~
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
Cieanout/Manhole /,~'7'7'/ To Nearest Sewer Service Line on Lot
Water Sample Collected by ~)/.~/ ~ ; Date
Water Sample Test Results ..~-/-~%~?~--Ac_~--~'z.c/ ~'~-4~r*~')
B. SEPTIC/HOLDING TANK DATA
Dat~ _ Size No. of Compartments
Standpipe~~ _ Air-tight Caps (Y/N) _ _ __ Foundation Cleanout (Y/N)
Depression over Tank (~,..,,~~--- Date Last Pumped __-
Pu~eContracto~N) ~----~;for----
Hold~igh-Water Alarm (Y/N) '""'-~.~.. Temporary Holdidg Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank: ~~
To Water-Supply Well To ~undation __ --
To Property Line __ _ To Disposa~~ --
To Water Main/Service Line - To Strea~ke, or Major
Course i -.,. Drainage
Comments ~~'~¢~ ~--~ ~:2~~ o ~ ~.
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils, Absorption Strata
Width 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 Vehicle Storage Area
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To .ine
; On Adjoining Lots
To Cutbank (if present)
or Abandoned System on
D. LIFT STATION
Date I n st a'~'lt~L.
Size in Gallons~'~
"Pump On" Level at ~
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
ing Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed '~'"~ '~'~ '--~' Date
Company ~fF(; ¢ t~ MOA No. ~'~- o~-~
Receipt No. "~ q ~o~'<~ ~
Date of Payment I~ -~ I ~-~5'-
Amount:
Page 2 of 2
72-026 (11/84)
ALASKA e UIRO[lme[ TAL CONTROL SeRb Ce$, I[1C.
HELEN MORGAN
SRA BOX 7-K
ANCHORAGE ALASKA
99507
SELLER-
HELEN MORGAN
SRA BOX 7-K
ANCHORAGE ALASKA
99507
JUNE 18 1985
50255
LEGAL:ELMORE SUBDIVISION LOT 1 BLOCK 3
FLOW TEST ON,~WELL
WELL FLOW DATE-9/6/84
A FLOW TEST WAS PERFORMED ON THE WELL. 1635 GALLONS OF WATER WAS
PUMPED AT A RATE OF 8.02 GPM OVER A DURATION OF 4.4 HOURS.
THE DRAWDOWN WAS 14 ' WITH A RECOVERY TIME OF 30 MINUTES
AND THE STATIC WATER LEVEL WAS 33 FEET.
THE WELL IS ADEQUATE FOR THIS 2 BEDROOM HOME.
1200 LUcsl 33r(J Aucnu¢, 5uitg Bo Anchoro% Alosk~ 99503°[907) 561-50/40
9213
~_~c~----J ®
5H 320
KEEP THIS SLiP
FOR REFERENCE