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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