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Home My WebLink AboutCREEKSIDE PARK #3 LT 23L IOI MUNICIPALITY OF ANCHORAGE ,.,iVISION OF ENVIRO~R~NTAL ~.ALT~._, DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROIqiCTION APPLICATION FOR HEALTH AlYrHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applican~s Name ~/wr~ ~~ Telephone - Home Busines~ Applicants ~dress 7~ / O~ (c) Applicant is (check one) Le~inS InsCi=ucion ~ ; ~er/b~lder ~; Buyer ~ ; Ocher ~ (=plain); (e) Real Estate Co. & Agent Address TelephOne (f) Mail the HAA to the following address: 2. Type of Residence Single-Family~ Number of Bedrooms 3. Water Supp17 Individual Well~ Multi-Family Other (describe) Community ~ Public ~--~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewase Disposal Onsite ~--~ Public ~-~ Community ~ Holding Tank ~-~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting co the legality and status. [Page 1 of 2] gn~ineerin~ Firm Providin~ Inspections~ Tests~ File Search~ Data and Informa~ion As certified by my seal affixed hereto and as of the validation date shown below, verify that my investigation of. this Health Authority Approval shows that the om-site water supply and/or wsstewater disposal system is safe, functional and adequate for the number of bedrooms and t~pe of structure in~icated herein.- I further verify that, based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the om-site water supply and/or wastewater disposal system is in compliance with all Municipal and State co, es, ordinances, and regula- tions in effect on the date of this inspection. 6 D~P A rov~ · , P P Approved Disapproved CAUTION THE MUNICIPALITY OF ANCHORAG~ ~PARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOg EERORS OK OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK, (DHEP SEAL) RR4/eJ/Di8 [Page 2 of 2] 7-19-84 a,e -~MUNICIPALITY OF ANC~DRAGE (MOA~ HEALTH AD~DRZTY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITY OF ANCHORAOE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION NOV 0 Legal Description: oECEIVED L,, 7"_~.. ?.. d~~/~^- Well Classification _~-x/w/~(~{/W~ If A, B, c~ C, D.E.C. Approved(Y/N) Well Log Present (Y/N) //S ,~. ~_e ~leted ~ ]*d //;~_ Yield Static Wate~ Level ~ ~ ...... -' '~ Pu~p Set At Casing Height Above Ground Electrical Wi~ing in Conduit (Y/N) Separation Distances frcm Well: /~//~~ Sanitary Seal on Casing (Y/N)/~ IL~¢'~ ~'~z)Da~ession Around Wellhead (Y/N)//~ To Septic/Holding Tank on Lot ////~, ; On Adjoining Lots . To Nearest Edge of Absorption Field on Lot ~//~ ; On Adjoining Lots TO Nearest Public Se~r Line /~30~, / TO Nearest Public Se~r Cleanout/Manhole / fO ~ TO Nearest Se~r Service Line on Lot Wate~ Sample Collected By Z~./2,~¢~/~'/~/~,~./ ; Date /¢/~./F~ Water Sample Test Results O C~c, ~-~,%,//~o ~-- Date Installed Size No. of Ccmpartments Standpipes (Y/N) At=-tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (Y/N) Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High-Water Alarm (Y/N) Temporaz-y Holding Tank Permit (Y/N) Separation Distances f=cm Septic/Holding Tank: To Water-Supply Well To Building Foundation To Property Line To Disposal Field To Water Main/Service Line To Strew, Pond, Lake, or Major Drainage Course C~,,,ents Receipt Amount: 2-15-84 Soils Rating in Absorption StFata Date .Installed Width of Field Square Feet of Absorption A=ea Dep=ession over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes PTesent (Y/N) Date of Last Adequacy Test Separation Distance f-rcm A~sc~ption Field: To Water-Supply Well To P=operty Line To Building Foundation To ExistiD~3 cr Abandoned System cn Lot ; On Adjoining Lots To Water Main/Service Line To Cutbank(if p~esent) To St~eam/Pond/Lake/c~ Majo= D=ainage Ccurse To D=iveway, Parking Area, c~ Vehicle Storage A=ea Comments D. LIFT STATION ~//~ Date installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dimensions Ma~ole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Cc~nents ** ** Check Permitted Bedrocm Rating Against HAA Request I certify that I have checked, verified, c= conformed to all MOA HAA Guidelines in effect on the ~~ction.. Signed Date ////~9/ KB1/d5/s [Pa~e 2 of 2] 2-15-84 ~,c\ ¢~,'" CHEMICAL & G~.x~LOGICAL LABORATORI~-~tF ALAgKA, INC. ~ Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATE~SYSTEM: [I.1~ I I I] 'Water System Name , / /~ City / State Zip Code Mo. Day Year SAMPLE TYPE: n Routine [] Check Sample (for routine sample with lab ref. no. I-] Special Purpose El Treated Water ) ~;2'Untreated Water SAMPLE NO. LOCATION 3 I 4 I Time Collected 06-1220 (O) Rev. 1911 TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~ Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample, o.te .eco,..d -//' / ;2- ;;'¥ Time Received / Analytical Method: [] Fermentation Tube /~ Membrane Filter Lab Ref. No. Result* Analyst BACTERIOLOGICAL WATER ANA~ LYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAM PLE Date CMlecte~l Source Received Time Recelw~l D.m.i.au. mo. F)t'esumPt lye iOml 1Omi 1Omi 1Omi 1Omi 1.Omi O.$ml_ 24 Hours 41 Hours Confir rn~torv 24 HO4JrS 4B Ho4JrS - EMB Broth 24 houri: Brc~h Multiple TuI)i Report: Membrane Fater: Direct Count Verification: LTB Final Membrane Filter Results 10mi Tubes pMitlv~/Totll 10fltl MIMII Coilform/100ml BGB CollfolTn/'. 0~111 Date VISION GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 ~~' Date of Inspection INDIVIDUAL SEWER & WATER FACILITIES FOR Date Received <~/7/~'~'~' Time of Inspection /0 1. Approval requested by: ._y~__~~ ~/ ~. Mailing Address: ~/~ ~Y J--~-~ 2. Property Owner: ~~,~ ,~~1~~~ Mailing Address: 7~ ~~-/ ~- 3. Legal Description: ..... ~.~' ~ ' z~" ~ 4. Location:. ~/ 5. Type of facility to be inspected ~.y~ 6. Well Data: , A. Type ~ J~L 4 .~ ~ ~ ~ B. Depth Phone: Phone: No. of bedrooms C. Construction 7. Sewage Disposal System: A. Installed C. Septic Tank: ,,_ D. Bacterial Analysis 1. Size 2. Manufacturer D. Seepage Pit: 1. Absorption Area 2. Material E. Disposal Field: Total length of lines 8. Distances: A. Well to: Septic tank , Absorption area , Sewer Lines , Nearest lot line , Other contamination B. Foundation to septic tank , Absorption area C. Absorption area to nearest lot line EQ-034 (1/74) Page 1 of two pages ;~,-.:'~l~ge 2 of two pages - Req~ ' ~r Approval of Individual Water Facilities Legal Description Comments Approved ~ Disapproved Date Approval Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED ~ EQ-034 (1/74) Date