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Home My WebLink AboutCOLONIAL PARK BLK 1 LT 10Onsite File Colonial Park Block 1 Lot 10 #050-302-20 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP221377 Work Type: SepticTank Renewal Tax Code Number: 05030220000 Site Legal Address: COLONIAL PARK BLK 1 LT 10 G:0055 Site Mailing Address: 19600 CITATION RD, Eagle River Owner: KOVARIK BRUCE E & BARBARA P Design Engineer: C & M Engineering This permit is for the construction of: Effective Date: Expiration Date ll�cnt n � f Department Lot Size in Sq Ft Total Bedrooms: 9/29/2022 9/29/2023 35640 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Issued By: 4,/' Date: Date: q A 6( ZZ 3 MMHMPALry OF ANCHORAGE Development Services Department - Phone: 907-343-7904 On -Site Water & Wastewater Section - Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 050302200 Property owner(s) KOVARIK Mailing address Site address 19600 CITATION Day phone Legal description (Sub'd., Block & Lot) COLONIAL PARK BLOCK 1 LOT 10 Legal description (Township, Range & Section) Lot Size 35,640 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) El (w/wo ADU) Septic Tank 0 Upgrade ❑ Duplex (D) El Holding Tank ❑ RenewalX Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: NA Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 1`45 - Date- Date of Payment: 0161-2,2, 04 Receipt Number: 04OR $ r3 Permit No. 6 S f 22, -;),-1-1 Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: Proposed Septic System for Colonial Park Block 1 Lot 10 Dear Reviewer, The owner would like to renew their permit OSP 211254 for the above referenced property. We are not making any revisions to the permitted design prepared by Pannone Engineering Services. We did visit the site and it appears there have not been any changes which would impact the tank replacement. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE 9/19/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221377, Deb Wockenfuss, 09/29/22 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP211254 Work Type: SepticTank Upgrade Tax Code Number: 05030220000 Site Legal Address: COLONIAL PARK BLK 1 LT 10 6:0055 Site Mailing Address: 19600 CITATION RD, Eagle River Owner: KOVARIK BRUCE E & BARBARA P Design Engineer: PANNONE ENGINEERING SERVICES This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Effective Date Expiration Date Lot Size in Sq Ft Total Bedrooms: �mcnr S' .:-TV Department 7/7/2021 7/7/2022 35640 ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: ' ex�-UAQ Issued By: �► Ci%� Date: Date: 0� 3 MUNIUPALITY OF ANCHORAGE Community Development Department Phone 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 050-302-20 Property owner(s) Bruce & Barbara Kovarik Day phone Mailing address 19600 Citation Rd Eagle River, AK 99577 Site address same Legal description (Sub'd., Block & Lot) Colonial Park B1 L10 Legal description (Township, Range & Section) Lot Size 35,640 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) X❑ Septic Tank X❑ Upgrade E (w/wo AD U) Holding Tank ❑ Renewal ❑ Duplex (D) ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: -9 2-25 Waiver Fees: Date of Payment: 7//h 1 Date of Payment: Receipt Number: 02Z 05 (r Receipt Number: Permit No. Waiver No. Permit App_:- : :-'..,:c Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211254, Rebecca Carroll, 07/07/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211254, Rebecca Carroll, 07/07/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211254, Rebecca Carroll, 07/07/21 i v MUNICIPALITY OF ANCHORAGE ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME 1P:ONE LEGAL DESCRIPT ~ - LOCATION NO. OF BEDR~MS ~ ~ Man ufacture~; ~, ' MSge~ / No. of comments 'on ~ ~ Well Dwelling~/J~ PERMITNO. ~ ~Z DISTANCE TO: O ~ ~ Manufacturer Material Liquid capacity in gallons Well Foun2~ I Neares~ linE~ PER~d 3 DISTANCE TO: ~ ~ ~ ,eng2 ~i~s Trench width 1, Distance be~ ~ Top of tile to finish ~r e t Material beneath tho Total effec~s io~a ' ~W 7~ ~inches~ gt Length idth Depth PERMIT ~ ~ Type of crib Crib diameter C~dep__g~ou~ Total effective absorption area ~ Well ~uildin on Nearest lot line ~ DISTANCE TO: ~ CJass - Depth Driller Distance to lot line PERMIT NO. ~ ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOILTESTRATINGiNsTALLER. / ~T/ff ~ *'a~ ~' REMARKS A PPR,OVED . ~.~'--"~ DATE LEGAL~/~ 72-013 (Rev. 3/78) 3 D' E; !:::' -F H 'l"E) F' ]: IZ'E B(_')'I'T'E)M (F'T.) [3 F;: A VE] .... ~-~ i::' c:,'~ i...~ / I:::"T' 'T'Eq'rrH.... !:)E':;F"T'H -':.' F:"!" . ) G F;: A V E; L.. W ! D T l"'J ( F:"!". (3F;:A'v'EL. L~:. ,t!.':lr'~(r" ,. ~"-'~- . GF:;'.AVE:I ....VOL. UME (CU. YDS,, ) T A Iq!< S :r. z E (G A L!'3 .'.', '.'-:-q'~ ~;',":','~"~i'.~r.'.'-' (Sa F:'T' ' MIjI~ICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: /O/' 1 2 3 4 5 6 7 8 9 Z_lO SLOPE I DATE PERFORMED= SITE PLAN COM M E NTS ~.:, ,-~LE RIVER, A~S~ ~C577 PERFORMED BY: 72-0O8 (6/79) WAS GROUND WATER /~'/.~ SL ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop RATE RUN BETWEEN FT AND FT (minutes/inch) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES. Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage,' Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Day phone Day phone Mailing address Agent Day phone Address 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well Community well ~ Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-0?..5(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 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 Address Engine,s signature ~/[~ ~ SIGNATURE Approved for ~ Disapproved. Conditional approval for bedrooms. DHHS bedrooms, with the following stipulations: Additional Comments By: 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, I/91) Back MOAi¢21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /--/,o .~=~ x ~._~.c~/~- ..~'~,~ Parcel I.D. A. Well Data Well type Log present (Y/N) Total depth ~,~,,,~'J.~', ~ If A, B, or C, attach ADEC letter. ADEC water system number '~- i I ~- ~0 ~- Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 Date completed Driller Cased to Casing height ,,.// Wires properly protected (Y/N) ~ FROM WELL LOG AT INSPECTION ~ o .g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line ~ WATER SAMP~ULTS: Date of sample: ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Nitrate Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) )/ High water alarm (Y/N) Date of pumping ,../~, Tank size ~ o~ Compartments ~ Foundation cleanout (Y/N) ,3/ Depression (Y/N) ,~/ Alarm tested (Y/N) ~/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /¥/,~' To property line Surface water/drainage On adjacent lots Absorption field Foundation ~" Water main/service line 72-026 (3/93)*Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Manufacturer Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump High water alarm level .~-~Y~/ Meets MOA electrical codes (Y/N) SEPARATION DIST~I~~~~ LIFT STATION TO: Well~n lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed 'P'/'///~5- Soil rating (GPD/FF) '~'~'~ Systemtype --/'-'.~_.~x.~.~M Length ~ 7' / WMth -~ "/ Gravel thickness ~J~' "/ Total depth / ~-~' ''/ Date of adequacy test --'//-,'-<~,~" ~ ~_~Results (pass/fail) _ ~~ _Je~_ -~ Bed.roon]s Water level in absorption field before~st ,.~',~.. ?',5"' ' ...~st Peroxide treatment (past 12 months) (~fN). ~-,~ ~,,~',~',,~-~'~ ~ .---'ff yes, g'lve.~te SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /~//'~ On adjacent I~1~. ~,, ~--~4=- Property line To building foundation / .E / To existing or abandoned system on lot On adjacent lots Surface watei: ~,x~ -,'--,~-~.~ Cutbank ,',,-~, Water main/service line Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I cer~fy ~hat I have checked, vedfied, or conformed to all MOA and HAA guidelines inj~i~.t o~.,~,e. ~. t~ this inspec~on. _,.,?~.. . . . . .~,~.-.'_,..,,e Signature Engineer's Name ~::~.~,-~z_.-~,~./.-/~J. HAA Fee $ ~bO Date of Payment '"7~/2- Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ~--~)" ~, -,"~ haa # GENERAL INFORMATION Complete legal description Lot I01 Block I~ Colonial Park Subdivision; Location (site address or directions) 19600 Citation Property owner Mailing address Lending agency Mailing address Agent Address Virqinia (Jam~s) Lusk 19600 Citation Drive Eagle NorW~st Mortgage Day phone 696-2242 River: Ak. 99577 Day ,phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: $ ~ TYPE OF WATER SUPPLY: Individual well Community well Public water xx NOTE: 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 ')JJOM s~eeu!Bue leUO!SS~,toJd eqi u! SUO!SS!LUO JO sJoJJe Jot elq!suodseJ lou s! e§eJoqouv to /q!led!o!unl~t eq± 'penss! s! e~,eo!,t!~J~O ~ eJo~eq elep eZXl~Ue Jo suo!3oedsu! i3npuoo ~,ou op SHHQ to sea,Old LU~] 's),ueuaeJ!nbeJ m,e),s pue leJepe~ u!~Je3/g,s!les ol Jap Jo u! suop, nip, su! §u!puel J!eql pue seuJoq ,to sJeseqoJ nd m, ~sepnoo e se s!ql seop SHHO eq.L 'miSelV,to elelS eq3 u! peJe~,s!§eJ Jeeu!§ue leUO!SSeloJd ],uepuedepu! ue Xq e^oqe g qdeJ§eJ~d u! ua^!§ suo!l~lueseJdeJ eql uodn /quo peseq sm,~o!~!lJeO i~^oJdd¥ /q!Joq~,nv q~leeH senss! (SHHO) seo!/ueS ueuJnH pu~ qlleeH to lueuJpedeo e§eJoqou¥ ~o ~l!l~d!o!unl~l eq.L / /_ s),uewwoo leUO!)!PPV :suop,8lnd!is §U!MOIIOJ alii q:J!M 'SLUOOJpaq 'suJooJpeq le^oJdde leuop,!puoo 'peAoJddes!a JOJ. peAoJddv ~ :II=IrlJ.~NIDI$ SHHa eJnieu6!s s,Jaau!Bu3 Z.~g66 eNselV '.m~,!)l t,0~ 'ON peoa dool ~e^!a ~16e3 I,~'OZ [ aUOqd ................. uJJ!..-I lo au JaN sseJppv '9 I::I:::i:::INION:I AG NOIJ. O:IdSNI dO .LN=I~=ilYIS Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L.,o'F ~,~' '~ ~ A. WELL DATA Well type ~ If A, B, or C, attach ADEC letter. Parcel I.D. ADEC water system number Log present (Y/N) Date completed Driller Total depth Cased to Casing height Sanitary seal (Y/N) Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot g.p.m. AT INSPECTION ; On adjacent lots ; On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~"' [ '~" Tank size Cleanouts(~t~N) High water alarm (Y/N) Date of pumping "% '" Compartments ~ Foundation cleanout~N) '~ Depression (Y~ Alarm tested (Y/N) \ · '-'~ Pumper "'~-'~--~ ~'~~l~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface water/drainage On adjacent lots Absorption field ( ~o Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) "Pump on" level at Manhole/Access (Y/N) "Pump off" level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed '~'-I "' ~' Length '~-"'~ Width Total absorption area Z~Y'~P~ Depression over field(~)'N) Results ~/fail) Peroxide treatment (past 12 months) (Y/N~ Soil rating \,d~ ~/~.._ Gravel thickness System type~ Total depth \'~ I..~ Cleanouts presen~P/N) for SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~ To building foundation On adjacent lots ~ Surface water / t~C>l Curtain drain Date of adequacy test If yes, give date On adjacent lots ~ ~'~ Property line To existing or abandoned system on lot Cutbank ~ ~>~t~_. Water main/service line Driveway, parking/vehicle storage area bedrooms t I,~c>t ~ 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 inspection. Signature 17034 Eagle River L~ R~d No. 2~ Ea le River, Alaska 995~ GngineeF's Name HAA Fee $ / 7~ Waiver Fee: Date of Payment--2-----5--~ ~ Date of Payment Receipt Number ~ ~ ~ 7~ ~ ~ Receipt Number 72-026 (Rev. 3/91) Back MOA 21 ~. 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 c:~ '7 L~2.0._~ {,O1, ~.~' GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) (b) (c) Location (address or directions) Applicant Name ~_'_~..~', --'~'l::Ne~r'~-c' Telephone: Home ~q' ~ff~ Business ~ Applicant is (check one): Lending Institution ~ · Owner/builder ~; Buyer D; Other ~ (explain); Lending Institution ~T')~_ SC~. ~.3~t"x¢'~, Telephone Real Estate Company and Agent Address Telephone (f) ~the HAA to the following address: SRB 196x Ea;!3 ~iver, Alasl(a 99~77 TYPE OF RESIDENCE Single-Family I~. Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Individual Well [] Community [] Public I~ 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 I~. Public [] Community [] Holding Tank [] Note: If community welt system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (11184) Page I of 2 5. ENGINEERING FIRM PROVIDIN~..,4SPECTIONS, TESTS, FILE SEARCH, DA,-..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 · ~ & S Engineer|ng Address Date Telephone DHEP APPROVA_~_~_L, (~') Approved for [t~z~ 'bedrooms by Approved ,..,,f~ Disapprove~d/ Conditional 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 72-025 (11/84) MUNICIPALITY OF ANCHORAGE (MOAT _RA(~ALTH AUTHORITY APPROVAL (HAA) ~uHtCtPAIJTY_. ,~ALTH & CHECKLIST- FEBRUARY 1984 I~EPT..~,r. ~'~';~ OTECTtOH 264-4720 Et,tvlRO~l~et't'[AL _R WELL DATA Well Classification A Well Log Present (Y/N) Total Depth Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/J:~4dmg Tank on Lot '~:~5> / -~¢- · On Adjoining Lots To Nearest Edge of Absorption Field on Lot ~ · On Adjoining Lots To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments ~'~'~, LegalDescrjption: 1 If A, B, C, D.E.C. Approved~N) Date Completed Yield Cased to .Del~h of Grouting t~ / Pump Set At / ~oanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) To Nearest Public Sewer To Nearest Sewer Service Line on Lot · Date B, SEPTIC/kI~8~I~G TANK DATA Date Installed Standpipes (~TN) Depression over Tank (Y/~ Pumping/Maintenance Contract on File (Y/N~j Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/I,4~c~tmg Tank: To Water-Supply Well To Property Line To Water Main/Service Lir~e Course Air-tight Caps (~)/N) '~ '"' ~ - ~:~ Size ~ ~:::~::::' No. of Compartments Foundation Cleanout~N) Date Last Pumped · for '-----'- Temporary Holding Tank Permit (Y/N) ~ C>WJ,-- To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 72-026111/84)