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HomeMy WebLinkAboutALDERWOOD BLK 1 LT 16 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 ,.'it- ~'~--<~'~----~ GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name~.~c~) Applicant Address Telephone: Home 'Z~ Business Z~'~ - j q ~-~ (c) Applicant is (check one): Lending Institution [] · Owner/builder~;~; Buyer [] · Other [] (explain); (d) Lending Institution " Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single-Family'~ Multi-Family [] Other Number of Bedrooms 3. WATER SUPPLY Individual Well [;~ 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. 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 I of 2 72-025 (11/84) ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DA, A 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 ~x-~'~--~/ ~:-'-.~/,,.'~e/';,.~',; Telephone ~-~ ~'~ ~ 5-$"~ Address Engineer's Seal Date CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the repr~esentations 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 §tate 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) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 WELL DATA ,MUNiCIPALI'Di' OF ANC~ORAG~ DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION NOV? RECEIVED Legal Description: /_ pT' /6 X~'~ Well Classification //~-~I ~".~--' If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) A~ Date Completed /~'~ - / ~ ZS-~' Yield Total Depth ~' '~' '- ~ Cased to ~' ~'~ / - ~' Depth of Grouting Static Water Level L~ ~' ~ Casing Height Above Ground Electrical Wiring in 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 Sample Collected by //~- ~ ~ ~ Water Sample Test Results -~'~, -~ ~'.~ ~ ~ Comments -~<~'~'- ~: -"~ ~-,-~---~, ,~--~' '"~/'~'~/' ~"~ Pump Set At ~'~' ~' Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) B. SEPTIC/HOLDING TANK DATA ~ ; On Adjoining Lots ~ ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot 'Date //~ D-a~ed Size No. of Compartments Standpipes~ Air-tight Caps (Y/N) ______ Foundation Cleanout (Y/N) Depression over Tant~.~ ..... Date Last Pumped ____ P~ace ContrarY/N) .... ; for ____ H~igh-Water Alarm (Y/N) ""--.~ Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank~'~..~ To Water-Supply Well __ To__Foundation ___ To Property Line ____ To DisposalS___ To W:t:urr:ain/Service Line To Stre~ke, or Major Drainage Co m ments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA S<~S,,.~ in Absorption Strata Square Feet of Abso~ 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 Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test · On Adjoining Lots _ To ~g or Ab~andoned System on To Cutbank (if present) Comments 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) es 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. .'~'_ ~z ~ ~ Date Signed/-,~~ /'¢~~ ~'//-- -~---- ~ ~' Co m pan y ,,~2~"~;?¢ Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) Engineer's Seal ;549-5552 (Office) AREA ENGINEERING 1207 E. 74th Ave. Suite 20:5 Anchorage, Alosko 99518 562-2161 Ext. 583 (Message) 11-5-86 Subject: Well Flow Test for Lot 16, Block 1, Alderwood Subdivision On 11-4-86, the undersigned conducted a well flow test for the subject property. The well was pumped at 8 gpm for 2 hours with a drawdown of 7.5 feet. Recovery was made in 1! minutes. The ~tatic water level was 38' with a total casing depth measured at 63'. The well is considered adequate for the 3-BR house on the property. Robert D. Schilling, P.E., L.S. DATE DRAWN BY ;205 AREA ENGINEERING 1207 EAST 74th. Ave. Seita t~OS Anchorage, Alaska g~$18 :549- 5552 SCALE SHEET /OF/ NORTHERN TESTING LABORATORIES, INC. 600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907-479-3115 6957 OLD SEWARD HIGHWAY, SUITE 101 ANCHORAGE, ALASKA 99518 907-349-8623 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY CLIENT [] PUBLIC WATER SYSTEM I.D. # I~]~IVATE WATER SYSTEM NAME ,~,~.~n g Address__ City SAMPLE DATE: // ~/' Mo. Day I~Routine ~ Special Purpose ~ Check Sample (for original contaminated sample with lab reference no. le ~me L~tion Coll~ 2 3 4 5 6 7 8 9 10 Signature of Representative State Zip Code __ ~'/~ Phone :~O~A'-~,' Year Purchase Order No. [] Treated Water [] Untreated Water ) Collected by ,/~b~bo~ato~ R~. No. CASH CHARGE PREPAIO TRANSMITTAL SPECIAL INSTRUCTIO MAIL HOLO FOR PICKUP t TO BE COMI~ETE9, BY LABORATORY Received at:/'~], Anch. [] Fbks. Date Received /.////~ Time Received Next Sample Due COMMENTS: SATISFACTORY ~ UNSATISFACTORY U RESAMPLE R OTHER BACTERIA ~ "~/ TOO NUMEROUS TNTC TO COUNT Direct Verification Final Count LSB BGB Result* Comments *N~' ~)f,,.T. qtal,J~oliform Colonies per 100 mis. Timet GREATER ANCHORAGE AREA BOROUGH Department of Environmental Qualtty 3500 Tudor Road, Anchorage, Alaska 99507 279-8686 Date Received 7/,i Time of Inspection~ ~ Date of Inspection RF. QUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR Address~ 7' C3- ~ ~ ~, ,~ Phone: 5. Type of Facility to~ Inspected: ,~ of A. Type B. C. Construction D. Sewage Disoosal System: ~~ Deoth A. Installed Installer C. Septic Tank: 1. Size 2. Manufacturer D. Seepage Pit: 1. Size 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 Foundation to Septic Tank Absorption Area Absorption Area to Nearest Lot Line · Request for Approval r Individua! Sewer & Wa%er Facil." .~s Page Two ' 9. Comments: Aoorov ed_~?~ Disapproved Approval V3lid for One Year From Date Signed Gv~ater Anchorage Area Borough, DeFartment of Environ~.ental Quality D ~.A'~ ~AM OF Date ~ ce:-t~fv thst the information contained in this request for approval to be a true and accurate represet~t~tion of the sub~ec~ sewer and water facf!tttes located 8%: Signed Date