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