HomeMy WebLinkAboutALPINE WOODS BLK 4 LT 3
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 IPHON~ I J~NEW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
]Well I Absorption area , Dwelling PERMIT NO.
DISTANCE TO:
~ ~ Manufacturer Mat~dal No. of eom~m~nts
Liq. capacity in gallons Inside length Width Liquid depth
J,~EO IF HOMEMADE:
~ ~ Well Dwelling PERMIT NO.
~Z DISTANCE TO:
O ~ ~ Manufacturer Material Liquid capacity in gallons
~ Well Foundation , Nearest lot line PER~T~
~ DISTANCE TO: ~,~ I')
~ No. ofline, Length of each'line. Totalleng,h of line, Trench width . Distancebe~ne,
~ ~ ~ Top of tile to finish grade Material beneath tile ~ Total eff~tive-~absorpU~n~rea
Length Width Depth PERMIT NO.
~ W Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOIL TEST RATING
~ , .~1~ t~ ~.6.~
'~,APPROVED' DATE LEGAL
72-013 (Rev. 3/78)
C E:'H':'M::'T' F':..!7)HE:
L. E::,": ~::: L. D. :::::".:: CFt ]: F' ::
."[:: X 'Fd:::' E:, I:' r'~ C: :r-I F; ::
SOl LS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street. Anchorage, Alaska 99501 264~720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
SLOPE
SITE PLAN
lO
11
12
13
14
15
16
17
18
19
20
COMMENTS
ENCOUNTERED7 O
P
~ E
IF YES, AT WHAT
DE.T.? I'q5 ,
Gross Net Depth to Net
Reading Date Time Time Water Drop
~X..'"'7,",,...~. ~,.,,~
~ ~','~:
. .,:,--
TEST RUN BETWE.E~ I · FT AND
CERTIFIED BY:
PER~OR',"EO B": (~ ~nF(~
~'DATE~
72-008 (6/79)
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)
(b) Applicant Nam~ ' .Jo~,~ f'-/'~?x~,~- Telephone: Home Business
Applicant Address ~.xoY' Cie .... 1~¢~ I~ z_o. i
(c) Applicant is (check one): Lending Institutio~ r"i; Owner ; Buyer []; Other [] (explain);
(d) Lending Institution
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the fol~w/~g address:
TYPE OF RESIDENCE
i~' Multi-Family
Single-Family
Number of Bedrooms
Other
WATER SUPPLY
Individual Well [] Commun 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 welt system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 (11/84)
Page 1 of 2
ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DAi 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 ,dE4 £' Telephone
Address i ~0~ c.~ -~ ) ~c~--~ ~ //~ ~"~ ~
Date
Approved ~"'~' 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)
HI~ICIPALITY OF ANCHORAGE
DMSION OF ENVIRONMEI~kL HEALTH
DEPAR~iENT OF HEALTH AND ENVIROI~E~ PROTECTION
APPLIC~TION FOK ~ALTH AUTHORITY APPROVAL CERTIFICATE
1. ~eneral Information Application Date /~ 7
(a) Legal Description iinclude lot, block, subdi,vision, sect,ion, to~nship, range)
Location (address or directions)
(c)Applicant~is (check one) Lending Institution ~ ; OWner/builder ~ ;
Buyer ~--~ ; Ocher ~--~ (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Co. & Agent
Address
Telephone
(f) ~ the HAA to the following address:
2. Type of Residence
$ingle-Famtly~
Nmaber of Bedrooms
Multi-Family ~--~
¥
Other (describe)
Water supp!~'
'rndividual Well ~--~ Community ~ Public [----[
Note: If community well system, must have written confirmatiou from the State
Department of Emvironmental Conservation attesting to the legality and status.
4. Sewage Disposal
0nsite ./~]. Public .~ Community ~ Holding Tank ~--~
Note: If community well system, must have written confirmation from the State
~Department~ of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
5- En$ineerin$ Firm Provtdtn~ Inspections~ Tests~ Pile 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 amd/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, amd regula-
tions in effect on the date of this inspection.
Same of /W(L
Date / ' 7- g.9'"
DHEP Approval
Approved for ~ ,,
Approved
(ENGINEER SEAL)
Disapproved Conditional
Telephone ~/' Sd ~
CAUTION
TH~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF ~r~ALTH AND E~IRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON TH~ REPRESENT-
ATIONS GIVEN IN PAiLAGRAi~ 5 ABOVE BY AN INDEPENDENT PROFESSIO~NAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE ~HEP DOES THIS AS A COURTESY TO PTJRCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OP DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS LN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
KR.4/eJ/D18
[Page 2 of 2]
7-19-84
ae
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH A/3THORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Well Log Present (Y/N)
Total Depth /3/~ Cased to
Static Water Level /~
Casing Height Above Grcund
Electrical Wiring in Conduit (Y/N)
Separation Distances frcm Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ~/~
Cle ancu t/Ma nho le
Water Sample Collected By
Water Sample Test Results
C~{~ nts
Legal Description:
If A, B, cr C, D.E.C. Approved(Y/N)
Date Completed
Pump Set At
Depth of Grouting
Sanitary Seal on Casing (Y/N)&/~
Depression Around Wellhead (Y/N)~/~
To Nearest Public Sewer
To Nearest Sewer Service Line on LOt
; Date £)/~
; On Adjoining Lots
/-~ ; On Adjoining Lots
Be
SEPTIC/HOLDING TANK DATA
Date Installed /e ~-3/- Size /7~.~ ¢' ~Z. No. of Ccmpartments
Standpipes ~/N) Air-tight Caps ~N) Foundation Cieanout ~-~ )
Depres~sion over Tank (Y~ Date Last P ~umped
Pumping/Maintenance Contract on File (Y/N) /9//} ; for ~//~
Holding Tank High-Water Alarm (Y/N) /~[/;~ Temporary Holdin~ Tank Permit (Y/N) ~//~.
Separation Distances frcm Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course ~//~
To Building Foundaticn
To Disposal Field
To S~e~, Pond, Lake, c~r Major Drainage
Receipt ~
Date Paid: I
Amount:
[Page 1 of 2] 2-15-84
C, ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed / 0 -~/- ~t
Width of Field 3 /
Square Feet of Absorption Area
Depression over Field .(Y~
Results of Last Adequacy Test
/~'~ ~ Type of System Design ~-~J ~/
Length of Field ~. ~' /
~p~ of Field /d,~/
Gravel ~d ~i~ss ~,~ /
~.~ ~ Stan~ims ~e~nt~)
~te of ~st A~a~ ~st
Separation Distance from A~scrption Field:
/
Z~T -~ TO P~operty Line
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/c= Major Drainage Ccurse
To Driveway, Parking Area, c~ Vehicle Storage .area
f~ w To Existing or Abandoned System cn
/
; On Adjoining Lots
To Cutbank( if present) ~//~
LIFT SqlITION
Date I P.-~ talled
Size in Gallons
"Pump. On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Corm~nts
Dim~nsicns
Manhole/Access (Y/N)
Level
(Y/N)
during Adequa~ Test.
~eets MOA
** Check Permitted Bedrocm Rating .~]ainst HAA Request **
I certify that I have checked, %~rified, cr confc~m~d to all MOA HAA Guidelines in effect
on the date of th~s i~nspect~c~.
KB1/d5/s
MOA No.
[Page 2 of 2]
DEPT. OFENVIRONMENTAL CONSERVATION
437 "E" STREET, SUITE 3fl3
ANCHORAGE, ALASKA q9501
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-?533
To Whom it May Concern:
Accordin§ to records on file in this office the ~/~
Water System is in compliance'with the State Drinking
Ware. Regulations
Sincerely,