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Home My WebLink AboutALYESKA BASIN #4 BLK 11 LT 6 G E !:) R (3 E T, I"IU R P H ¥ I"', Im *") ,'", "" '.. .......... , ::~,..~,.. ,:~. I"'t1=(..~ j HE:.I'~ ii I RCLE (.'::NCHOF;~AL"'~I~:~ :, AK 995CK-}~ "'" ::" I :dl.E:DIVIS ON: AL. YESKA BASIN SEC'T' I ON: 16 TOWNSH I F",: I()N :: :,:!.;~(:}1 ( i]Q ,, F:]" ,, OF;-.' AC;I:;,'EL"} ) L. OT: 6 R A NG E: ~2,[ii: BLOCI<: :1.1 t.i"'y that: ]: am -}'am:Ll:i. ar w:i.'l:..h the r'equ:i.r'emer":'l:..s for' c]n...-.si~.J.'[..,[}~.:: sewers and wells as se'L t:'or, tl"i l::~'._,,.,' the Mur'::i.c:i. pal:i, ty ot~' Ar"icl"lor. ac.;:~ (MOA) ar'id tl"'le" ....... .', }' ,, I w:i. ll :i.r":stal]. the system :i.r": accor'dance w:i.'Lh all MOA codes ,ar'id regulat:i.c)r':s, and in compl:i, ance wit:.h the desigr': cr:i. teria ~.':~:' th:i.s permit,, I. u.,::i, ll adl"':ere 'Lo all MOA ar":d State o¢ Alaska requirements for' tl'":e set ba,::::l.:: :::' i star":ces -; r'c,m an,;/ e::.:: :i. st :i. ng wel '.Il, wast ewater d :i. sposa.'l, system or'. I:::,ut::) 1 :i. c Cal'-,ll"['j {;}l!:~:(l;)[::;.',(~.}l!ii: .Il.. ML. F;~PI"IY "' N~)IID~IO~d ~lVi~gV~NO~iA~ i' ALASKA ENVIRONMENTAL CONTROL SERVIC INC. 1200 west 33rd Avenue, Suite B ANCHORAGE. ALASKA 99503 (907) 561-5040 SHEET NO. OF CALCULATED BY d Tg DATE CHECKED BY DATE l~ou$~ ............... 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) BII ,qL¢ SK/ 4 Location (addresS' o~,directions) ~. 2~[~C~· o~~l~T ~ ~ OR. 0~ oF. ~~~ ~ (b)' 'Applicant Name '~'~E ~~Y Telephone: Home ~,~"~/ Business ~/- (c) Applicant is (check one): '~ending Institution ~ · Owner/builder ~; Buyer ~ · Other ~ (explain); (d) Lending Institution Address (e) Real Estate Company and Agent (f) / Telephone./// Telephone j Mail the HAA to the following°ad--dress: TYPE OF RESIDENCE Single-Family I-,"~' Multi-Family [] Number of Bedrooms .~ Other 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 1 of 2 72-025(11/84) o ~ Iv ~ ~ /'z&7'~;~/~/'-/ / , 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 alt Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm /~-~ ~--_~ //~':~ TelePhone Address ..... Date DHEP APPROV:~, .~2 ~~/~ ~ ~ Approved for ~=/..ZZT..F..J(-~edrooms by//~ '""~! Date Approved ~ Disapprove~ Conditiona 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) ENVIRONMENTAL PI~TECTICII~ALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 NOV 3 ~ 264-4720 RECEIVED Legal Description: ~11 ~-~ T ioN' , ec, 17' WELL DATA Well Classification P~ ! ~/~"r'~-- Well Log Present (~N) Total Depth /~)~- / Cased to , /"/~// Static Water Level '7~ / Casing Height Above Ground Electrical Wiring in Conduit {~/N) Separation Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D.E.C. Approved (Y/N) /V'/A Date Completed / O/Z~/~I~ Yield ,2~//~ <~,~/-,/~E,~ /-/~, ~'~, Depth of Grouting /%//~ Pump Set At t 70 ' Sanitary Seal on Casing ~N) Depression Around Wellhead (Y/{~ /~?~ · On Adjoining Lots N~//~' ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ¢¥//'r To Nearest Public Sewer Line '~'/'iL ! ' Cleanout/Manhole Water Sample Collected by Water Sample Test Results To Nearest Public Sewer / O0 / ~ To Nearest Sewer Service Line on Lot <5, ~ ~l~[]~.~. 'Date ! Comments B. SEPTIC/HOLDING TANK DATA Date Installed Size No. of Compartments Standpipes (Y/N) Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Tem Separation Distances from Septic/Holdin To Water-Supply Well To Property Line To Water Main/Service Line Course '' ~ comments .... · ~ Foundation Clea~ (Y/N) Date Last Pum ; for Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026(11/84) C, ABSORPTION FIELD DATA Soils Rating in Absorption Strata Type of System Design Date Installed Length of Field Width of Field Depth of Field , Gravel Bed Thickness Square Feet of Absorption Area Standpipes Presen. J~N) Depression over Field (Y/N) __ ~ Date of Last Ad~l~acy~Test Results of Last Adequacy Test ~ / /// Separati°n Distance fr°m Abs°rpti°n ti[e~/'d//''~ To Water-Supply Well J To Property Line __ To Building Foundation J To Existing Or Abandoned System on Lot J ; On Adjoining Lots ___ _ To Water Main/Service Line J To Cutbank (if present) To Stream/Pond/Lake/~,ajlSr Drainage Course _ To Driveway, Pa.,~,~l~Area, or Vehicle Storage Area C°m/~''~ LIFT STATION Date Installed i Dimensions Size in Gallons _ Manhole/Ac~r4~')- "Pump On" Level at . , / "Pumj;~Level at _ High Water Alarm Level at ~1~/4 ~ Vent(Y/N)___-~- Tested for /~.~'" Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) C°mment~~~~'~ ** Check Permitted Bedroom Rating Against HAA Request ** I certify that.[ ha~/W c/l~/ck~e~d,~erifi~l, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ( )z~/J//~/.~ Date /~~ /~/ - _ -/ ./ company ~-~ /~, MOA No. ~- ~ ~ Receipt No. ~O/ -- ~~ Amoun,: Page 2 of 2 72-026 (11/84) TO BE COMPLETED BY MATER SUPPLIER TIME COLLECTED___ i TYPE OF SYSTEM CIRCLE CLASS I A B C, NAHE,.QF SYSTEM .... TELEPHONE NUMBER l',i,I ''-- (~,~ ' , , , SYSTEM ADDRESS DATE COLLECTED I.D. #0. (PUBLIC 'SYSTEMS) ~_ i j I t I.. ~YPE OF SAMPLE CITY STATE ZiP CODE ' L~)CATIO" WHERE SAMPLE WAS COLLECTEd .... "COLLECTED BY: (SIGNATUR~'~ /]/~(~-~-~,.,, C.../,~f / (CHECK ONLY ONE THIS COLUHN) DRINKING MATER ~/CHECK TREATMENT ri RAW SOURCE WATER I'l NEW CONSTRUCTION OR REPAIRS Iml OTHER(Specify) I-ICHLORINATED i~]FILI~ERED ~NTREATED OR OTHER IS THIS SAMPLE A CHECK SAMPLE TO A PREVIOUS ,ON-COflFOIUqINJ SAMPLE? O YES I~NO PREVIOUS COLLECTION DATE ANALYSIS ,[OJESTED (IF OTHER THAN TOTAL COLIFORH) "~E~D REPOR~TO:(P~I~T FU~L NAME.ADDRESS AND ZIP CODE '' NAME ~(~*~ //'~/"~--~ · FOR LAB USE ONLY i RESUBMIT SAMPLE Sample rejected because: CHECK ONE OR HORE [] Sample too long in transit. Sample should not be over 30 hours. i-1 Sample received too late in ~ek []Not in proper container []Leaked out r-I Insufficient tnfor~ation provided. Please read instructions on form. Other (Specify) RECEIVED - REC. EIVEO ~:jt~,~Z'" DATE A. ACYTXCAL D: ~NE FILTER ~FERME~TATION TUBE Date & Time Started CITY Date & Time Completed LABORATORY RESULTS Aealrst ~,._?//]_.~/_.~-~,~.,~ . [] Other Bacteria [3 Test unsuitable because: ~ Confluent Growth ~ TNTC SATISFACTORY URSATISFACTORY D BACTERIOLOGICAL MATER ANALYSIS RECORD FOR LAB USE ONLY ~TAL COLIFO~ D F ECAL COLIFORI~ D OTHER Membrane Filter: Direct Count Verification: LTB Final Membrane Filter Results Reported By BGB Date Coliform/lOOml .Coliform/lOOml Time A.M. READ SANPLE COLLECTION INSTRUCTIONS ON BACK OF FORN STA 12.04,3 N