HomeMy WebLinkAboutALPINE WOODS BLK 5 LT 10Alpin
Woods
Block 5
Lot
#015-234-40
t~- 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 [PHONE I ~NEW
~.,~"0 H I~[ ~c ,/*vt bt R PH ~ [~3-~166 ~ UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
DR
~-- DISTANCE TO: J Wel'~o~ l Absorptionarea.~... Dwel~ngp~o~ PERMIT NO.8¢07**
~ Z Manufacturer ~ ~ E~ Material~~ No. of co~rtments
Liq. capacity in gallons Inside length Wiath Liquid depth
jl~0 IF HOMEMADE:
~ DISTANCE TO: Well Dwelling PERMIT NO.
~ ~ ~ Manufacturer Material Liquid capacity in gallons
O Well Foundation Nearest lot ,in~ ,
~Z No. of lines Length ofe~,~n, Total length~e, Trench wi~ I Distance betwee~ lines
;Q ~ Top of tile to finish grade ~l Material beneath.lie 8 ' ~ Total effe~v~so~on area
Length Width Depth PERMIT NO.
( ~ Type of crib Crib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
D 3o3~
SOlE TEST RATING
at
INSTALLER
REMARKS
~S~tEn ~: ~o14~ GATE~ 0
I
~ cZ J CZ
4
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
I"IUN 1' E:: 1' P~A~L Z T'"¢ (IF
DEPARTMENT825OFL HEALTH AND ENVIRONMENTAL' F'ROTECTION
STREET, ANCHORAGE~ AK 99501
~64-47~0
PERM I T NO:
DATE ISSUED:
ON--.ti ITE SEWER
840,777'
09 f 12184
P[-~-RMI T
APPLICANT:
ADDRESS:
CONTACT PHONE~'
JOHN E MURPHY
126~1 SCHOONER DRIVE
ANCHORAGE, AK 995 15
243-2166
LEGAL DESCRIP:
LOT'SIZE:
MAX BEDROOMS:
SUBDIVISION: At, PINE WOODS
SECTION: 23 TOWNSHIP:
· Jo~.54 (SO. FT. OR ACRES)
3 ,
LOT: l0 BLOCK:
RANGE:.>W = '
Listed below are the options, available t~ you in designing your septic
system. Choose the option that best ~its your site.
DEPTH TO PIPE BOTTOM (FT.)
GRAVEL DEPTH (FT.)
TOTAL DEPTH (FT.)
GRAVEL WIDTH (FT.)
GRAVEL LENGTH (FT.)
GRAVEL VOLUME. (C'D. YDS.)
TANK SIZE
SOIL RATi~ (SQ.FT./BR)
TRENCH ii~ . I)F~:A
5.0 5.0
8.0 ~.0
15.0 '8.0
2.5 5.0 ~,0 ~.~
27.0 55, 0 ~.
2t. ,~ 34.4
1,000.0143 ** 1,000.0150 **/~
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
I certify that:
1. I am familiar with the requirements ¢or on-site sewers and wells as set
¢orth by the Municipality o¢ Anchorage (MOA) and the State o£ Alaska.
2. I will install the system in accordance with all MOA codes and regulations~
and in compliance with the de.s!,~n criteria o£ this Permit.
3. I will adhere to all MOA and State of Alaska requirements for ,the set back
distances er, om any,.existing well, waStewater disposal system or publ.ic
sewerage system.,gn EHis or any adjacent .or nearby lot.
4. I understand ,t~h.'a{. t-his permit is valid for a maximum o~ 3 bedrooms and
any enlargement will require an additional permit.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
ELECTRICAL WOR~~/B~DONE BY A LICENSED ELECTRICIAN. - " - , - .
SIGNED ~ - 'DATE:
I~UED BY ~ ~
' MUNICIPALITY OF ANCHORAGE -.
DEPARTMENT OF HEALTH AND'ENVIRONMENTAL PROTECTION []
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS kOG
PERCOLATION
*~TEST
PERFORMED FOR:
LEGAL
1
2
3
4
5
6
7
~8
10
SLOPE
srSs-02¢
SITE PLAN
WAS GRQUND WATER ~r'~
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
O
P
E
Gross Net Depth to .Net
Reading Date Time Tim -- Water Drop
~ .~ . ~:.!-~ - .:-~
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DV','ELLING
Parcel I.D. O 15-' ~.3 i,//_ L/0
1. GENERAL INFORMATION
Complete legal description LO
Location (si'~e add,.'ess er directions)
Expiration Date:
Current Property owner(s)
Mailing address
Day phone '"5 Lf ~_. 7 .~ ~_~
Lending agency
Day phone
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: ~
3. TYPE OF WATER SUPPLY: ·
Individual Well
Individual Water Storage
Community Class A, Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
[]
[]
[]
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for g0 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a pedod of up to one ye3r with valid water samples.)
Certificates are valid for one year for properties served by Class A er B wells or a public water system. The
Municipality cf Anchorage is not responsible for errors er omissicns Jn the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the vaJidation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system blare) safe, functional and adequate for the number of
bedrooms and tTpe of structure indicated herein. I further vedfy that based on the information chained from the
Municipality of Anchorage files and from my investigation and inspection, the eh-site w~ter supply and/or
wastewater disposal system is(are) in compli=nce with a!l applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm "~"'c, loJ~-~ ~
Address ,P~ ~
Engineer's Printed Name
5. DSD SIGNATURE
V'/' Approved for _ L.~._-
Disapproved.
Conditional approval for
bedrcoms, with the fcllowing stipulations:
Additional Comments
Attachments: HAA Checklist
Septic System Advisor~
Well Flow Adviso~
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date:_
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site W~ter & Wastewater Program
4700 South Bragaw St.
P.O. Box 196850 Anchorage, AK 99519-6650
www.cL anchorage, ak.us
(907) 343-79O4
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
WELL DATA
Well type ~'AiI
Date completed
Total depth ~
Parcel ID: 01S- ~3 ~1- qD
If A, B, or C provide PWSID # ~.~ 3,~ Well Log (Y/N)
Sanitary seat (Y/N) Wires property protected (Y/N)
Cased to., ff. Casing height (above ground) ....
FROM WELL LOG AT INSPECTION
in.
Date of test
Static water level ff.. It.
Well production
WATER SAMPLE RESULTS:
Collfon~ colonies/100 mi,
g.p.m, g.p.m.
Nitrate mg./I. Other bacteria __ colonies/lO0 mi.
Arsenic: ~ mg./I. Date of sample:
B. SEPTIC/HOLDING TANK DATA
Tank size I ~ gal. Number of Compartments
Foundation deanout (Y/N) ~/
Date of pumping ~l~J ~1 ~ 0 ~L
Depression over tank (Y/N) , /~
Pumper A
Collu~'ted
Date instelmed IO/(eI ~
Cleanouts (Y/N)
High water alarm (Y/N) /V'o
C. ABSORPTION FIELD DATA
Date installed 10/fei ~ Soil rating (g.p.d./fl~ or ~/bdrm),I q~ System type
Length ~ ft. Width I,{ I ff. Gravel below pipe
Total depth J~' ff. Eft. absorption area ,~fo ~ Monitoring tube
Date of adequacy test ~'c~'0 ~, Resulte (Pass/Fail)
Fluid depth in absorption field before test 6[ in. Wetsr added.~.~:t,~gal.
Elapsed Time: ~1.0 min. Final fluid depth ~ in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type) JV'o
-- Depression over field ~
For y bedrooms
New depth../~_~,, in,
b~ gp.d,
If yes. give date "/
D. LIFT STATION
Date installed
'Pump on' level at
Eo
S
in. ~Pump off' level at
/
Datum / Cycles tested
SEPARATION DISTANCES
in.
Manhol~/~ ~/N)
H~ter alarm level at
,M'eqts alarm & circuit requirements?
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
/
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer/septic service line,~/V/~ Holding tank /V'/
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 53. ~ ~ Property line
Water main ~ :~O Water service line
Wells on adjacent lots yA /%
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Propen'y line ~-~'
Water Sewice line
Curtain drain /V'A
F. COMMENTS
Building foundation
Surface water
Wells on adjacent lots
G. ENGINEER'S CERTIFICATION
Water main
Driveway, pafldng/vehic~e storage.
I cergfy that I have determined through fidld inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name
Date ~--I O -Q 'L
HAAFee $ ~7,~b~'~'-
Date of Pa ent
Receipt Number
(Rev. 12/01)
Waiver Fee $
Date of Payment
Receipt Number
Absorption field
Surface water
MUNICIPALITY_0F ANCHORAGE - _-.. :-.
DEPARTMENT OF HEAl.TH & HUMAN SERVICES-.
....... : Division of Environmental Services ....
.i?: ...... On-Site Services Section ·
P.O. BOx 196650 'AnChorage, Alaska 99519~6650
· ;,: 343-4744
Parcel I.D. # O,/~-'- ~g.3p L~ --~-~ O
1. GENERALINFORMATION .......... '-
Complet,e i;~ai ~leScription LeT' I {); ':'~ ~ .~'
CERTIFICATE OF HEALTH AUTHORITY -
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA# HAqb-Ol o
Location (site address or directions)
~i?;.~!",.-:.i~i~.~, ./~757 '../'-:~ ~ .~ ~ ' .~
Individual well '"'
Commun_ity well '
' ;-;.:Mailing'address ~/,-'.'~0 ',,~-/D;.~.~
.J-~; Lending agency Day phone
'~?~ ............. ' . ~ · 7; -
- .-... ?'" Mailina address-' ::~':'- :: .......
' '*;¢¢,~¢,~~0~ otheM!se ,requested;-H~ will"be-held fOr ptckup~,:;¢~¢;~}~
............... ,. ........... ":%"':* :.-:" '*'?¢:':",-" :?':?'.;:-':'?':',:";: ....... , ............ . / ........ : ....... :~: - -" .' '.¢: :=-:.¥':*' "%:.' - ?;:.-% ~ :-:"~¢::;~F:~' ~'~' . :' '."-"' -
. '-':d-*-¢~*--~'-.+.,::,-+,,~:'?..?,~'~q~-;w.- ,-.%:,. ....... ,-.~; ,...u.~.', ..... '.; ..........- .. - . . : ....... ~_ .:~
' 3.: 'PE OF WATER SUPPLY: '"" ''' ' '" "¢'~"
....
".--"'"u ,eua,.~ ~y~m. "' ' -':'7; .... : ..........
,.. ,. ,_-_~-'~':' ,.. ";;'?'Jlndi'vidUal'on.site - ... ~ ' . : ' . ~' ...:_~.:._.,_..:',...
"""'~ ................. -..,,::;, ' ............ site" .................................. ......................
..,?-':'.~.:~:' ~;,,::';:?:.,:t.:?~.~,. ~:¢:,. Pubhc sewer...'..,,.;~:, ,;: ,:-..': ¢:..? · .... -'" "*' ._.:-': .':: .-~,;::::U .-j.-,; ;: 4:. ~,.,.,, ,~. ... . ,. ':.,,, :,; ::::::::::::::::::::::: ....
...... ¢"-NOTE: :?' If communi~ ,wastewater system,.provide wri~en confirmation from State ADEC
a~esting ~o ~e i~li~ and sMtus of sy~m. ' ':
72-025 (Rev. 1/91) Front MOA~21
5. STATEMENT OF..INSPECTION BY ENGINEER
As ce~ifi~ ~ mY~seai affixed hereto and as of the val~dat;on
inv~tig=io~f"~S Health AuthoriW Approval aPplication Shows that the on-Site w=er suPply
and/or wastewater dispo~l system is ~fe, functional and adequate for the number of b~moms
and Wpe*of stm~umindicated heroin. I fu~her veri~ that based on the information obtain~ from
the MunicipaliW of Anchorage fil~ and from my investigation and inspection, the on-site water
supply and/or wa=ewater dispo~l system is in compliance ~ith all Municipal and State codes,
ordinance, and r~ulations in eff~t on the date of this inspection.
Date
............ ,~:.: . .... , ...... ..... .:,,:: · ..... ,. ,., ~ . ::, .-: . :~:-'::::~::::
:' .=:: : ::::?:' . ::'?::: ::::~: . . : . ~ . . : :,: .....
=;?,= .: : ~ :: : .. . : , : ,:-:: : .: · : -,:.::': :- r.:..:,:
' ;~ .. t, ....... Th~' Muni~Jp~J{~ :~' ~'::: ~::~:':: ~: ;":' ti:~::?:;:;~':'< ~::$~?:::::~?' :":' 'of An~ho~g~ D~p~e~t'" :"" ' ' of' H~]th' ' ~nd ~Human~ '::: ~': :':':"S~J~.'"' ~;~'":~ .......... (~H HS) '"J~u~' ::'<'~= ~
· :..-:. · ApplbCal m~ifi~t~: b~ 0nly uPon the'repm~nmtions given ]n:~am'~h`:5-ab0ve:bg':~ninde~'~hdent
. :: -. :., :pr~i0nal sn~in:~r' r~iste~ i~'the State of. Alask~ The DHHS d~ thiS.~ a ~u~:~0 p~r~h~ ~f ~0~
: ' .'. andtheir lending in~itutiOns in offier to ~ti~ oe~in f~eml and ~te ~uimmen~. Employ~.0f
, ~(:C~ndfi~:in:~ioh,-or~an~l~ ~dm ~om a ~ifi~t~ i~ Muhi~i~li~ 0I Ano~6m~, i~ not '
m~n~ibl~ rorermm or"Omi~ion~ in th~ prol~ional ,n~in~ wo~.' ~ - ~- (~:: :. ':'-.}-'5' :': ~'"
/2~2~(ReV. 1/91) ~ MOA~I
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type ~k
Parcel I.D.
Log present (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Cased to Casing height
Total depth
Sanitary seal (Y/N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Wires properly protected (Y/N)
AT INSPECTION
g.p.m.
; On adjacent lots
; On adjacent lots
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
Cleanouts (Y/N)
High water alarm (Y/N)
Tank size /~-
Foundation cleanout (Y/N)
Date of pumping
Compartments
Depression (Y/N)
Alarm tested (Y/N) ~/~-
Pumper A +
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ' ' / ~'",
To property line
Surface water/drainage
On adjacent lots
Absorption field
I ,.I o,
Foundation ~
Water main/service line
72-026 (3/93)* 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
Meets MOA electrical codes (Y/N)
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
ABSORPTION FIELD DATA
Date installed I~//.~/~f
Length ~ ~,.~ I Width
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/FF) J L3/-~ System type ~"~
Gravel thickness {:~ I Total depth
Cleanout present (Y/N) Z Depression over field (Y/N)
Results (pass/fail) ,-~ for ~ Bedr({oms
/Y If yes, give date /'"//'~ /
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~N///
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots ~'/>,G, Property line --~
-- To existing or abandoned system on lot
Cutbank ~ ~ v'/-~__ Water main/service line
Driveway, parking/vehicle storage area '~ /'7/ ~.~
E=
HAA Fee $ ~'//'~ · ~
Date of Payment
Receipt Number
ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in e~~e ~~js inspection.
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or direction~)
(b) Prope~y.O'wner~' -- -- Telephone: Home ----~'
(C) Cen;'n~ Inst,tution~~~' ~' {~'~' lelep~o0e
(d) Real Estate Company and Agent / ~/~
Business
Address
(e)
Telephone .~
Mail the HAA to the followinc~ address: or; Check here [~, if hold for pick up.
TYPE OF RESIDENCE
Single-Family'[
Number of Bedrooms
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.
SEWAGE DISPOSAL
Onsite'l~, 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 ~Rev 8/861 Front
leUO!SSajoJd eq~ u! SUO!SS]LUO JO SJOJJe JOJ alq!suodsaJ lou s! e§sJoqou¥ ~o 41!led!o!un~ CHi 'panss! s! elso!J!peo s eJo~eq
elep eZXleUe Jo suo!joadsu! jonpuoo jou op SHHQ jo seeXoldUJ~ 'sjueuJeJ!nbeJ alsls pue leJapaJ u!e~eo ~Js!lss oj
u! suo!inl!lsu! 6u!puel J!aql puc satuoq ~o sJaseqoJnd oj ~se~noo e ss s!ql seop SHHQ aq~ 'e~SelV ~o eleiS eqj u!
Jaau!6ua leUO!SSajoJd 1uepuadapu! ue iq a^oqe 9 qde,~e~ed u! ua^!6 suo!leiuasaJdaJ aq~ uodn XlUO paseq
leAoJddv Xlpoqjnv qJlSaH sanss! (SHHQ) sao!^JaS ueLunH pue q~leaH jo juaLu~edea a6eJoqou¥ jo ~l!led!o!un~
NoI/nVo
IS^oJdd¥ ISUOp,!puoo jo swJai
leUO!J!puoo peAoJdd~s!a
pe^oJdd¥
JOl pe^oJddv
'l¥^O~ldd~ SHHa
'9
'uo!loedsu! s!ql jo alep
uo loej;a u! suo!1eln§eJ pus 'seoueu~pJo 'sepOo elelS pus led~o!un~ lie ~I!M eoUe~ld~oo u! s~ ~elSXS lesodsip JeleMelS~M
Jo/pus Xlddns JeI~M e1~S-UO eql 'uolloedsu! pus uolls6tlsaAu! ~ ~oJ~ pus sel!l e6eJoqouv ~o X~Hsd!olun~ eq1 moji
peu~elqo uo~lewJolu~ eql uo peseq Jsql ~IpeA Jequn~ I 'u~eJeq peleo~pu~ eJnlonJ1s JO ed~l pus swooJpeq 1o Jeqwnu eql JOj
ei~nbep~ pu~ I~UO~ouni 'e~s s~ wels~s I~sods~p Jel~MelS~M Jo/pu~ ~lddns Jel~M el~S-uo eqll~ql SMOHS leAoJddv ~lpoqlnv
qileeH mql lo uo~l~6~lseAu~ ~ 1~ql ~jpeA I '~oleq u~oqs el~p uoflePileA eql to se pus oleJeq pex~jje IEeS ~ ~q pmj~eo sV
NOI~V~MO~NI ONV V~VO 'HOMV~S ~ql~ 'S~S~ 'SNOI~O~dSNI DNIQIAOMd ~MI~ ~NIM~NI~N~
.g
.~lassification
I Lot.
Static Water
Casing Hei
in Condui
Separation Distances from Well:
-To Septic/Holding Tank' on ,Lot
To Nearest Edge of Ab$oi:~ _
To Nearest Public Sewer line' ' " To Nearest Publ '
Cleanout/Manh01e ....
'Water Sample COllected by . . - ; Date
I~{~ B, C, D.E
d
Cased to Depth of Grouting .
Pump S~At_ '
_ (Y/N)
Date Installed /O'-;~-'~ Size /Z.~"o No. of Compartments ~ .
' standpipesCN) · Air-tight Caps~'N) . F°undation'CteanoUt ~)..
Depress on over Tank (Y(~) . .· . _ Date LastPumped ~.--~t.~,'~f~
Pumping/Maintenance COntract-on File (Y/N) /~///4; ; for , ¢ .
Holding Tank H,gh-Water Alarm (Y/N) ,4)?~'" Temporary Ho ding Tank_Permit (Y/N)
Separat on Distances from Septic/HOlding Tank: . -
To Water-Supply Well I~ ~ To Building Foundation ' . -~ ' ~ -
To Property Line /O/'/~ To Disposal Field ' ~' ~'' / .
To water Main/Service Line /O.!"~ To Stream, Pond, Lake, or Major Drainage
Comments .......
72-026(t 1/84)~ ~=
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot ~//,~'
To Water Main/Service Line
Type of System Design ~~/
Length of Field
Depth of Field
Gravel Bed Thickness o~ t
Standpipes Present~)'N)
Date of Last Adequacy Test
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line
/0 ~ To Existing or Abandoned System on
; On Adjoining Lots
/0/'f' To Cutbank (if present) //'/,4-
Comments
D. LIFT STATION
/
"'~~led ~/ Dimensions
Size in G~~'~-~//'~ Manhole/Access (Y/N)
'PumpOn"Levelat ~"PumpOff Levelat '
High Water Alarm Level at ~,~..~Y/N)
Tested for __ . Pumpin(~ es during Adequacy Test. Meets MOA
Electrical Codes (Y/N) '
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I h~,~he~ed~;v~?ed, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~--~-~_~'~//"~"-"-~ Date ~"' ~'~'
Company ~'~
Receipt NO. "~"~
Date of Payment
Amount: $ /
Page 2 of 2
72-026 (11/84)
MOA No.
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 1334 /
ANCHORAGE, ALASKA 99503
STEVE COWPER, GOVERNOR
563-6775
DATE: July 6, 1988
PWSID: 213598
To Whom It May Concern:
According to the records on ?ile in this o??ice, the ALPINE WO00S
SU8DIVISION Water System is in compliance with the State o?
Alaska Orinking Water Regulations.
RSK:pkk
Sincerely,
Ronald S. Klein
Environmental Field O??icer
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
GENERAL INFORMATION
(a) Le(.
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application
Date
lot, blo~
Loc
Applicant "~¢/¢/") ~'
Applicant Address ~/-~--~-~
Applicant is (check one): Lending Institution [] · Owner/builder ~; Buyer [] · Other []
~ubdivision/,~ection/town~hip? r~ange),..,...~
'/~ele )hone:
(explain);
(c) ;-
(d) Lending Institution (/~// A .f--Z/?~.¢.~-/'~~, ,, Telephoae _ .,.~r'"~,, ¢57_ 6./~
Address _~ (~ 4/ '~ ~-~-~~ ~~ - ~? ?~ ¢ ¢-~-/'~"~
(e) Real Estate Company and Agent
Address
(f)
Telephone
Mail the HAA to tJ3e~ollowing add~'e~s:
TYPE OF RESIDENCE
Single-Family,~[;~- Multi-Fam, ily
Number of Bedrooms'
Other
WATER SUPPLY
Individual Well [] Community,S' Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsitc~' 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 (11,841
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe. functional and
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 /~/:-C ,~ . f ~c~ Telephone :~'~; / 5'-D Y O
Address / 2~(~ '/J .~ ~ ~'' ~ ,/~ ,'~cA A.J~ ¢ ~ %'-~ i
Date ~- /0 ~'~' ~
APPRO,~L
Approved for bedrooms by
Approved ~ Disapp~__~ nal
Terms of Conditional Approval ,~'
Date
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
Casing Height Abo~ Ground .A ,al on CaSing (,~/N)
Ete~ical wi=lng in conduit (.Y/N} ~R ..... De$~essiOn ASound Wellhead
To Septic/Hoidir~ Tank cn Lot ~oo/. ; On
[Pa~ 1 of 2] ' 4
2-15-8,
ABSORPTION FIELD DATA
Soils Bating in Absorption St=ata
Date Installed
Width of Field
Square Feet of Absorption A~ea ~' 9 6 ~7
Dep=ession ore= Field (Y~
Gravel Bed Thickness
Standpipes P~esent
Date ~ ~st ~a~ ~st
~ati~ Dist~ ~ ~pti~ Field~
To Wate=-Supply Wall . 2o o '~ To PT rty Line ~ f
To Building Foundation ~)-' To 'Existing c~ Abandoned System cn
Lot /~ A ; On Adjoining Lots 3o ~ ~
To Water Main/Service Line /o '~ TO ~utbank(if p~e. sent) ~.-~
To Stream/Pond/Lake/c~ Majo= D~ainage Course /~o' ~
To D=iveway, Pa=king A=ea, c~ Vehicle Stc~age A=ea 5-~/ ~ ~,.-~ . .
Cc~ents
D. LIFT STATION
· ~- Date Installed
~ Si~e in Gallons
"Pump On" level at
High Water Alarm Ievel at
Tested for ,,
Elect=icai Codes (Y/N.),.
cc~msnts
Dimsnsions
, , Manhole/Access
Vent (Y/N) ~/w ....
Pumping Cycles du=ing Adequacy Test. Meets M~A
Check. Permitted Bed~ocm Rating Against HAA Bequest
I ~tify that I .have. cbscked, verified, c~ confcz~ed to all MOA HAA Gui~,s in effect
on the date of this ~nsDection. _
~ I -_~.A~, ,." A -"..I~.. '~-
· 'Signed' ~...~ ~,~---~.'-. ...... Date ~/° m?r~ ' z"~'"'"'""'~"~"~
I
[Pa~ 2 of 2] "
2-15-84
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
BILL .~IEFFIELD,, GOVERNOR
Telephone: (907)
Address:
274-2533
To Whom it May Concern:
According to records on file in this office the ~ ~
~ Water System is in compliance with the S~:e Drinking
Water Regulations
Sincerely,