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HomeMy WebLinkAboutATELIER #1 BLK 2 LT 6A  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 MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS I We,./ O I Ab p on area Dwelling PERM,TNO. ~ DISTANCE TO: /.~--- / ~ ~ Manufactur~~ Material~ ~ No. of ~ partments Liq. capacity in gallons Inside length Width Liquid dep~ /~ ~ IF HOMEMADE: ~ ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. ~ -- ~ Manufacturer Material Liquid capacity in gallons Q Well Foundation Nea~t line PERMIT NO. ~ ~ DISTANCE TO: //~ ~ ~~ N°' °f lines / Length ~ °f each ~ line To~al ~g~ of lines ~ Trench ~ width inches Distance betwee~ lines ~ ~ ~ Top of tile to finish grade .... Material beneath tile Total effect~e absorption area O 4~ /~' ~ ~ inches Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: :Class ~ Dept~ Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: B~ ildi n~n~ Sewer ~/~line~ Septic//~tank Absorption/~area(s) OTHER ~ . PIPE MATERIALS SOIL TEST RATING RE~ARKS ~ ..,~ -~ ........ ~. ~ - -. ~:~ ',,~?gOF~cm~~ ~0 ' APPROVED ~ ~~E LEGAL 72-013 (Rev. 3/78) r~i.J~ I CIPALITY OF A~-IC:HCIRAI]E DEPARTMENT OF HEALTH AN~ENVIRONMENTAL PROTECTION 825 L STREET, ~4CHORAGE, 8K 99501 264-4720 ON--'_S I T'E SELLER 8= NELL PE~:FI ! T PER~4IT NO: DATE ISSUED: 0571i/84 APPLICANT: ADDRESS: CONTACT PHONE: ALASKRAFTS INC. 6953 CUTTY SARK ANCHORAGE, AK 99502 264-44~3 LEGAL DESCRIP: LOT SIZE: MAX BEDROOMS: SUBDIVISION: ATELIER SECTION: 6 TOWNSHIP: 12N 64194 (SQ. FT. OR RCRES) LOT~ 6A RANGE~ 2W BLOCK: 2 LISTED BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR SEPTIC SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR SITE. DEPTH TO PIPE BOTTOM (FT.) GRRVEL DEPTH (FT. > TOTRL DEPTH (FT. GRAVEL WIDTH (FT. > GRAVEL LENGTH (FT. GRAVEL ~OLUME <.CU. YDS.') TANK SIZE (GALS> SOIL RATING <S~.FT. JBR) TRE~gCH BED ~4. ORAI~-~ 4.0 4.0 4.0 ~_8. ~._ 0.5 3.5 ,,.~,,.0 4. 5 7. 5 2.~ t7,0 5.0 34. o 41. e · 8. 8 2i. 4 30. 3 l.,80O, 0 ** i~O80, 0 ** l.,8OO. 0 ** i25 i25 125 ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS I CERTIFY THAT: i. I tim FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE <MO8> AND THE STATE OF ALBSKA. 2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MO8 CODES AND REGULATIONS, AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. 1 I WILL ADHERE TO ALL 1~08 AND STATE OF ALASKA REQUIREMENTS FOR THE SET 8ACK DISTANCES FROM ANY E~ISTING WELL, WASTEWATER DISPO$RL SYSTEM OR PUBLIC SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT. 4. I UNDERSTA~.~THAT THIS PERMIT IS VALID FOR A MAXIMUM OF ~ BEDROOMS 8ND ANY ENLARGEMENT WILL REQUIRE 8N ADDITIONAL PERMIT. IF A LIFT STATION IS INSTALLED IN AN 8REft COVERED BY MO8 BUILDING CODES, THEN (l> AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED~ <2> AS-BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT~ AND <~> THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. ENGINEERS, INC. 7125 OL0 SEWAR0 HIGHWAY ANCHORAGE. ALASKA 99502 (907) 349-6561 PERFORMED FOR SOIL LOG SOIL LOG TEST PERCOLATION TEST JOB NUMBER: ........................ LEGAL DESCRIPTION 2 : 3 ~ 4 ~ SLOPE SITE PLAN '--I Z ~2--~ ~5 17 -- ~ 18 - 20- (FEET) WAS GROUND WATER ENCOUNTERED? W E IF YES. AT WHAT ..--.- - DEPTH? ................. L Gross Net : Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN FT AND FT F8rforn, ud Lecat Thi S 22r~ C~--~' ' ' ' ~,~ ~a£1,~a °°50~' For_. Tom Taylor 0ate Performed_]i}__~.l]_~ ................. Cescription' Lot~ ...... ~] ecl: 2 S u b d ~ v i s i ° n-.~}S3-~-e-~--SRbd~-isi°nz zorm F',eaorts Soils [oo____~_~ ........................ Percolation Test ...... r~,~t - Soil Characteristics z .... Peat Silty Sandy Gravel Slightly Silty Sand 16 -- Bottom of test bole. bedrock encountered. No 20_--- _ ......................... C-rour, d k'ater Fncount. ered? .... No___ '~? - Yes, ,~t what Denth? ........................... "r,c [ 5at.e Srnss li¢;e Net T~,ne i" ~ .......... j ..... I J · - i- - , _-_.' "i_.. i..._'i-i.;__'." .__' ' ... 'J.'_"_' .......... ] ..................... i ........ I Fercolatir~n Rate ~i nute Frnr, c,~ed ln~t~'~.-~i'0~-' C~enace Pit ~rain Field ~ec, th of Inlet.. ...... D,?r, th {o >ot'o{n Of ~it Or'irenc~ .... -,u',FX-q- 150 square foQt required per_ bedroom from minus t5-' t.o 7', ' - ................................... ~d-- ~,.-A --~ ........................... ..... ..~.i.-- -, . , ~-- ~ David Paul [~[a Sir ', pti Jot6 'Flock 2 'Subdivision Atelier S.bd.ivi~ion Per, th Soil 2 .... Pea t Char,~cter~stics . _ Slightly Silty Sand !-~c) t!.OT10~ to.st hole. No 1-c~(.]rcn'::~, erlc:o!]]~ t.e:[od. ~-r c, und ~ter [r, cour,'..ered? .No _ Der, th? ............... ..] .& [ ,'? ?, t .Srr'ss li::e :at Ti,r,e ?,'-r,t?, ' r, u r i~tir, n F, ate _ ?rr, r{.:ed ]r, stai-l~tic, n' Seer, Leu F~L ~..~:',th io :,-: ~ h 0f ]r,i '-' d ?y David Paul [,7-i , ..,( ;' .'7 ?ot'r.:' Of ?it Or ~ :C .[.'> Itl Jll '~. 11 !1 [3 T, I' :! F) u il 1 WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geologicol ~ Geophysical Surveys Drilling Permit No. LOCATION OF WELL (Please complete either la, lb or lc.) A.D.L. No, ~lBorouohSubdivision La,B,ook ~1 I/,,tr,. Soc,,on No. Town,,,p,o Ronoe ED Mar,al,an ,; --of__of--of -- sl[-] wi] ~1 DISTA,CE AND DiRECTiON FROM ,DAD INTE,SECTIONS ,. OW,~, O~ Address: Street Address and Area of Well Location Material Type Top Bottom ~ V~;, · ~,;;~,:~?>J~./ ~'{~?:-~ <~/ ~i ~;: ~. ~ ~.. 6. ~Cable tool ~Rotary ~Driven ~Dug ~:~ ~L' ~ :.~) J~:~'~ ~ ~,~. ';~(/ 7. USE: ~ Domeltlc ~ Public Supply ~ Induetry ~ "'~ '; :: Y - 8. CASING: ~ Threaded ~ Welded dlom. in, fo~ fi, O~plh Stlckup__ ft, 9, FINISH OF WELL: Type: Diameter: Slot/Mesh Size: Length: Set between ft. and ft. Backfilling Gravel pack I0. STATIC WATER LEVEL: ~ { ft. : ~ ~/¢/' ~,'~ ~ Above or ~ Below lend surfoce Dele Equipmenf used: II. PUMPING LEVEL below land surface ond YIELD ~ [~ fl, after ~ hrl. pumping /~ ~, g.p,m. ~ft' after ~hrs' pumping g.p.m. MUN'CIPALI~ Of ANCHO~C~E~=.e~OUTi~G well Grouted: ~ Ye= ~ No =~/ D~i~TAI PROTE~IC ~ Material: ~ Neat Cement ~ Other: I~. PUMP: (if available) HP _ OCT ~ 9 ~984 ~..,,~ o, ~rop ,,p. ~,,. ~ Sub.. 16. WATER WELL OONTRAOTOR'S OERTIPIgATION: 15. Water Temperature ~o ~ F ~ C This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Registered Busines~ Name Oo~lracl License Number , / ~' ~/,' ~'; Dots: Authorized Representative Form O~-WWR (11/81) Copy Distribution: WHITE-Stele D668~ PINK-Driller~ CANARY-Customer Parcel I.D. # MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 041 -031 -44 GENERAL INFORMATION Complete legal description Lot 6A Block 2 Atelier ~\ Location (site address or directions) 7041 Montagne Anchorage, AK 99507 Property owner Mailing address 7041 Lending agency N/A Mailing address Lorie Ace Montaqne Day phone Anchorage~ AK 99507 Day phone 562-7131 Agent Realty North Address 3724 Spinnaker Dr., Anchorage, AK Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well x Community well Public water NOTE: Day phone 333-811 7 99516 If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: X Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesfing to the legality and status of system. 72-025 JRev 1/91) Fron! M©A ~21 5. STATEMENT OF INSPECTION BY ENGINEER 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 application 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 inves.tLgation 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 DHI Consulting Engineers Address 800 E. Dim ~ Blvd. Suit~ 3%5;45, \ -'! I /. Engineer's signature .,k~ ~- ~/,,' Phone Anchorage, Date 344-1385 AK 9951 5 ,,- ,,z SIGNATURE Approved for T ../~---~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: Date '- / ' The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS 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. (Rev 1,91) ~.c~ MOA #21 W.O. 96294 Municipality of Anchorage .............. .,~?,.~¢'~u~, o~ DEPARTMENT Of HEALTH & HUMAN ~LKV.S~:~ENT~L SERVIcEs Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-~t7(~~ 7 2 7,9,96 Health Authority Approval Checklist E CE I V E D Legal Description: Lot 6A Block 2 Atelier WELL DATA Well type Res Log present (Y/N) No Total depth 79.5 Sanitary seal (Y/N) Yes Date of test Static water level 1 1 ' Well production 2 2 WATER SAMPLE RESULTS: Coliform 0 Date of sample: 1 0 - 1 5 - 96 SEPTIC/HOLDING TANK DATA Parcel I.D.: 041 -031 -44 If A, B, or C, attach ADEC letter. ADEC water system number Date completed 6 - 21 - 84 Cased to 79.5 Casing height (above ground) Wires properly protected (Y/N) Yes AT INSPECTION 10-15-96 FROM WELL LOG 6-21 -84 13' g.p.m. 4.5 g.p.m Nitrate I . 24 Other bacteria 0 Collected by: Dustin High Fluid depth in absorption field before test (in.); 0" Fluid depth 0" (ins.) Minutes later: 1 220 Peroxide treatment (past 12 months) (YfN) No ABSORPTION FIELD DATA Date installed 9 - 11 - 84 Length 28 ' Width Effective absorption area 560 s f Date of adequacy test 1 0 - 1 5 - 96 Soil rating (g.p.d./ftx or ft2/bdrm) 4 ' Gravel thickness below pipe Monitoring Tube present(Y/N)Ye s Results (Pass/Fail) Pas s Number of Compartments 2 Cleanouts (Y/N) Ye s High water alarm (Y/N) No 85 System type Deep Trench 8 ' Total depth. I 78" __ Depression over field (YfN) No For 3 bedrooms Immediately after 463gal. water added (in.): 4" Absorption rate = 450 g.p.d. If yes, give date --- Date installed 9-1 1 - 8 4 Tank size 1 2 5 0 Foundation cleanout (Y/N) Ye,s Depression (Y/N) No Date of Pumping /,~-;t~'- ~/'ff, Vumper Roto Rooter LIFT STATION ' Date installed Size in gallons Manhole/Access (Y/N) J"Pump on" level at* High water alarm level at*~ *Datum Cycles tested E. SEPARATION DISTANCES "Pump off' level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot '1 0 5 ' + ; On adjacent lots 1 0 5 ' + Absorption field on lot 1 0 5 ' + .; On adjacent lots '1 0 5 ' + Public sewer main None Public sewer manhole/cleanout None Sewer/septic service line 'I 0 5 ' + Lift station None SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 7 ' + Property line S 0 ' + Absorption field Water main/service line 7 5 ' + Surface water/drainage None Wells on adjacent lots ~ 0 5 ' + SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation 1 0 ' + Water main/service line 7 5 ' + Surface water NOne Driveway, parking/vehicle storage area 6'0 ' + Curtain drain NOne Wells on adjacent lots 1 0 5 ' + Property line ENGINEER'S CERTIFICATION I certify th~.~ve determined thru field inspections and review Signature, ~ Engineer's Nam~ Date //-la- ~'~, are HAA Fee $ ~' Date of Payment Receipt Number Rev. 8/95 OSS: haa. Wk.doc Waiver Fee $ Date of Payment Receipt Number 31Itt] I'"~lt~* ttuad, t'.'.'.~d;:;~&~, AK 99709-5~71 - Tel; I'( J i'~OX 1t ~68B PI lONE 345 ~tI] ANCH©nAF, F. Al ASKA 99511-2608 "1 V CAMEl I^ IH,~JI'PI~; I'ION MATE FI IAL5 .............. HR~t, HRS. worlK ACCEPTED BY ................................................. 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 Name ~"~.,~'/ L~.. ~,-,¢~'-'~,,-.,~'Telephone: Home ~',.;',.,¢ ',,"'~..~-/ Applicant Address ~.~_/-/,~ ~ ~'~,~' ,,~:'~ .--~',,/, ~ ,//~ (c) Applicant is (check one): Lending Institution I-I~builder.~, Buyer [] ' Other [] (explain); (d) Lending Institution Address :~'~,p"-" (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Famil~t~ 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. SEWAGE DISPOSAL Onsitex Public [] Community I-I 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) ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE 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 o 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 FRONTIER ENGINEERS INC. 2440 E. TUDOR 5UI1-E l'J40 Telephone . Engineer's Seal DHEP APPROVAL Approved for Approved bedrooms by Disapproved Conditional Date 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-o25 (, WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: MUNICIPALITy OF ANCHORAGE DEPT, OF HEALTH & ENVIRONMENTAL PROTECTION Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: Well Classification ~"'~"~.~,.,,/~ ~,,,~,v~'/~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N)~_.~_..,~_~ Date Completed 4./~/~/' Yield Total Depth ,,~' Cased to, ;~',~. ~ , Depth of Grouting ,4~/~J~' Static Water Level //~' Pump Set At "~'¢ ~' · ,~ Sanitary Seal on Casing (Y/N) ~-"'~' Depression Around Wellhead (,.Y/N) .... ,~'~ To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line .,~.~,"e 1~~',e*w ~ Nearest Public Sewer Cleanout/Manhole .~.-.,~ -/.4'.~,, ~ · To Nearest Sewer Service Line on Lot Water Sample Test Results ~ ~.~'~ ~,"',~ Comments ; On Adjoining Lots , On Adjoining Lots ~ B. SEPTIC/HOLDING TANK DATA Date Installed .5~/~.~/ Size . ~ No. of Compa~ments ~ Standpipes (Y/N)~¢~ Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) ~ Depression over Tank (Y/N) ~ ~t Pumped ~ ~~, ~ ~ Pumping/Maintenance Contract on File (Y/N) ~~ · for/~ ~~ '~ ~ Holding Tank High-Water Alarm (Y/N) ~~ Temporary Holding Tank Permit (Y/N) ~ Separation Distances from Septic/Holding Tank: To Water-Supply Well .//~ '~ To Property Line '_~~ '~ To Water Main/Service Line ~,~,~:~ To Building Foundation To Disposal Field To Stream, Pond Lake, or Major Drainage Comments Page I of 2 72-026(11/84) C, ABSORPTION FIELD DATA Soils Rating in AbsorPtion Strata Date Installed Width of Field Square Feet of Absorption Area 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 To Property Line ~"~ To Existing or Abandoned System on · On Adjoining Lots ,/,P'",:~ ~ To Cutbank (if present) .,,~o7~' ~'~,,.~--~,,~' Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) ~/~¢'~'~ i ~ne n si, si~s Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have chec~f~ed~~r m ed to all MOA and HAA guidelines in effect on the date of this inspection. Sign~,~~' i ~ Date ~~T.~ Company Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL ~ALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHOEITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 6A Block 2 Atelier Subdivision Location (a~dress or directions) 7041 Nontasne (b) Applicants Name Loci J. Mc BAin Telephone - Home Business Applicants Address 1440 East Tudor Road, Suite 1140 Anchorage (c) Applican_t_is (check one) Lending Institution ~--~ ; Owner/builder ~--~ ; Buyer ~ ; Other ~ (explain); (d) Lending Institution Alaska Continental Bank Telephone 562-0880 Address Box 43659 Anchorage, Alaska 99509 (e) Real Estate Co. & Agent Address (f) Telephone Mail the HAA to the following address: Call: Mary Banister % Geolab 344-8042 2. Type of Residence Single-Family~ Number of Bedrooms 3. Water Supply Individual Well~ Multi-Family Three Other (describe) co.unity 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] 5. Ensineerin~ Firm Prov~din~ Inspections; Tests~ File Search; Data and Information As certified by my seal affixed hereto and as of the validation date shown below, I verify chat my investigation of'this Health Authority Approval shows that the om-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 regula- tions in effect on the date of this insPeCtiOn. Name of Firm Telephone Address ® Da~e DREP Approval Approved for 'three bedrooms Approved xxx (ENGINEER SEAL) Disapproved This is a re-type of the original approval. The first one was appara~tly misplaced. Copies of the first original approval are in our files at this office, if verification is needed. This property was approved on the date Conditional Terms of Conditional Approval CAI~ION THE ,MUNICIPALITY OF ANCHORAGE ~PARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES ~ALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. EMPLOYEES OF D~EP 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. (DEEP SEAL) RR4/eJ/D18 [Page 2 of 2] 7-19-84 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicants Name Lo~, ~1, ~c ~,,j Applicants Address {~'0 ~ TOb~ Telephone- Home Business 'e P Jr~ /140, A~r ~_~ (c) Applicant is (check one) Lending Institution ~-~ ; Owner/builder Buyer .~,; Other ~-~ <explain>; (d) Lending Institution Address ~i)W ~-_~6~ (e) Real Estate Co. & Agent ~/~ Address (f) Telephone Mail the HAA to the following address: Octal' 2. Type of Residence Single-Family~ Number of Bedrooms 3. Water Supply Individual Well~ Multi-Family ~-~ Other (describe) 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] e En~ineerin~ Firm Providin~ Inspections~ Tests~ File Search~ Data and Information As certified by my seal affixed hereto and as of the validation date shown below, I verify that mI, 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 regula- tions in effect on the date of this inspection. Name of Firm Address !!TI (ENGINEER SEAL) DHEP Approval Approved for ~ bedrooms Approved ..~ Disapproved Terms of Conditional Approval Conditional CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRO~MENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS.' 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 ~ PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 ao MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 OCT 2 9 RECEIVED Well Classification 1~3Did,D&;nc. Well Log P~esent (Y/N) ~ Total Depth 8} / Cased to Static Water Level 79 ' casing Height Above Ground Z ' Electrical Wiring in Conduit (Y/N) ~ Separation Distances f~c~ Well: To Septic/Holding Tank on Lot ~ I[ C To Nearest Edge of Absorption Field on Lot ~1~ / To Nearest Public Se~r Line ~/~. , Cleanout/Manhole ~ / ~ Water Sample Collec~ced By Water Sample Test Bssults ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewe~ Se~vi~e Line on LOt Ccm~snts B. SEPTIC/HOLDING TANK DATA Date Installed (% ~c-PT ~ Size I.Z$O eA.[- No. cf Ccmpa~tmsnts Standpipes (Y/N) %~-~ Air-tight Caps (Y/N)N 3 Foundation Cleanout (Y/N) Depression ove~ Tank (Y/N) ~40 Date Last Pumped Pumping/Maintenanc~ Contract on File (Y/N) /0//%; fo~ Holding Tank High-Water Alamu (Y/N) A)/~ ~mpo~a~ Holding Tank Permit (Y/N) ~/~ Separation Distances f~cm Septic/Holding Tank: To Water-Supply Wall ~ % O' To P~ope~ty Line ~ 7 ~; To Water Main/Servic~ Line Course ~/A To Building Foundation ~ ~..! To Disposal Field ~/ To Stream, Pond, Lake, c~ Major D~ainage Comuants [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed IJ 5~°7- ~ Width of Field 4/ Length of Field Depth of Field Gravel Bed Thickness , ~, LQ ! Square Feet of Absorption A~ea . .~.(~P Standpipes ~e~nt (Y~) ~p~ession o~ Field (Y~) ~ / ~ of ~st ~a~ ~st .~/~ Results of ~st ~a~ ~st ~/~ Sep~ation DiStan~ f~ ~pti~ Field: To ~ter-Supply ~11 .... ~g' To ~o~rty Li~ To Building Foun~tion .30 / To Existing ~ ~ndo~d System Lot N/~ ; ~ ~joining ~ts > ~OO / To ~te~ ~in/~vi~ Line ~/~ To ~t~( if pre~nt) ~/~ To Stre~ond~ke/~ ~jo= ~ai~ C~ ~ ~ / To ~i~way, Pa~ki~ ~ea, ~ Vehicle St~a~ ~ea ~ ~O/ Comments LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at TeSted for Electrical Codes (Y/N) ,~PPL~ C A~ I~ Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA Cc~ments ** ** Check Permitted Bedroom Rating Agairmt HAA ~quest I certify that I have checked, verified, or conformed to all MOA HAA Guidel on the date of this inspection. Company ('~_; ~7/._~ MOA No. 57-~ ~ --00 ~l Km/d5/s [Page 2 of 2] 2-15-84