HomeMy WebLinkAboutBELLA VISTA #1 LT 11A
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
Parcel I.D. # /~/3 -O~-! - ~:~o
1. GENERAL INFORMATION
Complete legal description
Lot 11A; Bcll~ V/sta S~bdivi6ion #I
J
Location (site address or directions) 7708 Lu~bZ~ Avencce
Anchor_age, AK
Propeftyowner ~' Robe~ct M,~ ., '~ Day phone
Mailing address 708 Lu~bZ~ Ay n~e Anchora ~. AK 99518
Lending agency Day phone
Mailing address_
NUMBER OF BEDROOMs:
TYPE OF WATER sUPPLy:
$49-2169
Agent Rocky K~bek/ VISTA REAL ESTATE Day phone 562-6464 '
Address 4241 "B" Str~.~ Anchora.q¢, AK' 99503
Unless otherwise requested, HAA will be held for pickup. ' ' ':
, Individual well
·. Community Well
NOTE:
×Y,X
Public water
If community well system, provide written confirmation from State ADE. C.,attest-\
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding:tank .,
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system. ~ ..... ,... ~..~.: ,~. ,:
72-025 (Rev, 1/91) Front MOA#21
5
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 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.
S & S ENGINEERING ' ..... :*- .... Phone ~' '~ ~'":* "~"~ '~ '~
Name of Firm '.."C=4 r".~.~|.. ~.;,,r L.~op Road No. zu4
Eagle River, Alaska 99577
Address
Engineer's signature
DHHS SIGNATURE
Approved' fo bedrooms.
__ -Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
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. '-:,',.' ...... ~ . ' .............. ...
72-~lS(Rev. 1/91) Back MOAi~21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L.o~'/I/4 ~)(E/_(_~ V157'-~ ~,/~F-I Parcel I.D.
A. Well Data
Well type ~/&l
Log present (Y~)/"-)~
Total depth
Sanitary seal Y~N)
Date of test
Static water level
Well flow
Pump level1
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~ J~ Driller
Cased to ~:~--O r?C Casing height /'
.Wires properly protected ~1) ~'~-~ ~ ~
FROM WELL LOG AT INSPECTION ,:.,? ~ (~
g.p.m. __ __
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main /'-~- r
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform 0///(~ ~
Date of sample: ~/'~°/
Nitrate
Collected by:
Date installed Tank size Compartments ~
Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) _~'-
High water alarm (Y/N) Alarm tested (Y/N) ~
Date of pumping Pumper~.~''''~'~-
SEPARATION DISTANCES FROM SEPTI~ANK TO:
Well(s) on lot _On-~acent lots Foundation
To property line _.~'"""~ Absorption field Water main/service line
age
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM ~ATION TO:
Well on lot ..~---'"'"'~~ On adjacent lots
D. ABSORPTION FIELD DATA
Manufacturer
Manhole/Access (Y/N)
"Pump o~
Cycles t~3~
Surface water
Date installed
Length
Total absorption area
Date of adequacy test
Width
Soil rating (GPD/FF)
Gravel thickness
Cleanout present (Y/N)
Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
System type ..-.'"'
Total depth ~
De~ (Y/N) Bedrooms
..~ffer test
Jif yes, give date
SEPARATION DISTANCE FROM ABSORPTION FI~)'~'O~
Well on lot On~jacen'~t ~ots Property line
To building foundation j To existing or abandoned system on lot
On adjacent lots. ~ Cutbank Water main/service line
Surface wat~''''''~ Driveway, parking/vehicle storage area
C i~n~rain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in
Signature
Engineer's Name
Date
HAA Fee $
Date of Payment
the dat~o~..~s inspection.
Waiver Fee $
Receipt Number
Date of Payment
Receipt Number
72-026 (3/93) Back
CT&E Ref.#
Client Sample ID
Matrix
Commercial Testing & Engineering Co.
Environmental Laboratory Services
LABORATORY ANALYSIS REPORT
94.4830-1
LOT 11ABELLA VISTA S/D #1
WATER
ClientName S & S ENGINEERING WORK Order 82382
Ordered By R. SHAFER Printed Date 09/22/94 ~ 10:38 hrs,
Project Name Collected Date 09/20/94 ~11:55 hrs.
Project# Received Date 09/20/94 ~ 13:00 hrs.
PWSD UA
Technical Director
STEPHEN C. EDE
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: SS.
Parameter
QC Allowable Ext.
Results Qual Units Method Limits Date
Anal
Date Init
Nitrate-N
0.10 U mg/L EPA 353.2/300.0
10 09/21/94 CIvlR
* See Special Instructions Above
** See Sample Remarks Above
U = Undetected, Reported value is the practical quantification limit.
D = Secondary dilution.
UA = Unavailable
NA = Not Analyzed
LT = Less Than
GT = Greater Than
5633 B Street, Anchorage, AK 9951 8-1600 --Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Lot I IA, B~lla Vista Subdivision #I
Location (address or directions)
7708 L~bis Avenue, Anchorage, Alaska 99518
(b) Property owner HHO_ #!
Mailing Address
Telephone · (home)
Business
(c) Lending Institution
Mailing Address
Telephone
(d)
(e)
Real Estate Company and Agent ROGERS REALTY ATTN:
Address 8_=;01 ARctic Blvd. Anchorage. Ak. 99518
Telephone 344-8492
Mail the HAA to the following address: (or check here I~, if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
Eagle River, Alaska 995~
2. TYPE OF RESIDENCE
Single-Family [~X Number of bedrooms 4 .
3. WATER SUPPLY
Individual Well ~x.
Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site {~x. 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.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING 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 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 Telephone ~ ~zz'~ ~--?~' 7~/''
Address
S & S ENGINEERING
Date
17034 Eagle Ri.ver Loop Road No. 204
Eagle River, Alaska 99527
6. DHHS APPROVAL
Approved'for Z//...__ Bedrooms by
Approved ~x,.~. . Disapproved
Terms of Conditional Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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.
72-025 (Rev, 7/88) Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (NAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: /--~,-/' ! ! "/~. '~
Date Completed
If A, B, C, D.E.Co Approved
~ ~ Yield ~
Total Depth ~ ~ Cased to ~O"f -
Depth of Grouting
Static Water Level '~ -~ ~
Pump Set At
Casing Height Above Ground I ]Z. -P Sanitary Seal on Casing (Y/N)
Electrical Wiring Jn Conduit (Y/N) ~1 Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot A)/J~
To Nearest Edge of Absorption Field on Lot
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Line ~. % "/~ To Nearest Public Sewer Cleanout/Manhole ! CO
To Nearest Sewer Service Line On Lot ~ ~ /'/~'
Water Sample Collected by .~ '~ .~ ~--~J~ild~.C.¢;l~ ;date /--/ -.20 - ~'~
Water Sample Test Results .~¢k'~/.~f~C'-J(~£C~ -- ~:~C"'~J'i/,~ "~ /~,'~-J'"'~$
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed Size~ No. of Compartments
Standpipes (Y/N) __ Air~,~t Caps (Y/N) Foundation Cleanout (Y/N)
DepresSion over Tank (Y/N) '~ Date Last Pumped _
Pumping/Maintenance Contact on File (Y/N)~, ; for
Holding Tank High-Water Alarm (Y/I~ / ~. ?~mporary Holding Tank Permit (Y/N)
;~?~iTION DISTANCES FROM s~pVTIc/HOLDIN~K:
a e -Supply Well .... To'~ding Foundation
To Property Line .... To Di%sal Field
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments J)~b Il'c-
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absor n Strata
Date Installed
Width of Field
Square Feet of Absortion Area __
Depression over Field (Y/N)
Results of Last Adequacy Test __
SEPARATION DISTANCE FROM
To Water-Supply Well
To Building Foundation
Lot
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
__ Date of Last Adequacy Test
ELD:
To Property Line
; On Ad Lots
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Existing or Abandoned System on
To ,ack (if present)
D. LIFT STATION
Date Installed '~. Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at ". _ "Pump Off" Level at
High Water Alarm Level at ~ t ~.~ I~/~ Vent (Y/N)
Tested for ~V %,, Pumping Cycles during Adequacy Test.
Meets MOA Electrical Codes (Y/N)
Comments
**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.
11034 Eagle River Loop Road No. 20,!
Eagle Rive_j;, ~s~9577
~//~'~
Signed
Company
Date
MOA No.
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
Date gepozt P~lnted: kP~ 24 9~i @ J.O:ztb
Cii~ Sample iD:LiiA BELLA VESTA
?WSTD :UA
Coiiect~d APR lQ 90 ~ 17:06 nfs.
5eeeiYe~ AP~ 20 90 ~ 17:35
~nmttab R~ ~: 901011 Lab Stop! ID: I M~trix: W~T~:R
NiT~ATE-N NU(O. lO) ~/k ~PA 353~ 2
~enia~t.:_s: fiAI4PLI~t COLLECiI'EP, BY hDJ.
None Detected "' S,~eoa~.p~e ~ ' g~nazks ~bow
Nat AnaJ. yzed LT~besa 'fhan, (~T~Gzea't. ez Them
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISlONOF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lOt, block, subdivision, section, township, range)
Lot 11A, Bella Vista Subdivision #I
Location (address or directions)
7708 Lu. mbis Avenue Anchorage, AK 99518
(b) Property owner
Mailing Address
(c) Lending Institution
Mailing Address
HUD #111-025580-203B
Telephone'(home)
Telephone
Business
(d) Real Estate Company and Agent
Address 609 WpA~
Telephone ~M.~-8490
Tn£2¢y ROCF~ RFALTV
Nan~y Nisonger
(e) Mail the HAA to the following address: (or check here,~, if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
17034 Eagle Ri~er Loop Road No. 204
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single-Family [] Number of bedrooms 4[
3. WATER SUPPLY
Individual Well,V~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status~
4. SEWAGE DISPOSAL
On-site [] PublicJ~ Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION~ ~'~'~ .i:
5.
ENGINEERING
FIRM
PROVIDING
As certified by my seal affixed hereto and as of the validation date shown below. I verify that my nvestigation,,f t.\of tf~ ~. ·
Health Author ty Approva shows that the on-site water supply and/or wastewater disposal system is sar
functional and adequate for the number of bedrooms and type Ofof structurefilesindicatedand fromhere myn' I furtherinvestigationVerify thai ,,and
based on the information obtained from the Municipality Anchorage~'-"
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 Telephone
Address
Date
S & $ ENGINEERING
17034 P..agte R;:,,~r '.--"~-; R_-=_-2
Eagle Rtver~ Nm~ka 99577
6. DHHS APPROVAL
Approved for ~ bedrooms by
Approved ')/',, Disapproved
Terms of Conditional Approval
¢ ~,V~ t'G.-t Date
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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.
72-025 (Rev. 7/88) Back
Page 2 of 2
MUNICIPALITY OF ANCH~
ENVIRONMENTAL Sf:RVICES~
JUL 6 19 9
^. VE D
Well Classification
Well Log Present (Y~)
MUNICIPALITY OF ANCHORAGE (MOA) ~
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: ~:="'~ ~\ ,~'
Date Completed
Total Depth
Static Water Level ~-~
Casing Height Above Ground
Electrical Wiring in ConduitdC~'N) ' '7'
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot i~/'~'
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line "'~-~
Cased to '~¢~'k'~ Depth of Grouting
If A, B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At OIL.-
Sanitary Seal on Casing~)'N)
Depression Around Wellhead (Y~J~ I
; On Adjoining Lots ~/~
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot '?---~--~ I-Jr-
Water Sample Collected by ~ ~ ~::::~ It~:=:~=,"L~C,t ; Date .(.~-'Z~ -~'
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA N//~
Date ~stalled ____.~___ Size I' No. of Compartments
Standp~/N) _____ Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N)
Depre~Sio..n.o.~-- ~ Date Last Pumped ....
PU m Pi ,g/Mai~t.e.n.an~, co,!ac~~; for ....
H old ' nRgATT~k~j H~qh~ ~W:,tce. r, qAI;7~ (~/qN~~ 7.r~rm it (Y/N)
SEPARATION'DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well To Building Foundation ~_~....~
To Property Line To Disposal Field
To Water Main/Service Line
To Stream, Pond,-Lake or Major Drainage Course
Comments .r~"~-.4 ~-~ ~
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
Date. Installed
Widt~~.,~
Square Feet of Absortion~,-e~
Depression over Field (Y/N) ~
Results of Last Adequacy Test ~
SEPARATION DISTANCE FROM ABSORPTION FIELD: ~
To Property
To Water-Supply Well Lin-'e--~.
To Building Foundation To E~d System on
Lot ; On Adjoining Lots
To Water Main/Service Line To Cutback (if present) """..,
To Stream, Pond, Lake, or Major Drainage Course ~
To Driveway, Par_kj. ng Area, or Vehicle Storage Area
Comments
Dat~
Size in Gallon%'---~_
"Pump On" Level at '~'-'---~
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
---.-. Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA gu
inspection.
Signed
Company
Date
MOA No.
17034 Eagle River Loop Road
Receipt No.
Date of Payment
Amount: $
Receipt No.
Waiver Fee: $
Date of Payment
ideline~=l~;..e..l~.~! ~1t~'.~t~ of this
72-026 (Rev. 7/88) Back Page 2 of 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
~~.~ 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)562-2343
FEDERAL TAX ID # 92-0040440
ANALYBIS REPORT El SAMPLE for Work Ozdox % 14475
Date Rsport Printed: JUL 5 89 @ 14:21
Client Sample ID:LIIA BELLA VISTA
PWSID :
Collected JUN 29 89 i 17:30
Received JUN 30 89 t 15:00 h~s.
Preserved ~ith :AS REQUIRED
Client Name : S & S ENGR
Client Acct: SNSENGP
P.O.t LETTER
Req t .~
(kdexed By : RJS
Analysis Completed :JUL 3 89 Se~d Reports to:
~ab~latoI¥ Supelvlsor :STEPHEN C. EDE 1)S & S ENGR
Special ADEC
Irmt.ruct:
C~ab Ref %: 6046 Lab Smpl ID: 1 Matrix: WATER
Allowable
Pa~ametex Tested Result/Units Method Limits
NITRATE-N ND(O.IO) ~/l EPA 353.2 lO
Sample SAMPLED BY R3S. ROUTINE SAMPLE.
Re~rks:
1 Tests Perfoxmed ' See Special Instructions Above UA-Unavailable
ND- None Detected "See Sample Rema=ks Above
NA- Not Analyzed LT-Less Than, GT-Greater Than
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date November ~7. 1984
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot llA, ~ellevlsta g~h~~m
Location (address or directions)
7708 Lumbi~ Ave.
(b) Applicants Name H~n~v Han Telephone - Home349-17~usiness
Applicants Address 7708 Lumbis Ave.
(c) Applicant is (check one) Lending Institution ~-~
Buyer ~-~ ; Other ~-~, (explain); ' '
(d) Lending Institution Colonial Mortgage Services ~o. Asst.. ~phone 562-2181
Address 701 East Tudor , Anchoraqe, Alaska
(e) Real Estate Co. & Agent None
Address
(f)
Telephone
Mail the HAA to the following address:
Wil'l pick up
2. Type of Residence
Single-Family.~.
Number of Bedrooms
3. Water Supply
Multi-Family
4
Other (describe)
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
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 Providin~ Inspectio~p~.' 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 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 Arctic Enqineers, %n9. Telephone~-~e~K~-~n~
Address 1506 West 36th Ave., Ste. 201 AnchoraGe, Alaska 99503
Date Nove~er 27, 1984
DHEP Approval
Approved for ~ bedrooms
f
Approved ~ Disapproved Condition~ __
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL 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 RESPQNSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
A. WELL DATA
DEPT, OF HE?I_'~:i ~,
MUNICIPALITY OF ANCHORAGE (MOA) [~,?,/i~,:OXX,C:.?i,AL i.':._ ,: 'x:~:~
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
1
LEGAL: Lot IiI, Be evista Subd. #1
Well Classification Individual
Well Log P~esent (Y/N) N
Total Depth 100' approx. Cased to
Static Water Level 40.5'
Casing Height Above Ground '12"+
Electrical Wiring in Conduit (Y/N) N
Separation Distances f~cm Well:
To Septic/Holding Tarlk on Lot N/A
TO Nearest Edge of Absc~ption Field on Lot
To Nearest Public Se~r Line 100' +
Cleancut/Manhole 100' +
Water Sample Collected By
Water Sample Test Results
If A, B, (mr C, D.E.C. Approved(Y/N) ---
Date Ccmpleted --- Yield
unknown Depth of Grouting. unknown
Pump Set At unknown
6 gpm .....
Sanitary seal on Casing (Y/N)Y ,,,
Depression A~ound Wellhead (Y_Y_Y_Y_Y_Y_Y_Y_Y_~N)N
Duane Manev
SatisfactOry for Total Coliform
; 0n Adjoining Lots N/A
N/A ; On Adjoining Lots N/A
To Nearest Public se~r
To Nearest sewer Service Line on Lot 25' +
; Date 11-26-84
p,,,r, qducinq 600 qallons of'
C~Mts The well pumped at 6 gpm for 100 continuous misuses,
water which is adequate for a 4 bsdroo~ hQ~$, ,
B. SEPTIC/HOLDING TANK DATA N/A
Date Installed Size No. of Compartments
Standpipes (Y/N) Air-tight Caps (Y/N). Foundation Cleanout (Y/N)
Depression over Tank (Y/N) Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ; fo~
Holding Tank High-Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances f~om septic/Holding Tank:
To Water-Supplywell
To P~operty Line
To Water Main/Service Line
Course
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, c~ Major D~ainage
COlllll~ntS Public Sewer
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2-15-84
C. ABSORPTION FIELD DATA N/A
Soils Rating in Abso=ption Strata
Date Installed
Width of Field
Square Feet of Absorption A~ea
· Depression over Field (y/N)
Results of Last Adequacy Test
Separation Distance f-rcm Absorption Field:
To Water-Supply Well TO PToperty Line
To Building Foundation
Lot
To Water Main/Service Line
To St~eam/Pond/Lake/c~ Major D=ainage Course
To D~iveway, Parking A~ea, c~ Vehicle Stc~age Area
Cfx~lle nts Public .Sewer
Type of System DesiGn
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes P~esent (Y/N)
Date of Last Adequacy Test
To Existing or Abandoned System cn
; On Adjoining Lots
To Cutbank(if present)
D' LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Elect=ical Codes(Y/N) '
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Meets MOA
**
** Check Pez~uitted Bedroom Rating Against HAA Request
I certify that I have checked, verified, c~ eonfo~med to all MOA HAA Guidelines in effect
on the date of this inspection.
Cc~any Arctic Enqin&e~s'~ ~Inc.
MOA NO. ~
KB1/d5/s
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