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HomeMy WebLinkAboutT12N R3W SEC 15 LT 123 MUNICIPALITY OF ANCHORAGE DE 1TMENT OF HEALTH AND HUMAN SER Environmental Health Division 825 'L" Street, Anchorage, Alaska 99502, Telephone 264 4720 ' ON-StYE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ~,ddress LEGAL DESCRIPTION 3' e~ t.~- _S,,o l/q TANKS SEPTIC ~ HOLDING TYPE OF SYSTEM ~QrRENCH L] BED F] W. DRAIN [] OTHER F'r / 3 I= f3to 5'00 ~o- {~'Z i~ SOFT //-2~ -8.5' WELLS PRIVATE [~] OTHER fldentifv) DISTANCES WELL 81:_PTID TANK 15o LOT LINE FOUNDATION ABSORPTION FIELD 141 /I WELL REMARKS: ~t off ..~ old I~ Municipal and Slate guigelines ill ellect on IhJs dale: t - cefliiy Ihal IlliS inspection was porlnrmod according iD all 72 013 (3/85) l (::) r, 'l:. l'l I::)y t.l'~:.:, I"lLu'l:Lc::i.l:),!.~].J't.Y of' .(:~nl:::l'lc:wag,~e (MC)A) ariel ;::,, ]: ~J:ll :in~wLa]l t.l'm:, ~[sy~[5'l',(:2ffl :i.l"l C:'tC:C;C)['C]~:'~IIC:(~.) wit. h all :S,, :1:wiZ1 adl"~l..:,t'~:~) t.c~ all PI(IA a~::l l~;'[.i:.tt.(:.) of (~a[~fl.,:a r'equ:Lr.~,mex~t.~ ['(::m 'l:.h~¢~ ~i~'.:~'t. bad< s~.~e:~r'ag[~ ~syst.~:?m on t.h:i.~ ~::)~' any au:l.jac:e)nt, cw n[:~au"l:)y lcyl'..,, /I,, :[ hu-~d~,.)r'[~t.,'al-ld 't'.h~t. Lh:i.s~ i::) e) l, m i lt. :i.~[!t Ma:l.:i.d [c)r' a III¢~I.(iI~LU]i C)~' ~. I:)~?(::h"C)(::ml~ and ):F:' A I..:1:1::"1' [B'I'A'I"I[)N IS :I:N~T(.~L. LliE:O ]:iq (.~N (-~I:~IEI-~ CEIVER[i:D BY MO(~ BLJII_DIIq[:) 'f'HIEN (1) (~N EI.EC:"I'I::~IC:AI... I::'IEI':~MZT AND :I:NJ~F'ECTION MUST BIJE OB't"FIIIqI~J[D~ (2) Nil. J. NOT BI::~: (~F'F:'IROVI~:D WI"I'I'I[)I.J'F (>~hl I~:I_..LZC'I"I:R];C(~L INDF'I~:C'I"]:ON F~EI::'CIFCF~ (~lxll) C3) "FI"IE IZL.IECTI::(IC:hl. NI::)I?I-::: MI. 18'T E{B: O[]lqE.: BY (:~ I...]:I:',I}ZIqG[~'D S I GNED /~ F:' [::'t . I (3 ,q Iq T' :: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG --. PERCOLATION TEST PEREORMED FOR: ( E N GI~.~_S EA L) DATE PERFORMI;D: ,/O - ~ -/ - 6~'~, 1 2 3 4 5- 6- 7- 8- 9- 10- 11 13- 14- 15- 16- 17----- 18- 19- 20- COMMENTS '[ownship, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? S L IF YES, ATWHAT O DEPTH? __ p E Depth lo Water ADer ,'~oflileriflg? Date: SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop /t ?- - PERCOLA'rlON RATE f 8''L' /-3(rnlnutosnnch~PERO HOLE DIAMETER __ PERFORMED BY: /~[:~.~ ,*~' ~'~)- ~-3~ ~, ~-,/ ' CEHTIFY FHAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL. GUIDELINES IN EF TON THIS DATE. DATE: /o- 3 / -- ~ 008 (Rev. 4/85) ALASKA eF UIROFImI F1TAL COF1TROL SeRUICeS, IFIL ~n~ineerinq 8 ~noironmenlal $1urhes December 3, 1985 Department of Health and Human Services 825 L Street Anchorage, Alaska 99503 Re: BLM Lot 123 - SW 1/4 T12N R3W Section 15 - E. Bumgardner Removal of Conditional On November 29, 1985 a new absorption trench was installed on the above lot. This replaced the original trench which was located entirely within a road easement. The old trench was cut-off and a new cleanout installed leading to the new trench. During installation, the original 1250 gallon metal septic tank was exposed. It was observed to be entire and in good shape and was located 17' from the nearest lot line (see attached inspection form). If you have any further qoestions, please contact 561-5040. Sincerely, .wen Turner ;nulronmenta 1 Scientist 1200 LUcsl 33rd Auenu,. SuiI~ [~,Anchoro% Alasko 99503,(907) 561-5040 GREA,,- ANCHORAGE AREA BORL. H Department of Environmental Quality 3330 C Street: Anchorage, Alaska 99503 INSPE, CTI, ON REPORT ON-SITE SEWAGE DISPOSAL SY~T,B_~. LOCATION LEGAL D E SC R I PT I 0 N y/% "~- __.~/ SEPTIC TANK: DISTANCE FROM W E L L Z~_(-/O INSIDE LENG]H__ __ INSIDE WiDTN .... LIQUID [)EPTtt LIQUID CAPACITY._/~L~.-<~2GALLON$. TILE DRAIN FIELD: DISTANCE FROM WELL //¢¢)r.~,'/- FOUNDATION NUMBER OF LINES _~_/_ DISTANCE BETWEEN LINES DEPTIh TOP OF TILE TO FINISH GRADE ~ / DEPTH OF FILTER MATERIAL BENEATH TILE NEAREST LOT LINE /~ ~ TOFAL LENGTH-- / OF LINES ~g TYPE ~t,,~/ -, _ CONSTRUCTION BUILDING NEAREST NEAREST SEPTIC FOUNDATION LOT LINE SEWER LINE TANK DEPTH . __ SEEPAGE , SYSTEM. DISTANCE FROM: CESSPOOL OTIIER SOURCES APPROVED DISAPPROVED . REMARKS ............. DISTANCES: . DIAGRAM OF SYSTEM INSTALLED BY: SEWER LINE DEPTH: PIPE MATERIAL: LOT SLOPE:~.~ ' REMARKS: ©ATE ,~I~'-'~'¢~APPROVED ~¢ ~~j GREA'. ,, ANCHORAGE AREA BOR~ H DEPARTMENT OF E:NVIRONMENTAL QUALITY SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT NAME OF APPLICANT - INSTALLATION LOCATION PERMIT NO. COMPLETION DA're AN'rlCIPATED _ FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF A[~IY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE/ ' YPE FOUNDATION TO SEPTIC TANK -- FOUNDATION TO SEEPAGE PIT SEEPAGE AREA SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK~'~'~ /" -, SEEPAGE PIT TO NEAREST LOT LINE, WELL TO SEPTIC TANK -- DRAIN FIELD . DRAIN ~ / ~I , SEEPAGE PIT /~/~*~ aLSO CONSIDER ArEa WELLS. WATER MAIN TO SEPTIC TANK DRAIN FIELD SEP~IIC TANK, SEEPAGE PIT TO RIVer. LAKE, STREAM. , SEEPAGE PIT /'//~ ~/~ ~'~RAIN FIELD CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEet INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. CON"ORm TO BOrOUgH RE(TULATIONS REGARDING ,NSTA~¢~' i 'J i I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGh ORDINANCE NO. 28-68 AND THA'r THE ABOVE DESCR{BE SYSTEM IS IN ACCORDANCE WITH SAID CODE. D~T ~: / ?AP.~iCANT'S SIGNATURE (;R[ATER ANCII(}I<A(;I At~.IA b'Ola)UG,~ I)epar'tnlenL of Enviror,ncmLal Qua'Ii Ly 3330 "C" S[reet Anchorage, Alaska 99bU3 S()ll..fi 1,()(i t'I(I~.()I,ATION TEST lhis form reports: Soils log2~- .................. Percolation I:est .......................... Dep Ch Feet lO- 12- 13- 14- Was ground water encountered? _~.~ ........ If yes, at what. dei~th? ............ Reading Date Gross Time Net Time _Oepth__~__o ~_V~ater Net ~Jrop Percol d~ion rate minute. -Proposed ~ stallat~on: ~eepage Pit Drain Field Dept~-~)' }$~}Y-p~ t or trench Del)th of Inle~ COMMEN~S: ......................................................................... Performed By: /~,--~ ] ~:~Cert]f]ed By: ~,Ja~e EO- 040 iREATER ANCtlORAGE AREA BOROUGt' Jepartmerlt of Environmental Qua, 3330 "C" Street Anchorage, Alaska 99503 SOILS I,OG PEROI,ATION TEST Performed for Legal De s c ri p~:~i~[n? This form reports: ~]~-~"~']'S~: ........... Percol~ .... at]on~ ............................... test Depth Feet 3 - 10 . 21o/~(~ 12 1 4 .- Nas ground water encountered? .-~(,__~ .... If yes, at what depth? Reading Date Gross Time __~ Net Time Depth to Water Net Drop Percolation rate minute. Proposed installat~)~?-'-.~!ii~ge Pit Drain Field .................. :A~pth of hllet DepLii-~i{ ([o~i[~:~)i t or trench Well Owner _ /~/' f WILSON WELL DRILLIN~ Location (address of: Townships. Range, 1305 W. 4STH STREET ' ANCHORAGE, ALASKA 99S03 PHONe 272-9343 ,~ DRILLING LOG Use of Well Section, if known; or distance main road Size of casing__. --Depth of Hole~ Static water level 1~(~ -ft. (above) Screen ( ); Perforated ( Describe screen or perforation I I1 . feet Cased to.t~'O I -.~ feet (~.1o~ land surface. Finish of well (cheek one) ). Well pumping test at t~__gallons per (hour) of drawdown from static level. Date of completion~ open end( &-- ); (~_~ for. -~ hours with ~O .--ft. WELL LOG Depth in feet from ground surface TO_ TO_ --.TO -----TO .TO. Give details of formations penetrated, size of material, color and hardness April 2~ 197~ 4.1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICFS DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date ~[~3 GENERAL INFORMATION fMUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Properly Owner ~,~"~ ~ ~'~'¢...~,-~1 __ Telephone: Home Business Mailing Address (c) Lending Institution Mailing Address ~ Telephone (d) Real Estate Company and Agent Address (e) Telephone ~'~ .O.. - '~ ~ Mail the HAA to the followina address: or: Check here.~ if hold for pick up List contact person and day phone number below. TYPE OF RESIDENCE Si ngle- Fa rnily ~i~ Number of Bedrooms WATER SUPPLY Individual Well ~i~ 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~' Public [] Community [] Holding Tank [] Note: If community well system, must i~ave written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72 025 IRev 8/8RI Fronl · '~JOtA S,JaaU!bUa leUO!SSa,toJd aql u! suo!as!uJo Jo sJOJJa Joj alq]suodsaJ 1au s! abeJoqauV ,to/0,!led!o!unv~ aqJ. 'panss! s! atea!,t!iJaa e aJo,teq e,tep az/~leUe Jo suo!,taadau! ianpuo3 lou ap SHHQ j.o saaXOldLU3 's~.UaLUaJ!nbaJ ale,ts pue leJapa,t uielJaa ~,tsp, es oi Jap Jo u! suo!lm,!lsu! 6u!pual J!aql pue saw oq ,to sJeseqaJnd o,t Xsapnoa e se siqi saop SH HQ eql 'e>isef¥ Jo ale,tS aq,t u! paJa,ts!baJ Jaau!6ua leUO!SSaloJd iuapuadapu! ue ,~q aAoqe S; qdeJbeJad uf ua^ih suo!ieiuasaJdaJ aqi uodn ,~lUO p@seq salaa!,tipao le^oJdd¥ ~liJoqinv Li),leaH senssf (SMHQ) saO!AJaS uemnH pue qlleaH ,to lUaLUpedaQ abeJoqouv ,to Xi!led!a!un~ aq/ NOLLO¥O le^oJdd¥ leuo!l!puo0 ,to smJaJ_ 88- leUO!,t!puoc) paAoJddesi(] ,,~" paAoJddv ~JOl pa^o]dd'¢ -I~'AOUdd¥ SHHQ '9 lees s,Jaeu!bu3 ¢::)//~ ~, , ~ ~,.~ auoLidala.L ua loej,ta u! euoflelnaaj pue '$eaueufpJo 'aapoo alelS pue led!o!un~ lie Lil!~ aoUe!ldLUOa u! s! malsXs lesodsfp Jo/pue ,~lddns JaleM al!s-ua alii 'uoLiaadsu! pue uoLieb!lsa^u! ,~LU UJOJ,t pue Self,t a6eJOLiauv ,to ,~l!led!o!unF~ aLi~ moji pau!elqo UO!leLUJOJU! eql ua paseq leql ,~J!Ja^ Jaqpn,t I 'u!e~aq paleO!pu! aJnlonJls jo ad,~l pue ewooJpeq ,to Jaqwnu elenbape pue lauoilaun,t 'a jag a! LU @lS/;S leeods!p JeleMaise~ Jo/pue Xlddns Jale~ ails-ua eql 1eql s~oqs le^oJddv/~l!Joqln¥ qlleaH e!ql ,to uoile6!lsa^u! ,~uJ leql/~JfJa^ [ ',~olaq u~oqs alep ua!lap!la^ aql ,to se pue oleJaq pex!,t,ta leaS,~LU Xq NOIJ.¥~I:IO:INI aN~' YJ.~'a 'HOIJ¥~]S :1'11_-I 'SJ. S3.L 'SNOIJ. O:tdSNI 9NlalAO~Jct ~J:llJ ~DNIIJ~:INI~DN~] 'g A+ MUNICIPALITY dP ANCHORAGE (MOA) rxoHEALTH AUTHORITY APPROVAL (HAA) ,:, 0,~ CHECKLIST - FEBRUARY 1984 264-4744 Legal Description: WELL DATA Well Classification Well Log Present (Y/N) Total Depth ,~--. C, / __ Static Water Level · i~ If A, B, C, D.E.C. Approved (Y/N) _ ? __ Date Completed . ~//.,'~/7,.,~ Yield Cased to _~'~O/___ Depth of Grouting N C, rVL~ Pump Set At _? /7 ~ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) ~/' Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot. To Nearest Public Sewer Line ~ C' ~/L.~ Cleanoet/Manhole /"q Water Sample Collected by Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Water Sample Test Results Comments ; Oo Adjoining Lots __ /L~L~- '.~ ; On Adjoining Lots _ To Nearest Public Sewer To Nearest Sewer Service Line on Lot B. SEPTIC/HOLDING TANK DATA Date Installed ~ o/~'Z7'~ Standpipes (Y/N) Depression over Tank (Y/N) __ Pumping/Maintenance Contract on File (Y/N) __ Holding Tank High-Water Alarm (Y/N) Separation [Distances from Septic/Holding Tank: To Water-Supply Well _ l L/ To Property Line / 0 Size ~/~-¢o __ No. of Compartments __ Air-tight Caps (Y/N) /~' Foundation Cleanout (Y/N) Date Last Pumped '~/Ot/g~ t y'~,~, ;for __ __ Temporary Holding Tank Permit (Y/N) _ To Building Foundation To Disposal Field 1.5 To Water Main/Service Line ;;>/0 Course /'h/~/~ To Stream, Pood, Lake. or Major Drainage Comments Page 1 of 2 72-026 IRev 8~861 Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~ h'¢//~ 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 ,~ ! O To Stream/Pond/La'l~e/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 l To Existing or Abandoned System on ; On Adjoining Lots -~"~ To Cutbank (if present) /N/O H o,,../E Comments O. LIFT STATION IN LO/%///% Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions 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 checked, verifie~, or conformed to all MOA and HAA guidelines in effect on Signed ~ ~ Date ¢'/~/~'~ (~ Company MOA No, Receipt No. //¢ 0,/~ 0 -~2- Date of Payment ~/' ~/~ Amount: $ / > ~ ~ CF'(..) Page 2 of 2 the date of this inspection. Engineer's Seal L~ 203W 151hAVE 'C SUITt 20:~ CONSULTING ENGINEER tELEPHONE (9071 279 SEPTIC SYSTEM ADEQUACY TEST LEGAL: LOCATION: OWNER: RESIDENCE: WELL: SEPTIC SYSTEM: Lot ].23, Sec. ].4, T12N, R3W 4410 E 101th. Ave. LaMar Steen Single Family. Four Bedrooms On Site FROM MUNICIPAL RECORDS: TANK:Sunset Plastic, One Compartment 1250 gallons ABSORPTION SYSTEM: Trench ABSORPTION AREA: 900 sq. ft. SO1L RATING: 212 INSTALLATION DATE: Tank 10-75 Trench December 1985 DATE OF LAST PUMPING: February 9, 1988. Isaac's DATE OF TEST: February 9, 1988 TEST PROCEDURE: System was inspected and measured. Tank was found with two feet of cover and 48 inches of liquid. Clean out at start of trench was three feet deep and dry. Sump at end of trench was 11.5 feet deep and had a liquid depth of 21 inches. 500 gallons of clean water was added tot he trench clean out while the water levels in tank and sump were monitored. Tank level remained constant while the water level in the sump rose 17 inches, infiltration was monitored for 30 minutes. During this period the water level dropped 1.5 inches, indication an absorption rate of 88 gallons per hour. TEST RESULT: This system meets the code requirements of the Health and Social Services Department of the Municipality of Anchorage. NOTE The operational life of all septic systems depends on 'the local soil conditions, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this septic system. We can therefore not give any estimate of how long this system will function satisfactory for current or future occupants. CONSULTING ENGINEER TELEPHONE (9Q7) 279391 RESIDENTIAL WELL INSPECTION LEGAL: Lot 123, Sec. 15, T12N, LOCATION: 4410 E. 101th. Avenue OWNER: LaMar Steen TYPE OF WELL: Residential. Single WELL LOG AVAILABLE: Yes INSTALLATION REQUIREMENTS MET:Yes WELL YIELD FROM WELL LOG: family R3w 8 Gallons per minute PUMP YIELD FROM TEST: 6 Gallons per Minute DATE OF INSPECTION: February 10, 1988 TEST PROCEDURE: Well was pumped at a constant rate while the drawdown was monitored with an acoustic probe. At the beginning of the test water level was found at 179 feet below top of casing. At a pumping rate of 6 gallons per minute the water level dropped to 181 feet after two minutes of pumping and remained at that level for the remainder of the test, 90 minutes. A total of 500 gallons were pumped. The well recovery rate was monitored for 10 minutes. The well recover to 179 feet during this period, a 100% recovery. TEST FOR E.COLI AND TOTAL NITROGEN: Water was tested for E.Coli and total nitrates on Feb. 8, 1988 E.Coli 0. Total Nitrates 0.33mg/1. Max. allowable Total Nitrates 10mg/].. TEST RESULTS: This well meets the requireme~]ts of the Municipality of Anchorage. THIS WELL WILL PRODUCE MORE THAN 3 GALLONS PER MINUTE FOR MORE THAN FOUR HOURS The Municipal requirement for well flow is 150 gallo~s of water per bedroom per day. This well exceed this requirement. The assessment of the condition of the well applies only to the conditions as of the day tested. The flow rate may change due to subsurface conditions that may not be observed from the surface, and changes in the land use and other factors that may impact the aquifer feeding the well. MUNICIPALITY OF ANCNORAGE DEPARTMENT OF HEALTH AND ENVIRONIVlENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CER-I IFICATE OF INSPECTION FOR I-IEALTH AUTHORI]-Y APPROVAL OI- ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFER MA'I'IC, N (a) Legal Description (include lot, block, subdivision, section, township, range) T12N R3W Section 15 Lot ]23 S~ Location (address or directions) East 101 & Pacer (b) Applicant Name _E.'_L~B_~_Lm.g_ardner Applicant Address Telephone: Home 345-1089 Business 522-1030 (c) Applicant is (cbeck one): Lending Institution []; Owner/builder []; Buyer []; Other [,~x(explain); _ Real estate agent (d) [endinglnstitution Alaska Mutual Savings Address Telepbone 349-5800 (e) Real Esthete Company and Agent Address ..................................... Telephone (f) Mail the HAA to the following address: YYPE OF RESIDENCE Single-Family ~x MultFFamily Number of Bedrooms Four Other WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from tbe State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite ~kx Public [] Community [] Fielding Tank [] Note: If community well system, must have written confirmation from tbe State Department of Environmental Conservation attesting to tire legality and status. 72-025 (I 1/84) Page 1 of 2 ENGINEERING FIRM PROVIDING INSPECTIONS, TFSTS, FILE SEARCI'I, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date sl~own 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 tbe number of bedrooms and type of structure indicated herein. I furtlqor verify that based on the informatioe obtained fi'om the Municipality of Aachorage 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 tl~is inspection. Name of Firm Telephone Address Date This Department has received and reviewed the as-builts of the new on-site sewer system as per the conditional approval of November 11, 1985. This property now meets with MOA requirements and codes and is approved. Engineer's Seal D I'IEP APPROVAL Approved for Four(4) Approved xxxxxxxxxx bedrooms by Disapproved Terms of Conditional Approval '"~?"' '""-¢" Date Coaditional December CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solel)/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 ceurtesy 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 cerfificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 MUNICIPALITY OF ANCHORAC:E DFPARTMENT 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 -~ (b) ~f' (c) 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name ,.. Applicant Address Telephone: Home .~.~T~/~- Business Applicant is (check one): Lending Institution 13: Owner/builder B' Buyer El; Other]l] '(explain);"/ .o,.-,- . .../zyZ~ ~_z'¢¢-,6-~-- ' // Cd) Lending lnstitntion ~t~-.h.-~k-LL'~.('-k-.E Address Real Estate Company and Agent . -~> ,'., Address (e) Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family~ Multi-Family [] Other Number of Bedrooms _ l-/ WATER SUPPLY Individual Well¢ Community [] Public [] Note: If community well system, must have written confimration from tho State Department of Environmental Conservation attest n~ to the legality eno status. SE:WAGE DISPOSAL 0''Sit~ ~· Public [--I Community El Holding Tank U Note; If community well system, must have written confirmation from the State Department of Environmental Conservation alt6atin9 to the legality and states. ENGINEERING FIRM PROVIDINg. .~ISPECTIONS, TESTS, FILE SEARC, H, DA, AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this I-lealth Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adeq aate for the number of bedrooms and type of structure indicated herein. I further verify that based on the reformation obtained from the Municipality of Aechorage files and from my investigation and inspection, the on-site water supply and/or wastowater disposaJ system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm . _/~. (~'.-~ ~,- CL. Telephone Date Approved for /~/~"/~'~ bedrooms by ~(~-.¢~.J ~-~' __Conditional 4~ Approved ~ Disapproved , ~ .... Terms of Conditional A~proval ~.-- CAUTION The Muncipality of Anchorage Department of Health 8nd Environmental Protection (DHEP) issues Health Authority Approval certificetes 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 ol homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DlflEP do not conduct inspections or analyze data before a cortificate is issued, The Municipality of Anchorago is not responsiblo for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHIFCKLIST- FEBRUARY 1984 264-4720 IVIUNICIPALIrry OF ANCJ'tORAGE D~p'& OF Hi~AL~H & NOV 0 WELL DATA _____ D.E.C, Well Classification ¢)J~f V'~"~¢ If A, B, C,, Approved (Y/N) Weft Log Present C/N) Date Complet(;d ~/~/~¢ Yield Total Depth _~_[ '~ ~ased to ~l1~/ Depth of Grouting _ Static Water Level _ / ~, ~/¢ Pump Set A~ Casing Height Above Ground Electrical Wiring in Condui (~N) Separation Distances from Well: '~¢~ To Septic/Holding Tank on Lot Sanitary Seal on Casing~C~N) Depression Around Wellhead 130 / '~ ; On Adjoining Lots "~/'¢'¢ "'"~' 4'¢'To Nearest Edge of Absorption Field on Lot __/ To Nearest Public Sewer Line ~ Cleanout/Manhole _ Water Sample Oollected by _ Water Sample Test Results Comme~ts ~.~ On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot 4/¢''- ; Date __ B. SEPTIC/HOLDING TANK DATA Date Installed '01"1~[~ ~Size Standpipes ON) _ __ Air-tight Caps ,~Depression over Tank (Y~) Pumping/Maintenance Contract on File (Y/N) Flolding Tank High-Water Alarm (Y/N) J'~-'~ Separation Distances from Septic/Holding Tank: To Water-Supply Well ~'~ To Property Line ~,'2''1 'j~ ~ ~) To Water Main/Service Line Course _'~'/Oo! ~ No. of Compartments Foundation Cleanout (Y,~ Date Last Pumped ; for Temporary Ho ding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Page ~ of 2 72-026(11/84) ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of F'ield Square Feet of Absorption Area Depression over Field (YO 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 Type of System Design Length of Field ~2/~ / Depth of Field ~¢~ / Gravel Bed Thickness ~:~ / Standpipes Present~C~N) Date of Last Adequacy Test TO Property Line 0~.~ To Existing or Abandoned System on ; On Adjoining Lots .~-,~z¢ To Cutbank (if present) · t-I ~0 To Driveway, Parking Area, or Vehicle Storage Area Comments ¢¢'/'~./-.~'¢~.,,,"k~..~"'" ..,t~.~ ,~,~ -~- · - , I // · '- LIFT STATION ~ Dimensions ~ Vent (Y/N) __ Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) _ Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for ** Check Permitted Bedroom Bating Against HAA Request ** I certify that I l].~/e checked, v~ified, or conformed to all MO/A and P/AA guidelines in effect on the date of this inspection. Signed ~///~~/'*"~Date /~/"~ ~/'(~'~. ~'~ ' Company ~)~ ~ .,- MOA No. Receipt No. ~%~ ~