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Home My WebLink AboutT12N R3W SEC 25 S2SW4NE4SE4NW4 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 directions) (b) Property Owner ~'/~ -~/x/~,ff' Telephone: Home Mailing Address /;$'¢/! ,~./~ ' ~~,~./,.~ ~ Telephone (c) L~n.ding Institution . Mailing Address ~-~ ~/' ~''~ . (d)AddressReall~stateC0mpanyandAgent Telephone (e) Mail the HAA to the followin(] address: or: Check here ~old for pick up. List contact pers. pn and day phone nu.m. ber below./ Business 2. 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~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. Page 1 of 2 72-025 fRev 8/86~ Front ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION AS certdied 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, end regulations in effect on the date of this inspection. ~- Name of Firm '"~"~-'~"~ Telephone .~.-~-"~w/-~,~ Date DHHS APPROVAL Approved for ~bedrooms be Approved ~ Disapproved Terms of Conditional Approval ~onditiona~ CAUTION 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. Page 2 of 2 72-025 fRev 8/86) Back MUNICIPALITY OF ANCHORAGE/-~ I '~ 0 I DEPARTMENT OF HEALTH & HUMAN SERVICES CJ ' DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL' ~'~"~/t~'~- ~.~,'"'~ 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 directions) I z~'~// (b).. Property Owner ~'/~/~-- ~'-/,'~/~,~' Telephone:Home ~' Mailing Address /¢?// (c) Leeding Institution - Mailing Address (d) R~al Estate company and Agent Address (e) Telephone ~-.. Mail the HAA to the followina address: or; Check here~], if hold'"'Cor pick up. List contact person and dayphone number below. 2. TYPE OF RESIDENCE Single-Family ~[~ Number of Bedrooms WATER SUPPLY Individual Well.~ Community [] Public I-I Note: If c'~)'mmunity 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 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 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 sate, 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 ~-'/~/- Address /'~-~'D bJ .,~,~ /¢//'~". ,~¢f/~"--¢' z~ /~/ Date Approved for ~"'~'//--~¢~bedrooms by Approved Disapproved Terms of Conditional Approval CAUTION The Municipality of Anchorage Depadment 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. WELL DATA f~M~I~(?~ALITY OF ANCHORAGE (MOA) 5E~V~I~THORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4744 Legal Desoriplio.; ~ Well Classification Well Log Presentl~N) Total Depth /0 Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/~ Separation Distances from Well: To Septic/Holding Tank on Lot ,~,~'////''~;;~' If A, B. C. D.E.C. Approved (Y/N) Date Completed '~3D- ~ ? Yield Ca~ed to, -~'? Depth of Grouting ~--,f" Pump Set At , ' ~--~,,~- Sanitary Seal on Casin ) ~> Depression Around Wellhead (Y~ .Water Sample Collected by Water Sample Test Results To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Comments ~ ~/~' ; On Adjoining Lots ; On Adjoining Lots To Nearest PUblic Sewer To Nearest Sewer Service Lin~ on Lot B. SEPTIC/HOLDING TANK DATA Date Installed ~"~'"?g~' Size /~,7_) No. of Compartments Standpipes(~N) Air-tight Caps''d) Foundation Cleanout(~N) Depression over Tank (Y~) Date Last Pumped /-~ -~'~' ,~,;~ ,~,7~"~ Pumping/Maintenance Contract on File (Y/N) ~/-'dr, ; for Holding Tank High-Water Alarm (Y/N) /J//~ Temporary Holding Tank Permit (Y/N) ~//~ Separation Distances from Septic/Holding Tank: To Water-Supply Wel /O.~ ' To Property Line. /~) To Water Mai~/Service Line / Commems To Building Foundation ~' ~' To Disposal Field /0 To Stream, Pond, Lake, or Major Drainage Page :1 of 2 72-026 IRev 8/861 Fronl C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field To Water-Supply Well To Building Foundation Lot To Water Main/Service Line Square Feet of Absorption Area Depression over Field (Y~) Results of Last Adequacy Test Separation Distance from Absorption Field: //~- /~¢/4-- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Stora~g.g~,~rea Comments LIFT STATION Pump On Level at ~. High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Type of System Design Length of Field ~'~ / Depth of Field ~" Gravel Bed Thickness Standpipes Present&N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots /6 To Cutbank (if present) /d//.~' /0 Dimensions Manhole/Access (Y/N) "Pump Off" Level at ~'""-~ %Ye nt (Y/N) Pumpin~'~'"Gg yc~ during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I h,~che~ed~ ve, fifi. ed, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~ ~"~'"~"--' - Date Company ,'~)'~,~ MOA NO. Receipt No. Date of Payme,t Amount: Page 2 of 2 72 026 fRev 8/86) Back CHEMICAL & GEOLOGICAL LABOK4TORIE$ OF ALASKA, INC. ~5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ~ ~ ~',e;~...~I FEDERAL TAX ID # 92'0040440 '~' '~ ANAL¥8I$ REPORT BY ~AMPLE Client PO~ : VENBAL Req #~ Client S~I)I ID: T12NR3W $NC25 SI/28WI/2NE1/48NI/4 ~1/4 Sample Rec'd : DEC 31 87 Ordered By : CINDY LOVELACE Send Reports To: AECS Work Order No. : 4562 Client Account : AKECb"RP Date Report Printed: JAN 5 88 ~ 11:38 Released By : Reports Address #2 1280 W33RD AVE, STE B ANCHORAGE, AK. 99503 ~ecial COLLECTED 12-31-87 1230 BY A WIEN Instruct: Chemlab Ref #: 8733 Lab Sm~I ID: 1 Matrix= Water Allowable Parameter Tested Result/Units Method Limits NITRATE-N 4.0mN/1 10 Sample ROUTINE SAMPLE Remarks: ANALYSIS COMPLETED: 1-4-88 LABORATORY SUPERVISOR: STEPHEN C, EDE~'~--'' ~ I Tests Performed * See ~ecial Instructions Above ND= None Detected ** See Semele Remarks ~ove NA= Not Analyzed LT=Less Than, GT=Greater Than