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Home My WebLink AboutT12N R3W SEC 33 LT 141A MUNICIPALITY OF AN(;HORAGE ,?'~,~ DEPARTMENT OF HEAl.TH & ENVIRONMENTAl. PROTECTION ,I~ ENVIRONMENTAI~ ENGINEERING DI\/ISION 825 L Street- Anchorage, Alaska 99501 Telepi~one 264-472_0 ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WEI. I_ INSPECTION REPORT _"~A'~'E~"I (~ ....................................................................... ~.~_ [ ~ L-[ ~T,~,~ ..._ ~ ~ ~ ~NEW Ph~n~ ~ UPGRADE MAILINGADD~ESS ~AL DESCRIPTION I.OCATION NO, OF BEDROOMS DISTANCE l'O: DISTANCE TO: No, of lines 'Fop of lile to ElliSh grade Type of crib DIS FANCE TO: Well Depth Crib depth 'NO. Nealest lot line Class Depth Building foundation Sewer line Septic tank DISTANCE TO: Distance to lot Dine OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS DATE LEGAL 72-013 (Rev. 3/78) iHF. I...I.i]'.,]Gi'H [:C[HiEN:~J;:[Cd',~! IS 'I"I.!E i.E.?.4(~r~l <:i:N F:tii:E:'T::, O1:: "I'Ht!:i: I'F;'.IEI'IC:H C"ll:;i: 'iPttZ I:::'Ei:F:'TH L')!:::' F:! "lF;:~i]"!(Zq'"t CIIq: I::':[T ]:'.~; -I'I'-IE~: D]]S'I"I:INI:]:DJ E',E:'i;I.,IE:IEN TI'"JE~' 'E:I.IRFFIIZ]:E I:]ll::' i~l..!!E GJ:~%d. JhE~ F:IrE:, I'HE I~nZFl"l'Ot'q OF:' THE J{~'::lZ]:F¢,,/l::lT]:i]tJ~',J '::Z[i",l FEE't). q"HE: Gt:~ff::I',,,'E:L DE]::'!J[ ]:~:: !'HF t'l :[ Iq J[ l"tlJl'] DEI?:"['H OF (]ff?.F:l'v%L. ~:E:)"[,IEEI",J THE Fff',l[:, iJ'iE: }7437-[OFI Cd::: THE E:"¢CRVFF/'~CIhJ <Z[H F::' ]: F:'E !"!:[i'.J:[Htlhl [::,!:'.i:'i'!:il'.,ll:::E: BEI"Pli:ZEH I::t HELL. I::ti',1[;:, F:Ii".I'¢ Oiq'"S:[!"E :J.Ed2:.l !::'lEE:'!' FOR ,~:1 F'?I:V',:::!t-IZ !,!l:ii:!...t.. O1;;: ;:t.!3Ed 'FO i..IPOl'-,I THE -F"r'F'E[ ElF' F:'UE',L :i; C: ~'ib:[q i"t :[ H I HIJH [:' ! STANCE FROH i::t F:'I~: I "?f:t i'i.~; !'iE:L.L TO t:::l E:Cd'!t'tUNIT"r~ %EI.'.IEI::it L. iI",IE :!::~; 'F'tT:i F:'EECT HE]..).. L OGee; ~:::lf;~[E I:REE:!U ;i: RED F:ff',ID HU:E;I" OF I'i'J!E i,JEi_i. O'I'HEI:;;: l:;~:li~:li:!l..li[¢;irEZl'!E~:l"If'd; HFI"¢ Ff!:::'F'I...'T'. SF'ECi[F:']ZCFIT:[OI",!S F:IND C:EIi'-,!Si"RI.J[i:"F':[CIN t)II::IGI:,;:I::IMS FIIq:IE ffv'F!:[LI:~E&.E 1'O ~:I'.4SIt~;;:E F:'f;~'OF'(;I;;: ~i"f:~;-I"RI]..FTI'):Ot'-,f. l; C:E:!:~'I']LF'¥ l"lil:::fl' :i: ]] FiI'! FFti'! :i: L. :I: F:IF,: 14 :t;-i"11 I 1~[. t:;?.EI;!LI :[ Fi:E:H[i!:I"! l'i:'; F::'OFi: CIt",I-."S ): TIZ; . .,LI. I1: .F..., FIBID HE!_.I...:~:; ~:::, S;E i F:'CiP'm,'~ ~'.~'¢ THE I'".. N :[ ": ! PI:ti_ i' 't"Y [)F: ;:~:: ): },!:[}_}. ]:NS;-!"FII..L. THE ~;'%;'I"E]"I , '~ . ":~ '- )" E'F': --F: t' r, 'i'HF::l'f' '!'~iE; Ot",I-.-:E;]:'T'E; SIEHEF~: ' ' "=' :" :~; ~ G I'-,!E D: F:!F'F:'I.. ]: C:t:::II"t-!' [;'. :i: C:t( I,! ]: L].. :[ F~t"t? i :~};:~:i il:ri:::, IE'.Y i:'l::I ] i~: ............. SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 2 3 5 6 7 8 9 10- 11 oL'~O'~¢j~' ~ C, ZIl'~ s LOPE 13 14 15- 16 17 18- 19- 20- COMMENTS_ WAS GROUND WATER ~0 IS- ENCOUNTERED? ~ IF YES, AT WHAT DEPTH? SITE PLAN P E Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN (minutes/inch) FT AND FT 72-008 (6/79) 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. # (]~\~- -¢~"l-q~)--k,~q. HAA # 1. GENERAL INFORMATION Completelegaldescription ~o¢- I~/ A__/ .~¢c~o,~ '~3., Location (site address or directions) Property owner 3'¢a~,~ ¢ /'<6r~ Day phone Mailing address '8~ oo por cC~[, /,~¢ '~r,c~; i Lending agency /~r~¢~r /'~o~'~,o,~,¢ Day phone Mailing address Agent ff-er,-y p~ ~rz/- ~ R~ I~ p~:,?¢rt-¢,,/ Day phone Address "8~'OO Cor¢/o~,¢, _~¢.,, A,~c. Aora~e. ~< e'~-o.2 Unless otherwise requested, HAA will be held for pickup: NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: NOTE: ' "e_Tg' -~.TKf Individual well ~ - Community well Public water If community well system, provide written confirmation from State AD£C attest- ing to the legality and status of system. 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. 724125 (Rev. 1/91} Front MOA #21 o 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 yvith all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. NameofFirm ~'/~I,~,? 7-ec/,,,;~/ S¢,-c,,¢~ Phone Address 1'~/5'£d2 ¢~,Ao £/.J A,~cAo~-c~¢/~,. .,~/< --?e~-/d Enginee¢s signature ~-~/-~-~Z~,~ ~' ~ Date '3 VS-- / . Cc - ~ac9 ,' ,,~, *F bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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 ti~e State of Alaska. The DHHS does this as e courtesy to purchasers of homes and their lending institutions in order to satisfl/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. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /- o F / ~' / A. Well Data Parcel I.D. Well type ? Log present (Y(~-~ Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 'F FROM WELL LOG Wires properly protected (Y/N) AT INSPECTION g.p.m. ~. ~ I ~7 ~ /5-5- ' If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~ !9~ ~ Driller 6X,~ k' Cased to _/.FO ' ~.,, .~ ~-,~,,-, Casing height /' SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot / 6' ,7 ' Absorption field on lot ¢ I ¢5 ' Public sewer main ;> / o,~ ' Sewer service line ..~ ; On adjacent lots -~. .; On adjacent lots Public sewer manhole/cleanout N. ,~. Petroleum tank iV WATER SAMPLE RESULTS: Coliform O ¢o/ /too ~,,.~' Date of sample:_ 7/DY /95'- Nitrate ~, o,/ mC/-.( Other bacteria_ ^/o.,¢ C011ectedby:_ F-/~,/-/~/~ 7'~,~A,~;~-~,/ B. SEPTIC/HOLDING TANK DATA Date installed ~¢/ ~ ;~ Cleanouts (Y/N) 'f' High water alarm (Y/N) Date of pumping Io/I Tank size I ~--,.~-~ q,c,/ Compartments L/ Foundation cleanout (Y/N) Y' Depression (Y/N) /V. /J. Alarm tested (Y/N) N. ,~ Pumper ,_7 -~' ¢, ~.. £ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 1~'3' ~,-¢,~ ¢.o. On adjacent lots To property line ~/5-' Absorption field Sudace water/drainage Foundation Water main/service line I0' 72.028 (3/93). Front CONTINUED ON BACK PAGE C. LIFT STATION ,N. ,~. 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 LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA Date installed ~'/~' ;~ Length '-~5-' Total absorption area Date of adequacy test Width 5-' 3~g'5- /~/~'/ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Sudace water Soil rating (GPD/FF) ! zZ- ~' /¢,N,',~ System type ~" ~-',~'~' ~,~,,~ ~,,¢/~ Gravel thickness '~ ¢ Total depth Cleanout present (Y/N) ~" Depression over field (Y/N) N Results (pass/fail) P.~'~ for ~' Bedrooms 0 After test IVo,~¢ k,~ o ~,,, .~/ If yes, give date N, SEPARATION DISTANCE FROM ABSORPTION FIELDTO: ~-,~,~ Welt on lot ~ I To building foundation On adjacent lots Surface water Curtain drain On adjacent lots ~ io,~' Property line ~ ~',;' To existing or abandoned system on lot ..'q, A. Cutbank N, ,4 Water main/service line ~ ~o ' Driveway. parking'vehicle storage area ,sd,' E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA date of this inspection. Signature .~-~ d~ ~.'2~ Engineer's Name 7",~ Date D-~(? ?/,, HAA Fee $ Date of Payment Receipt Number 72-026 (3]93)* Back Waiver Fee $ Date of Payment Receipt Number CT&E Ref.~ Matrix Client S~mpTe ID L141A SEC33 T12N R3W N. HOSE BIB Client Name FLATTOP TECHIqIC/%L SRV WORK Order 16564 Ordered By TED MOORE Printed Date 07/27/95 ~ 13:53 hrs. Project Name Collected Date 07/24/95 ® 14:00 hrs. Project~ Received Date 07/24/95 ~ 14:50 hrs. PWSID UA CT&E Environmental Services Inc. Laboratory Division 95.209 -1 Laboratory Analysis Report WATER Technical Director STEPHEN C. EDE Sample Remarks: S~PLE COLLECTED BY: T.F. MOORE. QC Allowable Ext. Parameter Results Qual Units Method Limits Date Date Init Ninrate-N 0.10 U mg/L EPA 353.2 10. 07/25/95 CMR See Special Instructions Above UA = Unavailable ** See Sample Remarks ~tbove NA = Not ~%nalyzed U: = Undetected, Reported value is the practical cfuantification limit. LT = Less Than D = Secondary dilution. GT = Greater Than 200 W. Potter Drive, Anchorage, AK 99518-1605 -- Tel: (907) 562-2343 Fax: (907) 56]-5301 ENVIRONMENTAL FACILITIES ~N ALASKA, CALiFORNiA. FLORIDA, ILLINOIS, MARYLAND. MICHIGAN, MISSOURI, NEW J~RSEY, OHIO, WEST VIRGINIA 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 1. GENERAL INFORMATION Complete legal description HAA # H ¢~/ 9 (-~'Z., Location (site address or directions) Property owner 3-~r-~r Mailingaddress 13o~ SE 3g'f" /r~.e. .~?t- ~., Lending agency ?~zc<J:~c Mailing address ~d'Oo Do~/; Agent £t,~'e/ ~e~,~,~_, Address ~d'OC) ~ ,',¢.Zo ~.. Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: Day phone. . Day phone '~,5',¢ - '7'6'3y Day phone .. ¢--,5-7 -o/s-'7 A-~: 9 %-03 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. . ,: ,., , NOTE: If eommunity wastewater system, provide written confirmation from '$tate 'ADEO attesting to the legality and status of system. 72-025 (Rev, 1191) Front MOA~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 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 ~'('~ Address Engineer's signature Phone ~' ¥,5'-- 135-5- Date ¢c./ ~., /¢e~ DHHS SIGNATURE ~ Approved for Disapproved. bedrooms. Conditional approval for ..,. ~,. CE-8589 .*'.~' bedrooms, with the following stipulations: Additional Comments ", 'The Municipality o!,Anchorage Department of Hes th and Human Services (DHHa) isaues Heelth Authority "Approvel Oertificatas based only upon the representations given in paragraph 5 above by an independent profess!o([alengmeerregistered.., ntheStateofAlaska TheDHHSdoesthisasacourtesytopurchasersofhomes 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-~25(R~w. 1/91) Back MOAt,'21 ' I ~ ~ : I Municipality of Anchorage ,~ Department of Health and Human services HEALTH AUTHORITY APPROVAL CHECKLIST Parcel I.D. Legal Description: L= (- I *tf /~) A. Well Data Well type ¢(/~- Log present (Y~'~ If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~ f?¢~' Driller Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 1 CF Casedto 15-¢./' cc,. 5c,-~e,-, Casing height ~'- Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION g.p.m, r~, 9-- g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot I' Absorption field on lot .2 Public sewer main .~ Ic,¢ Sewer service line -.~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ ¢ol ,/¢c,o ,4.,.~ Nitrate Date of sample:_ ?/'Z~ / 9 yg Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~/ E~ Cleanouts (Y/N) ~ High water alarm (Y/N) Date of pumping Tank size Foundation cleanout (Y/N) fo I ~ /gy Compartments ..Depression (Y/N) Alarm tested (Y/N) N. 4 Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /o~' ~¢/~ (.c,. On adjacent lots '~ ~o~,.,~ To property line HS-' Absorption field ~ 5" Sudace water/drainage ,~,., ~ o ~,' 72-026 (3/93)' Front Foundation . '?~" Water main/service line ';> lO CONTINUED ON BACK PAGE C. LIFT STATION N,/~'. 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 LIFT STATION TO: Well on lot D, ABSORPTION FIELD DATA Date installed ~ r' ,~ ~ Length .¥,~' ' Width Total absorption area ~ ,9~" Date of adequacy test ?? [ ;z~' ? 'f' Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) F/un On adjacent lots Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Surface water Soil rating (GPD/Ft2) Gravel thickness 3' ~ Total depth ¢ ' Cleanout present (Y/N) '~ Depression over field (Y/N) Results (pass/fail) ['o.~ for ~ Bedrooms O After test ~ O t<~ o,~o/~ o/- If yes, give date N.A. SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot ~ To building foundation Onadjacent [dts '7~ ,3o' Sudaco water '-~ too Cudain drain ~Jo n~ E, ENGINEER'S CERTIFICATION On adjacent lots ~ t o o' Prope~ line To existing 0r aband0n~ system on 10t Cutbank N. ~, Water maiWse~ice line Driveway, parking/vehicle storage area HAA Fee $ ~OO Date of Payment Receipt Numbe ~-~'~ 72-026 (;~93)" Back Waiver Fee $ Date of Payment Receipt Number I ced/fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effe~¢~'fCCc~l~,e~c)f this inspection ~ ~*....i ...... ;i~;:. ~ ~' CT&E Ref.// Client Sample ID Mah'ix Commercial Testing & Engineering Co.: LABORATORY ANALYSIS REPORT 94.4867-1 BLM LOT 14lA, SEC 33,TI2N, R3W WATER Client Name FLATIOP 'I'll, ClINICAL SRV WORK Order 82439 Ordered By Printed Date 09/26/94 @ 14:42 hrs. Project Name Collected Date 09/21/94 (¢13:30 lu's. Project# Received Date 09/21/94 616:10 hrs. PWSiD [JA Tectmical Director S'DiPHEN C. EDE Released B y~-~-~ .......... fi'z--~.~,~z ~-~-. ~__ Sample Return'ks: ROUTINE SAMPLE COLLECTED BY: T.F. MOORE. QC Allowable Ext. Aeal Parainctm' P, esults Qual /Jnits Method Limits Dale Date hilt Nih-ate-N 0.10 U mg/L EPA 353.2/300.0 10 09/23/94 CMR * Sec Special lestntctions Above UA = Unavailable ** See Sample Remarks Ab o v e NA = Nol Aealyzed U- [h~&tected, Reported value is the practical q~mntification limit. LT- Less llmn D - SccoBdal'y dilut iolt. Gl'- th'cater 2hah 5633 B Street, Anchorage, Al( 99518-1 600 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 SER'VICES 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. # ¢-"/'~ ~ -- ,~.~ - t ~ HAA# 1, GENERAL INFORMATION Complete leg.al description Location (site address or directions) 8 gOO ?,~'e~?/,~e. 'T~i ! Propertyowner (~zrr _ ~-o /4-~ /-~,n ~'/r4.¢o c Dayphone Mailingaddress ~ R~I ~z~ ~n6%;~ )1900 ~n~ ~ Lending agency ~or ~ (~ ~ Day phone Mailing address. ~¢o~ Oe~¢l;¢ 5~f~ (~j ~, ~ Agent %~'~ ~,~¢ ~ R¢~/ ~ ~1/~, ~ Day phone. %ff%- Y/lC Address ~00 ~~/~ ~( M-~ ~chor~ Unless otherwise requested, HAA will ~ h~l~ for pickup. NUMBER OF BEDROOMS: TYP~ OF WATER SUPPLY: Individual well Community well ~ublic water NOTE: If oommu~ity well s~stom, ~rovi~ wrffte~ confirmation from State ADEC attest-. lng ~o the legality amd stat~s of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Pu~lio sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting ~o the legality and status of system. 72-025 (Rev. 1/91) Front MOA ~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 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 Address Engineer's signature Phone Date Approved for ~ ~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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. 724)25 (Rev, 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: ~/~//J'/ -~¢-'~... 7WT./V., .R.~ /..~' ParcelI.D. A, WELL DATA Welltype I¢'u'}', IfA, B, orC, attach ADEC letter. ADEC water system number Log present (Y(~ c,,~ :%1¢ Date completed ~ 1¢~2~ __ Driller Total depth I ¢~'.~- ' Cased to I.¢'¢ ' ~-...q c¢'~,¢,~ Casing height Sanitary seal (Y/N) Y' Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line '~ ~.~-' g.p.m. AT INSPECTION ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank ~.~ WATER SAMPLE RESULTS: Coliform ~ fcc,( /ic, o ,~,~ Date of sample: I~,/~¢1 Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~'/Io Cleanouts (Y/N) High water alarm Date of pumping Tank size 1 8.s-~',~,~( Compartments Foundation cleanout (Y/N) Y' Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: WelJ(s)onlot tO/ ' Onadjacentlots It ~ ' To propertyline ~/.¢ ' ~ Surface water/drainage Absorption field ,'~ ~od2' Foundation ,~ ' .Water main/service line '7> ~-,5- ' 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION /'4, Date installed Manufacturer Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed (¢/! O / (~ ~ Soil rating ¢ ~---¢ System type Length_ ~5- ~ Width 3" Gravel thickness 30'" Total depth Total absorption area _ 3 ~..~- ~' Cleanouts present (Y/N) Depression over field (Y/N) N Date of adequacy test. I / ~ ~ Results (pass/fail) /'~ ~-'.~-/ for Peroxide treatment (past 12 months) (Y/N) N If yes, give date ~ / bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellonlot ~ I 15" To building foundation On adjacent lots_ '~. Surface water ':~ f o Curtain drain N.// Onadjacentlots '~. fo'o' Propertyline ~ 5'5-' To existing or abandoned system on lot M, ,~. Cutbank_ Ft,.4, Watermain/serviceline '~ 'L,~-' Driveway, parking/vehicle storage area ~ d,~' ' E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on thedate_.of this inspection. Signature. ~_~-~ ~, ~ ' ' ' " Engineer's Name Date HAA Fee $ Date of Payment c:~- /,,.~ /~ ~c:~ 72 026 (Rev 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVIS ON OF COMMERCIAl. TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 ~=.!d,L~U~ ~Ii~L![,'~'~; roi ,Vile,, ~, 50011! ~ ....... - '!'iTL,'t~[?O? ¢}CII~BCJ, b :~1:~ ~-~$ Member ef the SGS Group (Soci~t~ G~nCrale de Surveillance)