HomeMy WebLinkAboutT13N R3W SEC 13 LT 97 S85'
MUNICIPALITY oF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
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 (includ..~l~, block, subdivision, section, township, range)
~i~"~of Tract.~-'/'; Section 13/ TI3N; R3W
Location (address or directions)
520 Pat~,' Anchora.qe, Alaska
(b) Property owner HUD Business
Mailing Address #111-018671-203
Telephone: (home)
W0 #327
(c) Lending Institution GMAC Telephone 562-2181
Mailing Address 460 West Tudor, Anchorage. Alaska - ATTENTION: Terry Corbett
(d) Real Estate Company and Agent THE REALTY STORE/Larry Hardes~y
Address 8040 Opa~~- Cirele~ Anchorage. Alaska ' ~9502
Telephone
(e)
243-1022
Mail the HAA to the following address: (or check here ~, if hold for pick up.
List contact person and day phone number below:
S ~ R FN~,INEERIN~/~94-2979-
170.~ Eog~v ~2u~ Loop Rood: ~u2;~a. ?04
Fag£v R2u~; A£aAba 99577
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
ConSer~,ation attesting to ~h legality and status.· " : ~' ' '
SEWAGE DISPOSAL
On-site [] 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
Health Authority Approval (HAA)
~..¢,~-,,~C~CKLIST - FEBRUARY 1984
[ IVh- h
Legal Description:
A. WELL DATA t~! ~
We,, O,ass,,,cat,on
Well Log Present~ 1'~o Date Completed
If A, B, C, D.E.C. Approved (Y/N)
Total Depth "1,o'v~ Cased to "~¢"~' Depth of Grouting
Static Water Level ~ ~
Casing Height Above Ground
Electrical Wiring in Conduit ~[~/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
Pump Set At L~-~
Sanitary Seal on CasingdC~N) ~//
Depression Around Wellhead (Y/I~
; On Adjoining Lots
Edge of Absorption Field on ~ot ¢1¢~/' ; On Adjoining Lots
To
Nearest
To Nearest Public Sewer Line ~ To Nea[est Pub c Sewer C eanout/Manho e
TO Nearest Sewer Service Line on Lot t'~' ~
Water Sample Collected by ~'¢~'~ ~;~¢"~-'~t~ ;Date
Water Sample Test Results ~/~.~-~-~--¢'~-~'~~ ~ ~, ~
Comments ~ ~'L-'oV~ ~'1~:~--¢17~> ~-
B. SEPTIC/HOLDING TANK DATA .
Date~ 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 Contact on~ ~ ; for __ __ __
Holding Tank High-Water Alarm (Y/N) __~lding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: ~
To Water-Supply Well To B iu Iding Foundation ~
To Property Line To Disposal Field ~
i'o Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments ~::) ~ ~'-~ ~"~
72-026 (Rev, 7/88) Front Page 1 of 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
Dote P,~por~ P~inted: JA~] 26 $9 Q !5:42
Client Sm,plo '[5:L3
('oll~c%~d JAIl 23
/
Special
· i052 Lab Smpl ID: S · b. ix WATER
Allowable
Par amet e): Testad ts~u].t/Units Her hod Limits
}lD(O.iO) ~9/1 EP~, 353.2 !fl
.t Tests ?e~£or~;)~. See Special Inst~uctim~s hbovf Uh~UnaYailsbie
~D~ }Ions Detected '* See San~ple B, mqarks Above
A CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343 5633 B Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
(:>~-PRIVATE WATER SYSTEM
Narn~ & $ ENGINEERING
17034 Eagle Ri.vet Loop Roa~{ No. ~O4
MailiE$9'~R~FCer, Alaska 99577
Phone No.
City State
Mo. Day Year
SAMPLE TYPE:
.~¢'~ Routine
E3 Check Sample (for routine sample
with lab ref. no.
L~ Special Purpose
zip Code
[] Treated Water
L] Untreated Water
SAMPLE
NO. LOCATION
4 I
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
saSiS shows this Water SAMPLE to be:
tisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received t'//'~,¢~ Y-- ~¢
Time Received / ?'~'O O
Analytical Method: Membrane Filter
* No. of colonies/100 mi.
Lab Ref. No. Result*
J
I
Analyst
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER:ANALYSIS RECORD ~'~:~
Membrane FilIe~ Direct Count ~
CoilformllOOml
Verlllcatlon: LTB ~ ~o BGB ~ ?o
CoilformllOOml
Final Membrane Filter Res Its
TNTC = Too Numberous To Count
OB = Other Bacteria