HomeMy WebLinkAboutT13N R3W SEC 26 NW Corner SW4 NE4 3271 Baxter Road
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ¥'~1~- o ~'~
OF ON-SITE SEWER AND WATER FACILITY
264-4720
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (~ddress or ~irections) ~
(b) Appl~cantName~i~O~ ~P~$Te~ephone:Home ~ ~O Business
Applicant Address ,~1! '~ ~ T~I~
(c) Applicant is (check one): Lending Institution ~; Owner/~r~; Buyer ~; Other ~ (explain);
. . . ¢
(d) Lending Insbtutton Telephone
(e) Real Estate Company and Agent
Address
(f)
Telephone
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family.~ Multi-Family i-1 Other
Number of Bedroomsf
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 Environmental Conservation
attesting to the legality and status.
page 1 of 2 72-025 (11/84}
ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DA~A AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of thi's 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
Address ?~::;, 0 J
Date ~ ~ I~'~
DHEP APPROVAL
Approved for ~
Approved .~ i Disapproved
Terms of Codditibnal Apprqval
· bedroomsby ,~~.~ ~'~Date /~ -/"/-'~'
Conditional
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates 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 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 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 (I 1/84)
N01 THERN TESTING LABORATORIES, INC,
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907-479-3115
6957 OLD SEWARD HIGHWAY, SUITE 101 ANCHORAGE, ALASKA 90518 907-349-8623
TO BE cOMPLETED BY CLIENT
yPRIVATE WATER SYSTEM
NAME ~
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETE? BY LABORATORY
Received at:,,~ Anch. [] Fbks.
Mailing Address
Ci~ State Zip Code
SAMPLE DATE: /~"~ Phone
Mn. Day Year
Purchase Order No.
SAMPLE TYPE:
~1~ Routine [] Treated Water
[]' Special Purpose [] Untreated Water
[] Check Sample (for original contaminated
sample with lab reference no.. )
10
Signature of Representative
CASH CHARGE
FOR LABORATORY USE ONLY PICKUP
Time Received /O ~ 4'~
Next Sample Due
COMMENTS:
SATISFACTORY ~
UNSATISFACTORY U
RESAMPLE R
OTHER BACTERIA OB
TOO NUMEROUS TNTC
TO COUNT
Direct Verification Final
C~ LSS BGB Resuif*
comments
_~.~al Coliform Colonies per 100 mis.
Time
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Date Completed
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
t4~CKLIST- FEBRUARY 1984 ~jlzJ.~OODic~zf2~. '/~"/~r
264-4720 ~~/~ /~ ~ ~'o~
~'~ LegalDescription: ~ ~ *Z~ F/~
I~A, B, C, D.E.C. Approved (Y/N)
/~ ~ ~ Yield ~ .~
Total Depth III' ' Cased to III '
Static Water Level ~ '~' '
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
Depth of Grouting
Pump Set At /g~'
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line -¢' /~O '
Cleanout/Manhole -~/~ cc ~
Water Sample Collected by ~:~ ~'"'~',
Water Sample Test Results
Corn ments%4' ~c~ ~-- 4.(L- /5
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sea, er Service Line on Lot
;Date '~-';"~"~' ~
; On Adjoining Lots
Size No. of Compartments
Air-tight Caps (Y/N) Foundation Cleanout
Depression over Tan-~:'~V/N) __ Date Last Pumped
H~g -Water Alarm (y/N)~--- Temporary,.,~ding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:"~"'~~¢"'~ . -.
To Water-Supply Well ~.¢.¢~ T~g Foundation
To Property Line ~ To DisposaFFie did~
To Water Main/Service Line~ ~
Co urs~.~_~.,-J
Page 1 of 2
To ~,~aY~l,~.Pond, Lake, or Major Drainage
72-026(11/84)
ABSORPTION FIELD DATA re"') 0 ~'' C'¢,~'"~' ~'~'J ~"'/~"'*"
~5~Rating in Absorption Strata
Date In~d ____
Width of Field,
Square Feet of Absorption ~
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
Drainage Course
Area, or Vehicle Storage Area
To
To Driveway,
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present
Date of Last Ad, , Test
To Property Line
To Existing or Abandoned System on
; On Adjoining ~
To Cutbank (if p"r~nt)
D. LIFT STATION ~L.¢. (~ "~'"'
'Purnp On" Level at ~ "Pump Off" Level at
High Water Alarm Level at
Tested for ~ ~"Pt~cles during Adequacy TesL M~eis MOA
Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and
Signed ~ ~'c~.~,..,,...~ Date "~T,"~.~ '~t '/~¢¢"~
Company (~/~ ~ MOA NO. ~ ~ '-¢~'~
ReceiptNo. /0 ¢ / 0 0 ¢~
Date of Payment [~/Z/~~
Amount: $ ~%~
HAA guidelines in effect on the date of this inspection.
Page 2 of 2
72-026 (11/84)