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HomeMy WebLinkAboutKNIK HEIGHTS BLK H LT 12NAME MUNICIPALITY OF ANCHORAGE " DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT h'- ~OC~ I [] UP~R^DE MAI LING ADDR~S~ A LEGAL DESCRIPTION LOCATIDN DISTANCE TO: I \, t O Manufacturer Liq. capacity in DISTANCE TO: Absorption area IF HOMEMADE:j~ l~,sidelDwellinglength Manufacturer Foundation lit Material beneath tile Crib depth DISTANCE TO: ({.) No. of lines Length of each~_e), Top of tile to finish grade Length Width Crib diameter Well Building foundetion Depth Driller Building foundation Sewer line OTHER DISTANCE TO: DISTANCE TO: PIPE~ ~"~),'~MATERIALS 4 SOIL TEST RATING iNSTALLER REMARKS DATE LEGAL l ~atDwelling ~---~--~/ idtil PERMIT NO. Material Liquid capacity in gallons Nearest lot line PERMIT NO, 30 -7 ~c> ?S I Trench wid~ ~ hlches inches NO. OF BEDROOMS Lf PERMIT NO. "-7 Fo oe S f No, of compar.~nts Liquid depth Distance b e t wael~il~_e s Total effectiveeb~So~ll~tion~ area PERMIT NO. Total effective absorption area Nearest lot line Distance to lot line PERMIT NO' ~" ~)~O Absorption area(s) Septictank ~ l0 ~l O lql ii'"i · I: :;;' r'!l:: i:;:il?.ix; 1' D!!i?..l(Zi:lii'.::; i'i ii::i't 1'I 1;;:' I,.II(I I I.,.!"' I ,"' ',',, ,1 i;:,Iii:'!::II;;7:'1 Hiii.,!'! !,i]i]!..I !..',E %i.lh',..)'l 7(3 i ri! Pti: 3':: i:::;! [:! '! ?i SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6,650, Anchorage, Alaska 991502 276-2221 SOILS LOG - PERCOLATION TEST PERFORMED FOR: / - 7,~~'-¢'d- /Q LEGAL DESCRIPTION: ,/(%..-/ /'~ I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O [] PERCOLATION TEST . DATE PERFORMED: (':) i' "' ' " SLOPE/ SITE PLAN S WASENCOUNTERED? GROUND WATER IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop (minutes/inch) COMMENTS PERFORMED BY: PERCOLATION RATE DATE: TEST RUN BETWEEN FT AND FT · . -~ : ? ¥~,.~ ~ .. ~ ,- ~'~'~:..2~_~c~ . ~ ~C~-~' CERTIFIED BY: 72 008 (7/7 WATER WELL LOG 1336 Ingra Stre~ Anchorage, Alaska . SIZE OF CA~INGD/.~J DEPTH OF HOLE.~[~T. CASED TO ......... J ....... FT. FEET OF DRAWDOWN. REMARKS /~ o.~Z~ f~ ~ c ,~.K . ~to~ H ~t Om 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. # C)t' ~-'~'--7~ --1'7_._. HAA # 1. GENERAL INFORMATION Complete legal description /_ ~.¢~- ('-Z( ~oc~. (~L Location (site address or directions) j ~il ~ (-D~ ~. co~'~ Property owner Mailing address Lending agency '~''~ t-2 ~_~.~ i~¢z Mailing address Agent Address Day phone C 0 Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: z~ TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TypE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: Public sewer ;:. '' If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Front MOA #21 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-~rS/,J.~o/v~; ~,~-~. ~',~'¢ Phone Address ~'~ 0/"-~ o Y,-. EngineeFs signature- -----~'~~.- Date DHHS SIGNATURE ' ,~ Approved for /Cf_ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of A~'chorage Department of Health and Human Services (DHHS) issues Health Authority Approval certificates"~basc~ only upon the representations given in paragraph 5 above by an independent professional engineer rog stored n the State of Alaska. The DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satis~ certain federal and state requirements. Employes 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. 72-025(Re¥.1/91) Back MeAl CZ1 MUNICIPALII¥ .DF AIN~HgRA~k ENVIRONMENTAL 85RVICE$ DIVISION Municipality of Anchorage JAN , 2¢2 1997// DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division R ['~ C E J V E 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description:_j~/~_/ ~j~ i,4_,vi P'-, i-I"7~ Parcel I.D.: A. WELL DATA Well type Log present (~_Y)N) Total depth Sanitary seal If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to /£,c~. ~ Casing height (above ground) fz/ Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well production WATER SAMPLE RESULTS: g.p.m. Coliform ~ Nitrate Date of sample: !'~ I q'- ¢?~- ¢),. ('Z o Collected by: Other bacteria Number of Compartments ,-- Cleanouts (Y/N)__ B. SEPTIC/HOLDING TANK DATA Date installed ?-¢, Tank size Foundation cleanout ("'~/N) "~ ~i~'¢; .z Depression (Y/N) ~/~) High water alarm (Y/N) Date of Pumping I-1~-~'7-" ! Pumper C, ABSORPTION FIELD DATA Date installed q'- lq -- ~i~;' Soil rating (g.p.d./fF o~'~'~/~-~-~'m~ ! ? Length :/-~ ('~)/¢/¢& W dth ;.~' ~ (R) Gravel thickness below pipe Effective absorption area System type '.~ ~lZ) _Total depth Date of adequacy test i "1 ~)'F (~ ~ Monitoring Tube present (Y/N) '~(' Depression over field (Y/N) Results (Pass/Fail) ¢f),-~_t For x'( bedrooms Fluid depth in absorption field before test (in.); /W .... Immediately afterb~';* gal. water added (in.): Fluid depth /O~' (ins) Minutes later: //,/~-iL2 Absorption rate =.¢/T~ ¢0~ g.p.d. Peroxide treatment (past 12 months) (Y/N) I,,)f,4,1~ ,,4/c~,~,-~,~ If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed / Size in gallons " or)" level at*-"' Manhole/Access (Y/N) _ .p. ...... ' High water alarm level at*, .................... turn C.y..c. Jes-te~t~ E. SEPARATION DISTANCES "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on tot / Absorption field on lot Public sewer main '"'~' (' Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: · .p. ~Z~' Foundation Propertyline ¢~"l~ /~- Absorption field Water main/service line '2~S-'i' Surface water/drainage / ~'o'~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIEED ON LOTTO: Property line Surface water Curtain drain Building foundation .~.~ .LG ¢ Water main/service line Driveway, parking/vehicle storage area ~ / Wells on adjacent lots /(~ '~ ENGINEER'S CERTIFICATION ,.,.,:'?; ':'- I certify that l have determined thru field inspections and review of Municipal a~O(/esys~erns are in conformance with MOA HAA guidelines in effect on this date. Signature ........ >.~,'"~'~,~'-4 Engineer's Name '<.-~~ Date HAA Fee $. Date of Payment Receipt Number 72-026 (Rev, 3/96)* Waiver Fee $ Date of Payment Receipt Number m,CT&E Environmental Servioes hlc, CT&E llef,# Client Name Project Name/# Client Sample ID Matrix Ordered By PWS1D 970294O01 Paimon¢ Eng Stw', LI2 BH Kllik Outsid~ HuseBib Drinldl~g Water Sample Remarks: Nitrate-N Total OoL~form 0,1~0 0 Client PO# Prit~ted Date/Time 01/22/97 14:37 Collected Date/Time 01/19/97 12:15 Received Date/Time 01/20/97 ('18:20 Tec}mical Direclor: Stephen C, Ede PaL Unlt~ Method 0,100 mg/L ¢ol/tOOmL SN18 4500-}~03F 10 ma~ $M18 92225 0~/21/97 J~L 01/20/97 TAV 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 Parcel I.D, # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 017-372-12 HAA ft HA930108 1. GENERAL INFORMATION Complete legal description Lot 12 Block H Knik Heights Subdivision Location (site address or directions) 13041 Rtdgewood Drive, Anchorage, Alaska 99516 Property owner Robert & Patricia Harik Mailing address Day phone Lending agency City Mortgage % Rosalin Mailing address 121 West Fireweed Lane, Agent Charlen Mc Lean % 2001 Realty Address Day phone 277-0700 Anchorage, Alska 99503 Day phone 276.-2001 2600 Denali Street, Suite 400, Anchorage, Alaska 99503 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Three (3) Individual well Community well Public water XXXXXX If community well system, provide written confirmation from State ADEC 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. XXXXXX 72-025(Rev. 1/91) Front MOA~21 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/orwastewaterdisposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. Ifurtherverifythatbasedontheinformationobtained 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 S & s En~;ineering Phone 694-2979 17034 Eagle River Loop Road, Suite 204, Eagle River, Alaska 99577 Address Engineer's signature Date DHHS SIGNATURE .X' Approved for ~ Disappr°ved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments i)~-~lJ i[~] ~ 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. 72-025 (Rev. 1/91) Back MOA ~21 ROBERT SHAFER, P.E. ROGER SHAFER, P.E. Ju~e 18~ 1993 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTN AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. Box 196650 Anchorage, AK 99519 RECEIVED JUN 2 2 1995 Municipalily of Anct]orage Dept. Health & Human Services REFERENCE: Lot 12; B~ock H; Knik Height~ Subdivision A Conditional Health Authority Approval 11, 1993 for the referenced property. Conditional H.A.A. has been completed. Authority Approval. (H.A.A.) was issued on March 311 work required for the Please Zssue a final Health WELL INSPECTION & FLOW TEST If you have any qu~tions or require any additional information, please contact us. T A. SHAFER, P.E. SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSALSYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot 12; Bloc~. H; KypLlz He.~ghts Subdivision Location (site address or directions) Property oWner Mailing address 13041 Ridgewood Drive Anchorage, AK Robert & Patrieia Harik C/O Charlene McLean 2001 Realty Day phone 2600 DencZi St. Suite 400 Lending agency City Mortgage (Rosalin) Mailing address 121W. Fire~ed La~e Agent Charlen McLean - 2001 Realty Address 2600 Denali Street Suite 400, Anchorage, Day phone 271-0700 A~chorage, AK 99503 Day phone 27B-7001 AK 99503 Unless otherwise requested, HAA will be held for pickup. 3 ¼ NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well XX× Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: XXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 fRev. 11911 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/orwastewater 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 Add ress Engineer's signature ,& & S ENGINEERING 17034 Eagle River Loop Road No, 204 E~g!e R!v,'r~ AlisOn 99577 Request a Conditional H.A.A. under the. condition that fill is placed around the w~l h¢~d to achieve. positive drainage away in all directions. Extend we~l casing if necessary to maintain a 12" casing h~ght. DHHS SIGNATURE Phone Approved for bedrooms. Disapproved. Conditional approval for ~ bedrooms, with the following stipulations: TH ',u I ?¢3. I Ox'D/Z-/O/V 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 the State of Alaska. The DHHS does th is 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 w,~rk. (~ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: /__.-OT J~, /~ HI ~--¢UII< /L/Ts,~/-CParcell. D, A. WELL DATA Well type ~.UD/~ ~ Log present.N) Total depth Sanitary seal (~N) IfA, B, orC, attach ADEC letter. ADEC water system number Date completed ,/0 -/~' -':~' Driller Cased to [0~ t Casing height Wires properly protected (Y~ ¢ FROM WELL LOG Date of test Static water level Well flow Pump level g.p,m. AT INSPECTION SFPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~(~C_~ nL Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank /¢~(~/0 ~ /Oo z WATER SAMPLE RESULTS: Coliform O Nitrate Date of sample: ¢'~'~/'-----~ -c~ ~ d/U/'~T-~-c.?-~/::~ Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~- (¢J'- "~r-~ Tank size I~0 G-Pie. Compartments Cleanouts ~) OtdE- ~ ~? ¢..r~o, Foundation cleanout (~N) ~" C.,T-, Depression (Y/~L)~ High water alarm (Y/~_~ /~/~ Alarm tested (Y/r~ Date of pumping ____ ~-Jg-~ Pumper ~L //C¢~- SEPARATION DISTANCES FROM SEPTIC/~G TANK TO: Well(s) on lot l0 To property line ¢~.~ Surface water/drainage On adjacent lots Absorption field lOC 72-026 (Rev. 7191) Front Foundation Water main/service line CONTINUED ON BACK PAGE '----C.. LIFT STATION / ~ Manufacturer ..~~_~ Size in gallons % Manhole/Access (Y/N) Vent(Y/N) ~ '~-~r~ump off" level at High water alarm level Cycles tested Meets MOA electrical co~ ~ SEPAR~E FROM LIFT STATION TO: _~;~W'O~n lot On adjacent lots D. ABSORPTION FIELD DATA Date installed C;:~-/c~-~(~ Soil rating System type _/~ Lengt~tJL~'¢~/~o'~ ¢'~,~' Width . 2/ Total absorption area Depression over field (Y/(~ Results (a~/fail) ~'~¢f% S Peroxide treatment (past 12 months) (Y/~.~ (~© Gravel thickness ~ / Total depth /6 / ~(::,O~--~ F Cleanouts present (~1) Date of adequacy test for ~_. ~ bedrooms b~ ~l'~0t''Jrd If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /~0 ~'~ On adjacent lots /~)/'/Property line To building foundation ,~,~/4 To existing or abandoned system on lot On adjacent lots ~¢¢ Cutbank ~/~ Water main/service line Surface water [,~ '+ Driveway, parking/vehicle storage area Curtain drain ~O~ E. ENGINEER'S CERTIFICATION ¢ ~¢~ I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. HAA Fee $ / ~¢ ~ D Waiver Fee: $ Date of Payment ~ ~/~--~ ~ Date of Payment Receipt Number ~e~--/&~ & ~Z 7~) Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX:(907) 561-5301 Chemlab Re£.~ :93.0656-1 REPORT of ANALYSIS Client Sample ID :DRINKING WATER L12 B H KNIK HTS S/D : WATER Client Name :$ & S ENGINZERING Ordered By :R.J.S. Project Name : Project~ : PWSID :UA Collected :02/17/93 6 17:00 hrs. Received :02/18/93 6 14:20 bzs. WORK Order :63300 Report Completed :02/19/93 Sample Remarks: ROUTINE SAMPLE COLLECTED BY: J.W. QC Allowable Extract Analysis Parameter Results Qual. Units Method Limits Date Date Init NITRATE-N O.lO U ms/1 EPA 353.2/300.0 10 02/19/93 02/19/93 LLH · See Special Instructions Above UA = Unavailable '* See Sample Remarks Above NA= Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT = Less Than D ~ Secondary dilution. GT = Greater Than isa Sl~!~ Member o,,,e SGS Oro.p/Soc,~t* G~n*ra,e de S.r.o,,,anoo/ Application Date GENERAL INFORMATION £: ~ _r (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 12~ Block H I~ik ~.i~¢~ts Subdivision MUNICIPALITY OF ANCHORAGE DEPARTMENT 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 Location (address or directions) (b) Applicant Name ~o~rb F~I-r:ik Telephone: Home Applicant Address ]1308_ ~b. ~ht;j;h~rr] ~r~.,~Anohnr~¢~__._ , ~~.~8 (c) Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain); Business 271 ~46l~ (d) Lending Institution -A.3_~,qa!f'i Address 10]. ~enson~ AnchoraEe~ Aka. (e) Real Estate Company and Agent Address Telephone Telephone - (f)~e HAA to th w address: TYPE OF RESIDENCE Single-Family:[] Multi-Family [] Number of Bedrooms 3 Other 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, Page 1 of 2 SEWAGE DISPOSAl. Onsite iii Public [] Community [] Holding Tank I-1 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status, 72-02,5 111,84) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DA] A AND INFORMATION As cer{ified 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, and regulations in effect on the date of this inspection. Name of Firm h~a~c~n O,gr~,st~J,LOt,~nn f,nbOr.qt',Dz:y Telephone Address P. 0o Box 1~-~623 J~nchorage, &ko Date 1-~30~86 Engineer's Seal Approved f o r ~,~4-~-~ Approved ~ DisapproveY Terms of Conditional Approval 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 (11/84) MUNICIPALITY OF ANCHORAGE (MOL! HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: ~rlui~i~it'~LIfy OF ANCHOP, AG~ DI~PT, OF HEALTH & "NVIRONMt!NTAL PROTEcT/oN RECEIVED WELL DATA Well Classification :b~div±du~l Well Log Present (Y/N) Total Depth 2481 Cased to 3_08 Static Water Level Unknown Casing Height Above Ground Electrical Wiring in Conduit=(Y/N) Y Separation Distances from Well: To Septic/Holding Tank on Lot ]-]-~ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line 1~,/~ Cleanout/Manhole N/A If A, B, C, D.E.C. Approved (Y/N) Date Completed _lO~'] 4-?~ Yield Depth of Grouting JJnk'no'~;r~ Pump Set At Unknown Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) (See ; On Adjoining Lots 200 ; On Adjoining Lots 200 To Nearest Public Sewer To Nearest Sewer Service Line on Lot N/A Water SampleCollected by R. Mark Hnn,~en; P, E, ;Date 'J-29-86 Water Sample Test Results S~tisf~otor.v Comments 4 hz'.. pumping test cond;~cted 1-2_9~86o Average, flow wgs 4~3 ~pm for first 90 min. during dra~down, ~'md 2.8,~ Epm for rem~ininE l~O m±n. B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Y._ (one) Depression over Tank (Y/N) N Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: 9-19-78 Size ~1.2¢0 gal,, No. of Compartments 2_. Air-tight Caps (Y/N) _Ir Foundation Cleanout (Y/N) Y Date Last Pumped 9-2~-'~,,.8~ N/A ; for N/A Temporary Holding Tank Permit (Y/N) To Water-Supply Well 115' To Property Line 17 To Water Main/Service Line 2~one Course Non~, Comments To Building Foundation 2-9t To Disposal Field i~ I .~ To Stream, P~)nd, Lake, or Major Drainage Sept±c Tank and ~bsorption treDch were prem:Ltted for 4 bedrooms Reapproval 12-~3 w.~s for 3 bedrooms~ Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 9-19~78 Width of Field Unknown Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well 120~ To Building Foundation Lot None Observed 12.~ Type of System Design Length of Field 40~ Depth of Field 16~ Gravel Bed Thickness 7 ~ $60 Standpipes Present (Y/N) N Date of Last Adequacy Test S~'bisf~o-boz~y (see comments:) To Water Main/Service Line N/A To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Adequacy test: Trench Y' (c,n¢.) 1~29-86 other $8'~roperty Line 1~"~ To Existing or Abandoned System on ; On Adjoining Lots ~0~+ To Cutbank (if present) None None' Observed Added 780 gs,]., w.ater in ~$ hr, with ~fi.nimal rise in water Ievelo No rise in water level during l~st 2 hours of water additiOn. D. LIFT STATION N/~ 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 h_g.ave checked, ver. i~ed, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed~~_-~. Date /' '/' ¢,4' ~ Company Alask~ Construction ~Rr~ot.°rY Receipt No. Date .of Payment Amount: $ Page 2 of 2 72-026 (11/84) Engineer's Seal INVOIr'E R AND I)RAIN P.O. BOX 4-2841 PHONE 345~2513 CLEANING SERVICE ANCHORAGE, ALASKA 99509 Job Address DATE I SALESMAN ROTOR ROOTER SERV!CE CALL HRS. STEAM THAWING HRS~_~ TRIP CHARGE HRS. OVERTIME CHA~GE HRS. A_DDITIONAL LAf~O__R C~I_-IARGE r¢~ PUMPING SERVICE PLUMBING REPAIR_ CHARGE MATERIALS TERMS -- 30 DAYS , [ CUSTOMER ORDER # PLEASE PAY FROM THIS INVOICE TOTAL APPLIC FILLS OUT UPPER HA[. ONLY Mailing Addre~ /'3~ ,j ~'-' ~ ~2Z~/~Z~I] Buyer , , ~. [~¢ /,_/gbj(~(7 !~,,?~ .... . . Address Zip Code Zip Code Phone .,~ -~ .g. Lending Institution Address Realty Co. & Agent Address Zip Code Zip Code Phone Phone Legal Deseription ~- ~' /Z~. ~- Type of Residence ~ngle Family ~ Multiple Family No, of Bedrooms ~ Other // ._.rog ,h/¢ Wa~ter ~pply UC,~lhdividual ATTACH WELL LOG, A we;I log ie required for all welle drilled since June 1975, I~ Community For wells drilled prior ~o that date, give well depth (attach log if available), [] Public Utility Sewer L~d~ndividual ~ Public Utility [] Holding Tank Year Individual lestalled: //y When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. e Time Time Time Date inspector Date Inspector Date Inspector inspector Field Notes: (~: ) APPROVED BEDROOMS ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' DATE ~ ?- ~ ::~ :'~-% BY: MUNICIPALi'ry OF ANCHORAGI p.r.t~r ~ ~_ ,, *CONDITIONS OF APPROVAL Soils Rating Date Sewer Installed Well To Absorption Ares Well to 'rank Well Log Received Septic Tank Size Lot !2, L~lr)Ck 4, l{.nik ]ici,]i~t,'.~ .3dbdJ. vi. sion ;Jincor~.ly ~ MUNICIPALITY OF ANCHOR~'~-GE MUNICIPALITY OF ANCHORAGE DEPT. OF l::-k, LTi l &  DEPARTMPNT OF HEALTH & ENVIRONMENTAL PROTF~',~NMEN1.AL PEOTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION JUL 1979 Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER A ' DIRECTIONS: Complete all parts ce page 1, Incomplete requests will not be processed. Please allow ten (10) days for processing, I. PROPERTY OWNER PHONE PROPERTY RESIDENT (If different from above) / PHONE PHONE MAILING ADDRESS 3. LENDINGINSTITUT~ON ~ PHONE 4, REALTOR/AGeNT ~ PHONE' MAILIN~ ADDRESS 5, LEGAL DESCRIPTION STR E E.T LOCATION 6. "I~PE OF RESIDENCE ~ SIN6LE FAMILY MULTIPLE FAMILY NUMBER OF BEDROOMS [] One [] Four [] Two [] Five '~.. Three [] Six Other 7, WATER SUPPLY INDIVIDUAL~ [] COMMUNITY [] PUBLIC UTILITY ATTACH WELL LOG. A well Icg is required for all wells drilled since uune 1975. For wells drilled prior to that date, give wel depth (attach Icg Jf available.) B. SEWAGE DISPOSAL SYSTEM "'~' iNDiViDUAL/C N.SiTE*~ Z~] PUBLIC UTILITY ** f individual/on-site, give installation date //~ '-.l-- 7 ~ f systerr is over two (2) years old an adequacy test is required by this Department, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR I NSP ECTOR DIRECTIONS: 1, TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE E~] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED-- 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [~ INDIVI DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY ~'~ Connection Verified INSTALLER [] Septic~Tan,~p~r E~] Holding Tank ¢~ Size:_!¢~.~ ~' If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTIQN AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line I WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS [~'~APPROV E D FOR .~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY {T~e (,,,.._ LEGAL DESCRIPTION 72-010 (Rev, 3/78)