HomeMy WebLinkAboutMOUNTAIN VALLEY ESTATES #1 BLK 3 LT 11
MUNICIPALITY OF ANCHORAGE
DE ITMENT OF HEALTH AND HUMAN SER' ES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name
Addless
Phone(s) ] Porm~t NO. JNo. ol Bedrooms
LEGAL DESCRIPTION
~, SEPTIC [] HOLDING
/F,~./~: j~'. /o ~ £>
.~' ~-~_ 1
TYPE OF SYSTEM
~TRENCH ~ BED ~ W, DRAIN ~ OTHER
o,~,,.,g,~d~ '~ F'r ~ FT
Fill added above ongmal grade Gravel depth beneath pipe
~ 0 - FT FT
~ ~'0 SO FT
/~ /~'~ s~ FT
Installer
WELLS
PRIVATE [] OTHER (Identity)
'fold Depth FT Cased to
Date Inslalled:
FT
REIVIARKS:
DISTANCES
'~R~ SEPTIC ABSORPTION
TANK FIELD WELL
WELL I I ,,') *1 ~ o
LOT LINE o/- "- G'o / / ~ ~
FOUNDATION g6 / +. ~_ i ,20/
AS-BUILT DIAGRAM (Snow Iocanon of well, sepUc system, properly lines. Ioundanon,
Municipal and Slate guidelines in ellecl on this date:
Health Department Approval:
72-013 (3/85)
Inspections Pertormed by: /, ,
I
~C~.'' :,~°'~' ~ :
~, ... ,,, 1' .,0
r.',' : ,, ?' ~,:'::~ '.?' ~ ',-
cerlilythalthisinspeclionwasperlornledaccordingtoall .... / q;::;'"?J,?,. ?,.,:,
I .C] T ~!!; ]: Z E ,",
MAX B[.}::DF;:OEiMS:
DIZAN I]ONSTRUE~TIOI'..I
!~:;RA BO X 9:2!;~;;.',~ W I I....[) M]'lxl
EAGLE': RIVER, AK 99'577
SUBD I V I S :1: (:IN: H]"N .,, VALLIZY E!:dITATE.C3
,'-3EC"I" I ON: 33 TC)WI',ISId :[ I=': :~. 41',t
1.5A (!~;gL. F'T'. OR ACIRL=.':S)
3
L. OT: :1. 1
IR A N G E: 1 W
BLOCK:...,
Listed be:l.c:)~ a.r't.}:.~ 'Lhe (=,p'Lic)ns avai:l, al::):l.e 'L(:~ ¥(::)u J. Fi (::[~!!i~:i.(~tf]J.l"'~i~ yC3LLP ~?ff:.:-:,[:)'iL:i.~:::
.:.~ys'Lem. Cl"t(::)c)se the opt:i.c:,rl tha'L best f:i'Ls ye, ur' sJ.'Le.
Dlili:I=:"T'H 'T'C] I=' I I='E BO]'"I"OM (I= '1
(:{;RAVIZI... )]I]!:P']H CF'T.
]'O'T'AI.~. DI~:I:::'"['H (FT.)
GRAVIZI.... WI DTH (F:'T.
GRAVI~:I.. LIZNGTH (FT.)
GRAVEl.. VOI..UMIZ ([:;U, YDS.
'I'ANI< S:I:ZIZ (GALS)
SOIl.... RA"I'ING (SQ,, I:::'"1",, /BR)
'~".~'? DEI::'TH ]'0 I:::' ]: F'E BO"['"I"[)M < . ::!!;. ~,:!:; I:::T. I':~EI]!U I RES I NSLILAT I [)1".1
~...~.DI~i!I::'"I-I..j '1"0 I"11-'t~::. BOTTOI"J < 4. :':' t::'"1",, MAY REQU:[RI}ii: A I...II:::T !~TATIOI',I
· ~"~ 'T'AI',II< I II.J~:l HAV.~: AT L. EAST 'f'WO (::;OMPARTMEN"I]ii;
I c e r' 'L :i. f' y t. h a'L ,",
1 ,, I am f' am .'i ]. i a t'. w :i. t h 'L he r' equ :i. i~ emen t s f' c)i" (Dn.-..~ i ~LE'? t~iE.~H,'JE~ P ~L9 f:Al"i(J ~,.JE~) ]. ], ~;, ,':':'~E~ ?~f':':'t
,';:~,,I Wi].]. :i.I]Sti:;~].]. 'L}'i(~;~ s,/s{em in acc(z)r'dan(:::e with all MOA [::(::)(:J(~:H]t;
and :i.n comp].:i.a',.rtce with the desigri cr':i.'Ler'ia (::~f 'Ll't:~s pepm:i.t.
3, I ~J.].l a(::lher',.~ to ali. MOA al-id f]t,;~v[:.~z~ (;)f' Alaska requii'emc~nts f'c3l" the set back
s(:~.,~er'age sys'~.,:~)(~ (3J'~ 'Lb :L s (:)P arty ad.j a<::ent (:H' i'1~.:.taPby ].o'L.
z].,, ]: L.H]C]f{~P~;'~.~U]Cl '[LI]6~V~. '~.h].~ per'miT, is val:i.d rcm a iil~A)-~:~liiL.ffil f3{'
Il:::' A I..IF:'T S't"A"I'[ON ~}~ IN.:~ [AI....L.~:.D IN AN AREA. COVERED BY HOA BUIL.DING E.[.)DI:::.,:,,
'IHEN (1) AN EI...ECTF;:IE;AL PERMI]' AND INSF:'ECTION I*11..~;"1' BE OB'T'AINED~ (
WILL. NOT BE AF'F:'ROVED WI"I'HOUT" AN EI.~ECTRICAL INSF'EE;'1"ION RI]H::'ORT; AND (:~) THE
ELEC]"R I CAI.... N(]I::~K HLJST BE ..... I')[.)NF' BY A L. "I L,L.I"' '::' xI,..~L. Dc::' ':: E~]...E[;]'I::~ I [; :[ AN ,,
S I C{')NED ~ ~ ~ DA t"E
....... .................. ........................ ......................................
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
DATE PERFORMED:
LEGAL DESCRIPTION:
4
?
'lO
~3
~4
20.-
SLOPE
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
O
P
E
IF YES, ATWHAT
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
P DRG,- O LA-T4O~I RATE
TEST RUN BETWEEN FT AND FT
COMMENTS
PERFORMED BY:
finer Englnaerin~ Services
P. 0. lox 773294
g~gle ~lw~ AK
694-5195
CERTIFIED BY:
,~-DATE:
72-008 (6/79)
([rrlif rh rillin6
b~
DOC Co. dba
SULLIVAN WATER WELLS REI EIVED
P.O, BOX 1170272, CHUGIAK, ALASKA 0§56? * TELEPHONE 888-27§B
OWNER OF LAND ,:' : ~'., '
ADDRESS
LEGAL DESCRIPTION :',:',~ : .... ".~ :'
DATE-Started '" ~,:, ' _ Ended
PERMIT NUMBER
I)EPTtt OF VqELL ~'
ST:\ 1'1(' LEVEL OF' V,'ATEI1 FT.
" I)RAW DOWN FT.
GALS. PER HR ___c=,d;: '
KIND OF CASIN(; d :' ,,.;
KIND OF FORMATION:
From d' Ft. to / Ft.
From / Ft. to ~ Ft.
From :, Ft. to ( '; Ft.
From Ft. to Ft.
From , -_? Ft. to '~iL ~ ~ Ft.
From ' ~;
+ . Ft. to '~ :'~, . Ft.
From Ft. to Ft.
From f, ' Ft. to ."
From Y__J Ft. to.
From Ft. to.__
From~k Ft. to ,, ~-~
From i .Ft. to ; .: _Ft.
From Ft. to Ft.
From i:i Ft. to; ' ~Ft,
From .... Ft. to_ Ft.
From Ft. to Ft.
From Ft. to ....... Irt.
From .... Ft. to ....... Ft
;'/: /;~&:,','~' ":&~' :; [:rom Fl. to Fl.
...... ~UF41CIffA'~i-TY OF ANCHORAOI~
From Fl. Io ~EPT. OF HEALTH &
...... E~I~ONMENT~ PROT~ION
6
1986
Frol~l
~ :,' d From~_~Fl. lo .......... Ft.
From___ Ft. to_ Fl.
From.__Ft. to _____Ft.
Frmn Ft. lo__Ft._
From. Ft. to_ Ft
From Ft. to .... Ft
From Ft. to_ _Ft
From Ft. to Ft.
From Ft. to Ft.
From_ Ft. to Ft
MISCL. INFORMATION:
DRILLER'S NAME
Parcel I.D. #
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 Lot 11; Block 3; MourutccLn Vo?ZZe~ Estates
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
NHN Johnny Dhive
Eagle Rive~. AK
Doug Shalhoob Day phone 696-2032
P.0. Box 772016 Eaqle Rive~, AK 99577
Day phone
Agent Joe, Perozzi/ Red,ax o,~ Eagle River
Address 16600 Center~ield Drive Eagle, Rive,',,
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well ;<×X
Community well
Public water
NOTE:
Day phone 696-2032
AK 99577
NOTE:
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
XX×
If community wastewater system, provide written confirmation from State ADEC
attesting to fhe legality and status of system.
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
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 ~q ~ ~' ~/,, 4,,,, ~ h~/,,, & Phone
Address /~ o 3 ~ ~ ~/v'~M~ ~p/~ ,~/~ ' ~ .~-
Engineer's signature . , ' . .,~ Date
DHHS SIGNATURE
X Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
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 DH HS 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~)25 (Rev. 1/91) Back MOA#21
Legal Description:
A. WELL DATA
Well type te¢-v4,o.,q'¢j
Log present (~) _ ,-/
Total depth ] o o j
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES,,
Environmental serVices Division
825"L' Street, Room 502 · Anchorage, Alaska 99501e (907)
Health Authority Approval Checklist
/
If A. B, or C. attach ADEC letter. ADEC water system nnmber
Date completed ~ ~ ~
Cased to ~o, 3 ' ~, ~, Casing height (above ground)
Sanitary seal
FROM WELL LOG
Wires properly protected,l~q)
AT INSPECT[ON
Date of test
Static water level
Well production /0, 0 g.p.m. /, ~ g.p.m.
WATER SAMPLE RESULTS:
Coliform 0
Date of sample: ] -,,Tt ~' ~-- ~ 6,
]~I~'}HOLDING TANK DATA
B.
Nitrate
Collected by:
Other bacteria
S & $ ENGINEERING
17034 Eagle River Loop Road No.
Eagle River, Alaska 99577
Date installed ~' -/4, - 05- Tmtk size /o o O Number of Cotnpartments
Foundation cleanout (~xl) y Depression (¥/g:~ /d High water ahu'm (Y~_
Date of Pumping ! ~,P.? ~? ~, Pumper ,7~"~ff~,,
C. ABSORPTION FIELD DATA
Date installed ~ -! b, ~ ~,,~'-'- Soil rating (g.p.d./ft2 or ft2/bdrm) /5'~ ~/~.~System type ~'7'~/_.-~.~/-/_
Leugth /ao t Width ~ ' Gravel thickness below pipe ~ t Total depth /_.¢ t
Effective absorption area t¢/O O / Monitoring Tnbe presentl~N) V' Depression over field (Y/I~ r.J
Date of adequacy test / ~,9~' & Results ~ail) /~p~'5 For .~ bedromns
Fluid depth iii absorptiou field before test (iii.); O hnmediately after ,.Sra-Cgal. water added (iii.):
Finial depth ? o (ins.) Minutes later: /¢0 Abso~tion rate ¢~a ~
= g.p.d.
Peroxide treatment (past 12 months) (Y~ ~O~ /d~o~f yes, give date ~
D. LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N) ~
High water alarm level at* ~ *Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
~holding tank on lot I ~ t:>~
' On adjacent lots
Absorption field on lot
Public sewer main
Sewer/septic service line
: On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM&E~--"~HOLDING TANK ON LOT TO:
Building foundation la (¢ ~ Property. line } O I d- Absorption field
Water main/service line (o t& Surface water/drainage / oo I'f Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation {? 5" ~ Water main/service line /o t
Surface water leo I ~ Driveway. parking/vehicle storage area
Curtain drain t'J'/,4 Wells on adjacent lots / Oot & Property line
F. ENGINEER'S CERTIFICATION
I certify that ! have determined thru field inspections and review of Municipal records t/_~.qr~t~'cr~vg ~¥~7.~,~' are
m co ~Jbr, a we w~th MOA l[~ guldehnes m effect on thts date. ,~ ~ % ......... 7 ~ ~,
Signature ?f, f~/' ~3~ ~
Engineer's Name ~OBe~ ~ C. Co,~,o ~; ~,$
e',,~;~mr ........ .......... d '~ ~
'~a ~'" "'": "'
............................................................................................................. ~ ~.A~r~2¢z~X~ ~7~ .....
HAA Fee $ ~ ' Waiver Fee $
Date of Payment //O //~ ~ Date of Pay men t
Receipt Number /~/ (~¢ Receipt Number
Rev. 8/95 eSS: haa.wk.doc
MUNiCiPALITY OF ANCHORAGE
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAl.
OF ON-SITE SEWER AND WATER FACILITY
Application Date
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL'~ ,
(a) Legal Description (include lot, block, subdivision, section, tow~ip., range)
Lot 11; Block 3; Mountain Valley Estates '~ J
Location (address or directions)
Johnny Road
(b)
Property Owner
Mailing Address
Dan Berkstrom Telephone: Home
P.O. BOX 775486, Eagle River, Alaska 99577
(c) Lending Institution Western Mortgage Telephone
Mailing Address
(d)
Business
Real Estate Company and Agent RE/MAX OF EAGLE RIVER - Don McKenzie
Address 16600 Centerfield Drive, Suite 201, Eagle River, Alaska 99577
Telephone 694-4200
Mail the HAA to the followinc~ address: or: Check here [~[, if hold for pick up.
List contact person and day phone number below. S & S ENGINEERING/694-2979
17034 Eagle River Road, Suite 204
Eagle River, Alaska 99577
(e)
ordered by Don McKenzie
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 Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72 025 IRev 8/86~ Fronl
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 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 dispo, sal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
S & $ ENGINEERING &?W - ~ "~L-~'
Name of Firm i 7034 ~agie River Loop ~oa~ ~o. ~14 Telephone
Address Eagle ElY, er, Alaska ~577
Date '~-- ~'-- ~ ~
Approved for ,7'"~,,~-~'k,.~)bedrooms by . . _
Approved v/"~ Disapproved Conditional
Terms of Conditional Approval
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-o25 IRev 8/86~ Back
MUNICIPALITY OF ANCHORAI2E
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
FEB 1 0 t988
RECEIVE[)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4744
Legal Description: [.,..-c.~
WELL DATA
Well Classification
Well Log Present ~.~N)
Total Depth
Static Water Level
Casing Height Above Ground /
Electrical Wiring in Condui~N)
Separation Distances from Well:
To Septic/I-4elding Tank on Lot /
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line. Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments ~ \..d/~
If A, B, C, D.E.C. Approved (Y/N)
Date C, ompleted 2/c~5 Yield
Cased to ~,.t~/~-~.¢~- Depth of Grouting
~ Cc ' Pump Set At ,(..-J./cz._
Sanitary Seal on Casing (~N)
Depression Around Wellhead (Y,~
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
~//A-- To Nearest Sewer Service Line on Lot
142C~ /'/"
B. SEPTIC/HOL-DqNG TANK DATA
Date Installed
Standpipes~N) Air-tight Caps ~N)
Depression over Tank (Y/(~
Pumping/Maintenance Contract on File (Y/N)
,/
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
~ ~/f~ ' ~_ Size /(pc, p No. of Compartments ~
Foundation Cleanout ~N)
Date Last Pumped -~/¢/.'~,¢' //~ 0'?~
; for
Temporary Holding Tank Permit (Y/N) nj/A-
To Water-Supply Well //'¢2 r
To Property Line /O
To Water Main/Service Line
Course
To Building Foundation (~, L, /
To Disposal Field / ¢ -- : :
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72~026 fRev 8/86~ Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata /
Date Installed 9 - / ~ ¢ ~5"
Width of Field ,'~ ~
Square Feet of Absorption Area
Depression over Field (Y~_.~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
Date of Last Adequacy Test
Type of System Design / jT...-~,,,J 0-/,.4'
Length of Field
Lc/ ·
Depth of Field
Gravel Bed Thickness c//
Standpipes Present
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Cutbank (if present)
To Property Line C/O /
To Existing or Abandoned System on
; On Adjoining Lots 3o !
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~,,
//IF~ ~,FC. L~,~,
LIFT STATION
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 Lhj~'~,c(~,~l¥~(~fied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
CompanyEagle River; Alaska 9~577 MOA
¢¢
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72 026 (Rev 8/861 Back
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONbiENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date 2/28/86
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 11 Block 3 MOUNTAIN VALLEY ESTATES
Location (address or directions)
NHN Johnny Drive EAGLE RIVER, AK 99577
694 9117
(b) Applicants Name Robert Dean Telephone - Home Business
Applicants Address S R Box 9352 Eagle River, AK 99577
(c) Applicant is (chec~!one) Lending Institution ~ ; Owner/builder ~ ;
Buyer ~--~ ; Other'~ (explain);
(d) Lending Institutiqn Western Mortgage Co. Telephone 694 7872
Address
(e) Real Estate Co. & Agent
Address
None
(f)
Telephone
Mail the ~ to the following address:
Robert Dean
S R Box 9352
Eagle River, AK 99577
2. Type of Residence
Single-Family ~
Number of Bedrooms
Multi-Family ~--~
Other (describe)
3. Water Supply
Individual Well ~ Community ~ Pablic ~--~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the Iegality and status.
4. 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]
5. Engineering Firm Providin~ Inspections~ Tests~ File Search~ Data and Information
Name of Firm
Address
Date
As certified by ~y 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 regula-
tions in effect on the date of this inspection.
~A~LE~IVER EN~NEERIN~ SERVICES Telephone
EA~L~HIVEa, AK99577
P. 0. BOX 773294
U94-5195
DtlEP Approval
Approved for~,
Approved
bedrooms
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HF~LTH AUTHORITY APPROVAL CERTIFICATES BASED~SOLELY UPON THE REPRESEnt-
ATIONS 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 H~ES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORACE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY '1984
264-4720
Legal Description:~ z/bo ~-
MUNICIPALITY OF ANCHoRAGb'
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
0 6 1988'
WELL DATA
Well Classification /Z~ / ¢,,4- T-/~'~ If A, B, C, D.E.C. Approved (Y/N) ////'//~
Well Log Present (Y/N) ,Y Date Completed ~',~'/~*,~¢- Yield
Total Depth /Co / Cased to ,,~O / /'
~' 4¢¢d,','~Depth of Grouting
Static Water Level ,,~o/ /¢e/~,~ 5',~,-¢~,o¢_ PumpSetAt ,zc¢?'yo*~
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) /V Depression Around Wellhead (Y/N)
Separation DiStances from Well:
To sePtic/Holding Tank.on Lot //~2 / ; On Adjoining Lots '"~/~ /
To Nearest Edge of Absorptio.n Field on Lot /~ o / ?// ; On Adjoining Lots 'i'/~'°
To Nearest Public Sewer Line /~d/¢~ To Nearest Public Sewer
Cleanout/Manhole )¢~/O/¢~ To Nearest Sewer Service Line on Lot '~- ;;~- '
Water Sample Collected by L~,)'/e /~,~...i /~,~s~,~¢ ,-,,~' ; Date~/.~//'";E¢',:¢
Water Sample Test Results .S-Z¢ ~/Lr ~¢~ ~"/-o,~ ~-
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N) /b/
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well //¢ /
To Property Line W/b' /
To Water Main/Service Line Y-//D /'
Course ¢/'0"-:' '
Size ./O(_.P~ 0% / No. of Compartments
Air-tight Caps (Y/N) __ /k/ Foundation Cleanout (Y/N)
Date Last Pumped
;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation _~,,2/~/f
To Disposal Field ~%/¢ /
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field -~/'
Square Feet of Absorption Area
Depression over Field (Y/N) /V
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well %/~- d /
To Building Foundation '
Lot ,-'/--/~.
To Water Main/Service Line ¢-/¢
~/~.~ Type of System Design
Length of Field ~ O /
Depth of Field __~,"
Gravel Bed Thickness /-~/
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area ¢'~J'0' ~:~'~-/¢ ¢-~ ~'~'~',/
Comments ,2_,~,~'/,:,~. ~',',,~ ,.¢,:,~, , ,'¢~¢/, ¢,~e~,
,/
To Property Line ¢',~'¢ /'
To Existing or Abandoned System on
; On Adjoining Lots /-~¢..~ /
To Cutbank (if present)
LIFT STATION
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 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date.of this inspection.
Signed ,,~_~.~-..,..--¢'"¢'~Z7~'"'~ ~ ~ -- Date /' .//
Company Z~c'''/~,/-?''¢', MOA No. ~T'Z'~,¢ 6',5'
Receipt No. ~ ~ ~.~'~ c:;j
Date of Payment
Amount: $
Page 2 of 2