HomeMy WebLinkAboutPALOS VERDES BLK 3 LT 1I
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
D~VISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
Legal Description (include lot, block, subdivision, section, township, range)
f.,~-h. 1 B_lock 3~ Pa]os Verdes T14N; R2W~ Section ]_2
Location (address or directions)
;c) App!icant is (check one): Lending Institution []; Owner/builder/.~Buyer []; Other [] (explain); _
Lending Institution ~'~/~Qk E)~_
Real ~state Company and Agent
Telephone
Address
Te!ephone
Mad the HAA to the following address:
.... -P'
TYPE OF RESIDENCE
Sm. gie-Famil~ Multi-Family []
Number of Bedrooms -~
Other
WATER SUPPLY
.,.,.., .~_.. d, -' Well ~ Community~, Public [] Og;c . £~,.,.,~/.~..~_ /~ ~¢-
h;o:e: ~f community well system, must have written confirmation from the State Department of Environmental Conservation
attes:~r, 9 ~o the legality and status.
SEWAGE DISPOSAL
Cr, s,te [] Publi~""~ Community [] Holding Tank []
~,;o~e: If community well system, must have written confirmation from the State Department of Environmental Conservation
a.:.tes;~n.9 to the legality and status.
Pa~'e 1 of 2
72 025 (11,84)
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 verity 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 Telephone
Address EAGLE RIVER ENGINEERING SERVICES
Date
EAGLE RIVER, Al( 99577
P;-OTBOX-7¢329-4-
6¢4-5195
Engineer's Seal
Approved for ~~'room~by
Approved /_~/' Disapproved/ ' ''~ / Conditional
f ond,t,on~l~al
Terms o C ' ' PP
Date
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEF) 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
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description:
WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding 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
If A, B, C, D.E.C. Approved (Y/N) Y
Date Completed Yield
Cased to Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On.Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
Comments
SEPTIC/HOLDING TANK DATA/¢///~
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
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
To Water Main/Service Line
Course
Size No. of Compartments
Air-tight Caps (Y/N) Foundation Cleanout (Y/N)
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream,' Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Type of System Design
Length of Field
Depth of Field
Square Feet of Absorption Area
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
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
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 ~;::~¢"~ ~ Date
Company ,~-~/~ ~' -'f' MOA No.
Receipt No. ~Sq~4q
Dateof Payment~ ~'J-~L~' ~
Amount:$ ~,~ I Engineer's Seal
72-026 ( 11/84)
DEPT. OF ENVIRONMENTAL CONSERVATION
BILL SHEFFIELD, GOVERNOR
TelePhone: (907)
Address:
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
274-2533
TO Whom it May Concern:
According to records on file in this office the m~/~
}(_xWater System is in compliance with the State Drinking
Water Regulations
Sincerely,