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GR~TER ANCHORAGE AREA BOROUOH
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 27~'-2511
" INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
LOCATION
SEPTIC TANK:
LEGAL DESCRIPTION
PHONE
DISTANCE FROM WELl
LIQUID CAPACITY
GALLONS.
MATERIAL ,~,.~, / NUMBER OF
COMPAR]MENTS
~.~ ~/ ~/ /(j4~) ~(*?LIQUID
INSIDE LENGTH~ INSIDE WIDTH DEPTH
SEEPAGE SYSTEM: SEEPAGE PiT:
NUMBER OF PITS
NEAREST LOT LINE__
OUTSIDE DIAMETER OR WIDTH
DISTANCE FROM WELL
. TO]AL EFFECTIVE ABSORP]ION AREA (WALL AREA)
TiLE DRAIN FIELD:
DIS]ANCE FROM WELL
, FOUNDATION
, NEAREST LOT LINE
BUILDING FOUNDATION
TOTAL LENGTH
, OF LINES
NUMBER OF LINES
DISTANCE BETWEEN LINES
TRENCFI WIDTH
IN. TOTAL EFFECTIVE
ABSORPTION AREA__
SQ. FT. LENGTH OF EACH LINE
DEPTH: TOP OF TILE TO FINISH GRADE_
DEPTH OF FILTER MATERIAL BENEATH TILE
IN. ABOVE TILE
TYPE DEI~H_ _, BUILDING FOUNDATION._ _SAMPLE
NEAREST SEPTIC SEEPAGE
LOT LINE , SEWER LINE ., TANK , SYSTEM , CESSPOOL.
DIAGRAM OF SYSTEM
DISTANCES:
NEAREST
OTHER
, SOURCES__
DATE APPROVED
GAAB-HD-2
GREATER
327 Eagle St.
ANCHORAGE AREA L )ROUGH
HEALTH DEPARTMENT
Anchorage, Alaska 99501 279-2511
Casa No. '~'--/
SEWAGE DISPOSAL SYSTEM - APPLICA'rlON & PERMIT
NAME OE APPLICANT.
RESIDENCE ADDRESS
LEGAL DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH ~¢¢] ~
PERCOkATION TEST RESUkTS ~' -]3
MAILING ADDRESS ~_/v/~¢~' PHDNE NO.
LOCAT,ON OE ,NSTALL^T ON_ 4-'y
., SEEPAGE PIT ~ , DRAIN FIELD , OTHER
~ ~ TO BE INSTALLED BY '-> ~-O~J¢~ ]~ I ~_~
//'¢~/r~NTIOIPATED BATE OF 60~PLETION ~ '( ,k,.- /UO ~Ic:~'
BELOW TO BE FILLED OUT BY HEALTH DF. PARTMENT
THIS IS TO SERVE AS , ~'¢-~¢¢ _ , PERMIT TO INSTALL A -~J~'¢/
AS DESCRIBED B~ SIZE_ OF UNIT TO BE SERVED
_,,¢SEPTI6 TANK, SIZE .__/'.~'7~ _TYPE ~_~'/~t'.~ SEEPAGE AREA ~=~CTYPE
,,-' ,, ' DIA6R OF SYSTEM
Health Authority
! certify that [ am familiar with the requirements of Greater Anchorage Area ~orottgh Ot'd~lallce No. 28-68 81~d that the
above described system is in accordance with saki
DATE ¢//A* APPLI CANTS SlG NATU R ¢ ~*~¢"~ ~
JREATER ANCHORAGE AREA BOROUGH
HEALTtf DEPARTMENT
327 EAGLE STREET
A~CHORAGE, ALASKA 99501
CASE
Legal Descrzptxon: Lot ~_Block~i;~szon ~ht, c~_~ ~ ' ~'-~ck~_'~7
This Form Reports a: So~ls Log ....... ~_~?~rco~~ .... Depth
Feet Soll Characteris%ics Location Sketch
3
Was Ground Water Encoun'~ered?,....~
If Yes, At ~,az Depth
~Peola% ton
Gross Time
Net Time
Depth To H20
Net Drop
Fropo~:ed Instal~'~.o~,'Seepage Pit~__.___~.--/ Drain Field
Depth Of. Inle~ Depth To Botto~ O~ P--it Or 'l'rencl~
1.
DIUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HE. ALTH AND ENVIRONDIENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SFWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal D~escription (incl,ucFo~To~,-b¥ 5~l~Teu~bd v s on, sect on. townsbip, range) ~ 0 ~' / ~)
(c)
Location (address or directio_Ds,)~, ~ ...... ~
(b) Applicant Nam¢~, ,Z¢~-~¢~?)~lephone: Flome :~¢/~:,¢~'¢/~'~ _ Business
Applicant Address ~
Applicant is (check one): Lending Institution ~; Owner/builder ~Buyer D; Othe~ ~ (explain);
(d) Lendieg Institution
Address
_ _ Telephone
(e) Real Estate Company and Agent
Address
Telephone
(f) M.ail the HAA to Ihe following address:
TYPE OF RESIDENCE
Single-Family/~' Multi-Family []
Number of Bedrooms .... 7~
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.
SEWAGE DISPOSAL
Onsit Public BI. Community [~ Holdieg Tank b--]
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legaliy and status.
Page 1 of 2 72-025 (11/84)
ENGINEERING FIRM PROVIDIN~ ,NSPEC'rlONS, TESTS, FILE SEARCH, I:;)A'i ,-~ AND INFORMATION
As certified by my seal affi×ed 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 i~dicated herein, I furtl~er 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, end regulations in effect on
the date o,,f-thisl~spe.~ctk)n. ;
Name of Firrp_~'~-.- ,~ .,:_;,%:~__:~:~?~ ~''~' ~ ~'~_,~/ele p h o n e ._._ > ~¢¢'~
Date .~' ~ ~2'~ ~
Engineer's Seal
Approved ~ Disapproved Conditio/_
Terms of Conditiohal 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 tile 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
?2-02§ (1 ~/84)
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE (MO~i DEPT. OF HEALTH &
HEALTH AUTHORITY APPROVAL (HAA) ENVIRONMENTAL PROTECTION
CHECKLIST- FEBRUARY 1984 i ] ~- 1986
264-4720
Legal De cription: .~__~-~%,.-z-~'-'~' ',~-
WELL DAI'A
Well Classificatien~ :z'/,f/'~'/'z~ ~,-,'//,z-~/" __ If A. B. C, D.E,C. Approved (Y/N)
Well Log Present (Y~,~ Date Completed __ J,C*J ~' Yield _
Total Depth
Static Water Level
Casing Height Above Ground
Electrical Wiring in Condu~'~)
Separation Distances from Well:
,~//?' _ Cased to ¢,~ /.~.~I¢' Depth of Grouting
Pump Set At ~_.~,-1~://~
Sanitary Seal on Dasing )
Depression Around Wellhead (~'/
To Septic/Holding Tank on Lot //.~ /z' / ' On Adjoining Lots .~//_/¢
To Nearest Edge of Absorption Field on. jot //~ "TL-~ Old. Adjoining Lots ./~' /'-/~-- /
To Nearest Public Sewer Line_ ,/'~'/'/~/¢ / To Neareot Public Sewer
Cleanout/Manhole ...~/'~..4 _ ToNearest Sewer Service Line on Lot
Water Sample Collected by ,.~/~ L 'y .~/m ,"]//f A./; Date
Water Sample 1'est Results ' /'-~-~¢~/:~/~:"~:'-P'(~/~ ~/
Comments . .~:,¢=- " -- ~'
B. SEP'rlC/H~I~TANK DATA
Date Installed .?'-~ ~':'7 -- .,,.,.~/~ Size ./~'¢~'~ED No. of Compartmeets __~// /
Standpipe,~N, ~: Air-tig~Caps~) ,-:~ Foundation Oleanou, (~_
Depressionover~nk~_ ~ ~'z Date Last Pumped . ~
Pumping/Maintenance Contract on File (Y/N) ~ ; for
Holding Tank kligh-Water Alarm (Y/N) ..~ . Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Hold~g Tank:
To Water-Supply Well /~ ¢/ To Building Foundation
To Property Line ¢ /'// - To Disposal Field Z~¢~
To W~/Service LJ~ ,-~¢~ / '/f
Course ~¢ ~
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ -- J-
Width of Field .~-' -~¢ ¢'
. J~_~:Tz'pr;c~rC~ype of System Design
Length of Field, ~ ~z¢
Depth of Field ~' ~
Gravel Bed Thickness .~ ~
Square Feet of Absorption Area ~..:¢,z_J / ~_~--~: ~ Standpipe,/CPreser~L~)
Depression over Field (~__~ //~ Date of Last Adequacy Test
Results of Last Adequacy Test ~..~
Separation Distance from Absorption Field:
To Water-Supply Well ~/'/"~ ~ To Property Line
To Building Fo~,~d~en ~ -') ,~ '/~z~ To Existing or Abandoned System on
Lot ,/"P'~.¢¢~'/.~'~ -2~=7L;,~---,¢//'~--'-~ ; On Adjoining Lots
To ~./Service Line ~-~ /~/ ~~~nt) ~/
To Stream/Pond/Lake/or Major Drainage Course ~/~ / ~¢'~
To Driveway, Parking Area, or vehicle storage Area
/
D. 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 t her ~.. ave ch.,e,,~d, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Sign~ /*'~--~¢'Z¢¢?~.; ,~%¢, Date .~--/~'-¢~' ~
Co m pa e¢~,~_~¢ ~-.
Receipt No. ~94~q ¢
Date of Payment
Amount: $ (~
Page 2 of 2
72-026 (11/84)
Engineer's Seal
BF~$SEt EPPS & POq~i'S
2220 EAST 88 AVE1NUE
ANCHO~AGEt ~K 99507
(907) 349-6451
WATER [~LL T'E~D
Date:
Lo~ t ion:
Client's Name:
Address:
Tester:
Initial R~%ding on Meter:
Production Rate.~_~ GPM 24-Hour Capacity. Gallo~s