HomeMy WebLinkAboutSKYWAY PARK ESTATES BLK 6 LT 12
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 I::)WELLING
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Day phone
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
2. NUMBER OF BEDROOMS:
3, TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer /
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72~)25 (Rev. 1/91) Front MOA #21
o
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and ¢s 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, ~unctional 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.
NameofFirm I---'~l~J¢,c~ ~~ ~.L~. Phone
Address ~ '% ¢¢~ / ~--/.-¢4 /~- %0 ~
~ c~~ Date
Engineers signature
DHHS SIGNATURE
~/ 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 orderto 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,
MUNICIPALITY OF ANCFIORAG E
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. # ( . \'~'\ ""*' ,
1. GENERAL INFORMATION
Complete legal description
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
NAA#_ ~:~i-"~- i .,( '-'~ .~
"6F-- g-. Lo'r'
Location (site address or directions)
Property owner
Mailing address
Day phone
Lending agency
Mailin. g address
Agent
Address
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: y
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State AD£C attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATFR 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.
72-025 (Re¥. 1/91) Fronl 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/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.
NameofFirm l'-'~o~,,t ~¢~-~/,_[~.w~ ~'b.]~_ Phone
Address ,~0~ ~ /,~'/..z~ mc' ¢.o~
EngineeCs signature ~ ~
DHHS SIGNATURE
~'~ Approved for
Disapproved.
Conditional approval for
Date
bedrooms.
bedrooms, with the following stipulations:
Additiona~ 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 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.
Municipality of Anchorage i;~ E C ~E I V ~! D ~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division OCT 1 9 1998
825 L Street Room 502 · Anchorage, Alaska 99501 · (~07~ 343-4744 .
~v~udlclpality of Anchorage
Dept. Health & Ruman Services
Health Authority Approval Checklist
Legal Description: _L_crf' l'2., ~,, ~ _ Parcel I,D.:
A. WELL DATA
Well type __ ~ . IfA, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) ~ Date completed
Total depth ~ ~ ~ t Cased to _ ~ ~ ~ '
Sanitary seal (Y/N) "'/
FROM WELL LOG
Casing height (above groundl
Wires properly protected (Y/N)
AT INSPECTION
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
],/-/7 ~'*~i//.. Other bacteria
Collected by: ~ ~
Tank size
Depression (Y/N)
Pumper
Soil rating (g,p.d,/fF or ft~/bdrm)
Gravel thickness below pipe
Monitoring Tube present (Y/N) _
Results (Pass/Fail)
__ Immediately after
Cleanouts {Y/N). _
Number of Compartments
High water alarm (Y/N}
System type
Total depth
Depression over field (Y/N) __
For
Coliform ¢ Nitrate
Date of sample: /o~;~/? ~
B. SEPTIC/HOLDING TANK DATA
Date installed
Foundation cleanout (Y/N)
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
Length Width
Effective absorption area
Date of adequacy test
Fluid depth in absorption field befere test (in,);
Fluid depth (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
Absorption rate =
If yes, give date
gal, water added (in.):
g.p.d,
g,p,m.
bedrooms
D. LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
"Pump on" level at*
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
High water alarm level at* *Datum
Cycles tested
E, SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
"Pump off" level at*
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
Absorption field
Wells on adjacent lots
Water main/service line
Foundation Property line
Water main/service line Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTION FI ELD ON LOT TO:
Property line Building foundation
Driveway, parking/vehicle storage area
Sur ' ',,ce water
Wells on adjacent lots
Curtain drain
CERTIFICATION ' "~:"" '
F.
ENGINEER'S
I certify that I have determined thru field tnspections and review of Municipal recor~ds that the abdve systems are
in conformance with MOA HAA guidelines in effect on this date.
Signature ~ ~
I
Date (0. t3~"~
HAA Fee $
Date of Payment
Receipt Number ~, ?'Z¢ ~)~ ~
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
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. # 019-102-16 HAA # HA950260
1. GENERAL INFORMATION
Complete legal description Lot 12 Block 6 Skyway Park Estates Subdivision
Location (site address or directions) 1521 Shore Drive
Property owner Pat Owens
Mailing address 1521. Shore Drive, Anchorage,
Day phone_349-6881
Alaska 99515
l.ending agency Priemier Mortgage Day phone_ 563-7736
Mailing address_300 A Street, Anchorage, Alaska 99501
Agent Day phone
Address
Un!ess otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: Three (3)
3. TYPE OF WATER SUPPLY:
NOTI--:
Individual well
XXXXXX
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community well ,, ' ....... "
.., \\, [~l I,./,'"",
- ~.~,, .....(~. ,,.
Publfc water
If community well system, provide written confirmation frott~ ~tate A~EC'attest-t. '
lng to the legality and status of system. ,
Community on-site
Public sewer xxxxxx
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Roy, 1/91) Front MOA ~21
STATFMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I varify 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 DHI Consulting Engineers Phone 344-1385
Address 800 East Dimond Boulevard, Suite 3-545, Anchorage 99515
Engineer's signature
Date
Note: This is a re-certified type original
due to the original certificate has been
picked up by someone else. A true copy of
the original certificate is on file with
MOA, DHHS, On-site Services. ~
DHHS SIGNATURE
xxxxx Approved for Three (3)
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
,' Additi'onal Comments
. -,, . ~'/~ .~. ,, ,
Date_July 11, 1995
The Municipality of Anchorage D~partment 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.
72-025 (Rev. 1/91) 8ack MOA~f21
~ MUNICIPALITY OF ANCHORAGE
i, eAl¢,*"./ DEPARTMENT OF HEALTH & HUMAN SERVICES '
~.~.~J ' 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 kD.# ~)\°t ~ '~0.~,'-~ - ~o HAA # I~(~ q ~ [)~
1. GENERAL INFORMATION '
Co~pletelegal description ~t 12 Block 6 Sk~a7 ~k Estates
Location (Site address or directions)
1521 Shore Drive
Property owner~Pat owens
Mailing add~eSs 1521 Shore D~., Anchorage ~J~. 99515
Lending agency ' '
~aillng. address 300A R'Pw~'P~ Anc~hc~t-~q-R. AK ggso~
Agent .............. -'
Address
Day phone 3._.49-6881
Day phone _sF;q-'?7q~
Day PhOne
:~ ~ '. Unless otherWise r. equested~ HAA will be held for pickup. ...,.:'.,.. . ..
2. NUMBER OF BEDROOMS: 3
.... :. ndvdua we
... ~...Oommunity well
............... : ~ Public water
NOTE: If community.well system, provide written confirmation from State ADEC attest-
ing to.~he legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
: COmmunity site
..... Public sewer . ,..... -.:.. · .
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
5.
STATEMENT
OF
INSPECTION
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 tl~at based on the information obtained from
the Municipality of Anchorage files and from my invest, i_.qation 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.
. . Nameof Firm D g ]~zgineers ' Phone 344-1385
Address 800 E~aqe Ak. 99515 ~/~/
Engineer's signature Date ~'-.f'
6. - DHHS SIGNATURE
-~ Di~pprov~
Conditional approval
· -~' , -bedrooms,*with the.following stipulations:
Additional Comments
r
The Municipality of Anchorage Department of Health and Human Services'(DHHS) issues Health Authority
Approval Certificates based only upon the representations giyen 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 satis~ 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
'"' ~.e~p0ns'ible for errOrs or om ss ons in the proiessionaJ,'~ngi~eer% ~rk. '
95199
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:~ot 1 2 ]C~ock 6 SkT?vcay Park EstateParcel I.D.
A. Well Data
Well type ~J~S. ,.
Log present (Y/N)
Total depth N/A
Sanitary seal (Y/N) Yes
If A, B, or C, attach ADEC letter. ADEC water system number N/A
Date completed N/A Driller N/A
Cased to 40'+ Casing height 1.5'
Wires properly protected (Y/N) Yes
FROM WF-LL LOG
Date of test N/A
Static water level t',f/A
Well flow N/A
Pump level1 N/A
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot N/A
Absorption field on lot N/A
Public sewer main 100 ' +
Sewer service line 100 ' +
_g.p.m.
AT INSPECTION
6/23/95
44.8
1 0 g.p.m.
64 '+
'(meter O±ocKect 12o this level~.~
; On adjacent lots N/A
; On adjacent lots N/A
Public sewer manhole/cleanout 100 ' +
Petroleum tank N/A
WATER SAMPLE RESULTS:
Coliform 0 Nitrate 0.85 Other bacteria
Date of sample: 6/23/95 Collected by: Dustin High
Date installed ~ Tank size .-----~n~e.ts
Cleanouts (Y/N) _____Fou~ - Depression (Y/N)~__
High water alarm (Y/N) ~ ~------'/ Al~arm ~e~L~__
Da~ Pumper
Well(s) on lot .____~"On-adjac~~...._-.~~' Foundation
To property line ~AAb_.sOrpt~Ffi~- ~---._. Water main/service line
72-026 (3/93)° Front
CONTINUED ON BACK PAGF
Date installed '"'---.., Manufacturer
Size in gallons '""'""'"'~ _ Manhole/Access (Y/N)
Vent(Y/N)__ __"Pump o~ .~, '~el at ~
SEPARATION DIS~ON TO:
Well 0~,~ On adjacent lots Surface water
· 'LD DATA
Length __ Width
Total absorption ama
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/FF)
Gravel thickness
Cleanout present (Y/N)
__Results (pass/fail)
System type
)n over field (Y/N)
for
After test
If yes, give date
Bedrooms
SEPARATION DISTANCE FR(~
Well on lot
To building foundation
On adjacent lots
Surface
To existinc.
C
E. ENGINEER'S CERTIFICATION
Cutbank Wate
Driveway, parkinCvehicle storage area
line
em on lot
;line
/ cer~'fyftbaU~hav~ecked, verified, or conformed to all MOA and HAA
Signature~(// ~ '~'l'',.,.~-~L-f ~-
Dateof Payme~ d ¢ ~'- ~ ~
Receipt Numar /O ~ ~ (1 ~%
Waiver Fee $
Date of Payment
Receipt Number
; of this inspection.
72-026 (3/93)* Back
,,- '~;'i: ./~,~ MUNICIPALITY'OF ANCHORAGE
. .:, ':.f, ,~.,~ ~,, .(,.~-~,~ , Department o, Health & Human Services
..:..;.~;/,~.,.~.;., :. -., .......... 343-4744-,-,.
~ ,': ~,,::,,G~.~. CERTIFICATE OF INSPECTION [b~ H~ALTH ~6*~Oaif+
- ON-SIT~ SEWER AND WA'F~R FACILITY FOR SINGLE FAMILY DWELLING
,";.,',Pa~l'l.D.~ ~t~-~ -~(~ HAA~
:2~'; ;,.', ;.- ?.; ,'.;, ' - ....... ' ' ' ' '
1. GENERAL INFORMATION (Must be completed prior ~o submittal)
(a) Legal Descripuon (include lot. block, subdivision, section, township, range)
· .... : .ocation (address or directions)
(b) Property owner
Mailing Address
(c) Lending Institution
Telephone
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e)
Mail the HAA to the following address: (or check here El, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms
3. WA'rER SUPPLY
Individual Well [~9// Community [] Publ c.[]
Note: If community well system, must have wri{ten confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGF DISPOSAL
On-site[] Public ~ Community [] Nolding Tank []
Note: if community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page 1 of 2
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A. W~L DATA
Well Log Present (Y/N) / Date Completed
Total Depth ;;' .£"~J¢ Cased to .> 4°/_ Depth of Grouting
Static Water Level -'¢/~ ~?
Casing Height Above Ground J~ //
Electrical Wiring in Conduit (Y/N) //~
SFPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot ~/¢>~' / 7z¢
MUNICIPALITY OF ANCHORAGE-' (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: ~'~:'Tz /
If A, B, C, D.E.C. Approved (Y/N)
Pump Set At ~¥¢'/"¢://7~ ~/'~
Sanitary Seal on Casing (Y/N) ./'~ ~
Depression Around Wellhead (Y/N) ~
¢-t'/~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ~ /oo ' ; On Adjoining Lots
To Nearest Public Sewer Line "~/~ '~ ' To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments "~'.4// ~"'-£/~'/?
SEPTIC/HOLDING TANK DATA
Date Installed Size
Standpipes (Y/N)
Depression over Tank (Y/N)
No. of Compartments
Air-tight Caps (Y/N) Foundation Cleanout (Y/N)
Date Last Pumped
Pumping/Maintenance Coetact on File (Y/N) ; for
Holding Tank High-Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
SE:PARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well To Building Foundation
To Property Line To Disposal Field
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments
72-026 (Rev. 7/88) Fronl Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strsts
Date Installed
Width of Field
Square Feet of Absortion 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
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
_ To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if present)
D. LIFT STATION
Date installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**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 f
Company ~/
Date 5 7/¢ P ~'* / 49~ *~ ~ ~ Engineer's Seal
MOA
No.
Date of Payment ~ -~ ~ ~ Waiver Fee:$
Amount:$ /~. ~O Date of Payment
72-026 (Rev. 7/88)Back Page 2 of 2
BRUST & ASSOCIATES
tiNG NEI=RS., PLANNERS - SURVEYORS
1610 DIMOND DRIVE
ANCHORAGE, ALASKA 99507
FIELD PUMPING TEST
DATA SHEET
PROJECT:
LOCATIOfi OF WELL (Legal Description): ~7~ /~
WELL DEPTH:.~z//~o~.n FT. CASIMG: ~ ~o ~
DATE DRILLIHG CON, L:TED: .
STATIC WATER LEVEL (Top of Casing): Gzg-~ FT
Clock
Time
Elapseu Time Since
Pumping Started/
Stopped, Hin.
hours)i
1~ hours){
2;O
RECOVERY
I/5/
0
i5
iO (1 hour)
Depth to
Water, ft.
Drawdown/
Recovery
Pumping
Rate, GPM
0 0
Start
Remarks
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET ' ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
ANALYSIS REPORT BY SAMPLE fo~ Work Ozder # 21873
Date Report P~lnted: MAY 22 90 ~ 15:30
Client Sample ID;Li2 86 SKYWAY PANE ESTATES
PWSID :UA
Collected NAY 20 90 @ 09:20 hrs.
Neceived ~AT 21 90 8 07:80
P~oserved with :AN REQUIRED
Client Name : 8gUST & ASSOC
Client Acct: 8NDSTAT
P.O.~ NONE NECEIVED
Neq ~
Ordered By :
Analysis Completed :1~ 21 90 Send Reports to:
Laboratory 3upervl%o~,:RTMpMEN C. EDE 1)ERUST & ASBOC
Neleased Ey : ~~."*~.~ 2)
/
Special
Instruct:
Chemlab Re£ ~: 901441 Lab Smpl ID: I Matrix: WATEN
Allowable
Pazameter Tested Result Units Method Limlts
NITRATE-N 0.90 ~cg/1 EPA 353.2 10
Seraple ROUTINE SAMPLE. SAMPLE COLLECTED BY S. BRUNT.
i Tests Pemformed See Special Instructions Above UA~Un~vallable
ND- None Detected "gee Sample Re~axks Above
NA~ Not Analyzed LT:Less Than. GT-Greate~ Then
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC=.
TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER
5633 B Street t : ,
Drinking Water Analysis R~port for Total Colif, orm Bacteria
WATER SYSTEM:
TO BE COMPLETED BY WATER SUPPLIER
Phone No.
Mailing Address
Ci~/ "State Zip Code
MO. Day Year
TO BE COMPLETED BY LABORATORY
Ana!ysis shows this Water SAMPLE to be:
~atisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination to
indicate reliable results. Please send new
sample via special delivery mail,
Date Received ~-~- t -CiO
Time Received
SAMPLE TYPE:
Routine
Check Sample (for routine sample
with lab ref. no.
G~'Speclal Purpose
[] Treated Water
E3 Untreated Water
SAMPLE ~ Time Collected
NO, LOCATION Collected By
t
READ INSTRUCTIONS
BEFORE
Analytical Method:
06.1220 (b)
Rev. 1983
[] Fermentation Tube
[] Membrane Filter
Lab Ref. No. Result* Analyst
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
BGB.
Membrane Filter: Direct Count (~
Verlllcatlon: LTB
Final Membrane Filter Results
'rlma:
TNTC = Too Numerou~ To Count
Coilform/100ml
Coilformll00ml
PART ONE OF TWO
REMAINDER TO FOLLOW
~ ~° 40~00" ~/
.4.
.~HORE
190,00~
PF41VE ·
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTI-I & HUMAN SERVICES
DIVISION OF FNVlRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF (:)N-SiTE SEWER AN[) WATER FACILITY
264~4744
Application Date
(b)
GENERAL INFORMATION (MUST BE COMPLE'TED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
. Property Owner C ~(~pho~e'
Mailing Address /~-~-~ ~//~"~'~' ~/
Lending Institution _
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the followino address: or; Check he~,~, if~old for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family ~
Number of Bedrooms.
WATER SUPPLY ¢ /! I~"\ '
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 corn munity 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 fray 8/861 Front
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of tile 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 lhe number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage tiles and from my investigation and inspection, lhe 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 ///~
Date /'"~ fX'~ ~
Telephone __~--C ~D __ ~7~/
DHH$ AI~p~RO~AI
Approved for
Terms of Oon~iitional Appr6,Jal
//--' bedrooms by Date
"'Disapproved Conditional
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
WELL DATA
MU MUNICIPALITY,, .' F, OF ANCHORAGEE ( MOA )
APPROVAL
E NV~N~O ~ R UA R Y 1984
264-4744
~]t~(', ~ 9 l~aI Description: Z,,~
P, EC! IVEI)
Well Classification //¢ ~'~"/~'"~// If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) ,,~ Date Completed /'~¢."" 7~¢' /~,--('~ __ Yield
Total Depth -, ~ '('¢~ Cased to
Static Water Level __ ~'zz .~', .~,"~"
Casing Height Above Ground /'¢
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
Depth of Grouting
Pump Set At ¢'~,'¢/~,~'~ ~'.~
Sanitary Seal on Casing (Y/N) __/
Depression Around Wellhead (Y/N)
To Septic/Holding Tank on Lot ...~/~-~'~ / 7%. ,*/,¢' 4'/"//' ; On Adjoining Lots ~
To Nearest Edge of Absorption Field on Lot ,.>/'¢~c') / ; On Adjoining Lots ~' / "* ~'' /
To Nearest Public Sewer Line .~k / ¢.,
To Nearest Public Sewer
Cleanout/Manhole .~ / ~ o" To Nearest Sewer Service Line on Lot
Water Sample Collected by ,~:~,/¢¢' ..4 / ; Date
Water Sample Test Results ,~/x.~,~ ~":~ ,f
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Waler 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
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 fRev 8/86i Fronl
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width 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
Type of System Design
Length of Field
Depth of Field
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)
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 that I hav~,chj~cked, v~rified, or conformed to all MOA ancJ HAA guidelines in effect on the date of this inspection.
Signed ,=..,_~--¢~''~¢'~ Date
Company ~ ~¢4: MOA No. ~T~
Receipt No. I ¢ O0
Date of Payment Z~ z ~ ~.~' ..... '~", ~, ,
Amount: $ ~'¢°~UNICIPALI~ OF ANCHORAeE ~." ~ ~'~j Engineers Seal
ENVIRONMENTAl P,; ..... N
420 L Street, Suite 302
Anchorage, Alaska 99501
September 22, 1983
Mr. and Mrs. James T. Edelen
1521 Shore Drive
Box 199E
Anchorage, Alaska 99515
Dear Jim and Esther:
This letter will confirm our conversation on September 21,
1983, concerning the septic tank used by you before your house
was connected to the Municipal sewer system. You told me that
the connecting line between the house and the septic system has
been severed or disconnected and that the septic tank has been
capped. We have been informed by the Municipality that such
severance and capping will satisfy the Munlc£pality's require-
ments about on--site sewer systems that have been replaced by use
of Municipal sewer systems, in lieu of abandonment and filling of
the septic tank .as referenced in the Municipality's August 17
letter to you. Thus, the situation will not negatively impact
our ability to sell the property to a person who wants to have
bank financing.
To confirm our conversation, please countersign below.
Thank you.
JSC/kt
Very~uly yours,
S. Crane
COUNTE RS I GNATURE?~ .~~
Esther~del~
Angust 17, 1983
James Edelen
1521 Shore, SRA
Anchorage, AK 99502
Subject: Lot 12, Block 6, Skyway Park Estates
Approval for tho individual sewer and water facilit'ies ca,not
be granted until tile following items have been completed~
Exposed electrical wires to the well head are in violation
of' the llunicipality of Ancboyase codes and must be encased
in conduit.
° Public sewer is available to tile above proper.gy. Prior to
this department's approval~ the property must be conn'ected
to the pub.lie sewer a~d verification of the connect sub-
mitred to this office. _.
The on-site' sewer
fil~ed with'- dir-t.
Please no~£fy' 'this Depargmeng
noted discrepancies have
further questions, please
system will need to-be abandoned and
for a rei~ ~peetion when the
been corrected. If there are any.
call this office at 264-4720.
SincerelM,
Robert C. Pratt
Associate Environmental Specialist
RP31/eJ/E2
MUNICIPALITY
OF ANCHORAGE --=- SEWER UTILITY
PRO.~P~TY:
Name Addre~ _
Plat No,
· Residential ~ Commeriet ~ ~ndustrial ~ No. of units
CONNECT= J~O) ~E~L.
Moin T~p ~ ~ ~rCpe;ty/_~ Permit No,
Acct. No
..Lot /~--- _Block
Size .Type
_ Type
Insulation [] Cleanouts Type
Connect Agent.,. ' Inspector.,
Comments__
Depth at Connect
Dete
'Connect Location
ASSESSMENTS:
L.I,D. NO,, Private Dev. No..
Sewer Agreement [] No.
_Subd, Agreement []
RT, E. [] Roll No.
DYE 'rEST:
Positive [] Negative [] N.S,A. [] Dater
Page No., ' M.H. No, .__Billing Cycle
Tested By...
Comments_
o
LU
Z
19~00'
N O'F~:
T'HI~ ,'tS-E~UIL-T N~T VALID ' ~ITH~UT
O~IdlNAL. 5TAIHF2 ~- 51d~NATIJR~.
TRIAD
ENGINEERING PLANNING
&$UflVEYING
6957' Otd Se~rdH~,y., Anchoro~e A~,
O/~AWN
SCALE
.JL K
W,O, NO,
__/~.5'-/5- ;7
· ONLY
APP[.If' NT FILLS OUT UPPER HA'
Mailing Address
Buyer "
Address ~; (:~ i'~ :* , ~ ~' /
Lending institution
Phone
Address ///" ~'(~ Zip Code
Realty Co. & Agent Phone
Address "/~/(" '(''('~ Zip Code
Type of Residence ~ ~~
~ingle Family -:~. ~~
~ Multiple Family No. of Bedrooms -~,~ ~
[~ Other ~
Water Supply
~,4ddlvid ual
[] Community
[] Public Utility
ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975.
For wells drlged prior to that (late, give well depth (attach Icg if available).
Sewer Disposal
(] Individual
iD Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Date
Inspector
Time
Date
Inspector
Time
Date
Inspegtor
Field Notes:
Ins or
MUNICIPALITY OF ANCHORAGE,
DEPT. OF H~ALTH
ENVIRONMr:NTAL PROTECTION
AUG 2
RECEIVED
) APPROVED BEDROOMS
~-" ) DISAPPROVED
( >.
( ) CONDITIONAL APPROVAL'
DATE I ~ ' -~ - ~'-:~ .
BY: ( ~-~\ (= -'~
*CONDITIONS OF APPBOVAL
'\
.: J ~,5 9'..~ .
Soils Rating Date Sewer Installed
72-023
Well TO Absorption Area
Well to Tank
fWe5 Log Received
Septic T&nk Size
A CtlEMICAL & G_ )LOGICAL LABORATORIEL )F ALASKA, INC.
~ '- T~"LE'~ON--~7-'~ ANCHORAGE NDUSTRIAL CENTER
5633 B Street
~_~_~_~_=.',?~-'~ Dnnking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
I.D, NO.
Water System Name Phon~ No.
sample ~ ~reate~ water '
~ Untreated Water
Mo, Day
SAMPLE TYPE:
I-I Routine
[] Check Sample (for routine
with lab rof. no,
I-] Special Purpose
SAMPLE
NO.
31
,I
LOCATION
z_. / ~- 'Ztr~ ~'"-~'~ ,l
Time Collected
Collected [ By
TO SE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[] Unsatisfactory
[] Semele too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample.
Date Fleoelved
Time Received
· ' Analytical Method:
[~ Fermentation Tube
cl~Membrane Filter
Lab Ref. No. Result* Analyst
~- F77
- J I~1~]
E:~ACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
152.1 Shore., St~3
Anchor~ga, A}~ 99502
Subject; Lot 12, Block 6, Skyway ~.'ark Estates
Approval for tho individual sew,:zz~ and ~mt:er :ifa<;llil;ien ct/iltlot
be grauted until th~ golJ. owing iteras have been completed;
Exposed electrical wires to tilt: wel:L head are J.n violation
of the ~lunicipality of Anchorage code~ and mt*st be encased
:l.n Conduit.
Public sewer J.s available to tim above propet~tyo Pr[or to
this departmmxt~l approval, the prop~rty ~aust be co~mected
to the publ:[c sewer and verilficatJ, o~ of tim connect
~litted to th:Is off:£c~,
The on-site sewe. r [~y~;l:em ~-;ii[ nc~-,'.:d to be abaudoued and
filled with dirt,
further que~';tions~ pl~a~c', call this office at 264~'472().
Sincerely,
F~.obe~:t C, Pratt
Specla.[tst