The URL can be used to link to this page

Home My WebLink AboutNORTON PARK #3 BLK 3 LT 4orca MUNICIPALITY OF ANCHORAGE 'DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE /- 1. General Infornnal-ion Application Date (a) Legal Description (include lot, block, subdivision, section, towush~p% range) Location (address or directions) (b) Applicants Name (c) Applicant is (check one) Lending Institution [~_~.. ; ~wne~/buiLder I'.~:2~ ; Buyer ~--7[ ; Other F ..... [ (explain); (d) Lending Insl:itutJ. on Telel)hOn,:~ Address (e) Real Estate Co, & Agent Address Teiepi~one (f) Mail the [~*u% to the following address: 2, .T~yjoe of Residence Single-Family Number of Bedrooms 3. Water Su~]~E Individual Mul ti=Family Community ~_'-~j Public L~--~] Note: If comnmnzLty well system, must have written confirnation from the State Department of Environmental Conservation attesting t:o the legality and status, 4. Sewage Disposal Onsite ~__~ Public [~[ Community ~--I Holding "Mnk ~2 Note: If community well system, must have written confirmatiou from the State Department of Environmental Conservation attesting to the legality and status, [Page ]. of 2] 5. Engineering Firm Providing Inspections, Tests, File Searchz Data and Information o 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 strncture 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. Name of Firm ,:~ ~. ~ .~ ~ ~" /~i-:_~ ,' '~ ~ "' ' Address ?.~ ~ be(1 rooms Disapproved DHEP Approval Approved for Approved ~_...~ (ENGINEER SEAL) Cond J. t ional Terms of Conditional Approval ............................................................... CAUTION TIlE I,!UNICIPALITY OF ~UNC;IORAGE DEPAR~DIENT OF HEALTH AND ENVIiiO:8.!EifFAL PROTECTIO[i (DHEP) ISSUF, S IIEALTtt AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPOi; THL REPiIESEi,iT- ATiONS GIVEN IN PA~kGFL5PH 5 ABOVE BY ,MW INDEPENDENT PROFESSIO;iAL ENGi?iF, i:iR REGISTERED IN THE STATF, OF ALASKa\. TIlE D[-ti£P DOES THIS AS A COURTESY TO PURCitASERS OF HOMES t~;D THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. E24PLOYEES OF DIIEP DO NOT CONDUCT INSPECTIONS OR A2.~ALYZE DATA BEFOR[", A CERTIFICATE iS ISSUED. THE MUNICIPALITY OF )~NCIIORAGE IS NOT RESPONSIBLF, FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SE~) IR4/ej/D18 [Page 2 of 2] o4 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 ae Well Classification _~'ftl Well Log P~esent (Y/N) Total Depth ~_E 7o ' '"--~ Cased to Static Water Level .. /~ ~ Casing Height Above Ground Date Completed Pump Set At - .~'- 0tf If A, B, Or C, D.E.C. Approved(Y/N~~ U/uhm0u~g/ Yield or~C~/~Wd Depth of Grouting ~ % Sanita~,y Seal on Casing (Y_~_~ Electrical Wiring in Conduit (Y/N) ~/ Depression Around Wellhead (Y/N). Separation Distances from Well: To Septic/Holding Tank on Lot /d0At~ ; On. Adjoining Lots__ To Hea~est Edge of Absorption Field on Lot --~ ; On Adjoining Lots To Nearest Public Sewe~ Line '7.~ ! To Nearest Public Sewer Cleancut/MapJ~ole___J 7~ ' To Nearest Sewer Service~ine on Lot Water. Sample Collected By 7~ ~<///~/ZgW~t%~ ; Date ,~ .b/~ ~ Wate~ Sample Test Results SEPTIC/HOLDING TANK DATA ~t;f~L[C b~-flt/7-/S _~ ~ -~' 'Vt/3 ~/~' S alled · Size (Y/N) Air-tight Caps (Y/N) Foundation Cleanout (Y/N_! Depression o~i~'-T~pk (Y/N) Date Last Pumped _ Pumping/Ma i nte nance~dFi Holding Tank High-Water Alarm _~q~N) Temporary Holding Tank Permit (Y/N) Separation Distances f~om Septic/}~k: To Water-Supply Well To~ Foundation To Disposal'-~e ld To Property Li~ To Water Main/Service Line To Stream, Pon~~nage CourSe. Cormmnts ~'~ [Page 1 of 2] Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption A~ea Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test Separation Distance from Absorption Field: -To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank(if present) To Stream/Pond/Lake/c= Major D~ainage Course To D~iveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water AlarmLevel 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 Con~ents ** Check Permitted Bedrocm Rating A~ainst HAA Request I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the ~/~y~tion. S i 9ne d "~//~..-"'~__------- Date ~.~///~/~/ Company ~,, ~ ~s~ MOA No. 3'~-'~? KB1/dS/s [Page 2 of 2] ENGINEERS SEAL 2-15-84 APPLIC ~IT FILLS OUT UPPER HA[ ONLY zip Code Phone /,? / Lending Institution Address Realty Co. & Agent Address Legal Description Street Locatio~ Zip Code q'~'~.; O ( Zip Code Phone Phone Type 9f Residence [~' Single Family // ~J Multiple Family No. of Bedrooms ~, Other Water Sapply ~¢'individual ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. [] Community For wells drilled prior to that date, give well depth (attach Icg il available)· ) [] Public Utility / . Sewer Disposal E] Individual ... I . :' ( :~ : ¢~ Public Utility '-' / Holding Tank Year Individual Installed: When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN Bi-_* INITIATED Time Time Date Inspector Date Inspector Time Inspector Date Inspector Field Notes: ') APPROVED BEDROOMS · ) DISAPPROVED t CONDITIONAl· APPROVAL' DATE Soils Rating *CONDITIONS OF APPROVAL ' ' Well' Log Received Well To Absorption Area Woll to Tank Septic T~nk Size Date Sewer Installed November 9, 1981 Larry Johnson Post Office Box 1042 Anchorage, Alaska 99502 Subject: Lot 4 Block 3 Norton Park Subdivision Approval for the individual sewer and water facilities cannot be granted until the following items have been completed: (1) (2) An outside faucet was not available at 'the property to obtain a water sample for-analysis. Please call this office for another appointment. Locate and expose the well for our inspection to determine proper construction. Please notify this office for a relnspection when the noted descrepan~ies have been corrected. If there are any further questions, please call this office ah 264-4720. Sincerely, Robert C. Pratt, R.S. Associate Specialist RCP/ljw DATE RECEIVED // INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE MUNICIPALITY OF ANCHORAGE ) DEPARTMENT OF HEALTH & ENVIRONMENTAL pROTEcTI~N~CIPALITY OF 825 L Street - Anchorage, Aleska 99501 DEPT. Ol: ENVIRO~MLNTi~L ~::(;~CI ION ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 U , I REQUEST F~PPROVAL OF INDIVIDUAL WATER AND SEWE~I~I~[ p DIRECTIONS: Complete all parts on page 1. Incomplete requests will not ba processed. Please allow ten (t0) days for processing. 1, PROPERTY OWNER ~ PHONE MAILING ADDRES~ PROPERTY RESIDENT (If different from / PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION / I MAILING ADDRESS ~4. REALTOR/AGENT ' PHONE 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS [] One ~'~ Four ,[~' SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [] Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** ~ PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MIJST ACCOMPANY EACH REQUFST BEFORE PROcEsSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] 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 []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified ~ INSTALLER []Septic Tank or [] Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION 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 [] APPROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [~- DISAPPROVED DATE BY ~__~