HomeMy WebLinkAboutNORTH WOODS UNIT 4 BLK 16 LT 8I
. ~' MUNICIPALITY OF ANCHORAGE
'~)~,-~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHONE
MAILING ADDRESS
LEGAL DESCRIPTION .~
LOCATION NO. OF BEDROOMS
Well ~ o f I Absorption area Dwelling PERMIT NO.
DtSTANCETO: ', ~ / / ~ /
~ 4 ~ Manufacturer ~ ~ ~ ~ ~ Material ~ ~ [ No. of compartm~
Liq. qaBacity in gallons Inside length Width , Liquid depth
/~O~ IF HOME.DE:
~ ~ Well Dwelling PERMIT NO.
DISTANCE
TO:
~ ~ ~ Manufacturer Material Liquid capacity in gallons
I Well ~o'~ ~ , Foundation~ / Nearestlotline /~ / PERMITNO,
~ ~. DISTANCE TO: Co~ ~
~'.~' i No. of lines ~ LengthT~of e~h line ~//~T°tal length= of~lolines T~ width/~ / ~ Distance between lines
"1 : Top of the to finish grade¢~ / Material beneath tile~ // inches Total effective/~oabso~gtion~ ~area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
m DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
tNSTAELER I I I
/
REMARKS
,,
, .L.g - ,
APPROVED ~/~ ¢ ~t ~ DATE LEGAL
72-013 (Rev, 3/78)
PERMIT NO:
DATE ISSUED:
MUNICI F'AL_ ITt' CJF' AN.CF~[IRASF
DEPARTMENT OF HEAL. TH AND ENVIRONMENTAL PROTECTION
825 L STREET~ ANCHORAGE~ AK 99501
264-4720
ON--S ][ 'TE SEWER PERil I ~[
84065P
08/01/84
APPLICANT:
ADDRESS:
CONTACT PHONE:
LEGAL DESCRIP:
LOT SIZE:
MAX BEDROOMS:
HAMMAN CONST.
BOX 672 EAOLE RIVER
EAGLE RIVER, AK 99577
694-2776
SUBDIVISION: NORTHWOO~PH~4
SECTION: 5-4 TOWNSHIP: 15N
.5A (SO. FT. OR ACRES)
5
LOT: 8 BLOCK: 16
RANGE:
4_isted below are the options available to you in designing your septic.
system. Choose the option thai. best fits your site.
DEPTH TO PIPE BOTTOM (FT.) 4.0 -4.~ ~
(FT.) O. 5 ~ ~ ~ ~
GRAVEL
DEPTH
TOTAL DEPTH (FT~)
GRAVEL WIDTH (FT.)
GRAVEL LENGTH (FT.)
GRAVEL VOLUME (CU.YDS.)
TANK SIZE (GALS)
SOIL RATING (SQ. FT. /BR)
** GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH)
I certify that: t
1. I am familiar with the requirements for on-site sewers and wells as se~
forth by the Municipality o£ Anchorage (MOA) and the State o~ Alaska.
2. I will install the system in accordance with all MOA.codes.and regula-tionS-~
and in compliance with the design criteria o£ this, permit.
5. I will adhere to all MOA and State of Alaska requirements ~or the se& back
distances from any existing well~ wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot.
4. I understand that this permit is valid ~or a maximum o~ 5 bedrooms and
any enlargement will require an additional permit,
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
]"HEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (~) THE
ELECTRICAL WORK MUST BE DONE,BY A LICENSED ELECTRICIAN-.
SIGNED
APPLICANT: HAMMAN NST.
ISSUED BY ~_~
'MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 Lo Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
PER,ORMED EOR= -¢~a~+ ~'
SLOPE
.ATE PERFORMED: -~-- I~ -- ~ ~
SITE PLAN
WAS GROUND WATER ~\~ S
ENCOUNTERED? I VC) oL
P
E
IF YES. AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
~ ~0 t- f~ 11:.~5 ___.. 0,$~ ._.
/z,'9~ ~0 o,?l o,
Iz,'~ IQ 0.97
¢~z~ ~ ~ 50 ~ 0.~ .
PERCOLATION RATE ~ Z (minutes/inch)
'TEST RUN BETWEEN ~ FT AND '~ FT
PERFORMED BY: G~'"(~ '~ ,~ CERTIFIED BY: ' DATE:
72-008 (6/79}
"~ MUNICIPALITY OF ANCHORAGE
~ ~ " Departmen~-Aof Health and Environment~A Protection
. . 825 L Street, Anchorage, AK. ~99501
264-4720
* * * HANDWRITTEN PERMIT * * *
Permit ~ WELL ~D/OR ON-SITE SEWER PERMIT.
*,°cation: Phone Number
Type of Soil Absorption System Is:
Trench: L---~' Drainfield: Seepage Bed: Holding Tank:
Number of Bedrooms: Soil Rating(sq.ft/br)
Maximum
The Required Size of the Soil Absorption System Is:
DEPTH LENGTH /_ / ~) GRAVEL DEPTH /
The length dimension is 'the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = GALLONS * *
Permit has o~~
applicant he responsibility to inform this department during the
installation inspecti s of any,~ells adjacent to ~s property and the number
of residences that thelwell wi~ !serve.
Backfilling of any system ~ithou~i~al ins~on and approval by this departme]
to pr/e/tion/O~ c~ ./ / / / ~///~/~''/~ ~.wage disposal system is 100 fe
will
be
subject
Minimum distance betwe~a we~lA a_~-any~ o~site,/~
ic~well d~ending upon the type
for a private well or~0 to. 2~Q//f,_e,~et from a/~.~
of public well. Mini~/m distan~rom a ~Frl~ar/E w~ic-~b~ private sewer line
is 25 feet and to a co~unit~~ine i~5/~e~. ~1 logs are required
and must be returned to this/~q~a~t~nt with~h/3C_ ;a~ /of t. he well completion.
othe~ requirements may applf~ ~pe~/fications ~and/cohs/ruction diagrams are
available to insure proper (i~s~a~tion.
/
* * * PER~--~XP RES DECEMBER 1' 1 9 o~ * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may re~ire enlargement if~
the residence is remodeled to in~dm~~~ei~s~ ~O~-
Appli~an~ : ~-~/~
Date: ·
~MUNICIPALITY OF ANCHORAGE~.~
~,, Department~ ~f ~ealth and Environmenta protection
~' 825~ Street, Anchorage, AK. 99501
264-4720
* * * HANDWRITTEN PERMIT * * *
~e'rmit ~
WELL AND/OR ON-SITE SEWER PERMIT
Location: PhOne Number: ~ ~ F-- ~F~ ~ ....
Legal Description: ~] ~ /~
Lot
Size:
Type of Soil Absorption System Is:
Trench: Drainfield: Seepage Bed: ~ Holding Tank:
Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br) ~?W~'.
The Required Size of the Soil Absorption System Is:
DEPTH .-~°~ LENGTH ,_,.C-'_~ GRAVEL DEPTH ~, WIDTH
The length dimension is the length(in feet) of the trench or drainfield, The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = /dO~ GALLONS * *
Permit applicant has the responsibility to'inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
~ackfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
f~r a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days Of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31~ 1 9 * *
I certify that:
(1) I am familiar with the reqUirements for on-site sewers and wells as
set forth by the Municipalit~ of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 bedrooms.
Applicant
SWP/024(1/8t)
i
~--~UNICIPALITY OF ANCHORAGE~,
~ ~' Department~' ~ Health and Environmenta: ?rotection
~, ~ 825 ~ Street, Anchorage, AK. ~9501
264-4720
* * * HANDWRITTEN PERMIT * * *
Permit ~ ~~ ON-SITE SEWER PERMI~
Applicant: C~D~ , Mailing Address~p~X~ ~
Location: Phone Numar: &~-- ~S~
Legal Description: &~ ~. ~ ~ ~ ~ ~O~~ ~9[~~:
Type of Soil ~sorption System Is:
Trench: Drainfield: Seepage Bed: /Holding Tan~: ~
Maxim~ N~ber of Bedrooms: ,~ Soil Rating (sq. ft/br) ~'
Th~ Required Size of, the Soil ~sorption System Is: ~ -- v
~/1 ~'~~ / ~ ~ ~ ~/~1~'
DEPTH ~ 3'~7~'"~ ~,,~ . GRAVEL DEPTH ~/~' WIDTH'
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minim~ dept~ of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = /d~ GALLONS * *
Permit applicant nas tee responsibility to i~form this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage di~posal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more-~~ ~~ t_hat ~ed~ro?ms. ~
Applica~ Date: ~ ~'/~] ~
SWP/024 (1/81)
I
,,---~ ~-~
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
PERFORMED FOR:
LEGAL DESCRIPTION:
I
· ~4 I
I
7
8
9
10
11
12
13
14
15-
16
17,
18-
19-
20-
C. Reid, Jr.
2251-E
SLOPE
SITE PLAN
WAS GROUND WATER ~1 S
ENCOUNTERED? IV~) 0L
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
I I~:1~ ~o' o, 9~ O,
Iz;~ ) O 0,97
PERCOLATION RATE g"Z (minutes/inch)
'TEST RUN BETWEEN ~--~ FT AND 3 FT
PERFORMED BY: ~-~'r~ ~/~
CERTIFIED BY: DATE:
72-008 (6/79}
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. # (~")51 --(~)b3L~ - ~___~
1, GENERAL INFORMATION
Complete legal description
Lot 8; Block 16; North Woods S~bdivision #4
Location (site address or directions)
Pr(~Perty owner Larry ~ Karcn P~rde
Mailing address
Lending agency
Mailing address
Agent '"'P~¢ OstdZek/ Tcu[g~ R~
Address 17054 E~gl~ ~v~ Loop Rd.
21751 Sheering Spruce
Cl~zg,~zlz, AK
21751Shelt~cinq Spruce
Day phone
AK 99567
Day phone
688-5~150
Day phone 694-2588
Eagle River, AK 99577
Unl~s,s otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 5 N
3. TYPE OF WATER SUPPLY:
Individual well
....... . ....... Community well YJO(
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
XXX
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
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 wastpwater disposal system is safe, functional and adequate for the number of bedrooms
and type~ of s~ructure indicated herein; I further verify that based on the informer on obta ned 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 *" S&~$ ENGINEERING Phone
/zo;f4 Eagle I{iver LOOp Road No. 204
Address Eagle River, AlesEa 99577
Engineer's signature ~r~. _/l ~ Date ~ /~'o/~7~
DHHS SIGNATURE
'~ Approved for 3
Disapproved.
Conditional approval for
bedrooms. ..
"bedrooms, with the following stipulations:
Additional Comments
B~y: ~,~%. ' , Date ~''--
'iq'he Mc~ni~:i~lity of A~:-I~'o'rage Department of Health and Human Services (DHHS) issues Health Authority
Approval C~ificates.'based only upon the representations given in paragraph 5 above by an independent
Pr0fe'~sione! enginee~ ~egistered in the State of Alaska. The DHHS does th s 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) Back MOA ~21
825"L" Street;
Ce
&. V~ELL DATA
Well type
Log
If A. B, or C,: attach ADEC le~ter~ ADEC water'system number
Sanitary seal
AT INSPECTION
Date of test
Static water level
Well pro0uction
J ~ g.p m.
g.p,m.
. *~Nitrate . ,-,~
: C011ect~d by:
TANK DATA~
B. SEPTIC/HOLDING : ~ -
Date installed Ta~k size /~0 ' , Nmnber of Compartments
Foundation
C.
ABSORPTION F1ELD DATA
Date installed '7'~*'' - soil:rating (g.p:d-'ft2;i}'
-; l: ' "e b,~ Tgtal depth
Length 70 ' Widfli [~ : Gravelthckness below pip
effective absowtionarea [3%* :Monitoring ~ube Present)
Date of adequa~ test ~,[b~ ? :. ResuRs ~ail} e~ For.
: : ~ ~ ' r 'al Watefhflded On.):
_ , ............ r ~. i~e~ately ~e ~g
Fluid depth in abso~aon nero oetm~ tc~t liB./, O ., '
Fluid depth ~ (ins.) Minutes lhter Abso~tion rate =
Peroxide treatment (past 12
SEPg3RATR
onl6t:- ~·
: line)
SEPARATIO
Building foundation
Water main/servic~
Building foundation
Date
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
1° GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Lot 8, Block 16, North Woods ~4
Location (address or directions)
Sheltering Spruce Loop
(b) Property owner H.U.D. %111-026274-203
Mailing Address 605 W~t 4th,
(c) Lending Institution
Mailing Address
Telephone: (home)
~t~ 0~1, Anchorage, A]~
Telephone
Business
(d) Real Estate Company and Agent ~=~1 ~-y Ft-~-,=- r._~Z r~r-ct~.~-y
Address Pfiz~0 ~a] C~-: ~n'~hn'~e. ge: ;H~: qq~02
Telephone 243-1022
(e) Mail the HAA to the following address: (or check here E~, if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
17034 Eagle RLver Loop Road No. 204
Ea,~le River, Alaska 99577
2. TYPE OF RESIDENCE
Single-Family [~ Number of bedrooms 3
3. WATER SUPPLY
Individual Well[] Community~ Public[] P.W.S. ID. ~213001
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site E~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev, 7/88) Page 1 of 2
F l
ENGINEERING IRM 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 thi~
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functiona and adequate for the number of bedrooms and type of structure indicated herein. I further verif,) 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
Address
Date
170:34 G. agle RJ~er Loop Road No. 204
~aska 99577
6. DHHS APPROVAL
Approved for '~" bedrooms by
Approved /~vt~ Disapproved
Terms of Conditional Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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.
72-025 (Rev. 7/88) 8ack Page 2 of 2
~ MUNICIPALITY OF ANCHORAGE (MOA)
[ ',~*b'~ '~ Health Authority Approval (HAA)
ENVIR13~i~I&~q'AL $ E DIVISION- 343-4744
WELL DATA
Well Classification
Well Log Present (Y/N/
Tote Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
MAR ! 4 1989
RECEIVED
Legal Description:
Date Completed
Depth of Grouting
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank o'n Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments ~;::~¢ ~ \~¢:) "~
If A, B, C, D.E.C. Approved<~N) y
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B, SEPTIC/HOLDING TANK DATA
Date Installed ~ Size t
Standpipes ¢¢~YN) y Air-tight Caps 4[~t~N)
No. of Compartments
Depression over Tank (Y~
Pump!ng/Maintenance Contact 0n File (Y/N)i,~
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
· To WaterrSupply Well
To Property Line
To Water Main/Service Line
Foundation Cleanout ~TN)
1,) [j;)ate//~ Last Pumped. "~ ~ ~o -
; for ~
Temporary Holding Tank Permit (Y/N)
!
To Building Foundation
To Disposal Field
To Stream, Pond, Lake or Major Drainage Course
,
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
TO Water-Supply Well
To Building Foundationl~
Lot
C. ABSORPTION FIELD DATA /
Soils Rating in Absorption Strata . '~-~'~c> ~"~ Type of System Desig~n
Date Installed /'~'~/?/'~ ~..¢~ Length of Field ~ ,
Width of Field \'~ ~ Depth of Field '~
Gravel Bed Thickness C;x~:~ J
Square Feet of Absortion Area \.--z~.--~ o-~- Statndpipes PresentdCFYN)
Depression over Field (Y/~ t- ~ Date of Last Adequacy Test
Results of Last Adequacy Test ~~c-~'~---~7~s~ ~ ~-~ ~
SEPARATION DISTANCE FROM ABSORPTION FIELD:
~ -'¢ To Property L ne \~
'~'~'Z.~ ' To Existing or Abandoned System on
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area or Vehicle Storage Area
On Adjoining Lots '~P ~
~. ~ ~ To Cutback (if present)
Comments
D. LIFT STATION '[ /
DaJ~nstalled ~,,/~'
Size ~
"Pump 0~~
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)
Test.
~n~¥~
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect
inspection.
Signed
Company
Date
MOA No.
1703~ ~_.~_le River Loep Road No. 204
Eagle River, Ala'~ka 9~7~, / ~/~ ~
D~te of PaYment ~
Amount: $ / 7~,~
72-026 (Rev. 7/88) Back
Receipt No,
Waiver Fee: $
Date of Payment
Page 2 of 2
)f t
, /
DI~PT. OF ENV~RONMI~NTA~ ~O~$~%T~ON
ANCHORAGE/WESTERN DISTRICT OFFICE /
3601 C STREET, SUITE 316
A/~CHORAGE, ALASKA 99503
ST~'V~: COWP£R, GOVERNOR
563-6775
DATE: March 10, 1989
PWSID:. 213001
To Whom It May Concern:
According to the records on file in this office, the ~
UTILITY/~ORTh~WQQDS/DEE~ EN is in compliance with the State of
~laska Drinking Water Regulations.
sincerely,
VERA E. CRAIG
Environmental Field Officer
MUNICIPALITY OF ANCHORAGE
DIVISION ov Z VIHON AL
DEPARTMENT OV ~<H AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date -
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicants Name C~z~ ~$ ~z'~ c , Telephone -~ Business
Applicants ~dress ~ ~o~, ~ ~ ~ ~ ~/ ~S ~ ~' ~ ~
(c) Applic~nt~is (check one) Lending Institution ~ ; ~er/builde~
Buyer ~ ; Other ~ (explain);
(e) Real Estate Co. & Agent
Address
Telephone
(f)
Mail the H~ to the following address:
2. Type of Residence
Single-Family~
Number of Bedrooms
Multi-Family~
Other (describe)
3. Water Suppl_z-
Individual ~ Communit Public~-~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewase Dis.pos.a~.
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. Engineerin$ Firm Providing Inspections~ Tests, File Search~ Data and Information
e
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 M~nicipality 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 ~~ ~.3'~z~ ~-/z'/~-~/ ~Z~-~ Telephone
Address ~-g3 ~ ~/ / ~'- ~ ~ ~
(ENGINEER SE~)
Approved for - ('f!TL bedrooms By
Approved ~ Disapproved __ Condition~
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT ,OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABO%~ 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 REQUIRE-
MENTS. 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.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
MUNICIPALITY OF ANCHORAQI:
DEPT. OF hEALTH &
MUNICIPALITY OF ANChORAgE (MOA) I:NVIRONMENTAL PROTECTION
m0 TY OCT 9 1984
CHECKLIST - FEBRUARY 1984
Legal Description:
Well Classification C~,'~ .... If~, c~ C, D.E.C. Approved(Y/N)
Well Log P~esent (Y/N) Date Completed Yield
Total Depth Cased to Depth of G~outinq
Static Water Level Pump Set At
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) Depression A~ound Wellhead (Y/N)
Separation Distances f~cm Well:
To Septic/Holding Tank on Lot ; On Adjoining Lots
To Nearest Edge of Absc~ption Field on Lot ; On Adjoining Lots
To Nearest Public Se~= Line To Nearest Public Sewer
Cleancut/M~nhole To Nearest Sewer Service Line on Lot ._
Date
Ware= Sample Collected By .;
Water Sample Test P~sults
SEPTIC/HOLDING TANK DATA
Date Installed '7/~={
Standpipes (Y/N) /
Size /~o o ~ ~ No. of Cc~pa~tzf~nts ~
Ai~-tight Caps (Y/N) ~/ Foundation Cleanout (Y/N) ~/
Depression ove= Tank (Y/N) /~ Date Last Pumped /lYSOl/
Pumping/Maintenance Contract on File (Y/N) /~ ; for --
Holding Tank High-Water Ala~ (Y/N) ~ Temporally Holding Tank Permit (Y/N)
Separation Distances f~cm Septic/Holding Tank:
To Water-Supply W~ll ~1~- To Building Foundation '/~/ /
To P~operty Line /0 z- TO Disposal Field ~ ~
TO Water Mai~service Line ~ {-
Course 7%/8 ~
TO stream, Pond, Lake, c~ Majo~ D~ainage
Co~ents
[Page 1 of 2]
2-15-84