HomeMy WebLinkAboutNORTH WOODS UNIT 4 BLK 18 LT 4
~ 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
NAME ~PHONE
[] UPGRADE
LEGAL DESCRIPTION ~ '
TO e A ,t Absorption area Dwelling PERMIT NO,
., ~,s~..c. : i t'~m~c~t.~ /0~ /3 ~
~ ~ Manufacturer ~o. of comoartments
Liq. capa~i3);~ailons 'IF H~MADE: Inside length Width Liquid depth
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
· --~O Z ~ Manufacturer Material Liquid capacity in gallons
~ Well~/~ '. Foundation Nearest lot line / PERMIT NO.
No. oflines ~ Len*hofea~hlinoaS, Total lengtho, TrenchwidtS, Distance between lines SI
- inches
~ Total effective absorption area
~ TOp of tilo tO finish ~rade ~:}~ , ~ Mater,al boneath tilo ~ inch0s
ken,th ~idth De~th P~M~T ~0.
~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot Hne
m DISTANCE TO:
~ Class Depth DHJler Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATIN~'~ ~Z~ ~
INSTALLER t ~'~
, I [ h
DSPL O~ HEALTH ~ j
ENVIEONMEHTAL
APPROVED ' ~ ~A~E ~ EEGAL
72-013 *
-- :' h---} L 1': T %-" £1F A I'-,1 E: H El F--." i.'-":t ¢'Z.':.~ E
[)EF'FIRTMENT OF HEFILTH FIND ENVIRO1`,IMENTFIL PR:. TE 3'r'ION
:{::25 L STREET.. FINCHORFIGE., F:IK 995Ed.
;~i: 64-,:.1.72El
PERI`alIT NO:
F.:,RTE ISSIJE:D:
RPPL I CFINT:
FtDDRESS:
CONTFICT PHONE:
L. EGRL DESCRIP:
[..OT S, IZE '
~'IRX BE[:,ROOMS:
STE'¢EN L . SI'-'::FIGGS CONST.
F'O BOX 670690
CHUG I FIE, I::tK 9L::)SE. 7
St..JBD I 'v' I S 101'4: NORTHI.4OOD ~4
SECTION: 2 TOI.4NSHIP: ±5N
2d;457 ('.'_-";Q F'T OR FIC':RE'.'~;)
3:
LOT: 4
RFiNGE:
BLOCK: 18
LISTED BEL.ON F::tRE THE OPTION'.:.-.'; FI'¢FIILFIBLE TO '-r'OU IN DESIGNING "fOUR SEPTIC
:.'];"~'STEH. CHOOSE THE: OF'TION THRT BEST FI]-S 'T'OUR SITE.
'"'iF' tF~: EE INt .LC..]: ~-.~ lIE: E [:, 14_ It") F...: R I' ~"-,~
DEPTH TO PIF'E BOTTOM (F::T. :.', 4. t:'_"~ ,:-1.. 0 4. 0
GRR',,,'EL DEPTH ':.'FT. ) 4. ,E~ E"~. 5 :2:. 5
TOTFIL. [:'EF'TH (FT .':' ,...,.':' ~-'~ 4.. 5 ¢0 7. ._.~
GRFI'¢EL 1.4I[:'TH ':.'FT. ::' 2. 5 2i. 0 × 5. 0
GRFI',,,'EL. LENGTH (FI'.) GS. (~ 4E~. 0 60. 0
GRFIVE[.; VOLUME (CU. "r'DS. ) 28. 7 ]'.:::1.. t 44. 4
TFINK SIZE (GFIL. S) i.., 00t.T:i. 0 :+,:+: % .E~00. 0 :+::+: 1., 000. 0 :+::+:
SOIL RRTING (S(;!. FT. ,."BI:;;:::, :1.8]:..': it83: 18:2:
:+::+: TRNK MLI::::iT HR'v'E R"F LEFIST TI.40 COMPRR'TMENTS
I CERTIFh.' THFIT:
i I RM FRMILIRR NITH THE: F::E(.:gJIREME:N'T'S FOR ON-SITE SEWER'_:'; FI1`',ID NELL. S FI'_=; SET
FORTH B'.¢ THE MUHICIPFILIT"r' 01:: RNCHORF:IGE (MOB) FIND THE STRTE OF' FILFISKFI.
2. I .WILl...]:N'E..,TF~L.L. THE ':T:;"r'STEH I1`',i FICCOR'[:'DFINCE .WITH RI..L. i"tOR CO[:'ES F:IND REGULRTIONS.,
FIND IN COMPL. IFII",ICE HITH 'T'HE DESIGN CRITERIR 01:'": THIS PERMIT.
"-:-::. I '.,.Ii[..L. FIDHERE TO F::tLL. MOFI FIN[:' STI:::ITE OF' RLR'}]KFI REQUIREMENTS FOR ;]"HE '.=-"';ET BFICK
D I STFINCES FROM FINh" EX I ST 11`',t(:'; !4EL. L., I.,.IFISTE]4RTER D I SPOSRL S'¢S]"EM OR PUBL I C
SEHERFIGE S'T'STEM ON THIS OR Fl1`',l"r' FIt}JFICENT OR NEFIRB'¢ LOT.
4. I UN[:..'ERSTFli'-,!D THRT THIS F'ERMIT IS VFtLID FOR Fl MFIXIMUM OF' 3: BE[:'RO01"IS RND
RN? E1'',IL. RRGEMENT t41LL REQU I RE RN RD[:'I"I"I ONRL PERM I T.
IF' R L. IFT STFITION IS II",I2-:;TF:IL. LED IN FIN RRER CO',,,'ERE[:, B"r' MOB BUILDING CODES.,
THEN (it) 81`.,t EL. ECTRICFIL. PERMIT FIN[) INSPECTIGN MUST BE OBTFIINED; (2) FIS-BUILTS
HILL NGT BE FIPPROVE[:, HI]-HOUT FIN EL. ECTRIE:BL INSPECTION REPOR]".~ FIN[:, (3:) THE
ELECTRICF:~L t40RK' MUST E:E DONE B'¢ FI LICENSE[) EL.ECTRICtFIN.
,_ .....
ALASKA%UIROnmenTAL CONTROL
~n(jinecrin(] ~ ~nuironmcnlaJ Sludi~s
$E%lCl $, II'lC.
SOILS LOG - PERCOLATION TEST
· EGAL CE~0R,PT,0N: No, r~.,oo~s .~
7
8
9-
10-
11
12
13
SLOPE
CATE PERFORMED:
SITE PLAN
14
.'15
16
17-
18-
19-
20-
WAS GROUNC WATER S
ENCOUNTERED?
IF YES. AT WHAT E
DEPTH?
Reading Date Gross filet Cepth to Net
Time Time Water Drop
e
PERCOLATION RATE "' ' 6 (/~ '~ (minutes/,~[/ '
TEST RUN BETWEEN
PERFORMED BY: -~ ~¢"-~"~'o-~1 CERTIFIED BY:
DATE:
Parcel I.D. # ("~/~
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
GENERAL INFORMATION
Complete legal description
Location (site address or directions) ,~_~ ~OG 1~ ~
Property owner
Mailing address
Day phone '
Lending agency
Mailing address
Day phone
Agent
Address
Unless otherwise requested, HAA will be held for picku
NUMBER OF BEDROOMS:
Day phone b ~ ~'L ~ I;g.4~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER 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 (Rev. 1/91) Front 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 ~ ~J~.e~l ~-~~ "~- Phone
Address ~ "~ ~ ,~ ~.~,-~d ~ ~
/~ SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By: / /
Date
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.
72q)25 (Rev. 1/91 ) Back MOA #21
Municipality of Anchorage ~
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L.~ c~, ~VLt~. _~.~.~..~.~.~>~ t~ Parcel I.D. 05'1-- d)(~ ~/-- ~/~---
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Cased to Casing height
Wires properly protected (Y/N)
AT INSPECTION
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
g.p.m.
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed G/III ~;~/ Tank size ~ ~ Compartments
Cleanouts (Y/N) y Foundation cleanout (Y/N) ~'/ Depression (Y/N)
High water alarm (Y/N) J'~/~ Alarm tested (Y/N)
Date of pumping ,Z~ C).~ L j ~..~'". ~ ~ q ~ Pumper '~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
On adjacent lots I"/'//5~ Foundation
Absorption field I C) Water main/service line
Well(s) on lot
To property line
Surface water/drainage
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
' Total absorption area
Depression o~/er field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Soil rating
Gravel thickness
11
Cleanouts present (Y/N)
Date of adequacy test
for
System type
Total depth t.~
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~/A On adjacent lots
_ Property line
To building foundation
On adjacent lots .~>
Surface water
Curtain drain _ ~"'[
To existing or abandoned system on lot ~//"-~
Cutbank N e V1 '~' .Water main/serviceline ~
Driveway, parking/vehicle storage area .~ ~'o
E. ENGINEER'S CERTIFICATION
g ~ ~:'~ ':~ 7, "~:: ~ i'~
I certify that I have checked, verified, or conformed to all MOA and HAA uidelines in affection the~ate, r~f this inspection.
SignatUre ~;, ~- .....,:, (;~
En-ineer's Name ' i ~ ~ ~ ~' ~ u ¢~ ~ ~ '~ ,~
HAA Fee $ ~ /
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
DEPT, OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99515
WALTER J, HICKEL, GOVERNOR
(907) 349-7755
April 16, 1993
Mr. Tobben Spurkland
SUBJECT: Northwoods Subdivision (Chuglak Utilities)
Class "A" Public Water System, PWSID 213001
Dear Mr, Spurkland:
i have oompletecl a review of this office's files concerning the monitoring status of the
above-referenced Class "A" Public Water System and found the following:
The last satisfactory Total Coliform Bacteria Sample results was submitted
to this Department on March 4, 1993. This does meet the provision~ of 18
AAC 80.200(a), of the State Drinking Water Regulations.
The last inorganic Chemical Contaminants Sample results were submitted
to this Department on April 21, 1992. This does meet the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
The last Radioactive Contaminants Sample results were submitted to the
Department on July 1, 1992. This does not meet the provisions of 18 AAC
80,200(a), State Drlnking Water Regulations.
4. The last Organic Chemical Contaminants/Volatile Organic Chemical (VOC)
were submitted to this Department on June 2, 1992. Based on analysis of
the previous VOC samples results have been satisfactory. This does meet
the provisions of 18 AAC 80,20~3(a), State Drinking Water Regulations.
Issuance of this letter does not imply that the above-referenced Class "A" Public Water
System is in compliance with other provisions of the State Drinking Regulations.
If you have any questions on the above information, please do not hesitate to contact this
office at 349-7755.
Sincerely,
Michael Lu
Environmental Eng. Asst. I1
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D, Cf
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
051-064-42 HAACf ~,(~ - ~/'~L..~ ~O~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lOt, block, subdivision, section, township, range)
L, ot 4 Block 18 Northwood Subdivision Unit 4
Location (address or directions)
NHN Blue Skies Drive
(b)
Property owner
Mailing Address
EDERAL ~TIONAL MORTGAGE ASSOCIATION
)~/~ /"lO,~ Telephone:(home) Business
10920 Wilshire Blve, Suite 1800, Los Angeles CA 90024
(c)
Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent
Address
Telephone
(e)
Mail the HAA to the following address: (or check here~, if hold for pick up.)
List contact person and d?y~phone number below:
/
2, TYPE OF RESIDENCE
Single-Family~ Number of bedrooms 3
3. WATER SUPPLY
· Individual Well [] Community~ Public []
Note: If community well system,rmust have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ~ 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.
72-025 (R~v. 7/88) Page 1 of 2
5. 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 verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional end 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 JEEIS Ponsulting F, ng~neer~-,-1Trg~eph°ne (907) 274-7611
Address
Date ~p~m~r 27~ lqRR
Engineer's Seal
6. DHHS APPROVAL
Approved for _
Approved_
bedroomsby ~--~~ ~Date /~-~0 ~?--~
_ Disapproved Conditional
Terms of Conditional Approval
The Municipality of Anchorage Department'oi H'ealth 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 eng'neer s work,
72-025 (Rev. 7/88) Back Page 2 of 2
~,,o' MUNICIPALITY OF ANCHORAGE (MOA) ,~, ·
~ Health Authority Approval (HAA)
o<~,~',i!~J,/ CHECKLIST, FEBRUARY 1984
~t ~'~%'~"~-~'~.c~'o 343.4744
.,~"~ _q%?- ,~ ' Legal Description: ~ot 4 ~o~ ~8
A. WELL DATA {.~v ~
Well Classif cat on ~mu~ ~Y no~ cZos~ ~ ~c Zo~lf A, B~ C, D.E.C. Approved (Y/N)
Well Log Present (Y/N)
Total Depth Cased to
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
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments See ADEC letter
Date Completed Yield
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 Cleanout/Manhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed 6/14/84'Size1000'
Standpipes (Y/N) Yes Air-tight Caps (Y/N) Yes
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N) No
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well N/A To Building Foundation
To Property Line 60 re-et To Disposal Field
To Water Main/Service Line 35 fee%
To Stream, Pond, Lake or Major Drainage Course Ovcr 200 foot
Comments *
No
Temporary Holding Tank Permit (Y/N)
No. of Compartments 2*
Foundation Cleanout (Y/N) Yes_
Date Last Pumped 9/23/88 ~'~ · ~*~;~'&
; for
T~./A
Over lOfee~
]O *
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata_ 1R3
Date Installed June ~1984*
Width of Field 23 *
Square Feet of Absortion Area 9 R9
f~-.* Type of System Design
Length of Field 43 *
Depth of Field 3.7 feet *
Gravel Bed Thickness
, Statndpipes Present (Y/N) Yes
Date of Last Adequacy Test 9/21/88
Depression over Field (Y/N) No
Resuits ofLastAdequacyTest Passed sufficient for 3 bedroom
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well N/A
31
To Building Foundation
Lot . N/A
To Water Main/Service Line 5f~ fc. et
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line Over 30 feet
feet * To Existing or Abandoned System on
; On Adjoining Lots Over ~-0 feet
To Cutback (if present) Nnn~
None within 200 feet
Over 50 feet
Comments
D. LIFT STATION
Date Installed N/A
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 th~t'~ have ch/e~l~, ver~ied, or conformed to all MOA and
inspection.~'
Signed
Company ~.~T$ Co~su[t~g ~L~ee~s~ ~c.
Date September 27, 1988
MOA No.CE88-285
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
:t on the date of this
Engineer's Seal
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
36F)1 C STREET. SUITE 1334
ANCHORAGE. ALASKA 99503
STEVE COWPER, GOVERNOR
563-6775
DATE: September 27, 1988
PWSIB: 213001
To Whom It May Concern:
According to the records on ?ile in this o??ice, the CHUGIAK
UTILITIES/NORTHWOOBS Water System is in compliance with the State
o¢ Alaska Drinking Water Regulations.
MPl_:pkk
Si ncere 1 y,
Michael P. Lewis, PE
Environmental Engineer
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ·
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date '~i~ ¢~//
GENERAL INFORMATION
(a)
Lega/I Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) ApplicantName~~ Telephone:Home~-¢~ Business
(c) Applicant is (check one): Lending Institution ~; owner/builder ~~er~ (explain);
(d) Lending Institution ~ ~~/2 Telephone
Address ¢ ' - ~- /-~ ~~
(e) Real Estate Company and Agent
Address
hone
(f) -Mai~he HAA to the following address:
TYPE OF RESIDENCE
Single-Family,S' Multi-Family []
Number of Bedrooms '-~
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
Onsite~' Public [] Community [] Holding Tank []
Note: If cornmunity well system, must have written confirmation from the State Department of Environmental conservation
attesting to the legality and status. ,
Pa~e 1 of 2 72~025 (11/84)
EF?;~!5~EE. RING FtR~{ PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORM~,TION~
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 tile 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 disposat system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm 5 &'$'F-ng~,~:;~iiJ' Telephone
Address $~B 1~6x
Date
Eagle ~iver, AlaSka 9957?
Term. of nal 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 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.
WELL DATA
MU NICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
C.ECKL,ST-FE.RUARY
Well Classification
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above G round
ElectriC:al 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
Comments 'P ~k.j ~
RECEIVED
If A, B, C, D.E.C. Approved
Date Completed Yield
D~t~ of Grouting
!~- Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
: On Adjoining Lots
'Z-c,c) ~ 4- ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
: Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ~,,..L.(~C/ Size !(90o -No. of Compartments
Stand pipes~',N-)'- - Air-tight Caps (~/J~ Foundation Cleanout~,N1
Depression over Tank ~ Date Last Pumped "~Z'~°'"~?'~
Pumping/Maintenance Contract on File (Y/N) ¢'~ [/~'- : for ~-
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well 7_.~o
To Property Line ~
To Water Main/Ser-W~e-Line
Temporary Holding Tank Permit (Y/N)
To Building Foundation '~-~ ~
To Disposal Field
To Stream
Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
72-026( 11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well "Z..~"~
TO Building Foundation '-~t
Lot
To Water Main/Service Line r'-{
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments' z~nnn~"~r~'_,'¢ ~"~
Type of System Design "~--~"'~
Length of Field ~'~' oF ~ h~l~ ~z~c~ zae}'
Depth of Field ~.~ I
Gravel Bed Thickness ~' '
Standpipes Present ~0J~)
Date of Last Adequacy Test f--I ¢_~ V,,.(
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 tY/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pure ping 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 ~ ~,~ En_uineerin~l_ Date
SEB 196x MOA No. ~0 ~ ~~ ·
Date of Payment 3 '~.~ ~
Page 2 of 2
72-026 ~1/84)
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA gg501
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
PWS
To Whom it May Concern:
According to re cord.s qn file in this office the ~//~~./~J
)' System is in compliance with the State Drinking
Water Regulations
Sincerely,
,, MUNICIPALIT~ OF ANCHORAGE
~-'x,
MUNICIPALITY OF ANCHORAGE ENVIRONMffNI'AL PROTECTION
DMSION OF ENVIRONMENTAL HEAL~'H .
DEPARTMENT OF HEALTH AND flgVIRONMENTAL PROTECTZO
APPLICATION FOR HEALTH AUI'HORITY APPROVAL CERTIFICATE
1. General Information Application C E iV E D
(a) L~aal Description (include lot, block, subdivision, section, township, range)
l _nh 4; ~1~ 1~ '~:M/:~ ~ -/~,~,,,~.st~//n
(b)
(a) Appli .cant is (c~ck one) Lending Institution ~; Owner/builder ~;
Buyer ,[--! ; Othe= ~ (explain); ,
(d) Lending Institution Telephone
Address
e
e
e
(e) R~al Estate Co. & Agent __
Address
Telephone
~ of N-=sidence
Single-Family ~
Number of Bedrofm~
Multi-Family ~-~
O~e~(des~i~)
Water Supply_
Note: If c~,,onity ~11 system, must have w~itten confirmation from the State
Department of Enviro~rental Conservation attesting to the legality and status.
Is the ~11 adequate fo~ the number of hedrocms specified in this' ~L~A ~/N)
Sewage Disposal_
Onsite ~-~' Public ~ Co.[r~]rlity ~ Holding Tam]~ ~-~
Is the wastewater disposal system adequate fc~ the numbe~ of bedrocn~ _~/N)
[Page 1 of 2]
2-15-84
5. Engineering Firi, Providing Inspections, Tests, Data and Information
I certify that I have checked, verified, c~ confur~d to all MOA
effect on the da~e of this inspection.
- · '- '/-FA
Telep,hone ~?1' ~ / ~)l
( ENGINEER SEAL)
6. DHEP Approval
Approved for
Appro~d
Disapproved ~ Conditional ~-~
Terms of .Conditional Approval
The Municipality of Anchorage D~pa~tn~nt of Health and Enviro~-~¥~ntal Protection dces
not guarantee the continued satisfactory perfo£~lnce of the water supply and/c~ the
wastewater disposal system. This approval indicates that, as of the validation date
shown above, based on the data and information furnished by an engineer registered i~
the State of Alaska, the water supply and wastewater disposal system is safe and fun~
tional fo~ the rnmber of bedrooms and type of structure indicated.
( EP SEAL)
7. Mail the HAA to the following address:
KB2/d5/s
[Pag~ 2 of 2]
2-15-84
ao
Well Classification
Well Log P~esent (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances frcm Well:
To SeDtic/Holding Tank c~ Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cle anout/Manhole
Water Sample Collected By
Water Sample Test ~esults
C~u~nts .
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
I~ A, B, c~ ¢, D.~.o¢. A~proved(¥/~)
Date Completed Yield
~pth of G~outing
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
,SEPTIC/HOLDING TANK DATA
Date Installed ~-~-~/~ Size !/~D a~.~.~C~'; NO. of C(~,~artments
Standpipes (Y/N) ~.~ Air-tight Caps (Z/N) ~/~f~ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ~I¢ Date Last Pu~ped '-- /~{]
Pumping/Maintenance Contract an File (Y/N) -- ; fo~ - ~
Holding Tank High-Water Alarm (Y/N) -' Temporary Holding Tank Pe~,,~t (Y/N)
Separation Distanees f~cm' Septic/Holding Tank:
To Water-Supply Well ~f?0 '~ ~ To ~uilding Foundation /l~
TO Property Line ~' To Disposal Field
To Water Main/service Line /~ To Stream, Pond, Lake, o~ Major D=ainage
Counts
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~-~- ~/>
Width of Field ~/
Square Feet of Absc~ption A~ea ~ ~
Length of Field ,~
Depth of Field
Gravel Bed Thickness
Standpipes P~esent (Y/N)
Depression over Field (Y/N) . Date of Last Adequacy Test
Results of Last Adequacy Test --
Separation Distance f~cm Absc~ption Field:
To Building Foundation ~/ To Existing or Abandoned System cn
Lot - -- ; On Adjoining Lots
To Wate~ Main/Service Line /~ To Cutbank(if present)
To Stream/Pond/Lake/c~ Majo~ Drainage Course
To D~iveway, Parking A~ea, or Vehicle Storage A~ea ~O/
D. LIFT STATION
Date Installed
Size in Gallons
"lkat9 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 du~ing Adequacy Test.
Meets MOA
C~,~ents
** Check Pezmtitted Bed~ocm Ra~ing ~ainst HAA Request ** ~, ~6O-~Y~_7
I certify that I have checked, verified, o~ confc~m~d to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed ~r~/('~,/~/'[~ c~
Company
KB1/d5/s
[Page 2 of 2]
ENGINEERS
' . .SEAL
2-15-84
DEPT. OF ENVIRONMENTAL CONSERVATION /
SOUTHCENTRAL REGIONAL OFFICE
437 "E" STREET, SUITE 200
ANCHORAGE, ALASKA 99501
PWS ~.o. ~ ~3001
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
To Whom It May Concern:
According to r, ecords on file in this office the
~i~i~tOl~J Water System is in compliance with the State Drinking
Water Regu ations.
Sincerely,~~~/~