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HomeMy WebLinkAboutNORTH WOODS UNIT 4 BLK 18 LT 6 1 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 MAI LING ADDRESS LEGAL DESCRIPTION LOCATION ~ ~ DISTANCE TO: IWell .0 ~[, Absorptio~ Dwelling  Manufacturer Liq. eapnoity in gallons Inside length Width Liquid depth /O~ ~ IF HOMEMA DE: ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O ~ ~ Manufacturer ·--~ Material Liquid capacity in gallons ~ ~ ~ ~ DISTANCE TO: Well ~O ~''[' Foundation ~ Neares'~' ~ ~ No. of lines ~ L~flth of each line Total length of lines Trene~ Distance b een lines ~ =~ Top of tile to finisl~ade O gg~ ) Material beneat ile Total effective absorption area ~ inches ~ ' Length Width Depth ~ PERMIT NO. ~ ~ Type of crib CHb diameter Crib depth Total effective absorption area ~ DISTANCE TO: Well Building foundation Nearest lot line ~ Class Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS INSTALLER S~Z~ REMARKS , / APPROVED E:,EPRRTHENT OF HERLTH RND EN',,,' I F.:OI'.,IMENTFIL PF,:OTEC:T I ON ,~.-~.~ 99.~Fli ,:,,=.._ L :,1 BEET., F:Ii'.,IC:I"iCd:;i:f'::IGE:, RK .... 264- - '::!. 7 ;2 PERMIT ?'40: L.~M I ~ .~ -,-,,.,~.- . RDDRESS: CONTRCT PHONE:. LEGRL DESCRZF': 'LOT SiZE: 84.0047 ENG I NEERED DEE;I GN . SKRGCiS CONSTRUCTION PO BOX D CHUG :[ RK., Fd-( LaL~567 688--283:::L SUBD I'¢ I~[,!~LN: !'~f3RTHWCICIDS I',,,' S Er.' T i ON ' '~: TOWNSH I P ..L._ I,i 24294 ,::SC.L FT. OR RC'RE2;> LOT: 6 F..HN ',E: 11.4 BL. CICK: I CER'I"IF"r' TFIFtT: i. I RFI FRklILII:::tR t.4]:TH THE REQIJIREFIENTS FOR ON-SITE S['ZWERS IRND WELLS RS SET FORTH B"r' THE P1UNICII='FIL:[T"r' OF FINCHORFIGE (i'"[OR) FIN[:, THE S'I"FITE OF: RLRSKR, 2. I t,.IILL. INSTRL. L. THE S~'~':STEhl :iN F:iC::COR[:'RNCE WITH FILL HOR CODES RND REGULRTIONS., RND :l:i",i C':OHPLIRNCE 1.4ITH THE DESIGN C'RITERIR OF THiS PERHI'T'. .'2:.I WIL. L. Ri.'.:,FiERE TO RLL. FlOR RI",IE:, STRTE OF RLRSKR RE6:!LIIREI"IENTS FOR 'THE SET BRCK DISTRNCES FROhl F:!N"r' EXISTINC:i WELL, WRSTEWRTER DISPOSRL S"¢STEH OR PUBLIC SEI.4ERFIGE S"r'STEP'I ON ]"HIS OR F:¢',l"r' RDJRC:ENT OR NERR8"¢ LO]'. IF R LIFT STFI'T'ICIN IS INSTRLLE[:, IN RN RR[:.:FI C:O'v'EF.:ED B"r' HOFt BUILDING CODES., "FFIEN <::L::, FiN ELECTR. IC:FiI_ F'E:RMIT RND If..ISF'ECTION hlUST BE FiBTRINED.; ,::2) RS-BI_lILTS I.,.IILL NOT E:E RF'F'RO',,,'ED 1.4ITHOUT FIN ELECTF.:ICRL II'.,ISPE'"TI3N 'r';'EPZI.;.'T.; RND ,.':~',', THE ELECTRIC:FIL. WCRK I',I_I':ST E:E F:,CtNE E:"r' F't L. IC:EIqSE[:' ELECTRIC:IRI",!. /--~MUNI~!PALITY OF ANCHORAGF-~ epartmen~ ~f Health and Environment, ~Protection D 825 L Street, Anchorage, AK. 99501 264-4720 '~ * * * HANDWRITTEN PERMIT * * * ?e~mit ~ ~0o~7 WELL AND/OR ON-SITE SEWER PERMIT Applicant: ~}C~ ~o~/~ ~c~7o~-)Mailing Address: Location: Phone Nu~er: Legal Description: ~-/~/ ~ ~z~oc=~ /~ Lot Size: Type of Soil Absorption ~'~~.~z>~. /~' ~.- ~c~ ~ ~-~F~ ~/ Trench: ~---- Drainfield: Seepage Bed': / Holding Tank: ~4aximum Ntunber of Bedrooms: 3 Soil Rating(sq.ft/br) The Re~ired Size of the Soil Absorption System Is: /~ ~'D~TH 2_~' LENGTH 2tL~/4 - 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 = /~__~._~jl GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of a~_l~jacen~his property and the number of residences that the we~--'~lll serve. ~ ,, * *.(,.%...C_wp(2) INSPECTIONS ARE REQUIR Backfilling of any system~i~ u~ final inSpec~t_tiD~ approval by this departmen~ will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimura 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 ~re available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9.8 A F* * * 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 that 3 bedrooms. Signe~: ApPlicant Issued by: Date: SWD/024 (1/81) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST SOl LS LOG PERCOLATION TEST PERFORMED FOR: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19. 20- I COMMENTS PERFORMED BY: 72-008 (6/79) SLOPE DATEPEREOR~ED: M.~,/~ I~, Iq,~ WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? S L 0 P E SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop IOV2. ~ ,75 PERCOLATION RATE TEST RUN BETWEEN v' ~V~'L~ /'~ 0~- CERTIFIED BY: ~T~ ~ o zy (minutes/inch) / [/~¢~- FTAND~ FT MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION S25 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOtLS LOG PERCOLATION TEST SLOPE ~/~ /s L~,f~ SITE PLAN / / 11 12- 13- 14- 15 ;. Reid, .Jr. 2251 -E WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Reading 4- ~-H~ O Date Gross Time ~ /~/ t Net Time /O Depth to Net Water 3 Drop PERCOLATION RATE (minutes/inch) COMMENTS FT AND -- FT MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTI(~N 825 IL. Street, Anchorage, Alaska 99501 264-4720 SOIL S LOG - PERCOLATION TEST SOILS LOG [] PERCOLATION TEST 4- 10- 11- 15- 19 20- COMMENTS. SLOPE SITE PLAN PERFORMED BY: 72-o08 {6/79) WAS GROUND WATER ~ S ENCOUNTERED? _ ~ P IF YES, AT WHAT E DEPTH? Reading te Gross Net Depth to Time Net Time Water Drop PERCOLATION RATE .Jminutes]inch) TEST RUN BETWEEN . FT AND , FT IFIED BY:. .~-,~ A, [] SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264:4720 SOILS LOG - PERCOLATION T ESi~ SLOPE PERCOLATION TEST WAS .GROUND WATER ENCOUNTERED? DATE PERFORMED: $~TE PLA~ IF YES. AT WHAT DEPTH?. ~Rea~ing Date - .: .Gross Net Depth~to Net ri ' ~ Time Time, Water Drop ~#~.¥' ~-I~ ~:~ ~ ...- 3,"7~. - '~, ~1 ~0 3:,~ ' ~, ~l -, ~, ~ ~ . .. '~5; I~ 3. ~ . PERCOLAT ON RATE (minutesl!nch) :" VEE. ~2. ~T AND ~ FT 0,~ ~o -~ PERFORMED BY: 72-008 (6/79) CERTIFIED BY: ' Parcel I.D. # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lOt, block, subdivision, section, township, range) Lot 6 Block 18 Northwoods #4 Sec. 3 T15N R1W Location (address or directions) 112 Blue Skies Peters Creek (b) Property owner T, sr~7_ Walker Mailing Address HC R0 Be× 112 B]~¢. Skies Driv~ Ch~?giak: AK (c) Lending Institution Cc~mrnnnw~slfh Mnwf?? Telephone Mailing Address 33'~'~ r3c`na'l-i .qfc,_ 110 Anc~hn'r'~c`: AK 995~)~ (d) Real Estate Company and Agent ~.RA P~alfy .q'l-r~'r-~ ,ch~n~ Rilsf Address 8400 Ha~tzel Rd. A~chorage, AK 99507 Telephone 344-0501 -~/V ~/~ ,U-,A//C/'~ MUNICIPALITY OF ANCHORAGE ",,v~, ' Department of Health & Human Se~ices (~ . ,,..,, ',~ DIVISION OF ENVIRONMENTAL SERVICES =~ "::',' ;~ ~'~z~- 343-4744 ~ ~ '~ ~: ' wO'V ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Telephone: (home) 688-4809 99567 278-5229 Business (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: Leu Butera 694-5195 2. TYPE OF RESIDENCE Single-Family [] Number of bedrooms . 3. WATER SUPPLY Individual Well [] Community [] Public [] 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 I~ 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 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 investigatior~ of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system i~ safe, functional end adequate for the number of bedrooms and type of structure indicated herein. I further verify th.at 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 Ea.gle River Engineerinq Svcs. Telephone 694-5195 Address P.O. Box 773294 Eaqle River , AK 99577 Date 1//~ 0/o~=~~' Approved for ~ bedrooms by , Approved ~ ' Disapproved Conditional Terms of Cor~ditional Approval 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) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) 13' OF Al,~l~jl~Uthority Approval (HAA) OF HEALI'I~I~'I~LIST, FEBRUARy 1984 E ~I~i$~VIENTAL PROTECTION 343-4744 NOV 3 0 988 A. WELL DATA Well Classification ~/~-~ Well Log Present (Y/N) Total Depth Cased to Static Water Leve 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 ,RECEI. VED Legal Description: .~ &' Date Completed If A, .,B, C, D.E.C. Approved (Y/N) ,,Y ~z~ 1~.~. 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 ~?,/,¢z_./ Size /~ Standpipes (Y/N) ,,I/ Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on FUe (Y/N). Holding Tank High-Water Alarm (Y/N) No. of Compartments Y Foundation Cleanout (Y/N) Date Last Pumped /I/9~'/?~' ; for Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: TO Water-Supply Well -/-,.~z~ ~ To Property Line ~/~ / To Water Main/Service Line ~'/~ / To Stream, Pond, Lake or Major Drainage Course ~'/¢'~) ' Comments To Building Foundation /~ / To Disposal Field 7~-~' o" 72-026 (Rev. 7/88} Front Page ~1 of 2 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) TyPe qf S~t(~m Design" Length of Field z/?/ Depth of Field ,~2 / Gravel Bed Thickness ~ *~ 7 .~ StatndPip~s Present (~;1~1) /t2 Date of Last Adequacy Test Y Results of Last Adequacy Test .5',~/7~:z'~z-->~'~,~, J~-&~'~-Z~ ,~,,:.~ ~-e~ :~- SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-SUpply Well f,,~z~ To Property Line ~i~ ~ To Building Foundation To Existing or Abandoned System on Lot ,u,),~l ; On Adjoining LOts f'~,~ / To Water Main/Service Line */~) / To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course ~','~,~ / To Driveway, Parking Area, or Vehicle Storage Area f-~,z~ / Comments 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 guideli; inspection. Signed Eagle River Engineering Services Company P. 0. B-.x 773291 /:/,~ ~/~...~. Eagle River, AK 99577 Date ~9~, ?.05 MOA No. date of this Seal Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88) Back ~5- ~ ~,~/ Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 DEPT. OF ENVIRONMENTAL CONSERVATION~ STEVE COWPER, GOVERNOR ANCHORAGE/WESTERN DISTRICT OFFICE 3601 C STREET, SUITE 1334 ANCHORAGE, ALASKA 99503 563-6775 DATE: PWSID: ~f3a~t To Whom It May Concern: According to the records on file in this office, the ~UCf~ ~-l~/~/~ Water System is in compliance with the State of Alaska Drinking Water Regulations. / MPL: pkk Sincerely, Michael P. Lewis, PE Environmentgl Engineer MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF ~LTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR ~R._~LTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Appli'cation Date (a) Lega~ Description (include lot, block, subdivision, section, to~wnship, range) Location, (address or ,directions) (b) Applicants Name__~/O-~,,~/~ ~,_ ~ ~ {~, Teiephome ~ . - Home ~' Business Applicants ~dress (7(~ (c) Applicant is (check one) Lending fnstitut~on ~ ; Owner/builder ~ BuYer ~ ; Other ~ (explain), .[~.y~_~,~.(~ ' (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single-Family~--~ Number of Bedrooms 3. Water Supply- Individual Well~ Multi-Family.~. Other .(describe) Community~ Publfc~---] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. ~ewage Disposal 0nsit. ~ Public ~. Commlmity ~-~ Holding Tank Note: If community well system, must have written confirmation from t~e State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] 5. Engineering Firm Providin~ 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 sh6ws 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 compliamce with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firm ()/Of'[~ ~/')~y/~'~(!~'~.~.~ . Telephone · . . / . ~ '.." -" ... '~ i .'~' 6. DHEP Approval · /. . Approved for bedrooms By ,~~ f Date Approved~ Disapproved __ Conditional __ Terms o~ Conditional Appgoval ~~ ~~~~ 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 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 REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORH 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 Well Classification ~/)mj$$~/j~/i.~ Well Log P~esent .(.Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wi~ing in Conduit (Y/N) Separation Distances f~cm Wall: To Septic/Holding Tank on Lot To Nearest Edge of Absoz~ption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected By Wate~ Sample Test Results Cc~nts MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAL) CHECKLIST - FEBRUARY 1984 Legal Description: ~/~ If A, B, c~ C, D.E.C. Approved(Y/N) ~5 Date Ccmpleted Yield Depth of (~outing Pump Set At Sanitary Seal on Casin~ (.Y./N.) Depression A~ound Wallhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewe~ To Nearest Sewe~ Service Line on LOt B. SEPTIC/HOLDING TANK DATA Date Installed ~ -Z -~ Size /~ ~/~ No. of C~a~tments ~ Standpipes (Y/N) ~.~ Air-tight Caps'(Y/N) Y~S Foundation Cleanout (Y/N) Depression ove~ Tank (Y/N) ~0 Date Last Pumped ~/~3 Pumping/Maintenance Contract on File (Y/N)/~/~ ; for /~/~ ' Holdin~ Tank High-Water Alarm (Y_ZN) ~/~ Tempo~az~lr Holding Tank Permit (Y/N) Separation Distances f~cm Septic/Holding Tank: To Water-Supply Wall + ~' To P~operty Line ~ ~O! To Water Main/Service Line ~' Course Counts To Building Foundation /~ ! To Disposal Field ~ ! To St~esm, Pond, Lake, c~ Major D~ainage [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD ~ATA Soils ~ating in Absorption St=ara /l&~/~97~ Type of System ~sign Date I~talled ~-Z~ ~ ~ng~ of Field ~' Width of Field /f'W ~p~ of Field Grail ~d ~ick~ss S~e Feet of ~s~ti~ ~ea 7~m'~ Stan~i~s ~e~nt (Y~) ~p=ession o~= Field (Y~) ~0 ~te of ~st A~a~ ~st . Results of ~st ~a~ ~st ~p~ation Distan~ f~ ~s~pti~ Field: To ~te~-Supply ~11 ~ ~ / To ~ty Li~ To Buildi~ F~n~tion ~' To Existing Lot ~ ; ~ ~joining To ~te= Main/~rvi~ Line ;~' To ~t~(if ~e~nt) To St~e~ond~ke/~ ~j~ ~ai~ ~ To ~i~way, P~ki~ ~ea, ~ Vehicle St~a~ ~a De Date Installed Size in Gallons "Pump On" Level at High Water Ala~-m Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles duming Adequacy Test. Meets MOA Cc~ments ** Check Permitted Bedroom Rating A~ainst HAA Request ** ~ ~;-66~'~6~/'~<~. I certify that I have checked, verified, c~ confc~med to all MOA HAA Guidelines in effect MOA No. ~'~- ~$ ~ on the date of this inepection. KB1/d5/s [Page 2 of 2] 2-15-84 DEPT. OF ENVIRONMENTAL CONSERVATION SOUTHCENTRAL REGIONAL OFFICE 437 "E" STRgET, SUITE 200 ANCHORAGE, ALASKA 99501 PWS I.D. BILL SHEFFIELD, GOVERNOR Telephone: (907) Address: 274-2533 To Whom tt Way Concern: According to records Water Regulations. on file in this office the LI~](/~I~)~ Water System's in comp iance with the State Drinking Sincerely, ~ MUNICIPALITY OF ANCHORAGE DMSlON OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE General Info~mation Application Date '-~?//~ / (a) Legal Description (include lot, block, subdivision, section, township, range) . ¥_. 'i ~,'~/J/~i,,?,'~,~,~-'~:<" ~ '7-,c~ ~ ~--~,,~. . ~...~ Location (add, ess or directions) (b) Applicants Nam~.__~J~4__ Applicants Add~ess (c) Appli~nt~3s (che~ (d) ~ndi~ Institution Address (e) R~al Estate COo & Agent Address e Tele phone ~ of N~sidenoe Single-Family ~' Number of Bedrooms Mult i-Fmnily ~--~ Othe~ (describe) Water Supply Individual Well ~ C~,m~nity ~_~ Public ~ Note: If oz~munity '~.11 system, must ha~ written confirmation f-rcm the State Depa.~tment of Environmental Conservation attesting to the legality and status. Is t_he ~11 adequate fo= the number of bedrocms specified in this HAA ~?/N) Se___~ge Disposal Onsite ~ Public ~ Community ~-~ Holding TaDk ~ Is the wastewate~ disposal system adequate fc~ the numbe~ of bedrooms _~Y/N) [Page 1 of 2] 2-15-84 5. Engir~cring Firm P~oviding Inspections, Tests, Data and Information I certify that I have checked, verified, or conformed to all MDA FAA Guidelines in effect on the date of this inspection. Sigmd by (ENGINEER SEAL) 6. DHEP Approval Approved for Approved ~--~ The Municipality. of Ancho~,age Department of Health and Environmental Protection does not guarantee the continued satisfactory performance of the water supply and/or the wast~water disposal system. This approval indicates that, as of the validation date shcwn above, based on the data and informationfurnished by an engineer registered in the State of Alaska, t_he water supply and wastewater disposal system is safe and func- tional for the number of bedrcc~us and type of structure indicated. (DHEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s [Page 2 of 2] 2-,15-84 A® Be MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (FAA) CHECKLIST - FEBRUARY 1984 W~.r ,]'. DATA Well Classification Well Log P~esent (Y/N) A///~_ Total Depth 4]~/~ Cased to Static Water Level ~ Pump Set At Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Sepa=ation Distances f=c~ Well: ~JA To Septic/Holding Tank c~ Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/~anhole Water Sample Collected By Water Sample Test Results Date Cc~pleted ; On Adjoining Lots ~/~ ; On Adjoining Lots To Nearest Public Sewer TO Nearest Sewer Service Line on Lot ,/'u//.'~ ; Date C~=nts SEPTIC/HOLDING TANK DATA Date Installed 5{/~'t ?/ Standpipes ~/N) Size /Do o Air-tight Caps ~/N) No. of Ccmpa~tments 2_ Foundation Cleanout ~/N) Depression over Tank (Ye Date Last Pumped /U/,;~- Pumping/Maintenance Contract on File (Y/N) ~/.Fc ; for Holding Tank High-Water Alarm (Y/N) ~/~c Te~po=a=y Holding Tank Permit (Y/N) Separation Distances f~cm Septic/Holding Tank: To Water-Supply W~ll To Property Line To Water Main/Service Line Course ! To Building Foundation To Disposal Field ?(3' To Stream, Pond, Lake, c~ Major D~ainage Comments [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~/~ Width of Field /~ Square Feet of Absorption A~ea ~3/~ I1~ Type of System Design Length of Field ~// Depth of Field ~ ~ G~'avol Bod Thicknoss ~ Standpipes P~esent ~/N) Depression ove~ Field ~/N) ~ Date of-Last Adequacy Test ~//~ Results of Last Adequacy~Test Separation Distance f~cm Absorption Field: To Water-Supply Well~ ~- To P~operty Line To Buildin~ Foundation ~/~ / To Existin~ c~ Abandoned System cn Lot A3 [2~ ; O~ Adjoining Lots To Water Main/Service Line ~$~ To Cutbank(if present) To Stream/Pond/Lake/c~ Majo~ D~ainage Course To D~iveway, Pa~kin9 A~ea, c~ Vehicle Stc~age A~ea LIFT STATION Date Installed Size in Gallons "Pump On" Level at Dimensions Manhole/Access (Y/N) "Pump Off" Level at High Water Alarm Level at ~/./~ Vent (Y/N) ~3/~ Tested for ~J/~ Pumpin~ Cycles F~in~ Adequacy Test. Electm~ical Codes(Y/N) ~/~ C~nts M~ets MOA Check Permitted Bed~ocm Rating Against HAA Request I certify that I have checked, verified, o~ conf~d to all ~DA HAA Guidelines in effect on t~. date of this inspection. Signed /~. ~~ Ccmpany [Page 2 of 2] Fr-"- ×, · 2-15-84 DEPT. OF ENVIRONMENTAL CONSERVATION SOUThC~.~TP~AL REGIONAL OFFICE 437 "E" STP~EET, SUITE 200 ~CHOP~AGE, ALASKA 99501 BILL ~IEFFIELD, GOYERNOR Telephone: (907) Address: 274-2533 To Whom It May Concern: records on ~i~iO~ Water System is in compliance with the State Drinking Water Regulations. cerely,