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,