HomeMy WebLinkAboutPENNINGTON PARK BLK 3 LT 8
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: _________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
GR'"'~TER ANCHORAGE AREA BOROU'"H
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
N? 235
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
MAILING 4-z//7 /~/~C PHONE
ADDRESS ~ / / /
,.~o.~,. o~sc,~,,.,o~ L~ ~ ~z ~ ~~
SEPTIC TANK:
DISTANCE FROM WELL
LIQUID CAPACITY
MATERIAL 5~(t / NUMBER OF
COMPARTMENTS ~-
~'/~-/( ,~"~L /'~/~'? LIQUID
GALLONS. INSIDE LENGTH. INSIDE WIDTH DEPTH
SEEPAGE SYSTEM:
SEEPAGE PIT:
NUMBER OF PiTS ~ OUTSIDE DIAMETER 6 ~ OR WIDTH LENGTH ~'
LINING MATERIAL ~'~;'1/.~ DISTANCE FROM WELL
NEAREST LOT LINE
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
, DEPTH
BUILDING FOUNDATION
/?0 SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM W/L FOU~r/~'~ NEAREST L0~'L~ TOTAL LENGTH
OF LINES
"/"/' / /"//" / ,/'~N. TOTAL EFFECTIVE
NUMBER OF LINEl_ DIST~E BETWEEN LINES ../' TRENCH WIDTI~/
ABSORPTION AREA~,~.~../ SQ. FT. LENGT
DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE
WELL: TYPE J/';/~(/ ,DEPTH j 69~') ` DISTANCE FROM WATER
,BUILDING FOUNDATION SAMPLE , NEAREST
,..,~...,~s., s~,.~-.c/0y" s~,..,.~/~- o~-,-,~,
LOT LINE SEWER LINE ,TANK , SYSTEM , CESSPOOL , SOURCES
DISTANCES:
DATE
DIAGRAM OF SYSTEM
APPROVED
HEALTH AUTHORITY
GREATEI
327 Eagle St.
ANCHORAGE AREA { OUGH
HEALTH DEPARTMENT . . '\~ ~J~- ~
Anchorage, Alaska 99501 '~~Skj~ 279-2511
Case No. ~
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
RESIDENCE ADDRESS /'~-'~
LEGAL DESCRIPTION./-~'~-
APPLICATION TO INSTALL: SEPTIC TANK ~
, SEEPAGE PIT.
LOCATION OF INSTALLATION f'~"'%'"~/ ~ctt,,, _
, BRAI~FIELB.. , OTHER
FINANCED THROUGH ,/~_~z'-~' A
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS
· SEPTIC TANK SIZE
DISTANCES:
AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED.
/~ TYPE ~"~,z,,~-~,- SEEPAGE AREA ~/-'~- TYPE
I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the
a bovedescribed system is in accordance with said code. ~-~ D~//tUti~-~~,/ff~6~,''//~ ~ ' ~
DATE
De?'th
I_.
3---
¥--
Was Ground Water Encountered?__~ ....
9 a't e
~~27.1~~_7LT2LJ .....
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, # /~- I%~ -~-'~-')
1. GENERAL INFORMATION
Complete legal description
Lot
HAA # ¥~ ~¢~ .~. (")~ \
8: Block '3;' Penningt0h Park Subdivision
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Dyke Smith
17500 Golden V~ew Drive,
Day phone 345-1589
Anchor~qe, Al~,~ka ggS] 6
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
XXX
Individual well
Community well
Public water
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
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.
Name of Firm
Address
Engineer's signature
S & S ENGINEERING
Eagle Rlver~sk~577
DHHS SIGNATURE
X' Approved. fo r '7'/,~'-~.f~? bedrooms.
Date
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:'
Additional Comments
The Municipality of An~.horage 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 regist,=.red in the State of Alaska. The DHH$ 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 om,ssions in the professional engineer's work.
72..025(Rev. 1/91) Back MOA#21
Legal Description: Lo'/-
A. WELL DATA
Well type /ND/p'/Cz~L_
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
/D_~/JAJ//JGT-o/,J I~,F4/~' Parcel I.D.
If A, B, or C, attach ADEC letter. ADEC water system number ~"/~
Log present(~
Total depth /~/~ ~EC~)~Cased to ~D~o~ Casing height
Sanitary seal ~N)
FROM WELL LOG AT INSPECTION
Date of test
E~ikONME~AL
Static water level J
Well flow g.p.m.
~p level
SEPARATION DI~ ....
Septic/holding tank on lot
Absorption field on lot
Public sewer main /f~/-~6¢
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
JO0 fy__
WATER SAMPLE RESULTS:
Coliform (~//0~/'/'~_
Nitrate
Collected by:
Other bacteria
a. SEPTIC~TANK DATA
Date installed /0 /
I
Cleanouts (~N)
High water alarm (YN~
Date of pumping
Tank size /~573 Compartments ..,~ /
Foundation cleanout (Y~),'~0 Depression, (YN~_~
Alarm te~t'ed (Y/N)'": '~'('///~' ' '
,~/Z'"//~/,,,~ Pumper /~ * ~'Idle ~E~,VIC~...%
SEPARATION DISTANCES FROM SEPTIC/ ......... TANK TO:
Well(s) on lot / (.),-~ ' On adjacent Io,~ /6YO / J"
To property line ~.Or¢- Absorption field
Surface water/drainage
72-026 (Rev. 7/91) Front
Foundation J~--~ /
Water main/service line
CONTINUED ON BACK PAGE
12:~6 CI'&E ENUIRONMENTAL L~B SERUICES ~ '"i~'~'~;~"~' ~'~i~' ' NO. 59~ '~
COMMERCIAL TESTING & ENGINEERING CO. AK DIV
cHEMiCAL & GEOLOGICAL BO TORY
T~LEPHONE (907) 562-2343 5633 B Btreet
Anchorage, Alaska 99516
Drinking Water Anatysis Repod for Total Coliform Bacteria
TO DE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LA~ORATORY
--/PRIVATE WATER SYSTEM
Narre $ & S ENGIN£ERING
17034
Mo. Day
~AMPLE
Routlne
Check ~mp:e (for routine ~mple
with lab ref.
~ Special Purpo~
SAMPLE
No. LOCATION
3L
Year
[] Treated Wpter
[] Untreated Water
Time Collected
C~lleoled By
READ INSTRUCTIONS M~'nbrar~e Filter; Dire~t Count
BEFORE Verification[ Lt~B __
· COLLECTING SAMPLE
An~tysis shows this Water SAMPLE to be;
il~_Satisfactory
[] Unsatisfactory
CJ Sample too long in transit; sample should
not be over :30 hours old at examination
to indicate reliable resu~s, P!ease send
new sample via s~cia{ detive~ mall,
Data Re~v~ ~ -. ~.,
Tired R~celwd ~,' ~ ~
Anal~lcel ~thod: Membren~
Re~uIt*
* No. of colonies/100
Lab Ref. Fie,
,-.?_
95.'1875
BACTERIOLOGICAL WATER ANALYSIS RECORD
BOB
,knalyet
~------~') Coliform/100 mi
Fat Coliform Confirmation
Final Membrane Fltte?.L~qa~,ulta
TNTC = Too Numerous To Count ~me:
OB = Other Bacteria ~:~ .....
' PAET ONE OF.TWO
...' ¢~ ~om~er of the SGS REHAINDER TO ~FO
ENV I-OHHENTALR LAB ' "~'~ ' ~~ ....
CT&E
ERV ICES · -.~i~.'~-~ ~ . NO. ~ ~0~
CtlEMICAL & GEOLOGICAL LABORATORY
~,,, A DIVISION OF COMMERCIAl.. TESTING & ENGINEERING CO:
'x,, 5633 B STREET ANCHORAGE ALASKA 99518 TELEPHONE (g07) 582?343 FAX: (907) 561-5301
REFORT of ANALYSIS
Chemlab Ref,~ :93,1873-1
Client S~ple ID :LB B3 pElqNIN~TON PARK 9/D
Matt ix : WATFR
Client Na~e :S & S ENGINE~.RING
Ordered By :R. SHAFE~R
Project Name :
Projects :
PWSID :UA
Sample Remarks: ROUTINE SAMPLE C0[LE[.TE BY: S.S,
Collected :04/28/93 @ 08.'30
Received :04/29/93 @ 14:00
WORK O['der : 65495
Re~ort Colnpleted .: 05/04/93
Techn ical Director ;:: SIEF~E'~ _C .y EDE
Released By : ~~
hfs.
hfs.
QC Allowable Ext. Anal
Parameter Results Qual. 0n~t5 Method Limits Date Date Init
NITRA~[~-N ............................................ 0,10 [] ~9/1 EPA 353,2/300, 0 10 04/30 Lt~
* See Special Instructions Above . ,.-::~:.~.-_
~,?i.~.A _
** 'See Sample'Remarks.,A~ve .-..',, , ~.,-.. N - Not An~
U ~Undetected, Re.fred va].ue is the ~ctica[ ~,tiftcation limit
O =:,Secondary dilution, : :'~; .
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lOt, block, subdivision, section, township, range)
Lot 8, Blk. 3, Pennington Park Subdivision
Location (address or direCtions)
17500 Goldenview Drive, Anchorage, Alaska
(b) Property owner
Mailing Address
Merrill Lynch Equity M~l~h;~).
Four Landmark Square, Stamford, CT
Business
06901-2502
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent Marston Real Estate/Dale
Address 2804 W. Northern Liqhts Blvd.
Telephone 2 4 8- 2 8 0 4
Tyree
(e) Mail the HAA to the following address: (or check here [~,'if hold for pick up.)
List contact person and day 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, must 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 (Rev. 7/88) Page 1 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4744
Legal Description: 'r,ot 8, BT,K
3, Pennington Pk.
Individual
Well Classification If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) N D~te_~ted,,i 10/70 Yield
~'--" O~/~o.n Unknown
Total Depth 100 Ca~to _'._~ !~____,.th of Grouting
Static Water Level 85 ..... Pump Set At UN'I~
Casing Height Above Ground N ~ - ...... _ , Sanitary Seal on Casing (Y/N)
Electrical Wiring in Condui/N~{-~'~~ "~N~' ~ fl~, 0,~/~ ~epression Around Wellhead (Y/N)
Separation Distances from Well:
125'
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line D/A
Cleanout/Manhole N/A
A.~ 10/z8/88
Water Sample Collected by ~ --- _ _~_.,. ? · Date
Water Sample Test Result~/SatisfactorC?/_ 0 ¢o,//oo ~/
Comments ~'~'~--------*--~--- O d' o/ /~% ~/ )
100 '+
· On Adjoining Lots
135 ' · On Adjoining Lots N/A
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot N/A
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N)¥
Depression over Tank (Y/N) N
Pumping/Maintenance Contract on File (Y/N)
N/A
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
125'
To Water-Supply Well
30'+
To Property Line
To Water Main/Service Line 40 '
~o 100'
'Course
10/70 Size 1250 Gal. ~1o. of Compartments 2
Air-tight Caps (Y/N) Y Foundation Cle~an~ut~(¥/N)~ Date Last Pumpe<10/19/88 ............. t
N
· for
N/A
Temporary Holding Tank Permit (Y/N)
12'
To Building Foundation
15'
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026 fRev 8/86~ Front
DEPA'RTN.
825
#1: Time
Date
Insp
MUNICIPALITY OF ANCHORAG~
OF HEALTH AND ENVIRONMEI. .L PROTECTION
L Street, Anchorao~, Alaska 99501
264-4720
Date Received:
#2: Time #3: Time
Date Date
Insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
Lending Institution Request: Nat~nal
Mailing Address: P.O. Box 3-3859 Phone: 279-2560
Property Owner:
Mailing Address:
Roger Purcell
Box 472Y SRA
Phone: 344~2260
3. Legal Description: Lot 8 Block 3 P~nnington Park Subdivision
4:
Single Family Residence: (x)
Multiple Family Residence: ( )
Number of Bedrooms: three
Number of Bedrooms:
5. Well System:
Permit % Depth of Well
Construction ~
6. Sewage Disposal System: On-site System (x)
Permit # Installed
Septic Tank Size
Absorption Area
Individual Well (x) Community/Public System ( )
Well Log on File ( )
Bacterial Analysis ~
Public Utility ( )
Installe~
Manufacturer
Soils Rate Material
Distances: Well to Septic Tank '%.~
to Sewer Line Nearest Lot line
to Nearest Lot Line
to Absorption Area \~
Absorption Area
Page Two
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 8 Block 3 Pennington Park Subdivision
Comments:
Affadavit Attached:
Disapproved: ~ Date:
Letter Attached: ( )
Department Worksheet:
MUNICIPAI.ITY OF ANb.-IORAGE
DEPARTMENT OF ENVIRONMENTAL QUALITY
Anchorage, Alaska 99503
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection: CMRO VA
2. Property Owner: II ROGER PURCE~t
II
BOX 472Y SR A
ANCHORAGE, AK
Mailing Address:
3. Name of Buyer:
F HA
CONV
Day Phone
Mailing Address:
Name of Lending Institution:
Mailing Address: ~p r-
Day Phone
Phone
5. Name of Realtor or Agent:
Mailing Add~ess:
Phone
Legal Description:
Location'._
Type oi' Facility to be inspected:
Water Supply
Type of Supply: Public Utility
If Individual, number of dwellings presently served
If Individual, depth of well
Individual
Sewage Disposal Syster;'~
Type of System: Public Utility
If Individual, date of installation
06-1220(a) Rev, 1973
DATE
AL/ DEPARTMENT OF HEALTH AND SOCIAL ~~ES
DIVISION OF PUBLIC HEALTH
INDIVIDUAL AND SEMI-PUBLIC
BACTERIOLOGICAL WATER ANALYSIS
Lab No.
OFFICE
INDIVIDUAL []
NAME
SEMI.PUBLIC [] CHLORINE RESIDUAL PPM
REPORT RESULTS TO
ADDRESS
CITY
ZIP CODE
ADDRESS
OF SOURCE
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[] Unsatisfactory
[] Questionable
[] Sample too long in transit; sample should not be over 48
hours old at examination to indlcafe reliable results. Please
send new sample.
[] Bottle broken in transit, please send new sample.
SANITARIAN'S REMARKS
SAMPLE COLLECTED BY
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDIVIDUAL SUPPLY
~ TIME COLLECTED ', :~ i '
DATE COLLECTED
Sample Collected From I-~~' Kitchen Tap [] Bathroom Tap [] Basement Tap
[] Other (List)
Well- [] Dug [] Driven [] Drilled [] Bored
SOURCE: [] Spring [] Cistern [] Other_
Dug Well or Cistern Construction:
Walls--[] Wood [] Concrete [] Metal [] Tile Brick or
Top -- [] Wood [] Concrete [] Metal [] Open Top [] Concrete
LOCATION:
[] In Basement [] Basement Offset [] Under House
I--Un Yard [] Other
Building Sewer Septic
Tank Feet.
DISTANCE TO: or Other Drainage I~ipe. .Feet.
Tile Seepage Cess-
Field -- Feet. Pit .---- Feet. Pool .-- Feet. Privy, Feet.
Other Possible
Sources of Contamination
MATERIAL: Building Sewer- [] Cast Iron [] Wood [] Tile [] Fibre [] Asbestos
Cement
[] Plastic Joint Material - Type
GENERAL: Does Water Become Muddy or Discolored? [] Yes [] No
When?
Diameter of Well Depth Feet.
Well Casing
Material Diameter Depth
Length of Water Depth
From Bottom Feet.
Drop Pipe Offset in In Utility
PUMP LOCATION: [] In Well [] Basement [] In Basement [] Room
On Top
[] Of Well [] Other
PURPOSE OF EXAMINATION: Illness Suspected? [] Yes
New Source of Supply? [] Yes [] No Repairs to System?
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
[] No
[] Yes [] No Signature
06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD ::
Rev. 1973
/ -~::," ' ; :' Lab. No.
Date Received " ~ ,: ' Time Received .... pm
Lactose Broth 10cc 10cc 10cc 10cc 10cc 1.0cc 1.0cc
24 Hours
48 Hours --- -~
Brilliant Green
24 Hours
48 Hours
EMB AGAR
Lactose Broth, 24 hrs. 48 hrs.. Gram~s stain
Coliform Density (Most probable No. per 100cc)
MF Results
Reported by
This analysis indicates Coliform Organisms to be:
Absent~
Present
C. LIFT STATION
Da~ Manufacturer
Size in gallons~'""--~ Manho
Vent(Y/N) ~vel at -~off" level at
High water
alarm level
Meets MOA electric~
W.,~eWO~n lot On adjacent lots
ABSORPTION FIELD DATA
Date installed /0 / ~ O
Length <:~ ~ Width
Soil rating <~,~ ~//~g"~'~ System type
Gravel thickness ~ / ~ Total depth
Total absorption area
Depression over field (Y/~.)~
Resulted/fail)
Peroxide treatment (past 12 months) (Y/N) .
Cleanouts present (Y/N)
Date of adequacy test ZJ../Z ~/~.~
/~,/tJ~/,.~ If yes, give date ,"'('//~
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water /()0/-F
Curtain drain
On adjacent lots /(~O (..jz Property line
To existing or abandoned system on lot
Cutbank /f./¢/()E'/~e-.rc-~U¢- Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
$ & S ENGII";~ERIN~
Signature 1703~
Eagle Eiver, Alaska ~577 '
Engineer's Name
HAA Fee $ ,/. ,~.~
Date ~,f Payment
Waiver Fee: $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
10/70
Date Installed
(2) 8' X 8' x 3'
Seepage Pit
192 Sq.
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well 1:20 '
105'
To Building Foundation
Lot N/A
To Water Main/Service Line N
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
85 Sq.Ft./BR Type of System Design
Length of Field N/A
n/A
Depth of Field
Gravel Bed Thickness UNK
Ft.
Standpipes Present (Y/N)
Date of Last Adequacy Test
Satisfactory
Seepage Pit (2)
Y (1)
10/19/88
To Property Line 30 '
To Existing or Abandoned System on
; On Adjoining Lots N/_A
To Cutbank (if present) N/A
~/A
25'
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
N/A
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effe,
Signed Date
Company MOA No.
Date of Payment /'/--,.~2- -
0
Amount: $ /.,~.
Page 2 of 2
72-026 fRev 8/86/ Back
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 .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.
EEIS Consulting Engineers,IN~lephone 274-7611
Name
of
Firm
200 West 34th, Box 267, Anchorage, Ak. 99503
Address
Date
October 21, 1988
En
i
g
6. DHHS APPROVAL
Approved for '~ bedrooms by
Approved ~ Disapproved
Terms of Conditional Approval
Conditional
Y:VIIL'J
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
