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Home My WebLink AboutPETTIS LT 15* ~ MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES ,. 343-4744 , ,~: CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ~r' , ON--SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING :'': ' . · HAA# : ~[~ ~c:'l(-'~,C'~ 1. GENERAL INFORMATION (Must be completed prior to submittal)-:.: (a) Legal Description (include lot, block, subdivision, section, township, range) LoT' Telephone: (home) Business (b) Location (address or directions) Property owner Mailing Address (c) Lending Institution N o~/~ Telephone Mailing Address (d) Real Estate Company and Agent No N],E Address Telephone" (e) Mail the HAA to the following address: (or check here ID. if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family,, Number of bedrooms 31' WATER SUPPLY Individual Well~ Community [] Public [] c:Note: If commun,tyv~e syStem, must have written confirmat on. from thehState Department,of.Environmental :*:'~ote' f commun tY'we system must have wr tten confirmation, from.the State Department of Enwr~pm.e~tal - ' Conservabon attesting to the legaflty and 'status. 72425 (Rev. 7/88) Page 1 of 2 ::' ' ~; : ' 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal ~ffi~ed hereto and as of the validation aate'shown below, I verify that my investigation of this -'Health Authority Appr6vJ~ shows'that the o'n~site"~wate"r supply and/or-~astewater~.disposal systemJs safe :-' ~Un~ti0r~al..and adequate fo~ the number of bedroo~ns"an'd t~/pe of structure indicated herein', further verify that .. based on the i~formation obtained from the Mun c pality of Anchorage files and from my investigation and inspection, the on-site wat~"'supply and/or wastewa'te~ ~1 sp0sa system is n C6rnplian% with all Municipal and ; .' State cedes, o rdinances,'and regulations in effect On thedate of this inspection. .Name of.Firm Address Date 6, DHHS APPROVAL · Approved for · ,, ,;-~:.\ ApproVed '~ "47¢ Disapproved T~'rms of Conditional Ap'proval Engineer's Seal '' :' ~": .':..; .':~(3 -¢ bedrooms by Date ~%,';-:~',~,~_.,¢~ . Oonditiona The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Hea Ith Authority Approval cerificated based only upon the representations given in paragraph 5 above byan independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of hemes and their lending institutions in order to satisfy certain federal and state requirements. Emp oyees of DHHS do not conduct inspections or a~al'y:;'e 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 A. WELL DATA Well Classification MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: Well Log Present (Y/N) I'~ Date Completed TotalDepth ,~'7 _Casedto ,~'7 Depth of Grouting Static Water Level <: Casing Height Above Ground ~0¢ Electrical Wiring in Conduit (Y/N). /~' SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot _ ~'"J, o [~ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line q..5 To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Pump Set At ~7 Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) If A, B, C, D.E.C. Approved (Y/N) Yield .~ 4'~ CRi_~ ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ; Date ~¢O 'r Comments SEPTIC/HOLDING TANK DATA N~ o I',.I ~"'- Date Installed Size Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) t No. of Compartments Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments To Building Foundation To Disposal Field 72 026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION' DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area 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 guidelines in effect on the date of this Signed ' : ~""" Company Date MOA No. 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 Engineer's Seal 6751 W Dirnond Anchorage. Alaska 99502 (907) 246-!5095 RESIDENTIAL WELL INSPECTION LEOAL: Lot 15, Block 1 Pettis.S/D LOCATION: 11 I Pettis Road '" · , OWNER: Dannis, Adr'ienr~e 6riffitb WELL CLASS: 5ingle Farnily Residential Well INSI'ALLATION REQUIREMENTS MET: WELt. LO8 AVAILABLE: No No Well Pit. Well casing extending 30" above natural ground surface. WELL YIELD FROM WELL LO8: Not Available PUMP YIELD FROM TEST: 6,25 gal, per' rninute DATE OF INSPECTION: August 30, 1990 TEST I>ROOEDURE: Well was pumped at aconstant rate while tlledrawdown was monitored with an acoustic probe. At the beginning of the test water level was found at less than 24 feet below the top of the casing. At a pumping rate of 6.25 gallons per rninuto the water' level dropped to 30 feet and remained at that level during the test. A total of 600 gallons were removed, At tne end of the pumping thewaterlevel recovered immediately. TEST FOR E.COLI AND fOTAL NITROGEN: A sample of water taken frorn the well was tested for E.Coli and nitrates on August 31, 1990 E. Coli counted O, Total Nitrates 1.8 mB./1 E.Coli allowable O, Plax. allowable total nitrates l O.O mg./l TEST RESULTS: This well meets the requirement of tile MunieipalityofAncborage. THIS WEI. L WILl_ f)RODUCE MORE THAN ~ (IALI_ONS PER MINUTE FOR MORE THAN FOUR HOURS. The Plunicipal requirement for well flow is 150 gallons of water per bedroom per day. This well exceeds thi~ requirement. The assessment of the con(ti'rich of the well applies only to the uonditions as they were oil the day the well was tasted. The flow fate nlay cliar]ge due to subsurface conditions that can not be observed from the surface, or from changes in the land use or' other factors that may impact the aquifer feeding the well. CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343 FEDERAL TAX I.D. #92-0040440 ,kl~M,}liiS ~d~POP,? Iff SA~d'!,?; fox Uo~k e Send l\epo;ts to: Allo~a})ie }>a~ am~t e~. ?est ed f(esult Uoit~ ~{e hhod Limits NIT~M'~-~ ~.8 :~:g/1 ~ 353 2 ~0 APPLIC' Property Owne~: Mailing Address Buyer Address ',IT FILLS OUT UPPER HALF` ONLY Zip Cede Phone Zip Code Lending Institution Address . Zip Cede Realty Co. & AgentPhone Address ~ / Zip Code LegalDescriptlon /~_~,' [' / il' f',t!:.. / !'),;~'i'i: ~ ,,:i,-f,'u, -, .... Street Location / Type of Residence []~Si'~ lo Family [] Multiple Family [] Other No. of Bedrooms. Water Supply [].-tnd'ividual E] Community [] Public Utility Sewer Disposal [] Individual [],- P0blic Utility [] Flolding Tank ATTACH WELL LOG. A well Icg is required for all wells drilled since June For wells drilled prior to that date, give well depth (attach Icg if available). Year Individual Installed; When Connected to Public Utility: , .,,, ,., ~_( , ,/, _ .- 1975. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time -,~ J · ~ :,~:_~ (,,_,~:.J_._ Date Date Date , Insp~tor Insp~tor Insp~tor Field Notes: ~ ', / ,,/Z/-'4-' O /¢,~ ~ ~ ~, ./ RECEIVED ~)¢ APPROVED BEDROOMS ) DISAPPROVED ) CONDITIONAL APPROVAL· *CONDITIONS Of: APPROVAL Soils Rating 72-023 (3/82) Date ,Sewer Installed Well Log Received Well To Absorption Area Well to Tank Septic Tank Size