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HomeMy WebLinkAboutRAYMOND TEDROW BLK 1 LT 5-B1 ~0 U' 0 0 0 0 0 0 0 © 0 0 0 0 0 0 0 0 0 lq .<: ~ 0 0 V~mNMm' , OCT< 1984 :: RECEIVED C ,~OLJ_,~ 6 650 ANQHORAGB, /\~ Aol A 99502 0650 (907) 264-~ I ~l I DEPAR'rlVIEN'F OF HEALTH AND ENVIRONMENTAL P,qO'[ECTIQN Permit ti: 840827 January 31, 1985 TO: Permit Applicant SUBJECT: Lot 5B Block 1 Raymond Tedrow Subdivision A permit issued }Dy this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as~built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264~4720. Sincerely, Keith E. Bandt, SupeYvisor Environmental Engineering Program XSS/ljw enc: Copy of Permit SWP/057 ,I II L. II ,,..I JILL C'.7; ]E II::::" ~I~'.::~i~ IL..... X. -'ti"" % .... )]EPAFi:"f'MEI',I'I" OF:' I'LIE:AI-TH AND ENV]'R(]I',II"ILT.''~''A ~ II,OIL( 82'.5 L. S'I"RELIE".,"":, x,=..,.,. ~1',t ]HOF;~AGI!E: ,,z,., -. zL'?'c>C,. ,...... P,l'::: ~", , ,.. ,.. :':':"" C:]~ Ih,,.ll ......... '.E:]; % "IF' IE!E II,,,,,ll IIEE IL..... IL ...... tl '" I,:::. t~ .,,. II ,, % '"11 .... S 4 ()82 '7 0 ~ ? / 2. 7 / 13 ,/I. ::',[]I',I"f'AC'I" I:::'1"11:)1',11!!!i: .... Iii!'.C':'}AI... .'Olii!iSCF;: I I:::' .... OT S ]i 2'..' E'.: R I CHARI} ['.') I I..BE]:'Cf' I:::'~ E),, BOX 'T7262D E:AGL..E: F;.: ]] VIER, Al< 688"" 3:1. 53 9 9 U 7 '7 (S(";! ,, I:::T. C)R AC, RES ) 1_(3T :: 5).3 RANGE:: ,';2W BL. OC',I< :', J. c ~ r' t :i. f' y t h a'L: .. ~. Y~ .,r .,, :1. ,,'.l: am f am :i. ]. :i. ~'.?, p t,J :i. t h 'k. h St:.) r' (':~ qt..t :i. r' ef'ncm'l't..s {' (:] p or'v'"'s :i. 'k.(.:) ~::' '.'.' ' '"' ' ' and ~,,~t:.p ]. ]. for"Lh by 'l'.l'ie Mun:i.c:i.l:lal:i. ty of' Anchc:u"a(.~e <MCIA) and 'Ll"le~ St'.at~ of Alaska,, 2, :[ (,~:i.:l.:l. :i. nsta].l 'LNE) ~Byst6~fil J.l'i a6:i:::E)r'cl/~=tr"g:::6] wi'Lb all ME)A cc:~[:l¢'~s and ar'id :i.r] corfiII ]. ;i. alq[:E.) wi. th 'l'..IqE~ de~,;i.(:]f'i c:r' :i.t(:)l" :i.~ o¢ 'l:.l"l :i.s p[.:~r'ff~it ,, 3,, ~ i,~:i.].:l, a(::lh(.z.:r'e 'Lc:l all HOA ar'id State c~f A:Lasl.,:a I"E)qLt:i.l'i:::.)fflEWF['.!!~ '¢'01' 'l:.. h t:.:) ';Xie'L bacl:: d :i. statices f' r' (:~m any ex :i. st i n(.:j t,,x~.:.~ :1. 1 :, was'L~.:m,a'Lep d :i. st::x:~sal sys't..~::,m or' i::iub ). J. c ..... ..... ,,.,,, ...... . .... E:i 4 ")1:3 2 2 SUB;i:) :1: V :1: S ]: (::)N ',: I::i('~Yl'4131xl)::) 'T'EDF;~EII.~ I._(::)"1": t".13,/2 5B StECT :I: Dl'q ,", :1. 2 "FC:ll, glxll:3H :1: F:': :1. 41",1 SOO0 (I!!iQ. I:::'"f',, OR I::;~l!.:.:F':'l!i~:F~li!:l".lCl!i: S""77,?.Ei FI:')R F'~IESLIB TD T..,. ~5'"-I:'F"':I. :1: c:~..m t. J. l'y t.h,':;d'.. ,~ 2,, :1: ~:i.].]. :i.n~'t'..<'~:l.]. t. he s .,. c,, ~,:.: ~ ~ ... ~ ....~ ........ ~.~,~: .................... F~ F:' F'I.... ]: C; ~-~lq"f' ~ C/E) · ' c,c,.l. ,:~ ~:l L, ,::: L) : ......................................................... · .............................................................. MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAl- SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # '~.~(~) 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 5BI; Block I; Raymond Tedrow Subdivision; Location (address or directions) 17344 Adams Lane (b) Property owner Go,dome Realty Cred~t Cooke.Telephone: (home) Mailing Address 3903 GeneSee Stre¢.~ Buf~cZo, Nm York 14225 Business (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent RE/MAX OF Eagle. Riu¢.r AZZn: Al Roma~z¢~z~: Address 1~600 ~¢~¢.~f/~d D~Ju~ Suite. ¢¢01 EagZ¢. Riu¢~ A~.. 99577 Telephone 694-4200 (e) Mail the HAA to the following address: (or check here~ if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING Ea.qle Rivet', Alaska 99577 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 Sta{e Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site [] Pqblic [~X Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the tegailty and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATIO~ As certified by mysealaffixed hereto and as of thevalidationdateshown 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. Name of Firm Telephone S & S ENGINEERING Address 17034 Eagle Rive~' Loop Road No, 204 Date Eag,a River, Ala,ka 9~57:7 6. DHHS APPROVAL Approved for .0 bedrooms by Approved ~ _ Disapproved Terms of Conditional Approval ~Date /-17- ¢4:~ Conditional The Municipality of Anchorage Department of Health and Human Services (DHHS) issues HealthAuthorityApproval cerificated based only upon the representations given in paragraph S 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 DHHSdonotconductinspections or analyze data before a certificate is issued. The MunicipalityofAnchorageis 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 Well Log PresentKZC'/N) '7/ Total Depth ~'¢~--~ Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit~:~/N) MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: ~ ~-~ ~ ~2~u.~4_, t~¢'~\~u ~ ¢L_b ~ If A, B, C, D.E.C. Approved (Y/N) Date Completed ~ -%'- ' '~..¢J¢' Yield /~,'¢~ Depth of Grouting ~ ( ~. ~ '~- '¢~ ~ ") Pump Set At \'Z-'tx J¢ Sanitary Seal on Casing/¢~) "-(/ Depression Around Wellhead (Y~ 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 ; On Adjoining Lots ~ ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ! Water Sample Collected by Water Sample Test Results ~-~~~ Comments '"'~t'~::::¢~ ¢~t~ B. SEPTIC/HOLDING TANK DATA Date Installed Size No. of Compartments s' - ' (Y/N) Foundation Cleanout (Y/N) Standpipes ~epression over Iank (Y/~). Date kast ~umped ~umoin~/Maintonanco Contact on Filo (Y/~) ~~ ; for Holdin~ Tank Hi,h-Water Alarm (Y/~) ~ ~Temporary H~mit (Y/~) To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Fronl Page 1 of 2 C. ABSORPTION FIELD DATA ~/A Soils Rating in Absorption Strata Date Installed Width of.F'~ Square Feet of Absortion Depression over Field (Y/N) 'Date~L~t Adequacy Test Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) To Property Line ~ To Existing or Abandone~ ; On Adjoining Lots To Cutback (if present) SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~x) ~M ~.~ ~~ D. LIFT STATION / Date Installed Size in Gallons "Pump O~ High Water Alarm Level a~ ~ 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 inspection. Signed Company Date MOA No. $ ~,, .~ ENGINEERING ~7034 Eagle River Loop Road No. 204 Receipt No. Date of Payment Amount: $ /Y:'- 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 ~fUNICIPALITY OF 3aNCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPAR%SiENT OF I{EALTtt AND ENVIRONblENTAL PROTECTION APPLICATION FOR }[EALTH AUTHORITY APPROVAL CERTIFICATE 1o General Information Application Date ./~ '~-g' .~ township~ (a) Legal Descri_ption (~cl~ude lot.~, block, subdivision, section, ~'ange) Location (addresa or Applicants Applicants Address . .J.~:"' Buyer [7_--~ ; Other I777~t (explain); (d) Lending Iastitution ~.7,~27,k_~-~'' Telephone Address (e) Rea]. Estate Coo & Agent Address (f) Telephone Mail the HAA to the following address: Single-Family ~.~7~ Multi-Family ~_~ Number of Bedrooms , 3. Wa t e r S_~jqu~ ~j!~.~_i Individual. Well [~ Commuaity ~[7~ Public. Note: If commmxity well system, must have ~ittea co~irmation from the State l)ep,~rt~[~ent of Envfrot~ental Conservation attesting to the legality and status, 4. Sewage Disposai Note: If community well system, must have write-eh confirmation from the State Department of'Environmental Conservation attesting to the legality and status~ Other.(.d_e.j~_r. jb__e) ............................... {Page 1 of 2] 5. Engineering Firm Providing Inspectiom~, Tests, File Search, Data and Info~m~atio~t As certified by my seal affixed hereto and as of the validation date sho~.m below~ I verify that my investigation of this Health Authority Approval shous that the on-site water supply and/~r wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I fu~'ther verify that, based on the infotnnation 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 M~nicipal and State codes, ordinances, and regula~ tions in effect on the date of this inspection. Name of Firm Address Date Telephone (ENGINEER SEAL) ])HEP Approval Approved for /';.,~ ,. /.'fi/bedrooms Approved ?~. Disapproved Conditional Terms of Conditional Approval CAUTION THE MI~..~ICIPALITY OF ANCHORAGE DEPAWIi~ENT OF H]~AI,TH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVA£, CERTIFICATES BASED SOLELY UPON THE REPRESENT~ ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN TtH£ STATE OF ALASKA. THE DHEP DOES Tills AS A COURTESY TO PURCHASERS OF HOMES AN]) TttEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEI)ERAJ', AND STATE REQUIRE~ ~t. ENTS. EMPLOYEES OF DHE]? DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE iS ISSUED. THE MUNICIPALITY OF P:~CHORAGE IS NOT RESPONSIBLE FOR ERROR: OR OMISSIONS IN THE PROFESSIOi~kL ENGINEER'S WORK° (DHEP SEAI,) RR4/ej/D18 [Page 2 of 2] '7.~.1%.84 Well Classificati~ I~/U~'~ Well Log P~esent((~l~-- Total Depth //_~-~ / Cased to MUNICIPALITY OF ANCH©RA~ DEPT. OF H£ALTH & ~:NVIRONM~NTAL PROTECTJOI~ MUNICIP~I~ OF ~CHO~GE (MOA) H~TH ~HORITY ~PROV~ (~) 0~T ~ ~ loQ~. CHECKLIST - FEBRU~Y 1984 ~C ely ID L ~al Descript~on· ~-~fi ~ ~ / Static Water Level z/~ z Pump Set At Casing Height ~bove Ground 9' ~-~O ~r Electrical ~iring in Conduit~/~)- Separation Distances from Well: Depth of Groutinq Sanitary Seal on Casin~(~ Depressicn A~ound Wellhead (~.)/ To Septic/H0iding Tank onLot ~///~ ; On Adjoining Lots To NeareSt Edge of Absorption Field on Lot /{J/~ ; On Adjoining Lots To Nearest Public Sewer 'Line ~ ~z_ To Nearest Public Sewer~>~-~ Cleancu%/~ac~a~_~- //~3~ /__ To Nearest Sewer Service Line 9n ~t /~ '~" Water SamPle C°l~ec~ed By ~ ? ~ ~///~¢'~//~.; Date /t/~/~ Water Sample Test Results ~c~-~/9 ~.3~'/~z~ Cc~Tents B. SEPTIC/HOLDING TANK DATA Date Installed Size Standpipes (Y/N) Air-tight Caps (Y/N) Depression over Tank iY/N___J) Date Last Pumped Pumping/Maintenance Contract on File (¥/N~ / ~r ~ Holding Tank High-Water Alarm (Y/N) &/~ ~~o~oing , Separation Distances f~om Septic/Holding Ta/~k: To Water-Supply Well To Property Line To Water Main/Service Line Course No. of Ccmpa~tn~nts Foundation Cleanout (Y/N) Tank Permit (Y/N) To Building-Foundation To Disposal Field To Stream, Pond, Lake, o~ Major Drainage Cor~nents Receipt # '~ ' Date Paid: \(',o -D ct _~cf Amount: L(<~.(DO [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Width of Square Feet of Absor~ ?ea Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorpti~ To Water-Supply Well To Building Foundation Lot To Water To To Type of System Design Length of Field Depth of Field Gravel Bed Thick P~esent (Y/N) __ Date Adequacy Test To P~o~ .~ine To Existing o~ndoned System on ; On Adjoining Lots ~ Line To Cutbank(if present) ~.~. Major Drainage Course Parking A~ea, or Vehicle Storage A~ea LIFT STAIN Date Installo~x~ Size in Gallons Dimensions 'Pump On Level at ~ ~ Off" Level at _- High Water Alarm ~ Vent (Y/N) Tested for ~ Pump~cles du~ing Adequ-----~ ~st. W~ets ~VDA Cor~nents ~ ** Check Permitted Bedroom Rating Against HAA Request ** ~ I certify that I have checked, verified, or conforn~d to all ~DA HAA Gui.delines in effect on the date of this inspection. / ~.~,~' Or /~;'~9 '; 2-15-84