HomeMy WebLinkAboutROSEWOOD PARK ESTATES BLK 1 LT 8For
Date completed
.{' :~Sand ::and:
: .: ~"::SOMMERVILL~. W~LL'DRILLING:
' ' We. adze you to attach th~ certificate to yo~ deed.
MUNICIPALITY OF ANCHORAGE
DEPART~ ENT OF HEALTH AND ENVIRONMENTAL PROTECTION
· "' . DIVISION OF ENVIRONMENTAL HEALTH
· CE TIFICA E'O SP CTION FOR AliT OR A
~ R T FIN E HE H AUTH ITY PPROVAL"' "''
264-4720
1. GENERAL iNFORMATION
,.'(a~' Legal Description (include lot block s~bdivisie~ section, townshi~
' - .... '" ',/~,~/J zeal. /~Z-~./~.¢4:// -- /)~ ~ ~' /'~ ~.
Location (address or directions)
(b) Applicant ~am m ~~ ielephone: Home ~--~
~usmoss
~pplicant ~0dress
(c) Applicant is (chec~ one): kon~in~ Institution ~; Owner/~uilder ~; Bu~or ~: Other ~ (explain);
OF ON-SITE SEWER AND WATER FACILITY
App,cation Da e
(d) Lending nstitution (~'/7-./ /-/4',~ / ¢~.X~ ~ Telephone
Address '/"¢6~" ~ _'f~"_~/,
(e) Real Estate Corn pany and Agent .z.--/,~ , .- . '"
Address
Telephone
(f) Mail the HAA to the following address:
".:-:;-: ~::?;:;~' ~:' N0te?lf ~omm u~it¢ well sy~t0~,'must have wdtt0n cdnfirmatioh from tho Stato Bepa~tment o~ Environmontal Conservation
.... Note: If community well system must have written confirmation from the State Depadment of Environmental Conse~ation
, a}testing to the legalit~ and status.?~ -:: , ~ :
.5.
ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DA1 ,~ 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 o~tion. /r -
Name 'of Firm .~C~'~'~'-~------~~' ~.5' ~'- ~'-~ _, Telephone
Date
6o
DHEP APPROVAL
Approved for '~'~/'~ ~eOrooms by ~
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations 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 requirements. Employees of DHEP 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.
Page 2 of 2 : '
MUNICIPALITY OF ANCHORAGE (MO~-,~
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
MUNICIPALITY OF ANCHORAGe.
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
WELL DATA
Well Classification
Well Log Present) ~
Total Depth /'2 ~_ Cased to
Static Water Level ~..~ ?
Casing Height Above Ground
Electrical Wiring in Conduit (Y~,,)_
Separation Distances from Well: ./~
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
If A, B, C, D.E.C. Approved (Y/N)
Date Completed ~>~.;.o, ...~¢/~. //¢¢.27 Yield
Depth of Grouting ~
Pump Set At ~
Sanitary Seal on Casing t~,,)
Depression Around Wellhead (Y~
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
; On Adjoining Lots
; On Adjoining Lots /b
To Nearest Public Sewer
~ I0 ~ To Nearest Sewer Service Line on Lot '+ 7~ /
Comments
SEPTIC/HOLDING TANK DATA
Date Installed Size No. of Compartments
Standpipes (Y/N) Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
Foundation Cleanout (Y/N)
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
ABSORPTION FIELD DATA / ~'
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption 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
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that Lhave checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed (q~ ~'t-6(,/~-/'~'~ ¢~ ,~ Date
Company :~J/~5~ F0'~ MOA No.
Amount: $ ~ %~ ,,~.~49.H ~( ~. ~ Engineer's Seal
Page 2 of 2
72-026 {11/84)
NORIHERN TESTING LABORATORIES, INC.
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99701 907-479-3115
6957 OLD SEWARD HIGHWAY, SUITE 101 ANCHORAGE, ALASKA 99518 907-349-8623
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY CLIENT
[] PUBLIC WATER SYSTEM I.D. #
[] PRIVATE WATER SYSTEM
NAME ~."~ ~-~--~ ~' ~
Mailing A ess
City
SAMPLE DATE: .~ ~/ ~-~'
Mo. Day Year
State
Phone
Purchase Order No.
SAMPLE TYPE:
yRoutine
[] Special Purpose
[] Check Sample (for original contaminated
sample with lab reference no.
Sample ~
N~o. Location CoUected~
2
Zip Code
[] Treated Water
[] Untreated Water
C,~h~*m-by /~bo[atory RA.f. N,o.
6
7
8
9
10
Signature of Representative
FOR LABORATORY USE ONLY
CASH CHARGE PREPAID TRANSMITTAL SPECIAL INSTRUCTIONS
MAIL
HOLD FOR
PICKUP
TO BE COMPLET? BY LABORATORY
Received at: [~' Aoqh. [] Fbks.
Date Received
Time Received
Next Sample Due
COMMENTS:
SATISFACTORY
UNSATISFACTORY U
RESAMPLE R
OTHER BACTERIA OB
TOO NUMEROUS TNTC
TO COUNT
Direct Verification Final
Count LSB BGB Result*
0 0
iforrn Colonies per 100 mis.
Client's Name:
Address:
BESSE, EPPS & POTTS
2220 EAST 88 AVengE
ANCH0~AGE, AK 99507
(907) 349--6451
WATER W~Lr. TF~-T
Date:
GPM 24-Hour CaDacity~O~ c~lloas