HomeMy WebLinkAboutKASILOF HILLS BLK 8 LT 15'Bt.r
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ZO
J U 1 ;%'2 1 L 6- a An c. h o -p VVe. I i o puna,) Se 1 p"';
Legal Deser; j,11,
�016�4 W\s M U5
1;'rnperf.�y Owner Mime &- Address;.
PaInp histallatioul Date: 7,-- 7-7
pUnAr, Intake nepth nfetww'T")p nf'Xell Iasi In: ?-wreel
y1 f
]?Ump 'Malr3t2ccurer S Name
PUMP Model,
Pump Sire.
I'MesS Adapter T'1S12J1Pr,.
Well Disinfected Upor.
No
Method of Djsjnfcuij�or:
Comments: PC
Attention: Tht Pu.'n,- in::*di u 3,Itlt J)SLE -0
P',11110 11,4ti D. log to The DSD within 30 days of- a
.D-r,.,p . -toll
A F1 .t
bevelopment Services Department
Buildin.9
at
Safety bivision
011 -Site Wal-ar GY Wastew &er Prooratr
47rjo C:Iqlore por
P.hyr,-
Anchortaoe, AK 95507
—nllr—�ixro,",-1-151t-e-
(907) 343-7904
PUMP Installation Log
Well Drilling Pei mit Nu,nb,,,j,-
S3V--- Date: Of Issue -
Legal Deser; j,11,
�016�4 W\s M U5
1;'rnperf.�y Owner Mime &- Address;.
PaInp histallatioul Date: 7,-- 7-7
pUnAr, Intake nepth nfetww'T")p nf'Xell Iasi In: ?-wreel
y1 f
]?Ump 'Malr3t2ccurer S Name
PUMP Model,
Pump Sire.
I'MesS Adapter T'1S12J1Pr,.
Well Disinfected Upor.
No
Method of Djsjnfcuij�or:
Comments: PC
Attention: Tht Pu.'n,- in::*di u 3,Itlt J)SLE -0
P',11110 11,4ti D. log to The DSD within 30 days of- a
.D-r,.,p . -toll
A F1 .t
,~~ MUNICIPALITY OF ANCHORAGE
li~ ; ,~ 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
'=~AM E [P H~-N E J~EW
MAI LING A D ~.~t_ESS
LEGAL DESCRIPTION
LO~ATION
Well Absorption ~,)~ PERMIT ~L.O.
~ ~_~ Meter,.,~ No. ofcompar,ment~
Liq. ciP~t~g.~llons ' IF HOMEMADE: Inside length __ __ Width ~ Liquid depth .....
~ '" DISTANCE TO: Well Dwelling PERMIT NO,
~O ~ ~ Manufacturer Material Liquid capacity in gallons
C) Well
u~ DISTANCE TO: ~ ~h,..~]i?~._~ F°unda~ NearestJotline PERMIT~.~*-~
.j ~ Z No, of lines / Length of each Total length of lin~t,,~..~ Trench wid~.b.)/,.,,¢.,.~L-Jinches Distance het!e~.Ils~!ie, ' es~
~'~_ Topof t,'. to f,,.,sh grade ~, 5.?+~ M.ter,e, beneeth t,,e *ota, ef,ecti t, .,ree
~ Length Width Depth PERMIT NO.
<~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ DISTANCE TO: Well Building foundation Nearest lot line
~ Class Depth Driller Distance to lot line ~ERMI-F NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER i
PIPE MATERIALS
SOIL TEST RATING..., j I
INSTAl-hER
'~EMARKS
APPROVED DATE LEGAl_
ALASKA FNVIRONMENTAL
CONTROl. SERVI( , INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 56~.~o4o
SHEET NO OF
CALCULATED BY~
CHECKED BY
SCALE ~ .
DATE.
105'
~UELC
HElaL. TH Fflq[) F..NV ]: I';.:OI",IH[-:;NTF:IL ' OTECT ): EIf'.,I
:~.; T R E E T., la I",1C 1'*10 F':: Ft G E., FI K. 9 9 :...J ::L
,.'2, Ii',.~ ....... ~}:; %. -'ii- E: :F_.'-.';; EC.] ~...l~ IFS{
LOT :E;:[ZE
i'iR;:.:;];HLiiq i'.,tlJHE:EF~: OF BEDROOI,tLE; == 5
.~;F'lIl.~ IRlaTIN6 <:5I;! F'T,.'BF.:>=:: 2d..4
THE F;:EI.i:!UZF;:ED ::};ZZE OF:' 'THE:
THIE LENGTH [:, I HEt",IE~; I ON :ii :~ 'THIE I....ENGTH ,:; :[ I",1 FEET ) Elf:' ]'PIE TF.'.ENCFI. ,:."IF...' D, RFI:[ I'.,IF :1: EI....E:,.
THE DEPTH OF FI TFi:E:i'.,IC:FI OF4: P:IIT :['.~1 THE I:) ]: ~;TF~i'.,IC:E E:E"FHEEI'.,I THE ~I...IRFFtE:E OF:' THE
GI~:OUII.,ID FIi'.,l[.':, THE E:OT"i"Oi'I OF THE E;=.:;C:FIVRT~ON ,::]:1',t FEE'F::,.
THEF~:EE Z:E; Ii'~O :-~;ET I,.I;[E.,TH FOR TF..'Ei',iCHIES.
THE (;~[~:I'"-'I~,,,~E[.. £:,II'ZF'TH Z'.5 THE H.~:I'.,I.'[HI. jH t::.,EF'TH OF' GI:~:FI',,,'EL BETT'I.qEEI'.,I 'T'HE OUTFI=IL.L P:IF'E
F:lt",ll:::, THE E',OTTOH OF THE E;:.:;L'.':Ffv'Ft.]" Z Lqi",l ,:: ]:1"4 FEET ::,.
F'EF:i'l '[ 'i"; F:tPF:'L Z IZ;lahlT HFIE; THE F..:EfSF'Obi'.5 ~. E~ '[. L.. :ii T'~; 'l"O Z NF'OI;'.I"I i"H .T :i'S E:,EPRF..'"t"I"IEt'.,I'I' E:,LIR Z NG THE
Z N~;'TFtLLFtT Z ON .T. N:E;F'EIi':T :[ Oi'.,l:!~, OF RN'T' 1.4ELL..~ FIE:,J'FICENT TO .]"H ]: :5 F'ROPERT'¢ FIhlF.:, ']"PIE
iWL.ii'iBEF?. OF:' RE:..E;J:E.,EI',ICEE; 'l"HFl'F THE HELL. NI]ZL.L E;EII;:',/E.
..................... -'If- H.-..tl C31 ,::; ;.'.';;~: [:, %. ]]"-,.!1 ,"E:7, F" El L,'Z: -F %. K;31 ~'-,~ :~.".; IF:Il IF;;i: ~E' !~::;E,': E C~.T.!! ~....,~ :E if~:! [% E:: ......................
E~F:tC:f:::F't LL. Z lNG OF FIN'T' S'T':STEH 14 ]: Tt.-113L.IT F' I I'.,!FIL ~ N:SPEE:T I I)l'-,I laNE:, RF'F'l~:O'v'FIl._ E:'T' TH I S
DEF'laRTHEh,IT !-,.1:[ LL E;E SUB..TEC.'i' TO F'F.:O:SEE. UT ]:
i'i ): i",i .T. i'ILII'I
'J..OEI F'EE'T F'iii)R FI F'R:['v'WFE l.'.l[."'.:i._l... OF:: :.LSO TO ;?.00 F%ET FF.:OH Ft F'UE:LIC HELL. DEF:'EI",ID:I;t",tG
i..iPOi",l THE TVF'E OF F'IJE:II_IC t,.tELII ....
I'IIN.T. fqLIH E:, ]: :.'.C, TFII",tE:E F'l;:Oi'"l FI F'F.:t',,,'IaTE t,.tELL "FO F:l F'R:[',,,'FI'T'E SIEI,.IEI:~: LII",IE
TO FI CEIFIhlUN.T.'I"'f E;Ei4[ER L. II",IE IS 75 F:'IIEET.
t.,.IE:L.L.. LOGS FIRE F.:E6:.!LiIF.:E:D FIblD I"IU!;T E:E RE"FUII~:t',IEi:> TO THE DEPFlF.'.'TFIFZNT P.I:I:TH:I:I'.,I .3:0 E:,Fl'.r'~i;
OF THE !.,.IELL CEU'"IF'LE"F 1'
(:)THEIR 1"4.:E6:!I...I:[f;'.Ei'fEN.]"$ I"IF:IY' FIF'F'L..'t'. :~F'E:CZF.'[E:FtT:[Ed'.,IS FIND C:OI',I'.'.-'.';TRUCT]:E$1 E:,l'flGh~':Fli"12; F:IF.:E:
F:t V Fl ]: L FE!];L.. E
]: CE:RT.i:F'T' THF:IT
v4,. i~l
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
.... 4
5
6
7
8
9
10
11
.~42
13
14
15
16
17
18
19
20
COMMENTS
PERFORMED BY:
72-008 (6/79)
SLOPE
DATE PERFORMED: 4u, hI Zb_,2'Z
SITE PLAN
ENCOUNTERED? L
'O
P
E
IF YES, ATWHAT
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
/ 7.2(¢ .8¢ 2,','./o l/>/¢la,~ /,.~ ,
.~ ~;~ /o /~ I, F~d ,0<t6
DATE:
'SOILS LOG
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVI~F;~Ji~A~D~PBOTECTION
~ ~. r ANCHORAGE
825 L. Street, Anchorage, Alaska~dl T2~.z,~ ,
SOI LSLO~-PE~OLATIONT~T ,o , I
~ ~T E PERFORMED:
15
16
17
18
19
20
PERCOLATION
TEST
SLOPE SITE PLAN
WAS GROUND WATER S
ENCOUNTERED? ~() L --
IF YES, ATWHAT E
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time ( k,"~ f~'~') Water Drop
:L h "?- r~ to ,3~(, ,
PERCOLATION RATE ~-- '~:''~ (minutes/inch)
t '/Z Z..
TEST RUN BETWEEN FT AND FT
c~.¢,',~¢x,,, \~ ' " - ~,~'
CERTIFIED BY: DATE:
72-008 (6/79)
Box 1369, ~TAR I~OI~'TE A ANCHORAGE, .dLLASKA 9950~
344"~?14
SIX INCH WATEr WELL DRILLED AND CASED OUT TO THE DEPTH OF
DRILLED AT THE rate OF ¢,r9.~. 00 Per FOOT.
LOCATION OF WELL Sits
WELL LOG:
O .... 7.0~ %.'u::.~,e.L ~:;.O~ 3?5 ~_,~;.
COST INCLUDES ALL LABOr AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF x,~(,,9.
THANK YOU VERY MUCh;
Date
BerNIFK-~-AUS Of RAMPART I:~ILLING WORKS ,.. C~
SERVICE Charge OF I~% PER MONTH WILL BE ASSESSED ON PAST DUE AOOOUNT~-~~
ALASKA eI1UIROFIllleFITAL COFITROL SE!RLIIC S, IFIC.
~nqineefinq $ (~nuironmenlal ,~tudies
September 20, 1984
Department of Health &
Environmental Protection
825 L. Street
Anchorage, Alaska 99501
Dear Keith:
This is in regards to the well log I am submitting for the Health
Authority for Kasilo? Hllls, Block 8, Lot 15. As you can see, there is
no legal on the well log. On September 20, 1984, I contacted the
drlller, Bernie Claus, and asked hlm if he could check his records and
verlfy that this well log was for tort.~, Blaqk._8,.gasilof Hllls. He
assured me that it was, and'-~f-~ey had never drilled a we11 on any
other lot for Steve and Karen Kulin, and apoloQlzed for the leQal not
being on the paperwork.
If you have any questions please do not hesitate to call.
Sincerely,
Darcy Bevens
Engineering Geologist
1200 LLlesl 33rd ~uenue. Suile ~ .,~nchoreqe, /~losko 99503 ~*{907) 561-5040
'i.
MI;NICIPALITY OF ANCHORAGE
DEPAP, TP, tlENT OF I IEALTH ANi.) ENV!IqONM{-~Iq'i",,'~L PRO'TECTIObl
Dh.,'!S',ON OF i:.NViP, ONi~AEF:FAL
CERTIFICA'iLi Of INSPI-C-fION I':OR FIEALTH AU-tI~ORI rY APPROVAL
OF ON-Sli [.. S[:.W[:R AFl[) WA'I El-? FACILI i-Y
264-4720
Ap,,)lication Date _
GENERAL INFORMAYiON
(~)
Legal Description (include IoL block, subdivision, seciion, townsl~ip, ran,qe)
£-' /.) ' , ,'~-' L<' ~ ~.. ~, f::: '.L ~. ' '2 ' r ) .) ~ ,/ ..) !.. ( ... ~ ,.
'._'tu~ /~i:.:: :,f~.t~L G!~.: _~'l-IL.(._. =?_ ~:. : &L._. :: ......."'-' '" '/
Location (address or directions)
,:' /~
(b) Applicant Name__
(c) Applicant is (check one):
!'.
(d) t_ending h]siitu~ion ._ _~ t;.?¢::~ ........... Telephone
Address
_~ta e (]ompany and /\gent
(e) Real : .....
Address
,/i///:~L
(I) Mail the HA,^, to ~.l~e following address: ,,
TVPE OF RESIDF-"~,,!CE
Sing!e~Family~j Multi-Family L~ Otl~er
[',,lumber of Bedrooms ,%
WATER SLIPPLY
h~dividual Well [~_,w~' Cornmunity [] Public [~l
Note: If cornmunity well system, must have \rvritten confirmation from the State Department of Environmental COlqServatioFI
attesting to the legality and statu,';.
4, SEWAGE DiSPOSAl.
Onsite:' PublicL] Community[il NoldingTank~
Note: If col~'lmunity well system, must have written (;oafirmetton from the State/)opartment of Environmental Conservation
attesling to the legality and status.
ENGINEERING FIRM PROVIDIIX~G INSPECTIONS, TESTS, FILE SEARCH, Dt~FA AND INFOR~,~ATION
As ce~ tiffed by my seat affixed hereto and as of tho validation date shown below, I verify that my invesii0ation of this I-leaith
Authority Apploval shows that the on-site water supply ariEl/or wastewater disposal system is safe, fenctional and adequate
for the number of bedrooms and type of structure indicated herein. I further verily that based on ihe inforinaiion obtained
~ronq the Municipality el 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, ordinaiqco5, and regulations in ef ecl on
the date of this inspection.
Date
At}proved for '!;' ) bedrooms bw
Aoproved } Disapprove(l Conditional~/
Terms of Conditional Approval
'rhe Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given m paragraph ,5 above I.)y an independent professional
engineer registered in the State of Alaska. Tho 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 !31-11':P do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsd)te for errors or omissioRs ip the
professional engineer's work.
Page 2 of 2
WELL DATA
MUNICIPALITY OF ANCHORAGE (MO*,/
MUNiCiPALITY OF A!I~UTHORITY APPROVAL (HAA)
N 264-4720
~*1~0~ 8 ~G Legal Descrip~/~ / ~/-/_5-'
RECEIVED
MUNICiPALITV OF ANCHORAGE
DEPT. OF HEAl. TH &
ENVIRONMENTAL Pk'O'I'ECT ON
Well Classification {,&('~)/t/! ~)l~/d/L- If A B, C, D.E.C.~pproved (Y/N)
Well Log Present ~/N) ____ q~tp Completed __q/~/e~ ,Yield
Total Depth ~ ~) Cased to ]~2 ~0 Depth of Grouting
Static Water Level ~? / ~ Pump Set At -- 2. q~
Casing Height Above Ground
Electrical Wiring in Conduit ~¢~)/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line Cleanout/Manhole
Water Sample Collected by
Water Sample Test ResuRs
Comments /~
Sanitary Seal on Casing ~.~N)
Depression Around Wellhead (Y~
fO0 / ¢-
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
'TesT-
B. SEPTIC/HOLDING 'rANK DATA
Date Installed ?/q/~.-.~ Size
Standpipes ~/N) Air-tight Caps t~/N)
Depression over Tank (Y,~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) /'V~//'~
Separation Distances from Septic/Holding Tank:
To Water-Supply Well I O0 f'7'~'-
To Property Line 20 / 'TL-
To Water Main/Service Line /~///~
Course t00 / '7/--
/,500 NO. of Compartments
Foundation Cleanou,t ON)
Date Last Pumped
-!
:fo,
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field ~ /
ZO /''/"'
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorpti_o~...Str/8~ta_
Date Installed
Width of Field ~ ,-,-~- /
Square Feet of Absorption Area
Depression over Field (Y/~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well I (~ r-../~
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
Type of System Design
Length of Field ~ /7 /
Depth of Field /,~ /
Gravel Bed Thickness ~,-~/
Standpipes Present ~)N)
Date of Last Adequacy Test
F/CC Y
To Property Line ,20 7~''
To Existing or Abandoned System on
; On Adjoining Lots ,-~)/'¢'
To Cutbank (if present) '/~//~
lO0/'/-
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
Dimensions --~ ~
~ Manhole/Access (Y/N) ~
~/~ ~u~/Omf~:~ ~est. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that Lhav~ (zbe~ke~d,.v_e~ified,.or conformed to all M CA and HAA guidelines in
Signed LI~/~~~'~ Date 7/~//~ effect on the date of this inspection.
Company t¢ .~1 ~:~[~.~S I/~.C, MOA No. ,~2"'%-' O Z ¢'1~
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
ALASKA k,,dlIgOFImEFITAL COFITIgOL SE,,JIC $, IthC.
~n§ineCrin§ f~ ~nuironmcntal $1udics
KAREN ~ KULIN
P.O. BOX 196577 #905
ANCHORAGE ALASKA
99519
SELLER-SAME
60327
LEGAL:KASILOF HILLS BLOCK 8 LOT 15
ADEQUACY TEST FOR SEWER SYSTEM
ADEQUACY TEST DATE-JUNE 29 1986
JULY 2 1986
KAREN J KULIN
P.O. BOX 196577 #905
ANCHORAGE ALASKA
99519
M~!NICIPALI~ OF ANCHORAG~
D~!PT, OF HEALTH &
ENVIRONMENTAL PROTE~ION
'AU 81986
KcCEIVED
THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 1139 SQFT.
THE SYSTEM IS CAPABLE OF ACCEPTING 750 GALLONS OF WATER PER DAY.
THE SUROE CAPACITY OF THE SYSTEM IS 1167 GALLONS.
BASED UPON THE TEST DATA TIlE SYSTEM IS ACCEPTABLE FOR A
5 BEDROOM HOME.
SEPTIC 'rANK ADEQUACY
TIlE EXISTING SEPTIC TANK VOLUME OF 1500 IS ADEQUATE FOR
THIS 5 BEDROOM HOUSE.
THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON JULY I 1986 .
THIS REPORT DOES NOT VERIFY THE INTEGRITY OF THE PIPING FOR THE WATER
SUPPLY OR WASTEWATER SYSTEM.
FLOW TEST ON WELL
WELL FLOW DATE-JUNE 29 1986
A FLOW TEST WAS PERFORMED ON THE WELL. 1167 GALLONS OF WATER WAS
PUMPED AT A RATE OF 5.07 GPM OVER A DURATION OF 4 HOURS.
THE DRAWDOWN WAS 100 ' WITH A RECOVERY TIME OF 30 MINUTES
AND THE STATIC WATER LEVEL WAS 29 FEET.
THE WELL IS ADEQUATE FOR THIS 5 BEDRO0M HOME.
1200 U]¢st 33rd Auenue. ~uil¢ [~oAnchoro% Aloska 99503.(907) 561-5040
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAl, IH';ALTH
DEPARTMENT OF BEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTItORITY APPROVAL CERTIFICATE
1. General Information
(a) Legal Descriptiou (include lot, block,
Application Date__ '~--~Ax~ r~ Lc~'' lc( ,12_1r ?~-'/
subdivision, section, township, tm%ge)
Location (address or directions)
(b) Applicants Name 5'\-¢42.~>.!~__/<~____~_j;_~'_n Telephone - Home 5~( 61Y~;~usiness
Applicants Address Fo,,.~cl~
(c) Applicant is (check one)I,ending Institution [--'-[j ; Owner/builder ~;
Buyer [ffff~ ; Othe.r ~i] (explain);
....
(e) Real Estate Co. & Agent
Address
Telephone
(f) Mail the HAA to the following address:
2..T~.e of Residence
S ingle-F amily I~[~
Number of Bedrooms
Multi-Family
Other (describe)
Individual Well..}::i: Community [:2: Public
Note: If community well system~ must have ~rcitten confirmation ~rom the State
Department of Enw[ronmental Conservation at'tasting to the legality and status.
4..s~y~3 D~s_a~
Note: If community well system~ must have writteu cm:irmation from the
Department of Enviroumenta]. Conse~ation attesting to the legality and status.
{Page 1 of 2]
_En__g.ineerin~ Firm Providin_~...~.n_t~__pectionsz Tests, File Search~. Data and Information
As certified by my seal Jffixed hereto and as of the validation date sho~m below, I
verify that my investigation of this tlealth Authority Approval shows that the on-site
water supply and/or wastewater disposal system is .,;afe~ 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 blunicipality of Anchorage files and from my
investigation and. inspection, the on-site water supply and/or wastewater disposal
system is in compliance ~,rith all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm
Address ....
(ENGINEE]i SEAL)
Approved for~ bedrooms
Approved ~._. Disapproved
Conditional
Terms of Conditional Approw~l .................................................................
CAUTION
T}LE ~/NICIPALITY OF ANCIlORAGE DEPAR'[~iENT OF HEALTH ~ND ENVIRO~biENTAL PROTECTIO~
(I)HEP) ISSUES k~ALTH AUTI.i0RITY APPROVAL CERTIFICATES BASE[) SOIJgLY UPON THE llEPRESENT-
ATIONS GIVEN IN P.AI[AGRAPH 5 ABOVE BY A>~ INDEPENDENT PROFF, SSIO[~kL ENGINEF, R REGISTERF~O
IN THE STATE OF kJ, ASKAo 'file DHEP DOES THIS AS A COURIESY TO PURCHASERS OF HOMES 'AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE=
MENTS. Eb[PLOYEES OF DHEP DO NOT CONDUCT INSPEC'flONS OR ANALYZE DATA BF, FORE A
CERTIFICATE IS ISSUk[ ,, THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSI~LE FOR ERRORS
OR OMISSIONS IN THE PROFESS!O~XhiL ENGtNF, ER'S WOR. K.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-1 9-84
WELL DATA
Well Classification
Well Log P~esent (Y/N)
Total Depth ~h~o Cased to
Static Water Level d~+
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
If A, B, c~ C, D.E.C. Approved(Y/N)
Date Completed ~fp'~ ~S/Z?3 Yield ~ (PP~
~k & ~ ~pth of G~outin~. ~ ~
Sanit~,y ~al on Casing (~)~ .
~ession ~ound ~l~ead .(,X~) 1W
Pump Set At
Separation Distances from Well:
To Septic/Holding Tank on Lot 1%~ 6y px~"~~
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot I[7 ~?~ Adjoining Lots
To Nearest Public Sew~=~ Line ff$~c To Nearest Public ~
Clean, t/MaXcie ~ ~ , To ~est ~ ~vi~ Li~ on ~t
Wate~ S~le Collected By ~ ~ ~ ; ~to ~p '~ I ~
Wato~ S~le Test ~sults ~s ~
B. SEPTIC/HOLDING TANK DATA
Date Installed ~f_pr ~ / 72~ Size I ~oo No. of C~a~tm~nts ~
Standpipes .(.Y/N) J Air-tight Caps (Y~) y Foundation Cleanout (Y~) ~
~p~ession ove~ Ta~ (Y~) ~ ~te ~st P~d ~ ~
P~ing~aintenan~ Con~a~ on File (Y~) ~ ; fo~ ~
Holding Ta~ High-Wate~ Ala~ (Y~) ~ ~%~a~y Holdi~ Tank Pe~t (Y~1) ~
Sep~ation Distan~s ~ ~ptic~old~g Tank:
To Water-Supply ~11 I% 6 ~l ~1~'~ To ~ilding Foundation 2~
To ~o~ty Li~ ~ I,'~ TO Dis~sal F~eld ~
To ~ter Main/~vi~i~ ~ To S~e~, Pond, ~e, ~ ~jor ~aina~
Co~ ' ~ [ O O ~
Counts
[Page 'l'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
Depression over Field (Y/N)
Results of Last Adequacy Test
,[~;/L Type of System Design
· Length of Field ~ c/-
Depth of Field { '~
Gravel Bed Thickness '~' ~
Date of Last Adequacy Test
To Water-Supply W~ll
To Building Foundation
Lot gAk-
To Water Main/Service Line
To Stream/Pond/Lake/ca: Majo~ D~ainage Course ~ 10o '+
TO D~iveway, Parking Area, ca? Vehicle Sto~age Area t 5
Separation Distance from Absorption Field:
To lhzoperty Line IN
~_ ~rz_. TO Existing or Abandoned System on
; On Adjoining Lots ~vlA-
~7~ To Cutbank(if present) A~
Comments
nxrr
Date Installed
Size in Gallons
/Manhole/Access (Y/N)
"Pump on" Level at
High Water Alarm Level at
Tested fop
Electrical Codes(Y/N) /
Coa~t~nts
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Meets MOA
** Check Permitted Bedroom RatingA~ainst HAA Request
I certify that I have checked, verified, or conforrc~d to all MOA HAA Guide2
on the date of this inspection.
Signed ~~ ~~--~ Date ~P /~ /~
Company /~ ~c~ ~ /~¢. MOA NO.
KB1/d5/s
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2-15-84