HomeMy WebLinkAboutMEADOW BROOK Block 6 Lot 11
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date_ /~2,_/~
1, GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or dire. ction_s),
(b) Applicant Namo~r/ef ~,rS' Telephone: Home $~gB~([ Business ~¢~
Applicant Address -~/¢ ¢ ~ 6&/~ C ~~/ ~ ¢~6~
(c) Applicant is (check one): Lending Institution ~; Owner/builder~; Buyer ~; Other ~ (explain);
(d) Lending Institution z~_;/~*-C'd'..M~¢4~///'¢~"/ ~hf'~/,~. Telephone
Address
(e) Real Estate Company and Agent
Address
Tele. phone
(f) ,~tl~e P~IAA to the following address:
ENGINEERING
~ 96X
E~GLE P4VliR, AK 99577
TYPE OF RESIDENCE
Single-Family Multi-Family []
Number of Bedrooms _
Other
WATER SUPPLV
Individual Well [] Community [] Public~ ~,t~bO/k..) - 0.2'~ ~r~,~ ~.~<¢).
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
OnsiteX Public [] Community [] Holding 'rank
NoteT If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to tl~e legality and status.
Page 1 of 2 72-025 (i~,84}
ENGINEERING FIRM PROVIDING .$PECTIONS, TESTS, FILE SEARCH, DA'I. ,ND 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 cisposal system is safe, functional and adequate
for tile number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage flies and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in cornpliance with all Municipal and State (:odes, ordinances, and regulations in effect on
the date of this inspection.
Narne of Firm
Address
Date
Approved for ~"---,~..__~._ bedrooms by ~
-..-/~--_ Disapproved ____ Conditional
Approved
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
72-025 (! 1/84)
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOAj
MUNICIPALITY OFFIEAAf~'[II~I~A~'HORITY APPROVAL (HAA)
DEPT. OF HEALT~EcKLIST ' FEBRUARY 1984
Well Classification _
Well Log Present (Y/N)
Total Depth
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/M~diftg-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 Results
Comments
ENVIRONMENTAL PRO'tECTtON
RECEIVED
264-4720
Legal D,e~cription:
If A, B, C, D.E.C. Approved~N) LC
Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
Date Completed
'Casedt° [¢,
; On Adjoining Lots
"2-¢~ o ~ JO' ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B, SEPTIC/~ TANK DATA
To Property Line
To Water Main/Service Line
Course
Comments
Date Installed. (¢~::~ ¢~"~
Stand pipes(~:55/N)
Depression over Tank (Y~
Pumping/Maintenance Contract on File (Y/N).
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/.Moldincj-Tank:
To Water-Supply Well '~¢~
!
Size k, e:;:,~:;)C:) No. of Compartments 'Z.-.
Air-tight CapsdC~/N) Foundation Cleanout4~N)
Date Last Pumped 'C't..~'2~,¢~-~L..~ z
r4 ~ ;for
/
Temporary Holding Tank Permit (Y/N)
To Building Foundation _
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed I~:,~ ~
Width of Field ~
Square Feet of Absorption Area
Depression over Field (Y/,_~.
Results of Last Adequacy Test
Separation Distance from Absorption Field:
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (~,J)
Date of Last Adequacy Test
/
· To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line \ ~ ~ To Cutbank
To Stream/Pond/Lake/or Major Drainage Course F~ I¢, (~ \ ~ I.~ "-).
To Driveway, Parking Area, or Vehicle Storage Area ~-----~ ~ ~
Comments "~ ~.~¢q~t~-- ~..J~r~-~-~ ~--~ ~ ~ ~
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots "2~::=,~
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
Company~R_~ 196X MOA No. ,~ '-"~<:~ '~
Receipt No.EAGLE RIVER, AK 995772~¢j/ ¢,~¢ ~
Date of Payment /~/~/~ ._~. , / ~/
Amount: $ ~O.~ ~
Page 2 of 2
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all?__MOA and HAA g uidelines in effect on the date of this inspection.
Signed ~ & S ENG!N_~!_N6 Date
,. . ' ' ' '~ ~:-~gl
72-026 (11/84)
ANCHORAGE/WESTERN DISTRIC'F OFFICE
437 "E" STREET, SUII'E 303
ANCHORAGE, ALASKA gg501
Bill SH£FFI£LD, GOVERNOR
7-e,h~phone: (907)
lress:
274-2533
DATE: 12-29-86
PWS I.l).# 2].:L431
To Whom it Ma}~ Concern:
According to records on file 'in this office the
Water Regulations
DAWN WATER COMPANY
Water System is in compliance with the State Drinking
Sincerely,
Michael P. Lewis
Environmental Engineer
