HomeMy WebLinkAboutLot 03, 04A
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Application Date
GENERAL INFOR['CIATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
MUNICIPALITY OF ANCHORAGE
DEPAR'I'MENT OF HEAI.Ttt AND ENVIRONMENTAL. PROTEC'f'ION
DIVISION OF E. NViRONMENTAL HEALTH
CER1 IF1CAq E OF INSPECTION FOR HEALI'I4 AUTIqORI-FY APPROVAL
OF ON SITE SEWER AND WATER FACILITY
264-4720
(b)
(c)
Location (address o,~ directions)
Applicant Name [~G~]; _ k//~--~.O_~_(~_~_ Telephone: Home [(~tk.~.?.~b Business
Applicant Address ~ ¢P, ~>~2~ ~"] ~ f3 1'~ .~g~l.-.~:.. ~,,~<~ ~,. ~.~ ~ ~'t ~,~'~ ....
Applicant is (check one): t_ending Institution El; Owner/builder~_; Buyer [~; Other El (explain);
(d) Lending institution
Address .......
(e) Real Estate Company arid Agent
Address
Telephone
(f)
Telephone
%O~p~ ~ HAA tO the following eddress:
TYPE OF RESIDENCf~
Single-Family,~ Multi-Family L]
Number of Bedrooms __ '~' .....
Other
WATER SUPPLY
Individual Well~' Community [~ Public E]
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAl.
El Pul)lic~'-. Community ~ Holding Tank E]
Onsite
Note; If community well system, must have written confirmation from the State Department of Environmental Coaservation
attesting to the legality and status.
Page I of 2 72-025
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA 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 of this inspection.
Name of Firm Telephone
Address . 8R~tg~ ~. _ _~
Date _f~14~6fl~9~ ......
DHEP APPROVAL
Approved for .7~,:~,,:.~:.,)_.._ bedrooms by
Approved ........ ~_ ..... Disapproved
Terms of Conditional Approval
Conditional
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 ii 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 (MOA)
HEALTH AUTHORITY APPROVAl.. (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: ~-~'r'~
,-°
Well Classification "~' ~ If A, B, C, D.E.C. Approved (Y/N)
Well Log Present~/N) Date Completed ~o_.~,,¢~.1 ~j Yield
Total Depth ~ °¢.~-2~ __ Cased to ~OJ Depth of Grouting '=
Static Water Level ~.~_~, i .~. Pump Set At '
Casing Height Above Ground ¥'~ Sanitary Seal on Casing ~N)
Electrical Wiring in Conduit (Y,~.3, ~-~¢¢~.~. ykr~Js_~._ Depression Around Wellhead (Y/4~
Separation Distances from Well:
To-,~°,eC~~ank on Lot ~"~ ~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot "~/,,':L ; On Adjoining Lots ___
To Nearest Public Sewer Line r'] ~ , To Nearest Public Sewer
Cleanout/Manhole _ ~.~O ~ ~)/~-~'~ 'Fo Nearest Sewer Service Line on Lot
Water Sample Collected by '~'~¢~ ~:~ ~d;-~ ( zc,-31DC.,c'Z_4~ , Date ~-'~_~..~'
Water Sample Test Results _
Comments /~- 'v,~.~... \/j_~,O~..¢~ .~.~¢¢,.~ ":..%'~_~-¢,v,5¢=¢'~ ~.JLC't_L~ .,,~,~
SEPTIC/HOLDING TANK DATA
Date Installed Size No. of Compartments
Standpipes (Y/N) Air-tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ~..~) /~ Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ; for
Holding Tank High.-Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026(11/84)
C. 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
Type of System Design
Length of Field
Depth of Field
ravel Bed Thickness
Standpipes Present (Y/N)
/'~ Date of Last Adequacy Test
To Property L~ne
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments _~-'~~ "~Z.~ "{'P~,~¢~
LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Dimensions
i)~ManhCe/Access (Y/N)
"P//(Jmp Off" Level at
!/~ Vent (Y/N)
/~/ 'Pumping Cycles during Adequacy Test. Meets MOA
Electrical Cod~s (Y/N)
Comments
** 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 inspection.
//
Signed_ :~ "_.~,..~, t~ .~! ~, ~ ~ ~ .m., ,! ~ Date .~/~/,/~'~5 -
· ., 8RB lg6:~[t ·
Receipt No.
Date of Payment
Amount: $ &~
Page 2 of 2
72-026 (11/84)