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Home My WebLink AboutLOMA ESTATES BLK 1 LT 9 ~ MUNICIPALITY OF ANCHORAGE DE .:ITMENT OF HEALTH AND HUMAN SER ES /') Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT N~,~e DISTANCES Address TANK FIELD WELL / ~00 ~M~o~ ~qC WELL Phone(s) Permit No. NO gl Bedrooms i~ Lot q J ~ ~ FOUNDATION l/ Township, RBnge, Section AS-BUiLT DIAGRAM [Show Ioc~hon of well septic system, p~operty hnes, Iound~hon, l/ ~ ~ ~ d ...... y, water bodies, etc) TANKS ~ SEPTIC ~ HOLDING m Manu/acturer Capacity mn gallons m Mmerial No. gl Compartments TYPE OF SYSTEM ~TRENCH ~ BED ~ W. DRAIN ~ OTHER Depth to pipe bottom from Total depth lrom original grade ormglna[ grade ~ + FT ~ ~ FT ' ~ ~ Fdl added above ougmnal grade Gravel depth beneath pipe ~bl -t~ FT J( ~ ~ FTjD,s, .... bet .... min~s ET ~' Total absorption area ( ~ ~ Number gl hnes Sod rating Pipe material Installer gate Installed WELLS g Y g~ ~ PRIVATE ~ OTHER (Identifv) Scale: :' '.. ENGINEER's SEAL I ~ codify that this inspection was peflormed according to all Health Depadment Approval: Date: ';~ ~., .-' h'UPF$~'j'~ '~ WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological 8, Geophysical Surveys Orilli.~ Permit Ne. Q7Q2D5 LOCATION OF WELL (PIioee complele ellher ID, lb ow lc.) A.D.L. NO. ANCH 9 1 --o'--~'--o'-- sO ~O ..... DIGTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELL: ?~ WILLIAM & JANINE STRICKLER LOMA ESTATES ,~ Address: SirDar Address end Area of Well Location ;] ~. w~ ~o~ s.,,.~. 250 ,,. 8 - 12 -87 M olerlol Type Top Bottom hard pan 15 25 ~.~.~ ~ ~.,,.~ be'drock hard-gray 65 1 gpm streaks of white rock :i 130 170 gray-white rock-med, hard '~ 220 225 s., ~"~''" fL ."4 fl* ~ Above or ~elow land surface Ogle ~ . ~ ~ Length of Drop Pipe fl. c0pocily ~ Ae~omoto~ A12-75 3/4 hp K 8~ 14-0784 F~a~klln ~ A-87 A~ NOH:HET,T,-VRR~"g nRTT.L[NG A~27 , ~ 24] . F O r m S ' g ,, d: __.. '" _~_- ...~..~.l~.l~t...~_ .,Z~~ I)'ul.: ~-'f ~' -- e ~ O~'WWR (11/81) Copy DislrlbullOn: WNITE-$1ule DGGS~ PIN:4-Driller, CANARY-Customer SURVEY TYPE [] AS-BUILT-- NO CORNERS SET I_--~ PLOT PLAN' - AS-BUILT - LOT SURVEY -TOPOGRAPHY [] LOT SURVE~ [] RECERTIFICATION AS-BUILT -- NO CORNERS SET It isthe responsibility of the builder or owr~, I~ior to co~struotion, fo verify proposed buildin§ grade rlletiYe to finished grade end utility connections end to determine the existence of any easements, coven~nts or restrictions which do not app~c~r o~ the recorded subdivision plot. Lot Survey Certific~t~n i hereby cerfi~b/that I hove. surveyed the property the improvements situated therec~ ore within the prol)erty lines end do ~ot overlap or encroach on , adiacerff property, except es.indicated hereo~. Easemenll of record, other 'then those shown on the recorded plat are not shown hereon. SYMBOLS ~ ASSUMED ELEV. ~ WOOD FENCE ~ ~..-- CHAIN LINK FENCE NOTE: Fences ere shown in their approximate locations only. LEGEND .hub 15 tack-found [] set 13 DRAINAGE WOOD DECK ASPHALT CONCRETE iron tabor -found 0 set e iron pipe -found ® s~t O brass cap -found (~) set ~ alum. cap -found (~ sol ~__~. Prep~or~ed by L ENCH MAnK /NC. Professional L~nd Surveyors some: 1" = 50' I ~n bi' REJ .,. ~e Surveyed:lQ_il_ 87 { ~cked ~: MLJ Dete~u~: 10,1[~ .~ ~id~ ~7 W.O. ~7-0~_ ~gal ~ript~n: LOMA ESTATES SURVEY TYPE . AS- BUILT -- NO CORNERS SET ASSUM EO ELEV. wOOD FENCE DRAINAGE ~ WOOD DECK ~ ASPHALT i~ PLOT PI. AN - AS-BUILT- LOT SURVEY-~TOPOGRAPHY ~ CHAIN LINK FENCE ~ CONCRETE_ [] LOT SURV~( NOTE: Fences ore shown in their oppro~im~ locotio~s only. r'l RECERTIFICATION AS-BUILT -- NO CORNERS SET construction, to verify i~'Opole(l DUllam9 grooe .re.,u ,~. 1 iron ,,i,,' -found ® · ' ufili ~ (md 1o oele~mlr4 I i- to f,m~ grade ~n~ fY ...... Ixoss ~'-"'~ -found eh. ex~menCe of ony eosemen~ cove~Y]nfs ~' r.e??~r,=, i .,.,.,, ~ -fr.,nd ;~l~ich do nO~ op~ Da the rec~'ded subd,vll4on .pl~t. ~ ...... p, -:-.-- _ s~,,/~ t~ ~ ~ I z~.~,." A ".. ~:---.~'. ! I ~,.m,, b~ ~. Ic~c~'~'r~ _h~'~..?. I ~_~*;.~ ~ ".?,-)v61scal': 1" = 50' I -- t~,,~ property I~s end ~ ~t ~?~e~y ~' ~- 21-87 I oojocem p,u~ y~ cl.-ir.~~ ~'K M,~I / ! Eoslmeml of reco~d, I Y6~" 4121~ ,- ~ ! UO.I ~rlpt.;- I I ' / ' , Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O DATE PERFORMED Township, Range, Section: SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? ~ (/ S DEPTH? /~) p E Depth t0 Water Alter Monitoring? Dote: Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER __ PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 5 6 7 8 9- 10- 11 12 13- 14- 15 16 17 18 19 20 PERFORMED: Township, Range, Section: SITE PLAN SLOPE WAS GROUND WATER ENCOUNTERED? } S IF YES, AT WHAT Il ~' ~ DEPTH? p E Depth lo Water Alter ~ Monitoring? t I ~ Dale: ~ PERCOLATION RATE '~* ;~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~- FT AND ~'~' FT COMMENTS / t - PERFORMED BY' ~,- ~ I~~~CER F~ TH.~ %'I'HIS~TE~.,ST ~S PERFORMED IN ACCORDANCE ~/~/,TH~ALL ST(~E'/~D MUNICIPAL GUIDELINES 'N~FFE~[ ON THIS DATE. Gross Net Depth to Net Reading Date Time Time Water Drop PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: Township, Range, Section: SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19 20- WAS GROUND WATER ENCOUNTERED? ~J'~-~ S k IF YES, AT WHAT DEPTH? //~- ~ E' Depth lo Water After.. Moniloring? ~/~" Dale:. Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER __ ~, tEST RUN BETWEEN FT AND FT PERFORMED BY: ~) I _~1~,.~.. (/ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WiTH ALL STATE AND MUNICIPAL GUIDELINES iN EFFECT ON THIS DATE. DATE: 0~0o~w .% · .-.% ~' ,' ,':~, %1 ~, - ..' ...'~?:.'v- / :":'" ,,' / /'"'-. ..... -- . 4.~ .~- '-. . - ,,., i \ ' -'-- - 7. ..... ' ao' I SYMBOl-. ' ~1~ ~ I / SURVEY TYPE . /l~ ;LOT ~-~ ' ~S-BUtL;- tOT SURV[~-'roeO~RAP"Y ~ REC[RTIRCATION AS-BuILT -- NO 41214. hub & toc~-fc~md irm febor -found iron pipe -fmmd s~t · set' · set · BENCH ~ofes~io~MI Land 1" = 50' /NC. 87-086 ~ool Deocrlpfloe,. __ lOT 9, BLO~ 1, LOMA ESTATES Parcel I.D. # MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES_ Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING C~c]~ ~(~'~ NAA# ~'~"~% ,.~-'~\.~ GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address, Day phone Lending agency Mailing address Agent Ad dress Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~/ TYPE OF WATER SUPPLY: Individual well X Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1/91) Front MOACt21 STATEMENT OF INSPECTION BY ENGINEER 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 application 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 An_chorage 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 /t/~/. (~ ~/ Engineer's signature Phone Date DHHS SIGNATURE / Approved for /--"E) (~/'¢k. bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 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 DHHS 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. 72-025(Rev. 1/91) Back MOA~I RECEIVb[ Municipality of Anchorage MA.Y 1 41999 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division MUNICIPALITY OF ANCHORA ENVIR. ~QN~ F--J'~TAL.~ ER ~/ ICES DIVISION 825 L Street, Room 502, Anchorage, Alaska 99501, Health Authority Approval Checklist ~,,~z-/ ,~.~,_,~2,~_ ~,f~:~ Parcel I.D.: If A, B, or c, attach ADEC letter. ADEC water system number Date completed ~' .- / 2. - ~; 'Y Cased to ~ ¢.~//"2L' Casing height (above ground) Wires properly protected (Y/N) ~/ AT INSPECTION g.p.m. 62, ~ g.p.m. tO ~ Other bacteria -~'~ Collected by: --~, ~-~-/~0~/'~- FROM WELL LOG /~,,~'~ Number of Compartments. ~ Cleanouts (Y/N) . Depression (Y/N) /V/ High water alarm (Y/N) Pumper ~-~'~ Legal DesCription: A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: S. SEPTIC/HOLDING TANK DATA Date installed ~-- ~' ~ZY Tanksize Foundation cleanout (Y/N) / Date of Pumping C. ABSORPTION FIELD DATA Date installed ~'-f; ~,f' J Length -~ f~/w ¥~- / Width Soil rating (g.p.d./ft~ or fF/bdrm) / ~,.,~.',z System type ~¢¢~ · ~ / Gravel thickness below pipe "~ / Total depth Effective absorption area ~¢ !//;~/:Z~onitoring TubcCi~resent (Y/N)__~ Depression over field (Y/N) __ Date of adequacy test ¢-% ~'' - ¢ ~ Results (Pass/Fail) /¢2¢8~¢~ For $ Fluid depth in absorption field before test (in.); Fluid depth 2, ~-~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N). 72-026 (Rev. 3/96)* Immediately after///¥~'gal, water added (in.): Absorption rate ~¢?/- = g.p.d. If yes, give date ^? bedrooms D. LIFT STATION Date installed Manhole/Access (Y/~,~/~-- Hi:h~rm level at. es ~ested * Size in gallon~'//~ ~ "Pump on" .eve~ "Pump off" I~'el~t~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line / 2. O/¢ On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation /// Properly line /~ / '~ Absorption field -~'/ Water main/service line ~.~' /''~ Surface water/drainage. / ¢¢'/~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Surface water Curtain drain /~/.A Building foundation /~" / Water main/service line / ¢'-~ / ¢~ Driveway, parking/vehicle storage area / /~/¢¢,'?~- /~;~¢'~'-~,*'~ Wells on adjacent lots // E HAA Fee $ .. Date of Payment Receipt Nutone, ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records th~aL~t~e~'~,*b~tems are in conformance with MOA,C-IA~ ~uidelines in effect on this date. ~ .~T.?c ,?r.'../? ~,~ , - ~..'~,, -- ~ '~:, . CE~ 9409 , Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* MUNICIPALITY OF ANCHORAGE MEMORANDUM WATER WELL ADVISORY HEALTH AUTHORITY APPROVAL NO. During a recent Health Authority Approval on-site inspection and test of tl~e potable water supply well on Lot ~ Block [ of Z 0 /~ /~ Subdivision, the well's productivity was determined to be d}o~ gallons per minute. The minimum Well productivity required by this Department (~C !5.55) for a ~ bedroom residence is O,V~ gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies hf the subject Health Authority Approval. T-874 P.02/03 CT&E Ref,~ Cliem Name Project Name/// Client Sample tD Matrix Ordered By PWSID 991985001 Susan Os~val! & AssociaTes 17150 Betfijean L 9 Bk 1 Loraa 17150 Bemjean L 9 Bk I Loma Dnnking Water Sample Remarks: Client PO# Primed Date/Time 05/I 1/99 13:14 Collected Date/Time 05106/99 09:35 Received Date/Time 05/07/99 08:30 Technical Director: Stephen C, Ede CoLiform Ni[Pa:e-N 0 1 .O~ PQL o.sao coL/~0mL mg/L ALLowabLe Prep AnaLysis SM18 9~S 05/07/99 rAP EPA 500.0 10 ~r.ux 05107/99 05/07/99 SCL MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 1. GENERAL INFORMATION .. Complete legal description HAA # ~ ~'~c~ \ ~ I Lc~ Location (site address or directiOns) Property owner Mailing address Day phone Lending agency Mailing address Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 STATEMENT OF INSPECTION BY ENGINEER 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 application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and typeofstructureindicatedherein. Ifurtherverifythatbasedontheinformationobtained from the Municipality of Anchorage flies 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 Cor~"~,"'~c"~¢,,,~ ~S ~¢-...~'r~ Phone '"-ZJ~rC"Ze°° Address ~Go~ '~'Ak VOc'"ccx~'~' ''~'¢ /Ac, t.xr,~,~e..,,,~ .,9.,q51(~ Engineer's signature ~~'~'~"~ Date /¢//~,Y' ~ /¢'¢/ Approved for Disapproved. ~bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: /~ ~ ///"~~. -- ' -- Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 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 DHHS 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. 724325 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Serwces ENV~R~L HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~ <~ ~;t< [ Loch~ E~'~'~ Parcel I.D. A. WELL DATA Well type 'Pr<tv A~¢: If A, B, or C, attach ADEC letter. Log present (Y/N) ~/ Date completed Total depth Cased to Sanitary seal (Y/N) MAY 8 199I RECEIVED ADEC water system number ~- ~7'- ~'? Driller VeC, fv's Casing height Wires properly protected (Y/N) FROM WELL LOG Date of '~est ~- 12- ~ ' Static water'level (5~ t Well flow ~/~ Pump level "~ ~ ~: SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Public sewer service line WATER SAMPLE RESULTS: Coliform ~,,4-r/5 F,~.-'- ?'~)/~Y Nitrate AT INSPECTION g.p,m, g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Pet~bleum tank Date of sample: q-z5 Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~ ~ ~ 7' Tank size t'Z~O ~ Compartments Cleanouts (Y/N) ~ Foundation cleanout (Y/N) '"/ Depression (Y/N) High water alarm (Y/N) Date of pumping kJ SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK TO: Well(s) on lot 1'~, ~ On adjacent lots iccp% To property line ~-0 ~ Absorption field ~" Surface water/drainage '* }00 ' Foundation 10' Water main/service line * %$ ' 72-0?6 (Rev. 3/91) Front MOA 21 CONTI NU ED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) ~ SEPARATION DISTANCE~-R~OM LIFT STATION TO: Well on lot~-~- On adjacent lots Manufacturer Manhole/Ac/ "Pump on" leve~ f "Pump off" level at Surface wat~r Soil rating ~$~ ~:/b,~ System type 'T'~J¢~ Gravel thickness 4 ' Total depth Cleanouts present (Y/N) Date of adequacy test 4 for If yes, give date D. ABSORPTION FIELD DATA Date installed (~' ~- Length Je ~.' Width Total absorption area ~l(~ Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on, lot 'To building foundation On adjacent lots Surlace water Curtain drain ~'~ On adjacent lots ~¢4, Property line To existing or abandoned system on lot Cutbank ~ /~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines, Signature Engineer's Name [)ate /'~,/ HAA Fee $ "t'~O, O(,~ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number in effect g...r~-.~e~.~o.f this inspection. NORTI ERN TEST N8 LABORATORIES, INC. 8330 INDUSTRIAL WAY FAIRBANKS, ALASKA 99701 (907) 456-3116 · FAX 456-S125 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 277-8378 · FAX 274-9645 Constructing Engineers 9601 Buddy Werner Drive Anchorage AK 99516 Attn: Bill Strickler Our Lab #: Location/Project: Your Sample ID: Sample Matrix: Comments: A109813 L9 BK1 LOMA ESTATES Water Method Parameter Units Report Date: 04/30/91 Date Arrived: 04/25/91 Date Sampled: 04/25/91 Time Sampled: 1550 Collected By: ~ ~&~.~ Flag Definitions U = Below Detection Limit DL Stated in Result B = Below Regulatory Min. H = Above Regulatory Max. E = Below Detection Limit Estimated Value Date Result Flag Analyzed EPA 300.0 Nitrate-N mg/1 0.1 04/26/91 Reported By: William E. Buchan Anchorage Operations Manager MUNICIPALITY OF ANCHORAGE ~) ~'~ ~) D ~' DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date ~ ~J~! /~'~'~ GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Locs. tion (address or directions) (b) Applicant Name ~)/,//~¢~,-x',-? ,,..~.-jc~e~. Telephone: Home ~~--- Business Applicant Address (c) Applicant is (check one): Lending Institution []; Owner/builderJ~; Buyer []; Other [] (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family ~ Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Well~ Community[] Public 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 Onsite~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) ~E,NG NEERING FIRM PROVIDIN. .NSPECTIONS, TESTS, FILE SEARCH, DA ~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 /~c~e~o~:,v 'T~,.~J~,qff ~c~'~,,~e~ Telephone Address Date ~) I¢) DHEP APPROVAL Approved for /~'~,," ~__/~ 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 5 above by an ipdependent 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 i~AuNiCI?AUt'Y OF ANCHORAGE ~Nvi~ONMENTAL sERVICES DIVISION NOV 2 0 1987 w oABECEIYED MUNICIPALITY OF ANCHORAGE (MO~.~ HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: Well Classification /~-/~J.4--/~ If A, B, C, D.E.C. Approved (Y/N) m Well Log Present (Y/N) r/ Date Completed ~-I~ -g'7 Yield Total Depth ~-~'~ ! Cased to (o~ "~', ~' t~ Depth of Grouting Static Water Level G,~z Pump Set At ~ Sanitary Seal on Casing (Y/N) "¢ DepresSion Around Wellhead (Y/N) ; On Adjoining Lots ! ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ;Date Casing Height Above Ground ,3 Electrical Wiring in Conduit (Y/N) y 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 I~ Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed _~, ~!~*/ Size _/,,b,,.5~ No. of Compartments Standpipes (Y/N) V Air-tight Caps (Y/N) ~ Foundation Cieanout (Y/N) Depression over Tank (Y/N) *'q 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 1~-~" To Property Line ,OfO! To Water Main/Service Line "'"- Course To Building Foundation /! ¢ To Disposal Field ~' To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 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 '~/~ Type of System Design Length of Field ..~¢,Ca Depth of Field '~ · Gravel Bed Thickness ¢'~ Standpipes Present (Y/N) Date of Last Adequacy Test To Water Main/Service Line -- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line 27-,~" To Existing or Abandoned System on ; On Adjoining Lots /g"6¢' To Cutbank (if present) ~ LIFT STATION Date Installed ~ / Dimensions Size in Gallons %, ./ Manhole/Access (Y/N) "Pump On" Level at . "Pump Off" Level at High Water Alarm Level at. Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA CommentsElectricalC°des(Y/N) / ~ ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have c~ecked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~'~L~4~,.. ~_'~.L~ Date 0/'~ /¢; I~ Company~~~ MOANo ~-~ Date of Payment // ~ ...' .... . ~. t~ ~ Page 2 of 2 ~e~'~',. CE 51~0 ,.'.G''~ 72-026 (11/84) ~%~ ~%~¢* NORTHERN TESTING LABORATORIES, INC. 600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907479-3115 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-8378 William R. Strickler 17150 Bettijean St. Anchorage, AK 99516 Attn: 345-5828/266-1547 Date Arrived: Time Arrived: Date Sampled: Time Sampled: Date Completed: 11/17/87 1048 11/17/87 0930 11/18/87 Sample ID#: Al11787-1 Parameter Unit Result ADEC MCC* ================================================================================= Nitrate-N mg/L 0.18 10 Reported By: ~__ - Da%e: 11/19/87 Carol J. Garrison, Vice-President NORTHERN TESTIN6 LABORATORIES, INC. 600 UNIVERSITY PLAZA WEST, SUITE A 2505 FAIRBANKS STREE'r FAIRBANKS, ALASKA 99709 ANCHORAGE, ALASKA 99503 907-479.3115 907-277.8378 Quality Control Report Client: ID#: William Strickler Al11787-1 Listed below are quality control assurance reference samples with a known concentration prior to analysis. The acceptable limits represent a 95% confidence interval established by the Environmental Protection Agency or by our laboratory through repetitive analyses of the reference sample. The reference samples indicated below were analyzed at the same time as your sample, ensuring the accuracy of your results. Sample # Parameter Unit Result Acceptable Limit EPA WS 378-6 Nitrate-N mg/L 0.99 0.84 - 1.02 Reported By: Date: 11/19/87 Carol J. GarriSon/, Vice-President