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Home My WebLink AboutHIGHLAND PARK BLK 1 LT 5A MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES C Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264.-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT N~m~ ~ DISTANCES ':~tL.I~ ~0~1~o~ T0 SEPTIC ABSORPTION -- Phone(s) Permit ~o. No. of ~roo~ WELL ~ Township. Range, Section ~ ~>~ ~,/,/~ ~.~ 2~ ~S-BUILT DIAGRAM (Show location of well, septic sysle., properly hnes, ,oundat,on, TANKS ~L i ~ SEPTIC ~ HOLDING No. ol Compadments original graO;~ ~T FT )ye origlpal gr8~ ~Distan~Gravel depth beneath pipe FT FT Gravel length ~ Gravel width ~.,, FT ~ FT _ SQ FI WELLS ~~ATE ~ OTHER {Identify) -- FT REMARKS: ~UIq ~¢~ ¢~¢¢ ~.¢~1 k p~¢' C¢~ Scate:lnspections~¢Pedormed ENGINEER'S SEAL i3~m'u,~:.:,F. (:'~,:::ll::t r'. i.:.,.)!!!~!~!~ ',', &'):JOg Cl..Il?i),? ]: F'd',l I::; ]...I C)}::/F:~ {3 }iii: :~ T MUNICIPALITY OF ANCHORAGE D \RTMENT OF HEALTH AND HUMAN SEf ~ES O/ ¢ ~ f Environmental Health Division 825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SFWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ~] SEPTIC ~ HOLDING Material [ No. of Compadments TYPE OF SYSTEM []TRENCH ~ BED ~ W. DRAIN E] OTHER Ff Total deplh from original grade Gravel w~dtl/ ¥ 80 FT ..... P~pe material ~/~l~Ot~- Installer WELLS FT PRIVATE L~ OTHER FT FT TO WELL LOT LINE FOUNDATION DISTANCES SEPTIC TANK ABSORPTION FIELD WELL AS-BUILT DIAGRAM tSho',v Iocahon OI wel sephc system p~operty hnes, Ioundat[on. REMARKS: Scale: /" Z.o~ f Inspections PeHormud by ~ ~ certify Ihat this inspection was performed according to all MueJcipsI and Stale guideli,es in elfect on this d~ie: ~?. ~~ " : ENGINEER'S SEAl_ INSPECTIO.~ REPORT MUNICII~.LITY OF ANCHORAGE, BUlL. DING SAFETY DIVISION 3500 EAST TUDOR ROAD INSPECTIONS I907 563-3464 ADMINISTRATION f907~ 786-8301 NAME i 1' , ' ~ r ' / PERMIT NO STREET ADDR ESS. PHONE - LOT BLOCK / '- SUBDIV. I , ~ /DATE FOO,,T,t~NG __ [] ELEC. TEMP [] PLBG. UNDGR. FOUNDATION [] ELEC. SERVICE [] PLBG. ROUGH BOND BEAM [] ELEC. ROUGH [] GAS TEMP. FRAMING [] ELEC. FINAL [] GAS INSULATION [] OTHER r,' [] MECHANICAL SHEETROCK [] MECH. FINAL __ STRUQ% FINAL [] FIRE FINAL [] PLBG, FINAL OTHER [] ZONING [] OTHER ~"NO NONCOMPLIANCE OBSERVED [] CORRECTIONS ESSENTIAL AS EXPLAINED BELOW [] DO NOT CONCEAL UNTIL REINSPECTED ~ WILL REEXAMINE AT NEXT INSPECTION COMMENTS [] [] [] [] [] INSPECTOR WHEN CORRECTIONS ARE MADE, PLEASE CALL FOR INSPECTION DATE DO NOT REMOVE THIS NOTICE 84-002 (Rev 10186) MUNICIPALITY of ANCHORAGE MEMORANDUM DATE: TO: FROM: SUBJECT: January 19, 1988 File of Lot 5~Block 1 Highland Park Subdivision Daniel J. Roth, civil Engineer, On-Site Service~ Documentation for the waiver approval of an absorption field to lot line on Lot 5 Block 1 Highland Park Subdivision This memo documents the waiver approval for a septic system encroachment of 5 feet to the lot line between the subject lot and the lot to the north. Because the lot to the north of the subject lot is on public sewer, the encroachment of the septic system will not cause a conflict. PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION:,~' ~/,*:t~ / ~7~/~ ~ Township, Range, Section:7/.~/~ ~ SLOPE SITE PLAN 2 3 4 5 6 7 8 9 10 11 12 13 14- 15- 16- 17 18 19- 20- Jl l.J WAS GROUND WATER ENCOUNTERED? /~' ,,"' DEPTH? //, ,~ p S IF YES, AT WHAT E Deplh to Water After Monitoring? 7' ''~ Date: ,~/'~ 2/~'~. Reading Date Gross Net Depth to Net Time Time Water Drop ~,~, PERCOLATION RATE/_~.' ~( TEST RUN BETWEEN __,~ zF/ ,z . · (mmutes/~nch) PERC HOLE DIAMETER .. FT AND '~ FT PERFORMED BY: /(' '4/ I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: _,~// /~ 7' 72-008 (Rev 4/85) ALASKA ENVIRONMENTAL CONTROL SERVIC' INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561.5040 JOB SHEET NO. OF CALCULATED BY DATE CHECKED BY DATE SCALE 'I'ANK I::'OR L, II=T SYSTEHS Anchorage Tank & Welding, Inc. 2700 Porcupine Dr. Anchorage, Alaska ggSOl (907) 272-3543 SEP'/ll: TANK SHAL, L, BE A HOBII=']]I~!iI) ANC'~ORAGE TANK .S'¥'~ I!]1.~ 'YANK, THE: DESIO)N OR ANAI..,YS[S SHAI_,I~ BIE IN A C C 0 R I) A N C E: 1.41 T I-I A C C Iii: I:": ii!: £1 E N G I NIE E R I N G I::' R A C T I C I..i: fiND COCAI.., J~'.I]i:GL.,~.,(:~'I'(]RY AGENCI[...:S, THE TANI<S SI..IAI..,L, BE ]OE:SIGNlii:D F:OR I..,OADING COND]:T CiN!i~ AS I~I?:DtJ]:I;~ED BY NtJNIC:[P;:tH.~ (;H3 STATE REGUL, AT IONS, Al.J, W!!iC'F~ING SHAL, L, BE IN AC:C[)I~I)Ai'.q.:Ii!: WiTH A I:"' F:' L, I C A B L, I::.: C 0 I) E S A N I) ::i !"A N I) A R D S, COA'FING SHAL, I.., BIZ TNlii:MIE~: H. 6' q. 55 HI....BU]:I..,I) "'(::NK COATING ANZI AI::'I::'I.,IED AS F:'OI. !JigS: SURFACE I::'I~E:I:~AI~.AT]:O;' ..... AL, L, SUI:~I::'ACES MUST BE DRY, CL, EAN, Al',.!)3 RF. EAS(]NABI./Y I::'I~E:E OF RUST ANI) H!CL SCAI..,!: EXCESS RUST, MIL, L, SCAI..,E AN:O UEL, r~ING SL, AG SHAL, C BE I:: klO'v'lZI) BY HIRE BRUSH (:lit O'iI-.IER MEANS AS NI!i:CESSARY, AI:~F'!.,]:CATION SI..IAI.d.~ BE AIRI..,ESS SI:~RAY TOtJCH UP UT. TH BRLISH 0~'~ 'i"H !?N:[NG SHAL, C BE ACCOMI:U.~ISHE:O I,.J:l. ;'1..I AF:'I::'ROV[:.'D MA'¥'IiiI'J:AL, ANI) I,JIl..,I.., NOT E,XCE:IZ:O 5%, StJRFACIZ TEMPERA'¥'t.':!E SI-IAI.J., NOT BE BEI..,OU OR 5 BEI..,O~,J DIEU F'OINT LIHICH li::v'.: R IS I..,OI.JEI:~, IN'IER:I::jiR SI-IAL, L BE COATEI:J "['HO 'T]:M::S AND SHAL,,L, BE A MINIt,IUM 01::' :20 ORY MIL.,LS EX'TE:R:I:OR SI~:',I_,I.., BE COATED ONE 'TINE AN~:t SI.-I~I.,I.., BE A HINIHUN 0i.:' ZO :ORY HZ[J.,S, Anchorage Tank & welding, Inc. 2700 Porcup|ne Dr, Anchorage, Alaska 99501 (907) 272-3543 OUTI..,E'T RZSERS SI..IAI...I.., BE (EiAL, VAN]'.ZED S"I'IEEL, CUI..VCRT, ~ND SI..I~LL [~E 5~.~ INCl..lES (MINIMIJM), HIGH, HAVE A MINIMUM NOMINAL D]:A?-~IETER OF' 2~ INCHES, ~NEI SHALL E-:IE CAPAf~I~E] OF ~dSING EQUIPPED WI I'H "lille F'OCI, OWI A, A ,JUNCTION (NIEMA 1.t-X) L) R fa T T A C H FZ ]]1 T 0 T I-~ E R ]] ~ ~.~ R , B, UI., I.,ISTED IEI.,~ECTI~]iCAL, COR~i~ GRIPS, INSTAL, I.,IED IN THE J....~8OX, A !,ID .... .SHAL, I.. [,:di!: FURNISHED WITH HIE RISER, IT SHAI..,I,,, :(:~IE C~iNS'I'RUCTI!~:D 01:-" I.':'Z~:,qERGI..~S8 OR li~:(~]t~!:",.,"~':~t..IF.N'l' I:~IS[:.'R INSTAI.,,LATIOF! "- lEACH R:[SIEI:~ SHAI..,L BE SIi."AL, tE]O OR t,.II:SI..DED TO THI'.':- '¥OP OF TI-lIE TANK IN SUCH A NANNIER AS "['0 PIREV[:~NT INFII./¥RA'I'I[)N OF' [.)ROUND I,.IHI RIE PR[-:SENT, INSLJI.,ATION -' 2" RIGID EX'I'RUDI!!::O P[)I.,YS'rYRENIii: :MiAI..t,., ]:.~E PI..,P~Cli..:D IN THE I~ISER ):?IF?ECTL, Y :(:.q,'-': L, Ot.,I THE INSUI..ATION - 2" SPRAYI!':D I.~RIETI-:ANE C)N C, I R C U N FIE R E N C E 0 I::' R I S Iii: R, Anchorage Tank & Welding, Inc. 2700 Porcupine Dr. Anchorage, Alaska 99501 (907) 2?2-3543 EF"FL, UENI' PUN: ING ASSEMBt.,Y A, E I::' I::' L, UFNT PUffi?ING ASSEMBL, Y SHAL, L BE ORENCO SYSTIEMS (TM) MODEL OSI WE '_1.000 SERIES C[)NSISTING OF FOLLOW]]NG: 1 1/3 H,P, MYERS SSM25 115 VOL, T OR EQtJAL, SCREENED PUMP VAtJL"F (U,S, F:'ATIL'NT 59" DEEP, 3/16" THICK kI'.IZ(iH-'BENSITY PVC CYCLIr'Ok~LFR HOUSES THE PUMP, t..,EVEI.~ ANB SCREEN AND SER",,"~ES AS A BAF'F'LE TO PREVENT 'T'HE SCREEN ','RC)H C!.,OGGING, THE F'IF'I', EN 1"":1./2" DIA, HOl..,lii:S ARE )[)RIL, I,i:::B IN 'f'HE VAULT AT A LEVEb FHAT P!..,ACIrES THEM A"f' A[':OUT THE MIDWAY I:~O:I:NT ]:N TI"Ii!: :()EP'FH OF' THE S 1::i P 'F I C, f:'L, AP CHIECK: AL,!.~OWS THI~! VALIL, T 'FO ;OF~AIN WHlii:N I:~.I:T. HOV ]:Nr:; l::' ROM TANK , B t SCREEN: :i. 5" DIA, CYI.,:I:i'.~DFR 0t::' HIGH...-BENS]:TY POLYETI4YI..IF. NE :l./fJt" HESH CAS"f' INTO F:IBlii:RGbASS [,:'~O T T O~"4, AL!., PI.,tJMBING ,SHAI..,L, BE PVC OR C!"f!.' :R NON .... C 0 R R 0:01 N G H ~ T iii: R I A I .... CONTROL, S AN:(:! AI..,ARH SYSTEM -" CONTI~OI~ SHAL, I.. )::;Fi ORIENCO SYSTEMS ('f'M) HI.., I S 1' I N f."; O I::' ', 1, At..!D:[BL, I"E ALARM PANEC MOUNT-t,J:! i'l"l A MINIMUM OFr 80 .OB SOljN][) PRI.'T. SSURE AT 2q.-INCHES, TEMPERATLJI:~E .... SOA(' TO 65AC, CONTINOLIS SOUND, Anchorage Tank & Welding, Inc. 2700 Porcaplne Dr. Anchorage, Alaska 99501 (9O7) 272-3543 OtL-I'IGHT ¥1] .S I] A1,, AI_,ARM WITH PUSH-TO-SII~ENCI!..] Frli..ATUIRE, AUTOMATIC AU~()IO-'-AI..,AI:~.~ ]5 AMI:-" MOTOR IRATEO 'J'OGGM!i] SWITCH., SINGI~E POCE, DOUBLE-I'HR[?J WI. TH THIRL:~]E POSI]'IONS~ MANUAL (~AN), AUJ'O~A'I'IC (ALITO)~ AND CENTEIR (OF'F) (H,O,A,), ,1::[ F :1: BE R[:')I..,ASS, OR NEHA q.X"' RA" .... ENCL, Cn;..IIRE WI:TH I"IINGEI)COVE:IR, Mi]Vl.'-]]... CON'TIROL Fl.,OATS SHALl.., BE [)I~!I'~;NCI] SYSTEMS (TM) i"lF2 CONSISilNG [)F' i:.~ MIERCURY I::'I..,OATS ON AI).'ISTABI..,E PVC STEM I,,IHICH ATI'ACHES TI.] VAUI..,'F, (]NE FI..,OAT SIGNAI_,S AL, ARM; 'I'HE OTHI]I:/ SIJITCHtE;S PUMI:~ ON""Ol:rl::', INSTAL, CATION, ALL PUMPING SYSTI:T. MS SHALL BE INSTAI.J..,EO :IN AC[,OR!ANC[: WITH THE MANUF'ACTUI]ER S RECOMFilENDATIONS AN~J S'TAN]]AI:Z[~S, ~nd re'~oJ."~n9 ~ech~ls~ NEMA 4X Jurtc'l;Ion box ~ PVC b~tU. v~Lve 24' ID x 4' 6'C~Rver~ M~nhote ?Le~Jb[e hose ~' sprayed ure~h~ne ~c~ 1/4' PVC p~pe Typ 1 1/4' PVC check v~ive AdJus~.~ble F~o~ S:ertch Assembly ~ea[ elth RAH-NEJ( or Equ~t r~dl0ber oronne~ or we[ded s~eel ! 1/4' pipe 1/4' cil~ drain back hole 1 3/8' bores 6' nC 1/8' Mesh potye~hyiene screen tS' dl~ x :39' high Re't~lnlng ~nstes 1/3 1%o e?F[uen~ pu~p, v~lous ~nu~c"L'ures L.I:FT STATION ]}AI'A GeRlons per' ~ TYP~AL PUle P~'.RFDR,qANC~: CURV~' NOTE SIZE CHART - LIFT STATII:~I TAN~S MU~T ~1£ ESO C~LLDN'~ LAR~R THAN STAN~DAt~ TANKS MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Se trices Section P.O. Box 196650 Anchorage, Alaska'-99519-6650 ParcelI,D.# OI ¢L 0~ ~'.-~ 1, GENERAL INFORMATION Complete legal description 343-4744 CERTIFICATE OF HEALTH AUTHORITY ,. ,., APPROVAL FOR A SINGLF FAMILY DWELLING ' ' ........... u Location (site address or directions) /~._~O q Property owner -~.,~ Mailing address Lending agency. Mailing address_ Agent Ad dress Day phone Day p~one . Day phone Unless otherwise requested, HAA will be held for pickup.....,. ........... ' 2: NUMBER'OFBEDRooM$: ~ k,~' 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation f~om State A. DEC attest- . . ing to the legality and status of system. ~,:. 4, TYPE OF WASTEWATER DISPOSAL: · . ndiv!dual 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 5. 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 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. NameofFirm 'i ~/¢~-~ ~)i~-~L~l~(./ Phone ~'7~-~j/,~ Address ~ ~ ~ /~'('/ /(¢~¢- Engineer's signature ~ ~... DHHS SIGNATURE X Approved for '~'~ L/'~) bed rooms. Date ?' ?"...' ', ', Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: .,,,~'~'~ ~¢-"~"'-x-''/'---:L~- Date I~/:~LIii [~]~ 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 Jn the professional engineeCs work. 72~025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage ~ Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~,~7~-: ~',4~] 1~.! ~III~i.~4~"~yK_ Parcel I.D. ~1~"-- ~)(..e~-- ¢_~ A. WELL DATA Well type ,~J~.,") If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed Driller Total depth Cased to Casing height Sanitary seal (Y/N) Wires properly protected (Y/N) AT INSPECTION g.p.m. FROM WELl. LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Other bacteria Collected by: B. S["PTIC/I=t~:bI:RcN~ TANK DATA Date installed J O ,?,,c~, ~-' ~ Cleanouts (Y/N) 7 High water alarm (Y/N) Date of pumping Tank size Io-O'~ Compartments Foundation cleanout (Y/N) _ IX/ Depression (Y/N) I~/,¢~, __ Alarm tested (Y/N) I'Y'//A /~30..,dc¢. /$ Pumper q/~/'¢l Z_ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~//~ On adjacent lots To property line ~ 7 Surface water/drainage Absorption field __ ~k/O 14 ~ Foundation Water main/service line. ,/ 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) N High water alarm level "Pump on" level at /-/o Meets MOA electrical codes (Y/N) Y / Manhole/Access (Y/N) Y '~ ~ "Pump off" level at ~ ~'¢/ Cycles tested 7 SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot ¢¢'/~ On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length C;~ Width Total absorption area Soil rating //~ System type Gravel thickness /¢~- '~ Total depth Cleanouts present (Y/N) Depression over field (Y/N) ~'~ Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Date of adequacy test for If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot J"~/~/ To building foundation On adjacent lots Surface water Curtain drain On adjacent lots Property Pine ,> ¢o To existing or abandoned system on lot Cutbank J~o ~4 ~-- Water main/service line ~ ID Driveway, parking/vehicle storage area ~ ~ ~ E, ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Date (~)d.~ l,,/ /~ ~-~ HAA Fee $ Date of Payment Receipt Number e~- / Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE O / 2 DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION fMUST BE COMPLETED PRIOR TO SUBMITTAL) (a) (b) (c) 064 Legal Description (include lot, bloc.k;/subd, ivisiqn, sp_.ption, township, ran.~e). Location ~ddre~scd,,~c,,~2/. Properly Owner~.~/ .Z;~~elephone: Home ~ '/Z~ .¢~usiness Mailing Addre~ ' Lending Institution Mailing A'ddress ' (d) Real Estate Company an.d Age'n( Add/'ess Telephone (e) Mail the HAA to th~ f011owina address: or: Check here [], if hold for pick up. List contact person and day phone number below. TYPE OF RES~ Single-Family lcd Number of Bedrooms ,~._'~) 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. SEWAGEDISPOSAL 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 77-025 fRev 8/861 Front '~JO~ s,J@eu!6ue leUO!SSe~oJd eq~ u! suo!ss!uJo Jo s Jo J JO JO1 elq!suodseJ ~,ou s! ebe~oqouv ,to Al!led!ojuniAl eq/'penss! s! a],eoit!~JeO e @Jo,~sq e~ep eZAleUe Jo suoi~oadsu! ~,onpuoo lou op SHHQ ~o se@AoldLu:t 's~ueLueJinb@J @~e~s pue leJepa~ u!e~Je3 /,~siles o~ Jap Jo u! suo!~n~!~su! 6u!pual J!eq~ pue seLuoq Jo sJeseqoJnd o~ Ase~Jnoo e se s!q~ saop SHHQ eqJ. 'e)tSelV ~o @~e1S @q~, u! peJ@~s!6eJ ~aeu!bue leUOiSSe~oJd ~uapuedapu! ue ~q a^oqe g qdeJl~eJed u! ua^ih suofle~uasaJdaJ eqi uodn /~lUO p@seq se~eo!~!pao le^oJdd¥ Alpoq~nv q~leeH senss! (SHHQ) seo!^JaS ueuJnH pue qlleeH ~o lueLupedeQ ebeJoqou¥ ~o /9,!led!o!unv~ aq.L NOI.Lrl¥o leAoJddv leUO!~!puoc) ~o SLUJeJ. pe^oJdd~s~Q leUO!~!puoo · ~ pa^oJdd¥ ~~/y:~A q SuJ OOJ paq(¢ ~,,~-IVAO UcldV lOl PeA°Jddv ,MI-ICJ .g MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~,'-,J ~ ~ ~)~.~,L.//O OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date .~/.7//?/~'' ~' GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ~'~/'--/-~'~ D¢c~¢~ F Telephone: Home ¢'-4, ~. -¢Z,2// Business / Al~plica, nt Address ~ 5'-¢ ? (c) Ap!~licant is (check one)':' L~nding Institution [~]'; Owner/builder []; Buyer []; Other ['q (explain); (d) Lending Institution' Address Telephone (e) Real Estate Company and Agent /"~?~ Address ¢:~o? /-? ~7z-~¢~,'~ /(,,~-/~;/_r ,~/~'~/.. /¢¢~'/~-¢-.-.-~t'. Telephone 0<~ ?E- - / ? .? Z (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 J~ 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) Ei',~GINEERING FIRM PROVIDII ~NSPECTIONS, TESTS, FiLE SEARCH, D~ , 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. Telephone 5'~ /--~-'o P' ~ Name of Firm ,,~c Address /~-o [)ate ~/ ~, /¢~. DHEP APPROVAL Approved for .¢¢,,.~r.~'_~ bedrooms by ~ ,4;2. ".~-,..,..~ Date Approved Disapproved Conditional Terms of Conditional Approval ~.~=,.,.~,wv '~..~-~ ~ ~',~ ~"~' --~'~'"~ CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given Jn 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 (11/84) MUNICIPALffY OF ANCHORAG~'/IUNIClPALITY OF ANCHORAGE (MOA) i~NVIRONMENTAL SERVICES DIVI$1~IEALTH AUTHORITY APPROVAL (HAA) CH£CKUST- FEB.UA.Y 1984 APR 2 8 1987 264-4720 Legal Description: ~ RECEIVED WELL DATA Well Classification /'/u ,¢,,//c If A, B, C, D.E.C. Approved (Y/N) //-'/ Well Log Present (Y/N) /'-/,/~- Date Completed /t/'-/// Yield /'¢'///? Total Depth " Cased to Depth of Grouting Static Water Level Pump Se/__ Casing Height Above Ground S~eal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) /.~ression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot ,~ /h~//r/h/~/,/ ; On Adjoining Lots To Nearest Edge of Absorption Field ~Ot ; On Adjoining Lots To Nearest Public Sewer Line ,--" To Nearest Public Sewer Cleanout/Manhole / To Nearest Sewer Service Line on Lot Sample Collec~y ; Date Water ./ Water Sam~st ~su'ts B. SEPTIC/HOLDING TANK DATA Date Installed Stand pipes~/('~N) Depression over Tank (Y/~.~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarrn (Y/N) Separation Distances from Septic/Holding Tank: Size /¢¢ E~ No. of Compartments / Air-tight CapsL~l) Foundation Cleanout (Y/Lt~. Date Last Pumped ;for ,X./,/',,~ Temporary Holding Tank Permit (Y/N) ,~./","~ To Water-Supply Well To Property Line To Water Main/Service Line Course /U ~_ To Building Foundation _ To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments -,,~/,v~ ¢' Page I of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed .2'/'? Width of Field Type of System Design ~,L¢'~/ Length of Field 20/ Depth of Field ~'~ / Gravel Bed Thickness Standpipes Present L(~N) Date of Last Adequacy Test Square Feet of Absorption Area /-TZ Depression over Field ~'/N) Results of Last Adequacy Test ~,?//~¢¢ Separation Distance from Absorption Field: To Water-Supply Well /tJ-.///~)- To Building Foundation Lot ,~ 2. To Water Main/Service Line ¢ 2-/ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~ ,'~ 0 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) Comments Dimensions M a n hole/A~.(.Yl~/ "Pur. ccrlDff" Level at ,..,~~"~'~ Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request** I certify that I hav..p_~hecked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. S gned ~/--'~~/~ Date .~//"~/"¢' '~ Company'" "~"~ ~ MOA No. Receipt No. ~' O~ /--dO0~ V Date of Payment ¢-~ ~- ~ 7 Amount: $ . ~ ~ Page 2 of 2 72-026 (11/84)