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Home My WebLink AboutHILLSIDE HEIGHTS LT 1 MUNICIPALITY OF ANCHORAGE DEPARTMEN'F OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephonic 264.-4720 ON-SITE SEWAGE DISPOSAl_ SYSTEM AND/OR WELL INSPECTION REPORI' NAME ~AILING ,~DR ESS LEGAL DESCRIPTION LOCATION $ I%) LF/ NO. OF BEDROOMS I Well~") .... I I Abs0rptien ar. ea "-[ Dwelling~ . , PERMli~'~N~ ...... D1STANCE TO' / ' ...... ~, /0 Manufaot.l~ ~ ....... f ............... q ~at~ , No7 of c~a~FtFnent' s ~L~q ~a~actdn ga o~sl ! Inside~ .... /Widt~ I Liquid~q~th ~ ~ ~ ~f~urer ~aterial Eluid copacity in gallons ~ '~lLm0*h ~¢'' ~;~h I' i;~e Total ~th o~- lines -~rench widt-h [~%tance be~n~ nes Top of t,le to ffi~,~i~ E~ESd& ~, M~e~eath tile -~ ........ l%t~Fde~%~so~Eion~Fea ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ FI~ Depth Driller Distance to lot line ] PERMIT NO. ~, ~~- ,u,,d,~..,o..~,,o.- ', ~.~,,,n- -~ ~,~,,o,~,,' ~ -,*,,~or,:t,on~,'~,,, J_ OTHER PIPE MATERIALS --SOl L T ES~RATI~N Z,~ REMARKS APPROV~~: ~~--~'~-'~"'~DATE LEGAL '!"l.Iii!}l i.>!.¢N:::"TH OF:' !:::! r!:;;:E!'.!E:N OR F'I'!' ;!iS 'T'HE E:,i'~;TFI!'.:!E:E E:EI!,.!!i{Ei!',! "i'N!iil 5UF;':;!::'!=i!i:tl!ii Il'5!:= 'N..!!E '!"l~Ei:i:~.:; ;!::~; NO SEN' H!D"NI ~::;'(.}~:;~: F!HC' ']"Nil E'.O-!"i"C$'! OF: '!'I'J~}~: !i;',:'Oi:FI'v'FKF!ON '::;i:J",~ F:'EE'T'::'. SOILS LOG MUNICIPALITY OF ANCHORAGE ~.__.M__'~, DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION [3 PERCOLATION Pouch 6-650, Aochorago, Alaska 99502 276-222'[ SOILS LOG - PERCOLATION TEST SLOPE" ' SITE PLAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 '17 18 19 20 WAS GROUND WATER ENCOUNTERED? COMMENTS IF YES, AT WHAT DEPTH? Gross Net Depth to Net Readiug Date Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN FT AND (minutes/inch) -- FT PERFORMED 72-008 (7/76) P. O. Box 10-681 Anchorage, Alaska 99511 SIX INCH WATEr WELL DRILLED AND CASED OUT TO TH~ DEPTH OF DRILLED AT THE rate OF PEr FOOT. PRoPerTY OWNER ~//~', .... :' ..... LOCATION OF WELL. SITE ',, DRILLER WELL LOG: COST INCLUDES ALl. LABOR AND MATERIAL FOr COMPLETION OF SAID DRILLING. WRITe CHECK PAYABLE TO RAMPArt DRILLING WORKS For THE SUM OF THANK YOU very MUCH. DATE BERNIE CLAUS OF RAMPArt DRILLING WORKS SERVICE CI-tARGE Of 1V~:% PER MONTH WILL BE ASSESSED ON'PAST DUEACOouNTS' 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 CE~RTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING "'HAA# GENERAL INFORMATION Complete legal description Location (site address or directions) Agent Address Property oWner..' Mailing address- Lending agency M~iling address' ~--UO~ Day phone -~-o-- 2~'770 Day phone Day phone --~4~r-77:3 0 Unless otherwise requested, be held NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community welt Public water NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site ' Holding tank ~ ' Community on-site Public sewer NOTE: 72-025 (Rev. 1191) Front MOA~21 If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. ," ,~ , If community wastewater system, provide wri~en confirmation from State ADEC attesting to the legalit~rand status O'f o 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 regulatio~l~llm, e'~et~)n the date of this inspection. Wastewater Services 8471 Brookridge Dr ,4 Name of Firm '~ Phone -~' ~ 7-6/'~(~ Address ~//'~-~/, ~/'//// Engineer's signature Date Alaska Water & U/// Wastewater Services 8471 B¢ookrldge Dr Anch., AK 9¢504 ' DHHS SIGNATURE ~ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date /0- 2 / - ~'~- ~'The Mt~r,'fci~,ality of.A¢~tbhorage Department of Health and Human Services (DHHS) issues Health Authority 'APProval C~ificat~§;~a~ed only upon the representations given in paragraph 5 above by an independent · p~;of~ssional eng ~'registered n the State of Alaska The DHHS does th s as a courtes to urchasers of homes aha emtendmg~nsttutonsinordertosatsfycertanfedera andstaterequrements EmployeesofDHHSdonot 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.. '/'2-025 (Re~,1/91) Back MOAt21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data or~'- o~'z-74- Well type '(::'~ ~r~;~'",~ Log present (Y/N) Total depth Sanitary seal (Y/N) if A, B, or C, attach ADEC letter. ADEC water system number Date completed c~/4-/B.3 Driller ~-A~¢, 1 7 ~ Cased to / -7 Z. / Casing height ~ I'Z-~ ",/_~?-. Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG AT INSPECTION I0 >,-':8:, .g.p.m. .g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot /[~' / '+.-: Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots >~ leo Public sewer manhole/cleanout Petroleum tank ~//~ WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate ~,~-. ~/~ Other bacteria Collected by: ~A¢.,./¢,¢' B. SEPTIC/HOLDING TANK DATA Date installed -7 / 9 ¢, Cleanouts (Y/N) ~ High water alarm (Y/N) Date of pumping Tank size 17___ ~'0 Compartments Z. Foundation cleanout (Y/N) x,,/~__._q Depression (Y/N) ,'V/A Alarm tested (Y/N) c~/z ~/c:zar Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: / Well(s) on lot FZ..O To properly line Absorption field Surface water/drainage Foundation Water main/service line 72-026 (~g3)° Front CONTINUED ON BACK PAGE Manufacturer Size in gallons ~ Manhole/Access (Y/N) ~ Vent (Y/N) High water alarm level ~'~~~ed Meets MOA electrical codes (Y/N) .~ ~ "~ SEPARAT~TION TO: :~ ~ On adjacent lots ,~.% D. ABSORPTION FIELD DATA Dateinstalied '7/~?-- Soil rating (~[.~,Ft=) J~-~' Pr/~'~ Systemt,/pe ~ Length ~----------------~'~' (~ Width Total absorption area 5'~0 ® Date of adequacy test ~/24-/,+ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Gravel thickness Total depth /// Cleanout present (Y/N) 5'urn? Depression over field (Y/N) Results (pass/fail) P/dr~<S for "~- M/~ If yes, give date ~/~ t~O Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: / Well on lot (1¢ +- On adjacent lots :~ 1~ Property line To building foundation ~-~' 'To s~,~P (~ To existing or abandoned system on lot On adjacent lots > ~0 Cutbank Sudace water % /OD Cudain drain E. ENGINEER'S CERTIFICATION ~ ~ Water mai~se~ice line >~o' o~o~,,~ Driveway, parkinCvehicle storage area /~/~ I certify that I have checkeo verified, or/conformed to all MOA and HAA guidelines in effect on the date el ~this inspection. Signature 7g)~ ; :'~ / Date HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number CT&E Ref.# Client Sample ID Matrix Commercial Testing & Engineering Co. Environmental Laboratory Services ~,,~o?×~.y~7,c;~-/r¥c?/y,~/7×.~/-,;rT/~,zc??~:~7×~~c~ LABORATORY ANALYSIS REPORT 94.4826-1 9601 ItlLLSIDE DRIVE WATER Client Nmne AK WATER & WASTEWA'I~R SERVICES WORK Order 82383 Ordered By JEFF GARNESS Printed Date 09/22/94 ~ 10:z~2 hrs. Project Name Collected Date 09/20/94 ~10:00 lu's. Project// Received Date 09/20/94 ~ I2:50 lu's. PWSID UA Technical Director STEPHEN C. EDE Released Smnple Remtu'ks: ROU 11NE SAMPLE COLLECTED BY: GAI~IESS. QC Allowable Ext. Anal Parameter Results Qual Units Method Li]nits Date Date hilt Nitrale-N 3.20 mg/L EPA 353.2/300.0 10 09/21/94 CMR * See Special Instructions Above ** See Sample RemmScs Above U = Undetected, Reported value is the practical quantification limit. D = Secondary dilution. UA = Unavailable NA = Not Analyzed LT= Less Than GT = Greater 'lhan 5633 B Street, Anchorage, AK 99618-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, U'rAH, WEST VIRGINIA I ,PLO~ PLAN~, & L_O~T SUR_VE~J~ ........... CONSI~UC~ON, TO ~RI~ PROPQ~D BUI~INO ~ADE R~ TO RNI~ ~ADE ~D U~U'~ C~NEC~8 AND TO ~-"'~ ~ ~ ..~.t~-~.l-----~ .~ ~ ~ ~ ,~ ~ ............ . ~ -~' ONLY '0t0~ IMPROV~MENT'~ 'ABOVE OROUND AND ~SrBLE M~ ~lO~, ~ ~, ~0 ~NOU~ ~ID~W~, D~m~WA~ ~., AR~ ~O~ IN ~R APPRO~MA~ C~A~ON, ONLY. MAY PRINT ~E IMPRQ~ ~ B~NO ~k~ AND ' - ........... Pre~ored b~ ........ Robert E. dohns, dr. ~ Professional Land Surve~rs ~.. - ........... I ............ 9~23-94 I R~j I LOT 1, MILLSIDE HEIO~ITS SUBDIVISION MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING . ,. 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) ? ,of ,be-;' . (b) Property owner Mailing Address Telephone · (home) Business (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent ,~.~W/4-× ~-"~,/ ~'.~/ Address ;~..¢a ~,~'.b~, '¢~ ~ /~ ~'~ ~ Telephone ~7~ ~ ~7~ ) (e) Mail the HAA to the following address: (or check here"~if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESlDENOE Single-Family'~ Number of bedrooms 3. WATER SUPPLY Individual Wel I"~' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site'¢~. 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. ~ ,to ~ eSBd ')pOM s,JeeuibuB iBuo!sse,~oJd SUO!SS!LUO JO S JO J J8 JO~L elq!suodseJ ].ou si ebBJoqou¥,to .L].!lBd!o!u nR eqJ. 'penss! s! e].Bo!J!].Je3 B eJO,t@q B:~Bp ez.LIBUe Jo suo?].oedsu! ].onpuoo l. ou op SHHG ~.o see.LOldLU3 's].ueuueJinbeJ el.e],s pub IB..lepe~. u!B].Jeo .L,ts!].Bs o:]. JepJo 8u!puel .J!eq:l puc SeLUOq ,tO sJeseqoJnd o1..Lsm. Jnoo e sB siq]. seop SHHG eqJ. 'B>IsBIV ~.o e:IB].S eq]. u! peJe].s!beJ .Jeeu!l~ue IBUO!SS@,to..~d :].uepued@pu! uB .Lq aAoqB ~ LIdB,,~SB,,~Bd U! ua^ih suo!].e].ueseJdeJ eq]. uodn/~lUO peseq pe],Bo!ipeo leAoJddv.Ll!Joqlnv qllBeH senss! (SHHQ) seo!AJeS uemnH pub qllBaH J.o lUeLUlJBdac] eSl~JOqOUV .J.o .Ll!lBd!o!u nv',i eq..L iBAo.Jdd'¢ IBUOR!puoo ,to st.uJel elea A. W E L~(i~T~ Well Classification Well Log Present~N) Date Completed Total Depth /¢2-- ¢ Cased to /~ Depth of Grouting Static Water Level MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: ~¢)~" Casing Height Above Ground / Electrical Wiring in ConduitON) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments ~/~/~-/'/' /~r,J '7~'¢¢ If A, B, C, D.E.C. Ap?roved (Y/N) Pump Set At Sanitary Seal on Casingl~N) Depression Around Wellhead (Yt~ I ; On Adjoining Lots /,'o'O i¢,f 1 I/~.,,5 '7"~ '~/~ ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole /.2/4 ;Date SEPTIC/HOLDING TANK DATA Date Installed ~¢/1~''~'~ Size Standpipes~.~N) Depression over Tank Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Aiarm.(Y/N) /,~.~:' No. of Compartments Air-tight Caps {~,N) Foundation Cleanout~.~N) Date Last Pumped ?' ; for Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FR'QMSEPT C/HOLDING TANK: To Water-Supply Well .: /~-o. To Property Line lO To Water Main/Service Line . . To Stream, Pond, Lake or Major Drainage Course Comments To Building Foundation To Disposal Field 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 7-/¢" ~'" Width of Field ,,¢0~ ¢~/' /¢'~'b~f/z.'7"; Square Feet of Absortion Area Depression over Field (Y~__~ Results of Last Adequacy Test Type of System Design Length of Field --5'~¢¢// t Depth of Field /O f Gravel Bed Thickness Statndpipes Present'N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well /I f~"~'~"' ' ~ ''''''~.f- 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 £ To Property Line /O To Existing or Abandoned System on ; On Adjoining Lots /¢ .r To Cutback (if present) Comments D. LI~.~ATION Date I n~.L~ Size in Gallon~ "Pump On" Level at ~, High Water Alarm Level at ~ Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidel inspection. Signed Company Date MOA No, fect on the date of this ReceiptNo. c~/¢¢/ Date of Payment Amount: $ r/,7 ~:~ ~ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ i',, .~E,~gineer's Seal CE - 2251 Date of Payment Page 2 of 2 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONq~NTAL PROTECTION APPLICATION FOR H~TH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) (b) Location (address or directions) Applicants Name o~fL Applicants Address (c) Applicant is (chec% one) Lending Institution Buyer ~--~ ; Other ~--~ (explain); (d) Lending Institution ~7~ Business ~ ; Owner/builder~ ; Telephone Address (e) Real Estate Co. & ~gent ~/~ Address (f) Telephone Mail the HZLA to the following address: ~.-,~, ~,f_ ~/c~. ~/ct~ ~f~ 2. ~ype of Residence Single2Family~ Number of Bedrooms 3. Water Supp1M~ Individual Well ~-~ Multi-Family ~--~ Other (describe) 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] 5. 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 regula- tions in effect on the date of this inspection. Name of Firm Address ~/ ~/ DHEP Approval Approved for f"F;C;~- bedrooms ' Approved ~? Disapproved Condition~ Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON T}~ REPRESENT- ATIONS 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 REQUIRE-' MENTSo 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. (DHEP SF~4L) RR4/ej/D18 [Page 2 of 2] 7 -19- 84 A® ' MUNICIPALITY OF ANCHOr' DEPT. OF HEALTH & ENVIRONMENTAL PROTECTIONMUNICIPALITY OF ANCHORAGE (MOA) HF~kLTH AUTHORITY APPROVAL {HAA) MAY 3 2 1986 CHECKLIST - F~RUARY 1984 RECEIVED WELL DATA Legal Description: Well Classification /Pwt ~'-- ~= Well Log Present (Y/N) ~ Total Depth /??-' Cased to Static Water Level / 37 ' Casing Height Above Ground ~' Electrical Wiring in Conduit (Y/N) / ,. Separation Distances from Well: To Septic/Holding Tank o~ Lot ~/Dd' If A, B, or C, D.E.C. Approved(Y/N) Date Completed /2z-' Pump Set At ~-~/- ~'~ __ Yield ~-57.,,.~,~ Depth of Grouting /J~ /&7 ' Sanitary Seal on Casing (.Y/N)/ Depression Around Wellhead (Y/N) /u7 To Nearest Edge of Absorption Field on Lot To Nearest Public Se.~r Line Cleancut/Manhole /t///4 To Nearest Sewer ,~rvice Line on Lot Water Sample Collected By Water Sample Test P~sults ; On Adjoining Lots ~ ; (k7 Adjoining Lots To Nearest Public Sewer ~f~,~ B. SEPTIC/HOLDING TANK DATA Date Installed ~-//" FZ' Size /ZS-d No. of Ca~partamnts t- Standpipes (y/N) / Air-tight Caps (Y/N) /~ Foundation Cleanout (Y/N) /__ Depression over Tank (Y/N) A) Date Last P~,ped ~--~-F~ Pumping/Maintenance Contract on File (Y/N) A3 ; for Holding Tank High-Water Ala=m {Y/N) AJ~ Temporary Holding Tank Permit (Y/N) ~ Separation Distances from Septic/Holding Tank: To Water-Supply We 11 To Property Line +/~' To Water Main/Service Line ~/~ ' Course To Building Foundation ~ ~O To Disposal Field /~ ' To Stream, Pondr L~e, or Major Drainage Receipt ~ Date Paid: Amount: [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date .Installed 7- / 9¢ - ~ ~- Width of Field Square Feet of Absorption A~ea Depression over Field (Y/N) Results of Last Adequacy Test //3 Type of System Design Length of Field 56~ ' Depth of Field /D ' Gravel Bed Thickness 5' Standpipes Present (Y/N) Date of Last Adequacy Test. Separation Distance frcm A~sorption Field: To Water-Supply Well ¢-/~' To Property Line ~/~ ' To Building Foundation ~ 9/~' To Existing or Abandoned System cn Lot /t; ~ ; On Adjoining Lots + 6/o ' To Water Main/Service Line + ~o' To Cutbank(if present) "~/-~ To Stream/Pond/Lake/c~ Major D~ainage Course +/¢)~ ' To Driveway, Parking Area, o~ Vehicle Storage A=ea + 'LO' Co~ents ~-'~$P '~F~'~'~ ~- //J ;r/c~'. D. LIFT STATION -- A~.~' Installed Size in "Puinp Orl" Level at High Water Alarm Level at Tested for Elec~ical Codes Co~'~nts Dirrensions Manhole/Access "Pump Off" Level (Y/N) Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Pequest I certify that I have checked, verified, or conformad to all MOA HAA Gui on the date of this inspection. Signed ~ ~/~w~_, Date ~ f~' ~" Company ~o~/, ~,¢~/~. _~.. MOA No. F~-~ KB1/d5/s in effect [Page 2 of 2] . .. 2-15-84 MUNICIP~fLITY OF ANCHOgAGE DIVISION OF ~qViRONMENTkL HEALI]~ DEPA3fflMENT OF HEALTH AND ENVI}~DNMENTAL PROTECTION APPLICATION ~)R HEALTH AUTHORITY APPROVAL CERTIFICA'~E \ 1. General Inform~tion Application Date (a) [~gal Description (inc].uc~; lot, block, subdivision, sect:Lon, to, reship, range) Location (ad.ess o~ directions) (c) Applicant is (check o~) ~nding ~nstitution ~j ~ ~ne,/buil~ ~] ~ (e) mai Estate Co, & Agent Address Te le phone Single-Family Nt/mbe~ Of ~edroo~ 3. Water S~I Individual ~,~ll Othe~ (descri[~) Community L-~ t~3. blic Note: If co~'~nity ~llL system, must ~ave v~citten ccnfirn~ticn fr~n the State Departn~nt of 51nviron~ntal Conservation attesting tc the legality and status. Is tJqe %~11 adequate for the number of bedrocks specified in this H~A (Y/N) 4..Se. urage Disposal / ~ Is the wastewater disposal system adequate fo: the nurd~e~: of ~drocms (YA'I) ~ [Page 1. of 2] 2.-15-,84 !5. ........ )~!.neer~in_~q t~i..rm Providi~~[t~ions ,_71e. sts ~., Da_t_a_a I. certify that I have checked, ~?rified, or confozT~d to all MOA NAA Ck~ideline. s in effect on the date of this inspection. 6. DHEP Approval Approved for b'.~ dr c~ Disapproved ~ Terms of Cx~nditional Approval Conditional ,P~ Municipality of Anchc~a.ge l~partn~.,.,nt of ~,alth and Environn.enta]. Protecticn dces not guarantee the continued satisfactory ~rforman~ of t~ wate~z supply and/ct the wastewater dis~sal system. ~is approval indicates that, as of tl~ ~lidation ~te shom~ ~ b~sed on t~ ~ta and infor~qtion f~nished ~ an e~i~er registered the State of A ..... ,ka, the ~ater supply ~d wastewate~, disposal sFstem is safe and tional for the nu~er of ~ ~d t~ of structure indicated. 7. Mail the HAA to the foll KB2/dS/s [Pag~ 2 of 2] A® ,CoS I /4,fi MUNICIPALITY OF A/~CHORAGE (MOA) HF2kLTH AUTHORIZer APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 WELL DATA Well Classification ~'~Y'I k."'~,~ ~t-F-,L· Well Log P~esent (Y/N) Total Depth /'7'Z_~ Cased to Static Water Level /~7 ' Pump. Set At Casing Height Above Ground ~ ' Electrical Wi~ing in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot ~-/~9 i To Nearest Edge of Absorption Field on Lot '~' To Nearest Public Sewe~ Line Date Completed / 7 Li ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cle ancut/Manhole AT/~ Wate~ Sample Collected By ~,/ ~J~p'/~% ; D~te Wate~ S~le Test ~sults _. 3>~ / s ~ ~- ~ "~ To Nearest Se%~ Service Linc on Lot B. SEPTIC/HOLDING TANK DATA Date Installed _~-/~~ gT_~ Size /?-50 Standpipes (Y/N) ~/ Air-tight Caps (Y~_~_~__ Depression ove~ Tank (Y/N) ~Q Date Last Pumpe. d_ No. of Compartments ~-- Foundation Cteanout (Y/N) Pumping/Maintenance Contract on File (Y/N) AT//{; for Holding Tank High-Wate~ Alarm (~Y/N)/~,//~ Tempo~a~!; Holding Tank Permit (Y/N)~ Separation Distances f~om Septic/Holding Tan~k: To Water-Supply Well To P~operty Line 7 To Water Main/Service Line To Building Foundation 7L~) To Disposal Field __~ .~" To Stream, Pond, Lake,, cm' Major Drainage co=se [Page 1 of 2] 2-15~84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata TyDe of System Design Date Installed ~ _ / ~.. ~/~ Length of Field Width of Field ~ Depth of Field /6> ' Square Feet of Absorption A~ea '~O /Gravel Bed Thickness ~-/ Standpipes P~esent (Y/N) Depression over Field (Y/N) ~ Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well /-/O~) To P~operty Line -/- /69 To Building Foundation ~ ~/O / To Existing or Abandoned System on Lot /J//~ ; On Adjoining Lots ~ To water Main/Service Line /~,/A To Cutbank(if present) +~ ' To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area ~ Comments ~/~/~/~ F~/)z) '~ /~ ~_~ LIFT STATION ~ Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Dimensions Manhole/Access (Y/N) "Pur~p Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedrccxn Rating Against HAA Request I certify that I have checked, verified, or conformed to all MOA HAA ~~_n effect on the date of this lnspe tlC~. [Pa~ 2 of 2] 2-15-84