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HomeMy WebLinkAboutHENKINS BLK 2 LT 5 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME LEGAL DESCRIPTION LOCATION []UPGRADE DISTANCE TO: Well/,~_.~ I Manufacturer Liq, ca~a~ in Aallons ~ IF ~OME~DE Inside I~ngth , Manufacturer I Well ~ / _~ /~ Foundation DISTANCE TO: I / No, of lines ~ I Length ~h li~e Total Top of tile to finish grade ~ /~ Material beneath tile Length Width I Type of crib Crib diameter DISTANCE TO: Well Bui~ing foundation Class ~ ~ ~. ~pth ~ ~/ / ~ Driller DISTANC~ ~ TO: ~il~ing f~undat:on ~ Sewer line NO. OF BEDROOMS Dwelling W dth ~ Material Nearest lot li.r~( .~ g~ I Trench w~l~) inches inches P EELM IT NO. ' No. of compartments Liquid e_qL~l~h PERMIT NO. Liquid capacity in gallons Distance between lines Total effective absorption area PERMIT NO. Total effective absorption area Nearest lot line Distance to lot line PERMIT NO. Septic tank Absorption area(s) OTHER IR E iVit~KS PIPE MAT F....R iA LS P Ko SOIL TEST RATING . / / I--1LIN I ~D I pt:iL I L CHORADtE o , DEPRRTMENT OF HERLTH RND ENVIRONMENTFtL PROTECTION ~ 825 'L'" STREET.. RNCHORRGE., RK, _q..~50'1 264:4720' ON--S I Ti SEI.4ER PERM I T PERMIT NO. ( 821072 ) RPF'LICBNT RUSTIC HOMES RL LARSON PO BOX 594 E.R. 694-.°~0D 694-.o~_09 LOCAT I ON LEGFIL L5 B2 HENKINS LOT SIZE ~ ~QURRE FEET TYPE OF SOIL ~B~ORPTION SYSTEM I~~ ~ MRXIMUM NUMBER OF BEDROOMS = ~ SOIL RRTINO (~t~ FT/BR>= 85 THE REQUIRED, SIZE OF THE SOIL RBSORPTION SYSTEM IS: [:,EPTH= 6. L E i'-,II]T H = _?--6 f3 R !--]'"." E L DEPTH= 2 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT tS THE DIST8NCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRV8TION (IN FEET). THE TRE~-4CH L-IlQTH IS ~ 5. ~)8E4 FEET.~ THE GR~VEL DEPTH IS THE ~INIMUM DEPTH OF 6RffiV~BETWEEN THE OLITFR~PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). ~.'E _~-J.U I ~:ED SEPT I I--.~ TA[~K S I :'-:'E = 2L000 BFtLLE~NS PERMIT RPPLIC8NT HBS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE INSTRLLRTION INSPECTIONS OF 8N¥ WELLS RD.$RCENT TO THIS PROPERTY 8ND THE NU~,IBER OF RESIDENCES THRT THE WELL WILL SERVE. TPIO (2) I[4SPFCTIOf4S RRE REQUI~:ED'. ~--.. -- BRCKFILLING OF RN~ S~STEM WITHOUT FINRL INSPECTION RND RPPROVRL BY THIS '...¢',::.'.,,.' ¢ T DEPRRTMENT WILL BE ~UB,.ECT TO PROSECUTION. MINIMUM DISTRNCE BETWEEN ~00 FEET FOR R PRIVRTE WELL OR t50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTRNCE FROM ~ PRIVRTE ~4ELL TO 8 PRI¥~TE ~EWER LINE IS 25 FEET RND TO R COMMUNIT9 SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MRY BPPL9. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS 8RE RVRILBBLE TO INSURE PR. OPER INSTRLLRTION. PERP1 I T EXP I RES BECEPIBER I CERTIFM THRT i: I AM FRMILIBR WITH THE REQUIREMENTS FOR ON-SITE SB,.IERS RN 85 SET FORTH BY THE MUNICIPRLITM OF 8NCHORRGE. 2: I WILL INSTRLL THE SMSTEM IN RCCORDB~CE WITH THE CODES. 2:: I UNDERSTRND THRT THE ON-SITE SEWER SMSTEM M8M REQUIRE ENLRRGEMENT IF THE RESIDENC. E IS REMODELED TO ~NCLIJDE MORE THRN ~PPLIC~NT '~T.~C HOME5 ~L LRRSON I SSI.lED BY_- ':":'~" .... __~?~' *- - (...C. . ' ' ALASK^ DE"ARTMENT ENVIRONMENTAL CONSERVATION PUBLIC WATER SYSTEM Plans~ of ~'- C~ ~7) ~ C~'~ /~' public water systerelocated in ~~~ ~'~-~ C ~ ~-~ska, submitted in accordance with 18 AAC 80.100 by, ~/ .~ ~/~ ~ ~ ~/t~ have been reviewed and are approved. / [] conditionally approved~ (see attached conditions). DATE If construction has not started within two years of the approval date, this certificate is void and new plans and specifications must be submitted for review and approval before construction. APPROVED CHANGE ORDERS Change (contract order no. Approved by Date or descriptive reference) The "APPROVAL TO OPERATE" section must be completed before any water is made available to the public. APPROVAL TO OPERATE The construction of the i'~? ~.., £,-~.~/"' i'i/.,- .'~ ? ':. ~.~ '~/ ., ~ ' · "" . ' public water system was completed on ..... (date). The system is hereby granted interim approval to operate for 90 days following the cpmpletion date. BY TITLE DATE As-built plans submitted during the interim appr~)val period, or an inspection by the Department has confirmed the system was constructed according to the approved plans. The system is hereby granted final approval to operate. \, i" :-:~ BY '~' ~ ~ ~ TITLE t O & E ENG,NEERING & DEVELOrMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 Performed for' Name: ~-~ ~-~ ~'~' Mailing AddresS: Legal Description: Earl Ellis SOIL LOG 688-2280 · ~'~ ~ ~ Tel. No. ~?'~/- Z' ~ ? Depth (feet) 0 3__ 4__ 5__ 6__ 7__ 8__ 9__ 10 Soil Characteristics 11__ 12__ 13__ 14__ 15__ 16__ Ground Water Encountered: Yes__ Proposed Installation: Seepage Pit Comments: No If yes, what depth Drain Field ~'/ PLOT PLAN PERC. TEST ,---., ~ ~ so~Ls LoG MUNICIPALITY OF ANCHORAGE DEPARTIV1EI~T OF HEALTH AND ENVIRONIVIENTAL. PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 DATE PERFORMED: SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19- 20- WAS GROUND WATER ~ O ENCOUNTERED? P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE //~ (minutes/inch) TEST RUN BETWEEN FT AND ~ FT CERTIFIED BY: DATE: Parcel I.D.# 1. GENERAL INFORMATION (Must be cOmPleted prior to subm ttal)¥:~ ~.... , . :,...:; .. (a) Legal Description (include lot, block, subdivision, section, townshilS.:!a~ge). Lot 5, Blk. 2 Henkins Subdv. T15N, R1W, Sec. 30  MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES :...:~,,':i:' 343-4744 .' :~,~ · . ~,! ~ :: CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Location (address or directions) Old Glenn Hwy. NHN (b) Property owner HUD Mailing Address 640 W. 36 'ch (c) Lending Institution n/a Telephone: (home) n/a Ave., Suite 1, Anchoraqe, AK. 99503 Business 563-3333 Telephone Mailing Address (d) Real Estate Company and Agent. Address n/a Telephone (e) Mail the HAA to the following address: (or check here i-i, if hold for pick List contact person and day phone number below: Pickup by Engineer 2. TYPE OF RESIDENCE Single-Family [] Number of bedrooms 3 ~4 3. WATER SUPPLY Individual Well [] Community [] Public [] - Note: If. community well system, must have written conf rmation from the State Department of Environmental ' Conservatimi:attestina t6 th lethality an'd'sta~us!,: :-: ~*~:~.:' ":~ "r~ ~:" %~: ~:''~; ::":";: "~ :~ ~ 4. SEWAGE DISPOSAL .. ',~-,;¥;,: .... : '":;i ;:. ~ ": : "::: ' ' On-site~] PublicE] , Communityi-I :.:,~,~'HoldingTankFh:.~' ~;::"~: · ': · ' : : ....... ~ ~ ..... ' .... "Note: If community well system, must h~':written conf rmati~'~ f~b~ the State 'Department Of EnVi~'onmental Conservation attesting t° the legality and status. .,:...: -., ..-,~: 72-025 (Rev. 7/88) Page 1 of 2 ~\ '"' eAoJdd'~' 8uo!~!Puoo jo suJJej. peAoJdd~s!a "//, ;'/ / ,/~ , ~ ,' , ,, POAO.IddV qs' · lVAOI:lddV SHHa I~UOp,!puoo meg ~oJppv WJ!.-I ~.0 OWeN MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: WELL DATA Well Classification If A, B, C, D.E.C. Approved (Y/N) ,~' '~'~ i Well Log Present (Y/N) Date Completed Yield Total Depth Cased to Static Water Level Depth of Grouting Pump Set At Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by ; Date Water Sample Test Results Comments ~ j/'e ' " SEPTIC/HOLDING TANK DATA Date Installed ~/~c~ Size Standpipes (Y/N) /k Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: '/~'~"'~ 5" ! No. of Compartments ,k' Foundation Cleanout (Y/N) Date Last Pumped ~,~//'~ ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Water-Supply Well To Property Line -/fo ; To Water Main/Service Line ¢-/~ / To Stream. Pond, Lake or Major Drainage Course Comments 7~; ,~-4~ ,,/~ ,-.. 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed .,/'2 ~-? Width of Field ~"-/ Type of System Design Length of Field ~¢' / Depth of Field ¢ / Square Feet of Absortion Area -~":- ? Depression over Field (Y/N) Results of Last Adequacy Test ._~4 4-, it r&. SEPARATION DISTANCE FROM ABSORPTION FIELD: / To Water-Supply Well ¢-/._4"~ 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 Comments (~ ~'"¢"- /'¢~,, /' >~ '~ /~ , -~ ~'~'~'~ /,:,.~,v Gravel Bed Thickness -)" ~ Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line "? ~ To Existing or Abandoned System on ; On Adjoining Lots f- .70 ~' To Cutback (if present) D. LIFT STATION Date Installed Size in Gallons "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 guidelines in.effect on the date of this inspection. Signed .~.----~' E,~uI~ River [:ngineering Services Company P. 0. Box 773294 Eagle River, AK 99577 Date /,~ ~.,./* / 69~,-§195 MOA No. ~'U ReceiptNo, °~)~ ¢~ ~C Y~- / Receipt No, Date of Payment / - c~ ~ --'~.~ ¢ Waiver Fee: $ Amount: $ A~'~---j - .~(-~' Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 ;ENT ~Y: DEPT. OF ENVIRONMENTAL CONSERVATION WALTER J. HIOKEL, GOVERNOR ANCHORAGE WESTERN DISTRICT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE~ AK 99503 563-6775 January 28, 1991 Eagle River Engineering Services P.O. Box 773294 Eagle Rive~, AK 99577 Dear Birl ~nk~D$ ~2.. L_5 .6.. 7 B & 10 Cla~s C Public Wate~ System is in compliance with the 9rovis~ona o~ 18 A~C 80.060, Slate of Alaska Drinking waber Regulations. Stnuecely, · Ka~'nOw~ i Envi~onmental Enginee~ TK: act ENCLOSURES 3ON~IalS3~I JO 3dA~ '~ z@~uT. Bu~ :MOleq JeqLunu euoqd/~ep pu~ uosJed loEluoo 1s!-1 ('dn)Io!d Jo,t ploq j! 'FI eJeq :>loeqo Jo) :ss@Jpp~ ISU!MOIIO euoqdel@L (e) sseJpp¥ V/N ),ueSv pue Xu~duJoo el~lS=l I~ebt (P) ssaJppv £££g-£9§ sseu!sn8 doo~I poot~qoaT. 8 'os a-~u '-A~H uusig PIO (suo!loeJ!p Jo sseJppe) uo!leoo-1 0g 'oeS Mia NSI,T, 'pqns suT. hq~SH 'E 'siTa '§ :~o~i (el~ueJ 'd!qsuMol 'uo!Joes 'UO[S!A!pqns '~o01q '~01 epnlou!) uop, d!JoseQ lei}e-I (e) (lel~!mqns ol Jopd pe~eldLUOO eq lsnlN) NOIJ.¥~I:IO_-INI IYB~N~9 'L DNIq-F~Ma Aql~VJ =I'IQNIS bJO:l AIIIlOVJ J:F1J. VM CINV bl3AA3S 3/IS-NO :10 -IVAOblddV A/IblOH±rlV HI-IV:IH MO-I NOI/O:lclCjN140 BJ. VOI:II/B:::IO S=~OIAt:I~IS lYiNg. NO,lAN3 JO NOISIAiO seo!~JeS ueuJnH ~ qJleaH lo lue[ulJede(] ~©V~OHONV -IO ,LJ_I-1VclIOI N Fl~ 5. ENGINEERING FIRM PROV D NG INspEcTIONS, TESTS, FILESEARCH, 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 Autl~ority Approval'shows that the on-site water'supply and/or wastewa:[er dis'posal system is safe, i . , functional.~nd adequate for the number of bedrooms and type of structure indicate~l 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/orwastewater 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 Eagle River Engineering ~3~ , ~. Telephone 694-5195 ... "~ "· . .. : Address P.O. Box 773294, Eagle-River, Ak. 99577 " ,..':'?,-': ....--.-~ Date June 28, 1990 6. DHHS APPROVAL Approved for Apprbved ',x' ,//,, · /.-. ' · ~ u~sapproveo ?.~ Terms of Conditional Approval .;~,~-. · :~:.,, %; .... ,~. ,.} '. ,, , ' ',l,,',,, bedroomsby _Z~~/ ~Date Conditional The MunicipalityofAnchorage Departmentof Health and Human Services(DHHS) issues HealthAuthorityApproval cerificated 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. 7/88) Back Page 2 of 2 ~ MUNICIPALITY OF ANCHORAGE (MOA) (~1i¢,~,) Health Authority Approval (.AA) MUNiCiPALJT~C~--fOI~AGE CHECKLIST - FEBRUARY 1984 EN~iP, ONMENTAL S'~CE $ DiViSION 343-4744 JUN 2 9 1990 A. WELL DATA R E C E IV ED Well Classification Z-~/~s-r Well Log Present (Y/N) Date Completed Legal Description: If A, B, C. D.E.C. Approved (Y/N) Yield Total Depth Cased to Static Water Level Casing Height Above Ground Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of AbsOrption Field on Lot ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by ; Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed oc"/,t 3 Size /¢~ ~ No. of Compartments StandpiPes (Y/N) ,v Air-tight Caps (Y/N) Y Foundation Cleanout (Y/N) Depression over Tank (Y/N) ,,,v' Date Last Pumped ~'~¢; pumping/Maintenance Contact 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 ~/~ / To Stream, Pond, Lake or Major Drainage Course Comments ~".¢,,~.~ ,,g~, ¢__~ /.3 ,~/,-, ~', T ° 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 /? ,~'3' / Width of Field ~ Type of System Design Length of Field 3' ¢' ' Depth of Field ~' / Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well C- To Building Foundation ,¢"~'~ / z Lot ,4'// To Water Main/Service Line ¢'/'~ ' To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments c¢~ o~ /¢~ ~ Gravel Bed Thickness ¢n/ Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line ~-/~" To Existing or Abandoned System on ; On Adjoining Lots ~'~F~ "' To Cutback (if present) D. lIFT STATION Date Installed Size in Gallons "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 tha.t I have checked,.verified, or conforme~ to all MOA and HAA guidelines. .in ~f.!~i~t*,~'i~";th¢ date of this inspection..)~.~,-,,¢,~ .z~,-r~/.¢ -~~ ~ ~ ~~ ~ .... ~:: ~.¢ ~ Company Eagle River Engineering Se~ices P, 0, 8ux 773z~4 Seal Date Eagle River, AK 99577 MOA No.2~-~ ~ Fleceipt No. ~ Oate of Payment Amount: $ 72-026 (Rev. 7/88) [ ack Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 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 GENERAl. INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name", ~.'~,, ~--~ ~::~ Telephone: Home ~ Business Applicant..A~d, dress.. ,~'~ '~/~. ~"~'~.~;:;:~'-~ ~ -'~>¢_.¢_¢~ I~.-~IE:~¢-" , (c) Applicant is (checl~ o6~): Lending Institution []; Owner/builder~, Buyer []; Other [] (explain); (d) Lending Institution Address Telephone (e) Real Estate Company and Agent Address Telephone (f) ¢~'~tthe HAA to the following address: 2/': TYPE OF RESIDENCE Single-Family¢~- Multi-Family [] Number of Bedrooms '~ : 3. WATER SUPPLY Other : Individual Well [] Community'~ Public [] ; :' ;: ~ttesting to the legality and status, 4; SEWAGE DISPOSAL Note: If community well system, must have written confirmation from the State Department of Environmental Conservation · 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. ; 72-025 (11/84) , Page I of 2 ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DAI'A AND INFORMATION As' certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Heal[h Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and aeequate 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 Address Date ,- ,:,,-,~ ' ,, ~ Telephone Approved for -~r,~.- Approved ' ~, '_: ~ Disa~ved Terms of Cdndiiional Approval bedrooms by -2~~'~'~ '~' "'~/~'-'~-'~'~'~" Date Cond~al CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Approval certificates based solely upon the representations given in paragraph 5 above by engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and thei institutions in order to satisfy certain federal and state requirements. Employees of.DHEP do not conduct ins analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for professional engineer's work. Page 2 of 2 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Well Classification Well Log Present (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot t~'-~' To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole MUNIcIPALiTY OF ANCHoRA , DEPT, OF HEALTH & GE ENVIRONMENTAL PROTECTION Legal Descry. C~,~ ~ ~ ~'-~--- If A, B, C, D.E.C. Approved ~1) Date Completed Yield l,..~/;pth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) .. Depression Around Wellhead (Y/N) Water Sample Collected by ,~', ~ ~.-b'--%d~-'¢'--)~¢''~c''' ; Date Water Sample Test Results Comments 1:~,~.~, ~~~ ; On Adjoining Lots \ ._~"-D~ b ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot B. SEPTIC/~TANK DATA Date Installed ~' Standpipes CN) Air-tight Caps (~)N) Depression over Tank Pumping/Maintenance Contract on File (Y/N) . , 1 Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/.H~ Tank: To Water-Supply Well ~'~-~ To Property Line ~ ~ ~ To Water Main/Service Line Course Comments ~ Size ~, ~ No. of Compartments ~' Foundation Cleanout ~;~N) Date Last Pumped ~ ~ I~ A~ ;for Temporary Holding Tank Permit (Y/N) To Building Foundation Lo ~ To Disposal Field (z~ ( To Stream, Pond, Lake, or Major Drainage Page I 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~j) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ! ~.~ To Building Foundation ¢~' ~ Lot ~.x /p Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (¢~N) Date of Last Adequacy Test To Water Main/Service Line ~,.~ To Stream/Pond/Lake/or Major Drainage Course To Drivewa~_~ Parking Areal or Vehicle Storage Area Comments To Property Line -f To Existing or Abandoned System on ; On Adjoining Lots ~ (4- ,~.,To/¢ Cutbank (if present) D. LIFT STATION Date Installed Size in Gallons ~.~ t//~ "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 ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have che'cke~, v~erified, or conformed to all MOA a, nd ,HAA guidelines in effect on the date of this inspection. Signed ~:~ ~ .,_~;;~,~ ~.~[~j!~'.~,~ ,[ f,~] , Date <~//I/~'" uomDanv ". .-, .... n~ ~qT~ MOA No. Receipt No. ~ ~-~ Date of Payment ~-//-~ Amount: $ Page 2 of 2 72-026 (11/84)