HomeMy WebLinkAboutHERITAGE PARK BLK 1 LT 17
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
Name DISTANCES
/-/~/~ -'"'~'¢'/." ~/'~')'~ J ~r~' ~ ~ ~ Tn SEPTIC ABSORPTION
~ddressFROM~ TANK FIELD WELL
Phone(s) [ Permit No. No. of Bedrooms WELL
LEGAL DESCRIPTION LOT LINE /
Lot / '~ J Bloc~ Subdiwsion
/ //e~, ~r~ ~ ~ FOUNDATION /o ' /~ ' ~/~
Township, Range, Section
AS-BUILT DIAGRAM {Show Iocabon of well. septic system, property hnes, loundabon,
~ /~ ~ ~ / ~ ~C , ~ d ...... y, water bodies, etc.)
TANKS N
~ SEPTIC ~ HOLDING -~
TYPE OF SYSTEM
~TRENCH ~ BED ~ W. DRAIN ~ OTHER,, ,~
Depth to pipe bottom fromTotal depth ,rom original grade
original grade ~ FT /~ FT ~
~r~;ell~gth ~ FT Gravel width ~ 'ET 4~c'~*" .
~ SOFT ~/~ Fl
WELLS
/
~ PRIVATE ~ OTHER (Identify)
~lassflicabon (A,B,C) Total Depth Cased to
~ ET FT
I
REMARKS:
nsp~ct OhS Peflormed ~ :, ',,J:
agfa Rwer Engmeer~ng 8.ervic~'
Da[e: Eagle River, AK ~9~- :
I cedify that Ibis inspection was pedormed according;J~ }lb ' : - [:u~s A. Bu~e:d ~ ~;.
municipal and State ouidelines in effect on this date: ~'~ S- .
72-013 13/85)
CF)NTACT PHONE:
LO't'
L,[] I L. OCAT]70N
MAX BEDROI]i'~S
I'-IAMANN C[)NS]"R, ,
F:' 0 BOX 7'7C)6:1.7
EAGLE] I:-::tVIER, AK 99577
694-;?776
SUBD I V 1:,~ I ON :~ HER I TAGE PARK I_OT:
SE:CT :ION: 7 "t"OWIqStd I F': :L4. N RANGE
:4?57 1::? (Eli;!. t::'T. OR ACRFEE; )
]: VY I.,]C,IME C I RCI._E
E I_(]l ,r... ," 1.
Listed belcm,~ ,ar'.e 't.l"'~e ,.:)FrLior~s av,:~a.~.,::b].(.= 't.o you in des:i, gning your' .~,~..~..t..L~...
system. Choose 'Lhe option that~ best. fi'Ls youp site,,
DEF:']"H "FI]) F:' I I:::'E BO"F'T'OM (1::"1" ,. )
GRAV['EI_ DEF'TH (F'T,,
TCITAL. DEF:"I"H (F'"f'.)
GRAVE]- W]:DTH (FT.
E~J~tAVE]~.. LE:iq['.~]]'"t (I:::T,,)
GI:RAVJE]... VC}L.JJME~ (CL.t. Y:OE;,, )
TAtqI< SIZE (GAL..S)
E~C:}]:I.. Ra"[']:i'41i3 (S(:~!. FI".
L.I:.A~: t b .J Lx.I II'"t....~ I MEN ,~
-X-';'~' TANI< MUST HAVE A] ...... c'"," .,' ...... '','-"' ..... '~'
:I: ceptJ, fy 'Lha'L:
' z ,... ,.>E,t.FD:i' ...
f'or'"Lh by 'Lhe Mur'):Lc::ipa:J. Lty of' Anchopage (MOA) and 'Lhe ,M.~d..E of' A].asl.::a~
'"~ I t,4j. 1 ]. ~r'~s'La].]. L'"e ~Zs'k(~i~l
and itl comp!:i, ance ~:J.'J:.t'] the des:Lfln Cp~'Lep:i.a of 'Lhis pepm:Lt,
3,, ]: w:i.].l adhePe 'Lo a].l I"lC}~ ar'id State of Alaska r, equ~pements ('oP the set back
d istai'](2E)~B f' P c:)11i ed']y (.~X ist :Lng ~e 1 ~ ~, wa~}..~)~cTLeP d :L ~5t::)osaZ ~ys'Lem op pub 1 ~c
seb~er'age system c)n 'Lh:Ls op any a(::IjcL.~r"L (::H" near'by lo'L,
4,, ]: L.u'~der~stand that this pepmi'L is va}id fop at max:LmL.~m of' 4 bec]p.oom% arid
ally E))n].apgeJflE.)r/t t, gJ.].], r'eclu:i.r'~ an addit:Lt3na].
IF: A L. 1F"t" STATtOIq ]:S ZN,:~I~-.&..I.,J::.D IN AN ~..~.x~z~..~ C[)zE.RED BY MDA BI.JZLDZNG CODES~
. N!::..u, .,::.. AS-BUI .... S
'I'HIEIq (1) AN EI.JECTRIC2:~L'PERM]:T AN1} ZIXlSF'J~ZCTZON MUST EE' OBTA:['-"'" · .....
u~].L.L. IqDT BE Al FF.OVEL W:['H'"tOUT AN EL..EC'-TRICAL. INSPECTZOq REF:'DRT~ AND (3) 'T'HE:
EL..ECTR]:C~L. WORK MLIST BE DE}NE BY A
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAl- PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
/~ SOILS LOG
[] PERCOLATION
TEST
DATE PERFORMED:
SLOPE
SITE PLAN
1
2
3
4
§
6
7
8
9
10
11
12
13-
GROUNDWATER /~0 I~
OUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
14-
15-
16-
17
18
19~
20 - u' ,.,,,-.-~. /
PE~ON RATE /~r' z)~ .~ ¥6 (minutes/inch)
TEST RUN BETWEEN FT AND -- FT
COMMENTS ~:~)~_z~./~ ~-~'~-~ ~ A .~'/Y.~ ~r,-~ ,~ / ~ /~- /
PERFORMED BY: Eagle River Engineering Services CERTIFIED BY:
F. 6. ~vx
Eagle River, AK 99577
694-5195
72-008 (6/79)
DATE:
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
Lot 17; Block 1; Heritage Park Subdivision
Location (site address or directions)
19708 Ivy Home Circle, Eaqle River, Alaska
Property owner Nina Caternichio Day phone
Mailing address P.O. Box 770651, Eagle River, Alaska 99577
Lending agency Day phone
Mailin~ address ..... '
694-3745
Agent
Address
Day phone - ,
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
NOTE:
Individual Well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site XXX
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 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.
Name of Firm S & S ~.NG!NEER!NG
17034 Engle River Loop Road No. 204
Address Ea~Ju F,;wr, Alaska 22577
Engineer's signature
D..s S,G.ATU.E
./~-------~ Appro~/ed for. /~/'~/~/~-~/~/? bedrooms.
Disapproved.
Conditional approval for
Phone
Date
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. Em ployees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage i8 not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
' MUnicipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Parcel I.D.
Well type
Log present (Y/N)
Total depth
sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Cased to Casing height
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
g.p.m.
AT INSPECTION
MUNICIPALITY OF ANCHORAGE
~.~"¢~OHMENTAL SERVICES DIVISION
,J'JN 2 9 1992
RgEPCmE i V E D
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Public 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. SEPTIC/HOLDING TANK DATA
Date installed I.~. ?..,~ <~'/
Cleanouts ~)/N ) ~f
High water alarm (Y/~
Date of pumping L~ .ct-b-
Tank size I"b~"~ ~A'L~ Compartments ~'
Foundation cleanout (~i~N) x[ '/Depress, ion (Y/~
Alarm teSied (Y/N)~j*
SEPARATION DISTANCES 'FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surface water/drainage
~1~.
On adjacent lots Foundation
Absorption field Iv ' ~' Water main/service line
72-026 (Rev. 3/91)Front MOA21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at ~at
High water alarm level ~ ~"~Cyo es tested
Meets MOA electrical codes
SEPARA~ANCE FROM LIFT STATION TO:
WeTI on lot
On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed Id-' ?.71 - ~,'~
Length ~¢'~' Width ~"
Total absorption area I..,¢1'L ~ J
Depression over field (Y/~f) ~
Results ~;~fail) ~,~
Peroxide treatment (past 12 months) (Y/~ ¢*~b'
Soil rating \ ?..5" ~/~F-
Gravel thickness ~ '
Cteanouts present(~/N)
Date of adequacy test
System type ~¢--¢~
Total depth
¢.._~.c,.~ ~ If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot "/~ ~'
To building foundation
On adjacent lots
Surface water ~ Or~
Curtain drain
On adjacent lots £1~. Propertyline
~.o' '¥' To existing or abandoned system on lot
Cutbank ~ I~- 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 in effect on the date of this inspection.
Signature
S & $ ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Engineer's Name
Date
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
~_~ MUNICIPALITY OF ANCHORAGE ~ ,
DEPARTMENT OF HEALTH AND ENVIRONMENTAL P'rr~'FECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
GENERAL INFORMATION
(a)
Application Date 2/24/86
Legal Description (include lot, block, subdivision, section, township, range)
Lot 17~ Block 1~ Heritage Park TlqN R1W¢~ Sec. 7
Location (address or directions)
Eagle River, Tradition Drive
(b) Applicant Name Chris Brown Telephone: Home 694-~t058 Business 694-4058
Applicant Address P.O. Box 771~150 Eagle River AK 99577
(c) Applicant is (check one): Lending Institution []; Owner/builder [~[; Buyer []; Other [] (explain);
(d) Lending Institution Alaska Pacific Bank Telephone
Address 101 W Benson, Anchorage Alaska
(e) Real Estate Company and Agent N/A
562-6100
Address
Telephone
(f)
Mail the HAA to the following address:
Pickup by Applicant (,~/!
TYPE OF RESIDENCE
Single-Family [~ Multi-Family []
Number of Bedrooms /I
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.
72-025 (11/84)
Page 1 of 2
ENGINEERING FIRM ~ ~ : '
~ PROVIDING .INSPECTIONS, TESTS, FILE SEARCH, DA~I~AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection. ~
Name of Firm Telephone
EAGLE RIVER ENGINEERING SERVICES
Address c*~" ~- r31~lrn ~.v nnl;7"7
694-5195 .
Engineer's Seal
Approved for ¢'~-oZz/~. bedrooms by _ Date
Approved /~. Disapproved Conditiona
Terms of Conditional Approval
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 independent professional
~ngineer 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 (1
MUNICIPALITY OF ANCHORAGE (MOAT'
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
MUNICIPALITY OF ANCHORAO~:
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
WELL DATA
264-4720
Legal Description:
Well Classification .f~ )¢ Z. / (:
Welt 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
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
Z'z"7~-'4 If A, B, C, D.E.C. Approved (Y/N)
Date Completed Yield
Depth of Grouting
Pump Set At
Sanitary Seat 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
B. SEPTIC/HOLDING TANK DATA
Date Installed /O/Jz~/.,/,E'd Size /~:,L~-O No. of Compartments
Standpipes (Y/N) ./Y' Air-tight Caps (Y/N) /v' Foundation Cleanout (Y/N) ,,~'
Depression over Tank (Y/N) /~/ Date Last Pumped /¢e~,.¢
Pumping/Maintenance Contract on File (Y/N) /¢///~ ; for
Holding Tank High-Water Alarm (Y/N) //"///,¢~ Temporary Holding Tank Permit (Y/N)
Separation Distances fror~ Septic/Holding Tank:
To Water-Supply Well ~'~'¢'~ ¢
To Property Line ~-/0 /
To Water Main/Service Line +/~ /
Course ,ct/c, ~ ~, ,'7'~, ;, /'~;'~ /
To Building Foundation
To Disposal Field ~/2 /
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-02601/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed / ~,.~ ¢'/~¢P ~
Width of Field .~ /
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation / ~
Lot
To Water Main/Service Line ~'/~"
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
"¢J~2P.,¢ Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line ? .2"
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"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 checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~ /'¢¢~'~¢:::¢~*~'~ Date
Company
Receipt No.
Date of Payment
Amount: $
MOA No.
Seal
Page 2 of 2
72-026 (1 ~/84)
