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Home My WebLink AboutHIDDEN ACRES LT 4 W2 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) W ~ of Lot 4; Hidden Acres Subdivision; Location (address or directions) 3636 West 78th Avenue, Anchorage, (b) Property owner H.U.D. #111-031-377-203 Mailing Address 605 West 4th Avenue (c) Lending institution · Telephone:(home) Anchorage, Alccek~ 99501 Telephone Business Mailing Address (d) Real Estate Company and Agent MAR_qTON p~¢)pERTIES ATTN: (e) Address 4105 Tri~,~g~/. B£uH.: ~,~ohn~gp; ,~.P~AI~,,z qq517 Telephone ¢4R-1717 Mail the HAA to the following address: (or check hereX~, if hold for pick up.) List contact person and day phone number below: $ & S ENGINEERING Eagle River, Alaska 995~ 2. TYPE OF RESIDENCE Single-Family [~× Number of bedrooms 4 3. WATER SUPPLY Individual Well E~X Community [] Public [] Note: If community well system,, must have written confirmation from the State Department of Environmental Conservation att?sting 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 legailty 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 dateshown below, Iverifythatmyinvestigation of th is 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 ~ ,~ ~=N6INEERIN6 Telephone /~/~'/~/" -~ ~ ~ 17~34 Eagle River Loop Road No. 204 Address Ea~le ~ive~: AJasEa 99577 / // 6. DHHS APPROVAL Approv.,edfor ¢ bedroomsby ~~' ~-"~ Date Approved ..~<~ ' Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Heatth and Human Services (DHHS) issues Health Authorit~-~,pproval 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) Health Authority Approval (HAA) ,.'~,i'i,~- ,/'CHECKLIST~ FEBRUARY 1984 Legal Description: t&) Well Classification ~._~, ~ ? IL /~ ~ ;I ~ Well Log Present (Y/N) /~) Date ComPleted __ Total Depth .'A z/'O 'Cased to -~/--'/O / Depth of Grouting Static Water Level "~ ,2 Casing Height Above Ground ./-~ Electrical Wiring in Conduit (Y/N) ~ SEPARATION DISTANCES FROM WELL: If A, B, C, D.E.C. Approved (Y/N) ("~ 70 ? Yield ~. ! Pump Set At ~ C)L~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) To Septic/Holding Tank on Lot ~/~ ~Dcg/fg ~ekx:c';OnAdjoiningLOts To Nearest Edge of Absorption Field on Lot ~/~ ; On Adjoining Lots To Nearest PubliC Sewer Line / 0 2~ ? To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by ~'~.~, ,:~¢v~ildd'.~.~£[~J~ ;Date /,~ - Water Sample Test Results ~ ,q "~ _~ ?¢'~ ,.%-/~ ¢ ~ - Comments B. SEPTIC/HOLDING TANK DATA Date Installed Size Standpipes (Y/N) Depression over Tank (Y/N) No. of Compartments Air-tight Caps (Y/N) Foundation Cleanout (Y/N) 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 Prope.rty Line 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 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 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 Comments Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots 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 Company Date MOA No. 17~,34 Eagle River Loop Roacl No. 204 Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88) Back 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 December GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, sect[on, township, range) Location (address or directions) (b) Applicant Name _~..PauT~ ~Lime Telephone: Home Applicant Address _36_~6 W. 78th Street Anchorage_, Ak, (c) ~ 98g Business ~61_-_'1 Applicant is (check one): Lending Institution [2~; Owner/builder []; Buyer []; Other [] (explain); (d) Lendidg, lnstitution, ~me $~v~n~a ?~ Io~n Telephone Addrb~s Dimond Br=nch (e) Real Estate Company and Agent _~sr d Re~].ty Address .I ~,2020 Old Seward Telephone 3 ¢2 (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family [~ Multi-Family [] Number of Bedrooms Fm~v- 0!) 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 83{' Community E] Holding Tank [] Note: If com'munity 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, 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 sale, 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 regulctions in effect on the date of this inspection. Name of l~irm D : ' , ! ~ 2G Telephone Address ;360~ Arctic~, $~.ite 993 ~.nchor~ge~. Ako' 99~:03 Date .'0eeember ~7~ 198~ Engineer's Seal DHEP APPROVAL [" .'~ . Approved for }:tOc,~....~.~/~edroomsx~' by ~'~'~ '~' '~"~'~Date Approv~ ,'/¢~ ¢' ~Disa¢~ed ¢ Cond~<;al 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 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 fl 1/84} WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) MUNICIPALITY o~THORITY APPROVAL (HAA) DEPT OF HEALTH..~.~A · 'C~IECKLIST - FEBRUARY 1984 ENVIRONMENTAL pROTEC,;'flgI~' 264-4720 BEC 1 8 198,5 Legal Description: '~ Lo% RECEIVED SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Depress!on over Tank (Y/N) Well Classification Pri~rn%e- S±nsle l?~m±]_ylf A, B, C, D.E.C. Approved (Y/N) N Well Log Present (Y/N) N Date Completed '1.970 ,~/- Yield 1 Total Depth _3hO~ Cased to _3~401 Depth of Grouting [~]o+. Static Water Level 8~.t Pump Set At '~06~ Casing Height Above Ground ~__~" Sanitary Seal on Casing (Y/N) Y Electrical Wiring in Conduit (Y/N) '~ Depression Around Wellhead (Y/N) N Separation Distances from Well: To Septic/Holding Tank on Lot ~/[\ 'r~l~l 4 n Rm-z¢,.-,' ; On Adjoining Lots ¢~]'hl ~ .: Sewer To Nearest Edge of Absorption Field on Lot N/A ; On Adjoining Lots To Nearest Public Sewer Line lO~~ +/- To Nearest Public Sewer Cleanout/Manhole 3_~? ~ To Nearest Sewer Service Line on Lot Water Sample Collected by ~aul L~L&me & ;Dee ~.~ ;Date ]_2/ ~.~./ 8¢ Water Sample Test Results Comments Well wes test ~mped and stabilized at 10 F=pm with a drawdown ~a~ to 222' Well is ndequate to -produce ~re then the minimum required for ~ [~ bedroom home o Size No. of Compartments Air-tight Caps (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 * 72-026H1/84) 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 To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, br Vehicle Storage Area Comments 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 To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) \ D, LIFT STATION n/~ Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" LEvel at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Chec~;~mitt%Bedroom Ratin,g Against HAA Request ** I certify t~.t I~have ch~cke~l~di/d,'o~onformed to all MOA and HAA guidelines in effect on the date of this inspection. Company Do ;liLiih ~'ngiriek~.'-~ n¢., MOA No 3T8~-29.5 Receipt No. 3 Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) En~eer's Seal ~¢. ;... , -...o.;f.,,,. ;'~. ~:..- ..%~.... :.~..~_.¢,. ~_ '~?.. ........ ..: k 1 N N -N Q q c'ti t _1 -r- /..d 1 ^_ L _ b --s. / � � E m � � �u CD ro n d o \ 1 \ LQ 2S�oZ�\ a Q fl \/60L OK R A �'�)cv rr/c D\vG Ll..,t t,-3 cti (' T` a 4 'rQ✓'� //c Q .SYS y.S Yo Gnci \ � . p ` F7c ( � \\ m 0 Z ., e 1p Ta +1 4 " O �' 1771+-/ 1-:a:, S. / 6 I V +9 V) 7 trt,rtUr Ghali erlcrOa6� e2e✓t c'��GL ,-t,1 any gawan� -ar-w� AS -BUILT NO CORNERS SET THIS DATE ,w�� jo * #:", �A R'p#t'4.'4lcb Ro¢;SG'-'•',t��,l�h3^`! \P 1 +Dle�.t�re,� oa�o �.,.n 4r•,e � �4 n �A � fig, 374 -S � ' R�� I hereby certify that I have performed a Mortgagee's in- spection of the,, following described property: ._— Anchorage Recording Precinct, Alaska, and that the improve- ments situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent there- to, that no improvemcnts on property lying adjacent thereto encroach on the premises in question and that there are no roadway's, itansmission lines or other visible casements on said property except as indicated hereon. Dated at Anchorage, Alaska this 2�2__.day 1 MVITT V. LUUNSBU.RY Sz'ASSOCIATLS