HomeMy WebLinkAboutLAMPERT ESTATES BLK 2 LT 9t,o'r
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
ia)
(b)
(c)
Legal Description (include lot, block, subdivision, section, tow. nship, range)
Location (address or directions)
Applicant Name~Z* ~ ¢,~ Telephone: Home ;~- ~'¢/ Business
Applicant Address _~
Applicant is (check one): Lending Institution
(d)
Lending Institution ~--~:~.¢~
Address
(e) Real Estate Company and Agent
Telephone
Address
Telephone __
(f) -l~e~A to the following address:
TYPE OF RESIDENCE[
Single-Family ~' Multi-Family []
Number of B'edrooms ___ ~
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 E] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to th~ legality and status.
Page I of 2 72-025 (11184)
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 regulations in effect on
the date of this inspection.
Name of Firm
Address
Date ~
Telephone
[)HEP APPROVAl.
Approved for ~/f.A..'
Approved ' /~'~"/
bedrooms by//~
Disapprovdj~
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 DFIEP 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
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed -'~
Width of Field
Square Feet of Absorption Area
Depression over Field (Y,~
Besults of Last Adequacy Test
Separation Distance from Absorption Field:
'Fo Water-Supply Well
To Building Foundation
Lot
Type of System Design
Length of Field (--), ~'-,
Depth of Field
Gravel Bed Thickness
1~½, ~'~, Standpipes Present~'4)
Date of Last Adequacy Test
Mt./NICIPALIT~ OF
DEPT. OF HEALTH
ENVIRONMENTAL PROTECTIOh~
JUN 2 lqR
RECEIVED
To Property Line LC:) I "~--
/
To Water IV~"nTService Line ~--~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage'Area
Comments I".--~, ~_ ~"~.~ ~ L_D 1'),..4,'~ ~
To Existing or Abandoned System on
; On Adjoining Lots
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)
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 HA¢ guidelines in effect on the date of this inspection.
Signed Date 6/'/"L' '"2"/0
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
~UN1CIPALITY OF ANCHORAGE
DE DF HEAt. TH &
~NVIP, Oh,,,cNTAL PROTECTtO~
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAJ~ ~
CHECKLIST- FEBRUARY 1984
264-4720 RECEIVED
Legal Description: L~___....~
WELL DATA
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/l=teldi~g. 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
If A, B, C, D.E.C. Approved,~N)
Date Completed Yield
Dep~th of Grouting
~d/, Pump Set At
//~Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
I
~-~¢.2~ -J' ; On Adjoining Lots
!
'~---g¢c:::~ W ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
B. SEPTIC/ ........ ..~ TANK DATA
Date Installed ""~ I ~ "1
Stand pipes ~N)
Depression over Tank (Y,~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) t")//
Separation Distances from SepticAHCrdtrrg Tank:
To Water-Supply Well ~-":~-~ )''¥
To Property Line I~-- t ~_
To Water Main/,ge¢-,,~ Line '~-'~
Course
Size ! ~'~-~ No. of Compartments L)~ ~"~,
Air-tight Caps ~N) Foundation Cleanout (Y~).
Date Last Pumped (,¢~--
~ t~ ; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation ,'~_~,~
To Disposal Field "~-~'
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11184)
SUBJECT:
C(,.,~vlPUTATION SHEET
DATE:
SHEET
BY
CKD
OF
?
~EPT. 0~' ENV~RONJ~NT/~ CONSERV~T~O~
/
ANCHORAGE/WESTERN DISTRICT ~FFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA g9501
gILL SHEFFIELD, GOYERNOI~
Telephone: rD07)
Address:
274-2533
To Whom it May Concern:
According I:.o records on file in this office the ~ .... ((~.~,~,,
¥
/[ ,t Water System is in compliance with the Stat~
Water Regulations
Sincerely,
Dri nki ng