HomeMy WebLinkAboutLAMPERT ESTATES BLK 2 LT 14
MUNICIPALITY OE ANCHORAGE
DEPARTMENT OF HEAl. TH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEEI-]ING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone ;?64-4720
QN-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WELL INSPECTIQN REPORT
Inside length
Dwel ing
NO, OF 8E.._.~OOMS
P E R MI.T NO.
No. o~m.~pa.r t me nts
Liq, I F HOMEMADE: Liquid depth
Well PERMIT NO,
DISTANCE TO:
DISTANCE TO:
No, of lines~t.~
Top of tile tcJ'fi _c~l
weu/)
Width
Crib diameter
Material beneath tile
Depth
Crib depth
Well Building foundation
Depth Driller
Building foundation
Sewer line
OTHER
Length
Type of crib
DISTANCE TO:
Class
DISTANCE TO:
PIPE MATERIALS
SOIL TEST RATING
REMARKS
JWidth
IMateria]
Trench widE~
--~5~ inches
inches
Liquid capacity in gallons
Distance betv~er~lines
~~b.~o rptio n area
PERMIT NO.
Tot_al effectiv_ e ~i]sj rpti onlq reda
Nearest lot line
D'T~~ee PERMIT NO.
DA'rE
Permit ~
Applicant:
Location:
Legal Description: L/L/
Type of Soil Absorption System Is:
Trench: Drainfield:
Maximum Number of Bedrooms: 6.
MUNICIPALITY OF ANCHORAGE
Department ~ Health and Environments.~ 'rotection
825 ~ S~reet, Anchorage, AK. ~9501 '
264-4 7 20
* * * HANDWRITTEN PERMIT * * *
~ AND/OR ON-SITE SEWER PERMIT
~V~ C~3/~ ~ ~ Mailing Address:
Seepage BeC: ~ Holding Tank: Soil Rating (sq. ft/br) ~'
The Required Size of the Soil Absorption System Is:
DEPTH ~ LENGTH .~ft~-'~v,~Q-(~RAVEL DEPTH
.... WIDTH
The length dimension is the length(in feet) of the trench or drainfield.' The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = /060 GALLONS
P~rmit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * ~
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum dista..pce between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are 'required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 2 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence~ is remodeled to include more that 3 bedrooms.
Signe~: ~ ~~ IssueS by: __~. ~;-"(,3..C~0'3/~
Appl ~cant J' 6]
~-/]
PERFORMED FOR:
LEGAL DESCRIPTION:
4
5
6
,7
8
11
12
13
14
,15
16
17
18
19~
20
MUNICIPALITY 0; ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRO~MENTALPROTECTION
825 L. Stre.t. Anchorage, Alaska 9950! 2G4~4720
SOILS LOG - PERCOLATION TEST
SLOPE
SOILS LOG
[] PERCOLATION
T~ST
Reading Date Gross Net ' Depth to Net
- Time Time Water Drop"
/
,":.:; '"];' PERCOLATION ~ATE .... Ir ~r'~tes/inch)
TEST RUN BETWEEN ~ , FT AND---- FT
~o~,F- ' ~ //) ///
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. #
0 ,~'- [
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Lot 14, Block 2, Lampert Estates
Location (site address or directions)
22506 Lampert Circle
Property owner
Mailing address
Day phone
Lending agency Day phone
Mailing address
Agent [-]arvey Prickett/Dynamic ProDert±es Day phone
Address 31z1 C Street, Su±t.e 100, Anchorage, AK 99503
Unless otherwise requested, HAA will be held for pickup.
3
NUMBER OF BEDROOMS:
261-7646
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
XXX
NOTE: 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 states'of sysfem, '
72-025 {Rev. 1t91) Fronl MOA #21
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 & $ ENGINEERING
Address
Engineer's signature
170-3;4 Ea¢~ ~iverE'oop Road No. 2U~ Phone
E~le Rive~ Alaska 99577
DHHS ~SlGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
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 ~ngineer 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. 1/gl) Back MOA
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES APl:{ 0 1 1909
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (90~T~4:~
ENVIRONMENTAL SERVICES DIVISION
Health Authority Approval Checklist
Legal Description: ]--0 ~' IV 8'~ ~.. Lg~¢,¢47 ~$7, ParcelI.D.: O'&*t~'7~lt
A. WELLDATA ~u/~-I c_
Well type C t. r~ s .,( "¢ If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
ht (above ground)
...-'~res properly protected (Y/N)
AT INSPECTION
Collected by:
Other bacteria
Cased to
Date of test FRO.,~.~M WELL L~
Static water level
Well production __ / g.p.m.
WATER SAM~LTS:
Coliform / Nitrate
Date~sample:
B. SEPTIC/HOLDING TANK DATA
Date installed (~ /-~[ 9'z Tanksize
Foundation cleanout CN) Yfc.J
Date of Pumping ~/I /
g.p.m.
/ ~¢ O Number of Compartments ~ Cleanouts~-~/N). Y~- .r
Depression (Y/~,~)~ /v 0 High water alarm (Y~ ~ O
Pumper :7 ~ 5'
C. ABSORPTION FIELD DATA
Length ~ $- Width
Effective absorption aroa
Soil rating (g.p.d./fF oi ~.~'-~:~_~ ¢ 5'- System type
'~ Gravel thickness below pipe 0 o .S'- Total depth
/*r z. Monitoring Tube present (~/N) ¥¢~J Depression over field (Y/I~ /" o
Date of adequacy test (-t / ! ~- / q -/ Results ~Fail) f~4 f_$ For ~
Fluid depth in absorption field before test (in.); P P'Y Immediately after ~1 ~ gal. water added (in.): __
Fluid depth O (ins) Minutes later: /~- ~-,,,., Absorption rate = 2-/ 5-O -,' .g.p.d.
Peroxide treatment (past 12 months) (Y/N) ~ ~ '~'''- ~r ,,, o ~'~,-' If yes, give date ~
bedrooms
O
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N) ~
"Pump off" level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/s~ep~t_ic~s~ervice-lii'i~ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~ -)- Property line / 0 .-,k Absorption field
Water main/service line ~ 5' '~ Surface water/drainage /o0 -~- Wells on adjacent lots
On adjacent lots
~ut
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line
Surface water
Curtain drain
/0
Building foundation ) 0 -')- Water main/service line
-/- Driveway, parking/vehicle storage area
¢¢~ w ~ Wells on adjacent lots ~ O0 -/-
F. ENGINEER'S CERTIFICATION
I certify tha, l have determined thru field inspections and review of Municipal recor._C~.~_t~a~..t~eJa~O?~.C(~ms are
· . . ~,,/,.¥ · ........ ,?~-
in conformance with MOA HAA gu~defines ~n effect on this date.
Engineers Name
ROBERT
~ ~ .... ~.~
Date
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
Parcel I.D.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services ~ ~i. iTYo~ .
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744 75 1997
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Day phone
Lending agency
Mailing address
Agent
Address
/
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
Day phone
Day phone ~"~- 9/z¢¢¢
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State AD£C
attesting to the legality and status of system.
NOTE:
72-025 (Rev, 1/91) Front MOA #21
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
Address
Engineer's signature
KND Engineering
20441 Ptarmigan B~vd.
Ea(~le River. AK ~.77. -87~
Phone
Date
DHHS SIGNATURE
~ Approved for --~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
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 D H HS 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. 1/91) Back MOA ~1
Mun,c,pality of Anchorage ~NYI~ON~E ....
· ' -~ ,~r,o& SERVICEs DI
DEPARTMENT OF HEALTH & HUMAN SERVIC~ ~v~
Environmental Services Division ~P 76 1997
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907~ 343-4744
H~alth ~uthorit~ ~ppro~al Checklist
Legal Description:
A. WELL DATA
V~ell type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Parcel I.D,:~),~,/- 7~'/'-/,.~
If A, B, or C, attach ADEC letter. ADEC water system number
/ Date oempleted
/
/ Cas,ng he,ght/above ground/
Cased
to
// Wires properly protected (Y/N)
FROM WELL LOG /
/
Static water level
Well production
WATERColiform SAMPLE RESULTS:/
Date of sample: /
/
B, SEPTIC/HOLDING TANK DATA
Date installed ~/,¢,~- Tank size
Foundation cleanout (Y/N)
?
?
Nitrate
AT INSPECTIOI /
g.p.m. ~ / g.p.m.
~Other bacteria
/
Collected by:
//.)¢~) Number of Compartments ,2. Cleanouts (Y/N)
Depression (Y/N) /f// High water alarm (Y/N) --
Pumper J--< /'~d~:~¢
Date of Pumping
Soil rating (g.p.d./ft2 or ft2/bdrm)
C. ABSORPTION FIELD DATA
Date installed
/
Gravel thickness below pipe
Monitoring Tube present (Y/N) /
Results (Pass/Fail)_ ~'~ D 5
System type ~J
/~ // Total depth ~,,~,,~ '4-
Depression over field (Y/N) /
For ~
Length .2_..'~ / Width
Effective absorption area _5'~¢'-E~
Date of adequacy test ¢~/.~
Fluid depth in absorption field before test (in.); ~ Immediately after ¢/~) gal. water added (in.):
Fluid depth .__/~___. (ins) Minutes later: /O~'-.,,¢¢/~ Absorption rate = ¢~,%'-~) ~ g.p.d.
Peroxide treatment (past 12 months) (Y/N) /~// If yes, give date
bedrooms
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*~/~
Cycles tested
Size in gallons ~
"Pump on" level at* /'~"Pump off" level at*
*Datum /~
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Sewer/septic service line /'~ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ,~ ~F Property line /~ ~ Absorption field /'~
Water main/service line ~',t- Surface water/drainage j~)t9 f
'¢' Wells on adjacent lots ~)
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line //~ ~' Building foundation /,/.~ ~¢ Water main/service line
Surface water ~//~ (~ /¥- Driveway, parking/vehicle storage area
Curtain drain //~"~) /¢~ Wells on adjacent lots
F, ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal records
in conformance with MOA HAA guidelines in effect on this date.
Engineer's Name' /,¢~'¢~-¢~'/¢~ ~'/. ~
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
thatCher, stems are
72-026 (Rev. 3/96)*
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.# 0~"/
1. GENERALINFORMATION ~ .
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address.
Agent
Ad dress
Day phone
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ..~ ',,r
TYPE OF WATER SUPPLY:
Individual well :,
Community well
NOTE:
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
Public water
If community well system, provide written confirmation from State ADE~"'attest-
lng to the legality and status of system. .
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
s~uewwoo leUOp,!ppv
:suo!Jelndi~s 8U!MOIIOJ eqj HJIM 'su~ooJpeq
'swoo~peq
Jo~ I~^oJdde leUO!3!puoo
'peAoJddes!Q
Jo~. peAoJddv ~
a~ln&¥N91S SHHO
'9
.g
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~':~'~/¢ ~¢',~ ~'
A. Well Data
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Well type
Cased to Casing height
Wires properly protected (Y/N)
AT INSPECTION
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~ 7----
Absorption field on lot
Public sewer main
Sewer service line
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size /¢ ~ ¢
Foundation cleanout (Y/N) ~
/%/,/./~-~ Alarm tested (Y/N)
/4fy?.~/¢ ~_~ Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot 'c'///'~ On adjacent lots "'~'"//~
/
To property line /~ ~ Absorption field .~o ~
Surface wateddrainage
Cornpartments
Depression (Y/N)
Foundation
Water main/service line ~,~-':/
72-020 (3/93)' Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed
/
Length
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/Ft2)
Width '2~-7~ Gravel thickness
~;~'~ ~ ¢-- Cleanout present (Y/N)
/¢Z-//~/~ Results(pass/fail)
System type
/" Total depth
Depression over field (Y/N) /V'
for ~ Bedrooms
After test
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots '~,/,'¢-- Property line
~ O /~- To existing or abandoned system on lot
' ~' ¢' ~ Cutbank ,,v//,/,¢.~ Water main/service line
/V'~,~,,/~ Driveway, parking/vehicle storage area
,/o
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.
David R. Dayton P.E.
Sia natu re 202'10 Don alar St. ·
Engineer's Name
Date / ~/~ ~/~ ~
HAA Fee $ ~ ~¢~) ~ cr~) Waiver Fee $
Date of Payment /,2 - ~-~./~_.~ Date of Payment
Receipt Number ¢'Z*S-7,.~P~ ,~""/'~ ,/'.~/) Receipt Number
72-026 (3/93)* Back
FIEI'T. OF ENVIRON MENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99515
WALTER J. HICKEL, GOVERNOR
(907) 349-7755
December 21, 1993
Mr. Dick Dayto
20210 Donalar -'
Chugiak, AK 99567/ ' ' ·
SUBJE(::;T: Lo~t 11, Block 2' (22544 Lamperl Circle), Lampert Estates/
M~Kinley View Estates
Ctass "A" Public Water System, PWSID ?.210697
i
Dear Mr. Dayton:
I haVe completed a review of this' offiCe's'flies Conc~ning tlq'b monitoring status of the
above-referenced Class "A" Public Water System and found the following:
1. Tl~e last satisfactory Total Coliform Bacteria Sample results was submitted
.. to this Department on December 14,1993_. This .does meet the provisions
·. :' :',-- ' of 18 AAC 80.200(a), of the State Drinking Water Regulations,
2. The last inorganic chemical Contamir~a'nts Sample results Were'submitted
to this Department on FebrUary 4., 1991. This does meet the provisions of
18 AAC 80.200(a), of the State Drinking Water Regulations.
3. The last Radioactive Contaminants Sample results were submitted to the
Department on February 18., 1993. This does. meet the provisions of 18
AAC. 80.200(a), State Drinking Water Regulations. :...
4.. Thb last Organic Chemical Contaminants/Volatile Organic Chemical (VOC)
were submitted to this Department on December 14, 1993. Based on
· an~dysis of the previous VOC samples results have been satisfactory. This
does 'meet the provisions of 18 AAC 80.200(a), State Drinking Water
R(~gulations. "
Issuance of this letter doe~ not 'imply that the above-referenced Class "A" Public water
System is in compliance with other provisions of the State Drinking Regulations. Unless
otherwise noted, this letter is valid for 30 days and is for the.specified !ega! descril~tion
'. i.' :!.':.'~ ~_?'"'" " .... "' ?" '~';' '~ ...... '
printed on ,ec,:'ycled pape, b y ~,b.
D. R. DAYTON, P.E., R.L.S.
~ Chugiak, Alaska 99567
(907)
December 23, 1993
Septic System Adequac~v Test
Date of test: December 21, 1993
Septic Tank: 1,000 gallon, 2 compartmrnt, stee
Absorption System: 22' x 25' seepage bed
Soils Rating: 85 sq. ft. per bedroom
Requirements: 3 BR - 450 gallons per day
Test:
(DHHSRecords)
(DHHS Re~ords)
(DHHS Records)
As the house has been vacant, the bed waspresoaked with 1000 gallons
of water, 24 hfs after presoaking water was pumped into the bed while measuring
time, volume and water level rise. After pumping was stopped, the water
level drop was measured at timed intervals.
Results:
The seepage bed accepted 600 gallons with no rise in the water level.
The system is currently functioning adequately for a 3 Br home.
MUNICIPALITY OF ANCHORAGE
, DIVISION OF ENVIRONMENTAL HEALTH
~' DEPAR~iENT OF H~ALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
I. Genera]. Information Application Date .~ g~/~
(a) Legal Description (include lot~ block, subdivision~ section, township, range)
Location (address or directions)
(b) Applicants Name ~/~i~ ~/~ ~Z ~'/F~ Telephone - Home Business
Applicants Address~ /~0 , ~/r ~ 70 7~
(c) Applicant is (check one) Lending Institution
(d) Lending institution
Address __~q~-~, ~'- /?~ ~'e-~
(e) Real Estate Co. & Agent
(f)
Telephone
~--~ ; Owner/builder,S';
Mail the IblA 'to the following eddress:
Other (describe)
Community ~' Public
~e of Residence
Single-Family~
Number of Bedrooms
Water Supply
Individual Well' LX~I
Note: If community well system, must have %~itten confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
Sewage Disposal
Onsi te ~_/~'-x,~.~' Public ~_~ Community ~-~-i Holding Tank fill
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]
Engineerin2$' Firm Providin~tions, Test__s~_Fi~3. e 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 ~th all ~nicipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Address
Date
Telephone .~ 2~-- 3 7/.~
DHEP _A~or oval
Approved for <~
bedrooms
Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF [~ALTH AND ENVIRONMENTAL PROTECTION
(DREP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE 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 PURCILASERS OF HOMES AND
TIIEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CER~ZIN ~]DERAL AND STATE REQUIRE-
MENTS. ~4PLOYEES 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 SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
Well Classification f.'/~ Z4
Well Log P~esent (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances feom Well:
To Septic/Holding Tank on Lot ~o-~ ~
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
C leancut/Manhole
Water Sample Collected By
Water Sample Test Pesults
Cc~ rlts
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITYAPPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
MU,NIqiPALiTY O,: Ai~qCI~OP, AO~
JAlii.';.1085
Date Completed Yield
Depth of Grouting.
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
~O ~ ~ ; On Adjoining Lots
To Nearest Public Se~r
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ./~ ~D~ Size / 0~0 NO. of C~a~tm~nts
Standpipes (Y/N) Y Air-tight Caps (y/N).J/ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) A/ Date Last Pumped ~7~
Pumping/Maintenano~ Contract on File (Y/N) ~A ; for
Holding Tank High-Wate~ Alarm (~/N) ~ Temporary Holdirx3 Tank Permit (Y/N)
Separation Dist'ances f~cm Septic/Holding Tank:
To Water-Supply Well ~Tt~ ~ To Building Foundation
To P~operty Line /~ 4. To Disposal Field ~ .~ ~ '
To Water Main/Servioe Line /~ To Stream, Pond, Lake, o~ Major D~ainage
Course
Conments
[Page 1 of 2]
C. ABSORPTION FIELD DATA
De
Soils Rating in Absorption Strata
Date Installed /f~ ~
Width of Field ~-3 '
Squaze Feet of Absorption A~ea
Depression over Field (Y/N)
Type of System Design
Length of Field ~ 3-
Depth of Field ~ /
Gravel Bed Thickness ~'
Standpipes P~esent (Y/N)
Date of Last Adequacy Test
Results of Last Adequacy Test
Separation Distance f~om Absorption Field:
To Wate=-Supply Well L~ * To P~operty Line /~ ~
To Building Foundation-~ ~/~ ' To Existing or Abandoned System cn
Lot /~ ; On Adjoining Lots ~ ~-
To Water Main/Service Line /~ ~ TO Cutbank(if present)
To Stream/Pond/Lake/or Major Drainage Course ,~ ~
To Driveway, Parking A~ea, or Vehicle Storage Area *~-o ~
LIFT STATION
Date Installed
Size in Gallons
"Pm~ On" Level at
High ~ter Alarm Level at
Tested for
Electrical Codes(Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent .(Y/N)
Pumping Cycles du~ing Adequacy Test.
Maets MOA
Comments
Signed
Company
** Check Permitted Bedroom Rating Against HAA Request
I certify that I have checked, verified, o~ confc~ed to all MOA HAA Guidelines in effect
on tP~ date of this inspection.
Date
MOA No.
KB1/d5/s
[Page 2 of 2]
2-15-84
BILL SHEFFIELD, GOVERNOR
DEPT. OFENVIRONMENT/~L CONSERVATION
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
Telephone: (907)
Addres¢:
274-2_533
DATE
To Whom it May Concern:
According to records on file in this office the //;~c~:~/e.$/. !//ff~c.~
~'/,_~ Water System is in compliance.with the State/ Drinking
Water Regulations
Sincerely,
'APPLIC FILLS OUT UPPER HAl. ONLY
Property Owner ~2/~ y/"-//~ <':'~(~ (~'/ --~ /~~ . Phone
Address Zip Cede
Lending Institution ~)(~ (2& ~:~ ~/:~ ~ ~ Phone
Address Zip Code
' Phone
Address ~ X J, · ~ I ~.~ /~ I~/~ A Zip Code ~ ~
Slreet Locatl~
Type of Resl~nce
~Singlo Family~ ~ x ~ ~ ~q~'X - ~ ¢'
U Multiple Family No. of Bedroo~ -~
Water Supply ~_~ ~ ~-~ ~'~ ~
~ Individual A~ACH WELL LOG. A w~l Icg is required for all wells drilled since June 1975,
Community For wells drilled prior to that date, give wall depth (attach Icg if available, /
Public Utility ~.~ SA~.
Sewer Disposal / 7~'¢
Individual Year Individual Installed:
Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Dale Date
Inspector Inspector Inspector Inspector
Field Notes:
("~) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
Well to Tank Seplic Tank Size
72-023 (3/82)