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HomeMy WebLinkAboutLAKE O THE HILLS BLK 1 LT 4 Municipality of Anchorage Page I of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: '-~v~Cl~OOS'~ PIDNumber: Ot.~'~17 Name:Wastewater System: [] New [] Upgrade CH/~RLE% MILLER Address: ll3~1 ~ou~T&~ L~E b~. ABSORPTION FIELDEx~ST/~ NO. of Bedrooms: ~ Phone: ~N~- ~ ~ rench ~ Shallow Trench ~Bed ~Mound LEGAL DESCRIPTION SoilRating: ~GPD/Sq. FE Total Depth f~grade: Subdivision: Oepth to Cpc hot,om from od~ ~ bonoat" pipe Township: I% ~ Range: ~ ~ Section: Z~ / Ft.~h Ft. Fill added above original gr~e/ WELL: EXi~T~New ~ Upgrade Gravelwidth:~ ~u~boro[li~tanc.~elweenlines: Classification {~rivate~ A.~.C): Total ~epth: Gase~ 1o: lolal ~tion area: ~riller: Date Drilled: StaticWa~er kevel:Ft. Installer:(.~L~ ~C~ ~T Yield: GPM Pump Set at: F . Casing Height Above Ground:Ft. TAN K ~E PL~c¢.~-~ O.L' SEPARATION DISTANCES ~s~.tic u Ho~din~ U S.T.E,~. TO Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Slation Tank S .... Lines ~ ~6~o~AGE %~Nl< Number of Compartments: Surface Water >lDO' ?/oo' _ - ?/o~ LIFT STATION Lot Size in gallons: Manufacturer; / "Punlp on" level at: "Pump oil" level at: High waler alarm at: Foundation ~ ~OI ~ ~ O Curtain Pump Make & Model ~ Electrical Inspections performed by: Drain Remarks: I~ I~1(~ ~ BENCH MARK Location and Description: ) [ Assumed Elevation: ENGINEER'S SEAL Inspections performed by: FZ~To¢ %Ec~. 5YE~. Dates: 1st 6/2a/~ ~,--:,, .... , ...... Department of Health and Human Services approval Reviewed and approved by: ~/. ~ Date:~-/¢-¢~ 72-013 tRey. 9/91) MOA 25 /,-.-- T. 8. t4. CONCRETE [~oTToF4 STEP ~NLET ELF. V. ¢Jg.l ~ NEar' IzSo 6~L ~,E PTIC T/iNK .,OvTLET PROFILE " S I VE~T~C~tL SCALE: =- LOT ~, BLF, I, LAN£ (~ '[fie HILLS ~WN By: ~ . MLrNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGP,3tDE) PERMIT PERMIT NUMBER:SW940085 DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES OWNER NAME:MILLER CHARLES G & DENISE M OWNER ADDRESS:Il371 MOUNTAIN LAKE DR ANCHORAGE, ALASKA 99516 DATE ISSUED: 4/21/94 EXPIRATION DATE: 4/21/95 PARCEL ID:01533117 LEGAL DESCRIPTION: LAKE 0 THE HILLS BLK 4 1 LT LOT SIZE: 54606 (SQ. FT.) NID4BER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MIINICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ISSUED BY: ~ DATE: DATE: EXISTING SOIL ABS TRENCH SEPTIC TST LOT 5 o SEPTIC SYSTEM _ _  ,~EPTIC TANK TO BE EPLACED W. NEW TANK~~ . - ~ -,, ' -. Y "' LOT 3 ~. ~ ;_/ R ~oo, ~ '-..~,.. R 100' WELL LOT 4 L4, BLK 1, LAKE O'THE HILLS S/D SEPTIC TANK REPLACEMENT SITE PLAN ~3_,ATTO? TECHNICAL SERVICES 1 INCH = 50 FEET 14530 ECHO STREET DRAWN BY TFM ANCHORAGE, ALASKA 99516 APRIL, 1994 NOTE: THiS IS NOT A SURVEYED PLAT. ALL LOCATIONS SHOWN ARE APPROXIMATE. Flattop Techn~al Serv~es 14530 Echo Street, Anchorage, AK99516 Phone (907) 345-1355 Lot 4, Block 1, Lake O'The Hills S/D 11371 Mountain Lake Drive Wastewater disposal system installation Specifications 1.0 General: 1.1 The scope of the project consists of replacement of a rested out 1250 gallon steel septic tank with a new 1250 gallon septic tank. 1.2 Construction shall be as depicted on the approved site plan. Minor deviations from these drawings may be allowed or required by the engineer conducting the inspections. All construction procedures and material specifications shall conform with Municipal and State requirements. All separation distances shall be in conformance with Municipal requirements, unless specifically waived. 1.3 The contractor shall be responsible to obtain any necessm~ utility locates, and to work around any buried utilities. 1.4 The contractor shall provide adequate cover material and rough grading over all system components to ensure that proper drainage is achieved after settlement and that there are no residual depressions. Insofar as possible the contractor shah minimize damage to trees and existing lawn areas. 1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after the soil is compacted, as well as placement of topsoil and reseeding all areas disturbed by the construction. 2.0 Septic Tank: 2.1 The existing septic tank must be properly abandoned by thoroughly pumping, removing the top and backfilling with soil. If the existing tank is removed to allow the new tank to be installed in the same location, the old tank must be either crushed and buried on site or transported to the Municipal landfill. 2.2 The new 1250 gallon, 2 compartment septic tank shall be Municipally approved and shah be set level on undisturbed soil. Each compm~maent shall be equipped with a watertight manhole cover and a 4" cleanout. If the tank is buried less than 4 feet, it shall be insulated with 2 inches of approved burial type, rigid insulation. 2.3 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The waste line from the residence to the septic tank shall have a minimum slope of 1/4'" per foot, and the waste line between the tank and the soil absorption system shall have a minimum slope of 1/8" per foot. A cleanout shall be installed within 5 feet of the building foundation, and a double cleanout shall be installed within 5 feet downstream of the septic tank. 3.0 Inspection: 3.1 One engineering inspection will be required dmSng the course of the project, after the tank is set and the piping connected but prior to backfdl. The installer shall coordinate the timing of the inspections with the engineer sufficienHy far in advance to ensure the availability of the engineer. MUNICIPALITY OF ANCHORAGE " DErf %TMENT OF HEALTH AND HUMAN SER1 '~'~.S ' Environmental Health Division · ~ ~' 825 "L" Street, Anc.horage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES Address J Permit NO. NO. of Bedrooms WELL / Township, Range. Section AS-BUILT DIAGRAM (Show Iocahon of well. septic system, property hnes, Ioundahon. TANKS ~ SEPTIC [] ~ Maten~ No- ol Compadments [~TRENCH [] BED [] W. DRAIN [] OTHER Depth to p~pe bottom lrom ! Total depth from original grade~J Fill added abc .... iglnal grade~. Gravel depth beneath p.pe ~" ..~ /J '~ FT i distance between lines ~' FT '~' Number ol lines Soil rating Pipe materia Installer WELLS· [] PRIVATE [] OTHER Classdicahon (^,B,C) 1o~ Cased to REMARKS: ' · -. ' '. Scale: ENGINEER'S SEAL Inspections Perlormed by: I ,~, ~c t'l cedily Ihat Ibis in~pcclion was pcdormcd a,oording to all Municipal 81~d St~(, guJ[JBJirla$ Jl~ ,JJEBt on this dsJe: Health Department Approval: ~ Date: . 0'7 / i /./~3 7 ~Rt)-V'EL LEN6TH // ' PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN 825 "L" Street, Anchorage, Alaska 99502-06~ LEGAL DESCRIPTION: )EPTH (FEET) 1 3 4 7 8 o-.~ 12 '-'"('i 13 20 ~/e-~-~ or-r'7',de ,'/~///c 5~Township, Range, Section: T/2- 4) SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH.7 p E Depth Io Water After /// /i~'~ /'&/ Monitoring? ~ Date: . / GEoss Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~'0'¢ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~,.c" FT AND $% 0 FT ,,v,,~,. ,~lg .G, I¢ /,'2 PERFORMED BY: ~/, ~"/ I ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. CERT,F~ THAT TH,S TEST WAS PERFORMED ," DATE: '~/~'~. . 72-008 (Rev. 4/85) Woo'b ~Fz~ cg Gastalc~ ; AS BUILT ~11 BETTLE8 BAY LOOP MCH~A~E ~k. ~44- 4~72 ~,,~. iy: ~.A.~. .,TE~ 2-28-87 FIELD BO0~: 4 I HEREBY CERTIFY THAT I NAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY: LO'r. /; Block 1 L~KE O' THE HILLS SUBD. AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUB- DIVISION Pr. AT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CON- STRUCTION OR FOR ESTABLfSHING BOUNDARY O~ FENCE LINES LAICE GRE,-,.ER ANCHORAGE AREA BOk_JGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM ~ ' ~ PHONE SEPTIC TANK: DISTANCE \ NUMBER OF FROM WELL /00 /'MANUFACTURER ~--'r~--'~--~. MATER,AL$'T~---~*l COMPARTMENTS INSIDE LENGTH ~ INSIDE WIDTH ~ ~ LIQUID DEPTH ~ LIQUID CAPACITY /~G~LLONS. TILE DRAIN FIELD: / FOUNDATION DISTANCE FROM WELL NUMBER OF LINES / DISTANCE BETWEEN LINES ABSORPTION AREA_ ~C.~b SQ. FT. LENGTH OF EACH LINE DEPTH OF FILTER DEPTH: TOP OF TILE TO FINISH GRADE ~ f' MATERIAL BENEATH TILE IN. ABOVE TILE '~/ TOTAL LENGTH . NEAREST LOT LINE-~/-~ / OF LINES '~O / TRENCH WIDTH~,~' IN. TOTAL EFFECTIVE WELL: ,--- · BUILDING NEAREST NEAREST SEPTIC SEEPAGE FOUNDATION LOT LINE__ SEWER LINE__ TANK , SYSTEM IN. DISTANCE FROM: CESSPOOl . OTHER SOURCES APPROVED DISAPPROVED , ?.-.p - DISTANCES: /~ ~- /~O INSTALLED BY=~ SEWER LINE DEPTH: ,:5'- ~T DIAGRAM OF SYSTEM APPROVED~ . .- , GAA B (.? /3V." DELTA !ANC~4ORAGI;.ALA~IKA 90~07,i '~: i::1F:' F'I.... I E:I:::II",i"I" I_. JZi I:;: l::;I T ]: IZ;I I'.,I 'i-'YF:'iE EtF' SEtiL. RE'.::';iRE'T'I';t'.,I ':'~;Y:E;"FE;H IS' "I-F.~ENC;H "i"HE I;i:E(;:!I...iI,';;;:E:D SIZE OF' THE ':::r'II FIE::5OF=:F"i"tOI'.,I :, .:': Ih. Il IE!;' "f'HIE. L;~.EN;i~%f'H E:, :i: I"iE!'.,I:E; Z Ed'.,I i S THEE LEt'-,IGTH ,:: I I",1 F:EIET ::, OF "I"HE: TRE:H": 1-'I 0i:(: [::, [(:1::1 ]: NF' i E-:L..[:,. .'T:Hi~:!:' [::,E!:'"i"I-'I OF FI 'TI:;;:E:NE:H OF: PIT :I::.:::; THE £:,:i:S"i"F::IIqC:E: IEli'~:"l"l.,tEEl:'t'.,t THE': :~:~;I...tI:;::I:::I::IC:E 01::;' 'T'HE (31:;i:C!IJl'.,t[:, FII'.,I[) THE:: I_:~',ErT'TCH"1 01::' '!"HE E::.:: 'l I:::t',,,'F:IT 1131'.,I < :I: i",l F:'E:ET ::'. ~t'i-...IEEF;::.EI t :5 NO SET t.,.11 D'i"H F(3F: 'T'I:;;:E:i'-,ICHE'.E;. ......... '"'" ... . bid, I::L. E~IETHLEE~I'.,I TI'"IIE ". TF:¢:tL.I.... PIF'E THE:: ~I~H,EL DEi::"I"H i':5 THE I'"tli'.,IIHIJH DEF:'TH OF F:IND THE E;OTTCiH EtF THE IFX-:i:::I',,,'FITi(:'d'-,! (i1',1 F'EE:I"). i!!i: FI C: I< I:::' i Lt_ I i'.,tG "d::: FIi",!Y :!~;'T":'~';"i'E;t"t [,.l I THI3UT F:' I i",IFIL.. ! i",!SF:'[E(3T I 1111'-4 t:11"413, .::IF'I'-:'F' i 'v'Fll.... E?r' 'T'H t S i::,E?I:::Ii;i:THI~!I",IT i-,.I I L..L. DE: ':: D TI:3E:I' 'T'13 F'I:;:O!!.:,EC:IJT i i'"i i N i i"'tI. JH D i :[~;'i"FtI',tC:IE !E:E"Iq.,.IEEI'q l:::l I.,IE!:L.L. F:II",ID FINY Ot'-,I-'S I "FE E;Ei.,.II::II3E: [::, i SF'C~SF:IL. ?.¢STIEH i El; ::LEi¢:'!t F:'IEET !::'OF;: 1::t F:'F~ttVFI'I"E I.,.IiEI_L OF,'. 21EIEi!l F'EE:T FO,q'. F:t F:'t...!Ii?,L..IC I,JiEL..I ..... HELL.. LOG:E; Rl:;?_(i: t~:E:QLIlF;'.EI::, F:II'.,![> I',II..I:~;T !:]~E I;;i:ETUI:;:NiED "1'0 THE [::,EPI:::tF;:THENT !4ITHII'.,I :':!:E~ DF:!Y'.~i; OF' THE HEM... COHi::'I_ETiEI!'.,i. '3.';F'ECiI:::'ICFIT!Cff.,IE; FII",I[> COI'.,ItiS"I"I;::UC:T!OI'.,I [::,t1::I(:!ii:;.':1::11"1:5 FIF:E I::I',,,'FIII...RBL. E '1"0 Ii'.,I:!.:.;I...IF~:E F:'I:;;:OI:::'E:I;;: :i: I'-,I:.'.:.; T I::t L. LY¢I" i Oi'-,I. :L: t f::ll"'l F:RI"'iiL. I I::II:;t i.4i"I"H THE RE{;!L.t!I4tE]"IEI'.,IT:ii; I::'O1:;.': OI',I..-Si'T'E SE].,.IIEF;;~S FIND I,.IIEI....L.S I::lti~; I::'CI?."i"H BY THE I"IUi'.,I I C t F'FIL I "F'.r' O1:::' F!I',iC:HOi:,~:I:::IGE. ;::: i Hi!....I... iNt!!!;TI::il....L THE S'¥'S'[EH f l'.,l F:tE:CCd:;i:DF:INCE I.,.IiTH THIE 3':: t Ui'-,It>Ei-;;:S'FFIN[> 'T'HRT THiL::'. Cfi,I-SiT.E: 5Et.,.IE[F;: :iS"r'l~;"l"Et"t I"IF:IY I:;~:E(;:,:L.iIF.:E ENM::Ifq:GE:HE:I",IT IF THE .F?.IE:i~;iDIEI'.,iE:t;:i: !E; t:?.E:HEE)EI._ED "i'O ii',iE:I....I...!E:,Ii~: I'"iORE THFIN 3: Performed For tenal This "On~ ~ ~ ~ort~ ~ ~s~n~ opinlon~" 2204 Cleveland Anchorage, Alaska 99503 G~ry_ Stephens , Date Performed_ Qescri~tion: Lot 4 Block 1 Form Re~orts Soils Log F~¥ 16, 1977 . Subdivision Lake. of the~ Percolation Test 6 8 10 12 14 16 18 20 De~th Feet Soil Characteristics Peat Gravelly Silty Sand Slightly Silty Sandy Gravel IGtVl - GP] Bottom of Test Hole Was Ground Water Encountered? No I¢ Yes, At what Depth? Reading Date Gross Time Net Time Depth to H20 Net Drop } I I : Percolation ate ~linute Proposed Installation: Seenane Pit Drain Field Deoth of Inlet Depth To Bottom Of Pit Or Trench Cm"t~ENTS: 150 S~qu~e Feet clrainage area r~_ i~Lc:~;l_[~r t~:~troc~m frc~minu~ 4 f~ 16 ~- Data Certified B~:C~)NS~flq~JCgION ~ST I2L13 Test Performed By flare: ~/17/77 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL/ (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) hT z.'4''z'¢' h,8, (b) PFoperty Owner Telephone: Home 7,~'7' ~5/';5~/¢ Business (c) Lending Institution ~ ~ Telephone Mailing Address ~,- ~ /~} ~c~ (d) Real Estate Company and Agent ¢~ -,~Z_h~ - Telephone ¢~ ~ ~7 ~ '7~ (e) Mail the HAA to the followino address: or: Check here ~old for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family~ / Number of Bedrooms 4/_ 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 legatity and status. SEWAGE DISPOSAL Onsite~L 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. Page I of 2 72-025 fRev 8/86~ Front 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 varify 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 ~'~C.,/-...~c* ~'C, Date DHHS APPROVAL Approved for ~ bedrooms by Approved C~ Disapproved Terms of Conditional Approval Conditional CAUTION The Municipality of Anchorage Depadment of Health and Human Services fDHHS) 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 DHHSdoesthis 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. Page 2 of 2 72-025 IRe,/ 8'~61 Back MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) .~©,~,F,G~::HECKLIST - FEBRUARY 1984 \,~ \$\o~4 : Z~,'?'- WELL DATA Well Classification ~ /'~2'/z'''J/~)~'''' If A, B, C, D.E.C. Approved (Y/N) Well Log Present/~/)N) __ Date Completed ~.-~O- ~'? Yield Total Depth /~,Z~ Cased to /~2,- Depth of Grouting Static Water Level t~ /O,~; Pump Set At Casing Height Above Ground Electrical Wiring in ConduitON) Separation Distances from Well: Sanitary Seal on Casing~N) Depression Around Wellhead (Y& To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line 4/¢ Gleanout/Manhole Water Sample Collected by Water Sample Test Results Comments ('~ /,~O .¢~ ; On Adjoining Lots /.~'~/ ; On Adjoining Lots //~'¢ / '7~ To Nearest Public Sewer ~ To Near/est Sewer Service Line on Lot ~"'~" '¢' /u/?~-M2~:~ O, i · B. SEPTIC/HOLDING TANK DATA Date Installed 6 Stand pipes ~)N) Depression over Tank (Y/~) Pumping/Maintenance Contract on File (Y/N) ~-}]~ ;for Holding Tank High-Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Size /,~-5'~ No. of Compartments Air-tight Caps ~1) Foundation Cleanout (Y(~ Date Last Pumped To Building Foundation To Disposal Field Separation Distances from Septic/Holding Tank: To Water-SUpply ,Well To Property Line Td water MainZService Lie'8-; ' :¢ Course: ..... ' ' ....¢:,: To Stream, Pond, Lake, or Major Drainage Page I of 2 72-026 fRev 8/86~ Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed O/Z/(7' Width of Field Square Feet of Absorption Area Depression over Field (Y,~. Results of Last Adequacy Test Type of System Design Depth of Field 0'~/~ /2- Gravel Bed Thickness ~ Standpipes Present CN) Date of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation /'~ Lot ~/'~' ~L"7'Jd~'t~ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area / To Property Line To Existing or Abandoned System on ; On Adjoining Lots / To Cutbank (if present) ,,6)/¢4 Comments LIFT STATION Date I 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) ' "'""Pu4~ng~ Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** ~"~- ..... I certifythat I hav/~ec/~,~eri~Jed, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~/¢',Z~-----~ //,-//~--~'"'~ Date ~'~'-~ Company /'~ -'~ MOA No. ('~¢/" ~;~ ~//' Date of Payment '~/ ¢/ S ~ Amount: $ .//"~) ~ Page 2 of 2 72 026 fRev 8/861 Back MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-S TE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) -' LocatiOn (addres~ o'r dii'ections) ' (b) App icant Namb ',t.v~4' ..¢~'.,~/].~/¢ _4 Telephone: Home Business Applicant Address (c) 'AppliCant is (ch~ck bh'e);'Lend[ng Institution B ;; Owner/builder []; Buyer D; Other [] (explain); (d) - (e) Lending lgstitution Address ~ Real Estate Company and. Agent Address Telephone _.~q(fj- /--~r~¢¢~ Mail the HAA to the following address: Telephone (f) TYPE OF RESIDENCE Single-Family J[~ Multi-Family Number of Bedrooms '~ Other WATER SUPPLY Individual Well,J~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite~I~' 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) ,;2: ? NOl.l.n¥o leUO!l,!puoo oe^oJddes!a ~-'¢¢r' (~r£.<~ m? C2_~2¢Z / ssaJppv uo ~oe~)e u! euo!lelnOeJ pub 'seoueu]pJo '9epoo e)elS pub led!o!un~ lie MI!M aoUeildmoo u! s! ~els~9 lesods!p Je)eMe)S~M , Jo/pue ~lddn9 JeleM eHB-uo e~) 'uo!)oadBu! pue UOi~eO!iBaAU! X~ moji pue 9cig aOeJo~ouv ~o ~l!led!olunR emi peu!eiqo uo!]e~Jo/ui eqj uo peseq leql XJpGA Jeqpnj I 'uieJeq peleo!pu! eJnlonJls ~o edXl pue smooJpeq ~o Jeq~nu aql e~enbape pue leUOijoun~ 'ejes s! mels~s lesods!p JeleMe~SeM Jo/pue Xlddns JeleM a~is-uo eql leql SMOqS leAoJddv ~lpoq~nv qlleeH siql 1o uo!leSllSeAU! Xm leql ~jpeA I 'MOleq UMOqS elep uo!l~p!leA eql jo se pue oleJeq pax!jle lees ~ ~q peg!peo sV NOIZY~OJNI aNY v&Ya 'HOMY3S ~qlJ 'SZS]~ 'SNOIXO~dSNI 9NIOIAOMd ~14 .g ~ ~cwtO,~,GE .MUNICIPALITY OF ANCHORAGE (MOA) 0~' ~ .... ~.C~P,k~-~ .... ~c~.s O~V~s ~I.-IEALTH AUTHORITY APPROVAL (HAA) ~u~ .~1~LS~ CHECKLIST - FEBRUARY 1984 264-4744 Legel Description: ~ ~ 4/ Well Classification t~.,I V'/~T~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (~)N) Date Completed "'7/"~O (-7 ? Yield Total Depth ( ~, ~ !Cased to I?~ ! Depth of Grouting Static Water Level I0 ~ I '.., Casing Height Above Ground Electrical Wiring in Conduit CH) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line "lC/* Pump Set At I ~ ! Sanitary Seal on Casing CH) Depression Around Wellhead (YG ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout~Manhole Water Sample Collected by ( Od /VOX/ To Nearest Sewer Service Line on Lot ;Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Datelnstalled ~ /?/ '~Tsize l~¢'~"0 No. of Compartments Standpipes CN) Air-tight Caps CN) Foundation Cleanout (Y/~_~ Depression over Tank (Y~ Date Last Pumped Pumping/Maintenance Contract on File (Y/N) /~//A ; for Holding Tank High-Water Alarm (Y/N) /~'//A Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well I ~t I To Building Foundation ~" ! To Disposal Field To Stream Pond, Lake,.or Major Drainage 72-026 fRev 8/86~ Front C. ADSORPTION FIELD DATA Soils Rating in Absorption Strata / 50 i~ V~)/~ Type of System Desig Date Installed ~0 f~_- / '7 7 a.~ 7/~//¢? Length of Field ~0 / Width of Field ~ t' , Depth of Field Gravel Bed Thickness ~ ~ ¢~1~ Standpipes Present~) Date of Last Adequacy Test Square Feet of Absorption Area Depression over Field (Y/(~) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well I ~'~/ i To Building Foundation Lot To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~ 0 / To Water Main/Service Line ~,J'OME- /%/~-4/q.- To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course ~.'.'~0/~'-t¢-- [t~O / To Driveway, Parking Area, or~/hicle Storage Area / ,~ / Comments I-J,,?'c~,a/~.o:/ 7Lo/~)Jeo/.'~c~.-~¢.~J~/.//¢,Y. ~?/o~,~/ ~-'~'~-/z~'t[7~., LIFT ST~,,~.~ Date Installed ~ Size in G_allons ~ .. ~ Pumping Cycles during Adequacy Test, Meets MOA Tested for CommentsElectrical Codes (Y/N~,/.~,'~/ ~ ** 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 MOA No. Receipt No. ~/"~-~ / Date of Payment Amount: $ Page 2 of 2 72-026 fRev 8/861 8ack Dimensions ¢~ Manhole/~N) ~.......~ Off" Level at Vent (Y/N) A CHEMICAL & GEOLOGICAL' ~ORATORJES OF ALASKA, INC. ,~~~,~ 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)562-2343 FEDERAL TAX ID # 92-0040440 JUL i'? L47 Sand C1 ient ~cco~.'.;',t : A!tECSF, r REports Addrss~ ~2 ~¢~= N~t Anawzed ..l=Les5 Than, G'F=Sreater i'nan CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 ~ 5633 S Street ~ Anchorage, Alaska 99518 Drinking Wat~ Analysis Report for TOtal Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER PRIVATE WATER SYSTEM ' ,'.:'>0 Wes* 23rd ~alling Address Ci, ty State SAMPLE DATE: ~ ~ ~ Mo. Day Year S ~,MPLE TYPE: Routine Check Sample (for routine sample with lab ref. no. Special Purpose '! LOC~ .? C: Zip Code & [] Treated Water' [] Untreated WelterS, · ,,, .-'r, II Collected READ INSTRUCTIONS Date Received :: Time Received Analytical Method: / TO BE COMPLETED BY LABOF~ATORY Analysis shows this Water SAMPLE to be: ~ satisfactory t / / [] ~;l~;tlieS,::;t~r..y~ ; ~s~mpleshould [] ,~,,,u in tran it; not be over 30 hours old et.examination to indicate reliable results. Please send new sample via special delivery mail. Membrane Filter * No. of colonies/100 mi. / 'Lab Ref. No. Result~t Membrane Filt~ ~irect Count RECORD Verification: LIB ~ '% BGB.~ Final Membrar~e Filter Results (~i': ii,.- Reported By i;!% BEFORE COLLECTING SAMPLE ~ITC -- Too Numberous To COunt (:.B = Other Bacteria Analyst Coilformll00ml Coilformll00ml a.mo