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Home My WebLink AboutSOUTHPARK #2 BLK 3 LT 5 / MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street-~Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE [~NEW MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS DISTANCE TO: IWelr ~ AbsorPtion area/O I ~0~'~)Dwelling: I 0' PERMIT NO'~Oe ]~ ~ ~ Manufacturer ~aterlal No. of compartments ~ h Liq, capacity in gallons Inside length Width Liquid depth /~D IF HOME.DE: ~ DISTANCE TO: Well Dweging PERMIT NO. Manufacturer Material Liquid capacity in gallons ~~ No. of lines / Length of each~/line Total length ~/°f lines Trench width'~o inches Distance between mines . Q~ mopof ' to finish grade~ ~ $,7 / Materialbeneath~E ~ inches Total effective absorption~ea Length Width Depth PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot llne DISTANCE TO: Class Depth Driller Distance to lot llne PERMIT NO. DISTANCE TO: Building foundation Sewer llne Septic tank Absorption area(s) OTHER PIPE MATERIALS 72-013 1/78) ~dLIr~IBSI~ .~LIT~· CBF ANCHk_,~:AI]E DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 294-~720 OPt--$ I TE SEI,IER PERbl I T F'ERMIT NO: 8404i8 C.,RTE ISSUED: 0~,, E'~4,-' M4 APF'L I CANT: Ar)DRESS: CONTRCT PHONE: GREAT LAKES CONSTR. 200 W. ~4TH SUITE 687 ANCHORRGE~ RK 9950~ ~44--880 LEGAL DESCRIP: SUBDIVISION: SOUTH PARK ~2 LOT: 5 SECTION: ~ TOWNSHIP: lin RANGE: ~W LOT SIZE: 29090 (SQ. FT. OR ACRES> MAX BEDROOMS: 4 BLOCK: LISTED BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DE-~IuNINJ YOUR SEPTIC: _.~sTEM. CHOOSE THE OPTION THAT BE--.T FITS YOUR SITE. T~:E~C:H BE[:', DEPTH TO PIPE BOTTOM (FT.) 4. 0 5. 0 4. 0 GRA',,','EL DEPTH (FT.) 8. 0 0. 5 -?,. 5 TOTAL DEPTH (FT.) t2. 0 5. 5 7. 5 GRRVEL WIDTH <FT. ::' 2. 5 2-~. 0 5. 0 GRAVEL LENGTH (FT. > 4~3_ ~ '45. 0 75. _,.~. 8 ,,A ?, 55. 5 GRAVEL VOLUME (CLI. "r'DS. ) -~-~ -' _ TANK SIZE (GALS.':' l, 250..0 .a~. ±., 250. 0 SOIL RATING <SQ. FT ,."DR) ±?2 i72 · :~ TANK MUST HR',,,'E RT LEAST TWO COMPARTMENTS I CERTIFY THAT: ±. I AM FAMILIBR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET FORTH B~ THE MUNICIPALITY OF ANCHORAGE (MOA) .BND THE STATE OF ALASKA. 2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS, AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. ~. I WILL ADHERE TO ALL MOA AND STRTE OF ALASKA REQUIREMENTS FOR THE,SET BACK DISTANCES FROM A~Y--EXISTING WELL, WASTEWRTER DISPOSAL SYSTEM OR PUBLIC SEWERAGE SYSTEM ON THIS OR BNY ADJACENT OR NEARBY LOT. 4. I UNDERSTAND THRT THIS PERMIT IS VALID FOR A MAXIMUM OF 4 BEDROOMS AND ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT. THEN WILL ELECTRICAL WORK I"IUS. T BE DONE BY A LICENSE[:' ELECTRICIAN. APPLICANT: GREAT LAKE=, CONSTR. i ~:,UED E:Y LIFT STATION IS INSTALLED IN AN ARER COVERED E:Y MOA BLIILDING CODES., (iL) RN ELE_.T~.IL. AL PERMIT RND INSPECTION MUST BE OBTAINED; (2) A--,-BUILT_. NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT) AND (-~) THE I%vNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION S25 L. Street, Anchorage, Alaska 99501 264*4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: LEGAL DESCRiPTiON: ~"H 2 3 PERCOLATION' SLOPE ~--.. 10- 11 WAS GROUND WATER ENCOUNTERED? 12 13 14 15 16 17 IF' YES. AT WHAT DEPTH? S Gross Net Depth to Net Reading Date Time Time . Water Drop (minutes/inch} FT AND ,, FT COMMENTS PERFORMED ~Y; CERTIFIED BY: DATE: DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA g9501 BILL SHEFFIELD, GOVERNOR 274-2533 MUNICIP/\LWY OF ANCHORAQE DEPT. OF HEALTH & ENVIROJ'qMENTAL PROTECTION NOV 6 /984 RECEIVED To Whom it May Concern: ,; According to records on file in this office the - ~]C,C~,'y_X,~r~'/,,~ Water System is in compliance-with the State Drinking Nater Regulations 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 _~. '~_~ -- ~"~ NAA # ////~ GENERAL INFORMATION Complete legal description ~-,'~ /-~,~P -~'~-'-~ Location (site address or directions) -_~ ~ ~-~ t~ Property owner /~}/~ *- f ¢'~(~-~ /¢~_/~//~/C~2 ,(/' Day phone ~4/_~_ / c-~ ,/!~ ,ending agency Mailing address Agent Day phone. Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ TYPE OF WATER SUPPLY: NOTE: Individual well Community well -~ Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site 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 dc-~/'~--~ ~-' ~/'~-2~,~//~°~/~'~'_~;C'*~ Phone Address ~/~ ~'~'/~~ ~/~// ~~ ~' Engineer's signature .~~ ¢~p/~ ¢ ,¢,/~ Ma[e DHHS SIGNATURE ~,,,, ..... ,'"~ ~ Approved for I~~ ~. 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 engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in ord. er 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. 72~325 (Rev. 1/91) Back MOA ~25 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 1. GENERAL INFORMATION Complete legal description Location (site address or directions) "~ ~0 ~-'~2~/~/~,/~/'~.~ Property owner '' ~/~-J¢2¢_.//~:_ ~ /~.///¢~//~. ?~ Day phone --Lending agency ' ~ .... Day phon~ Mailing address Agent Day phone Address 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well Community well X Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written 6onfirmation 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. Phone Date /"2¢E. "'f>/ # ~517 E 6. DHHS SIGNATURE °° ........ ' _ ._ 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 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. Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~ ~ b.~ ,~[_l~'f~~arcel I.D, A. WELL DATA Log present (Y/N) Date completed Total depth Sanitary seal (Y/N) Date of test Static water level Weld flow Pump level SEPARATION DISTAN, N~ Septic/holding taxplan lot Absorption fi~?r~ lot WATER SAMPLE RESULT / Coliform AD EC.~w~..~ystem numbe~,.," ~-~ ~/ ' Driller Casedto / Casin~ height W~rly protected (Y/N) FROM WELL LO/~ AT/~SI~'EcTION / / // FROM WELL TO/ / ; On adjacent lots // ;On adjacent lots Public sewer manhole/cleanout Petroleum tank Nitrate Other bacteria Date of sampl,~/ B. SEPTIC/ Date installed Clean°uts(~. High water alarm Date of pumping Collected by: ,,~undation cleanout (Y/N) Compartments Depression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TAN~ T~O: Well(s) on lot ~'/ /, p~. On adjacent lots ~/)~; Foundation (~ '/ To property line ~"~ Absorption field '~ ~ Watermain/serviceline /~f~ Surface water/drainage ~ ~~ ~ ~~ 72-0~6 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent(Y/N) "Pump on" I e"~v.~ ~'~, :~t; r: le~: rlie:al lc o d e s (y/N )/' ~Cycles / SEPARATION DISTANCE FROM LIFT STATION TO: ufao~ turer ..hole/Acoess "Pump off" level at tested Well on lot On adjacent lots Surface water D' ABSORPTION FIELD DATA ?:¢!z.'~¢~¢ ::/ Date installed [/~ 0~-~'-"/~' ' ~/'~' ~ ~Soil rating /~7 'W~¢'~ ~ ' Totaldepth /~¢ Z ~ Length E? Width ~¢ Gravel thickness ~em type Total absorption area ¢~ ;~ '~ Cleanouts present (Y/N) % ~ ~-) Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Date of adequacy test fgr '~ ~r yes, give dat~ bedrooms SEPARATION DISTC, NCE FROM ABSORPTION FIELD TO: Wellon lot /~/~ ~:~-----~ O,.0 adjacent lots ,,/'V/¢'~ 'F~-~--- Property line To building foundatioZ~-'~ ~ O To ex st ng-.or~andoned, system on lot On adjacent lots _ Cutbank _ Water main/service line Surface water / ~-~ ~_~? ~.~'P'""~/ Driveway, parking/vehicle storage area Curtain dr,ain E. ENGINEER'S CERTIFICATrON'~ I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on of this Inspection. Signature Eng neer's Name ~.[>'~,¢¢~-'-~ ~.~ Date HAA Fee $ ~/'~) Date of Payment Receipt Number 72-026 (Rev, 3/91) Otmk MOA Waiver Fee: $ Date of Payment Receipt Number DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE DISTRICT OFFICE 3601 "C" STREET, SUITE 322 ANCHORAGE, ALASKA 99503 WALTER J. HICKEL, GOVERNOR (907) 563-6775 December 11, 1991 FOR: Jim Sizemore PWSID Cf 213475 My review of the records on file in this office reveals that the South Park Subdivision Class "A" Public Water System, is in compliance with the routine coliform bacteria sampling requirements listed in Table C, and with the inorganic sampling requirements listed in Table B of 18 AAC 80.200. Sincerely, Byron Roys Environmental Engineer BR/cf ~ MUNICIPALITY OF ANCHORAGE ?) · UNICIPALITYO~ ANCHORAGE DEPARTMEN~ OF HEALTH AND ENVIRONMENTAL pRuTECTI(~J~iiRONMENTAL SERVICES DIVISION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~.' ~: B 2 Q ]988 OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION Ia) (b) (c) Lega! Description (include lot, block, subdivision, section, township, range) Location (address or direct ons} / ' / Applicant Name ~;~'~/"f~¢"¢'~2,,/~!f'~- _-'rdeph6ne: Home '~4~---ZlZT'ausiness ;~'~--~1 Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other,.~ (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family,,,~3 Multi-Family [] Number of Bedrooms ~- Other WATER SUPPLY Individual Well [] Community.~,~ Public [] Note: If community well system, mu~t have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsitev~ Public [] Community [] Holding Tank [] Note: If community well system; must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. 72-025 (11/84) Page 1 of 2 ENGINEERING FIRM PROVIDII ,NSPECTIONS, TESTS, FILE SEARCH, Do A 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 ir) effect on the date of this inspection. Engineer's Seal [;)HEP APPROVAL Approved for ,~.-P-/- ~"~,'~ bedrooms by Approved ~/~_ Disapproved Terms of Conditional Approval ~onditiona~ 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 MUNIClPALII'Y OF ANCHORAGI~ DEPT OF HEALTH & · .. _ROTECTi(~NIOIPALITY OF ANCHORAGE (MOA) ENVIRONMENT^t- ~' HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY lg84 FEB g g 1988 2e4-4744 RECEIVED Legal Description: WELL DATA Well Classification C-,C)~"'~ vY~U,~.3\"'f'~.~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) ~,,~/J¢~', Date Completed Yield 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 Depth of Grouting Pump Set At Sanitary Seal on C¢- Depre~Wellhead (Y/N) .~;; On Adjoining Lot/ ;On Adjoinings Lots ~To Nearest Public Sewer /~'To Nearest Sewer Service Line on Lot ; Date B. SEPTIC/HOLDING TANK DATA Date Installed~ "7/~ Standpipes (Y/N) ~"~'~ Depression over Tank (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 ~_. O~ '-Jr- TO Property Line j To Water Main/Service Line t',~/'/~ ' Course ~ O0 I Size~ ~.-~ No. of Compartments Air-tight Caps (Y/N) ~'~ Foundation Cleanout½Y/N) Date Last Pumped c~/[ ~-, ;for Temporary Holding Tank Permit (Y/N) To Building Foundation J ~) ~' ~ To Disposal Field ~ J ~ / To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026 fRev 81861 Fronl C. ABSORPTION FIELD DATA Soils Rating in Absorption StroJa Date Installed _~_/' ~- Width of Field b~(7) ¢.//~)~"l~ype of System Design Length of Field Depth of Field .~--~,2:.N~, Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test Square Feet of Absorption Area~'''''~ -'~'~O Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ,~OC3 ~.'-~- To Building Foundation -~ ,.-"z.,~. Lot ~'~/'1~' To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~ To Property Line To Existing or Abandoned System on ; On Adjoining Lots TO Cutbank (if present) D. LIFT STATION Date Installed .~imef~ions Size in Gall, ons /..//~anhole/A~c~ss (Y/N) ~ "Pump On' Level at J "Pump/Off' Level at ~ THie:the~Nf~r Alarm Le~el ~ /-uVmep:::Y/c~:les during/acy Test. Meet/ s MOA Electrical Codes (Y/NJ/ / / Comments ~~~. ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or~onformed to all MOA and HAA guidelines in effect on the date of this inspection. Company C~_~;~ ~' ~(-MOA No. Date of Payment Amount: $ /~ [~-~ .... Engineer's Seal Page 2 of 2 72-026 fRev 8/86/ Back 3601 "C" STREET. SUITE 1334 ANCHORAGE. ALASKA 99503 STEVE COWPER, GOVERNOR 563-6775 DATE: ................. To Whom It May Concern: According to the records on File in this o¢¢ice, the ____C.~__LJ_ __ _ State o¢ Alaska Drinking Water Regulations, Sincerely, Environmental Field OFFicer ?HOM CUSTOMER INVOICE # 2 t~5 1 SERVICES, : NC "15000 Francesca Drive ' . Anchorage, AlaSka 09516 ~345-1890 or 345-2444 · !. Gay Leslie q-~. -.: 4620 SoUth Park Bluff DriVe '~: Anchoraqe, Alaska 345-2935, 261-4424 ,, Block' Lot DATE DESCRIPTION AMOUNT 9-15-87 Pump Septic 75,O0 afternoon If no one at home slip copies under garage door if possible, TOTAL REMARKS /f~) ~allons ~Septic Cesspool Holding Tank ~ Standpipes ~-~ Time ~ ~O~LE~ AREA--CALL FOR ~ORE INFORMATION DS TO BE DONE AGAIN IN 8 ~ONTHS Shape ~ Sludge buildup on bottom ~ Floater on top ap missing or ~ Cut standpipe to 1' above ground ~ Needs Septlctrine needs replacing --PLEASE PAY FROM THIS INVOICE-- f~ MUNICIPALII"f OF ANCHORAGE~ DIVISION OF ENVIRONMENTAL HEA~fH - DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE General Information Application Date /0~o~ (a) Legal Description (include lot, block, eub.divi.~.ion, section, township, r~ar~e.)~ Location (address or directions) (b) Applicants Name ~/~ Applicants Address Telephone - Home Business (c) Applicant is (check one) Lending Institution Buyer [--~ ; Other [222 (~,plain); - (d) Lending Institution Address Telephone (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. Type of Residence Number of Bedrooms 3. Water Supply Individual Multi-Family~ Other (describe) 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 Che legality and status° [Page 1 of 2] 5. En~ineerin~ Firm Providin~ Inspeetions~ 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 Mun%eipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wsstewater disposal system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firm ~z5~-., ~L-~ .-~ ~Ff Telephone ~z/~-~f~/ Address ~/~o '.~ ~ ~ ~. ~e- Date (ENGINEER SEAL)' DHEP Approval Approved for~_~bedrooms By Approved_~_ Disapproved__ Conditional Terms of Conditional Approva~ ~ADTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN T~ STATE OF ALASKA° THE I~tEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE PfONICIPALITY 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 A. ~LL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITY O/: ANCHORA(DI~ DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION OCT '! 984 RECEIVED Well Classification Well Log P~esent (Y/N) Total Depth. ~ Cased to Static Water Level Casing Height Above Ground Elect~ical Wiring in Conduit (Y/N) Separation Distances f~om 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 Legal Description: If A, B, c~ C, D.E.C. Approved(Y/N) Date C~%~leted -- Yield -- -- Depth of Grouting. Pump Set At Sanitary Seal on Casing (Y/N) Depression A~ound Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To ~%arest Public Sewer To'Nearest Sewer Service Line on Lot ; Date SEPTIC/HOLDING TANK DATA Date Installed ~/~/ Size /~o Standpipes (Y/N) ? Air-tight Caps (Y/N) Depression ove~ Tank (Y/N) /%/ Date Last Pumped Pumping/~aintenance Contract o~ File (Y/N) - ; for -- Holding Tank High-Water Alarm (Y/N) -- Temporary Holding Tank Permit (Y/N) Separation Distances f~om Septic/Holding Tank: To Water-Supply Well ~//~ To Building Foundation ~/~ To P~operty Line ~o~ To Di.sposal Field To Water Main/Service Line' Course No. of Compartments ~ Foundation Cleanout (Y/N) -/V To Stream, Pond, Lake, c~ Major D~ainage [Page 1 of 2] ~ L~ ,~_~ZD 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~/~/ Width of Field 2~o" Square Feet of Absorption A~ea Depression over Field (Y/N) Results of Last Adequacy Test /~.~. Type of System Design Length of Field ~/'~ / Depth of Field ~7~ / Grail ~d ~ick~ss ~ ~ ~ 7~ Stan~i~s ~esent (Y~) ~te of ~st A~a~ ~st Separation Distance f~om Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Majo= D~ainage Co~se To D~iveway, Parking Area, or Vehicle Stc~age. Area To P~operty Line ~ ~ ~ ~o "' TO Existing or Abandoned System cn ; On Adjoining Lots ,~'.~' /~/~ TO Cutbank(if p~esen~) Date Installed Size in Gallons "Pump On" Level at High Water Alarm L~vel 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. Meets MOA Comments ** Check Permitted Bed~ocm Rating Against HAA Request I certify that I have checked, verified, or conformed to all MOA on tho dato of thi~.~ inspocticr~. KB1/d5/s [Page 2 of 2] 2-15-84