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HomeMy WebLinkAboutSPRING HILLS ESTATES BLK 2 LT 18LoT' Development Services Department Building Safety Division On -Site Water & Wastewater Program o °G£ $`'<a =3 4700 Elmore Road z P.O. Box 196650 Mark Begich Anchorage, AK 99507 s n E T Y Mayor www.muni.org/onsite (907)343-7904 Pump Installation Log Well Drilling Permit Number: SW Date of Issue: Parcel Identification Number: 015- 051 "53 Legal Description SCr'ir,� FS- B2. L18 Pump Installation Date: (, /1�/, .9 Pump Intake Depth Below Top of Well Casing: 236 feet Pump Manufacturer's Name: 1,R4e49 -/CCT Pump Model: Gu :PS/6 Pump Size 3/� hp Pitless Adapter Burial Depth: l 90 feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: AA Well Disinfected Upon Completion?XYes ❑ No Method of Disinfection: Comments: Property Owner Name & Address: gyp SPRii16�crrcc. �R 6gMC,vAAA Gdr A 44507•'13T5 �� +z"'"+e ANCHORAGE WELL & PUMP SERV. Pump Installer Name: 330 EAST 76TH AVENUE •,�,,, ANCHORAGE, AK 99518 PHONE: 907-243-0740 AWPS.COM Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. MIJNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVlRONMENI'AL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE! DISPOSAL SYSTEM AND/OR WELL INSPECI'ION REPORT NAME LEGAL DESCRIPTION LOCATION ~ d ' Well Absorption area ~ Dwelling ~' Liq, capacity~a OhS Inside length Width P N-~--N ~ NO, OF BEDROOMS/ PERMIT NO. No. of compartments Liquid depth Length feacbljne I-~ Top of die to finish grade --,~1 Foun ati n Total length of lines~z/ ~ Material beneath tile Material Nearest lot line Trench widtl It:2(') inches ~_.LI inches PERMIT NO, Liquid capacity in gallons PE~IMIT NO. ~-\ ANb We ~ l EN Distance between lines Total effective a rption area (oql Length Type of crib DISTANCE TO: Class DISTANCE TO: Width Depth PERMIT NO, Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest ~ot Eno Depth Driller Distance to lot line PL:RMIT NO, Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS ~,PPROV ED / 72-013 (Rev. 3/78) DATE LEGAL t / I ' MUNICIPALITY OF ANCHORAGE f Health and Environmenta ~ Street, Anchorage, AK. Department Protection 825 ~9501· * * * HANDWRITTEN PERMIT * * * psrmit ~ ~a~-~~ ON-SITE SEWER PERMIT LO'cation: ~ ~. ~-~ ~/Z~,. Phone. Nu~er: ~1--~ r/ L~gal Description: Z /~ d a ~/~ Lot Size: ~2 T~pe of Soil ~sorption System Is~ ~ /~ ~/~ ~ Trench: Drainfield: ~_. Seepage Bed: Holding Tank: M~xim~m Number of Bedrooms: ~ Soil Rating(sq.ft/br) ~ The Required Size of the Soil Absorption System Is: 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 minim~ depth of gravel between the outfall pipe and the bottom of the excavation(in feet). Permit 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 wiI1 be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feel for'a private well or 150 to 200 feet from a public well depending upon the type ofl public well. Minim~un distance from a private well to a private sewer line is. 25 feet and to a com/aunity 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. ~>'t' * * * PERMIT EXPIRES DECEMBER 31, 1 9 ~, f ~'.~certi y that: ~ ~ (1) I ~ f~iliar with the requirements for on-site sewers and wells as ....~ s'et forth by the Municipality of Anchorage. h ~ ~ (2) I w~ll ~nstall the system ~n accordance w~th codes. ~, ~' (3) I understand that the on-s~te sewer system may require enlargement ~f ~3 .~ the~residence is remodeled to include more that 3 bedrooms. ~' ' Issued by: _ Permit Applicant: Location: Legal Description: Type of Soil Absorption System Is: Trench: · ~/~ Drainfield: ~~z Seepage Bed Maximum Number of Bedrooms: MUNICIPALITY OF ANCHORAGE Department f Health and Environment~ Protection 825 ,'. Street, Anchorage, AK. 99501 * * * HANDWRITTEN PERMIT * * * / ~ WEL/J~ ~~~~ PERMIT ~[3(~t Size: ~J//~ Holding Soil Rating (sq.ft/br) DEPTH The Required Size of the Soil Absorption System Is: LENGTH ~ GRAVEL 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 = /(J//~ · GALLONS Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of resid%nces that the well will serve. · * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this departmen will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fee 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 * * 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 r~uire enlargement if the residence is remodeled to include mor~.that ~ bedrooms. Signe~: Issued by:~'~ ?/~:)~./~_~u_~2_~ Applicant Date: SWP/024(1/81) DRILLING LOG Well Owner--'2h~t~'qen Constr~ctioz~ Znc, M-W DRILLING, Inc, P.O. Box 10-378 ~, 10300 Old Sev,'srd 'tighwe~. , (90'~ 349-8535 '~)L, NIC PA.L(Ty OF ANCHORAGE ANCHORAGE, ALASKA 99511 D[PT. O~: HEALTH & ENVIRON!v~EhjTAL PROTECTION 2 1984 Location (address of: Township, Range, Section, if known; or distance main road Size of casing 6" .Depth of Hole 2~2 feet Cased to. 240.~0 feet Static water level 200 ft. (/~gq~) (below) land surface. Finish of well (check one) open end (,~×). ); Screen ( ); Perforated ( ). Describe screen or.pcrfprat~qn.. None Well pumping test 9t;/10 gallons~] per (h~Ut9 of drawdown /yom statie_Jev%l. Date of completion V. ay ~.8, 198h (minute) for_l __hours with ~00 ~',, Depth in feet from ground surface WELL LOG Give details of formations penetrated, size of material, color and hardness TO. 2 __ 2 TO. ~5 :0 TO 160 l~O TO 2.00 Soo TO. ~ 2;?~_TO 235 ,-35 TO_ 2h2 .... i__TO. .TO. Oasing stickup Brown L~a~ld & Grmvel Gray. S:ll.ty ,Gravel r_d~amp Gray Hardpan Bro~ Silty Gravel Brow~ Silty Gravel - da~.p Waterhearing Oravel- Silty W~terbearing Gravel - clean SOILS LOG MUNICIPALITY OF ANCHORAGE ,,, ' DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3- 4- 5- 6- 7 8 9- 10- 11 13- 14- 15- 16- 17- 18- 19- 20- COMMENTS SLOPE DATE PERFORMED:__ SITE PLAN WAS GROUND WATER S ENCOUNTERED? /q c I~ YES, A'F WHAT E DEPTH? .... Gross Net Depth to Net Reading Date Time Time Water Orop PERFORMED BY: 72.008' (6/79) CERTIFIED BY; MUNICIPAEITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG -, PERCOLATION TEST SOILS LOG [] PERCOLATION TEST L.GAL DESCR,PT,ON:__ ~L-n~' ~U~--E~U I~ '?" ~SLOPESt DATE PERFORMED: ', SI~'E--P LAN 1 2 3 4 5 6 7 8 10 11 12 13 14 15 16 17 18 19 WAS GROUND WATER ENCOUNTERED? IF YI:S, AT WHAT DEPTH? Reading Date Time Time Water Drop 2O COMMENTS PERFORMED BY: lATE s/inch) 5TB3-ozH SEr{¥1CE,~ NO. ~uite B ALASKA 99503 276.1361 2,79-2917 CHEDKED BY .... SCALE DATE DATE ALASKA ENVIRONNIENTAL CONTROL SERVI( ~, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 ~o~ B2 L-18 SHEET NO. CALCULATED DY CHECKED ElY. ~D^~E__1% 30' OF DATE 40' \ . MUNICIPALITY OF ANCHORAGF DEPARTMEN'r 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 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (addrossor directions) '~E) "Applican't Name ~¢~~e~ Telephone: Home --~/ ~ Business B~-~tS[IJ ,,(C) Ap~lidant is (c.~eck ofie~: Lending Institution ~; Owner/builder ~; Buyer ~; Other D (explain); (d) L~nding I~titution Address ~1/~L, (e) Real Estate Company and Agent Address ~/~,- Telephone ~ / ~,- Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family [~ Multi-Family Number of Bedrooms Other WATER ,~)UPPLY individual Well 0~, Community r-1 Public r~ 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 el Environmental Conservation attesting to the legality and status, Page 1 of 2 72 025 ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the vafldation 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 reGula[ions in effect on the date of this inspection. Name of Firm h.E.C~ ~). ~nC Telephone 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. '['he DH£P 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 z~-o2,~ (~0,~) _?.MUNICIPALITY OF ANCHORAGE (MO~,I ~¢ t~c¥;°.~/~ HEALTH AUTHORITY APPROVAL (HAA) · ,.,~c~?l~x~. ~'~.~.~c~o~ CHECKLIST - FEBRUARY 1984 [~,~ ¢~..~¢~ ~. t~- ~ 264-4720 Legal Description: ~ WELL DATA Well Classification ~I]V,~)I[/I~OUI~/~. If A, B. O, D,E.C.. Approved (Y/N) Well Log Present i~)_ ~ Date Comp eted ~/~ ~/~ ~/ total Depth ~Z C~sed to .2¢O, 3 De.th of Grouting Static Water Level ~.~ Pump Set At Casing Height Above Ground Electrical Wiring in Conduit ~)N) Separation Distances from Well: To Septic/Holding Tank on Lot !0~' z To Nearest Edge of Absoroeon Field on Lot ! ! '7 To Nearest Public Sewer Line Cleanour/Mannole Water Samole Collected by Water Sample Test Results ~~~."r~¢_ Sanitary Seal on Casing (~N) Deoression Around Wellhead (Y,(~ ; On Adjoining Lots /(~O / 7~' : On Adjoining Lots __ To Nearest Public Sewer To Nearest Sewer Service Line on Lot _~ Date ~:;'/~ ~/~:~ Comments SEPTIC/HOLDING TANK DATA Date nstalled_ ~'~ '-~"~ Size _[2-5 Standpipes ~'N) __ __ Air-tight Caps ~N) Depression over Tank (Y/(~ Pumping/Maintenance Contract on File ~Y/N) Holding Tank Fligh-Water Alarm [Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ~OL · To Properly Line _ ~- To Water Main/Service Line /V/,~' Course _ I _(~)~), No. of Compartments Foundation Cleanou.t ~N) Date Last Pumped ;for_ _ Temporary Holding Tank Permit (Y/N) __ To Building Foundation To Disposal Field __ I O/ / '¥o Stream, Pond, Lake, or Major Drainage Commems Page 1 of 2 72-026(!1/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~//~ -~/~ ("/ Width of Field ~ / To Water-Supply Well To Building Foundation _ Lot To Water Main/Service Line Square Feet of Absorption Area Depression over Field (Y~ Results of Last Adequacy Test _ Separation Distance from Absorption Field: ll'Z/ ¥o Stream/Pond/Lake/or Maior Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field ~z../ w Depth of Field ~'~'.~ Gravel Bed Thickness 2~ ~) Standpipes Present (i~N) . Date of Last Adequacy Test _ ;rd&'¢ To Property Line __ /~- / To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) __ /V//~ IQ© Comments D. LIFT STATION 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) ~ _ ~.z/~ n t (Y/N) ~ Pumping Cycles during Adequacy Test, Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I ~.ave/¢.~,¢~ k.e.d., v.,erifie¢, or conformed to all MOA and HAA guidelines Signed L1.,¢~//~ Date <~2//~'/0~¢/ Company ¢./~,/,~.ES //~/L~, MOA No. _ ~::::>,~-~2¢ Date of Payment Amount: $ Page 2 of 2 in effect on the date of this inspection. ALASKA UIRODIll DTAL COI1TROL $ I ulCE $, InC. JEFF 'rlIIMSEN 9940 SPRING HILL DRIVE ANCHORAGE ALASKA 99516 SELLER- 8/14/86 JEFF THIMSEN 9940 SPRING HILL DRIVE ANCHORAGE ALASKA 99516 60439 LEGAL:SPRING HILLS ESTATES BLOCK 2 LOT 18 ADEQUACY TEST FOR SEWER SYSTEM ADEQUACY TEST DATE-8/12/86 TEE TYPE OF ABSORPTION SYSTEM IS A DRAINFIELD WITB AN AREA OF 671SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 943 GALLONS OF WATER PER DAY, THE SUROE CAPACITY OF THE SYSTEM IS 943 GALLONS. BASED UPON TBE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 4 BEDROOM HOME. SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1250 IS ADEQUATE FOR THIS 4 BEDROOM HOUSE. THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON 7/10/86 . THIS REPORT DOES NOT VERIFY THE INTEGRITY OF THE PIPING FOR THE WATER SUPPLY OR WASTEWATER SYSTEM. FLOW TEST ON WELL WELL FLOW DATE-8/12/86 A FI, OW TEST WAS PERFORMED ON THE WELL. 943 GALLONS OF WATER WAS PUMPED AT A RATE DF 6.73 GPM OVER A DURATION OF 2.3 HOURS. THE DRAWDOWN WAS 3.1 ' WITH A RECOVERY TIME OF I MINUTES AND THE STATIC WATER LEVEL WAS 205.5 FEET. THE WELL IS ADEQUATE FOR THIS 4 BEDROOM HOME. ~Ucsl 33rd Au~nue. Suile [~, Anc~oroq¢, ~lds~d 99503,,(907) 561-5040 ~ TO ~ C~LE]~D BY ~R ,,~PL]ER ~ ' [ F~R ~ USE ~LY I C LECTEBI C L CTE. I 'r PE SYSTE. / ~ I ~I~TH ~Y ~_ I ,., ~ AN I ~ POBLI~ND~VIDOAL/~ RESUBNIT SABLE aTO/Cn "UUKCO3 ~ ~ Not tn proper container ~ Leaked out CITY STATE LOCATION WHERE SAMPLE WAS COLLECTED 'COLLECTED BY:($1GNATURE) TYPE OF SAMPLE (CHECK ONLY ONE THIS COLUMN) ~DRINKING WATER ~CHECK TREA"fMEIsrT f"l RAW SOURCE WATER [~ NEW CONSTRUCTION OR REPAIRS ~ OTHER(Specify) ZIP CODE [-] CHLORINATED ~ I'IFILTERED ~NTREATED OR OiHER IS THIS SAMPLE A CHECK SAMPLE TO A PREVIOUS NON-CONFORMING SAMPLE? r'l YES PREVIOUS COLLECTION DATE ANALYSIS REQUESTED (IF OTHER THAN TOTAL COLIFORM) "~END REPORT TO:(PRINT FUEL NAME,ADDRESS AND ZIP CODE [] Insufficient information provided. Please read instructions on form. []Other (Specify) RECEIVED FROM,...J RECEIVED DY DATE ~-'/~ -~o TIME ANALYTICAL METHOD: [~MBRANE FILTER []FERMEHTATION TUBE Date & Time Started ~ '/~ Date & Time Completed~"])'~-~ IJ~BOP~ATORY IUiSULTS Anelyst~.._ [] Other Bacteria I-] Test unsuitable because: [] Confluent Growth [] TNTC SATISFACTORY G2/ mlSATISFACTORY BACTERIOLOGICAL WATER ANALYSIS RECORD FOR LAD USE ONLY [~FTOTAL COLIFORMS ~m FECAL COLIFOi~MS ~-~ OTHER Membrane Filter: Direct Count Verification: LTB Final Membrane Filter Results .. Reported BY . Coliform/lOOml BGB _Coltform/lOOml Date Time AoMo READ SAMPLE COLLECTIOR INSTRUCTIONS ON BACK OF FORD( NAME ISAACS PUMPING SERVICF. (Norm Tlbbetts Owner) 6218 Quinhagak Street ANCHORAGE, ALASKA 99507 Phone 563-3300 iPHONE RECEIVED aY TOTAL I I I MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL, HEALTN CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACiLiTY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) -SEC, [,~ Location (address or directions) (b) Applicant Name '-,-~lc"~: '~',/~/[/[d,~O/~ Telephone: Home _ ~ Business Applic~ntAddress. ~¢¢ ~'¢~J~ ~//~ ~, ¢~, "(c) Applicant is (check one):'Lending Institution ~; Owner/builder, S; Buyer ~; Other ~ (explain); (d), Lending Institu]ion:~ _ Telepho~'__ TYPE OF RESIDENCE Single-Family~.~ Multi-Family [] Number of Bedrooms C/~ Other WA'rER SUPPLY Individual Well ~ Community [] Public [] Note: If corn munity well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. , ~ ' Page 1 of 2 SEWAGE DISPOSAL Onsite ~ Public [] Community [] Holding 'rank Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 5. ENGINEERING FIRM PROVIDh,,d INSPECTIONS, TESTS, FILE SEARCH, D~ FA 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 wator 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 obtaieed 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 Date Telephone ~-~' g/-'~--~'/'~-') Approved for /z_":...~//~_~ bedrooms b~'L'/~'~u/ Approved ~C''~''~ Disapproved Conditional 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 s~tisfy certain federal and state requiremeots. 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 (11/84) MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE · 1. Ceneral Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Loc~tion (addres~i~.o~L directions) (b) Applicants Nameable:/' ?1l.~9~_~/ Telephone - Home Business~6)22(D Applicants Address___z,~'¢, J__~O (c) Applic_an__t. is (ch'eck one) Landing Institution [~ ; Owner/builder ~ ; (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address <f) Telephone Mail the HAA to the following address: 2. T_yjl~_of Residence Single-Family ~ Number of Bedrooms 3. W_a. ter Supply Individual Well [~ Multi-FamIly~-~ Other (describe) Community~_~ Public E_~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Note: If community well system, must have written confirmation from the State Department of Environmantal Conservation attesting to the legality and status. ~[Page 1 of 2] 5. ~lnsineerin8 Firm Provid:[n8 I~tio~s~ 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 regula- tions in effect on the date of this inspection. (ENGINEER SEAL) DHEPA_p~p~rova_l_ Approved for/~4z/l bedrooms Approved .,A _ Disapproved Conditional Terms of Conditional Approval CAUTION TIlE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONmeNTAL PROTECTION (DHEP) ISSUES IIEALTH 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 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 MUNICIPALITY OF ANCHORAGF. IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN TIlE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/eJ/D18 . [Page 2 of 2] 7-19-84 HEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC~ ~ TELEPH(~,IE (907)-562-2343 ANCHORAGE INDUSTRIAL CENTE~ " ?' 5633 B Street //' Drinking Wa,tot Analysis Floport for Total Coliform Baetoria TO BE COMPLETED S,,Y WATER SUPPLIER [ TO BE COMPLETED BY LABORATORY I WATER SYSTEM: C'ILt III ") Sac b °n bn°~ I ,,._./B:~'YSi~ sh°w" thi~ W"tsr SAMPLE t° b": ,.o.,o. II s ,b,c,ory c~ty MO. SAMPLE TYPE: _,~Routlne · ', [] Check Sample (for routine sarnple with lab ref. no. ) [] Special Purpose ~..Treat ed Water Untreated Water Time CollecteO Collected By )~,' I~~- ~-/<~6 [] Unsatisfactory ['1 Sample too long in transit; sample should not bs over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received Time Received Anal.y, tical Method: ~ Fermentation Tube p Membrane Filter ~.ab Ref. No. I I Result* Analyet BACTERIOLOGtCAL. WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter:. Direct Count Verification: I.TB BGB Final Membrane~-" ~L~ --FIIter~_s~ulte ._.~,_._~ ; Reported By_ .~'~-~.(~,~.~/~_O~J~-- Date Time: TNTC-- Too Numerous To Count Collformll00ml Collfon'nll00rnl MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIg~ - FEBRUARY 1984 [JU~4ICIW L 7'( OF ANCHORAG,~ [:~ i"/I.;ON;¢ENiAL PkO I ECiION Nov 2 1984"' WEIJ~ DATA Well Classification Well Log P~esent Legal Description: __ If A, B, o= C, D.E.C. Approved(Y/N) ,Date Completed .~'~-; ~_~.--~ '-/ Yie~d_~J~ Total Depth ~L[~ Cased to ~...L/~.,-~ Depth of G~outing [J~ Static Water fGvel ..~ ~34:~ ' Casing Height Above Ground __.. Electrical Wiring in Conduit Separation Distances f~om Well: To Septic/Holding Tar~ on Lot Pump Set At; Sanitary Sea1 on Casing Depression Around Wellhead (Y~ · -,/06 ¢ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot__. /~ / (p ; On Adjoining Lots_~;,¢~O' To Nearest Public Sewe~ Line ~-t- To Nearest Public Sewer Cleanout/Manhole '~/¢~ To Nearest Sewer Service Li~ on Lot Water Sample Collected By ~-uJd~/(c.~CD __; ~te $/-~"l Water Sample Test Results _5~/'.¢~-¢¢~/~ B. SEPTIC/HOLDING TANK DATA Date Installed V-~3--2~/ Size_ 1~5~ No. of Compartments ,_~ Standpipes~N) Air-tight Caps E¢~N) Foundation C:~anout (~/~) Depression over Tank .(Y~) Date Last Pumped_ kJ~% Pumping/Maintenance Contract on File (Y/N) k~ ; for ~ Holding Tank High--Wate~ Alarm (Y~) ~]/~ Temporary Holding Ta~k Permit (Y/N~ ~/~_ Separation Distances from Septic/Holding Tank: TO Water-SupplyWell. [~)(.,~¢t TO Building Foundatloq..~r~( / To t~opert~ ~±ne I~' To Disposal F&eZd I~. To Water Hain/Service Line _~/~ To S~ea~ ~ond, Iake~ or Ha]or D~ainage Cor~ents Receipt 9 Date Paid: Amount: ~ 1 of 2] 2-15-84 C~ ' ABSORPTION FIELD DATA Soils Rating in Absorption Strata l%~0 Date Installed L/_~,~._~/ Width of Field /;~" Square Feet of Absorption Area ~/ Depression Over Field (Y~) Results of last Adequacy Test Date of last Adequacy Test Type of System Design Length of Field Gravel Bed Thickness Standpipes P~esent ~) Separation Distance from Absorption Field: To Water-Supply Well I,c~-~' To P~operty Line · To Building Foundation ~ To Existing or Abai~dowed System on Lot ,j~)/~ ; On Adjoining Lots To Water Main/Service Line ~/~ To CutbapJ¢(if present) To Stream/Pond/lake/or Majo Drainage Course To D~iveway, Parking Area, or Vehicle Storage Area 7 D. LIFT STATION Date Installed ~IT size in Gallons k)/ "Pump On." Level at High Water Alarm Level at Tested for ~/f ~ Electrical Codes(Y/N) Corar~nts Din~nsions ~) / Manhole/Access (Y/N) "Pump Off" Level at .... Vent (Y/N) ~f Pumping Cycles ~ing Adequa~ ~st. Meets MOA ** Check Rerntitted Bedroom Rating Against HAA Request I certify that I have checked, verified, or conformad to all MOA [t~k Guidelines in effect on the date of this inspection. [Pa~ 2 of 2] ~-- 2-15-8~ OJ(~l£-~)