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HomeMy WebLinkAboutT15N R1W SEC 8 LT 108Onsite File · ~,~, .'~ · ENVIRONMENTAL PROTECTION, i?.7 :l-"2'77~.:? /c~ 7 /vl~A ~ 3 ~zz / 7' _-.23 o_ P,4T[.'_M T P,.O. ky'. t~ESZ--_f~ MUNICIPALITN .~r 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 PFION b MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO, O F~)DR OOMS Well ~ Absorption area /~ {~~ IF HOMEMADE' Insidelength /___L/__~'Z~ ~ I ' -z~ ~ ~ ~ Ix~~ ~ h ~ ~ ( Width / (> Depth~H ~] Type of crib Crib diameter Crib dep,~ ~ ~1 DISTANCE TO: /00 / ~ ~ DISTANCE TO: Width Liquid dep. t~h~ Liquid capacity in gallons PERMIT NO. Material Nearest lot line Trench widthinches Distance between lines Nearestl6tline ~' F'~;~ Distance to lot line Septic tank OTHER PIPE MATERIALS SOl L TEST RATIC~G INSTALLER REMARKS 72-013 (Rev, 3/78) WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division oi Geological Geophysical Surveys !2. WELL. LOG F Grave:[ and Clay Gravel, sand, silt, wet er Top 88 107 Section NO. 88 92 lO7 122 OWNER OF WELL: MX, Hayes 7. usE~i~]~)ome~llo [] Publlo Supply [] tndu*try E] Irrlga,lOn [] noohor9' [] Commerlcol E] TQ~! Welt [] Other: G. CASING: [] Tbraacl~Xz~ W~ld~d mo,..~.__tn, to 91__-. Ua,,, w¢9.t 17 .,~,./,,. Dot9 Magnuson ~rtlllng AA 5385 ~°~' Bo× 770504 Eagle River, Ak. 15. Water Temperature __=o ~.,~.~A,XS: ?reduction of 5 GPM 5" perforated llner betw 80 and 120 ft. Perforations at 105-119 DEFHR FHENT b, 0~ L RL ][ T'¢ II!= FI I'.,,ll~l-- 1RFi~.3E HERLTH RHD ENVIRONMENTFII- , RDTEIZ:TION _,TF. EET., RNL. HORRbE., Rt.; B950i 264-4?20 PERMI'T NO: DRTE ISSJED; 05,.¢07,.--'84. RPPLICRNT: RDDRESS: CONTRCT PHONE: LEGRL DESCRIP: LOT SIZE: MR~<BEDROOMS: CZO S & S ENGCG. LRRRY HRYES ERGLE RIVER¢ RK 99577 694-29?9 SUBDIVISION: NR LOT: =,EbTION. 8 TOWNSHIP: .LN RSNGE: 44000 r.:SQ, FT. OF.'. RCRES) 4, BLOCK: HR L.I_qTED BELOW RRE THE OPTIONS FIVRILRBLE TO YOU IN DE_,IuNIN~.~- '= YOUR SEPTI_. S'.¢STEM, CHOOSE THE OPTION THRT E,E_T FIT--q" VOUR _,ITE, DEPTH TO PIPE BOTTOM (FT.) ..~. 0 mm ORRVEL DEP'I"H 4FT. ) 0. 5 I'OTRL DEPTH (FT. ;' ~. 5 GRRVEL WIDTH (FT.) %6. 8 · ~GRR',/EL'LENGTH (FT.) ~2, 8 GRR',/EL VOLUME (CU. YDS. ) 18, 9 TFiHK ~IZE (GRI_5) l, 250. 0 SOIL; RRTI'NG <Sk~, FT. /BR) ' ; ~:~::'DBPTt'I TO PIPE BOTTOM < ~. 5 FT,. REQUIRES IN_,ULRIlON DEPTH TO PIF'E BOTTOM < 4. 0 FT. MFIY REQUIRE R LIFT STRTION :,TRNI< MI.I~,T HFIVI~ RT LERST Thio C:OMPRRTMENTS I"OERTIF'¥' THRT: ,,~ ~ , "q '= SET '":' J...;"I RM FRMILIFIR WITH THE REQUIREMENTS FOR ON _,ITE SEWERS RND 14ELL- R_, FORTH 8~ THE 'RUNICIPRLITV OF RNCHORRGE (MOR) RND THE STRTE OF RLRSKR. 2. ':;I WILL INSTRLL THE SVSTEM IN RCCORDRNCE HITH RLL MOR CODES RHD REGULRTIONS., RND 'IN CORPLIRNOE P~ITH THE I)ESIdN CRITERIR OF THIS PERHIT. ttLR_,KH REQUIREMENTS FOR THE SET BRCK 3, I WILL RDHERE 'TO FILL MOR RND STRTE OF ' ~"' DISTRNCES FROM RNV Eh~ISTING WELL, WRSTEP~RTER DISPOSRL 5YSTEH OR PUBLIC : .~ :~:;SEI.4ERRGE SV'.~TEH ON THIS OR RNV RDJRCENT OR NERRBV LOT; : :'4. [ IJNDERSTRND THRT THiS F'ERM~T IS VRL~D FOR R MRXZMUH OF 4 BEDROOMS FIND :.. 'RN~ ENLRRGEIgENT NILL REQU ~RE RN RDDI T[ONRL PEF. MZT. ~ ;[F FI LIFT STRT~oN .ZS [NSTRLLED ZN RN RRER COVERED BV NOR BLI]LD~NG CODES, :THEN (d.') RN ELE_,TRIORL PERMIT RND INSPECTION HUST BE OBTRINED~ ~2~ RS.-BUILTS W~EI; NOT BE RPPROVED WITHOUT RN ELEC, TR~..RL, [NSPECTZON REPORT~ RND (:~) THE EbECTRICRL WORK MUST BE'DONE BV R LI~.ENzE~ ELECTRIC[RN. PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3- 4~ 5- 6 7 8 9 10 11 12 13 14 15- 16- 17- 18- 19- 20- MUNICIPALITY OF ANCHORAGE DEPARTM[-'NT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 /, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SLOPE DE ERED? _ 0 P ATWHAT ~ / E /~ SOILS LOG [] PERCOLATION TEST SITE PLAN Gross Net Depth to Net Read n(.I Date Time Time Water Drop - PERCOLATION RATE 4//~ (minutes/inch} //.[/¢ T~ ..~RUN BETWEEN - FT AND __~ FT r'H, 694, 2~7~ 72-008 (6/79) MUNICIP'ALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF FNVII:{ONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1, GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) LOT 108; S¢c. 8, T15N, RIW, S.M. Location (address or directions) 20232 Birchw0od Loop (b) Property owner Mailing Address H.UD. #111-033723-203 Telephone : (home) Business (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent ASSOCIATED BROKERS ATTN: Sand~/ Address (t~Z~Lez~ 3~'b Aucm~.¢. SuJl'o ~'1 A~o~n~age~ ~ Telephone 563-5~33 (e) Mail the HAA to the following address: (or check hereXSt, if hold for pick up.i List contact person and day phone number below: 17034 Eagle RiYer Loop Road EaCe4llve.", A! asks9<)57¢. 2. TYPE OF RI=SIDENCF Single-Family E~x Number of bedrooms 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SFWAGE DISPOSAL On-site E~x 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 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. S & S ENGINEERING Name of Firm 'L7~iver Loop Read N~. ~04 Telephone ~ g:~[ ,~'¢__ ~/;2 ¢' Eagle River, Ala~l~a ~9577 Address Date 6. DHHS APPROVAL .2. Approved for __ 7,.2L__ bedrooms by Approved /.~. Disapproved Terms of Conditional Approval Conditional The Mu nicipality of Anchorage Department of Health and Human Services (DH HS) issues Health Authority Approval cerificated 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 (MOA) ,AC©_ ~',~'__~ Health Authority Approval ("AA) O~ ~ ~ CHECKLIST- FEBRUARY 1984 ~ ~ ~ 343-4744 ~ ~ ~ %. ~ Legal Description' ~ I~: ~ ~O~ ~k,~ ~N~ ' ' ~ A. WELL DATA Well Classifi~ion' ~;~ {~ ~ If A, B, C, D.E.C. Approved Wall Log Present (Y/N) ~ Date Completed ~ ~ / ~- E O Yield Total Depth ~Cased to ~:~ I ' Depth of Grouting ~ Static Water Level ~ ¢ Pump Set At (2 lc Casing Height Above Ground / ~- ' ' ~ Sanitary Seal on Casing (Y/N) _ Electrical Wiring in Conduit (Y/N) ~ Depression Around Wellhead (Y/N) _ SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot / CO ~' ; On Adjoining Lots _ To Nearest Edge of Absorption Field on Lot / ~ , On Adjoining Lots TO Nearest Public Sewer Line ~/~ To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ~ ~- ~ ~ Water Sample Collected by ~ ¢ % ~d~¢¢/'M~ ; Date ~ - .~ ~ - ~0 Water Sample Test Results ~¢~C'~o¢w -- ~0~¢[~ ~ Comments ~*~ ~(~ B. SEPTIC/HOLDING TANK.DATA Date Installed ~ -~t Size_ ! O00~io~No. of Compartments Standpipes (Y/N) c~ Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) Depression over Tank (Y/N) /t) Date Last Pumped ~ _ ~ ,~ Purnping/Maintenance Contact on File (Y/N) _ /~/~ ;for_ Holding 'rank High-Water Alarm (Y/N) f,)/¢~ Temporary Holding Tank Permit (Y/N) _ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well _ / ~O r'i~ To Building Foundation To Property Line / O 7~ To Disposal Field To Water Main/Service Line ~O /'~ To Stream, Pond, Lake or Major Drainage Course Comments ~,¢ '/--[ ¢- ~50 ~.,~ ~ ~ ~ 72-028 (Rev 7/88)Fronl Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field ..~ ,~ ' Depth of Field 3.~ ' Gravel Bed Thickness ~" -~--! 2-~ Statndpipes Present (Y/N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot ~/~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~'1 ~ To Property Line ,/ To Existing or Abandoned System on ; On Adjoining Lots /~ O/"J~- To Cutback (if present) D. LIFT STATION Date Installed ~ Dimensions Size in Gallons '~, Manhole/Access (Y/N) "Pump On" Level at '%, High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect inspection. $ & $ ENGINEERING 17034 Eagle River Loop J~oad No. F.u~;~ River~ Aiask~ ~Y,~Z7 - ' Signed Company Date MOA No. of th~s '- Receipt No. Date of Payment Amount: $ // 72-026 (Rev 7188) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAl. SEFIVlCF. S 343-4744 Parcel I.D. # CERTIFICATE! OF INSPECTION FOR HEALTH AUTFIORI'rY APPROVAL OF ON-SITE SEWER AND WATIER FACILITY FOR SINGLE FAMILY DWELLING 0 '~'/' / ~'~2- d> '~ NAA# 1. GENFRAL INFGRMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) 108! S~.o.. 8; TI5N_l RIW... S.M. Location (address or directions) 2503 Birchwood (b) Property owner H.U.D.Property Disp~(~on Mailing Address Telephone: (home) Business #111-033123 605 West 4th Ave, Anchorage., AK 99501 (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent ASSOCIATED BROKERS ATTN: Earl Mc, Zone Address 640 West 36th Avenue Suite #I, Anchorage, AK 99503 Telephone 563-3333 (e) Mail the HAA to the following address: (or check here,'~, if hold for pick up,) List contact person and day phone number below: S & Il ENGINI[ERING Eagle River, Alaska 995~ 2. TYPE OF RESIDENCE Single-Family [~}X Number of bedrooms 3, WATER SUPPLY Individual Well,~St~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting te th legality and status. 41 SEWAGE DISPOSAL On-siteX~X Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting te the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 5. 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 th i~ Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Telephone Address Date S & S ENGINEERING F,agle River~ Alaska 99577 6. DHHS APPROVAL Approved for bedrooms by Date Approved Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 72-025 (Rev. 7/88) Back Page 2 of 2 A. WELL DATA Well Classification MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST-FEBRUARY 1984 '~:~F4]CIPALI'fY OF ANCHORA,~E 343-4744 FNVIRONMENrAL SE~I/~C~$ DIVblON Legal Description: /J.¢/~ Well Log Present (Y/N) y' Date Completed ~O Total Depth_1 _2 ~-_ Cased to ~_L__ Depth of Grouting 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 _ t~/~ To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results -~-~'-~ If A, B, C, D.E.C. Approved (Y/N) - ~/~ Yield (,/~, ~-~rrf~, Comments Pump Set At L.)I~' Sanitary Seal on Casing (Y/N) Y Depression Around Wellhead (Y/N) ~ I OO "/'- To Nearest Public Sewer Cleanout/Manhole 3 I ; On Adjoining Lots. / ; On Adjoining Lots B. SEPTIC/HOLDING TANK DATA Datelnstalled (o-~"~' Size /000~¢,1 No. of Compartments ,~ __ Standpipes (Y/N) ? Air-tight Caps (Y/N)_ Y _ Foundation Cleanout (Y/N) F Depression over Tank (Y/N) "~J Date Last Pumped _ ,~O Ou/~ ~ c~ Pumping/Maintenance Cor~tact on File (Y/N) J~J~/~ ; for '-'-- Holding Tank High-Water Alarm (Y/N) __ ~0/~q Temporary Holding Tank Permit (Y/N) AJ/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well / Co / '~ To Building Foundation To Property Line. /(2 ¢' To Disposal Field To Water Main/Service Line , ~.2o 0 '~ To Stream, Pond, Lake or Major Drainage Course Comments ~<~.?~[-'~ -t~ft~J~''' ~ptJ¢-~,~¢±~/ 72 026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~ ~ ~ Width of Field I (¢ Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field Depth of Field .--~. Gravel Bed Thickness Statndpipes Present (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well [Oc, 't- To Building Foundation Lot M/¢1 To Water Main/Service Line jO/ 'h To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Date of Last Adequacy Test To Property Line / O To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **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 S & ', Ei,iGh',L"~P-&HG Company 17034 Ea~ile River Loop Road No, 204 EagJe River, Ala~.a Date MOA NO. (: ~ ~7)~ I Receipt No. ~/~ ~ Date of Payment ~'~ Amount: $ / 72-026 [Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 MUNIC, IPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVlRONMI=NTAL HEALTH 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) Lot 108; Section 8; TI5N; RIW; SM May 19, I~86 Location (address or directions) Sou~h Birchwood Loop Road (b) Applicant Name Larry Hayes Telephone: Home 688-4972 Business Applicant Address 2503 South Bire. hwood Loop Road, Chu~iak, Alaska 99567 (c) Applicant is (check one): Lending Institution []; Owner/builder E~; Buyer []; Other [] (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address none/refinance Telephone ~i'¢the HAA to the following address: S & S Engine~£in_q SRB 196X Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Sir~gle-Family [~ Multi-Family [] Other ," Nmnber of Bedrooms 3 3, WATER SUPPLY "individual. Well r~ C0m~unity [] Public [] N olj~: If cOm m unit'y well ~stem, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite [] Public ['1 Community [] Holding Tank [] Note: If commuuity well system, must have written confirmation from the State Department et Environmental Conservation attestiag to the legality and status. Page 1 of 2 72-025 ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the inlormation 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 compliaace with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspectioa. S & S ENGINEE~IN~ Name of Firm ~R ~ ~ 9OX Telephone ~ ~_~ -~ ~ ~ Address ~GLERIVffR~()~, ~I0~- -- Date Approved for ~/~t~.t' , bedrooms by Approved /~' Disapproved Terms of Conditionel Approval Conditional 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. Tile 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 ol Anchorage is not responsible for errors or omissions in the professional engineer's work, Page 2 of 2 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) /VlUNICIPAUTY OF ANCHORAt~.~HECKLIST - FEBRUARY 1984 DEPT. OF REALTH & 264-4720 ENVIRONMENTAL PROTECTION Legal Desoription: 1986 RECElJ/Eg If A, B, C, D.E.C. Approved (Y/N) Date Completed ~' ~ ~'q/ Yield Cased to ~' / Depth of Grouting Well Classification Well Log Total Depth Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (~'N')' Separation Distances from Well: To Septic/Holding Tank on Lot Pump Set At Sanitary Seal on Casing Depression Around Wellhead (.'Y~ ; On Adjoining Lots To Nearesi Edge of Absorption Field on L~)t J 82 Z) "'~'; On Adjoining Lots To Nearest Public Sewer Line' ~'J/~ To Nearest Public Sewer Cleanout/Manhoie : ~ To Nearest Sewer Service Line on Lot Water Sample Collected by ~ ~ ~ ~,-~t~-L ~. ~ ~.4 ~ ~/,,,~,; Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed ~ ,- ~ 6//' Size /~¢~ o o No. of Compartments Standpipes ~ Air-tight Caps~,N~ Foundation C eanout~4N~ Depression over Tank/¢W~7' Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ""~t-- ; for Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well / ¢..2 ~ / ~'' To Property Line /~ / ~- To Water..MaffVService Line ~,~ t ~ Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field Io / Course "~'f/x~ To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026[11/84) ABSORPTION FII-'LD r)ATA Soils Rating in Absorption Strata ~-- Date Installed ~¢~"~ Width of Field Type of System Design Length of Field ~'~" Depth of Field ~"~' J"~ Square Feet of Absorption Area Depression over Field (.Y~) Results of Last Adequacy Test Gravel Bed Thickness Standpipes Present(~N} Date of I~ast Adequacy Test Separation r)istance from Absorption Field: To Water-Supply Well __ To Building Foundation ~o Lot To Water .MeCcEService Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Perking Area, or Vehicle Storage Area To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) Comments D. LIFT STATION Date installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Flectrical Codes (Y/N) Dimensions Manhole/Access (Y/N) '~ump Off" Level at ~// _.Vent(Y/N) ! ~ /~4~- Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed S & S ENGINEERING Bate _-- SR B 196X MOA No. Company EAGLE RIVER,~K 99577 Receipt No. ~',,~'=_/o~ ~ Date of Payment ~/~ ~ Amount: $ Page 2 of 2 72-026 (11/84) 2 3-1986- -- MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRO[fMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE General Information (a) Legal Description (include lot,__b_~ock~.~sqbdivision, section, township, range) Locatio~ (addr.evss or~irections) . . (b) Applicants Name ~z~/~/ .~_~. Telephone - Home Business Applicants Address (c) Applicant is (check one) Lending Institution Buyer Other (explaiu); (d) Lending Institution Address O=erZbuilderD--CT,; Tele_~hone (e) Real Estate Co. & Agent: Address me (f) Telephone the HAA to the following address: .Type of Residence Number of Bedrooms Multi-Family~ Other _~ describe) 3. Wa ter_S_upply. Individual Well,~I Commnnity ~-~ Public [----~ Note: If community well system, must have written coafirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. ~ewa~e Disposal OnsiteL~ Public f~ Community ~ Holding Tank [~ Note: If community well system, must have ~itten co~trmation from the State Department of Enviro~ental Conservation attesting to the legality and status. [Page 1 of 2] .E_ngineerin~ Firm Providing Inspections~ Tests~ File Search_z Data and Information As certified by my seal affixed hereto and as of the validation date shows 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 ~nicipality of ~chorage files and from my inve~tigation and inspection, the on-site water supply and/or ~stewatar disposal system is in compliance ~th ~1 Mnnicipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firm~'.~TM ~/~z/~ Approved for ~ bedrooms Approved Disapproved Te~s of Conditional Approval ~l.C CAUTION TI{E MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (I)HEP) ISSUES IIEALTH ALFFHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-. ATIONS GIVEN IN PARAGF~AP!{ 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN T}~ STATE OF ALAS1Q%. THE, DHEP DOES THIS AS A COURTESY TO PURCIL~SERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EiMPLOYEES 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 ENOINEER~S WORK, (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-1. 9-84 WELL DATA MUNICIPAl.I?( OF ~- ( I ~ ..... MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: Well Classification ~/~)L;d~'~ If A, B, Well ~ ~esent Date Co~leted Total ~pt~ /~ Card to ~ ~/' ~pth of G~outing~ Static Water Level ~ cO Pump ,9at At Casing Height Above Ground .~? Eleet=ical wiring in Conduit J_Y/N) Sepaz, ation Distanoes f~om Well: ,d Sanitary Seal on Casing(~:) Depz, ession A~ound Wellhead To Septic/~l~kid~J--Tank on Lot /~CO ,/- ; On Adjoining Lots To ~a=est Edge of ~so=ption Field on Lot /¢)O ~ ; ~ Adjoining no~ To Nearest Public ~ Line /.3 /~ To Nearest Public Clean. t/Manhole /J /~ TO ~arest ~ ~rvi~ Li~ WateE Sample Collected By .5 ,, ff ~/~/~g [~te SEPTIC/HOLDING TANK DATA Date Instal]jakd ~/~ ~/ Si~.~ /~.~,d) No. of C(mk082ztments '~. ,~p~ession ~ Ta~' (~ Date ~st y~d .__~- ¢-~: P~ing/Malntenan~ Con.act on F~le (~{ ~/~ ; fo~ ------ , Holding Tank High-Ware= Ala~ (Y/N)/¢//~ ~,~=a~y Holding Tank Permt &Y~) Separation Distan~s ~,~ptic~olding Tank: To Water-Supply ~11" /~ ~ z~ To ~lilding Foundation To P~o~rty Li~ /(2 ~ To Disposal Field / To Water Main/Se~vi~ Li~ ~(~ / To S~eam, Pond~ ~ke, ~ Major D~aina~ Cour~ /~ ~ ~3 ~ Cor~rents ~ 0 ¢.3 Receipt ~ Date Paid: Ameunt: . ~t [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils 9ating in Absorpt. ion Strata Date Installed ~ /8 ~6 Width of Field / //~ r Square Feet of Absorption Area Depression over Field (~ Results of Last Adequacy Test Length of Field ~_~ Depth of Field Gravel Bed Thickness Standpipes Present (~/W) Date of Last Adequacy Test Separation Distanoe from Absorption Field: /0o "/- To Property Line To Water-Supply Well To Building Foundation Lot To Water Me~i~%/Service Line To Stream/Pond/Lake/or Major Drainage To Driveway, Parking Area, or Vehicle Storage Area Cor~asnts /~ To Existing or Abandoned System cn ; On Adjoining Lots ~£ /~ D~ c3 kTO ~ To Cutbank(if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" f~vel at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dimensions nhole/Access (Y/N) ~'~' Level at ~ ' ~ Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comnents ** Check Permitted Bedroom Rating Against HAA 9equest ** I certify t~a~have checke, d, verified, or conformed to all MOA HAA Guidelines in effect on the dat~e~ of/chi~/~.~sD~'~ctlon. / KBlld5/s [Page, 2 of 2] 2-15-84