HomeMy WebLinkAboutT15N R1W SEC 9 LT 62 SW PTN
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
LOCATION
NO. OF BEDROOMS
~, DISTANCE TO: ] We,,f~O /~_ I Absorptionare~ , Dwelling ~ PERMIT NO~/ ~.~
Manufacturer Material No. of compartments
Liq' 7~¢all°ns. IF HOM.MADE; Inside length~__ ~idth ~ Liquid depth
~ Q DISTANCE TO: Well ~undation Nearest lot line PERMIT NO.
~ ~ ~ No. of Hnes Le,gth of each line ~
~al length of lines Trench width Distance between lines
~ ~ ~ Top of tile to finish grade / Materia~ beneath tile Total effective absorption area
inches
~ ~Length I Width / De~ / ~__ ~ ~ ~/' PERMITNO.
~ DISTANCE~/TO: Building foundation -- Sewer line Septic tank Absorption area(s)
OTHER
REMARKS .
DATE LEGAL '
72-
MUNICIPALITY OF ANCHORAGE
Department f Health and Environmenta ?rotection
825 ~ Street, Anchorage, AK. 39501
264-4720
~ * * * HANDWRITTEN PERMIT * * *
Permit ~ , WELL AND/OR ON-SITE SEWER PERMIT
Applicant: ~-~. ~ ~& ~..3,~'~ Mailing Address: ~-~
Location: p~ L ~ '~ ,~ Phone Number: ~ ~ -- a ~
Legal Description~_-~-~ $ ~ -~(~$1~{ ,~ %~o Lot Size:
Type of Soil Absorption System Is:
Trench: Drainfield: Seepage Bed: ~ Holding Tank:
Maximum Number of Bedrooms: .~ Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is:
/
LENGTH '"2-2-- i
GRAVEL DEPTH ~9~ o WIDTH
DEPTH
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(~G~ TANK SIZE : I~ ~>~-) GALLONS * *
Pe~-mit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
· * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a co~tmunity 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 $ 3 * * *
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 ~equire enlargement if
~the residence ~ remodeled to q .-'(/~'Q ~"-'"- include more ~o~o~
Signe~: ~-~/~ Issued by:
Date: .
SWP/024(1/81)
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
n r-¢../ ~ 'z
LEGAL OESCR,PT,O~'' L--O"F.-.'--'-'-'-'-'-'-'-~¢ %~.-O ~
~ J~(,-~ ~ ~_~,~ SLOPE
1
2
SITE PLAN
10-
11
13-
14-
15-
16
17,
18
19
2O
COMMENTS
PERFORMED BY:
72-008 (6/79)
WAS GROUND WATER ~0 ~
E
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~V'//~ (minutes/inch)
r'
TEST RUN BETWEEN /T AND FT
//
DOC Co. cica
AI~ASKA ~;, · TEL~PHONI~ 6fj8.2759
DEPTH OF W~LL
STATIC l
GA~. PER H~
KIND.OF~
From Ft, to
Fgom
From
F~am ..... : Ft.
From . Ft, to~. ~r
, -,~ DRILLE
P.O. BOX 670272, ~H UGI~.K
· TEI[EPHONE 688-2759
ST~,TI( LEVEL OF W~TER FI' '~!I~, ,r
Ended
Ft. ~ro__ . _~Ft.
Fmm ...... Ft ~.{~, ...... Ft.
DRAW DOWN FT
GALS. PER HR
KIND OF CASING
From. Ft. to
From Ft. to ·
From Ft. to
~.Z&From
From Ft. to
Ft. to
Fropl
From
From Ft. to
From Ft. to
From Ft. to~
From Ft. to
From Ft. to
From _Ft, to
From Ft to
From , . Ft. to
From Fi/to
Ft
FI
Ft.
Ft,
Ft
Ft.
Fl.
Ft.
Ft
Ft ~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.#
1. GENERAL INFORMATION
Complete legal description
HAA # ~-~\L~
Sbut~APortion o4 Lot 62i S~c. 9~ T15N, RIW,
Location (site address or directions) NHN ~n#n~a ~aa~
..... Property owner A,H.F,¢. # 102200 : .... Dayphone
Mailing address 520 Eas~ 34th Avenue.. Anchorage. Alas~za
Lending agency Day phone
Mailing address
AgentS~aron Minsch RE/MAX OF EAGLE RIVER Day phone 694-4~00
Address 1~;~00 2~.~t~rfi~cd ~,~'ue. #¢01 kagla lZxuo#; A£aZbrz 9qr;77
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEO attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72~325 (Rev. 1/91} Front MOA #21 ~
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify th,~t 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.
$ & $ ENGINEERING
Name of Firm i7034 Ea~ie F,i~w~ .'ap ~.,.~&~ ~,~,. 2(~'~ __ Phone
Address Eagle River, Alaska 99577
Engineer's signature
DHHS SIGNATURE
Approved for .~'
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
By:
Additional Comments
The Municipality of Anchorage Depactment 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 professiona~ engineer's work.
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:~:;',
A, WELL DATA
Well type ~'~,,~-~/.z~,1-~. If A, B, or C, attach ADEC letter.
Log presentl~)'N) '~ Date completed
Total depth I~,O' '~" Cased to
Sanitary seal ~)'N) '~'
FROM WELL LOG
Date of test ~ ' ?,-O - ~-5
Static water level ~'~ ~
Well flow "z.'.'~C~, ~
Pump level ~ ~)~--
ParcelI.D.
Wires propedy protected ~'N)
ADEC water system number I'~1/~/'
I~'- ~o ~ ~ Driller ~ou4.4 V'~,,J.
Casing height 17-
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot tC:;,c~ ~ '~
Absorption field on lot
Public sewer main
Public sewer service tine
g.p.m.
AT INSPECTION
V't' L~"
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~ ~'°~'~/~r~o ~.
Date of sample: '~ - '7-~' ~
Nitrate \,c~ w~l~
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~
Cleanouts~'~N) "~
High water alarm (Y~_~
Date of pumping~
Tank size
Foundation cleanout ~/N)
Other bacteria
S & S ENGINEERING
~7054 ~-agie I~iver Leop
Eagle River, Alaska ~9577
Alarm tested (-Y/N)
~' ~oOSe..- 0~o~°?~-~ ~,~r~ ~'e~.~,.k~oo5
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Compartments
Depression (Y~:) /~J
Well(s) on lot L c>~ On adjacent lots
To property line I c:, ~ ~ Absorption field
Surface water/drainage
Foundation ~ ~ ~
Water main/service line tO
72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level .~
Meets MOA electrical c~/N)'~
NCE FROM LIFT STATION TO:
~¢¢ell on lot On adjacent lots
Manhole/Access (,~,/N ) ~
~~~p"Pump off" level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed ~ ' ~ -
Length V'~' Width )~,
Total absorption area ~.~
Depression over field (Y~)
Results(~/fail)
Peroxide treatment (past 12 months) (Y~)
Soil rating ~'~'~/~rz... System type
Gravel thickness ~,"~'~ Total depth
Cleanouts present (~/N)
Date of adequacy test
for ~-'~ ~.~ c__
bedrooms
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots
Surface water
Curtain drain
Wellon lot ~.~o~'
To building foundation
,~ t-~
E. ENGINEER'S CERTIFICATION
On adjacent lots Ic~o ~ Property line
Ic, ~- To existing or abandoned system on lot
Cutbank A)~ Water main/service line
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in
$ & S ENGINEERING
Signature 17034 Eagle RJ~er Loop Road NO. 2~
Eagle River, Alaska 99577
Engineer's Name
Date "~"' "'~ I '-~1
HAA Fee $ !r-~).
Date of Payment I ' 'i I
Receipt Number ~--~
72-026 (Rev. 3/91) Back MOA 2~
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX:(907) 561-5301
ANALYSIS EEFOET ET SABLE £or WORNorder$ 36584
Date Report Printed: JUL 29 91 ~ 16:12
Client Sample ID:SO PORTION OE L62 SEC 9 T1SN
PWSID :UA
Collected JUL 25 91 ~ 17:45
Received 2UL 26 91 ~ 14:30
Preserved with :AS REQUIRED
Client Name :S & S ENGINEERING
Client Acct :SNDENGP
BPO $ PO # NONE RECEIVED
Req #
O[dered By :
Analysis Completed :JUL 29 91 Send Reports to:
Labo~atoW Duperviso~ :~EPHEN C. EDE i)S & S ENGINEERING
Chemlab Roi #: 913685 Lab Smpl ID: 1 Matrix: WATER
Allocable
Parameter Tested Result Units Method Limits
...............................................................................................................
NITRATE-N [.9 ~J/1 EPA 353,2
Sample ROUTINE SAMPLE COLLECTED BY: RAY.
Remarks:
1 Tests Performed ' See Special Instructions Above UA-Unavailable
ND- None Detected '* See Sample Remarks Above
NA- Net Analyzed ET-Less Than, GT-Grnate~ Than
~SGS Member of the SGS Group (Soci~)td GOndrale de Surveillance)
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I,D. #
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 10t, block, subdivision, section, township, range)
South Portion of Lot 62; Section 9; T15N; R1W; S.M.
Location (address or directions)
(b) Property owner A~FC ~102200
Mailing Address WA #80750
(c) Lending Institution
Mailing Address
Telephone: (home)
Business
Telephone
(d) Real Estate Company and Agent RE/MAX OF EAGLE RIVER - Sharon MJnsch
16600 Centerfield Drive, Suite 201, Eagle River, Alaska
Address
99577
Telephone 694-4200
(e) Mail the HAA to the following address: (or check here ~], if hold for pick up.)
t p y ph
List contac erson and da one number below:
S & S ENGINEERING/694-2979
17034 Eagle River Loop Road, Suite 204,
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Number of bedrooms
Single-Family ~
3. WATER SUPPLY
Individual Well E~
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. SEWAGE DISPOSAL
On-site E~ 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. ;'/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.
Name of Firm
Address
· ~'~ ~'."~gle River Loop Road No. 204
Date
6. DHHS ApPROy~L
,,' Approves for ..~__bedrooms by
: ' App?6ve~Ji Disapproved
Tera~ of;Oonditio~al ~pproval
Conditional
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 M unicipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
?-025 (Rev. 7/88} Back
Page 2 of 2
~',O'~'~ MUNICIPALITY OF ANCHORAGE (MOA)
..~.',/ Health Authority Approval (HAA)
o~ ~,,.~,,/~ CHECKLIST- FEBRUARY 1984
343-4744
Legal Description:
A. WELL DATA
Well Olassification ]~-,~4~,,_~.,,.~_
Well Lag Present ~)/N) "~ Date Oompleted
Total Depth~ ~Oased to 4~D~+ Depth of Grouting
Static Water Level
Casing Height Above Ground \"'~---'~ ~""
Electrical Wiring in Conduit(~N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
If A, B, C, D.E.C. Approved (Y/N) ~"~l~,-J
Yield
Pump Set At ~,J~--
Sanitary Seal on Casing ~,J)
Depression Around Wellhead (Y~)
; On Adjoining Lots \ a'-~ ."2~ ~'
; On Adjoining Lots \ Co ~ '~
To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by ~ Z, % ~.~lx~M~..~ ; Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed ~'"~--~-~"~Size ~O~C, No. of Compartments
Standpipes~N) '~ Air-tight Caps~N)
Depression over Tank (Y4~D
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well \c~'~
To Property Line ~ ~ ~ ~
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments '~r.~?~-~'~ ~
~'~ Foundation Cleanout ,~N) 'N/
Date Last Pumped ~'- ~.~.-~ c~
1,4 IA- ; for --
Temporary Holding Tank Permit (Y/N) ~ IA,
To Building Foundation
To Disposal Field
72-026 (Rew 7/881 Front Page 1 of 2 '
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~,-7..?....- c~,-~
Width of Field \~
Square Feet of Absortion Area
Depression over Field (Y~)
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field
Gravel Bed~Thickness
? / Statndpipes Present4~)/N)
Date of Last Adequacy Test
[
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well \ ~..~ c:, ~¥- To Property Line lc:, ~ ,c
To Building Foundation \o ~e-- To Existing or Abandoned System on
Lot ~J' I~-- ; On Adjoining Lots ~::> ~"~'
To Water Main/Service Line \~ ~ '~
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Cutback (if present)
D. LIFT STATION
Date Installed
Size in Gallons
High Water Alarm Level at ~
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent ~
Tested for ~ ~
Meets MOA Electrical Codes (Y/N) ~ Pumping Cycles during Adequacy Test.
Comments / ~
**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
inspection.
Signed S & 5 ENGINEER~flG
17034 Eagle River Loop I<oad No. 204
Company .... ,.,..,~b,, 99~.77
Date
MOA No.
of this
Receipt No.
Date of Payment
Amount: $
72-026 (Rev, 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
ROBERT SHAFER, P.E.
ROGER SHAFER
October 10, 1990
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
ANO REPORTS
WELL INSPECTION
& PLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
Municipality of Anchorage
DEPARFMENT OF HEALTH AND HUMAN SERVICES
825 L Street
Anchorage, Alaska 99501
REFERENCE: South Portion of Lot 62; Se~ion 9; FI5N; RIW; S.M.
In the process of obtaining information for a Health Authority
Approval (HAA) on the referenced property we found that the well
located on the north section of Lot 62 is serving two homes. Fhis
well has not been ~assified as a Class C well with the Alaska
Department of Environmental Conservation (ADEC) and is located less
than 150 feet from the septic system on the referenced property. Fhe
w~ll was drilled in 1988 and the septic system on the referenced lot
was installed August 2, 1983. Fherefore, the septic system on this
property met its separation distances at the time of i~tallation.
If you need additional information
s,~r~ease co,act us.
[OBER~A. SHAFER, P.E.
~LS/ss
or if we may be of further
ON S~TE
WASTE WATER
DISPOSAL SYSTEM
DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
ANALYSIS REPORT BY SAMPLE fox Wol;k Ordex ~ 21745 Date Repoxt P:int. ed~ MAY 18 90 @ 08:41
Client S.mple ID:],62; TIER; RIW, SEC R SM
PW$ID :UA
Collected }~AY 14 90 ~ 13~00 D~
RecelYed MAY 15 90 @ 16:55 ln'm.
Client Acc+ ~ SNSENOP
P.O,$ NO~E RECEIVED
Req ~
Ordered By : 5.3MAFER
Analy~18 Compioted :MAY 16 90 Send Reports to:
Laboratoxy Supervisor :STEPHEN C. EDE 1)R & S ~NGR
Special
Inatxuct~
ChomAab Rei ~: 901~65 Eob Smpl ID: L Matrix; WATER
Allowable
SAMPLE COLLECTED BY RDJ. ROUTINE
I Tel'tr ?m:for~aod See ~,pec:kal ir~structions I~boYe UA,-Unawa~.iabi~
ND~ llon~ Det~cted *' S~e Sample Remarks Abow
MA- tlot Analyzed LT-Leas Than, GT-greator T}mn
MUNICIPALITY OF ~2qCHORAGE
DIVISION OF ENVIRONME, NTAL HEALTH
DEPARTMENT OF HE~TH AND ENVIRONMENTAL PROTECTION
A~PLICATION FOR HF~%LTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date ~/~ ~.~ -'- ~> ~
(a)
Legal Description (include lot, block, ~subdivision,
section, township, range)
Location (address or directions) ,H .
(b) Applicants Nam~ PL%~\~;~. 'Z.:~yulE.q~ Telephone - Home Bus._iness
Applicants Address,~ 150, /~-~- ~-~"Z'-.,~o f.~.:,~- ~'~7 ~-?~. ~/?
(c) Applicant is (check one) Lending Institution ~-~ ; Owner/builder ~--~ ~
Buyer 5~ ; Other ~ (explain); __~~____~ --
(d) Lending Institntien ____~ C~ zx/ C~ .~ .....
Address
(e) Real Estate Co. & Agent
Address
(f)
Telephone
-M~l~l the HAA to the following address:
T~e__ofResidence
Single-Family~
Number of Bedrooms__
Multi-Family~
Other (describe)________~
Water Suppl~
Individual Well~ Community~ Public~
Note: If community w~ll system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and statue.
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and sta~ue.
[Page 1 of 2]
5- En~__~ineering. Firm Providin~ Inspections~ Tests~ File~SSe.ar~h~ Data and Information
u
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 vrastewater 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.
Name of Firm
Address
DaCe
~Telephone
DHEP Approval
Approved for ~ bedrooms By
Approved /~' Disapproved
Terms of Conditional Approval
Dat~'
Conditional
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL FROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO 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 Mb~ICIPALITY 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
ae
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUI~ORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Well Classification
Well Log Pnesent~.,
Total Depth ~ / ' Cased to
Static Water Level /~ I
Casing Height Above Ground /_~
Elec ical wiring tn ndui (jY
Separation Distances fTcm Well:
To Septic~Tark on Lot
MUNJC PAI.iTY OF /,' ;[ , /,'j ~ ~"
DEPL OF IL/
Legal Description:
If A, B, c~ C, D.E.C. Approved(Y/N)
~tAt
Sanit~
~essi~n ~nd ~l~ead
; On Adjoining Lots
To Nea~sst Edge of Absorption Field on Lot/OO r 7a ; On Adjoining Lots
Cleanout/Manhole /J//~ TO Ne=est Se~= Se=vice Lzne _on Lot
Water Sample Collected By ~')Sf~F~'/~/; Date
/
cc ,,, nts /t2'°
B%
SEPTIC/~--'-'_::" TANK DATA
Date Install.~d ~ /~ 3 Size /m~i) No. of C~,va~tments . ,
Standpipe~/N~ ' Air-tight CaD./~~) Foundation Cleanou~)7~/~-~
, / '
Separation Distances f=cm Septic~ank..
To Wete=-Suppl¥ Well /~0 ~ To Building Foundation,, ~-- '
To P~o~e=t¥ Line /Q
To Water Main/Se=vice Line
Course
Conm~nts
To Disposal Field ,, ~-- ~
To Stneam, Pond, Lake, c~ Major Drainage
Receipt $ ~'~Q9~
Date Paid: ~-i%~
Amount: %~
[Pa~e 1 of 2]
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Stmata
Date Installed F ~/~3,
Width of Field
Squa=e Feet of Absc~Dtion.f~._A~. ea
Dep=ession over Field (~)
Bssults of Last Adequacy Test
Length of Field
Depth of Field
Gra%~l Bed Thick~ess
Standpipes P=esent (~)
Date of Last A~L=quacy Test
,//4
Separation Distance f~cm A~sc~ptio~ Field:
To Wate=-Supply Well //~ To ~ty Li~ /O ~
To Buildi~ Foun~tion ~ ~ ' To Existing ~ ~ndo~d System
Lot ~ ~ ; ~ ~joining ~ ~-~ ~
TO ~te~ Mai~=vi~ Line /o + To ~t~( if ~e~nt)
To St~e~ond~ke/~ ~3o~ ~ai~ ~se ~ ~
To ~i~way, P~ki~ ~ea, ~ Vehicle St~a~ ~ea ~ ~
D. LIFT STATION
Date Installed
Size in Gallons
"P~mp Oa" Level at
High Water Alarm Level at
Tested for
Elect~ical Codes(Y/N)
Cc~a~snts
Dimensions
Manhole/Access (Y/N)
C.'~'/C les p ~'"Adequacy
Test. Meets M~A
** Check Pe=mitted Bedrocm Rating A£3ainst HAA Rsquest
certify that I ham d~ecked, verified, c~ uonfc~red to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed
K~i/d5/s
[Page 2 of 2]
2-15-84
APPLI( NT FILLS OUT UPPER HA! ONLY
Property OwL3r
Address Zip Code
Address Zip Code
Address Zip Code
Street [ocaBm ~v::~
Type of Residence
SlngleFamily
Multiple Family No. of Bedroo~ ~ )
.~ther
Water Supply
.~ndivld~al ' ATTACH WELL LOG. A well Icg Is required for all wells drilled since June 1975,
~ Community.~? For wells drilled prior to that date, give weg depth (attach Icg If available).
~ Public Utility ;~
Sewer Disposal
~ndivldual Year Individual Installed:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Date Date Date Date
Inspector Inspector Inspector Inspector
ANCHO~GE
( ~ ) APPROVED BEDflOO~8 'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
Soils Rating Date ~wer installed Well To Absorption Area t ~ ' ~ Well Log Received
Well to Tank ~ t ~ Septic T~k Size
72.023
October 26, 1983
Phyllis L. Janke
P. O. )lox 567
Eagle RJ. ver~ At{
99577
Subject: ~'1'5., RtW,~ec."' 9, Lot 62
A])(>row~i for the individual sewer and water facilities cannot
be granted until tile following items have been completed:
o A %.;ell log :~ub]~itted to this office ior our files and
Please submit a copy of your Health permit, ,~oilo test
e~gineer's as-built of the
sewer
system.
~lease notify this Department for a relnsl~ection when tile
noted discrepancies have been corrected. If there are any
further questions, plea~e call this office ~t 264-4720.
lncercly,
CW89/e3/E2
Cory %'~illis, k.o.
Act ing "' ~
Program Manager