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Home My WebLink AboutTURPIN #1 BLK 6 LT 7LoT ' MUNICIPALITY OF ANCHORAGE DEPARTMENT 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 ~ ~'.~'~'5- GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) ,_/o7" '7,,, ~ /' r~c/c. & ,. 7~k~,,/ ~-t;,~. ,~ ~- / Location (~ddress or directions) ~flo/ ~44Ksr/eo~ 2 (b) Applicant Name ~ ~/~ Telephone: Home (c) ' ~c 14 '.~pplicant is (check o'ne): Lending Institutionfl~'; Owner/builder.,~uu-yer ~; Other [] (explain); (d) Len(~ing In§titution ~¢,~&~'h,,,~, 'AddreSS' ~., -;. ' ' (e) Real E~ta~; ~par~Y'and Agent Address. ,. Telephone Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family. J~' Multi-Family [] Other Number of Bedrooms WATER SUPPLY Individual Well~ Community [] Public [] Note: If community well sy§tem, 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 the legality and status. 72-025 (11/84) Page I of 2 ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DA'I~ AND INFORMATIO ,N ~ 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 intormation 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 /~/~Y~'~A//~ ~-/,¢~//¢e~'/'~/A/~ Telephone ,~-~'/~ / ~(5' Address ¢~ ~/ ~/c/~ ~. / ~~ Date ~-- ~ ~ ~ ¢ DHEP APPROVAL Approved for ~-'~-~'~'~,J bedrooms by ~ Disapproved Terms of Conditional 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. 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 /2-o~ (~/84) CHEMICAL & G~ TELEPHONE Drinldng ATORIES'.~£ ALASKA, INC. RAGE INDUSTRIAL CENTER 5633 B Street Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: I,D, NO, ..,~Ow:~'r ~.4 c.-rr..z~_c~ ~r,~(r,---' Water System Name Phone No. Mai lng ,~.dd r ess City State Mo. Day Year Zip ~ SAMPLE TYPE: ~l..Routlne [] Check Sample (for routine with lab ref. no. [] Special Purpose sample I [] Treated Water ,,,~ntreated Water SAMPLE NO. LOCATION 3 I J Time Collected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: /~]'qati~fact cry [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail, .ate Reca,ved Time Received Analytical Method: [] Fermentation Tube ~[~ Membrane Filter Lab Ref. No. Result* Analyst, I I-]-'1 FTq FT"I 08-1220 (b) Rev. 1983 BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter. Direct Count Coltformll00ml Verification: LTB. Final Membrane Filter Re, suits (~ /, TNTC = Too Numerous To Count BGB. Date Time: Collformll00ml / ..m. ~// / ~ ' REQUEST F~R APPR-(TVA-D OF [ ,~fi/z~/ ,-~ ~J~/// INDIVIDUAR~Q~EE~TAGE AND WATER FACILITIES k // (Fill ~ in Triplicate) ~. ~umber:o~. ~edeooms in houso 5. Wate~,~Anal~sls: a. Bacte~i&l b. Detergent. Well data: b. d. Type ~ Depth ...., ~ Casing Size ..... ~ ~. Distance from well to closest existing or proposed: 1. Sewer line 2. Septic tank ,/~7~ 3. Seepage APea _,~ ~z 4. Cesspool' 5. Property Line houses, barn, drainage ditch, etc. Sewage disposal system. a. ^ge system b. Septic tank caPacity in gallons.,,/~dPz~P c. Name of septic tank manufacturer Other sources of possible contamination, i.e.~ creeks, lakes, 1. If "home made" show i d agram on reverse side of this form. d.' Disposal field or seepage pit size and type, 1, Distance to proper~cy, line / 0/ to house fo.undation ,? ,~' . e, Percolatic~,Te'st'Y~sults f. Percolation Test performed by Use the reverse.side of this form to show dia£ram, Diagmam should include ~X~he fo~].o~[ing infoPmation: p~opePty lines~.well location, house location, ~t~t-~c tank location, disposal area location, location of percolation test, ar.~ direction of ground slope. The ~nqo~.,~t~on on this form is true ~d correct to]the best of my knowledge, S~ghaXt-ur~ of ~p~ica~t' ' "" ' b~te giEn'ed TO.___BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL ~[e above described sanitary facilities are hereby approved, subject to the ........ ~611owing conditions i Conditions: The above described sanitary f ' ' acml~t~es are disapproved for the following Approval is v'aT[~d for one yea~ following the date of approval. CPJ: cw DATE STATE OF'~ALASKA . "-~-"~RTMENT OF HE,~.LTH'AND V~'~-%RE Lob..~. '' - ' '~ ' DIVISION OF' PUBLIC HEALTH BACTERIOLOGICAL WATER ANALYSIS OFFICE REPORT RESULTS TO SAMPLE COLLECTED BY ~ )' ~' am DATE COLLECTED tIME COLLECTED / ! ~pm Well- ~ Dug E Driven ~ Drilled ~1 Bored SOURCE: [] Spring [] Cislern [~ Olher Dug Well or Cistern Construcflon: Brick or When? Records in this office indicale this WATER SUPPLY to be oh [] Satisfactory [] Questionable [] Unsaflsfaclory Sanitary Status. Anarysis shows Ihls Waler SAMPLE to be: [~ Safislaclory [] Questionable [] UnsalJsfacfory. % ? ~ an "Unsatlslaclory" or "Ouesllonable" slatus is indicated above you should take immediate action as recommended below. · Notify consumers waler is polluted. Bali or c~temlcally lreat this walel as oullined Jn the enclosed leaflel -- "Drink It Pare." 2. I~crease chlorJnalJon suJJicJentl¥ to meet recommended resJdua standards. Determine source of conlaminalion and fake action necessary fo maJnlaJn p sale wafer supply al all times. '~. Check ~hlorJnalJnn and other m~chanJcal equipment. Make certain it is functioning properly· --4. If a~J~r ~J~klng equipmen~ a dislnJect~ng residual is noJ obtained, alease 5. This is a surJace waler source and sublectlo pollution by man and animals. · 6. Improve your [] spring [] dug well [] driven well [] drilled well [] cistern. disposal system. [] see enclosure 8. Sample mo ong in transil: sample should not be over 48 hours old al examination 1o indicale reliable results, please send new sample. [] Raffle BroJcen in lranslb please send new sample. 9: Conldcl -/our nearesl [] Local Health Deparlmenl or [] Alaska Division of Public Health. sanUafion off;ce for bullelins, consultation and SANITARIAN'S REMARKS, Diameter ol Weft Deplh Feel Well Casing [] O[ Well [] Other PURPOSE OF EXAMINATION:Illness Suspected? [] Yes [~ No READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD 48 hours _,. '- Brillianl Green 24 hours 48 hours EMB AGAR Coliform Dens ~y .IMost probable No. aer 100c¢.1 WELL DATA MUNICIPALITY OF ANCHORAGE (MOAi HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION JUN 0 Well Classification //t/D/v/~'~',,~ ~ II~ A, B, C, D.E.C. Approved (Y/N) '/~,~ Well Log Present (Y/N) /4/ Date Completed _ /~2[~1c. Z/.t/~'oc~ Yield Total Depth /O~, / Cased to /O(~ / Depth of Grouting Static Water Level ~'-5'- ' 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 To Nearest Public Sewer Line Cleanout/Manhole //5' Water Sample Collected by Water Sample Test Results Comments ~./~' /.~r't./.L /$ Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ,4/.//.4 ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date "~- / ~ Date Installed ~ ~ Size No. of Compadments Standpipes (Y/N) Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Date Last Pumped 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 To Property Line To Water Main/Service Line ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Course Comments Page I of 2 72 026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results 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 Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (it present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I cerCdy t h~//:~ ave check, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. S i g n b~,/////-'~ ~'/~ ~ Date Company ,,~¢¢'~,./7'" /,/,/,/,/,/,/,/,/,{~,J4UN~C'~'~'~MOA No. Receipt No. Date of Payment ~ Amount: $ ~ MUNiciPALiTY OF ANCHORAGE . DEPT. O~~ ~ '~.¥-T'.: & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONA.'~N'It L i",. ~':C~ION PffC 2 8 978 825 L Street - Anchorage, Alaska 99501 MAIEING'ADD~ES$ 2, BUYER ~. PHONE MAILING ADDRESS 3. LENDING INSTITUTION PHONE MAILING ADD REALTOR//~GENT MAILING ADDF ESS 5. LEGAL DESI PTION STREET LOCATIOF ~-- SING FAMILY [] .E FAMILY 7. WATER SUPPLY [] PUBLIC UTI LITY d~ 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE*' If ir~ ~ PUBLIC UTILITY by thi~ ree IEDROOMS [] Four [] Five [] Six [] Other is required for all wells drilled June 197E 9lis drilled prior to that date, give well (attach available.) , give installation date s over two (2) years old an adequacy t~t is required rtment. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOI NTM ENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SiX PERMIT NUMBER 2, WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDiVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or []Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5, COMMENTS [] APPROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title} LEGAL DESCRIPTION 72-010 (Rev, 3/78)