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Home My WebLink AboutTURPIN BLK 1 LT 9 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 GENERAL INFORMATION (a) (b) (c) Application Date Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name/~'/~- ~.f~Gu(~.~ Applicant Address ~,5'-~:~ ~ul~, Telephone: Home ~,"]?- ~,_~'~' Business Applicant is (check one): Lending Institution,~ Owner/builder []; Buyer []; Other [] (explain); (d) Lending Institution ~.~/'~'~'~/', "~/'~'¢ ¢..~,¢c,;, Telephone Address ,~0 ~. ~ ~/7~ /o~ ~ (e) Real Estate Company and Agent Address ~ ~ ~ ~ Telephone (f) ~..~t~e H~,,~t~l~'~i~eSS: TYPE OF RESIDENCE Single-Family)~' Multi-Fa'mily [] Number of Bedrooms ~'- Other WATER SUPPLY Well~ Community [] Public [] individual Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 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. Page 1 of 2 72-025 (11/84) ~ DA ..~.~ AND INFORMATION ENGINEERING FIRM PROVIDINg. oNSPECTIONS, TESTS, FILE SEARCH, ... 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 alt Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm $ & $ ENGiNEERInG Telephone ~ ~- ~- ~ 7 ~ Address SEB ~96X Date EAGLE RIVER, AK 99577 DHEP APPROVAL Approved for Approved bedroomsby ~,x ate. -,~.,, ____/'~"~'. ~/'~ 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 satisfy certain federal and state requirements. Employees of DHEP do not conduct inspect[oas 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) a ceoroo~c,z r, ao~*°~es o~'r,s~:a. ~vc. 7~ Water Anal ysis Report for Total Coliform Bacteria · TO BE COMPLETED BY WATER SUPPLIER [] PUBLIC WATER SYSTEM I.D.# [ I I J I I I J;3<'PRIVATE WATER SYSTEM Mailing Address City State tMo. Day SAMPLE TYPE: ~ Routine [] Check Sample (for routine sample with lab ref. no. ) [] Special Purpose SAMPLE NO. LOCATION Phone No. Zip Code Year [] Treated Water [] Untreated Water Time Collected Collected By TO BE COMPLETED BY LABORATORY AnalySis shows this Water SAMPLE to be: '4 S~?sfactory [] 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. Date Received C-'~ / :) Time Received / Analytical Method: Membrane Filter * N0~ of co onies/100 mL Lab~!Ref. No. Result* I ~d;o.,-~, · I I FF~ Analyst READ INSTRUCTIONS BEFORE ¢ COLLECTING SAMPLE! BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Count Verification: LTB Final M e m bra ne ~.~./l~sults /~/ Reported By TNTC = Too Numberous To Count OB = Oth)~ R~cteria ~ WELL DATA ~!MUNICIPALITY OF ANCHORAGE (MOA) T RITY APPROVAL HAA HEALTH AU HO ( ) CHECKLIST - FEBRUARY 1984 264-4720 Legal DeSC,.,~:)tion: ~ ~ ~:~'~" t Well Classification '~--~,{~, If A, B, ~ed (Y/N) Well Log Present Y,~ Date Completed ~~ Yield Total Depth L(~'~+~)Cased to ' tJCC) J~ Depth of Grouting Static Water Level c~..~;~ ~ Pump Set At O t~ Casing Height Above Ground Electrical Wiring in Conduit ~'N) Separation Distances from Well: To Septic/Holding Tank on Lot Sanitary Seal on Casing 7~N) Depression Around Wellhead (Y/~ To Nearest E~lge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole I~/~ -/~' ;On OnAdjoiningLots t,~//& ~ ;Adjoining Lots ~' To Nearest Public Sewer Water Sample Collected by ~ ~ ~ Water Sample Test Results Comments To Nearest Sewer Service Line on Lot B. SEPTIC/HOLDING TANK DATA Date Installed 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 To Property Line To Water Main/Service Line Course Size ~ No. of Compartments (~s~Y/N) __ Foundation Cleanout (Y/N) Air-tight /,r~ Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) . To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments ~_.~:> ~.3 e...~"._~---r'[~==o .--t'7-'~.~ ~E~-~z-~.a-r----- ~ Page 1 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 (if 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"Vent Level (Y/N)at Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request I certify thats& S ENGINEERINGI have checked~verified, or conformed to all/../~MOA and HAfA guidelines in effect on the date of this inspection. Signed Date SRB 196X Compan~(-~-7- MOA No, Receipt No. /O b\ Date of Payment ¢::~/~%/%~, Amount: $ Page 2 of 2 72-026 (11/84)