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HomeMy WebLinkAboutVILLAGE PARKWAY ESTATES #1 LT 4 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. ~-- MUNICIPALITY OF ANCHORAGE ~ DE~' TMENT OF HEALTH AND HUMAN SERV~' Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT name DISTANCES '~/~t~,' a ~ ~' - ~'-I ~,~ IZ~" ~ Tn SEPTIC ABSORPTION AddressFROM~ WELL ~ TANK FIELD Phone(s) P*r~it No. No. of rooms WELL ~ ~ ~ ~ ~ + LEGAL DESCRIPTION LOT LINE ~1~-~ ~ ~'~s FOUNDATION 14 ' ~o~' .+ 4~~ Township, Range, Section AS-BUILT DIAGRAM (Show location of well, septic system, properly lines, Ioundation, ~1 ~ ~ ~ ~ ~ /~ ~' ~J' driveway, water bodies, etc) TANKS i SEPTIC HOLDING ~ ~ Manulacturer Capacity in gallons , 'Material NO oJ C~mpadments TYPE OF SYSTEM ~TRENCH ~ BED ~ W. DRAIN ~ OTHER ~-l~z )epth to p~pe bottom lrom Total depth from original grade ~11 added above original grade Gravel depth beneath plp~ ~ FTI H .ber of lines So,lratlng/~ ~ Plpemateria, ~ ~,~ ~,O~ ~ lief I Date Installed WELLS /~' ~ PRIVATE ~ OTHER (Idenlilv) cation (A,B,C) Total Depth Cased to , P~u¢ 3l ~ ET '~a'~ FT Date Installed: -~- Scale: P¢~ ~' ~~ cedifythatthJsinapecti°nwasped°rmadac~°rdingl°all ~, ii and Slate ouidelJnGs in effect 0n Ihis date: ~ ~-- ~ ~ MUNICIPAL IT¥~ OF ANC~HORA '~- E DEPARTMENT OF HEALTH AND ENVIRONMENTAL F'ROTECTIOIg 825 L STREET.~ ANCHORAGE, AK 99501 264-4720 ON'--SITE PERMIT NO: DATE ISSUED: 840596 ENGINEERED DESIGN 07/20/84 APPL I CANT: ADDRESS: CONTACT PNONE: DAVE HAMRE 8740 HARTZELL DR ANCHORAGE, AK 99999 544-3454 LEGAL DESCRIP: I~IT SIZE: SUBDIVISION: VtLL. PARK EST..~1 LO]': SECT ION: 15 TOWNSHIP: liN RANGE: 11)~17 (SQ.FT. OR ACRES) BLOCK: N/A certi£y that: 1. I am £amiliar with 2. 5. the requirements £or on-site sewers and wetis as ~orth by the Municipality o~ Anchorage (MOA) and the State o~ Alaska. I wilI install the system in accordance with all MOA codes and.regulations, and in compliance '~ith the design criteria oF this permit. I Will adhere to all MOA and State of Alaska requirements CDr the set back distances £rom any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nmarby lot~ IF A LIFT STATION IS INSTALLED IN A~4 AREA COVERED BY MOA BUILDING CODES, ~ THEN (~) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAI. NED.; (2) AS-BUILTS --~-- ~-~- -- ~b ............................ ~--%~--¢ \¢0 ;'_ / SCHILLING AND ASSOC IATE,S ~721~ A~IC SCHILLING ASSOC I ATES ~'~7 Arctic Blvd. Anch ~,ge, Alaska 99502 344-9694 349-7724 CALCULATED BY ~' ~' ~'~ ~1~ DATE CHECKED BY DA~E SCALE ~q- SCHILLING ASSOCIATES /~7 Arctic Blvd. SHEET NO. ~ OF Anci~ ~ge, Alasko 99502 344-9694 349-7724 CALCULATED By ~ ' ~ ' ~:~'~ ~ *J/[ [ ~'~'c~ DATE CHECKED BY DATE SCALE SOILS LOG PERFORMED FOR: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS L~;)G~P E R C O bA-T4~T PERCOLATION TEST LEGAL DESCRIPTION: 1 2 3- 4- 5- 6- 7 8 9- 10- 11 13- 14- 15- 16- 17- 18- 19- 20- SLOPE SITE PLAN COMMENTS PERFORMED BY: 72-008 (6/79) Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~ ~ ' ''~ minutes/inch) TEST RUN BETWEEN "~ FTAND--~ FT ~---WA~ blSPOSAL A-b b I I-~ o,,U ./'dO. SCHiLLiI'4~ ASSOCIA1-ES 72'~ 7 Ar¢lic Blvd. Anchoroge, Alaska 99502 344-9694 349-7724 )ale: Grid: $CHILLI '4G _~EWA~ blZPOSAL 5Y_~TEt,~ ASSOCIATES 72t7 Arctic Blvd. Anchoroge, Alaska ~502 LoT &, VJLL~ ~W~'~ ~T~- 3~-9694 349-7724 AbblTIoM MO, J Date: -- Scale: Grid: SCHILLING 8~ ASSO C I ATES ;"~"? Arctic Blvd. Anch~. Jge, Alaska 99502 344-9694 349-7724 SHEET NO, ~ OF. CALCULATEDSY ~'~ -~'~'~;1\1~ DATE ~'7-- ~ ~ "'~' CHECKED BY. DATE SCALE SCHILLING ASSOCIATES ?-m? Arctic Blvd. Anch~..~ge, Alaska ~9,502 344-9694 349-7724 8HEETNO ~ OF C^LCUL^TE~B~ /2D 5'c_~,,~/,~) DATE '-7--/~--~4'-- CHECKED BY, DATE SCALE .i !.i. SCHILLING ASSOCIATES ,':'~'~7 Arctic Blvd. Anch~ Jge. Alaska 99-502 344-9694 349-7724 SHEETNO, ~ / OF CHECKED BY DATE SCALE. SOILS LOG MUNICIPALITY OF ANCHORAGE  DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ~J, PERCOLATION TEST · 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST /3--~ ,.Z~M ?_~ '~,/~ ~k~,~N /~S O~ , DATE PERFORMED: PERFORMED FOR: LEGAL DESCRIPTION: L~'~ 4- ~ ~) i LM..~c~,~'- ~IC~z,.IJN~'TJ ~--~ /~- C~L~I'~'IO/~J /k_)O. / 1 2 3 4 5 6 7 8 9 10 11 13- 14- 15- 16- 17- 18- 19- 20- SLOPE SITE PLAN S Gross Net Depth to Net Reading Date Time Time Water Drop ~ " &', o~ p,t~, ~o 4, g~~ ~ " 4;~P,~. ~o 4,~~ ~.~8t PERCOLATION RATE '~,/~j~(l~') ~ / ~. 8 ~ minutes/inch) TEST RUN BETWEEN '~ FT AND ~'- FT J PERFORMED BY: 72-008 (6/79) CERTIFIED BY: /~z~,~v~ DATE: SOILS LOG PERFORMED FOR: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264°4720 L~S LOG - PERCOLAT~..~ TEST ~o~ ~, DATE PERFORMED: [] PERCOLATION TEST LEGAL DESCRIPTION: 5 6 7 8 9 10 11 12 13- 14- 15- 16- 17- 18- 20- SLOPE SITE PLAN ITERED? --~O,~'lF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN COMMENTS .~:~ ~ I-?-~ t~'~ ~.r"~--~'*~ O*~ ~'~ ~ ~ '-~ S '~ FT AND -- FT 72-008 (6/79) CERTIFIED BY; /~.LJ.'~.~J__~.~2 ~.~&-~7" '7 o~' 7 SOILS LOG PERFORMED FOR: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - ~ j~ ~3 /O ~-55 DC, DATE PERFORMED: PERCOLATION TEST LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9- SLOPE SITE PLAN 10- 11 13- 14- ;GROUND WATER IUNTERED? "~'~'~ 4 %)~' ~i1-1F y E S, AT WHAT DEPTH? ANCHOEAOE HEALTH & ~7- 71984 lIVED Ig- 20- Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) ~'~' 4' O ET TEST RUN BETWEEN FT AND 72-008 (6/79) CERTIFIED BY: ~'"~'~>'~'~f 3 MUNICIPALITY OF ANCHORAG~ DEPT. OF HEALTH & ENVIRONMENTAL P~OTE¢/'ION lV/,/l'~ RECEIVED I herebycertify the following described property, LOT ~ , BLK - . Anchorage Recording Precinct, Alaska, has been surveyed by me, or at my direction, and that the Improvements situated thereon are within the property lines and do not ovedap or encroach on the property lying adja- cent thereto, that no Impi;oYements on property lying adjacent thereto encroach on the premlaes in question and that there are no roadways, transmission lines, or other visible easements on said property, except as indicated hereon. It ts the responsibility of the owner or builder, prior to construction, to verify proposed building grade relative to finished grade and utility con- nections and to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plot. SCHILLING ASSOCI AT£S · -- ~2~/-Arctic Blvd. Anchorage, Alaska 99502 344-9694 349-7724 Date: 7- lq - ,~ ~- Scale: 7"' =., oo' Grid: [V~-VV DRILLING, Inc. P.O. Box 10-378 * 10300 Old Seward Highway (907} 349-8535 ANCHORAGE1 ALASKA 99511 84-253 DRILLING LOG Well Owner DA~E I~2,'~P~ / / Use of Well Domestic Location (address of: nship, P~ange, Section, if known; or distance main road Lot 4 Addition ~/'1 Vtl'la~e Pazl~m¥ .Estates - And~orag, e Size of casing 6" Depth of Hole 310' feet Cased to 20.40 feet Static water level 55 ft. (~%;~ (below) land surface. Finish of well (cheek one) open end ( X Screen ( ); Perforated ( , ~ Describe screen or perforation None Well pumping test at___~__ga,ll~ns:Per ~ of drawdown from static i~vell ! : Date of completion August 20!;~984 minute) for 1 WELL LOG ); hours with 100% Depth in feet from ground surface 0 TO 5 5 TO 310 .TO _TO .TO. TO. TO _TO TO_ GP~ dOt,ils 6f formations penetrated, size of material, color and hardness seaps in sporadic fractures NOll.~'~lO~d 1V~N~NO~I^N] .... ~'HZ1V~N ~O U.d~Q TO TO .TO TO. .TO 3--CONTRACTOR ALASKA dlUIROnmdlTAL COI1TROL SeRUICeS, I[1C. ~nc~ineerJn§ 6 ~nuironmentar Studies ~UNICiPAUTY OF ANCHORAG;E April 1, 198~ ['~T' Cc ,1:5:'r'~ '~' I I:NVIF, , ~ t ....... o E ; ,I John Lynn Department of Health and Environmental Protection 825 L Street Anchorage, Ak. 99501 /,72 8 1gS2 RECEIVED Dear John: I have reviewed your letter concerning Village Parkway Estates addition ~1. I sm enclosing a profile of the holes along a line that nearly follows the Valley floor. Just north of the southernmost line for Lot 4 there is an apparent depression in the bedrock which would indicate a possible ponding site. I expect that it is apparent because the test hole was dry. If ponding would occur one could expect to find water at the bottom or up to four feet from the bottom of the test hole. See the attached drawings. If the water wells are placed high on the ridge, the tops will be well above any possible point where sewage contaminated surface water could enter the bore hole. As for fractures in the bedrock. I believe the ground slopes are such that water would move rapidly to the south. I think shallow beds are indicated by the soils. In this case I would stick by my earlier recommendation that a sub-bed of 12-18 inches of clean sand be installed under the septic rock. All soils in the test area are in the 85-125 sq. ft./bedroom (sqft/br) range. I recc~uend that the design be based on the sand bed @ 150 sqft/br. A typical 'three bedroom house would require a bed of 675 sqft. (150 x 3 x 1.5). A typical dimension with length (L) being two ti~es width (W) would be 18.5' x 37'. Lot 4 has an available area of 13,500 sqft so there is ample roc~ for many replacements. Lot 1 may be the most critical. Even it has a possible area of 6,700 sqft. on the top of the ridge. All other lots have a greater area. 1220 [llcst 25th Auenue ,, Anchora§e, Alaska 99503 "(907) 276-1361 The sand filter bed under the system coupled with tJ~e vertical and horizontal separation of the w~]]~ wo,,l~ all work to insure a safe system. /n addition one can grout the w~]]s with drilling mud to close the annular ring between the casing and the bore hole. These lots are quite large, around three acres. I believe with the controls outlined and others available to you, there is a reasonable belief that these lots could be developed with no more ~k to health then any other ]mt. If you have rely questions please let me know. Sincerely, N 75° 275 ' ~©T 4 \~o, 528 2':54 A~'RE ') / / 50'frO' / 50'/I /~/ / 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. # 020-291-52 HAA# HA920799 AMENDED GENERAL INFORMATION Complete iegaidescription Lot 4 Villaqe Parkway Estates Location (site address or directions) 19460 village Scenic Parkway Property owner Mailing address David/Patricia Hamre Day phone 561-1970 Lending agency ALASKA USA % Jo Ann Mailing address Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: Three ( 3 ) TYPE OF WATER SUPPLY: Individual well xxxxxx Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: XXXXXXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. I/gl) Front MOA ~21 5. STATEMENT OF INSPECTION BY ENGINEER 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 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. NameofFirm Tobben Spurkland, Po E. Phone 279-3916 Address 203 West 15th Avenue 9206, Anchorage, Alaska 99501 Engineer's signature Date DHHS SIGNATURE xxxx Approved fo~hree (3) Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: By: AdditionalComments Note: The well for this property meets existing State and Municipal Codes° There are nitrates present. It is suqqested %hat a periodic testing be performed to insure the wells continued suitability° Nitrate concentration is 6.6 mg/lo EPA mazimum ~oncentr~t~on is !O ,0. mg/1. The Municipality of Anchorage Department 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 professional engineer's work. 72-025 (Rev. 1/91) Back MOA~21 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Dayphone f~l- t~/~O Lending agency Mailing address Day phone Agent Day phone Address 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State AD£C attesting to the legality and status of system. 72-025 (Rev. 1/91) Fronl MOA ~21 5. STATEMENT OF INSPECTION BY ENGINEER 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 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 structu re 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. NameofFirm /, d)/¢~-e~'f O*"~'c~J'~''~j~' Phone PQ~7~-~C~~::~ Address ~0 ~ ~ ~--~ [~ ~ ~ Engineer's signature ~~ Date ti [ ~ DHNS SIGNATURE Approved for _/'~¢¢¢~//~/~bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Note: The well for this property meets existinq State and Municipal Codes. There are nitrates present. It is continued suitability. Nitrate concentration is 6.6 mg/1. EPA The Municipality of Anchorage Department of Health and Human Se~ices (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 professional engineer's work. 724)25 (Rev 1/91) Back MOA ~21 Legal Description: ~/// Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A, WELL DATA ~, ~Nelltype~ If A, B, crC, attach ADEC letter. Log pres~ Totaldepth .~ ~ O Sanitary seal (Y/N) Parcel I.D. ADE, C wit, er system .number /v//~ Date completed ~/~' ~ -/~/-- ~Z~)'/D~r i~ ie, '~'~' ! Cased to ~ (~' L~ ' Casing height Wires properly protected (Y/N) AT IN/SPE(~TI ,O_I~UNiClPALiTY OF ANCHORAGE II//e/~ ~3/~ViRONMENTALSERVICES DIVISION IVED Date of test Static water level Well flow Pump level g.p.m. FROM ¥~ELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot > Public sewer main Sewer service line > ; On adjacent lots '~" /.~6 ; On adjacent lots Public sewer manhole/cleanout Petroleum tank ~"ltS~ WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate ~::). ~ Collected by: Other bacteria Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping , ', ,,,~ Tank size /.5~O0 Compartments Foundation cleanout (Y/N) '~ . Depression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /~ On adjacent lots ~ ! (~) 5'"' '~Foundation Topropertyline ~',~-0 Absorption field > [.%"~0! Watermain/s~ Surface water/d rainage .~ ,~ 72-026 (Rev. 7/91)Front CONTINUED ON BACK PAGE C, LIFT STA'rlON Date installed Size in gallons Manufacturer Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump off" level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length ~r~/1' ! V~idth ~)~' ! Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating S~_ te. m/type ~rav~l thickness ~ ~ "~ Cleanouts present (Y/N) Date of adequacy test for If yes, give date bedrooms SEPARA'T'ION DISTANCE FROM ABSORPTION FIELD TO: Wellonlot ~ /-~--OI Onadjacentlots "~/5'-'O / Propertyline To building foundation ~.[.~C) f To existing or abandoned system on lot On adjacent lots '~[~"'0 ~ Cutbank Surface water ~./~.A~_.,-,~_ ¢'.?/¢z,~?~z/ Curtain drain _/}~, ~, , ¢/~/v~.~P~.~,eo Water main/s~ Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name 0 e'~¢~,~ ,~.~hu-c'/,~t,~t.~,~ I -- Date [ t[%'O /q''~- [ HAA Fee $ / Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Bsck MOA 21 '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 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ~ ~ Telephone: Home ~-~ Business Applicant Address / ~ ~ O ~/~ ~i~ /P~ (c) Applicant is (check one): Lending Institution ~; Owner/builder~; Buyer ~; Other ~ (explain); (d) Lending nsttut on Address / (e) Real Estate Company and Agent Address Telephone Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family J~ Multi-Family Number of Bedrooms Other WATER SUPPLY Individual Well ~ Community [] Public [] 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 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 72 025 (11/84) 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. ~-fi.~,~. - ~, I,~ I ~.~,~ ~,ercC-' L~. '~ c~-,.'~ I~ ( , ~] Telephone Name of Firm Address ~..~05- ,,~y~.?~. i~ ] JJ. .-¢¢ ~-~ ~ /,-~,./~k'~-'-~,~- Date 52' - Z ,¢' - Engineer's Seal DHEP APPROVAL Approved for Approved 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 ol 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 (MOA/ HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITf OF ANCHORAGe. DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION APR 2 9 198 ' A. WELL DATA Well Classification Well Log Present (Y/N) Total Depth ~'~/ Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To(~-eDti~Holding Tank on Lot If A, B, C, D.E.C. Approved (Y/N) Date Completed ,,¢~.o- ~ ,~ Yield Depth of Grouting Pump Set At 7~.-~-- ~ Sanitary Seal on Casing (Y/N) ~// Depression Around Wellhead (Y/N) J~o~4' ; On Adjoining Lots 1°~4- ; On Adjoining Lots I c, o' 4- ' ~ To Nearest Public Sewer ~ TO Nearest Sewer Service Line on Lot ~,/o .~/,2c¢,*/Z'//~.~-¢ ; Date 4¢- ~-~/~Z¢ ~, To Nearest Edge of Absorption Field on Lot '~9'z~' ~ To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by ~7. Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date lnstalled ~.)4~.~ ~- Size /,.¢~o Standpipes (Y/N) "// Air-tight Caps (Y/N) Depression over Tank (Y/N) ,~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) ~ Separation Distances from~eptic~Holding Tank: To Water-Supply Well ~,o ~ ~ V To Property Line ~ ~' ~ *' No. of Compar[ments Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) -- To Building Foundation To Disposal Field ~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course "'-'"- Page I of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~.-¢~/~ ~?' ,~- Width of Field .~-w Square Feet of Absorption Area ',~ Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well '~5"~ ' To B~ilding Foundation Lot To Water Main/Service Line "~ / ~< ~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments e¢- ,z~ c~. s~ ,~ ~ e~,...,¢/~=/ Type of System Design Length of Field Depth of Field Gravel Bed Thickness '~' Standpipes Present (Y/N) Date of Last Adequacy Test Y 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" Level at Vent (Y/N) Pumping Cycles during Adequacy Test, Meets MOA 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 the date of this inspection. S i g n e d,~.-J~-~J',*~..~ Date ,~- Company Receipt No, '~;~ Date of Payment Amount: $ MOA No, Page 2 of 2 72-026 {11/84) Engineer's Seal