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Home My WebLink AboutWENTWORTH BLK 1 LT 9 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # ~("~-- d~)Z ~ --z-z/~ HAA # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Lot 9; Block I; Wentworth Subdivision Location (address or directions) (b) Property owner Keith Laughlin Telephone: (home) Mailing Address 3210 East 40tht Anchoraqe~ Alaska 99508 (c) Lending Institution Telephone 562-4459 Business (d) Real Estate Company and Agent AREA COLDWELL BANKER/Mark Gilbert Address 4105 Tudor Center Drive, Ancheraqe, Alaska 99508 Telephone 561-2488 (e) Mailthe HAA tothefollowing address:(orcheck hereY~;~ifholdforpick up.) Listcontactperson and day phone numberbelow: S ~ S ENGINEERING/694~2979 17034 Eagl~ River Loop Road. Suit~ 204 Eagle River~ Alaska 99577 2. TYPE OF RESIDENCE Single-Family,~:;~ Number of bedrooms 3. WATER SUPPLY Individual Well ~] Community [] Public ordered by Mark Gilbert 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,iD( 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 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 'Cat my investigation of th is 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 Date S & $ ENGINEERING 17034 Eagle River Loop Read Eagle River~ Alaska 99577 Telephone 6. DHHS APPROVAL Approved for ~.~edrooms by Approved ~ Disapproved Terms of Conditional Approval 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 8o not conduct inspections or analyze data befm:e 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 MUNICIPALITY OF A,~!CHORAGE MUNICIPALITY OF ANCHORAGE (MOA) ~ ENVIRONMENTAL SERVI~.,.S CJVISION Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 SEP - 8 343-4744 A. WELL DATA Well Classification Well Log Present (Y/~ ¢ Date Completed )~t'-'-'-'-'-'-'-'~¢¢-¢/, I ~ [¢¢'¢~" Yield T°tal Depth L~'[('~ Cased t° '~'°14' Depth °f Gr°uting L Static Water Level ~ ~ ~ Pum et At ~ Casing Height Above Ground ~'¢"- Sanitary Seal on Casing(~N) Electrical Wiring in Conduit ¢~N) y Depression Around Wellhead SEPARATION DISTANCES FROM WELL: , To Se~Tank on Lot ~_~/j~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots To Nearest Public Sewer Line "¥~'c~'--~-- To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot '~' ~ Water Sample Collected by ~ ~::~"~tt-~:~r~,, ;Date Water Sample Test Results "~ ~ O ~/'1.~-~--~ [-'~~ '~ B. SEPTIC/HOLDING TANK DATA ~"~"//~¢' '-'-- ¥-~. O, ~"' /' N Size o. of Compartments Da~nstalled: , .Standp~) _ Air-tight Caps (Y/N) Foundation Cleanout Depression ove~ Date Last Pumped __ P~enance Con~(Y/N) ___ __; for __ H~igh-Water Alarm (Y/N) '""---. ~ Temporary Holding Tank Permit sEPARATiON DISTANCES FROM SEPTIC/HOLDI~ To Water-Supply Well To Buildin~on ' To Disposal Field '"'--. To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments If A, B, C, D.E.C. Approved (Y/N) ' //--~ 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata alled Square Feet of Absortion Area'""---.__ 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 Statndpipes Present (Y/N) Depression over Field (Y/N) Date of Last Adequacy Test Results of,Last Adequacy Test ~ SEPAR^IION DIST^NCE FROM ABSORPTION FIFLD: To Water-Supply Well To Property Cma.... To Building Foundation _To Exis'I'~g..~r Abandoned System on Lot ; On Adjoining Lots To Cutback (if present) ~ D. LIFT STATION Date Installed 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 Company Date MOA No. $ & $ ~,~¢=H',-~ ........ 17034 Eagle Ri~er Loop Read No. 204 Eagle R|ver, Alaska_9~5.,7~_ / Receipt No. 'Date of Payment Amount: $ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 · ' '·~ CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. .~ ~o.^... ~~.~.~t; ~: :;-~,.-~,x FEDERAL TAX ID Cf 92-0040440 AIIALYSIS REPORT BY SAMPLE fez Work Ordez ~ 8979 Data Report P~lnied: SEP 6 88 8 16:56 Clieni Sample ID:Lg, B1 WSNTWORTH, KIICgZ~ $IN[ PW$ID :UA CoLleoted SEPt2 88 8 13:LB h~. Eecelved SSP 2 88 @ 14:~0 Client Ma~e : 5 ~ $ ENOIIIEERIHO Client Acct : 3NHE~GP P.O.{ HONE REC'D O~dered By : R,P. Analy~l~ Completed :$EP 2 88 3end Report~ to: Laboratory Supervisor :STEEHEU C. ED8 1)8 & $ E~GINEERIHO /, Special Instruct: Chemlab Ro£ S: 2473 Lab 8mpl ID: i Matrix: WATER Allowable Para}~eteY Tested Result/Units Method Limits NITRATE-N ND(O.iO) my/1 ~ EPA 353.2 10 Setnplo ROUTINE 5A~LB ~e]narks: SAMPLE COLLECTED BY RP 32L0 3 Tests Per£ouned ' See Specfal ,I?~ru~tion~ Above UA-Unavailable ~ot Analyzed 'LT.LesS~Tha~, G~-G~ater Than 1. GENERAL iNFORMATION ': ~:;~(~'"~ -~:~?~")'-'[(:::) (a) Legal Description (include lot, block, subdivision, section, township, range) ~--~? MUNICIPALITY OF ANCHORAGE ~/' c'N~'~7;F=.~/Vc/,/O~ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ~ ~rCE3~/~GE Application Date ~ [~- ~ Location (address or directions) (b) Applicant Name ,.~?'-r}A_ ~)~[~ Telephone: Home ~'~'?''-II1'~. Business Applicant Addres~ (c) Applicant is (check one}: Lending Institution [] Owner/builder,E]:; Buyer []; Other [] (explain); (d} Lending Institution Telephone Address (e) Real Estate Corr pany and Aaent ~--c:;~:~l-~'~-~t~ '4J~C~-~t~/Z.~ · A'ddress ~-'1 .b,,.l~ ~'"-~ t Telepnone ~'~J ~ ~-'~ (f) ~the HAA to the following address: ~' & $ ENGINEERING Eagle River, Alaska 995~7. 2. TYPE OF RESIDENCE Single-Family~ Multi-Family !;:,-:-;./ - . f -'- Numbero Bedrooms 3. Other WATER SUPPLY IndMdual Well.~ Community [] Public [] : .; Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality anu status. 4. SEWAGE DISPOSAL Onsite [] Publicl~ Community [] Holding Tank [] Note: If community well sys[em, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page I of 2 72-025 11/84) 8 jo ~ abed leUOi)lpuoo leAoJddV leUO)lipuoo jo SLUJe/ PaA°Jddesia ~)i~" P@^°Jddv '9 /. / l~,Ol: 'oN pearl 8001 ..m~l~ ilB~l t~gO"l, sseJppv euoqdale.L SNJi:I~Ni-~N~S '~ S UJJ!-I ~0 ameN 'uo!)oedeu[ s!4) jo alep e4) ua lOajla u! sUO!lelnaaJ pub 'seoueu!pJo 'sepoo e)e)S pub ledlo!unR lie ql!M OOUe!IdLUOO U! s! LUale,~e lesods!p JeleMe)SeM Jo/puB /,Iddne Ja],BM a)!e-uo aLI1 'uo!)oedsu! pub uo!lel~!],ea^u! Xm LUOJ] pUB SalU eaBJOLIOUV 10 Xl!lBd!o!unR eLI1 LUOJJ pau!e)qo UO!iBLUJOJU! eLI], UO peseq lm~l ,~jpa^ JeqPnl I 'u!aJaLI palBo!pu! eJnlonqs jO adXl pub suJooJpaq jo jeqLunu e],enbepe pub IeUO!],ounj 'BiBs s! mels,~s Iesods!p Ja)BMB)SBM Jo/puB ,qddns Ja],BM ells~ua aH], Ieq], SMOLIS leAOJddv q)leaH s!q], Jo uol],e6!)se^u! ,%u ],Bq],,~jpe^ I 'MOleq UMOqS a],Bp UoRBpuBA eq) JO se pUB o],eJaq paxuJe leas Xm Xq peu!pea NOI.LVINI:IO4NI aNY ¥.LYa 'HDI:IV~i$ :~-I1-1 'S.LS~IJ. '$NOIJ. C)~IdSNI 9NlalAO~id INbll-I 9NIt~3NIBN~ .g DEPT. OF HEAL'fl'I & ENVIRONMENTAL i~O'I~CT iON gUN 9 19 7 MUNICIPALITY OF ANCHORAGE (MO~T'/ HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description:, ~ ~ ~L~--.. J Well Classification Well Log Present (Y/~]) Total Depth Static Water Level ~ ,¢, I(A, B, C, D.E.C. Approved (Y/N) Date Completed .~:2¢.~¢¢.. j~ I~:~ Yield Cased to ~ De~th of Grouting I ~ Pump Set At Casing Height Above Ground ~,'7'''? ~ Sanitary Seal on Casing ~?N) Electrical Wiring in Conduit Depression Around Wellhead (Y/(~J~ Separation Distances from Well: 14 To Septic/Holding Tank on Lot ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /'~ ; On Adjoining Lots To Nearest Public Sewer Line ¢ ,~,l .~. To Nearest Public Sewer Cleanout/Manhole ~ ~ J '{" To Nearest Sewer Service Line on Water Sample Collected by ~----~--/ ¢~:~--~1~¢c~''~(~ ; Date Water Sample Test Results ~-----~~ ~ Comments ~ ~ L.--II~¢" i1~~ ~,~-~ SEPTIC/HOLDING TANK DATA I-J/,~ CJ ~::~Pl ~ Date Installed Standpipes(Y/N) Air-tight Caps (Y/N) Depression ov e r-C"T-az:~/N ) Pumping/Maintenance_ C~ 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 Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Stream, ~ajor Drainage Comments Page I of 2 72-026(11/84} Soils Rating in Absorption Strata Date Instated Depression over Field (Y/N) Date of Last Adequacy Test ,,,% Results of Last Adequacy Test Separation Distance from Absorpt!on 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 Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) ~ine To Cutbank (if present) or Abandoned System on Comments UFT ST^T O. ¢ Date Installed 'Pump On" Level at ~ High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Oil" Level at Vent (Y/N) ~ing Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked verified, or conformed to all MO,~ and IdAA guidelines in effect on the date of this inspection $ & S EN$1NEERIN~ / / -- ' Signed 1 ;7034~.,~t~erLOepRolt, Compal~leRlVer'"l~''k'¢¢$7'.... MOA No. _,~"~'c:~.~ ':'"' ..... Receipt No. _~:~ ~¢2',...~ ./- 042¢ Date of Payment ~2.~ ~'"~ Amount: $ ,~-¢L~ ---"-' Page 2 of 2 72-026 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. /~~~X FEDERA~ T,,AX ID #, ?2-0040,4,40 Ye[ emeter 'reset ea Result/Units hethod ~.,i ~i ts I Tes~sPerfodned ~ See Soecia. t instruct~o.sF~oove [,~P= [-]one l)e[ected ~ See 8~m~le ~eMarks Above }~,:* !~ot ~ricJyzed L.~=~es5 l~an, di'=6ceater'.t'han Z CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC., 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (607) 562-2343 FEDERAL ,T.A, X~,D # 92-0040440 F/034 EAGLE 2IVER LOOP P,B,, *~204 EAGEE R!vg~h AX, 9957? i lot t-oct: Sample ~0OTiNE .SAHPLE, LA~oRA'fO[e~SUPRRV!SOR: Si'gPHEi~(:. BL~g MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI(~*~CJNICtPALITY O~: ANCHOR^GE 825 L Street - Anchorage, Alaska 99501 DEPt. ~F E~VIRONMENT/ ENVlflO~E~TAL ENGINEERING Telephone 264-4720 FEB 3 9 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER~I~[ D DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER MAILING ADDRESS PROPERTY RESIDENT (If different from above) 2, BUYER MAI LING ADDRESS 3, LENDING INSTITUTION PHONE PHONE PHONE '7'£- MAILING ADDRESS 4. ,,REACTOR/AGENT MAILING ADDRESS PHONE B. LEGAL DESCRIPTION /.or ¢. TREET LOCATION B. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] One [] Four []~'//Sl NG LE FAMILY [] Two [] Five [] MULTIPLE FAMILY E~'/'Three [] Six [] Other 7. WATERR SUP~I;~SUE LY ~/' INDIVI DUAL* * ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For welJs drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [] INDIVI DUAL/ON-SITE** **If individual/on-site, give installation date If system is over two (2) years old an adequacy test is required [;~'PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72~]10(3/78) ~j~j~--~_ /£ our OF 7~//J~J. THIS SIDE FOR oFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS 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 UTI LITY 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, DISTANCESwELL TO: Septic/HoldinaTank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS ~ APPROVED FOR 3 BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) /// LEGAL DESCRIPTION 72-010 (Rev, 3/78)