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Home My WebLink AboutWENTWORTH BLK 1 LT 22 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF ,~EALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 , .Afl, IC~ ..... OF ..I,, AUTH( -h, OgALFORA,~ ,~, .;FAMILYD GENERAL INFORMATION Corn plete legal description Lot 22; Bloc]( il Wentworth Subdivision Loc:ztion (s]~¢ addro oF (,;rections) 3231 .g~ dlst ?.venue Anchorage, AK Pr(~pert~;owner ._ ; ~ Teresa. Easnman Day phone 561-8424 Mai!ing address .... 323i E. 41st Avenue Anchorage, AK 99308 Lending agency .'"-National Bank of Alaska . Mailing address Day phone 257-3427 A-.'ont Day phone Address 2. NUMBER OF BEDROOI~S: 3. TYPE OF WATER SUP?kY: U,,less otherwise req~ ,~sted, HAA will be held for pickup. 3 NOTE: Individual well xxx Community well Public water If communi%, well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If communiiy wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 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 verifythat 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 Add ress Engineer's signature s & s ENGINEERING · ,."03-!. ~-~3I'~ River LoO13 Road No, 204 Eagle River~ Alaska 99577 Phone ~cf Date DHHS SIGNATURE .~ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By:' ~ Date The Municipality of Anchorage Department of Health and Human Services IDHHS) 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 DH HS does this as a courtesy to pumhssers 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. I " ..... of Anchora-e MUNICIPALITY OF Mun clpal [y g ENVIRONMENTAL' DEPARTMENT OF HEALTH & HUMAN SERVICES SERMON Environmental Services Division ~PR 2 R 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-47~ Health Authority Approval Checklist E C E I V E D LegalDescription: LeT ~-'3- I~o~.~< I '~,~-,'~'~/~-~ ~/6 Parcel I.D.: ~)O~-O~-~ A. WELL DATA Welltype PRIV~T£ IfA, B, orC, attach ADEC letter. ADEO water system number Log present (Y/~_ /V O Date completed ~'~'£~- Total depth 5-0 Cased to ,5'O : Casing height (above ground) Sanitary seal (~N) ~' ~ ~ -X-- Wires properly protected (~N) FROM WELL LOG AT INSPECTION Date of test Static water level Well production g.p.m. WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria O S & S ENGINEERING Date of sample: ~ ~ ~- -/ / ¢~ 7 Collected by: Eagle River, Alaska 99577 B. SEPTIC/HOLDING TANK DATA ~/~ ~ CO~u~y Date installed Tanksize . Numberof Compa~ments Cleano~ FoundatJo~ cleanout (Y/N) Depression ~/N) ~ High Dat~f:~ping" . ,. ,~:'. Pumper . C. AB~RpTION FIELD DATA :;. D~te ,ns{~lled .... - Soil rating (g.p.d.~ ~ Effective absorption area .: ~~) ~pm,~ o~r field (Y/N) Date of adequacy test / R~Pass/Fail) Fcr bedrooms Fluid depth in/before test (in.);. Immediately after gal. water added (in.): FI~ (i~) Minutes later:._ Absorption rate = g.p.d. P~ide tre~me~ (past 12 months) (WN) If yes, give date 72-026 (Rev. 3/96)* D, LIFT STATION Date instal]ed Size in gallons .------~-~ ~ Manhole/Access (Y/N) ~.j~P.u~t*~ "Pump off" level at* w~~ *Datu m High C.~e le'-s tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPT]C/HOLDING TANK ON LOTTO: Foundation Property line Absorption field Water main/service line Surface water/drainage Wells on~.~dja"c~lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON ~ Property line Build~ Water main/service line Surface water ~ Driveway, parking/vehicle storage area C~ Wells on adjacent lots F. ENGINEER'S CERTIFICATION I certify that l have determined thru field inspections and review of Municipal records~ .~.,.~..?~/~'~s are in conformance with ~A~ guid~ines in effect on this date Sgnature ~/~ ~. ~~ Date ~ / ~ w / ~ ~ HAA Fee $ Date of Payment Receipt Number 72-026 (Rev, 3/96)* 3 Waiver Fee $_ Date of Payment Receipt Number , APR-02-199? 17:42 CT&E ESI ANCHORAGE 90? 551 5~01 P.04/04 ~ll~mm~ CT&E Environme.tal Services Inc. CT&E Ref.# Client Name Project Name/// Client Sample ID Matrix Ordered By PW$ID Sample R~m~rl~: 971495002 S & S l~ng~needng N/A I_22, BK 1, Wentworth S/D Dfi~kiug Water Client PO// Printed Date/Time 04/02/97 15:59 Collected Date/Time 03/27/97 18:00 Received Date/Time 03/25/97 12:10 Technical Director: Stephen C. Erie S~mple collected by: Bob C- Nitrate-N Tote[ CoLiform o.]OO u o POL Unit~ Method Attowabte Prep Limits Date 0.100 m$/L ~PA ~00.0 cot/lOOmL $H18 92~2B Ana[ysls 03128/97 051Z9/97 RAM TOTAL P. 84 GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received Time of Inspection /0:(9~ ~./~o Date of Inspection INDIVIDUAL SEWER & WATER FACILITIES FOR 1. Approval requested by: Mailing Address: 2. Property Owner: Phone: Phone: Mailing Address: 3. Legal Description: 4. Location: 5. Type of facility to be inspected 6. Well Data: A. Type ~=- ~ B. Depth C. Construction (~),~ ~-/~-7~ D. Bacterial Analysis 7. Sewage Disposal System: B. Installer A. Installed C. Septic Tank: D. Seepage Pit: 1. Size 1. Absorption Area E. Disposal Field: Total length of lines Distances: A. Well to: Septic tank Nearest lot line B. Foundation to septic tank C. Absorption area to nearest lot line __ 2. Manufacturer , Absorption area Other contamination No. of bedrooms , Absorption area 2. Material , Sewer Lines __ EQ-034 (1/74) Page 1 of two pages Page?~of two pages - Re~,~st for Approval Lo~Jal Description of Individual ~_~er & Water Facilities Comments Approved~ ?~'?~¥ ~'~ Disapproved Date ~-/~-~? App~6V~q[~.~]id for one year from date signed Greater Anchorage-Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (l/74) GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received ~--'l Time of Inspection Date of Inspection 1. Approval requested by: 4. 5. 6. REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR Mailing Address: Phone: Property Owner: Mailing Address: Location: of facility to be inspected~ ~o~No. of bedrooms Type Well Data: A. Type B. Depth C. Construction ~/~/gJX~'mo~,~/) Sewage Disposal System: D. Bacterial Analysis A. Installed B. Installer C. Septic Tank: 1. Size 2. Manufacturer D. Seepage Pit: 1. Absorption Area 2. Material E. Disposal Field: Total length of lines 8. Distances: A. Well to: Septic tank , Absorption area ~, Sewer Lines __, Nearest lot line Other contamination B. Foundation to septic tank , Absorption area C. Absorption area to nearest lot line EQ-034 (1/74) Page 1 of two pages ~g~ 2 of two pages - Re'st for Approval of Individual ~.~er & Water Facilities Legal Description Comments Approved Disapproved Date Approval Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM ,1 certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date £0-034 ~1/74) ~arch 11. 1~?~ Spokane [.~rtgage 523 ~ost 8th Avenue Anchorage, Alaska 9g~O1 SUgJ[CT~ On.slte se~er and water facilities serving Lot 22, ~lock 1, ~en~o~th Subdivision At your request, the aLive facilities ~ere inspected by this gepa~t~mnt on ~arch ?~ 1974. At that tt(~e it wa~ found that the ~ater serving the subject property is via a private ~ell, th~ top of ~htcb is located In order to cm~ply fully with the O~eater Anchorage A~ea ~e~ough Cede of Ordtnancest~he ~ell must be reconat~Jcted so that the ~ell eastn~ is 18" above ground level. A sanitary seal is also required. This must take place before'June 30, 1974. The present ~ater syst~ l~ funettenin~ satisfactorily and therefore, is given temporary approval pending escro~ of funds Cot the ~ell upgrade. Sewage is disposed of via the ~o~ough Sewe~ System. If you have m)yquesttons concern[nO the above, please contact me. SincerelY, Charles F. Sellers, Envtro~eet~l Control Officer CF$/ko ~ REQUEST FOR APPROVAL , dY ND V DUA, SEWAGE.^ND i,'AT ,R FAC L /h ~. '~L ~a~ .of ~son ~e~es~in~ s~p~ow~/~~~ / ~. N~r~.~dr~ms in house, ,,, a. Ba cte-ris_l b. Der ergent data: a. Type . C4 Septic tank 5. Property Line Other sources of possible contamination, houses, barn, drainage ditch, etc. i.e.~ creeks, lakes, Sew~age disposal system. a. Age of system /~ b, Septic tank capacity in gallons c. Name of septic tank manufactume~ 1. If "home made" show diagram on reverse side of ~his form. Disposal field or seepale pit size and type /~/-~ ~. ~. Distancezo prope~, ~7~/ ~<housedfo~uation4 3d~ . f. PePcolatlon Test performed by . ~Use the PevePse.szde of this form to show diagram. Dl~gra~ should include . _~..~he ~ollowlng, inf?Pmation: ~DopePty llnes;.w~ll loaatzon, house locatlon, '~pt~c tank locatzon~ disposa~ area location, location of pePaolation test, an~..direction of KPound slope. g. The l~f-ommation on this form is tmue and comPect to the best of my knowledEe. 'Signature of Applicant TO BE FILLED OUT BY HEALTH DEPART~.'.,'ENT PERSONNEL Date Szgned ~e above described sanitary facilities ama hereby approved, ,s~bjecr to the ......... ~l%owing cond~ionsi The above descvibed sanitary facilities ave dlsspproved for the following Sig f ~.f, fiei;~..'l.~ <' '.":., ~ .~, 'Date .-~ · Aplymoval is valid for one year following the date of approval, CPJ: cw