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Home My WebLink AboutWOODRIDGE BLK 2 LT 14 ~¢~-:-~ MUNICIPALITY OF ANCHORAGE !e DEPARTMENT OF HEAL'rH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ~AILING AUDRESS LEGAL DESCRIPTION ' ' / ~'~ ~ Absorption area Dw Iling ~P'Z~ ~anu focturer C'~.t t r~ Mater~ ,Z~/,,, __, N°' °f c°mpartmentsz Liq, capacity~in aliens InMde length Width Liquid depth ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O ~ ~ Manufacturer Material Liquid capacity in gallons -- ~ W.'~?~ Foundat'on~3~ ~J Nearest ~?l°t line PER~IT ~ -- O ' ' Distanc. betw~l~es ~ Z No. of hnes Length of each hn Total length of lines Trench width ~¢~ b Top of tile to finish grade~ / Material beneath tXew~ / i~ Length Width Depth PERMIT ul Well Building foundation Nearest lot line ~ DISTANCE TO: ~ DISTANCE TO: Building foundation Sewer Pine Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING '2-013 (Rev. 3/78) rV~-W DRILLING, Inc. P.O, Box 10-378 *' 10300 Old Seward Highway (907) 349-8535 ANCHORAGE, ALASKA 99511 84-230 DRILLING LOG We]! Owner CLkRK, J01lN Use of We]l Domestic Location (address of: Township, Range, Section, if Maown; or distance main road Lot 14~ Block 2 B/oodrldge - Anchorage Size of casing. 6" Depth of Hole 250 feet Cased to 56~,15 feet Static water level 50 ft. {'~t'b'~o'~) (below) land surface. Finish~w~ell/~[ (cheek one) Screen ( ); Perforated ~.) ........ Describe screen or perforati~ 12 Perf. charges from h0 to Well pumping test at 13~ gallons per ~r) (minute) fro' 1 hours with o~ drawdown ~rom static level, open end ( loo~ Date of completion August 9, 1984 WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness 0 .TO 2 Casing stiekup 2 .TO. 45 45 .TO. 250 .TO .TO. .TO. .TO. .TO. ~ .TO. .TO .TO. .TO .TO. __.TO. . .TO. ); Brown silty gravel w/ cobbles Bedrock 3--CONTRACTOR DEPRR:TMENT OF.~ HERLTH fiND ENVIR. ONMENTRL PROTEC'TIOi';I 825 L STREET, ANCHORRGE, 264-4?20 PERMIT NO: DRTE ISSUED: 840~47 057i6784 RPPLICRNT: RDDRESS: CONTRCT PHONE: CLRRK CONSTRUCTION P 0 BOX ±i0741 RNCHORRGE, RK 995~± ~4.4-722~ LEGRL DESCRIP: LOT SIZE; LOT LOCRTION: MRX BEDROOHS: SUBDIVISION: WOODRIDGE LOT: ±4 SECTION: ~ TOWNSHIP: ±iN RRNi]E: ~W 4~1757 (SI;!. FT, OR RCRES;:, NBODRIDGE CIRCLE 4 BLOCK: 2 LISTED BELOW RRE THE OPTIONS RVRIL. RBLE TO YOU IN DESIGNING YOUR SEPTIC S~'STEt','I. CHOOSE TFIE OPTION THRT BEST FITS '¥'OUR SITE. DEPTH TO PIF'E BOTTOM (FT.) GR. RVEL DEPTH (FT.) TOTRL DEPTH (FT.) GRRVEL WIDTN (FT.) GRRVEL LENGTH (FT.) GRRVEL VOLUME (CU. '-r'DS. ) TFJNK SIZE (GRLS) SOIL RRTING (Si2. FT. ZBR) T F.; E: f-~ (2- H 4.8 8.0 ±2. 0 2.5 7~5. 0 27. 5 t., 2~0. 0 12:7 :~.:m TRNK MUST HRV'E RT LERST TWO C. LNFARTHENF- BEE) W. [:,R¢~I~ 4.0 4.0 0.5 ~.0 4,5 7.0 20.0 5.0 ~8.0 5~.0 28.± 48.1 125 I CERTIFY THRT: ±. I RM FRMIL. IRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH BY.THE MUNICIPRLITY OF RNCHORRGE (MOR) 8ND THE STRTE OF RLRSKR. I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH RLL MOFI CODES RND REGULRTIONS.. RND IN COMPLIANCE WITH THE DESIGN CRITIERIR OF THIS PERMIT. I WILL 8DHERE TO RLL MOB RND 'STRTE OF RLRSKR REQUIREHENTS' FOR THE SET BRCK DISTBNCES FROM RN'Y EXISTING WELB WFISTEWRTER DISPOS8L SYSTEM OR PUBLIC SEWERRGE SYSTEM ON THIS OR FINY 8DJ8CENT OR NE:RRBY LOT. I I_INDERSTRND THRT THiS F'ERMIT IS VRL. ID FOR R MRNINLIbl OF 4 BEDROOMS RND RNY ENI_RRGEMENT WILl_ REQUIRE RN RDDITIONRL PERMIT. IF R LIFT STRTION IS INSTRLLED IN RN RRER COVERED B'¢ MOR E~LIILDING CODES., THEN (±) RN ELECTRICRL PERMIT RND INSPECTION MUST BE OBTRINED.~ (2) 'BS-BUILTS WILL NOT BE RPPROVED WITHOUT RN ELECTRICRL INSPECTION REPORT.~ RND (~) THE ]LECTRICBL 140R. K MU¢T BE DONE B~r' R LIC.~4SEQ ELECTRICIRN. ......................... ~PPL I CFINT/C~RK CONSTRUCTION PERFORMED FOR: LEGAL DESCRIPTION: 4- 5 6 7 8 9 10 11 12 13 14 15 16 17- 18- 19- 20- MUNICIPALITY OF ANCHORAGE DEPARTIVIENT OF HEALTH AND ENVIRONMENTAL PROTECTION B25 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ,d YAS GROUND WATER S ENCOUNTERED? P E IF YES, AT WHAT DEPTH? SOILS LOG TEST DATE PERFORMED:~~ , Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) COMMENTS TEST RUN BETWEEN 72-008 (6/79) FT AND FT CERTIFIED BY:.~_7 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services Qn-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. # _[¢) r-~ (*') - ~c,~..~_ ._~-~.~,,,~ _ HAA f~ 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner _¢'f, ~¢ F~e((¢, Mailing address 6/¢81 (Z/ooc4r,¢~,¢ 0rc(¢¢ Lending agency h/o r vc~£f /'~'or ,~' Mailing address_ ~5'5-0, p¢~,~,, .c-f.., ,,.C~,f-~_ Day phone Day phone Agent C~rore ~¢nn ¢¢'f,, F'or~-~ ?roper/'~¢.f Day phone Address ~5'85 '8" £~, ~ /~¢~or~. ., ~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ "~ TYPE OF WATER SUPPLY: Individual well 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: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1/91) Front MOA #21 STATEMFNT 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 inves!i_gation 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 Engineer's signature Phone Date ~C¢?/- I~"~ ~¢~-7~ D~,HS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Departrnent o~ 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 th, e professional engineer's work, Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: P'/,/'~ [,¢/o~¢-.~r',,::,¢~ & A. Well Data Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Y If A, B, or C, attach ADEC letter. ADEC water system number h././J-. Date completed ~/? / ,~¢ Driller p/. ~,. Ca,~ed to 5'-~ , , Casing height ~O" ¥' Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well flow Pump level1 /, 5"- g.p.m. 8. 8 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot _ /(2 ~' Absorption field on lot t '~¢~ ' + Public sewer main N./4. Iyo' ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout g.p.m. Sewer service line ~ ~.¢' Petroleum tank WATER SAMPLE RESULTS: Coliform ~ co( /(oo,m ~ Nitrate /~ 0, ! ~ /"-,( Other bacteria ~lo~c r'e/ccr*b,~' Date of sample:_ ?/~ / 9~ Collected by: /¢'/~f,G/¢ ?-¢c/, -('~'~ lB. SEPTIC/HOLDING TANK DATA Date installed 5' / ~ I / ¢' ¥ Tank size I z5-¢ ~, ~ / Compadments "~ Cleanouts (Y/N) '-'~ Foundation cleanout (Y/N) Y' Depression (Y/N) High water alarm (Y/N) IN. ~. Alarm tested (Y/N) Date of pumping ? ,//? /?~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOt_DING TANK TO: Well(s) on lot I o'~, On adjacent lots To property line '~- fo' Absorption field Surface water/drainage '~ f oo' Foundation Water main/service line ? ?-5~' 72-026 (3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION /',l./r. Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA Date installed 5-~' ~_ i / ~ ,~ Length .~d" Width Total absorption area ~-Td' ~' Date of adequacy test ?/? / ?_7 Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / ~ o ' To building foundation 3.~ On adjacent lots ~, 3'¢' ' Surface water ;~ rc~o ' Cudain drain t, io~ ~ ~' e ~4 E, ENGINEER'S CERTIFICATION Sudace water Soil rating (GPD/FF) I 3' 7 ~'/¢~r~, System type "f-r"C,~ Gravel thickness ~' Total depth Cleanout present (Y/N) 'r' Depression over field (Y/N) Results (pass/fail) ~'¢z $.r' for ~ Bedrooms (~) After test 0 ~ ~,n~ /,o~ oc~ o jc If yes, give date /~. ,4. On adjacent lots '~ (c,o' Property line To existing or abandoned system on lot Cutbank N, ,4. Water main/service line Driveway, parking/vehicle storage area I certify that I have checked, verified, or conformed to all MOA and HAA guidelines Signature '~~ Engineer's Name /"'-~o~0~ F. Date ~4'~/-¢ ~/~r HAA Fee $ ¢ ~:)~ ¢ ~ Date of Payment ~'~ Z~ -- ~'-~ Receipt Number ¢'-5-'/ 77 ? 72-026 (3/93)* Sack Waiver Fee $ Date of Payment Receipt Number CE - 3589 ENVIRONN1ENTAL LABORATORY SERVICES 14,M:'c ix : WATER 5633 B STREET ANCHORAGE, AK 99518 TEL: (907) 562-2343 FAX: (907) 561-5301 Report Compl.eted ;09/13/93 C<~].].e/; ted : 09/09/93 R~ceiw~d : 09/09/93 ~,a~l.l.e Rcli/arka: ROUI H,, SA/-IPLE COL!,ECTI,?O BY'. 1.~., HOORL. * FRONT DOOR. ~', See Specia]. IJ ::, Undetected, Repo~:ted va].uo J.~ 'th(~ pi:nc'ti, cai q~/an'tJl:i~'.a'i:]o~ limi'i:. LT := I,i~1{) Thon Member Ol the SGS Group (Soel~t~ G~n~rale de Survgillanee) ENVIRONMENTAl_ SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA 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. # GENERAL INFORMATION Complete legal description Lot 14; Block 2; Woodridg¢ SuSdivision; Location (site address or directions) 4921 Woodridg~ Circl6 Property owner Kc_.Z~y & Sh6rro~ PeJ~ry Mailing address 4921 Wood~J~d9~ Cir6¢¢ Day phone 345-1876 Anchorage, Alaska 99516 Lending agency Mailing address Day phone = Agent Susan Campbell 2001 REALTY 2600 D¢.nali Address L~tEe DenaEi Tower 4t~. F~,r , ., ~nehorag~ ~a ~0372~~ . , umess o~nerw se reques~e~, ~/~ wm ~e ne~ mr pm~up. NUMBER OF BEDROOMS: 4 ~ TYPE OF WATER SUPPLY: Individual well XX Community well Public water Day phone 276-2001 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 XX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. · NJo~ s,J@au!§ue I~UO!SSa,~oJd aq~ u! suo!ss!uJo JO sJoJJa Jo~ alq!suodsaJ ~ou s! abeJoqou¥ J.o X~!led!o]uny~ eql 'panss! s! a~eog!peo e eJojeq e~ep ez,q~ue Jo suo!~o@dsu! ~onpuoo ]ou op SHHQ ~o saa~old~U~ 'SWeLUeJ!nbaJ e~e~s pue Imepal u!epe3/~si~es ol J@p]o u! suo!~n~ilsu! 8u!puel ]!eql pue sacuoq jo s~eseqoJnd ol Xseunoo e se s!qi seop SHHQ eqJ. 'mtSelV ¢o ele~,S eql u! pe~e~sf6eJ ~eau!6ue i~uo!sselo~d ~,uepuadepu! ue/~q e^oqe § qdeJS~J~d uf ue^i8 suo!~e~uese~de] eq~, uodn ,quo peseq smeoiJ!~Jeo le^o~ddv Xlpoq~nv qileeH sanss! (SHHQ) seoFdeS ueuJnH pue q~leeH lo ~UeLUMedeQ eSeJoqouv jo ,~!led!o!un!hl eq/ s~ueLuLuoo leUO!~!ppv :suogelnd!ls OU!MOIIO~. eq~ ql!M 'sLuooJpeq JoJ. le^oJdde leUO!~.]puoo 'peAoJddesiQ 'suJoo~peq ~ .~OJ peAo~ddV ~ ~R£~NDI$ SHHa euoqd 'uo!~oedsu! siql ~.o elep eq), uo ),oejJe u! suop, elnSe~ pue 'seoueu!p~o 'sepoo e~elS pue led!o!unR lie q~!~ eoUe!ld~uo3 u! s! uu@~s,~s lesods!p je~eMelSeM ~o/pue Xlddns JaleM el!s-uo eq~ 'uo!loedsu! pue uo!~eS!~seAu! Xuu uJo]j pue Sel!J eSe]oqouv Jo Xl!ledio!unl~ buo]~ peule~qo uo!leLUJOJU! eq~ uo peseq leq~, AJpeA Jeqpnj I 'ufeJeq pe~eo!pu] eJn~on]~s ,to edX1 pue scuooJpaq jo JeqLunu eq), ~oj e~enbepe pue leUO!~Ounj 'e,tes s! LUe~SXS lesods!p ~e~e~e~se~ Jo/pue ,qddns ~ele~ e~js-uo eq~ ~eq~ SMOqS uo!~eo!ldde leAoJddv X~poq~nv q~leeH s!ql jo uo!leBi~se^u! ,~LU ~eq~/~JpeA I '~oleq u~oqs elep uogepileA eq~ Jo se pue o~e~eq pex!jje f~es ,~LU Xq peg!Meo s¥ '9 ~NI~NB A8 NOIIO~dSNI 40 IN~IV£S Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAl.. CHECKLIST Legal Description: ~'C~'¢ ~,~ ~'2)pc-'Z- k~°~P¢"b~l~lrcel I.D. A. WELL DATA Well type ¢~'~ k.lt.~l-¢~. If A, B, or C, attach ADEC letter. Log present ~/N) ~ Total depth ~- ~6;:) Sanitary seal (.~/N) V ADEC water system number Date completed ~:~' ~, ?~ Driller _Cased to ~-f~, IS ' Casing height_ Wires properly protected I~b/N) ',7 FROM WELl. LOG Date of test ~ .x;j ~, ~ Static water level ~"C:) I Well flow / , ~ Pump level ~ I(. g.p.m. AT INSPECTION 2. ,"/- g.p.m, i-¢~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot JC,~ ~- Absorption field on lot Public sewer main /_1 Sewer service line .~.~. j ; On adjacent lots 1 co ~ ~' ; On adjacent lots / O¢ ~ 4- Public sewer manhole/cleanout ,d/j_ Petroleum tank ~..~.- ~ 4-- WATER SAMPLE RESULTS: Coliform () ~'" c'"/I~O~'ff Nitrate_ Date of sample: ~'- 7'7 ~} ~ B. SEiPTIC/HOLDING TANK DATA Date installed ~' - ~' Cleanouts(~/N) y High water alarm (Y/~) Date of pumping Collected by: Other bacteria _ S & S ENGINEERING 'P7034 Eagle River, Alaska 99577 Tank size / 2-~'~ /-~x¥¢-~ Compartments Foundation cleanout (~/N) ',/ . Depression (Y~ ~J Alarm tested (Y/N) '~/,4 '¢~'- ~.~ .~ '~ 2_- Pumper A+ /-~F- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot \O To property line Surface water/drainage On adjacent lots Absorption field ~' _Foundation Water main/service line 72 026 (Rev. 7/'91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) .-------~ · ~t Vent (Y/N) "Pump on" level at --~"""-~Cycle~s High water alarm level tested Meets MOA electrical c~ SEPA~CE FROM LIFT STATION TO: Wel'l on lot On adjacent lots Surface water Date installed Length ~L~ ~ Total absorption area D. ABSORPTION FIELD DATA Width ~ ~ .s"-7 u ¢ Depression over field (Y/~ /'J Resu Itsd~[~.fail) /;2,~ ~ Peroxide treatment (past 12 months) (Y~) Soil rating ,/~7 ~/~'¢- System type G ravel thickness '¢' ~ Total depth / Cleanouts present ~N) Date of adequacy test ,,~ - 2- ~. - ~ ~.- for ~ 'J' ~-'~ (/"¢-') bedrooms ,~'~ ~/~ /~'/J~ ~'( If yes, give date ~/~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot ~.o~ t4- To building foundation On adjacent lots '~0 t~-' Surface water J¢O J '/' Curtain drain /'~/~' On adjacent lots t ~c~ ~ Propertyline ;~0 ~ To existing or abandoned system on lot Cutbank /J/'¢¢" Water main/service line Driveway, parldng/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in, date of this inspection. Signature S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, A aska 99577 Engineer's Name Date ,~ ~¢¢~L.~ -~ ~ HAA Fee $ Date of Payment Receipt Number 72-O26 (Rev 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number CHEMICAl; & GEOLOGICAL LABORATORY 5S8¢ B ~TR~T ANGHgH~QE ALAskA ~8 T~L~PItON~ (007) 50~-~4~ FAX: t00~) 50t-5~01 ),~Ah~SlS kgsgl,T8 for i~OI~g ~ MZ&D PO{ :~O~E RECEIVED ~) ROUTINE SA~L~ COLLBCTCD [~: R,J 3. Rot Analyzed L~,l, oe{ 'f~n, ~-¢tea~r Than ~Od 0~'0 O0(lOOCi(l(}OI) f)(l(if)O00000 O0000000000OO0000000 ~S: b [ 68-'b', 0-8661 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 Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) ~ 7¢_~ Business (b) Applicant Name~-~-~/-~-_(~5.~ Telephone: Home '~'~//(/'~* ~ ';~ Applicant Address /96)~(-9~~_ //¢ '~f.~// /.~- ,4./(~/7///4//6~, 2~,,~%--// (c) Applicant is (check one): Lending Institution F'J; Owner/builder I~-'~. Buyer El; Other [] (explain); (d) Lending Institution _ Address (e} Reel Estate Company and Agent Address Telephone (f) Telephone ................................ Mail the IdAA to the following address: TYPE OF RESIDENCE Single-Family/;~ Multi-Family [] Number of Bedrooms Other WATER SIJPPLY Individual Well,~ Community r'q Public [] Note: if corn munity well system, must have written confirmation from the State Department ol Environmental Conservation attesting to the legality and status, SEWAGE DISPOSAL Onsite"~ Public [] Community D Holding Tank [] / Note: If community well system, must have written confirmation from the State Deparlment of Environmental Conservation attesting to the legality and status. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION AS certified by my seal affixed hereto and as of the validation date showe below, ~ 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. Name of Firm L.-c~ o z-- Telephone DHEP APPROV/~. Approved Terms of Conditional APl~roval CAUTION The Muncipality of Anchorage Department of Health and Environmental ProtecIion (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 72-02[, (11/84~ WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL [HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Descnpbon: Well Classification P~'~/~¢' ;~''`' If A B. C. D.E.C. Approved (Y/N) Well Log Present (Y/N) Z~.5' Date Completed ~ -~'- "~''¢¢ Yield Total Deeth ¢'5-0t Cased to~'~ Depth of Grouting _ static Water Leve ' ¢¢ ' '/C - Pum, set At Casing Height Above Ground /' '~' ' Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) ~ :)enress~on Around Wellhead (Y/N) Separation Distances from Well: To Sept~c/Idoldmg Tank on Lot '¢"/~ On Adjoining LOtS To Nearest Edge of Absoreuon Field on Lot ..,z/00 / ¢-'' : On Adjoining Lots To Nearest Public Sewer Line ,4,/~,4 To Nearest Public Sewer Cleanout/Manhole Water Samele Collected by Water Sample Test Results Comments ~ ~'~' ~' /t"~/'¢ To Nearest Sewer Service Line on Lot ¢-~'~ ' B. SEPTIC/HOLDING TANK DATA Date lnstalled '5--Z/z--~"~ Size Standetees (Y/N) _ /v' Air-tight Caps (Y/N) _ Deeress~on over Tank (Y/N) '~/ :umplng/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Senaration Distances from Seotic/Holding Tank To Water-SUpply Wel ~'/¢~' To Property Line ~?,~,4-- ,' ~.~ To Water Main/Service Line '7°/'- Course '/~///~ ,' No. of Comoartments Foundation Cleanout (Y/N. Date Last Pumpea ~¢'//¢ " : for Temporary ~oldmg Tank Permit (Y/N) To Building Foundation '~"-~ To Diseosal Field ~ / To Stream Pond, Lake, or Maior Drainage Comments Page 1 of 2 72-026 111841 C, ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~,~-- Width of Field '~ / Square Feet of Absorption Area ,,~ 7~' Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well '¢' /~d::) '" "" 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) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) Comments 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 Bequest ** I certify t bat. J,h a.v.¢ c.h.e0k~d, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~/¢~/'f'f'f'f'f'f'f'f'f~ ~"'-- Date Date of Payment ~: ~ Amount: $ ~ ,: