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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTFI 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)
(b) Applicant Name ,¢~/~e----k'I O_7¢ ~ k, Telephone:J:~m.e ,:.,~, .~2_~ ~
Applicant Address '~1 ~ ~¢¢~k~¢ ~-~ & ~5'
(c) Applicant is (check one): Lending Institution~; Owner/builder ~; Buyer ~; Other ~ (explain); _
Address t~ bo J ~:
(e) Real Estate Company and Agent d--'o-I~.,.~lt -,/~,--~o--- 5~-,-¢, ~y~
Address
(f)
Telephone ~'~' 1 -- ~2~4 ~:~,~
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family ~ Multi-Family []
Number of Bedrooms ~2 ____
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.
SEWAGE DISPOSAL
Public E'] Community"~/ Holding Tank []
Onsite
[]
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)
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 Approvat 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 /'¢'~/¢"'~ ~'-~'~'~'""~- ~ ~,~ Y~ Telephone ~..~,¢:~/-~ ~-1L7 /I
Address -~ / ~ -'~ ~ ,,~' //(,,'.~ ~/
Date ~'/~ /z¢~ "7
WATER WELL NOTE: This Health Authority Approval inspection n~rely
certifies that the subject water well produced 150 gallons per
bedroom per day and that certified laboratory tests showed no
presence of colifom bacteria in a sample of that water. No warantee
or certification is expressed or implied concerning the long te~
adequacy or safety of the water supply.
ON-SITE/SEWAGE D~SPOSAL SYSTE NOTE: This Health Authority Ap~oval
Syst~ accepto¢ at least ~C gal]onspf water pC bedroomAor day
as/detemtne~by method~ap~ ~ved ~ the Munlc~altty of~nchor~ge
~p~[~nt /of Healt~ and Hu,~ Service~ No ~antee /or
/qrMficatTon is ex~ossed or/replied co~erning tp~ long~e~
adequacy/of the on gtte sewag~dtsposal ~stem. CoWstructio~ data
reporte~ on buri~ system components is from MOA files and was
not verified dur-'' ' ' lng this inspection.
DHEP APPROVAL
Approved for "~"¢ (/~,) bedrooms by _~~ ''~' "~,~
Approved L'"'~ 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 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
j:.NVJRONMENTAL SERVICES DIVISION
MAR 2 3 1987
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHFCKLIST- FEBFIUARY 1984
264-4720
RECEIVED
A, WELL DATA
Description:
Well Classification
Well Log Present (Y/N)
Total Depth ~::2~) ~
Cased to
Static Water Level ,~.5'"' ·
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N) _
Separation Distances from Well:
Septic/Holding 'rank on Lot
To
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ~¢'~.~ '~
Cleanout/Manhole _ ,~2~' "-X" · _
Water Sample Collected by _
Water Sample Test Results ,.-~"'
If A, B, C, D.E.C. Approved (Y/N)
. Date Completed ~-/,4'~/-~,,'~/.~,~¢]_ ~ Yield
Depth of Grouting _
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots //.~/~
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date __¢4'-/,~
B. SEPTIC/HOLDINGTANK DATA
Date Installed.
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 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 Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
^.so.. lo..ELD
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)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test, Meets MOA
** 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 /U'/~', /
Company .,/~¢~ ~j .-~ l~, ¢, ~ ~.¢_ MOA No.
Receipt NO. ~'~
Date of Payment
Amount: $ /
Page 2 of 2
72-026 (11/84)
MUNICIPALITY OF ANCHORAGE
DIVISION OF P]flVIRONMENT~j~
DERAF~£MENT OF HE/~UI~.! AND ENVIRONMENTAL PROTEC£ION
APPLICATION FOR HI'iALTH AUTHORITY APPROVAL CERTIFICATE
1. Cene~al Inform-~tion Application Date 2/!.7/S4
(a) Legal Description ( include lot., block, subdivision, section, township, range )
lot 1, block 5 Zodiak Manor~,._A. j3_chora_q_c Recordin_~ District
Location (adck, ess or directions)
844~_J_~u_piter Street_~_Anch_q_ra_~qe_~ ......
(b) Applicants Name CENTURY 21 John DiBene & Co
Applicants Address 20] East 56th Street
(c) Applicant is (check o~_q~?~) I~nding Institution
(d) Lending Institution Nail Bank of Alaska
Address Northern Li__qhts & "C" Streets~_ Pouch 7-02_5~_.bnc!l~_33jQ_995].0
(e) Real Estate Co. & Agent CENTURY 21 John Di
Address 201 East 56th Stree!t~_.._An__cJlP_%%~gLC~__gj%~gutljjia_jLD/~+_3_9_%O~.>. __
Te le phon~, 907-563-3~ 2
2.3' ._oi '
Single-Famil~ L~_~_/I Multi-Family E'~-~ Otheu (~,scrihe)
Numges of Redrcc~s .__~ix
Note: If ~a']ity %.ell system, must have %~itten c~nfirm~tion fr~ the State
· ~pa~z~nt of [hviroP~ntal Conservation attesting to tim legality ~d status.
Is the ~.[1 adequate roi, the nu~r of ~s s~oified in.this ~k [Y~]) Yes
4. ~9~q~a 1
O~site Li~[ mblic ~[ ~ity ~ Holdieg Ta~k
Is the wastewate]~ dis~sal s~fstem adequate for ~e ~dm~r cf ~dro~ (Y~) Yes
[Pa{~ 1 of 2]
2-15-84
5. ED~. ].neerin~__ _Firm- Prov~]i~ Ins~_etions, l%sts, Data and Infor~rmtion
I o~,tify that I have cJ~ecked, verified, or c~nformed to all MOA NAA Guidelines
affect on the date of ~Jais insF~cticn.
N~r~ of Finn .--~r~JaJ~.,~raJJ~In~ ..... Telephone
Address 1506 West 36th Aw,~.,
~te. 201
( FMGINEER SEAL)
Ap~co~d for be dr corns By
~:,ans of Conditional Approval
The Municipality of Ancho~a~ Ibpa~tm~nt of t~alth and Environmental Prctecticn does
not guarantee the continued satisfactory performance of the watel, supply and/cr the
wastewate~ disi~osal system. This approval indicates that, as of th~ validation ~i~[:e
sho~;n above, based on the data and information furl~.ished by an er:gineer registered in
the State of Alaska, the water supply and wastewater disposal system is safe and func-
tional fo~ the numbe~, of ted~.oc~s ~md type of structu~re indicated.
( DHEP SEAL)
7. Mail the HAA to the following address:
KB2,/dS/s
[Page 2 of 2]
2-15-84
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Lot 1 Block 5
MUNICiPALiTY OF ANCHOP,~AGI~
DEPT, OF HEALTH &
ENVIRONMENTAL PROTECTION
RECEIVED
Zodiak Manor Subdivision
Well Classification_~Ipdividual
Well Log P~esent ~Y/N) Y
Total I~pth 70' Cased to
Static Water Level 56,
Casing HeightAbove G]round 2' +
Electrical Wiring in Conduit (Y/N)
Separation Distances f~omWell:
To Septic/Holding Tank on Lot N/A
TO Nearest Edge of Absorption Field on Lot__N/A
TO Nearest Public Se~ Line
Cleanc~t/Manhole ~.I
Water Sample Collected By M. McLean
If A, B, Or C, D.E.C. Approved(Y/N). N/A,
[~te Completed Unknown Yield }3~qpm:~
70' Depth of Grouting Unknown
Pump Set At Unknown
Sanitary Seal on Casing
Y
(Y/N) Y
Depression A~ound Wellhead (Y/N)
; On .Adjoining Lots__N/A
. ._; On Adjoining Lots__N/A
To Nearest Public Sewer
To Nearest Sewer Service Li~on Lot 30,
; Date 2-28-8~
Wate~ Sample Test Results Satisfactory for Total Coliform
Cc~nts The well is located in front of the house approximately 40' from the
centerline of Jupiter Street.
B. SEPTIC/HOLDING TANK DATA
Date Installed Size No. of Cc~pa~b~nts
Standpipes (Y/N) Ai~-tight Caps (Y/N) Foundation Cleanout (y/N)
Depression ove~ Tank (Y/N) Date-r~st Pumped
Pumping/Maintenance Contract on File ~Y/N) ..; for
Holding Tank High-Water Alazmt (Y/N) Tem~ra~z; Holding Tank Permit (Y/N)
Sepa~atio9 Distances f~om Septic/Holding Tank:
To Water-Supply Well
To P~operty Line
To Water Main/Se~vice Lin~
Course
To Building Foundation
To Dis[~sal Field
To Stream, Pond, I~ke, or Major D~ainage
Colorants
[Page 1 of 2] 2-15-84
Co ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption A~ea
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes P~esent (Y/N)
Date of Last Ac~quacy Test
Separation Distance from Absorption Field:
To k~ter-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To P~operty Line
To Existing or Abandoned System cn
; On Adjoining Lots
To Cutbad~(if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Con~aents
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Ala_~m Level at
Tested for
Electrical Codes(Y/N)
Dimensions
Manhole/Acc,.ss . ! ~/N)
"Pump. Off" Level at
Vent JY/N)
Pumping Cycles du~ing Adequacy Test.
Meets ~VOA
Comments
** Check Permitted Bedroom Rating Against HAA Request
oIcertify I h. ave checked, verified, or conformed to all MOA HAA C_~uidelin~s in effect
that
n the date of this inspection.
Signed .;/~.~- ~ ~-~ Date
2-15-84
DATE RECEIVED
TIME TIME TIME
DATE DATE DATE
MUNICIPALITY OF ANCHORA~
MIJNICIPALITY OF ANCHORAGE DEE'F. OFI~ ~r~ &
) DEPARTMENT OF H ALTF & ENV RONMENTAL PROTECT~ RONM[ NI,~.i ;'CIION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION ~IVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE f I
DIRECTIONS', Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for p~ocessing,
LEGAL DriSCRIP~
SIDE NUMBE-R OF~BEDROOMS
~ One ~ Four ~ Other
~ SINGLE FAMILY [~ Two ~ Five
~ MULTIPLE FAMILY ~ Three ~ Six
7. WATER SUPPLY
~' INDIVIDUAL* * ATTACH WEL - LOC; A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled 9rior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
8, SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED.
.~ PUBLIC UTILITY
NOTE; THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFQRE PROCESSING CAN BE INITIATED.
72-010 (Rev, 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMSER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMSER
[] INDIVIDUAL/ON -SITE DATE iNSTALLED
[]PUBLIC UTILITY
Connection Verified iNSTALLER
E~]Septic Tank or [] Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
§, COMMENTS
' A PROVEDFOR BEDROOMS
[] CONDITIONAL APPROVAL Iletter must accompany certificatel
[] DISAPPROVED 2/~~
DATE BY
72-010 (Rev, 6/79)
MUNICIPALITY.OF ANCHORAGF
OF HEALTH AND ENVIRONMEN', I)ROI'I--CTION
I, Street, Anchorage, Alaska 99501
279-2511, ext. 224 or 225
]}ate Raceivcd: ._._{Lu~ll!~8
t~2: Time ~[3:
Date
IllSp .................
Time
Date
In sp
REQUES'P FOR API?ROVAL OF INDIVIDUAL SEWER AND WATER I'~ACII, iq.'II'IS
Lending lnstitutien Request: Alaska Pacific Bank % Rosie Parks
Mailing Address: Post office Box 420 99510 Phone: 276-3110
Mailing Address: 8442 Jupiter Drive
Legal r)escripLion: Lot 1 Block 5 Zodiak Manor Subdivision
8442 Jupiter Drive
Single Family Residence: (xl
Nnmber of Bedrooms: Six
Multip].e Family Residence: ( )
Number of Bedrooms:
Well,-[ System: fndJvidua]. We]] (xk Conm]unJty/Pub].ic System ( )
Permit ~ Depth of Well Well I,og on FJ]e )
Construction Bacterial Ana].ysis
6. Sewage Disposal System: On-site System ( )
Pub]_ic Utility (xRx
PerraJ.t ~ In stalled Installer
Septic Tank Size Manufacturer
Absorpuion Area Soils Rate
Material __~
7, Distances: We].] to Septic Tank
to Absorption Area
co Sower Line
Nearest Lot lJ_ne Absorption Area
to Nearest Lot Line
De}.~artmc~nt of t~e~x].th and Environmental Protec[:ion
R¢.,<:lue·~ .... k '~'.,- o].~ Ap~3roval of Individual Sewer and Water Facilities
Legal D~scription
Comments
Lot 1 Block 5 Zodiak Manor Subdivision
Affsdav[~; Att~tched~ ~ Letter Attached: ( )
D J_sa~,p~:ove(~: ........................................... Date: ...........................
Depar [:m~Bt
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEAL[H AND ENVIRONMENTAL PROTECTiION
825 L St'~-~.ot , Al',cho~:a{j,~, Alaska 99501
279-2511, ext. 224, 225
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspectton:
2. Property Owner: Clifford Martin
8442 Jupiter Dr.
Mailing Address:
VA _FHA CONV.
Anch.
Day Phone:.
XX
3, Name of Buyer:
Ray Cool<
Mailing Address:
4. Name of Lending Institution
Mailing Address:.
Jess Holliday
5. Name of Realtor or Agent:
Mailing Address:
L1 B5 Zodiak Manor
(4. Legal Description:
Alaska Pacific BAnk
_ Day Phone:.
274 7227
P. O. box 420 (99510_)Phone:
276 3110
278 8188
Phone:_
Location:
8442 Jupiter Dr.
7. Type of Facility to be Inspected:
8. Water Supply
Type of Supply:
6
No. 0drms,
XX
Public Utility Individual
If Individual, number of dwellings presently served
If Individual, depth of well
Sewage Disposal System
Type of System:
If Individual, date of installation.
Public Utility XX Individual (on-site)
Rosie Parks
Alaska Pacific Bank
276 3110 x 41
July 1, 1977