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HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 5 LT 31 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMFNTAL PROTECTION DIVI.;ION OF ENVIRONMENTAL HEALTN CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON~SITE SEWER AND WATER FACILITY 264-4?20 GENERAL INFORMATION (a) (b) (c) Application Date ~.~/~ /~ Legal Descriptioa (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name L~ ~;~----~d~i¢~Telephone: Home ;~4-O-- ;5(¢ ¢~ Business Applicant Address ~%;2o ,) ~¢; 'be_ ¢ Applicant is (check one): Lending Institution J~; Owner/builder~; Buyer ~; Other ~ (explain); (d) Lending Institution ~_¢,'~ "~'~c~'~ '~ Address .'~© ¢' O ~ % ~,-' ,//... ¢--,'~u','~¢z: (e) Real Estate Company and Agent __Z~']_ Address Telephone (f) Telephone Mail the HAA to the following address: TYPE OF RESIDENCE Sin glo~ Famil¥~M ulti- Family Number o~ Bedrooms __. Other WATER SUPPLY Individual Well~ Community [] Public [] Note: If com m unity well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite F3 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 72 025 (11,84) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, I)ATA 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 ieformation obtained from the Municipality of Anchorage files and from my investigation and mspection, the on-site water supply and/or wastewater d~sposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~ ~n ~ -~ ~ ~- :__ Telephoner ~/~''~~ I J Address _~.~ O ~ Y/~ / Date '~/;2 ~/~L DHEP APPROVAL Approved for Approved bedrooms by .,~7~-',~' ,~ Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval celtificates 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 end 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 IH~841 MAR 0 1gini A, WELLDAT E£EIVF-D MUNICIPALITY OF ANCHORAGE (MOA) MUNICIPALIIY OF ANCHORAGE HEALTH AUTHORITY APPROVAL (HAA) DEPT. OF HEALTH & FJqVIRONMENTAL PROTECTION CHECKLIST- FERRUARY 1984 264-4720 Legal Description: L..'~ Well Classification ~'~ U¢'--q~--8 If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N). .~/ Date Completed ~/~ 72 ¢ Yield Total Depth _~¢ (-~A~e-'~;ased to¢¢ L'/c2m~''¢"¢5 Depth of Grouting _ Static Water Level ,¢'.,,& ¢,~ ..... Casing Height Above Ground ~ o Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding 'rank on Lot To Nearest Edge of Absorption Field o,n Lot _ To Nearest Public Sewer Line ~(~ Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead ; On Adjoining Lots /V~-"] ; On Adjoining Lots __ To Nearest Public Sewer Cleanout/Manhole _~0 '_4;- '~' To Nearest Sewer Service Line on Lot '~,f~ Water Sample Collected by _/vi ~L/~¢._w ; Date _~./t ~ .~ Water Sample Test Results _ ,~ B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Depression over Tank (Y/N) Size No, of Compartments Air-tight Caps (Y/N) Foundation Cleanout (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 Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Course Comments ____~L/IC ~¢-'-'~e-¢- .... 4~~. ~:<'-',~'/~" "-~¢.-¢-¢,.'~-¢:.~b~,~ ...... " Page 1 of 2 72-026(11/84) ABSORPTION FIELD DATA Soils Rating ia 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) 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 t ~... J~/~c~e d, Company /f-~/c- Receipt No. Date of Payment ~- - ~(~(,-~ Amount: $ or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Date MOA No. Page 2 of 2 ACItEMICAL & O~,'OLOGICAL LABORATORIE5 OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER //(/PRIVATE WATER sys'rEM ' Name Phone NO. City State SAMPLE DATE: ~ ~ ~ Mo. Day Year Zip Cede SAMPLE 'POPE: [] Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. LOCATION 3 I Time Collected Collected B>3~:? TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received Time Received Analytical Method: Membrane Filter No. of colonies/100 mi. Lab Ref. No. Result* FTq J FT3 Analyst BACTERIOLOGICAL WATER ANALYSIS RECORD RI-_-AD INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter: Direct Count Verification: LTD _BGB Final Membrane Filter Results_~ Time: TNTC = Too Numberous To Count CollformllO0ml Coiltorm/100ml e..,. OB = Other Bacteria APPLI., ,NT FILLS ()UT UPPER HA~ : ONLY Buyer Address Zip Code Realty Co. & Agent Phone Address /~,/) Zip Code Type of Residence ~, Single Family ~ Multiple Family NO. of Bedrooms Water Supply ~ Individual ~ ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. ~ Community ~ ' ;: ") For wells drilled prior to that date, give well depth (attach Icg if available). Sewer Disposal ~ Individual _ ~ Year Individual Installed: ~ Rolding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN SE INITIATED. Time Time Time Date Date Date Bate Inspector Inspector Inspector Inspector tUNICIPALITY OF ANCHORAGE DEPT. OF HE/*,LTII Pi ~NVIRONMENTAL PRO (ECTION RECEIVED (~) APPROVED BEDROOMS (-,~ ) DISAPPROVED ( ) CONDI]IONAL APPROVAL* / DATE 'CONDITIONS OF APPROVAL Soils Rating Date Sewer Installed · Well To Absorption Area Well to Ta*~k Well LOg Received Septic TEmk Size CHEMICAL & G~JLOGICAL LABORATORIES OF ALASKA, INC. TELEPJ~ONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER 5633 B Street , A/t c ) /~ .. Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER I.D. NO. WATER SYSTEM: Water System Name Phone No. Mailing Address City State Zi~ Code Mo, Oay, Year SAMPLE TYPE: [] Routine [] Check Sample (for routine setup, lc with lab ref. no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. I I I LOCATION Time Collected J Collected By TO BE COMPLETED BY LABORATORY Analysm shows this Water SAMPLE to be: J~:8~tisfactory [] Unsatisfactory [] Sam~letoolono ntransit: ssmoleshould nol be over 48 nours old at examination [o ndmate 'eliable results Please send Date Received Time. Received Analytical Method: [] Fermentation Tube ,{~'Membrane Filter Lab Ref. No. Result* Analyst .':~ ?'?.-/,,ri,r-I:) r-r-I READ INSTRUCTIONS BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD NFIAWTHORNE~ENGINEERI. NG 7127 OlD SEWARC) HIGHWAY ANCHORAGE, ALaSI<A 99502 {)07-344-47 ! ! 'JOHi A ANO El)IT~ A L, USTNA,~ g/g OJV OF V£T~RAN$ AFFAXR$ A"~C~'uRAG~ AK Y951') 203,62 207.12 235,00 3~.2~ ~0,000, ,uO 06/23 39,512.j5 3a.521.]5 O?/l 35,72o,;1 C7/1~ 35,56?°32 uT/l? 07/21 32,299.4~ 07/31 25~306,Z~ O~/d3 26~273.