HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 6 LT 6Lc,
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CFRTIFIOATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAl. INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner ~'~ ~,./
Mailing Address .~_ ~ ?,~t.~--
(c) Lending Institution _
(d)
(e)
Telephone: Home ~/-7L~ --,~,,, B~usiness
Telephone
Mailing Address
Real Estate Company and Agent
Address /¢ Z-~ ,¢4/e...-~,-~ .~'~4-'-.¢'7 ,¢ ~¢ ~'~¢ /
Telephone ~ ~ ~,-~ ~ ~
Mail the HAA to the followinq address: or: Check here ~old for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family.,~'
Number of Bedrooms
WATER SUPPLY
Individual Well ~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite [] 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 fRev 8/861 Front
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AN[) INFORMATION
As certified by my seal affixed hereto and as of the validati on date shown below, I veri fy that my investigation of this Health
Authority Approva~ 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 disposer system is Jn compliance with ell Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
DHHS APPROVAL
Approved for '¢'~'*~'(=~,~ bedrooms by ~'~" -~'
Approved Disapproved Conditional _
Terms of Conditional Approval
Enair~.Seal
...~,~. OP ,At.
Date ~-- Z~-- R ~
CAUTION
The Municipality of Anchorage Department of 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 DH HS does th is es a courtesy to purchasers of ho mas 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.
Page 2 of 2 72 025 IRev 8/86) Back
MUNICIPALITY OF ANCHORAGI:! (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4744
Legal Description:
RECEIVL:D
WELL DATA
Well Classification /~c.~//),5_/.;n,~6 (~)La?(~' ?~?/.4,'~ If A B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) /'V/"}tu Date Completed ./~)~'?-;/" Yield
Total Depth - ";' Cased to ~/~¢/? ¢
Static Water Level ,.~ -,7 ?L?z-
Casing Height Above Ground __ /',z
Electrical Wiring in Conduit (Y/N) ~ ':
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
Depth of Grouting
Pump Set At /,Y//>/¢/?
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots _ /V/
; On Adjoining Lots
To Nearest Public Sewer Line ' ¢- ~ ~ ;¢~ To Nearest Public Sewer
Cleanout/Manhole -N- //¢.~O~f~ To Nearest Sewer Service Line on Lot ~/~/
, ,,
Water Sample Collected by 7~/~ ; Date ~ ..,:~ ~_, // .
Water Sample Test Results ~) 7%5'>~/~rr~¢~7~/ ~/¢~d~t I/J /I /1<¢~/:~ ~
Comments ~ ~ .', ,., z/ .... , / /
B. SEPTIC/HOLDING TANK 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)
Comments
Page 1 of 2
72 026tRey 8861
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
ABSORPTION FIELD DATA
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)
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 that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date
Company MOA No.
Receipt No. ~ - O d/,/ -- O O O ...~'""
Date of Payment 2/¢¢~- (///<¢/' 7 ___
Amount: $ /'/~. ¢ ~ Engineer's Seal
Page 2 of 2
8F. SSE, EP~S & POTTS
2220 EAST 88 AVENUE
AN(~{C~A~.', AK 99507
(9O7) 3~9--~5~
WA-TEA ~/LL TEST
Location:
Subdivisio~:
Lot:
Block:
Tester:
Initial Reading ~ Meter: ~ (~ .:,_.
It:"/.:' "; _
~ VOLUP~
Pro-~,~ctJon Rat~.: ~,0~ GP.~ 24-Hour CapacitT_~/~-C~l]c~a
NOE HERN ESE'INE LABOIRATORIES, INC.
600 UNIVERSITY PLAZA WES F, SUllE A FAIRBANKS, ALASKA 99709 907479,3115
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-8378
Besse, Epps, & Ports Date
2220 E. 88th Avenue Time
Anchorage, Alaska 99507 Date
Time
Attn: Andy Ports Date
Source: Nova Properties,
Samp].e ID#: A061187--1
L 6,B 6, Zodiak
Arrived
Arrived
Sampled
Sampled
Completed:
6/11/87
1200
6/11/87
1100
6/12/87
Parameter Unit Result ADEC MCC
NJ.t rate-N mg/L O. 29 10
* MCC = Maximum Contaminant Concentration
NOR I IHERN 1 ES tNG LASOIRATORES, INC,
000 UNIVERSITY PLAZA WESTr SUI]£ A FAIRBANKS, ALASKA 99709 907-479-3115
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-8378
Ouality Control Report
Client: Besse, Epps, & Potts
ID#: A061187--1
Listed below are quality control assurance reference samples with a known
concentration prior to analysis. The acceptable limits represent
a 95% confidence interval established by bhe Environmental Protection
Agency or by our' laboratory through repetitive analyses of the
reference sample. The reference samples indicated below were analyzed
at the same time as your sample, ensuring the accuracy of your results.
Sample# Parameter Unit Result Acceptable Limit
~PA WS378-6 Nitrate-N mg/L 1.O0 0.84 - 1.02
lleported B y: ~.~ ~ Date: 6/15/87
Car~F'J, Garrison, Vice-President
Department of Environmental quallt~-~-
3500 Tudor Road, AnchoYaoe, Alaska 99507~'"B'79.8686
.LQ .... l i::r m APDRO',]AL OF
INDTVIDIJAL SEt~ER & WATER FACI!,ITII~S
l,
Requested
.... one,T., t.~mer.
I ocatlon ~ ~ ~ ~ ( e
5. Tree of Fac]lltv t;o
Number of Bedrooms: .........
6. Well Data:
C. C on s t ru C'ti on__.~,_.]/~_ ....... D.
7.Sewege Pi~oosal Svsten:
itacterial Analysis
Ir~stslled
Septic Tank', ], Size 2.
Seepage Pit: !.. Size
Instal]er
2. Material
Distances:
A. Wel] To:
Disposal Pleld: Tot:al !.er:gth of Lines
Set, tic Tank , Absmcp~on Area _, Sewe~ Lines
F,),;ndatiot~ t-~ [;,~:-,:'oc Tank .~ ,. Absorption Area .
Absorof;ior~ A'rea t:e !qeare~i LoC fane ~'
Rec~sest for Approve[ of fdual Sewer & Water Factlit~
Ap~,~o,;a! Valid for One Yoar F-,;on~ Date Stqn(.~d
;~att*~ Ancho~acm ~'
.~rea q(~rouqh, 9a[~a'ctmen~ tff Envjron~.eBtal Quality
D?AG;~hM OF SYSTE~(
(.~z~ t:hat the infr~rmat~on contained ~.n a request for appro al to be a true
and accurat,~ repr<~ent:at~.o~ of the (m~)iact sewer and waC. er facilities located at:
Date