The URL can be used to link to this page

Home My WebLink AboutZODIAK MANOR ALASKA BLK 6 LT 16 / /,'-.~ !?.'1 :'-, 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 (a) Legal Descdptioe (include lot, block, subdivision, seclion, township, raege) Location (address or directions) (b) Applicant Name ~'~/W/ Applicant Address (c) Applicant is (check one): Lending Institution []; Owner/builder~f~; Buyer []; Other [] (explain); (d) (e) (f) [_ending Institution ~'-'~'% ~-.~- Real Estate Company and Agent Address %~ .~ ~ 1.~ "' ._ '-' Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single-FamilyV Multi-Fm~i..~z_,/[] Other Number of Bedrooms__ 7' WATI:R 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. 4. SEWAGE DISPOSAL Oesite [] Public/t~ Community E] Holding Tank [] Note: II community well system, must have written confirmation from the State Department of Environnrental Conservation attesting to the legality and status. 72-025 (I 1~84) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DAIA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my i nvesligation 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 tire informalion obtained from tile 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 tbis inspection. Name of Firm /¢~'¢'Q ~; Telephone ~/~d Address _~-t~ ~ ~ ~¢ ~/t/'~~ ~ ~4~/1 t~ ~;~ Approved for ..~:~'-,~//C. bedrooms byk//~'/'/'- -~_~'~_'¢:,.%~A~'~ Approved ~' DisapproVed// -- /~/ Con diti~a/I Terms of Conditional Approval CAUTION Tbe Muncipality ol Anchorage Depadment 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 tile State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institulions 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 profession~.l engineer's work. Page 2 of 2 72-025 (I 1/84} MUNICIPALITY OF ANCHORAGE (MO,~I HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY '1984 264-4720 Legal Description: WELl. DATA Well Classification - Well Log PresentCN)/ Total Depth ~ Cased to Static Water Level _~/') ¢)./,[¢'~' Casing Height Above Ground Electrical Wiring in Conduit~.)N) Separation Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D.E.C. Approved (Y/N) Date Completed /¢¢V/ /¢¢'~ Yield _(~ Depth of Grouting Pump Set At Sanitary Seal on Casing~Xl) Depression Around Wellhead (Y4~ W/C- ; On Adjoining Lots . /'//.~?' To Nearest Edge of Absorption Field on Lot ,W"/~ ;On Adjoining Lots To Nearest Public Sewer Line _ //'~/ To Nearest Public Sewer Cleanout/Manhole /'/"~/'¢' To Nearest Sewer Service Line on Lot _ Water Sample Test Results -'5"/~"~2"/r'~'/-~7~'~/' ?? SEP'rlC/HOLDING TANK DATA ~% Size No, of Compartments Standpipes (Y/~ Air-tight Cap~- (Y/N) _ _ Foundation Cleanout (Y/N) Depression o~r ~nk (~ Pumping/Maintenance COntractile (Y/N) ..... ; for Holding Tank High-Water Alarm (Y/N) %~ .... Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tan~- To Water-Supply Well ~ ~ing Foundation To Property Line ~ To Dispo~ld Water Main/Service Line '~m, Pond, Lake, or Major Drainage To Course Comments Page 1 of 2 ~ 72-026(11/84) ABSORPTION FIELD DATA ~/~.C/~ ~/~/~ Absorption Strata Type of System Design Date [nstaff~____ Length of Field ____ Width of Field ~. Depth of Field ____ ..... ~ Gravel Bed Thickness ____ ~ et o f A b_~0 r ptio n A rea-'"",,,~,,,,. Standpipes Present (Y/N) _Depression over Field (Y/N) ~ Date of Last Adequacy Test_ Results of Last Adequacy Test ~_ Separation Distance from Absorption Field: ~ To Water-Supply Well ~ To Property Line __ ~ ~' To Existing or Abandoned System on To Building Foundation Lot ~; On Adjoining Lot% To Water Main/Service Line __ To Cutbank (if pr~__ __ To Stream/Pond/Lake/or Major Drainage Course _ ~ To Driveway, Parking Area, or Vehicle Storage Area ~ Comments ~ LIFT STATION Date~. /,~4~ Dimensions ,,S, ize in Gallons '""'""'~ Manhole/Access (Y/N) Pump On" Level at ~ "Pump Off" Level at High Water Alarm Level at ~~ Vent (Y/N) . Tested for -"'""'"'"Pt~ng Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments Page 2 of 2 72-026 (11/84) ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have,c'~ eclled, verJfi~ed, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Z'~'/'~//tff,/"~ Date Company ~¢~ MOA No. Receipt No. '~ ~ ~ (c 'q ALASKA IUIROFlm FffAL COFITROL S , dlCe$, II]C. ~nqin¢¢rinq $ ~uironmcnl(~l $1u~ics NAN GUNDERSON 8561 JUPITER DRIVER ANCHORAGE ALAS F. A 995O7 S]gLLER-SAME FEB 11 WILL PICK UP FROM OUR OFFICE 60053 LEGAL: ZODIA K blANOR/BLOC K 6/LOT 16 FLOW TEST ON WELL WELL FLOW DATE-FEB 10 1986 A FLOW TEST WAS PERFORMED ON THE WELL. 729 GALLONS OF WATER WAS PUMPED AT A RATE OF 6.08 GPM OVER A DURATION OF 2 HOURS. THE DRAWDOWN WAS 4.02 ' WITH A RECOVERY TIME OF 10 MINUTES AND THE STATIC WATER LEVEL WAS 91.65 FEET. THE WELL IS ADEQUATE FOR THIS 4 BEDROOM HOb~. 1200 LU~sl 33r(~ Auenu¢. 5ui~ [! · An~Noroq¢, AIo ko 99503'.(907) 561-50/~0 CONTROL SI:.RVIC~', INC. 1200 West 33rd Aven~., Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 SHEET NO CALCULATED BY CHECKED BY SCALE OF DATE OATE_ ' MUNICIP'A 'LISY 0~- -- ' MUN[CIPALIt~ OF ANCHORAGE ~ ~ DEPARTMENT OF HEALT~ & ENVIRONMENTAL PROTECTION DEPT. OF HEALTH & 825 L Street - Anchorage, Alaska 99501 ENVIEONMENTAL ~ROTECTION OCT ? 1978 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEW~ ~'~p 1. pROPERTVOWNER / .~ -- I PHONE I ~AI El N~ ADDRESS PROPERT9 RESIDENT (if difforont from above/ -- ' ' PHONE 2, BUYER MAI _lNG ADDRESS 3, LENDING INSTITLi~ION ' PHONE 4, REALTOR/AGENT MAILING ADDRESS 6. LEGAL DESCRIPTION ' STREET LOCATION 6. TYPE O'¢ RESIDENCE [~ SINGLE FAMILY [] MULTIPLF FAMILY 7. WATER SUPPLY INDIVIDUAL* [] OOMMUNITY [] PUBLIC UTILITY 8, SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** PUBLIC UTILITY NUMBER OF BEDROOMS E] One ~ Four [] Two [] Five ~]' Three [] Six ~] Omer ATTACH WELL LOG. A well log is required for all wells drilled since June 1975, C:or wells drilled orior to that cate give well deptlt (attach log f available.) '"If individual/on-site, give installation date If system is over two (2) voars old an adequacy test is required by this Department, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72.010(3/78) THIS SIDE FOR OFFICIAL USE ONLY CATE RECEI~-~D INSPECTION APPOINTMENTS ," TIME TIME TIME DATE CATE DATE INSPECTOR I NSP ECTO R INSPECTOR DIRECTIONS,. 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX 2. WATER SUPPLY PERMIT NUMEER [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTI LITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []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 5. COMMENTS ~..~'~PP R OV E D FO R ~;~'"~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION - ,== 72-010 (Rev, 3/78)