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HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 6 LT 20NAME ~AILtNGADDRESS LEGAL DI:SCRIPTION MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION E-NVH~ONMENI'AI. ENGINEERING DIVISION 825 L Street* Anchorage, Alasl(a 99501 Telephone 264-4720 ON-SII'E SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PTPF ON E ~] NEW ~.b_~b~LE.~ ~ UPGRADE Material Material bene,rdl~tile ! ~ /~-'"--~- / / NO. OF BEDROOMS PERMIT NO. PERMIT NO. Liquid capacity in gallons PERMIT NO. inches PERMIT NO. LOCATION ~-~' DISTANCE TO: "T-~ %., DiSTANC~T0: IWell Well DISTANCE TO: Length Width Type of crib Crib diameter Well DISTANCE TO: Building ,~undation Depth Crib depth 13uilding foundation DISTANCE TO: OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER LEGAL WATER WELL REC'ORD : STATE OF ALASKA DEPARTMENT OF NATURAL RESOURFS Divisio~ Of Geologicol ~ Geophysicel Surveys LOCATION OF WELL (Pleose complefe either JoI lb or lc,) A.D.L. NO, ---of--of--of -- SE] W[~ f') ~ G. 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MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARI~ENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE (a) Legal Description (include lot~ block, snbdivision, section, township, range~)/ Location (address or diroctions) (b) Applicants Name~~_~; Z ~~ene. ___.__"' Home Business Applicant is (check one) Lending Institution Buyer ~t ; Other E~ (explain); Tele~pho ne ~ Lending Institution Address Telephone (f) Mail the HAA to the following address: ~f R_~esidence Single-Family ~] Number o~ Bedrooms Wa..~ e r .S.upply Individual WoiL1 ~ n-~ Other (describe) Multi-Fami:Ly Community C~ Public ~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Sewage Dis o~a__l Onsite ~-~ Public ~ Community ~-] Holding Tank [~--~... Note: If community well system, must have written confirmation from the State Department of Enviror~mental Conservation attesting to the legality and status. [Page 1 of 2] 5. E}lgi~eeri. n__gz Firm Providing I%~s_~[ctio~n~t TestsLFile~_Se_~arch_~_~D~t__a and Info£matlo~l As certified hy my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authorit~ Approval shows that the on-,alta water supply and/or wastewater disposal system is safe, function~ and ~equate for the number of bedrooms and type of structure indicated herein. I further verify that, based 'on the info~tion obtained from the ~nicipality of ~chorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance ~rlth all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firm ..... ""'" Da~e ........ ~ ..... Cond~o~ Approved for ~ Approved ~ Terms of Conditional Approval CAUTION TILE MUNICIPALITY OF ANCHORAGE DEPAR%}[ENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAl, CERTIFICATES BASED SOLELY UPON TIlE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFES'SIONAL ENGINEP]R REGISTERED IN TIiE STATE OF ALASKA. THE DNEP DOES Tills AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTSo 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 ONISSIONS IN THE. PROFESSIONAL ENGIbH']ER~S WORK° ; : RR4/eJ/D18 [Page 2 of 2] (DHEP SEAL) 7-19-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: WELL DATA Well Classification ~, Well Log Present (Y/N) Total Depth J ,~.- ~/'/ _ Cased to Static Water Level '//O Casing tteight Above Ground Electrical Wiring in Conduit (Y/N) _ Y ~ If A, B, C, D.E.C. Approved (Y/N) Date Completed ~/~-~ Yield . Depth of Grouting Pump Set At _ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot ___ ["'.J, O/'4 ~ _ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot _ ~ _~1..~ _; On Adjoining Lots __ To Nearest Public Sewer Line _ Cleanout/Manhole Water Sample Collected by Water Sample Test Results 'Comments N. ~:~![~ ~" __ To Nearest Public Sewer ;2, I1~ ~" To Nearest Sewer Service Line on Lot B. SEPTIC/HOLDING TANK DATA ~,JO~ L~ 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) 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,.,Cr conformed to all [¢O,~ and HAA guidelines in effect on the date of this inspection. Signed _'"~'~. ~ Date Company T~ ~'~¢~ MOA NO. Receipt No. _ ':~ Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) Engineer's Seal MUNICIPALITY OF ANCHORAGE MUNICIPALITY Oi' ANCHORAGE DEPT. Oi- ' .....  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION~ivIRONMENi'AL PROIECTION 826 L Street · Anahoraga, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION obi ~[ ~;~. Telephone 264-4720 I~[ E (i E J V J~ D REQUEST FOR APPROVAL OF IN[:>IVlDUAL WATER AND SEWER · Y OWNER I PHONE ,~ Y f/ .-. / j ~' ~p;- ONE S'rHE.T LOOAT,O ~//~NGLE FAMILY ~ One ~ Four ~ Two ~: Five ~] MULTIPLE FAMILY ~ Three ~ Six 7. WATER SUPPLY '~ INDIVIDUAL' * A'~ACH WELL LOG A well log Is required for all wel s drilled ~ COMMUNITY since June 1975. For wells drilled ~rior to that aa~e, give well [] PUBLIC UTILITY depth (a~ach Io~ if available.) 8. SEWAGE DISPOSAL SYSTEM NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PRDCESSING CAN BE INITIATED, INDIVIDUAL/ON-SITE*' PUBLIC UTILITY [] Other **If individual/on-site, give installation date .... If system is over two (2) cears old an adequacy test is required by this Deoar~men'[. 72,010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER I-1 MULTIPLE FAMILY [] TWO [] FOUR [] SIX 2, WATER SUPPLY PERMIT NUMBER [] 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 E~Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4, DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewar Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS I~"A~P ROV ED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) //-/~ LEGAL DESCRIPTION 72-010 (Rev, 3/78)