HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 6 LT 21Lo '
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PRO'rECTION
DIVISION OF ENVIRONMENTAL H["ALTH ~-~ - ~ ~--'~(~""~
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAl-
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
'1.
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~(( '-7"~-"/':~r-'¢~'/7 Telephone: Home ~Y~- ~.e'"'8~ Business
ApplicantAddress ~¢~'.~,.,4"" ,.T~l,¢i /.-~,'~ ., /r~c/~o,"~'~-,'e' ~("~
(c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain); -,
(d) Lending Institution ~'o..tl'~.
Address Ib"O0 ~. ~'0~
(e) Real Estate Company and Agent
Address [ ~ ~
Telephone ~ ~ ~"
(f) Mail the HAA to the following address:
TYPE OF RI=SIDENCE
Single-Family [] Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well [] Community [] Public []
Note: It communily well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite [] Public [] Community [] Holding Tank []
Note: If community well system, must have writlen confirmation from the State Department of Environmenlal 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 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 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 ~'[~tL~/o 7-¢c~',,~cct/ ~,-.~/'~_¢.~/* Telephone ~,~-I,~
Address
DHEP APPROVAL
Approved for "~,z~z~z~ .'~/bedrooms by
Approved ,/~ Disapproved
Terms of Conditional Approval
Conditional
Date
CAUTION
The Muncipality of Anchorage Depadment of Health and Environmental Protection (DFIEP) 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
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
MUNICIPALI'IY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
SEP 2 4 I!)8
Legal Description: /,-o ~' E EJ;VED_
WEI. L DATA
If A, B, C, D,E,C. Approved (Y/N)
Date Completed ~/7 / ?'~ Yield
Depth of Grouting .
Pump Set At
Sanitary Seal on Casing (WN)
Depression Around Wellhead (Y/N)
Well Classification . r~.~ u¢~ ~-~
Well Log Present (Y/N) - ~
Total Depth I ~_.g' ~ Cased to
Static Water Level _ II
Casing Height Above Ground I
Electrical Wiring in Conduit (Y/N) _
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot __
To Nearest Public Sewer Line.
¢ (/'V' c..¢c~ ~ r' ; On Adjoining Lots
~¢At. ; On Adjoining Lots ____ N~
To Nearest Public Sewer
Cleanout/Manhole _~ O_ ~ :t. To Nearest Sewer Service Line on Lot
Water Sample Collected by 'r"~'/'-r ; Date
WaterSampleTestResults .~e.z.~l't~,~C/.o,".y· o. rio e::c,(l'~ ~m o,"'
Comments Vg,r''~C~¢'~' ~'~.c~¢~ Con~l'~_~' c~J, t~'c~,'4~ .
B. SEPTIC/HOLDING TANK DATA
Date Installed
Staadpipes (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)
ABSORPTION FIELD DATA ~,/~. ~(~,~ .~ r.-~ e'. ~~''
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 -¢~~ ~'~ ~/4¢-¢,< Date
Company /u~('~.~/~ ~4 ~¢..4' MOA No.
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
Seal
NORTHERN TESTING LABORATORIES, INC.
600 UNIVERSITY PLAZA WESTi SUITE A ~ ,,~ FAIRBANKS, ALASKA 99709 907-479-3115
6957 OLD SEWARD HIGHWAY, SUITE 101 ANCHORAGE, ALASKA 99518 907-349-8623
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE cOMPLETED BY CLIENT
PRIVATE WATER SYSTEM
NAME
Mailing Address
Zip Code
SAMPLE DATE:
SAMPLE TYPE:
[~ Routine
[] Special Purpose
Purchase Order No, _
[] Treated Wat~
[] Untreated Water
[] Check Sample (for original contaminated
sample with lab reference no. _ )
Sample Time
No. Location Collected Collected by
2 . ~} '~'<)71/q ii' 'f: t' ~' ....
~L~aboratory Ref, No,
4
5
6
7
8
9
10
Signature of Representative
FOR LABORATORY USE ONLY
TO BE COMPL,ETED BY LABORATORY
Received at: rich. [] Fbks,
Date Received
Time Received _ /- · ~- '
Next Sample Due
COMMENTS:
SATISFACTORY
UNSATISFACTORY
RESAMPLE R
OTHER BACTERIA OB
TOO NUMEROUS TNTC
TO COUNT
Direct Vorificstion Final
Count LSB BGB Result"
* or,of -t:ooi~l Coliform Colonies per 100 mis.
? :' (,./
R'e~orted b,/~ ~ . .-~
!'
Time