HomeMy WebLinkAboutGREENBROOK BLK 1 LT 7PO U C'~, .~6-650
ANCHORAGE, ALASKA 99502-0650
(907) 264-4111
TONY KNOWL£S
MA YOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Permit ~: 840226
January 31, 1985
TO: Permit Applicant
SUBJECT: Lot 7 Block 1 Greenbrook Subdivision
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1984.
Permits are issued on a calendar year basis by authority
of Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system not
installed by the expiration date.
If you have drilled the well, a well log needs to be sent
to this Department for documentation of the installation
and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, the original as-built inspection, report
and the yellow copy must be sent to this office for review
and approval, and for documentation.
If there are any further questions, please call this office
at 264-4720.
Sincerely,
orKeith E. Bandt, SupeYvis
Environmental Engineering Program
KEB/ljw
enc: Copy of Permit
SWP/057
I.":,EF'Fff~:THENT Cfi::' FiEFiLTH FIND E:hlV:[I:~'.Oi'.~.?'!FJ:hiTFtL PROTECTION
FIPF'L ! CF!NT:
C:ONT.,q. CT F'HCdqE:-.:
I...EGF!L i::,ESCF;: I F':
LOT SIZE'
T ::F.R'rTF'T' THF!T-
L, ,, TH:IS O!7 F~i'.,!"? Fii?.:rRc:IENT OFi: !'.4EF!RB'T' LOT.
iF FI L.I:FT STF!T:[OI'.,! :i:S :(NSTI:::!L!....EI.3 ]:!'.,i Fff.! !:::i F:: E FI r":F¢,.,'I::F?F:I3 ;F:i:'¢ I'"iO1::I. [::~'[tJ:',Zi'.,tG
'.¥.HE:N (::l..) Ri",! EL. EC:TF.:]:C::F:I[... F'!EFU"i:£T t::IND ".',I::?PFZ:'3',':r'"i'.I 1_.:I OI~!',TFi]:i'.,iEE:u ,::;;F.", FI'5-E:
~4]:L.L. N-"r E',E: FiI:::'I:::'F"3b'[:T, ,.,.!.f. !,.*,I...,L, I FIN iELF'r' TF', .... L :i'i'.J'~:;F'E".'T]:Cff-,t F~:EF'OR:T.~ I:~;ND ,:'] ::, THE
[.TL. ECTI;;:]:CFiL. !.,.]C)[~:I<: I"!UST E~I:i~ D(::I!'.,iE B'¢ F:I L:[C:Ei'-,f'.'SED
'F :[ 31'.,t [:' F:, 7~ DI::tTIi'Z
................................................
RF'F'!... :1: L':: FI I",! T DE .~.:[ 0 T T
Z ?51..IE~.:' .:F.':',"r' ,~/' DI::!TE
825 ' L~ Street, Anchorage, AK.
264-4720
Permit ~ ~0 '~ * * * HANDWRITTEN PERMIT * * *
WELL AND/OR ON-SITE sEWER PERMIT
Applicant: ~A/ ~"~/Q~/- Mailing Address: ~
Location: JPhone Number:
Legal Description:,~ ~-"7'"/[~"/~ ~'?'~'; LOt Size:
Type of Soil Absorption System Is:
Trench: ~ . Drainfield: Seepage Bed: Holding Tank:
Maximum Ntu~ber of Bedrooms: ~;~/,~ Soil Rating(sq.ft/br) ~/~
The Required Size of the Soil Absorption System Is: '
DEPTH / O LENGTH ,,;,~3 GRAVEL DEPTH ~' WIDTH '-~
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
· * REQUIRED SEPTIC(HOLDING) TANK SIZE = ,.~<'~O GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of!residences that the well will serve.
· * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling'of any' system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
fo~ a private well or 150 to 200 feet from a public well depending upon the type
o.f"public well. Minimum distance from a private well to a private sewer line
i!s~ 25 feet and to a connmunity sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days Of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
· * * PERMIT EXPIRES DECEMBER 3L 1 9 $ 3 * * *
I certify that:
(1) I ar~ fa~niliar with the requirements for on-site sewers and wells as
set forth by the Municipality of A~chorage.
(2) I will install the system in accordance with codes.
I understand that~h~n-site sewer system may require enlargement if
(3) the~esi~9~ce~// is~remo~eled to
~i ~n~t~~// include more t~/~r~x
SWP/024 (1/81)
Heak ja and Environmental Prote¢ ,on
' Fourth Floor West k._2
825 L Street
Anchorage, Alaska 99501
264-4720
INspECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME__~-."~__%__ ~6~-.-~-- ......... MAILING ADDRESS ~,JOO\ ~:. ,'-'~)tITI. OJ~)D PHONE ~S~
LOCATION~N-~ ~_~._k.'~_~.~'~_P~--_Jk) ~"~ LEGAL DESCRIPTION ~--'] ~.D-~ ~J,g~)g.l:2C~,F... ~;~/~_
SEPTIC TANK:
DISTANCE
FROM WELL
INSIDE LENGTH _~_~ I h_____
MAN U FAC 1 U R E ~ _~ I')._l~_~:[~.,~____ MATE RIAL
INSIDE WI D1-H__~_..J.~ LIQUID DEPTH ~__~
NUMBER OF
COMPARTMENTS
LIQUID CAPACITY\"~__ GALLONS.
TILE DRAIN FIELD:
DISTANCE [:ROM WELL ...... FOUNDATION ''~ ~
# of Lines Q_O_~ _ DISTANCE BETWEEN LINES
ABSORPTION AREA ~"~'"~-- % SQ. FT. LENGTH OF EACH LINE
~ DEPTH OF FILTER
DEPTlt: TOP OF TILE TO FINIS}t GRADE ~J~ MATERIAL BENEATH TILE
TOTAL LENGTH
NEAREST LOT LINE _~_. ~"~_ OF LINE
~) I ~ .TRENCH WIDTH'~O_ IN. TOTAL EFFECTIVE
IN. ABOVE TILE ~ IN.
SEEPAGE PIT:
Log Crib
Rings
BUILDING FOUNDATION
DIAMETER __OR WIDTH
Crib Size: DIAMETER___
NEAREST I._OT LINE ____
LENGTH DEPTH
DEPTH DISTANCE FROM: WELL
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA)
SQ. FT.
' WelI ~c~r~
Class: Depth:
Well Distance To: Lot Line
Bldg: Sewer Line:
Pipe Materials:
# of Bedrooms:
Installer: ~'~
Remarks:
-!
FIPPI.. Z CFINT
L.OCFIT }- ON
I ..r_'.
t3,EPFIP.]"i'tENT OF HEFIL.TH FIND ENk,'! ROi'.,IM~NTRI... F'F~:OTECT ]' ON
:i.::;;?.5 '" L. '" ~Tt:;.!E:ET., FINCHORFIC~E:, FIK '_~SiE~:'i
t..ES I::'FICE I,, :"~-Kt-,.IOOD HOi',IES
VON SCHEBE'N E:,RT
I..7? B::I.. 13F.':EENB,r4p3OK
'J..e;E.d. E E:,)7 h'tON[:,
r4EN .H
'¥"¢PE OF S;i.".'i ]; I... FiB:F_';ORE:T I ON $"r'STEH :i; S: -" .....
HFt;:.:;ZHI..IH Nt..iHSER OF BE[:,F~:OOi'"tS;., = 7-.':
THE LENGTH [:,IMEN:SION .T'.S ]"HE i..ENI3TH '::iN FEET)
'THE r)EP'f'H OF R TRENCH OF..' P:[T I.S; THE
GROUi'.4E:, FINK.:, THE BOTTOM OF THE EXCFIVFFFi'ON
THERE ]:'.'F; NO SET I.,-!:t:E.','TPt EOF..' TRENCHES.
THE GF-::FtVEL [:,EF'TH I'.F, THE M]:t':,f]'MUi',i E:,EPTPI
RND ]'HE BOTTOM OF THE EXCI::t',,,'R'T):Oi",I (tN
OR DRR :[ NF ~' E.7.[ .D.
N THE ~,tJF. F H_.c. OF' ]'HE
BETWEEN 'THE "ii 'T'FFtL.t P i/F:'E
If=" FIt C: ~
iR PRCKRGE PLRNT MR'¢ BE
F'OLL..Oi4 t NEi CON[:, I T t ONS:
t. EITHER FI CL..FISS Z OI
FIGREEMENT ~S NOT KI
FIB:E;ORPTION SMS;TEM RNE
F'EF.:i',1.'[ T'r'EE '" S; OP'T]:CIN 'SLIE:..TECT "r'O THE
:'ROVE[:, PLFINT l"tR'-r' E:E ]:NL:.;"FRL. I_E[:,.
EMENT 15; REg!UZF.'.ED. ZF FI MRINTENFINCE
'¢OU i'IR'¢ 8E RE(.:!t.,lt!RED TL'.'i ENi...FIRGE THiS %0:i'i
ilJ t"iRb' E:E SUBJECT 'TO F:'ROSECUTION.
E:R]KFtLt_.ING OF Ri",t"r' ='r._-. rE. fl P.IITHOIJT F]:I'.,IR1..T. NSPECTiON RNt} RPPI~'q'¢RL E:'-r' TH:i:S;
DEPRF.;:TMENT i.,.t t LL BE '-: LiE:.i'EC"IH TO PF.:OLF, ECtJ]' Z ON.
HtNZHi..jM [:,ZS.;'T'RNCE BETWEEN R 14ELL RND RN'-r' ON-S]:'TE %EWEIGE DI'.:.;POSFIL S"r'?TEhi
:J..E1E) FEE'I" FOR R PR :t: ',,,'FITE WEL.I.. OR 2E~.9 FEET FOF.'. IR PUBLIC !4ELL..
OTHER REE. EJiREI'dENTL:.; f'IFI'T' FIF:'F:'L'?'. S;PECIFICFI'I"iCiNS FINE.', CONSTRLiCT~:ON D]:FIGRi::!i'"IS; RE:E:
RVRILFIBi._E 'TO INS.;URE Pi:;..'OPER iNF~TFI[J...RTZON.
i CERT'IFY THFIT
:_i.: I FII"I FFIMILiFIR ~4I-i"H THE REE.!U:[REMENT?., FOR ON-SITE 9EHERS Rt",i[:' !-4EL.LS iRS; SET
FORTH B~' TFIE I"ILIN]'CIPRI....'[T'¢ OF RNCHORRGE.
2:: :[ P. IZL. L IN:L:;TRLL THE E;'¢:E;TEM IN RCCOR[)RNCE t.4tTH THE COE:'EL--.,.
Z-':: ]: UN[)ER:E;"r'RN[:, 'f'HRT THE EIN.-S]:TE ~SEWER :E;"r'S]"E:l'"i MR"r' REt.-]I...IIRE ENLFIRGE;P1Ei".IT iF' THE
F..:ES :[ [:'ENCE ~tO[).F2c. E[:' ]"l~L':l..t...ti~ i"iORE THFIN 3: BEC, F.'.OOHL:';.
5; I GNE[:,:
2204 Cleveland
("Performed For Les Pace
Lena1 qescriDtton: Lot 7 Block
This Korm Renorts Soils
Anchorage, Alaska 99503
Date Performed
1 Subdivision
yes Percolation Test__~_~s
8/2QZ!6
6
8
10
-'Lki 12
14
16
.18
20 ,
nenth
Feet
,
Soil Characteristics
· Silt (ML)
pocket of coarse gravel
between 8 and 10 feet
Bottom of Test Hole
Was Ground Water Encountered? No
IF Yes, At what Denth?
~ NO bedrock encountered
Date Gross Time Net Time Depth to H20 Net Dro
inches inches
---8-/-2~F-/7 6 ' 0 3 -- __0 _
8/25/7-6 Saturate per.~>d 24' hrs
8/25/76 0 3 _ Q___
8/25/76 3.0 hfs 6-3/4__
8/25/76-- ..... 3.5 b~s .7-3/4
8/25/7~ 4.0 hfs ..8-5/8 7/8
Percolation Rate 1"/35 )iinute
Proposed Installation: Seenaoe Pit -Drain Field
Deoth of Inlet Depth To Bottom Of Pit Or Trench
CmU~ENTS: 265 squa.re feet drain~qe area required per bedroom.
/'/~',~,~,_ ,/9 ~/~.~,,,/.~. Data Certified ~' 'CONSTRUCTION TEST
dames U Mac~ ; · Date: 8/20/76 " ~.
~.~ ~. O~
.... 'iV, 87°~-7'd1"~'. '. /6'o. oo_.
6/14/7~ - This ~s to certify that there have been
no s~£uctural changes since the date of this
asbutlt
A~t Forrest~r
hc,'cb¥ ¢crtify that I hnvc .~urvcyed %h~ followin~ d~scribcd
,~chor:,l:e Becordinl: Precinct, AIn~ka, and tlmt th~ improve-
~,~t~ :.~tu~t~d U~rc,Jn m'e withi~ the prb~erty li~cs ~l~cl do
,t 9v~rlap or ~ncrond~ on ~l~. property lying ad}~t.unt %~crcto,
ropcr~y cxc~pt as indicot~d hcrcon,
-a,~d nt Anchora~, Alaska ·
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
H87-0586A
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Descriptign (include lot, block, subdivision, section, township, range)
Lot 7 Block 1 Greenbrook Subdivision (T12N R3W
Location (address or directions)
12801 Von Scheben Drive
Section 26)
(b) Property Owner Don Elliot Telephone: Home
Mailing Address % Alene Palmer, Polar Realty, Inc.
Business
(c) Lending Institution Unknown Telephone
Mailing Address
(d)
Alene Palmer, Polar Realty
Real Estate Company and Agent
Address 1101 East 76th Avenue, Suite B, Anchorage, Alaska 99518
349-7681 (bus.); 345-7129 (res.)
Telephone
Mail the HAA to the followina address: or: Check here I~, if hold for pick up.
List contact person and day phone number below.
Alene Palmer, % Polar Realty 349-7681 or 345-7129
(e)
TYPE OF RESIDENCE
Single-Family [~:
Number of Bedrooms ~_ur ,f4 )
(Note: this was. corrected by On-site
Services staff)
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 [~x 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 (Rev 8/86~ Front
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 Peninsula Engineering Telephone 561-5107
Address 440 West Benson Boulevard, Anchorage, Alaska 99503
Date
The septic system for this property is approved for four(4) bedroom
use. However, due to the reduced size of the absorption area
(-16 square feet), the longevity of the septic system may be less
than one properly sized.
Engineer's Seal
DHHS APPROVAL
Approved for four (4) bedrooms:/i,i,b~'~-"(
Approved XXXXXXXXX Disapproved
Conditional
Date January 21, 1988
Terms of Conditional Approval
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 DHHS does this as a courtesy to purchasers of homes 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) 8ack
POLAR REALTY
1101 E. 76th AVENUE, SUITE B
ANCHORAGE, ALASKA 99518
ALENE PALMER
Associate Broker, GRI, CRS
OFFICE: (907) 349-7681
HOME: (907) 345-7129
Dan Bolles
Muncipality of Anchorage
Dept. of Health & Human Services
Division of Environmental Services
Dear M~. Bolles,
As per our conversation regarding Greenbrook Subd Lot 7 Block 1 attached
please find the new purchasers request for your department to approve the
septic system as a 4 bedroom. The mortgage company went to the property
to inspect since the engineer requested 3 bedroom but stated it to be 5 bedroom
and the appraiser stated 3 bedrooms plus den and loft area. The mortgage
company felt the den could be converted to a bedroom in the future and since
the engineer stated the system is adequate for a 4 bedroom they want the
house rated as a 4 bedroom to grant a loan on this property.
Thank you for YOur assistance in this matter.
Sincerely,
Alene Palmer
¢ ·
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include tot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner ~0¢0 ~L. LI (~T Telephone: Home Business
(c) Lending Institution ~o ~ ~ Telephone
Mailing Address
(d) Real Estate Company an~Agent ~(~ ~.~u . ~l~ ~--~
Address '~OI ~.~ ~ ., ~ ~,~ ~ · ~. ~
(e)
Telephone ~-~'- 7~'
Mail the HAA to the followin~ address: or: Check here~ if hold for pick up.
List contact person and day phone number below.
2. TYPE OF RESIDENCE
· single-Family'~
Number of Bedrooms "~
3. WATER SUPPLY
Individual. Well [] Community~f~" Public []
Note: If Community well system, must have written confirmation from the State Department of Environmental Conservation
attestin~ to the legality and status.
4. :SEWAGE DISPOSAL _ , -"
Onsite,~ Public [] Community [] Holding Tank []
Note: If community well system, rnust have written confirmation from the State Department of Envir0nmental Conservation ~'~
attesting to the legality and status.
72*025 (Rev 8/86~ Front
Page I of 2
5, 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. .
Name of Firm '~-~ ~' ~,~' <~; '~' I c~ .Fm~,.¢~ ~ . Telephone ~ / -- ~/~ '7
/
~ ~ Engineer's Seal
DHHS APPROVAL
Approved for
Approved
Terms Of Conditional Approval
bedrooms by /~ ~ Date
Disapproved Conditional
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 DHHS does this as a courtesy to purchasers of homes and their lending institution.s 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 Jn the professional
engineer's work.
Page 2 of 2
72-025 fRev 8/86~ Back
WELL DATA
r
_\~&.\-~.~ O, ,~,,4~_~t, Cb~'~t'~ALITY OF ANCHORAGE (MOA)
~'~S~ HEALTH AUTHORITY APPROVAL (HAA)
.~%O~' ~HECKLIST - FEBRUARY 1984
~ ~,. ~-. '~ ~ ~ 264-4744
Well Classification _[~¢v,~,.~q_ ,.-/',4 If A, B, C, D.E.C. Approved (Y/N)
·
Well Log Present (Y/N) ate Completed Yield
Total Depth Cased to
Static Water Level
Casing Height Above Ground
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
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
j~ Depression Around Wellhead (Y/N)
/~n Adjoining Lots
/ ; On ~Adjoining Lots
To Nearest Public Sewer
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
To Nearest Sewer Service Line on Lot
; Date
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 ~-'~'~m~[~
To Property Line
To Water Main/Service Line
Course /¢/o/¢' ,~-
J/~e/7~ Size /~-'~) .~-'/ No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped /
/tM ; for
Temporary Holding Tank Permit (Y/N)
TO Building Foundation / ~ /' '"'/Z"z~ ~'~* a
To Disposal Field ~--~'~--~ /
To Stream; Pond, Lake, or Major Drainage
IOO r
Page I of 2
72 026 fRev 8/86~ Fronl
ABSORPTION FIELD DATA
Date Installed / / '~'~/'7 ~ Length of Field ~ 7
Width of Field ~'~ o" Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area ~ ~ ~ ~ / Standpipes Present (Y/N)
Depression over Field (Y/N) ~ Date of Last Adequacy Test / 7
Results of Last Adequacy Test ~¢~- '~¢ ~ ~¢~
Separation Distance from Absorption Field:
To Water-Supply Well ~ ~o,~"¢~ ~,¢~/ To Prope~y Line
' ~ '
To Building Foundation ~ ~ To Existing or Abandoned System on
Lot ~ O ~ ; On Adjoining Lots / ~ /
To Water Main/Se~ice Line ~~ ~-- / To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course ~O ~ ~ ~ '~/~//~
To Driveway, Parking Area, or Vehicle Storage Area / ~ ~ ~-~ ~ ~
Comments ~/~'¢~/ ~, ~ ~ ~ ~ ~¢ %~ ~ ~ ~-~
LIFT ~ATION
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, vecfieA, or conformed to all MOA and HAA gpidelines in effect on the date of this inspection.
Signe~/'~X/~'-¢~.~'~//' ~~ate / ~'~/'2-'2/~ 7
Company
Receipt No.
o,
Amount: $
Page 2 of 2
72-026 fRev 8/861 Back
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/bIESTERN DISTRICT OFFICE /
3501 "C" STREET. SUITE 1334
ANCHORAGE, ALASKA 99503
STEVE COWPER, GOVERNOR
To tJhom It MaY Concern:
Acc:ordinq to the records on file in this office, the ~RE~SBRODY ....
SUBDIVISION Uater SYstem is in compliance with the
State oF Alaska Drinking Water Regulations.
Sincerely.
Ronald S. Klein
Environmental Field OFficer
CHEMICAL & GEOLOGICAL LABORATORIES OF AL~SKA, INC. ~°~
',e~'~I FEDERAL TAX ID # 92-0040440 ~
ANALYSIS REPORT BY SAMPLI~
Client ?0# : VERBAL Req #:
Client Smpl ID: LT 7 BLK 1GREENBROOK 12-29-87
Sample Rec'd : DEC 29 87
Ordered By : W HENDERSON
Send
Reports To:
PENINSIILA ENGINEERS
440 W BENSON STE 206
ANCHORAGE, AK. 99503
Work Order No. : 4516
Client Account : ?ENINSP
Date Report Pdnt~dI DEC 31 87 g 10:37
Released By~' 2
Reports Address #2
Special CALL FOR PICK UP 12-31-87
Instruct:
Chemlab Ref #: 8714 Lab Smpl ID: 1 Matrix: Water
Allowable
Parameter Tested ResultAlnlts Method Limits
NITRATE-N 3.S mc/1 10
MUNICIPALiTy ~ , ,
~NvIP, o~,,,~_~r~~ ~,,x,,~,C~o::x~
~o ~"IVI$10N
RECEIVED
Sar~le
Remarks:
ROUTINE SAMPLE
ANALYSIS COMPLETED: 12-31-87
LABORATORY SUPERVISOR: STEPHEN C. EBE
1 Tests Performed
ND=None Detected
NA= Not Analyzed
* See Special Instructions Above
** See Sample Remarks Above
LT=Less Than, GT=Greater Than
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
1, GENERAL INFORMATION
Application Date I --'7.~'~='
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~o~ ~t O ~ Telephone: Home ~ ~' ~55 ~ Business
Applicant Address I~ ~o I ~o,~ ~ ~ ~¢ ~c[&, ~ ~
(c) Applicant is (check one): Lending Institution D; Owner/builder ~uyer ~; Other ~ (explain);
(d) Lending Institution ~*~----
Address ~
(e) Real Estate Company and Agent L~
(f)
Address
Telephone
Mail the HAA~
Telephone
Single-Family LM Multi-Family[] Other
Number of Bedrooms "~
WATER 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. SEWA~)ISPOSAL
Onsite I.~ 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~'~4)
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.
Name of Firm _'~),~-r-~,~. '~-~c?;,,.3 ,E~.~"t-~ Telephone
Address c.~--~O 0 '~,~ c~ i,,,~ G~. ~ ~ ~d~_ ~ ~
Date t- ~
Approved ,oDHEP APPRO~,~,~ bedrooms b ~ ~~ _~te
Approved /~ Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department 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 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
Legal Description:
WELL DATA
Well Classification
V~..II Log Present (Y/N).
Total'~pth ____ Cased to
Static Wat'er~.evel. ___ __
Casing Height Al::~e. eGround __
Electrical Wiring in Co'~.t.(Y/N) __
Separation Distances from W~II'"~'~,.
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
~j e~-~i~.- '¢~¢-'t E~''~
If A, B, C, D.E.C Approved (Y/N) Y
Date Completed Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
On Adjoining Lots
To Ne~¢~LEublic Sewer
To Nearest Sewer Service Line on Lot
; Date '~'-~ ..
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed [-'2.~4~-7~, Size I~.~ No. of Compartments ~"
Standpipes (Y/N) ~' Air-tight Caps (Y/N) Y' Foundation Cleanout (Y/N) 'Y'
Depression over Tank (Y/N) ~ Date Last Pumped I ~ 1. ¢- ~"~ (¢,
Pumping/Maintenance Contract on File (Y/N) 'NI/A ; for MI^
Holding Tank High-Water Alarm (Y/N) I,,J/.~ Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Li~e
Course !'%'~/~
Comm.~nts /'-~-' ~
~;~To Building Foundation
I
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Dat~ Installed I ' ~O- '-~'~
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
Type of System Design
Length of Field ~?
Depth of Field '"7~
Gravel Bed Thickness ?~
Standpipes Present (Y/N)
Date of Last Adequacy Test
~G.1'-8.2¢,. To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checkecJ~vej~ied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed //,/,~,~ ?".,~/~/~/~"¢¢ Date
Company ~"~,,~.'f"k;l'~. ~~ MOA No.
Receipt No. ~ ~ I ~
Date of Payment ~ ' / ~' ~
Amount: $ ~ ~
DEPT. OF ENVIRONMENTAL CONSERVATION
· ~ ..' ~.}/ L. t. _~ ~
ANCHORAGE/WESTERN
DISTRICT OFFICE ri'il
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501 FEB J 1 1986
,/
BILL SHEFFIELD, GOVERNOR
Telephone: (90?)
-. Address:
DATUM ENGINEERING & SURVEYING
274-2533
Pws i.~.~ ~/~ 3¢ ~
To Whom it May Concern:
According to records on file in this office the'
~ Water SYstem is in compliance with the State Drinking
!
Water Regulations
S~ncerely,
MUNICIPALITY OF ANCHORAGE
DEPT O= ~:~'~
"~' DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIQN ...... ~r- ......
~-~vH~u~%;eNI'AL F:::Oi ECTION
825 L Street - Anchorage, Alaska 99501
( ENVIRONMENTAL ENGINEERING DIVISION . JUN R 0
Telephone 264-4720
..ou.s..o. o.
DIREOTION8: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER j PHONE
PROPEflTY RESIdeNT (If different from above) PHONE
3. LENDING INSTITUTION PHONE
MAI LING~DRESS ~
4, REAL~OR/AGEN~ ~'~ ~ I PHONE
MAILING ADDRESS
5. LI~GAL DESCRIPTION
STREET LOCA~"IO~
TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One [] Four
'~,Q~' SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY ~]" Three [] Six
7. WATER SUPPLY
[] INDIVIDUAL*
.~L" COMMUNITY
[] PUBLIC UTILITY
[] Other
*ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
IN DIVI DUAL/ON-SITE** **If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
[] PUBLIC UTI LITY by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72~10(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR I NS PECTOR I NSP ECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
~ SINGLE FAMILY [] ONE -~] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [~ TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
-E~ COMMUNITY DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
' 3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
~ I NDIVI DUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
'E~SepticTank or [] Holding Tank --~'t¢ ~'~
'Size: ) ~,~(~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCES ~) ~ ; Septic/Ho]ding Tank Absorption Area Sewer Line [ Nearest Lot Line
WELL TO:
I
Absorption Area to nearest Lot Line
5, COMMENTS
[~ APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
LEGAL DESCRIPTION
72-010 (Rev, 3/78)
o~