HomeMy WebLinkAboutPROSPECT HEIGHTS #1 BLK 6 LT 9AProspect Heights
#1
Lot 9A
Block 6
#015-092-21
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SiTE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHONE [~;~Ew
~ ~--- (~ Z~'~ [] UPGRADE
NAME
MAILIN~
LOCATION
DISTANCE TO:
~ ~Z Manufacturer
Liq. capacity in gallons'l- IF HOME.DE
I :
~OZ~ ~ DISTANCE TO: Iwell
O ~ ~ ~ Manufacturer
Absorption are~,
Inside length
Dwelling
Dwelling
//
Width
Material
NO. OF BEDROOMS
PERMIT NO.
No. of~ompartments
Liquid depth
PERMIT NO.
Liquid capacity in gallons
Well /'
DISTANCE TO: / OO ~
No. of lines I Length o~/a~h ~ne
Top of tile to finish grade (,9 /
Length
Type of crib
DISTANCE TO:
DISTANCE TO:
Width
Crib diameter
Well
Depth
Building foundation
Foundation/
Material beneath tile
Depth
Crib depth
Building foundation
Driller
Sewer line
Nearelt~/t line
Trench width /f
~._~-' inches
inches
Distance between lines
Tota ~fe(~t %bsorption area
PERMIT NO.
Total effective absorption area
Nearest lot line
Distance to lot line
Septic tank
PERMIT NO..
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
R EMAR KS ~
APPROVED
DATE LEGAL
WELL CONSTRUCTION LOG
ori~li.~ co. ~e,'~'~.~ .l.l,-'~ll,,,,~, ,~ l/:.~t~.,'~ri.~m, usos ,o.,
L ' '
_ Type of r~g :.~1=, ,'~,,1
Well location(? (address & legal ,.scriptio.)Lot~J& &~
OepJh ct w~ll ~j fi. asking: de ~h lt. di~m. ~ in.
Date well compteted~-Tg
Nearest community
' Location sketch or remarks
Static water '.vel ~.~ ft. (a"~, below) land surface. Dater
Finish of well: (open-end, screen, p~o~{~, op~--h~-e~ other)
Describe intervals and size: .~.~ ~,'~ ~ /?~
for hoers with ,,. of drawdown from static
DRILLER'S MATERIAL LOG
Depth below land Give description of strata penetrated
surface in feat (size of material, color, hardness of drilling, and water content)
DEF'FIRtTHEN'I" OF HEFffL. TN I:I~.~D EN,,,]:RONPlENTFIL'" F'ROTECTIEIN ~- ......
,::,~=._L STREET., F~NCHORFIGE., FIK. ~:5~50:t ~ ~ I ~ I ~ ~ 'z.~ ? //
FIF:'F'L ~ CBNT .JOHN L..FI[,IRENE:E 241E) GLENk. ERR* [: R ,~- ~ ~ :~:[~'
L. OC~T I ON ::ON I FEF'
LEGFIL LgR E,:, PRESF'ECT HTS _,. [. LCIT 2;IZE :36E~RB
'I"'¢F'E OF SOIL RBSORBT:[ON S'¢STEH ~S: TRENCH
I"IFI)',',ZHUM NLIHBER OF' BEE.',RC~OMS ---., 5 SOIL RRTING ,::SO Fr,.."E:R)=,
THE REOUIF.:ED SIZE OF THE SOIL FIE'S)F.:F'TIE~N S"r'STEH ]:':S'
:35
'THE LENGTN DIHENSION :[~':; THE LENGTH (IN FEET;' OF THE TRENC:H
THE DEP'rFI OF R TRENCH OF..' PIT ):S THE DISTRNCE BETklEEN THE 2;IJRFRCE OF' THE
GROLINL', FIND THE BOTTOH OF THE E'?,CR',,,'RTZON ,::TN FEET>·
THERE Z S NO SET NIDTH FOR TF.:ENCHES.
'THE: 6RFI'v'EL. r.:,EF'TH IS THE H):NIHLIH DEPTH OF' GRR',,,'E:[.. BETI.4EEN THE CiUTFFiL. L F'IF'E
FINE:, THE BO'f'TOH OF' THE EXCFIVRTiON ,:.~.N FEET.'.',.
PERHI]fr FIF'F'LICRNT HFIS THE RESPONSIBt L. IT"r' TO INFORf,t THIS [:,EPFIF::THEN"I" DURING THE
I NSTFILLFIT I ON INSPECT I ON'.:--.., OF F~N"r' P.IEL.LS RD,!RCENT TO TH I L:; PROPERT'¢ FIND, THE:
NUHBER OF RESIDENCES THRT ]'HE ktEL. L 1.4ILL SERVE.
BRCKF'ILLING OF FIN'¢ Sh"STEH I.,.IZ'I"HOUT FINFtL INSPECTION RND RPP~.i:O',,,'FIL B"r' TI'-IIE;
DEPFIF.:THENT NIL/.. BE SUB..'rECT TO PROSECUTION.
f'tlNII'dUM DISTFINCE BETFIEEN FI HELL. FIND FIN'-r' ON-SITE SEI.,IFIGE DIS;F'OSRL
.'1..(~63 FEET FOr.: R PRI',/RTE 14EL. L.~ OR
±~SE~ TO 288 FEE]- FROH FI PUBLIC 1.4ELL [:,Ef:'END];NG ur'oN THE T'.r'PE OF: F:'t..IBL]:C klEL.[...
14ELL LOGS RRE REQUIRE[:, FIND HLIST BE RETURNED TO THE DEF'RFi:THEhlT t.4ITIqIN ]j:EI DFI'¢~;
OF THE I.,.IELL COHPLETION.
OTHER REE. ILI I REHENTS HFI"r' F1F'F'L"r'. SF'EC: I F I CRT I ON'_'5 FIND CON~;TRLIC:T
t::I',,,'Ff I L.FIBLE 'rEs INSURE PROPER I NSTRL_.LFI'f' I ON.
:[ CERTIF".¢ THFtT
±: t RH FRHIL_IFtR [4ITH THE: RE6!UIREfqEIqT~, FOR ON-:5~.TE SEklER'.'-~; FINE:, I.,IELL.:~;
FORTH B"r' THE HUNICIPF~LIT'¢ OF' RNCHOF.:FIGr-::.
2: I klILL INSTFILL THE S"r'E;TEPl IN RCCORDRNCE 1.4ITH THE COl>ES.
:5:: ~. UNr:,ERSTFtND THRT 'T'HE ON-S.f.'f.'E 5EI.'.IE'F.: S"r"_=;TE:H I"lFI"r' RE6!Lll:RE ENL. FIRGIEHE":NT .~F:' THE
RESICDENE:E 12; REr'IODELE[:, "FO INCLUDE t, IC.~REi 'f'I-1RN 5 BE[:,ROOHS.
I
I']iNED
· ..._ ...... =-_'~' ..... ...... ''Z
HF'F'L, ~,~ .JOH~ LIdLIE;ENE;E
SOELS LOG
Date
16
1.8
Soil Type Water I,evel
Rema r ks
Total Depth of Excavation
G~:oundwat er
,0"-) Not Reached
Depth', if Reached
Classification Hethod
,(~.). V:£sua 1
( ) Sieve Analysis
()
~,_atez]_al at Total Depth -
Bedrock
(~'~. Not Reached
Depth, if Reached
Gar3, F. Player, Consulting Geologist
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
,/
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Day phone '~ ¥~' ~ ;~5~'~
Day phone
Agent ?'~'~'/ I-~ell,~ Dx,/~zn)c lPro,p~rP"~J Day phone
Address ~/~ "¢" ~/>, £~,/~e /oo .~,**~o*'~ ~.:
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
5. STATEMENT OF INSPECTION BY ENGINEER
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 application 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 verifythat 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 ~/~/-,z~? ~-~,c/,,~,'~/ ~'~,-~.,¢</ Phone
Address /5'_C ~, ~ d~-c A~ %/.~ /)-,', cAo,-~.., /¢~
Engineer's signature ~'~.~-~/'~.~,_ ~ ~-/z~,~-~ Date
DHHS SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
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 DHP~S 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 engineeCs work.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVIgF~
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501
Legal Description:
A. WELL DATA
Well type ? '-"~'~ ~-c
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Health Authority Approval Checklist
.L.~f- PA.,, l~11<~ ?rc.J?,,¢t' ftt':,'f~l ParcelI.D.: O~5- -c'92. -'Z./
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~ / 2./7
Cased to ! '~ ~ ' Casing height (above ground)
¥ Wires properly protected (Y/N)
FROM WELL LOG
i,/;? '
AT INSPECTION
Coliform 42 c~ Jo,,~,~ /~oo
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed 7/.~1/7~ Tanksize
Foundation cleanout (Y/N)
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed -7/~'//7
Length q i' Width
Nitrate
Oollected by:
Other bacteria Ho," e
15'~'~ Number of Compartments ~- Cleanouts (Y/N) ¥' (0
,/
Depression (Y/N) /V High water alarm (Y/N) /~./x
Pumper
Soil rating (g.p.d./ff~ or ff~/bdrm) ~'~ o~/_,~,~ystem type
~' Gravel thickness belOw pipe ~' ' Total depth
Effective absorption area 5/ ) 2_ ~=' Monitoring Tube present (Y/N) ¥
Date of adequacy test ~ ./,~ / 2~ Results (Pass/Fail) ~'~-¢J bedrooms
Fluid depth in absorption field before test (in.); ~ ~ '/~'' Immediately after'7 ~'~ gal. water added (in.):
Fluid depth ~ g, Vz (ins) Minutes later: /7 Absorption rate = .',> ~.5"~' g.p.d.
Peroxide treatment (past 12 months) (Y/N) No,~f' /.<~oo-,,~ If yes, give date /V. ,'~.
__ Depression over field (Y/N) __
For -~-
72-026 (Rev. 3/96)*
D. LIFT STATION ~J. ,~.
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
SEPARATION DISTANCES
Septic/holding tank on lot
Absorption field on lot
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
/575'~ ~. c.c.
Public sewer main ~. A.
Sewer/septic se~ice line ~ ~-'
On adjacent lots
On adjacent lots
"Pump off" level at*
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~ (¢2 ~ Property line ~ '7¢2 ~ Absorption field l¢ '
Water main/service line ~ /,~ ' Surface water/drainage >too ' Wells on adjacent lots > /o~ '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Propertyline ~ 1'7' Building foundation ~-- '2_0,
Surface water ~ /~-'~ '
Curtain drain /V,¢,,, ~
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal records that the abqve,systems are
in conformance with MOA HAA guidelines in effect on this date. : , i' ~:i i~, '~ L,
Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots /3'O' 2¢,~ ,~
Signature ~¢~'..,/~
Engineer's Name
Date ~
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
05-i3-00 16:35 FROM-CTE ENVIROH~flTAL
CT&E Environmental
Services
Inc,
T-Og8 P.OZ/03 F-056
CT&E Ruf.#
Client Name
Project Name~
Cliest Sample LD
Matrix
Ordered By
PWSLO
S~.mplo l~marks:
1002_794001
Fhuop Teclmic~l Sty.
LgA, Btk 6, Prosp~c; H~' ~1
L9A, B~ 6, Pros~c[ H~ ~ 1
Drink~g Wazer
0
PQL
0,500 ~n~/L fPA 300.0
lO ~ o~/o~/oo SCL
Nicro~ietoa/ La~oretory
Toter Cotiform O cet/lOOmt. Sl418 9~2~ 06/08/00 ~,AP
06-13-00 16:35 FRO~-CTE ENVIRONt~TAL 5815301 T-098 P 09/03 F-059
CT&E Environmental Services Inc.
Laboratory Division r~,i,e-~,d,~',e,,e-~'~'.e,~'av~'a~'~'~'~f~ .................... J,e-I~
Drinking Water Analysis Report for Total Coliform Bacteria
RE[AD INSTRUCTIONS ON REVERSE[ ~IDE BE[FORE[ COLLECTING SAMPLE
MuST BE COMPLETED BY WATER SUPPLIER
PUI~LiC WATE[R SYSTEM IDI~
)4 PRIVATE WATE[R SYSTE[M
SAMPLE TYPE
Treated Water
,,~ Roue,ne _
-~ Untreated Water
Repeat Sample ' .__
(refer to Iai) nec, )
Special Purpose'
Anchor~9~, AK
Teh (90~ 562-2343
TO 8E COMPLETED B~ ~BO~TOR~
Time Receive,:
BACTERIOLOgiCAL WATER ANAYSlS RECORD
Total Cotitorm ~.~ E. Coli
BGB COLIFORM
Client notified of unsatisfactory results:
COhform~100m$
lbd ff'
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
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (addr~ss?r directions)
(b) Applicant Name ~//~ ~~ Telephone: Home
; Applicant Address ¢~/ ~/~ ~d~,,, ~/~
(c) Applicant is (check one): Lending institution ~; Owner/builder ~; Buyer ~; Other D (explain);
Business
~D ~ ,~ o7
(d) Lending Institution
Address,
(e) Real Estate ~ompany and Agent ~~/~
Address ,~
Telephone ~Z-
(f)
Telephone
Mail the HAA to the following address:
2. TYPE OF RESIDE/~CE
Single-Family ~1~ 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.
SEWA~JSPOSAL
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 (11/84)
5. ENGINEERING FIRM PROVIDINL~ ,NSPECTIONS, TESTS, FILE SEARCH, DA'IA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, t 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 ,~' ,/~//""/~7/ /ZD:-,/V'~./~'//v/~--~//v/~ Telephone ~?~ %-~/~
Address ~/~.~ ~/~ ~D ~ ~/~/T~ ~-~., ~/~' ~ ~
Approved for _-~-" ~. \J ~, bedrooms by,/~' //~/~7//~~~,~
Approved ~ Disapprove/d/ ' Conditi~"'J.
Terms of Conditional Approval
Date
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 (MOL)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
DEPT. Of: HEALTH &
ENVIRONMENTAL PROTECTION
: i IgB§
Legal Description:
WELL DATA
Well Classification /¢~/~",'~7"'~ If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) Y Date Completed ,~,/e/7 ~ yi el d ..~. G ~'/:2fl//
Total Depth ~,~/~"~'~ Cased to ~,~'~' Depth of Grouting /V/~A/~-~'
Static Water Level /z~',~ F'7'' ~(~2 ' Pump Set At ~,~.~,~
Casing Height Above Ground //~2 .~-~--O Sanitary Seal on Casing (Y/N) ~/'
Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N)
Separation Distances from Well: /(~)
To Septic/Holding Tank on Lot //z:~.~ ; On Adjoining Lots /~:2--/-
To Nearest Edge of Absorption Field on Lot ~/~'~/(~ ;On Adjoining Lots //~:~)~-/- ~(-'~
To Nearest Public Sewer Line /v/,'4t~ To Nearest Public Sewer
Cleanout/Manhole A/'/~ To Nearest Sewer Service Line on Lot
Water Sample Collected by '~"~'~ ?//~-~'~/~;;~' ;Date ?//"~/~
Water Sample Test Results ~'./q~'/~"/~'~/"' 7"'~::~,~.,v/
Comments (~ /:~'~ Z2,/'/~"~:~ -/~~
B. SEPTIC/HOLDING TANK DATA
Date Installed O
Standpipes (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 /'d~''~ / (~)
To Property Line ~:~/ (~)
To Water Main/Service Line
qourse' :, ~..
Size ~_-~)4~',4-¢-~ No. of Compartments
Y
Air-tight Caps (Y/N) Foundation Cleanout (Y/N)
Pumped~,l
Date Last
A/ ; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field /,~--¢'"/(~)
To Stream, Pond, Lake, or Major Drainage
.Comments
Page I of 2
ABSORPTION FIELD DATA
Soils Rating in Absorption,Strata
Date installed_ 7/'~//~
Width of Field ~-~-//®
Square Feet of Absorption Area
Type of System DesigE
Length of Field ~! ®
Depth of Field -- ¢~/~-- 7~--,/~'
Gravel Bed Thickness ----~// ®
Standpipes Present (Y/N)
Depression over Field (Y/N) -- ./A~ Date of Last Adequacy Test ~.~~~/~(~
Results of Last Adequacy Test ~-~/)~,~-- ¢""~z~"~'~'~')~--~ 2- ~7/~./~ ~,_..~'7~/"-~'~,~'~'~/
Separation Distance from Absorption Field:
To Water-Supply Well --/*~ ®
To Building Foundation ---~ ¢ / ®
Lot ~-
To Property Line ~ / ®
To Existing or Abandoned System on
; On Adjoining Lots ,A//~ (~ --
To Water Main/Service Line _ ,/~--~ To Cutbank (if present) ~ ~-"~-
d/Lake/or Major Drainage Course
To Stream/Pon
To Driveway, Parking Area, or Vehicle Storage Area ~_/g)~
Comments (~) _,,¢2~,~ ~:2//'~'F:~
LIFT J
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify t~ check~ed,~erifj,¢], or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~ ~ - Date :~//'~
Company I~-~. ~ l~,,//LCz¢~. MOA N .
Receipt No. ~"~ L.\ k~
Date of Payment - ~/-
Amount: $
Page 2 of 2
72-026 (11/84)
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC
TELEPHONE (90D 562-2343 5633 B Street
Alaska 99518
Anchorage,
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
o ,UB',OWATERSYSTEM,.D.# I I I I I I I
[]3'~RIVATE WATER SYSTEM
Name
Mailing Address
City
State Zip Code
Mo. Day Year '
E TYPE:
tine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
) [] Treated Water
[] Untreated Water
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate'reliable results. Please send
new sample via special delivery mail.
Date Received 7-fJ'-- ~
Time Received //~ ~
Analytical Method: Membrane Filter
* No. of colonies/100 mi.
SAMPLE Time Collected Lab Ref. No.
/¢71
Result*
Analyst
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Membrane Filter: Direct Count
Verification: LTB
Final Membrane Filter Results/
Reported By ~/~-/'~'/r"~t¢~--*/~
TNTC = Too Numberous To Count
OB = Other Bacteria
Coilform/100ml
BGB
Date
Time:
Collformll00ml
a.m.
p.m.
MUNICIPALITY OF AiNCHORAGE
DIVISION OF ENVIRONMEIffAL ~n~ALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1o General Information
Application Date 7/26/85
(a) Legal Description (include lot, block, subdivision, section~ township, range)
Lt 9A Blk 6 Prospect Heights S/D
Location (address or directions)
9901 Conifer, Anchorage, AK 99517
349-3105
(b) Applicants NameJohn & Judy Lawrence Telephone - Home
Applicants Address 99_Ol~C~nifer. Anqhor~ge, AK 99~17
(c) Applicant .is (check on~e) Lending Institution ~ ; Owner/builder~ ~
Buyer[--q.; Othe=[22/ ( plain);
(d) Lending Institution ...... __ Telephone ......
Business
Ad~S s ...........
(e)
(f)
Real Estate Coo & Agent
Address _202 E. Northern Lights Blvd, Anchora~
Telephone 276-1333
Herita~ge Homes - Helen Henderson
Mail the HAA to the following address:
~lRe pf Residence
Single-Family~ Multi~Family.~ Other (describe)
Number of Bedrooms5
Water Su~
Note: If community well syscem, must have written confirmation from the State
Depar~menc of EnvironmenCal Conservation attesting to the legality amd sta~uso
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page I of 2]
5o ~n$ineerin~ 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 investiga~ion of this Health Authority Approval shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
=he 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~si~e water supply and/or wastewater disposal
system is in compliance wi~h all Municipal ~6 State codes, ordinances, and regula-
tions in effect on the date of this inspection.
o
Name of Firm
Address
Date
Arctic Engineers, Inc.
1506 W 36th Avenue, .~.9~
bedrooms By
Approved
Approved
Telephone 561-1345
Disapproved~
Conditional
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPAR~fENT OF ~%LTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES ~JLLTH AUTHORIT'f APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 A~OVE BY AN !NI~PENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF AJ~ASKAo THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT I/qSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE }fUNICIPALIT~f OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS LN TME PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/DI8
[Page 2 of 2]
7-19-84
ae
Be
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AU%/qORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
WELL DATA Legal Description: Lt 9A Blk 6
Well Classification Individual
Well Log P~esent (Y/N) Y
Total Depth 251' Cased to
Static Water Level 148'
Casing Height Above Ground 12' +
Electrical Wiring in Conduit (Y/N) Y
Separation Distances f~om Well:
To Septic/Holding Tank on Lot 100' +
To Nearest Edge of Absorption Field on Lot
To Nearest Public Se~r Line N/A
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTIO~
IJUL 3 '1
RECEIVED
Prospect Hts.
If A, B, c~ C, D.E.C. Ap~/N) N/A
Date Completed 8/2/~l~7%~-z°~/ Yield 7 GPM
179' Depth of Grouting --
Pump Set At 235'
Sanitary Seal on Casing (Y/N) Y
Depression AroundWellhead (Y/N) N
; On AdjoiniJg Lots..100. +
100' + ; On Adjoining Lots 100' +
To Nearest Public Sewer
Cleancut/Manhole N/A To Nearest Sewer Service Line on Lot 25' +
Water Sample Collected By Duane Maney ; Date 7/25/85
Water Sample Test Results Satisfactory
SEPTIC/HOLDING TANK BATA~.~
Date Installed ~/314~ Size J_%Q_Q_D_~I No. of Compartments g
Standpipes (Y/N) y Air-tight Caps .(Y/N) y Foundation Cleanout (Y/N) y
Depression over TaNk (Y/N) N Date Last Pumped_ 7/25/85~,i
Pumping/Maintenance Cont~a~ ~n File (Y/N) N ; for
Holding Tank High-Water Alarm (Y/N) N Temporary Holding Tank Permit (Y/N) N
Separation Distances f~om Septic/Holding Tank:
To Water-Supply Well 100' +
To Property L~ne 5' +
To ~l~ter Main/Service Line N/A
Course None Noted
To Building Foundation 11'
To Disposal Field 10'
To Stream, Pond, Lake', c~ Major.D~ainage
Cor~nts
[Page 1 of 2]
2~15=84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Str~~
Date Installed 7/31/~[" ~:~'~
Width of Field ~2"
Square Feet of Absorption A~ea
Depression over Field (Y/N) N
Results of Last Adequacy Test
Separation Distance f~om Absorption Field:
To Water-Supply W~ll 100' + To P~operty Line 14'
492
Date of Last Adequacy Test
Adequate
85 Type of System Design Trench
Length of Field 41
Depth of Field 12'
Gravel P~d Thickness 6'
Standpipes P~esent (Y/N)
7/25/85
To Building Foundation 31'
Lot None ; On Adjoining Lots 30' +
To Water Main/Service Line N/A To Cutbank(if present) 'None
TO Stream/Pond/Lake/c~ Major D~aina~e Course None Noted
TO D~iveway, Parking Area, o~ Vehicle Storage Area 10' +
Con~e nts
To Existing or Abandoned System cn
There is a standpipe at the mhd of:'r'bm l~mrh f~ld thme ~ nme
shown on the 7/78 as-built.
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alazm Level at
Tested for
Electrical Codes(Y/N)
Dimmnsions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Meets MOA
Comn~nts
** Check Permitted Bedroom RatingAgainst HAARequest
I certify that I have checked, verified, or conforrc~d to all MOA HAA
on the~~is~ ~
· Date 7/76/g5 ..
~/~r~~rs,/~inc.~'~ NO. ST85-001
L~ MOA
KB1/dS/s
'.n effect
[Page 2 of 2]
2-15-84
HEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343 ANCHORAGE iNDUSTRIAL CENTER
/~ - /- r- __ r. 5633BStreet
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
I.D. NO,
Water Systern'Name
Phone No.
(*) See h on back
Mailing AzJd ress
Mo. Day Y~
Zip Code
SAMPLE TYPE:
.~ Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO,
LOCATION
3 I
4 I
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
~Satisfactor~"J
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination to
indicate reliable results. Please send new
sample via special delivery mail.
Date Received ""-~- ~'Q~-"'- ~ j~
Time Received /J 4',-~"~
Analytical Method:
I-1' Fermentation Tube
,~Membrane Filter
Lab Ref. No. Result* Analyst
I
0~122~ (b)
RI¥. 1983
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
Membrane Filter:. Direct Count
Verification: LTB
Final Membrane Filter. Results
/
BGB.
Collformll00ml
Collformll00ml
COLLECTING SAMPLE TNTC = Too Numerous To Count
MUNICIPALITY OF ANCHORAGE
OF
ANCHORAGI~
DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO~Ec'wrfOl~'' '
825 L Street - Anchorage, Alaska 99501 D~PT. OF I ~SALTH &
ENVIRONMENTAL P~o fECTION
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720 JAN 1 lgTg
REQUEST
FOR
APPROVAL
DIRECTIONS= Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
PHONE
MAILING ADDRESS
pROPERTY RESIDENT (If different fr~m abov )
PHONE
PHONE
2, BUYER
MAILING ADDRESS
3. LENDING tflSTITUTION ~ . z PHONE
MAILING ADDRESS
4. REAL~OR/AGENT J PHONE
MAILING ADDRESS ~
NUMBER OF BEDROOMS
B. TYPE OF RESIDENCE
[] One [] Four []
.~ SINGLE FAMILY [] Two ~i~ Five
[] MULTIPLE FAMILY [] Three [] Six
Other~
7, WATER S.UPPLY
iNDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
8. SEWAGE DISPOSAL SYSTEM ~ INDIViDUAL/ON-SITE**
I~] PUBLIC UTILITY
*ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975 For wells dr ed prior to that date, give well
· I
depth (attach log if available.) 0R
**if individual/on-site, give installation date'~"~J ~/~"~ , /¢~ °1~
If system is over two {2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
-7~:010(3/78)
/
/
THIS SIDE FOR OFFICIAL USE ONLY i '
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
I NSP ECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OFBEDROOMS
[] SINGLE FAMILY [] ONE [~ THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVI DUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
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: /'.~00 If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
WELL TO: ~ [ O0 ~f[ O0
Absorption Area to nearest Eot Line
ROVED FOR ,~ BEDROOMS
[] CONDITIONAL APPROVAL {letter must a~mpan¥ certificate)
//
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
ACHEMICAL & GEOLOGICAL LABORATORIES OF AL~JKA, lNG.
P.O. BOX 4-1276 4649 BUSINESS PARK BLVD.
ANCHORAGE, ALASKA 99509
Drinking Water Analysis Report for Total Coliform Bacteria
TELEPHONE
(907) 279-4014
TO BE COMPLETED BY WATER SUPPLIER
PUBLIC WATER SYSTEM: I I I ,olNoI I ' I
MaS~ .... !
City state
Mo. Day Year
Zip Code
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water'"
[] Untreated Water
SAMPLE
NO.
t
LOCATION
Time Collected
Collected ~. By
TO BE COMPLETED BY LABORATORY
LABORATORY:
NAME
CITY
Date Received / ~t ~-~
Time Received f-~-(--)
Analytical Method:
[] Fermentation Tube
.~mbrane Filter
Lab Ref. No. Result* Analyst
NO. of colonl. I 11~0 mi, or No, of Pollllve podlons.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18-310 (3-78)
06-1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
Date Received Time Received __ 3.m. Lab. No.
Presumptive ]Omi :1Omi ].Omi 1Omi :1Omi 1.0mi 0.1mi
24 Hours
EMB Broth 24 hours:
Multiple Tube Report:
Membrane Filter: Direct Count
Verification: LTB
Broth 48 hours:
,.~ 10mi Tubes Positive/Total 10nll Portions