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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