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Home My WebLink AboutHERITAGE PARK BLK 2 LT 22Heritage Park Lot 22 Block 2 #050-211-58 NAME i~..,, 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 MAILING ADDRESS LEGAL DESCRIPTION DISTANCE TO: Manufacturer LOCATION Liq. capacity in DISTANCE TO: Manufacturer IF HOMEMADE: Well I nside length Dwelling DISTANCE TO: Well No. of lines I I Length of each Top of tile to finish grade ~f crib Length DISTANCE TO: DISTANCE TO: Width Crib diameter Well Depth Building foundation Foundation Total length of lines, Material beneath tile Depth Crib depth ' Building foundation Driller Sewer line Dwelling Mat e~.~ Width Material Nearest lot Trench widt~:)inches NO. OF BEDROOMS PERMIT NO. No. of compartme,~ Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT N0.O0.3~)~.~ / Distance b et we~7~/.~ Total effective a~/:~¢~n area PERMIT NO, Total effective absorption area Nearest lot line Distance to lot line PERMIT NO. Sept c tank Absorption area(s) OTHER SOIL TEST RATING /y3 INSTALLE~/~ ,.% S~ ~-~, '¢'2-013 (R-~v. 3/7B) ~ DATE LEGAL DEF'FtF:TMEI'.,t'f' C..._:....HEFILTH FIND ENV I RONMENTFtL t._._ ,OTECT I ON ,:,c.,.=; .' L" '--,TREET., FIN ] HE RFI.SE, RI-:::. 9950"1 .=:.~,4- 4 ~.- ~M ,, C,~'-41--"_-~; Z TE __,E!I--JIEF-: F"ER~"-I ."E T' F'E.F4MIT': NO. ( .=:_..3:0]:E'~:L ', _~~ .... RPF'L i C:RN'r LOCFtT I ON LEGFIL , I -,L EF. CONSTF.:UCT I ON L22 E:2 HERITRGE F'FIRI< ..... 14::L4-N FINCHORRGE '..9. '.-].~R2 .:..,='4=...._,-_.-.... :Lb ":"-'" '- LOT SIZE 99'3.999 SL-]UFIF.:E FEET T"r'F'E OF SOiL FIE:SORF'TION S'"r'STEM IS: TRENCH i"'IFIXZMI.JM N. UMBER OF BEDRFiOI'"t$ = SOtL. F:RTING ,::SQ FT,-"E;R)= 129 =, ~.:,TEt 1 IS: THE REQUIRED SIZE: OF THE SOIL RBSOF-:PTION '-'"- E:.EF'TH= THE LENGTH DIMENSION IS 'THE LENGTH '(iN FEET) OF THE TRENCH OR [:'RRINFIELD. THE DEPTH OF FI TRENCH OR PIT IS THE [:'ISTFlNCE BETWEEN THE SURFFICE OF THE GROUND RND THE BOTTOM OF THE EXCFI',,,'FITION (iN FEET). THERE IS NO SET WIDTH FOR' TRENCHES. THE ',r.:.n,,.c..u. DEPTH IS THE HINIMLIM DEPTH OF GRFlVEL BETI.,.IEEN THE CiUTFFtLL PIPE FIND THE BOTTOM OF THE EXCR","RTION (IN FEET). F-:E ~]:_., Lit :[ F.". E E;, "_--]EF" ]- ..T_ C: T F-~ i'-~ !'::: S ..T_T ZE == 1 £-'1 ,-.7_-i C", t3 R LIL_ C, ~-~ S F'ERMIT FIF'F'LiCFINT HFIS THE F.E--,F .N.:,IE, ILITT TO INFORM THIS [:,EPFIRTi"IENT [:,URING THE iNSTFILLFITION INSF'EC:TIONS OF FIN"r' WELLS FIDJFICENT TO THIS PROPERTb' FIN[:, THE NLIME,'ER OF RESIDENCES THRT THE WELL WILL SERVE. B.FlCKFILLiNG OF FIN'¢ S'¢STEM WITHOUT FINFIL tN=,FEUTILN FIND FIF'PRO',,,'FtL B'¢ THIS DEPRRTHENT t.,.IILL BE SUE..'fECT TO F'ROSECLITION. MINIMUM DISTBNCE BETWEEN R WELL FIND FINY ON-SITE SEWRGE DISPOSRL SYSTEM IS ±OE~ FEET FOR FI PRIVFITE WELL OR ±5R TO 200 FEET FROM FI PUBLIC WELL DEPENDING UPON THE T'¢PE OF PUBLIC WELL. MINIMUM DISTFINCE FROM FI PRI',/FITE WELL TO FI PRiVFITE SEWER LINE IS 25 FEET FIND TO FI COMMUNIT'¢ SEWER LINE IS 75 FEET. OTHER REL--.!UIREMENTS MFI'¢ FIPPL'¢. SPECIFICFITIONS liND CONSTRUCTION [:'IFIGRFIMS FIRE R',,,'FIILFIBLE TO INSURE PROPER INSTFtLLFITION. I CERTIFY THFIT .:L: I FIM FFIHILIFIR WITH THE REQUIREMENTS FOR ON-SITE SEWERS FIND WELLS RS SET FORTH B'¢ THE MUNICIPFILIT"r' OF FtNCHOF.'.FIGE. 2: I WILL INSTRLL THE S"r'STEM IN RCCORDFINCE WITH THE CO[:'ES. 2: I UNDERSTFIND THRT THE ON-SITE SEWER S'¢STEM I'"lFl"¢ REQUIRE ENLFIRGEHENT IF THE RESIDENCE IS REHODELED TO INCLUDE MORE THFlN ~: BEDROOMS. PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 12 14 17 ~8 2O ~.~_., ,,.~_/ [] SOILS LOG MUNICIPALITY OF ANCHORAGE [] PERCOLATION DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST 825 L. Street. Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST SLOPE ~ S~TE PLAN WAS GROUND WATER ~ SE ENCOUNTER ED? O P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop COMMENTS PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT ~,ND ~ FT Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-211-58 1. GENERAL INFORMATION Complete legal description Lot 22, Location (site address or directions) Expiration Date: Block 2, Heritage Park S/D 19542 Laura Lee Circle Current Properly owner(s) Doug Mailing address 19542 Laura Lending agency Shattuck Lee Circle, Eagle Dayphone 787-8803 River, AK 99577 Day phone Mailing address Real Estate Agent Target/Dick Brown Dayphone 694-2388 Mailing Address PO Box 774627, Eagle River, AK 99577 ~, Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: '~.~. Z. ~'~.._ NUMBER OF BEDROOMS: 3 9//~ ~/ao TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] Individual Holding Tank [] Community On-site [] Public Sewer The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Name of Firm Address 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 based on procedures outlined in the Health Authority Approval Guidelines for the Health Authority Approval application show 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. S 8, S ENGINEERING 17034 Eagle River Loop Road No, 204 5ogle Rf,?% &l=,l,-~ q0~77 Phone _ ~_c] 7~-/ ___ Engineer's Printed Name Robert C. Co,can Date DHHS SIGNATURE I,./ Approved for ~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: ~ - .~_. ~f- - O / Original Certificate Date: ¢/ - ~.._~-- LO 0 Reissue Date: Legal Description: /~ ~--~; f"~COC~ 2)' A. WELL DATA Well type ~1~ If A, B, or C provide PWSID ~ ~ Well Log Date completed Sanitary seal . Wi~operly protected Total depth ft Cased to ~ _ FROM WELL LOG ~T INSPECTION Date of test Static water level ~ ~ Well production ~m __ g.p.m WATER SAMPLE RE~ ..... Coliform ~~e ~1 Oth~acteria colonies/100 mi Date of s~ Collected by: Municipality of Anchorage Department of Health and Human Servic~ E C E ! V E Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 SEP :1. 9 Z001] P.O. Box 196650 Anchorage, AK 99519-6650 www.oi.anchorage.ak.us (907) 343-4744 MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION HEALTH AUTHORITY APPROVAL CHECKLIST ~"~__ X/~ Parcel I.D.: '-- in, Tank TyPe/Material DaUb installed ~-/~_,z' ~ '~ Tank size /~ gal Number of Compadments ~ Clbanouts'~¢/Foundationcleanout ~ Depression over tank ~ High wateralarm Da~e'0f pumping ~/~ Pumper C. ABSORPTION FIELD DATA Date installed ~/~ ~ Soil rating (g.p.d.lft2 o~ /Z~ ~System type ~ / Length ~ fl Width ~,~ Gravel below pipe ~ ff Total dept~/O~ Effective absorptionarea~ft2 Monitoring tube~ Depression over field A/d Date of adequacy test ~ Results (Pass~) ~ For ~ bedrooms Fluid depth in absorption field before test //~ ~/in Water added ~ gal. New dePth ~//' in. Elapsed Time: ~ min Final fluid depth ~ /~ in Absorption rate ~ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) ~ ~ If yes, give date 72-026 (Rev. 0~/o0)* /~ ~ ~ ~, D. LIFT STATION Date installed ~S'~ "Pump on" level at ~p off" level at Datum ~-/'/ Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: in Manhole/Access High water alarm level at __ in Meets alarm & circuit requirements Septic tank/lift station on lot On adjacent lots Absorption field on lot O~ lots Public sewer main / Public sewer manhole/cleaneut Sewer/septic service I'h-re'~'~ Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~-'/7/- Property line ~- Water main /~ /¢- Water service line /E~ ./- Drainage ,~'~) /~ Wells on adjacent lots / SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ,/O/',~ Building foundation /~ ~ Water Service line ,/(~ ~- Surface water ///~ /~ Curtain drain ,d/¢~/4~ ~4,/¢7/r//,/Wells on adjacent lots /D?~) ~ Absorption field Surface water Water main Driveway, parking/vehicle storage / E) '~.- F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conform.a..nce with MOA HAA guidelines in effect on this date. Engineers Printed Name Date o)/{ ¢1/0o HAAFee $ :~ ' ~ Date of Payment ~//~/~-C~ Receipt Number ~ '~-'~-~ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev, 01/00)* DEPARTMENT OF HEALTH & HUMAN SERVICES_ ' - - Division of Environmental Services -'-~- ' ~.~ . ,,,.:..,: ~ On-Site Service~ Section .... . ;.,-.,:,:, .~,.... .... · P.O. Box 196650 Anchorage,':Alaska 99519-6650 -;::'~.';~.,;., .. :~:~ :, :;,; .-.. .~:?,::~_. ..... "': ~:., 343-4744 ~ "'" ' "'"' ' ' - ' CERTIFICATE OF HEALTH AUTHORITY - ' APPROVAL FOR A SINGLE FAMILY DWELLING '-' . Parcel I.D. # ~)~"~2-,) I - ~"~ NAA#" :~ f~'c:~C~' 1,' GENERAL INFORMATION Complete legal description Lot 22; Block 2; He,/~bC~g~ .P~tk Subd~u,~ion Location (site address or directions) 19542 Laura L~ Cirel~ Eagl~ River, AK .Property owner Mailing address Glenn Yates 19542;'Laura L~ Cir~l~ Day phone 265-6566 (w) Eaq£¢ River, AK 99577 Lending agency Day phone Mailing address. Agent Day phone Address 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well ..... .............. P~blic water ' XY, X ' NOTE: '""~f com~n~nity W~II syst~'m, Provid~Written confirmation from state ADEC attest- -~ "lng to the legality and status of system. - WAS~EWATER DISPOSAL: ...... 4. TYPE OF Indiv?ual On-site -,",',*-'-.? .......... Holding tank ..... - ........... ~ ....... ¥~-' '~' -~-,':,r'':</,¥ ,..;;~,, _: ~'t?:~ PubliC sewer--~ .~; .-:':?-:' ;-: - '- :.- NOTE: · If community wastewater system, proWde wfi~en confirmation' from State ADEG ' , %' '? ..' . ' ~'a~esting to the legali~ and status of system."~ -72~(~ev, 1/91) Frent MOA~ ..: , ....: .- .~..'. ,.~ . . . ...... -. ·-~_.¢7,...~-:-~.~ Unless otherwise requested, HAA will be held for pickup. ' -' '. -.~.-: -. ' - '.: , ._~-:~ '.: _ ;. '~. :'- ;L,...,.~'~ ~ ' .... :. - .'. -':-': , ~ '.~ .. '. i'.' ':' ~:;~; . , : ~?...-.,..' ~. As certified by my seal affixed hereto and as of the validation date shown below, I verify tha:[ ~ny :' investigation of this Health Authority Approval application shows that the On-s te water supp y and/or wastewater disposal System is safe, functional and adequate for the number of bedrooms and tyPe of structure indicated herein. I fUrthei'verify that based on the information 0b;mined fr0m'' the Municipality of Anchorage files a~:HTO'~ my investigation and inspection, the omsite'water supply and/or wastewater dispo/~_al'syste.~is in compliance With'all MuniciPal a'ndState (J0deS'; ordinances a, nd'regulati0ns ,f.e'ffect o.~,r'the date of this inspection. ?... .,i'i.~'''' '. i .'LI.: Name of Firm //~ ' ~ ":Phone L,~:~/-~--~ ~ '- . Z'"'/ // ' ,'+...'..: ....... . '.-.- -,'.. Address $&/~ £,l~ NPT~RIN~ ': ' ..... : ' 17{)5~Ea e/River Loop Rode] No. 2~ · Engineer's signature~,-2,~,~ ~L._~!,_., 9°.577 Conditional approval for · .: . ,* . , , c.:),.~.::~ ..... .: .- ~. . '~" ,..' .... · ...:,. 'c:.:.. ',_.L .'(i' .:: ':': ':' ;["'" '-'.:' ' ' bedrooms. ' '. -': - :'-- .' :'.': ': .... ': ',;:: ': ........ :i. Disapproved. ..... - '" ' ~'-'": . . -. .' .?, - ..: . '.'-*.:/.", , : ?. ', . .,.:' bedrooms,'~ith the following'stipulations::. - · .t ~.~-~: . :,:.'~ ?-:~ ."; r~i~ ;~.~,~ ,:: r(-.," By: Additional Comments ' ' c, - "' ' ""' ' ' ';;'*'~.-'-}~ [ "f; , llPli The' Municipality of Anchorage Department of Health and Human ServiceSliDHHS)i!ssues Healih Authority Approval Certificates based only upon the representations given in 'Pa'~g-~Ph'~ ~.b:~ve by an 'independent professional ~ngineer registered in the State of Alaska. The DHHS does this asa cou~syto purcha~ers of h0~m~s and their lending institutions in order to satisfy certain federal and state requirements. EmPi&ye~S of DHR8 'c0nduct':ir~s'pections Or analYZe'data before a Certificate is iSsued, TheMuniCi ' . responsible for errors or omissions in the professional engineer's Municipality of Anchorage Department of Health and Human Services · HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~_-o-~ ?.-'7-.- ~ 7-.- ~~~,~¢/--Parcel I.D. If A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to Casing height FROM WELL LOG A. Well Data Well type ~'~ ~/~- Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line Wires properly protected (Y/N) AT INSPECTION g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed 5'~-~ ~'''~ Cleanouts,~l) High water alarm (Y/~J~ Date of pumping Tank size ~. (~ o O Compartments ~-- Foundation cleanout (~N) ~ Depreslion (Y/{~) Alarm tested (Y/N) Pumper ~,.~ ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot t~[ "- ,~ ' On adjacent lots To property line [ ,~ ~ ~ Absorption field ~ ' Sudace water/drainage [ o o t ~'~ Foundation Water main/service line 7~-o2s (3/~)' F~t CONTINUED ON BACK PAGE C. LiFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical ccd~ ~~'~ ~E~OE FROM LIFT STATION TO: ~11 on lot On adjacent lots Manufacturer Manhole/Access (Y/N) ~ ....-.~"~~vel at ~ tested Sudace water D. ABSORPTION FIELD DATA Date installed Gf--' 7..~ -~ %'5 Length '~'z--~ 'Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) ('~ Soil rating (GPD/FF) 1'7-~ ~/15¢. System type Width ~. ~ ~ Gravel thinness ~ ~ Total depth . ~ ~ ~ ~ Cleanout present ~) ¢ Depressbn over field (Y~. ~ ~ ~ ~ Resu~s~ail) ~ for ~ Bedr~ms ~ A~er test / ~ '¢ ,%~ ~ If yes, gbe date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~\ ~ On adjacent lots ~\ ~ Property line To building foundation ~ ~ ~5 / To existing or abandoned system on lot ~/.~ On adjacent lots ~,~, ~ ~'- Cutbank "J/,,¢ Water main/service line / c~ ' ~' Surface water /oO I ~ Driveway, parking/vehicle storage area /c, / ~' Curtain drain 'J /,~ E. ENGINEER'S CERTIFICATION I cer~'fy that/have checked, ve~~formedtoall MOA and HAA guidelines ineff~c~ Signature /~ ~ ~{'~r Engineer's Nal~§3,~ ~.~;. L/~c~ =~..j :~.,':r~ / ~ HAA Fee $ ,~-~, ¢~"~ Date of Payment ~?/~'~ '~-~2 Receipt Number ~':'~'~-[ '~7~ ~} 72-026 (3/93)' Back Waiver Fee $ Date of Payment Receipt Number 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 ~/~ ~''~J~ GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) ......,. _ . / Location ;(addre§s b~' d~rections) - · Mailing. Address ,. Telephone: Home Business (c),. 'L~'ndi n g;I n~tit u~io n.'' Mail. i. ng~ Add r~ss_ ', ~'~ (d) Real E§tate Cor~p~ny and Agent Telephone Address Telephone (e) Mail the HAA to the followino address: or: Check here [], if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family~ Number of Bedrooms WATER SUPPLY Individual Weft [] Community [] Public'~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite/~ Public [] Community [] Holding Tank [] Note: If comm unity 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 fRev 8/86) Front '~JOA~ s,JaaU!bU@ leuo!ssaj, oJd aql u! SUO!SS!LUO JO SJOJJa ~OJ elqisuodsaJ ~,ou s! ebeJoqou'¢ Jo AlilBd!o!un~ eq/'penss! s! al. eo!j!peo e aJo,Leq e~ep eZAIBUB JO suoBoadsu! ~.onpuo3 lou op SHHQ ,Lo s@@XolduJ:q 's},ueLueJ!nbeJ a~eis pub IeJepa,L u!elJeO Xjs!!.es oi Jap Jo u! suo!lnip, su! 5u!pual J!aq), pub S@Luoq JO sJaseqoJnd Oi As@pno3 B se siq~. saop SHHQ @q/'B~SBI¥ ,LO @l-elS eqi u! peJ@!.s!l~aJ Jaeu!bua IBUO!SSajoJd J, uapuadapu! ue Xq eAoqe ~ qdeJaeJBd u! UaA¢5 suop, eluasaJdaJ aql uodn /(lUO paseq se~Bo!j!pa3 leAoJdd¥ Alpoqin¥ qileeH sanss! (SHHG) sao!^]eS uBL,UnH pub q~leaH ,Lo !.UaLUpBdaQ aaeJoqou¥ ,Lo Al.!led!o!unlAI aq/ IeAeJddv leUOp,!puoc) ,Lo swJa/ leUO!l!puoo - pa^oJdde~!c]~ ~ j,,,,,,._ pa^o~ddv '9 / ¢ a.o.d a_L u Ju ,Lo ,.BN 'uoBoadsu! s!Li~, jo @IBp aLi1 uo ),oaj,ta u! suoBBinaeJ pub 'saouBu!pJo '9apoo ale19 pub iBd!o!unv~l lib q~,!M eoUB!lduJoo u! s! uJm, sXs IBsods!p Ja~.B~eiSBM Jo/puB Alddns JelBM al!s-uo aqj 'uoBoedsu! pub uop, eaBsa^u! XuJ LUOJJ pUB Sel!J aaBJoqouv ,Lo ,q!lBd!o!un~ aLI1 UJOJI pau!mqo UO!IBLUJOJU! alii uo pasBq 1eql XJpaA JalilJn~ I 'u!eJeq palBo!pu! aJnlonJls jo edX1 pub suJooJpeq ,Lo JeqLunu alii Joj @lBnbape pub leuop, ounj 'a,Les s! uJalsXs Iesods!p Ja~BMelSBM Jo/puB Xlddns JeleM al!s-uo aql ~,eql SMOqS leAoJddv Xlpoliln¥ LilleaH s!ql jo UO!IBa!iSaAU! XUJ leq~ XJpeA I 'MOleq UMOliS alBp UO!lep!le^ aqj ~o se pub oleJeq pax!~e leas XuJ Xq pa!j!lJeo sV NOIJ.¥1NI:IO,-INI aN~' ¥.L~'a 'FIC)UV~S ~!-I1_-I 'SJ.S:~J. 'SNOIJ. O~IclSNI ~9NlalAOMd ItIUl=l ~9NIt:I~;:INI~DNB ~ MUNICIPALITY OF ANCHORAGE (MO~r MUNICIPALITY (DF ANCHORAGE ENVIRONMENTAL .SERVICES DI¥1SIoHEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY '1984 JUI.. 1 ? ]987 RECEIVED WELL DATA Well Classification 264-4720 Legal Description: If A, B, C, D.E.C. Approved (Y/N) Present (Y/N) Total De Static Water Casing Height Above Electrical Wiring in Conduit (Y/N) Separation Distances from Welk 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 Comments Date Completed Cased to Depth of Grouting Yield Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) __; On Adjoining Lots ; joining Lots To Ne To Nearest Se~ on Lot ; Date B. SEPTIC/HOLDING TANK DATA Date Installed ...~,~Z,) Standpipes ~N) Air-tight Caps (~_'~N) Depression over Tank (YN~ 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 ,/~TD Size ./~'~ No. of Compartments ~ Foundation Cleanout (~.~N) Date Last Pumped ~"' ~'"5¢~ /~)//'~ ;for X)/~¢ Temporary Holding Tank Permit (Y/N) Comments To Building Foundation 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 Date Installed ~-.~ 2:3 "~ Width of Field ~" ~ Square Feet of Absorption Area Depression over Field (Y/~')~). 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 Gravel Bed Thickness Standpipes Present C(~¢N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots /~ ~! £ To Cutbank (if present) ~F,''') Comments D. LIFT STATION "-'~ / Dimensions Size in Gallon~"--.~, / Manhole/Access (Y/N) "Pump On" Level at ~'"~-~/~] "Pump Off" Level at High Water Alarm Level at -"'~._ Vent (Y/N) Tested for ~~ Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments Bedroom Rating Against HAA Request ** Check Permitted I certify that I h~¢. ~..e~he~¢ked, vcr~ied, or conformed to all MOA and HAA guidelinesin effect on the date of this inspection." Signed ~/~'-/~'~-- -~ ¢/~ '¢:~ Date ~-/~ Company /~z~d ~ MOA No. ~ 7" ~27~' Receipt No, ~ ~<~) (~) / ~-(___)O / b Date of Payment .,,~ --//'~ ~ Amount: $ ,/ g~ ~ ~ ~ Page 2 of 2 72-026 (11/84) APPLIC ,, FILLS OUT UPPER HAL, ?ONLY Property Owner ~..~-~.x.'~,~'x,~ ~ ~.~.~. ~j.~..~(.~, ~ Phone Mailing Address ~,~-,~'g~ '~!-?/--~. ~L-~-~} ~,&~'~,- ~V Zip Code ~;~'O ~,, Buyer ~'e ~ ~ -~ ~ -~/, Yk~ -J~ ~ ~ Address Zip Code Le,ding Institution ~X'~ ~O(~'~ ~,:~-.k ~¢',~vO~_ c~~kV~ Phone Address ¢~" ~ ~ ~ ~*~;~L i?, - ~ ~ ~ :,~.~ ~,,~%,...)~'~ ~ Zip Code Phone Realty Co. & Agent Address Zip Code Type of Residence ~ Single Family ,~ ~ Multiple Family No. of Bedroo~s: ~ ~ Other Water Supply ~ Individual A~ACH WELL LOG. A w~l Icg is required for all wells drilled since June ]975. ~ Community For wells drilled prior to that date. give well depth (attach Icg if available). ~ Public Utility Sewer Disposal Year Individual Installed: ~ ~ ~ lndividual Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Tittle Time Time Inspector Insp~tor Insp~tor Insp~tor Field Notes: AUG 1 1983 "Municip~Hty 0f "Dept. of ( /APPROVED BEDROOM~ *CONDITIONS OF aPPR~t'0~O~tal Protection" ( ) DISAPPROVED (DAT; CONDITIO~PPR*V~q Soils Rating D~~led~/~ WelIWell TOto TankAbS°rpti°n Area SepticWell LogT~kReceived ~Size 72,023 (3182)