HomeMy WebLinkAboutOUR MOUNTAIN BLK 1 LT 3Our IVlountain Lot 3 Block 1 #051-111-42 IVIUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH& ENVIRONMEN'iALPROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 2_64-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME MAILING A D./I~ R ESS LEGAL DESCRIPTION LOCATION r~ t~ IAbsorption area __¢ ¢ Dwelling ,~/w'//~-~ /~ ~/( [ Material ~ Liq. cyaSy~n ~llons IF HOMEMADE: Inside length 'Width DISTANCE TO: Iwell Dwefiin9 Ne. OF BEDROOMS PERMIT NO. No, of compartm~.~ Liquid depth PERMIT NO. Manufacture~ Material Liquid capacity in gallons DISTANCE TO: Foundation~:.~ g/, I Nearest lot lil~.~ ! PERMIT NO, Total len~no~ We, // ? / No. of lines // Length of~ne ~ Top of tile to finish grade ~__ ~ Material beneath tile Length Width Depth PERMIT NO, Type of crib Crib diameter Crib depth Well Building foundation Driller Depth DISTANCE TO: DISTANCE TO: Building foundation Sewer line Distance between lines Total effective absorption area tTotal effective absorption area Nearest lot line Distance to lot line PERMIT NO. OTHER PIPE MATERIALS ///~ ..,,~ _~ ,~.. REMARKS DATE LEGAL 0 0 0 0 0 0 0 0 0 0 0 0 ~_ ~ ~ E~. ,~ ~_ ~ ~ ~. ~) ~ 0 0 0 0 0 0 0 0 0 0 FI F' F' L I C: F:Ii"4 T LC)I:::FIT ]: ON I... E G I::'1L. L"E:F'FIFCTME:NT ~: HEFI!...TH FIND EI",I',,,' I F'.ONHENTFII 3TECT I O1'.,I S;2.~5 '" [.. '" S'I"[~:EET., FINC:HOI:;.'.FICi[E., FtI-:::. 'S, 9)!SEI'LI. ;2 6,4.-- d. 7'2,'...3 .%::;; E~.: I~?.1~ EE: If:~: If::" Eiii:: IF;Z: If'.'if % '-~ .... "1" E: E:, H ! S;:5 1 G I'"tFI[~:I.::: E:,I:;i: Z ',,,'E L.EIT :~: BL.K Z OUR MT. L. OT SIZE ,::il:!.SE;C:~ SL';]I.JFtI:~tE: FEE~r' 'r'T'PE OF SO I L. FIE:SEIF'.F'T :1:O1'.,1 S.';'T'S;TE:H I :E;: TF.:ENCH HI::I',:'=:IMI...I;r'I NLIME~E.:.Fi: OF E:E[:'ROOH~; = SOIL. RFFrlNG ,:: ,'S, i:;! F'T,.."DR:: THE F;:EC!I...I ]~ F:ED S; J Z.F.'. OF 'T'I--IE L:.;O I L. FIEL'.5Of~:F'T ~ Eilq S'T"Z';TEH ]: :S: THE: LENGTH E:, I I'"IEI'.,IS; I Oi'.,l I S; THE [...E:I'.,IGTH ,:; 11'4 F:'EET ::, OF' THE "I"f~:ENCH OR [:,RFI I I'.,IF' I El_.[;,. THE DEF'TN OF R TF4:EI'.,IE:H OF: F'IT I~; THE E:,ISTFINCE BETI,.tEEI'-,I THE SLIRFFtC:E OF' THE: GF'.OLINE:, FIND THE: BE)TTOH OF THE EMCFI',,,'FIT]:Cd'.,I ,:: IN FEET::,. TPIEF:E: I:5 NO SET HiDTH FOR 'TREI'.,ICFIES. THE GRFI',,,'EL E:,EF'TH IS; THE: I"IINIHIJH B, EF'TFI OF GRFI',,,'EL BETHEEN THE OLITFFIL. L. F'IF'E FIND THE BOTTE)H ElF THE E'XCFIVFIT I O1'.,I ,:: :[ N FEET .'.',. F:'[!~:[;i:I',t I 'T FIF'PL :1: C:I::INT HI::IS; THE I:;~'.E:SI::'OI'.,IrB I D I L Z T'¢ 'rE, I I'.,tFOF4:H ']"FI I 'Z-'; DEF'FI~'.'I"HEi'.,tT I)UF-.". 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E:,IEF'EN[>ING UI::'ON THE T'T'F'E Cfi:' F'I..IE:LIE: HELL HIt",IIMLfH E:, ]i :i!;I"FINCE F'Fi:OM FI F'RI',,,'FITE P.IEL.L TO FI F'IE:I',,,'FITE E;EP.I[.T.R LINE I'S; 2!5 F'EE'f' Fli'.,ll.":, TO Fi COMHUNIT'T' :SEI.,.!ER LINE ]::E; 7!5 FEET. CFt"HE..'R I~'E'..:~ IF.':EHENTS; I"1F1'¢ FIF'F'L.'T'. S;F'EC]:F]:CFIUFIOI'.4'..:.:. F:Ii'.4E:, COi'.,I'~STF~'.I..ICTICd'-,! E:, ]i FIGf4:F:II','I:S I:I[;i:E:: FI',,,'FI ]: L. FI[.:~LE TO f I'.,ISI_I[;:E F'F4:OF'ER I NtSTFtLLFt'F T FII'.,I. I E:EF:T I F'"r' THFIT ::L: I Rf,1 FFIM :[ L I FIR I.,.1:[ TH THE REQIJ I F:E:I"'IEI'.,IT:E; F'OF..: OIq-S I TE SEI.,.IEF:S F:INE:, I,.IEI....I...S FE5 SET F'CII:;i:TH E','T' THE HUI'.,IIC:IF'FILIT'¢ OF FINCHORFIGE. ;.:.i'.: I I.,.IIL. L IN:'STFILL THE S"r'S'FEH IN FICCCff~:E:,FINCE H:[TH THE CODE::L:;. :7;: I UI'.,IE:,EF.'.':STFII'.~D THFFI" THE CR.,I-5IT[.:: 'r-.,EI,.IER S"r'STEM HWT' t:i:EL::.'UI[;;'.E EN[..FIF.:GE:ME:NT :IF THE r~:E'.S l DEIqC:E I ~ RE:I',IO[::,ELEI:::, TO ]: t'.,ICLUE~ HOF.:E "EHFd'.,I ~: ..................... ....................... :: .... ,,,, O&E ENG,NEERING & DEVELOr ,,4EN'F CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 hu~aell Oyster 694-2774 F'erformed for: Name:_ f/~ f Mailing Address: '~-"~'¢~' Legal Description: ~'-¢;,r- '~-; ~_~,~./c-_ // SOIL LOG Earl Ellis 688-2280 Depth (feet) 0 Soil Characteristics 5__ 6__ 7__ 9__ 14__ 16 Ground Water Encountered: Yes Proposed Installation: Seepage Pit__ No ~/'~' If yes, what depth. Drain Field PLOT PLAN PERC. TEST Comments: Performed b:~'~ 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 liD: '~2~'/'-////-,¢¢~- ,. GE.E. :L . ORMAT,O. Complete legal description Lot 3, ' Location (site address or directions) Current Property owner(s) Mailin~ ~dress HAA# ~::~(~1("~-~ Expiration Date: Block 1, Our Mountain S/D 20527 Mark Circle Nieves Miljure Day phone Lending agency Day phone Mailing address Real Estate AgentBAcky Powell/Remax Day phone 276-2761 MailingAddress2600 Cordova, Ste 100, Anchorage, Ak 99503 Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: 3 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 ~alid 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. 72-025 (Rev. 01/00)* 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 & S ENGINEERING 17034 Eagle River Loop Road No. 204 Phone Engineer's Printed Name DHHS SIGNATURE ~ Approved for ~ bedrooms. Disapproved. Conditional approval for __ ~"~.0 L'J/~/'J Date '3 / ~ Q_.~. o ¢ ~ ........ ~,.~,.,,~.,,,:,..,,~, "O"ERT C. COWAN . bedrooms, with the following sti~ulations. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: ~ - ~/_../z. ¢ 0 Original Certificate Date: Reissue Date: 75-025 (Rev. 01/00)' A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal 0/N) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVIC~[ (.. L I V [~ [J Environmental Services Division 825 L Street, Room 502° Anchorage, Alaska 99501° (90~/~3~z07~00 Health Authority Approval Checklistr,~ur~c,~^u~ or IfA, B, or C, attach ADEC letter. ADEC water system number Cased to Casirig height (above ground) Wires properly proteetec~) FROM WELL LOG Date of test ~/~-~'/,/~'~ Static water level ~,~' Well production ~ g.p.m. AT INSPECTION g.p.m. WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: B. SEPTIC/HOLDING TANK DATA (¢]¢ ~ ~)~;;:~ Other bacteria Collected by: ! Date installed ~/~/ Tank size Number of Compartments ~ Cleanouts ,~N) Foundationcleanout ~,J).?;f~--'~/ , Depression(Y/d ~(/'(') High water alarm (Y/N) ,,/~//,/~ ,W , .- i Date of Pumping ~/J~'/¢/'~ Pumper ..J?~ 5' / C. ABSORPTION FIELD DATA Date installed ~'/,,~/ Soil rating (g.p.d./ft2 o~ ~b~ ~ System t y p e '"~- ~'~-/~ Length ~ / Width ///~/~- Gravelthickness below pipe /('~ /Total depth // / Effective absorption area z~ /~ Monitoring Tube presen~/N)~'~ Depression over field (Y~/(/'O Date of adequacy test ,'~//~/~,~rT.j Results~Fail)/,,/~,5' For '~"'/2/~--'~'~ bedrooms Fluid depth in absorption field before test (in,); .~- Immediately afte'~¢'//7) gal, water added (in.): ? // Fluiddepth '~ (ins) Minutes later: /~ Absorption rate = 4,~/0 "'~g,p.d. Peroxide treatment (past 12 months)(Y/N)/(~('-'/~/~'~(//"~/ If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed ,// Manhole/Access (Y/N) ~,~ High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot On adjacent lots On adjacent lots Public sewer main /'~,//.,/~ Sewer/septic service line ~-/''/~ Lift station A,,/ //¢J' / SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation //(-,~ ~ Property line ;~/'~ Absorption field Water main/service line .~ '¢~ Surface water/drainage /~,~/ ~ Wails on adjacent lots Public sewer manhole/cleaeout ,/~//~r SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /~.) ~'¢'- Building foundation /~) /'¢- Water main/service line Surface water / ~'7) / '¢- Driveway, parking/vehicle storage area Curtain drain /N/ O/~/~- /~-"~/~/"~/~/,/1,/ Wells on adjacent lots /) ~ 0 F. ENGINEER'S CERTIFICATION I certify that l have determined thru field inspections and review of Municipal record.~.~¢~t~Jl~'~b~¢,tems are in conformance with.MO~ H4A..~ideline, c,in effect on this date, Signature ~ Engineer's Name ~,3~;- ~. ~o~ Date ~/~o/¢o . __,?...:, .~,,,.,,-¢- Receipt Number ~/'~ ~) ~,) .,L Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* ~2-23'00 16:05 FROM'CTE ENVIRONM~NTAL zt~.~ CT&E Environmental Servicee Inc. T-??B P.02/0~ CT&£ Ref.# Client Name Project Name/~ Client Scruple Matrix Ordered By PWSID Sample Remarks: 1001131001 S & S E~gineerhag L3; B1; O~ Mm L3; BI; Our Mm S/D Dnnking Wa~er 0 Client PO~ Printed Date/Time 03/23/2000 13:54 Collected Date/Time 03/19/2000 11:15 Received Date/Time 03/20/2000 10:30 Technical Director Stephen C. Ede Release~ ~~// ~ATERe DEPT PQL units Heth~ Atto.aWe Prep AnaLy$i~ LimiTS On:e Dn:e Init 0.608 O.SO0 mO/L EPA 300.0 (~10) 0~/20/00 S% HICRO LAB Tota~ CoLiform 0 cot/lOOmL SH18 9222B KaP MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D.# ~....~ \ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property owner Mailing Address '7~; (' ('~ (c) Lending Institution AL/~- Mailing Address _/t,./ /,~9 (d) Real Estate Company and Agent Address Telephone: (home) Telephone_ Business ~-----7/-~: .-d- <~ -- (e) Telephone~._~ ~. '~ '- /('.?~ ~- Mail the HAA to the following address: (or check here I~, :'if hold for pick up.) List contact person and day phone number below: TYPE OF RESIDENCE Single-Family~ Number of bedrooms --% WATER SUPPLY Individual Wel~"-- Community [] Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. SEWAGE DISPOSAL On-sit 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. 72-025 (Rev 7/88) Page 1 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 Address Date Engineer's Seal 6. DHHS APPROVAL ~ .'* ~" Approved for o2 bedrooms by,~,~-,'?,__//~ ~///~/~-;?, -,.¢~<~-- Date Approved ~/~ Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 DHHSdo not conduct inspections or analyze data before a certificate is issued. The MunicipalityofAnchorage is not responsibleforerrorsoromissions in the professional engineer's work. 72-025 (Rev 7/88)Back Page 2 of 2 A. WELL DATA Well Classification MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: Well Log Present (Y/N) , Date Completed Total Depth ~.~' Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Y SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot / (~_%.) ~ ..fo. To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line /~/,//ti. To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results If A, B, C, D.E.C. Approved (Y/N) __ Yield ~-'~) ,.. Pump Set At ;%'~/~ ' Sanitary Seal on Casing (Y/N) ~ Depression Around Wellhead (Y/N) ; On Adjoining Lots ~i~o ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole .~/~/_E_~' ,' ; Date ~/d;/~' Comments SEPTIC/HOLDING TANK D~¢~A ate ,nsta,,ed ¢ / /~0C-2(2~-',[ No, of Compartments Standpipes (Y/N) Y Air-tight Caps (Y/N) __~' Foundation Cleanout (Y/N) .~/ Depression over Tank (Y/N) /~J Date Last Pumped. ~// Pumping/Maintenance Contact on File (Y/N) /~//~ ;for /~// Holding Tank High-Water Alarm (Y/N) k(//~ Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Building Foundation 'Fo Disposal Field -7 · -/ To Water-Supply Well To Property Line '~© To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA .,.-- 7 /i~,~i/r~.' Soils Bating Jn Absorption Strata ~.g 5'f '/~f- Type of System Design ~ .c / Date Installed ~"/~-- ~-,~'~/)/ ~,~) Length of Field Width of Field ~-~ ~ ~ Depth of Field Gravel Bed Thickness /© ~ .... Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well :~ / To Building Foundation Lot h,,/ To Water Main/Service Line ~) To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line ~¢C) ' To Existing or Abandoned System on ; On Adjoining Lots -~ ':¢-© ~ To Cutback (if present) Comments Date Installed N Size in Gallons "Pump On" Level at Alarm Level at High Water Tested for Meets MOA Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) Comments "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitt'e,.~'~ Bedroom~ating Against HAA Request** I certify that I h,~ye checke¢~_vedCied, or conformed to all MOA and inspection. /// ~. /' ~ ~ Signed ~/~'~// ~ - Receipt No. ~/4~/,,~ Date of Payment Amount: $ 72-026 IRev 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 ~in effect on the date of this Engineer's Seal CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE(907) 562-2343 FEDERAL TAX ID # 92-0040440 !,r, boratory Supel;'~lsm :,S?};?lfflI C. ?',DE MUNICIPALITY OF ANCHOFIAGE t' .,-_!'AP, ~IWEN'I OF HEALTH AND ENVIRONMENTAL PROTEC'I'~ON DIVISION OF FNVIRONMENTAL HEALTH (~,:~ ! IF!CA rE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 4/9/86 :,-~-. A- INFOFIMATION I_egal Description (include lot, block, subdivision, section, township, range) ,;'7 ,,;:', ()Z~,z _~/~) LoZ 7A~z~ (3) Ou~ Rou~Z~.Ln Locahon (address or directions) (b) ikppl~cantNall~e~z:~zb~. .?r~m./r'/v~Telephone:Home Applicant Address P, ~oz ~71~22 (c) Applicant is (check one): Lending Institution ~; Owner/builder~; Buyer ~ · Other ~ (exp[ n~; _. ;10 (d) Lending Institution Address _L(ZD~__ ¢~ r/. ZL.L_/2~.~/, o ~. (e) Real Estate Company'and Agent ~o~_ Address ~l r, ~ Telephone ~1o ~ (f) Telephone 272- 1 99508 Mail the HAA to the following address: ~.Z,~ 6xS-_~Y~Z~ (,,_~_,) 522-1212 TYPE OF RESIDENCE Single-Family[] Multi-Family [] Other Number of Bedrooms 7/z/t~z¢. ( J ) WATER SUPPLY Individual Well E~¥ 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, SEWAGE DISPOSAL 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 I of 2 72-025(ll/84) ~ -~,~V~i)li"~O NSPECI OhS, ~'ES'IS, FILE SEARCH, DA'IAANL~INFOttMAIION h :~'}d helelo al~d as of the validation date shown below, I verify that my investigation of this I-lealH1 that the on-site water supply and/or wastewater disposal syslem is sale, functional and adequate ~s and type of structure indicated herein. I further verity that based on the information Anchorage files and lrom my investigation and inspection, the on-site water supply and/or system is m compliance with all Municipal and State codes, ordinances, and regulations in effect on I.~AGLBgI~LBB,-A~ 99577 _. P, 0. BOX 773294 694-5195 " Approved for ~.~/',L,~?~_ bedrooms by ..... -~x~ te Approved ','~k~''~ Disapproved Conditional lerms 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 HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 MUNICIPALITY OF ANCHORAG2 DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION Legal Description: WELL DATA Well Classification ,/Cg~,~ / /./'~// ,~-/./~.~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) /v' Date Completed_~-~/~--';-/°¢~q-- . Yield '-~ Total Depth '~'~'//%'~ z~¢ Cased to/'z/~' / D~pth of Grouting Casing Height Above Ground Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot /¢)¢' / To Nearest Edge of Absorption Field on Lot //,F' / To Nearest Public Sewer Line Cleanout/Manhole /¢/~J To Nearest Sewer Service Line on Lot ¢'~ ~- / Water Sample Collected by ~)' 4 ~ ~-,,~.:~/,~,~'¢ r,~.1 ; Date Water Sample Test Results ....~, ¢,..~r ~ Depression Around Wellhead (Y/N) ~/// ; On Adjoining Lots ¢'/¢)¢* ~ ; On Adjoining Lots ~'/'¢¢ / To Nearest Public Sewer B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) _/F Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) //'b// Separation Distances from Septic/Holding Tank: To Water-Supply Well /~¢2" To Property Line Z/..~- / To Water Main/Service Line ¢/,,~ '" Course ~' ~" ¢) / Size /~¢'¢ ~.4~,/ No. of Compartments ~ Air-tight Caps (Y/N) ~/t,' Foundation Cleanout (Y/N) /V Date Last Pumped '~/,~.//¢?'~'~ ii' I ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test ,fi'* ¢'j ~ ,~ Separation Distance from Absorption Field: To Water-Supply Well //P ' To Building Foundation /¢¢' / Lot /¢,/~,,-2 ~_ 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 (Y/N) Date of Last Adequacy Test To Property Line ',~-2.~ / To Existing or Abandoned System on ; On Adjoining Lots '/-'2.~ / To Cutbank (if present) Comments LIFT STATIO N,,¢/,~ 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 Bedroon~ Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~-'~2"~~ Date Company .~/'~'~',~-,¢¢-,$, MOA No. .... Receipt No. Date of Payment : ~ .~ ~ ~, .: , . . :~; .~'/'e?~;,'~:'?,~ /:}:: '~"' ~ 'Engineer's Seal Amount: $. Page 2 of 2 DA'I' ~'"~"'~ C E I V E D INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE ~,,, DATE MUNICIPALI'[Y OF ANCHORAG~ MUNICIPALITY OF ANCHORAGE DEPT. OF I!FAL]'II &  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~viRONMENTAL i'hO~ECTION 825 L Street - Anchorage, Alaska 99501 ,z 1981 ENVIRONMENTAL SANITATION DIVISION -)b'~" Telephone 264-4720 ..o .ST .o.A...OVA. o. DIRECTIONS'. Complete all parts oe page 1, Incomplete requests will not be processed, Please allow ten (10) days for processing, 1, PROPERTY OWN~ /' ~ .~' ' I PROPERTY RESIDENT (If different trom auo~ . ' ' ~ ' ~ PHONE 2, BUYE~ ~ PHONE MAILING ADDRESS -- / ~/ / / 3. LENDING I~ST)TUTIO~- ~ ~ ,~ ~ ', ' / , MAILINGADDRE~) .~ ~ _ ~ / / 4.MAiREALTOR/AGENTLi NG ADDR E~ ~/'~ ~~ I PHONE' 5. LEGAL DESCRIPTION STREET L C TION . 6. TYPE OF RESIDENCE  S INGLE FAMILY [] MULTIPLE FAMILY i~U M'~B E R/R"~ F ~B E D R O O MS [] One I--~ Four [] Other [] Two [] Five .~,, Three E] Six 7. WATE~ BUPPLY ~ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTILITY depth (attach log if available,) 8. SEWAGE DISPOSAL SYSTEM [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS  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 [] INDIVI DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified. INSTALLER []Septic Tank or [] Holding Tank Size: /(~)C) If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER~~ TOTAL ABSORPTION AREA MATERIAL Septic/Holding Tank [Absorption Area ISewer Line I Nearest Lot Line 4, DISTANCES / I WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS / / _. BEDROOMS )e~ [~] CONDITIONAL APPROVAL (letter must ac~/~mp.n¥