HomeMy WebLinkAboutPTARMIGAN ROOST BLK 2 LT 10Ptarmigan Roost
Lot 10
Block 2
#020-042-78
i~ .AUNICIPALITY OF ANCHORAGE
~ DEPARTMENT OF FIEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL DESCRIPTIQN
~ ,Y~e J No. of compar~mts~ --
Liq,.z~ca ~a~ in gallons inside length Width Liquid depth
~ ~ DISTANCE TO: Well ~elling/ PERMIT NO.
O ~ ~ Manufacturer ..... ~ Material Liquid capacity in gal]ohs
~ i Togof tileto finish r de Material beneath tile
Length Width Depth PERMIT NO.
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
m~~O'~ ~uild~iU(i/~g foundat on ~ ~ ~ ~J~' ~S0~er line~/j Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
INST~LLER ~ ~ /
t
72-013 (Rev. 3/78)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geologicol & GeophysicelSurveys
Drilling Permit No.
OCATION OF WELL (Pleael complete ilther lev lb or lc.) A.D.L. No.
ic.J~OISTANCE AND DIRECTION FROM ROAD INTERSECTIONS ~, OWNER
~2. WELL LOG ~. WELL DEPTH; (flnul) 5. DATE OF COMPLETION
Fief
6clew
Molerlol Type Top Botlom
~ Tilt Well ~ Other:
~ 8. CASING: ~ Threaded ~ Welded
~ Y 9 ~ ' ~ ~ ~ ~V~ diom. in. to__ fl. Depth Stlckup__ ft.
/cod T~v~q t~'- lcd' 9. FINISH OF WELL:
Type: D~amefe~:
Set between ft. end ft.
Backfilling Gravel
Date
~ Above or ~ Below Fend lurfoce
Equipment used:
II. PUMPING LEVEL belo~ land *urfaoe and YIELD
1~5~. ft. ~fter. ~ hr,. pumping I g.p.m.
ft. after hrl. ,pumping g.p.m.
~ I~.GROUTING Will Grouted: ~ Yea ~ No
Moterial: ~ Neat Cement ~ Other:
13. PUMP: (if avoiloble) HP
Length of Drop Pipe ff. ¢apooify ~g.p.m.
~ ~ Subm. ~ Jet ~ Centrifical D-Other
: 14. REMARKS:
~ 16, WATER WELL CONTRACTOR'S CERTIFICATION:
15. W~llr. TeAperoture ~o ~ F ~ C
I t:xl~d I11
DFF'HE ]: SSI.IIED,~
~i) 4-() 7 '7 E~
(~1:1
ADDI ,E,.,m.~.,
541 :L OLD SE':N(~I':'d[) HNY
t56 :L
DE:F'TH T(] P]:I:~E Eft:FI'TOPi (F-"T.) 4.0
[~F,:(.~VI:!L. :[)[i~I::'TH (F'T.) 2,, 0
'I'[:FI'~I_ DIEF::"I'TI (F'I".) 6.0
GI::~(WEL. W:I:D'I'FI (F:T.)
(:)R~VEL L,.ElxlI:'iI'H (F'I".) 125,, 0 .~..~.
GF~(.~VIEI..VOI_UME: (CL.J. YDS.,) 2~2.0
'TAIxII< S I ZIE (FI(/I....S) 1,2',50.0 'x"~'
SO~L.. R~I"IN6 (S[~.Fr'f',. ZBR) 125
¢,"~' 6FRAVIEL,, LEN('%Iq'-I > 75 I:::T,. I:',E.[JJ,TId:'.: [ll,,ll.._l].l LE. I;tUNS (NErI' E,-.L,I::.I::DIII(:¢ F'T,,
· ~'¢',' "I"{~N[< 1'41.J,~f I"]~,'¢v'E ,qT L.E(~ST "I"NC~ COl II ~1~11dEd I/c
I c:l;~r'Lify 'Lh~'t.'.'
d.,, I ,~lll ]'aifl:i. lial- ~i'Lh 'l;,hl;:! r<.~qt_t:i.r'r~mc~n'L~*; for on.-...~it.c* ,a~¢wel"s* and N(~¢].].sl a~ ~a~**'t:.
for'Lh by the Plunic::Lpal:i.'Ly of Ar'icl'aorage (idOl) ar'id t. he~ St. at:.6~ of
2. ~ *~i].]. ir'~;'[a].l '[.1'~*~ ~iiy~rL~ln ir'l ac:c:or, clanc:(~ ~:i.'Lh a:t. 1 PI(]~ code~:i And
3;. I NJ].1 mdhf:>r<:~ 't:.Q all IdC)A ar'id St. at.e of (~:Lmsl<a r'(::H~lz:i, rEHflEH'tt:i ~'or '{LBO J:i(~'l/. I::}ack
dis~'[.ance:~i From any ~xi~:~t. ir:g w~ell, wastewct'Ler dis:~pos~a]. ~y~:,t. em I:)r,
]: t..tl-1¢srJst, aFid 'l:]]a'L 'Lhi~ permi'L is va].id for a maximLim of 4 I]edr, oom~
al'iy or'l:l, al"g(~morY~. ~itl reqt.t:i, rD afl addi'Lional perm:i.L.
THEN (1). fin IEI..IECTF~:I:C¢~I~. F'EF~Mt'I' ~ND INSF:*IECTION I~IIJST ~)E CIEFFfi]:NIED~ (2) ~IS'-.E~IJIL.TS
W]:L.L.. NOT E~E: ~I::'I='I~[)MED M'I'TI..IOUT ~N IEL. IECYTI~IC~L. INSI=,EECTION FdEF'ORT~ Cd,ID C5) TI. fiE
EI...ECTF~ZCAL. MI]RI< MLJ~T Erie DQNE t.)Y fi L. ICI::NEiE~D IELEC]"F~ZCI(.~N.
^~,~- ~f 9->'z Department '- Health and Environmental ~otectipm~ .
z[~ /~).~;~ 825 ~. Street, Anchorage, AK. ~p501~ F~ ~ ,n
~ ~/~ 264-4720 ~ ~ F~-~.
Location: ~ '~ ~>~7~',~Xone Nu~er/: / ¢
'~ ~ , 1~ ~/ '
C;Z t~0n: ~ ~ q ¢~Jt Size
Trench: ~ Drainf'ieid: :eepake Bed://~O:~=~
-- ', ~--~ . , ~,~ ,
The Req~ir~d kine of(th:Soil ~sorption Syste~ Is:
DEPTH /':) LENGTHI &P~ .' GRAV- EL DEPTH & [ WIDTH
· he length dimension is the length(in feet) of the trench or drainfield. The
depth of ~ trench or pit is the dj. stance betwee~ the surface of the gronnd
the bottom of ~he excavation(in feet). There is no sbt width for
· he gz~vel de~th is ~he ~inimnm depth of gr~vel between the ontf~ll ~ipe ~nd
the bottom of the excavation(in feet).
~ ~ REQUIRED SEPTIC(HOLDING) TANK SIZE = GALLONS ~
Permit applicant has the responsibility to inform this department during the
installation inspections of. any wells adjacent to this property and the number
of residences that the well will serve.
T 0(2) NS CT ONS
Backfilling of any syste~ without final in~pe~tio~.a~o,y~{~L~dep~.ht
will be ~bj ect tq pros~)tion. ~ ~ t'~d ~]-'[~z ' .[ n~ _ ~-~ ' ..~[~-~
Mini.mum ~~etwe~n~~%nd~Y~e~s~e('~s~al0~st~'~ ~00 feet
for a private well or 150 to 200 fee¢)from a public well depending upon the type
of public well. Minim~a distance f~bm a private well to a private sewer line
is 25 feet and to a co--unity sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are ~
available to insure proper installation. /[
PERM XPIR S DECEMBER 1 9
I certify that:
(1) I ~ f~iliar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
~)) ~ h~ ~ ~ ~ lo ~ ~ ~ ~ ~ ~ }~ a~x ~tw~t~a~o[~~ ~ eo~ls ~r g~me~~
&- ENG'iNEERS, INC.
7125 OL0 SEWARD HIGHWAY
ANCHORAGE, ALASKA 99502
(907) 349-6561
2
3
5
6
7
8
9
SOIL LOG
PERCOLATION TEST
SOIL LOG
:V/'/PERCOLATiON
TEST
BEDROOMS
JOB NUMBER: ........
SLOPE SITE PLAN
W E
I I
WAS GROUND WATER S
¢ Gross Net Depth to Net
~ ,~ ~,l~eading Date
~, Time Time Water Drop
14--
15--
16--
17
18
19'--
2ot__
DEPTH PERCOLATION RATE ~J/~_AL= (.minutes/inch)
(FEET)
TEST RUN BETWEEN ~! (?__ FT AND ~:::::~," ~ FT
PERFORMED BY: ~. ~N I 5Z~ ....... ~ CERTIFIED BY: / : L D¢TE:
May ~4, 1978
$77340
Mike Carey
406 Pearl Drive
Anchorage, Alaska
99502
SubjGot ~ Pe).~it E}{piration
A permit issued by this depart~,~ent for well and/or on-site
sewer installation oi% Lo~ 10 Blook 2 P%a~mligan Roos~
.~iubdivision has expired sinue ~he issue da~e excseds one(l)
year o
In the event you still plan to install the well and/or
on~osite sewer system, a now peri,lit is required. The original
soil t~st may bet u'ae(l to obtain a ourrent permit°
If the well has been drilled,, a well log should be sent
to this department to document the installation date.
If you have any questions re~%arding tho above matter~ please
contact this office ~'h~mediately at 264.-4720o
8incer~ly~
Les ~. Bu¢~hholz,
Senior Envirenmental Specialist
LNB/1 j h
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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
020_042_78 HAA
GENERAL INFORMATION
Complete legal description
Lot 10; Block 2; Ptarmigan Roost
Location (site address or directions)
Property owner
Mailing address
16240 Sandpiper Drive
Anchoraqe, AK
Conrad & Cheryl Perry Dayphone
16240 Sandpiper Drive Anchorage, AK
345-9679
99516
Lending agency
Mailing address
Day phone
Agent Donna Orr/ Prudential Jack White
Address
Day 3hone_ 762-31 21
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
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.
'f'YPE OF WASTEWATFR DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTF:
xx
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72~O25 (Rev. 1/91) Front MOA
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, funotional 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 dispo,s¢l s,yste,rp/s m~compliance with all Municipal and State codes,
aS a a~' .
lations in e-~cSt~gn%~edrat~ of/~h/ kspection.
__ Phone ~-27-~/"7¢
ordinances, and regulations in
Name of Firm
Address
Engineer's signature
Wastewater Consultont~ Inc,
Shall be PA D $ 2~
or prior to, clpsing for the
Engineering Sentices Provided.
6, DHHS ,SIGNATURE
k'~ Approved for
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By: j /~" -- ~--- Date -
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) ~ck MOA ~r21
Municipality of Anchorage
DEPARTMENT OF HEALTH & IflUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
A. WE;LL DATA
Well type __ PR.!VATE
Log present (Y/N)
Total depth 1 BO'
Sanitary seal (Y/N)
Health Authority Approval Checldist
PTARMIGAN ROOST: LOT 10. BLOCK 2 Parcel I.D.:
If A, B, or C, attach ADEC letter. ADEC water system number
020-042-71]
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform n ,'~ o/o~ /oo~
Date of sample: _ 12,/--tS/99--~9~12,r~ ! /99----
S. SEPTIC/HOLDING TANK DATA
Date installed 18/1 ¢~/R4 Tank size 1250
Foundation Ce~,n0ut (Y/N)
Date of Pumping_' 12/3/99
C. A B SOR~TION' FI FI. Di)ATA
YFR [)ate completed
Cased to 32' (To BEOROCK)
YES
FROM WFLL LOG
17'
1.0 g.p.m,
1
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
9/23/99
23'
N/A
YES
2,67 g.p.m.
WELL WAS CHLORINATED AND FLUSHE[) PRIOR TO RESTEST
Nitrate ,~ ~.~ mo/I Other bacteria 0 (12/21/99)__
Collected by: A.W.W.C., INC,
Number of Compartments __
YES __ Depression (Y/N) NO High water alarm (Y/N)
_ Pumper A+ HOblE SERVICES
BO'FrOM OF SUMP IS 15.5" BELOW DRAINPIPE INVERT
2 Cleanouts (Y/N). YES
N/A
Date insta~fle'd :1t3/16/1~. Sail rating (g.p.d./fF or fF/bdrm) 125 System type TRENCH
Length. ~ Width. 5' Gravel thickness below pipe 1' _ Total depth 4'-5'
Effective absorption area_SOO SO_E[_ Monitoring Tube present (Y/N) YES Depression over field (Y/N)
Date of adequacy test _ 12_/3_/~9___ Results (Pass/Fail) PASS For 4.
Fluid depth in absorption field before test (in.); 2"
Fluid depth _ 7" (ins) Minutes later: 900
Peroxide treatment (past 12 months) (Y/N)
Immediately after 790 gal. water added (in.):
Absorption rate = 600+ .g.p.d.
If yes, give date 10/7/99
NO
bedrooms
11,5"
72-026 (Rev. 3/96)*
D. LIFT STATION ~
Date installed Size in ga
Manhole/Access (Y/N) ~at* "Pump off" level at*
High water alarm level at*~...-.----'""~ *Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
100'+ On adjacent lots
100'+
Absorption field on lot
100'+ On adjacent lots 100'+
Public sewer main N/A
Public sewer manhole/cleanout N/A
Sewer/septic service line
25'+ Lift station N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 5'+ Property line 5% Absorption field 5'+
Water main/service line 10'+ Surface water/drainage 100'+ Wells on adjacent lots
100%
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ _ Building foundation_ 10' Water main/service line 10'+
Surface water 100'+ Driveway, parking/vehicle storage area 10%
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
eld inspections
'nes in effect on this date.
F, ENGINEER'S CERTIFICATION
,nconforma¢cew
Signature
Engineer's Nam~
Date
JEFFREY A, CARNESS
HAA Fee $.
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
ALASKA WATER & WASTE, WATER CONSULTANTS, INC.
69D1 DEflARR ROAD, SUITE 2B * ANCHORAGE, ALASKA 99504 * PHONE: 337-6179 FAX: 338-3246
SEPTT_C ADEQUACY TEST DATA
.EGAL DESCRIPTION:JO~~r~''~t ~:~:~c)r~.; L~'~' ~.,
STREET ADDRESS: I~A~O u~K4~J
CLIENT: ~"~Ar,,~2 ~e.¢f'V " . PHONE NUMBER:--~'~&'~./~7~.
/
NUMBER OF BEDROOMS ~-~
'rEST DATE START I~L3/~¢/ . TEST DATE END_J..~/~Jq~. __
SEPTIC TANK SIZE:_~gD LIFT STATION YES / NO ~'~-~
DATE: Of PUMPING:'!a/3/~ PUMPER:.
SYSTEM TYPE: ,
DEPRESSIONS: YES / NO
WHERE ALL STANDPIPES FOUND THAT__'
WHERE ALE W~TER TIGHT ~APS
ARE ON THE INSPECTION REPORT? ~)/ NO
If NO, WHICH ONE/S?_
METER GALLONS SEPTIC TANK MONITORING TUBE AMONITOEING TUBE
TIME READING ADDED LIQUID LEVEL LIQUID LEVEL LIOUID LEVEL
~',oo ~gm~ 47/7 I
5:sq - 53"
, ~;~ ;lqo2~ ~1/ 7~
-- 5U'
tESULTS: ~PASSED: GOO+ ~ FAILED:_
COMMENTS:_
Sent By: HP LaserJet 3100; JetSu±te; 8ep-20-99 12:0@PM; Page 1/1
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
1. GENERAL INFORMATION
Complete legal description
Lot 10; Block 2; Ptarmiqan Roost Subdivision;
Location (site address or directions) 16240 Sandpiper Drive
Property owner
Mailing address
Lending agency
Mailing address
Steve Howell
Day phone
Elk Grove, Ca~fornia
Day phone
Agent Jan Pennington RE/MAX PROPERTIES Day phone
Address 2600 Cordova St. #101 Anchorage, Alaska 99503
276-2761
2, NUMBER OF BEDROOMS:
3, TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
4
NOTE:
Individual well XX
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site X×
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72*025 (Rev. 1/91) Front MOA #21
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Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Welltype ~¢-~'J~1~¢,.- IfA, B, orC, attach ADEC letter. ADEC water system number
Log present (~N) X/ Date completed t ~ - "Z-'~'-' -E~ ~ Driller '~, ~,
Totaldepth \ ~>~' ~ Casedto '~'~/~ ~,~ . Casing height
Sanitary seal ~/~) ',/ Wires properly protected
FROM WELL LOG AT INSPECTION
Static water level ["~
Pump level I ~.~'~ ' t.'~ ~
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot /°c:>
Absorption field on lot ~06;~'4-
Public sewer main ~Jb,
Public sewer service line ¢'IA,
z~o
ParcelI.D.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Nitrate
Date of sample: I "~ ¢ 7.. ¢c) I
Collected by:
B. SEPTIC/HOLDING TANK DATA
Other bacteria
S & S ENGINEERING
17034 Eagle River Loop Roa~ No. 204
Eagle River, Alaska 99577
Date installed
Cleanouts~;~N)
High water alarm (Y~I~
Date of pumping
Tank size / "~'~ c> Compartments
Foundation cleanout (~/N) ~ Depression (Y~)
Alarm tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~¢d.~ ~-V- On adjacent lots
To property line [ ~ Absorption field
Surface water/drainage
Foundation ~'
Water main/service Pine
72-026 (Rev. 3/91)Front MOA21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
M.t MOA
SEPARATI~NdD~STANCE FROM LIFT STATION TO:
W-el'l on lot On adjacent Pots
Manufacturer
Manhole/Access (Y/N)
"Pump on" level at ~ "Pump off" level at
Cycles tested
Surface water
D, ABSORPTION FIELD DATA
Gravel thickness __J~ ~O
~ Cleanouts present'r/N) _
Date of adequacy test
~Z-~{o k/.d' If yes, give date
Date installed
Length ~ I Width ~* /
Total absorption area ~-'~:::;~ ¢
Depression over field (Y~ /"/
Resultsd~/fail) ~/N~S
Peroxide treatment (past 12 months) (Y~_/~ ~/'z' '~/¢~-
Soil rating I'?-'~' ~/.,¢~- System type 'DC.cci
Total depth
12- - Z ~/
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot [cz::, t ~
To building foundation
On adjacent lots__ ~ I ,~
Surface water ~ ,Cc, ~ 4'~
Curtain drain ~1,~
On adjacent lots [ c~,¢'~ ~ 4- . Property line
To existing or abandoned system on lot
Cutbank____ ~'f¢~ .Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect
date of this inspection.
2 & 5 ENGINEERING
Signature ,. ,~:~.,~ ~aBla River Loop
:.,. :. ~,.,er, Alaska 9957~
Engineer's Name
Date ~ ~ ~1
HAA Fee $ ~/7~)'
Date of Payment /
Receipt Number ~_~,~, ,~/('~/
Waiver Fee: $
Date of Payrnent
Receipt Number
72-028 (Rev. 3/91) Back MOA 21
CLOOK
lIME
7034
ROBER1'A,$HAFER
CIVIL£NoINEER
ELAPSED TIME 81NOE
PUMPING 8TARI'EDI DEPTH TO
81'OPPED~ MIN. WATER, FT.
DRAWDOWNI PUMPINO
FIECOVERY ItA1,F-, OPM ~EUARK~
0
!
10
40
E0 II houri
gO
0 O
E40 [i hOur~)
~ECOV£RY
0
8
$$
0
Comments: %,,~-,c.,~ ~C>OC~_~--~ '~?-~ c~.~V~ FlowisnotG
~'0~ ~ ~ ~.~.~/~ ~,~c~/~ ~/~/~.,--~ (~ SubsequentVariafions
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
2§4-4720
App,,cat,on Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
A licant Name ~'~' ~¢-](~/ Teephone' Home!'/¢--'?¢~-¢ Business ~'~ "~)¢
(b) pp - ' , ..... - · -
(c) Applicant is (check one): Lending Institution ~; Owner/builder~'; Buyer ~; Other ~ (explain);
(d) Lending Institution L:,~.'~'~_~¢-"~c~
(e) Real Estate Company and Agent
Telephone
Address
(f)
Telephone
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-FamilyJ~ Multi-Family
Number of Bedrooms
Other
WATER SUPPLY
Individual Well[~ Community
Public
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. 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.
72-025 (11/84)
Page 1 of 2
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DA rA AND INFORI~IATION
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 flies 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 Oh
the date of this inspection.
Telephone
Name of Firrr~.~,~ S
Address $ ~'~-,
Date Esrj!e ~iver,/~[asb~ 9¢57~
Approved for ~b~',~¢~. _~ bedrooms by
Approved ~"~'~' Disapproved _ _ Conditional
Date
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Pa(3e 2 of 2
WELL DATA
_ ... ~HC~MICIPALITY OF ANCHORAGE (MOA)
~UN~CIpAL~TY ur
L'TH
I)~PT. OF B~A ~ H AUTHOHITY APPROVAL (HAA)
i~NVIRONM~,NTAL pROT~'--~HECKLIST - F~:BRUARY 1984
Legal Description:
Well Classification
Well Log Present~/N)
Total Depth ~, ~-¢~'~
Static Water Level
If A, B, C, D,E.C. Approved (Y/N)
Date Completed ~¢3 . ~..~ ¢ ~z/L. Yield
.._ Cased to'~, ~4r "~ Depth of Grouting
~,"f ~ Pump Set At
Casing Height Above Ground
Electrical Wiring in Conduit CN)
Separation Distances from Well:
To Septic/Nek:ffng Tank on Lot
Sanitary Seal on Casing(.~/N)
Depression Around Wellhead (Y/~
~ ~-~ ¢ ~ ~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot [ ~ ~ 4- ; On Adjoining Lots [ ~.~c2
To Nearest Public Sewer Line ¢4//~ To Nearest Public Sewer
C[eanout/Manhole r,~/¢~ To Nearest Sewer Service Line on Lot
Water Sample Collected by ~ ~, ~ ¢:~,~¢~.¢.~4 ,~JG ; Date t~. - ~ * ~'
Water Sample Test R.esults
Comments '¢ 4~-¢¢¢-~ ~,~lq~
B. SEPTIC/H~LD|,~G TANK DATA
Date Installed \d::>- ~. L~-~ ~_ Size ~"Z.~ ¢
Standpipes~N) Air-tight Caps C/N)
Depression over Tank (Y/~)
Pumping/Maintenance Contract on File (Y/N}
/
Holding Tank High-Water Alarm (Y/N) ~z~'
Separation Distances from Septic/Nold=,ng--Tank:
To Water-Supply Well _
To Property Line
To Water Main/Service Line
Course
Comments
CbC t'Z..- ~ -~S' ·
No. of Compartments ~
Foundation Cleanout CN)
Date L~ast Pumped
· ¢.5/~, ;for '-
Temporary Holding Tank Permit (Y/N)
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 _ ~- ~L~- '~--(-'
Width of Field
Square Feet of Absorption Area
Depression over Field (Y4CP
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well \ ~,~'
~_'7~'~P I¢~0-~- Type of System Design
Length of Field
t
Depth of Field
Gravel Bed Thickness
Stgndpipes Present ~/N)
D~te of Last Adequacy Test
To Bud ng Foundation
Lot
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To (~utbank (if present) '~--~:~
To Water Main/Service Line ~ .'o ~P¢
To Stream/Pond/Lake/or Major Drainage Course
'To Driveway, Parking Area. or Vehicle Storage Area
Comments
D. LIFT STATION
Date installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
-rested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
__ "Pump Off" Level at
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom 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 '~ & 5 Engleeerin~l Date _ /~. ~ 1 ~,~ ~'""
Company
Receipt No.
Date of Payment /~ ~/~-~&-
Amount: $
Page 2 of 2
72-026(11/84)