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Home My WebLink AboutNORTON PARK #2 BLK 4 LT 7No ton Pa k #2 Lot 7 Block 4 #016-211-57 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. (907) 243h2282 KEN JOHNSON KEN'S COMPANY WATER WELL DRILLING PUMP SALES & SERVICE 30 YEARS ALASKA DRILLING 3163 LINDEN DRIVE ANCHORAGE, ALASKA 99502 OCTOBER 11, 1985 DON DEARMOUN 13140 SPECKING AVE, ANCHORAGE, ALASKA 99516 ( 562-?653 ) ( HM 345-4506 ) REs LOT ? BLK 4 NORTON PA_RK SUBD. ( 32~ 123rd ) ~ATER ~ELL LOG 0 £t to 8 ft 8 ft to 11 ft 11 ft to 18 ft 18 ft to 22 ft 22 ft to 33 ft 33 ft to 34 ft 34 ft to 40 ft 40 ft to 44 ft 44 ft to 48 ft 48 ft to 58 ft 58 ft TOTAL CASING 60 Ft. Brown silt with some course gravel Course gray with some brown silt Course gray & gray silt Same with courser grav( tight ) Same with cobbles Course grav& gray silt ( 1' open ) Same with trace of clay Med. grav with dark gray clay ( 2' open ) Weep in H20 overnite.. 14' static GL Bail dry.. poor recovery.. Course grav& gray silt ( dry ) Clean med. gray & sand.. Water bearing.. Static water level 14 ft. 0 in TOG., Test bailed at 10 GPM Drawdown to 45 ft. Good recovery Bottom stable..( left 1 ft in casing ) SEE TEST PUMP DATA BELOW.. Static water level 14 ft 0 in. TOG Pump set at 53 ft Time GPM Water level REMUS 1402 7.5 i4i4 ii 36 1420 ii 38 1425 10+ 38-6 Recovery One min. 33 ft two min 29 ft three min 26 ft four min 23 ft five min 20-9 Clean Dirty ..Clearing Light cloudy , trace of sand Clear Clean & clear Installed 1/3 HP Fairbanks morse Mod 3B3310 Submersible at 55 ft. MUNICIPALITY OF ANCHo,~A(¢~ DEPT. OF HEALTH & I=-NVIRONMEN?'AL PROTECTION RECEIV! D Apri] 22,, 1973 M.L. Willets Skyway Realty 3202 Spenard Road Anchorage, Alaska 99503 SUDJECT: Lot 7, Block 4, Norton Parkway Subdivision Dear Sir: Tho subject lot has a septic tank which is acting as a holding tank at this time. The insl:allatton was never inspected or approved by this department. No approval of the tank syst(lm can he made until the t~nk and sower lines are exposed. The neighboring lots; (lot 13, block 4) and (}or 6, block 4) indicate by soil test ground water at seven feet an unsuitable soil for on-site sewage disposal, l'he subject 'lot (lot 7, block 4) is located between these two, thus making it questionable as to on-site sewage disposal and borough approval. A soil test dated October 1969, has been conducted on lot 7, block 4, however,, the required depth of four feet below permeable strata and system was not 'lndtcated~ tlmrefore, another soil test: is required. This department can~not approve any system placed within four feet of ground water. Therefore, the sewer pemit issued to David A. Harris on l~ay 22, 1973, is void. If you have any questions concerning this matter, please contact me at 274-.4561, extension 153. Sincerely, Les N. Buchholz, R.S. Sanitarian I 1 b CC: David A. Itarris 9441 ~I. 11th Avenue Anctmrage, Alaska ..... GREAT1 SEWAGE NCHORAGE ARE, ItEALTH DEPARTMENT Anchorage, Alaska 99501 DISPOSAL SYSTEM ROUGH coseNo.---- 279-2511 - APPLICATION & PERMIT RESIDENCE ADDRESS LEGAL DESCRIPTION APPLICATION TO INSTALL: SEPTIC TANK TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH ~'~,~ ,'~ NAME OF APPLICANT/~/f//~,q-/ ,//F.~.~'.(?Y?)/~/ _ MAILING ADDRESS ~/~o~/d}~2~ . PHONE NO. LO~TIOB OF INSTALLATION //~)/~ ._. ~"~ ~'[ ,-~ A ~ o :' '/.~ I~0~:~ Z~/l~%-' ~D~/:,~:J,. YZ~ ~ ~ ,SE~PAO~ ~T ~ , ORA~N F~ELD __, OTUER T0 BE INSTAkkED BY .~-~G~'TEST RESULTS ANTICIPATED DATE OF COMPLETION m:~, ~ ~ _ ~ BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT THIS IS TO SERVE AS /-//~' ,/~z.,¢~?~,,C) , PERMIT TO INSTALL A AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED /"/~"~,~, ,.. SEPTIC TANK SIZE, '.7-.5 & TYPE. SEEPAGE AREA TYPE -Hea'lti[Authorit¥'- / DIAGRAM OF SYSTEM I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the above described system is in accordanc'e w~th sa~d ;ATER ANCHORAGE AREA BOROU ' HEALTII DEPAI.:TMENT CASE 327 EAGLE STREET ANCHORAGE, ALASKA 99501 " ~ -7~/,~ /~/,~ ~~.. ' ~, . , Date Performed~/fl3~'~' ~ ~.~ Legal Descrlpt~on: ~ot .~loc~ T~ or R ~o~ts a' So~ls Log ~ ~~6n Tes~ Depth Feet Soil Characteristics .ocation Sketch Water Enoou ter a?__ %1 If Yes, At What DePth , _ -- Readin Gross Time Depth Net Drop Prop)sed Instal'l-~xo--~?Seepage Pit ~--~-~ Drain Field COMMENTS: Test Perfortaed By:.~.~ ........ Data Certified Date :,~ Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 RO. 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. 1. GENERAL iNFORMATION Complete legal description Expiration Date: Location (site address or directions) .'~.¢--0 b,../, /.Y-D~/~¢'~'~ ~t~c'r~,~.,~ ~/~ ~¢¢/? ~f~/¢,, ~/~¢ Day phone ~¢~- ~/~ Current Properly owner(s) ~ ffru~¢/ , / Mailing address ~ ~. /~.~¢~ ~//~r~/<. ~/( ¢~¢Z~ Lending agency Day phone Mailing address Real Estate Agent ~¢'~[ Mailing Address Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: individual Well Individual Water Storage Community Class Public Water System Well f"~-~¢k,, ~ ' AZ,"-~¢7~ ~¢..'~/g,~ [) Day phone 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. 72 025 ~Rev 01 00)' 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that ['ny 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 Ch- 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. Address ~-~ Engineer's Printed Name ~- ...../"/ /~, /'-//C~,/.~C~_:.:.:.:.:.:.:.:.:.~..-<~ Phone DHHS SIGNATURE P/ 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 Original Certificate Date: ~ - ~L ~ - C 'c Reissue Date: L'- Municipality of Anchorage 'CEIV D Department of Health and Human Servicesd[/L' Division of Environmental Services On-Site Services Section 825 "L" Street Room P.O. Box 196650 Anchorage, AK 99519-665e~,~Q~M~NT4LSE~WCEs p~v o. www.ci.anchorage.ak.us (907) 343-4744 HEALTH AUTHORITY APPROVAL CHECKLIST Date of test Static water level Well production Legal Description: A. WELL DATA Well type ;~/~',~f,~. If A, B, or C provide PWSID # __ Date completed/¢?~.¢' Sanitary seal .)/ Total depth ~ ft Cased to J~,~ ft FROM WELL LOG /~2 g.p.m WATER SAMPLE RESULTS: Coliform 42 colonies/100 mi B. SEPTIC/HOLDING TANK DATA Tank,T~'pe/Material ' Da nstalled : '!:, Tank size Cieanouts Foundation cleanout Date of pumping ,. ;v Parcel I.D.: Well Log ./v/ Wires properly protected Casing height (above ground) _.~-~ in. AT INSPECTION 1 /,7 . ~ g.p.m Nitrate O mg/I Collected by: Other bacteria ~) colonies/100 mi gal Number of Compartments __ Depression over tank Pumper C. ABSORPTION FIELD~ATA Date installed /[////~ Soil rating (g.p.d./ft2 or ft2/bdrm) __ Length ft Width __ft Gravel below pipe Total depth ft Effective absorption area ft2 Monitoring tube Date of adequacy test __ Results (Pass/Fail) Fluid depth in absorption field before test __ in Water added__ Elapsed Time: min Final fluid depth in Any rejuvenation treatment (past 12 mo.) (Y/N & type)_ High water alarm System type ft __ Depression over field For bedrooms gal. New depth Absorption rate >= .If yes, give date __ in. g.p.d. 72-026 (Rev. 01/00)* LIFT STATION Date installed "Pump on" level at __. in Datum E. SEPARATION DISTANCES Size in gallons __ "Pump off" level at in Cycles tested Manhole/Access High water alarm level at in Meets alarm & circuit requirements SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/rift station on lot /f//~ Absorption field on lot .,,[,///~ t Public sewer main / Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank ,4/'//~ rico SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ,4/'//t Water main Drainage Property line Water service line Wells on adjacent lots Absorption field Surface water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: ,,M//~ Building foundation Water main Property line Water Service line Surface water Driveway, parking/vehicle storage Curtain drain F. COMMENTS G. ENGINEER'S CERTIFICATION Wells on adjacent lots __ I certify that I have determined through field inspections and review of Municipal records that the above systems are in conform~,nce with MOA HAA guidelines in eft/ect on this date. Engineers Printed Name /.~,~ Date ~7/~ '~//,/~0 / "49TH' ' ', ~. No. CE-9698 HAA Fee * J,,c~z¢ ¢'""' '~ Date of Payment ~'~ ¢'--~/~ Receipt Number ~/~//~'~,¢0'/_..¢ ,~ Waiver Fee $ Date of Payment Receipt Number 72-026 {Rev. 01/00)' 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 01 6211 5? HAA # GENERAL INFORMATION Complete legal description Lot 7, Block 4, Norton Park Subdivision Addition No. 2 Location (site address or directions) 320 W. 1 23rd Avenue Property owner Mailing address Julie Mitchell Dayph0ne 349-5164 320 W. 123rd Anchorage, AK 99515 Lending agency Mailing address Agent B-i 11 Address Seattle Mortgage Day phone 4300 B Street Anchorage, AK 99503 Minuse Dayphone Vista Reas Estate 762-3228 562-6464 4241 B Street Anchorage, AK 99503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: XX 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: XX If community wasteWater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Fronl MOA ~21 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 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 Anderson Enqineerinq Phone 563-7155 Address P.O. Box 240773 Anchoraqe, AK 99524 Engineer's signature ~ ~__.,~t¢,~C,---- Date 10/29/97 DHHS SIGNATURE /'¥ Approved for --~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date /~; - -~/- ~' 7 The Municipality of AnChorage Department of Health and Human Services (DHHS) issues Health Authority Approval Cemificates 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 engineers work. 72~, ;(Rev, 1/91) Back MOA ~1 Legal Description: A. WELL DATA Well type Private Log present (Y/N) Total depth 5 R ' Sanitary seal (Y/N) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVIC~.' (~; El V E D Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907)0~4[t3-~941997 ...... Municipahty ct Anchorage Health Authority Approval ~necKIl~ept, Health & Human Services Lot 7, Block 4, Norton Park #2ParcelI.D.: 01621157 If A, 13, or C, attach ADEC letter. ADEC water system number Date completed 1 0/11 Cased to 58 ' Casing height (above ground) _ ¥ Wires properly protected (Y/N) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 Date of sample: 1 0/24/97 B. SEPTIC/HOLDING TANKDATA - Date installed Foundation cleanout (Y/N) Date of Pumping C, ABSORPTION FIELD r)ATA - Date installed Length Width Effective absorption area Date of adequacy test Fluid depth in absorption field before test (in.); Fluid depth (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* FROM WELL LOG AT INSPECTION 10/11 /85 10/24/97 14' 15' 1 0 g.p.m. 6.1 g.p.m. Nitrate .1 mg/L Collected by: Municipal Sewer Tank size Number of Compartments Depression (Y/N) Pumper Municipal Sewer Soil rating (g.p.d./ft~ or ft~/bdrm) Gravel thickness below pipe Monitoring Tube present (Y/N)__ Results (Pass/Fail) Immediately after Absorption rate = . If yes, give date 'Other bacteria Jim N:icodemus Cleanouts (Y/N).___ High water alarm (Y/N) _ System type Total depth Depression over field (Y/N) __ For gal. water added (in,): __ g.p.d. bedrooms Municipal D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line Sewer Size in gallons "Pump on" level at*. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: "Pump off" level at* Absorption field Wells on adjacent lots Municipal Sewer Water main/service line HAA Fee $ _0~(-'3~'/, Date of Payment ~(~-,) ~ ~,~ Receipt Number 72-026 (Rev. 3/96)* Driveway, parking/vehicle storage area Wells on adjacent lots I certify that I have determined thru field inspections and review of Municipal in conformance with MOA HAA guidelines in effect on this date. Engineer's Name Michael E. Anderson, P.E. Date 10/29/97 Waiver Fee $ Date of Payment Receipt Number Surface water Curtain drain ENGINEER'S CERTIFICATION Foundation Property line Water main/service line Surface water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Building foundation N/A On adjacent lots N/A N/A On adjacent lots N/A 1 0 0 ' Public sewer manhole/cleanout > 1 0 0 ' > 20 ' Lift station N/A - Municipal Sewer 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 Location (site address or directions) :Z,,21 0 ~ ICL%-~¢'-~) Property owner b¢¢~1 '"'~.A,cv~ oU~ Day phone Mailing address ~? '.-5'7 P.~-- ~¢'t,,~ O~J~ ~ Lending agency ~¢*. ~ ~' ,~¢ ~'~'~,r~4 Day phone Mailing address Agent Day phone Ad dress 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. 72-025 (Rev 1191) Front MOA~21 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/orwastewater 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. Engineer's signature ~ ~f ~f-cL- )L.~'~ Date DHHS SIGNATURE /~ Approved for Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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~)25 (Rev. 1i91) Back MOA//21 Legal Description: A. WELL DATA Well type Log present (Y/N). Municipality of Anchorage ~ Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LoT '1 [~Kq N orzvoh\ Parcel I.D. ~'~'-)/d- ~'"//-'~-~ If A, B, or C, attach ADEC letter. Date completed Cased to ,~ Total depth ~'~ Sanitary seal (Y/N) Y FROM WELL LOG Date of test Static water level I q Well flow If.2 Pump level _ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Public sewer service line ADEC water system number '°/nl$E, Driller Casing height Wires properly protected (Y/N) g.p.m. AT INSPECTION o (, . ,2 5 . ~ ~ g.p.m~. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Nitrate Tank size N..i'~ Other bacteria Collected by: ~'~ ~ ~ Compartments Foundation cleanout (Y/N) Depression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface water/drainage On adjacent lots Absorption field Foundation Water main/service line 72-026 (Rev. 3/91)Frol~t MOA21 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 codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Surface water D. ABSORPTION FIELD DATA Date installed Length Width Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FBOM ABSORPTION FIELD TO: Well on lot On adjacent lots Soil rating Gravel thickness Cleanouts present (Y/N) Date of adequacy test for If yes, give date System type Total depth bedrooms To building foundation On adjacent lots_ Surface water Curtain drain Property line. To existing or abandoned system on lot Cutbank 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 on the date of this inspection. Signature Engineer's Name Date HAA Fee $ /'~' ~ Date of Payment 9- /' -~:~ / 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number ~IUNICIPALITY 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 /~/3'/'~/C~ GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name 'J~)cz'vl '~__~'Vt4OUvl Telephone: Home Business Applicant Address tql~ (c) Applicant is (check one): I:.ending Institution []; Owner/builder~['; Buyer []; Other [] (explain); (d) Lending institution Telephone Address (e) Real Estate Company and'Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family,S[ Multi-Family [] Number of Bedrooms "~' Other WATER SUPPLY individual Well'l~ 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 Page 1 of 2 ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DA"IA 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. "T"o~.i4 ~,ll~,,,~t, t4,~ ~,~ Telephone ~7~'~ Name of Firm Address ~0'~ ~ I~ Date . Engineer's Seal Approved for __~... bedrooms b Date /.~__ Disapproved Conditional Approved 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. Page 2 of 2 72-025 (11/84) WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: L MUNICIPALITY OF ANCHORAG~ DFpT. OF HEALTH & ENVIRONMENTAL PROfECTION FEB 0 3 1986 Well Classification ___-'J~ ~' -(~' If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) _ )/ Date Completed lc~,'/l//l~ .'.-'.-'.-'.-'.-'.-¢~ Yield Total Depth '~ ~ Cased to ~ ¢' Depth of Grouting Static Water Level / G/ Casing Height Above Ground _,~2--- ~ Electrical Wiring in Conduit (Y/N) ¢v' Separation Distances from Well: To Septic/Holding Tank on Lot ~'//"/~ Pump Set At ~ ~ Sanitary Seal on Casing (Y/N) ",'/ Depression Around Wellhead (Y/N) To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ___ I O O Cleanout/Manhole I O _[.--~ _ Water Sample Collected by /..E~ Water Sample Test Results Comments ' ; On Adjoining Lots 1',//,-~- ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ;Date B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) _ Air-tight Caps (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 To Property Line To Water Main/Service Line Course Size No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) . To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA ~"x] C) ~.,1 ~..~ 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 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 Comments 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 To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) D. LIFT STATION lV 0 ~ ~:~- 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 Bedroom Rating Against HAA Request ** IS ic~ rnt ~ef~ t h ~¢ h~~.~' ~c c n'~ ratT d~,//~; ~...~ Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) the date of this inspection. Engineer's Seal