HomeMy WebLinkAboutGALATEA ESTATES BLK 2 LT 5V\ok Lk . I D's W -,ab
Ceveiapment Services Oepartment
Suilding Safety Division
07 -Site ;Y'cter a Wastzwater Pragrar
4700 Bragaw 51reei
P.O. box 195650
Vark 2egich Ancharag=_, AIC 99519-b650
Mayor Iag4N, 111UlILOP'.l If1O51Te
(907'-43-79104
Pump Installation Log
Nell Drillin; Permit Number. SW_
?arcel Identification Number:_
Date of Issue:
,esal Description Property owner Name & A dress:
Ae
?ump
�Ir 2—
?ump Intake Depth Below TopofWell Casing:8 & feet
K
?UnIp Manufacturer's Name: e .k'tC*ei-
Pump Model: Sf,�r �Jl� �S ! a -
Pump Size ��— hp
pitless Adapter Burial Depth:
feet
pitless Adapter Manufacturer's Name:
pitless Adapter Installer:
'.,VelI Disinfected Upon ,-OMD[et on"'r es Q o
lYlethod nFDisinfect:on:
C{- 6c" petted -s
Comments:
pump Installer Name:
,!4wl-e -0a)dR-" ,
s
O
A.ttentio n: 'I7s e pump installer shall provide a pump installation lag to the DSD within 30 days of pump instaLlatioa.
MUNICIPALITY OF ANCHORAGE
• Department of Health & Human Services a}j
DIVISION OF ENVIRONMENTAL SERVICES GI -1
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel 1. D. # C V-( - )C) )- —q( HAA #
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
/S .9 o2_ C L/2
Location (address or directions)..
(b) Property owner . �� Telephone: (home) Business
Mailing Address
(c) Lending Institution
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
Telephone
(e) Mail the HAA to the following address: (or check hereKif hold for pick up.)
List contact person and day phone number below:
SCS C ST��3
2. TYPE OF RESIDENCE
Single -Family Number of bedrooms 3
3. WATER SUPPLY
Individual Well( Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ❑ PublicV Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty 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 �o-�S l—? -G Telephone C�2_ 79J rT 3
Address�� �, C2=W eU ?_ 5 �
Date
e
.V°• � ••• ••011°Y•P•0 �L
00•C�
OA I..'ire@R)Q.speb° u
•"•
-2251 9-" X61. e•
44 4-
6. DHHS APPROVAL /��-1
Approved for .i bedrooms by �(//) K Date
Approved Disapproved Conditional
Terms of Conditional Approval
4CAION,;
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 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. 7/88) Back Page 2 of 2
G�°'*
MSN\
IVIV
A. WELL D ,
.A
17✓zf
Well Classification
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA) M�
CHECKLIST - FEBRUARY 1984
343-4744
Well Log Present (Y� Date Cobmpleted
i UN u A vF
Total Depth Cased to Depth of Grouting
Static Water Level ZZ
i
Legal Description: � 5-,6 2 45 a l? le o
7 /?_,00 4>_�w ss'
Casing Height Above Ground —
Electrical Wiring in Conduit 6?N)
7—/
SEPARATION DISTANCES FROM WELL:
If A, B, C, D.E.C. Approved (Y/N) 44
Yield�� g�,�" ' x,69 0
vn maw A
Pump Set At U,, 4,A_4'14
Sanitary Seal on Casing62N)
Depression Around Wellhead (Y&) -
To Septic/Holding Tank on Lot On Adjoining Lots NVQ
To Nearest Edge of Absorption Field on Lot N-41- ; On Adjoining Lots
/60 t l 1
To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot 06-71- /
Water Sample Collected by �e 7d ; DateL d
Water Sample Test Results �eG� pU'z�es N D
Comments c_ e 5-t,(-ye5 74 /s to {
p4y/ pr?) L J/, ez red 7�p 40114.-1 2, b"a= is U'Veod--f .+z o., , n _91.r >r" -
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N)
Size No. of Compartments
Depression over Tank (Y/N)
Air -tight Caps (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High -Water Alarm (Y/N)
SEPARATION .DISTANCES FROM SEPTIC/I
To Water -Supply Wel I
(;
To Property Line '
To Water lvMairf/Service Line'':
To Stream; Pond`, Lake'' Major Drainage Course
Comments '
Cleanout(Y/N)
Pumped
;for
Temporary Holding Tank Permit (Y/N)
D/1 d0 TANK:
To Building Foundation
To Disposal Field
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION„ IEL
To Water -Supply Well ry
To Building Foundation
Lot
To Water Main/Service Line
To Stream, Pond, Lake, or N
To Driveway, Parking Ar ,
Comments
ZZ
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Code,
Comments
Drainage Course
_ Statndpipes Pr sent (Y/N)
Date of La Adequacy Test
To Property Line
To Existing or Abandoned System on
On Adjoining Lots
To Cutback (if present)
or Vehicle Storage Area
/N)
Dime75sions
le/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines,i
inspection. rJ v', f;
L� 00gB0009
Signed ; a
Company S �`
Date /��/y
poofoo •nav404
MOA No. I cO/Z �O I • ROY C. REID, JR.
Receipt No. , ✓ oifc�
Date of Payment
Amount: $
Receipt No.
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
008 UL: •22s1
060.0600*66 4
®VV�� V!
date of this
Seal