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Home My WebLink AboutCAMPBELL HEIGHTS Block 1 Lot 10COLAW‘701 Ks. lb wc it) 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 264-4720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include Iot~ block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name /'~, [-F' ~ .,v ~-~ -~ Telephone: Hom. e ,~ .,~ A"~,~'PBusiness Applicant Address /~ ~.,n v~' (c) Applicant is (check one): Lending Institution []; Owner/builder,~; Buyer []; Other [] (explain); (d) Lending Institution Address Telephone (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single-Family t~ Multi-Family [] Number of Bedrooms ~'~ Other 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 the legality and status. 4. SEWAGE DISPOSAL o. 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-o25 (tt/84) 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 liles 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. NameofFirm /~L~.~d'~.ev-,~e -- ~-"~v- Telephone Address "~ I ~.'7 C) ,~ H~,¥ Ap pr oved ior ;'~__~..,,. bed roo m s by '~t/~ 4 .'~,,.~---" ~ ~(~4 (gate Approved .:'~. Disapprove~'' - ~ ' ' ConditiOnal ~ 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 certilicate 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(11194) WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) OF ANCHO~I~[CKLIST - FEBRUARY 1984 I~NJTY 264-4720 DroOl'. OF HEALTH & Well Classification ~VII~O~Nff~AL I~ROTECTtON Legal Description: ,,:-/,o 8-/ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) M~ Cased to ~'~'~ ' Total Depth - Static Water Level ~ Casing Height Above Ground ,/Z" Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot ..,~/~ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line /,~t V- /f;7Z. Yield Date Completed /- Depth of Grouting A~/'~'~jz)t~/~' Pump Set Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ,~ ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole /~;~/~ To Nearest ~wer Se~ice Line on Water Sample Collect~ by ~~ ; Date ~// Water Sample Test Results ,~ Comments ~//- ~ ~t~ ~ ~ O~ ~ ~ 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/sen/ice 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 I of 2 72-026(11/84) 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 Separation Distance from Absorption Field: To Water-Supply Well To Building Foundalion 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 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 I certify th~, e~e~k~, ve ri_r_r_~,, o r conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed J.4'~x~ .~'~-~''~--'''~''~ Date Company ~Z~r.r --~ MOA NO. Receipt No. ~ ~ Date of Payment Amount: $ ~ Page 2 of 2 12-026 (11/84) APPLIC'"'NT FILLS OUT UPPER HA!-'TONLY Prope..rt~ Owne)' J~)'J , C h C-./~-~I ~)'-.. ~y~' Phone Buyer Address Zip Code Type of Resl~nce ~ $ingte Family ~ Other Water Supply ~mm~lty For wells frilled prior to Ih~ date, give well depth (attach I~ If available). Sewer Disposal ~ Holding Tank NOTE: THE INSPE~ION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~OCESS~NG CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector ,nspecto¢ Inspect~¢;5~? .~.'~.~. ,nsp~to~ ~ Field Notes: M~tCIP~I~ DEPT. RECEI. Y. ED. (~ ) APPHOVED BEDHOO~S 'OONDITIONS OF APPHOVAL J ) DISAP~OVED ( ) CONDIT~NAL APPROVAL* Oolls Rating Date ~wer Instalt~ Well To ~sorpflon Area Well Log Recelv~ Well to Tank Septic T~k Size APPLI¢-'NT FILLS OUT UPPER HA['"'~ oNLy Address Zip Address ' Zip Type of Resl~nce ingle Family ~ultlpte Family NO. of B~r~ ~ 0 Other Water Supply NOTE: THE INSPE~ION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~ESSING Time Time Time Time %J Date Date Date Date Inspector Inspector Inspector Inspector Field Notes:t~(ll~)~ J~UNICIPALITY OF ANCHOP, AGE ~'F~T C~ I,:-~;.?:~ ~. ~ ,, ..~ Q~, E~:u.',~r;~. r.,o.~cnoN ~ ~,~ ~ ~~- ~ ~, . RECEIVED (~ APPROVED ~DR~S *CONDITIONS OF APPROVA~ /t' ~ ( ) D~SAPffiOVED ( ) CONDIT~NAL APPROVAL* { DATE ~1' ~'~ ~ ~lte Rating Oale ~wer Install~ Well TO ~sorptlon Area Well L~ R~eiv~ Well to Tank Septic I~k 81z* P O..., G H 6-650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 DEPARTMENT OF HEALTH AND E NVliIONMENTAL PHOI LC rlOr~ October 15, 1982 TO: Whom It May Concern Subject: Lot 10 Block 1 Campbell IIeights Subdivision The well serving the above subject property is of approved construction. A water sample was drawn on October 13, 1982 and is satisfactory. This letter does not consitute a full health authority approval. If there are any further questions, please call this office at 264-4720. Sincerely, Robert C. Pratt, R.S. Associate Specialist RcP/ljw