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Home My WebLink AboutCAMPBELL HEIGHTS BLK 3 LT 16BH CoT' MUNI.C:IPAU'TY Oi~ r. [~T. 0c IJ[;'LT'4 /~ATER WELL RECORD STATE OF"ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological 8 Geophysical Surveys 2EC~eeVe.~gre Orllllne Permit No. LOCATION OF' WE le either Io, lb or lc.) A.D.L. No. eoroueh ~JoIsTANCE AND,OIR~CTION FROM R~ADJ~ER~CTIONI I. OWNER OF WELL: I0. STATIC WATER LEVEL: J/~ It, ~ ~,"~ I 0 AbOve or ~ Below lend lurfoce r.lurq T C 1' ~ RL T T'T' OF RI'-,ICh " DEPARTMENT OF HEALTH AND EHVIRO~"IMENTRL PROTECTIOJ"I -' 825 "L~' STREET, RNCHORAGE, AK. 2~4-472~ I-IELL PEAr4 I T PERMIT NO, .( e2el~9 ) APPLICANT C&E,ENT. INC PO BOX 10-991 LOCATIOH LEGAL L16B B~ CAMPBELL HTS LOT SIZE 87~3 SQUARE FEET MINIMUM DISTANCE E.'ETHEEN R WELL AND ANY ON-SITE SEHRGE DISPOSRL SYSTEH IS 100 FEET FOR A PRIVATE HELL OR 450 TO 200 FEET FROM R PUBLIC HELL DEPENDING UPON THE TYPE OF PUBLIC HELL. MINIMUM DISTANCE FROM R PRIVATE HELL TO R PRIYRTE SEHER LINE IS 25 FEET AND TO R COMMUNITY ~EHER LIME IS 75 FEET. HELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT HITHIH 30 DAYS OF THE HELL COMPLETION. OTHER REOUIREHEHTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIRGRRM~ ARE AVAILABLE TO IHSURE PROPER INSTALLATION. PER~I I T E >-'.P I RE5 DECEr'IBER 3~_.. :L982 I CERTIFY THAT l: I AM FAMILIAR HITH THE REO. UIREMENT$ FOR ON-SITE SEHERS RND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I HILL IMSTRLL THE SYSTEM IN ACCORDANCE HITH THE CODES. S I GNED: APPLICANT C~E ENT. INC V4, 0 :.I]F1UI'I [,]."-;'T~:IH£:E F~E"lrF.I,~EF! t:: .',fi:Lt. l.~..fl', ~.'i.*'-':' OI,I~.C. llE' c.,,E.I, IFiO[. l".l_c'.f'o~lriL .':,,','F."I'LI'I l"- ]!:,! II-E; 1.~'.'~. iF.: rllj'.'L!C.' IdEl. l. II[.fLr::t.E !(' Jl':¢'J.l[~[ F"kCll-'EF.~ ~ ) MUNICIPALITY OF ANCHORAGE ~ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~J~ OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date ~ ~:) GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ~,~ ~c. _p~r,!,,.,~) r.._~. Telephone: Home Applicant Address (c) Applicant is (check one): Lending Institution D; Owner/builder~[[; Buyer []; Other [] (explain); (d) Lending Institution C~""~ ~-~/~j~ Telephone Address (e) Real Estate Company and Agent Address (f) Telephone Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family"~ Multi-Family [] Other Number of Bedrooms ~ ~,D~I~ 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. SEWAGE DISPOSAL [] Public~: Community [] Holding Tank [] entire Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 {11,~4) 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 ~ t~?~ ~ PoT"?".~ Telephone Address ?'~'~ ~ ~ ~, ~.~ ~.--J~O~ "" "APPROVA, Approved for/'~,'_~,'~ ~)bedrooms by -///?-~//~/-/~//~ Approved ~ Disapproved "- -- Conditional Terms of Conditional Approval Date 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 $ 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. ge 2 of 2 72-025 (11/~4) IV, UNICIPAU1Y OF ANCHOI~,GE DEFI' OF HEALTH & ' ·" ENVIRO~I~NTAL PROTECTI~JNIclPALITY OF ANCHORAGE (MOA) HEALTH AUTHOBITY APPBOVAL (HAA) ~EB ~ '~g~7~ :' CHECKLIST- FEBRUARY 1984 264-4744 R E C E I V E D . : . Legal Description ! iI ; On Adjoining Lots JJO~. ; On Adjoining Lots , To Nearest Public Sewer . . Nearest Sewer Service Une on Lot A. WELL DATA Well Classification "'~./~/,4Y/!~' ! ..... "' ' If A, B, C, D.F-C. Approved (Y/N) Well Log Present (Y/N)~'~ Date Completed Total Depth ~1 Cased to~'~l Depth of Grouting * ~" Static Water Level ~'(~IE~, I~,rTH,~) PumpSetAt Casing Height Above Ground Sanita~ ~al on Casing (Y/N) Electrical ~ring in Conduit (Y/N) ~ Depression Around Wellhead ~paration Distances from We , · :. ,'. To ~pti~Holding Tank on Lot ~ ~ To Nearest Edge of Absorption Field on Lot To Nearest Public Gewer Line Cleanou~Manhole Water Sample Coffered by Water Sample Test Results Comments ~ ~ ~ B. -~,'1 ;~L~:~ T~X DP. TA , , ~ , ' · ' · '. Date Installed Standpipes (WN) Air-tight Caps (WN) 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 (WN) 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 Soils Rating in Absorption Strata Date Installed Width of Field ~ ;': ~' "; ' "'Typ~ofSystemDesign Length of Field ·" ...... ' ;' Depth of Field L" -:'" Gravel Bed Thickness Standpipes Present (Y/N} Date of Last Adequacy Test 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 To Property Line: To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) · - Date Installed Size in Gallons 'Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (WN) · Comments ?!. '* i .'. Dimensions Manhole/Access (Y/N) , "Pump Off" Level at Vent (Y/N) ': ' ' '" Pumping Cyclesdudng Adequacy Test. Meets MOA *' Check Permitted Bedroom Rating Against HAA Request °* . TM ' ' .' I certify that I have checked, verified, or conformed to all MOA and HAA guidelines Ih effect 0n the date of ibis inspection. Signed AJ~l,~--~v~ ' Date' Receipt No. ~/I' ~~ Date of Payment ~ Amount: $ ~ .... Page 2 of 2 BP-q-gC~ EPPS & l~.7~J.~ 2220 FAb~ 88 AV'I/I~J~ J~I/CRAC~:, Ai~ 99507 (~07) 34.q-64st Block: ~nitial Reading cn ~eter: ~7~ vroaucLion i~t~: 4.:Z~/ ca:'w 24~o~ capacitY~/7~' c~ttoe.= I.'- '. APPL"-'~NT FILLS OUT UI~PER H,"'-~ ONLY ~ ~lnole Family ~ Other ~ Indlvld~l A~ACH ~LL L~. A ~1 I~ Is r~ult~ for all wells drll~ since June 1975. ~ Public Utility Sewer Disposal ~ Holding Tank NOTE: THE INSPECTION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~ESSING CAN BE INITIATED. Time Time Time Time Date ~. Date Date Date Inspector Inspector Inspector Inspector Fle~d Notes: ~ ~ _ SOIls Rating Date ~we~ Install~ Well TO ~sorptlon Area Well L~ R~elv~ Well lo Tank ~pttc T~k Size