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HomeMy WebLinkAboutSAND LAKE #2 BLK 3 LT 20401 t OMW 12) q 00- MUNICIPALITY OF ANCHORAGE ® DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL_ SYSTEM AND/OR WELL INSPECTION REPORT NAME - - -�_ - iI PHONE NEW ' %� , ! (� ❑ UPGRADE MAILING ADDRE�- i 0 �-' JUZ DISTANCE TO: Well Dwelling LEGAL DESCRIPTION PERMIT NO. J �j Material Liquid capacity in gallons w = DISTANCE Tn: Well lot) �j- Foundation ` /, i LOCATION PERMIT NO. J Z w ~ No. of lines % w Length of each line NO.OF BEDROOMS "CE H o Top of the to finish grade _ ` / (fa - Material beneath the �� ` U Total eff c�t/ive absorption area U y Well Ft ,t (!di Absorption area 1 Dwelling C7 PERMIT NO. r �� GGG✓ F z cW H Manufacturer ��� r / W a Material Crib diameter No. of compartments y Liq. capaciI ir1 allons I/`I/xl!\g IF HnMFMAnF Inside length Width �� Liquid deoth 0 �-' JUZ DISTANCE TO: Well Dwelling PERMIT NO. = z F Manufacturer Material Liquid capacity in gallons w = DISTANCE Tn: Well lot) �j- Foundation ` /, i Nearest lot line (�. PERMIT NO. J Z w ~ No. of lines % w Length of each line . • / Total length of lines �i Trench width ��nches Distance between lines H o Top of the to finish grade _ ` / (fa - Material beneath the �� ` U Total eff c�t/ive absorption area W Length Width Depth C/.L/_ inches 7 F.I I PERMIT NO. C7 W a Type of crib Crib diameter Crib depth Total effective absorption area w DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERMIT NO. W DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE �MATERIALS %/n^ � 1 P l� I I s SOIL TEST RATING 23 �✓ r INSTALLER � r e e_ REMARKS `T le I Al f , 0 N APPROVED DATE LEGAL 7� l�� '5611 ` 2 K. " L. 26 72-013 (Rev. 3/78) .e_ , P"ll T ����� ���� ���� ������ DEPHRTMEPTF HEHLTH HND ENVIRONMENTHL/-\p�TECTION STREET/ ` 264-4720 ��~���� ��.4 EA -� � �� 9��T t.9'4.( ��0��1 ` HPPLICHNT HULTQUIST CONST INC 4761 MHRS 99507 ]49~91]] LOCRTION LEGHL L-20 B] SHNM 1L.AKE #2 LOT SIZE 6300 SQUHRE FEET MHXIMUM NUMBER OF BEDROOMS SOIL RHTI�G THE REQUIRED -'I7F OF TXc �nn �ncmpprr�u cvcrcm �c THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD THE DEPTH OF Fl TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE . GROUND HND THE B8T7OM OF THE EXCHVHTION (IN FEET) THERE IS NO SET WIDTH FOR TRENCHES� THE GRHVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OLTFHLL PIPE HND TH�� B(}TTOM OF THE EXCHVHTION (IN FEET) ����P-Z !�DC.ET PERMIT HPPLICHNT HHS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE INSTHLLHTION INSPECTIONS OF AP -JY WELLS HDJHCENT TO THIS PROPERTY F'llND THE NUMBER OF RESIDENCESTHHT THE WELL WILL SERVE 1� I HM FHMILIHRWITH ��p J, I U%K :E- F-` ZEE:7­������� FOR BHCKFILLING OF RNY SYST�M WITHOUT FINHL INSPECTION AND HPPROVA- BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTIONL OF 8NC40RHGE MINIMUM DISTF�N�� BETWEEN H WELL HND HNY ON-SITE SEWHGE DISPOSHL SYSTEM I'S 100 FEET FOR H PRIVHTE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING OPON THE TYPE OF PUBLIC WELL WITH THE CODES. MINIMUM DISTHNCE FROM H PRIYHTE WELL TO H PRIVHTE SEWER LINE IS 25 FEET HND TO H CQMMUNITY 5EWER LINE IS 75 FEET MHY REQUIRE ENLHRGEMENT IF THE QMAY HPPLY. AND CQNSTRUCTION DIAGRAMS, HRE HVHILHBLE TO INSURE PROPER INSTHLLHTIQN. �NCLUD� MORE THHN 1 7-��������� I C�RTIFY THHT 1� I HM FHMILIHRWITH THE FOR ON-SITE SEWERS HHD WELL.S HS SET FORTH BY THE MUNICIPALITY OF 8NC40RHGE 2� I WILL INSTALL THE SYSTEM IN HCCGRDHNCE WITH THE CODES. UNDER--TFND THAT THE QN^5ITE SEWER SYSTEM MHY REQUIRE ENLHRGEMENT IF THE RESII'ENCE IS REMODELED TO �NCLUD� MORE THHN ] BEDROOMS. HPPLICONST INC Y4. [-.-I E c 1C 11 13 14 15 16 17 18 19 20 COMMENTS PERFORMED BY: 72-008 (6/79) Sil� S�;Id 2.39 L/ WAS GROUND WATER �///1 S ENCOUNTERED? Iyl.i L -— - D P IF YES, AT WHAT E DEPTH2 Reading Date Gross Time ] SOILS LOG Net Drop rt LO -Z S: oj o, s MUNICIPALITY OF ANCHORAuE ® DEPARTNiFNT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION S; li 82.5 L Street, Anchorage, Alaska 99501 264-4720 0.55 TEST SOILS LOG — PERCOLATION TEST lO "may O. EIL? PERFORMED FOR: A' `to 1 L % 1 _DATE PERFORMED: S t LEGAL DESCRIPTION: -L Zoc- l_,,k� UUU PPZ'_-, --r S�/ J /lob 1 SLOPE SITE I ` % T-F—�- PLAN O,O.S i -- O. Lt L E c 1C 11 13 14 15 16 17 18 19 20 COMMENTS PERFORMED BY: 72-008 (6/79) Sil� S�;Id 2.39 L/ WAS GROUND WATER �///1 S ENCOUNTERED? Iyl.i L -— - D P IF YES, AT WHAT E DEPTH2 Reading Date Gross Time Net Time Depth to Water Net Drop rt LO -Z S: oj o, s 6L z S; li 0.55 lO "may O. EIL? N S; _aS % 1 0107 S t t a S IOMln 01-5-0 O,O.S O. Lt L 0. I,IV 6;05 /U O.�f9S 1- ejloe N PERCOLATION RATE--- (minutes/nch)��E'o'.00ao�'? ayA,,.' o /j dJ C A o TEST RUN BETWEEN -�J �l� FT AND /Z FT P *?'tk;}�.� 0. Lyroy C. Paid,ra 44�. CONSTRUCTION AND OPERATION CERTIFICATE ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION PUBLIC WATER SYSTEM APPROVAL TO CONSTRUCT , Plans for the construction of�/ atir) L ►4c E LI Sinz-T al S (od __(i l AMC IC V Gats %ef-� nZ14 q` 0/0'ct 17h (922.(— frh— /c) S) public water system located in t) i �, r �S P Alaska, submitted in accordance with 18 AAC 80.100 by JCO 0j - li Ctt kiC o_t nc-e' have been reviewed and are K approved. ❑ conditionally approved ee attached conditions). T �t1VnNk).4PA7a� �;l1J�14PNvsDATE If construction has not started within two years of the approval date, this certificate is void and new plans and specifications must be submitted for review and approval before construction. APPROVED CHANGE ORDERS Change (contract order no. Approved by Date or descriptive reference) The "APPROVAL TO OPERATE" section must be completed before any water is made available to the public. APPROVAL TO OPERATE The construction of the ca >^ r j t, k 4 / +f /G - 'tpublic water system was completed on /S L-FQ vt e ��— (date). The system is hereby 4grandterim approval to operate for 90 days following the completion date. '24--� `- _ TITL Lj DATE As -built plans submitted during the interim approval period, or an inspection by the Department has confirmed the system was constructed according to the approved plans. The system is hereby granted final approval to operate. / !U `',.-/ ft'Y'+s.�-.vY '�_.e._- �rITLE DATE 1/7 MUNICIPALITY OF ANCHORAGE S • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section l 7 P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 02 - Parcel I.D. # 2Parcell.D.# ���� �3�-d� HAA# 1��19�iL1L 1. GENERAL INFORMATION Complete legal description LoT ao F3x'< -SAN t, Lu4Kl= dZ Location (site address or directions) 80g& Property owner 1- iz Day phone ,2y5- yrSO Mailing address 75011(o -44_�W- 11G y c r. iKs.r Lending agency W'`y��� Day phone Zi 2 - fS$m'c Mailing address Agent Day phone Add ress Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: -S'111 3. 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. 4. 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(Rw.1191) From MOA*21 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, functional and adequate forthe number of bedrooms and type of structure indicated herein. I furtherverifythat 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 lo�dzWaV�klra 171= Phone P-79-39� Address Engineer's signature 6. DHHS SIGNATURE 1W2 -0:!z. &"� Approved for T 2EE bedrooms. Disapproved. Conditional approval for Additional Comments WIF , _, at1TIC <1 ) bedrooms, with the following stipulations: Date 17—) 0 - g i 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 thei r lending institutions in orderto 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. 92-025(Rw.1191) BaCk MOAN21 RECEIVED Municipality of Anchorage 08 X99 DEPARTMENT OF HEALTH & HUMAN SERVICESSEP Environmental Services Division C v �Iiy OF ANCHO 825 L Street, Room 502 - Anchorage, Alaska 99501 - (E9d���stvICES DIVISIO Health Authority Approval Checklist Legal Description: Lo T O.f . 5Y,°> _5ANP LAKE R -Parcel I.D.: ®II A. WELL DATA h if Well type If A, B, or C, attach ADEC letter. ADEC water system number $6 Log present(Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well production Date completed Cased to FROM WELL LOG WATER SAMPLE RESULTS: Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION g.p.m. Coliform Nitrate N Other bacteria Date of sample: /3 ! 1 Collected by: 7.3 B. SEPTIC/HOLDING TANK DATA Date installed G -7-87- Tank size Ic o e, Number of Compartments 9- Cleanouts (Y/N)--Y-_ Foundation cleanout (YIN) i_ Depression (Y/N) IN High water alarm (Y/N) 1 Date of Pumping Pumper ec'S C. ABSORPTION FIELD DATA Date installed %' 7 Soil rating (g.p.d./ft2 or ftz/bdrm)A-62A System type /A444 St 4a. Length ___51LF M Width r Gravel thickness below pipe s L Total depth 10-/5 Effective absorption area•%6 Monitoring Tube present (Y/N)-Y-- Depression over field (Y/N) Date of adequacy test S�IA9111 Results (Pass/Fail) P For _Z> bedrooms a! � � r I Fluid depth in absorption field before test (in.); y3 Immediately afterb�0gal. water added (in.): 5— rt 1 ist3 Abso tion rate=�•P•d• Fluid depth �/ (ins) Minutes later: rP Peroxide treatment (past 12 months) (YM) N If yes, give date 72-026 (Rev. 3/96)' D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested Size in gallons on" level at* *Datum E. SEPARATION DISTANCES SE2✓IIl(7 SEPARATION DISTANCES FROM WELLA LOT TO: Septic/holding tank on lot i too On adjacent lots "Pump off" level at* t�'//A Absorption field on lot >1L-,-0 On adjacent lots N Public sewer main N14 Public sewer manhole/cleanout �!/A Sewer /septic service line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation l L Property line (r Absorption field I Water main/service line _surface water/drainage � Wells on adjacent lots t ofJ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: f Property line Building foundation Water main/service line 45 Z) Surface water Driveway, parking/vehicle storage area > y D Curtain drain MIC) Wells on adjacent lots F. ENGINEER'S CERTIFICATION I certify that 1 have determined thru field inspections and review of Municipal records-thaff the above systems) qre in conformance with MOA HAA guidelines in effect on this date. Signature Engineer's Name Date q -10 - HAA TIVl HAA Fee $ 5l D 00 Date of Payment 9 ��- Receipt Number 5 j l 0 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 67'v7i�� MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services Mei DIVISION OF ENVIRONMENTAL SERVICES — 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # D// — 17 Y -•-OJT HAA # 6l A SS 0 '1 {(n 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) V/ 0" (b) Property owner �/�G Telephone: (home) Business Mailing Address (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent ,rare �'''t°E``7eu' Address Telephone S'G z —761 (e) Mail the HAA to the following address: (or check hereO�'if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single -Family Number of bedrooms 3. WATER SUPPLY Individual Well ❑ Community 1 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 Public ❑ . 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 4R CS .c Telephone —2-"2 S7t 3 Address �D 6OX aYO�GS G�Co/ zc� �q1'a/ 06�� Date �•se• >9AAAAA�• ry �� a^�-•�oe.Nu� �r`O - 6. DHHS APPROVAL / C /�'�a �22—Z Approved for —bedrooms by Date Approved Disapproved Conditional Terms of Conditional Approval CAUTION 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 MUNICIPALITY OF ANCHORAGE (MOA) I�> • Health Authority Approval (HAA) y CHECKLIST - FEBRUARY 1984 343-4744 A. WELL DATA Well Classification C— Well Log Present (Y/N) Total Depth Cased to Static Water Level Legal Description: .1 - a0 ✓,7 57 ,,, d /' 4 //z 7-1.2-V % `f 4J Si O Date Completed Depth of Grouting Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Fief To Nearest Public Sewer Li To Nearest Se Se( Water Sampl ollected by Line on Lot If A, B.E.C. Approve (Y N) Yield Pump Set At Sanitary Simon Casing (Y/N) Around Wellhead (Y/N) On Adjoining Lots On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole Wate�mple Test Results Comments /p��ekAz? e - ; Date B. SEPTIC/HOLDING TANK DATA Date Installeda Size No. of Compartments Standpipes 191N) Air -tight Caps 60N) - Foundation Cleanout &N) Depression over Tank (Y/Nr- Date Last Pumped 31��8'92ze !• Pumping/Maintenance Contact on File (Y/N) Holding Tan k'High-WaterrAlarm (Y/N) A&.Q- Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well / �D �� To Building Foundation To Property Line �b '` To Disposal Field To Water Main/Service'Line. �`2_r`� / To Stream, Pond, Lake.or'Major Drainage Course /O D Comments 'AOL -`r 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 3!? Type of System Design T Date Installed 47A."-; Length of Field p /� Width of Field /r 62 Depth of Field Gravel Bed Thickness Square Feet of Absortion Area Statndpipes PresentON) Depression over Field (Y/O Date of Last Adequacy Test -?/ Arx Results of Last Adequacy Test Z uz SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well To Property Line Y / To Building Foundation /b�/ To Existing or Abandoned System on Lot 110V/ 1- ; On Adjoining Lots 16 To Water Main/Service Line 2-5- To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course —>16e To Driveway, Parking Area, or Vehicle Storage Area '210" Comments Ilause !/ 2 'f Sin cc- a o% a4r, r D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes Comments — Dimensions Manhole/Access (Y/N) "Pump Off" Le ent (Y/N) ""Check Permitted Bedroom Rating Against HAA Request" Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA guidel inspection. Signed Company hv--­Cf � Date Wo7/'moi MOA No. D7--ax_y' Receipt No. Date of Payment /5� Amount: $ l/120' 0J Receipt No Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 gate of this Seal SY&YE OF a aSK& DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE WESTERN DISTRICT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE, ALASKA 99503 November 13, 1989 Dr. Leroy C. Reid, Jr. Alaska Environmental Control Services P.O. Box 240668 Anchorage, AK 99524-0668 PWSID: Class C STEVE COWPER, GOVERNOR 563-6775 According to the records on file in this office, the Sand Lake #2, State of Alaska Drinking Water Regulations. Blk 3, Lot 20 Subdivision Water System is in compliance with the VEC:bas Sincerely,( 0-'/ �1 " , Vera E. Craig Environmental F d Officer I/Z-7c `i ' '' 6 ova N�3. i1 1/,0 -2- " /�'f MUNICIPALITY OF ANCHORAGE ° Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES M}j 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I. D. # L l � - I - C:�) HAA # _ �' c) �F� , \ :a(1 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) ucz(� 3 t df g sand G.ake' tl�Z 7 11 ov R. i W SCc . Location (a � rg ` VICIQ (b) Propertypwner Mailing Ati� (c) Lending Ins t�"+•. <•.*'�r� Mailing Address Telephone: (home) Telephone (d) Real Estate Company and Agent Fnrkune - >'aren G-r'rr,.4 Address Telephone '74527) S6 - %6 S3 (e) Mail the HAA to the following address: (or check here W, if hold for pick up.) List contact person and day phone number below: Al 0 46!� w ; tl D rCJ; u � \ i ) I ri✓�N,C �/Ou 2. TYPE OF RESIDENCE Single -Family p Number of bedrooms Business 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 0� Public ❑ 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. 7188) Page 1 of 2 � v � 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. �•E G.S. Tele `l07) 2 fiC�-ss-,5,3 Name of Firm phone Address l y ll W. n 5L Inc. '00. 99S"o3 Date 3 6. DHHS APPROVAL Approved for 3 bedrooms by Approved Disapproved Terms of Conditional Approval Date 3 —S cl Conditional CAUTION 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 oranalyze 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 MUNICIPALITY OF ANCHORAGE (MOA) • Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 A. WELL DATA Well Classification Gomes WWeeH.og Present (Y/N) Date Completed Legal Description: lVor-K 3 L.ot Z0 Spwn )Lmc * %x 8'M Seav;eV _r) K) R y,l.t/ :5e -c.. 10 Total Dept�__Cased to Depth of Grouting Static Water Level Casing Height Above G Electrical Wiring in Conduit (Y SEPARATION DISTANCES FROM WELD To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field To Nearest Public Sewer Line To Nearest Sewer Slice Line on Lot Water Sample Colleted by Water SampleXst Results B. SEPTIC/HOLDING TANK DATA If A, B4OD.E.C. Approved (Y/N) Yield Pump Set At Sanitary §pffron Casing (Y/N) Dep.w§sion Around Wellhead (Y/N) On Adjoining Lots ; On Adjoining Lots To Nearest Pu6SqSewer Cleanout/Manhole Date Installed `�-9X Size 1000 GA,-. No. of Compartments Standpipes (9/N) Air -tight Caps (tS N) ; Date Foundation Cleanout &N) Depression over Tank (Y/O Date Last Pumped OZ-O(-e-ct IMAt"5 Pumping/Maintenance Contact on File (Y/N) /VI►A ; for A) Holding Tank (Y/N) moi_ Temporary Holding Tank Permit (Y/N) AZW— SEt'ARATIOWDISTAN81N_*ROM SEPTIC/HOLDING TANK: To WateG Supply We�I! '� /� -I- To Building Foundation /v � To Property Lima, gl•,`. To Disposal Field .xti Via ;- 4- T6,WateT M9WSJrv(ce To S�frgam, Pond, �ak2 or"Major Drainage Course %w � Commends"`~�=;" 72-026 (Rev. 7/88) Front Page 1, of 2 '� g L y0 Sand t.hkc �� C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Type of System Design Tfewc lti Date Installed G-7--6%, Length of Field SG Width of Field 6 // -/p /3 Depth of Field Gravel Bed Thickness q6 f/ +0 Square Feet of Absortion Area 1% 1-/ Depression over Field (Y/A Results of Last Adequacy Test Statndpipes Present}/N) Date of Last Adequacy Test D3 -D( `" SEPARATION DISTANCE FROM ABSORPTION FIELD: �— To Water -Supply Well W*' l4) rt / To Property Line w� To Building Foundation I()- : = To E=)dsting or Abandoned System on Lot ; On Adjoining Lots 16'4- To Water Main/Service Line %s To Cutback (if present) 11 II �V To Stream, Pond, Lake, or Major Drainage Course 100 /; To Driveway, Parking Area, or Vehicle, Storage Area (d� Comments LIFT STATION Date alled Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "'Check Permitted Bedroom Rating Against HAA Request" "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, inspection. [� verified, or conformed to all MOA and HAA guidelines in date of this m @ ! -1 Signed Company .(✓,G .5. l��.......,e��®� 'dam*e� Date 3'1�-`�q �•••�, •• •�Pr4�P�"d eal MOA No. 02-4 Receipt No. Date of Payment V-7- P% Amount: $ % 70, M Receipt No. Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 G Aflo,1R 04 " 1 eeeeeMeee tC � 4 STEVE COWPER, GOVERNOR DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 563-6775 3601 C STREET, SUITE 316 ANCHORAGE, ALASKA 99503 DATE: March 9, 1989 PWSID: CLASS C To Whom It May Concern: According to the records on file in this office, the SANDLAKE S D 2 BLK 3 LOT 20 is in compliance with the State of Alaska Drinking Water Regulations. Sincerely, 17 VERA E*CRAIG Environmental Field Officer 0 0 9 CHEMICAL & GEOLOGICAL LABORATORIES OFALASKA, INC. ineownroaies ` 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order # 12118 Date Report Printed: MAR 14 89 @ 10:40 Client Sample ID:L20, B3 SAND LAKE #2 PWSID :UA Client Name A E C S Collected MAR 10 89 @ 16:15 hrs. Client Acct AKECSRP Received MAR 10 89 @ 16:45 hrs. P.O.# NONE REC"D Preserved with :NONE Req # Ordered By Analysis Completed :MAR 13 89 ReleasedLaboratoryB Supexva :STEPHEN C. EDE Send Reports to: Released ByrILL 1)A E C S 2) Special Instruct: Chemlab Ref #: 4497 Lab Smpl ID: 1 Matrix: WATER Parameter Tested Result/Unfits ----------------------------------------- NITRATE -N ND(0.1) mg/l Sample ROUTINE SAMPLE. Remarks: SAMPLE COLLECTED BY RP. Allowable Method Limits --------- EPA 353.2 to 1 ND= Tests Performed==== _ None Detected See " Special Instructions Above=_ UA=Unavailable NA- Not Analyzed See Sample Remarks Above LT=Less Than, GT -Greater Than Time Time ne Date Date Date Inspector Inspector Inspector Comments Conditional Approval Badrooms t al Approval Date Sewer Installed Permit No. Septic Tank Size Holding Tank Size Soils Rating Well To Absorption Area Well Log Received Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Property Owner ✓' i '' ' L' Phone Mailing Address tt 1Y- c� Buyer Address Lending Institution Phone Address y S Realty Co. &Agent- f5fi`� 5 1Gjw( In °. ;; Phone AddressAr J �tc £' 7; ��vr�f Legal Description Street Location Type of Residence Single Family ,6 ❑ Multiple Family No. of Bedrooms ❑ Other Water Supply Individual ATTACH WELL LOG. A well log is required for all wells drilled since June Community 1975. For wells drilled prior to that date, give well depth (attach log if ❑ Public Utility available. Sewage Disposal �11 Individual Year Individual Installed: ❑ Public Utility When Connected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.