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
�
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e
e_
REMARKS
`T
le
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Al
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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.