HomeMy WebLinkAboutEAGLE PARK BLK 1 LT 12A ' *~' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Divialon 825 'L" Street, Anchorage, Alaska 99502. Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ,.r,. DISTANCES '//*~' ~ROM~ SEPTIC ABSORPTION WELL ,~o,m I ~TANK FIELD P--"'~ ?/-~'3 ',/~_ I~''r"'' '''°'$? ~W,,', I~' °' B'"''~'"'~ WELL LEGAL OE$CflIPTION LOT LINE /-/'.5" / ! p,' / ,..~'~ / 'rAN~S I I ,~ J N [] SEPT,C ,./.,~,. [] .OLD,.O --b~ .~ ,4' ~.u,...,.c..,,.,.0.,,o. II ./~ TYPE o~ SYSTEM I.-,* i .... ~'' ........ I'X ...."~'"'' "- []..E.c. ~ .ED . [] ~,.o.*.,. []OT.E. ~[I I WE~CS I~1 REMARKS: P,O, ~x~ ~.~ ..' I ~~ ~ly BM ~is I~p~ wu p~med ~ding ~ ill ~ ~ - LouTs A~ Basra : ,~'~ 72-013 (3/8~) Permit Number: Date Issued: MUNICIPALITY°OF ANCHORAGE Department o[ Health ~ Human Services 825 L Street, Anchorage, Alaska 99501 545-~ O N - S I T E S E W E ~ P E R M I T ~~'~i~ 890149 Upg fade ~ 0 ~ ~ ~. 08/02/89 Engineer Designed Owner Address: SECETARY OF HUD 222 W. EIGHTH AVE. ANCHORAGE, AK 97515 Day Phone: 271-4542 Parcel Id: 050-782-56 ~- .... ~ '' Lot Legal: Subdivision: !EAGLE PARK'ILot: I~A Block: Section: ~ Township: |~W Range: 1W Lot Size 57026 (sq.¢t. or acres) Max Bedrooms: This Permit: I Total Capacity: 5 SEPTIC TANK: Minimum ~otal septic tank: capacity: tank must have at least 2 compartments. ~eet requires insulation over tank(s). 1,000 gallons. Each septic Depth to top o[ septic tank(m) < 4.0 INSTALL PER ENGINEERS ATTACHED DESIGN. NOTIFY DHHS PRIOR TO EACH INSPECTION BY THE ENGINEER. THIS PERMIT IS ISSUED FOR THE EXISTING 5 BEDROOM DWELLING ONLY AND EXPIRES ON 12/51/87. I CERTIFY THAT: 1. I am ~amiliar with the ~equirements for 2. on-~ite sewers and wells as set [orth by the Municipality o~ Anchorage (MOA) and the State o[ Alaska. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria o~ this permit. I will adhere to all MOA and State of Alaska requirements ~or the set back distances from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot. I understand that this permit is valid ~o~ a maximum o~ 1 bedrooms. I also understand that the capacity o~ the total system is 5 bedrooms and any enlargement will require an additional permit. Signed: (Owner) Issued By: SECETARY OF HUD DATE: DATE: DATE: 8/2/8~ TO: Lot 12A Blk.1 Eagle Park FROM: D.N. Golles, On-site ~ Subject: Permit application for upgrade. Per telecon with Lou Butera on 8/1/89 existing system is not adequate for 3 bedrooms. Bed design and location is warranted due to site conditions and ground water history. Upgrade is for one bedroom. db/85 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AN~ ENVIRONMENTAL PROTECTION 825 L Street, Anchotlge, Ale~ka 99501 264-4720 SOILS LOG -- PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: DATE PERFORMED: LEGAL DESCRIPTION: SLOPE SITE PLAN 1 2 3 4 5 6- 7- 8- 9- 10- 11 13 14 15 16 17 18 19 20 COMMENTS /~ ~','"~. WAS GROUND WATER ~L ENCOUNTERED? ,/~' Gr~.,;.'~,e*: pO E IF YES, AT WHAT I? ~-4V~J' ' DEPTH? Gross · Net Depth to Net Reading Date Time ' Time Water Drop i " ~:a~/~. /..-,.~. ~-"/'/~" / ~," PERCOLATION RATE ~ minutes/inch TEST RUN BETWEEN ~'/ FT AND '~-- FT PERFORMED 72-oo8 16/79) Eagre River Engineering Services P. O. Box 773294 Ea~]le River, AK 99577 Eg~-$195 CERTIFIED BY: ~~ DATE: ND £XI~TINF, ~/ELL~ ~/I?HIN 100~ ~tR ~A~BN. LEACH BED .'.' ' s - SE~ER CLEAN~T + - ~ELL :::::::::::- PROPOSED SEPTIC SITE PLAN LEGAL: EAGLE PARK SUBDV, LOT 1SA BLK 1 ~.... CONIRACTOR: N/A ~...,.~ ......... . ~0~ ~' a,-0771 ~r: 07/~/a~I sc~k[ r' = so' ~~~...,..~,.,.~.,,.... .... . _~:.~" EAGLE' RIVER ENGINEERING SERVICES w.~ ...... P.O. Bo= 773294 '**,~;'... EAGLE RIVER, 'AK. 99577 SPECIFICATIONS ~OR ON-SITE SEPTIC SYSTEN LEGAL: A. LOT 12A, BLOCK 1, GENERAL 1. 2. EAGLE PARK SUB. The well end septic plan ere for a single family residence only. The drawing and or site plan shall be a part of this specification. All materiels end workmanship shall meet the Anchorage Department of Health end State Department of Environmental Conservation requirements. 4..All soil tests are advisory to the design end ere to be verified or · modified in the field by the engineer. 5. All excavations and depths ere advisory end are to be verified or modified in the field by the contractor to meet Municipa'ltty 'of Anchorage, Department of Environmental Conservation 'requirements. 6,. It is the responsibility of the owner to obtain ell necessary permits or easements end to locate any adjacent muEtl-femily wells. ?o The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. It is eEways recommended that a surveyor locate the nearest lot lire position and the location of any easements. BED 1. The bed is to follow the natural lend contour to maintain uniform total depth of the bed bottom. 2. The bottom of the bed shell be level, plus or minus 3. The total depth of the bed excavation is not to exceed 4' at any point. 4. The sewer ~ine is to replace the existing sewer line that leeds to the existing pit which needs to be connected into the existing leach line to allow effluent distribution to the upgrade 5. The bed gravel is to be covered with typer fabric materiel. 6. Sell or combination of soil and extruded board insulation to a depth of 4' or equivalent is to be placed over the leachfteld. ?. The area over tho bed is to be finish-graded to prevent pending of surface water runoff. 8. THe septic tank end leachfield must not bc cloeer than 100' to any existing private well, 150' to any Class "C" well, or 200 feet to any community well. RECOMMENDED LEACHFIELD DIMENSIONS TOTAL DEPTH : 4' GRAVEL DEPTH = 6" BED LENGTH = 28' BED NIDTH= 12' Soil Rating = 225 Bedroom Capacity = 3 total S~tic Tank Size ~ E~istfng *~*NOTE: w**NOTE: *~NOTE: MOUND 1' COVER OVER LEACH BED AREA AS REQUIRED. PROVIDE 2ND COMPARTMENT CLEANOUT OM EXISTING SEPTIC TANK. PROVIDE FOUNDATION CLEANOUT BETWEEN HOUSE AND TANK AT HOUSE. EAGLE RIVER ENGINEERING SERVICES P.O. Box 773294 ,. -' EAGLE RIVER, ALASKA 99577 MUN~P~3~' OF A~:HORAC~ DEPT. OF HEALTH & Phone 694-5195 B',M~O~' FROTECt'IO~ To .,~,.~./~. ~ 3 0 m~ RECFIVI D LETTER Date Subject SIGNED Please reply [] No reply necessary LEGAL: 1.0 SPECIFICATIONS FOR LIFT STATION Eagle Park Subdv. Lot 12a Blk 1 GENERAL 1.1 The original drawings shall be a part of this specification. 1.2 All matertal~ and workmanship shall meet the requirements of Anchorage Department of Health and Environmental Protection Permit. 2.0 THE SEPTIC TANK LIFT STATION COMBINATION 2.1 Tank construction shall be a steel 2 compartment prefabricated tank approved by the Municipality of Anchorage. 2.2 Septic tank is to be installed level on compacted base material. 2.3 All connections are to be made with cauldEr couplings. 2.a The existing tank is to be pumped, crushed or removed. Area over new tank to be mounded to prevent future depression of soil. 2.5 Sewer line to tank to be et minimum grade of ~" per foot property bedded to.~revent settling. 2.6 New lift station to be wired to MOA electrical code by electrician. 2.7 Pressure line to leach area to be 1~" PVC, with invert to allow drainback. NO EXISTING WELLS WITHIN 100' NO EXISTING WELLS WI?HIN 100° EAST 125.65 ...... 10' UT]LIlY ~AS~H~NT PRIVATE WELL +100' coPY SEPTIC SITE PLAN LEGAL: EAGLE PARK SUBDV, LBT IPA BLK 1 OWNER: H.U.D. PROPERTIES CONTRACTOR: N/A JOB ..// 89-077I DATE: 07/28/89! SCALE 1" = 50' EA GLO, RIVER £NG/NEER/NG SERVICES ,1~.~, P.O. Bo~ 773294 EAGLE RIVER, 'AK. 99577 (907) 694-5195 ?AX: (SO?') 694-32,97  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 PHONE MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS ~ Men.lecturer ~, M,te, No. of comp,rtment, ~ , Liq, capacity in gellons Inside length Width ' Liquid depth /~ ~v HOME~OE= ~o ~ Well Dwegmg PERMIT NO, DISTANCE TO: Z ~ _ N°' °f Ime'~ Length o>e~c~ne To,al ~ k Type of crib Crib diameter Crib depth Total efl~tiw absorption area w Well BuXding foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller D~stance to lot hne PERMIT NO. m Building Ioundation ;e~r line Septic tank Absorption area(si ~ DISTANCE TO: OTHER PiPE MATERIAL~/n~ ~C SOIL TEST RATING REMARKS Orllll'ngCo~nyN~M Cotte~-~'.ac~n',J~ ~')r~'li~.~ U.S.G.S. Local f~o. Anc~ ~aFlc P~rk 12 ~ / / / N/$ [/V Don Ec~fle I~lver, Ak. uravel ~ Co ~ ~b 7. CASIN~: ~Th,Md,4 U~AX ~ 9QI IQI I,. to ft. Oipth ~,lghC lbs/fO.  SeC betwin ft. ~nd fO. 12. GROUTING; ~11 G~uted: ~ Yes }'erfo~tlcn~ ~t ~0-92 ft. ~sres,: ~ .~. ~{ox 50;~ Eacle Hiver, Ak. 99~77 r,ll._l[~ I i_.~ I~. ~L I T'v' . ~F DEPARTMENT C~HEALTH AND'ENVIRONMENTAL P~TECTION 825 'L _~TF'.EET, ANCHORAGE, 264-4720 --$'-- I TE PERMIT,, NO. LOCATIOU LOT SIZE ~ ~0 SQUARE FEET LEGAL ~.¢r7' 1'2.. -~l~, l £a &le P~i~i ~ T~PE OF SOIL ~8SORPTION ~TEM I~: ~ MAXIMUM NUNEER OF BEDROOMS = ~ ~OIL RATING ($0 FT/BR)= ~/~ THE REQUIRED SIZE OF THE SOIL ~BS0RPTION SYSTEM IS: ~ ~/ ORR~.-'EL DEPTH= 2 DEE'TH= LE~4GTH= /~ / THE LENGTH DIMENSION IS THE LENGTH (IN FEET) 0F THE TRENCH OR DRRINFIEL0. THE DEPTH O~ R TRENCH 0R PIT I5 THE DISTANCE BETWEEN THE SURFACE 0F THE GROUND AND THE BOTTOM 0F THE EXCRVRTION (IN FEET). THERE I5 NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE AND THE BOTT0~ 0F THE E~CRVRTION (IN FEET). PE~[T RPPLZCRNT HR~ THE RESPONSiBILiTY TO ~NFOE~ TH~S DEPARTMENT DU~ZNG ~HE ZNSTRLLST~OU ZNSPECTZONS OF RN~ HELLS ADJACENT TO TH~5 PROPERTY ~ND THE HUMgE~ OF ~ESZDENCES THAT THE ~ELL ~ZLL SERVE. ------ TI-.IO < 2 ~' I I'-I_'-~PECT I O I'-,t_'~ ARE REQLm I RED ERCKFILLING OF ANY SYSTEM HITHOUT FINAL INSPECTION AND RPPROVRL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R HELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR R PRIVATE HELL OR 150 TO 200 FEET FROM 8 PUBLIC HELL DEPEHDING UPON THE TYPE O~ PUELIC WELL. MINIMUM DISTANCE FROM R PRIVATE HELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUr~ITY SEWER LINE IS 75 FEET. WELL LOGS ARE REOUIRED AND MUST EE ~ETURNED TO THE DEPARTMENT WITHIN ~e DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SP~CIFICRTION5 AND CONSTRUCTION DIAGRAMS ARE AVAILABLE T0 INSURE PROPER INSTRLLRTION. PEAr, IT' EXPIRE~ DECEMBER Si.. 19BO I CERTIFY THAT l: I ~M FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS A~ SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL'THE SYSTEM Itt ACCORDANCE WITH THE CODE~. 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS. RPPL I CANT SOILS LOG MUNICIPALITY OF ANCHORAGE ~ PERCOLATION OEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST Pouch 6-6S0, Ancho~agao Alaska 99502 276-2221 SOILS LOG -- PERCOLATION TEST AS][ NO. 00680 PERFORMEOFOR: 0 & L Construction (Don Zimmerman) DATE PERFORMED:. 5/][.4/80 LEGALOE~RIPTION: Lot 12, Block 1~ 0rsanic Haterial 1 Sandy Silt Red Brown 2 Silty Sandy Gravel 3 w/some cobbles 6 7 g- 10- Gray Brown sl. Moist Wet 11 Eeqle Park Subdivision (GM) 13 SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? Y e s L '-. PI IF YES, AT WHAT 0 DEPTH? 14- 15- 16- 17- 18- 19- 20- COMMENTS Slow water seepage from accumulation in bottom of pit. PERFORMEOBY: S. Shrader 72.OO8 (7/76) I PERCOLATION RATE 20 HIN/INCH Im(nulesllmch} TEST RUN BETWEEN 4~0 . FTAND ~.f) FT 8-t'oot depth to total depth. No water Pit excavated 5/13/80 by client. CERTIFIEDBY: So Shcader DATE: 5/15/B0 Alaska Soils InvestiQations 624 W. Intll. Airport Rd. Anchorage, AK 99502 Reading Data Time ~me Water Drop 5/14/8C 10:08am -0- 0.20', -0- " 10:23 15 min 0.~5' 0.15' "' 10:38 15 min 0.41' 0.06' " 10:53 15'min 0.47' 0.06' " 11:08 15 min 0.53', O.OG' MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Eagle Park Lot 12A, Block ! T14N, R1W, Sec.17 Location (address or directions) 20445 Raven Drive, Eagle River, AK 99577 (b) Property owner H. U. D. · . Mailing Address 222 W. 8th Ave., (c) Lending Insiitution Telephone:(home) 'Anchorage'; AK 99813 Telephon~ Business 271-4342 Mailing Address (d) (e) Real Estate Company and Agent ;%S$ociated Brokers Address 640 W. 36th Ave.. Suite #1, Anchoraae. Telephone 563-3333 AK 99503-5807 Mail the HAA to the following address: (or check here I-1. if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Number of bedrooms Single-Family E] 3. WATER SUPPLY Individual Well I~ 3 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 [] 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 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 sys[em 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. NameofFirm Eagle River Engineering Serv~p~one 694-5195 Address P.O.B. 773294 Eagle River, AK 99577 Date 6. DHHS APPROVAL Approved for '~ ApproVed' ' /~' Disapproved Conditional Date Terms of Conditional Approval 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 an alyze 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 (ReY. 1/88) Back Page 2 of 2 A. WELL DATA ~ MUNICIPALITY OF ANCHORAGE (MOA) {, e~[~'T. ,Ii, ,.~-,oALtl-~ea th ~uthe~ty Approval (H~) ~ "'" '~'~:'~ApH~KLlSTs~BRUARY 1984 ' ' ' 6 19 9 Legal Descriptiom ~ · . ·RECEIVED /" Well Olassifioation Well Log Present (Y/N) ~ Date Oomplete~ ~ · ·otal Dept~/~/' O~se~ to ~' Dept~ of ~routing 8ratio Water Level ~2 '~z~ ~ ~,,~ ~ump get At OasJng Height Above ~roun~ /~ ' 8anita~ 8eal on O~sJng (Y/N) [leotrio~l Wiring in OonduJt (Y/N) Y Depression Around Wellhead (YIN) SEPARATION DISTANCES FROM WELL: ' -.- To Septic/Holding Tank on Lot ~/~ "' ; On Adjoining Lots ~/~ To Nearest Edge of Absorption F~eld on Lot /~= ; On Adjoining Lots. To Nearest Public Sewer Line . ~ To Nearest Public Sewer CleanouVManhole To Nearest Sewer Se~ice Line on Lot Water Sample Collected by ~¢~-~ ~ ; Date ~///~ Water Sample Test Results ~-~ = ~ ~/~ ~ ~,f ~5/~' If A, B, C, D.E.©. Approved (Y/N) ~',"~ Yield ?,~ ~-~'~', ~/g's Comments ' B. SEPTIC/HOLDING TANK DATA Date Installed ~,/,~ Size Standpipes (Y/N) Y Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (y/N) Holding Tank High-Water Alarm (Y/N) No~0f Compartments" :' ~ ' Foundation Cleanout (Y/N) Date,Last Pumped ,,T-,, ~ Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well '''/~' · To Property Line ~'/*'" To Water Main/Service Line -v-/~) · To Stream, Pond, Lake or Major Drainage Course To Building Foundation · '.':~ '"':" ':' ' To Disposal Field "'~ · '.~" '"~ "' Comments (Rev. 7/Sa) From Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata, Date Installed 7/~'~ Width of Field - ~' ' ~'/.z Square Feet of Absortion Area. z/.~g. Type of System Design Length of Field /'~' ~' · Depth of Field z/,~' ~,~, Gravel Bed Thickness . ,~ · ("' 6 "') Statndpipes Present (WN) D. epression over Field (.Y/N) ~ Date of Last AdequacY.Test 7//',~.//,~.~, · ResultsofLastAdequacyTest .~',r ;, ;~.,~ ~'~ r~..,. ~r'~, ,~. ~ .~ ,~',~. 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 Cutback (if present) ,e.,,/~ · D. LIFT STATION Date Installed ~ Size in Gallons /-~ J-~ ': ~' '" "Pump On" Level at ~ ~xz High Water Alarm Level at. 3g" Tested for Meets MOA Electrical Codes (Y/N) Comments ·".,~-~.~/~--,,~' ~' Dimensions" Manhole/Access iY/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against tIAA Request'* · I certify that I have checked, verified, or conformed to all MOA and HAA guidelines '~.,~/'~.~tCo~- t~_~ te of this inspection. ' Signed Date . MOA NO. .,.'.~ Re(~ipt No. ~"~["~ Receipt No. Date of Payment (~--~" ,'~ Waiver Fee: $ Amount: $ ? ~:~" ~ Date of Payment ~.o=e (n~,. 7/~) ~,,~ Page 2 of 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH o 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 lot, block, subdivision, section, township, range) · / · Location (address or direc~ons) Applicant Name ~ Telephone: Homo ~ ~Y- ~-~'77 Business Applicant Addreo$ (c) Applicant is (check one): Lending Institution D; Owner/builder,~. Buyer D; Other [] (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address r Telephone '/-O (f) '~fV~l the HAA io the following address: $ ~,'S-[~ii~,~I~- SRB 196x 2. TYPE OF RESIDENCE Single-Family,~ Multi-Family [] Number of Bedrooms ~ Other" WATER SUPPLY Individual Well,,~ Community [] Public [] Note: If community wel~ system, must have written Confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite, J~ Pul~lic [] Community [] .i-lolding Tank I-I Note: If community well system, must have written confirmation from the State Deparlment of Environmental Conservation attesting to the legality and status. Page 1 of 2 12-o2~ (~t/~) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION ** · As certified by my seal atlixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows Ihat 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 Ihe information obtained from the Municipality of Anchorage files and fro~ 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 Telephone S & s F. Agtne~Ntng · Address -.RB'lg~x Date .F~g~ ~:;rm~V;~condl~lc~naI Approva~iSapprovedJ Conditiona,(~ 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 Alasks. The DHEP does this as a courtesy lo purchasers of homes and Iheir lending Institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze dala before a certificate ~s issued. The Municipality of Anchorage is not responsible for errors or omissions ~n the professional engineer*s work. Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MO,-., HEALTH AUTHORITY APPROVAL (HAA) Hi~IOPAUTY C~ ANO~KLiST . FEBRUARY 1~ ~. ~ H~L~ & 2~ ~720 ~1~ ~T~I~ ~ Legal D~riptio~ ~ WELL.ATA RE([EIVED. Well Classification '"~iZ.I k/APr'~ If A, R, C, D.E.C. Approved (Y/N) Well Log Present ~ Date Completed ' I~::~ ~(:~ Yield Total Depth ~ O ~ ~ Cased to Static Water Level ~ ;5' ' Casing Height Above Ground Electrical Wiring in Conduit Separation Distances from Well: To Septic/Holding Tank on Lot Depth of Grouting -"--" Pump Set At Sanitary Seal on Casing (~J~ Depression Around Wellhead (-Y~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line t"t(l~-~ Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments ~,OO t ~ ; On Adjoining Lots ~.CO~ ~ To Nearest Public Sewer '~- To Nearest Sewer Sen/ice Line on Lot ~ ~-I ¥' ~,~.S ~.-~..~ (..~ ~ ~ ; Date ~- ~0 - ~ B, SEPTIC/HOLDING TANK DATA ~7' J'~'l "~0 Size /~)cC:) No. of Compartments ~' Foundation Cleanout ~ Date Last Pumped ,~-~.1~ ~o , for ~ Temporary Holding Tank Permit {Y/N) Date Installed Standpipes ~.N~ Air-tight Caps Depression over Tank.(.Y'~') Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well /0~ To Property Line To Water-Ma~/Ser;~ice Lithe Course r To Building Foundation To Disposal Field To Streaml Pond, Lake, or Major Drainage Comments Page I of 2 72-026{ 11/84 ) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed .ri .. I ~ - Width of Field '~ Square Feet of Absorption Area Depression over Field Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ! ~)c.~ I /.- To Building Foundation Lot 7-.- I ~ ~ 1 ~ ~ Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Presontt~:~. Date of Last Adequacy Test To Wate, ;v;,~;,,/Service Line gO t ~ To Stream/Pond/Lake/or Major Drainage Course To Driveway. Parking Area, or Vehicle Storage Area To Property Line ~ O I ~- To Existing or Abandoned System on ; On Adjoining Lots ,.5'-~, ' ~' TO Cutbank (if present) /"~-~-- Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at . . / High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) ,. "Pump Off" Level at Vent {WN) Pumping Cycles during Adequacy Test. Meets MOA Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MO~ and HAA guidelines in effect on the date of this inspection. Signed S & S F_~glm=m"i~l Date SEB 196x CompanyEc~e ~]v~. ~1.~ ~ MOA No. Receipt No. ~ ~ Date of Payment ~ ~ ~q- ~ ~ Amount: $ (O ~ ~ Page 2 of 2 -- [ DATE RECEIVED " INSPECTION APPOINTMENTS TIME~ - TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR~ DI~PT. OF I.- .T,l &  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT~J~iRONM[NTAL ~;.O;~_CTiON  825 L Street - Anchor~, Alaska 99501 { ' ENVIRONMENTAL SANITATION DIVISION DEC 1 1980 T~lephona 2644720 I~ r"/' I-/% I I- ~ REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEW~R~J l¥,~jj DIRECTIONS: Complete all parts o~t page 1. Incomplete request~ will not be processed. P~ease allow ten {10) days for proce~sing, MAILINC~DRESS .~. O T, f RESIDENT (I d ee tiro abov~Y~ PHONE MAILII~G ADDRESS STREET L~.$A~ION I .~_ ~/ 6. TYPEOF RESIDENCE NUMBER OF~BEDROOMS ~ SINGLE FAMILY i"1 One [] Four ~ Two I--} Five [] MULTIPLE FAMILY I-'] Three I--I Six [] Other 7. WATER UI~LY ~-~-~ INDIVI DUAL* * ATI'ACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM ~--.INDIVIDUAL/ON-SITE** ~.~_/~ YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-o~o (Rev. 6/?9) /j J THIS SIDE FOR OFFICIAL USE ONLY : ' 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY D TWO f-i FOUR i--t SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL r-I COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER I-'IINDIVIDUAL/ON -SITE DATE INSTALLED Connection Verified INSTALLER r-lSeptic Tan_k~or I--I Holding Tank Size: (~)-~'~ If Tank is homemade SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL/ ~'~/~'''~1 ,~_~p Absorption Area to nearest Lot Line 5. COMMENTS ~ APPROVED FOR '~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev. 6/79)