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Home My WebLink AboutT13N R3W SEC 13 LT 4 OF 26TI 3N R3W ction 13 Lot 4 of 26 #006-042-37 4. 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, based on procedures outlined in the Health Authority Approval Guidelines for this agplication, shows that the on- site water supply and/or wastewater disposal system is(are) 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. NameofFirm F /~-A,~ 7-ec4 ~,¢~! Address I~'.~ ~c'~, £t, ,4~c~,o,'~,,c, (/ - Engineer's Printed Name 3"4,.o ~_-~,.-e F', Phone Date 5. DSD SIGNATURE /..,- ..~'~,,.* Approved for ~... Dearooms ~ . , c=.~-~ , k ~' Disapproved. . '~ ...: ..." ....... cc, ~ . . . ...~ '. Conditional approval for bedrooms, w~th the follomn~ sbpulabons:~,,-:~':'-' Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: Municipality of Anchorage o Development Services Department Build'mo Safety Division On-Site Water & Wastewater Program 4700 South Bragaw SL V P.O. Box 196650 Anchorage, AK gg519-.6650 www.ci, anctmrage.ak.us HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescri~on: /.,o/ 'r'~[ ~ 5',¢~to~ /~/ If A, B, or C provide PWSID # . Sanitary seal (Y/N) Y FROM WELL LOG A. WELL DATA Well type Date completed Total depth ~, '/'~, Date of test Static water level Well production WATER SAMPLE RESULTS: Colifom~ tO colonies/lO0 mi. ~ mg.A. B. fl. g.p.m. Niffate O,,f~'4'mg/L Date of sample: SEPTIC/HOLDING TANK DATA ~.,4. ~* Tank Type/Material Tank size ' ' gal. Founda~n cleanout (Y/N) Date of pumping ABSORPTION FIELD DATA Number of Comparffnents, Depressio~ over tank (Y/N) Pumper /~/. A. Well Log (Y/N) ~ W~res propelS/protected (Y/N) Casing height (above ground) AT INSPECTION 915-1zoo~ I~"¢~' Date installed Length Total depth lt. Data of adequacy test Fluid depth in absorption field before test in. Elapsed Time: min. Final fluid depth Any rejuvenation treatment (past 12 mo.) [YIN & type} Soil rating (g.p.d./fl2 or ~lbdrm) It. ~ ft. Eft. absorption ama ~ Monitoring tube Results (Pass/Fail) Water added in. System type Gravel below pipe Depmesion over field For gal. New depth , Absorption rate >= If yes, give date g.p.d. Septic tank/lilt station on lot Absorption field on ;or M. Public sewer main D. LIFT STATION ~J. ~. Date installed 'Pump on' level at in. Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Building foundation Water main Wells on adjacent lots Size in gallons "Pump off' level at ___ in. Cycte= tested Manhole/Acces-$ (Y/N) High water alarm level at Meats alarm & circuit requirements? in. On adjacent lots On adjacent lots Public sewer manhole/cdeanout Water main Driveway, parking/vehicle storage G. ENGINEER'S CERTIFICATION ~' I ~ ~at I ha~ de~tn~ thigh field ~n$ m~w of Mun~pal ~s ~at ~e a~ s~ms am in Engineeds Pfin~ Name ~h~ ..-- D~ of Payment ~ / ;N / ~ ~ ~ ~ Pa~ent R~ipt Number ~G ~ ~ R~ipt Numar (Rev. 1~I) PropertY/line Water Service line Curtain drain F. COMMENTS SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO. /~./1.. Building foundation Surface water Wells on adjacent lots Sewerlsepticcen4celine q' (t,'.c,~t cr'~'~$~,.}' Holdlngtank A/.~. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: A/. A (A Proper['/line Absorption field Water service line Surface water I HERE~Y CERTIFY .THAT I HAVr SURVEYED THE SCALE: FOLLOWING DESCRIBED PROPERTY= /'-.',z'"~' AND THAT ND EN",?,ROACHMENTS EXIST EXCEPT ,~.$ IN~)ICATI~D, IT IS THE RESPONSIBILITY OF THE OWNE~R TO DE'TER/~INE THE EXISTENCE OF ANY EAS[MENTS, COVENANTS, OR RESTRICTIONS WHZCH DO NOT APPEAR ON THE RECORDE~ SUBDI- VISION PEAT. UNDER NO CIRCUMSTANCES SHOLL~ F~ ANY DATA HEREON i~E USED F'OR CONSTRUCTION "~"~""~ OF' FENCE LINES, OR FOR ES'I'.~'~LISHING ~IJN~- 'DRAvfN~ ARY LINES. $£j~-gg-~Z 04:ZZPg I:~pCU, c. EK¥1R~II,'EKT/,L SRV CT&E Environmentel So~lcea Inc. i S~m~ple Rr~tcs: Par.me~ Re~ut~ PQL Nitrat~N 0.466 0.200 All Dt te.../Tltnel are Alaska Stimlard Time P~nl~ Dat~ ~/~2 i0:33 Receded Dnt~ ~/05~ ]7:~ · ' ' AllowaMe Prep ~is' ' mg/L EPA 300.0 (<-10) 09/05/02 , JD'F T~dColEorm 0 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Completeilegal description LoT Location (site address or directions) Property owner Mailing address Lending agency Mailin. g address Agent Address-' Day phone Day phone · Day phone Unless otherwise requested, HAA will be held for pickup. .UMSE. .E .OO S: 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 v' NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~25 (Rey. 1/91) Front MOA#21 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 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 Address ~.0~ Engineer's signature / Phone Date DHHS SIGNATURE X Approved for 3 -- b~drooms. Disapproved. Conditional approval for bedrooms, with th-e following stipulations: Additional Comments Date/0- 2 ~:~- ~8 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 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, 1/91) I~cX MOA~t21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Well type Log present (Y/N) ~'J Total depth Sanitary seal (Y/N~O) Health AuthoritY Approval Checklist Lo-I- ~.,_ ~> ~ ;;~.,G ,_ ~ ~.4~~ Parcel I.D.: IfA, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to ~ ~D FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ~) Date of sample: i°/t'~/~l~'--- B, SEPTIC/HOLDING TANK DATA Date installed Foundation cleanout (Y/N) Date of Pumping C, ABSORPTION FIELD DATA Date installed Length Width Effective absorption area Date of adequacy test Fluid depth in absorption field before test (in.); Fluid depth (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* Casing height (above ground) Wires prope~;ly protected (Y/N) ~1~ o / AT INSPECTION }0. Nitrate /~)./-~ J~ ~*4°~/L- Other bacteria Collected by: t . ~ Tank size Depression (Y/N) Pumper Soil rating (g.p.d./fF or ft~/bdrm) Gravel thickness below pipe. Monitoring Tube present (Y/N) Results (Pass/Fail) Immediately after Absorption rate = Number of Compartments __ Cleanouts (Y/N).__ High water alarm (Y/N) System type Total depth Depression over field (Y/N) __ For gal. water added (in.): .g.p.d. bedrooms If yes. give date D. LIFT STATION ~X Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Size in gallons "Pump on" level at* *Datum Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots "Pump off" level at* SEPARATION DISTANCES FROM SEPTIO/HO/DING TANK ON lOTTO: Public sewer manhole/cleanout ~. 1 ~ c> Lift station I'~'//,,~- Foundation Property line Water main/service line Surface water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Properly line Building foundation Absorption field Wells on adjacent lots Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain Wells on adjacent lots ENGINEER'S CERTIFICATION , ,. ,c,: , ;-:. I certify that I have determined thru held inspections and rewew of Mumc/pal reco~ds, that'lhe above.¢ystem.,s are Signature / · , Engineer s Name D.t. HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 9075~1530i P.~3/07 CT&E Ref.# Client Nalrie Project Nm~xe/~' Clie~/Sample Matrix Ordered ~y 985371007 Tobben 8p~Idand P.E. ~l/a Lt 4, Bk 26 Homecrest DrSz:&ing Water Client PO// Printed Date/TLme 10/15/98 15:15 Collected Date/Thne 10/13/98 12:30 Received DatefTime 10/I3/98 13:25 Technlcal Director: Stephen C, Ede PWSID ' 0 Released By j .~ · ~ , , ~, Sam--" pie R~e'~s~r[~: 0.4'lg 0.?00 rr~/L EPA 300,0 10 mnx ~ APPLIC~":~T FILLS OUT UPPER HAL ONLY Proj~ert..y C.~-~l~r ~ W' ~ Phone Address Zip Code ~ Individual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975. ~ Community For wells drilled prior to that date, give well depth (attach log if available). ~ Public Utility Sewer Disposal /,_ / ~ -- ~ ~ ~ Individual Year Individual Installed: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFOR~ ~OC~SSING CAN B~ INITIATED. Date Date Date Field Notes: '' ¢ ~¢~ MUNICIPALI~ OF ANCHO~GE ~__/~ --~ ENVIRONMENTAL PROTECTION ( '~APPROVEO BEDROOMS / 'CONDITIONS OF APPROVAL ( ) DISAPPROVED CONDITIONAL APPR~VAL~ 72-023(3/~) Dat¢~ Date Date Inspector Inspector Inspector Comments Conditional Approval -~ ~ t ~ ~co'oved Bedrooms ~.~) D;s~?roved Date Sewer Installed Permit No. Septic Tank Size Holding Ta~k Size Soils Rating Well To Absorption Area Well Log Received Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Properly Owner ~ ~ ¢ ~ ~4/¢~ ~ Phone Buyer Address Realty Co. & Agent ~/~ Phone Street Location /~/ ~Z~C~ TypetCesidence B Single Family B Multiple Family NO. of Bedrooms B Ot~er Watel~Pply ~ Individual A~ACH WELL LOG. A well Icg is required for all wells drilled since June B Community ~975. For wells drilled prior to that date, give well depth (attach Icg if ~ Public UtiJit~ ~vailable.). Sewage~isposal ~ndividua[ Year Individual Installed: ~ Public Utility When Con&aCted to Bublic Utility:~ $~ NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE ~RO'8~SlNe CAN BE INITIATED. Nay 20, 1982 C~L. Rodriguez 171 Place St. Anchorage, subject: I~ot 4 of BL~4 Lot 26 T13N R3W Approval for the individual sewer and water facilities cannot be granted until the following items have been completed: ~]e water analysis report needs to be submitted to this office from 'the Chem Lab, 5~33 B Street, for onr review. ExDose the well for our inspection to determine proper construction, also to insure minimum distance requirements -~ ,. system. are met between the well and Please notify this Department for a reinspection when the noted discrepancies have been corrected. If there are any further questions, please call %fhis office at 264.-4720. Sincerely, Robert C. Pratt Associate Environmental Specio list Place Vacant ~ ENVIRoNM~.N, TA L EN~INEERiN~ DiVisioN elephone264.4720 i ~'' ; i ~) REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIEs DIRECTIONS: CompJete all Parts on Page I. InComplete requests w/fl not be processed pj . ease allow ten {~0~ days for processing, Calistro L. Rodriguez P.O. Box 8493, Anch. Ak. 99508 Peoples Bank & Trust Co. Pouch 7-007, Anch. Ak. 99510 Syndic Realty/Jim Duggan 2603 Denali Street, Anch. Ak. SINGLE FAMiLy MULTIPLE FAMILy INDIVIDUAL* COMMUNITY 3 UTILITY INDIVIDUAL/ON_SiTE** PUBLIC UTILITY .M. 5O4 [Z] One ~ FOur [Z] Other /Z~ Two [Z~ Five ~] Three [Z] Six * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well lattach log if available.) **if individual/on.site, give installation date If system is OVer two (2) years old an ' by this Department. adeq~ired NOTE: THE INSPECTioN FEE MUST ACCOMPANy EACH REQUEST BEFORE 72-01 PROCESSING CAN RE INITIATED. ~aH£O [~l s~3N¥ A-I ti. NV :~ ~qdt£'qO~ ~ -3ON'~QIS'~ dO ::3dA-L ~HO£ODdSNI~ s]_N-31AI£NIoddV NOLLO~asNt :SNC aaa AqNO aSR 1¥131:I::10 ~0::t acllS SIH-L