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HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 8 LT 1odl*ak Manor Block 8 Lot 1 #015-042-28 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 015- o4 �­-Z1; 1. GENERAL INFORMATION Complete legal description L -o l 9 �r- 6 ZoDIAN�_ t. ANOVL Location (site address or directions) q;7-" Z X1.1.1 %4 b ri of Property owner DC4xj( -K Day phone 3 46 - 36 4 7 Mailing address y Zao Z e1� 1�(� l7r g4� Ib Lending agency K v Mailing add Agent Address _ Unless otherwise requested, HAA will be held for pickup. '' 2. NUMBER OF BEDROOMS: `4 3. TYPE OF WATER SUPPLY: Individual well Community well Public water ft!�,Day phone _ 3 0 S _ Day phone — 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(Rev.1/91) Front 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 for the number of bedrooms and type of structure indicated herein. I furtherverify 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 Sl2u)r1,ta"-X LtE Phone L (-1916 Address H Engineer's signature Date 4 z4 A F` 6. DHHS SIGNATURE C/ Approved for l- 0yR bedrooms. Disapproved. Conditional approval for Additional Comments 0 MITIC bedrooms, with the following stipulations: 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 (R .1Nt) Back MOA 021 RECEIVED Municipality of Anchorage OCT 05 1999 DEPARTMENT OF HEALTH & HUMAN SERVI9A RA& Environmental Services Division GPAttA sE VI CS DIV tNYiR(}NMENTAL SERVICES DIY 825 L Street, Room 502 • Anchorage, Alaska 99501 e (907) 343-4744 Health Authority Approval Checklist Legal Description: L o T L 3 K b 7 -OD I A1L H AMb 2 Parcel I.D.: 015— 0 4 Z— Z S A. WELL DATA Well type If A, B, or C, attach ADEC letter. ADEC water system number Vi A6, Log present (Y/N) %1 Date completed 14 7 Total depth 1 $ U Cased to Sanitary seal (Y/N) FROM WELL LOG Date of test Static water level I fro Well production 9.p -m. Casing height (above ground) a, Wires properly protected (YIN) N AT INSPECTION 9- �29- 99 )b D g.p.m. WATER SAMPLE RESULTS: Coliform 6 / Nitrate ©.k q9 Other bacteria Date of sample: '1y9L f Collected by: d -� B. SEPTIC/HOLDING TANK DATA Date installed Tank size umber of Compartments Cleanouts (YM) Foundation cleanout (YM) D ression (Y/N) High water alarm (Y/N) Date of Pumping P per C. ABSORPTION FIELD DATA Date installed Soil rating Length Width Effective absorption area Date of adequacy test Fluid depth in absorption field before Fluid depth (ins) Minute, Peroxide treatment (past 12 mon s) 72-026 (Rev. 3/96)* orft2/bdrm) below pipe System type Total depth Tube present (Y/N)_ Depression over field (YM) (Pass(Fail) For bedrooms Immediately after_ gal. water added (in.): Absorption rate = c.p.d. (YM) If yes, give date D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested "Pump,W level at* *Datum gallons "Pump oft"level at* E. SEPARATION DISTANCES J r.wi AyYl" Ara • SEPARATION DISTANCES FROM WELL ON LOT TO: R D E C U a t." Septiclholding tank on lot M�Ar On adjacent lots IA} - Absorption field on lot N�� On adjacent lots Public sewer main 490 Public sewer manhole/cleanout % 6 (L.O Sewer /septic service line i m Lift station 111A SEPARATION DISTANCES FROM SEPTIC/HOLDING T64K ON LOTTO: Foundation Property line Absorption field Water main/service line Surface wate drainage Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPT N FIELD ON LOT TO: Property line Buildin foundation Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain Wells on adjacent lots F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records that time above systems are in conformance with MDA NAA guidelines in effect on this date. Signature t w Engineer's NameRA P Date HAA Fee $ '2-, rf Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number I r-1VIUI1 IV AM IN Community on-site' Public sewer. t stewAtersystem,%provide written: attesting to �fla. 1/91) Front MOA0211 - Location (site address or. directions) 7ewe %C_L.A Pro perty owner Day phone MaHin q oq) Mailing address Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held, for pickup., Ll 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community.well Public water. NOTE: If communitywell system, provide written, confirmation from State ADEC attest- ing to the legality, and status' of system'wr 4.' TYPE OF'WASTEWATEWDISPOSAL...- Individual, on-site r-1VIUI1 IV AM IN Community on-site' Public sewer. t stewAtersystem,%provide written: attesting to �fla. 1/91) Front MOA0211 nicipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority rl Ce'rtificates-based only upon the representations given in paragraph 5 above by an independent onal engineer registered in theState of Alaska. The DHHS does this as a courtesy to purchasers of homes r lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not: inspections or analyze data before a certificate is issued: The Municipality of Anchorage is note responsible for errors or omissions in the professional engineer's work: 72-02 (ROV•1i91) BSCk MOA#21 �," Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Parcel I.D. A. Well Data Well type __ If A, B, or C, attach ADEC letter. ADEC water system number ,:i y. Log present (Y/N) Date completed I Driller Total depth ) Cased to Casing height Sanitary seal (Y/N) FROM WELL LOG Date of test Static water level Wires properly protected (Y/N) Well flow g.p.m. Pump levell SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot (' AT INSPECTION Az 4L-4-g•pz! r A ISI CD m (Z' A N S O C y C O m On adjacent lots M Z Absorption field on lot 'r ; On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer service line Petroleum tank N /A WATER SAMPLE RESULTS: Coliform ` Nitrate �. 7 Z Other bacteria Date of sample: W I j' Collected by: Y r B. SEPTIC/HOLDING TANK DATA Nk Date installed Tank size Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) High water alarm (Y/N) Date of pumping tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot On adjacent lots Foundation To property line Absorption field Surface water/drainage Water main/service line 72-026(3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION /r Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent(Y/N) High water alarm level "Pump on" level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on D. ABSORPTION FIELD DATA �( Date installed Length Width On adjacent lots "Pump off" Level at Cycles tested Soil rating (GPD/Ft) Gravel thickness Total absorption area Cleanout present (Y/N) Date of adequacy test Results (pass/fail) Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent adjacent lots _Surface water System type Total depth Depression over field (Y/N) for Bedrooms _After test yes, give date Property line To existing or abandoned system on Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effeotpn.*c-�te.of this inspection. HAA Fee $ 3 U d Date of Payment —4�— ,Cl 4 q Gj Receipt Number a 7 J 7 r 72-026 (3/93)" Back Waiver Fee $ Date of Payment Receipt Number E La Signature e S t- Engineer's Name mob h Pu rola r Date(i/t V HAA Fee $ 3 U d Date of Payment —4�— ,Cl 4 q Gj Receipt Number a 7 J 7 r 72-026 (3/93)" Back Waiver Fee $ Date of Payment Receipt Number APR -19-94 TUE 8:32 AWWU FIELD SERVICES FAX NO. 9075625427 P.01 f BILL SHErFIELD, GOVERNOR DEPT. OF E NVIItOiVMENTA[. CONSERVATION f ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA 99501 274-2533 April 22, 1985 Mr. Louis J. Bonito Anchorage hater & Wastewater utility 3000 Arctic Boulevard Anchorage, Alaska 99503-3898 SUBJECT; Waiver Horizontal Separation between Wells and Sewerline Zodiak Manor L,I.D. 154, Anchorage, Alaska (85214,''A-134) Dear Mr. Bonito: The Department has reviewed the subject waiver request and hereby waives the horizontal separation between the wells and the Zodiak Manor L.I.D. 154, as detailed in your March 26, 1985 report. Tyton joints with the "Field Lok Gasket System" should be used in those areas requiring this horizontal separation waiver. The Raychem WPC/87 or TPS appear to provide the added assurance of no wastewater leakage in these sensitive areas. Inspection and installation of this L.I.D. is especially critical to assure non -contamination of water wells. I would like to observe installation of this line during construction. Sincerely, Steven W. Eng, District Engineer SWE/num Time APPLIONT FILLS OUT UPPER HAIlONLY • r- Time Property Owner / ��,ioI,r�t D(o)Y" IllKe- CliCufi Phone V K ;7'r-. Mailing Address - Zip Code 4Q Buyer Date Address (\J I Zip Code Lending Institution _ !� �ti"t:,JCG IYLd t LdC L7Lk — l'TUU CIS 1 on IRI✓C Phone Address fz „ .. Zip Code Inspector Realty Co. & Agent - - Phone Address Zip Code Field Notes: Legal Description I-, I 1) f 0C I YIL tf C 1 2 luJI `a� vt)(V��o)� Street Location Type of Residence S(Single Family Wilple Family No. of Bedrooms ❑ Other ) APPROVED BEDROOMS Water Supply ( ) DISAPPROVED Q/Individual �: J ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. ?T-Community DATE For wells drilled prior to that date, give well depth (attach log if available). ❑ Public Utility BY: Sewer Disposal Soils Rating ❑ Individual Year Individual Installed: U Public Utility When Connected to Public Utility: -��� VT"Molding Tank � „o,J Well to Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE I ITIATED. Time Time Time Time 4'I._.9 Ac Date Date Date Date S.-'A'SiJ U-:� Inspector Inspector Inspector Inspector I i I Field Notes: MUNICIPALITY OF ANCHORAGE DEPT. OF H`F.LTH <"I ENVIRONMLNTAL PROTECTION MAY 2 RECEIVED ) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' DATE V� �. '% % BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Septic Tank Size Well to Tank 720x3 f318n r GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Receivedu�7�7� Time of Inspection C/' Date of Inspection / / REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR 1. Approval requested by: Mailing Address: 2. Property Owner: Mailing Address: 3. Legal Description: 4. Location: 5. Type of facility to be inspec 6. Well Data: No. of bedrooms A. Type A B. Depth C. Construction D. Bacterial Analysis 7. Sewage Disposal System: A. Installed B. Installer C. Septic Tank: 1. Size 2. Manufacturer D. Seepage Pit: 1. Absorption Area 2. Material E. Disposal Field: Total length of lines 8. Distances: A. Well to: Septic tank Absorption area Sewer Lines , Nearest lot line Other contamination B. Foundation to septic tank , Absorption area C. Absorption area.to nearest lot line EQ -034 (1/74) Page 1 of two pages C Page 2 of two pages - Rest for Approval of Individual Or & Water Facilities Legal Description Comments Approved Disapproved Date Approval,Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED—(_, Date _ 1,1--7— 7T EQ -034 (1/74)