HomeMy WebLinkAboutPROSPECT HEIGHTS #1 BLK 6 LT 6AH
Prospect
ights
Block 6
Lot 6A
#015-092
-25
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
MAILING ADDRESS
PHONE
~]' NEW
[] UPGRADE
.OCATION
DISTANCE TO: Well //~U_.2 '//! Absorption area / ,j Dwelling ~"-)/~
Manufacturer ' -- ~/~-) "/"- Materi~ll
Inside length Width
Lq. capacty nga OhS
// .~0. I IF HOMEMADE:
I~ISTANCE TO: IWell
Manufacturer
Dwelling
DISTANCE TO: WelF~~ /.~Z~ Foundation..~ /
No. of lines Len,th of e~ach lithe Total len.qtb_of I)nes
Top of tile to ~ioish grade
Width
Length
Type of crib Crib diameter
Well
DISTANCE TO:
Dep ?
Building fpun~tion
DISTANCE TO:
Material
Nearest lot line
Trench width
inches
Material beneath~>/
inches
Depth
NO. OF BED~?~/[S
No. of com~_..ments
Liquid depth
PERMIT NO,
Liquid capacity in gallons
P E R~.~T N,N,N~O.
Distance I~,et.~we~ lines ...
Total effective absbrption area
PERMIT NO.
Crib depth Total effective absorption area
Building foundation I Nearest lot line
I
DrUler I Distance t,9,1ot line PEP~IT~NO. ~/
,z/~-~,.~y ~_~,~;~z//i//~ /Z'~' ·/~ c5L5' ~-'~C~-/, r<., ..
Sept c tank
Sewer l[ne,~,-/._/Z~ ¢~'~' ~ Absorption area(s) /
OTHER
PIPE MATERIALS
SOIL TEST RATING
REMARKS
APPROVED
DATE LEGAL
Date Drilleds
Static Water Level 152 feet
Gallons Per Minute
Draw Down ~L/A feet
Total Feet of~asin~ ~75
Type Material Drilled~
0 feet
~45 lent
Feet
foot
to 170 q!a]:~ ~ravel
to 289 he,rock
to
~0
Hefty Drilling
S.R.A. Box 1553 H
Anchorage,Alaska
995o
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15-
16-
17-
18-
19-
20
DATE PERFORMED:
IF YES, AT WHAT
DEPTH?
WAS GROUND WATER ,,4
ENCOUNTERED? /~/ 0
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE (minutes/inch)
S
L
O
P
E
SLOPE SITE PLAN
TEST RUN BETWEEN FT AND ~ FT
COMMENTS Pr-~p~-~4 .¢>o~p-flo;. /,;,e Io~...~;,~ /:~ t,.~..~.a ,~ ('L,)i,~ ~.~.~
PERFORMED BY: ~ ~ ~'Lbl~)~ ~ ~%~, CERTIFIED BY: IZD ~'~('~ DATE: ~*~Z-~'~
~JM , A.J J ~, Do, I
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING '
Parcel I.D.
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
HAA#
Expiration Date:,
Current Property owner(s) ~",~ { ~7'~ h, £~,"~ H-
Mailing address ~,o. Gox /I
Lending agency
Mailing address
Day phone.
Day phone
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.'
2. NUMBEROFBEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
[]
[]
[]
[]
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State o~ Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Heatth Authority Approval are
valid for 90 days from the date of issue for prcperties served by a private or Class C well and may be reissued with
new water jsample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The MunicipaIity of Anchorage is not responsible for errors or omissions In the professional
engineer's work.
STATEMENT OF INSPECTION BY ENGINEER
As codified 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 application, 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 ~'lat-~?"f-ec4,,;¢"l £e~'~¢"/ Phone
Address
Engineer's Printed Name --7~,,,~.4c,,-t- F'. r.-toc,,-~., Date
5.. DSD SIGNATURE
~ Approved for L/L . bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
....... -.
~. WATER AND . "'
: · WASTEWAI~A:
~ ~ PROG~M ,'
...... ..,
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bregaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchotage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
.........Leg,.,,' ...... ...... :..::--,... /...c~ ~'4, /'~lo, g~ ~'~ P~>.rpe~.t H~ ~l~t Parcel ID: OI..C-o'~ [- Z$-
A. WELL DATA
We, type
Date completed
Totel depth ~
If A, B, o~ C provide PWSID # ~./~
Sanitary seal (Y/N) ¥
Cased to I'/~' ft.
Well Log (Y/N) T
Wwes properly protected (Y/N) ~
Casing height (above ground) I ~ in.
FROM WELL LOG
AT INSPECTION
Date of test
Static water level
Well production
WATER SAMPLE I~ESULTS:
~'/.9't /,~,~" I el re(et
I~' ~ ft. . I,,~'"t ft.
,~ g.p.m. 0~. O '/' g.p.m.
Coliform {:~ colonies/100 mi.
Dateofsample: i {l /to
Nitrate ~,'/~' rng./i. Other bacteria ~ colonies/100 mi.
Cal ectedby:
'B. SEPTIC/HOLDING TANK DATA
TankType/Material ~?~r.. / J~o&.
Tank size { '~ $'~ gal. Number of Compartments
Foundation ctaanout (Y/N) '~' Depression over tank (Y/N)
Date of pumping ,~5"/~'/~'(:;~1~1 Pumper /~"/'
Date installed
Ctaanouts (Y/N)
High water alarm (Y/N)
C. ABSORPTION FIELD DATA
Dateinsteltad '~'b"/~5"' Soilrating (g.p.d./lt~or~/bdrm) t'~' ~,.,,,,Systemtype.
Length ~ ? 1~/~( ff. Width '~.5"' ft. Gravel below pipe
Total depth ~ lt. Eft. absorption area~.3~' ~ Monit~ing tube 'r' Depression over field
Date of adequa~ ~st ~o11~ 1OI ~ Resu~ (P~Fail) ~ F~ ~ bedr~ms
Flu~ depth in a~o~fion field b~m t~t ~ ~ in. Wat~ add~t=~ gal. N~ dept~, ~ in.
Elapsed Time: ff ~ ~n. Final flu~ d~th~ in. Absorption rate >= ~ O~ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type)
N~n~ /~oe.o. If yes, give date fJ, ~.
D. LIFT STATION Id. ~-.
Size in gallons
in. "Pump off' level at
Cycles te~ted
Date installed
'Pump on" level at
Datum
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tanldllfii station on lot ~ IIO ',
Absorption field on lot ~ I ~'
Public sewer main ~/. A
Se~er/septic service line '~ ~-,~"
in,
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots ",> ¢ ~,~'
On adjacent lots ~ ~c~,
Public sewer manhole/cteanout
Holding tank P./. ~.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Property line ~
Water service line
Building foundation ,~ '
Water main i~.~.
Wells on adjacent lots _~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Water Service line
Absorption field
Surface water
in.
Curtain drain ~o~g
F. COMMENTS
Building foundation ~
Surface water ~,/co
Wells on adjacent lots
Water main
Driveway. parking/vehicle storage
ENGINEER'S CERTIFICATION
I ceftin~ that I have determined through field ir~oectJons and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name
Date ~::~ ¢.~,/~ .~,.. I~',
Waiver Fee $
Date of Payment
Receipt Number
90T5515301
T-94~ P.0Z/03 F-471
CT&£ RzI. N
Order~-d By
PWSID
Remarks:
1017040001
Fl~op Ten,ica! Sty.
L 6A Blk 6 Prospect Hts #l
L 6A B]k 6 Prospect' Hfs # 1
Drir~dng Water
Cllest PON Pre-Paid Co]Ls/~O3
Printed Datefrlme 10/17/2001 17:39
Collected Dare, Time 10/10/2001 15:00
Received Date/Time 10/10/2001 16:15
Technical Director ' 81ephen C. F-.de
P~tCT
Nitrate-N
Total Coliform
Unit~ Method
0.500 mg/L EPA ~00.0
col/I OOmL SMI8 ~222D
Prep Analysh--
Dat~ Date Init
(<10) IO/lO/Ol SCL
(<1) 10/10/01 KAP
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 Descriptidn (include 10t, block, subdivision, section, township, range)
Location (address or directions)
(b) Property owner
Mailing Address
Telephone: (t~ome) '~77-~_~_~/7_ Business
(c) Lending Institution
Telephone
Mailing Address
(d) Real Estate Company and Agent
Telephone
(e) Mail the HAA to the following address: (er check here I~, 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 [] Public []
· Note: If 9,0mmunity 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.
72-025 (Rev. 7/88) Page 1 of 2
,.\%"
~. WELL~AT~
Well Clas~tion
Well Log Present (Y/N)
Total Depth ~ ~ ' Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description:
Date Completed
1'~5~ Depth of Grouting
PROSPECT HTS /tb~N -~ I
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot 15~.' To
If A, B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At UNk',
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
N
; On AdjOining Lots "~
C.O, ; On Adjoining Lots
To Nearest Public Sewer Line 7/°o / To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ~ tlo~
Water Sample Collected by FLATTOP T~:cE 5vc$ ; Date
WaterSampleTestResults ~TISF~CTO~Y ' O coc~o~ /IOO ~[ * 1.2 ~/~ N~1~ATE,N
Comments O~r~ ~ ~El/ ~(o~ ~ o~ ~//~1~ ~/~ ~)~
· j
SEPTIC/HOLDING TANK ~ATA
Date Installed ,,5 3iJ-~-E'-Size 1~5o G. Nc. of Compartments
Standpipes (Y/N) ~ Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) H Date Last Pumped 3/1~/~/
Pumping/Maintenance Contact on File (Y/N) N/~ ; for
Holding Tank High-Water Alarm (Y/N) N/~ Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING'TANK:
To Water-Supply Well Jl~ F~o~ ~.0. To B~ilding Foundation ~ p~o~ ~.0.
To Property Line ~0~ To Disposal Field
To Water Main/Service Line ~ ~o
To Stream, Pond, Lake or Major Drainage Course ~/oo
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX:(907) 561-5301
A].lo;~abl s
}.lJTg~,T~--~i J, 2 ~/t ~PA 353.2 10
Ear,~ple ROIJ~'T!{Z ,~At ..... COL[,ECTgD l~I T.F.
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Location (address or directions)
(b) Property owner / ~-; '"~
Mailing Address '"'/°\ ~_.~\
(c) Lending Institution
Telephone: (home)
Telephone
Business
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here~ if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms /7/
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 ~ 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.
72-025 (Rev. 7/88) Page I of 2
A. WELL ~A
Well ClasSification
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description:
If A, B, C, D.E.C. Approved (Y/N) /V/~
Yield
Well Log Present (Y/N) /V' Date Completed ~ -/-~"~"
Total Depth ~' / Cased to /7'--5''' Depth of Grouting
Static Water Level /v~/ / T4,'J'
Casing Height Above Ground //'¢' /
Electrical Wiring in-Conduit (Y/N) ~"
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot ' /OO
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot
NeareSt Public Sewer Line
To
To Nearest Sewer Service Line on LOt
Water Sample Collected by
Water Sample Test Results .~'~)
Comments 1,4,/~-// F/~, ,.../
/OO -/- ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole /V//~
¢-
/~¢ 7~'--5' ;Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ~/-~//~¢'~' Size /;2~.~0 No. of Compartments '2 _
Standpipes (Y/N) ~/ Air-tight CapS (Y/N) ~' Foundation Cleanout (Y/N)
Depression over Tank (Y/N) cA/' Date Last Pumped ,~/'7/'0:2'~;/ /~ '/'
Pumping/Maintenance Contact on File (Y/N) /~//¢ ;for
Holding Tank High-Water Alarm (Y/N) /¢'//~ Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well
To Property Line
To Water Main/Service Line /'~ '?
To Stream, Pond; Lake or Major Drainage Course
Comments
//~)O "7" To Building Foundation
~O ' To Disposal Field
72-026 (Rev. 7/88) Front Page 1 of 2
O THE N TESTING LA ORATOR]ES, NC.
600 UNIVERSITY PLAZA WEST. SUITE A
2505 FAIRBANKS STREET
FAIRBANKS. ALASKA 9~709
'ANCHORAGE. ALASKA 99503
907~ 79-3115
907-277-8378
Besse, Epps, & Potts
2220 East 88th
Anchorage, Alaska 99518
Attn: Andy Ports
Source: LGA,/B6 Prospect Heights
Sample ID#; A030289-5
Date Arrived:
Time Arrived:
Date Sampled:
Time Sampled:
Date Completed:
03/02/89
1400
03/02/89
1230
03/09/89
Parameter Unit Result ADEC MCC*
Nitrate-N mg/1 2.45 10
Reported By: Date: 03/09/89
Francois Rodigari, Anchorage Operations Manager
$ MCC = Maximum Contaminant Concentration
NORTHERN TESTING LABORATORIES,
INC.
650 U,NIVERS'.TY PLAZA WEST SUITE A
2505 FAIRBANKS STREET
FAIRBANKS. ALASKA 9~709
ANCHORAGE. ALASKA 29503
907-d79-2 ': 5
907-277-E ~ 75
Quality Control Report
Client:
ID#:
Besse, Epps & Ports
A030289-5
Listed below are quality control assurance reference samples with a known
concentration prior to analysis. The acceptable limits represent
a 95% confidence interval established by the Environmental Protection
Agency or by our laboratory through repetitive analyses of the
reference samiple. The reference samples indicated below were analyzed
at the same time as your sample, ensurinE the accuracy of your results.
Sample # Parameter Unit Result Acceptable Limit
EPA WP284-3 Nitrate-N mE/1 0.14 0.10 - 0.18
Reported By: Date: 03/09/89
Francois Rodigari, Anchorage Operation Manager
~30 EAST 88 AVflNUE
A~<~C~E, AK 99507
(9o7) 349-6451
WATER wk-r.r, TEST
LOCATION:
Subdivision: . ,
Lot:
Block:
Client's Name:
Address:
T~T~:
!.
7
Initial Reading o~ Meter:
DRAW GAr.r.ONS GAr.tONS FIEr,n METER
DOWN TIME GPM /% VOLUME TOTAL MONITOR LE~/EL READING
/dF/' F: ~'-o -- ~-+,~ ."+'- 0 ?, v' i%-y .~/ 7 ~/~
I~ o' I~; oo 5'. z-
./& v' lO:3o
t& 'l' lO:3'o
,, 5~ot ~l,~ '~'-~o ~eF~,'~ ~c)~1
?rcJuction Rate: ~ -/- GP.X! 24-Hour Capaci~:, Gallcn_~
.1. : GENERAL INFORMATION
/~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITy APPROVAL
,.OF 0N-SITE SEWER AND WATER FACILITY
264-4720" :.:
. .~:, :- , . Application Date
(a~ga.__~N~cription (include lo, t, block, subdivision, section, township, range)
·., ':."Location (address or directions): , - ' '!;:~' "
· ' ~ ' ~' ~ ~' ~'~ ' ; 'Teleph
Z... (b)'i Applicant Name.~/~'.'' ~7''/ e: Home
- Apphcant Address -.~ - ~ ~
.,-.-(c). ~pp cants (q~eck~'~j~e~:l'~stitut0~ ~"~':0~ner;;';i]~ Buyer~
,' ,::~;:,::,:~dy3~.Le~.i~g Instit~t!0p~ ,"., ,~- :: '):-..:;:. .... ~,;~.:?,~,'::,-,-'` .:_:..'~;'~;~.e!ephone :~
'.'::: (e)" Real Estate Corn pany and Agent
~;':' -:/~ '.."Address .v.-,
Telephone
'i:'(f) Mail the HAA to the following address: : ,
Single-Family,; Multi-Family ~ Other
Number of ~edr'ooms' '
~ote: I~ community woll system, must havo written confirmation from tho Stato Department O~ [nvironmental Conservation
attostin~ to the locality, and status· . ,~ ' ::. ' ' '
Note; f community well system, must have written c~nfirmati0n from the State Department of Environmental Conse~ation '
72-025 (11/84)
ENGINEERING FIRM PROVIDb..,~ INSPECTIONS, TESTS, FILE SEARCH, D,,
As certified by my seal affixed hereto and as of the Validation date shown below, I v~~
shows that the on-site water supply and/or wastewater disposal ~nal and adequate ' ~'~.
Authority
Approval
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 Munici pal and State codes, ordinances, and regulations in effect
the date of t~ion, t
Name of Firm ~//%.~:~5~' ,~'~'~,/.5 ~ /'~'~,.~-_4' Telephone
/
Address .~-.Z-.~--~2 ~,~ 2 ~'~'~¢- .~'~ .-'~"*'~ -
Date
DHEP APPROVAL C~/] ~'~
Approved for /'~/]¢'~-- bedrooms by
Approved ./~ Disapproved .'
Terms of Conditional Approval
'~.-~---/~-z.. ¢¢.._~ Date
Conditional
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 Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements, Employees of DHEP 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.
Page 2 of 2
~ MUNICIPALITY OF ANCHORAG~
MUNICIPALITY OF ANCHORAGE (MOA,, DEPT. OF HEALTH &
HEALTH AUTHORITY APPROVAL (HAA) ENVIRONMENTAL PROTECTION
') 0 lYSfi
CHECKLIST - FEBRUARY 1984 ~. j~ ~ ~
264-4720 ' ~
Legal Description :'~/~ ~ '~'~'/;~ .~'.-¢~ ~
WELL DATA
Well Classification ~'/~'~;~ ~'~- /~'~/'¢//- '-/ If A, B, C, D.E,C. Approved (Y/N)
Well Log Present~) Date Completed ,/~' -/--c~'C-~ Yield
Total Depth
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit~_.N)
Separation Distances from Well:
Depth of Grouting
Pump Set At
Sanitary Seal on Casing(~J~l)
Depression Around Wellhead
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
/
To Septic/Holding Tank on Lot /~¢¢' '/*- ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot /~'/'-~- ; On Adjoining Lots To Nearest Public Sewer
:./ / To Nearest Sewer Service Line on
./¢'.¢~/ ; Date~__~
B. SEPTIC/HOLDING TANK DATA
~-~
Date Installed '~'; %.~/-¢¢4} Size :~.-z'~'-d"~ No. of Compartments
Standpipe~;N) Air-tight Caps.4) . Foundation Cleanou(~)
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 ."/¢¢~
To Property Line ~ /
To Water Main/Service Line
Course
Comments
Date Last Pumped .-f/'--~,~/
; for
Temporary Holding Tank Permit (Y/N)
?
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
NOR1rlERN TESTING LABORATORIES, INC.
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99701 907-479-3115
6~57 OLD SEWARD HIGHWAY, SUITE 101 ANCHORAGE, ALASKA 99518 907-349-8623
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY CLIENT
] PUBLIC WATER SYSTEM I.D. Cf
] PRIVATE WATER SYSTEM
AMPLE DATE: ~-~
MO.
AMPLE TYPE:
r Routine
I Special Purpose
Day Year
State Zip Code
Phone ~-..~.~. -- ~--'.z.x__~'-- /
Purchase Order No.
[] Treated Water
[] Untreated Water
I Check Sample (for original contaminated
sample with lab reference no. )
~mple Time
No. Location Colle,=ted Coll~ed by ~.aboratory Ref, No.
2
3
4
7
lO
~nature of Representative
FOR LABORATORY USE ONLY
CASH CHARGE PREPAID TRANSMaTAL $PECIAL iN STRU CTIOi'/G MAIL
PICKUP
TO BE COMPLETE/~ BY LABORATORY
Received at: E~Anc_h. [] Fbks.
Time Received /O~
Next Sample Due
COMMENTS:
SATISFACTORY
UNSATISFACTORY U
RESAMPLE R
OTHER BACTERIA OB
TOO NUMEROUS TNTC
TO COUNT
Direct Verification Final
Count LSB BGB Result*
;DEPT. OF H~-,~,LT~
:EC-E-I VEl
*No. of TotaL.Coliform Colonies per 100 rnls.
Reported by
Date
Location:
BBS.SE, EPPS & POTTS
2220 EAST 88 AV~qUE
ANC~IORAGE, AK 99507
(907) 349-6451
WATER ~.L TEST
Lot: ~/
Block: ~'
,MUNICIPALITY OF ,,, ,CHORAQ~-
ENVIRONMENTAL PROTECTION
RECEIVED
JO'
UTILITY
fl
~A
?
· W~.I I 0
To Water-Supply Well
To Building Foundation
Lot /5///)
To Water Main/Service Line ~ O / ''/-'
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
C. ABSORPTION FIELD DATA
Soils Rating in Absorptio0 Strata /~.~'¢/ .. r~. Type of System Design
Date Installed -~'/~?//~:;~.--~' Length of Field CdC .
Width of Field 3 (_2 // Depth of Field ~' /
Gravel Bed Thickness ~ /
Square Feet of Absortion Area ...~.. z_/¢/¢ Statndpipes Present (Y/N)
Depression over Field (Y/N) /~/ Date of Last Adequacy Test 3/~/~"~
Results of Last Adequacy Test /~, gl ~ u/~ 7L~ /~,,_ ~'
SEPARATION DISTANCE FROM ABSORPTION FIELD:
/0('~ -t- To Property Line 70
.;2..L2 ~ To Existing or Abandoned System on
; On Adjoining Lots /~:)~
To Cutback (if present)
Comments
D. LIFT STATION
Date Installed
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)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
chec. ked, v~ifJed~or conformed to all MOA and HAA guidelines in effect o.n~.ttL:~"~%tcr~o..f this
I
certify
that
I
have
/I
inspection. //~5~._ .[~ .~~
Company
MOA
No.
Receipt NO. c~/~ 0 ~% /L~////~ Receipt NO. "~"~'~ ;~
Date of Payment ~ ¢ '~/,~ ~¢'~ Waiver Fee: $
Amount: $ /~ tsar) Date of Payment
72-026 (Rev, 7/88)8ack Page 2 of 2
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C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N) N
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well ~5'2' FRoH
To Building Foundation I~
Lot N
TO Water Main/Service Line ¢
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field ~,~
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N) ¥'
Date of Last Adequacy Test
To Property Line ~ 5'O f
To Existing or Abandoned System on
I
; On Adjoining Lots '7/oO
To Cutback (if present)
~/oo
Comments
D. LIFT STATION .N, ~.
Date Installed
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)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA,
inspection.
Signed ~'..'//-~'~¢/~"~ ¢ ~
Company F/~/'/'°~F "j-~c~/ ~}¢~[ ~'~r~¥~ c W 2 ~
Date ~ f~ ~[
MOANo. ¢¢ -~/~
on the date of this
ineer's Seal
Date of Payment '~ --c~?-//'~; ,/
Amount: $
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 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 m/cx~'~°/~ T~cJ~n'~/ _C~rv~r,~_r Telephone '~ ~- /~
Address /~ ~c~ ~ ~c~ ~ 9~/~
Date ~Fc~ /~, /~9/ '
DHHS APPROVAL
ApprOVed for
Approved
_ Disapproved. ._ Conditional
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 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) I~ack Page 2 of 2
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata -/'~-~ f./;"'~-.~/~¢--'~¢' Type of System Design
Date Installed .-¢ __ ~-/ Length of Reid
//
Width of Field ~ Depth of Field
Gravel Bed Thickness /
Square Feet of Absorption Area
Depression over Field (Y~)
Results of Last Adequacy Test
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 ~Z-~-~
Standpipes Preset)
Date of Last Adequacy Test
To Property Line ~//'¢¢
To Existing or Abandoned System on
/
; On Adjoining Lots
To Cutbank (if present) ,
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I ha)ce checke. CCverified, or conformed to alt MOA and HAA guidelines in effect on the date of this inspection.
Date of Payment ¢.~ .... ?¢~ ~ ~
Seal
Pro
H
P
c1'
ights
Block 6
Lot 6A
#015-092-25
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cLanchorage.ak, us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. E;' t&-- O9 E- ~-
GENERAL INFORMATION
Complete legat description
Expiration Date:
Location (site address or directions) '7 9 ¢ / ~', ,'cz ,'~- ~' C5 ~/~.
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
/'d~zf'~n /4fa c,~a ~',)/ Day phone
Mr k Day phone
/,¢.~/-~,y ~er. aa~_~e~_~ ?,'~F_.X, //;..r/'~ Day phone
,'¢ ,0
Unless otherwise requested, HAA will be held by DSD for pickup. ?1.~ c~ l l [~.~ ~,o ~ g.,,c, /,/-c,,-a
NUMBER OF BEDROOMS: '"/
TYPE OF WATER SUPPLY: '
Individual Well []
Individual Water Storage []
Community Class ~ Welt []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Heal(h Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a pedod of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
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 application, 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 ,¢/~¢z"2~/¢ -7-~A,~;¢~/ ~r.-~,'~c.~.,,- Phone
Address /"/_5- ~ ~..~_~,4¢ .~'/'{.~ /~'~cAo,",¢~
Engineer's Printed Name -7% ~0~__z¢¢ ¢-~ 7=. /'-foo~d' Date
DSD SIGNATURE
~ Approved for ¥ bedrooms. '.'/ ....
Disapproved. - .: * :t.: ~ '
Conditional approval for bedrooms, with the following stipulations:-
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By:
(Rev. 01/02)
Original Certificate Date:
H,.EAL~HAUTHQRI~ APPROVAL C:HECKLIS~..:;
FROM:WELL,LOG
· static:waterilevet -' luS':".~-
Well product on" ' ' .~:~ g;p..rO:
Casing.heigh~'(abm/e ground)
-.. AT I.NSPEO'I:ION
t.o t.:tO".'/o.?
:/.,5'r:~ ft..'
g.:p.m
~/VA~R!.SAMPL;E': R~ULi:S:
B;. SEPTICIHOLOIN.G.~ANK
Any'~eju~nation;:treat~nt (p~l-12.;m0.)(Y/N &~pe) ~.A~"~ '~o.~ :1[ yes, give date
D. ='LIF.T..STATION
Date .installed
"Pump on" level.at
Size in gallons ....
"Pumpoff' level at :'"~".'in;
Datum Cycles tested
E. SEPARATION DISTANCES
Manhole/Access (Y/N)
High wateralarm level at.
. ' "- Meets alarm & circuit, requirements?
SEPARATION DISTANCES FROM WELL ON kOT TO:
Septic tahldliff station on.lot ~ ! ! C7 ' "Od'a~tjacent 16ts
Absorption field on lot ~ I ~-~," On adjacent lots
Public.Sewer main /,./. ,4,
-> /~,
~ tc,~,
Public sewer manhole/cleanout
Sewer ~se'ptic service line ~ Z...C" Holding tank
SEPARATION DISTANCES FROM' SEPTIC/HOLDING TANK ON LOT .TO:
Building foundation Piopertty line ~'o ' Absorption field
Water main fi/. ,4. Water service line _O ~' ..... Sui-fA~:e ~vater
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON. LOT TO:
Property line
Water Ser{,ice line ~' ~"
Curtain drain /~/~Y~'
Building foundation ~ '~2' Water main
Surface water ~ 4o~
Wells on adjacent 10ts ~ .,too ·
F. COMMENTS
IO'
ENGINEER'S CERTIFICATION
I certify'that I have determined through field inspections and
review of Municipal recofds.that, the above..:systems are; in
conformance with MOA HAA guidelines in effect on thig date.
(Rev.. 12/01) '
- "~' Date ~f.Payment -,
.;; ,~ .Receipt~Ndml~er - -
Driveway, parking/vehicle storage ~ ~:)'"'~ ·
11-27-02 14:25 FROUcCT&E EItVIROlt~NTAL SRV gDTSO15301 T-g03 P.03/03 F-SB5
CT&E Environmental Se~ices Inc, ,, ,~.~t~,~,-~ ~ ,, .,:,~
Drinking Water AnAlys~s RepoA for Tora~ uomo~ uacmna
R~ ~Ne~UCTIONS ON REVERS~ SIDE BEFORE CO~ t F~ING S~P[E
20OW. Po~er Drive
MUST BE COMPLETED BY WATER SUPPLIER
' i PUBLIC WATER SYSTEM
PRIVATE WATER SYSTEM
[_~ Senti Results [j Send InvOiCe
Wal~ System F~.m(,~,~pafly Name ~mcl Name
Phone Nu r~m' Fax
Mining
i s~ Results [_~ Send Invoice
Company Nerve Conla~ Name
SAMPLE DATE:
SAMPLE TYPE:
,~ Routine
": Repeat Sample
(refer to lab no,
I'-! Special Purpose
Location Corrected from;
Z,p Co~
Anchorage, AK 99518-1605
Tek (~07) 562 2343
TO BE COMPLETED BY LABI~.~61-5301
Anal,,,vais ~ws ~is Wa~ ~PLE ~ ~:
Safisfa~
~ UnsaUsfa~
[~ Sample ~er 30 ~ o~. R~ul~ ~y be unmiiab~.
[~ Sample ~ long In ~it. Sample ~ould not ~ o~r
48 ~m ~ ~ anay~ to i~i~te mli~le msul~.
P~ sen~ a n~ ~m~e ~ia spe~at deli~ ~il.
Date Received:
Time Received:,
Analysis Began:
Analytical Method:
I¥00
Membrane Filter
Lab Ref No.
Result' Analyst
:,, . ~,:. .~. , .
[-'~j Treated Water sent to APEC:
i~ Untreated Water Bate:
ANC FBK JUN
Time:
Client notified of unsatisfaotory results:
Time Colle~ed [~
Collected: by (inRial): Phme
I1:~ '"['-~'~ Dam:
BACTERIOLOGICAL WATER ANAYSIS RECORD
MMO-MUG Result: Total Colifor~ E. Coil _
Membrane Filter: Direct Count {~ Colonies/1O0ral
Ve¢~,ficafion: LTB BGB COLIFORM
Comments:
S~a~e w~
Time:
hr~
Member of the SCS Group (Soci~te Generaie de Surveillance)
14:25 FRO~CT&E ENVIRONVENTAL SRV
~lr~ C T&EEnvironmental Services lnc.
9075615301
CT& E Ref.~
Clien! Name
Project Name~O
Client Sample ID
Matrix
PWSID 0
Sample Remarks:
1027993001
Flattop Technical Sty.
Prospect Hts #1 L6A, B6
Prospect Hts #i L6A, B6
Drinkiag Water
All Datec/Times are Alaska Standard Time
Printed Date/Time 11/26/2002 14:21
Collected Date/Time 11/22/2002 11:30
Received Date/Time 11/22/2002 I2:00
Technical Dir~~
Released By
' Nitrate-N
Re~ult~
2.05
PQL
Unim
Allowable Prep Analys/s
Limits Date Date
0.200 mg/L EPA 300.0 (<=10) 11/22/02
Init
IS
Mi=robiology Laboratory
Total Coliform 0
col/100mL SM18 9222B
(<=1)
1 !/22/02 SKW