HomeMy WebLinkAboutSCHROEDER EAST BLK 3 LT 8�� MUNICIPALITY OF ANCHORAGE
' DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 2.04-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT?
NAME .--�� 3P oL� PGRADE
/ADDRESS
MAILING
LEGAL DESCRIPTION
6' 13 3 Sc) e c%f 6�_,p i
LOCATION / 7
O 61
NO. OF BEDROOM
vAbsorpt}�nare �-
DISTANCE TO: ( /\_/__]
Dwellin J„ (
PERI
—1
—
H z
Manufacturer62, //
Ma fl
No, of cornpartc "Is
V)
Liy. yap cioin,g9l Ions
<y (_
IF HOMEMADE:
Inside length
Width
Liquid depth
6 C7 z
Z
DISTANCE TO: Well Dwelling
PERMIT NO.
Liquid capacity in gallons
2 FQ-
Manufacturer Material
O
-f
w-
X,�Iy
UISTANCC- TO: ✓V /
FOUndat in �
yr -_
Nearest of line/
.�
1(J _
PFR Noy / �-
-
w u
---------
No. of lines / �ength reach li�ie �.
-.._-�----z'
Total ie h of Iin�s� Trench yvidth (
inches
- — -- �ZCJ —_--—
Distance bet e n lines
i
�orption
e[
}e �C
To f ti to finish grade
Ma er�al ben atl] it � // (,
palV
S�
Total effective area
O
_--
_.5 inches
Le tyth
Width
epth
PERMIT NO.
w
Q F-
0. d
w._-
Tyne of crib
Cril
Crib depth
Total effective absorption area
N
—-_-
DISTANCE "i0:
Well
Building foundation
Nearest lot line
Class 1 J -7-
(
DISTANCE TO:
Depth
Building foundation
Dyitter - —
Sewer line
Distance to lot line ^PERMIT NO. a
Septic tank Absorption area(s)
OTHER
"_�
-
-.-- --
PIPE MATERIALS
SOIL TES"I RATING
INSTAL:-
REMARKSLc
S J V 2 C4/%�.6 e-1 /ti—
Na �' .S els �N c.(,-( F,Ale-
—
-
-
--
- _�,
--
---
A P P R O V E D----- D E
�
r
MUNICIPALITY OF ANCHORAGE
%• DEPARIMENT 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 V Alf— — — JT7�r6 ZUEW-- ❑UPGRADE`
MAI LING ADDRESS.0
/f—�
LEGAL DESCRIPTION
G �' 3 SC' l
LOCATION
NO. OF BEDROOM��
U
W II Absorptj are /
DISTANCE TO: �:J( �AlJ7
Dwelling r�G
C-�—
PERkTy N3. - I�1 i
/ ! l
y
LU Q
Manufacturer
C
C
No. of compartrsiglts
C
NF'
Li ap�ci�,y, i n,gallons
// ((�� C-
IF HOMEMADE:
Inside length
Width
Liquid depth
�®
Well
Dwelling
PERMIT NO.
®Ly Z
DISTANCE TO:
z Q
Manufacturer
Material
Liquid capacity in gallons
T F
_
❑
J
w
DISTANCE TO:
W� II/ �^
UVJ -Z_
FoundatJ�n _ (
(F7,-.S ---
Nearest of line/ ,�
�V
PER
J LL
No. of lines /
Length pieach li'e
Total le, c Ih of linys
Trench idth !�
__inches
Distance bet e i ljnes
�_—
~
_
Top _tile toyfinish grade
Ma erial beneati1 HEI C, j C,
Z t%
dotal effective a sorption area
❑7—
Z� r _inches _
Le,gth
Width'Depth
PERMIT NO.
,u
i r
Type of crib
Crib diamet,67 /fit
Crib depth
Total effective absorption area
GG
W9.
Well
Building foundation
Nearest lot line
DISTANCE TO:
®,
J
Class 1 J _
/
Depth`zxti.,/
!
DytttEr
f
Distance to lot line ______][PERMIT
NO.
LU
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorpvon area (sl
OTHER
—
—
-
PIPE MATERIALS
/1/
SOILTF_STRATING
/51)INSTAL
REMARKS
f.
lJ f� 764 01111,6
7--
'N C Or'r
n
1
Tic
APPROVED DATE LEGAL
4r,'4i.
s��x 171Vini,
T __ F� ����C IR., F�-1 C3,�
DEPHRTMENT / HEHLTH HND ENV IRONMENTHL OTECl' ION
825 'L STREET, HNCHORHGE, �
AK. 9��1
264-4720
M v E-:- ILA F-7 F--, EE F--" 1-0 IF "I"
PERMIT NO. ( 8]0191 )
HPPLICHNI' TOM MHRONEY 2:50 FERN ANCHORAGE 99504 ]]]~6026
LOCHTION
LEGAL L8B] SCHROEDER EAST- LTT SIZE 999999 SQUARE FEET
TYPE OF SOIL ABSORPTION 5YSTEN IS: DRHINFIELL
MAXIMUM NUMBER OF BEDROOMS r= SOIL RHTING (SQ FT/BF')= 85
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
�C-M C3 FPO F-��o flNOF��
THE I-EhIGTH DIMENSION IS THE LENGT-I (lN FEET) O1"' THE TRENCH OR DRHINFIEL�.
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND HND THE BOTTOM QF THE EXCAVATION (IN FEET").Y�A� ����VA��� ��E��VA I � �75.
THE GRAVEL DEPTH IS THE MINIIOM DEPTH OF BETWEE.Pl TFIE OUTFHLL PIPE
HND THE BOTTOM OF THE EXCHVHTION (IN FEET).
�L.0 -1 F -a E-.- R_--- ����I C_' 7-�0,4 IF. -C ����E". EL ���uZo �n L_ L_ H_ffV9."_*",
PEF'11111" APP1.1CANT HAS TFIE RE�SPONSIBILIT� TO INFORII THIS DEPARTMEI'lT DuR'1�-jcl TH�
INSTHLLHTION INSPECTIONS OF HN� WELLS ADJACENT' TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THHT THE WELL WILL SERVE.
��� ��� �V��������T��� ���� ��C���T����
BACKFILLING OF AN',` WITHOUT FINHL INSPECTION HND HPPROVHL BY THIS
DEPARTMENT kill -L BE SUBJECT TO PROSECUTION.
MINIMUM DI�THNCE BETWEEN A WELL AND ANY ON --SITE SEWAGE DISPOSHL SYSTEM IS
100 FEET FOR H PRIVHTE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM H PRIVATE WELL TO R PRIVATE SEWER LINE IS 25 FEET HND
TFD H I SEWER LINE IS 75 FEET.
OTAER �EQUIREMENTS MHY HPPLY� SPECIFICHTIONS �ND ��NSTRUCTION DIHGRHMS HRE
FIYHILHBLE TO INSURE PROPER INSTHLLHTION
����1� ���������� ������������ ���L, �L���
I CERTIFY THAT
J. I A M FHMILIHR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS HS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
]� I UNDERSTAND THAI' THE ON-SITE SEWER SYSTEM MHY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMUDELED TO INCLUDE MORE THF ] BEDROOMS.
APPLIC:ANT TOM MHRONEY ./
^� /4
ISSUED BY
�r~�7~~�~����-~~~ �------- --��-``~7------
7125 OLD SEWARD HWY. "1" Loc,
& ENGINEERS, INC. ANCHORAGE, ALASKA 99503
S 349-6561 G` PERCOLATION
TEST
SOILS LOG -- PERCOLATION TES1
P E H FORMFD FOR:_/[_ ! .f G� ' (' \ DAFE PFHFORMED
-
�,n/� > Q
LEGAL DescRlPrloN:
r.k I CI (1PF CITE PI AN
r'
11 WAS GROUND WATER
ENCOUNTERED?
12
IF YES, AT WHAT
DEPTH'
s
Oate
Gross
Time•
14
-_ • =d.
.Jet
Drop
2
--
bIP 01 A�q ,.
9
0 00�
�
3
.Vp
—.=-"
17
c
4 -
M�
18
�?
ON—°U
�, ". JOHN H. MANS19
e
6
o-
7
n" p- „
°
g7'ROFCSSI()0
20
8
G
9
r'
11 WAS GROUND WATER
ENCOUNTERED?
12
IF YES, AT WHAT
DEPTH'
s
Oate
Gross
Time•
14
-_ • =d.
.Jet
Drop
15
bIP 01 A�q ,.
9
is
t�tA
16
17
c
18
�?
ON—°U
�, ". JOHN H. MANS19
g7'ROFCSSI()0
20
COMMENTS
A)
t (1 S
- ) L--
- O
Reading
Oate
Gross
Time•
Net
Time
Depth .,
Water
.Jet
Drop
.f
PERCOLATION RATE _� -7y11t. (minutes/inch)
TEST RUN BETWEEN •�"-�_. FT AND -/ FT
12008 (6/79)
Y
a
J �
Q
Q
G
o
o
O
o
O
o
0
0
0
0
0
0
F
F
F
F
F
F
F
F
F
F
F
F
w
w
w
w
w
w
rF�
w
w
w
w
w
u,
rA
i
E
0
0
0
00®
0
0
0
0
0
0
��
O
X
y
J
Fes•
3
wd
A
a
a
a
a
a
a
a
a
x
a
a
a
V
a
w
w
w
w
w
w
w
w
w
w
w
w
w
a
a
A
cn
A
O
J
J
D
�
Q
T
LU
I
CC
W
co
X
LU
ro
LL
0
O
a
F
F
F
F
F
w
F
w
F
w
F
w
F
w
F
w
F
w
O
O
O
O
O
O
O
O
O
O
O
O
F
F
F
F
F
F
F
F
F
F
F
F
rI-
w
w
w
Q
Y
z
O
z
O
Q �
d
'
F•
W
M
a
p
w
h
z
W
c
a
Q 000
v
u
O
OO
Q
O
O
O
O
O
O
O
O
z
(Da
w
11
p
a
a
a
a
a
a
a
a
Z
a
w
w
q
w
w
w
v.
�,
w
w
w
w
w
w
w
►i
U
O
A
@
a
3
F
A
F
A
u z
v
December 31., 1979
'y
i' z' at
Su,'1j ect Lot S... J.�'IC J SG:i 0('--..� - "••:C•_� - i. ...,.Oil
A permit issued by this department for well and/or sewer
system has expired.
Permits are issued on a calendar year basis, as stated on
J --he oer_mit, by authority of Municipal ordinance.
if you have drilled the well, a well log should be sent
to this department to document the installation date.
if an engineer has inspected the installation of the
on --site sewer system, please have then,' send us the as-builts
for our files.
if there are any further questions, :Tease contact this
Office at. 264-1720.
Sincerely,
Les N. Buchholz, R.S.
Senior. Environmental. Spec 5
LNB j w
enc: Copy of Per,.iit
^ »'-," . ~ `~ '� , . .'-' .. ' _
0EPHRTMENT OF HEHLTH HHD MIS IRONMENTHL P10TECTION
825 'L STREET, HNCHORHGE, Tim 99'
264-4720
'�
FERMIT NO ( 790128 )
II �: REQUIRED SIZE OF THE SOIL HBSORPTlON SYSTEM IS�
�.�� TA ��bp �F �^ ����.����
M AR Of H -1 � 1: TOOKE: I A 524 052 1 " F 1 Ell Y FIR 140 T< ����� f 0 � nit T5 ff m ii !�:: :T1 ij. K_���
PERMIT HPPLICHNT HHS THE RESPUNSIBILITY TU INFORM THIS DEPRRTMENT DURING THE
INSTHLLHTION INSPECTIONS O� H�Y W�LLS HDJHCENT TO THIS PROPERTY HND THE
NUM8ER OF RESIDENCES THHT THE WELL WILL SERVE.
!I- AT CA ;:�, �������1 WTI 141 YK; lot I it H M ER 1 �y HN R GO 47 Q A
BHCKFILLING OF HNY SYSTEM WITHOUT FINHL INSPECTlON HND HPPROVHL 8Y THIS
DEPHRTMENT 1-1) LL BE SUBJEC1 T0 PROSECUTION.
V H to? IV 0 :1 -. M4, FD, j! F" ILE �S:,: ��li.,: �:: W 'I I KEY F � I R! �-A.., 'I- .: 7 �, :7 :�fl
) CERTIFY IHT
1� l HM FRMILIHR WITH THE REQUIREMENTS FUR ON-SITE 5EWERS HND WELLS 8S SET
FORTH BY THE MUNICIPHLITY OF HNCHORHGE
2� I WILL INSTHLL THE SYSTEM TN HCCORDRIII CE WITH THE CODES
]� I UNDERSTHN� T T THE ON-SlTE SEWER SYSTEM MAY REQUIRE ENLHRGEMENT IF THE
RESIDENCE IS R�MUmtLED TO INCLUDE MORE THAN 4 BEDROOMS
SIGNED,.�
H
YI2
SOILS LOG
/---� MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
�• \ TEST
Pouch 6650, Anchorage, Alaska 99502 276-2221
SOILS LOG — PERCOLATION TEST
8
9
10
11
12
13
14
COMMENTS
31) 7-ry/v or- i-loc,'
/U/o i31 X) 100c-�r
0
WAS GROUND WATER �� S _
ENCOUNTERED? L
0,®
P-�'s`L-�r=
IF YES, AT WHAT % ..�.
DEPTH?
Reading
Date
Gross
Time
Net
Time
PERFORMED FOR:
/� /
DATE PERFORMED:_ �^ `4
r
� �L k 3
C
`y 1+'�/ZDI` �
�L �, DILI--
LEGAL DESCRIPTION:
4�n
SLOPE
SITE PLAN
I U
DEPTH
(FEET)
—
/ V� tS C)/ L-od
!j
�cp
l
j'n
Gl: H
"T�
4
5
peecoLl}r�vA-1 TZ4X7
6
S�
8
9
10
11
12
13
14
COMMENTS
31) 7-ry/v or- i-loc,'
/U/o i31 X) 100c-�r
0
WAS GROUND WATER �� S _
ENCOUNTERED? L
0,®
P-�'s`L-�r=
IF YES, AT WHAT % ..�.
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
IY
I U
//() 114 f n
�i Vii' `'
!j
�cp
j'n
Gl: H
"T�
PERCOLATION RATE
TEST RUN BETWEEN —!:E
1
PERFORMED BY: -5.r ��ZE`-/A%L=l�.G//i�c CERTIFIED
72-008 (7/76)
(minutes/inch)�j I1,Pk:
/
FT AND 4 L- - FT 7�
DATE:2-
MUNICIPALITY OF ANCHORAGE
• 4 Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343.4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
G[�,!C' n C,
Parcel 1. D. # CisCJ - 12i,-, ..-). - . HAA #
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 8; Block 3; Schn.oeden East Subdivision
Location (address or directions)
1715 Cha,%ity C.incte
(b) Property owner Hakof-d Mahoney Telephone: (home) ---Business
Mailing Address P.O. Box 37641 Mitwaukee. Wisconsin 53237
(c) Lending Institution
Mailing Address
'Telephone
(d) Heal Estate Company and Agent PERKINS REALTY ATTN: Geon.ge ekkins
Address Eagle Riven, A2a.6ka
Telephone
(e) Mail the HAA to the following address: (or check here43, if hold for pick up.)
List contact person and day phone number below:
S & S ENGINBERiNU
17034 Eagle River Loop Road No. 204
saxle River, Alaska
2. TYPE OF RESIDENCE
Single-FamilyU
3. WATER SUPPLY
Individual Well Nk
Number of bedrooms 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 ffi 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. 7/00) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AD 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 Telephone �9��Zrti 9
S & S'sNCbiNEER:ivv
Address iyo34 E3avie River Loop Roacs No. 204 _
Facile ,River, .Alaska 99
577
Date
6. DHHS APPROVAL
Approved for 3 bedrooms by —k" K SVIA(I-1-+ Date _ 10 1c Yc
Approved X Disapproved Conditional
Terms of Conditional Approval
V
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
F C� s\0a
MUNICIPALITY OF ANCHORAGE (MOA)
G\Qp� �P� S • Health Authority Approval (HAA)
v� �Fa ���� CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: L 'Or e)
A. WELL DATA /
Well Classification rtDody;�?ulL _ If A, B, C, D.E.C. Approved (Y/N) ^i!A
Well Log Present ON) Date Completed 5- 5' 83 _ Yield —3,3 Ln2d
Total Depth '_� Cased to 4d Depth of Grouting _ ��'Z.L, `1D�
Static Water Level — 33� — Pump Set At �6i -
Casing Height Above Ground _ l� Sanitary Seal on Casing ON)
Electrical Wiring in Conduit 0)/N) V Depression Around Wellhead (Y/Q _
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot N1 ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot 14IA- ; On Adjoining Lots _
-
To Nearest Public Sewer Line i5t �rTo Nearest Public Sewer Cleanout/Manhole�'� _
To Nearest Sewer Service Line on Lot 25I i
Water Sample Collected by ) N wear lLm ; Date `\cN _
Water Sample Test Results Csa ')5� _ 1?Ae.E �V t � 1n"2-AZ'TCn
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N)
Size ---No. of Compartments
Depression over Tank (Y/N)
Air -tight Caps (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High -Water Alarm (Y/N)
Foundation Clea
Date Last ped
_;for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FRO 4--REPTIC/I-IOLDING TANK:
To Water -Supply
To Pro
To Water Main/Service Line
To Building Foundation
To Disposal Field
To Stream, Po1nd, Lake or Major Drainage Course
`-
Comments �Z-a1-0 -TU "?tLu,10_ -SF--\A{Ekm= 9-1V—L Ja CY" Ct-7-(40-`10
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square f=eet of Absortion Area —
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSOR
To Water -Supply Well
To Building Foundation
Type of System Design.
Length of Field
Depth of Field —
Gravel Bed Thickness
StatndpipesP ent (Y/N)
Date ast Adequacy Test
FIELD:
To Property Line
To Existing or Abandoned System on
Lot ; On Adjoining Lots
To Water Mai l3ervice Line To Cutback (if present)
To Stre Pond, Lake, or Major Drainage Course
To riveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Cet
Comments
(Y/N)
Dimensions
Manhole/Access (Y/N
"Pf" Level at_Lm_
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 guidelines in effect on the date of this
inspection.
iFr
Signed V 0" UFh I_00P P%0.1 i IyTo_ 9()6.
FR910 k1yor, Alar&F, 90577 ��6P n epees }F- F V
Company
:.agih rOSeal
Date —
MOA No
/0 3
CC qo
C 3
Receipt No. S - �"�'Z `'/ `� Receipt No.
Date of Payment `e' 9 U Waiver Fee: $ —
Amount: $ Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
cm
L400NATO RiE6
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC
5633 B STREET • ANCHORAGE, ALASKA 99518 • TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
ANALYSIS REPORT BY SAMPLE for Work Order R 27614
Date Report Printed: OCT 1 90 @ 12:56
Client Sample ID:L8; B3: SCHROEDER EAST S/D Client Name : S & S ENGINEERING
PVISID :UA Client Acct SNSENGP
Collected SEP 26 90 @ 14:20 his. P.O.# NONE RECEIVED
Received SEP 27 90 @ 15:00 his. Req 14
Preserved with :AS REQUIRED Ordered By : R. SHAFER
Analysis Completed :SEP 28 90 Send Reports to:
Laboratory SupervisorTEPHEN C. EDE i)S & S ENGINEERING
Released By
Special
Instruct:
Chemlab Ref 4: 903920 Lab Smpl. ID: 1 Matrix: WATER
Allowable
Parameter Tested Result Units Method Limits
-----------------------------------------------------------------------------------------------------------------
NITRATE-ll 0.42 rsy;l EPA 353.2 10
Sample ROUTINE SAMPLE.
Remarks: SAMPLE COLLECTED BY RAY.
1
Tests Perfoanred
' See
Special Instructions Above UA=Unavailable
ND-
None Detected
See
Sample Remarks Above
NA=
Not Analyzed
LT -Less
Than, GT -Greater Than
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PRO'T'ECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL, CERTIFICATE
1. General Information
(a) Legal scri.ption (includ lour
5�
/"", 'c-�
Application Date
sub4ya'si.on section, township, range)
Location (address or directions)
(b) APpli.cants Nance �� f .td > r,/ t' `L-lephone _`
Applicants Address :51"
(c) Applicant is (check one) Lending Institution; omier/builderxK j
Buyer F ---T ; Other �`4 (explain);
(d) Tending Institution � . _�_ Tel_e�phone
Address
(e) Real. Estate Co. & Agent
Address
Telephone
2. of Resic�encp
Single -Family
Number of. Bedrooms
3. water Su221y.
Multi -Family
Other (describe
Individual. Wall. Community Public
Notes If ccm wni.ty well system, must have written confirmation from the State
Department of Environm.ntal Conservation attesting to the legality and status.
Is the well adequate for the number of bedrooms specified in this HAA (Y
4. Sewage Disposal
Onsite Xf Public Comminity Holding Tank
is the wastewater disposal. system adequate for the number of bedrooms
(Page 1 of 21
2--15-84
5. Enaim-erina Firm Providi.na Inspections, 7Y:sts, Data and Information
I o-rti.fy that-`[ have/checked, verified, or conforimd to all, 14DA HAA. Guidelines in
effect on tM date �pecti.on.
signed L -6F
_Olc:pilOPk
r'
Address _ i l_Jc
S1 ned. i7rc�:�V4r�r fliFlUi�n
Date
( ENGINEER SENL)
f
6.DHEP Approval
Approved for bedrooms By/' .i�_. �._ �� ;1 ,4 Date
Approv:)dDisapproved Conditional. F
'Perms of Conditional. Approval
The Municipality of Anchorage Department of Health and Environmental Protection does
not guarantee the continued satisfactory performance of the water supply and/or the
wastewater disposal system. This approval indicates that, as of the validation dram
shown above:, based on the data and information furnished by an engineer registered in
the State of Alaska, the crater supply and wastewater disposal system is safe and func-
tional
undtional for the number of bedrooms and type of structure indicated.
(DHFP SEAL)
7. Mail t. t r tY#' following address:
KB2/d5/s
(Page 2 of 21
2-15-•E4
A. WELL ARTA
m
MUNICIPALITY OF ANCHORAGE (MOA) G � A t
HEALTH AUTHORITY APPROVAL (HAA) /\
CHECKLIST - FEBRUARY 1984 uuo- a 8dd
Nolm:110N 'IV1NaMMIAN3
'E HUIVAH d0 WIG
20WOMNV d0 A 111VdD1Nf1W
Well Classificatio If A, B, or C, D.E.C. Approved(34± --
Well Log Pvesen (Y Date Completed 15-193 Yield " //
Total Depth Cased t�. e �( - Dept of Grouting
Static Water Level Pump �/ !1� Pump Set At Li
Casing Height Above Ground _ 2 e Sanitary Seal on Casingtem
1-
I
Electrical Wiring in Conduit (Y Depression Around Wellhead
Separation Distances from Wb11:
To Septic/Kc±di ng. Tank on Lot On Adjoining Lots N�r Ur
To Nearest Edge of Absorption field on Lot f`0 On Adjoining Lots G(N 0/=O
To Nearest Public Sewer �L/inl,e To Nearest Public Sewer
Cleanout/Manhole 0^J kit To Nearest Sewer Service Line on Lot =�f'q
Water Sample Collected By �,, '�'! i1�P1 ; Date �I -- 2 0 --0 �
Water Sample Test Results � �� 7 17014C o +2 I,
cam-ents l/%,FC. _0 TL -W'
SEPTIC/HOLDING TANK DATA
CEJ L �'X�AJ L�, /dL1L>!�
Date Installee .� Size ��C No. of Ccanpartne°nts
Standpipes/C_Yj 3 it -tight Caps (/ - foundation Cleanout
Depression over Tank `� Date Last Pumped a9
Pumping/Maintenance Contract on File (Y/N) /; for a®_
Holding Tank High -Water Alarm (Y�N3'�� Temporary Holding Tank Permit (x/N)!�
Separation Distances from Septic/Holding Tank;
To Water -Supply Well _f�( To Building Foundation
/r � To Disposal field
To Property Line // - �---.---�--,
To Water Main/Service Line -151C) T Tc, Stream, Pond, Lake, cir Major Drainage
Course
Comments
[Page 1 of 21 2-13-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata _J5� Type of System Designi��NF/�✓J
r
Date Installed J Length of Field
Width of Field _.Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Areae_, Standpipes Present ZM
Depression over Field ( Date of Last Adequacy Test /,u
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well _ //V / To Property Line
To Building Foundation 5 '% ( To Existing or Abandoned System on
Lot /LJ 1-n ; on Adjoining Lots CY AJ Qom' C� —
To Water Main/Service Line .7-0 To Cutbank(LL_2resent)
To Stream/Pond/Lake/or Major Drainage Course /(-/- — To Driveway, Parking Area, or Vehicle Storage Area 7Z-
rnmments l��e/ //,." 0
c /'/� l
D. LIFT STATION
Date Installed _ Dimensions`_
Size in Gallons " Manhole/Access—
"Pump On" Level at "Pump Off" Level at --
High Water Alarm Tavel at —_ Vent (Y/N) _
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (YM) �--- --
Comments -
** Check Permit
I certify th I
on the da of t
Signed
Compa
KBl/d5/s
[Page 2 of 21
F1
Bedroom Rating Against HAA4Request
n -checked, verified, or conformed to all MOA HAA Guidelines in effect
ion.