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Home My WebLink AboutHAMANN LT 14 MUNICIPALITY OF ANCHORAGE D~ ,RTMENT OF HEALTH AND HUMAN SEF. ;ES Environmental Heallh Division 825 %" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Address Phoneis) LEGAL DESCRIPTION TANKS SEPTIC ~] HOLDING TYPE o~ SYSTE~ ~"TRENCFI ['} BED ~} W. DRAI OTHER oug,nal grade Gravel lengtl~ __ _~o .Zl ~/~- FT FT ¢',/0 FT F'r WELL DISTANCES WELL SEPTIC ABSORPTION TANK FIELO /o '-/- /o LOT LINE FOUNDATION ~5~ ~ AS-BUILT DIAGRAM (Show Iocahon Gl well, sepho system, properly 1113es, foundatlOr]r driveway, waler bodies, etc.) FT WELLS ~ X'/ yPRIVATE [~ OTHER fldentifv) Classlhcahon (A.B,C~ /l oral DepU1 Cased to FT[ FI REMARKS: \ * 1 . [ s~a~: /V C ~(5 ~ I S & S ENGINEERING certify that this mSlmCtio was penormed aucording to all :~Depadment Approval: '~.~.~~ate.'~ SCALE .EILDCI<: NA ":,'., ?:'. ;t 2 J, i JJ:] PIF:'Jii; BE!FI-i:)I'.'I < q,, O i:::'1 ,, MA'-/ REi:E;;)U [I::;'.1!!!; ¢:'i L.l.r- , c:) Iml .... · ;.:.;~ tAJ'..llc; I"IUST HAUl:ii; A I I .:u..[. ) I I I,,,.IU CI.]PIF:'At:;'. IMl!ii]'q"lS ',(::)i'~.J"i I::i¥ 'L.h¢::':, Mur',:LC:il::h'~.~l:i.t'..y c::~f Al'iEhc)!"i:'~.(.~:l(.::~ (i"!E)A) Eq'l(::J 't:lu:;:, ;::: ;t: ~^i:i. ll :L rl.liid:.,:.'t ]. ]. 't'..h(:.:, !i;F?',B'(,E:!/f'~ :Jrt acc:(::)Pdar'tcc.:.:, ~,.,..,:L'!:.J'~ a;!.;I MOA (:).F}(:I :Jli(:::c, ffq::)]..i.;:';Hi(:::c0! ~,~!:i.t:.J"; tl'i,~:E, cJti:c,!i~-:J, gr'i (:::f':i. IL E::, p :J i:'~ C) J:' 't'i"J:J. fili :;:. ;I; ~.',¢:i..I.i ,'.] (;:f l"i (...:.:, P 6) 'L(::) ~;:'J].l MO¢'I ,'iid'ld E;'('. avL (.:..:, E){' A].ii',.Eil::i::~ PE:)qt..t:i.r,~'.!/ftE):ll'L!ii~ ~'(:)1' 'LI~E.', Ei,'::.~,'I.. back cJ :i.!i:Fi.,E:d ~C(..:'i~ .,'-' r'c,m u,.ny c:,x i st :i r'u::j w6~]. ]L ~, W4!'E;L('E;,~,~.~i:)'U(.?p (::! :i. spc)u;a ]. Ei(i?~,,,.u.,)l'd:'t('.](,;.;} !i!Uy'EF[~:':::,i~l C)F] 'l..hi!;!; or' Ed"iV adj,:::',(:::(.;~nt (::u' l"~('}h':'r~l't]w i!.C)(: /! ] LUi(:J:.:::'r'E;i:4:H'U:I '~.l];.i'cL LJ';.:i.E. J::)c:.:,l'rf~:i. tL J.S ',/alid '/'c:)P a rih'~tx:J, fi]Ltr¢l ,:Ld'~ ',.,.' E)n J ~':~ r' (il t::.!m!:i!l ~ ?. ~,'J i 1 ]. I' (.:':' (:jLt :i. r' e::, ,'::d i a(:Jd :J. J.. ;i. C)i't ~¢.i ]. i;) ~:? I' ffi :i. '['. ,, SCALE /78 PERFORMED FOR: '.EGA'. DESCR,PT,ON: /--//-/ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19- 20.- Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST -~"~ ("'~'~l~l~ ~AL) ~:~' . ~ % , '% ~ DATE PERFORM~. -,-¥ ~'~,~ ~ ~/~ To~,~hi~, Ra.~e, Section: ~ ~ ~ ~1 ~ ~' ~ SLOPE SITE PLAN ENCOUNTERED? s L-- IF YES, AT WHAT O DEPTH? p __ Deplh lo Waler Alter --'"'" ~' ~ Moniloring? Date: Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE __ ~JEJ3Gd-t~E'~OT,~C~ETER TEST RUN BETWEEN ,---'-"-/~T AND _ __ FT COMMENTS $ & 5 ENGiNEEr, lNG /' ) '~ /~-. //// / PERFORMEDI~ I?6X ' ~~m~ CERTIFY THAT TH~ TEST,WAS PERFORMED IN ACCORDANC~.,~,~~LGUIDELINES..~,~. v...,.~.~. DATE: 72-008 (Rev. 4/85) PERFORMED FOR: LEGAL DESCR IPTION:~' 1 2 3 8' ~0 14 ~? 20 Municipality of Anchorage ~ ~:~ DEPARTMENT OF HEALTH & HUMAN SERVICES~ ~ 825 "L" Street, Anchorage, Alaska 99502-0650 /~, ~ SOILS LOG-- PERCOLATION'rEST~ ~ ¢_ ~--"-~.,~ / ~"¢'¢7z'- DATE~E WAS GROUND WATER ENCOUNTERED? Township, Range, S~ect~ion: ~/SLOPE S L IF YES, AT WHAT ~ ~ O DEPTH? p Date D Gross Net Depth to Net Reading ate Time Time Water Drop ? ¢ PERCOLATION RATE ~'~'~ (m,nutes/mch) PERC HOLE DIAMETER TEST RUN BETWEEN I¢ FTAND /~'7 __FT COMMENTS THAT ~HIS TEST ~AS PERFORMED ACCORDANCE WI~¢~I~IDELIN~SqN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) oGRE 'ER ANCHORAGE AREA BO~' ~JGI'I Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPEC~TION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME ~-~'¢¢*'~"~/ MAILING ADDRESS /-L/./,L/~/g~'~/-, ~,t~----~ PHONE LOCATION LEGAL DESCRIPTION / g P/~[ /F~'~, SEPTIC TANK: DISTANCE FROM WELL INSIDE LENGTH M AN U FAC T U R E R..~f--~,]-t INSIDE WIDTH MATERIAL NUMBER OF COMPARTMENTS LIQUID DEPTH .LIQUID CAPACITY /pJb GALLONS. SEEPAGE PIT: NUMBER OF PITS MA*ER,AL}O LINING DIAMETER CRIB SIZE: BUILDING FOUNDATION__ WIDTH ~_0f,, t / , LENGTH o~ DEPTFI // OR DIAMETER f~/DEPTH ~-~ t DISTANCE FROM: WELL'C/O() t TOTAL EFFECTIVE NEAREST LOT LINE I ABSORPTION AREA (WALL AREA) SQ. FT. ADDITIONAL ABSORPTION TYPE BUILDING FOUNDATION __ CESSPOOL APPROVED CONSTRUCTION NEAREST LOT LINE OTHER SOURCES DISAPPROVED NEAREST SEWER LINE REMARKS DEPTH DISTANCE FROM: SEPTIC SEEPAGE TANK SYSTEM DISTANCES: INSTALLED BY: PIPE MATERIAl ' LOT SLOPE: REMARKS: Form No, EQ-031 DIAGRAM OF SYSTEM APPROWD71 /I G.A.A.B. ~ ;ii 4 i Ii::ii" !::'ii',!i',l i:il it',ill, (i;i;iiOi!iqi.:, i::i!',iD t'Iil:i( iiiiiOl'i'Ol-'t 0i::: I II1'~i !]i;:';;~]i;:t::!Vl::l'l'i!i()iq ':] ]'I",I I::'1'i1!i]'1' ;iii:' i];il:;?i::l",?i:~ii., i)ii!ii:::'Ti'i ]i]iii '1'1!1:!i i'"l]!;!',l'li!"lill'"l i;:,!!~:i~::'~t'1'1 0!::' (i!il:i;:lr:l',,,'~il li',!ii]'l'l,!!:i?i!",l '!'11i]:i 01. i'i'~:I:::ii i.:'] i:;i",iD Ti' Iii I:i',O I' i'01"1 Oi:: 'l'Hti!i !:i';;:-:;lil)i:::l',/l:::i'J' ii 0!",1 ( i!i t",I I::'I;!iI]i'I' ). o~E Russell Oyster 694-2774 Soils E~ Foundations petfo~ed for: GEO · ECHNI CAL El' DEVEL .~PMENT Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 CO. Earl Ellis 688-2280 Land Development Ground Water ~ncountered: Yes ....... No__~'..~< If yes, what depth.~ Proposed Installation: Seepage Pit January 5, 1977 4200 ~r~t~ve ~Jor a on~ (l) year Control Officc:c ~ GRE/ 'R ANCHORAGE AREA BO! JGH ,1"~0)''1'',, ~/~r~l~-~ DEPARTMENT OF ENVIRONMENTAL QUALIT ) ~/.{~ ' , / / ~ ' OTHER INSTALLATION Of: SEPTIC TANK % SEEPAGE P]T DRAIN PIELD - TYPE AND SIZE OF FACILITY TO ~E SERVED ~ , FINANCED THROUGH %.~%~O BE INSTALLED bY SOIL TEST RESULTS ~ _ NOTE~ THIS PERMIT I~ NOT V~LIB WITHOUT SOIL cOmPLETION DATE ANtiCIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING O~Y SYSTEM WITHOUT ~INAL INSPECTION bY THE DEPARTMENT OF ENVIRONMENTAL QUaliTY ~UTHOR[TY WILL BE SU~JECT TO PROSECUTION, SEPTIC TANK SIZE % TYPe I~INIMUM DISTANCES,N~R N~%UIREMENT5 TO SEEPAGE PIT WALL ~ ~ SEPTIC TANK WELL TO SEPTIC TANK SEEP GE PIT DRAIN FIELD ~ ALSO C NSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK ~, SEEPA E PIT GR~ ~ACKFILL SEEPAGE AREA SIZE TYPE DIAGRAM OP' SYE~TEM I' k4, z< %' :,-' ' i*"l I - ~ ; :- ~ ': , ' I %, , ~. . .; _ I , ; t .... i ' J ] ....... I CERTIFY THAT I AM FAMILIAR WiTH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE N~,.--~I~6-8-.~ND THAT THE ABOVE ACCORDANCE WITH SAID CODE. FORM NO, ~6 / ~ 22, z~ h;g l;l£y$ A£KOWLED~ ' .~ A T APP£O:AL . F,~broar~] --, !97~ ? ::..i.?, T:( 2~Lq CL',4~T,.'£,'. :,t.L'; O~-E Russell Oyster 694-2774 Soils 8' Foundations GF-OTECHNICAL E:r DEVELOPMENT Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 CO. Earl Ellis 688-2280 Land Development SOIL LOG Performed for: Legal Description:I 0 foil Characteristic) 4 6 7 8 g l0 Ground Water Encountered: Yes v'/' No__ If yes, what depth X(~ Proposed Installation: Seepage Pit Drain Fte~d~ Corr~ments: '- ~ Performed by: LOG OF DR" LING by A 8' L DRILL'~ 'G COMPANY ADDRESS ......................................................................... WELL SITE DATE--ENDED ......... KIND OF FORMATION: DRAW DOWN FT. G,~LS. PER HR ....... .~:~Z ............................................... KIND OF CASING .... .~._...~.. ..... -..~--.~- .................................. FROM..._.! ~_ ............ .~T. TO ...... ~5_¥~ ........... FT../~P'..,~. /5~V~'~ '~' ~O~_.._!.~ ........... ~. ~o~._._.$~.~ .......... ~w. wo...~i~ ......... F~J~. ~Z ~, '~o~ ............ ,.~.~.....~. ~o~ ........ ~ ....... ~. ~o..~./~ ............. ~.~..~_~.~-~' ~o~ ...... ~.~,.~.._..~. ~o~._...l_t~ ......... ~. ~o..._1.~.~ ......... ~...B~OQ.~.~.~ ~o~ ........................ ~. DRILLER'S NAME ..~/-. :~ ......................... 94171 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 AU~'HORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. HAA#_ 1. GENERAL INFORMATION Complete lega description ~ot 14 Hama~n Location (site address or directions) Property owner Mailing address Lending agency Mailing address John Waqner 24~0 E. Tudor Road, Premier Mortgage 300O 562-1915 Day phone Anchoraqe, Alaska 99507 Day phone 563-7736 'A' Street, Suite 102, Anchorage, Alaska 99503 Agent Address None Day phone ~ Unless otherwise reqUested, HAA will be held for pickup. i ':'::'; ,~ ; : ~ ' ! ! ,:, ~:~,, . ~'~ ;, ,, ~' ...... . -~.,, : , : ~ ~" ; '~:. :'::'' 2. NUMBER OF BEDROOMS: ' 3 ~ ' ' 'r 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: . If community well system, provide written confirmation from State ADEC atto ~-. . 4. TYPE OF WASTEWATER DISPOSAL: *'*'~ c~ ,,, Individual on-site '--'- '":.' ' ' ..... : '. ,'- · ' ,u ...... '" tank · ,:... · Community on-site ...... ,.. . · '""-' Pu~31ic sewer ' '~ NOTE:' If community wastewater sy§tem; ~'rovide ~['/tten confirmation from State'ADEC .' .. '" attestino___~ to the legali~,a'~id'~'ti~S'd¢"~,~t~m'."_____...________,__" :' '~'' ...... :;':" '~ ' L','i':' ' ?2*025(Rev, I/91) Front MO^~I' ' '" ; ~' · ¢" '; ' : ;' " s ?":~'""":;'( '' 5. STATEMENT OF INSPECTION BY ENGINEER As certified b~; my Seal affix'ed heret° and as o~ i~e'validation date shoWn balew, 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 inves_ti__gation 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 DHZ ~u]t-.i.n~ ~n~in~_~r.~ Phone (907) 34~,-1 Address P.O. Box ~11349~, 2820 ~o~Road, Anchorage, Alaska 99511:i~49 EngineeCs signature 6. DHHS SIGNATURE Additional Comments The Municipality of Anchorage Department of Health and Human Services(DHHSi"issbes He;Jith-A~th0~ity Approval Csrtificates based only upon the representations given in paragraph 5 ab~ge by an ihd~pe~dent ~:: 'profess onal engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes "· . and their lending nst tut ons n order to satisfy certa n federal and state requirements, Employees of DHHS do not ,~ ;, .'. 'conduct'·inspections'o~ .~nal~e. data before a cert'ificate is issued. The Municipality Of Anch0rag"~iis' n0~'~."-',.-!:, res onslb e for errors or om ss ons n the profess cna cng neer's work ...... , .... ,,: · ;.., · Municipality of Anchorage 941 7,~ Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~ot 14 Hamarm A. Well Data Parcel I.D. Well type --Individual Log present (Y/N) Y Total depth 300 ' ~ Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADECwater system number Date completed 09/05/75 (~ Driller 11 7.58 ' (~ Casing height Cased to FROM WELL LOG 09/05/75 Dale of test Static water level 100' Well flow 0.7 Pump level1 Unk~o~ SEPARATION DISTANCES FROM WELL TO: Wires properly protecled (Y/N) Septic/holding tank on lot 1 00' + (~ Absorption field on lot 120'+ ~ Public sewer rnain N/A Sewer service line N/A g.p.m. AT INSPECTION 11/27/94 0.5+ .290' +/- (Est) 0.67' (~ y (~) g.p.rn. ,~,,~, ..., ; On adjacent lots 1 50+ ~ ; On adjacent lots 1 50+ ~ Public sewer manhole/cleanout N/A Petroleum tank None Noted G WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate O. (~ i Other bacteria 11/23/94 (~ Collected by: Dustin High B, SEPTIC/HOLDING TANK DATA Date Inslalled 10/23/86 (~ Cleanouts (Y/N) Y (~ High water alarm (Y/N) Tank size 1 500 (~ Compadments Foundation cleanout (Y/N) ¥ (~ Depression (Y/N) N/A Alarm tested (Y/N) N/A Nd) Date of pumping Pumper -~r~r~y ?c~t.?¢,e.£ W' i/off _ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 110 +/- ~0 On adjacent tots 'To properly line 60 ' (~) Absorption field Surface water/drainage None (~ 100'+(~) 60' 0 Foundation 100'+ Water main/service line N/A 72-028 (3/g3)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons ,M~anufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles lested Vent (Y/N) "Pump on" leve/C,a'[ High water alarm level Meets MOA Y/N~/// electrical codes ( SEPARATION DISTANC/~OM LIFT STATION TO: Well on lot,,//' On adjacent lots D. ABSORPTION FIELD DATA Date installed 1 0/21/86 ~) Length (~ 55' Width Surface water Soil rating (GPD/Ft~) 21 2 ('~ 2.5' (~ Gravel thickness 6' (~ Cleanout present (Y/N) Results (pass/fail) 83" N Total absoq:)tion area 660 (~ Date of adequacy test 11/23/94 (~ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) ,System type Trench~ Total depth 9' ~) Y ~) Depression over field (Y/N) Passed ~) for 3 Bedrooms After lest 83" If yes, give date - SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 1 20 ' + To building foundation On adjacent lots Sudace water Cudain drain 120+ 100+ None None On adjacenl lots 100' + Properly line 60+ To existing or abandoned system on lot 60 ' Cutbank 15 ' + Water main/service line N/A Driveway, parking/vehicle slorage area 50 ' + E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effe ~) Per ~-Site Observation 11/23/94 ~ Per ~/Re~rds. / ,~ Date /Z_a.f~Dee Hig~ P.E. , of this inspection. HAA Fee $ L~(D Date of Payment Number Receipt Waiver Fee $ Date of Payment __ Receipt Number zTF_ Commercial Testing 8( Engineering Co, Ettvlronr,,enta( Laboratory Service~ LABORATOFtY ANALYSIS REPOR'r 94.5R~0-1 SE 1 BOX 1~16 ~k~L~ RIfflE WATER Client Namo D M I CONSULTING EM~INE~f WORK order 11005 PWSID UA ~TEP~EN C- ~DB O~ ~ ~dlowabl~ Ext. Anal Nitrmte-N 0,~1 m~/L R~A 300.0 I@~ 11/24/~4 ~m~ Speciml In.%ttuctiom~ /%k3ovm UA ~ ~$navailabl~ U is ~h~ llmlk, LT = ~m~ Th~ qualt~ I f ic'ati~ D., ~econ~ ~ilution. GT - G~eater Than 5633 8 Street A,mherege. AK 99518-1800 -- Tel; (~7) 562-2343 F.~: (907) 561-5301 E. NVI~IONMENTAI_ ¢!ACILIT1E~ IN ALASKA, COI_O.qAOO. FLORIDA. ILLINOIS, MARYLAND, NEW JER.'~.t~Y. OHIO, UTAH. WEST VIR01NIA Commercial Testing & Engineering Co, 6633 B Streel Anchm~ge. AK 99518,1600 Drinking Water Ailalysis Report for Total Coliform Bacteria READ IPlSTRLrCTIOP/S OIV REVERSE $ID~ )MdF(7~ COLLECTIN ~ SAMPZE Month Day Y~.ar SAMPLE TYPE: .,,- O ILou!i~5.,.... ..... U: Treated Water ~ Repeat Sample (for ~)uthle ~ample O Oul[e~ted Water wHh lab mi un, ) O Special ~urpose Time Collected S~LE LOCATION Collecled By Tel: (907} 562-2343 F~x: {90Y} 501-e0301 Tb 13,9., COMPLETED DY LABORATORY Analysis shows figs Water SAMPLE to be; Saisfnctmy 3mpl~ over 30 ho~s old, resulls may be S~ple t~ long ~ ~it; s~ple shoed not be over 4g ho~s oJd at ex~atJon to ~dicnte ~liable results. Plca~ ~nd flew smp]o via sp~i~ del~ve~ mil O~le Received ~ ~ Analysis Began AnalyHeal ~i[ethod: ~,51,~mbrane Filter ~ MMO.MUO J?huncd 81~0ke rdth Nmnber o£culoniedl00 ml. Lab Re/N,' Rc,ult+ Analyst S~nt to A.D.~C, ~b~ J~ ~ F~x~d Client notified o~ unsaf{sfac/or~' l'e~ulls: Date: Tim~; (..'.omlllen t5: BACTERIOLOGICAL WATER ANAd(,YSI$ RECORD Final Membrsne FUger ll~t~lt~ Coli coton~t~ ,~ ¢OLIIqRM ColiFom~/lOlt ml ONE OF TWO ENVIRONMENTAL IrACILI.T16[I IN. ^LAS~',~, COLORAbO, FLORIDA, ILLINOIS, MARYLANO, NEW JEfllg[Y, OHIO, Uq'AH, WEgT VIRGINIA FAX MEMORANDUM TO: Dept. of Health & Human Services DATE: 12L?,1\94 FAX NO.: 343-6740 W.O, NO.: 94171 ATTENTION: Dan Roth NO. OF PAGES: 1 SUBJECT: lot 14, Hamann Subd. Including this cover sheet) x FOR YOUR INFORMATION: Original Disposition: [] ~$11od g] Call for Pickup [] Flied [] For Your use [] For Revlew&Cornrnent X As Requested [] ForApprova[ MESSAGE: Dan, As a follow up to our phone conversation, I have reviewed our records of the adequacy test conducted on the above referenced lot. The measurement to the depth of the water level iFi the trench of 83" is from the top of the stand pipe. The top of pipe is 2' above the ground. Based on 9' total depth & 3' of cover, this makes the water level 25" below the bottom of the perforated pipe. We took another water sample today and turned it into the lab. I11 forward the results as soon as I get them. I hope this additional information answers all your concerns. Please call if you have any more questions. SENT BY: Dee High DHI CONSULTING ENGINEERS PO, BOX 111349 ANCHORAGE, ALASKA 99511-t349 PHONE', {907) 345-1385 FAX: (907) 345-1388 Dz/nk2ng Water Azxalysis P..¢port for Total Coliform Bacteria R.E, At) IN'ST.R,D'CTIO[v~ ON .P,J.'~E ~'ID.E: BEFOR.g COLLEG"TL,¥F~ ~,~~.~. · ............. ~~ . ~..~ · ~,~gO ~ ~ ,'~o~h Day Year O Rout~l¢ O Treated Water LOCATION /h~ k)~,,,~, ,,.-,__ A~aly$is P, egm~ rou~ ~a~ili ~llmh~(~ de ~urveill~r~el TOTAL P.02 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~-1~ - ~.--?).~i '~ OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date /~/2.,,/~ ,~ GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directipss)j · 4/¢¢,,-, (b) Applicant Name(..,~.¢¢~,~/¢¢ ~ ~f ?~, Telephone: Home Business Applicant Address¢~,~ ! L~O,~ /~/~/ ~----¢~,¢¢}~..~..,~? ,/~,._~,. ,,Z)t.-~,,~ ¢ ~;~J" (c) Applicant is (check one): Lending Institution []; Owner/builder,~; Buyer [-I; Other [] (explain); (d) Lending Institution _ .Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA t~ Lhe-fQUowirte address: TYPE OF RESIDENCl= Single-Family/~ Multi-Family r-] Number of Bedrooms . Other WATER SUPPLY Individual Well~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmentar Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite~ 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 72-025 (11/84) FNGINEERING FIRM PROVIDINb INSPECTIONS, TESTS, FILE SEARCH, DA1A AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Healtl~ 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 Address SRB 196X Date rff..~(~[~ RIVERt AK 99577 Telephone · Approved for ~'~-bed"-"' roomsby.~.~--'~ Approved ~ _ Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Fnvironmental 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 72-025 ¢ u~4} ENVIRONMENTAL P~,_ MUNICIPALITY OF ANCHORAGE (MO,-./ NOV 7 HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264..,2o RECEIVED Legal Description: ~"' /~ WELL DATA Well Classification _/")J"L")//"/¢¢;~ If A, B, C, D.E.C. Approved(Y)N) Well Log Present(fN) _____ Date Completed ¢/~"/~'=~'- Yield Total Depth ~ Cased to /1 -/'~ _ Depth of Grouting Static Water Level /¢O" Pump Set At ~, Casing Height Above Ground /2 ~' ~.~ g~ Sanitary Seal on Casin N) Electrical Wiring in Conduit(~/N) Depression Around Wellhead Separation Distances from Well: To Septic/H~Tank on Lot f~ 0 ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ~/~& ~'¢ ; On Adjoining Lots To Nearest Public Sewer Line j,..J/,d~ To Nearest Public Sewer Cleanout/Manhole ~'J//~ To Nearest Sewer Service Line on Lot Water Sample Collected by ~' 5 ~' ~' ; Date Water Sample Test Results Comments V/~=/---,O "r"Ez)c"-F' /'~¢~/,.J ,,Z~O 0'~ ¢ ~' B. SEPTIC/i~c~IN4~ TANK DATA Date Installed /~/~-" [~/~ ¢ Size /,,~"'~C~ No. of Compartments StandpipesbN)' I Air-tight Caps~N) Foundation CleanouGN) Depression over Tank (Y~) Date Last Pumped Pumping/Maintenance Contract on File (Y /kJ' /,~ ;for '-' Holding Tank High-Water Alarm (Y/N) /j~,.~/J4 _ Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/~ Tank: To Water-Supply Well To Property Line To Water Main/Service Line To Building Foundation To Disposal Field _ Course To Stream, Pond, Lake. or Major Drainage Comments Page 1 of 2 72-026Illt84) ABSORPTION FIELD DATA Soils Rating in Absorption .Strata Date Installed / ~/"2_ // Width of Field Z · ~ 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 Wate~Service Line /zO ~L 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 Standpipes Present 0N) Date of Last Adequacy Test To Property Line /'~ To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) /C/d) ~ ~'~'~'~'~'~'~'~'~'~' Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions ./~ / M a;:~: Ime/pA~ f°f,: [ :e(vYel Na)t //~ /Z.--L. Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I h.aye..c.h_eck_e.d., verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. S & S ENGINEERINe Sign~c~ B i ~b~. Date _ MOA No. ' ~'"~ Page 2 of 2 72-026 (11/84)