HomeMy WebLinkAboutJO VON LT 3
Depth of we[l~., 129~
S~ze of casln~. 6~
~is~n~ to water while
of . ~0
I certify the above true an~!
DOTTEN DRILL,LNG'
John's Road
SPENARD, AL/~KA
We adwsc you to attach tlh~s certificate
*~," I""*DEPRRTMENT O~""HEALTH AND ENVlRONMENTRL F~'OTECTION
'~ .~, 825 "L" S'[ REET., RI'.,ICHOF..'AGE, F-ti< 995E~::L
264-
PERMIT NO ,:' ?806 ?6 )
RPPL t C:RN [
LOC RTI I]IN
LEGAL
RICHRRD L ~4IL.=,E N
O'"BRIEN
LS' ,ICI VON =,. [.
,.._,,:,=, rt"BF.'IEN ST
LOI' S1ZE
S44 4SS?
.l.4~ S6,_IFIRE FEE7
MINIMUM DIS]`RNCE 8ET!.,.IEEI'.,I A WELL RND RN? ON-SITE SEWAGE DISPOSRL SYSTEM IS
]_FIEl FEEl' FOR R F."'RI',/ATE WELL, OR
15¢) ro 2EiE.'l FEET FROM A PUBLIC WELL DEPENDING UPON ]`HE FVPE OF PUBLIC WELL
WELL LOGS ARE REQUIRED FIND MUSl' 8E RETURNED TO ]'HE DEPRRTMENT WI:THIN
~OF ]'HE WELL COMPLE]'ION
OTHER REQIJIREMEN]'S Ml.'.i9 APPLY SPECIFICATIONS AND CONS]`RUCTION DIAORF:fMS I=IRE
AVAILABLE TO INSURE- PROPER INSTALLATION
I CERTIF"r' THAT
i I BM FAMILIAR W1]'H ]`HE REQUIREMENTS FOR ON--SI]'E SEWERS RI'.,ID WELLS;', AS 5, E7
FORTH 8"¢ THE MUNICIPALIT"? OF I=INCHORFtGE
2 I WILL. ]NSTAI_L THE SYSTEM IN FICCORDANCE WI]'H THE CODES
RPF'LICANT F.' I CHARD L WILSON
I :,:,uE [ B'¢_ ............ DATE '7-- ,,]- ~B ~ ~ ~
~, MUNICIPALITY OF ANCHORAGE (~
DIVISION OF ENVIRONMENTAL WR~LTH
DEPARTMENT OF ~R~A~LTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Data
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
7508 O'Brlen Street
(b)
. 344-9123 562 2124
Applicants NameRzchard & Marze WzlsonTelephone - Home Business -
Applicants Address 7508 O'Brzen Street
(c) Applicant is (check one) Lending Institution ~; Owner/builder~;
Buyer~; Other~(explain);
(d) Lending Institution aaznter Bank Alas:ca Telephone 276-8080
Address Pouch 7007 Anchorage, AlasKa 99501
(e)
(f)
Real Estate Co. & Agent
Address
Telephone
Mail the HAA to the following address:
F
///t l \
Type of Residence
Single-Pamily~X
Number of Bedrooms
Multi-Family~--~
4
Other (describe)
Water Supply
Individual Well ~ Corn_re,miry ~-~ Public ~--~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
Sewage Disposal
Onsite I '{ 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]
5. En~ineerin~ Firm Providin$ Ins~ections~ 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 ~ype of structure indicated herein. I further verify that,
based on the information obtained from the M~anicipality of Anchorage files and from my
investigation and inspection, the on-site water supply amd/or wastewater disposal
system is in compliance with all Municipal and State codes~ ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm C~,-~4'~'v~,<~ ~'~qIR~'~, ~,_ Telephone ~o
t~ ~,; NO 1782 fi - ~ ~,~
Approved fOr~ -bedrooms ~y ~ ~~'~- Date
Approved , ~ Disapproved__
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF ~ALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES ~rgALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. TH~ DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
M~NTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR Ei~ORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/eJ/D18
[Page 2 of 2]
7-19-84
A. WELL DATA
~_~
~'WMUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
Well Classification
Well Log P~esent~'~N)
Total Depth ~-t9I
Static Water Level
Casing F~zghtAbove Ground
Electrical Wiring zn Conduit _~N) Deu~esszon Around Wellhead (Y~
Separation Distances frcm Well:
To Septic/Holding Tank ca Lot %4A- ?u~c$~ ; On Ad]olning Lots IOO' ~.(p~u,t.$~,"~.~/-
TO Nearest Edge of Absc=ption Field on Lot N ~ ; On Adjoining Lots ~
To Nearest Public Sewer Line ICbm4- To Nearest Public Sewer
C leanout/Manhole )Oo
Wate~ Sample Collected By
Wate~ Sample Test Results
SE~IC~O~ING T~ ~TA
To Nearest Sewe~ Service Line on Lot S~'
; Date to-~4-
Date Installed ~.~. Size NO. of CQ~%0artme~ts
Standpipes (Y/N) Az~-tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression ove~ Tank (Y/N) Date fast Pumped
Pumping/Maintenanc~ Contract ca File (Y/N) ; for
Holdzng Tank High-Ware= Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances frcm Septic/Holding Tank:
To Wate=-Supplywell
To P=operty Line
To weter Main/Se=vice Line
Course
To Building Foundation
To Disposal Field
To St=eam, Pond, [~ke, c~ Ma]or D~ainage
Receipt
Date Paid:
Amount:
[Page 1 of 2] 2-15-84
Soils Rating in AbsorptIon Strata
Date Installed
Width of Field
Square Feet of Absorption A~ea
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes P~esent (Y/N)
Date of last Adequacy Test
Separation Distanoe from Absorption F~eld:
To Water-Supply Well
To Bulld~ng Foundation
Lot
To Water Main/Service Line
To P~operty L~ne
To Existing or Abandoned System on
; On AdjoIning Lots
To Cutbank(lf present)
To Stream/Pond/Lake/o~ Ma]or Drainage Course
To D~lveway, ParklngA~ea, c~Vehlcle Storage A~ea
Con, rents
D. LIFT STATION
Date Installed __. ~
Size in Gallons
"Pump On" Level at
H~gh Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~lng Adequacy Test.
Meets MOA
Comments
Check Permitted Bedrc~m Rating AGainst HAA Request
I certify that I have checked, verified, or conformed to all MOA HAA
on the date of this inspection.
Signed ~~b~-~ Date I-~-,-~
Ccn~pany ~~ ~?~./~,cMOA No. ~7~oL~
KB1/d5/s
[Page 2 of 2]
effect
2-15-84