HomeMy WebLinkAboutDORA #2 LT 13Dora
Lot I
014-251
-30
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MINIMUM DISTRNCE BE'rNEEN R HELL RND FtN'T' ON-SITE '_:;EHFtGE DIL:;PO?T, RI .... :5'.r'STEM If!;
:tF'iEI FEET FOR R F'RIVFtTE 1.4ELL OR ±SE'~ TO 2C',~ FEET FROM Ft PUE;LIC HELL DEPENDING
UPON THE 'T'"r'PE OF PUBLIC HELL
MINIf'ILIM DISTRNCE FROM R PRI',,,'FtTE I.,.tELL TO Ft PRIVRTE SENEF.: LINE l'.:;., 25 FEET RND
TO FI COMMLINIT'T' SEt.qER LINE I$ 75 FEET.
HELL LOGS FIRE: RELqUIRED FIND MUST BE RETURNED TO THE DEPRRTr"IENT N.!THIN ::!i:(:.'t DF~"r'S
OF THE HELL C:OMPLETION.
OTHER REQUIREMENTS MR'¢ FtF'PL"r'. SPECIFICRTIONS; RND CONSTRUCTION DIRGRFtMS FIRE:
R',/RILRBLE TO IN':"';LIRE F'F.'.OPER IN'_-q"f'RLLRTZON.
I ..EF.'. F l "FHFIT
::LI Fir,1 FFIr,IILIFtF.: t.,IITH THE F.'E.i~I IF..EHENT=, FLF.. _N-;.-.,ITE .:,E[.tEF..=, FIND !4ELL.$
F"'mRTH E;"r' THE MUNICIF'FtLIT¥ OF FINCHOF.~GE.
2'i 'I I.,tlLL..~IN~TLL THE ~I.N ¢4C.'.C}7/F.:[:,FtNCE HITH THE CO[:,E'::';.
FtF'F'I~ :.'~'4T T. .5'TEHAR CONLST.
iSSUEr.: ,.,.. ...... Z
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 014-251-30
GENERAL INFORMATION
Complete legal description
Location (site address)
COSA#
Expiration Date:
LOT 13; DORA #2 S/D
8520 ROSALIND ST., ANCHORAGE AK. 99516
Current Property owner(s) STRUCTURED ASSETS SECURITIES CORP. TRUST/US BANK Day phone
Mailing address 3476 STATEVIEW BLVD, FORT MILL SC. 29715
Lending agency
Day phone
Mailing address
Real Estate Agent
Mailing Address
NElL THOMAS W/COLDWELL BANKER Day phone 265-9106
2525 "C" STREET SUITE 100, ANCHORAGE AK. 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class ~ Well []
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 On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems 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 COSAs upon request to homeowners. Certificates of On-Site Systems 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 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 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 Certificate of On-Site Systems 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.
Name of Firm s & s Engineering
Address' 15861 S. BIRCHWOOD LOOP RD, CHUGIAKAK. 99567
Engineer's Printed Name R~6EP~A.
DSD SIGNATURE
/ Approved for ~-~
Disapproved.
Conditional approval for
bedrooms.
Phone 907-694-2979
Date
1;
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
By:
(Rev. 11/05)
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
· Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program.
4700 Elmore Street
P,O. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST.
LegalDescfiption: L~ !~Oi/~:>~r ~ '~PO~
WELL DATA
Well type~--4V~ IfA, B, or C provide PWSID #
Date completed ¥~o~-~! Sanitary seal~)
Total depth q~' ft. Cased to
Parcel ID:
Well Lo~ltl)
Wires properly protected([~)
Casing height (above ground) '}~ ~/-in.
' FROMWELL LOG AT INSPECTION
Date of test 4/~,.~J~/~)I
Static water level ¥~.~ ft.
Well production II, 0 g.p.m.
g.p.m.
Be
WATER SAMPLE RESULTS:
Coliform ~) colonies/100 mL Nitrate ~ mg/L Other bacteria __
Arsenic: ~, ~ uglL date of sample: ~/~)/[I~ Collected by:
Tank Type/Material Date installed
Tank size gal. Number of Compartments Cleanouts ~/.~"~.. ~
Foundation cleanout (Y/N) Depression over tank (Y/N) Higher alarm (Y/N)
Date of pumping Pumper J '
ABSORPTION FIELD DATA I~ I r'~ ~
Date installed _ ~_ Soil rating (g.p.~flc1~/bdrm) ~ System type
Length ~ ~ ft. ~,tt:~~ ~ ft. Gravel below pipe . ft.
Total depth ___ ft. Eft. abs~n~ area _ft2 Monitoring tube Depression over field
Date of adequacy test J Results (PasS/Fail) __ ~ For bedrooms
Fluid depth'in abs~ field before test in. Water addedm gal. New depth __ in.
Elaps~;~:~_ __ min. Final fluid depth in. Absorption rate >= g.p.d.
A,~y,,~juvenation treatment (past 12 mo.) (YIN & type) If yes, give date
(~) colonies/lO0 mL
· I
D. LIFT STATION k,I ~ ~"~O'l~/.,J,~
Date installed Size in gallons
"Pump on" level at ~ in. ~__ in. High water alarm level at
Datum ~
SEPARATION DISTANCES
Cycles tested
Meets alarm & circuit requirements?
in,
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot ~/~3r
Absorption field on lot
Public sewer main t--.j[~'
Sewer/septic service line
Animal containment areas ~) t'/'-
I certif~'~hat I havb determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name ~1)8 ¢~,'r- C ~'o ~-~
Date, '7/~//O
L
On adjacent lots AJ IT~
I.
On adjacent lots ~/~
Public sewer manhole/cleanout
Holding tank ~/~
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: I~JPr
Building foundation Prope~ line __ A ' -
Water main
Properly line Building foundation Water main
Water S~ice line" "~ ~ . SuEace water ~Ddveway, parkin~vehicle storage
C~~ ' Wells on adjacent lots
ENGINEER'S CERTIFICATION
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Arsenic Advisory
Certificate of On-Site Systems Approval # 101147
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
13 of Dora #2 Subdivision. This inspection revealed an arsenic concentration
of 28.7 micrograms per liter (ug/L) for the property's well water sample.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems.
While private wells are not subject to this regulation, EPA standards are
based on existing health information and can therefore be used to gauge the
relative quality of water from private wells. Information on arsenic is
available from the On-Site Water and Wastewater Program website
(www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
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
Parcel I.D. #
1, GENERAL INFORMATION
Complete legal description
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~ ~ L/- ~ \ - .~L'~ HAA # ~ ~'~ ~ C~ ~ ~
Lot 13; Dora Subdivision Two
Location (site address or directions)
8520 Rosalind
Anchorage, , AK
Anita Ros ~tt
Property owner
Mailing address
Lending agency
Mailing address
8520 Rosalind Street Anchorage,
Day phone
AK 99507
Day phone
522-8520
562-2262
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well XX×
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-._
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XXX
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
o
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 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 Phone _~7~../--/Z'-Z~',,~ -~'
Address ~a.~l~ ;~ r, ~i~yS~.,Z/ ~
Engineer's slgnature~ ~
bedrooms.
DHHS SIGNATURE
.'~ Approved for
Date
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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 th is 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. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /-oF 13 ~/'~ ~'~'~--~-
Parcel I.D.
A. Well Data
Well type
Log present(~N) ~'~'.~'
Total depth
Sanitary seal ~N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Z/r./Z~/~/ Driller /r~/d/U (7~f~.~'E~ L~ICLIIU6 CO.
Cased to /-1I- 0 ~ Casing height Z$"
Wires properly protected(~)
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG AT INSPECTION
I
/.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ,,L,)/~
Absorption field on lot
Public sewer main r~
Sewer service line ~' f'/~ Petroleum tank
; On adjacent lots ,'L,'/A
; On adjacent lots
Public sewer manhole/cleanout
WATER SAMPLE RESULTS:
Coliform
Date of sample: /Z / ! / ~..~
Nitrate
0.10 ~/~_
Collected by:
Other bacteria ~////o o ~_~
B. SEPTIC/HOLDING TANK DATA
'~a~te installed Tank size Compartments ..~
Cleanouts (Y/~'~_ Foundation cleanout (Y/N) D~N)
High water alarm (Y/N)-'"'""""'"--.~_ Alarm te~~Y/N)
Date of pumping ~ ~
SEPARATION DISTANCES FROM ~ - SEPT~ TANK~rDt--..~...~.~
TW;i(r~)p~;i~tine ~ Absorption field Water main/serviceline~"'"'"'"-----__
inage
72-026 (3/93)* Front CONTINUED ON BACK PAGE
~'"'-~ Manufacturer
Size in gallons ~ Manhole/Access (Y/N)
Vent (Y/N) vel at "Pump o~
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE F~)~/~FT STATION TO:
Well on
On adjacent lots Surface water
D, ABSORPTION FIELD DATA p(py~/_/~_
e installed Soil rating (GPD/Ft2) .System type
Length ~ Width Gravel thickness Total depth
Totalabsorpti;n"~are~a-.. Cleanoutpresent(Y/N) __ Depressionoj~ield(Y/N) __
Date of adequacy test "~'~ Results (pass/fail) ~ Bedrooms
Water level in absorption field bef~ e, Aff~r test __
Peroxide treatment (past 12 months)(Y/N) ~ ..~lf yes, give date
SEPARATION DISTANCE FROM ABSORPTION F~
Well on lot ..... ~:lja~ent lots _____~__'"~~ line
(~ ;;;; 'c~gn; I°oUtTat '° n ~ Cutbank Water main/service line"~-~
Surface w~ Driveway, parking/vehicle storage area ~'~
Cu.,~i~rain "~
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to
Signature $ & $ ENGINEERING
Engineer's Nam
Date
/ /'
17034 Eagle River Loo~~A
HAA Fee $ ~-- ¢~"~'
Date of Payment
Receipt Number
72-026 (3/93)* Back
and HAA guidelines in effect on the
,?
Waiver Fee $
Date of Payment
Receipt Number
12/06,.,'9~ 14: 51 ,:-;Tg, E ErqU I F.!OHHEr.,ITRL Li:~E~ -3EFcU I '-' '~
MERCIAL TEE1TING
& ENGINEERING CO.
IIRONMENTAL. LAI!iIOFIATOR'¢ 8I~'RVICES.
Chemlab Ref.~
Client Sample
Matrix
:93.6451--3
:LOT 13 DORA
REPORT of ANALYSIS
56,33 8 STREET
ANOHOF~AGE, AK 9951,9
TEL, i907) .552-2343
FAX: (907) 581-5301
Client Name :$ & $ ENGINeerING
Ordered By
Project Name :
Pro~ect~ :
PWSID :UA
Repo=t Completed
Collected :12/01/93 8 14:18 bra
Received :22/0~/93 @ 14~0 hfs
Technical Director, ~~''''~d~'~-
Released By
Sample Remark;: ROUTINE SAMPLE COLLECTED BY: 85
QC ~llowable Ext',. &hal
Parameter Results Qual unit~ Msthod Limi%8 Date Date Ini~
Nitrate-N 0.10 u mg/L EF'A 353.2/300.0 i0 12/03 C~"
* See Special Instructions Above
** See ~ample Remarks Above
U = Undo%et%ed, Reported value [$ the practical qusntification l~mit.
D = Secondary ¢tlution.
uA = Unavailable
NA = Not Analyzed
LT = Less Than
GT = Greater Than
ENV1RONMEN'fAL SERVICES IN ALASKA, COLORADO, UTAH. IL,:.INOIS 0~I0. MARYLANC~ WEST ViRGINt~,, NEW '-:' r.2:AROLf,'~A
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 Description (include lot, block, subdivision, section, township, range)
, ~ ,~°,¢,*"~ ¢- . .%, Z..~.
Locabon (.adgt~s,~,d~rect~o~'')
~ ~ ~ ,~,' ,~.~.~'~,t~. ~ ~.
(b) P operty.own.er., ..~ ..: . v:,~,,,." .'
Mailing Add.reSS',, -' ,.",~-'?,7
.... ~,,-% ..~ ~..
(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
3. WATER SUPPLY
Individual Well"J~ 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~i~[, 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
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~u!pual J!aql pue SaLUOq lO sJas~qoJnd oh ,~saunoo e se s!ql seop SHHQ eq.L 'e~is~lV jo aleIS aql u!
Jaau!§ua leUO!SSalo~d ~,uapuadapu! ue/~q e^oq~ ~; qde~§eJed u! ua^!§ suo!~lues~JdeJ eql uodn ,{lUO pas~q pm, eo!l!Jeo
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leAoJdd¥ leUOp,!puoo lo SLuJe.L
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'l~AOEIdd~ SHHQ '9
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: /.~"7'- /.~
Well Classification
Well Log PresentCN)
Total Depth ~'~' Cased to __
__ Date Completed
~'~ Depth of Grouting
Ao
Static Water Level
Casing Height Above Ground ~'
Electrical Wiring in Conduit~,~lN)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line '~;,',',',',',',',',~ ~'
To Nearest Sewer Service Line on Lot
Water Sample Collected by /~'"~'
If A, B, C, D.E.C. Approved (Y/N)
Yield ~J
Water. Sample Test Results
Comments A/'~-J--
Pump Set At
Sanitary Seal on Casing(~N)
Depression Around Wellhead (Y~
~/'/'~' ; On Adjoining Lots '~/'/~'
,~///~! ; On Adjoining Lots /'///~
To Nearest Public Sewer Cleanout/Manhole
~/~/'/~,-X/ ;Date
B. SEPTIC/HOLDING TANK DATA
Date Installed Size
,s (Y/N)
Depression ov, ~k (Y/N)
Pumping/Maintenam
Holding Tank Hi
SEPARATIO~
To Water-S
To Propert~ Line
To Water
To Stream, P~li['~...C'~,~,~,o.r.M,~~ge
Comments
No. of Compartments
Air-tight Caps (Y/N)
act on File (Y/N)
Foundation Cleanout (Y/N)
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
LDING TANK:
Building Foundation
To Field
Course
72-028 (Rev, 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA <~U~ .~'~---
oils Rating in Absorption Strata Type of System Design
D~,,.nstalled __ __ Length of Field
Width ~__ __ Depth of Field
Gravel Bed Thickness
Square Feet of Abs'O~Area _ Statndpipes Present (Y/N)
~io_n over- !ield (Y~__ Date of Last Adequacy Test
Resu sit of Last Ade.quacy Test ~
SEPARATION DISTANCE FROM
AB~'Q~, PTION FIELD:
To Water-Supply Well ~ To Property Line
To Building Foundation ~ To Existing or Abandoned System on
Lot ; On Ad]~g Lots _
To Water Main/Service Line To Ct~ck (if present)
To Stream, Pond, Lake, or Major Drainage Course ~
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Size inGallons ~
"Pump On" Level at -~-
High Water Alarm Level at . -~-
Tested for
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Meets MOA Electrical Codes (Y/N)
Comments
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 guide
inspection. ~~~..~
Signed
Company
Date
MOA No.
ReceiptNo. C~ / O ~Z~_ , ~'""'~'d~ ~-- // ~
Date of Payment ~,,~-- ~ ~-- .~' - Waiver Fee: $
Amount: $ ~/'.,~) 6... o Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
delines_.in effect on the date of this
Receipt No.
:ngineer's Seal
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
FEDERAL TAX ID # 92-0040440
ANALYSIS REPORT BY SAMPLE for Work Order ~ 12326
Date Report Printed: MAR 27 89 @ 10:37
Client Sample ID:L13, DORA $20/S TAP
PWSID :UA
Collected MAR 22 89 @ 15:15 hrs.
Received MAR 23 89 @ 14:00 h~s.
Preserved with :NONE
Client Name : A E C S
Client Acct: AKECSRP
P.O.# NONE REC'D
Req $
Ordezed By :
Analysis Completed :MAR 24 89 Send Reports to:
mabozatory Supezv~spz ;STEPHEN C. EDE 1)A E C S
Released By : ~f:~< ~
Special
Instruct:
Chemlab he£ $: 4640 Lab Smpl ID: 1 Matrix: WATER
Allowable
Parameter Tested Result/Units Method Limits
NITRATE-N ND(O.iO) mg/1 EPA 353.2 10
Sample ROUTINE SAMPLE.
Remarks: SAMPLE COLLECTED BY A. WIEN.
1 Tests Per£ormed ' See Special Instzuctions Above UA=Unavailable
ND= None Detected ** See Sample Remarks Above
NA= Not Analyzed LT=Less Than. GT=Greater Than
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744 "~) ] ~/~ /_~
Applica. tion Date
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
~- ~ ~{ .:._ '~;..~3 ..
~.. ~-~er,. · - ~ Business
. Telephone: Ho~
~ ~¢~di. ' stita ion.~ ~~~ ~ ~ Telephone
(d)Re~~.mp~y and Agent
Telephone
(e)
Mail the HAA to the followina address: or; Check here~J~ if hold for pick up.
List contact person and day phone number below.
2. TYPE OF RESIDENCE
Single-Family'S[.
· Number of Bedroom~ -~
3~'"' WATER SUPPLY
.. Individual Welt~[ Community [] - Public []
'd t \,
· , Note: I'f community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
On~ite [] 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 IRev 8/86~ Front
8 to 8 e§ed
· )po~ s,~eeui§ue
leUO!SSaIoJd aql u! Suo!ss!Luo ~O sJoJ~e JO~ elqisuodsaJ ~,ou s! eBeJoqouv ~o ~,!led!olunlhl eq.L 'penss! s! eleo!I!peo e e~o,taq
elep ez~leue ~o suo!,toedsu! ),onpuoo lou op SHHQ ¢o seeXOldW=l 's~ueuJeJ!nbe~ ele~,s pue leJepe~ u!speo/~¢sp, es ol Jap Jo
u! suo!~,n~!~su! 6u!puel J!eq~ pue seLuoq ~O sJeseqoJnd o~, Xsepnoo e se s!qI seop SHHQ eqJ. 'e>lsel¥ ~o e~,elS eq~ u! peJe),s!6e~
¢eeu!Sue leUO!ssetoJd luepuedepu! ue Xq e^oqe S qde~§e~ed u! ua^!6 suo!le~,ueseJdeJ eq~, uodn XlUO peseq se~,eoy!peo
le^oJdd¥/~,tpoqin¥ q~,leeH senss! (SHHQ) seo!^JaS uewnH puc q),leeH ,to ,tUaLUiJed@c! e6e~oqouv ,to X~,!lsd!o!UnlAt eq.L
NOIJ. rlY~)
le^oJdd¥ I~UO!l!puoo ~o swJei
leUOi),ipuoo pe^oJddes!a ~ pe^oJdd¥
'9
'S
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
~uNtCtPAL~'i'Y OF ^NC~KLIST ' FEBRUARY 1984
EN¥iRONMENTAL SERVICF. S DIV~SION 264-4720
Legal Description:
SEP, 7 1988
Date Corn pleted ~/' ~'?"a'~'! Yield
~'~' ' Depth of Grouting
Pump Set At
Sanitary Seal on Casing~)N)
Depression Around Wellhead (Y(~I
Well Classification
Well Log PresentGN)
Total Depth ~' / Cased to
Static Water Level "~ -~"'"~"
Casing Height Above Ground
Electrical Wiring in Conduit~N)
Separation Distances from Well:
,/.
To Septic/Holding Tank on Lot ,~/,4
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by ,~
Water Sample Test Results ~-~"~
Comments ~
· On Adjoining Lots ,,~//~.r
· J//~ ; On Adjoining Lots ~//~1~
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ~
/'~d'/~r'W/ ;Date ~lv,--,,{O-'~t~
B. SEPTIC/HOLDING TANK DATA
ed Size No. of Compartments
Standpipes~N~,,~.~ _ Air-tight Caps (Y/N) __ Foundation Cleanout (Y/N)
Depression over Tank (Y-TN~__ . Date Last Pumped '
Pumping/Maintenance Contra~-_._---~'; for
Holding Tank High-Water Alarm (Y/N) ~emporary Holding Tank Permit (WN) .
Separation Distances from Septic/Holding Tank: '~.
To Water-Supply Well To Building F~
To Property Line To Disposal Field ~
To Water Main/Service Line To Stream, P~ake, or Major Drainage
' , .Course
Comm(~nts
Page I of 2
72-026t11/84)
C. ABSORPTION FIELD DATA
"~Rating in Absorption Strata Type of System Design Date I~__ Length of Field
Width of Field '~- Depth of Field
Gravel Bed Thickness
Square Feet of Abs Standpipes Present (Y/N)
Depression over Field (Y/N) ~ Date of Last Adequacy Test
Results of Last Adequacy Test ~.
Separation Distance from Absorption Field: ~
To Water-Supply Well .... To ~Line ___ .
To Building Foundation '",,~Existing or Abandoned System on
Lot ~ On Adjoin'rog Lots ~
To Water Main/Service Line To Cutbank (if present) ~
To Stream/Pond/Lake/or Major Drainage Course ~ .
To Driveway, Parking Area, or Vehicle Storage Area ~
Comments ~
D. LIFT STATION
Dimensions
"Pump On" Level at Ma':~:/pA(~fcf'?~e(v:/INa)t
High Water Alarm Level at ~' Vent (Y/N)
Tested for ...... ~es during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that l h~ec~ed;_ve]'if, ied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~"'~2::-o ~J~"'"~ Date
Company 'f'~ MOA No.
Receipt No. ~7~ O j-- ~0~ ~
Date of Payment
Amount: $ / ~'~
Page 2 of 2
72-026 (11/84)
,_ o tro es
FEDERAL TAX ID # 92-0040440
ANALYSIS REPORT BY SAMPLE for Work Order ~ 8870
Date Report Printed: SEP 1 88 @ 13:37
Client Sample ID:L13 DORA $2
PWSID :UA
Collected AUG 30 88 @ 12:00
Received AUG 30 88 @ 16:00
Preserved with :NONE
hr s.
Client Name : AECS
Client Acct: AKECSRP
P.O.# NONE REC'D
Ordered By :
Analysis Completed :AUG 31 88 Send Reports to:
Laboratory Super¥~sor :STEPHEN C. EDE / 1)AECS
~eleased ~y:S~ C. fdA/ 2)
Special
Instruct;
Chemlab Ref ~: 2420 Lab Smpl ID: 3 Matrix: WATER
Allowable
Parameter Tested ~esult/Units Method Limits
NITRATE-N ND(O.iO) mg/1 EPA 353.2 10
Sample ROUTINE SAMPLE
Remarks:
1 Tests Performed ' See Special Instructions Above UA=Unavailable
ND= None Detected "See Sample Remarks Above
NA= Not Analyzed LT=Less Than, GT=Greater Than
APPLI¢ NT FILLS OUT UPPER HAl. ONLY
Property Owner "7-~/n./..~.,~.,_:;- /L~, ~/ ,.//g-' ~'~L~. x.g~/ t?~.,~ ~./ Phone
. . ~.LA,{~ ,~ , '~' '~?(' , ~: ~ Zip Code
Buyer /~, ~ ~ ~+ x~ ~
Address Zip Code
Lending Institution .,{) ' "
Address Zip Code
Realty Co. & A~nt Phone
Address Zip Code
8treet
Loaatt~
Type of ~esi~nce
Oingle FamiIx
Multlplo Family ~o. of ~droo~
~ Other
Water Supply
lndividual A~ACH WELL LOG, A wal Icg Is required for all wells drilled since June 1975.
Community For wells drilled prior to that date, give well depth (attach Icg if available).
~ Public Utility C~ /
Sewer Disposal ~ /~ -~0-~
~ Individual Year Individual Installed:
~ Public Utility When Connected to Public Utility:
Holding Tank
NOTE: THE INSPECTIO~ FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Tilme Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
/,//3,_,.~..~ MUNICIPALITY OF ANCHORAGE
' FNVIRONMENTAL PROTECTION
RECEIVED
( "'~APPROVED BEDROOMS 'OONDITION8 OF APPROVAL
( ) DISAPPROVED
( ) CON glTIO~IA L ,~ P PRQ. y,A L'
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
72-023 (3182)
4
DATE RECEIVED
· ~ I~SPECTION APPOINTMENTS
DATE / / DATE //' ' DATE
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
~R~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI(J~[PT. OF HEALTH &
825 L Street - Anchorage, Aleske99501 ENVIRONMENTAL PROTECTION
ENVIRONMENTAL S NITAT,ON DIVisiON OCT 1 6 1981
' Telephone 264-4720
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing,
1. PROPERTY OWNER '
MAILING ADDRESS ' ~ ' -
PROPERTY RESIDENT (If different from above) . PHONE
MAI LING ADDRESS
3; LENDING INSTITUTION . ~ A ,-- ~ ' I PHONE
MAILING ADbRESS
4. REALTOR/AGENT ~' _ , I PHONE-
MAILING ADDRESS
!~. ~EGA~ DES~ IPTION
STREET LOCATION
~. TYPE OF RESIDENCE
~ SINGLE FAMILY
NUMBER bF'~BEDRO(~MS
S One [] Four [] Other
~ Two [] Five
/~] Three [] SiX
[] MULTIPLE FAMILY
7. W/~TER SUPPLY
INDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
8, SEWAGE DISPOS/~,L SYSTEM
[] INDIVIDUAL/ON-SITE**
PUBLIC UTI LITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCES81NG CAN BE INITIATED.
72-010 (Rev. 6/79)
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FA, MI LY
2. WATER SUPP[~
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size:, If Tank is homemade
give dimensions:
TYPE OF TANK
TOTAL ABSORPTION AREA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
THIS SIDE FOR OFFICIAL USE ONLY
NUMBER OF BEDROOMS
[] ONE [] THREE [] FIVE
[] TWO ~. F-'I.-- FOUR [] SiX
PERMIT NUMBER .
OTHER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOILS RATING
MANUFACTURER
MATERIAL
Septic/Holding Tank IAbsorption Area
ISewer Line
Nearest Lot Line
DATE
[~PROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 [Rev. 6/79)