HomeMy WebLinkAboutTANAINA VALLEY LT 2
MUNICIPALITY OF ANCHORAGE
D[ RTMENT OF HEALTH AND HUMAN SER ES
Environmental Health I)ivislen ~)~//0 '~ / 7
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Address
,~o ol B(,aroo,~s I-ELL
FOUNDATION
7;4 ,v,4 / ,v,4
f~ffCFIol-I ~L
TANKS
[~} SEPTIC [] HOLDING
....
Materra,~.~7.,~..,~ ---- tN° °1~°*"3~a~ents'
TYPE OF SYSTEM
TRENCH ~] BED [] W. DRAIN [~ OTHER
orrgmal grade
FT
0 FT ~ a
*lZO SO Fr
Inslal~er [)ate Inslalled
WELLS
PRIVATE ~' OTHER fldentilv)
J Cased lo
I:1 FT
REMARKS:
_~ ' DISTANCES
~ TO SEPTIC
I FROM __-"'---~ TANK
//'
ABSORPTION
FIELD WELL
/,5'
ENGINEERS SEAL
i~ichael [!. Anderson
72-013 (3/85)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
E] SOILS LOG
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
SLOPE
SITE PLAN
10
11
12
13
14
15
16
17
18-
19-
20-
COMMENTS
WAS GROIJND WATER I~
ENCOUNTERED? /~(~ pO
E
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Crop
PERCOLATION RATE
TEST RUN BETWEEN
~ /' ~'~ (minutes/inch)
(~ . FT AND JC} FT
72-008 (6/79)
5
[ ,l -- 'SO'
SOILS LOG
PERFORMED FOR:
MUNICIPALITY OF ANCHORAGE
[] PERCOLATION
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTF. CTION
T ST
SOILS LOG - PERCOLATION TEST ~"~ '~'
/~ ~OO~ DATE PER FORMED: ~'/~
LEGAL DESCRIPTION:
6
7
SLOPE
SITE PLAN
10
11
13-
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
14-
15-
16
17
18
19
Gross Net Depth to Net
Reading Date Time Time Water Drop
20
PERCOLATION RATE
(minules/inch)
TEST RUN BETWEEN __-- FT AND ~ FT
COMMENTS _~iL T~'~?' ~:~',~/-~0,~/~2~'~ ~ ~---- ~0 ~,~,~/~,~ /41 ~o¢/~r/o ~/ 0~: ~'/0 ~/~_
72-008 (6/79)
LEGAL DESCRIPTION: ,~O'~",~
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
(ENGIN~L)
,,.~'~1.~ ~/~.. DATE PERFORMED:, 7-!~' '~
Township, Range, Section: '-~.,~/ ,~'~/'~J ~ ~
1
2
3-
4-
5-
7-
8-
9-
10-
11
13-
14
15
16
17
18
19
2O
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT L
DEPTH? pC
Oeplh lo Waler Aller~, ~,
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ~"'7, ~. {minutes/inch} PERC HOLE DIAMETER .
_1~. l/
PERFORMEO BY: ~ A~t~ ~//W/~ I - CERTIFY THAT THIS
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE;
72~00g (Rev. 4185)
TEST WAS PERFORMED IN
0
3
,
8
22
3~,645~,f.
21
35~,92 ? s.f.
EAST
2i0,46'
2O
3$,§lls.f.
S 66°§7'0,~' E
.~ B?.
I0 [~ec~ B~
Telecomm Esrrff~
330 s,f --
17
3B,B63 s.f
6
16
39,640
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORASE/WESTERN DISTRICT OFFICE /
3601 "C" STREET, SUITE 1334
ANCHORAGE, ALASKA 99503
STEVE COWPER, GOVERNOR
563-6775
To Whom It May Concern:
According to the records on file in this office, the _~_~_~_~_~_~__~___
~/~-~--E~-~E-~-S~J'-~m~-.m-/~--~--~_~ter SYstem is in compliance with the
State o~ Alaska Drinking Water Regulations.
Sincerely,
Environmental Field OFficer
u c p HtYof
P.O. BOX 196650
ANCHORAGE, ALASKA 99519-6650
(907) 343-4200
~R~ Tom Fink
MA YOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
January 12, 1988
Design In Wood
7021 Driftwood Drive
Anchorage, Alaska 99518
Subject: Lot 2 Tanaina Valley Subdivision
Permit 4870016, On-site Sewer Permit
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1987. The 1987 fees have not been paid for this permit,nor
was the permit signed for to be valid for installation.
Permits are issued on a calendar year basis by authority of
Municipal Ordinance. A new permit must be obtained from this
Department for any well and/or on-site sewer system not
installed by the expiration date.
If you have drilled the well, a well log needs to be sent to
this Department for documentation of the installation and to
close the permit.
If a private engineer inspected the installation of the on-site
sewer system, the original as-built inspection report (three-part
form) must be sent to this office for review and approval, and
for documentation.
Effective January 1, 1988, a new fee schedule is in effect.
When re-applying for a new permit, the new fees are; $90.00 for
an on-site sewer permit; $50.00 for a well permit; $140.00 for
a combined sewer and well permit.
If there are any further questions, please call this office at
343-4744.
Sincere, ~
/Robert W. Robinson
Program Manager
On-site Services
RWR/ljw
enc: Copy of Permit
:; ;* I/, I lCqq)') WI:;'. I 'I'TIi:N
CI 'J/;J.!;O
',i:~ Z [3 M E :(.)
C I!~ S Z[ [:)1..I ]: h{ I~,J(:l[2JZ)
Anchorage
P.O. )X 19665O
ANCHORAGE, ALASKA 99519-6650
(907) 264-~i.~1¢x 4 7 4 4
TONY KNOWLES,
MA YOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
January 9, 1987
Design In Wood
7021 Driftwood Drive
Anchorage, Alaska 99518
Subject: Lot 2 Tanaina Valley Subdivision
On-site Sewer Permit #860335
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1986.
Permits are issued on a calendar year basis by authority
of Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system not
installed by the expiration date.
If you have drilled the well, a well log needs to be sent to
this Department for documentation of the installation and to
close the permit.
If a private engineer inspected the installation of the on-site
sewer system the original as-built inspection report (three part
form) must be sent to this office for review and approval, and
for documentation.
If there are any further questions, please call this office
at 264-4744.
Sincerelv,
~.W. Robinson
Program Manager
On-site Services
RWR/ljw
eric: copy of permit
.OE:S]:E~N ]:N IgEJCLO
702.:l. DF;: :I: F:: TNEII::U) :01:::
F? L,II',IS (NE) I' X
Fc!l'.'Lh I::!y !;,hl:~ IqLu'~J.c:i~p~;C!,:i.'L¥ elf ~rll::hcH-ag~? (1'4!i)(~) and
zm,, :t: LU)(::h:';H"E:FI'CtF)d 'l'.ha~k t:.h:i:~ ):) L:,l" fl) J. '[. J.!:~ va].J.d F(;:)I' ,:~ m,'-zt.(:[fmlm Df' 4, l::)(¢,)(71r'c:)(:;).is:~ ~;~r'l(::l
:t:1:: F~ I...]:F::'I' EFI'(.YF:!:I3N :I:E3 :!:IxlEYF~L.L.I::D :IN (~lxl hRl::~ C()VE:RI~::D t3Y Iq[:)h
'tldF:N ( J ) ~lxl IE[.I:C'II::~]:C(.~I.. I='E~l::;tlq ]:T f~,N[) :I:IxlEff:;'F:C'F:I:EIIq IqUST DIE C)13T(~]:NE:[)!l (2) ~:~F~-'f:dJ:l:LTS
gJ:!:l.l_ IxlEJT }3[~: F~F'I:::'IROVE[) HI:l-HE)lIT (~N E:I.I:CTf?:!:Ct.hL ]:IxlSF:'E:E:I":I:E)N I::d~:F'E)IR'I'~i f~lqD (:2~;) TI.II:E:
I:Zf. IEE;TI::U[C(~I. MC!F~I.::: I¥1LJS'r' J31:: D(:llxll: J3Y f~ I..]:E;IE:NE~E:D
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, ARchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:
Township, Range, Section:
(ENGIN~p~L)
DATE PEREORM,=-D:.
1
2
3
4
5
6
7
8
9
10-
11
13
14
15
16
17
18
19-
20-
SLOPE
WAS GROUND WATER
ENCOUNTERED? _
NO
IF YES, AT WHAT
DEPTH?
Depll~ to Waler ^ller.~. ~,
Moniloring? .Dr,, ?
SITE PLAN
Reading
Time
v?~'.f //oo~
/~o'I /
COMMENTS .' ~O]/-
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEliNES IN EFFECT ON THIS DATE. DATE: _
72-008 (Rev. 4185)
Net
Time
Depth to
Water
,~?1 ,~?
,~7/,~
Net
Drop
. o~
PERCOLATION RATE ~-'7,'/~_~ (minutes/tach) PFRC ROLE DIAMETER
TEST RU~j~ BETWEEN ~'~,~"~ FTAND _ 7
195.00'
! , I
~ 3,1~,71 t s.f. 5.0o'(,}
3
I~1 IzJ-
I i,¢ Oc.o
~c. ~
3§,507 S f. zo
8
298
15'-~
:"6 W- 65977
139.00' -
32.645~.£
WEST- 659 ? 7.(R)
.....] 265.?'7'
21
35~516 ~.f.
2O
~$~ 92 t ~.f.
EAST
210.46'
6
32~542
.%
17
38,863 sf
16
39,640 sf.
i~EVISEB .$1?'E
195.00'
WflTE~, .-~d~ cE
I ~9.00' '-
\\
T
7
$4~550
2O
53,5rl s.f.
g
19
31~ 301 ~t
S 56°57'03F £
;53~.927'
I0 Elec. 8,
Tel~comm I
~,4, 330 ~.f
EAST
210.46'
17
~,8,8 6 3 s.f
6
32t542 ~,f.
I&
15
009,
General Contractor
7021 Driftwood Place
Anchorage, Alaska 99518
(907) 349-8014
September 9, 1986
Municipality of Anchorage
Dept. of Environmental Health
To Whom It May Concern;
I, Samuel P.
authorization to
the sewer permit
Hill, hereby give my assistant Debbie
act as my agent to sign all concerned
for Tanaina Valley Lot 2.
Palmquist
paperwork regarding
(Samuel P. Hill
President & Owner
State of Alaska
Third Judicial District
This is to certify that on the ~_~-- day of ~~), 1986
before me, a Notary ~ubI~c in and for~ State of ~~sonally
appeared~.nzz~ N F,=-~[]=~L~t~ known to me to be the person who executed
the foregoin~ document ~n~ acknowledged to me that he executed the
same as a free act and deed for the uses and purposes therein stated.
Witness my hand and notarial seal the day and year first above
written.
motary Public ' :~ -~k~
My commission expires~2-z_/-~7
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 FIEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.# t~3~\ - ~,-~\ - '--~,'~ HAA#
1, GI-'NERAL INFORMATION
Complete legal description /--,o'~ ~;~1 '~/) )~J,q
Location (site address or directions)
Property owner
Mailing address
Lendin'g agency
Day phone
Mailing address
Agent
Address
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well X
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site ~
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOAt/21
5. 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 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 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.
Nameof Firm //~0~-'TL~:)~J ~C/.,J ~"E/~(.., Phone '~/~ ~1
Address ~0, ~O~ Z~O~75 . ~~, ~ ~¢~Z~
Engineer's signature ~ ~ ~ Date ~// /~;
DHHS SIGNATURE
Approved for /'~'~/~_(/~'~ bed ro o m s.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date
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 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. 1/91) Back MOA #21
June 1, 1993
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, ALASKA 99524
REC£1VED
JUN 1 1993
Munloipa~JtY o~ Anchorage
Dept, Health & Human Services
Municipality of Anchorage
Department of Heath & Human
825 "L" Street
Anchorage, AK 99502-0650
Services
Subject:
Lot 2, Tanaina Valley Subdivision
Health Anthority Approval Certification
Dear On Site Services Engineer:
A conditional Health Authority Approval Certification was issued last fall
on Lot 2, Tanaina Valley Subdivision pending filling of a depression over
the drain field by June 1, 1993. On May 26, 1993, I inspected the drain
field on this lot and noted the depression had been filled and the area
regraded. The conditions of the Health Authority Approval Certification
have now been satisfied. I am hereby requesting an unconditional Health
Authority Approval Certification be issued for this lot. Please advise if you
have any questions or conunents.
Sincerely,
Michael E. Anderson, P.E.
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 AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA #
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner _/~'/~,.,~,,~/E/'~
Mailing address ~' ~Z~ ~/'<~/-~-~e/,/ ~/"]/,~/'~
Day phone
Lending agency
Mailing address
Day phone
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
Individual well
Community well
Public water
If community well system, provide written confirmation from State AD£C attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Fronl MOA ~21
STATEMENT OF INSPI--CTION BY IE-'NGINEER
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 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 ,~,Jb GT~.S*o,-J ~ ~,,,,~z='-lc%-/L4,,¢6 Phone
Address ~0 ~ox ~'¢077..¢ ,/~C~o,"cCd~(,-'~, ,/~
Engineer's signature "¢q//~--cJ-~zt~-~' ~ ~-¢-'-'"'--- Date
6. DHHS SIGNATURE
Approved for
bedrooms.
Disapproved.
Conditional approval for ,7~2'~-~'/~,J¢)~_
.'
bedrooms, with the following stipulations:
!
Additional Comments
By: __ .- ~ Date
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 this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS 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.
72~25 (Rev. 1/91) Back MOA ~21
Legal Description:
A. WELL DATA
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
ZoT~ Z 7~AIA/~/,4. [,lA l/eLI Parcel I.D. (~ II 0.'~1 77
Well type ~'¢~rc.p,g ct-?' If A, B, or C, attach ADEC letter.
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date completed
Cased to
FROM WELL. LOG
ADEC water system number
Driller
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Public sewer service line
WATER SAMPLE RESULTS:
Coliform Nitrate
Date of sample:
B, SEPTIC/HOLDING TANK DATA
Date installed $./~/G~
Cleanouts (Y/N)
High water alarm (Y/N) __
Casing height
Wires properly protected (Y/N)
g.p.m.
AT INSPECTION
MUNiCiPALITY OF ANCHORAGP.
ENVIP, ONMENT^L SERVICES DIVISION
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
JAN 0(.; 1995
g.p.m.
P, ECEIVED
Collected by:
Other bacteria
_Tank size _ Ieee Compartments
Foundation cleanout (Y/N) .Y' Depression (Y/N)
,,4'/,,//,4~ Alarm tested (Y/N)
Date of pumping
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s)onlot/J¢,4¢' ¢~-~ Lo?' Onadjacentlots
To property line ~o/ Absorption field
Surface water/drainage
72A326 (Rev. 3/91) Front MOA 21 CONTINU ED ON BACK PAGE
C, LIFT STATION
Date installed
Size in galtons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Su dace water
D. ABSORPTION FIELD DATA
Length ~; ~' Width .2, ~ '
Total absorption area ~ Z
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Soil rating ,~$? ~'/.~,~-- System type TK~'~Jc~(
Gravel thickness /~ / .Total depth /o'
Cleanouts present (Y/N) y
Date of adequacy test ~
for ~-///2~ ~-~ bedrooms
t,,I
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~J E~
TO building foundation
On adjacent lots
Surface water
If yes, give date _
On adjacentlots ~,,.v~- ~^, ~/¢~-s Propertyline
/~' To existing or abandoned system on lot
Cutbank //¢,~/.v ~n~ Water main/service line
Driveway, parking/vehicle storage area
Curtain drain /VerY_ //~ ..~',~/
ED ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Engineer's Name
Date
HAA Fee $ /'~)
Date of Payment
Receipt Number
72~28 (Rev. 3/91) Bsck MOA 21
Waiver Fee: $
Date of Psyment
Receipt Number
WALTER J. HICKEL, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99515
January 4, 1993
(907) 349-7755
Wayne McFadden
SUBJECT: Country Lane Estates
Class "A" Public Water System, PWSlD 214706
Dear Mr. McFadden:
I have completed a review of this office's files concerning the monitoring status of the
above-referenced Class "A" Public Water System and found the following:
The last satisfactory Total Coliform Bacteria Sample results was submitted
to this Department on December 21, 1992. This ~does__E~z~Eet the provisions
of 18 AAC 80.200(a), of the State Drinking Water Regulations.
The last inorganic Chemical Contaminants Sample results were submitted
to this Department on May 4, 1990. This ¢o~es_lz~e.t the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
The last Radioactive Contaminants Sample results were submitted to the
Department on December 5, 1990. This dome, s_racet the provisions of 18
AAC 80.200(a), State Drinking Water Regulations.
The last Organic Chemical Contaminants/Volatile Organic Chemical were
submitted to this Department on November 16, 1991. This d_q.e_s meet the
provisions of 18 AAC 80.200(a), State Drinking Water Regulations.
Issuance of this letter does not imply that the above-referenced Class "A" Public Water
System is in compliance with other provisions of the State Drinking Regulations.
If you have any questions on the above information, please do not hesitate to contact this
office at 349-7755.
Sincerely,
Michael Lu
Environmental Eng. Asst. II
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICFS
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # _("~-\ / - (~*~-~ \ ~ '~ ~ HAA # _ L--~ (~ ~ f-~;,"-,, ("1°~ ..-~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property owner
Mailing Address 4~
(c) Lending Institution
Mailing Address
Telephone: (home) N,,4.. _Business m,~.
(d) Real Estate Company and Agent
Address ~'O O ~'O ~'~o
Telephone ~ 7d"- P- 70~/
(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 SUPPt. Y
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 1 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 bel ow, I verify that my investigation of th is
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
Address
Date
Engineer's Seal
6. DHHS APPROVAL
Approved for '3--- bedrooms by
Approved /~ Disapproved
Terms of Conditional Approval
Conditional
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.
~ MUNIC PALITY OF ANCHORAGP (MOA) ~
~,L~I[~,Y O~ A;%.~;~thorlly Approval (HAA)
~NV~ - : IST - FEBRUARY 1984
343-4744
Legal Description: ~o~ ~., 7~r~
RECEIVED
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth__ Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SPPARATION 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
Water Sample Test Results
Comments 0 ~-~ I~/'¢-er- of Com/~['~¢4,,~c~¢
Date Completed
Depth of Grouting
If A, B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed 3/,'¢/~; Size
Standpipes (Y/N) 'r' _Air-tight Caps (Y/N)
Depression over Tank (Y/N) _ ~
Pumping/Maintenance Contact on File (Y/N) N,//.
Holding Tank High-Water Alarm (Y/N) I~,h/L
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
I ooo,~ No. of Compartments ~
t' Foundation Cleanout (Y/N) P'
Date Last Pumped _~ / / ~/'//cd /~ ? -¢'~ ,~ac./
; for iv. ,4.
Temporary Holding Tank Permit (Y/N) /~, 4.
To Building Foundation
1'o Disposal Field
To Water-Supply Well '~ ~ o~t
To Property Line ~O ~
To Water Main/Service Line__~ ¢¢"
To Stream, Pond, Lake or Major Drainage Course
Comments
72-026 (Rev. 7/88) Fronl Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~/// (O~
Width of Field ~, ¢'
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well ~ <T(,,a '
To Building Foundation '~ ¢¢'
Lot
To Water Main/Service Line ~ ~..?'
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parkin9 Area, or Vehicle Storage Area
Comments _,(' ~/.,¢~'~'~ /¢(~.¢'o~
D. LIFT STATION N,,4-.
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
//3 c¥¢',,~ Type of System Design
Length of Field o"O '
Depth of Field ! o~
Gravel Bed Thickness d' '
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line 1¢~~
To Existing or Abandoned System on
; On Adjoining Lots ~ $~ '
To Cutback (if present) N,
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 guidel.[~9.s~irl~ffect on the date of this
inspection.
Signed .¢7~'~ ¢ ~
Company ~[~ ~.;~ ~c'~
¢.,, ~ ...................... ~ng~neer s Seal
MOA No. ~¢ -Ot~
Receipt No. ~ [~ ¢ 0'~ Receipt No.
Date of Payment ~-' ~¢~ ¢~ Waiver Fee: $
Amount: $ ~ / ~ ~) Date of Payment
72-026 (Rev 7/88) Back
Page 2 of 2
DEPT. OF ENVIRONMENTAL CONSERVATION/
/
ANCHORAGE WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
February 20, 1990
STEVE COWPER, GOVERNOR
563-6775
Flat Top Technical Services
Anchorage, Alaska 99502
ATTN: Mr. Ted Moore
PWSID: ~t~14706
According to the records on file in this office, the Country Lan~
Estates Water System is in compliance with the State of Alaska
Drinking Water Regulations.
Sincerely,
Officer
VEC:bas