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'~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) GR I J-M Location (address or directions) i¢ DR/ I_,I (b) Applicant Name /~, /~L~f~/~L' /~'/'///~', Telephone: Home Applicant Address I~'~0 be (C) Applicant is (check one): Lending Institution []; Owner/builder J~; Buyer []; Other [] (explain); /dl Lending,nst,tution Address h11/ /1 (e) Real Estate Company and Agent Address Telephone /t//)~ Business (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family,[ Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. 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) 5. ii=NGII~EERING FIRM PROVIDIt~.~NSPECTIONS, 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 (~f 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 /~.~t~L~_('~ / /'~¢'L~ ~ Telephone --~-~/~'~'~'~ ~"/~ Date DHEP APPROVAL Approved for -~ bedrooms by Approved ~ Disapproved Terms of Conditional Approval Conditional CAUTION The Muncipality of Anchorage Department of Health and Environmental 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 (11/84) ~U.~C~PA,~TY OF A.CHORAGE (mOA) ^' '~mA~'~T'j~,,~,~r:~:~,,~ AUTHORITY APPROVAL (HAA) MUNICIPALI~ OF DEPT. OF HEALTH & CHECKLIST- FEBRUARY 1984 ENVIRONMENTAL PROTECTION 1986 264-4720 Legal Description: /"~' ~(/~//¢'~J/C/'J/J WEL' OATA I, U I V E D Well Classification ¢/~1~1 ~/~ ~'Z~ Ii A, B,C, D.E.C. Approved (Y/N) Well Log Present (Y/~ Date Completed ~,¢/V/~A/¢ 4~,44/ Yield '' / / '~2 /_(~ Depth A(/ Total Depth ~ 22- ~Cased/t/~, v of Grouting Static Water Level ~? (~ Pump Set At // Z// / Casing Height Above Ground '~, I / Sanitary Seal on Casing (~)N) Electrical Wiring in Conduit CN) Depression Around Wellhead (Y~ Separation Distances from Well: /V/~//]~_ To Septic/Holding Tank on Lot ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot , ~ ; On Adioining Lots .! To Nearest Public Sewer Line ~'~ / '¢- To Nearest Public Sewer Cleanout/Manhole I O('J ~J~ To Nearest Sewer Service Line on Lot Water Sample Collected by -~. /~/0ff~'(~/¢~/(./~ ;Date Water Sample Test Results .~-----~ ~- ¢"/~,% F/~'Z*'~/~ /U/ Comments ~ 7°~ ~¢¢f'¢~ ~""~"-~'~ /~2/"~// ~ TF4¢HE,O S.PT, C/.O'.."G TA.~.ATA F[/66/C ~E~¢Ef~ Date Installed Size No of compartments J Standpipes (Y/N) Air-tight Caps (Y/N) ' Foundation Cleanout ~Y/.~~'~- Depression over Tank (Y/N) .... Date Last Pumpt~,.,.~ Pumping/Maintenance Contract on File (Y/N) / jor ~ Holding Tank High-Water Alarm (Y/N) /'i//L~ Te~ingTankPermit(Y/N) ~ Separation Distances from Septic/Holdilg~ ~K:/'~ ~'-.. ' To Water-Supply Well / . _./'"To Building Foundation __-- To Property Line ~J To Disposal Field ..... T° Wcat°~rrsMeai n/Se rvice~~"*~/'"Comments i To Stream, Pond, Lake, or Major Drainage Page I of 2 72-026(11/84} ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Type of System Design Length of Field Depth of Field __ Square Feet of Absorption Area Depression over Field (Y/N) Resqlts of Last Adequacy Test Separation Distance from Abso~ To Water-Supply Well To Building Foundation Lot To Water Main/Service To Stream/Pond/O To Driveway, Major Drainage Course Area, or Vehicle Storage Area Gravel Bed Thickness Stand (Y/N) Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) / "Pump Off" Level at . Page 2 of 2 72-026 (11/84) ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I hav~e.cb..~cked, ~'erified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed (~, lI-~, ~;~{~M/~'J~..P Date Company ALASKA e rdlROFlm IqTAL COFITROL SE!RUIC S, IIqC. KlM WILMOTH SELLER-DEEN MARSTON REAL ESTATE 2804 WEST NORTHERN LIGHTS BLVD ANCHORAGE ALASKA 99517 i2/3]/86 KIM WILMOTH MARSTON REA1, ESTATE 2804 WEST NORTHERN LIGHTS BLVD ANCHORAGE ALASKA 99517 60653 LEGAL:GRAHAM SUBDIVISION LOT 6 PLOW TEST ON WELL WEI,L FLOW DATE-12/31/88 A FLOW TEST WAS PERFORMED ON THE WELL. 525 GALLONS OF WATER WAS PUMPED AT A RATE OF 7.5 GPM OVER A DURATION OF 1.1 HOURS. THE DRAWDOWN WAS 6.4 ' WITH A RECOVERY TIME OF 3 MINUTES AND THE STATIC WATER LEVEL WAS 39 FEET. THE WELL IS ADEQUATE FOR THIS 3 BEDROOM HOME. 1200 gJcsJ 33rd Auenue. %uite [~ ,, Anchorocle. Alosb 99503 ,,,(907) 561-5040 Alpine Drilling & Enterprises INVOICE Domestic -- Commercial N°_ 2 0 81 J., .~,n Pump & Water Systems P.O Box 110496 [ Jo' Na e / Loc "on chorage, Alaska 99511 / Z.'~/r~ (z~ ~7~,¢f ~" ~_ (907) 345-0202 / ~'A~'~ ' PHONE ~ / DATE QUANTITY DESCRIPTION AMOUNT ~BOR HOURS RATE AMOUNT TOTAL MATERIAL TOTAL LABOR .~ ¢ Thank You SIGNATURE (I Hereby Acknowledge the Satislactory Completion of the Above Described Work.) TERMS: ACCOUNTS PAYABLE AT lOTH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS. / CONTROL SERVI( ,:, INC. /"~'~ 1 SHEET,O. Or 1200 West 33rd Ave~, Suite B~ ANCHORAGE, ALASKA 99503 CALCULATED BY ~: ~K DATE (907) 56~-5040 CHECKED BY DATE ~' W MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL ~FEALTH DEPARTMENT OF ~F3~LTH ~ND E~P;IRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL GERTIFICATE General Information Application Date Legal~e~crip~i~n (in.nde lo~, ~ck, section, ra~e) / Location (~dresM~or diregtio~) (b) Applicants Name~/F~ f~ ~ Telephone~~ Z W/~ - Rome Business Buyer ~ ; Other ~ (~plain); (d) Landing Institution Telephone Address Address (f) the FAA to the following address:' Type of Residence Single-Family~ Number of Bedrooms Multi-Family Other (describe) Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Sewage Disposal Onsi~e ~-~ 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] ~ngineering Firm Providin~ Inspections, 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 type of structure indicated herein°. I further verify tha~, based on the information obtained from the M3anicipality 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 regula- tions in effect on the date of this inspection. Name of Firm ~M~?.~!N~ .... Telephone M/Z /I -'z ' - '." Approved for CADTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HE~TH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPKESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTEPQSD IN THE STATE OF ALASKA° THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HO}~S AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- M ENTSo EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF A/~CHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WOILKo (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 MUNICIPALITY OF ANCHORAGE (MOA) H ,LT mmO TY PROVAL ,iAi! 0 'i985 CHECKLIST FEBRUARY 1984 mr' .~ ~ Legal Description (3~/~ Well Classification Well Log P~esent ~) Total Depth /J~O '~- Cased to Static Water Level ~ Casing Height Above Ground~ ~ O ~'"' Electrical Wiring in Conduit (~) Separation Distances f~cm Well: TO Septic/H~t~i~g Tank on Lot ~//~ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line /6~O W~ Depression Around Wellhead (~f~N)/ , ; On Adjoining Lots ; On Adjoining Lots TO Nearest PUblic Sewer C leanout/Manhole /~ ¢7 Wate~ S~le Test ~sults ~ Dat~l%~-~ ~ Size No. of Ca~a~/~rents Standpipes (Y/N) ~'--..~A_ir-tight Caps (Y/N) Foundation~/N) Depression over Tank (Y/N) ~'~a~ Last Pta'--~d ' ~ Pumping/Maintenance Contract on File (Y~'/N~.~ ~;~"~r Holding Tank High-Wate~ Alarm (Y/N) ~ Holding Tank Pernd~t (Y/N) Se parati°n Distances f~°m sePtic/H°l/~ank: ~ To Water-Supply Well w"" To Building Foundation~'~.. To Property Line / To Disposal Field D~ ~"~ ~ Ma~ , Major To Water ne To Stream, Pond, Lake c= Course Receipt 9 Date Paid: Amount: [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils in Abso~-ption Strata Date ' Width of Field Square Feet of Abe( Depression over Field (Y/N Results of Last Adequacy Test Separation Distance frcm A~s°rption To Water-Supply Well To Building Foundation Lot To Water Main To To Type of System Design Length of Field Depth of Field Gravel Bed Thickr Date of (Y/N) Test Property Line To ~ing or' Abandoned System cn Adjoining Lots ~ To Cutbank (~ese mt) Major Drainage Course Area, cr Vehicle Storage Area ~ D. LIFT ION Date Install~e % D . Size in Gallons ,~ ' ~.~M~nhole/Access (Y/N) "P~u~ On" Level at ~ J "Pump Off" Level at High Water Alarm~ Vent (Y/N) Tested for~'/ P~ng Cycles during Adequacy Test. Meets MOA Electr ~s (Y/N) *~ Check Porn~tted Bedrcx:ra Rat±rig ,~:Jainst: HAA l~que.qt: I c~rtify that I have checked, verified, c~ conformed to all MOA HAA Guidelines in effect on tke date of this inspection. 2-15-84 ~ DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR I NS P ECTO~R--~ MUNICIPALITY OF ANCHORAGE ,MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~L~-. OF H~ALT;~ 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 ~ ~ (J~ I REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND ~~I~ES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE MAILIN~ ~ (~ V PROPERTY RESIDENT (If different from above) PHONE .HO,.z MAILING ADDRESS 3. LENDING INSTITUTION ~ PHONE 4. AE~LTOR/AGENT / PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE [~1~ NG LE FAMILY [] MULTIPLE FAMILY NUMBER OFtBEDROOMS [] One [] Four [] Two [] Five [Z~"'T~ree [] Six [] Other 7. WATE".SUJ"'"Y ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTI LITY * ATTACH WELL LOG. Awell log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [] INDIViDUAL/ON-SITE*' ~C UTI LITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) ~ ~' THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [~] SINGLE FAMILY [~1 ONE [] THREE (~] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL I DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG REOEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [~INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or []HoldingTank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4, DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5, COMMENT8 [~J/~PP Rev E D FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED ~ DATE BY 72-010 (Rev. 6/79)