HomeMy WebLinkAboutCARROLL LT 5Carroll
Lot 5
#006-322-11
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services y
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. tf (()()In - SQ ID - \ \ ... HAA # 0 Roc — C) it O'S
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
- *A i_iilb e711
Location (address or directions)
I
2643 Carroll St Anchorage, Ax
(b) Property owner Secretary of HUD Telephone: (home) na Business 271-4665
Mailing Address 701 " a Brno 64 �chorage, AIC 99513-0001
(c) Lending Institution
Mailing Address
(d) Real Estate Company and Agent na
Address
Telephone
Telephone .
(e) Mail the HAA to the following address: (or check here ❑, if hold for pickup.)
List contact person and day phone number below:
pick up by engineer - 694-5195
2. TYPE OF RESIDENCE
Single -Family ❑ Number of bedrooms 4
Multi-famil - Duplex
3. WATER SUPPLY
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 W 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 IR". 7W) Page 1 of 2
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s MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval • y P J OO )
CHECKLIST - FEBRUARY 1984
UQP�4 P�SEk 343-4744
Legal Description: Lo t S C'� pro // S•• s•r
AS
A. WELL
Well Cla)`f If A. B. C, D.E.C. Approved (Y/N)
s � ication
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Date Completed
Electrical Wiring in Conduit (Y/N)
Depth of Grouting
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
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA NI.t
Date Installed Size
Standpipes (Y/N)
Depression over Tank (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
No. of Compartments
Air -tight Caps (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High -Water Alarm (Y/N)
Foundation Cleanout (Y/N)
Date Last Pumped
;for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments
To Building Foundation
To Disposal Field
72-0M JR". Laa) From Page 1 of 2
C. ABSORPTION FIELD DATA n/V
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N) _
Results of Last Adequacy Test
!fib/.c .�QwGr
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well _
To Building Foundation
Lot
To Water Main/Service Line
_ Statndpipes Present(Y/N)
Date of Last AdequacyTest
To Property Line
; On Adjoining Lots
To Stream, Pond, Lake, or Major Drainage Course -
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION WA
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
W
To Existing or Abandoned System on
To Cutback (if present)
Dimensions
Manhole/Access (Y/N)
"Check Permitted Bedroom Rating Against HAA Request"
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test.
certify that I have checked, verified, or conformed to all MOA and HAA guidetff in elfpc1on the date of this
inspection.'`,,� •t,
Signed .•fir':` •�'q�g
Company Eagle giver Engineering Services ar* 49'l? Ps--� 6a
eeaa� ox G
Date �•/cA Eagle River, AK 99577
T��5t95
MOA No.
Receipt No. . o v & -Receipt No.
Date of Payment 9 - Waiver Fee: $ _
Amount: $ 0 Z ZQ Date of Payment
77-076 (R". 7/88) Beck Page 2 of 2
..................
Louis A. Butera
�•, CE -6736
neer's Seal
Development Services Department
Building Safety Division
On -Site Wcter & Wnstewcter rroornm ,•` �"",
/ 4700 Bragaw 5 -meet >
P.O. Box 156650
Mark Besich Anchorage,
AK 99519-6650 r' Y
Mayor www nun. oro /nneP.
(907 :43-7904
Pump Installation Log
Well Drilling Permit Number: SW_ Date of Issue:
Parcel Identification Number:_
a� v'✓ o ! / EIiRiSTi9x► /!bP_f��hf
�6y3'• CA�O�. f�
Pump Installation Date:
Pump Intake Depth Below Top of Well Casing: $O feet
Pump Manufacturer's Name:
�d Jac k£4 -
Pump Model:
6; cz✓3/lc-is42VZ
Pump Size �Z hp
Pitless Adapter Burial Depth:
Pitless Adapter Manufacturer's Name:
Pitless Adapter Installer.
Well Disinfected Upon CompletionCKYes ❑ No
Method of Disinfection:
Comments:
Pump Installer Name: &l-eo q. Ho , cl en
J .
Attention: The purnp instiller shall provide a pump installation log to the DSD within 30 days of pump installation.
Sn r or ^ STEVECOWPER, GOVERNOR
DEPT.(((WwwO}}}��1FENIVIRONMENTAAI,CCONNSEEiMATIOWWWjjjN
ANCHORAGE/WESTERN DISTRICT OFFICE 563-6775
3601 C STREET. SUITE 1334
ANCHORAGE, ALASKA 99503
DATE: -/�I���-----
PUSID #: ------------------
To Whom It May Concern:
Accordinq to the records on file in this office. the
_.LAG'-/\ S'j�4.----_,i1/_2---- Water System is in compliance with the
State of Alaska Drinkinq Water Requlations.
Sincerely.
Ronald S..,K ein
Environmental Field Officer
PSK: sa
DEPARTMENT O/ ENVInONMENT AL OON��wv0.1 q,�
CONSTRUCTION AND OPERATION CERTIFICATE
for
PUBLIC WATER SYSTEMS
A. APPROVAL TO CONSTRUCT
Plans for the construction or modification of O r �•/�•�� J r��' �'Ji•/r
C 4.rr ''C /' , l �6Z F/it " 16 3 public water system located
In ,d^e/leop" Alaska, submitted In accordance with 18 AAC 80.100
by /'?..flex Gtr 4f./0ci.11rJ have been reviewed and are
0 approved.
❑ conditionally approved (see attached conditions).
By TITLE DATE
If constriction has not started within two years of the approval date, this certificate Is void and new plans and
specifications must be submitted for review and approval before constriction.
B. APPROVED CHANGE ORDERS
Change owm ado NaaewrnwNmw-wwe Approved by Date
C. APPROVAL TO OPERATE
The "APPROVAL TO OPERATE" section must be completed and signed by the Department before any water
Is made available to the Dublic.
The construction of the
water system was completed on t{^ �''� (date). The system is hereby
granted Interim approval to operate for 90 days following the completion date.
TITLE DATE
As -built plans submitted during the Interim approval period, or an Inspection by the Department, has confirmed
the system was constructed according to the approved plans. The system is hereby granted final approval to
operate.
Z_
By ' TITLE DATE
DISTRIBUTION: I. WHITE • ENGINEER OU-0vu S"tW. Q
2 YELLOW . WATER SYSTEM RLE @Cm ,,W4 Sa flow Q
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