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Home My WebLink AboutMITCHELL-STEPHANS LT 2A ~,.~,~ MUNICIPALITY OF ANCHORAGE~ , D ,E. PARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEAL'['H 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) Location (address or directions) , (b) Applicant Nar~e Jo4n /V'~.-'~.,~e~ Telephone: Home 2 ¥~ SyZ ~ Business Applicant Address (c) Applicant is (check one): Lending Institution'S' Owner/builder []; Buyer []; Other [] (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address /0o0 ~ ~::~ ~ ~ o ,~ ~ · Telephone ,~ ~ zO .~ (f) Mail the HAA to the following address: L ,J TYPE OF RESIDENCE Single-Family'~ Multi-Family [] ~umber of Bedrooms Other 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 the legality and status. SEWAGE DISPOSAL Onsitei~ 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 I of 2 72-025 (11/84) ENGINEERING FIRM PROVIDII~,~.~,NSPECTIONS, TESTS, FILE SEARCH, D~*,~ ,: AND INFORIVIATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that ~y investigation of this Heatth Authority Approval shows that the on-site water supply and/or wastewa{er 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 /~ ~"~ Telephone Address / 2.O O W ~ 5 '~' ~"~c/n /4 K- ~ ~ ~-O I Date /O - ~ - e,5 DHEPAPPROVAL __~ , Approved for b,drooms by Approved X Disapproved Terms of Conditional Approval Conditional Date CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval c~rtificates 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) MUNICIPALITT OF ANCHORAGE DIVISION "OF ENVIRONMENTAL ~.~LTH DEPARTMEN/' OF ~ALTH AND ENVIRONMENTAL PROTECTION ~?PLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information (a) (c) (d) Legal Description (include lot, block, subdivision, section, township, .range) Applicants Name ~o[~ ~=~-~}D~Z~ Telephone- Home Bustness~-~ Applicant is (check one) Lending Institution ~; ~er~uilg~ ~; otn = I I ' ' ~ending Institution Telephone · Address (e) Address Telephone (f) Mail the HAA to the following address: '2* ~ype of Residence Single-Family,~. Number of Bedrooms Wate~ Supply- Multi-Family~-~ Other (describe) Note: ~f community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Sewage Dlspos.al. Onsite ~ Public ~--~ Community ~ Holding Tank ! I 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], Date (ENGINEER SEAL) Approved ~ Disapproved ~ Conditional -/~ ' ...... / ~ ~. ~. ~.-.u~. ~ (~_.-~...~ ,~-,.--~-~' ?~ ~ CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF H~ALTH AND EN~fIRONMJ~NTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CMRTIFI~ATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIO}L&L 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 ST_ATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE pPJNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. RR4/eJ/D18 [Page 2 of 2] (DHEP SEAL) 7'~19-84 A. WELL DATA MUNICIPALITY ,OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: Well Classification Well Log P~esent (Y~ Total Depth ~T ~ Static Water Level Cased to ~, r~ ~t117 OF ANCHORAG~ ,~ OF HEALTH & ~, ~ PROTECTIO~ i uv ! O 'igs If A, B, ~ C, D.E.C. App~oved(Y~) ~ Date ~leted ~L Yield GC~' ~pth of G~outing Pump Set At ~ Casing Height Above Ground /' ) ~ Sanitary Seal on Casing ~/N) Electrical Wiring in Conduit ~/N) ~ ~3 Depression A~ound Wellhead (Y/N) ~J~ Separation Distances f~om Well: T° Septic/Holding Tank on Lot ~,, ~' ~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /~0! ~F- ; On Adjoining Lots ~r-T/ To Nearest Public Sewe~ Line Zj~ / To Nearest Public Sewer A~/+-__ .~o Nearest Sewer Service Line on Lot ~/~ Cle ancu t/Ma nho le______ / Water-Sample Collected By ~_ ~o~9~d ; Date ~? 5~p ~c/ Wate~ Samp~T~- ~ ~ s ul ts ~ 4-'~/¢.~c T~, ~'N ' Date Installed p~ /~02~ ~{ Size / 7~O~/}~ No. of Ccmpa~tme~ts ~ ' Standpipes ~/N) W~5 Air-tight~p~) 7~3 Foundation Cleanout ~ Depression ove~ Tank (Y~OO Date Last Pumped Pumping/Maintenance Contract on File (,Y/N) ~ ; for Holding Tank High~Water Alarm (Y/N) ~- Temporary Holding Tank Permit (Y/N)~c¢ Separation Distances f~om Septic/Holding Tank: To Water-Supply Well ~, G~ ~,) To Building Foundation F~/ To P~operty Line -7 3' ~) To Disposal Field ~ ~-~ / To Water Main/Service Line ~J~ To Stream, Pond, Lake, c~ Major D~ainage Course ~ tooc //~ Date Paid: ~ .~3~ ~ , >~. C. ABSORPTION FIELD DATA Soils ~ating in Absorption Strata Date Installed ¢ ¥-%o-5o Width of Field · 5& ~ Square Feet of Absorption Area Type of System Design / Length of Field ~ c/% Depth of Field 4~-r / Gravel Bed Thickness f ~/ Standpipes Present ~/N) Depression over Field (Y~ ~o o Date of Last Adequacy Test ~7 ~k~ F~/ Results of Last Adequacy Test ~'~.f~c~,~ Separation Distance frcm ~sorption Field: To Water-Supply ~11 ~ /Oo~ To ~o~rty Line To Building Foundation F 4 5 o~ To Existing or ~andc~d System / Lot ~{~ ; ~ Adjoining ~ts To Water Main/~rvi~ Line ~ ~ To Cutba~(if pre~nt) To Stre~ond~ke/~ Majo~ ~aina~ Co, se ~ ~ co ' To ~iveway, Parking ~ea, o~ Vehicle Storage ~ea Co~nt~sq~+~ ~oe~ ~-~o-~o f~.~,,~ ~,'~c~ ~ ~--r~,'l~ Siz~ in Ga.].lons~--~.~ "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 Pu les'~3~%d~uacy Test. Meets MOA ** Check Permitted Bedroom Rating Against H.kA Request I certify that I have checked, verified, or conformed to all MOA on the?~this ' ' Company /+ecs MOA No. T"l - o z~ KB1/d5/s [Page 2 of 2] 2-15-84 'ALASKA I IlUIROFImffITAL COFITROL SeF¥OlCeS, IFIC. ~n§incerin~ 8 I~nuironmcnlol $1udics NOV 13 198# JCE4N NIE~ 9530 BIRCH ROAD ANCt-ICI~C~ AK SELLER - X)HN NIET~ BUYER - SUBDIVISION = STEPHANS BLOCK - ADEQ1JACYTESTFCR SEII~R SYSTEM THE TYPE OF /~SC1RPTION SYSTEM IS A TRENGq WITH AN AREA OF 34# SQFT. THE SYSTEM IS CAPABLE OF ACUEPTING 450 GiLL(~S OF WATI~R PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 501 C_ALLCNS. BASED ~ THE TEST DATA THE SYSTEM._....It ACUEPTABLE FOR A 3 BEI~(X3M I--[1VE. . .........~/~ THE SEPTIC TA~ WAS PU/vPED CN/NOV 9 1..954 A FLOI/ TEST ~/AS PREF~'vti-D-ON THE V~ELL, 501- G/~IXINS~OF WATER WA.S/-- n~ btX~WiX.~ WAb 12,5,-~ViT~f-/WRF. CDVERY-Ti1VE-CF--31---igliNErrES AND THE STATIC WATER LEVEL WAS 44,28 FEET, THE XliELL IS ,~OEQIJATE Pair THIS 3 BEDRiXSM ~'. SEPTIC TANK ADEQJ,~ZY ~_~. THE EXISTING SEPTIC T~L[VE OF'750 IS ADEQIJ~TE F~"~, THIS 3 BEDRCOM 1-12USE.~ ADDITIONAL CEIVIVENTS : SEPTIC TAN'< 'AS INSTAU. ED IN NO AS-BUILT EXIST, PUMPING C~WII~'vED SIZE IS IN EXCESS OF 700 GALL~S. 1200 ~est 33rd Aucnue. Suite [~ · Ptnchoroq¢, Abka 99503 ,(907} 5614040 ^LASK^ ~.211~orlm~rlTAL 1200 tll~sl ~3~1 Aucnue. Suile [;. Ancho~'aqe. Ah~ 99503-(907) 561-~040