HomeMy WebLinkAboutHANSEN SAND LAKE LT 16A
.: MUNICIPALITY OF ANCHORAGE
,RTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
I~E OE INSPECTION 'FOR HEALTH AUTHORITY APPROVAL
ON-SITE SEWER AND WATER FACILITY
264-4720
. :: - Application Date
: f .,. :
lock, subdivision, section, township, range)
phone: Home Business
check oho): Lending Ihstitution i-1; Owner/builder~'; Buyer i-1; Other [] (explain);
Telephone
:: .:':;: ::::~
to;the following address:
Other
SEWAGE DISPOSAL:*
I:~0 the leg~ ,and stat
ilof 2 : : ':
from the State Department of Environmental Conservation
Conservation
ENGINEERING FIRM PROVIDING 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 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
waste'water 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
DHEP APPROVAL
Approved for ./~,~,-e~.. ~¢bedrooms by
Terms of Conditional Approvah
Date
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Hea!th 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 ef 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
p'rofessional engineer's work.
Page 2 of 2
WELL DATA
Well Classification '~/"/v~/'>~
Well Log Present (Y/0 /
TotalDepthd') ;7-/O Casedt _~) ¢b',¢~
Static Water Level ~') ~.'.~/ / - '
If A, B, C, D.E.C. Approved (Y/N)
Date Completed ~A//~At~'/~//4 C~ /~'7!)Yield
Depth of Grouting
Pump SetAt ~
/, ~' / Sanitary Seal on Casing~N)
Depression Around Wellhead (Y/~)
,~/'/,,4 ; On Adjoining Lots
; On Adjoining Lots /g~ / "/~'
Casing Height Above Ground
Electrical Wiring in Conduit 0N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot -~,//¢'
To Nearest Public Sewer Line ~!.~ q-- To Nearest Public Sewer
;
Cleanout/Manhole ,.~¢v -f- To Nearest Sewer Service Line on Lot
Water Sample Collected by /~$ ~). ~¢2¢~"'~ ; Date
Water Sample Test Results
Comments 0
SEPTIC/HOLDING
TANK
DATA
_L No. of
Size
Compa~ments
Air-tight Caps (Y/N) ~ ~ ~ Foundation Cleanout (Y/N)
P~~~~~ (Y/N) .... ; for
H~an~h-Water Ala~ (Y/N~ Temporary Holding Tank Permit (Y/N)
S~¢H~di~ ~:~
~ W~uppl~l ~ ~~ Foundation ~~_
To Water Main/Service Line ~ eam, Pond, Lake, or Major Drainage
Course
Comments
Page I of 2
ABSORPTION FIELD DATA
gin Absorption Strata
Date Install'e~__ __
Results of Last Adequacy Test
Separation
Distance from Absorption Field:
;~ :~itl~i-r%u::l;n:a~illo~ .... "..~p:rty LineTo Existing or Abandoned System on
Lot ____ __; On Adjoining Lot8~.~,..~
To Water Main/Service Line ____ __ To Cutbank (if pres'e~,...
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
LIFT STATION
Da~"~"~-te d
Date ~ ~ Dimensions
High Water Alarm Level at ~~ Vent (Y/N)
;:~;~r~cfa~rco~es (y~N~ ~Cycl~..~,..e:during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I.,~j,~c~ck~d,~erified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~¢-,!2._.- (~ J't.,/~ Date ~ ~/O "~,~
Company /¢~'~ )' MOA No.
Receipt No,
Date of Payment .~:~--":f:=~
Amount: $
Page 2 of 2
72-026 {11/84)
ALASKA ENVIROI~ENTAL
CONTROL SERVIC J, INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
SHEET NO.
CALCULATED BY
OF
CHECKED BY
SCALE
DATE