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Home My WebLink AboutTHOMPSON BLK 15 LT 7Thompson Block 15 Lot 7 #002-196-21 Municipality of Anchorage. Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci,anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. OC~ '~ - I ? ~'- ~-/ e GENERAL INFORMATION Complete legal description /... o ~- Location (site address or directions) HAA#- Expiration Date: Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Day phone Unless otherwise requested, HAA will be held by DSD for pickup. Pl eo..r~, ccd/ 'NUMBER OF BEDROOMS: ~ ~.~4~. /-JLAJ ;j e .TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class. Public WaterSystem Well TYPE OF WASTEWATER DISPOSAL: ~] Individual On-site [] [] Individual Holding tank [] [] Community On-site [] [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD)Issues Cedificates of Health Authority Approval (HAA) based only upon the'representatiOnS 'given in paragraph 4 by an independent professional civil engineer re. gistered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 .days from the date of issUe for properties served by a.private or Class C well and may be reissued with new water sample results. (certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. NameofFirm ffl~'/-,-/-c,f 7",'c~;~/ ~.~,,-c,?~-~,- Phone' Address I Engineer's Printed Name .~~ ~,, ~ Date bedrooms. DSD SIGNATURE I/ Approved for Disapproved. Conditional approval for '__ bedrooms, with the followin~ stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Original'Certificate Date: /..J. _. J C~.... 0 L/_ (Rev. 01/02) Le, gal A. WELL DATA Well type Dat~ completed .. TOtal depth ~gO ft.: Date of test .. :. Mumc]pahty of.Anchorage :lgpment Sermces Department ~: '. ~; : ! :i. Building Safety Dlwslon r i ~ : i: On-,S~te Water & Wastewater Program i~: i :'ii ! i :; :. i 4700 South BragawSt. 'i! :::. P.O.'BoX 196650 Anch6rage,'AK 99519-6650 ' ; '; 'i! ii.i :;~.ci.anCh0rage.ak;us ~ . .~ .i ' :(907) 343-7904 : iHEALTH AUTHORITY AF, F, RoV, L CHECKLIST Description: '~,,~.7.,i ;i/~/oC~ I,~ T/lo,"~/,..c~,~ If A, B,i Or C provide PWSlD# :b/,,4. 19¢,7 sanitary seal (Y/N) ¥ ; c'aSed to ;"~'-/~ ft. FROM WEL!L :LOG , Parcel ID: Well Log (Y/N) Wires properly protected {Y/N) Casing height (above ground) AT INSPECTION ' "l;~" ~, 7~ g.p.m. Other bacteria ~ colOnies/lOO Collected by: Cleanouts (Y/N) " . High water alarm (YIN):. ~: I~ . ,..~ System type , ~ Gravel below pipe~ Depression Over,field For · :.~ ~ gal. New d~Pth Absorption rate >= ' ~ If yes, give date . ~; : I Static water level ~ : ft. Well production , . g.p.m. WATER SAMPLE RESULTS: ; Coliiorm t9 col6niesii00 mi. B, SEPTIC/HOLDING TANK DATA T~nkType/Material ' i Tank size __ gaI. i FOundation cleanout (Y/,N) Date of pumping c. A"SoRPT ON mLD Date installed : Length Total depth __ft. i Date of adequacy test FlUid depth in absorption field before test ~ in. Elapsed Time: min. Final fluid depth Afiy rejuvenation treatment (paSt 12 mO.) (WN & type) ;Nitrate~-,~. t mg./I. · DateI of sample: ¥/2/~ ¥ ;. Date installed ,, Numbe~ of Compartments ~ Depression over tank (Y/N) ~ ' . PumPer DATA!:' , Soil ra!ing. (g.P~.d./ft' or ft'/bdrm)~ .! ft. ~.1 Width: ft. Eft. absorption area ft~ Monitoring tube~ Results (Pass/Fail) Water added in. D.; L!FTSTATION ~. "~i ~D~te installed ~: ~ Size in gallons ':: "[Pump on" level: _'at!. in. "Pump off" level at :Datum ~, . Cycles tested E.: SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: iSeptic tank/lift ~;tati~)n on lot Jk/. /4. i, i~bsorption field On lot ~. fi. 'Public sewer main ""'... 5',4' Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? JR. On adjacent lots . :~. d,. On adjacent lots /V. ~, Public sewer manhole/cleanout Absorption field Surface water ;Sewer/septic service line ~, (o Holding tank M. ~. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: /J. ~. ;Building foundation' Property line ~water main i . Water service line i Wells on adjac?.nt .10ts iSEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: ',Propertyline ' .Building foundation Water Service line, Surface water iCurtain drain :. Wells on adjacent lots F, ~ COMMENTS I ENGINEER S CERTIFICATION . I certify that I have` 'determined through field inspections and review of Municipal records that the above systems are/n !conformance with MOA HAA guidelines in effect on this date. Engineer's Printed~=Name "'~',4 Date /'~-p,-',/ ~,'/, HAAFee $ ~.~ oc. WaiverFee$ Date Of Payment ~/15"/~ ~' Date of Payment ~.eceipt Number Receipt Number Rev. 12/01) -- __ Water main Driveway, parking/vehicle Storage in. i~j WEST TWENTY FIRST AVE. __ o ~ LOT 8 ~ ~ ~o WEST TWENTY CATHOLIC SCHOOL TRACT FIRST AVE. NOTE~ SNOW AND ICE uAY CONCEAL ~D · CONSTRUCfi~ SURVEY~S-~ANNERS-EN~N~RS '-- 440 ~ST DENSON BL~. ~ 105 (fox) 561-6626 -,- TH OM P SON I.-:':::':':':~.'~:':':' ::::::::::::::::::::::::::::::: .:~,'--:' ~: ~o., , I ,,',-r '~ ~':".~,~1.':'"'"::="1 ,,, . =7.6 -L:~ ..... - .ous~ s89'so'oo"E ..... ~'-~ ,' ~o.o0'"' ~1 LOT 8 ~, ~, T ~ ss~.sg"OO"~ l~o.oo. LOT 9 I- CATHOLIC SCHOOL TRACT Id ;4dI~S:£0 ~ ~,I '-~dU + ++ 6I£~9S : 'ON XUd : ~J