Loading...
HomeMy WebLinkAboutCLAYTON BLK 1 LT 17AClayton Block 1 Lot 17A #001-255-17 L,S, sp,,1057- Municipality of Anchorage -- Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anphorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING asp Parcel I.D.001- T1- 17 HAA # tb_QW!9 Expiration Date: S - 2 3' OS 1. GENERAL INFORMATION Complete legal description 1-o i 17A 13 k 1 CLAyTO N Location (site address or directions) . 1443 Vt'/ 951-4 Ave— Current Property owner(s) Quo i 6 ie K*th Makart Day phone +;;Lq' ]Y38 Mailing address 14W 3 W D -ti JA Lending agency Day phone Mailing address 1 Real Estate Agent lc�r.� � uArL"rs4. Z, 14# 1 Day phone )-57-0113 Mailing Address I 1 D y�[_�i f3 �Cr /00 .'Unless otherwise requested, HAA will be held by DSD for pickup. 2 • NUMBER OF -BEDROOMS: o� ".J7 Y!- 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: :Individual Well [f Individual On-site ❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer Q' The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered 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 seat 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. 1 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. Name of Firm 53EUf2l LAND jQ4(j1lQLtrQIr46 Phone 8-79-39/6 Address 010 3 tali 15:1-4 N 2c 3 Engineer's Printed Name ihbbfe S'n��6clw.t� 5. DSD SIGNATURE _ Approved for bedrooms. Disapproved. Conditional approval for Date x/-'97-0-5 bedrooms, with the following stipulations: Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: i��h Original Certificate Date: (R« oume) Municipality of Anchorage +.." Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: I_OT /7A 1311-( 0-1-A-/7cm 410 Parcellb: Do1-a27-17 A. WELL DATA Well type 1Z If A, B, or C provide PWSID # N/A Well Log (YIN) (� Date completed �' F Sanitary seal (YIN) Wires properly protected (YIN)_ Total depth 1 a ( ft. Cased to J -5 -Lit. ft. Casing height (above ground) 3 A in. FROM WELL LOG AT INSPECTION Date of test V�id p 6 Static water level ft. ft. 3 Well production g.p.m. y }� g.p.m. WATER SAMPLE RESULTS: Coliform Jam_colonies/100 ml. Nitrate N_ mg./I. Arsenic: / ' zoq-�,«/L Date of sample: 111U105 B. SEPTIC/HOLDING TANK DATA Tank TypelMaterial Tank size gal. Number o ompartments _ Foundation cleanout (YIN) _ Depr ssion over tank (YIN) Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed So' rating (g.p.d./ftp or ftp/bdrm) Length ft. Width ft. Total depth _ ft. Eff absorption area ft2 Monitoring Date of adequacy test Results (Pass/Fail) _ Fluid depth in absorption field before test _ in. Water add Elapsed Time:_ m' . Final fluid depth _ in. Any rejuvenation treatment (past 12 mo.) (YIN & type) Other bacteria N _ colonies/100 ml. Collectedby: 5pvrklAk1 Date installed Cleanouts( /N) High water farm (YIN) Ti type I below pipe Depression over field lid For bedrooms gal. New depth_ in. Absorption rate >= g.p.d. If yes, give date D. LIFT STATION Date installed `Pump on' level Datum 11 Size in gallons _ in. 'Pump off" level at Cycles tested _ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N A Absorption field on lot N A4 Public sewer main /66 Sewer/septic service line JLro Manhole/Access (Y/N) High water alarm Meets alarm & On adjacent lots Ar On adjacent lots N A - Public sewer manhole/cleanout J� Holding tank NZA SEPARATION DIS NCES FROM SEPTIC/HOLDING TANK O OT TO: Building foundati n Property line Absorption fiel Water main Water service line Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line I Building foundation Water Service lire Surface water Curtain drain f Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. p Engineer's Printed Name_�bbtq S'pvrtclk,tt� Date N- 97- O0 HAA Fee $ 430 Date of Payment S 1�107U Receipt Number is 7 / (Rev. 12101) Water m Drivew y, parkinglvehicle storage Waiver Fee $ Date of Payment Receipt Number in. 4-20-061 4131PMI SG9 SCS ReLa 1032075001 Client Name Tobben Spurkiand Pi. Project Namels Lot 17A Bkl Clayton Clkot S►mple ID Lot 17A Bkl Clayton Matrix Drinking Water Sample Remarks: 1607 6616001 All Dstt*Mmes are Alsaks Standard Time Twined Daterrime 04262005 16:08 Collected Date/time 04212003 13:30 Received DakMme 04212005 14:45 TeeAalni Director Stapheo C Ede Allowable Prop Anatyth pwwncw Resultl PQL wta Mnhod Conulnerm Lima Due Dm Ing Metals by ICP/M5 f Arsenk 12.3 5.00 vVL EP200.1 C 0422/OS 0425105 SCL Haters Departa»nt Nitrate -N MODU 0.100 mglL EPA 300.0 B (<-10) 0421105 WAW Microbiolocy Laboratory Total Coltbrm 0 coV100mL SM204222B A (¢1) 0421105 TLP LOT 11A N90.00'00"W 63.00' LOT 17A W SHED x Z 0 6.3 I o 0 C5 14.3 p x O I O C) O fTl A i x ZE LOT 18A u m 4 BASEMENT I J LOT 16A ENTRY A x C' 6.9 14.3 6.0I o OU10.5 P, x o 0 ON 10.2 o y x 0000pppp 20.6 EXISTING 3.a HOUSE 9.1 0,`� •,.... '9 �� :., a © 49TH X00 N I 0 a., i; ,o R I QQ '• Michael L. Jokeloi o0 LS -7839 p WINDOW WELL OOQ % '$ • I1-65' 500 O OFessiono, \•apo � �pO0�p0o .;; DO N90'00'00"E 63.00' N N U N TWENTY FIFTH AVENUE NOTE: THIS DRAWING IS NOT'TO BE MODIFIED FOR USE AS A PLOT PLAN. EXCLUSION NOTES: It Is the owners responsibilityto determine LEGEND- SET FND owocwe.. the existence of any easements, covenants, or rstrictions s/e'RB w/CAP* 5/e' RB O JERRY D E E W H U R S T which do not appear on the recorded Subdivision plot. NOTE: 3,25' ALMON. Q MONUMENT w i Under no circumstances should any data hereon be used for HUB k ,ACK t hl R E /M A X p g a; x` a wt ✓ K �. µ �. construction or for establishing properly lines. FENCE— —x— x — _ SURVEY CERTIFICATION: LANTECH has conducted o OVERHANG— ph VERHANG— physical and that of he property m nt shown on Mb WOOD DECKS— drl wlnq and that pr Improvements line an situated there CONCRETE— E^' rF ore within the than no Ides and no encroach— ASPHALT—wes 0 ■ menta exist Other (hon holed. ORAy,;L_ A S— B U I L T 0 F: LEGAL DESCRIPTION: SEPTIC STANDPIPES— AN dLN UCTION SURVEYORS—PLANNERS—ENGINEERS WATER NiLL- 440 WEST BENSON BLVD. M 200 (fax) 561-6626 ANCHORAGE. ALASKA 99503 (907) 562-5291 LOT 17A, BLOCK 1, WORK ORDER 2005—L—NU1MBER. MATY 2005 _0PLAT * AR P-50 7 CLAYTON SUBDIVISION 1 6 —eeom A MLJ rW1N5 REF: 83—L-706 MUNICIPALITY OF ANCHORAGE DIVISION 'OF ENVIRONMENTAL m~.ALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicants Name '/~,~/ /~,~/~W,~ Telephone - Home:2?~-~f~Business / Applicants Address (c) Applicant is (check one) Lending Institution ~-~ ; Owner/~uilder.~-~.; Buyer~ ; Other~ (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single-Family~.~--~, Number of Bedrooms 3. Water Supply- Individual Well~I Multi-Family~--~ Other (describe) 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.'Sewase 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] En~ineerin~ Firm Provtdin~ Insp~tionst Tests~ File Searcht 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 M~nicipa!ity of ~mchorage files and from my investigation and inspection, the om-site w~ter supply and/or w-as~ewater disposal system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. DHEP Approval Approved for Approved ~ ... (ENGINEER SEAL) bedrooms By Disapproved Conditional Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY ~O PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. TfIE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. -(DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 Be MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE (MOA) DEPT. OF HEALTH a [-]EALTH A~RITY APPI{OVAL (H~IRONMENTAL"''- PROTECTION CF~CKLIST - FEBRUARY 1984 g [j !] ~ lcj84 ._RECEIVED Well Classification ~f{q~ If A, B, o~ C, D.E.C. Approved(Y/N) Well Log P~esent (Y/N) ~ Date Campleted ~o~C- ~¢~] [q~ Yield I / I Total Depth ISJ Cased to j~j Depth of G~outing Static Water Level ~0' Casing Height Abo~ Ground Pump Set At ~/~ on Casing (~/N) ~5 Electrical Wiring in Conduit (Y/N) ~3 Depression .a~ound Wellhead/~z~,~ Separation Distances ~cm Well: 0 TO Septic/Holdir~3 Ta~Z on Lot ~l6 ; On Adjoining Lots To Nearest Edgeof Absc~ption , ~-'-l~ '{ ~ ~(~a~est Publli Sewer Fiel~l_~ Lot ,' -- . ; On Adjoining Lots -- To Nearest Pubtic Sewe~ Linej?_~ ~.~ ~ Nearest 'sewer- ne ~ Cleanout/Mar~hole ,~,' Service Li on. Lot Water Sample Collected By ~(~ ~C.%. ; Date ~ ~ Wate~ Sample Test Results n~.~g . Date installed Size No. Cf Cc~a~tments Standpipes (Y/N) Air-tight Caps (Y/N) Foundation Cleanout (y/N) Depression ove~ Tank (Y/N) Date Last Pun~ped Pumping/Maintenanc~ Contract on File (Y/N) ; fc~ Holding Tank High-Wate~ Alarm (Y/N) Te~porary Holding Tank Permit (Y/N) Separation Distanoes ~cm Septic/Holding Tank: Tc Water-Supply Well To Building Foundation To P~operty Line To Dispc~al Field To Water Mai~JSe~viae Line To St~e~m~ Pond, Lake, cr Major Drainage Cou~.,~ Comments [Page 1 of 2] ~PT- /*7 /~/c2 / Ce Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Abscrption A~ea Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes P~esent (Y/N) Date of Last Adequacy Test Separation Distance f~cmAbsorption Field: To Wate~-SupplyWell To Building Foundation Lot To Water Main/Service Line To P~operty Line To Existing ~r Abandoned System cn ; On~djoiningLots To Cutbank(if present) To St~eam/Pond/Lake/c~ Majo~ Drainage Course To D~iveway, Parking Area, c~ Vehicle Stc~age Area Cc~ents D. LIFT STATION Date Installed Size in Gallons "Pump On" ievel at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Cc~ments ** Check Permitted Bedrocm Rating AGainst HAA Request I certify that I have checked, verified, or oonfc~red to all MOA HAA Guidelines in effect on the date of this inspection. Signed ~~ 0~O3~ Cc~pany ~ ~nu~o~ KB1/d5/s MOA No. [Page 2 of 2] CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER ' , · ~ tI. 5633 B Street Drinking Wat Analysis Report for Total Coliform Bacteria i . TO BE COMPLETED BY~VATER SUPPLIER WATER SYSTEM: (*) See h on back / Water Systam Name . ~ Phone No. Mailing Address SAMPLE DATE: ~ MO. / t State SAMPLE TYPE: I~Routine Check ~arnple (for routine sample with lab ref. no. [] Special Purpoee i~neat ed Water treated Water SAMPLE Time NO. LOCATION / Collected m422o Co) R~. lg~ TO BE COMPLETED BY LABORATORY saalysis shows this Water SAMPLE to be: tiSfactory t [] Unsatisfactory [] Sarpple too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received Analytical Method: ~3 Fermentation Tul~ {:] Membrane Filter d Lat Ref. No. Result* Analyst I I READ INSTRUCTIONS BEFORE COLLECTING SAMPLE *NO. of colomel/lO0 mi, o~ NO of Politn~l portion4. ; CollformllOOml dTC = Too Numerous To Count eembrane Filter. Direct Count rification: LTB ~inal Membrane Filter Results (,~ BGB. BACTERIOLOGICAL WATER ANALYSIS RECORD ALASKA UI O mE TAL COnTrOL SEPJJICES, I C. ~nqin(rrinq [, ~nuironm~nlol Sludie$ June 1984 Alaska USA Federal Credit Union 4000 Credit Union Drive Anchorage, Alaska 99503 ' Attention: Mr. Weaver We have exa~n~ the location o~ the roll and the ~o: the e~ect at that t~ :e~i~ecl a sepa:ation distance o~ 50 ~et between the roll and tx~bli¢ sewe:. The well casing ~s above g:o~ an/e ~ets oocle. I~ yo~ have any questions, please let iCRjr/caj Sincerely, 1200 U Jest 33rd Au~nue. Su,t¢ B · Anc%roq~. A, loska ~503 e1907) r:'61-5040 ALASKA B.,UIRO[lmE[1TAL COI1TROL SEI VICES. IRC. {~nqineerinq $ {~nuironmental Studies June 4, 1984 Municipality of Anchorage Department of Health and Environmental Protection 825 L Street Anchorage, Alaska 99501 Attention: Keith Bandt Dear Mr. Bandt: On May 10, 1984, Alaska Environmental Control Services conducted a well flow test at Lot 17, Block 1, Clayton Subdivision (1443 W. 25th Ave). The average well flow was 4.79 gallons per minute during the 2 hour and 50 minute test period. The smallest flow rate for a ten minute period during the test was 4.2 gallons per minute. Based upon our data, the well is adequate for a 2 bedroom house. Sincerely, Alan Donner Civil Engineer Approved By: 1200 LUest 33rd Auenue. Suite B · J~nchoraqe. J~lasko 99503,(907) 561-5040