HomeMy WebLinkAboutCALAIS BLK 4 LT 4
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
-38
Location (site address or directions) .~/o o z~_.~r~_ ~ .f/.
Property owner
Mailing address
Lending agency
Mailing address
Agent hi, A-.
Address
Day phone
Day phone ~7 - ~o~
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer v-'-
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. 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 of this Health Authority Approval application 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 inves_tLgation 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 F:(~ F/~ 7-~c/,~',¢,/ _Cern,, ~'~/ Phone
Address
Engineer's signature ~~ ~ ~ Date
DHHS SIGNATURE
~.,',. ,.,-~, ...-~.
~ ... : ' 7:~ r. '.',T.'
~*,"::h.% CE- 353? .-".,2
Approved for ~~ ~)bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By: .,~~.. ~__.0~ Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS 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.
72-025 [Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L /'1/; /~/'/'/ ~{~.~ -q'/'_~
Parcel I.D.
A. Well Data
Well type Pr ~' v' ~/-~
Log present (Y/N)
Total depth ~ IO~
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level1
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed I ? d'¥ Driller
..~ 5/o' Casing height
Wires properly protected (Y/N)
f')~- hO~,r Cased to
FROM WELL LOG
Y
AT INSPECTION
~,~ /~? /~
g.p.m. '~. ~ ~ g.p.m.
~-~ ; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Other bacteria
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot N.
Absorption field on lot
Public sewer main '/' '-.> ,,~-~
Sewer service line ;> ~
WATER SAMPLE RESULTS:
Coliform 0 to! /IOq~_ Nitrate /-, o.t~- ,~,.~/-~'
Dateofsample: Io/ ~? / ? 7.., io /' ~[ /g Z Collectedby:
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size Compartments
Foundation cleanout (Y/N) Depression (Y/N)
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Sudace water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (3/93)° Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
Soil rating (GPD/FF)
Gravel thickness
Cleanout present (Y/N)
Results (pass/fail)
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA
Date installed
Length Width
Total absoq3tion area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot On adjacent lots
Sudace water
.System type
Total depth
Depression over field (Y/N)
for
After test
If yes, give date
Bedrooms
Property line
To building foundation
To existing or abandoned system on lot
On adjacent lots Cutbank
Water main/service line
Surface water
Driveway, parking/vehicle storage area
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name
Date Nov
Waiver Fee $
Date of Payment
Receipt Number
NORTHERN TESTING LABORATORIES, INC.
3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 907-456-3116
2505 FAIRBANKS ST. ANCHORAGE, ALASKA 99503 907-277-8378
Flattop Technical Services
14530 Echo Street
Anchorage AK 99516
Attn: -
Our Lab #:
Location/Project:
Your Sample ID:
Sample Matrix:
Comments:
F129899
L4, B~t~ Calais SiO
Water
Method Parameter
Units
Report Date: 10/28/93
Date Arrived: 10/22/93
Date Sampled: 10/19/93
Time Sampled: 1100
Collected By: TFM
MDL = Method Detection
Limit
* Flag Definitions
B = Below Regulatory Min.
H = Above Regulatory Max.
Results *
Date
MDL Prepared
Date
Analyzed
EPA 300.0 Nitrate-N
mg/1
<MDL 0.15
10/27/93
Repo~ted By: Jam~,s H~ Johnson
V i c e _~p-~=~i~en~ /