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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~ /