HomeMy WebLinkAboutT12N R3W SEC 8 SE4SE4SE4NE4 PTN PARCEL 11
Parcel I.D. #
1.
GENERAL INFORMATION
Complete legal description
Location (sit.e. address or directions) 8528 Lak~ 0ti~ ?/~,u~
,~ ........... Anehora~ AK
Property. owner ES~g o~ Ev~yn'~sa~ ' _ Day phone
~Mailing address" C/0..R~ax Pro~ 2600 Cordova S~te 100
'Lending, agency .... ' ~'
- ,~ Day phone
Meilina address '~ ?~: ~'
Agent.' T~e~a K~y/ R~ax Prop~ Day phone
Address 2600 Cordova S~e~ An'~oraq~, AK~:"99503' ~
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"
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
: '.: ~."' .' HAA # -
Anchorage, AK 99503
257-0171
" ....... Unless otherwise requested HAA w~ll be held for p~ckup. :.,, q-~ ,~i~,~ ..... ~ ...... =, ', ~ ¥.,...
.......... : ~ Individual well '
Community well '.,:.: RECEIVED ' '
Public water - -
NOTE: If community well system, provide written confirmation from State ADEC attest-
'ng to the legality and status of system , , '; I.)/ ~/,
TYPE OF WASTEWATER DISPOSAL : ' , ' ' ':? ~ ,' j:~; :a, : F'~
Individual on-site : ____ : ,, , .'{ *( ..
Pub csewer "' :' ~'" . ',, "~,',/ t~??;.."~.
NOTE: If community wastewater s~tem} provide wfitton con.marion from State AD~C
'to the /egalit~ and status of system ~ ~'~
· : . a~,es,~n~. . ~ · ; :?.~ . . ~,.~,.~,,...
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 investigation 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.
Phone
$ & $ ENGINEERING
I/u,~,~ t~ag[e River l. oop Road No, 204
Eagle RIv.er,.Alaska_99577.¢
-//.Z//
Name of Firm
Address
_ Engineer's signature
Date
6. DHHS SIGNATURE. t
· ' ~ : __ Dsa roved ' ,~?.-.. '~ ~'.~'~;~.'?~'..~-~.~::',,~
- ' · ~ ~. 'Cond~onal'apprgval for -: .' *bedrooms ~w~th~.the fo owng, stpuatons
Additional Comments
of Health and Human' 8e~/~es '(DHHS)' issues Health Authority
only upon the representations given in paragraph 5 above by an independent
fleer 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
c'~)~duct, inspections ~r ~i~iyz'e:data before a certificate is issued...The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's workl
Municipality of Anchor~l<ge31 - 15 1 ~ti~p~/~ ^~c HO~,^oI~"~
DEPARTMENT OF HFALTH~ .&:HUMAN... SEIRVI~t~ENTAL SERVIC['S_ ; D~VJ~.~
.... Environmental Se~lces Division ~ ~
825 . Street, Room 502 · Anchorage A aska 99501, (907) 343-!~ ~ ~ ]99¢ ~
RECt tVED
Health Authority Approval Checklist
Legal Dcscription:4~ Yq,M~.Yq~ ~l~c. ~,, T'I~.M .~ 12~t,J Parcel ].D.: ~9l q-~l. II- II
A. WELL DATA
Well type I°,q I v.~ }' [ If A, B, or C, attach ADEC letter. ADEC water system uombcr
Log preseet (Y/i~ WO Date cmnpleted o ]
/ ../_
Total depth U I t,,. Cased to q o ~ Casing height (above groued)
Sanitao, seal C~/N) 'Y g 3' Wires properly protected (~)/N)
FROM WELL LOG AT INSPECTION
Date oftest O [~(. I "')- "/&q/ 0,7'
Static water level ~ / ~' (~ cl
Well production ~,,/t~ g.p.m. "~" ! +-
WATER SAMPLE RESULTS
g.p.m.
Coliform O Nitrate
Dateofsample: I/q/q( ,~ 3~/~5/~/(
B. SEPTIC/HOLDING TANK DATA N/4
Date installed
Foundation cleanoot (Y/N)
Date of Puml)ing'
C. ABSORPTION FIELD DATA
Date installed
Length Width
Effective absorptiou area
Other bacteria O
Collected by: S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle Rlver~ Alaska 99527
Tatd( size Number of Compartmeuts ~ Clean~) __
Depression (Y~) High w~~).
Pumper ~
Soil rating (g.p.~m~ S~Wm type _
Date of adequacy test _ ~ Results (Pass.ail) For bedrooms
Fluid deptl~eld before test (in.); hnmediately after gal. water added (Re,):
FI~ ~Ous.) Minutes later:~ Absorption rote = g.p,d,
~ro~ot (lmst 12 m0utbs) (Y~) __ _ If yes, give date
LIFT STATION
Date iustalled Size in gallon.~s ~__
Manhole/Access (Y/N) ~,~5PaatqWO~evel at* "Pump ofF' level at*
High w~t, er~ *Datum
C.~ted
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank Oil lot
Absorptioo field on lot
Public sewer main
Sewer/septic service line
; Oo adjacent lots
; On adjacent lots
Poblic sewer maohole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: /x//~
Buildiog fouodation Property line Absorption field
Water mailffservice line Surface water/drainage Wells~
Surface water ~ Driveway, parkiug/vehicle storage area
C~ Wells on adjacent lots Properly line
F. ENGINEER'S CERTIFICATION
I cert![.? that 1 have determined thrufield in~?Jections and review of Municipal records th~a~ _t~Ip~_' ~vtems are
in coq/brmance wi¢ MOAflL4A gui~lines in ~&ct on this date.
. /IJ? ...........
Dale / / ~ ~ / ~ ~
................................................................................................ ,r:~57r-7-.:r.T,7-7.:7?T?~ .....
Date of Payment /1~/~ Data of Payment
Receipt Ntunber _/~ 7 9/~2~ Receipt Number
Rev. 8/95 OSS: haa.wk.doc
CT&E Environmental Services Inc.
Drinking Water Analysis Report for Total Coliform Bacteria :oo w. ,o.e, o,,ve
Anchorage, AK 99~18-160S
Tel: (90'/) 562.2343
/e£AD h¥2TRUCTIONS ON R~VERSE SID£ BEFORE COLLECTING SAMPLE
S,-\MPLE DATE:
SAMPLE TS'PE:
Year
O RoudnO 0 Treated Water
/~ Repeal Sample (roe redline sample O Unlraat~d Water
',vilh lab re[ no,~,~{ t 6 ~ ,~ )
O Special Purpose Time Collected
SAMPLE LOCATION Collected By
TO BE COMPCETED BY LABO~TORY
Analysis shows th[~ Water S&MPLE to
o Un~ati~ f*cto~
Sample over 30 hou~ old. re*uh~ may
be unreliable
Sam~ e too long in transit; zampl~ should
not b~ over 48 hour* old at exam nation
to indlcate reliabl~ r~ult~. Please send
new ~ample via ~pe~ial deliveU mail.
Da~e Received ..... I/~
Tim~ Received
Analysis
Analytical Method~
,81'~" Membrane Fiher
O MMO-MUG
{~llenl notifi~d o(unsatisfaeto~ results:
Phoned Spok~ with
Date: ...... Tim~; ......
BACTERIOLOGICAL WATER ANALYSIS RECORD
M?,IO-MUG Result: Total Coliform __
hlembra.eFilter: Direct Count
' Verifieaiion: LTB
Fecal Coil(Dcm Confirmalion
Final M~mbrano~l~r Result~ ~
Rcp0rted By ~: ~ ~
E, Coil
__~)__ Coloni,~a/100 mi
COIIFIRhl~~
..... Colh'orm/100 mi
Time. I~O-~ hfs
,~,-~=.~, rT?r~Aq).~, + ~qNIIS~I qUIDitBWN03 6P:~I 96/~/~0
C~&E Environmental Serwces Inc.
~,o~v o~io~!i"''~~''''''
c~E ~.~ ~-~-~ ~aboratorv Analysis Report
UA = Unavailable
200 W. Potter Drive, A~ohorage, AK 99518-1605 - ~el: (907) 562-2343 Fox; (907) S61-530~