HomeMy WebLinkAboutT12N R3W SEC 33 LT 16 W3
MUNICIPALITY OFANCHORAGE
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 HEAL:TH AUTHORITY
APPROVAL FOR A .SIN~LE FAMILYDWI=LLING
'-l'¢/I-'''0 I ,HAA#
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Lending agency
Day pnone
Day pnone
Mailing address
Agent "~ 4, vb ~' '~
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
individual well
Community well
Public water
RECEIVED
APR 23 1997
Municipality of Anchorage
Dept. Health & Human Service8
NOTE: IJ community well system, provide written confirmation from state ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
IndMdual on-site
Ho ding tank . _
Community on-site /_ ·
' Public sewer v
NOTE: If commUnity wastewater system, provide written confirmation from State ADEC
attesting to the legality and Status of system,
~'~tAk 81.:RVic~8 DIVI~
Municipality of Anchorage AP/~ ~ ~ -- Z~k
DEPARTMENT,OF HEALTH &,HUMAN SERVICES .0 1~97 (~
Envir°n'~e~{~l ~e~i~e& Division ~l, _ ~
825 L Street, Room 502. Anchorage. Alaska 99501. (907)~3~g~
Health Authority Approval Checklist
Legal Description: ~Z~,.~ '~,~,~ I~o ,~'~7-/~ TI ;L~ ~'~1,¢/ Parcel I,D.:
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
If A, B, or C, attach ADEC letter, ADEC water system number J"¢//~
Date completed [ ~ ~_
cased to_ k¢7 Casing height (above ground) /~:~* I)''
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
, /
g.p.m.
WATER SAMPLE RESULTS:
Coliform /~
Date of sample: ~/,/v,/~ '7
B. SEPTIC/HOI..DING TANK DATA
Date installed
Foundation cleanout (Y/N)
Date of Pumping
Nitrate ~),,¢~ ~5 ~,~4~/ Other bacteria N L~
Collected by: '~--~
Tank size ~Number of Compartments Cleanouts (Y/N)__
~ Depressi~ _ Fligh water alarm (Y/N)
Pumper ~
C. ABSORPTION FIELD DATA
Date installed Soil ratin p.d,/fF or fF/bdrm) ~ _ system type
Length Width __ __ Gr~l thickness below pipe _ _ __ Total depth
Effective absorption area __ Monitoring T~be present (Y/N) Depression over field (Y/N) __
Date of adequacy test __ Results (R,~/Fail) ....... For ____ __
Fluid depth in absorption field before test (in.); ~,mediately after gal. water added (in.):
Fluid depth (ins) Minutes later:. ~, Absorption rate = g.p.d.
bedrooms
Peroxide treatment (past 12 months) (Y/N)
If yes, give date
72-026 (Rev. 3/96)*
APR-== 1_~, 14:51 ET2,E E5I AFICHORAGE
~t~I~ C T&E Eh vi I'Orll~elltal ~;e fYi c es Inc.
90? 561 5301 P.03/03
CT&E Re£.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
971865001
Tobben Spurkland P, E.
W 1/3 Lot 16,Sec 33 T12,R3
W 1/3 Lot I6,8ec 3; T12,r3
DrJr~king Water
8aniplc Remarks:
Client PO//
Printed Date/Time 04/22/97 09:I9
Collected Date/Time 04/17/97 00:00
Received Date/Time 04/17/97 13:30
Technical Director: Stephen C. Ede
CT&E Microbiology Drinking Water Prugram certification status is p~ovisirnml as 4/8/97,
Nitrate N 0.265 0.100 m§/L
Total Petroteum Hydrocarbons 0,200 U 0.~00 mg/L
lorat Cotiform 0 cot/10OmL
SM18 4500-ao3~
EPA 418.1
$M18 9222B
04119197 JBL
04118/97
04/17/97 RAI4
;~a4u AKULA DRIVE
ANCHORAGE. AK 99516
5L320/01320 KEEP THIS SLIP
FOR REFERENCE