HomeMy WebLinkAboutT13N R3W SEC 13 LT 68 S2
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
~IPALI~ OF ANCHORAGE
ENVI~,ONMENTAL SERVICES DIVISION
JUL 0 8 1997
CERTIFICATE OF HEALTH'AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
RECEIVED
Parcel I.D.
GENERAL INFORMATION
Complete legal description
Sec 13; T13N; R3W; Lot 68; S¢~z~ ¢~
Location (site address or directions) 8349 Duben AVenue
Anchora9e, AK
':,~ : ' ' ..'~Laverne & Edna Pfeifer
Pr,operty. owner - Day phone
333-1801
": ' ~.~49 Duben
.Mailing address
Anchorage, AK 99504
Lendii~g agency
'Mailing address
Day phone
Ag,ent
Address
Tom Alexander/ Vista Real Estate
4241 "B" Street Anchorage, AK
Day phone
562-6464
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 2
TYPE OF WATER SUPPLY:
Individual well xxx
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
NOTE:
Public sewer
xxx
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-O25 (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 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.
S & S ENGINEERING
Name of Firm 17o:~4 ~..i. m,,,.. ~ ,,~.._ ~.:! N=. 2~ Phone ¢¢' q ~/- 3¢7 '~ c~
Eagle River~ Alaska 99577
Address , ~ ~ t
Engineer's signature - .-- Date '~//~ '/~? 7
DHHS SIGNATURE
· ~//'"'Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
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 DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS 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.
Legal Descriptio~ ~ 7" (; ~'
Municipality of Anchorage ~i~. ~.~
DEPARTMENT OF HEALTH & HUMAN SER~iI~,uTY o~= ANCHO~,AeE
Environmental Services Division Ei'qVIRONMENTALSERVICE$ DIVI$10
825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907)343-4744
JUL 0 8 1997
$'"~/, ~/~ 'F Health Authority Approval Checklist j~ E C E I V E D
$e~7,~,~ 15 71~1 , R~k) ParcelI.D.:
A. WELL DATA
Well type P~tv4r.f..-
'Log present (YA~ ,v o
Total depth ~ I r q_
Sanitary seal {~/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
~ ~y.~
Cased to
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
~ lq 7~-
Casing height (above ground)
Wires properly protected (~/N)
AT INSPECTION
Coliform O Nitrate (~ · ~/¢ ¢ Other bacteria
$ & $ ENGINEEEING
Date of sample: ~/. ~0 / ~ 7 Collected by: 37C=4 ."~. ~i,er L~p ,eau NO. 2~
Eagle Rive~; AlasEa
B. SEPTIC/HOLDING TANK DATA ~U ~ C ~ ~ i ; ~ ~
Date installed ~ Tank size __ Number of ComPa~ments Cleanou~
Foundation cleanout ~Y/N) ~ ~ Depression ~/N) ~ High wa~~)
Date o,, R,~Pih~7.. J ,' ;'. "/ '"-., Pumper ~~
Date(ifisi;ile~ ' "' ' Soil rating (g.p.d.~rm) ~ ~ System type
'''' T°ta'%
EffectiVe,:absorption area ' ' '" ~~¢mn over field (Y/N)
Date of adequacy test ' ~ Results (Pass/Fail). For bedrooms
Fluid dept~eld before test (in.); Immediately after gal. water added (in.):
h~ (ins)Minutes later: Absorption rate = g.p.d.
~de treatme~ (past 12 months) (Y/N) If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Size in gallons
"Pump on--Pump off" level at*
~atum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station //
/o0 '-~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: /0 ~t,~
Foundation .... Property line __ __~eld__
Property line .....-B'uilding foundation Water main/service line
Surface water
Driveway, parking/vehicle storage area
Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
I certify that l have determined thru tield inspections and review of Municipal recor~
in conformance with MO_A HAA guidelinj~s in effect on this date.
Signature
Engineer's Name
Date
HAA Fee $ ,~C¥_J, ~
Date of Payment
Receipt Number
72-026 (Rev, 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
1. Approval
Address
Phone
.½REATER gNCHOR~GE fi_PEA BOROUGH
L'EALTH DF.P.AR~NT '
327 E,~GLE STREET
ANCHORAGE, ALASKA 99501
279-2511
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE ~aND 1VATER FACILITIES
FOR
Requested By, ./~
.-97 7'' 0'' ?/
4. Type of Facility to be lnspected~/~ ~,~ STREET:
Number of Bedrooms
S. Well Data:
A. Type
B. Depth
C.
D.
Size
Construction
E. Bacterial Analysis
6. Sewage Disposal System:
Septic Tank
1. Size
2. Age
(If homemade, show diagram on back)
'
3. ~4anufacturer f.-'//tf/d~·
4. Installer t'/~//~/
AFproval Request for Sew..,_{ ~ Water Facilities
Page Two r
Seepage Pit
1. Size
2. Lining
C Disposal Field
1. Number of Lines
2. Total Length
7. Required Measurements
A. Well to Septic Tank
B.. ~ell to Seepage Pit
C. Well to Sewer Line
~. ~ell to Property Line
E. lVell to Other Possible
F. Foundation to Septic Tank
G. Foundation to Seepage Fit
H. Seepage Pit to Property Line
8. CO~4ENTS:
DATE: ~ ,~ /'~/A~Z/ DATE, .
APPROVAL VALID FOR ONE YEAR FRO~.~ DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT
EDll70
~uly 13, 1971
Kessler/West Mortgage Corporation
~ East 6th Avenue
Anchorage, Alaska
Subjects Water Supply at el/2 of Government Lot 68, Sac. 13
TI3N, R3W,
Upon inspection of the subject property the well wee found to
bo in a pit. Sefore approval for the water supply can be given
by this office a pitlees adapter needs to be installed en the
well, the well casing needs to be extended above ground and the
pit filled in with dirt.
Temporary approval can be given upon the escrow of funds to upgrade
the well as mentioned above.
Sincerely,
Lynn So Coed
Environ~ental Specialist
Veteran's Administration
Gloria and Carl i. Reall
ky