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HomeMy WebLinkAboutT13N R3W SEC 26 SE4SE4SE4NE4 PTN 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 Parcel I.D. # C~)"7 - J ~ -~ -- :~Z_ ,* GENERAL INFORMATION ' .~".,' Completelegaldescription ~_.t/~_ ) $~ ~J ~E: I~j <~_~.~ Location'(site address or directions) '~-/ Property owner d~ Mailing address ';',Lending agency' Day phone Mailing address Agent "~' ~-o~F-- Day phone D~y phone Unless Otherwise requested/HAA will be held for pickUp 2. "UMBER OF BEDROOMS: .:_. 4 .. . ' 3. I~PE OF WATER SUPPLY: ?.'-~.*: ............................ .............. Individual well-:~-----: _,.-!' . ' NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. ~ . .: 4. TYPE OF WASTEWATER DISPOSAL: ~ % *., - ....:' ndtvldual on-site* ;,<':-. i:~ - · .- Holding tank.~- ~ .' . NOTE' If community Was~ater system, pr, pvide written confirmation from'State ADEC,:~ STATEMENT OF INSPECTION BY ENGINEER B ] ' r ' vahdation date shown below I verify that my As certified by my seal affixed hereto and as of the , investigation of this Health AuthoritY Approval application shows that the on-site water supply and/or wastewater disposal system is'safe, fu~cti~nai ~nd adequate for the number of bedrooms and type of structure indicated hereinl I furth~verlfythat based on the information obtained from the Municipality of Anchorage files and from my inves.ti, gation and inspection, the on-site water supply and/or wastewater disposal system is in corn 31lance with all Municipal and State codes, ordinances, and regulations in'effect on the date f this inspection. Date 6. DHHS SIGNATURE /* ~,-,~./.,_ ~ I . ,., C/ .Approved for'. / ~-' Disappro,;'e~:l. f ConditionaFapproval for ........ ~.~ ,o' ..27~.'1~; '~ , e, "' · :. ' ~1 /~' L ~ ~ . .. · . ~~...~ ..... .... "~L~tt.( . ~.~ , -' b~rooms ............. .... ....... ~'~ ,' b~rooms, with the following stipulations: Additional Comments 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 oy an independent profess onal 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 c~f DHHS do not conduct nspect ons or aha yze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engi,neer's work.:~.~ ' -:,,., ,?'.~m m.,,!',,, ,. ,,.'~' ,:-,,.; .., -, Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST egal Description: l' A~ Parcel I.D. ~ ~ - / Well type 'P~t~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) ~ Date completed~' Driller Total depth U~ow~ Cased to ~- ~"~r ,C~sing height Sanitaw seal (Y/N) ~ Wires properly protected (Y/N) ~ FRO~ WELL LOG AT INSPECTION~ ~ Static water level +~ O~ _ . ~ ~ Well flow _ ~ .g.p.m. ~' ~ ~ 5 ~.p.m[%~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~/~ ; On adjacent ,o,, Absorption field on Public sewer main Sewer service line ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ¢ Nitrate ,* { [~q~/~ Other bacteria ¢ Date of sample: lO/-9"7/~7Z~- Collected by: ~¢:~'~1~'-~  NG TANK DATA O t"'r'~// Tank size __ Cleanouts (Y/N) ~ Foundation cleanout (Y/N) _~---~ Depression (Y/N) High water alarm (Y/N) ~ A~'m-'~tested (Y/N) Date of pumping ~ ~'"~Pumper SEPARATION DISTANCES FRQ~.TJ~ TW:i(r:)p;~;%tine J Absorpti/On adJ~~::°rv~ce line 72-~* Front .CONTINUED"~ BACK PAGE C. LIFT' STATION n gallons High water Meets Well on lot "Pump on" level at codes (Y/N) FROM LIFT STATION TO: __On adjacent lots D, AB.;ORPTION FIELD DATA Date installed Length Total absorption area Date of adequacy test Manufacturer Manhole/Access (Y/N) "Pump off" Level at .Cycles tested oil rating (GPD/FF) Width kness Cleanout Y/N) Water level in absorption field before test System type Total depth Depression over field (Y/N) for After test / Perexide treatment (past 12 months)~N) give date SEPARATION DISTANCE/~ A~SORPTION FIELD TO: Well on lot / On adjacent lots __ ~,,~perty line To building founyon __To existing or abandoned system~t_ On adjac.~.J~s Cutbank__ __ __Water main/service % Surf.~gj~.-vater Driveway, parking/vehicle storage area ....~aln drain ~ E. ENGINEER'S CERTIFICATION Bedrooms HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in eff~_, a[~b.~.~at6~ of this inspection. ,,o...o APPL (' NT F LLS OUT UPPER ONLY Property Owner ¥ i · , , Phone Mailing Address ~- Buyer Address Zip Code Phone Lending Institution Address Zip Code Phone Realty Co. & Agent Address Zip Code Legal Descriptior~ ? ~),.~.~,. ~ _ ~"'-' - ' Type of Residence ~ Single Family ~ Multiple Family No. of Bedrooms. ~ Other Water Supply ¢~ Individual A~ACH WELL LOG. A well Icg is required for all wells drilled since June 1975. ~ Community For wells drilled prior to that date, give well depth (attach Icg if available). ~ Public Utility Sewer Disposal ~ Individual Year Individual Installed: ¢~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED. Date Date Date Date Inspector Inspector Inspector Inspector (*~qAPPROVED BEDROOMS ~,'{ *CONDITIONS OF APPROVAL (/ ) DISAPPROVED ) CONDITIONAL APPROVAL* Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Well to Tank Septic Tank Size