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