HomeMy WebLinkAboutLITTLE BEAR BLK 2 LT 2
MUNICIPALITY OF ANCHORAGE Ru5vi
Development Services Department _4/ Phone: 907-343-7904
On-Site Water & Wastewater Section - Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 014-061-37
1. GENERAL INFORMATION
Expiration Date: 9 - 29-2Z
Complete legal description LITTLE BEAR BLK 2 LT 2
Location (site address) 6730 LITTLE BEAR, ANCH AK
Current property owner(s) ADKINS
Mailing address SAME
Real estate agent
2. TYPE OF DWELLING:
n Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Private Septic
❑
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
Q
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 14 LiWaiver Fee $
Date of Payment
Receipt Number
COSA # QSG 2 2 1-311
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) 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 (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864
Address 4661 NATRONA AVE ANCH AK
Engineer's Printed Name MIKE N ANDERSON, P.E. Date 6-2-22
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6. DSD SIGNATURE......... .......... , , „r;
System #1 Approved for 3 bedrooms �• ° ;•• •......... if
1 : MICHAEL N. ANDERXN :!*7,W
System #2 Approved for bedrooms +i� J•w. CE - 9AA9
Disapproved leo • ?-•'�t 4
FRd�ffssla,% t�4
Conditional approval for bedrooms, with the following stipulatt 't�,�"►-
svil In C a.� � t Za 0o� -vi 6k V&� 111.0 ['\A I
By: E42_61� Original Certificate Date:
OF
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WATER AND m
WAST,'_%V',`ATER z
AM
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The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineers work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
•
Legal Description: LITTLE BEAR SUBD. BLK 2, LOT 2
If more than 9 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled fff'
Total depth 54 ft
Cased to 54 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 20 in.
Date of flow test for COSA 6/8/22
Static water level at beginning of test 21 ft.
Comments
B. TANK DATA
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA
Which system tested (date installed)
❑ ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
❑ NIA — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
Parcel ID: 014-061-37
Structure served by this system
Well production at time of test 3.5+ gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by MNA
Date of Sample 6/8/22
G. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date
Results ❑ Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
❑ Code -required soil cover over field Final fluid depth in
❑ System presoaked Absorption rate gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months)
date of test) If yes, enter date
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
E. SEPARATION DISTANCES.
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
**
if No
Community Sewer Manhole/Cleanout > 100'
70
❑ Yes
if No
ft
❑ Yes
if No ft
Neighboring Tank > 100' ❑✓ Yes
if No
ft
Private Sewer/Septic Line > 25' [Z✓ Yes
if No ft
Absorption Field on Lot > 100'✓❑ Yes
if No
ft
Holding Tank > 100'Cj✓ Yes
if No ft
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' Yes
if No ft
✓❑ Yes
if No
ft
ft
If septic tank is under driveway comment below
*69
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑Yes
if No
ft
M Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
❑ Yes
if No
ft
Surface Water > 100'
❑ Yes if No ft
Property Line > 5'
❑ Yes
if No
ft
Wells on Adjacent Lots:
❑ Yes
Absorption Field > 5'
❑ Yes
if No
ft
Private Wells > 100'
❑ Yes if No ft
Water Main > 10'
❑ Yes
if No
ft
Community Welts > 200'
❑ Yes if No ft
Water Service Line > 10'
❑ Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
❑ Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
❑ Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
❑ Yes
if No
ft
Private Wells > 100' ❑ Yes if No ft
Water Service Line > 10'
❑ Yes
if No
ft
Community Wells > 200' ❑ Yes if No ft
Surface Water > 100'
❑ Yes
if No
ft
F. ENGINEER'S COMMENTS
* PER REG AT CONSTRUCTION, ** AWWU SEWER SERVICE
G. ENGINEER'S CERTIFICATION
1 certify that l have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
COSA Checklist yellow sheet
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F'ERMIT NO.
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DEPRRTMENT '-- HEFILTH RND ENVIRONhll'rNTFII.' ~ 'iRm]'fE:CTIOI"4
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MINIMUM [:,ISTRNCE E:ETNEEN R NELL RN[) RNV ON-SITE SEWRGE [:,ISF'OSRL. :~VSTEf" !'S
FRI cHrE. !.,.IELL OR 2~1~ FEET FOR R F'LIE:LIC: WELL.
t¢9C~ FEET FOR R '' ' -' -
WELL LOGS RRE REQUIRED RND MUST BE RETURNE[) TO THE DEPRRTMENT HITHIN 'S(:.~ DRV'.S
OF THE WELL COMPLETION.
SF'ECIFrIC:RTICmNS RND CONSTRIJCTION [:,IRGRRMS RRE RVRILRBLE TO iNSURE F'ROF:'ER
~ NSTRLLRT ! ON.
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fL: I RM F'FIMILIMR WITH THE F.'EQUIREMEN'['~ FOR ON-~ITE .~EI. IER=, RND [4ELLS FrS: S;ET
FORTH B'¢ THE MUNICIPALITV OF RNCHORRGE.
~. I WILL INSTRLL THE =,k_,TEM IN RCCORE:,RNCE WITH THE ROE,ES.
RF'PL I CRNT ED R INNER
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FEET FOR I=1 PRI',,,'FITE !.4ELL ()R ;;?.OE~ FEET FOR FI F'LIE~L];C I.,.IELL.
'i4E:LL. LOG:E; I::fi:;~:E F,.':EI.';4L.IIREE:, F~IN[:, MUE;T BE f4'.ETURNED TO THE DEPRRTMENT I.,.IITH]iN
THE 14ELL COMPLETION.
:E;F'EC i F I E:F:IT I ON'.E; FIND CONE;'T'RUC'f'I OI.4 E:, Z FtGRFIME; FIRE Ff,,,'F:I I L.FtEfl_E ]"O T N:.E;URE F'ROPER
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FORTH E',"r' THE; MUNtC
2::: I 14iLL INST!=ILI_ THE =,'r.: I E.t IN FICCOR[:'RNC:E .b.I.T. TH THE COB'ES.
S t GI'.,IED:
RPPL. I CRI'.4T El:::, R I 1'.41'.,tER
l :E;SLJEi} E:'.r'. ..................................................................................... [:,FITE .....................................................
:i: NSPECT i ON H I :E, TOR"? - SE].qER :i. E.:'~ :E';E.LIER 2
P.!EL_L.. ]:NSF' El WELL LOG DRTE E'~ [)RIL. I.~ER
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Municipality of Anchorage
On-Site Water and Wastewater Program 4 "'
®�4�9 1161
(907) 343-7904 SA CTY
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 014-061-37 Expiration Date: O- 1 ^/U
1. GENERAL INFORMATION
Complete legal description LITTLE BEAR BLOCK 2, LOT 2
Location (site address) 6730 BABY BEAR DRIVE,ANCHORAGE, AK 99507
Current Property owner(s) JOHN &BARBARA PHELPS Day phone
Mailing address 6730 BABY BEAR DRIVE,ANCHORAGE,AK 99507
Real Estate Agent Day phone
2. TYPE OF DWELLING:
Z Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Individual ❑
Individual Well ® Holding Tank ❑
Individual Water Storage ❑ Community ❑
Community Class_Well ❑ Public Sewer
Public Water System ❑
WaiverNariance request for: Distance:
Received by: 40/,( ,/ Air
/'/ ,�1. . _! Date: 052
COSA to be released to the engineer,unless otherwwi r sted by the engineer.
COSA Fee $ •(-32-6-2, Waiver Fee $
Date of Payment /7't 2 Date of Payment
Receipt Number U(05Y3 D Receipt Number
COSA# °'("C Iq +�� ) Waiver#
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,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING,INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD.,EAGLE RIVER,AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 5/4/2018
THIS COSA DOCUMENT CANNOT BE USED TO TRANSFER TITLE UNLESS ALL VENDORS(ENGINEERING,SURVEYING,CONTRACTORS,ETC...ASSOCIATED
WITH THIS COSA ARE PAID IN FULL AT OR BEFORE CLOSING. Engineer's Comments: This investigation was completed in compliance with
ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested.
The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface,changes inland use,
local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the
system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function
satisfactory for current or future occupants or can ArcTerra guarantee that no unseen +�\
encroachments,deficiencies or discrepancies exist. OFA./4 X
* 49TH
6. DSD SIGNATURE p— Air
System#1 Approved for 3 bedrooms. + �� ,;E,,,,E7'H M. s r
System#2 Approved for bedrooms. 1), 7 18 v/
Disapproved. •.P4b e s o8`
Conditional approval for bedrooms, with the following stipulations:
.�J' ON-SIyG
WATER AN
m WASTEWATETE DR
PROGRAM `C,
C1j��,' L,�l�f Gc.
•
y. Original Certificate Date: rJ
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheer 10-10-12.doc
If more than 1 septic system is on the lot:
COSA Checklist# of_
Structure served by this system ,
Certificate of On-Site Systems Approval Checklist
Legal Description: LITTLE BEAR BLOCK 2, LOT 2 Parcel ID: 014.061-37
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID#_ Well Log (Y/N)Y
Date completed 2/24/1977 Sanitary seal (Y/N)V Wires properly protected (Y/N) Y
Total depth 54 ft. Cased to 54 ft. Casing height(above ground) 18+ in.
FROM WELL LOG AT INSPECTION
Date of test 212411977 51212018
Static water level 17 ft. 20 ft.
Well production 10 g.p.m. 4+ g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate •t.7 2-mg/L
Arsenic: N9 9 ug/L Date of sample: 512/2018 Collected by: ARCTERRA
B. SEPTIC/HOLDING TANK DATA—PUBLIC SEWER
Tank Type/Material Date installed
Tank size gal. Number of Compartments Cleanouts(Y/N)
Foundation cleanout(Y/N) Depression over tank(Y/N) High water alarm (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2 or ft2/bdrm)_ System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption area ft2 Monitoring tube Depression over field
Date of adequacy test Results(Pass/Fail) For bedrooms
Fluid depth in absorption field before test in. Water added gal. New depth_in.
Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) If yes, give date
r .
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at_in. "Pump off' level at_in. High water alarm level at in.
Datum Cycles tested Meets alarm &circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot NA On adjacent lots NA
Absorption field on lot NA On adjacent lots NA
Public sewer main 69'(Per regulations A const.)* Public sewer manhole/cleanout *70'
Sewer/septic service line 25'+ Holding tank NA
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
ABSORPTION FIELD ON LOT TO: PUBLIC SEWER
Property line Building foundation Water main
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
F. COMMENTS
` - ' '
Ar-. ), OF 44,4 \ ,
G. ENGINEER'S CERTIFICATION
49 TH
/ certify that I have determined through field inspections and review ofA!i_'Whir
Municipal records that the above systems are in conformance with MOA
KENNETH D or /
COSA guidelines in effect on this date. 7116 Av
Engineer's Printed Name KENNETH M.DUFFUS 'Pik) s * Air
Date 5/4/2018
COSA canary sheet_2-6-15.doc
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UNDLR NO ARCLMSTANCES SNOtJI.0 AN A3-4A.ILT BC Ui4D MR CCNSTRkJCIION OR FOR£STABLISWNG BOUNDARY oR FENCE IJNES.
ri;E SURVEYOR TAKES RESPONSERLITY FOR THE NITLtt TRANSACTICS ONI.T AND ASSUMES FINANCIAL UABIUTT ONLY F170i THE COST OF THE SURVEY.
USrED DISTANCES PREVAIL OVER SCAL & REPRODUCT}CW WAY CAUSE ERRORS IN SCALE
,F SURVEY 7Y4'. `°r 5U SYMBOLS
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SJME (UV_ 4-41—K- METAL PIKE IIArIJ WOOD DEG(
PLOT PLANS do LOT SURVEYS NOTE:' •
IT IS THE RESPONS461UTY Op THE BUILDER OR OWNER, PRIOR ?a ONLY THOSE IMPROVEMENTS ABOVE OROUND AND Vl51BL.E wu5i BE
coNsTRucTION, To vCRIFy PROPOSED BUILDING GRADE TO FINISHED GRADE AND U L TTY CONNECTIONS AND IP DEETERRMINE ETC., ArSHOW; m SHOWN IN Taj•EIR SEPTIC MNATE LOCATION, oNL,r, SNOW
THE ExISTE_NcE of ANY EASE►424T$, COVENANTS OR RESTRICTIONS MAY PREvENT SOME IMPROVEMCNT5 FROM BEINO SEEN AND LOCATED.
WHICH co NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. ALL DISTANCES ARE RECORD UNLESS CTHe•Rti+nse NOTEO,
SURVEY CERTIFICATION v.~+ �14• Prepared byPLOT PI.M.,4 '
,M�..r_...�. .+7 . ., ,,...,,,, ''•, Robert E. Johns, Jr. &e Assoc.
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.Mai/...v.~\idol Mod,
Professional Land Surveyors
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^-�^.�.� -o...; ,44,t�'**or .��� LOT-2-,---B-LOCK 2 , LITfiLE BEAR SUBD.
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. # 014-061-37
HAA# HA920297
1. GENERAL INFORMATION
Complete legal description Lot 2 Block 2 Little Bear Subdivision
Location (site address or directions) 6730 Baby Bear Drive
Property owner
Mailing address
Lending agency
Mailing address
Agent
Ad dress
Peter Cahill Day phone ~79-5647
6730 Baby Bear Drive, Anchorage, Alaska 99507
Key Bank Dayphone 562-6100
101 West Benson Boulevard, Anchoraqe, Alaska 99503
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
Four (4)
Individual well
Community well
Public water
XXXXX
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
Public sewer
NOTE:
XXXXX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA ~21
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.
Name of Firm Ted Moore, P. E., Flattop Technic~o~rvices 345-1355
14530 Echo Street, AnChorage, Alaska 99516
Address
Engineer's signature
Date
This is a request for a four(4) bedroom
approval made by the property owner.
This property is approved for a
four (4) bedrrom single family dwelling
rather than the original three (3)
bedroom request. 5-28-92
DHHS SIGNATURE
XXXX Approved forFOUR(4)
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date May 29, 1992 '~.
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 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
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.
72~Y25 (Rev. 1/91) Back MOA fY21
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
Parcel I.D. # ~,_~\.D, -
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA # ~ ~,C.~i~ ~'~
1. GENERAL INFORMATION
Complete legal description
Location (site hddress or directions
Property owner
Mailing address
Lending agency
Day phone
Dr-.J ,A-,,,c/~o,'z~'~.
Day phone
.Mailing address
Agent /'1,c/, elle
Address ..~ ZO/ o
Unless otherwise requested, HAA will be held for pickup.
Day phone
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
MUNICIPALii y OF ANcHui~.~E
ENVIRONMEN/-AL S~RVlCEs DIVISION
RECEIVED
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:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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.
Name of Firm F'/~,/-/~/ ~c/~-', r~( %e,'¢,ic¢ Phone ¢ ~¢- ~5'5~
Address IY~ ~c~ ~ ~~ ~ ¢~/~
Engineer's signature ~~ ~ ~ Date Y//¢/~
DHHS SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
bedrooms,
bedrooms, 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 by an independent
professional engineer registered n the State of A aska. 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 DHHS 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.
72~25 (Rev. 1/91} Back MOA ~21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SF~:~{S,, _L
Environmental Services Division E~i~ON~AL_~ViEEs_ ..
825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343:~T4~ u vISiON
Health Authority Approval Checklist
l.-o/- ~ 131/r~ /..tk/'/¢ I~e~,'-c~'~ Parcc~].D.:
RECEIVED
If A, B, or C, attach ADEC letter. ADEC water system number
Legal Description:
A, WELL DATA
Well type
Log present (Y/N) Y' Date completed '~ / g ? / '?' 7
Total depth ~-q ' Cased to 5-¥' Casing height (above ground) I q
Sanitary seal (Y/N) f Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
Dateoftest '~'/Z¥ /77 ¥ / g /
Static water level 17 ' ~ ~, ~' f
Well production lO g.p.m. ~-~ ~. ~ g.p.m.
WATER SAMPLE RESULTS:
Coliform 6~ col/toc2~_ Nitrate ~.~, I ~.j~'/~' Other bacteria
Date of staple: q ? q / ? ~ Collected by: ~[~ff
B~' SE~ICmOLD~G T~ DATA
Date inst~le~ T~ size Number of Comp~ents Cle~outs
Fo~on cle ~ ~ Depression ~ ~ ~gh water M~
Date of emping
Date ins~led __ Soil rating ~~) __ System ~e__
Len~ Wid~ ~ra~c~ess belbw~ipe To~ dep~
Effective abso~on ~ea ~offitofing Tube present~~eEression over field
Date of adeq~ te Resets ~ass~l) For~ b~ooms
~p~;fion field before test (in.); I~e~ately ~er__ g~. water ~
TyZa//2
D. LIl~ STATION N, A.
Date installed
Manhole/Access (Y/N)
High water alarm level at* *Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
t~. ,4.
Septic/holding tank on lot
Absorption field on lot
~Public sewer main
Size in gallons
"Pump on" level at*
Fo
"Pump off" level at*
; On adjacent lots N. 3,
; On adjacent lots PL//.
~Public sewer manhole/cleanout 70 '
Lift station
Sewer/septic service line
5vq~xra3to~, atcr/'~, ce~c
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line Absorption field
Water main/service line Surface water/drainage Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property Line Water main/service line
Driveway, parkingJvehicle storage area
Wells on adjacent lots
Building foundation
Surface water
Curtain drain
ENGINEER'S CERTIFICATION .~ .. ~,..~,.
I certify that I have determined thrufield inspections and review of Municipal record~:tha~ ?b¢' abo¥~i~ys[e/h3~q, re
in conformance with MOA HAA guidelines in effect on this date. ~: : , ," ~: .: ~ ..... ..
Signature ~"'~e_~__
Engineer's Name
Date ~lo /,[ t ~,
HAA Fee $ 3:, ~5~0,
Date of Payment
Receipt Number
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number