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MUNICIPAL[~[Y OF ANCHORAGI~
ENV],qON.~ENTAL SERVICES DIVISIOH
,. MUNICIPALITY OF ANCHORAGE
JLllXl :~ 01987 DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAl-
R E C E I V E D oF ON-S,TE SEWBR A'~D WATER FAO,L,TY
264-4744
Application Date ~r~'~._
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include Icl, block, subdivision, section, township, range)
Location (address or directions)
l~//..c ~..~,~
(b) Property Owner
Mailing Address
(c) Lending Institution
Mailing Address
(d) Real Estate Company and Agent
Address
_ Telephone: Home
Business
Telephone
(e)
Telephone ~
Mail the HAA to the followina address: or; Check here [~, if hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family/~
Number of Bedrooms
WATER SUPPLY
IndMdual Well~ Community F] Public []
Note: If corn munity well system, mast have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SI"WAGE DISPOSAL
Onsite I-I Public/~ Community [] Holding Tank []
Note: If community well system, must have written confirrr~ation from tile State Department of Environmental Conservation
attesting to tile legality and status.
Page 1 of 2 72-025 fRev 8/86~ F¢onl
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
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 shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
fo~ the number of bedrooms and type of structure indicated herein. I further verify that based on the inlormation 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 ali Municipal and State codes, ordinances, and regulations in effect on
the date of this i~sDaction,
Name of Fir .C_,~¢' _ _ Telephone
Address ...~--,..-c, ~ ~-,~, ~_._,~
DHHS APPROVAL
Approved for '~'~ r"~--'~-~2bedrooms by
Approved __ Disapproved Conditional
Terms of Conditional Approval
Date ;Z - J - ~ '.~
CAUTION
The Municipality of Anchorage Department of Health and Fluman Services /DHHS) issues Health Authority Approval
cedificates based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does Ibis 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.
Page 2 of 2 72-o25 fRev 8/861 Back
NORTHERN TESTING LABORATORIES, INC,
2505 FAIRBANKS ST. ANCHORAGE, ALASKA 99503 907-277-8378
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY CLIENT
[] "U"L'C WAT':R SYSTEM "D' ~ L ¥~I'--f---I---
~PRIVATE WA'FER SYSTEM
Mailing Address
CiW State
'~,~, ~,
SAMPLE DATE:
Mo. Day Year
Purchase Order No.
Zip Code
SAMPLE TYPE:
f[~ Routine
[] Special Purpose
[] Check Sample (for original contaminated
sample with lab reference ne.
[] Treated Water
[] Untreated Water
CoUected by Laboratory Ref. NO.
10
Signature of Representative
FOR LABORATORY USE ONLY
TO BE COMPLE'rED ElY LABORATORY
Received at: ~Anch. [] Fbks.
'rime Received / '~ ¢0
Next Sample Due
COMMENTS:
SATISFACTORY
UNSATISFACTORY U
RESAMPLE R
OTHER BACTERIA
'rod NUMEROUS TNTC
'rD COUNT
q? o~--
~R~i~t~.~l Coliform Colonies per 100 mis,
Date
Time
NORTHERN TESTING LABOFIATORIES, INC.
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907-479-3115
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-8370
Besse, Epps, & Potts
2220 E.88th Avenue
Anchorage, Alaska 99507
Attn: Andy Po-bts
Date Arrived: 6/25/87
Time Arr:Lved: 1340
Date Sampled: 6/25/87
Time Sampled: 1145
Date Completed: 6/29/87
SOURCE: 14115 Hancock
Sample ID¢: A062576-2
Parameter Unit Result ADEC MCC*
Nitrate-N mg/L <0.10 10
Reported By: _~.~/ ./~ ~_ Date: 6/29/87
Carol J. Garrison, Vice-President
* MCC = Maximum Contaminant Concentration
NORTHERN TESTING LABORATORIFS, INC.
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907-479-3115
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-83?8
Quality Control Report
Client: Besse, Epps, & Ports
ID~:. A062587-2
Listed below are quality control assurance reference samples with a known
concentration prior to analysis. The acceptable limits represent
a 9~% confidence interval established by the Environmental Protection
Agency or by our laboratory through repetitive analyses of the
reference sample. The reference samples indicated below were analyzed
at 'the same time as your sample, ensuring the accuracy of your results.
Samples Parameter Unit Result Acceptable Limit
EPA WS378-6 Nitrate-N mg/L 0.84
0.84 - 1.02
Carol J. Garrison, Vice-President
3900 Arctic Blva., Suite 203 S,~ET NO
Anchorage. Alaska 99503 CALCULATED BY ~'~ ' [~)' ~'°
(907) 562'3252
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