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Home My WebLink AboutWENTWORTH BLK 4 LT 4 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. # GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent L~ ~'r,,i H~,~, Z~ I~¢r~ -~4~ C~an Day phone M~/~ ~c~ ~,'~ Co. Day phone Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water '7(2 -~/0~' · Mu~iC~PALtTv. OF ANCHORAGE ¢:Hx/17.Oi, q. MENTAL SSRVICES DIVISION AUG 2 5 1997 NOTE: If communify well system, provide written confirmation from State AD£C 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. 724)25 (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 Fl~/-/~,f~ Address I ~I£~ 0 Engineer's signature bedrooms. DHHS SIGNATURE ./%t'/ Approved for -~ Disapproved. Conditional approval for Phone Date bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Healt [hority 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. 72~25 (Rev. 1/91} 8ack MOA li21 Legal Description: .L~,/- ~,. A. WELL DATA Well type I°~' Log present (WN) Total depth Sanitary seal (Y/N) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES MUNt¢I~^LnY Environmental Services Division ENViP. OHMENTALSERVIC~r~ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 . AUG 2 5 1997 Health Authority Approval Checklist RECEIVED /~ (O'er< Y2 /_,,¢M~,n/~or"'/Y~ ~/_DParcel I.D.: Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ~ ~:ol /too Date of sample: 7/2 y/~ 7 B. SEPTIC/HOLDING TANK DATA Date installed Foundation c eanout (WN). Date of Pumping C. ABSORPTION FIELD DATA Date installed Length Width. Effective absorption area. Date of adequacy test Fluid depth in absorption field before test (in.); Fluid depth (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* IfA, B, or C, attach ADEC letter. ADEC water system number Date completed z¢ //.3 /,d'~,d Cased to z¢ 5' Casing height (above ground) / g" Y Wires properly protected (Y/N) ~' FROM WELL LOG AT INSPECTION ¥/131d'0 7 / 'z,) /~7 g.p.m. I o. ~' .+ g.p.m. Nitrate ~ / ~_ z / ¢ 7 Collected by: Tank size Number of Compartments __ Depression (Y/N) Other bacteria Cleanouts (Y/N)__ High water alarm (Y/N) System type Total depth Depression over field (Y/N) __ For __ gal. water added (in.): _g.p.d. Pumper Soil rating (g.p.d./ff~ or ff~/bdrm) Gravel thickness below pipe Monitoring Tube present (Y/N) Results (Pass/Fail) Immediately after Absorption rate = If yes, give date bedrooms D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Septic/holding tank on lot Absorption field on lot Public sewer main /E,o ' Sewer/septic service line Size in gallons "Pump on" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: hi. ~. ('_ /)~"' ~-'~ ..C~q,,~,,-.,) On adjacent lots "Pump off" level at* On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ONLOTTO: ~'.,4. ( Foundation Property line Absorption field Water main/service line Surface water/drainage Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots Property line. Surface water Curtain drain F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and in conformance with MOA HAA guidelines in effect on this date. Signature ~.~ ~, ~ Engineer's Name --~/~c~ ~o~ ~. I~o~. Date ~d~,c~,rf ~,~ J¢¢7 HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID 974036002 Flattop Technical Sty. N/A IA,B4,Wentworth S/D Drinking Water 0 Sample Remarks: Client PO# Printed Date/Time 07/28/97 16:32 Collected Date/Time 07/24/97 13:40 Received Date/Time 07/24/97 15:20 Technical Director: Stephen C. Ede Nitrate-g Total Coliform Results 0.100 U I oB w/o COLI PQL Units Allowable Prep Analysis Method Limits Date Date Init 0.100 mg/L SM18 4500-NO3F 10 max 07/25/97 JRJ SM18 9222B 07/24/97 TMW FHA Form 2'573 ~-~/ FEDERAL HOUSING ADMINISTRATION ~'~ Form Approved Budget Bureau No. 63-R296.8 Rev. July ]958 HEALTH AUTHORITY APPROVAL INDIVIDUAL ~/ATER SUPPLY AND SE~/AGE DISPOSAL SYSTEM PART I.mTO BE COMPLETED BY FHA INSURING OFFICE MORTGAGEE SERIAL NO. Auchorage~ Alaska National Bank of Al~ka 60-00~236 MORTGAGOR OR SPONSOR E~a A, Shosten SUBDIVISION NAME PROPERTY ADDRESS Anchorage BLOCK ~_[O. LOT~[j, NO. ~nt~or th ~ubdivision TOTAL NUMBER: LIVING UNITS BEDROOMS BAIH$ WATER SUPPLY BY: [~] Public system BASEMENT ] New installation [~] Community system Can attic or other area be made into addlhonal bedrooms? (If Yes, how rnany~) No. or SYSTBM DESIGNED FOR [~] Individual BDRMS. GARBAGE DISPOSAI- [] I, dividual 3 [] ¥e5 [] No SEWAGE DISPOSAL BY: [~] Public system ] Community system PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT ~EALTH DEPARTMENT iNSPECTOR'S SKETCH IIIII IIIIll Illlll IllllllllJ IIIIIIII III IIIIIJ I JlllJll Jllllllll[ IIIIIIII Illll IlJJll ijlllllll lilllllllJllllllllll "'11 '""'11 "'"'11 -I"'"'" "i'""'" "'""'"l,iii"'"' '"i""'""'""'"' IIII IIIIIIIIII IIIIIIIIIII 11 I I I Illll I I I III II {I fl IIIII IIIJllJllll IIIIIIII JllllllJll I III III I II I II II I III III I I I1[ I II II II II II I I I I IIIIII I'"'"""'i'tllllll"ll ''''''''''''''''''' illll IIIII IIIJllllll IIIllllllll IIIIIIII ,,,,,, "'"'' '"' '"'"'1" JlJlll IIIIIIII iJlllllllllll IIIIIIIIIIIIIIIIIIllll It is the opinion of the ~] State [] County [] Local Department of Health that this individual water-supply system [] is [] is not satisfactory as a domestic water supply for the subject property. It is the opinion of the ~J State [] County [] Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance:~' [~ ~ [~] Cannot be expected to function satisfactorily Can be expected to function satisfactorily, and is not likely to create an insanitary condition ~ DATE S ATU TITLE / ",,~'" - ' - -7' ' ' -'"' / ""'J "~' NOTE: The health authority should complete the~pprogl~iate opinion statement above and affix date~ s~gnature and title in the spaces provided. Use of the above grid for Health Deportment Inspector's s~k~tch os well as _use of the bock of this f~orm is at the option of the PART III.~FOR USE OF FHA OFFICE THE CHIEF UNDERWRITER: I have reviewed the foregoing and the pertinent FHA Coml~lia'nce Inspection Report, and recommend that'the Individual water-supply system be considered [] Acceptable [] Not Acceptable Sewa/~e disposal be considered [] Acceptable [] Not Acceptable. SIGNATURE CHIEF ARCHITECT DEPUTY FOR CHIEF ARCHITECT DATE HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FHA Form 257~s Rev. July 1958 REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of ~,Septic tank, Septic Tank: J~ ~ t tt~c Distance from well, ~ 0 feet. Material, Total liquid capacity, Inside length,, feet. Inside width, Cesspooh Dis~nce from: Well, feet; foundation, Inside diameter, feet. Depths. [] Cesspool. gallons. Capacity inlet compartment,. / feet, Liquid depth, Number of compartments .gallons. .feet. feet; neasest lot line at [] front, [] side, [] rear,. feet. Liquid capacity, _gallons. Lining material SECONOARY TREATMENT consists of [] Tile disposal field. ~ Seepage pits. Other Tile Disposal Field: Distance from: Well, Total length of tile lines, Trench width, Length of each line, feet. feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, feet. .feet. Number of lines, Distance between lines, feet. inches. Total effective absorption area in bottom of trenches, square feet. feet. Depth, top of tile to finish grade, _inches. Type of filter material: [] Gravel. [] Broken stone. Other. Depth of filter material beneath tile. inches. Depth of filter material over tile, inches. Seepage Plt$I I~v / d//~ Number of pits / Outside4ia.meter, & a ~ feet. Deptb,. 6 feet. Lining material Distance from: \Veil, .o feet bu Id ng foundat o , ~- feet; nearest lot line at [] front, [] side, ~J/rear, '~ feet. Inspettlon made by: [] State. [] County. ~ Local Health Authority .... Inspected by REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main, feet. Size of main, inches. Individual wells ~ are [] are not customary in neighborhood. Give most recent record of failure of wells in immediate vicinity to furnish adequate supply of water Properties in neighborhood?{l are [] ~re pot being developed with both individual water-supply and sewage-d!sposal systems. Lot size: ¢9' ~ feet wide, /O 6) feet deep. Dwelling set back from front proper~ line, ~ / feet. Individual water supply from: ~ Drilled well. ~ Driven well. ~ Dug well. ~ Bored well. Distance of well from: ' Building foundation, *.~ ~, feet; nearest lot line at ~ front, ~ side, ~ rear,. -fi-' .feet, cast iron sewer, ~ feet; tile sewer,~ fee; sept c tank. ~ l) feet; disposal field,, feet; seepage pit, 'lO feet; cesspool, .feet; other sources of possible pollution, ~ feet. Well construction: Diameter, ~" inches. Total depth, 7/ ket. Type of casing ~) /; ~z - ~epth of casing, }/ ~- ket. Approximate depth to pumping level of water in welk ~ feet ApProximate yield, ~ gallons per minute. Sealed watertight to depth of /,' feet. Exterior space around casing sealed with: ~ Cement grout. ~ ~ddled clay. ~ Ordina~ backfill. Well cover: ~ ~ncrete. ~ Wood. ~ Metal. Openings in well cover watertight: ~ Yes. ~ No. ~um,~ ~ Shallow well. ~ Deep well. Len~h of drop pipe, feet. ~mp capacity, _gallons per minute. ~cated in: ~ Basement. ~ Pumproom off basement. ~ Pumphouse above ground. ~ ~mp pit. ~mproom pro~rly drained: ~ Yes. ~ No. ~mp mounting watenighu ~ Yes. ~ No. Type of storage: ~ Pressure. ~ Grav~W. Capaoty, / 7 gallons. Has bacteriological examination of water been made? ~ Yes. ~ No. If answer is "yes," give date fi> '~/~7~" 19 ~' O Quali~ of water ~ is ~ is not satisfa~ory for human consumption. Installation ~ does ~ does not comply with approved exhibits, if any, lnsp<tion made by: ~ State. ~ County. ~.Local Health Au~oriw. Inspected by ~ , Date of inspection ~ --fl~ , 19 ~ 0 .-J&~,-,'~-O<~.~.'t.~L.'v~ ~ C 0 P Y CERTIFIED WELL For Location Date Completed 4/13/60 Depth of well 42 feet Size of casing 6 inch Distance to water 8 feet Distance to water while pumping of 480 gallons per hour Anton Shosten Lot 4, Block 4, Wentworth Subdivision 30 feet DSSCRIPTION OF FORMATION at rate FROM TO Till Till - brown Till - blue Till (w/h2o ~ 3 3 gpm Till Sand & Gravel w/h2o 0 2' 2' 24' 24' 34' 34' 36' 36' 41' 41' 42' I certify the above true and correct /s/ W. E. Clemenson Driller SWAFFORD DRILLING 3401 spenard Rd. Spenard, Alaska We advise you to attach this certifldate to your deed / :, , (4M) SUVVtY ALASKA DI~PA_-~.TM~I~T OF HEALTH Section o;[ Sanitation ,~ad Engineering Lab. No ACTION ON REQUEST FOR ~ACTERIOLOGICAL WATER ANALYSIS S%ar R~., Box Spenard, Alaska Your recent request for an analysis of a sample from the Individual Private Water Supply servingD~ /5, Blk* ~, Wentwo~ rece~ve~ 6/13/60 ~.a ex~ination has been completed. Satisfactory Questionable Unsatisfactory Records in this office indicate this Individual Private Water Supply to be of Analysis shows this SAMPLE to be --"'Satisfactory Questionable. ;Unsatisfactory. If an "Umatlsfactory" or "Questionable" stares is indicated above, you should take immediate action as recommended below. 1. Boil or chemically treat your water supply to protect yottr family from water-borne diseases as outlined in en- closed leaflet, "Drink It Pure." 2. Improve your spring--See bulletin HSE-6-2 3. Improve your cistern--See bulletin HSE-6-3 4. Improve your dug well- See bulletin HSE-6-4 5. Improve your driven well--See bulletin HSE-6-5 6. Improve your drilled well--See bulletin HSE-6-6 7. Relocate your well to a safe location in relationship to your sewage disposal system--See bulletin HSE-15 8. Bottle broken in transit, please send new sample. 9. Sample tooAong in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. 10. Contact your nearest [] Local Health Department or [] Alaska Heakh Department, Sanitation office for bulletins, consultation, and assistance. 1L This is a surface water source and subject to pollution by man and animals. An approved water supply source should be developed. SANITARIKN'S REMARKS ~ ADR--HS~-6-FI (e) This Form Must B ed Out Completely. ~ ratQ~V, 945 Sixth Ave. ~D~G~ WATER SUPPLY S~tion of Sa~d ~n~ee~g Please LOOk on ~ve~ of ~ Sh~t for S~ple Collection Reauest for Bacteriological Analysis ~ - ~ .~ Lab. No....,~.~r;~;~ .................. ~_~.~ / ) ~.~ . / q , ~_,~..~tD~-~ ,. · WsCer ~ample eolleeCe~ ~7 ....................... ~ ................................................................... (Name of person eoll~e~tng sample) (Date) (Time) W~er aam~e eolleeCed from ~Kt~hen Cap; ~ Ba~hr~m ~ap; ~ BasemenC Cap; OCher (I~) .......................................... ~ ................................. :'"'":~ ................. ::~:"::~ ...... Addr~s pre~e w~ero 8o~rco ~ i~o ........... ~ ........... ~------~---~ .............................. ~ ....................... y'- ~ ............. (Mr.) ,, ./} ~.~ ................. ~ ................ : .. ~ ~fl roper[ go (~ (~ame) (Box No. or stroe~ ad~oaa) ' Pleaao place an "X" In ~ho Box bofore t~ma whleh B~g ~eae~Bo 7our wager supplT: 80~C~: ~ell ~ ~ Dug, ~ Driven, ~ D~lled, ~ Bored ~ 8prig, ~ CB~em, ~ Ogher (~sg) ............................................................................................................... ~ ~reok, ~ ~lver, ~ Bake, ~ Pond .................................................................................................................. OR ~T~R~ CO~g~¢TIO~: Walla ~ ~ Wood, ~ Concrete, ~ ~gal, ~ ~le, ~ Brick or ~onerege Bloe~ Top ~ ~ Wood, ~ Concrete, ~Me~l, ~Open Top LOgA~O~: ~ In basemeng, ~ Basemeng offaeg, ~ Under Bo~e, ~ In 7ard Ogher .............................................................................. :>' .......................................... '~'":'; ................................................ DIST~¢~ TO: Building dewar or ogher drainage p~Pe.....~.fee~, 8e~ie ~nk ........ ~...feeg, Tile field .............. fee~, Seepage p~ .2..~:~..feet, gesspool .............. feeg, Prl~ .............. feeg. Ogher pmslble sources of eon~aminagion (l~g) ............................................................................................................................................. ~RI~:Building dewar ~ ~asg Ron, ~ Wood, ~ ~fle, ~ ~Bro pipe, ~ ~sbesgos eemeng 5oing magerlal ~ ~pe ....................................................................................................................................................... O~R~ ~O~O~: Does wager Become mudd7 or dlseolored~ ~ 7es,~ no ~en? ....................................................................................................................................................... DIame~er of wel~ ~ '~ ,: · aep~h ..... ~2...: ................................... fee~ ................... iL':'7: D won ........ ................. ......... ......... ................... ' heng~h of drop pipe ............................................................................................................................... · W~ger dopgh from BegUm ............................................................................................................ Pump location: ~ ~ well, ~ Off~e~ ~ basemen~, .~In basemeng . ~ ~ ugl~[~ ~m, ~ On ~op of well ~ Oghor (l~l ........................................................................................................ PURPOS~ O~ ~XA~A~ION: Illneas suspected? ~ 7es, ~no New 8ouree of supply? ~ yes, ~epai~ ~o existing s7sgem? ~ yes, ~.no ":: F" // ................... PLEASE DRAW A 8~TCH ~ ~ SPACE BELOW. ~I~ ~K~GH SHOULD SHOW ~CATIO~ OF HOUSE, WA'r~ SUPPLY SO.CE, ~EP~C T~K, 8E~R, DRA~ L~S OR O~ SOURCES OF POLLU~O~ ~D DIST~CES BE~N WAT~ ~UPPLY 80~CE A~D ~ OF ~O~ SAMPLES MUST BE SUBMITTED IN CONTAINERS PROVIDED BY T~ ALASKA DEPARTlVlI~NT OF HEALTH