The URL can be used to link to this page

Home My WebLink AboutSAND WILLHOLTH BLK 1 LT 5I 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. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete'legal description Location (site address or directions) Property owner Mailing address Lending agency Day phone Day phone Mailin. g address ..... . Da~phone ' Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ,~' TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OFWASTEWATER 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. 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 verifythat 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. NameofFirm 'J ~Jok~t ~dc'~-t.~c..~ -~ ~-~ Phone ~7~t~ Address ~o~ ~ 1~ ~ ~ ~ ~~ Date 1~/~/~? Enginee¢s signature DHHS SIGNATURE /./'/ Approved for T' [/['/0 Disapproved. Conditional approval for bedrooms. bedrooms, with th-e 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 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. t ECEIVE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES0cT Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (~)'~°~4~-~J'A~wc~s olVlSloN Health Authority Approval Checklist Legal Description: ~/~ N ~ A. WELL DATA Well type ~ Log present (Y/N) Total depth ~ g ? Sanitary seal (Y/N) ~/./ILLI--[oL1-'{-{ ParcelI.D.: ~tO- 1~- ~-~/ If A, B, or C, attach ADEC letter, ADEC water system number J~ Date completed t (~ ~ fl Cased to ) L/-~ Casing height (above ground) ,~ I y Wires properly protected (Y/N) '?/ Date of test Static water level FROM WELL LOG AT INSPECTION Well production g.p.m. 7 g.p.m. WATER SAMPLE RESULTS: Colifo~'m Date of sample: I0/~/ Nitrate (/~) Other bacteria Collected by: -~'. ~'. B. SEPTIC/HOLDING TANK DATA Date installed Foundation cleanout (Y/N) Date of Pumping C. ABSORPTION FIELD DATA Tank size ..:.blubber of Compartments Cleanouts (Y/N)__ pu Dep~on~ (Y/N) High water alarm (Y/N) Date installed Soil rating (g.p.d./ft~ Or ft~/bdrm) System type Length .Width Gravel thiek~elow pipe Total depth Effective absorption area __ Monitoring T/utSe present (Y/N) Depression over field (Y/N) __ / Date of adequacy test __ __ R~, ts (Pass/Fail) __ ' For / Fluid depth in absorption field before tes~.); Immediately after gal. water added (in.):_ Fluid depth (ins) Minut~'later: Absorption rate = q.p.d. / Peroxide treatment (past 12 m~lhs) (Y/N) If yes, give date 72-026 (Rev. 3/96)* bedrooms Septic/holding tank on lot Absorption field on lot Public sewer main D. LIFT STATION Date instal[ed Manhole/Access (Y/N) High water alarm level at* Cycles tested E, SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO; Size in gallons '_~p on" level at* *Datum Sewer/septic service line SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: "Pump off" level at* On adjacent lots t'"¢/~- On adjacent lots Public sewer manhole/c~ea~dt __ ~/~ -- Lift station Foundation Water main/service line Property line Surface water/drainage Absorption field. Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain Wells on adjacent lots =r~u.~ccn o"'"""'"'""'"' CERTIFICATION ..... · t - , : ~ F, I certify that I have determined thru field inspections and review of Municipal recor~tl~,~t'the..~, abbve.. ,' sy~temS,~re. ~.. in conformance with MOA HAA guidelines in effect on this date. Engineer's Name I ~ JcJ-)-~,.~ "~L) v'V..[~t.-~-~ ~' )~" ~ Date IO/¢ /q~ HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number ~t~ CT~E Envkonmental Services Inc. Loborato~ Division 2~ W Po~er Dr,ye A~chorege. AK 9951~-1 Drinking Water Analysis Report tbr Total Colifom~ Bacteria ,~,: ~.o~ INSTRUCTIONS ON ~[/E~E 5iDE BEFO~ cOLLECTING sAMPLE REAl) TO BE COMPLETED BY LABORATORY BE coMPLETED BY WATER 5UPPLIEK Analys~s shows tDs Water SAMPLE tv ?UBLIC wATER SYSq-E41 I.D. ~ pRIVATE wATER S Moutt~ Day Year sAMPLE TYPE: U Treated Water ~ Routine ~ ~t epest sample (for routine sample ~ Untreated Water ~iith lab ref. no.~ .... ) *3atisfactOry insat~sfactoty. Sample over 30 kourS old. results may de unrehable · Sample too long Is tran?,lt; sampl~ s~ou, not be over 48 hours oM at cxamma~m¢ t~ ia&cate tellable results, please send new sample via special dehv¢~ mad. Date Received Analysis B~an 1___2i ':0_.%° ~o--- .__ Anal~teal Metllod: 'lgg._Membra.e Fdtcr · b MMO-NtUO qO0 ml. 5477 -'Cinch Fbks .lan L2 Faxe6 Special Purpose - Time Collected ' ' Collected By S4M PLE LOCATION ' - '~-~-'~'~ BACTERIOLOGICAL WATER A2qALYSIS ~CO NIMO-~UG R~oIt; T~t~ Coliform E. coil 'Membrane Filter: Direct Cotmt ~ ,-~ ,.r BGB Verification: LiB ._ Fecal Coil{nrta Coa,.irmatlo~ ~_ Final Membrane Fii.:~ts~lts ...~- f Time Dats Client notified of ulqsatisfattor¥ resultS: phoned sp~ke with CT&E Ref,g Client Name Proj~ Name/// Ma~hx Ordered By PWS~ 995477001 Tobber, Spurldand 3209 Cope 3209 Cope Drinking Wa~er Cliem port Pre-l~aid Coils/NO3 Printed Date/Time 10/i 1/99 10:56 Collected Date/Til~e I0/06/99 10:30 Received Date/Time 10/06/99 11:00 T~hrfieal Director: Stephen C, l~de