HomeMy WebLinkAboutEAGLE RIVER VALLEY RANCHETTES LT 28DEagle Riwr Valley
P, anchel"l'e$
Lot 28b
#050-224-03
Municipality of Anchorage
Department of Health and Human Services
Division of Environmental Services
On-Site Services Section 825 "L' Street Room 502
P.O. Box 196650 Anchorage, AK 995'19-6650
www. ci.anchorage.ak,us
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. (~(~ '~ c~D'~J~-O:;;~
t, GENERAL' INFORMATION
Expiration Date:
;~ComPiete legal:descripti0n'~. Eagle River Ranchettes L 28 D
LoCafi6h':i~ite addres:~ or directions)
current Property owner(s) Dawn Nugen Day phone 688-9057
M~iling address P~) ~
Lending agency Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by:
2.' NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
ndividual Well []
Individual Water Storage' [] '
Community Class Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:v~:~ .
Individual On-site
Individual Holding .tank
Community On-site '
Public Sewer
The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Certificates of Health
Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional
civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water
supply system. DHHS also issues HAAs upon request to home owners. Cedificates of Health Authority Approval ara
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. Certificates ara valid for one year for properties served by Class A
or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
(Rev. 1 l~9g)
5. STATEMENT OF INSPECTION BY ENGINEER
,-~s 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 Health Authority Approval Guidelines for 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 fudher 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 applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
Name of Firm KNI3 Fn~in~_~riqg
Address ~nAA,I Pf~rrni0nr~ Frigid. R~iv~_r, Al4' -q-qR77
Engineer's Printed Name K~nn~fh rtHffll~
DHHS SIGNATURE - ., '
Approved for
Disapproved.
Conditional approval for
bedrooms.
Phone_698-G~t
bedrooms, with the following stipulations:
Additional Comments
Attachments: HAA Checklist
Septic System Advisory
Well Flow Advisory
Expiration Date'
(Rev. 11/99)
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Reissue Date:
-/-oo
Municipality of Anchorag~ E C E ] U I:::
Department of Health and Human Services
Division of Environmental Services ,~tUJ~ 3 ~ 2000
On-Site Services Section 825 "L" Street Room 502
P.O. Box 196650 Anchorage AK 99519-6650
www.ci.anchorage.ak.us MUN ClPALITY OFANcHORAGE
(907) 343-4744 ENVIRONMENTAL SERVICES DIVISION
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Eagle River Ranchettes L28 D
Parcel I.D.:
A. WELL DATA
Date completed __
Total depth
Date of test
Static water level
ft
Well production
WATER SAMPLE RESULTS..//
Coliform . colen~00 mi
Date of sample:
?
SEPTIC/HOLDING TANK DATA
IfA, B. or C provide PWSIDy
Sanitary seal
Cased t0 ~/
FROM WELL LOG
/
g.p.m
Well Log __
Wires prop~r~)teoted __
Casing height (ab, b,b,b~e ground)
AT INSPECTI?
g.p,m
/
in.
Nitrate
Collected by:
__. mg/I
Other bacteria /
/
/
colonies/100 mi
Tank Type/Material Steel
Date installed 5/6/'1976 Tank size 1000 gal
Number of Compartments 1_
Cleanouts y
Foundation cleanout ¥
Depression over tank n
High water alarm nla
Date of pumping 8/2/2000
Pumper JR's Pumping
C. ABSORPTION FIELD DATA
Date installed ~'l ~/~l~) Soil rating (g.p.d./ft2 or f~/bdrm) 125 System type Deep Trench
Length 65 fl Width 2 ft Gravel below pipe 3 ft
Total depth _8 ft Effective absorption area 390 ft2 Monitoring tube y Depression over field
Date of adequacy test 8/3/2000 Results (Pass/Fail) pass For 3 bedrooms
Fluid depth in absorption field before test dry in Water added460 gal. New depth,5 in.
Elapsed Time: '19 min Final fluid depth dry in
Any rejuvenation treatment (past 12 mo.) (YIN & type) n
Absorption rat(; >= 450+ g.p.d.
If yes, give (late
(Rev. ll/99)
D. LIFT STATION
Date installed ,/ Size in gallons _ //
"Pump on" level at ///~n"P, ump off' level at
Datum ': ~/ i "CYcles tested ×/ in
E, SEPARATION DISTANCES
Manhole/Access /
Meets alarm & cir~ requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tanldlift station on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Building foundation
Water main ~-~'+
Drainage _100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
10'+ Property line 10'+
Water service line
Wells on adjacent lots 2ca'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ,~n'+
Water Service line _2.~'+
Curtain drain
Building foundation 10'+
Surface water lnl¥+
Wells on adjacent lots _2nn'+
Absorption field_10'+
Surface water !Om+
Water main
Driveway, parking/vehicle storage 2.~'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name 14'~nn~fh r~.fflm
Date
HAAFee $ ' '~'
Date of Payment ,~7--/,..~/Z.~.--~
Receipt Number/
(Rev. 11/99)
Waiver Fee $
Date of Payment
Receipt Number