HomeMy WebLinkAboutEAGLE RIVER VALLEY RANCHETTES LT 29BEagle River' Valley
Ranch¢'l'i'¢$
Lot 29B
#050-224-25
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
,~,¢2~ -.~-~ HAA # ,'(~/~-~//~'~': ~/~-'~'~
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailin. g address
~A~T'T'~ ~IL'LDbi Dayphone ,z_~L~- q-(¢~
Day phone
Agent
Address '~ ~ ~ ~t~ t/,k- '~/ [5'=7 A,
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
Day phone
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
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 t
Address
Engineer's signature
Phone
Date
DHHS SIGNATURE
V 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 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 Municipalib/ of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
-' Municipality of Anchorage
· Department of Health and Human Services
Division of Environmental Services
R E C E ! V E D
On-Site Services Section 825 "L" Street Room 502 --
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us AUG 3 I Z000
(907) 343-4744
,-, MUN GIPAL'fY OF ANCHORAGE
HEALTH AUTHORITY APPROVAL L,,HE~/t, JV~::;TNMENTAL 8EBVtCES D ViS ON
Legal Description:
A. WELL DATA
Well type .__
Well Log
If A, B, or C provide PWSlD Ct __
Date completed Sanitary seal /..~Wires properly protected
Total depth __ ft Casedto _ ft ' //,...~ing height (above ground) __
FROM WELL LOG ~ AT INSPECTION
Date of test J __ _
Static water level ft ~ __ ft
Well production ____g~ ___ g.p.m
WATER SAMPLE RESULTS: J .....
Coliform colonie~te__ mg/I Other bacteria_ colonies/100 mi
Date of sample: // Collected by:
Tank size 1 ~ gal
Number of Compartments ~
Depression over tank t,~ High water alarm ~-~
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Date installed
Cleanouts ~_Foundation cleanout
Date of pumping
System type
in.
C. ABSORPTION FIELD DATA
Date installed. /¢~/~',/?~ Soil rating (g~./ft2~or ft2/bdrm) __
Length ,,?--~;~ ft.F:l~j~ Width ~_'fYp ft Gravel below pipe /,~ ft
Total depth J ~ ft Effective absorption area~*SG, ft2 Monitoring tube
Date of adequacy test E/;~o/oc, Results (Pass/Fail)
Fluid depth in absorption field before test .~ in
Elapsed Time: ~ min Final fluid depth
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
. Depression over field
For ~ bedrooms
Water added "~ gal. New depth ~7',,Z in.
6 ¢ in Absorption rate >= /-/'~-Og.p.d.
N If yes, give date
72~026 (Rev. 01100)*
LIFT STATION
Date installed
"Pump on" level at __
Datum
Size in gallons
in "Pump~ at in
Cy~ tested
SEPARATION DISTANCES WELL'LOT T
SEPARATION DISTANCES FROM O:
Septic tank/lift station on lot / On adjacent lots
Absorption field on lot / On adjacent lots
Public sewer main
Sewer/septic servic~e Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation
Water main
Drainage
Manhole/Access
High water alarm level at __ in
Meets alarm & circuit requirements
Public sewer manhole/cleanout
Property line
Water service line
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation
Surface water
Wells on adjacent lots
Absorption field
Surface water
Water main
Property line !
Water Service line /~ ;/'
Curtain drain
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 lo ~.~ ~ ~ L/,.[,~.,,,-,'~
Date /~.~. "~d, ¢Z¢,¢,~.¢
O
Driveway, parking/vehicle storage
HAAFee $ ,~FPOt
Date of Payment ~'/~ / /
· ENGINEER'S
Waiver Fee $
Date of Payment
Receipt Number ~. % ~,,L :~
Receipt Number
72-026 (Rev, 01/00)*
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 . .
www. ci.anchorage.ak, us ·
(907) 343-7904
CERTIFICATE Of H F. ALTH AUTHORITY APPROVAL
FOR A SINGLE FA~'ILY DWELLING' ~''; '- ':'
Parcel I,D...(~'O"..?_e3x/7['..~ ' .'.".'
GENERAL INFORMATION
Complete legal description ZOO'
Location (site address or directions)
Current Pr6perty owner(s)..
· -'.._ :,.,:,, HAX
Expiration Date:
Day phone
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone
Un/ess otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: ~
3. TYPE OF WATER SUPPLY: '
Individual Well r~
Individual Water Storage
Community Class Well []
Public Water System
TYPE OF WASTEWATER DISPOSAL:. ·
Individual On-site ~
Individual Holding tank []
Community On-site [] '
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by art 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) fer properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
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. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are 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.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I vedfy that my investigation,
based on procedures outlined in the Health Authority 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 vedfy 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.
~ '- Conditional appr(~val for ........ bedrooms, 'with'the following stipulations:
5. DSD SIGNATURE .'
1~~ Approved for ~ bedrooms.
~ Disapproved.
Additional Comments
,,,,,-;.~-. ...... .; "//'~-..-
~: ON-SITE
~ . WASTEWATER . :
.
·
Attachments:
HAA Checklist
Septic System Advisory ..
Well Flow Advisory
Maintenance' Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date:
(Rev. 01/02)
Municipality of Anchorage
Development Services Department ....
Suilding Safety Division
On-Site Water & Wastewater Program
4700 South Sragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:/_C:r~' .~/~ ~-,4/:Y_.~_ ,~'/V,~.~. t/'./Y_.~g~v',~4rxff.~ff'~.Par~l ID:
A. WELL DATA - J~t~/..I C. u,J,q 'r'~/L
IfA, B, orC provide PWSID # ~
Sanltapj seal (Y/N)
Cased to It.
FROM WELL LOG '~,' '
Well type
Date completed
Total depth ft.
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Well Log (Y/N)
VVires properly protected (Y/N)
Casing height (above ground)
AT INspECTION
g.p.m.
Coliform __.colonies,'100 mi. Nitrate ' .. ~ mg./I.
Arsenic: mg./I. Date of sample:
B. SEPTIC/HOLDING TANK DATA
Other bacteria
Collected by: ·
Tank Type/Material
Tank size I~G gal. Number of ~mpa~en~
Foundation ~eano~ ~)/~A~epm~ion over ~nk ~)
Oa~ of pu~ping ~T~/J O~ Pumper
C. ABSOR~ON FIELD DATA
Da~ ins~ll~ ~ Soil mBng ~.p.d.~ or.~d~)
Lengffi' ~ · ~d~
Total depffi ~ · Eft. abso~flon a~a
Date of adequa~ ~st ~O~ Resul~ (PasCall)
Fluid dep~ in abeo~flon field before test~ in. Water added ~ gal.
~apeed ~me~O min. Final fluid de~ ~ in. ~so~flon rote >=
~y mjuve~on ~a~ent (past 12 mo.) (WN & ~pe)
g.p.m.
~ colonies/100 mi.
System type ~
Gravel below pipe ~' ff.
Depression over field
For ~ bedrooms
New depth .~J> in.
If yes, give date
in.
Date installed ~'.,/ae./7,4'
Cleanouts (Y/N) y
Htgh water alarm (Y/N) /~'
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
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septi.c tank/lift station on lot"
Absorption field on lot
· On.adjacent Iols
On adjacent lois
Public sewer main
Public sewer manhole/cleanout
Sewer/septic service line
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation //7 / Property line _/_.~.~' Absorption field ,/
Water main ~'0 ~' Water service line /~'f' Surface water
Wells on adjacent lois
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
$
Property line / ~/*' Building foundation / 7 r Water main ,~'.S"/'
Water Service line /~ Surface water ,/~,/~ ~/~.T. Driveway. parking/vehicle storage
Curtain drain /V'O,~{E Wells on adjacent lois
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 Pdnted Name ~ ~'~E'V'~'P,[. c,,J. ~-~,~t'~'
Date
HAA Fee $
Date'o, Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
PO Box 773415
F..agle River. AK 99577
(907) 694-6454,
~eve ,.vi ~
1~00~ War Admkal
River. AK ~77
S~ic Set'vtce Und~ 2~, 1
~ Commenl~
P.O. N~,nbor:.
T~'m*: lq~ 30
· ,~;e'WiCe Agreement
~ b~: 04-Aw-2~O 12;00 em
TeOw~: Dw~ M~o
0
~owd I>/Ck~y Wd~m w~ Remex to ira,
Pt4c~ F...ae~ x2Me~ T~(
$115.00 No Ne
D~gmm:
No~Tm~b To~ Tau~d~ Tokai Ta~ To4a~ (3~ To4M
E~ift~d~ I:~arg~: $115.00 ~0.00 S~3~)0 8115.00
c.w.: .... liS,
Cu~m~ ~0~ee~ to I~. ~ end ~ p,~<l o~ ~ b~ THIS 19 A ~IN~:)~NG AOREEMEhlT.
V/AR
ADMIRAL
ROAD
N 89'57'15'E 133.00
X
~ STORY
F'RAt~ ~
UTILITY EA~HE:NT
89'59' 15' E 133.00
PR~:>~RTY CI~S rOUND
U~:~I) FOR: THIS SURV£Y HAV~
DI~P~ IN KFEK~ TO
T~ KC~D ~T ~T~ ~D
~D ~AS~D I~TI~ ~AT~
V~ ~ED TO ~[~I~ ~SITI~S
T~ r~T P~RTY ~RS.
AS-BIBLT ~URVEY
NO C, Om~J~ ,~rrT THIS DATE
[ I{R[~Iy C[RT~"Y THAT I HAV~ PI~
I'~RTGAGCE'$ INSP~CTIDN ~ THE Fill
I~$CRIB£D pI~PERTY,
LI3T ~'gB, EAGLE RIVER RAt4CHETT~S