HomeMy WebLinkAboutGALATEA ESTATES BLK 1 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.
1. GENERAL INFORMATION
Complete'legal description
Lot 4, Block l., Galatea Estates
Location fsite address or directions) 2315 East 72nd Avenue
pr.o'perty.owner
Mailing address
-L'e'n'd ing agency
M,ailing, . aSdress
Agent
Address ' '
~zl'l Namen
Day phone
9~d'{~Birch Road, Anchorage, AK 995~6
522-2946
Grea[land Mortgage/John Anders~yphone
320t' C Street, Suite 40 6, Anchorage,
563-3889
AK 99503
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well XXX
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XXX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOAii21
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that rny
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 s & s ENGINEERING
wO~4 F-~s;- ~i~- L:=~ .".~:d H-~. ')~4_ Phone ~'~ ' "~c( 7 ~ __
Address Eagle River, Alaska ~)9577
Engineer's signature ~'~//'Y~ 2 ~Z~.,.__ Date /'/, / ¢l, ~ __
DHHS SIGNATURE
/ Approved for ~'-/~'///"~F- E bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additiona~ 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.
K L 'IVtU
Municipality of Anchorage OCT 0 1 1999
DEPARTMENT OF HEALTH & HUMAN SERVlCE~~ ..... "
Environmental Services Division ~NVII~(JNMci,~iA, 3¢~v,~.,;~, .,,v
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
Legal Description: /.~)7-,~/ /~_~//$ ~-~-,~Z'~ ~'/- 5'//_~ Parcel I.D.:
A. WELL DATA
Well type ,'~/
Log present (Y/~) /~/~)
Total depth /-4/,/',J/~-
Sanitary seal k~/N)
Date completed
Casedto ?~
If A, B, or C, attach ADEC letter. ADEC Water system number
Casing height (above ground) !
Wires properly protected(~N)
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
g.p.m.
Coliform ~::.::.::.::.::.::.~Nitrate
AT INSPECTION
Other bacteria
g.p.m.
Date of sample: ~////,~'~'/~ Collected by: ~-/~
B. SEPTIC/HOLDING TANK DATA '~'/~: '~.~/~- ~'/~J~ ~
Foundation cleanout (Y/N)
Pu?pi~~'_ ' :..,
Date
of
ABSORPTION.
C. FIELD DATA
Date installed
Length ,. ' Width
Date installed Tank size Number of Compartments /-'~leanouts (Y/N).__
Depression (Y/N) H~arm (Y/N)
'~-. Pumper
· ,,/ Gravel thickness below pipe
Effective absorption area /Monitoring Tube present (Y/N)__
Date of adequacy test / Results (Pass/Fail)
Fluid depth in a~eld before test (in.); Immediately after /
Fluid depth / (ins) Minutes later: Absorption rate =
/
Perex'~treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
System type
Total depth
Depression over field (Y/N) __
For
__ gal. water added (in.):.
g.p.d.
If yes, give date
bedrooms
D. LIFT STATION
Date installed ,~//~' ~ns
Manhole/Access (Y/N) ~3;~lT~en" level at*
High water alarm level at*~ *Datum
Cycles.~
E. SEPARATION DISTANCES
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON. LOT TO:
/
Septic/holding tank on lot
Absorption field on lot /Y/,/~
/
On adjacent lots /~/,//&-
On adjacent lots /'~///~
/
Public sewer main
Public sewer manhole/oleanout
Sewer/septic service line /~) /'/- Lift station /~///~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation Property line /Absorption field
Water main/service line _Surface water__ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORP~7.dON FIELD ON LOT TO:
;:~fPa~Y~ia~r ~~ Driveway, parkin'~B~uilding foundation ~~g/v~hiWciaiesrto~:;nlSa~ervlce line
Curtain draip../'- Wells on adjacent lots
ENGINEER'S CERTIFICATION
I certify that l have determined thru field inspections and review of Municipal reco~i~at~.~, ab~T~ystems are
in conformance with' MOA HAA guideline~ in effect on this date.
J
Date
HAA Fee $_ q~/~P ~- ~
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
SEP-2(;-g§ 11:54 FROLI-CTE ENVIRON~NTAL
Zt~- C T&E Environmen,alServ,ces'nc-
5B15501
T-377 P.02/03 F-BBg
CT&E Ref.#
Client Name
Project Name/#
CU~at Sample ID
Matrix
Ordered By
PWSID
995234001
$ & $ l~ngineerbag
L4. B1 Gala~ea
1.4, B1 Oala~ea SID
Ddnktng Water
S~t"nple Ren~rks:
Client ~
PrLaled Date/Time 09128199 16:24
Collec'tt~ Date/Time 09/24/99 13:55
Received Date/Time 09124/99 14:15
Technical Dkector: ~tephea C. Ede
Released BY~.~ ~
ALLowabLe Prep
lnlt
Nitrate-N
cot/lOOmc SN16 92228
0.500 mg/L EPA 300,0
O9/2~/~gK~P
10 max 09/2~/99 09y2~y99 SCL