HomeMy WebLinkAboutSKY RANCH ESTATES #1 BLK 5 LT 24Sky Ranch
Estcttes #1
Block 5
Lot 24
#015-301-14
Parcel I.D, #
1.
MUNI(~IPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-SJte Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
9-~'-,~\ -\J~\ NAA#
GENERAl. INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. 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.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding ta~k
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
.6.
STATEMENT OF INSPECTION BY ENGINEER ~
As certified b,) m~/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 /~,~'~/? L.~ ~_,/,,/.~,,~,/.~.~/~_..~/,~,~' Phone
Engineer's signature / ,~o,-~ ~ V .~¢ 0~°
Y ,
DHHS SI(~NATURE
/~ Appr~veO for ~edrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
By:
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 !nspections 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.
72-0'25 (Rev. 1/91) Back MOA ~21 ,
Municipality of Anchorage
Department of Health & Human Services ~.._~,~
HEALTH AUTHORITY APPROVAL CHECKLISTR E~j,
Legal Description: ,~'--~'~7/~-~ ,f¢'~. / Parcel I.D._
A. WELL DATA Municipality of Anchorage
Dept. Health & Human Services
Well type ,~,:~':~'/~ If A, B, or C, attach ADEC letter. AD.EC water system number
Date completed W,/Z~/.e7 Fde ,~e,'/ad~briller
Log
present
(Y/N)
Total depth ~ :~ Cased to
Sanitary seal (Y/N) . /v'~ ;5 ~'-
Date.of test
Static water level
Well flow
FROM WELL LOG
Casing height
Wires properly protected (Y/N)
MUNIC~'P~LITY
AT I N S P E C~T~'~O N M E~iTA L
Pump level /~) '
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot /~ '
Absorption field on 10t //~' ' ; On adjacent lots
Public sewer main /V/~/~ Public sewer manhole/cleanout
Public sewer service line /~/0/~ Petroleum tank
~icCHORAGr'
E~ DIVISION
~2
¥[D
; On adjacent lots
)/~'
WATER SAMPLE RESULTS:
Coliform ~
D~.te of sample:
/////Cz 'and
Nitrate ~ ~'/(~ ~ Other bacterfa
Z/b.
B. SEPTIC/HOLDING TANK DATA
Cleanouts (Y/N) .)'/~ _ Foundat on cleanout (Y/N)
High water alarm (Y/N) /~//~0 Alarm t
Date of pumping /~/~'/~
Com ~-
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:'
Well(s)on lot *'/~d~ On adjacent lots ~ /~ ~ ~
To property line ~J~:) ~-: Absorption field '-~" / Water main/
Surface water/drainage
79-029 (Rev. 3/91 ) Front MOA 21
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N) ~
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manhole/Access (Y/N) --
-- ,,Pump off,, level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water -' -
D. ABSORPTION FIELD DATA
Date installed c~/U/)/
Length ~/'(/~'.~.)' Width
Total absorpt on area /~/7
Depression over field (Y/N)
Results (pass/fail)
Soil rating
Gravel thickness /~' '
Cleanouts present (Y/N)
Date of adequacy test,
for
System type 42',~_~?z~ ;~,~,~//.-/
Total depth /~ '
bedrooms
Peroxide treatment (past 12 months) (Y/N) "' If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot //~' On adjacent lots
To building foundation
~-"<"'~ Cutbank /'2~/'/~' __Water main/service line
On adjacent lots
Surface water
Curtain drain
E. ENGINEER'S CERTIFICATION
I certi~, that I have checked, verified= or c~nformed to all MOA and HAA
Signature ~
Engineer's Name
Date
inspection.
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev, 3/91) Back MOA 21
Date of Payment
Receipt Number
~f I I~1 L~ I I I I I,/~,~l~',~ v.
II I I I I I ~~_1 I I~ FI t
~IIIIITI
~-~,,,,,,,,111111 -
¢1-I ', I',/I
ISAACS PUMPING SERVICE
, (Norm Tlbbetts, .Owner) :,, ,:~
62~8 (~uinha~k Street ;,,, ~ ~
ANCHORAGE, ALASKA 99507" .....
I
I
TOTAL
POLY PAl( (50 SETS) 4P468