HomeMy WebLinkAboutCAMPBELL HEIGHTS BLK 3 LT 11 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
GENERAL INFORMATION
Complete legal description
Lot 11; Block 3; Campbell Heights Subdivision
Location (site address or directions) 6637 Winchester Street
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
James C. Goddard
69i3 M~adow Street Anchorage, Ak.
Seattle Mort.qag e
Day phone 344-9144
99507
Day phone
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
4 ',
NOTE:
Individual well XX
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.
72-025 (Rev. 1/91) Front MOA #21
5. 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
Address
S & S ENGINEER!.~'~G
17034 Eagle River Loop Road No. 204
Faa_la River. Alaska 99577
Phone
Engineer's signature
DHHS SIGNATURE
,/~ Approved for
/__ Disapproved.
bedrooms.
Conditional approval for
/ ,-~
bedrooms,
with the following stipulations:
Additional Comments
Date
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.
72-025 (Rev. 1/91) Back MOA ~21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: .Lo/' II; ~l,~r_l<'..s}~,~p~ll /~?/~.~,Parcel I.D.
A. WELL DATA
Well type ~ If A, B, or C, attach ADEC letter.
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
Date completed
LP ~'~7~/~ ~Cased ~/-, D
to "/'
ADEC water system number
L_) ~ Driller
Casing height
Absorption field on lot
Public sewer main
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Wires properly protected (Y/N)
AT INSPECTION
/
Public sewer service line
; On adjacent lots
; On adjacent lots
g.p.m.
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample: ~ - ~'
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA % -----
~ Tank size Compartments
Date
installed
Cleanouts (Y/N) ~Foundation cleanout (Y/N) __ Depression (Y/N)
High water alarm (Y/N) "~f,, Alarm tested (Y/N) ~
Date of pumping ~ '~
SEPARATION DISTANCES FROM SEPTIO/~LD, NG TANK TO:
Well(s) on lot__ .On adjacen't~__ ___Foundation
To property line Absorption field 'X.,. Water main/service line
Surface water/drainage
72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION ~
Date installed
Size in gallons
Vent (Y/N) ."P~p on" level at ~ -
High water alarm level
Meets MOA electrical codes (Y/N) "%.
SEPARATION DISTANCE FROM LIFT STATI~ TO:
D. AW~Ii~ I:~iON FIELD DATA On adjacent Ib~
Date installed
Length Width
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Surface water
Total absorption area ~ Cleanouts present (Y/N)
Depression over field (Y/N) '"% Date of adequacy test
Results (pass/fail) ~ for
Peroxide treatment (past 12 months) (Y/N) ~ '~ I.f yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot .On adjacent lots RPerty line
To building fou, ndation __ To existing or abandoned sy'~ on lot
On adjacent lots Cutbank
Surface water Driveway, parking/vehicle storage area
Curtain drain
bedrooms
~%,,, Soil rating System type
Gravel thickness Total depth
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this~!nspection.
Signature
] 7034 Eagle River Loop Road No. 204
Engineer's Name
Date
Date of Payment
Receipt Number
HAA Fee $ { -~~ Waiver Fee: $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
~. I D,~ .~RECEJVED
NSPECT ON XP"OI.TMENTS
DATE DATE DATE
MUNICIPALITY OF ANCHORAGE D~PT. OF H~ALTH &
i~ DEPAR~ENT OF HEALTH & ENVIRONMENTAL PROTE~NMENTAL
AUG 1 1 1981
ENVIRONMENTAL SANITATION DIVISION
~E~UEST FOR ~PROVAL OF INDIVIDUAL WATE~ ~D SEWE~ FAOlLITI~
PR~ERIY RESIDENT (If different from ebon) PHONE
PHONE
TYPE OF RESIDENCE NUMBER OF BEDROOMS
r-I One rT'i _tour
I~SINGLE FAMILY i--I Two I--I Five
I--1 MULTIPLE FAMILY [] Three [] Six
WATER SUI~LY
,g~.---'fNOl VI DUA L*
[] COMMUNITY
[] PUBLIC UTILITY
SEWAGE DIBI~)~AL SY~I'EM
[] INDIVIDUAL/ON-SITE**
(~.~PI3~L lC UTILITY
[] Other
· ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72.010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
I'--I SINGLE FAMILY [] ONE I'-I THREE [] FIVE i'-I OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SlX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTI LITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified '"~/~-"~) INSTALLER
[]Septic Tank or []Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELL TO: Bar, tlc/Holding Tank IAt:~orpt~o~t Area Sewe; Line I Nearest Lot Line
I
I
5. COMMENTS
/APPROVEDFOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED ~,~
(~ATE i)Y