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Home My WebLink AboutBROADMOOR HEIGHTS BLK 2 LT 3Broadmoor Heights Lot 3 Block 2 #010-083-23 Municipality of Anchorage Department o! Health and Human Services Division of Environmental Services On-Site Services Section 825 'L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. O Il' -- O~.~ -~_.~ 1. GENERAL INFORMATION Complete legal description HAA# Expiration Date: Location (site address or directions) Current Property owner(s) Mailing address Lending agency Day phone Mailing address Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well 5 TYPE OF WASTEWATER DISPOSAL: 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. 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 less than 30 days old. 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. 72.025 (Rev. 01:o0)' 5. STATEMENT OF INSPECTION BY ENGINEER o As 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 the Health Authority Approval application show 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 verity 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. Engineer's Printed Name ! c 1, ~.-- ~.~ ·-,~,~-' ,,~ I :., ~ ~ DHHS SIGNATURE Approved for '~ bedrooms. Disapproved. Conditional approval for __ bedrooms, with the ~ollowin~ stipulations. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: Original Certificate Date: Reissue Date: 72,025 (Rev. Municipality of Anchorage R E C E I V E Department of Health and Human Services- Division of Environmental Services On-Site Services Section 825 'L" Street Room 502 DEC 0 4 2000 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 MUNICIPALITY OF ANCHORAGE HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LoT ~_~ ~. ~ '~ D-O,~D t-~OO-t~. ~ I="l ~ H'~-.~ Parcel I.D.: olp-,,~.~ -z~ A. WELL DATA We, type * Date completed ! c~ 8~ Total depth ~O ~ fl FROM WELL LOG If A, B, or C provide PWSID # Sanitary seal ~/ Cased to ~[~r fl Date of test Static water level ft Well production WATER SAMPLE RESULTS: g.p.m Coliform ._~colonies/100 mi Date of sample: Ilia/~_~ Nitrate N ~) Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Date installed Clsanouts T~size Foundati~eanout Wires properly protected ~// Casing height (above ground) A-'-/'~ in. AT INSPECTION g.p.m mg/I Other becteria.__/~?~._colonies/100 mi gal Number of Compartments __ Depression over tank High water alarm Pumper Date of pumping / . C. ABSORPTION FIELD DATA // Date installed Soil rating(g~d.~ or ft2/txIrm) System type Length ft Width //ft Gravel below pipe Total depth fl Effective abso~on ama____ff~ Monitoring tube Date of adequacy test __ / Results (P.ass/Fail) _ __ Fluid depth in absorption field ~ore test ~ in Water added Elapsed Time:__ my Final fluid depth in Any rejuvenation treatm~3t~(past 12 mo.) (Y/N & type) ' ft __ Depression over field For bedrooms gal. New depth.__ Absorption rate >= If yes, give date __ in. g.p.d. 72-0~ (Rev. 01/00)° LIFT STATION Date installed 'Pump on" level at Datum Size in ga s~~ in "P.~"ofi' level at Cycles tested in E. SEPARATION DISTANCES Manhole/Access High water alarm level at in Meets alarm & circuit requirements SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot I"//~. On adjacent lots Absorption field on lot ~//f¥ On adjacent lots Public sewer main I ~..C' Public sewer manhole/cleanout Sewer/septic service line /~ ~L.~' Holding tank /'"/.~-~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line/// Absorption field ne Water main ~ Water s~'~/t'ce Ii Surface water Drainage ~ Well~;~ adjacent lots SEPARATION DISTANCE FROM ABSO/~PTION FIELD ON LOT TO: Properly line ~ Buil~ foundation_ Water main Water Service line ~ S,~;Cace water.__.:.._, Driveway, parking/vehicle storage Curtain drain ~/~ells on adjacent 10ts F. COMMEN~,,S, ~ .,.~.;-. ~.::-:' -~ . G. ENGINEER S CERTIFICATION ,;" I certify that I have determined through field inspections and .-'.. ,.~.;--~ .ENGINE review of Municipal records that the above systems are in .':; conformance with MOA HAA guidelines in effect on this date. ~.: Engineer's Printed Name Date f /o q HAA Fee $ Date of Payment Receipt Number 72-0~ (Rev. 01/00)* Waiver Fee $ Date of Payment Receipt Number 12-01-00 1§:5, FRO~-CTE ENV!~ONk~NTAL ~t~.' CT&EEnvironmentalServiceslnc. 5615301 T-O§8 P.02/03 F-62T : CT.rE Ref.# , '~ Client l~'ame · Project Name/a iOrdered By P~ SlO ~ Sumpl~ Remarks: 1007317001 Tobben Sl:urkland P.E. 2/3 Broadmore Ileighls 2/3 Broadmore Heights Drinking Water Parameter Results POL Units Ciient PO# Pr~-Paid Coli~/NO3 I'tinl'ed II,to/Time 12'0l~000 15:12 Collected Date/Time I 1/21/2000 14:30 Received Date/Time l 1/21/20CJ0 14:35 Technical ])lrerlor · Stephen C, Ede Ilel=ascd~ ~ AttooabLe Prep Anatyala . NiIrale-N ~l oral Colifmm 0.~0o U 0.500 mg/L £1'A 300.0 coL'100:nL IMIN 9222B 10 Ina× 11/21/00 SCL I 1.'21/00 KAP 12-e~-00 15':51' ° F[~O~,I-CTE EIWlRCI~I,~KTAL 55;5301 T-058 P ~3/03 F-627 : CT&E Environmental Services Inc. Laboratory Division Drinking Water Analysis Report for Total Coliform Bacteria READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE 2COW Po;tar Drive Anchorage. AK 99518-1605 3eh (907) 562-2343 Fax: (907~ 561-5301 MUST BE COMPLETED BY WA'f ER SUPPLIER PUELIC WATER SYSTEM ID# PRIVATE WATER SYSTEM SAMPLE DATE: SAMPLE TYPE: ~Roufine Repeat -qantple (refer to lab no. TO RE COMPLETED BY LABORATORY Ana~vs~s snc~ws Mis Water SAMPLE to ~: ~.~at~sfact~ry ;. _, Unsat[sfactcr¥ Date Received: Time RacelveO: Analysf$ Began? Analytical Metllod: ~amp!e t~' long in bans;t. Sample sr.cu!e not t3e over ~hfS old for a~aly$is to indicate ~el~able results Please send a ~ew sample wa spe~a~ ae~ive~ emCrane Fdter MMO. MUG LaD Roi No. Sentt~ADEC: ANC FEi< JUN _; Date: Time: __ Fa~ ,-' Treated Water ~(~ Untreated Water . Special Purpose Ti~',a Co]lectbd , .. Locatloo Collected from: Collectech by (initi31): ~,r, ~-/.~ B~-c,,,.,,.Cvc~,~l/-,./,,t,l-'., /,/::so i~ Da,-.: ' BACTER1OLO~3ICAL WATER ANAYSI$ RECORD BGB Client notified of unsatisfactory results: Time: E. Coil ,,, Colonies/1O0mt TNTC · T~ ~umo,o~, t~ C=.~I COLIFORM oB · ~fl., eacIe,~, _ Col!form/lO0ml (-') , --~ Data: \\\'"~j.L~ Time: MMO-MUG Result: Toter Coliform Memt~rane Filter: Direct Count Ve,hcationt LTD Fecal Coliform Cel%flrmat~oo: Final Membrane Filte¢ Results: Repo~tod BLt: P.O. r-sOX 6650 A.NCHORAGE, ALASKA 99502-0650 (907) 264-4 ~'I 1 '- ? ,"i '/ . ,1 ,%' 0 W L E ,% DEPARTMENT OF HEALTH & HUMAN SERVICES January 10, 1986 TO: Permit Applicant Subject: Permit # 850401 Lot 3 Block 2 Broadmoor Heights Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1985. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system the original as-built inspection report(three part form) must be sent to this office for review and approval,and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Susan E. Oswalt Program Manager On-site Services SEO/ljw enc: Copy of Permit MLINI:CIF'AL.I:T~ OF ANCHOI~(~GE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 PERM I T ND: DATE ISSUED: APPL I CANT: ADDRESS: CON"FAC'T' PHONE: []N--,SITE 850401 07/09/85 EDSEL. FORD 5515 TURNAGAIN BLVD. E. ANCHORAGE, AK 99505 245-6555 WELL PERM I 'T I....EbAL DEi-JCR I P: I...01' SIZE]: SUBDIVISION: BROADMOOR HEIGHTS SECTION: 26 TOWNSHIP: 15N 9000 (SQ.FT. OR ACRES) LOT: 5 BLOCK: RANGE: 4W I cert. i~y that.: 1. t am ~amiliar with the requirements for on-site sewers and wells as set. forth by the Municipality o~ Anchorage (MOA> and the ~tate of Alaska. ~. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria o~ this permit. 3. I will adhere to all MOA and State o~ Alaska requirements £or the ~set back distances ~rom any existing well, wastewater disposal system or public, sewerage system on th~'-~r~any adjacent ~or nearby lot. SIGNED~ APPLICANT: EDSEL FORD ISSUED BY 'k_.,,.-.~ 0/~ ' ~'C~'~ DATE: