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Home My WebLink AboutCAMPBELL LAKE ESTATES LT 1 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # L~I~ --.'~ ~- ,~..~. HAA # .~ ~-t~"~ ~, .~. ~-.~ ~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, s. ubdivision, section, township, range) Location' (ad.d'~'es's'6r d r~iions) ,.' (b) Property owner/4,~ ~,~ ~' ~-,~:~7'"' ~'~'~---- Telephone: (home) M al h rig..1~ rid, res s., ·: .,- ,:' ~'; "... '.' (c) Lending"r~'tutJor~ ' "" Telephone Mailing Address Business (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check heretiC, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family'~,, Number of bedrooms. 3. WATER SUPPLY Individual Well Community [] Public [] Note: If community well system~ must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site [] Public~, Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 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 liles 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 ,~'---~'c~' Telephone Address /z/~,~.. /,~ ,,T)''~ ,.~4'~/ ,~' Date 6. DHHS APPROVAL, .~. App.rovec~ for Approved bedrooms by Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. Page 2 of 2 · A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST * FEBRUARY 1984 343-4744 Legal Description:/~7"/ ~.~r~,,/d,~z/.. /..4,~e-' ,E'~7~. Well Classification Well Log Present (Ye Date Completed ~ Total Depth/C~'/..:5' Cased to ~ ~/O~- Depth of Grouting Static Water Level /~, 5'" / Casing Height Above Ground Electrical Wiring in Conduit ¢N) SEPARATION DISTANCES FROM WELL: TO Septic/Holding Tank on Lot A///~ ; On Adjoining Lots ,~//~4' TO Nearest Edge of Absorption Field on Lot ,d'/,4- ;On Adjoining Lots To Nearest Public'Sewer Line 6,0 ~ To Nearest Public Sewer Cleanout/Manhole /d'~ · To Nearest Sewer Service Line on Lot ,~-5" '* Water Sample Collected by ,'~'~ /'~* '~/~'"J' ; Date ~'~ Water Sample Test Results ~,~ 7"' ,' ('~ ,~/7-~',4-7Z~* : 0 .("/'.)~ ,) Comments ~/E'/-Z,- ~ '7~¢/" ~ '5"-~'~', ~J~-4z. ~/,~e'"A:' ~4/,~,~$~.' Yield Pump Set At. ~/,~ Sanitary Seal on Casing~)'N) Depression Around Wellhead (Ye B. SEPTIC/HOLDING TANK DATA '. Da~ Size ' No. of Compartments Standpipes (Y'TN,),_% Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank"~ --~ Da!e Last Pumped ' Pumping/Maintenance Contact Hold,ng Tank.H.,g.~;~V~.a.t.e~.~ji~.;_~i~/.N)"'"'"~... Temporary Holding Tank Permit (Y/N SEPARATI~f~I~'I~STA~,CES FRO .bf.~. {~PTIC/HOLD~NG TANK: · · TO Water-S~,' ppi~, .W. ylt~'=; _% ;~'~. :~..';. ~ .W.' To"~td~Foundation ~. _ To PropertY,Lin.~. ..... ..:~ ;- - ~ To Disposal'Fie_Id ' To Water Mair{/S~[vice To Stream, Pond,~ake Or ~,/or'brainage Course Comments Front Page I of 2 ~. C. ABSORPTION FIELD DATA "~&~/~ ~s Rating in Absorption Strata Type of System Design Date~ ~ Length of Field Width of Fiel~",, ' Depth of Field ~ Gravel Bed Thickness ~ Square Feet of Abso~'on A~ Statndpipes Present (Y/N) ' D e p r es sion over Fd.~e~ldu a(~NT)est ",,,.,,,,,~Date of Last Adequacy Test Resuits of L~st Adequacy st SEPARATION DISTANCE FROM ABSORPT~I N~LD: To Water-Supply Well ~ To Property Line To Building Foundation '""'~_ To Existing or Abandoned System on Lot ~ ; On Adjoining~'~ ' To Water Main/serVice Line ' ~ To Cutback"(i~sent) To Stream, Pond, Lake, or Major Drainage Course ~mD~en~/ty, Parking Area. or Vehicle Storage Area D. LIFT STATION ~alled Size in ~ - Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA gui inspection. ~._~,~_._ :* ~t,~'h~ ul~.ct on the date of this '-.,-~"~nginee~s Seal Signed Company MOA No. 72-026 (Rev. 1/88) Beck Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES .OF ALASKA, INC. TELEPHONE (907) 562.2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Colifor~n Bacteria TO BE COMPLETED BY WATER SUPPLIER [] PUBLIC WATER SYSTEM I.D.ff '"[] PRIVATE WATER SYSTEM Mailing Address City S~a~e Zip Code SAMPLE DATE: ~ ~ ~ Mo. Day Year SAMPLE TYPE: [] Routine [] Check Sample (for routine sampe w th lab ref. no. [] Special Purpose ) [] Treated Water ' [] Untreated Water SAMPLE NO. LOCATION i~-~-'-~ Time Collected Collected . By. .. I i~' y,-,u/~ I I I I TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: Satisfactory i--I Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to Indicate reliable results. Please send new sample via special delivery mail. Date Received & - I ?- ~' ~ Time Received ~/~: ~C) Analytical Method: Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Result* I I-t-I I ~rq I F'~ I F-~ Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALY$'$ RECORD ~,,~/~O~ Membrane Filter. Direct Count ~ Coliform/100 mi Verification: LTB BGB Final Membrane Filter Reeult~ ~) Coliform/100 mi Time: /,._~'~ TNTC = Too Numberous To Count OB = Other Bacteria CHEMICAL & GEOLOGICAL ORATORIES OF.4LASKA, INC. ,~"~.~o~,~ FEDERAL TAX ID ~ g2-~40440 JUN B 8~ ! 13;00 Client aaae : A [ C S Ozde~e~ by : i. lnalysl{ Completed :JUN B 89 Send Reports to: Laboreto[y Supervisor :STEPHEN C. BDE l)A B C S Special lr~truct: Chemlab ~sf t; 5579 E4b Smpl ID: A IL~trlx: ~ATER A~low~ble Parametez Te~ted Result/Un, t! Method Limits WITBATE-N ND(O.IO) m~/l SPA 353,2 iO ,/d Sample }{Cb~II NE SABLE. Remarks: SAXPL[ COLLECTED bY A. WIEN. I Tests Performed ' See Special lrmttuctiorm Above gA*Unavailable ~A- Mot Analy~ed ET-Lets Than, GT-Greatsz Than