HomeMy WebLinkAboutCAMPBELL PARK ACRES LT 49E
ParcelI.D.#
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Divlslon of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
cERTIFICATE OF HF/ALTH AUTHORITY
/~PPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION _
Completelegaldescription Lot 49~ Ca'~pb~l] ' P~,-~ ~,~,",~
Location (site address or directions) 655 Potter Drive .
Anchorage, AK 99515
Property owner _ Howard Wink~,lm~nn
Mailing address 30450 N. Street
Lending agency
Mailing address
Agent Katherine Herfindalf
Day phone~
Spirit Lake, Idaho
Day phone
Address2525 c Street Anchoraae. AK 9q~nt
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~
TYPE OF WATER SUPPLY: ~
Individual well X
Community well
Public water
Day phone_
NOTE:
If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system.
4. TYPE OFWASTEWATER DISPOSAL:
x
-. Individual on-site
Holding tank
-. Communltyon-slte . ·
· Public sewer
- '" .. * * ;..'..*-;f,,,,.;,o. ~,,",,,m nrovid~*writt~n Coh'firmation frO~n-stat, e ADEG
NOTEi Itc mmun.y wu
attesting to the le~;ality and status of system. ·
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as 0f 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
Ihe Municipality of Anchorage files and from my inves!~ation and inspection, the on-site water
supply and/or wastewater disposal sysiem is in compliance with all Municipa! and State codes.
ordinances, and regulations in effect on the date of this inspection.
Phone 90'"/-344-.1.385
Date ~-.~i-~' ~
o r- ;..,.
~[. '.'.: '.-~
t;~2'. CE-~2*? ( / '.7/5"
r*t.:, ,~ ,,.,,..,,lo ......
DHHS SIGNATURE
c-'" A .roved for bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Servlces'(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 requiremenL~. Employees of DHHS do not
conduct Inspections..Dr. analyze, data ..bef°re., .a certificate,.... Is. Issued.. The M, uniclpality of Anchorage Is not
responsible for errors or omissions In the professional engineer's work. ::" ; '-'"
Legal Oescrlption:
A. WELL DATA
JUN 0 1
Municipality
of
Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVI~E~]~ o~
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343°4744
Health Authority Approval Checklist
49A Campbell Park Acres
Parcel I.D.:
Lot
Well type .~ If A, B, or C, attach ADEC k~t~er. ADEC water system number.
Log presem (Y/N) ~ Date completed Unknown
Total depth 1 60 ' Cased to 80 + Cas~ height (above ground)
Sanitary seal (Y/N) Y Wires pmpedy protected (Y/N)
FROM WELL LOG AT INSPECTION
Oateofteat No Znfprmptton available on 5-26-99
this well. Nost l:i, kely
Statlowaterlevat ~ in early 19~0~s. 36-5~
We~l production
WATER SAMPLE RESULTS:
Col~orm .n_ ( ,~/.)~/c~q)
g.p.m. ~ g.~m.
Nitrate 0.~n t;/~a/qq) Other bacteria ~
Dateofsample:~-24-99 & 5-27-99 Collected by: Dustin High
B. SEPTIC/HOLDING ~rANK DATA
Date Installed /ank size Number of Co .~,~mnts Cleanouts (Y/N)
Foundation cleanuut (Y/Ny Depression (Y/N) / High water alarm (Y/N)
Date of Pumping / Pumper
C. ABSORPTION FIELD DATA ~..
E~ec~m a~sor~n amI Manaor~g Tube presem (Y/N)--/L Depress~. over ~
.bedrooms
72-026 (Rev. 3/96)*
D. UFT STATION
Dale Installed ?' Size in galicns ,,,.
oil'
level
ato
High water alarm level at ,/" *Datum /
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holdingtankonlol n/a On adjacent lots n/a
AbsoiT~ion field on lot n/a On adjacent lots n/a
Public eewer main 1 2 0 ' + Public sewer manhole/cleaneut 1 5o+
Sewer/septic service line 5 0, + Uft station n / a
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation n/a Propertyline n/e, Absoq:ltionflelcl n/;~
Water maln/servloe line n/~ Surfacewater/clralnage n/;~ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Properly line ./.,/.~dtng loundation /Z/~Vater maln/sewlce line .~.~.
I~,~ water ~ Driveway. ~/l~,'ventcte storage area
Curtain drain ,,,,,' Wells ~acljacent lots . - *
HA.~ Fee $~,~ ,- ----'
Date of Payment ~
72-026 (Rev. 3/g6)*
Waiver Fee $
Date of Payment
Receipt Number
1-1Gl
P.Qt/OI · F,24l ~..: ?,...
EiS_~:~- 1Dc3~ k'~ *- 4 4r:I-1
0 Trrit~d ~¥:lt~r
~ Ke~al 5ampl. Ifar ro.fint~m~c ~ UntOld Wiler
with I.b fl~. fl& . )
SAM P LK LOCATION Culttct.~ By