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Home My WebLink AboutEAGLE RIVER MID HEIGHTS BLK 4B LT 19Eagl Mid River - Heights Block 4B Lot 19 #050-271-29 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Expiration Date: GENE~L INFORMATION Complete legal description Lo'"~' tc{ ~ '~1,4 ~.~ ~L~-~t~v~ Lo~tion (site address or directions) I~o ~ ~ ~t ~ ~_ Cu~entPrope~owner(s) G~,o~ ~a ~¢~ Dayphone Mailing address Io~ ~l~ ~ ~ Lending agency Day phone Mailing address Real Estate Agent Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] Individual Holding tank [] Community On-site [] Public Sewer The Municipality of Anchorage Development Services Department (DSD) 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 ,aJaska. Certificates of Health Authority Approval are required for the transfer of flue (except between spouses) for properties served by a single family on-site wastawater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a pdvate or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) 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. 4. STATEMENT OF INSPECTION BY ENGINEER 5. DSD SIGNATURE Approved for Disapproved. Conditional approval for As certified by my seal affixed hereto and as of the validation date shown below, I vedfy that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastawater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further redly 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. .ameofF rm ?-iZ- Phone Address ~..o~ ~ lSl:"Ct Engineers Pdnted Name '-~/,,b¢. ,~O','"~-~:L~-~' Date 1'°1o2.101o. ..,"" " /.iL 'bedrooms. .. '~A_~..'.-~t,..,~..· ,,,~ESS',3~.?° bedrooms, with the following stipulations: Additional Comments ~=. WATER AND . . = , pROGRAM .. ~ --', ~ · _o ,,~'.~, Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: ,I D -'/.~- ~) / Municipality of Anchorage Development Services Department Building Safety DMsion On-Site Water & Wastewater Program 4700 South Bregaw St. P.O. Box 196850 Anchorage, AK 99519-6650 www.cLanchomge.ak.us (~07) 343-79O4 HEALTH AUTHORITY APPROVAL CHECKLIST . HI .9 A. WELL DATA we, ~,a ~. Date completed I'/~ Totaldepth /~,~-.. ft. Date of test Static water level ~ g.p.m. Nitrate ~ mg./I. 0~1t~1 by: Numb/ompartments //Oepmssio~ over tank (Y/N) Pumper d Wall Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION Well production WATER SAMPLE RESULTS: Coliform Date of sample: /O--o,/.- O I B. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size gal. Foundation cleanout (Y/N) Date of pumping in. Other bacteria g.p.m. ' °/~ /, , q ~" /9/3 colohie~/lO0 mi. Date installed Cleanouts (y/N) High wat~' alarm (Y/N) C. ABSORPTION FIELD DATA / installed Soil rating (g.p.~ or ftZ/bdrm) Date / Length ff. Wldy ft. / Total depth ft. Eft. absorptio~ area ft2 Monitoring tube Date of adequacy test /~/ Results (Pass/Fail) / Fluid depth in absorption field b~t'ore test in. Water added Elapsed Time: __ min. Final fluid depth in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) System type Gravel below pipe Depression over field For __ gal Absorption rate >= Now depth If yes, give date bedrooms in. g.p.d, D. UFT STATION Date installed 'Pump on" level at Datum E. in. SEPARATION DISTANCES Size in gallons Cycle.~~sd SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lilt station on lot I~/~r Absorption field on lot Public sewer main Sewer/septic sewice line Manhole/Acce~___~ (Y/N) High water elam~ level at Meets alarm & ~,,,~it requirements? in. On adjacent lots On adjacent lets Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDITTANK ON LOT TO: Building foundation . Property li~/.. Absorption field Water main , Water sea,ice line. Surface water Fe Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTIOn/FIELD ON LOT TO: Property line Building fou/~ation Water main Water Service line Surface/~ter D~iveway, pad lng/vehicle storage Curtain drain Wells ~fl adjacent lots COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspecifons and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name "'~"e/~ ~'~u rt~La~_~ Date ~ O - O ~-O ( C£.2225 HAA Fee $ '~0~ ~ Date of Payment ! e II 9.- !~ I Receipt Number ! ~ q ~ ~' ,~"'~ (Rev. ~) Waiver Fee $ Date of Payment Receipt Numbe~ 41~TK. CT&E Em/l~onmental Services Inc. 9C~5E15301 T-J~7 P.02/C3 r-8~2 CT&E Ret.# Client .%'a me Pro]ecl ~amenS Client Sample ID Ordered By PWSID 1015709001 Tobbcn $1~:zldand p.~.. Lotl9 Block4D Ea~lc River Earl9 B lock4B Eagle River Dt in:ong Water S~mpte Rcm..~ks. Client FO~ Pre-Pa:d Colis/~'O3 Prlntrd DatetTime 10/03/2001 9:20 Collected Date/Time 10/02/2901 14:00 Received Date/Time 10/02~rJOl 15;55 Teehaical Director Sfq~ken C. Kde 0.500 U 0.500 ml,/L EPA 300.0 (¢I01 10,o2/01 SCL M:L c ~:ob ~.o~.o~y' Labora~-orF Total Coliform 93 OB, W/Coli. No FC col/100~nL SMIS 9222B f<l~ 10/0~91 K.,M~ : ~r, ~' ~.~,~ CT&E Environmental Services Inc. Laboratory Division Drinking Water Analysis Report for Total Coliform Bacteda READ INSTRUCTIONS ON REVERSE SIDE BEFORE COI:LEC11NG SAMPLE MUST BE COMPLETED BY WATER SUPPLIER '- PUBLIC WATER SYSTEM ID~ __ ~ PRIVATE WATER SYSTEM -- Send InvOice Send Results L~ send Invoice SAMPLE DATE: SAMPLE TYPE: -- Routine *%~R(epe at Sample refer to lab no. [] Treated Water i~ Untreated Water -_ Special Purpose Location Collected ~om: llma Coltectad Coltect~l: by (Initial): 15H.~ 'T', $. Date Received: Time Received: Anllyele Began: 200W. Potter Drive Anchorage, AK 99518-1605 Tel: (907) 562-2343 Fax: (907) 561-5301 TO BE COMPLY. I ~-u BY LABORATORY ,~$ais shows ~is Wale~ SAMPLE to be: t~sfact~/ ~-1 UnsatJsfacto~ [] Sample ovm' 30 hours old. Results may be unreliable. [] Sample too k~g in fl'ansiL Sample should hot be over 48 hrs ~d for analysis to Indicate retlabte results. Please send a new ~mple via special delivery mail. ,.~Membrane Filter Analytical Me~hod: . Lab Ref No. Analyst Sent to ADEC: ANC FBK JUN ~.i Fax Date: Time: ~ Client notified of unsatisfactory results: [] Data: Time: BACTERIOLOGICAL WATER ANAYSIS RECORD MMO-MUG Result: Total Colifocm Membrane Filter: Direct Count Verification: LTB BGB Fecal Coliform Confirmation: Final Membrane Filtm' Resulta: Comments: E. Coil . ~ Colonle~J100mi l~rc · Too ~ k) C4~4 COUFORM OS - ~ ~ B~SGS Member of the SGS Group (Soct~t~ G~n~rale de Surveillance) 0CT-,38-~! 17:4S FR0~I-CT~E EtlVIR~I~NTAL SRV g:TSEI§101 T-iS? P.OZ/C3 ;°832 CT&E Environmental Services Inc. Laboratory Division Drinking Water Analysis Report for Total Coliform Bacteda READ INSTRUCTIONS ON RE¥~RSE SlOE BEFORE C .~CTItlG ~AMPLE MUST BE COMPLETED BY WATER SUPPLIER · ~ PUBLIC WATER IIySTEM IDII ~ PRIVATE WATER SYSTEM -. Se~ResJ~ SAMPLE DATE: SAMFLE TYPE.' 200 W Potter Drive Anehocage, AK 99518-1605 Tel: (907i 562-2343 Fax: (907) S61-5301 TO BE COMPLETED BY ~BO~TORY Time Re~elved: A~elyUeal Me~:I: La~ Raf NO, Treated Water [~ Untregted Water Resutt° A~,aly~t MnIIOADE~. · ANC F'OK JUN ['-' Fax Dam' T~z~e: ~ Client notified of unsatisfactory results: ~?]RoutJn · ~ Repeat Sample (~efet to lab no. I'.: Special Pu~'poee Time CoUeclld Location Collec~e~ from: Collected: by (Intlll]): BAOT£RIOLOGK~AL WATER AN~YSiS RECORD ~~ M eenber of the 8OS Group (~x;i§ta Gan&tale ae Surve~tar~:e) by A & L DRILLING COMPANY BOX 97, EAGLE RIVER, ALASKA 99577 · TELEPHONE 694-2588 OWNER OF LAND ADDRESS ~ " 7-. DEPTH OF WELL LEGAL DESCRIPTION DATE - Started Ended PERMIT NUMBER STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR KIND OF CASING ~.- ~ C ,') KIN D OF FORMATION: From_ ( Ft. to From 3! Ft. to From ,~ Ft. to From i3 Ft. to From '"' ~ Ft. to ~-~" Ft.~ From /C:~"Ft. to ":'-:~ Ft. From_,~' ~.. Ft. to i~,~, Ft. From Ft. to Ft. From Ft. to__Ft. From Ft. to__Ft From__Ft. to__Ft From__Ft. to--Ft From Ft. to__Ft From Ft. to__Ft From Ft. to__Ft. From__Ft. to_ Ft. From Ft. to____Ft. From__Ft. to--Ft From__Ft. to __Ft From__Ft. to__Ft. From__Ft. to _Ft From__Ft. to__Ft. ' ~,.C~ ~'~'~ From Ft. to__Ft. ~ ~;-.-~:'~. t '- '~t From__Ft. to____Ft. From Ft. to Ft From__Ft. to Ft. From__.Ft. to Ft From Ft. to__Ft From__Ft. to__Ft From Ft. to Ft From Ft. to___Ft From Ft. to__Ft. From Ft. to__Ft. From Ft. to Ft MISCL. INFORMATION: DRILLER'S NAME December 29, 1978 #780312 j & J Construction, Inc. Post Office Box 733 Eagle River, Alaska 99577 ~ Subjects Lot 19 Block 1 Eagle River Mid Heights Subdivision A permit issued by this department for well and/or sewer system has expired. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal ordinance. If you have drilled the well, a well log should be sent to this department to document the installation date. If there are any further questions, please contact this office at 264-4720. Sincerely, Les N. Buchholz, R.S. Senior Environmental Specialist LNB/ljw enc: copy of permit /VIUNICIPALI~F A'NCHOEAGE MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIOI~Nvji~,ONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 (~__ ~l~Y)) ENVIRONMENTAL ENGINEERING DIVISIONSEP 2 2 1978 Telephone 264-4720 nrrr/tlrn DIRECTIONS: Complete all parts on page 1. Incomplete requ~ will not be processed, Please alJow ten (10) days for processing. 1. PRqPERTYOWNER ,, - j ~ PHONE MAI~NG ADDRESS, PROPERTY RESIDENT (If different from a~ve) ~ , x - - PHONE 2~UYER . ~ ' , J PHONE MAILING ~REgS - , 3. LENDING INSTITUTION MAILING ~D~fiSS 4. 8~AL~OR/A~T , . :,, } ~ ~.~., " ~ ~ ~ I.~HONE MAILING ADDRESS i , 5. L~EGAL DESCRIPTION STREET LOCATI Ol~l _' 6, TYPE OF RESIDENC~E- ' '~ NUMBER OF BEDROO/MS [] SINGLE FAMILY [] One ~ Four [] Two [] Five [] MULTIPLE FAMILY [] Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** PUBLIC UTILITY * 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.) t -):~c-~ **If individual/on-site, give installation date If system is over two (2) years old an adequacy test is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX 2. WATER SUPPLY PERMIT NUMBER [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY 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. DISTANCES Septic/Holding Tank Absorption Area Sewer Line ] Nearest Lot Line WELL TO: I Absorption Area to nearest Lot Line I 5. COMMENTS ~ APPROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED BY (Title) DATE LEGAL DESCRIPTION 3/78) 99577 ~y further, the wu11 lo~ mu~t bu submitted to ~hi~ office. If ther~ are any questions~ p!~ase ¢ontaot this ~ob~rt C. Pr=tt~ 4449 B~sinem~ Park ~ulevard 99503 J~ith M. Rich % Realty Center ~301 Arctic ~ulevard 99503 P.O. BOX4-1276 ANCHORAGE, ALASKA 99509 4649 BUSINESS PARK BLVD. Drinking Water Analysis Report for Total Coliform Bacteria TELEPHONE (C37) 279-4014 TO BE COMPLETED BY WATER SUPPLIER PUBLIC WATER SYSTEM: I.D. NO. Public Water Syslem Name Mailing Address Cily State SA,,,PLEDATE: I--FS/ F5 '1 Mo. Day Year Zip Code SAMPLE TYPE: La Routine [] Check Sample (for routine sample (~_sWith lab ref. no. ) pecial Purpose ~ ~at ed Water reated Water SAMPLE NO. 5 [ LOCATION Time Collected Collected By TO BE COMPLETED BY LABORATORY LABORATORY: CHEM &GEO LABS OF AK., INC. NAME 4649 BUSINESS PARK BLVD. ADDRESS ~CHORAGE, ALASKA Date Received Time Received Analytical Method: CITY 9-28-78 1430 Fermentation Tube Membrane Filter Lab Ref. No. Result* Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Form No. 18-310 (3-78) 06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1978 O.t.,*e~e,w. 9-28-78 TimeReceivecl 1430 "'"~' 8754-28 Presumptive ]Omi 10mi lOml lOml 10mi 1.0mi O.lml 24 Hours 48 Hours Confirmatory 24 Hours Multiple Tube Report: __ Membrane Filter: Direct Count __ vedficatlon: LT8_ Reported __lOrnl Tubes Positive/Total 1Omi Portions