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Home My WebLink AboutPELLISSIER LT 1Pellisier Lot 1 #051-104-60 MUNICIPALITY OF ANCHORAGE Hea- and EnvironmenLal Fourth I,'loor West 825 L Street Anchorage, Alaska 99501 279-2511, x 224, 225 SEPTIC TANK: DISTANCE ~,,... ,_~. /1~ --~ ~ NUMBER OF ~ INSIDE LENGTH .................. INSIDE WIDi}t ~ .. L IQtlll) [)FPTH 1 t(.)t. Jl[) CAPACITY GALLONS. TILE DRAIN FIFLD: [ , ~ .I T()TAL LENGTH ............ Nt .ARES] I C,I LINE Af~SORPTION AREA _~. O SQ. i I I E. NGTI4 ()[' ~ ~('~t t I i)EPTti OIt /L_Fi.R t)EPIlt: -lOP ()[ ]'i1.[ IO f thllS!t CiliAliL ~t~ MAll t{i/tl Ii[Pi[Alii TIll ~O IN ABC)VI7 TI[f:. ~ SEEPAGE PiT: DI/~METE:R ......... OR WI[)~tt ..... I [N(;I!I .... DEPTH Log Crib Rings Crib Size: DtAMETLI~. .... DLPIlt ........ DISTANCE FP.(JM: WELl_ 'IOT.'~,I t2f I.ECTIVE BUll,[)lNG t-:OUt"iDAT!ON .......... hH2AP, I--_$T i.()t' LINE Id~hC, Rt"] ION ARFA (WALt. AREA) Class, Depth, m ' t ....... I- Well Dlstanpe To: Lot Line ~ ' ~ ; : , ' ' i ~ ~' ~.~ Bldg: ~ Sewer Line: '] ~ [ [ ; ; [ : ' ' '' '" '- ~ of Bedrooms: ~ ~u , . ~¢~,~m~ ~'~'¢: : ' ,~ ,: ' ,, · ,--, ,. ' ' ' i r i ~ ...... ' i' : ~ ~ ' ' :'N 'i i '"'ii"' ti ;;;i:: ;i; i.,i :I; L.!.. ;il NtE;'Ti:::iL,..! .... THE; :ii;"r';!!i;'i"Eh'i ]; N F::iE:(;::Oi:;;:Df::!NE:ii!!; i,,,i ]; '?'H 'i'HE F:I t:::' F:' i.,.. ;!; C: f:;I i'q'T' !.'.i, :!!:;, H U N 'T' ii!!] GARY PLAYE R VE NTUR S CONSULTING GEOLOGIST BOX 476-M, STAR ROUTE A · ANCHORAGE, ALASKA 99507 · PHONE 344-7071 SOILS LOG Performed for ~' ~' ~~-~ 6 = 10 -r~ g 14 16 18 Soil Type Water Level Remarks 20 Total Depth of Excavation Groundwater Not Reached Depth, if Reached__ Material at Total Depth Bedrock Not Reached Depth, if Reached Classification Method ~Vi'sual ( ) Sieve Analysis () Gary F. Player, Consulting Geologist GREATEr ANChORAgE ArEa BOROUgh DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-456! ....... ~ APPLICATION AND P£RMIT INSTALLATION OF: SEPTIC TANK TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH SOIL TEST RESULTS COMPLETION DATE ANTICIPATED DRAIN FIELD OTHER TO BE INSTALLED BY NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE TYPE MINIMUM DISTANCES, R£C~UlREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK ., SEEPAGE PIT TO NEAREST LOT LINE. WELL TO SEPTIC TANK / DRAIN FIELD WATER MAIN TO SEPTIC TANK DRAIN FIELD SEPTIC TANK, , SEEPAGE PIT TO RIVER, LAKE, STREAM. SEEPAGE AREA SIZE DRAIN FIELD ., DRAIN FIELD SEEPAGE PIT ~/~ ~) ALSO CONSIDER AREA WELLS. SEEPAGE PIT , DRAIN FIELD CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REG~ING INSTALLATION. // OR LICENSED DESIGNER TYPE DIAGRAM OF' SYSTEM I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO, 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS In ACCORDANCE WITH SAID CODE, FORM NO, EQ-OI 6 JAY WILLIAMS BRILLIN~ 3?6844? P. 01 Municipality o.f 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 DWEU'iNG Parcel I.D. 05-1 1. GENERAL INF6RI~IATION C. omplete legal descripti~)n ocat~on (s~.e address or i:h croons) "'" ' "" Current Property o~ne s)" 'Ma'iiin'g add. r,es, s,',? '",'5',' ' Lending'~h~"' Expiration Date: Day phone Day phone Mailing address Real Estate Agent '~f/3r Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: ~, Day phone 3. 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 Alaska. Cedificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal end/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 private 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 eno year for properties served by Class A or B we/Is or a public water system. The Municipality of Anchoraca is not responsible for errors or omissions in the professional engineer's work. STATEMENT ............... ~ '~ ,- ¢ , ~-~, ,: 4. OF INSPECTION BY ENGINEER "' As certified by my seal affixed hereto and as ~f the'vali(Jafi0n 'date shown~ below, I Veri~y that my Investigation, based on procedures outlined in the Health ~utherity~Approval Guidelides for this application, sh~)ws that the On-site water supply and/or Wastewater. dis~Osal ~ystem is(are)'safe, functional and adequate for the h6mber of bedrooms and type of structure Indicate~ herein.'l further verify th~,t b~d On the Information obtained from the Municipality of Anchorage files and from my Investigati(Jn add Iqs~ection, the on-site ,water supply and/or wastewater disposal system is(are) in compliance With all ~pplicable Mdnicipal and Stare'codes, ordinances, and regulations in effect at the time of installation. . . ,.. , ' :'.,'~.,,,. ~ ...... ~.%.: : · . :., - ~','. Name of Firm '¢TJr-~CT,~- ~'~" "' ....... :' "'"iPlab'n; .~o~ Engine'e~"s Printed Name ~ (~ ~ ~ (---'~'~ '~' ~-.~<5 D ~ ~'r..) ' ...Daie,,. ~_~//(¢/~ / ' : .... . .-;~ .OF, ~ ;'tt, . '.":,;~. ','C?'{~ :?;, ~;: ' ..,:.;,T ~,;.,jl;!~;r~:.;- ' ' [ .......... . ~,,~/"~ ~',,,~.~-Li'~;~,.;',-; ;'~¢,~~ N>,'~M~¢~~r' ~~rr,/ . 5, DSD SIGNATURE ...... · , , ,~'~; · ".":"'";.:' ';.. ;'. "', ..... ..,;.:. , .~. ........ ';5 '. CE '.' · "/,"~" ~ 'ApP?b~ed for"" '~'":'be~rooms."." .' "". ....... ";" ~ ;/~ [.. ~' .. · D,sapproved ..... ~'.....'.~ ,~..' ..... · · .. ~[~S.~ · .' · ,. ,..~,;::.-.~ .- :'!.'?."..':'. . . ., :. ~tt Conditional approval for .. bedrooms, with the following stipulati~l,~'[~ .O.F.. ... · :.. . ' .. ...... . ..... ,-..~.~ ~',;,.¢.':.:,. ".. · ,~,. , ..- ...-.,,~,,~.,_ · , · . E~'., UN-;5111 c: ". 'C~_ "' .......................................... :- ......................... ~_' WATER AND : .................... :-:"' .-. ~ . '. WASTEWATER .' .... :' "'" '" ' ' ................ : ........ ~' ',:' PPI3~PAEI ~<~,, . . ',o-',,~ ~?~...... . ..- Additional Comments ' -...~,,,. Note: The well for this property meets e×istia~ State and Muuicipa! Codes. There are nitrates Current nitrate eouceutratiou is 9.5 mg/I. [PA maximum eou~¢ntr~tim] is I0.0 mg/L More informullo~i ua nllru'~s Is available Irom tile ~u-;Site Services l'ro~ram, at ~43-?~04. Attachments: HAA Checklist Septic System Advisory · Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Original Certificate Date: ..~- ,/G "' ~ ! Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 wvnv.ct.ancflorage.ak.us (S07) 343-79O4 HEALTH AUTHORITY APPROVAL CHECKLIST LegalDascriptlon: LoT II Parcel ID: O~lt o~d~0 A. WELL DATA Well type ~)& Date.completed Date of test Static water level Well production If A, B, or C provide PWSID # san~ar~se~ (Y/N) Y Cased to ~ ft. FROM WELL LOG ~ L~ g.p.m. We~l coo (Yin) Wires property pmtectod (Y/N). Casing height (above ground) In. AT INSPECTION WATER SAMPLE RESULTS: Coliform {~ colonies/100 mi. Data ~ ~p~e: ~l~ti~/ Nitrate q. ~>~ mg./I. Ca,asted w: ~L B. SEPTIC/HOLDING TANK DATA Tank Type/M~terial'-- Ft.~'r~ 61.4'%5 Tank. iize ]?-.-<~C~ g~L'"" . Number of Compartments ._~ ~ 'Fodndation clean,ut Ct/N) g , Date of pumpin ~. · . :..,'.::.' . . ..:..~ C."ABSORPTION F. IELD OA'I'A Depression over tank (Y/N) ~J Pumper '~ ~ 0 colonieS/~ (~0 mi. c~eanouts (Y/N) High water alarm (Y/N) Leng~'"'/:~:~'''" 'ft. Width .-~ ft. Total deptl~,'<~ ft. Eft. absorption area ~;~.._f~ Monitoring tube . Dale of adequacy tast ~{q/OI Results(Pass/Fail) Fluid depth in absorption field before test O in. Water added~Z~ gal. · sysmm ~pe Gravel below pipe ~ ft. Depression over field For "J---bedrooms New depth~ I({~. Elapsed Time:~dOmtn. Final fluid dedtt~,q/~ Absorption rate >= · ~'~' ~'¢-~ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) z.pJy.~ If yes, give date. ' - D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) 'Pump on' level at in. 'Pump olr level at in. High water alarm level at Datum Cycles tested. Meets alarm & drcutt requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/tift station on lot (~ T/O o I Absorption field on lot Public sewer main Sewer/septic service line ~'~' On adjacent lots On adjacent lots Public sewer manhole/cleanout Holdlog tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation /(~ f Property line ~--.~T/O water main /~/o, water service line Wells on adjacent lots ~-1'/ Absorption field '~ I I Surface water ~.~ '/'~' Od SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line CT water senrice line ~.T~I Curtain drain J~-- Building foundation ~.-.I Water main ~ Surfacewatar ~T t OC~! Drivew'ay, paddnghmhictestorage "1~ ~ Wells on adjacont lots ~'T/Qof F. COMMENTS , G. ENGINEER S CE~FICA~ON I ~ ~at I ham dete~lned ~m~h fle~ i~pe~ ~ review of Munidpal m~s ~at the a~ sy~ am m ~n~nm ~ MOA ~ gu~ellnes ~ effe~ ~ ~s date. EngmeersPnn~dName ~'~ ~ ~ ~ ..... HAAFee $ ~C)~). O o Date of Payment ~"'- ,~/~:~ - ~/^ Receipt Number ''"' '~"~'~'~['] A ~ (Rev. '~2/00) ~.~/~ Waiver Fee $ Date of Payment Receipt Number Parcel I,D. # 1. GENERAL INFORMATI( Complete ~ ,. , :; - , ~!,: Location (site' addresS'or alrecl~qtl~)'?;"; ~ ;~ ". !'~ ',:'i: :!, ,., .., :.Property Gillan %,'..~.~;~~,...,, , ;~';~;~.~"Cit~" ~'~age/Jean~e Mee , . . Day phone ,.- · ,, .... Day phone Address Unless otherwise req be held for pickup. MUNICIPALITY OF ANCHORAGE, ,. DEPARTMENT OF HEALTH & HUMAN SERVICES ;.'~;!,.:~,~,, Divisi6n~ of 'EnVironmental Services ~ Services Section -' ie,"Alaska -:. 99519-6650 "'I~ORITY' IGLE FAMILY DWELLING ,~ ,~:',',' ? ' , :¥.~ ... Day .phone.' 688-6784 696-0701 99577 2. NUMBER OF BE . 3. TYPE OF WATER SUPPLY: Individual well X *'~ '' '"'~'.,,,. i~"'- ' -,,: ,. L, p... ?, Commumty well ,,~. ~.~ ~'..~ -.~' /.,_ ' ' ~ : ,, '':~ .'" '"'~,' ' ~-' ~'~"'~'Public water ~ :, ~ -~ :m~ to the legality and status system. :- '~;:'- 4. - TYPEOF:WASTEWATER DISPOSAL: "4/',. ' ' '" "" ',:[:, :'~' X , ~ - .... , - .~'j confirmation from State ADEC attest- NOTE: If provide written confirmation from State ADEC attesting to the legaiifY?~l'~atus of System: "~ ' ':<i, ..~. :,:,~ ~-;. ';;-~i..~ ' ,*,:'. 'i. -:!'i:.i" 7~-025 (Rev, 1/91) Front MOA#21 STATEMENT.OF INSPECTION BY: ENGINEI As certified by' my seal affixed hereto, , ate shown below, I verify that m nvestlgabon~of this Health Authority. Approva , ~ows that t~ 6n-site water supply and/or wastewater diSpO,~al sYstem i~ ~fe,~ fun ,ctl,~ i~i'~l~t~=.~o~ i~'~nui~ber of bedrooms and typ~ of structure indicated herein~.~l fU~he~.~e~ify th~ b'~S~d. ~~t~ei~ati0n obtained from .the MumciPaiity of AnchOrag~ ~ilres a.~,~m' ~in~t~i~~a~ ~:ns~'~'~; the on-site Water ordinances, and regulabons ~n effect on the date of this inspectiOn':~t Name of Firm ~gze By: DHHS SIGNATURE ,'~ Approved for _.. ¢ Disapproved. Conditional approval for A~di~ional CornineSs .~o~e: ~hG $~a~e a~d Nu~zc±pa[ Co~es suqqes~ed' [h~ .co:II±hued ;h_e_ roM~Jar~ ,~:r~li~fitYc;f A.nchor. age. Departm..ent of' ~eait.h~ ~i'~i~i;8erv,~'~ *.(D,.$)'*iSSUes Health Authority ~,~, [es Daseo only upon me representations glvei~'.l.~"pa~agraph 5 abOve by an inde endent r ' ' . , , ".,r~''~,.~., ~ ; .... p p ofesslonal engineer registered rathe State of Alaska. The DHH$ does ~hls ~...s~ courtesy to purchasers ot homes and their lending Institutions in order to satisfy c~rtal, federal'an~iat~'~[~i~i~fit'~i E~ployees of DHHS do not rC;n/uct ,n..ec.on. or ~n.z~ *t. ~,o~ ~ o~.,,,C~t~i,. ,'~u*i~ *~*,.,,t~ o, *n*or.~ ,~ no, Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744 Legal Description: A. WELL DATA Well type D ~ I V,4T& Log present (Y/N) \/~ ~ Total depth ] 0 .g / Sanitary seal (Y/N) Health Authority Approval Checklist ~£LLI£$1&R LOT' ~_ Parcel I.D.: o Ioq-bo Date of test Static water level Well production L/ WATER SAMPLE RESULTS: Coliform -~ Date of sample: O '7 / i ~] / e~ ~ B. SEPTIC/HOLDING TANK DATA If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to + c/O o$/zq /7? Casing height (above ground) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION 5' g.p.m. ~' ''] g.p.m. Nitrate 5. I Z ~/L Other bacteria Collected by: ~'f~ cd',~ Date installed 00o / 7 7 Tank size }Q.. S 0 Number of Compartments '2 Cleanouts (Y/N) x/~- ~ tt~ Foundation cleanout (Y/N) ¥~5, htOo~ca Depression (Y~ ~0 High water al~ (Y~ ~/~ Date of Pumping 0 q / 2 J Pumper ~ ~ ABSORPTION FIELD DATA Date installed ~ ~/77 Length ~ ~ / Width Soil rating (g.p.d./ft: or ft2/bdrm) °o ~ 1~1/~ Iq System type ~"~(K)L/4- Gravel thickness below pipe ~ Total depth ~- ~ / Effective absorption area "~ ~ 0 ~ . Monitoring Tube present(Y/N) x/~ S Depression over field (Y/N) Date of adequacy test O'7/}'~/~ ~ Results (Pass/Fail) QA' 55 For ~O L] (~ Fluid depth in abs, orption field before test (in.): "5'3, [" Immediately after fig?gal, water added (in.): Fluid de th ~ " = ¢ Mln r 6oo · p /~ ' utes later: 37,3'- (in.) Absorption rate g.p.d. bedrooms ~,~', ~. ,, Peroxide treatment (past 12 months) (Y/N) ~ If yes, give date LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at~...-f *Datum Size in gallons "Pump off' level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: 7 Septic/h~d3mg tank on lot ~- -I 690 Absorption field on lot Public sewer main Sewer/s~mi~ service line +lo0 / ~2Z / ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Lift station ,c/Oo / / SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: ! Foundation J O Property line '~' ! O t Absorption field Water mm~service line ~/0 Surface water/drainage tV/A, Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation :¢ / 69 t Surface water Lt/A- Curtain drain 4I/~ ENGINEER'S CERTIFICATION Water rem-in/service line ~ lO / Driveway, parking/vehicle storage area Wells on adjacent lots I certify that ! have determined thrufield inspections and review of Munic'~_~,~,~i in conformance with MOA ~ guidelines in effect on this date. tt'.'x .o Signature ~ +-100 Engineer's Name Date / '~1oo HAA Fee $ Date of Payment Receipt Number Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data Well type Log present (Y/N) Total depth Sanitary seal (Y/N) /05 ~ If A, B, or C, attach ADEC letter. ADEC water system number /~/~ ~'~, Date completed ~ ~/~-~/?? Driller :._T',~Y Cased to -t ~ ~" Casing height )/~.~ Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG AT INSPECTION iz l?? J-f .g.p.m. 6, 7 SEPARATION DISTANCES FROM WELL TO: Septic/he. lng tank on lot Absorption field on lot Public sewer main Sewer service line ~'~ g.p.m. ~'100 ' ; On adjacent lots ; On adjacent lots ~/~ Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: 0~//7/~ ~ ~,/~ //E 6/_/~ Other bacteria --~ Collected by: £~"~ ~- ~ B. SEPTIC/H,~)EBING TANK DATA Date installed 0 ~/? "] Cleanouts (Y/N) )/~-~ High water alarm (Y/N) Date of pumping Tank size /~:~ Compartments Foundation cleanout (Y/N) /'~/~ Depression (Y/N) /'.//~ Alarm tested (Y/N) /.////4 9 ~ Pumper SEPARATION DISTANCES FROM SEPTIC/I-JQL-BiNG TANK TO: Well(s) on lot 7~'10/.~; On adjacent lots To property line ~/-/0 Absorption field Sudace water/drainage Foundation Water raaiR/service line /D 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) ."Pump on" level at High water alarm level Meets MOA electrical codes (Y/N). / SEPA,~IO~STATION TO: On adjacent lots D. ABSORPTION FIELD DATA Manufacturer Manhole/Access (Y/N)~ ..-.~~Pump off" Level at ../~Cycles tested ¢~/"? ,Soil rating (GPD/FF) ~ 4:~7//~ Width ..~ t Gravel thickness .~;~ cO ~ Cleanout present (Y/N) . ~ ?/'~ )/~ ~ Results (pass/fail) Date installed Surface water Length Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) System type Total depth Depression over field (Y/N) --~-S, for /z~__ Bedrooms After test 3'5; /V/~ If yes, give date /'-///°r SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~'/O0 ~ On adjacent lots To building foundation On adjacent lots Surface water Curtain drain /4/4 Properly line To existing or abandoned system on lot /,//'~ Cutbank /.//,~ Water ma~Vservice line /-/~ / Driveway, parking/vehicle storage area '~2 / E. ENGINEER'S CERTIFICATION HAA Fee $ d'ZJ Date of Payment Receipt Number //~ I certify that I have checked, verified, or conformed to all MOA ........ ,,,,,,.:.,,u ?.,,,,,,, . . and HAA guidelines in eff~'tl¢,~he ~, (~is inspect/bn. Signature Engin~¢s Name ~ '~ % CE-6736 · ~'~ Date Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back 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 Parc§l,I.D. # I~\ - \~(~L'\Ic~"~ HAA# 1. GENERAL INFORMATION C, ,~mplete legal description Location (site address or directions) Property owner Mailing address Lending agency Day phone Mailing address Agent ^O(3 ress Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Day phone Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: 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 INSPECTIO~N BY ENGINEER 6. DHHS ordinances, and regulations in effect on the date of this inspection. Name of Firm ~ ~lZ$0,J -~-"~J6 ~J ~'l..qq..l~J6 Phone Address ~-O. ~O~, Z..'/O773 A~c,14~n.¢l. Ge.-' Engineer's signature ~/~-4.~c4zJ.- ~' _~_~.~ Date As certified by myseal affixed hereto and as of the validation date shown below, I verify that my investigation 'of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, SIGNATURE · Approved for Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1191) Back MOA MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # [C').~\ - \C'~\ - [~(__~ HAA # 1, GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address ~UFeT'I$ q-CAStlE, l-lAr~mo~D Dayphone L~8~- {lql Day phone Day phone UnlesS otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. Public sewer NOTE: 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 · )po~ s~eeu!~ue I~UO!SSejo~d eq~ u! suo!ss!wo Jo s~o~e ~oj elq!suodse~ ~,ou s! e§~oq9u¥ jo /q!l~d!~!unl~ eqj. 'penss! s! em~U!~e~ ~ e~ojeq ~),ep ezXmu~ Jo suo!medsu! ~npuo~ 3ou op SHHQ ~o see~oldu~ 's~ue~ue~!nbe~ em~,s pue le~epeJ u!mJe~/~s!)~s o3 Jep~o u! suop, n~p, su! ~u!puel 4eq3 pue sewoq ;o sJes~qoJnd ol Xse~noo e se s!ql seop SHHO eq.L '~)lSelV ~o e)~lS eql u! peJem!§a~ ~eeu!6ue I~UO!SSe~o~d luepuedepu! us ~q e^oqe ~ qd~J6sJed u! ue^!6 suo!mlueseJdeJ eql uodn ~lUO pes~q selsoU!PeO I~^oJddv ~lpoqln¥ qlleeH senss! (SHHQ) seoFaes uewnH pue qlleeH lo luew~edeQ e6sJoqou¥ ~o/q!md!o!un~ eqj. s)uewwoo leUOp,!pp¥ :SUOl),~lnd))9 §mMOIlOJ eq), q),lM 'S'"ooJpeq JO~. leAoJdde leUOl~.ipuoo I:l:agNIl~Ng Aa NOIIO=~dSNI dO .LN~IRi~II¥.i.S 'g Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ,( ~7- I P£4/./$.5/6~ Su~Z~ Parcel I.D. A. WELL DATA Well type pt~l V~T'~ Log present (Y/N) ~/ Total depth /~.5' / Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~/~ ~',//? ? Driller Cased to ~,;~ / Casing height Wires properly protected (Y/N) I~/11/,4 ,~/ ,' Date of test Static water level Well flow Pump level FROM WELL LOG AT INSPECTION ?o? 5'7' /" ~ g.p.m. _5- NOT SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Public sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Date of sample: ~//2./'?~ Nitrate 5', '/ (HORSE pA 5TUFt \ Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~/~ 3./'? 7 Cleanouts (Y/N) High water alarm (Y/N) /v',~ Date of pumping Tank size /'~ Foundation cleanout (Y/N) Compartments V Depression (Y/N) / Alarm tested (Y/N) ~,/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot //-,' ~ ' On adjacent lots /~ ' To property line ?¢' Absorption field Surface water/drainage tJe~-~ /Uo-r-~=b /JEAr~ Foundation Water main/service line 72-026 (Rev, 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Manufacturer Manhole/Access (Y/N) Well on lot D. ABSORPTION FIELD DATA Date installed ~/2 ~.//~? Length ~.E' Width On adjacent lots Soil rating r~.~ Gravel thickness. "Pump off" level at Cycles tested Total absorption area $.50 Depression over field (Y/N) /',/ Results (pass/fail) PA 5 5 Peroxide treatment (past 12 months) (Y/N) Surface water System type 7-/¢ Total depth Cleanouts present (Y/N) Date of adequacy test for SEPARATION DISTANCE FROM ABSORPTION FIELD TO: If yes, give date Well on lot /G To building foundation On adjacent lots /¢~' bedrooms On adjacent lots /~ '~ Property line To existing or abandoned system on lot Cutbank ~(~/¢7- ,~-5~,-~ 7' Water main/service line Surface water /J~ ~JEA ~ ~.c~'r' Driveway, parking/vehicle storage area . /'~ ' Curtain drain 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 inspection. Signature ~ Engineer's Name Date ~/~ /~ z.. HAA Fee $ / 7/-~' ~ L~ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number