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Home My WebLink AboutVANS BLK 5 LT 8EBlock 5 Lot 8 #014-202-72 Municipality of Anchorage Department of 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 I q'- ~.~:~7_.- '7 ~ GENERAL INFORMATION Complete legal description Location (site address or directions) Current Property owner(s) Mailing address HAA# 0 O0 Expiration Date: ~'~ ~c~'C/( Day phone qt7- 3~7- YYe~ Lending agency Mailing address Day phone Real Estate Agent %,-.,~ _h..~.._~l,~.,,,,~-, I~..~',,y,c Dayphone ,.27~.-~?~. I 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 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 AuthorityApproval (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 i ' a private or Class C well and may be re ssued w~th 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,'00)° STATEMENT OF INSPECTION BY ENGINEER 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 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Address Engineer's Printed Name DHHS SIGNATURE . t~ Approved for Disapproved. Conditional approval for __ Phone Date · ...-:.;: .~ ~ :.~--.~ STAMP ~ .,. bedrooms. bedrooms, with the following ~tipulations. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: 72.025 (Rev. 01,~0)' Original Certificate Date: Reissue Date: / ~-D.'7-O o Municipality of Anchorage Department of Health and Human Services Division of Environmental Sewices On-Site Services Section 825 "L' Street Room 502 RO. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343..4744 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L~ ,~ L~ J~k ~:~ VAN ~, '5/j~ Parcel I.D.: A. WELL DATA Well type ~ If A, B, or C provide PWSID # ~ Well Log [~ Date completed Sanitary seal y Wires properly protected y Total depth fl Cased to ~/~ 1~ ft Casing height (above ground) . I ~,~! in. FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ~ colonias/100 mi Date of sample:~~e AT INSPECTION Nitrate_~ mg/I Other bacteria lq ~ colonies/100 mi coIJ ed B. SEPTIC/HOLDING TANK DATA Tank Type/Material Date installed Cleanouts .Foundation cleano.~ Depression over tank High water alarm Date of pumping / ** Pumper C. ABSORPTION RELD DATA Date installed Soil rating (g.p.d./It2 or/J~rm) System type Length ~ .ft Width ~ .fi ~r, dvel/below pipe fl Total depth It Effective absorption amy ft= Monitoring tube Depression over field.~__ Date of adequacy test ~ R~lts (Pass/Fall) For ~ bedrooms Fluid depth in absorption field before t~(~ in Water added __ gal. New depth Elapsed Time: min Fihal fluid depth, in Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date in. g.p.d. 72-o26 (Rev. o~,~o)' D. UFT STATION Date installed 'Pump on" level at __ Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer/septic service line F. COMMENTS Size in gallons 7,/ in ~Pump o~ lev~t/ in Cycles te7 Manhole/Access __ High water alarm level at __ in Meets alarm & cimuit requirements ~'"/',-~ , On adjacent lots ~//,~-. On adjacent lots Public sewer manhole/cleanout Holding t~k SEPARATION DISTANCES FROM SEPTIC~OLDING TANK ON LOT TO: Building foundation ~ ~ Property line ~ ~ Absorption field Water main ~ ~ ~/~ter service line __ ~ Surface water . Drainage ~ ~ ,/Wells on adjacent lots _ ~ SEPARATION DISTANCE FROM/~iSORPTION FIELD ON LOT TO: Property line _ ~/Building foundation Water main ~ Water Sen/ice line ~ / Surface wat. er __ __ Driveway. paddng/vehicle storage Curtain drain "/ Wells on ad.j,acent lots G. ENGINEER'S CERTIFICATION ! I certify that I have determined through field inspections 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 Date I HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 01/00)° Waiver Fee $ Date of Payment Receipt Number D~c ~? OD D~¢ ~G O0 .Dec R7 O0 10~0~ E74-0113 p.?