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Home My WebLink AboutEAGLE RIVER HEIGHTS BLK 2 LT 21 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. # 1. GENERAL INFORMATION HAA # Completelegaldescription Lot 20 t: 21; 8~..ch ~ EA~e F. Zv~ He.Z~[~;_~ Location (site address or directions) 10~50 Ccuu[.bou. Ecc~l~.e I~.ve¢, AK Property owner Judy Nix Day phone Mailing address HC03 Box g335 P~_,r~t~ AK 99645 Lending agency Day phone Mailing address 745-42g0 3. Agent Ge*u~ C¢omi'.et// A~,:uc 'P¢op~t,~6 Day phone 557-0! 74 Address 5600 Co~r/ou,~ Su.[.~.e I00 A~cho~ct~e, AK 99505 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: $ TYPE OF WATER SUPPLY: NOTE: Individual well Community well xxx Publlcwater ~~° ~ ~ If community well system, provide written confirmation from State ADEC2a{~est lng to the legality and status of system. ~ 4. TYPE OFWASTEWATER 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. Se 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 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 inves.ti..qation 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. $ & $ ENGINEERING Phone Name of Firm : 7c*,,4 "..~,~:~ ~;.~: ~..~. ~.~,~J N,~. =84 Eacjle Ri~r, Alaska g9577 Address Engineer's signature Oate /C /~4/ ~- DHHS SIGNATURE ,X,,' Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: The Municipality of Anchorage Department of Health and Human Se~ices (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. Municipality of Anchorage ~um::,P,~Un, O~ ~ DEPARTMENT OF HEALTH & HUMAN S~I~ s~w~.s DW~S~ON Environmental Services Division 825'L" Street, Room 502 · Anchorage, Alaska 99501® (907)'"~,~-47,~ ]995 Legal bescrip~on: A. WELL DATA Well type I~l~.~//~q.~ If A. B. or C. attach ADEC Iclter. ADEC water system number Log present (Yi~ ~ Date completed ~-- RECEIVED Health Authoril¥ Approval Checklist FROM WELL I.,OG Date of I~ Static wamr level Well production WATER SAMPLE RESULTS: Coliform ~) Nitrate 'Z, ,"Z- ~""' Other bacteria Daleof~mplc: ~A'~ -~,~.- ~" Collcctedby: ' 3 ~, -~ ~-l~/.f,~..-~..~..t,~ ~ i~l~ T~ ~ ~-m~r ~ Com~ CI~~ A~ION ~i~ DATA ~O*~t ~ (Y~ ~l~d ~ ~~ ~ (~3: I~i~ly ~ ~. ~ ~ (in.): D. LIlT STATION Date ia~l.,tlled Manhole/Acce~ (Y/N) High wamr alarm level at* Size in gallons "Pump on" level at* ~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding lank on lot Absorption field on lot I~blic sewer main Sewer/septic service line : On a~t lots ; On adjacent lots Public sewer manllole/cleanout L. station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main/~ Fe Property line Absorption field C,,.~,.,, w-~r/d, ~ua~e Wells on adjacent SEPARATION DISTANCE FROM ABSORPTION ~ ON LOT TO-~ Building foundation Water main/service lin Surface warm' ~nghtehicle storage Wells on adjac~nl lots ENGINEER'S CERTIFICATION Property line I cert~..fv that I hate determined thrufieM inspections and review in conformance with ~.10.~ I~L.I guideli~l}s in effect on this date. Engineer's Name /~ O /~ ta~ C. Co~.t/ 4.d Date IO /1~/ ~'~ ~f Municipal re~ are Receipt Number Rex'. 8/95 OSS: haa.wk.doc Waiver Fee $ Da~ of Payment Rn:=ipt Numl~r CT&E Environmental Services Inc. Laboratory Division Drinking Water Analysis Report for Total Colit'otm Bacteria 200 w. Anc~ore~o. AK 99518-160S READ I[VSTR(JCTIO,¥5 0,¥ P,£}'ERSE. $ID£ BEFO~ COLLECTING SAMPLE Tel: (907) 562.2343 ~ax: {907) 561.5301 Year Treated Water Untreated 'Water Collected Month D~y ' ~^.MPLE TY'PE: Routine with lab ~L n0, ) S~eciat Put.se ~ime SA~L~ LOCATIOh' Collected TO BE COMPLEIT. D BY LABORATORY Analysis show{ this Wat-'r SAMPLE to be: Sati;faciory Unlatishctory. O Sampl: over 30 hours eld. r~sults may be unto'liable Sample too long in Imnsit; sample should t~o: be over 4S hours old mt to indicate reliab[e tesul~, pleas~ ~and ee~v sample via special dc v~ mail. Analysis B~gnn _, Anal)Ileal Wlethod: Membrane Filter MM0-MUO esult4 5.45o ~llent notified of aassii*fact0D' results: BACTERIOLOGICAl. WATER ..UV.~LYSIS RECORD ~i.MO-~L'G Result: Total Coliform Membrane Filte~: Direct Count _ COLI~IRM CT&E Environmental Se.rvices Inc. Lalx~ratory Division 7- .... ~- --:: . -- -- Laboratory Analysis Report 10/10/95 · 15:4s bra. Technical Director ~'/~H~N c. ~DE 2.25 u~/~ EPA 3{1o2 20. 10/11/95 see $&r~le gamarke ~ove ~A ~ l~oc l~alyze~ ~ececte~, ~orced value lo the praocleal ~ncificatton llmlc. LT 2~ W. Porte[ Drive, Anchorage. AK 99518-1605 ,--Tel: (907} 582-23~} Fax; (907) 561-6301 FNVtRONMENTAL FAClL~IES IN A~K~ ~LIFORNIA. ~LORIDA. ILLINOIS, MAR~O. MICHIG~. MIS$0~RI. N~ ~R~EY. OHIO, WEgT ~RGINIA MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTiFiCATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON.SiTE SE~ER AND WA~TER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property owner Mailing Address (c) Lending Institution · Telephone: (home) Telephone Business Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here/~if hold for pick up.) List contact person and day phone number below: -- . 2. TYPE OF RESIDENCE Single-Familyy Number of bed~;ooms 3. WATER SUPPLY Individual WellX Community r-I 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-si. te [] PublicX Community[] Holding Tank [] . Note. If communit~well system, must have written confirmation from the State Department o;~nvironmental Conse~ation attesting to the legailty and status.. ~';~.~s m,,,.?ds) Page I of 2 Name of Firm Address Date ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As ce rtified 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 an'd 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, ordinances, and regulations in effect on the date of this Inspection. / ~/~-~ ~),~u ~[4. l~.~ ~- ~-'Telephone ~"~; -~ ~/~ Engineer's Seal 6. DHHS APPROVAL Approved for'~ .~,~?) bedrooms by Approved ~ Disapproved Conditional Terms of Conditional Approval r il -- The Municipality of Anchorage Department of Health and Hym;n 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 condudt 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 MUNICIPALITY OF ANCHORAGE Department of Health & Human Servlces 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.O. if ~o~"~),.,~/~/. ~.,/,,//z./~ HAA if ~-- {""~ ~ L-~.~,~ 1. GENERAL INFORMATION (Must be completed prior Io submittal) .... ia) Legal Description (includ.q Igt,'blqck, subdivision, section, township, range) Location (address or directions) (b) Property owner "~:; ~ ~.~l.f..~.£~/. Telephone: (home) Mailing Address (c) Lending Institution ~ ~'t~ I ~.-- Telephone Business Mailing Address id) (e) Real Estate Company and Agent Address ~'OL'4~'''~-) /~ -- ~--.~ Telephone ,.~ ,,~- Mail the HAA to the following address: (or check here ~ if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family'~ 3. WATER SUPPLY Individual Well Number of bedrooms ~ Community [] Public r=1 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to Ih legality and status. 4. SEWAGE DISPOSAL On-site r-I Public./[~ Community I"] Holding Tank [] ' Note: If community'well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. ~:~s m.,,.7,~) Page I of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As cerhfled by my seal affixed hereto and as of the validation date shown below, I verify that my investigation df this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional end 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, ordinances, and regulations In effect on the date of this Inspection. Address 6. DHHS APPROVAL Approved for ,-'~'"' Approved ~ Disapproved Conditional Terms of Conditional Approval Engineer's Se~l Date 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 M u nicipality of Anchorage is not responsible for errors or omissions In the professional engineer's work. Page 2 of 2 ~.~'{ C~=',.~.~N,.ICIP'A~J~'I:Y OF ANCHORAGE (M~A) ~.~L~ ~1/~- "' ' Health Authority Approval (HAA) ~.~,.~"~'.,/ ' '-~CHECKLIST - FEBRUARY 1984 ' '~,~'~ C ~ ~ ~., o,.., 343-4744 A. WELL DATA Well Classification If A, B, C, D.E.Co Approved (Y/N) Well Log Present (Y/N) r~ Date Completed /¢~O/''~ Yield TotalDepth~C) Casedto~,~Y.) DepthofGrouting !%/0~'~.' ' Static Water Level ~'/'1/ Pump Set At ~ ~O Casing Height Above Ground '"'/~ ~' Sanitary Seal on Casing (Y/N) Y Electrical Wiring in Conduit (Y/N) ~// Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot l~///--~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ~"y/-~ ; On Adjoining Lots To Nearest Public Sewer Line /~'~ /' To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results ~ '~::=-- ~,~/' Comments ; Date B. SEPTIC/HOLDING TANK DATA Date Installed Size Standpipes (Y/N) Depression over Tank (WN) Nolq - No, of Compartments Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Date Last Pumped PumPing/M,ainten~nce Contact on ?ile (Y(N) ~ Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: ~To Water-Supply Well To Building Founda;i'o'n To Property Line To Disposal Field To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments ; for, Temporary Holding Tank Permit (Y/N) Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date installed Width of Field Type of System Design Length of Field Depth of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION *DISTANCE FROM ABSORPTION' FIELD: To Water-Supply Well To Building Foundation Lot ~ To Water: Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line' '1:o Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) D. LIFT STATION ' Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (WN) Comments Dimensions ManhOle/Access (Y/N) "Pump Off" Level at Vent (WN) 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 guidelines in effect on the date of this Company ~-' Date MOA No. Date of Payment '/"1///~//er,`' Amount: $ - JU HeceiptNo. ' .... ~' C~ - , Waiver Fee: ~ Da~e of Payment Page 2 of 2 Engineer's Seal