HomeMy WebLinkAboutEAGLE RIVER HEIGHTS BLK 2 LT 23
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
Parcell. D. #
CERTIFICATE Of HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Location (site add.ress or directions) I030g C~;_Sou.. Ect.~g~. RZue~, A~t~.~ 99577
Property owner ~,{.~ Day phone
e
e
Mailing address
Lending agency
Mailing address
Day phone
Agent ~,,,~ Ao..;,.,-,!7,-.,~:t,..,o ~~~?~.'~.~ Dayphone
Address $000 A. S~e.e,c., ,~.~zc.~o.~ge, At{ 9~50~
Unless
othe~ise
Ind~vidualwell X d~~ ~ ~ ,-~
co u.] y we, ' --
. Public water_
NOTE. If community well system, provide written confirmatton from State ~tt~
lng to the legality and status of system.
WPE OF WASTEWATER DISPOSAL:
o -s,,e.
Holding tank
Community on-site
Public sewer X
NOTE: If community wastewater system, provide wdtten confirmation from State ADEC
attesting to the legality and status of system.
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as o~' the validation daie 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,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm
5 &'S'ENGINEERIHG
Address 17034 EaSe R~ver Loep Roa~ NO~ 2~.
Eagle Ri?er, Alaska
Engineer's signature
Phone
DHHS SIGNATURe[
~/ Approved for
bedrooms.
Disapproved. . .....
Conditional approval for
hedrooq~s, with the following stipulations:
Additional Comments
By: -.-~O~N,~t'l,'rH* Date
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.
Legal Description:
A. WELL DATA '
Well type ~"'~'~-'~*~'/~--' If A, B, or C, attach ADEC letter,
Log present (Y~:) ~ Date completed
Total depth ~/-" Cased to
Sanitary seal~'/N)
Date of test
Static water level
Well flow
Pump level
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Parcel I.D. ~
FRO'M WELL LOG
/
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line ' ~.~. Ij~. ·
AOEC water sysi~m
,'-
Casing height N0~.f"~' 1991
Wires properly protected(~N)
AT INSPECTION
~ ~. '~J. ~ I~UNtClPAUl~ OF ANCHO;.AGE
,~,,.,,~ ! £NVIRONM~JqTAL SE RvICES DIVISION
,~',~ -{-- OCT 2 8 1991
g.p.m, g.p.m.
,.,v... RECEIVED
; On adjacent.lots
; On adjacent lots
Public sewer manhole/cleanout
P&troleum tank
WATER SAMPLE RESULt'S:
Coliform ~;) ,~l'~'' '''~ Nitrate ~'-(~' ~ Other bacteria
Date of sample: ~<~.?...~ ..c{~ Collected by: ~ ~''~
B. SEPTIC/HOLDING TANK DATA ~"~ 0 i,~ ~, ~.t r/,,.~<l~ ~
Date i~ Tank size ~ Compartments
Cleanouts (YTN.).~ ' Foundation cleanout (Y/N) ~ ~ ..... De?'ession (Y/N)
High water alarm (Y/N)~'~ & Alarm te~te~ iY~)'~
Date of pumping '' ' '~""~_ Pumper'~' ''~''~ _
SEPARATION DISTANCES FROM SEPTIC/HOL~
Well(s) on lot ' On adjacent lots Foundatio~tT''---
To proper[yline ' ' ' 'Absorption field Water main~se~ice line~'"'~
Surface water/drainage
72-026 (Rev. 7/91) rro~t CONTINUED ON BACK PAGE
Signature
Engln~er's Name
Date
C. LIFT STATION
Date insta'rfsd,,,,,~ ' ' Manufacturer : :. .*
S,zelngallons'~ '~,''. '"
Ve.t(Y/N) 'i ' '" "Pump off" ,eve,
High wateralarm level ~' ' Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FRoM LIFT STATION TO:
Well on lot ~ On adjacent lots
D.^"SO.PT,O"F,E' '"" DATA
Da~ J - -- Soil rating System type
; Length ;'""-C width ' Gravel thicl~ness Total depth
Total absorption area'~"x. ' ' Oleanouts pre'sent (Y/N)
' N~~ ' ' D~te of adequacy test
Depression.., over.. .field (Y/ .
ResUlts. (Pass/fail) '
for
Peroxide treatment (past 12 months) (Y/N)
.
SEPARATION DiSTAN?E FROM ABSORPTION FIELD TO:
' Well 0~ lot On adjacent lots Pr~y
To building foundation To existing or abandoned system on lot
On adjacent lots Cutbank Water main/se~ice line
Sudace water DrivewaY. parking/vehicle storage?rea
Cu~ain drain : ':. ' ' '
E. ENGINEER;~ CERTIFICATION
I ce~i~ that I have checked, verified, or ~onformed tO all MO~ and H~ ~uidelines in effect on the date Of thi~ inspection
Ca~ Rlvee, ~laska ~5~
Waiver Fee: $
Date of Payment
Receipt Number
bedrooms