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Home My WebLink AboutEAGLE RIVER HEIGHTS BLK 2 LT 32 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 SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal). (a) Legal Description (include lot, block, subdivision, section, township, range) LOT $2; 8LOCK ~= EAGLE I~VZEI~ HEZGHT$ Location (address or directions) 10£07 Ca..,~.b,,~rL (b) Property owner Mailing Address 520 Ea.~,t 34,~h ~qt~'~ Telephone: (home) Ar[~/to~ag~.. AK. 99~0~ Business (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent ~'F/AIAX' OF Telephone 694-4200 .... (e) Mail the HAA to the following address: (or check here~ if hold for pick up.) List contact person and day phone number below: " $ & $ ENGINEERING ~gre River, Alaska 2. TYPE OF RESIDENCE Single-Family,~ Number of bedrooms 3. WATER SUPPLY Individual Well [~ Community I-I Public I-I 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-site I-3 Public ~ Community i'-I Holding Tank Note: If community well system, must have written confirmation from the State Department of Environmental Consen/ation attesting to the legality and status. Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 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 Telephone S & S ENGINEERING Address 17034 Eagl~ River ---, ............ Date Eagle River, Alaska 99577 6. DHHS APPROVAL Approved for .-~' bedrooms by Approved ~'~-. Disapproved Terms of Conditional A'pproval Conditional 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 Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 A. WELL DATA ~'..IPAt. ~ -N! (~' P~t'~[~'EOF AN CHORAG E (M 0A); , ~ ~,e~[~,~ ~c~!.~.e~l~er~ty Approval (HAA) : ~MENI~ 5~j~. FEBRUARY 1984 v 343-4744 SEP 6 1989 -- Legal Description: ~~- ~ Well Log Present (¥~:) .J~ Date Completed Total Depth~ Cased to ~ Depth of Grouting Yield Static Water Level ..7 <=, Casing Height Above Ground ~'Z.. Electrical Wiring in Conduit (~/N) SEPARATION DISTANCES I~ROM WELL: To Septic/Holding Tank on Lot Pump Set At ~,~..- Sanitary Seal on Casing~;Z~N) . ~ Depression Around Wellhead (Y~ ~.~j~ ; On Adjoining Lots.., , t'~/~,/~,_, ~ To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots To Nearest Public Sewer Line "/~'"'~"~"~ To Nearest Public Sewer Cleanout/Manhole _~4~:~ '~ To Nearest Server Service Line on Lot, ~ I.~ Water Sample Collected by ~,~ ~::::I~Y_~I~~ ;Date ~:~-"~..~::~-~5~ Water Sample Test Results '~V~,t~,~,~c~,-t-t3W,.~f ..-- ~ .~ Comments'"~t..,b~.[~ ~__..,~p~ ~,~"'..-'[--'i~t~_.. ~ B. SEPTIC/HOLDING TANK DATA r~/,~[.. Date Ins~.~ed Size No. of Compartments Standpi_.p_e_s ~ ..... Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tan-"E~. ~ ' * Date Last Pumped _ Pumping/Maintenance Contac~ , for Holding Tank High-Water Alarm (Y/N) ' ~mit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: .~ '~ ~ · To Water-Supply Well To Building Foundation · ~ ~,, ~ ~'"-,~_, · To Property Line To Disposal Field ~ , To Water Main/Service Line, ' ~' "To Stream, Pond,'Lake or Maj, D~ Comments ' ~,c::>-dS' .or Page 1 of 2 C. ABSORPTION FIELD DATA Soils I~ng in Absorption Strata Type of System Design Date Insta-"tt~ Length of Field ~ Width of Field. ~.~;. ~ ~ I Depth of Field ~ Thickness S, quare Feet of Absortion At__resent (Y/N) Depression over Field (Y/N) Date of.Last A~eqt~w~est ~l~sultsof Last Adequacy Test . , ' _ . ~' ~' ~' '' sEPAR/~TIoN DISTANCE FROI~/BsORP'TION FIELD: ; ' ' +O Water S~Jppiy Well ..... TO Property Lir~ To Building Foundatio~ ' To Existing or Abandoned System on Lot ; On Adjoinir{g Lots To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway Parking Area, or Vehicle Storage Area Comments' 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 (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump ~)ff;' L~Vel at Vent (Y/N) 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 thi~'. inspection. Signed S & S ENGINEERING 17034 Eagle River LOOp KOad No. 204 Company ~ E.~I~ ~;.~r, .~.!~,L-. ~S77 Receipt No. Date of Payment Amount: $ Receipt No. Waiver Fee: $ Date of Payment. Page 2 of 2 CH~C~ ~ O~O'.O~C~ ~.~O~S O~ 56~ S STRE~ ANCHORAGE, A~S~ ~18 TELEPHONE ~ 562-2~3 ,. FEDERAL TAX ID ~ 92~40 .:;?, A,nalIsts Co~plste~: Client lcct= ~13[~P ~ecial l~truct: Allovibll 1.1 ~/1 ~PA 353.2 i0 .~...~... CHEMIC. dL & GEOLOGIC~4L LABORATORIES OF ,AL,,4SK~4, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER ~3 PUBLIC WATER SYSTEM I.D.# .j,~'PRIVATE WATER SYSTEM Maitmg AddreSs City ~' SAMPLE DATE: ~ ~ Mo. Day Phone No. Year SAMPLE TYPE: _,~-~_ outine [] Check Sample (for routine sample wlth lab ret. no. [] Special Purpose ) [3 Treated Water [] Untreated Water SAMPLE NO. LOCATION 51 Time Collected Collected By TO BE COMPLETED BY LABORATORY saSis shows this Water SAMPLE to be: tisfactory I'-1 Unsatisfactory [] Sample too long In transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send n~w sample via special delivery mail. Date Recelved Time Received Analytical Method: Membrane Filter No. of coloniesll00 mi. Lab Ret. No. Result* I I Analyst ~-~. READ INSTRUCTIONS FEFORE CCLI.[CTING SAMPLE Membrane Filter:. Direct Count _t~ Verification: LTB .BGB Final Membrane Filter Results O BACTERIOLOGICAL WATER ANALYSIS RECORD ~')~,* _ Colllorm/lOOml Reporled B~ Date 7NTg = Too Numberous To Count · :)~ --. Other Bacteria Time: Col[form/100ml p.mo