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Home My WebLink AboutT13N R4W SEC 25 N2N2NE4SE4 PTN.. t t Parcel I,D, Municipality of 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) 343-7g04 ' d/~"~ CERTIFICATE OF HEALTH ,AUTHORITY ,APPROVAL FOR A SINGLE FAMILY DWELLING Expiration Date: GENERAL INFORMATION Complete legal description Fo,- ho,, Location (site address or directions) Current Property owner(s) Day phone ~.~. Mailing address lOOt;, ~',t'4 A,,'~, ,4-~:,, /1~c~o,--o~¢, /~l.c (/ , Lending agency ~r.,,?. "3'0. & Day phone Mailing address Real Estate Agent Mailing Address ~111 V Unless otherwise requested, HAA will be held by DSD for pickup. Day phone ~-z3 -,5'5''/,5- NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: ' Individual Well [] Individual Water Storage [] Community Class ~ Well [] Public Water System [] 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 4 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) for properties served by a single-family on-site wastewater disposal and/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. (Certificates may be reissued for a period of up to one year with valid water samples.) 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. 4. 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 this application, shows that the on- site water supply and/or wastewater disposal system is(are) 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 disposa! system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm F /cz /'/-,¢,? "T.~cA~ e~ / .ffer'o,~¢~ Phone 3q~"'- I '~.~-.s- Address I q~'$~ ,~_cA~, _C/~ /~,~c/~o,'~,~ ~ Engineer's Printed Name "?",A~,:~/o,,~, F.(/~-~oo,.~ Date ~'"~,~ ~_, DSD SIGNATURE ~ Approved for -.~ Disapproved. Conditional approval for bedrooms. bedrooms, ~th the follo~ng sbpulat~pns~:'?~.~;'. ~'~ ;'..~..~t~¢:;~,~:. · Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: (Rev. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Pragram 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (9O7) 343.79O4 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Fo/'.-~'~"/'~ .C,,c~.~ '7',.T/V/ ~ 3~-.~ ..C./-~. A. WELL DATA Well type, Pn ,.'~'F 4 Date completed , Total depth '3W z~ 19~-O Sanitary seal (Y/N) , It. Cased to '2 ¥ Z- ff. FROM WELL LOG If A, B. or C provide PWSID # Y Date of test Static water level It. Well production g.p.m. WATER SAMPLE RESULTS: Coliform ~ colonies/100 mi. Arsenic: ~ mg./I. Ce NiUate 4o, I mg./I. 6' / z 7/0.3 Date of sample: ,y/t6'lo ) Number of Compartments Depression over tank (Y/N) Pumper Soil rating (g.p.d./it~ or ~/lxlrm) ~ Monitoring tube, Results (Pass/Fail) Water added SEPTIC/HOLDING TANK DATA t,/.,4.. Tank Type/Material Tank size ~ gal. Foundation cleanout (Y/N) Date of pumping ABSORPTION FIELD DATA Date installed Length. ff. Width Total depth It. Eft. absorption area Date of adequacy test Fluid depth in absorption field before test in. Elapsed Time: min. Final fluid depth Any rejuvenation treatment (past 12 mo.) (Y/N & type) Parcel ID: ,{~ t 49 -t / Well Log (Y/N). tv Wires pmperiy protected (Y/N) Casing height (above ground) '~{::> in. AT INSPECTION '~'. ~ Y' g.p.m. Other bacteria Collected by: Date installed Cleanouts (Y/N) High water alarm (Y/N) O colonies/100 mi. System type Gravel below pipe It. Depression over field For bedrooms gal. New depth in. Absorption rate >= g.p.d. If yes, give date D. lIFT STATION F/*/f'. Date installed Size in gallons Manhole/Access (Y/N) 'Pump on" level at .. in. 'Pump off' level at ~ in. High water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot ~/. ,~. ~'/) ~,u-,. ~ ~'~,,~*.~ On adjacent lots Absorption field on lot ~. ,4. Public sewer main ";> ,~-,~ ~ Sewer/septic service line ~ ~ ~ On adjacent lots ,~- ~. Public sewer manhole/cleanout Holding tank ~J- A. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: k/. ,4. Building foundation Water main Property line Water service line Absorption field Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: ~/. ~. Property line Building foundation Water main Water Service line Surface water Driveway, parking/vehicle storage Curtain drain Wells on adjacent lots COMMENTS 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. 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