HomeMy WebLinkAboutSEQUOIA ESTATES BLK 2 LT 7uoia Estat
Block
Lot 7
#017-152-19
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.anchcrage.ak, us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY, APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O1'~- I~;Z-'
1. GENERAL INFORMATION
Complete legal description LoT "1
Location (site. address or directions) ~
Current Properly owner(s) ~
. Mailing address
Expiration Date: f~- I ? 107,
Day phone
.Lending agency
Mailing address
Real Estate Agent
.Mailing Address
Day phone
Day phone
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: ~
3. 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 CeffJficates 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 Hsalth Authority Approval are
valid for g0 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 w~idatien date shown below, ] verify that my investigation,
based on procedures outlined in the Health Authority AplDmval Guidelines for this application, shows that the on-
site water supply and/or wastew~ter disposal system is(are) safe, functiona! and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the infomlation obtained from the
Municipality of Anchorage files and from my invest!gaSon and inspection, the ch-site water supply and/or
wastewater disposal system is(are) in compliance with ail applicable MunicipaI and State codes, ordinances,
and regulations in effect at the time of installation.
NameofFirm --~l,/')-~ Sj~r~:-I~.~
Address ~ ~"5 L~ I,~-~-'~ ~ 7.0 '5
Engineer's Printed Name "-~1~ &, ~t) ¢ ¥'..{~-~
DSD SIGNATURE
Approved for ~'J
Disapproved.
Conditional ~pproval for
Phone
bedrooms.
.,
bedrooms, with the following stipulations:
Additional Comments
By:
(Rev, 01/02)
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage o
Development Services Department ~A
;:
Building Safety Division ~,~*
"'*. On-Site Water & Wastewater Program '~.~.
4700 South 8mgaw St
P.O..~Ox 196650 Anchorage, AK gg519-6650 · www.cLanci~orage.ak, us
(907) 343-7904
WELL DATA '. a
Weil tyPe,..%~. ;..
Date completed q_/.~'"
Tataldepif~ ~-H'~ ~
HEALTH AUTHORITY APPROVAL CHECKLIST
If A. B, or C provide PWSID # ~_~
· ": FROM WELL LOG
Sta~ water level ~o '~ ft.
Weil production I o g.p.m.
WATER SAMPLE RESULTS: -' ...
Pa'~nio: mgJL
B. SEPTIC/HOLDING TANK DATA
well Log (Y/N)
W1res, lgt)perly protected (Y/N) ~-/
Casing height (above ground) ~r.~.._in.
AT INSPECTIQN
· ~, ~' g.p.m.
Ntirata'~2.~gJL Otherbactarta ~ ~ coionies/100 mi.
Dat~ ofsample: ~.~/, t~ Collected by: ~,¢~ ~ ~r ~--I~H .J~
Tank Type/Material ~U~.p~.~ ~. / S ~..~ J~ Date installed
Tank size ~ gal. Number of Compartments .~ Cleanouta
(Y/N)
Founda~.on cleanout (Y/N) '~/ Depression over lank (Y/N) ~ High water alarm (Y/N)
C. ABSORPTION FIEI.~ DATA
Date installed Soil rating .z-2 .., ,~ m= ,,r ~redrm) I I ~ System ~pa
Date of adequacy test
ft. . W~lth ~:~ It. Gravel below pipe "7 ft.
Eft. absorption area ~ Monitoring ttlbe..~ Depression over Itek] ~'1
8/~q I O'L Results (Pass/Fail) ~ For L~ bedrooms
Fluid depth in absorption field before test 4~_ in. W~ter added ~1~ gal.
Elapaed Tone: ~ min. Final fluid deptil "/'~ in. Absorption rata >=
Any rejuvenation tmalment (past 12 mo.) (Y/N & type) ~
NewdepU1 '7q in.
~O~;~ g.p.d.
If yes, give date ,/"
D. LIFT STATION
'Pump on' level at in. *.~3p'off' level et in. High wa.~r,.~arm level at
E. SEPARATION DISTANCES
SEPARATION DISTANCE~ FR~)M WELL ON LOT TO:
, Septic tank/lift St~tton on lot
Absorption field on lot I ~ ~'
Public sewer'main t,4//~.
Sewer/septic se~ce line ~ .~ ~
SEI~ARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
On edJdc~nt~lots
On adjacent
Public ~r
Holding ~nk
Building foundation ~. C) Property line
Water main; ~ I~ -; "'Water service line ,~- 5
Wells on adjacent lots '"
SEP TION D*ST i F OM =SO. nON Fm,D ON LOT TO:
water se~ce ilne- ' ~.5 ~'
· Building foundation
surface water
Absorption field.
Surface water
I cerUfy that I have determined through field inspections end
review of Municipal mcon~s that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name "~J~¢*.1 .~O r~C.~.~
water main
Driveway, pa~ng/vehlcle storage.
HAAFee $~"'"',,o/~'.,~~=~- )/Vaiver FeeS
Date of Paym~t ~/~.'~/0 ~-- :'. Date of Payment
Recei.;Number ' ~/--~7~ O (~. Receipt Number
(Rev. 12/01)
in.