HomeMy WebLinkAboutJOHNS ROAD BLK 1 LT 3 ohns Road
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Lot
! 6- 203
-34
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
~¢ 4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-§650
www. ci.anchorage.ak.us (907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
'1. 'GENERAL INFORMATION
Complete legal description Lot 3 Bk I Johns Road SID
Expiration Date: I - ;2. c~ - 0 Z.~
Location (site address or directions) . .!2001 Johns Road, Anchoraqe, AK
Current Property owner(s) Wayne Dotten
D~y phone 227-2335
Mailing address
,12001 Johns Rd, An.chora.qe, AK
Lending agency
· Day phone
Mailing address
Real Estate Agent
Day phone
· Mailing Address
Unless otherwise requested, HAA will be held by DHHS fo. r pickup. HAA picked up by;
2. NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[~ Individual On-site F'I
r~ Individual Holding tank [-'J
[-] Community On-site ' []
r-I Public Sewer [~
I ~,, rn II I
The Municipality of Anchorage Development Services Oepadment (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 .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) on properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to home owners. Cedificates 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 less than 30 days old. 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.
(Rev. 11/99)
5. 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 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 struciure 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 applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Enq. Svc. Phone 272-821
Address, P.O. Box 102954, Anch, AK 99510
Engineer's Printed Name.Steven R. Pannone, P.E. Date:
Engineers Comments: In conducting an adequacy test, I atte~npt to provide a thorough, conscientious '
engineering analysis of the system in accoidance with MOA DSD Guidelines & Regulations. The
reported results describe the performance of the system under the conditions encountered at the time of ~/.. Y~ ..........
the test, and separation d:stances measured to readily ~dentffiable features. The operabonal hfc of all ~ 6'9,,
wells and septic systems depend on the local soil condition, ground water levels that may fluctuate ~.¢
during thc year, and the water usage of the family being served by the system. These conditions are .~ ~.~ 4
outside thc control of the cvaluator of this system. Ali systems cvcntually fail and satisfactory test results _
do not guaraniee future performance of the system, nor do they guarantee that there are no hidden
or encroachments. PES can therefore not provide any warranty for future performance nor give any ~f;~*,.St even
estimate of how long the system will continue to meet the operational requirements of the ADEC or '~'C~/~
MOA DSD. The content ofthis report is for the sole benefit of the owner listed above. Any reliance u~on
or. use of this report by any other person or party is not authorized nor will it confer any le~al_ fi~zht~ -- ,,~c/~'~.....-~..,c-.' ~- .~......'
6. DSD SIGNATURE
V'" Approved for ~ bedrooms.
Disapproved.
Coriditional approval for
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Expiration Date:
(Rev. 11/99)
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate DateL _] O
Reissue Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci .anchorage .ak .us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Well type p
Date completed
Total depth. [~ [
Date of test
Static water level
Well production
Lot 3 Bk I Johns Road SID
If A, B, or C provide PWSlD # ~
Sanitary seal Y
Cased to 40'+ ft
FROM WELL LOG
~[ ~ g.p.m '
Parcel I.D.: O J ~o- ,~. 0 3 -3 Lit'
Well Log
Wires properly protected Y
Casing height (above grOund) 15 in.
AT INSPECTION
0~23~2003
46 ft
2.0 g.p.m
WATER SAMPLE RESULTS:
Coliform ~ colonies/10Oml Nitrate
Other bacteria.
~olonies/100 mi
Date of sample: 1012312003
Collected by: Laura Pannone
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material NIA Public Sewer
Date installed · . ~,.Tank si~ gal Number of Compartments.
Cleanouts Foundati~__ Depression over tank .' High water alarm
Date of pumping · ~ ~ump,er
C. ABSORPTION FIELD DATA
Date installed ~,, Soil rating (g.p.d./ft2~,/~2/bdrm) System type'
/
Length ft ~ Width ~ ft Gravel below pipe ft
Total depth ft Effective ab~ption~a ~ Monitoring tube Depression over field
Date of adequacy test --__~.//~'~,~s (Pass/Fail).~ For~bedro°ms
Fluid depth in absorption field b/e,~re test '~in Water added gal. New depth
Elapsed Time: 0 min / ~/ Final fluid de~)~,,,, in Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
in.
g.p.d.
(Rev. 11/99)
Do
LIFT STATION
Date installed
"Pump on" level at~
Datum
in"Pump off" le~~
C~tested 7'~
SEPARATION DISTANCES
SEPARATION DISTANCEs FROM WELL ON LOT TO:
in
Manhole/Access
High water alarm level at ~ in
Meets alarm & circuit requirements?
Septic tank/lift station on lot N/A
On adjacent lots- 100'+
Absorption field on lot N/A
Public sewer main ~ ,~1 .~/~x~
On adjacent lots 100°+
Public sewer manhole/cleanout 50'+
Sewer/septic service line 25'+
Holding tank' N/A
ON LOT TO:
Absorption field
Surface water
Propertyline. ~)/~t'~' ~Bui~tion_ . Watermain ~
Water Service line _ ~e ~3,~er___ . Driveway, parking/vehicle storage
Curtain drain ,,"' Wells on adjacent lots
F. COMMENTS
G. 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.
Engineer's Printed Name Steven R. Pannone~ P.E.
Date /C~ [~' ~, [~ <~
HAAFee $ ~"j',,.5 Jj-- lSD 12,o0¼
Date of Payment [ 0 {o~ ~ { 0'"'~
Receipt Number I'~Wg/7 J
(Rev. 11/99)
Waiver Fee $
Date of Paymeht
Receipt Number
F'I~H : 14QTCHER..PA.~j..MP_";'-~.4__ PHONE NO. : 9E~' ?~; 523~, Oc~, 2'] 2~3 09: :t6~t P!
10-~8°g3 11:54A,V F~,'-Cl'~ ESl, SGS ENV SE~I~ES
907§615~01 T-40T P.01/02 F-881
SGS Reg.#
Clleot Nam~
Client Sample ID
Matrix
1036951001
Paraon-~ Eng. Sty.
Lot 3 Blk 1 ]olu~. Rd S?D
Lot 3 B~ 1 ~o~ ~ S,~
D~i~ing Wa~r
All Dates/Times ~re Alaska Standard Time
Printed DatefTlme 1012g/2U03 10:44 .
Collectefl D~¢,rrlme 10/23/2003 11:50
Received Datefl~me 10/2~/200B 12:40
Technical Director Stephea C.
Sample ~:
Allo~able
Pa~met~ Qaalifi~s R~ulls ~L Unl~ M:tt~ Cmgia:r ~ Limi~ Date De~e Init
Nitrate-lq
1.74 O. 10(.1 nlg~L EPA 1O0.O B (<==101 10/23/03
Total Cclifmm
0 col/100mL $M18 9222B A [<=1} 10/23/03 DKC
CT&E Environmental Services Inc.
200 W. Potter Drive
Anchorage, AK 99518-1605
Telephone: (907) 562-2343
Facsimile: (907) 561-5301
200 W. Pitier DJ'lye
)flaking Water Analysis Keport for Total Coliform Bacteria ^.o~.o:.,~, a~ s,,~e.~6oe
Tel: {907) ~62.2343
,Month . D.ny Year
SAMPLE TY~E:
[] Routine
shows thi* .Water SAJVZPLE
Unsad~facto~ ..
S~l~.ov~ 30 hou~ eld, r~ul~ m~y .
notbe,ov~oun eli'at
.a~y:s~le via s~ecja)deliyew.m~t
Time R. ecci*cd
Analysis
Anglo'Method: ~ M~b~eFilt~ '
Date: Time:
Client noiffigd of Unsatbfmto~
Phbned 8poke
Analyst
Jun []
Faxcd
Faxed
Comm:nta:
BACTERIOLOGICAL WATER ANALYSIS ~:~EcO RD
Id3~O-MUO~es~It: Total C~Bform ,~ ~'ot/ ,.
Membrane l*llt~. Dlr~ Count 0~ __ C6~nles/I~.O mi
Verification: LTB B~ · COLIF~M
~eml Coliform Conflrmatlo~
~nl M~mbrsn~ Filter ~ul~ ~ ·
~po~ed By
Dat: ~
Callform/100 ml
Time '~ ~ hr~
t~ ~ '.~ ue,,,, o,,,e sos ~,o~, (?_?,:?,M=..?.d_,_s:?.?,d._'..Z._,. '._ ......... =-~ .......................
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