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HomeMy WebLinkAboutSCOTTISH HILLS BLK 1 LT 19ME bo I "ten- mea-Xq J'Y 1 V 7 MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services 44 On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 011-n`6 2-101 1. GENERAL INFORMATION HAA# 14A6)4hlo02 Complete legal description Lot 19 Block 1 Scottish Hills Subdivision Location (site address or directions) 7057 Terry Street Property owner Charles Simcox An horage Alaska 99502 Day phone Mailing address 9326 Houston Lane OoltTLah7. TN 37363 Lending agency Mailing Day phone 1I` -A (615) 855-1691 Agent Sleeper Realty / Chris Blake Day phone (907) 344-2501 Address 800 E. Dimond, Suite 3-300 99515 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 2 3. TYPE OF WATER SUPPLY: Individual well Community well Public water VA NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site x Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 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 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 DHI Consulting Engineers Phone (907) 345-1385 Address P.O. Engineer's signature 6. DHHS SIGNATURE Approved for Disapproved. 2 11134'9„ 2820,D4ArmouW,, Anchorage, Alaska 99511-1349 Dee High, 'P Conditional approval for Additional Comments bedrooms. Date - 3 - Y7"' bedrooms, with the following stipulations: 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. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health and Human Services an HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: AOr /9 d< / Scv77esN ,y1cc.s Parcel I.D. A. Well Data Ga?Y »ate Well type N/A If A, B, or C, attach ADEC Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level _ Well flow Pump levell SEPARATION DISTANCES F Septic/holding tank on lot _ AbsorptiFmple: Public se Sewer s WATER Coliform Date of s FROM B. SEPTIC/HOLDING TANK DATA Date Cased WELL TO: ADEC water system number Driller Casing height Wires properly protected (Y/N) L Q AT INSPECTION On U W tU V Q � m Ow v I.P.M.LU g.p.m. a W a U L_U - Z -- - w ; On adjacent lots On adjacent lots Public sewer manhole leanout Petroleum tank rate Other bacteria C0119 ted by: Date Installed 1962 Tank size /Ooo �jAc /. Corarc�eto _Compartments Cleanouts (Y/N) N Foundation cleanout (Y/N) N Depression (Y/N) N High water alarm (Y/N) N Alarm tested (Y/N) N Date of pumping It- 3- R Pumper _Dcneat.r ScWtl a V"IAJ '6,v, 6(Z— _r 0V ,V- 53.3.5 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot N/A On adjacent lots N/A Foundation To property line N 28.41 Absorption field 15.9 Water main/service line Surface water/drainage N/A 7.6' N/A 72-026(3193)'Front CONTINUED ON BACK PAGE C. LIFT STATION Dale installed N/A Size in gallons Vent (Y/N) "P mp on" level at High water alarm level Meets MOA electrical coos (Y/N) SEPARATION Well on lot FROM LIFT STATION D. ABSORPTION FIELD DATA On adiacernt lots Manufacturer (Y/N) "Pump off" Level at tested Surface water A) � Date Installed \\1962 Soil ratting (GPD/Ft2) CIIVA/0 A) System type aA4'/6Nb4/N/ Length (Ld14A)Dt0 K 1 Width Lw14 c-ryocJwJ Gravel thickness (,cua4uv,pcTotal depth 64" Total absorption area (YotcAo ,..gJ Cleanout present (Y/N) N Depression over field (Y/N) N Date of adequacy test 11/02/94 Results (passAo PA ss for 2 Bedrooms u Water level in absorption field before test �' 0100- 11 '21 1, (D0 After test `� %2 Peroxide treatment (past 12 months) (Y/N) 2 SEPARATION DISTANCE FROM ABSORPTION FIELD TO: If yes, give date Well on lot N/A On adjacent lots N/A _Property line 20.3' To building foundation _ 15. W � __—To existing or abandoned system on lot N/A On adjacent lots_ N/A Surface water N/A Cutbank ND6/ts' Water main/service line N/A Driveway, parking/vehicle storage area 64' Curtain drain _Ljg��a E. ENGINEER'S CERTIFICATION I certify that t have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Q PG2 Owx vneptuvemex ` O SYSTEM IS &tTHE/t .I Tat+`^iedf ooolof © 1 S 13GUV6 (T TO StE A�si�oL,i���1�f� ok--r E5:to IS NA 11,} Per (JG,m.�OLH� 2e. 7o Tk� wytHo�T GkeI�V,NeKL` © PU- Signature .av:y_ af... .h Engineer's Name Date /-3- 00 HAA Fee $ _ �% Waiver Fee $ Date of Payment �t=-� Date of Payment Receipt Number _00L1.(G 7_�`7.�_�7y)Receipt Number___ DRAIN SERVICE n;10 0,mfffice Pkwy., 4537 ANCHORAGE, ALASKA 99504. Phone 393.5794 bL320101320 KEEP Tmis SLIP FOR REFERENCE TOTAL P.01