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Home My WebLink AboutLot 01 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA # 1. GENERAL INFORMATION Complete legal description /, OT Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address ~'~o ?AC~F~C Day phone Day phone Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer 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 Add ress I q.¢'3 cc Engineer's signature DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Gertificates based only upon the representations given in paragraph 5 above by an independent professional engineer recjistemd 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 Anchora§e is not responsible for errors or omissions in the professional engineer's work. 724325 (Rev, 1191) Back MOA ~21 Municipality of Anchorage ~ Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LOT I LU~ NO~E Parcel I.D. ~/-~"~t._~ -'.'~ A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) If A. B. or C. attach ADEC letter. N ¥ FROM WELL LOG ADEC water system number Datecompleted ~ I? "fy Driller Casedto '",",",",",",",","~ IqT' Casing height Wires properly protected (Y/N) Y Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main ~ ~,~' Sewer service line 3 5' ~ g.p m. AT INSPECTION ; On adjacent lots N, On adjacent lots N'~ - Public sewer manhole/cleanout ~ I~.O Petroleum tank NO~t~ ~5~. WATER SAMPLE RESULTS: Coliform O co~.~Fo~ /lo0 ,,I Nitrate Date of sample: I0/:~/'~- B. SEPTIC/HOLDING TANK DATA (,,N, ~,. Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Other bacteria Collected by: F~A T'r0P Tank size Compartments Foundation cleanout (Y/N) Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTI C/HOLDING TANK TO: Well(s) on lot To property line '~ Surface water/drainage On adjacent lots Absorption field Foundation Water main/service line 72-026 ,Rev. 7/91/ Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots FIELD DATA [N.~, - D. ABSORPTION ~.- Width Date installed Length Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain E, ENGINEER'S CERTIFICATION Manufacturer HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA Manhole/Access (Y/N) "Pump off" level at Cycles tested Surface water bedrooms A ~ cc,c/_ Soil rating Gravel thickness Cleanouts present (Y/N) Date of adequacy test for If yes, give date On adjacent lots Property line To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area System type Total depth Waiver Fee: $ Date of Payment Receipt Number I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. OF Engineer's Name ........ L & OGICAL A DIVISION OF COMMERCIAL TESTING & EN¢ ORATORY !INEERING CO. TELEPHONE (907) 562-2343 56,~3 B Street An~or~e, Alaslm 99518 Drinklg ~Water Analysis Report for Total Coliform BaCteria TO BE COMPLETE~ BY WATER SUPPLIER T° BE ~OMPLETED BY LABORATORY £C~o ST SAMPLE DATE: ~ Mo. Year SAMPLE TYPE: State Zip Code ~4 ) [] Treated Water Untreated Water /~ Routine Check Sample (for ~ routine samP~le with lab ref. no. [] Special Purpose SAMPLE No. LOCATION I I LoT' t Lc, X 2 J ~v/EET' LJrosE Time Collected Collected By 41 Analysis shows this Water SAMPLE to be: ? S ',sfac ?, 'El UnsatiSfactory [] Sampl~'too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received Time Received Analytical Method: Membrane Filter * No. of colonies/lO0 mi. Lab Ref. No. Result* st ,~..0 .E .C. ~/!°tl~'Z- ~"""""""""~- BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS Membrane Filter: Direct Count Q Coliform/100 mi BEFORE Verification: LSB Fecal Coliform Confirmation BGB COLLECTING SAMPLE Final Uembrane~l)esu~. , ~ Reported By k -.~ // TNTC = Too Numerous TO Count OB = Other Bacteria Date Coliform/lO0 mi Time: CHEMICAL & GEOLOGIC,4L LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 ANALYSIS RESULTS for INVOICE ~ 60060 Chemlab Ref.~ 92.6016 Sample ~ 1 Matrxx: WATER Client Sample ID : LI LAXMORE S/D ~3~0 RASPBERRY RD W. ' PWSID UA Collected : OCT 28 92 @ 14:55 hrs. Received OCT 28 92 ~ 15:45 hrs. Preserved with : ~S REQUIRED Client Name :FLATTOP TECHNICAL SEV Client ~cct :FLATTOT BPO~ : PO~ :NONE RECEIVED Req~ : Ordered By Completed : OCT 29 92 Send Reports ~o: Laboratory Supe~vlsor ; STEPHEN C. EDE I)FLATTOP TECHNICAL SRV Parameter Results U~ts Method Allowable ............................................................................................................................................. N!TglTE-N ND(0.10) ~/1 gP& 353.2/300.0 Sample ROUTINE SAMPLE COLLECTED BY: T F. MOORE. ' HOSE BIB. Romrks: i Tests Performed See Special Instructions Above OA-~navatlable ND- None Detested "See ~ample Remarks Above NA~ Not Analyzed LT=Less Than, GT~G~eater Than Member of the SGS Group (Socii~t(~ G~n¢rale de Surveillance)