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Home My WebLink AboutSPERSTAD BLK B LT 13 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 O- 7~17~ - ~ '2 HAA# !'l~'"'~l,';f~-"t/''~ 1. GENERAL INFORMATION Complete legal description Lot 13;~ Sperstad Subdivision Location (site address or directions) Property owner Mailing address 1107 W. 53rd Avenue Anchora?.~ AK . Thomas & Mae Martin C/O Jack W~,e Co. 3201 "C" Stre, et Lending agency Day phone Anchoraqe.~ Day phone AK 99503 Mailing address Agent Janine Welch/ Jack W~te Co. Address Day phone 762-5818 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: XXX Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4, TYPE OFWASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer XXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. ~/gt) Front MOAtI21 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 $ & $ ENGINEERING 17034 Eagle River Loop Road No. 204 Address Eagle Riyer, Alaska 99~;77 Engineer's signature -~.~/t~, Phone Date DHHS SIGNATURE Approved for ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments 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. 72~25 (Rev. 1/91) Back MOA ~21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist LegalDescription:/-oT' I.~ Bt, oct< f~ $'?¢~,~sTgO fid ParcelI.D.: 010 -- 3q ;;1_ A. WELL DATA Well typo Log l)rCSCllt (Y~) ,.v 0 / Total depth '7 Sanitary seal ~) If A, B, or C, attach ADEC letter. ADEC water system number Datecompteted c~ /~, ~/~o4 re t¢lo°~) Cased to q o 4- Casing height (above ground) / o Wires properly protected (Y/N) Date of test FROM WELL LOG AT INSPECTION Static water level q / Well production or / WATER SAMPLE RESULTS: Coliform O Date of sample: 3 /oX 9 / '~ C B. SEPTIC/HOLDING TANK DATA Nitrate _ g.p.m, g, 2~ g~,~n. ~. O. ] Other bacteria 0 Collected by: S & S ENGINEERING 17054 ~,agie ~iver Loop iio~8 No. :204 Eagle River, Alaska 99577 Date installed Taltk size Number of Compartlnents __ Cleanouts ?mmdation clcanout (Y/N) Depression (Y/N) High water alarm Date of Pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil ratiag (g type Length Width pipe Total depth Effective absorption area Date of adequacy test Mo~ present(Y/N).__ __ Results (Pass/Fail) Depression over field (Y/N) __ For bedrooms Fhdd depth in absor test (ill.); · hnmediately after gal. water added (itl.): Fhfid .(ills.) Minutes later: Absorption rate = g.p.d. treatlnent (past 12 months) (Y/N) If yes, give date D. LIFT STATION Date installed Size in gallm?gg~~'/ Manhole/Access (Y/N) ~el at* "Pump ofF' level at* High wate~~ *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer lnain Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station ~/4 SEPARATION DISTANCES FROM SEPTICDtOLDING TANK ON LOT T, 0: ]3~liltiliigl~i;lff~arvti~ffline S~ur~rlePe~,,)~i'elri/iiiaillage~ ~fie]d__.~ Wells on adjacent ]~ts_ -- SEPARATION DISTANCE FROM A~ON LOT TO: Building foundation 'J)'J/ Water main/service line Surface water ~ Driveway, parking/vehicle storage area Cu~ ' Wells on adjacent lots Property line F. ENGINEER'S CERTIFICATION I certi~P that l have determined thru field inspections and review of ]clunicipal records ~_e ~vf~'~ns are " · · . · In conformance with MOA HAA gutdehnes m effect on tht Engineer's Name r0~da~ C. Gwdz~ ~,,'~~ ~ ~, ......... ;~,~:..?..~ Date ........................................................................................................... Date of Payment __ Receipt Nulnber Rev. 8/95 OSS: haa.xvk.doc Waiver Fee $ Date of Payment Receipt Number 0~/02/96 14;~9 CT~E ESI RNCNQ~RGE ~ 90769~1211 NO.8~l ~0~ CT&E Environmental Services lac, Drinking Water Analysis Report for Total Coliform Bacteria 200 w.'pot,,r Drive Anchorage, AK 99518,1505 READ IIY$TFR UCTtON$ ON.t~£FEJLt£ SIDE ~EFOJUf COLLECTING SAMPLE Tel: (907) 582-2343 Month Da)' Year SAMPLE TYPE: ~ Routine ~ Treated Wat*r O Repeo~ Sample (for routine sample ~ Untreated W~tcr with lab eel no, ) ~ Special purpose Time Collected SAMPLE LOCATIO~ Collected By F,x: (907) 561.5301 TO BE COMPLETED BY LABOP, ATOKY Analysis shows this ~Vat,r S~PLE to be: ~ Satisfacto~ Unsatisfacto~ Sample ouer ~0 hours old, results may be unreliable a Sample too long in Jtanfir. ~ample'*hould not b~ over 48 hour~ old a[ examination to indi¢ate reliable r~sul~. Please ~end new sample vla special del[v¢~ mail. Date Received ~ Tim~ Received [ ~~ Analysi~ Began . ~ ~ ~ Analytical Method: ~ Membrane Filter a MMO-MUO ' Number of colonies/100 mi. Lab Ref. No. Result* Sent Io A.D,E.C, . Fbk~ du~ Dat~/~ Time:, Client notified of uasali~ractory results: Comments; Phoned Spoke with Date; Tittle; . BACTERIOLOGICAL WATER ANALYSIS RECORD ,'dlvlO-MUG Re~ult: Total Coliform E. Coil (~ Colonies/100 mi blembrane Filter: Direct Count · Verification: LTD BCB COLIFIRM. · ColiformllO0 mi t ¢-'=~J hfs [] Faxed [] Fccal Coliform Confirmation Final Mombra.¢ Filter Result~ t PART ON~ OF CT&E Environmental Services Inc. Laboratory Division Laboratory Analysis Report CT&E Ret.# Clien( Samplc ID Matrix PW$ID 0 96 t 06'2.8547 LIS SPERSTAD S/DI Drinking Water Collected Date 03/27/96 Technical Director Sample Remarks: Results QC POL Units Method A[[ouab[e Prep Analysis Init 0ual Limits Date Date 0.100 U 0.I mg/L EPA 355.2 03/26/96 EH8 200 W. Poller Drive. Anchorage, AK 99518.1605 -- Tel: (907) 562-2343 Fax: (907) 561-530~ 3180 Peger Road, Fairbanks, AK 99709-5471 ,~ Tel: (907)474-8656 Fax; (907) 474-9685 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA. FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MIS$0URI, NEW JERSEY, OHIO, WEST VIRGINIA