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Home My WebLink AboutEAGLE RIVER VALLEY RANCHETTES LT 29BEagle River' Valley Ranch¢'l'i'¢$ Lot 29B #050-224-25 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 ,~,¢2~ -.~-~ HAA # ,'(~/~-~//~'~': ~/~-'~'~ GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailin. g address ~A~T'T'~ ~IL'LDbi Dayphone ,z_~L~- q-(¢~ Day phone Agent Address '~ ~ ~ ~t~ t/,k- '~/ [5'=7 A, Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Day phone 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. 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 t Address Engineer's signature Phone Date DHHS SIGNATURE V 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 Municipalib/ of Anchorage is not responsible for errors or omissions in the professional engineer's work. -' Municipality of Anchorage · Department of Health and Human Services Division of Environmental Services R E C E ! V E D On-Site Services Section 825 "L" Street Room 502 -- P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us AUG 3 I Z000 (907) 343-4744 ,-, MUN GIPAL'fY OF ANCHORAGE HEALTH AUTHORITY APPROVAL L,,HE~/t, JV~::;TNMENTAL 8EBVtCES D ViS ON Legal Description: A. WELL DATA Well type .__ Well Log If A, B, or C provide PWSlD Ct __ Date completed Sanitary seal /..~Wires properly protected Total depth __ ft Casedto _ ft ' //,...~ing height (above ground) __ FROM WELL LOG ~ AT INSPECTION Date of test J __ _ Static water level ft ~ __ ft Well production ____g~ ___ g.p.m WATER SAMPLE RESULTS: J ..... Coliform colonie~te__ mg/I Other bacteria_ colonies/100 mi Date of sample: // Collected by: Tank size 1 ~ gal Number of Compartments ~ Depression over tank t,~ High water alarm ~-~ B. SEPTIC/HOLDING TANK DATA Tank Type/Material Date installed Cleanouts ~_Foundation cleanout Date of pumping System type in. C. ABSORPTION FIELD DATA Date installed. /¢~/~',/?~ Soil rating (g~./ft2~or ft2/bdrm) __ Length ,,?--~;~ ft.F:l~j~ Width ~_'fYp ft Gravel below pipe /,~ ft Total depth J ~ ft Effective absorption area~*SG, ft2 Monitoring tube Date of adequacy test E/;~o/oc, Results (Pass/Fail) Fluid depth in absorption field before test .~ in Elapsed Time: ~ min Final fluid depth Any rejuvenation treatment (past 12 mo.) (Y/N & type) . Depression over field For ~ bedrooms Water added "~ gal. New depth ~7',,Z in. 6 ¢ in Absorption rate >= /-/'~-Og.p.d. N If yes, give date 72~026 (Rev. 01100)* LIFT STATION Date installed "Pump on" level at __ Datum Size in gallons in "Pump~ at in Cy~ tested SEPARATION DISTANCES WELL'LOT T SEPARATION DISTANCES FROM O: Septic tank/lift station on lot / On adjacent lots Absorption field on lot / On adjacent lots Public sewer main Sewer/septic servic~e Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main Drainage Manhole/Access High water alarm level at __ in Meets alarm & circuit requirements Public sewer manhole/cleanout Property line Water service line Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Surface water Wells on adjacent lots Absorption field Surface water Water main Property line ! Water Service line /~ ;/' Curtain drain 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 lo ~.~ ~ ~ L/,.[,~.,,,-,'~ Date /~.~. "~d, ¢Z¢,¢,~.¢ O Driveway, parking/vehicle storage HAAFee $ ,~FPOt Date of Payment ~'/~ / / · ENGINEER'S Waiver Fee $ Date of Payment Receipt Number ~. % ~,,L :~ Receipt Number 72-026 (Rev, 01/00)* 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.anchorage.ak, us · (907) 343-7904 CERTIFICATE Of H F. ALTH AUTHORITY APPROVAL FOR A SINGLE FA~'ILY DWELLING' ~''; '- ':' Parcel I,D...(~'O"..?_e3x/7['..~ ' .'.".' GENERAL INFORMATION Complete legal description ZOO' Location (site address or directions) Current Pr6perty owner(s).. · -'.._ :,.,:,, HAX Expiration Date: Day phone Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Day phone Un/ess otherwise requested, HAA will be held by DSD for pickup. NUMBER OF BEDROOMS: ~ 3. TYPE OF WATER SUPPLY: ' Individual Well r~ 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 Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by art 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) fer 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 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. (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 validation date shown below, I vedfy that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further vedfy 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. ~ '- Conditional appr(~val for ........ bedrooms, 'with'the following stipulations: 5. DSD SIGNATURE .' 1~~ Approved for ~ bedrooms. ~ Disapproved. Additional Comments ,,,,,-;.~-. ...... .; "//'~-..- ~: ON-SITE ~ . WASTEWATER . : . · Attachments: HAA Checklist Septic System Advisory .. Well Flow Advisory Maintenance' Agreements Supplemental Engineer's Report Other Odginal Certificate Date: (Rev. 01/02) Municipality of Anchorage Development Services Department .... Suilding Safety Division On-Site Water & Wastewater Program 4700 South Sragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:/_C:r~' .~/~ ~-,4/:Y_.~_ ,~'/V,~.~. t/'./Y_.~g~v',~4rxff.~ff'~.Par~l ID: A. WELL DATA - J~t~/..I C. u,J,q 'r'~/L IfA, B, orC provide PWSID # ~ Sanltapj seal (Y/N) Cased to It. FROM WELL LOG '~,' ' Well type Date completed Total depth ft. Date of test Static water level Well production WATER SAMPLE RESULTS: Well Log (Y/N) VVires properly protected (Y/N) Casing height (above ground) AT INspECTION g.p.m. Coliform __.colonies,'100 mi. Nitrate ' .. ~ mg./I. Arsenic: mg./I. Date of sample: B. SEPTIC/HOLDING TANK DATA Other bacteria Collected by: · Tank Type/Material Tank size I~G gal. Number of ~mpa~en~ Foundation ~eano~ ~)/~A~epm~ion over ~nk ~) Oa~ of pu~ping ~T~/J O~ Pumper C. ABSOR~ON FIELD DATA Da~ ins~ll~ ~ Soil mBng ~.p.d.~ or.~d~) Lengffi' ~ · ~d~ Total depffi ~ · Eft. abso~flon a~a Date of adequa~ ~st ~O~ Resul~ (PasCall) Fluid dep~ in abeo~flon field before test~ in. Water added ~ gal. ~apeed ~me~O min. Final fluid de~ ~ in. ~so~flon rote >= ~y mjuve~on ~a~ent (past 12 mo.) (WN & ~pe) g.p.m. ~ colonies/100 mi. System type ~ Gravel below pipe ~' ff. Depression over field For ~ bedrooms New depth .~J> in. If yes, give date in. Date installed ~'.,/ae./7,4' Cleanouts (Y/N) y Htgh water alarm (Y/N) /~' D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. 'Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septi.c tank/lift station on lot" Absorption field on lot · On.adjacent Iols On adjacent lois Public sewer main Public sewer manhole/cleanout Sewer/septic service line Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation //7 / Property line _/_.~.~' Absorption field ,/ Water main ~'0 ~' Water service line /~'f' Surface water Wells on adjacent lois SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: $ Property line / ~/*' Building foundation / 7 r Water main ,~'.S"/' Water Service line /~ Surface water ,/~,/~ ~/~.T. Driveway. parking/vehicle storage Curtain drain /V'O,~{E Wells on adjacent lois 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 Pdnted Name ~ ~'~E'V'~'P,[. c,,J. ~-~,~t'~' Date HAA Fee $ Date'o, Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number PO Box 773415 F..agle River. AK 99577 (907) 694-6454, ~eve ,.vi ~ 1~00~ War Admkal River. AK ~77 S~ic Set'vtce Und~ 2~, 1 ~ Commenl~ P.O. N~,nbor:. T~'m*: lq~ 30 · ,~;e'WiCe Agreement ~ b~: 04-Aw-2~O 12;00 em TeOw~: Dw~ M~o 0 ~owd I>/Ck~y Wd~m w~ Remex to ira, Pt4c~ F...ae~ x2Me~ T~( $115.00 No Ne D~gmm: No~Tm~b To~ Tau~d~ Tokai Ta~ To4a~ (3~ To4M E~ift~d~ I:~arg~: $115.00 ~0.00 S~3~)0 8115.00 c.w.: .... liS, Cu~m~ ~0~ee~ to I~. ~ end ~ p,~<l o~ ~ b~ THIS 19 A ~IN~:)~NG AOREEMEhlT. V/AR ADMIRAL ROAD N 89'57'15'E 133.00 X ~ STORY F'RAt~ ~ UTILITY EA~HE:NT 89'59' 15' E 133.00 PR~:>~RTY CI~S rOUND U~:~I) FOR: THIS SURV£Y HAV~ DI~P~ IN KFEK~ TO T~ KC~D ~T ~T~ ~D ~D ~AS~D I~TI~ ~AT~ V~ ~ED TO ~[~I~ ~SITI~S T~ r~T P~RTY ~RS. AS-BIBLT ~URVEY NO C, Om~J~ ,~rrT THIS DATE [ I{R[~Iy C[RT~"Y THAT I HAV~ PI~ I'~RTGAGCE'$ INSP~CTIDN ~ THE Fill I~$CRIB£D pI~PERTY, LI3T ~'gB, EAGLE RIVER RAt4CHETT~S