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Home My WebLink AboutUS SURVEY 3043 LT 4A Parcel I.D. # 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 CERTIFICATE oF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA# 1. GENERAL INFORMATION Completelegaldescription LoT q/A~ LP~b.~ ~ ;5o~,~ Location (site address or directions) Property owner Mailing address Day phone Lending agency Mailing address Day phone Agent '~oL '~,coc.~., '~c~M¢..~ Address ,~lll '~" Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~'- TYPE OF WATER SUPPLY: NOTE: Dayphone ~/- 7~'/~% 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, TYPE OF WASTEWATER DISPOSAL: 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. NOTE: 72-025(Rev. 1/91) Front MOA~21 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 Address Engineer's signature DHHS SIGNATURE ~"/Approved for ~-- bedrooms. Phone ~7~~ :~°zl.'~ 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 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. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LoT ~/A ~)~ ~/'~o~ Parcel I.D. 07~- (o(o/-- 9~"'"' A. Well Data Well type ~'~ Log present (Y/N) l%.1 Total depth ~ ~) Sanitary seal (Y/N) 7 If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~,-4- Iq 7 ~ Driller Cased to '~ ~ ~'~ Casing height Wires properly protected (Y/N) FROM WELL LOG g.p.m. Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot I'-//,~, Absorption field on lot h//,~ Public sewer main ~O ~ Sewer service line ~ O ''~ ; On adjacent lots ; On adjacent lots Public sewer manhote/cleanout Petroleum tank r,-,I WATER SAMPLE RESULTS: Coliform ~ Date of sample: 7//"/~ ~/ Nitrate ~. qc~ Other bacteria Collected by: "~ --~ B. SEPTIC/HOLDING TANK DATA Date installed Tank size Compartments Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Foundation cleanout (Y/N) Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line On adjacent lots Absorption field Foundation Water main/service line Surface water/drainage 72-026 (3/93)* Front CONTINU ED ON BACK PAGE LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA Date installed Length Width Total absorption area Date of adequacy test On adjacent lots Soil rating (GPD/Ft2) Gravel thickness Cleanout present (Y/N) Results (pass/fail) Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Surface water System type Total depth ~ Depression over field (Y/N) for After test If yes, give date Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water On adjacent lots Property line To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in, ~ffe~t:~ the date qf this inspection. Engineer's Name Date ~0/~) ~ HAAFee Date of Payment Receipt Number 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) (b) (c) (d) Location (address or directions) Applicant Name ~-'~_~-mP Telephone: Home L~j'~-~,~J I Business Applicant Address '~,c~'. I;~::.~ '7'7~.'~-4~ - E~,~.~,u.~. ~¢--~¢¢=~.. /~&-, Applicant is (~:;~eck one): Lending Institution []; Owner/builder []; Buyer []; Other,~- (explain); Address Telephone (e) Real Estate Company and Agent Address Telephone L~ ~c (f) ~'~'t'~e HAA to the following address: TYPE OF RESIDENCE Single-Family~ Multi-Family [] Number of Bedrooms Other WATER SUPPLY individual Well~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite [] Public~ Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department o~ Environmental Conservation attesting to the legality and status. 72-025 (11/84) Page 1 of 2 '5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION '* .... 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 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 regut~ations in effect on the date of this inspection. Name of Firm Address Date " ~/~., Telephone Approved for~~edr~ Approved /,'""/ Disappro~ Terms of Conditional Approval Condi~onal CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the rep'resentations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes ane their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do no~ 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. Page 2 of 2 72-025 (11/84) WELL DATA MUNiCIpALiTY OF ANCHORAG~ DEPT. OF HEALTH & '~/]NVIRONMENT^L PROTECTION MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECK,mT- RECEIVED Legal Description: ~ If A, B, C, D.E.C. Approved (Y/N) Well Classification Well Log Present (Y/~[~P Total Depth .¢~::2'~ 4-"'"~ased to Static Water Level :~ ~ Casing Height Above Ground Electrical Wiring in Conduit~¥N) Separation Distances from Well: Date Compteted /~ I'c~q.~ ~ Yield Depth of Grouting -- ' Pump Set At Sanitary Seal on Casing Depression Around Wellhead (Y/~ To Septic/Holding Tank on Lot /'~ ; On Adjoining Lots __ TO Nearest Public Se~Line ~ ~'* /) To Nearest Public Sewer , Cleanout/Manhol~ [ ~ ~ + / To Nearest Sewer Service Line on Lot ~ ~ Water Sample Collected b~~/~//~ ;Date ~/~ ~/~ ~ B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Air-tight Caps (Y/N) Depression over Tank (Y/N) /~//~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) _ Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course Size No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Page I of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) ~..~ "?mp Off" Level at //~ Vent (Y/N) _ ///~ Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked; verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ,:(i? ~, ? ~:~,'qf~ii~f~-.,£~?~ Date Date of Payment ~'~ ~'-~ Page 2 of 2 72-026 (11/84) APPLIC' FILLS OUT UPPER HAl: ONLY Property Ov~ner Address Zip Code Address Zip Code Address Legal Descript~n~ ' ~O~ 'J~ ~ ~ ,~ ~' ~'~- ~ Single Family Water Supply Individual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975. Community For wells drilled prior to that date, give well depth (attach log if available). ~ Public Utility Sewer Disposal ~ Individual Year Indiv~ual Installed: Public Utility ~ Holding When Connected to Public Utility: Tank ~OTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector inspector Inspector Inspector Field Notes: ~_~ ~UNICIPALITY OF ANCHORAGE ( ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL CO DITIONAL APPROVAL* ~ BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Well to Tank Septic Tank Size 72023 (31~2) DATE RECEIVED "~ - ; INSPECTION APPOINTMENTS~~~- ~,~/'~ TIME 'TIME TIME DATE DATE INSPECTOR NSPECTOR MUNICIPAMTY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~i~OHMENTAL p~OTE~IO~ 825 L Street - Anchorage, Alaska 99501 ( ENVIRONMENTAL SANITATION DIVISION OCT Z ? 1980 Telephone 264-4720 ~CI~/~ REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE~ ~A~E~~ DIRECTIONS: Complete all parts on page 1. incomplete requests will not be proce~ed. Please allow ten (10) days for processing. PHONE MAILIN~ADDRESS PROPER~Y RESIDENT (If different f~om above) U PHONE 2. BUYER MAILING ADDRESS MAILING ADDRESS STREET' LOCATI~N . ,~ SINGLE FAMILY E3 MULTIPLE FAMILY 7. WATER SUPPLY INDIVIDUAL~ [] COMMUNITY [] PUBLIC UTI LITY since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** ~ PUBLIC UTI LITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6179) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2, WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTI LITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED I~]PUBLIC UTILITY Connection Verified INSTALLER [~Septic Tank or [] Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5, COMMENTS [~"~APPROV ED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [~] DISAPPROVED DATE BY 72-010 (Rev, 6/79) MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL PROTECTION JUl_, 8 1979 ENVIRONMENTAL ENGINEERING DIVISION Teleph o,e 264-4720 RECEIVED~ REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. PHONE PROPERTY OWNER MAI L"EN G ADDR ~JS " PROPERTY RESIDENT ('If different fro~ above) 2, BUYER PHONE MAILING ADDRESS PHONE LENDING INSTITUTION MAILING ADDRESS 4. REALTOR/AGENT MAI LING ADDR ESS 5, LEGAL DESCRIPTION STREET LOCAT~N S. TYPE OF RESIDENCE ~ SINGLE FAMILY [] MULTIPLE FAMILY [] One [] Four ~ Two [] Five [] Three [] Six · [] Other 7. WATER SUPPLY INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach log if available.) ~'c,:~ '~'"7(- 8. SEWAGE DISPOSAL SYS.TEM [] INDIVIDUAL/ON-SITE** J~ PUBLIC UTILITY **if individual/on-site, give installation date If system is over two (2) years old an adequacy test is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TiME TIME r DATE DATE DATE iNSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] iNDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE CATE INSTALLED [~]PU BLIC UTILITY Connection Verified INSTALLER []Septic Tank or []Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS [] APPROVED FOR ~ BEDROOMS ~"~CON DITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION 72-010 (Rev. 3/78)