HomeMy WebLinkAboutLot 35 E2
Well Owner
Location
~add~ess of: T~wnsh~p~ Range~ Sect~on. if known; or distance main road
,~Jize of casing--~-Depth of Hole_
Static Water level~_~t. (above)
Screen ( ); Perforated (
escrloe screen or perforation ,/,.
Well pumping test t-~-gallons per (hour)
of drawdown from stalic ~evel.
Date o~ complelion~ -'~ ~ 'r /"
~feet Cased to_. _feet
(below) land surface. Finish of well (check one)
).
open end (_:
(minute) for ----hours w/th '
Depth in feet from
ground surface
Give details of formations penetrated, size of material, color and hardness
-' L_TO
------TO_
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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
GENERAL INFORi~]ATION
Complete legal description
UoS~ Survey 3044, Lot 35, E2
Location (site address or directions) NFLN A1yeska Hiqhway, Girdwood
Property owner
Mailing address
Lending agency
Mailing address
Jay Bergstrand
Day phone
1414 Turpin , Anchoraqe, Alaska~99504
Day phone
333-5361
Agent George McCoy / JACK WHITE COMPANY Day phone
Address 3201 c Street Suite 100 Anchoraqe, Alaska 99503
Unless otherwise requested, HAA will be held for pickup.
NtJ~BER OF BEDROOK~S: 2
TYPE OF WATER SUPPLY:
NOTE:
563-5500
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
XXX N
If community wastewater system, provide written confirmation from State ADEC
attestin9 to the legality and status of system.
NOTE:
72-025 (Rev 1/91) Front MOA #21
STATE~"iENT OF INSPECTION E]¥ 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 informat!on 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 Municipai ~nd State codes,
ordinances, and regulations in effect on the date of this inspection.
5 & S ENGINEERING
Name of Firm 179~4~4~ Phone
Eagle ~iYer, ~,[as~<a 99577'
Address
Engineer's signature
Date
DHHS SIGNATURE
_./~ Approved for _.~'/~'~¢2-~ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
By:
Date
The Municipality of Anchorage Department of Health and Human Se, vices (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.
72~325(Rev. 1191) Back MOA~Y21
Legal Description:
WELL DATA
Well type ~ZI
Log present~N)
Total depth
Sanitary seal (Y/N)
Municipality of Anchorage
Department of Health & Human Services
NEALYH AUTHO~r~ ¥ APPROVAL CHEC~:L~ST
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed. ~-)?' '~C°~__ DrillerN- ~¢ h'~ld~//Od-,
Casedto /~ ' Casing height ~c¢~r'A
Wires properly protected ~W~N)
[)ate of test
Static water level
Well [Iow
Pump level
SEPARATION DISTANCES FROM WELl.
WATER SAMPLE RESULTS:
Coliform
Septic/holdin9 ~ank ou
Absorption field on lot __
Public sewer main
Sewer service line ¢ ~"o-~.~¢
g.p.m.
Date o[ sample:
Nffrate
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Date
Cleanouts
High water alarm (Y/N)
Date of pumping
__ Other bacteria
Collected by: ~'~"f"'~ ~ ~h,~a_~5,,~-C_lFoj~ ....
Tank size C o.o.o.o.o.o.o.o.o.o~ ~t m e n t s
Foundation cleanout (Y/N) /~, ¢--/~ Depression (Y/N)
~A~rm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM
TANK TO:
Well(s) on lot
To property line.7__
S u r face.)~ ea~r/d rain age
7/2~0~7/~91) Front
adjacent
____Absorption field
Foundation
'service line_
lED ON BACK PAGE
/
I111[{~ ill:fmlll!d ~' '
Vi}iii (Y/N)
Iii!ih watel alarm Iow;I
()il [tdj;tcent Iot,'~
(~utv ,I thi(:l(Ims~
J'(]l oxich; hJ)ilLill()lll (t);lsi I? nlonths) (Y/N)
I(:~.liifylhnllhnw~chvckud, vm'ific'd, orcolffornledtr~nllM¢)A~ (I IAAq. idol~ (.,: ~J~;