HomeMy WebLinkAboutSHANE LEE ESTATES BLK 1 LT 10s, t, P, Lt..
r
AN
kko
o�y-aO t OW LOCO
u
0
rl
>
O
i coo
: 000
: 000
Jr
a)
>
tv
0
tv
m
>
>
cn
0
0
t-4
COP:
0:00
: 0:
00
H
H
)-3
H
H
1-3
>
a)
>
tv
0
tv
m
>
>
cn
t-4
I -Y N-0 (D F" nl�
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 /L/ STREET, ANCHORAGE, HK. 99501
279-2511
F:'E=—"F�l--R 1-T'
PERMIT NO. ( 77186:1 )
HPPLICHNT EDWIN RINNER 8]10 WELLSLEY CT
LOCHTION
LEGAL L10 B1 SHANE LEE ESTHTES LOT SIZE 8000 SQUARE FEET
MINIMUM DISTHNCE BETWEEN H WELL HND ANY ON—SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 200 FEET FOR H PUBLIC WELL
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT 1,1ITHIN ]0 DHYS
OF THE WELL COMPLETION.
SPECIFICHTIONS
AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER
INSTHLLHTION.
�H—.A����� ��� �E��F� F����P� 1 ��L���:
I CERTIFY THAT
1� I HM FHMILIHR WITH THE REQUIREMENTS FQR QN�SITE SEWERS AND WELLS AS SET
FORTH B9 THE MMNICIPHLITY OF ANCHORAGE.
2: I HE IN ACCORDANCE WITH THE CODES.
SECiZ..-..�__�����~~~_�_..~~.___~,,__~~_,~_-^_~~~~_
APPLICANT EDWIN RINNER
�
BY ...... -Q
to
. . . ....... =
f HWOOD
to
Q)
12DZ
2
7 Ile"
100
10D t,
71,
tell ' `__ �----- __moi,
......... ... . ... ------- C�
0i
. . .......... ....
o
------------------- - - - -
I ------- BUTRL.WOOD
Street
LW910�
00
CD
64RO,
F0D
j
to 2 7
v -
CD
N -D
8,2801
fo/
----------
Ipa
--------------- --- -
11
1Y,
0 iz -- ------ Pn
----------
URICH
rT
ILI
CD
JStreet m v, ABRIN A
t jr q e
16--
8 6V
�d
16D r316 I lex, 1
Q.
---------------
- - ----- ---
--------- --- -
. . ........ .......
ro
.......... ..
Of
-- — ----------- -
C Di
M
0,20
Stmet
FIT r'll
0 M Ir V
a I
13 1,li7; I I nl
Nji
IV
-A
m ZE
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 10 Block 1 Shane Lee Estates
Location (address or directions)
6630 Tiffany Terrace Anchorage 99507
(b) Property Owner Fred Di chter Telephone: Home 349-5674 Business 561-1158
Mailing Address 6630 Tiffany Terrace Anchorage 99507
Lending Institution
Mailing Address
Real Estate Company and Agent
Address
Telephone
Telephone
Mail the HAA to the following address: or: Check here ❑, if hold for pick up.
List contact person and day phone number below.
2. TYPE OF RESIDENCE
Single -Family LEI
Number of Bedrooms Three
3. WATER SUPPLY
Individual Well 13 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 Q Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
s
Page 1 of 2 72-025 (Rev 8/861 Front
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 regulations in effect on
the date of this inspection.
Name of Firm Brust and Associates Telephone 562-7878
Address 1610 Dimond Drive Anchorage 99507
Date
Engineer's Seal
This department has received confirmation that the improvements
required as a condition of the Health Authority Approval issued
2-11-87 have been completed. The terms of this conditional approval
have been met.
6. DHHS APPROVAL
Approved for three bedrooms by �'"'"`r Date June 19, 1987
Approved xxxxxxx Disapproved
Terms of Conditional Approval
Conditional
CAUTION
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. / V
Page 2 of 2 72-025 (Rev 8/86) Back
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL— ),_jQQ
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
lGG3 / ✓ FAQ/ %F%'i�i9cf✓c�Y��✓�l� %����
(b) Property Owner Telephone: Home 3y S(u% Business
.�/Gfif�-r
Mailing Address G'615 y
(c) Lending Institution
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
Telephone �/
(e) Mail the HAA to the followina address: or: Check here L�, if hold for pick up.
List contact person and day phone number below.
2. TYPE OF RESIDENCE
Single -Family 21"
Number of Bedrooms
3. WATER SUPPLY
Individual Well Lf 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 0 Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 tRev 8/861 Front
f \
i
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 regulations in effect on
the date of this inspection.fez �7%c�y� %� �Z`� Y
Names of Firm Telephone`—
Address 610
Date
6. DHHS APPROVAL
Approved for 4410.3 bedrooms by '°'"�Date
!/'
Approved
Disapproved Conditional
Terms of Conditional Approval "�"`� �' OPS '.�p.oVe
�ro..._..ad� c.t�l( c�.S �'wy� sa..�..c` ✓e�-'f�� lam.. u.� 6� Or.�/r�.f�
H QfT �� GsfG l c.� il'C'�•
CAUTION
o�' czDO.rov�! or.�fl.�ct.Q
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 n certificate is issued_ The Municipality of Anchorage is not responsible for errors or omissions in the professional
valnPAQ work.
Page 2 of 2 72-025 (Rev 8/86) Back
�NMEN
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL ( HAA)
CHECKLIST - FEBRUARY 1984 �6 G
A. MLL DATA Legal Description:
Well Classification If A, B, or C, D.E.C. Apprcved(Y/N) IV174
Well Log Present (Y/N) % s Dat//e Completed a%2sf�7� -fir Yield ,6
� 6
Total Depth 6 0 Cased to 0 _X Depth of Grouting//# dwdn'
Static Water Level , 2 E Pump Set At
Casing Height Above Ground a6 11 Sanitary Seal on Casing (Y/N) e5
Electrical Wiring in Conduit (Y/N) Ze-5 Depression Around Wellhead (Y/N)�-1-
Separation Distances from Well:
To Septic/Holding Tank on Lot /1/�'-, On Adjoining Lots A14
To Nearest Edge of Absorption Field on Lot ^%t,9 ; On Adjoining Lots 1/4
To Nearest Public Sewer Line .� � � To Nearest Public Sewer
Cleanout/Manhole %n To Nearest Sewer Service Line on Lot
Water Sample Collected By s7_ Date 1110V1g C.
Water Sample Test Results
Canr+ents JzY 74- Vie- urn GUc �a (�r� rr, a�r� � r— --
(-� > /
,�rs7X. 4e 73'- C�'-ei4E
B. SEPTIC/HOLDING TANK DATA 11W
Date Installed Size
No. of Ccmpartments
Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/N) Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ; for
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply 4b11 To Building Foundation
To Property,Line To Disposal Field
.To .Water" Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course:''
Comments_
Receipt # D 0 1 6C)0 S
Date Said:
Amount: 4�L 0_z/
(Page 1 of 21
2-15-84
C. ABSORPTION FIELD DATA I/�j
Soils Rating in Absorption Strata
Date Installed
Width of Field
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area Standpipes Present (Y/N)
Depression over Field (Y/N) Date.of Last Adequacy Test
Results of Last Adequacy 'lest
Separation Distance from Absorption Field:
To Water -Supply Well _
To Building Foundation
To Property Line
To Existing or Abandoned System cn
Lot ; On Adjoining Lots _
To Water Main/Service Line To Cutbank(ifpresent)
To Stream/Pond/Lake/or Major, Drainage Course
To Driveway, Parking Area, cr Vehicle Storage Area
Conments
D. LIFT STATION 141W
Date Installed
Size in Gallons
"Pump On" Level at
Dinensions
Manhole/Access (Y/N)
"Pump Off" Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MDA
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of th'sFs
i
Signed -� Date JAS
Coirpany MOA No.
KB1/d5/s
[Page 2 of 21
ENGINEERS
SEAL
2-15-84
Z
f3
Municipality
of
Anchorage
February 11, 1987
P.O. E 196650
ANCHORAGE, ALASKA 99519-6650
(907)264-4111
TONY KNOWLES,
MAYOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
Lorna Gleason
Mortgage Loan Production
National Bank of Alaska
Box 7-025
Anchorage, Alaska 99510
Subject: Health Authority Approval, Lot 10 Block 1 Shane
Lee Estates Subdivision
Dear Ms. Gleason:
The Department of Health and Human Services would like to
clarify its position regarding the Health Authority Approval
for the subject lot. The Department is satisfied that the
private well serving the subject lot can supply a safe and
adequate supply of water. Comprehensive tests have indicated
that the water supply is free from chemical and bacterial
contamination.
The current property owners, Fredric and Barbara Dichter, have
agreed to submit water samples to a local laboratory every
three months to insure that the water supply remains free of
chemical and bacterial contamination. They have also installed
an activated carbon filter that will improve the palatability
of the water. The area immediately around the well casing will
be regraded to insure positive drainage away from the well
casing.
In the remote event that the laboratory tests indicate that the
water supply has been contaminated, a disinfection unit can be
installed to treat the water. These units are relatively
inexpensive (less than $1000) and require a minimum amount of
maintenance. The Department would assist the Dichter's in
selecting this unit.
Again it should be emphasized that the Department does not
condone the existing location of the well 22 feet from the
sewer line. It should also be noted, however, that laboratory
tests have indicated that the well water supply has not been
contaminated by the sewer line. The Dichter's have entered
0
into an agreement with this Department that we believe will
insure that a safe and adequate supply of water will be
provided to the subject lot. We will issue a Health Authority
Approval for the subject lot with two stipulations:
1. The owners of the subject lot must connect to public
water within one year after it becomes available.
2. Laboratory tests for nitrate and total coliform must
be performed quarterly as long as the well is in use.
If the aforementioned conditions are satisfied, a Health
Authority Approval will be issued for the lot.
Sincerely,
Robbie W. Robinson
Section Manager
On-site Services
I
dB
H
H H H
J0,wH F,•
ex• �
d cn Ln N
14aa L4n
PV 00 r
• �lz (D
m
m H
ra "
na
rat (D (D
ti rt
(D P-
-40 0 0 O
oa :J
Pi
ftj
b rrt
+ P.
p
m
N
0
92
LTJ H r n
rt h :'
V P- F" F -j
'C 0 O
(HD NHO
003"
(D h h O
(D N• ti
0 rt 0 B
w tr tr
a L4 N ^
nHOx
0 (D h n
S O O n
N• (D (D t l
(D .3 v
ya
MM(D
0-
tLi
r
N kO O In
CC) J %D J
�O .P �. N
(n Cn .P kO
10 to
CYvcry
C
pi
CD
n
0
0
0
a
v O
g3
N
A /1
0,0
2 �
Qo
3 M
m
0
O
D_
Q
7
Q
pAp..
W
W
11.1
EBD
TCE
TCE
HCCL3
FF -i
0aa
ww
r
a0.a
n0.a
�
O N
O N
O w
O m
iG
nrt
tjrt
Fjrt
hrt
cn
0
m
m
(D
0
o
to
J
0
0
r
N
H
O
J
J
Ln
w
w
w
a
o
H
07
00
N
00
Ln
J
t0
w
J
r
o
cn
r
o
N
o
O,
kO
w
U7
%D
Ln
H
00
00
Ln
N
•
.
.
p
Ln
N
00
Ut
Ln
I
dB
H
H H H
J0,wH F,•
ex• �
d cn Ln N
14aa L4n
PV 00 r
• �lz (D
m
m H
ra "
na
rat (D (D
ti rt
(D P-
-40 0 0 O
oa :J
Pi
ftj
b rrt
+ P.
p
m
N
0
92
LTJ H r n
rt h :'
V P- F" F -j
'C 0 O
(HD NHO
003"
(D h h O
(D N• ti
0 rt 0 B
w tr tr
a L4 N ^
nHOx
0 (D h n
S O O n
N• (D (D t l
(D .3 v
ya
MM(D
0-
tLi
r
N kO O In
CC) J %D J
�O .P �. N
(n Cn .P kO
10 to
CYvcry
C
pi
CD
n
0
0
0
a
v O
g3
N
A /1
0,0
2 �
Qo
3 M
m
0
O
D_
Q
7
Q
pAp..
W
W
ACTIVATED CARBONS
. -
THESE ARE SOME OF THE CHEMICALS THAT ARE ELIMINATED OR WHOSE
LEVELS ARE SIGNIFICANTLY REDUCED BY ACTIVATED CARBON.
PYRENE
PCB -1260
TETRACHLORCETHYLENE
PCB -1016
TOLUENE
TOXAPHENE
TRICHLOROETHYLENE
2, 4-DICHLOROPHENOL
DIMETHYLPHTHALATE
1, 2-DICHLOROPHENOL
ADRIN
1, 3-DICHLOROPHENOL
DIELDRIN
2, 4 -DIMETHYLPHENOL
CHLORDANE
2, 4-DINITROTOLUENE
4, 4 -DDT
2, 6-DINITROTOLUENE
4, 4 -DDE
1, 2-DIPHENYLHYDRAZINE
4, 4 -DDD
ETHYLBENZENE
A-ENDOSULFAN
FLOURANTHENE
B-ENDOSULFAN
4-CHLOROPHERYL PHENYL ETHER
ENDOSULFAN SULFATE
BIS (2-CHLOROISOPROPYL) ETHER
ENDRIN
BIS (2-CHLOROETHOXY) METHANE
ENDRIN ALDEHYDE
METHYLENE CHLORIDE
HEPTACHLOR
DICHLOROBROMOMETHANE-
HEPTACHLOR EPDXIDE
DICHLORODIFLUORMETHANE
A -BHC
CHLORODIBROMOMETHANE
B -BHC
HEXACHLOROBUTADIENE
Y -BHC
HEXACHLOROCYCLOPENTADIENE
5 -BHC
4-NITROPHENOL
PCB -1242
2,4-DINITROPHENOL
PCB -1254
2, 6-DINITRO-O-CRESOL
PCB -.1221
N-NITROSODIMETHYLAMINE
PCB -1248
N-NITROSODI-N-PROPYLAMINE
CHLORINE
N-NITROSODI-N-PROPYLAMINE
THM'S
PENTACHLOROPHENOL
EDB.. , .
BIS (2 ETHYLHEXY 1) PHTHALA
BROMOFORM
BUTYL BENXYL PHTHALATE
ISOPHORONE
D1-N-BUTYLPHTHALATE
NAPHTHALENE
DI-N-OCYL PHTHALATE
NITROBENZENE
DIETHYL PHTHALATE
PHENOL
BENZO (A) ANTHRACENE
CHRYSENE
BENZO (A) PYRENE
ACENAPHTHYLENE
3, 4-BENZOFLUORNTHENE
ANTHRACENE
BENZO (K) FLUORANTHENE
FLUORENE
DIBENZO (A,H) ANTHRACENE
PHENANTHRENE
IDENO (1,2,3, -CD) PYRENE
PHENANTHRENE
'
2-NITROPHENOL
WAIVER
Fredric R. and Barbara Dicther hereby release and waive
any liability by the Municipality in connection with the granting
of Health Authority Approval on our property located at Lot 10,
Block 1, Shane Lee Estates. The Municipality is relieved of any
responsibility or liability in their granting of Health Authority
Approval at this time or any time in the past.
Dated this 22nd day of June, 1987, at Anchorage, Alaska.
4 06
Fr is R. Dic to
Bar a D i c t h e r
SUBSCRIBED AND SWORN before me this 222�0day of
June, 1987.
otary Publica't a d Ebr Alaska
My Commission xpires:>�7
a
O
M
w
My wife and I are the legal -owners- of our--homeat
6630 Tiffany Terrace, Anchorage, Alaska. The legal description
of the property is Lot 10, Bk. 1, Shane Lee Estates.
We have been trying to obtain the DEC Health
Authorization form for refinancing of our home and have been
denied this form. We now have the opportunity for an administrative
hearing to resolve this matter. May I ask that you please schedule
this hearing and advise me of the requirements needed, the place
and date. You may contact me at my office for any information
needed.
Thank you for your assistance in this matter.
Sincerely,
/-
Fredric R. Dichter
FRD:bd
Q rj '
� o V l(j I
0 *02
FREDRIC R. DICHTER
BARBARA DICHTER
6630 Tiffany Terrace
Anchorage, Alaska 99507
December 11, 1986
Mr. Skip Edinger
Assessment Supervisor
Anchorage Water & Wastewater Utility
401 W. International Airport Road
Anchorage, Alaska
Dear Mr. Edinger:
My husband and.iI are the legal owners of our
home on Tiffany Terrace. The legal description is Lot 10,
Block 1, Shane Lee Estates.
lie would like to apply for public water by AIAA%'U,
and will offer to you and your department any assistance in this
goal. We presently have public sewer and private wells, and our
present water situation needs to be changed.
I apprecio.te your help in this matter, and please
contact me for any questions.
,€2:t11L_ T.:. n
14�/ t
✓ � II'
Sincerely,
i
i
Barbara Dichter
Z-3 y.--�
December 30, 1986
P.O. BUX 196650
ANCHORAGE, ALASKA 99519-6650
(907) 264-4111
TONY KNO WLES,
MAYOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
Stanley Brust, P.E.
Brust & Associates
1610 Dimond Drive
Anchorage, Alaska 99507
Subject: Lot 10 Block 1 Shane .Lee Estates
Waiver Request WR86-176
Dear Mr. Brust:
This Department has reviewed your request for a waiver of the
75 foot separation required between the private well serving
the subject lot and two sewer lines running along the north and
southwest property lines of the subject lot. You have reported
that the existing separation distances to the well are 22 feet
for the sewer along the north property line and 53 feet for the
sewer running along the southwest property line.
You have noted that the well water has a musty odor and that
the owners have complained about the palatability of the
water. Given the degree of non-conformance with the 75 foot
separation requirement and intermittent problems with the
palatability of the water which could be the result of
contamination, a waiver cannot be granted.
This Department realizes that the denial of this waiver creates
a problem for your clients Fredric and Barbara Dichter, who
need a Health Authority Approval for the well in order to
refinance their home. The Department is aware that the
Dichters were not responsible for the location of the well, and
in fact purchased the house after the well had been drilled and
mistakenly given approval by the Health Department.
This situation is further exacerbated by the fact that the size
and geometry of the lot preclude the drilling of a new well
which would meet separation distance requirements. Given the
location of the two sewer lines and the manholes for these
sewers no acceptable location for a new well exists. It
appears the only acceptable source of water for this lot is
public water service.
F4
Stanley Brust, P.E.
December 30, 1986
Page Two
The Dichters have initiated a request for public water service
through the Anchorage Water and Wastewater Utility (AWWU). As
you know, the process of going from the petition stage to
preliminary design, the formation of a Water Improvement
District, and then final design and construction can take
considerable time. The Dichter's request has been placed as
"high priority" by AWWU. Despite this priority classification,
AWWU has estimated that water service probably would not be
available for at least another three years provided that the
residents approve the WID. The residents will be balloted in
approximately six months, after preliminary design and cost
estimates for the waterline have been completed. Final design
and construction will proceed only if the WID is approved by
more than 50 percent of the residents in the affected area.
In short, the Dichters are caught in a situation where the only
acceptable source of water will be, at best, available in three
years.
The Department realizes that the Dichter's predicament is a
special one. They have demonstrated their willingness to
improve the situation by petitioning AWWU for public water
service. The Dichters can do little more to improve the
present situation, at least in the short term. The Department
also realizes that the denial of a Health Authority Approval
(HAA) does nothing more than deny their ability to refinance
their home. This denial does not provide an incentive to
upgrade their water service.
Given the special conditions in this case, the Department is
willing to issue a conditional HAA for the subject lot.
Several conditions have been attached to this approval in an
effort to improve the existing water system and to exempt the
Municipality of any liability associated with this conditional
HAA. The owners of the well should be aware that some degree
of risk of contamination of their water will exist as long as
the private well is in use. The conditions of the HAA have
been based in part on your recommendations.
1. The property must connect to public water as soon as
it becomes available.
2. The concrete pad around the well must be removed and
replaced with soil in such away as to insure
positive drainage of surface water away from the
well.
Stanley Brust, P.E.
December 30, 1986
Page Three
3. A charcoal filter must be installed and used to
treat any of the well water used for drinking,
bathing etc. The design and installation of the
filter must be approved by a registered civil
engineer and reviewed by this department.
4. Periodic tests for total coliform and nitrate must
be conducted on a quarterly basis. The regular
collection and submission of samples to a State
approved laboratory shall be the sole responsibility
of the homeowner.
5. A waiver of liability must be provided by the
homeowner that exempts the Municipality from any
liability resulting from the use of the existing
private well.
Please note that this conditional HAA should be in no way
construed as a waiver of the 75 foot separation required
between the well and sewer lines on the subject lot. This
conditional HAA has been granted in light of the unique
circumstances involved in this case. The granting of this HAA
should not be construed as Department policy and does not
guarantee the issuance of future HAA for this or any other lot.
Sincerely,
Stephen S. Morris
Civil Engineer
On-site Services
cc Fredric and Barbara Dichter
6630 Tiffany Terrace
Anchorage, Alaska 99507
Skip Edinger, AWWU
LIST & ASSOCIATES * 4-
Engineers - Planners - Surveyors
1610 Dimond Drive
Anchorage, Alaska 99507
(907) 562-7878 {`
December 5, 1986
Anchorage Division of Environmental Services
805 L Street
Anchorage, Alaska 99501
RE: Lot 10, Block 1, Shane Lee Estates
Tests for a Health Authority Approval were recently performed at the
referenced property. The following attachments are enclosed for your
reference.
1. Application for Health Authority Approvel
2. MOA Checklist
3. Analytical reports for Total Coliform Bacteria, Surfactants,
Total Organic Carbon, Total Plate Count and Hydrocarbons
4. Well log
5. Survey As -Built
6. Well Permit
7. Water Utility Location Drawing
8. Sewer service connection record and connect card
9. Sanitary Sewer As -Built
10. Previous Health Authority Approvals.
The proporty is served by municipal sewer and has an on-site well. A
pumping test showed the well delivering 6.6 gpm at an eight foot drawdown.
During the test, the water was noted to have a musty odor, which gradually
lessened as the test proceeded.
Measurements were made and it was noted that the well was 96' from a
sewer manhole in the cul-de-sac, was 53' from a sewer at the southwest
property line, was 22' from a sewer at the north property line, and was 58'
from Little Campbell Creek to the north. A concrete slab had been poured
around the well, which does not insure positive drainage away from the
well.
r -a
Anchorage Division of Environmantal Services Page 2
In order to ascertain whether the odor was caused by leaky sewers or
by surface contamination several chemical and bacteriological tests were
run. These showed negative for fecal and total bacteria, and showed only
background traces for surfactants, total organic carbon and hydrocarbons.
No stains were noted on the bathroom fixtures, which would have been
indicative of iron. The samples were taken from a hose bib in the crawl
space, upstream of a filter.
The owners of the property are concerned about the odor, which
affects the palatability of the water, and plan to connect to a public
water supply when it becomes available. There is a water line about 500
feet away on 68th Street. There also is development activity to the north
which may also make water available to this property.
In the absence of any indications of sewage or surface pollution it is
recommended that a waiver for seperation distances be granted and that a
Conditional Health Authority Approval be issued, subject to the following
stipulations.
a. That this property connect to public water when available.
b. That the concrete immediatly around the well be removed and that
soil be placed to insure positive drainage away from the well.
C. That a charcoal filter be used to treat the water.
d. That periodic Total Coliform tests be taken, upstream of the
filter.
Sincerely,
Stanley Brust, PE
.L(�� •
'
-V) `.7. 986-E
��• gyp„ �� , �,
';f�••�;G'l�if�?.• Citi ��
i e
1
I
Corte-�-t.
I
P7 �4 �
CHEMICAL & GEOLOGICAL LABORATORIES OFALASKA, INC.
\ ANCHORAGE INDUSTRIAL CENTER 5633 B STREET ANCHORAGE, ALASKA 99518
TELEPHONE (907) 562-2343
CLIENT Brust & Associates CLIENT P. O. # Stan Brust
ADDRESS 1610 Dimond Dr. SAMPLES RECEIVED: 11/26/86
Anchorage, AK 99507 SAMPLES COLLECTED* --
REFER QUESTION TO: Daniel J. Bacon DATE ANALYZED: 11/26/86
APPROVED BY: Stephen C. Edell/ LAB SAMPLE NO. 4903
CLIENT SAMPLE I:D.: LID, Bl Shane -Lee S/D
MATRIX: Water
METHOD: Standard Methods, 16th Edition
Total Plate Count, col/100 ml
ND = NONE DETECTED
DE'IrECTION MINA' IN
RESIDUAL SAMPLES PdILL BE FIELD UNTIL: 1/3/874903
INVOICE 4903 —
l
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
ANCHORAGE INDUSTRIAL CENTER 5633 B STREET ANCHORAGE, ALASKA 99518
\ TELEPHONE (907) 562-2343
CLIENT Brust
& Associates
CLIENT P. 0. #
Stan Brust
DATE ANALYZED:
ADDRESS 1610
Dimond Dr.
SAMPLES RECEIVED:
11/26/86
Anchorage, AK 99507
SAMPLES COLLECTED: --
REE'ER QUESTION TO:
Daniel
J.
Bacon
DATE ANALYZED:
APPROVED BY: h jI,✓
Stephen
C.
Ede
LAB SAMPLE NO.
CLIENT SAMPLE I:D.:
MATS: Water
NtETFIOD: Standard Methods, 16th Edition
Surfactants (MBAS), mg/l
Total Organic Carbon (TOC), mg/l
RESIDUAL SAMPLES WILL BE HELD UNTIL: 1/3/87
12/3/86
4903
L10, B1 Shane Lee S/D
o.o04
2.0
ND- = NONE 1)E'1'E=
D=CTION tVIT V i )
INVOICE # 4903
CHEMICAL & GEvLOGICAL LABORATORIES OF ALASKA, INC.
5633 'B' STREET, ANCHORAGE, AK 99518
TELEPHONE (907) 562-2343
CLIENT:
SEND REPORT TO:
SEND REPORT TO:
EPA METHOD:
MATRIX:
REFER QUESTIONS:
REPORT OF ANALYSIS
Brust & Associafes
1610 Dimond Dr.
Anchorage, AK 99507
Copies held for pick up
602
Water
STEPHEN C EDE
CLIENT SAMPLE ID: L10, Bl Shane Lee S/D
CLIENT PO NO:
Stan Brust'
ORDERED BY:
Stan Brust
SAMPLE RECVD:
11/26/86
DATE ANALYZED:
12/2/86
APPROVED BY: STEPHEN C. EDE
SAMPLES HELD UNTIL: NOT HELD
LAB SAMPLE NO: 4903
VOLATILE AROMATIC HYDROCARBONS.pDb
RESULTS
BENZENE
ND (1)
TOLUENE
ND (1)
ETHYLBENZENE
ND (1)
CHLOROBENZENE
ND (1)
p -XYLENE
ND (1)
m -XYLENE
ND (1)
o -XYLENE
ND (1)
i,4 DICHLOROBENZENE
ND (1)
1, 3 DICHLOROBENZENE
ND (1)
1, 2 DICHLOROBENZENE
ND (1)
ND -NONE DETECTED
DETECTION LIMITS IN () INVOICE • 4903
.. .Nd"6t. . �v � ".. r'9:/� .�rsn w. �.✓p T+�Fmwwarw'�.m-tn�n n•..cM'M s+P..AVR; R+'a'!IP�Pa?rte=.
x
dItion
�
Orparty
0%,%-tar C-0
iZC—rvry /L
:�rnbs
tar
Nle�s
110 r
:,TCyA Iiha
.. .Nd"6t. . �v � ".. r'9:/� .�rsn w. �.✓p T+�Fmwwarw'�.m-tn�n n•..cM'M s+P..AVR; R+'a'!IP�Pa?rte=.
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
ANCHORAGE INDUSTRIAL CENTER 5633 B STREET ANCHORAGE, ALASKA 99518
LABOR, TORVES TELEPHONE (907) 562-2343
February 3, 1987
To Whom it May Concern:
The property located at Lot 10, Block 1, Shane Lee Estates has
been tested for potability in November 1986 and for potability
and nitrates in January 1987.
Sincerely,
EUG T. YONKIN
Pr sident
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
ANCHORAGE INDUSTRIAL CENTER 5633 B STREET ANCHORAGE, ALASKA 99518
\ TELEPHONE (907) 562-2343
ANALYTICAL REPORT
CLIENT Fredric Dichter CLIENT P. O. #_
ADDRESS 6630 Tiffany Terrace SAMPLES RECEIVED:_
Anchorage, AK 99507 SAMPLES COLLECIED:
REFER QUESTION TO: Daniel J. Bacon DATE ANALYZED:_
APPROVED BY:—Stephen C. Ede LAB SAMPLE NO.
CLIENT SA.MPIE I . D _
MATRIX: Water
METHOD: Standard Methods, 14th Edition
Nitrate -N, mg/l
RESIDUAL SAMPLES WILL BE HELD UNTIL: 2/27/87
1/23/87
1/23/87
1/26/87
5265
1_101 B1 Shane Lee Estates
Kitchen Faucet
ND (0.10)
Nn = NONE D =cYrED
DETECTION Tn]TT V ( )
INVOICE # 5265
•o.0�Q �Q
04040404
04040404
ON -W LnUl
N V'vas
9Cn9Cn
U')001N
M 14
U W
G ^ C]
O N W W
U �U"
,o _ (0 H
N M � ro
w a a) a)
U O 0
U S4 a) O
y xr°� -a
E U4JM
s4 •rl a)
Oppa)
44 H O 0
O r•{ (1)
p ri 4 ri
O • U >1
r -I ri •rl 4
4 • s4 4J
U r -I H W
W
N O o X
U 6 E Q >1
a) un Ln c0
s •xca
•r♦ r -I M �o r
H ri .•a
^
H
a
E-
14 R
df
I
ch
Lo
N
)P)
00
N
M
O
ri
V
10
�0
p
�
W
N
a
W
CO
ri
C
0
a%
ON
N
M
O
N
O
N
O
ri
)n
p
ri
o
+
rn
r
Ln
OD
0
•Hcc
w
N
ro
r.
ri
oe
=
O
OO
Ln
OV
tx
rn
r -i
v
a
r
N
Q\
01
X
4-J
p
O
-1
11) 4J
G
H
•
•
O
O
t0 :d
0
04
O
140
dt
d\
r -i
ri
O
DO
W
N O o X
U 6 E Q >1
a) un Ln c0
s •xca
•r♦ r -I M �o r
H ri .•a
^
H
a
E-
14 R
df
I
Lo
)P)
00
N
)P)
O
ri
V
•
�0
p
N
LO
W
CO
ri
V)
a%
ON
LO
M
m
%.0
O
N
O
ri
)n
p
ri
r
M
rn
r
Ln
OD
rn
O.
N
00
00
ri
Ln
rn
r -i
rn
rn
r
01
Q\
01
r
r
O
-1
N
rl
•
•
O
O
r
)11
O
O
dt
d\
r -i
ri
m
4-)
4J
4J
4-)
ro
HO
HE
O
HO
HO
£ZDDx
aDl
SDI
GSH
H
w
T,T•T
TAX CODE No.O/%o/— �� -� GRID No.
MUNICIPALITY OF ANCHORAGE —
SEWER UTILITY
PROPERTY
Name Addres 630 �c lf�T;!�etr,-,rg
Acct.No y6-00/,;' -S49-0
Plat No. Subd.s
Lot /0 Block /
Residential ❑ Commerial O Industrial ❑ No. of units
CONNECT -.SNE- r�Ittt
Main Tap d On Property ❑ Permit No.�/� tf�
Size 2ii Type /
Drawing No. 7 7 Size Main F- Type Depth at Connect
Insulation ❑ Cleanouts Type CL
Connect Agent G/ar 'P, _ Inspector 4nW--,- E
Date 10%,hk
Comments
.ltS/
Connect Location
f Ana %P
ASSESSMENTS:
L.I.D. No. Private Dev. No. Subd.Agreement ❑
No.
Sewer Agreement O No.—RTE. O Roll No.
DYE TEST=
Positive ❑ Negative ❑ N.S.A. ❑ Date
rage NO. -MA No, Dining Zycie
Tested By
Comments
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services -
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
i
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel 1. D. # n!,LA -innHAA # Ogg
1. GENERAL INFORMATION
jr� r
Loi 70; Btock 1' J/ Lne Leo Esta.tu i
Complete legal description
3
Location (site address or directions) 6630 Ti' a5any Texnace: _
Property owner Fned & 8anbaxa Dic+ken Day, phone
Mailing address 6630 Ti44any Te trace, Anch.onage, Alaska 99507
jz
Lending agency Day phone
Mailing address
Agent iDay phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well XA
Community well
Public water
NOTE: if community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer' XX
NOTE: If community wastewater system, provide written con{irmafion fe6 1 waft? ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
In
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 furtherverify that based on the information ob rained from
the Municipality of Anchorage files and from my investigation and inspection, the oii-site water
supply and/or wastewater disposal system is in compliance with all Municipal and : tate codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm Phone
S & S ENGINEERING
Address 17034 Eagle River Loop Road No. 294 _
UAgle River, Alaska 99577
Engineer's signature
DHHS SIGNATURE
Approved for 27 bedrooms.
—_ Disapproved.
Conditional approval for
Additional Comments
Date –_�L
bedrooms, with the following stil)ulations:
Date
IIITir
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 tending institutions in order to satisfy certain federal and state requirements. Employees of [)I-IHSdo 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.
72-025 (Rev. 1/91) Back MOA u21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST 44
Legal Description: ,� e I (� �ha i� 1�11A^ia A -p& �Zf parcel I.D.
A. WELL DATA
Well type &nu If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Date completed 7 -z!q -4 8 Driller
Total depth Cased to O Casing height z
Sanitary seal (Y/N) cl Wires properly protected (Y/N)
Sewer service line 5 3 Petroleum tank AJ nrJe 1:')0LJA)
WATER SAMPL.,1�E.. RESULTS: r"ms�s �r
Coliform I tG ctor� Nitrate d 1 S AC tor'(( Other bacteria z e 4' D
Date of sample: fes. _ 2 8 -1—I Collected by: �- f S L n14in1 eE1�irJF
B. SEPTIC/HOLDING TANK DATA JdIA C Y U (0110-
Date installed
Cleanouts(Y/N)
High water alarm (Y/N)
Date of pumping
Tank size
Foundation cleanout (Y/N)
SEPARATION DISTANCES FROM S
Wells) on lot
To property line
Surface water/drainage
72-026 (Rev. 7/91) Front
Compartments -
- Depression (Y/N)
Alarm tested (Y/N)
Pumper
C/HOLDING TANK TO:
On adjacent lots
Absorption
Foundation
water mein/service line
CONTINUED ON BACK PAGE
z
FROM WELL LOG
AT INSPECTION
UJ
Date of test z ' 2 L1' }
Static level 1 3
to
U
z a>
4M
•-,
W
water
Well flow Z g.p.m.
g.p.m.
t
W
ZZ
n.
U
Pump level L) l�
U K
W
SEPARATION DISTANCES FROM WELLTO:
z'
Septic/holding tank on lot
On adjacent lots
% A
Absorption field on lot ��
; On adjacent lots
r
i
Public sewer main Z Z Public sewer manhole/cleanout
�(
Sewer service line 5 3 Petroleum tank AJ nrJe 1:')0LJA)
WATER SAMPL.,1�E.. RESULTS: r"ms�s �r
Coliform I tG ctor� Nitrate d 1 S AC tor'(( Other bacteria z e 4' D
Date of sample: fes. _ 2 8 -1—I Collected by: �- f S L n14in1 eE1�irJF
B. SEPTIC/HOLDING TANK DATA JdIA C Y U (0110-
Date installed
Cleanouts(Y/N)
High water alarm (Y/N)
Date of pumping
Tank size
Foundation cleanout (Y/N)
SEPARATION DISTANCES FROM S
Wells) on lot
To property line
Surface water/drainage
72-026 (Rev. 7/91) Front
Compartments -
- Depression (Y/N)
Alarm tested (Y/N)
Pumper
C/HOLDING TANK TO:
On adjacent lots
Absorption
Foundation
water mein/service line
CONTINUED ON BACK PAGE
C. LIF1r STATION
Date installed
Size in gallons
Vent(Y/N) "Pu F
High water alarm level
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
on" level at "Pump off' level at _
Cycles tested
SEPARATION DISTANCE FROM LIFT STATIM TO:
Well on lot
D. ABSORPTION FIELD DATA
Length
Width
Total absorp ' n area
Depression over ' Id (Y/
Results (pass/fail)
Peroxide treat ent (past 1P onto
SEPARATION DISTANCE FRO
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
E. ENGINEER'S CERTIFICATION
On adjacent I
Soil rating
Gravel thickness
Surface water
System type
Cleanouts present(Y/N)
Date of adequacy test
for
s) (Y/N)
ABSORPTION FIELD TO:
n adjacent lots
Cutbank
Dr
Total depth_
If yes, give date
Property line
To existing or abandoned system on lot
Water main/service line
, parking/vehicle storage area
_— bedrooms
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in,Offoof;o`h't_*' of this inspection.
`XV._
S & S ENGINEERINGif
3.,
Signature 17034 Eaple River Loop Road No.29A `
Eagle River Joska 99577
i3
Engineer's Name
°
Date
00
HAA Fee $ n Q • 00
Date of Payment J s :3 -- of
Receipt Number .2,3 D ��
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 6 STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 582-2343 FAX: (907) 561-5301
ANALYSIS REPORT BY SAMPLE for RUSNoider# 37700
Date Report Printed: AUG 30 91 4 08:14
Client Sample ID:L10 E1 SEANE LEE ESTATES Client Kane :S & S ENGINEERING
PWSID Al Client Acct :SNSENGP
Collected AUG 28 91 # 11:40 his. BPO # PO # HONE RECEIVED
Received AUG 28 91 1 12:10 hre. Raq #
Preserved with :AS REQUIRED Ordered By :RODNEY
Analysis Completed :AUG 28 91 Send Reports to:
Laboratory Supe ie r STEPHEN C. EDE 03 & S ENGINEERING
Released By : : (f, -Wx-/ 2)
..................................................... u.........................................................................»u
Chemlab Ref #: 914430 Lab Snpl ID: 1 matrix: WATER
Allowable
Parameter Tested Result Units Method Limits
------------------------------------
-----------------------------------------
NITRATE-N ND(0.1) ng/1 EPA 353.2 10
Snnpie ROUTINE SAMPLE COLLECTED BY: R.D.J.
Remarks:
_ _ • . ............... . ................................,1...•
........1 _n ------.a •9 ••••• ••••• 5.. 9sacinl T. tructioe k66V6 UA -Unavailable
ND. None detected §ea hypli AA19ATki NO
NA. Not Analyzed LT -Lase Than, GT-Grsater Than
ra) Si�o,7 Member of the SGS Group (Soc!6t6 GAndrale de Surveillance)
Municipality ®f Anchorage
tet;
j Department of Health and Human Services
825 "L" Street
Tom Fink,
Mayor P.O. Box 196650 Anchorage, Alaska 99519-665
343-4744
October 11, 1991
Roger A. Shafer, P. E.
S & S Engineering
17034 Eagle River Loop Road
Suite 204
Eagle River, Alaska 99577
Subject: Waiver Request for Lot 10 Block 1 Shane Lee Estates S/D
Waiver Request #WR86-176A, PID #014-061-66, HA910395
Dear Mr. Shafer:
Your request for waiver of the required 75 foot horizontal
separation of a private well to a public sewer line has been
approved. The approved separation distance is 22 feet.
This waiver approval applies to the existing well and public
sewer line only. Any future upgrade will require all separation
distances be met or another approval from this department.
All previous conditions regarding this waiver have been met.
Sinc ly,
Robert W. Robinson
Acting Program Manager
On-site Services
RWR/ljm
Z97,
is
it
ezz
4v
Al
7 A�/
5 1112
a4� 01-1p/
17-16
Al
Z) o.'i
a4� 01-1p/
Page Two
Lot 10; Btock 1; Shane Lee Estates
October 7, 1991
2. DuiLing a gow .tut we. pen4onmed on August
water teve2 within the weU at 8 4t. 10
we 22 casing. Since the we ? 2 seems .to be
no water encountered above 58 4.t. This
evidence o4 an artuian aqu,i4en which is
clay taym. This con4in.ing tayen would
.into the weU.
29, 1991 we measured a static
.inches below the ,top 04 the
eased to 60 4.t. and .there was
static wateA tevet.is 4ukther
UaveP.i.ng beeow the eon4.in.ing
pi.event .intnus.ion 04 sewage
3. Baeteuiotogiea2 and nitAate samptu taken &%om the weU on August 28,
1991 showed satis4aetaKy Aesu t -S. In 4act, .these were no n.itnates
detected. Since was.tewaten .is typicaP.Ly high .in nitrates, .it appears
.there has been no in42uenee on the weU by the sewer tine. This is
a4ter .the sewea -Pine has been .in service 4on 14 years.
4. The sewer .Pine in question .is at a lower e.2evati.on .than .the weU. 14
.topog&aphi.ca2 .in4onmati.on .is any .indication o4 .the d.inecti.on o4 4tow 04
subsun4aee drainage, .then e6guent 4nom the sewer tine would .tAave2
away 4n.om .the well.
5. Atthough .it does not o44en a technical justi.4.icati.on 4on ,the .issuance
o4 a waiver, -these should be some consideration given to the 4aet that
.there -is no place on the pnopec.ty to dkitt a new wW and maintain .the
nequvred separation distances to the seiner tines.
14 you have any questions on %equ,ine additional .in4onmation 4on your.
Aeivew, please contact us.
S.ince+rety,
ROGER J. SNAFE , P.B.
RJS/gm
Fnctosunes
cc: D.iehtecs c/o Charlene. M.%PPiman
Renee Anderson- First National Bank o4 Aneho age
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF AN60RAGE
DEPARTMENT OF HEALTH & ENVf RONMENTAL PROTECT[ O&VI DEPT. OF 1'�ALTH &
825 L Street - Anchorage, Alaska 99501 RONMENTAL �.(_)i'_ECTION
ENVIRONMENTAL ENGINEERING DIVISION J A N 0 19 7 0
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER""
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER
PHONE
Sebring Builders, Inc.
734-2697
MAILING ADDRESS
Star Route 520 Bogard Road, Wasilla, Alaska
PROPERTY RESIDENT (if different from above)
PH E
2. BUYER
PHONE
Bruce/Tinka Randall
>MX INDIVIDUAL*
MAILING ADDRESS
3. LENDING INSTITUTION
PHONE
Securitv Pacific Mortgage
depth (attach log if available.)
MAILING ADDRESS
1011 East Tudor Road - Suite 190 99577
4. REALTOR/AGENT
PHONE
Bowden Realty
If system is over two (2) years old an adequacy test is required
MAILING ADDRESS
5. LEGAL DESCRIPTION
Lot 10 Block 1 Shane Lee Subdivision
STREET LOCATION
Tiffany Terrace off of
East 68th Avenue
6. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
0 One 0 Four E:1 Other
INX SINGLE FAMILY
0 Two 0 Five
ED MULTIPLE FAMILY
R9� Three E:1 Six
7. WATER SUPPLY
>MX INDIVIDUAL*
ATTACH WELL LOG. A well log is required for all wells drilled
0 COMMUNITY
since June 1975. For wells drilled prior to that date, give well
0 PUBLIC UTILITY
depth (attach log if available.)
S. SEWAGE DISPOSAL SYSTEM
E:1 INDIVIDUAL/ON-SITE**
**If individual/on-site, give. installation date-.
If system is over two (2) years old an adequacy test is required
X�gx PUBLIC UTILITY
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
INSPECTION APPOINTMENTS
DATE RECEIVED
TIME
TIME
TIME
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE
E] SINGLEFAMILY
0 MULTIPLEFAMILY
NUMBER OF BEDROOMS
E-1 ONE 0 THREE E-1 FIVE E] OTHER
0 TWO El FOUR EJ SIX
2. WATER SUPPLY
El INDIVIDUAL
El COMMUNITY
EJ PUBLIC UTILITY
Connection Verified_
PERMIT NUMBER
DEPTH OF WELL
DATE DR I LLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
El INDIVIDUAL/ON -SITE
OPUBLIC UTILITY
Connection Verified —
PERMIT NUMBER
DATEINSTALLED
INSTALLER
E]Septic Tank or 0 Holding Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELLTO:
Septic/Holding
7
bsorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
6,APPROVED FOR BEDROOMS
E] CONDITIONAL APPROVAL (letter must accompany certificate)
ED DISAPPROVED
DATE
-,C)- � (� —r-) <�
BY iTitle)
ec�
r7L DESCRIPTION V
72-010 (Rev. 3/78)
-�k
-Timti,
Time .ne
Date
Date
Date
Inspector
Inspector
Inspector
Comments
Conditional Approval
ON
V
0
Date Sewer Installed
Permit No.
Septic Tank Size
Holding Tank Size
Solis Rating
Well To Absorption Area
Well Log Received
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLY
Property Owner 75, 71 -
TII
e
Mailing Address (0 Lo -6
r- Ic:A 4J ktA Q 4=- 4 A) e /-/C) /e-/9 ('1 9'
Buyer r-, 0 1
Address
Lending Institution k)
77
Phone
Address AJ6p—i-14 tz;-:: e --A) (gl,4rs
Realty Co. & Agent
Phone
Address 0014
Legal Description
77A AJ t-- 1-7 15 25
Street Location &)Mo,>, of-- CP 0 T -5 10 of A (2 K
Type
OA-)
loesidence
ij ingle Family
1-1 Multiple Family
No. of Bedrooms
E) Other
WateL,S,apply
• Individual
ATT ACH WELL LOG. A well log is required for all wells drilled since June
• Community
1975. For wells drilled prior to that date, give well depth (attach log if
[1>dividual
ff Public Utility
Year Individual Installed:
When Connected to Public Utllity:L9-�
0 Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
MUNICIPALITY OF ANCHORATt
Department of Health and Environmental Protection
825 L Streeti Anchorage, Alaska 99501
279-2511, ext. 224, 225:
!�!Iequest for Approval of individual Sewer and Water Facilities
Prop I erty Owner: Tel K der -C
Mailing Address: S Rpoe2rA X&k.-Phone:
Name of Bu er:
y
Mail . i ng Address: Phone:
)9_(.�L ct-L �C_
Lendinq Institution: k -L
Mailing Address: Phone:.—
!Realtor/Agent:
I __A�4_w .
�Mailing Address: Phone:
Legal Description:
Street Location: 70'7� F 1= 4% A4 A- TC rrA? e Lo 0
i r
Single Family Residence: Number of Bedrooms:
Multiple Family Residence: Number of Bedrooms:
'Water Supply: *Individual Well Public/Community System
If Individual Well, well depth
If Community System, name of system
iSewage Disposal System: On-site System Public System
lif on-site System, date of installation:
*NOTE: A well log is required on ALL wells drilled since 6/75.
'3/7�
(J�