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DEPARTMENT ur HEALTH AND ENV I F::C NIIENT-AL r ROTEC T 10j1
=25 'L_� STREET, ANCHORAGE, AK 9950
279-25511
APPLIC"ANT EDWIN RINNE.R 8]2:10 WELLSLEY CT _4.4-4J_ :_L.
L.00Af I ON
i__EGAL. L K2 SHANE L..E:E. ESTATES LOT =; I 'E 8000 ::;G!UARE. FEET
E.T
M I N•d 114LIN'1 DISTANCE BETWEE N A WELL ANI) ANY ON—SITE =-El.•iAf3E DISPOSAL S'• ST-E'h1 1-
1.00 FEET FOR f PRIVATE WELL. OR 200 FEET FOR H PUBLIC f4ELL...
WELL LOGS ARE RECJU I RECD AND N'1iiST BE RETURNED D TCS THE DEPARTMENT PARTMENT WITHINd -:ki DAYS
OF THE WELL C OMPL.ET I ON•d. p.
SPECIFICATION' -, AND CONSTRUCT ION DIAGRAMS ARE. A'v'A I LABL_E. TO
INSURE PROPER
I N STALLAT I i )N•a.
V F -F L_ 1. Up F Ch F�' Ch k`'.1 EE* e -V F-:-. F -d FTM° $._._ F;;z cu M _1. 8....9 I=
I CERTIFY THAT
:i.: is AM FAP1I L I AR WITH THE REQUIREMENTS FOR ON—SITE SEWERE AN•dC; WELLS AS SET'
FORTH BY THE: MUNICIPALITY OF ANCHORAGE.
I WILL INSTALL 'THE SYSTEM IN tji::1::ORDANCE WITH THE CODE'
APPLICANT EDWIN ISN R I NNER
ti
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
4--_A'IENTALSE V!C:ESDIVI<,�,
L t—
Parcel I.D. # L. q a 061 _ 7�3 HAA # "'WC) CLLA O
1. GENERAL INFORMATION
Complete legal description � , N— l� FUZ • L E - C�ZIc A
Location (site address or directions) 6�at j iFf -:-A,,jY
Property owner (;zf1_t71Ak-IN Day phone
�"�-1 Tt�-:�'� 0261'-�6�`( f=xz.36o(
Mailing address G 1 Te142flt
Lending agency 1 � JU' Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: �ktR
3. TYPE OF WATER SUPPLY: S S:
Individual well 7-4 17`i
Community well ��S I,
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
NOTE: I f community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA#21
5. 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 Alrasi; v' "Ifea
.G,'1-Y,,F;'ric,
Address Anc
Engineer's signature
Phone
Date C/ 14-
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 courtesyto 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.
72-025 (Rev. 1/91) Back MOA k21
/ E
� Jj
`
C* G S i n) b k "\i l U— F4k4 ajD _ 1 zi
A.� �i✓� C f s T
`�%7-`.��
., .,s ansa aaea an 'j
1 i Fc -,j -964,0
1 ff ey A arnc s .,
6. DHHS SIGNATURE
4
,� L
for bedrooms.
—AL/'Approved
Disapproved.
Conditional approval for bedrooms,
with the following stipulations:
Additional Comments
By. �' �, r�
C �e , /'/
i
Date
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 courtesyto 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.
72-025 (Rev. 1/91) Back MOA k21
o.
o
t "7
Municipality of Anchorage MUNICIPALITY OF ANCH
DEPARTMENT OF HEALTH & HUMAN SERVICffIRONMENTAL SERVICE i
Environmental Services Division Fp 0 5 1991 dilrl5
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist RECEIVED
Legal Description: SAAre LZE ES–(, 1-3,92- Parcel I.D.:
A. WELL DATA
Well type If A, B, or C, attach ADEC letter. ADEC water system number
Log present &N) *S Date completed
�r
Total depth �� t Cased to L1014 Casing height (above ground) w`
Sanitary seal (Y/N) ��� Wires properly protected (Y/N) 'Y
FROM WELL LOG
Date of test
Static water level 31
Well production
AT INSPECTION
g.p.m. '7, Z/ 9 -
p.m -
WATER SAMP E RESULTS:
g/,x1�7 (06-9J-94)— 1 /v-rc. /ter S
Coliform ��26 5- Nitrate " I r,c� � Other bacteria
Date of sample: 68 I a t J9(- i (a6�R Collected by:
7OLDING TANK DATA � _ NgLtc S:�tEWOL
atenstalled a Number of ments Cleanouts (Y/N)
Foundation cleanout (Y/N) epression (Y/ High water alarm (Y/N)
D pmg
Pumper
C. ABSO�TIQN FIELD DATAN/�}
Date installed
Length Width
Effective absorption area
Date of adequacy test
Fluid depth in absorptioryiiew
Soil rating (g.p.d./ft2 or ft2/bdrm)
Gravel thickness below pi Total depth
Monitoring �sent (Y/N) Depression over field (Y/N)
esults (Pass/Fail) For bedrooms
test (in.); Immediately after_ . ater added (in.):
Fluid Cie tins) Minutes later: Absorption rate =
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)'
If yes, give date
D. LIFT STATION ► Af
Date installed
Manhole/Access (Y/N)
High water alarm
E. SEPARATION DISTANCES
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
I at*
"Pump off" level at*
Septic/holding tank on lot - )lk On adjacent lots
Absorption field on lot /U%%f On adjacent lots A✓1A c�
Public sewer main l Public sewer manhole/cleanout
r
Sewer /septic service line ols Lift station
SEPARATIO FROM SEPTIC/HOLDING TANK ON LOT TO: /U#
Foundation Property line Absorption field
Water m iee-ttPteSurface water/drainage Wells on adjacent 0
SEPARATIO CE FROM ABSORPTION FIELD ON LOT TO:�
iG �3Llc Size✓67
Property line Building on Water main/service line
Surface water Driveway, parking storage area
ain Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
l certify that I ha
�n conformancQr
Signature
OF A
field inspections and review of Municipal recosYfi'�t't a - siis are
felines in effect on this date. �'r n / ",` P°e. ®.
oa n6:¢ a 5P' ROBB OPoa^onn
I
Y .iWYF B IP 011 0 f 649Engineer's Name �J' ¢6 �, �.oQ 5p7i a CF 7953
Date / �/� f— o
c, 0 le
Gr .9 f
F �Oo en F4.
a •�`t�;. �-s� p'u's
HAA Fee $cam c,
Date of Payment ��apr
Receipt Number oz? -3
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
CT&E Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
CT&E Environmental Services Inc.
974887001
AK Water & Wastewater Services
L3, B2, Shane Lee Est.
L3, 132, Shane Lee Est.
Drinking Water
Client PO#
Printed Date/Time 08/25/97 10:25
Collected Date/Time 08/21/97 13:20
Received Date/Time 08/21/97 13:40
Technical Director: Stephen C. Ede
Released By
Allowable Prep Analysis
Parameter Results PQL Units Method Limits Date Date Init
Nitrate -N 0.100 U 0.100 mg/L SM18 4500-NO3F 10 max 08/21/97 JBL
Total Coliform TNTC OB SM18 92228 08/21/97 TMW
/1 CT&E Environmental Services Inc.
j.. Laboratory Division
Drinking Water Analysis Report for Total Coliform Bacteria 200 W. ort r Drive
99518-1605
READ INSTRUCTIONS ON REYERSE SIDE BEFORE COLLECTING SAMPLE Tel: (907) 562-2343
Fax: (907) 561-5301
MUST BE COMPLETED BY WATER SUPPLIER
❑ PUBLIC WATER SYSTEM I.D. N.
0< PRIVATE WATER SYSTEM
Send Results Send Invoice
A
7= 37� aeon mm.
SEFF CrA4nsF_fS
one. um Fa�u
=.G
.ry P
❑ Send Results ❑ Send Invoice
owaw
,qsawj
n, sur —T+PL�
SAMPLE DATE: b F8F9- 6 N-1 1 T I
Month- Day Year
SAMPLE TYPE:
�{ Routine
Repeat Sample (for roat%na sample
with lab ref. ao. 9'+,488"t
)
❑ Special Purpose
SAMPLE LOCATION
smNv-, Lim "16, Lo"T 3, &K�
Gommfflwi
(3 Traced Water
=�, Untreated Water
Time Collected
Colleetai BY
PLs reit
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
Satisfactory
❑ Unsatisfactory
O Sample over 30 hours old, results may
be unreliable
❑ Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable resylts. Please send
new sample via sRecia) deiivery tpail.
Date Received
Time Received ,W
Analysis Began
Analytical Method: 0:� Membrane Filter
❑ lvIIYfO-MUG
Number of colonies/ 100 ml,
Result*, Analyst
BACTERIOLOGICAL WELTER ANALYSIS RECORD
:etbf0-MUG Resulk Total Conform E coif
Membrane Filter. Direct Count Colonieslloo ml
T.vrC- r.. N..�...r Ti caw
Verification: LTH BG&ht
COLIFIR
ON -ra4rBsd c.
Fecal Coliform Confirmation
Final Membrane Filter Results a Coliform/100 ml
�� 2 ti d - firsReported Br _ Time
%1 Member of the SGS Group (Socibtb Gdntrale de Surveillance)
.n i........ra�.. ,... ..rr ... ,. .,. ,.. .... rnnw• �. r+Prnr u�n�n,e. ,.+av nun U�nV�nAo IAICCn-101 UN' 'CoQCV nwin WCC'T VIRMNIA
I
97.4997
.finch Fbks
Jun ❑
Faced
pair
Time•.
Client notified of unsatisfactory
results:
Cl-ClPhoned
Spoke with
Faxed
Da=
Tit=
BACTERIOLOGICAL WELTER ANALYSIS RECORD
:etbf0-MUG Resulk Total Conform E coif
Membrane Filter. Direct Count Colonieslloo ml
T.vrC- r.. N..�...r Ti caw
Verification: LTH BG&ht
COLIFIR
ON -ra4rBsd c.
Fecal Coliform Confirmation
Final Membrane Filter Results a Coliform/100 ml
�� 2 ti d - firsReported Br _ Time
%1 Member of the SGS Group (Socibtb Gdntrale de Surveillance)
.n i........ra�.. ,... ..rr ... ,. .,. ,.. .... rnnw• �. r+Prnr u�n�n,e. ,.+av nun U�nV�nAo IAICCn-101 UN' 'CoQCV nwin WCC'T VIRMNIA
MUNICIPALITY OF ANCHORAGE
° Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES �Zt
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel l.D.#_/ .Ij-I HAA#
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 3; Block 2; Shane Lee Eztatez
Location (address or directions)
6721 T,L66any Tennace, Anchorage, Ata6ka
(b) Property owner Dan Ca4ten Telephone. (home)` "'2' � Business
Mailing Address tc?21 �t � � en 0\5�(s
(c) Lending Institution CITY MORTGAGE Telephone
ATFN: Wa.7-ten Goz6ett
Mailing Address
(d) Real Estate Company and Agent Fortune Pnopekties, Inc. ATTN/Mary Maruge.6on
Address 3000 A Street, Anchonage,Ak. 99
Telephone 562-7653
(e) Mail the HAA to the following address: (or check here E�N hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
17034 Eagle Rive. Loop Road Nc�
Eagle River, Alaska 99577.
2. TYPE OF RESIDENCE
Single -Family Inx Number of bedrooms 4
3. WATER SUPPLY
Individual Well Lfx Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ❑fx Public ❑ Community ❑ Holding Tank ❑
We! If community well system, must have written confirmation from the State Department of Irnvironmental
Conservation attesting to the Iegailty and status.
72-025 (Rev. 7/88) Page 1 of 2
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N�RPGICIPALITY OF ANCHORAGE (MOA)
P� ES�� Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
�N�� NMN O �p9Q 343-4744
Legal Description: Z n e-,
ShAA) Lep C s�A�e� S lJ
A. WELL DATA
Well Classification .6i" (C (-.4 nn t �4 If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) Date Completed Yield M
Total Depth4 Cased to �D�t Depth of Grouting — C -7
Static Water Level .7-3 f Pump Set At V I<'
Casing Height Above Ground ( Sanitary Seal on Casing (Y/N) `1
Electrical Wiring in Conduit (Y/N) N Depression Around Wellhead (Y/N) IJ
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot A)/IA ; On Adjoining Lots
r
To Nearest Edge of Absorption Field on Lot �✓� ; On Adjoining Lots �O t
i
To Nearest Public Sewer Line u 4 To Nearest Public Sewer Cleanout/Manhole (00 f
i
To Nearest Sewer Service Line on Lot z`-� .t
Water Sample Collected by `� ��� - A14,ti1��J'tNcr ; !D_ate �7 - ` y DI
Water Sample Test Results �1� (1�fACG k)d'y — aAc' (e1(Pfc4 4- A) i -ha(r Te S
Comments tub Il cWAQ -&(SSDStAJ busIeM
B. SEPTIC/HOLDING TANK DATA
Date Installed —
h -
Standpipes (Y/N)
Depression over Tank (Y/N)
No. of Compartments
ght Caps (Y/N)
Pumping/Maintenance Contact on File (Y
Holding Tank High -Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLD
To Water -Supply Well
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments
Foundation Cleanout (Y/N)
Date Last Pumped
;for
Temporary Holding Tank Permit (Y/N)
TANK:
Building Foundation
To [Xsposal Field
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion A
Depression over Field (Y/N)
Results of Last Adequacy Test —
SEPARATION DISTANCE FROM
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
FIELD:
H
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
Meets MOA Electrical Codes (Y/N)
Comments
_ Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
ining Lots
To Cutback (if present)
Dimensions
Manhole/Access (Y/N)
"'Check Permitted Bedroom Rating Against HAA Request"
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test.
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of,this
a,.,.
inspection.
S & S ENGINEERING `; °�,�%n •�
Signed ,;�! one000
17034 Eagle River Loop Road No. 204
Company
Date 'W o
G � 9a 003
e
MOANo. — .. .......�,..
Receipt No. CQa0d-.) ( )
Date of Payment 7-. v — '� d
Amount: $ Z2 6 C)6
o fob�rl A. ahefcx• e '
J�•oo Na. 14..17-E. o
4 0 ••O.ua°.n° ,� �
Receipt No. 4���gSr►�"`�
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
�1.
Time
Time ie
Date
Date
Date
Inspector
Inspector
Inspector
Comments
Conditional Approval
n�
Da',Permit No.
a r7d
Septic Tank Size
Holding Tank Size
Soils Rating Well To Absorption Area
Well Log Received
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLY
Property Owner O ,3 b4
Phone
Mailing Address Y0 7 % I ' ' Gam t, 1 !`' e C 7j
-2-
Buyer Buyer
QO/jTi�t /
Address /..{�_, a441 ��—JJ �f�� ' '. 9 S-/
�u y
Lending Institutio /{,-/%� UrUG
Phone/
Address C��y,X J�^ Gc
a7Jy S
v
Realty C o& Agent xc)A
Phoge
Address c� /0
Legal Description % _ � _
{{
Street Location Ga
Type of Residence
X71 6jngle Family
❑ Multiple Family No. of Bedrooms
❑ Other
Wat— Supply
ndividual ATTACH 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
Public lJtilit ai16bIB
a
S2wag2 Disposal
❑ Individual Year Individual Installed:
Public Utility When Conne
"&=lily: �✓
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
n MUNICIPALITY OF ANCHORAGF'__,
DEPARTMEN. OF HEALTH AND ENVIRONMENTh�_ PROTECTION
825 L Street, AnchoraaP. Alaska 99501
264-4720
Date Received: April 10, 1978
#1: Time 9:30 a.m. #2: Time #3• Time
Date 4-12-78 Wed Date Date
Insp Pratt Insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
1. Lending Institution Request: Alaska Mutual Savings Bank
Mailing Address: Phone:
2. Property Owner: Sebring Builders Phone: 344-3069
Mailing Address: Star Route A Box 1540C 99507
3. Legal Description: Lot 3 Block 2 Shane Lee Estates Subdivision
4: Single Family Residence: (x) Number of Bedrooms: ?
Multiple Family Residence: ( ) Number of Bedrooms:
5. Well System: Individual Well fix) Community/Public System ( )
Permit # Depth of Well Well Log on File (x)
Construction Bacterial Analysis
6.
Sewage Disposal System: On-site System ( ) Public Utility (x)
Permit # Installed Installer
Septic Tank Size Manufacturer
Absorption Area Soils Rate Material
7. Distances: Well to Septic Tank
to Sewer Line Nearest Lot line
to Nearest Lot Line
to Absorption Area
Absorption Area
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Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 3 Block 2 Shane Lee Estates Subdivision
Comments:
Affadavit Attached:) Letter Attached: ( )
Approved: tK OL Date: (4- V
-7
Disapproved: Date:
Department Worksheet:
�'9UN I C I PAL I TY OF ANCHORAGE
-Department of Health and Environmental Protection q;�i���
825 L Street; Anchorage, Alaska 99501 j2'
d 279-2511, ext. 224, 225 i
quest for Approval of Individual Sewer and Water Facilities V
1. Property Owner:
Mailing Address:%5_T C�G�/�.__��� Phone:
2 . Name of Buyer:
Mailing Address: ��,.�• Phone:
,
1!3. (Lending Institution: ' t
Mailing Address: _ Phone:
4. Realtor/Agent: 11Vc
Mailing Address: Phone:
f
5.
6.
'7.
,Legal Description:
Street Location:
,Single Family Residence: (Y> Number of Bedrooms:
,Multiple Family Residence: ( ) Number of Bedrooms:
,Water Supply: *IndividualWell cV7 Public/Community System ( )
,If Individual Well, well depth
,If Community System, name of system
8. Sewage Disposal System: On-site System ( ) Public System)
If On-site System, date of installation:
*NOTE: A well log is required on ALL wells drilled since 6/75.
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