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HomeMy WebLinkAboutALPINE VILLAGE BLK 3 LT 11 PERMIT NO. DEPRRTMENT, HERLTH RND ENVIRONMENTRL :OTECTION 825 CE" STREET, RNCHORRGE., RK. DD50± 264-4720 l]4ibb i'iF:bl IT ( 830292 ) RPPLICRNT LOCRTION LEGRL COLONY BUILDERS INC L±i 83 RLPINE VILLRGE &407 N 47TH #2 DD503 LOT SIZE 562-53~D 999~D SQURRE FEET MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SENRGE DISPOSRL SYSTEM IS ±00 FEE]' FOR R PRIVRTE WELL OR i50 TO 200 FEET FROM R PUBLIC NELL DEPENDING UPON THE TYPE OF PUBLIC NELL. MINIMUM DISTRNCE FROM R PRIVRTE NELL TO R PRIVRTE SEWER LINE IS 25 FEET AND TO R COMMUNITY SEWER LINE IS 75 FEET. NELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN 30 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. I CERTIFY THRT ±' I BM FRMILIRR NITH THE REQUIREMENTS FOR ON-SITE SEWERS RND NELLS RS SE]' FORTH BY THE MUNICIPRLITY OF' RNCHORRGE. 2: I WILL INSTRLL THE SYSTEM IN RCCORDRNCE NITH THE CODES. SIGNED: RPF'L I CRNT COLONY BUILDERS INC V4. 0 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. muni.orglonsite (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 014-133-29 1. GENERAL INFORMATION Complete legal description Alpine Village, BIk 3, Lot 11 Expiration Date: 9 "' ~ "' O ¥ Location (site address or directions) 7333 Basel St., Anchorage, AK 99507 Current Property owner(s) Christine & Brad Gilgus Mailing address 7333 Basel St., Anchorage, AK 99507 Day phone 868-7049 Lending agency Mailing address Real Estate Agent Mailing Address Terrie Pisa / Prudential Jack White 3201 C St., Suite 200 Anchorage, AK 99503 Day phone Day phone 762-3157 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 e TYPE OF WATER SUPPLY: Individual Well [] 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 an 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) for 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 pdvate 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 verify 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. Name of Firm Watkins Engineering, Inc. . Phone 349-1851 Address P.O. Box 110443, Anchorage, AK 99511-0443 Engineer's Printed Name Cindy W. Ellis Date '5"-Z'7'~6 '~ "' Disapproved. Conditional approval for bedrooms, with the following stipulations:. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: (J~ - ~ ° O/'~ (Rev. 01/02) . Legal Description: A. WELL DATA Well typ'eI Prl uale completed To"tal i~le 31h' 96: ff. Date ~o test stati~ v,a{er level Well production WATER Coliform Ars~hic: · Municipality of Anchorage DevelopmentlServices Department ~. ~ r '~~,:~" ~ BUilding Safety Division ' ; .~"- On-Site Wate'r & Wastewater Program ' ': 4700S0uth BragawSt. ' : :. P.O~ Box 196650 !Ahchorage, AK 99519-6650. . www.muni.org/onsite : ~ (907) 343~7904' HEALTH AUTHORITM APPROVAL CHECKLIS' ' Alpine Village,'BIk 3, Lot 11 ..~ .. SAMPLE RESULTS: i '0 ' colonies/100 mi, .'- mg./I. ' If A, B, Or C provide pwSID # ,sanitary seal~ (WN) Y' Cased to: 961 , fl::., ~ , :, FROM WELL LOG .'i 6-1-83 : ~' ": 12 g.p.m. Nitrate !.<0.1 Date ofsampl,e: ~-~o-04, Parcel ID: 014-133-29 ; well Log (Y/N) Y ~Wires properly prOtected (Y/N) ¥ Casing height {above ground) 30 AT INSPECTION 5-10-04 6.48 Other bacteria :0 colonies/100 mi. Collected by: .Watkins Engr, Inc. in. B. SEPTIC/HOLDING TANK DATA ~ '. :i':,ril' II~ , : ! ~ Ta~T,y~a(edal ':PUBLICSEWER~AWWU!' : i ,:!'!..' Date installed - : : ~g .... Tanl<'siz'~ ~ gal. ~P~mbe~-o~.~mpadments r, 'Fo'u~dat~~ater ala~:m (Y/N) , ...... Date ~3f pbmping - , . Pumper C. ABSORP;,TION FIELD DATA - ! Date !r%"talle~,: Soil rating (g.p.d.lft or ft/bdrm). _ System type,_ ~.: . : Lerigih 'd hl '-: ~ '~ Width' ' ; .: '~ , ff. '~ Gravel below pipe , ff. Total~dept,h : . ft. Eft. abaft~. Monitoring tube Depression over field Date~s~ ReSultsi(Pa~'slEa~ : ~ ,: ' i For' ! bedrooms Fluld'd,,etp!! in absorption field before test : :~in': .:. Water added~"~-~.~' ' : Newdepth in. Elansed Time' ~ min ' Final fluid depth ~ in. ,: ,Absorptmn rate >= ~ g.p.d. Any'~ju~,~nation treatment (past 12 mo.) (YiN & type) . "' . ' ~ If yes, give date .... ;;'i; li~ " ' , ;: : ' ' LIFT STATION Daie' ,, 'Pump on" level at ~ in. Datum SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot NA Absorption field on lot NA Public sewer main 50+ (A(/"II~-~ O'~E') .' SeWer/septic service line 12' Size in gallons " Manhole/Access (Y/N) 'Pump off' levo~t~a~._~..High, water alarm level at Cycles tested Meets alarm & circ~ On adjacent lots NA On adjacent lots NA Public sewer manhole/cleanout 100+ · Holding tank. NA SEPAE~ION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT. TO: Building foundatio71'---~': Property line ' ' AbsOrption field Water main _~service line Surface water Wells on adjacent lots .... W~te'r Service line Building foundation Surface water ~ in. Curtain drain. .Wells on adjacent lots. COMMENTS ~ 5-~/ ~ ~ ..~/~¢C~_~ p, Cg~ , : *Waiver #970056 for 10 ft separation from well to sewer service line. ENGINEER'S CERTIFICATION', · '" I certify that I hgve determine'd through field inspections and review of Municipal records that the above systems are in conf(~n-nance with MOA HAA ~u.,i, delines in effect on this date. Engineer's Printed Name Date ~ ,- ~.'7- O 4 HAA Fee .$ Date Of Payment Receipt Number (Rev. 12101) . ,,[fo. Waiver Fee $ Date of Payment Receipt Number SGS Ref.# Client Name Project Name/# Client Sample ID Matrix 1042401001 Watkins Engineering LI I. B3. All~ine Vill 7333 Basel Street Drinking Water PWSID 0 All Dates/Times are Alaska Standard Time Printed Date/Time · 05/13/2004 14:07 Collected Date/Time 05/10/2004 8:40 Received Date/Time 05/10/2004 10:27 Technical Directo~,~- Stephen C. Ede /, Released By Sample Remarks: ' Allowable Prep Analysis Parameter Results PQL Units Method Container ID Limits Date Date Init Waters Department Nitrate-N 0.100U 0.100 mg/L EPA300.0 B (<=10) 05/10/04 JMP Microbiology Laboratory Total Coliform coFl00mL SM18 9222B A (<=1) 05/10/04 DKC ~O0'c~c~ ~A,,F, l,~ LeO N 0 0 ~O0'~c~ 'q,,6 l~l~' loO S BAS EL STREET ~ .I-- z ~m ~: ~0 -Z ,,_~ @ o =o ,, -~01 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 RECEIVED AUG 20 1997 Municipality ct Anchorage Dept. Health & Human Service8 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# (~) I ~ '" J 3] - 1. GENERAL INFORMATION Complete legal description HAA# ~ ~"~/~ ~ not 11; 'Block 3; Alpine ¥illage Location,(,sjte address or directions) ". "iS¢op~Ct'~ owner' ~Che~y~ G~aan ~,~.. ,: - . . ...... :Mailing' addres'~ .... n ing agency "' Mailing address 7333 Basel Street Anchoraqe, AK Jennifer Day phone 344-8919 Mortgage 4300 "B" St. Suite 206 Smith)Anchorage, AK 99503 Day phone Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 3 ~ xxx 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 NOTE: XXX If 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 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 ail Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature S & ~ ENGINEEI~ING 17034 Eagle River Loop Road No. 204 Et;!= ~!vcr, ~lacl== ??577 Phone. Date DHHS SIGNATURE ~ Approved for .~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: C//~/· 7~'~~ Date The Municipality of Anchorage Department of Health and Human Sen/ices (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. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services DMsion 825 L Street, Room 502 · Anchorage, Alaska. 99501 ° (907) 343-4744 Legal Description: LO T' Health Authority Approval Checklist ~'~-~ 3 ~Lp,,,,~ V)~.~Ac~. Parcel I.D.: O A. WELL DATA Well type P/~ ~ ¥/) 7'~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (~N) ¥ ~-~ Date completed do Total depth Sanitary seal (~/N) Cased to ~ 0 -'/- Casing height (above ground) Wires properly protected {~N) y g Date of test Static water level t//k Well production I ~ FROM WELL LOG AT INSPECTION g.p.m. ""'~" )- '')- g.p.m. WATER SAMPLE RESULTS: Coliform © Nitrate Date of sample: ''~ / ~ ~ / ~ 7 ". B. SEPTIC/HOLDING TANK DATA O- /' Other bacteria 7 Collected by: s · $ ~N~NEE~N~ ~ ~ ~ ~ ~ 17034 Eagle River Loop Road No. 2~ E~le River, Alaska 995~ Fluid depth in abso~q3tidn field before test (in.); Fluid de~ ' (ins) Minutes later: e~~roxlde treatment (past 12 months) (Y/N) Date installed Tank size Number of Compartments Cleanouts (Y/~bl-)-~ Foundation cleanout (Y/N) Depression (Y/N) High water alarm ~ Date of Punlping, "' ;' '~.- Pumper~__ /~ c. ABSOIibTiOa.F?LD DATA ';;'::" Date installed .... ' ............. ~ Soil rating (g.p.d./ff~ or ff~) ~ ~ System type ~ ....... :"'"'; ray/el~dk~es ' _ Length ~Width -'.? G s belOW pipe Total depth _ Effectiv% absOrption area ' Tube present (Y/N) Depression over field (Y/N) Date of adequacy test ' Results (Pass/Fail) For bedrooms Immediately after gal. water added (in.): Absorption rate = .g.p.d. If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* E. SEPARATION DISTANCES Size in gallons ~ "Pump on" lev "Pump off" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO:. Septic/holding tank on lot Absorption field on lot Public sewer main On adjacent lots On adjacent lots Public sewer manhole/cleanout Sewer/septic service line ;vT-/0 ' Lift station A,' ///) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation Property line ~ld Water main/service line .Surface water/drainag~~ Wells on adjacent lots SEPARATION DISTANCE FROM ABS~.~FIELD ON LOT TO,: Property line ....--'~uilding foundation Water main/service line Surface water Driveway, parking/vehicle storage area Cur ntat'h~drain Wells on adjacent lots F, HAA Fee $ ~ L~7'"~ "~'~ Date of Payment Receipt Number ENGINEER'S CERTIFICATION I certify that I have determined thru fie/d inspections and review of Municipa/reco~ms are ,nconformance w~th?/OA~,AAguidelinesineffectonthisdate. ~--~,;i~~f~,'~'~'~'~°--'-"~'~'~'~ Signature '~/~ ~~ ~ Engineer's Name ~ 0 ~ ~ ~ ~ C. ~ o ~ ~ ~ ' ~ 7 Waiver Fee $ ~ ~ ~. ~./ Date of Payment C'~._ ~ LC) -c~'-~ Receipt Number 72-026 (Rev. 3/96)* 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 RECEIVED AUG 20 1997 Municipality ot Anchorage Dept. Health & Human Services Parcel I.D.# O I~ 1. GENERAL INFORMATION : : " Complete legal description ~.ot iii'Block CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 3; Alpine ~illage Locatign,,(s, ite address or directions) ,,~' :,,..~.,"' .~.', ri', %. ' ~';;" ' ' ' ", ' v-'* ;2 zi.,.,~.,Prop(~rtY owne~'". ~'e~eryl Graan ........ '~ Seattle ""'J~ailing a'd~tess c/~ ~:t"':"~ending agency ,' f~ Mailing address '2. 7333 Basel Street Anchoraqe, AK Dayphone 344-8919 Mortgage 4300 "B" St. Suite 206 Smith)Anchorage, AK 99503 Jennifer Agent, Day phone Day phone Address 2: Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 3 'w XXX 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 NOTE: XXX If 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 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 S & -~ IfNGINI=ERING 17034 Eagle River Loop Road No. 204 Phone Date = DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments 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 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. 72-025 (Rev. 1/91) Back MOA ~21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: LOT- Health Authority Approval Checklist A. WELL DATA Well type Log present {~N) ¥ Total depth oj 0 Sanitary seal (~/N) If A, B, or C, attach ADEC letter. ADEC water system number /, Date completed Cased to ~ 0 4- Casing height (above ground) Wires properly protected ~N) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform O Date of sample: ~ j ~ ~ / ~ 7 B. SEPTIC/HOLDING TANK DATA FROM WELL LOG Nitrate AT INSPECTION g,p.m. g.p,m. l~¥ P~ £ I°Lo~a~ Collected by: Other bacteria 7 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Fluid depth ~before test (in.); F~____ (ins)M~Peroxide treatment (past 12 m~; I~tN~r: J Date installed Tank size Number of Compartments Cleanouts (Y/~N.)-~ Foundation cleanout (Y/N) Depression (Y/N) High water alarm (Y~N~ Date of P~r~l~i~g~ ~: i: i, ' ~'~.. Pumper ~__ ~ c. Date installed' ' ' ~ ~'j "'~' Soil rating (g.p.d./ff~ or~ __ System ~pe ~idth -J' Grav~ess below pipe ~Total depth Length '~' '' ' .:?' ~Tube present (WN) Depression over field (WN) Effective' absorption area _.. Date of adequacy test · ' Results (Pass/Fail) For bedrooms Immediately after gal, water added (in.): Absorption rate = g.p,d, If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) ~ High water alarm level at* ..,-- *Datum E. SEPARATION DISTANCES "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO:. Septic/holding tank on lot Absorption field on lot Public sewer main On adjacent lots On adjacent lots Public sewer manhole/cleanout Sewer/septic service line -M-7~) O ' Lift station A///,9 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation Property line Ab~l'~"'"'~ Water main/service line .Surface wate~Wells on adjacent lots SEPARATION DISTANCE FROM ABS~IELD ON LOTTO: Property line ..---'~uilding foundation Water main/service line Surface water ~ Driveway, parking/vehicle storage area Cur Wells on adjacent lots F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review in conformance w~th_MOA HA_A guidelines in effect on this date. Signature Engineer's Name. Date HAA Fee $ ~ ~"(~ Waiver Date of Payment ~/~5~//c/' ~ Date of Receipt Number ~ ~'~ ?-- ~-~--~"/~ Recei 72-026 (Rev. 3/96)* trCT&E Environmental Services Inc. CT&E Ref.# 974617001 Client Name S & S Engineering Project Name/# N/A Client Sample ID Lot 11, Blk 3 Alpine Village Matrix Drinking Water Ordered By PWSID 0 Sample Remarks: Client PO# Printed Date/Time 08/19/97 15:47 Collected Date/Time 08/14/97 10:30 Received Date/Time 08/14/97 11:10 Technical Director: Stephen C. Ede Released By~ ~ Parameter Nitrate-N Total Coliform Results PQL Units 0.100 U 0.100 mg/L 7 OB w/o coli per 100 ml Allowable Prep Analysis Method Limits Date Date Init SM18 4500-NO3F 10 max 08/15/97 JBL SM18 9222B 08/14/97 TMW Municipality of Anchorage "E0uEST FO" VOUC. E. C"ECK ,:FROM: Health and Human Services ii; ' (DEPARTMENT) TO! MUNICIPAL CONTROLLER ~DATE: September 18, 1997 1. THIS SECTION FOR ACCOUNTS PAYABLE USE ONLY ' REFEH~NCE NO. INVOICE DATE INVOICE NO. DESC CHECK DATE PREP APPR REQUEST THATA MUNICIPALITY OF ANCHORAGE CHECK BE ISSUED TO: Name S & S F..ngineertng Address 17034 Eagle River Loop Road, Suite 204 Eagle River, Alaska 99577 2. THI.SPAYMENTIS FOR THE FOLLOWING ~SUBSTANTIATION ATTACHED).. After the engineer re-measured the well to the a waiver of the "well to public sewer line" was feet of $920.00 to the above applicant. Lot 11 Block 3 Alpine Village Subdivision 3. DISposITION OF CHECK: .'7-------- pommunity sewer line it was discovered that not required. Please refund the waiver ~i (t) ~x MAiLTO PAYEE (2) [] MAILTO PAYEE WITH ATTACHMENT (3) [] NOTIFY PAYEE TO PICK UP IN TREASURY Name: Phone #: 4. ACCOUNTS TO BE CHARGED: DESCRIPTION Name: Org. #: (6) [] AUTHORIZED USE ONLY NOTIFY DEPARTMENT EMPLOYEE WHEN CHECK IS READY IN FINANCE Phone #: AMOUNT TOTAL AMOUNT OF CHECK Employee INSTRUCTIONS 343e4744 ~d~ Phone No. $ 920.00 Approving Authority a. To be used only when payment cannot be made by purchase order, travel expense report, travel authorization or petty cash. b. Must be approved by department head unless approval authority is delegated in accordance with Policy and Procedure 24-7. c. Retain carbon copy for your file. 40'001 (Rev 11/94)* Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Services Division Telephone: 343-4744 ON-SITE SERVICES FEE DOCUMENTATION Name of Payer: (Name on Check) O ealth Authority: ~ Sewer & Well Permit: Well Permit: Sewer Permit: Copy Request: 72-034 (Rev. 10/87) S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Permit Number: OS' 03184 Receipt #: Address: (Off of check) (s!' /.-.~.' .'~,' ,Check #: Legal es 'p i,~ Type of Payment: (Indicate Amount Paid) 7'~ --' ~/'//~ c~°~WAIVERS: Lot Line: Well to Tank: Excavator Permit: Engineer Permit: Pumper Permit: Well Driller Permit: Tank Manufacturer: (Waste Treatment) DISTRIBUTION: Field to Surface Water Tank to Surface Water WHITE--MASTER FILE CANARY--PROGRAM FILE Rick Mystrom, Mayor Mmdcipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 An, chorage, Alaska 99519-6650 343-4744 September 18, 1997 Robert C. Cowan, P.E. S & S Engineering 17034 Eagle River Loop Road, Suite 204 Eagle River, Alaska 99577 Re: Waiver Request For Lot 11 Block 3 Alpine Village Subdivision H. A. A. # HA970328, p. I. N. 014-133-29 Dear Mr. Cowan: Your request for waiver of the required separation distance between the water well serving the subject lot and the sewer service line serving the same lot has been approved. The approved separation distance is 10 feet. This approval applies the existing sewer service line and well separation only. Any future upgrade to either item will require all separation distances be met or another approval from this department. If you have any questions of the above please feel free to call me at 343-4744. Sincerely, Daniel J. Roth Civil Engineer On-Site Services MUNICIPALITY OF ANCHORAG= Department of Health and Human Services On-site Services Section Waiver Review ~orksheet $ WR%LL~_~L~2~LD_ PID% 014-133-29 HA% HA97~78 Date Received: September 10, 1997 Permit Legal Description: Lot 11 Block 3 Alpine Village Subdivision Engineer: Applicant: Robert C. Cowan, P.E,. S & S Engineering 17034 Eag-t~ Ri..ger Loop Road, Suite 204, Eagle River~ Alaska Cheryl Craan 99577 Waiver Requested: Private well and the public ~ewer main of 75 feat_.' and thru p.rivate well and the private sewer line at 10 feet Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: ~ Waiver is NOT Granted: List Conditions or Reasons for above: By: Name of Reviewer Rec ~: 03184/ Amount: $ 920.00 Date Paid: Se~t 10~ 1997 ~~~'-'----~.. ~L~ I ~...~~~unicipality v "~"DEPARTMENT September 8, 1997 ROBERT C. COWAN, P.E. of Anchorage OF HEALTH AND HUMAN SERVICES HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER &WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTEWATER DISPOSALSYSTEM DESIGN CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Lot 11, Block 3, Alpine Village Subdivision MUNICIPALITY OF ANCJ'IO~GE ENVIRONMENTAL SERVICES DIVISION SEP 10 1997 RECEIVED Request you issue a Health Authority Approval on the referenced property and grant a waiver for the horizontal separation distance between the private well and the public sewer main at 75feet; and the private well and the private sewer line at 10'. The mitigating factors involved which support the issuance of the waivers are as follows: 1. Well logs in the vicinity show mostly clay and gravel which would confine any released sewage from water bearing sand and gravel at about 90 feet to 120 feet (Attached). 2. The topography in the area, as shown on the site plan, is slightly sloped to the West. This would tend to direct any released effluent away from the well. 3. Nitrate sample taken from the well located on the referenced property indicated .1 mg/I. 4. Wells serving other properties throughout the neighborhood have been placed at similar distance from the public sewer line. With no well water related health problems reported, that we are aware of, this would appear to be an acceptable practice for the area. Attatched are surrounding well logs. We, therefore recommend a waiver for the separation distance between the well and the public sewer main, and a waiver between the well and the private sewer line. If we may be of further service please contact us. Sincerely, Robert C. Cowan, P.E. 17034 NORTH EAGLE RIVER LOOP SUITE 204 · EAGLE RIVER, ALASKA 99577 S--S-- ---s--s--s--s-- --s--~>--sn--s s / mm ---I-- S--S--S--S--S C~n BASEL STIlE]BT I-' o Z~ -- 0~ ~mZZ mm~mm ~mo~ ~Z zO HOUSE 10' UTILITY . APPLIr ',NT FILLS OUT UPPER HA' ONLY " i,J. '-'[' :\{f Phone PropertyOwn~er ('1( !:. ' t',U' ~ .... ~ ' ": ...... ,,~ Code Mailing Addre~ ~ '~ C: '~ /',~ ~, - '~/ .U"~ ~ , ~ Zip Buyer ~ ~ ~ ~ ~ (': >. :'. :.., . _. Lending Institution ~'~ f,~ ~.- ~'-'~ ~. t'. , ::' ("' ;.: : .,,:.. ,. ' :~- Phone .(:.., ,., L .... ZiP Code Address { . .... ~' L ' Realty Co. & Agent : ~ ( ~ . ? ~ }.~ .,~ , ~ ~,::. ~ .... Phone :. .... ~ /,' .. / ~:~ Address '.~-. ~' ~ ~:':' [~ ' ' ' -~ ~' v,. ~ ~ '. ~ ,'~' ' Zip Code Legal Description ~. ,. ~ I ~ ~'"'~ ~' ? ~'":~ ~ ¢;,,', ¢~- Street Locati~ [ ' ~ ' C': ~ Type of Residence ~ Single Family ~ Multiple Family No. of Bedrooms ~ Other Water Supply lndividual 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 Individual Installed: Public Utility ~o~ When Connected to Public Utility: /,'~')~?..~ ~ Holding Tank ..... ~ ~'' / ~ / NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED. Time Date Inspector Time Date Inspector Time Date Inspector Time Inspector ,/~ ~ ENVIRONM2NTAL PROTECTION RECEIVED C-~ ) APPROVED BEDROOMS ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL* DATE _ ~ "'-~( -~ '~''~ BY: >3 *CONDITIONS OF APPROVAL Soils Rating Date Sewer Installed 72-023 (3182) Well To Absorption Area Well to Tank Well Log Received Septic Tank Size