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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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ['~\lr~- I-'l~- \-'~ HAA#
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) I lflqO Hoe, T~t[~'~ ~i~V¢N
Property owner
Mailing address
Lending agency C t'r'f
Mailing address
Agent PETI~
$TfI.Dt, z t.'/ Day phone
E, loft A /c l, J/<
MORT GfIGE' t.~e,'o~) Day phone
2'7/- 23 18
27'7~ 080(0
5TRANG, ~£11/~ Day phone 2-5'7 - ol ~,~
Address ~-¢¢0 d'or-~'¢~,~x.
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
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
NOTE: 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/orwastewaterdisposalsystem 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.
NameofFirm FL^FTOP T£CH. $vc£ ~Ur,..S-~ 13£5'
Address IH- 5,3o
Engineer's signature
6. DHHS SIGNATURE
Approved for -~ bedrooms.
Disapproved.
Conditional approval for
Phone
Date.
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /-.aT ~ BLI( 3 ~l~/~kt~ Parcel I.D.
A. WELL DATA
Well type ~'~¢'~TE
Log present (Y/N)
Total depth Jl~ t
Sanitary seal (Y/N)
Y
If A, B. or C, attach ADEC letter. ADEC water system number
Date completed ,ff_/~.$c/ Driller /~l~
Cased to 1lur ~ Casing height
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
; On adjacent lots
; On adjacent lots N.
Date of test
Static water level
Well flow 2.
Pump level
SE-'PARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot K,,~,
Absorption field on lot
g,p.m.
Public sewer main '~
Sewer service line 70 '
WATER SAMPLE RESULTS:
Coliform C2 cc,[
Date of sample: ~" / 6
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Public sewer manhole/cleanout 7;>/cO'
Petroleum tank
Nitrate ~-. ¢. / ~,~'/-~-
Other
bacteria
5/8~7/?,.~ Collected by:
Tank size Compartments
Foundation cleanout (Y/N) Depression (Y/N)
Alarm tested (Y/N)
Pumper
,.5 YeS,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surface water/drainage
On adjacent lots
_Absorption field _
Foundation_
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
Width
Date installed
Length
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots
(
Soil rating
Gravel thickness
Cleanouts present (Y/N)
Date of adequacy test
for
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
E. ENGINEER'S CERTIFICATION
Surface water
System type
Total depth
bedrooms
If yes, give date
On adjacent lots Property line
To existing or abandoned system on lot
Cutbank Water main/service line
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines ~a6t on the date of this inspection
· ,~',,~. ,, .~.-~,,~ .
Engineer's Name ~~ ~ ~
Date ~ 2), /~27
HAA Fee $ ¢'?¢ °'-"'~
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee:$ ~-~0 ~ 6~,~'// - se~'
Date of Payment
Receipt Number
Tom Fink,
Mayor
N uni,.Apality Ar ct orage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
June 28, 1993
Ted Moore, P.E.
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
Subject: Waiver Request for Lot 8 Bloc]( 3 Kramp Subdivision
Waiver Request #WR930030, PID #016-171-71, HA930277
Dear Mr. Moore:
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 42 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.
Sincerely,
Daniel J. Roth
Civil Engineer
On-site Services
On-site Services
ljw#8
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR# WR930030 PID# 016-171-17 HA# HA930277
Date Received: June 2, 1993
Permit
Legal Description: ]Jot 8 Block 3 Kramp Subdivision
Engineer: Ted Moore, P.E., Flattop Technical Services
14530 Echo Street, Anchorage, Alaska 99516
Applicant: Mary Stadum
Waiver Requested: Well to public sewer line - 42 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: ~ .~.,~.~[~
Date:
Reviewer
Rec #: 24751 Amount: $ 590.00 Date Paid: June 2, 1993
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TECHNICAL:
CIVIL & ENVIRONMENTAl. ENGINEERING ', ENERGY CONSERVATION & ANALYSIS
THEODORE F. MOORE, P.E, 14530 ECHO ST.
PH: (907) 345-1355 June ~ z, 1993 ANCHORAGE, ALASKA 99516
M.O.A. DHHS
P.O. Box 196650
Anchorage, AK 99519
RE: Lot 8, Block 3, I~'amp S/D, Well - sewer sepm'ation distance waiver
Dem' Sirs:
By means of this letter we ale requesting issuance of a waiver allowing the existing private well on Lot
8, Block 3, Kramp S/D to be 42 feet from a public sewer line, instead of the 75 feet called for in Municipal
and State regulations. A site plan and copies of the well log, sewer as-built and other relevant backup
documents are enclosed for your reference.
According to the driller's log the well was completed in May of 1984, is cased to 114 feet,and has a
yield of 25 gpm. The log shows there to be relatively impermeable silt strata between 3 and 35 feet as
well as between 43 and 90 feet below ground level. The aquifer being &'awn upon by this well was
encountered between 110 and 114 feet below gn'ound level, and the fact that the static water level was
reported to be at 53 feet indicates that the aquifer is confined and m'tesian.
On May 10 we conducted a yield test of the well. On the date of our test the static water level stood at
37 feet below the top of the casing. Steady pumping of 722 gallons of water from the well at the
maximum pump output of 7.7 gpm caused the water level inside the casing to be ch'awn down to 54 feet,
but no further. Based on this test data we determined that the total yield of the well is in excess of 7.7
gpm, which is more than adequate to meet Municipal criteria; the well also meets the FHA lending criteria
which requires that it be able to supply 720 gallons of water within a 4 hour period. Water samples
collected on May 6 were satisfactory, showing no detectable nitrates and 0 col/100 ml of coliform bacteria.
The bacteria sample did, however, contain 2 colonies of unidentified other bacteria, apparently due to a
defective well seal. After the well seal was l'epait'ed and the well disinfected, the lab test results for a new
sample collected on May 27 showed no coliform or other bacteria.
In the summer of 1984, a few months after the well was ch'illed on the subject lot, an 8" Class 50
D.I.P. sanitm'y sewer was installed 10 feet south of the southern property line of the subject lot to serve
the Devonshire Subdivision (see enclosed excerpt from the AWWU as-built drawing). Based on a
combination of the property as-built survey and the sewer as-built di'awing, we determined that this sewer
line passes approximately 42 feet away fi'om the well on the subject lot. Apparently, neither the engineer,
the installer nor AWWU noticed this well, as there is no notation of it on any of the sewer ch'awings, nor is
there any record of a waiver ever being obtained.
The following is a breakdown of how waiver analysis points could be assigned using the DEC
SCRO's 1985 "Sepm'ation Distance Waiver Guidelines".
Category Points
Distance to aquifer (aquifer depth 110' - sewer depth 11' = 99') 6.9
Soil Smption (well log reports predominantly silt between 11' and 110') 3.5
Soil Type (predominantly soil with perc rate slower than 50 rain/in) 3.0
Water table gradient (assume 0%, pm'allel to ground surface) 2.9
Horizontal separation (42 feet) 0,9
Total 17.2
Based on this point assignment, there does not appem' to be any th'eat of contamination. Fm'ther
mitigating factors include: (1) the aquifer is confined/artesian, meaning that contamination originating in
the immediate vicinity would not be able to make its way into the aquifer, and (2) the sewer line was
consu'ucted to a high standm'd of Class 50 ductile h'on pipe, and has gasketed joints mid was pressure
tested before being placed in sm'vice.
For the above reasons it is my professional opinion that the requested waiver can be granted without
concern as to potential contamination of the subject well by effluent leaking fi.om the portion of the sewer
line which passes closer than 75 feet from it. Please give me a call if you have any questions on this
analysis. Anything you can do to expedite the waiver process will be most appreciated.
cc: John and Mary Stadum
Sincerely,
Ted Moore, P.E.
LOT 15'
~" b. I. P,
MANHOLE
LoT ~7 E, LK 5
LOT ~
LOT [t¥
/
SE~ER
LoT I0 BLK?.
~L~ ~ ~ ~ WELL
t House 2
Flattop Technical Services
14530 Echo Street
Anchorage, Alasl:a 99516
LoT 9 BLK3 KR~MP SuB.
SITE
SCALE ' I" = go'
DA-T £ '.
D~N 85': ~
NOTEt TH[5 IS NoT'
A SoRV£'~EB P/AT
ALL LOCATIONS
ARE A?PRo× ~tqAT£
COMMERCIAL TESTING & ENGINEERING CO.
ENVIRONMENTAL LABORATORY SERVICES
5633 B STREET
ANCHORAGE, AK 99518
TEL: (907) 562-2343
FAX: (907) 561-5301
~ SGS Member of the SGS Group (Soci~,~ G~n~rale de Surveillance)
ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, wEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMEWI'AL HEALTH
DEPARTMENT OF HEALTH AND E~IVIRONMENTAL PROTECTION
APPLICATION FOR ~EALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
(a) Legal. ~Description (include iot~ block, subdivision
Location (addle.ss or directions)
(b) Applicants Name
Applicants Address ~'[~t) t:_, l~'~LOf-'~)~bL "][~:{)1 I~,
Application Date
, section, township, range)
(c) Applicant is (check one) Lending Institution
Buyer 2--~[ ; Other -~--I (explain)~
(d) Lending Institution
(f) Mail the H~ to the following address:
Telephone
2. T_zpe of Residence
Single-Family ~
Number of Bedrooms
Multi-Family
Other (describe)
Water S up_~y_ ',
Individual Well ~-~ Community L~ Public ~ZZI
Note: If community well system, must have written confirmation from the State
Department of Environmental Conse~ation attesting to the legality and .status.
Note: If commnnity well system, must have ~itten confi~:mation from the State
Department of ~llvi~ogpte~tal Conse~v~tio~ ,~ttesti~8 to the legality and status.
[Page 1 of 2]
!5. .En=~gineerin_g Firm Providing Inspections, Tests, F~e.~S_9_~%.r__c.~.~ Data and Information
As certified by my seal affixed hereto and as of the validation date shown belo~¢, I
verify that my investigation of this ttealth Authority Approwtl 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 ~.~th all Municipal and State codes, ordinances~ and regula-
tions in effect on the date of this inspection.
Date
Dtmi' A_EE.r_of2~l~
Approved for .~. __ bedrooms
Apprcved ~.. Disapprow~d
Te~s of Condit:i.onal Approval
CA~£ION
THE; I~ONICIPALITY £iF ,DICHORAGE DEPARTMENT OF HEALTH A2'tD ENViRON,MENTAL PROTECTION
(DHEP) ISSUES tlEALTH AUTHORITY APPROVAL CERTIFICATES BASEl) SOLELY UPON TI!E REPRESENT-
ATIONS GIVEN IN PJ..I~XGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGI,¥EER REGISTERED
IN Tile STATE OF ALASKA. THE DHEP DOES %'HIS AS A COGRTESY TO PURCItA. SERS 07 HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERJL ~52qD STATE REQUIRE-.
~IENTS. EblPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANAI,YZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE blUNICiPALITY OF ANCHORAOE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAl, ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7.-1 9
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH /HJTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
MUNICIPALITY OF ANCHORAOI~
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
Well Classification
Well Log P~esent (_Y/N)
Total Depth ~l ~
Static Water Level
Ca
_ Date Oat~31eted ~ul &-8~
e ced to I1~' ~ Depth of G~outing
.... ~3! ~ Pump Set At ~)[%~n~3~
Casing Height Above G~ound
Eleatmical Wiring in Conduit (Y/N)
Separation Distances f~om Well:
Sanita~,y Seal on Casing (~
· Depression A~ound Wellhead (Y/N)7~
To Septic/Holding Tar~k on Lot .~t~{,8.[J'~';~l!(a.~ ; ~ ~joinin~ Lots
To ~a~est Ed~ of ~so~ption Field on ~t ~ ; ~ Adjoining ~ts
To Nearest ~blie ~ Line ~l TO ~est Public ~
Clean~t~anhole /~O' To ~est ~ ~vi~ Li~ on ~t
Wate~ S~le Collected By ~O~1~ ; ~te ~7~' ~
Wate~ S~le Test ~sults ~~
Be
Date Installed Size No. of Cc~f~a~tmsnts
Standpipes (Y/N) Aid-tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression ove~ Tank _(y/N) Date Last Pumped
Pun~ping/Maintenance Con~aet~ File (Y/N) ; fo~
Holding Tank HighTW~te~ Alarm (Y~) Temporary Holding Tank Permit (Y/N)
/
Separation Distances f~om Septic/Ho~.b~g Tank:
To Wator-SuDp//y Well
To Property~ine
To Water Ma~n/Se~vice
Course
Line
lding Foundation
~ Field
TO Stream, P6~d~La~e, c~ Major D~ainage
Comnents
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of ~s on
Depression ove~Field (Y/N)
/
Results of ~st Adequacy Test
Separation/Distanoe f~omAbsorptionF~ld:
To WaterTSupply Well
To Build~ng Foundation
Lot
To Water Main/Service Line
Type of System Design
LenGth of Field
Depth of Field
Gravel Bed Thickness
Standpipes P~esent (Y/N)
Date of Last Adequacy Test
~ToP~operty Line
T~ooE~sting or Abandoned System Ch
; On Adjoining Lots
To Cutbank(.if present)
To Stream/Pond/Lake/c~ Major Drainage Course
To Driveway, Parking A~ea, o~ Vehicle Storage Amea
Comments
LIFT STATION
Date Installed
Dimensions
Size in Gallons
High Water Al/at'Level at
Tested fo~/
Electrical Codes(Y/N)
'-~ Manhole/Access (Y/N)
xx~. ~ Off" Level at
Vent (Y/N)
Pumping Cycles~~quacy Test.
Meets MOA
Cc~fu~nts
** Check Permitted Bedroom Rating A(3ainst HAA Raquest
certify that I have checked, verified, or conformed to all MOA HAA
on the date of this inspection.
S~gned ~'~ / ~- ' ~' ~l Date
KB1/d5/s
~lines in effect
[Page 2 of 2]
2-15-84
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