HomeMy WebLinkAboutLAKE RIDGE TERRACE BLK 3 LT 4Aim
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CHARLES G BALZARINI
CE-13854R
E
GISTEREDPROFE S S I O N A L E N GINEER
9/1/24
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C&M ENGINEERING SERVICES
Ph: 907-854-5558
Municipality of Anchorage
Onsite Water & Wastewater Program
4700 Elmore Rd Anchorage, Ak 99507
RE: Septic System for Lake Ridge Terrace Block 3 Lot 4A
Dear Reviewer,
We are requesting separation distance waivers for the subject property.
One of the existing leachfields is within 100 feet of the existing onsite private well. This encroachment has
existed for over 40 years. The standpipe for the encroaching leachfield was hidden when the current
owner purchased the home and was not reflected on the survey or other available documentation.
We are requesting approval of the reduced separation distance of 89.5 feet.
Approval of this waiver will not have a substantive impact on the property for the following reasons:
• The ground is sloped to direct surface spillage of effluent away from the well.
• The encroachment has existed for 40+ years with no apparent impact on nitrate levels in the
drinking water.
• The well log shows clay layers beginning at 47- feet of depth and a static water level of around
100-feet below the top of casing. The clay layer and other fine-grained soils identified on the well
log help protect the well from surface contaminants.
The septic tank was installed within 5-feet of the property line. We are requesting approval of a reduced
separation distance of 3.7-feet. The reason for the encroachment is related to poor survey control
available at the site. The adjacent property is State of Alask Right of Way for the highway and the
installation of the septic tank will not have an adverse impact on that property.
Approval of these waivers will not have a significant adverse impact on this or the surrounding properties,
or public health.
Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854-
5558 or by email cgbalzarini@gmail.com with any questions or concerns.
Sincerely,
Charles Balzarini, PE
8/23/24
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
hftp://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP241076
Work Type: SepticTank Upgrade
Tax Code Number: 05131305000
Site Legal Address: LAKE RIDGE TERRACE BLK 3 LT 4A G:0653
Site Mailing Address: 17822 JAMES WAY, Eagle River
Owner: SCHUBERT LAURA M
Design Engineer: C&M ENGINEERING SERVICES
This permit is for the construction of:
Effective Date
Expiration Date:
s aws� f.
J �
w�
Department
Lot Size in Sq Ft:
Total Bedrooms:
5/9/2024
5/9/2025
22647
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: SS 1� C Date:
Issued By: Date: Zo -7 -
3
MUNICIPALITY F ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section _ Fax: 907-343-7997
ON -SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 05131305000
Property owner(s) SCHUBERT
Mailing address
Site address 17822 JAMES WAY
Day phone
Legal description (Sub'd., Block & Lot) LAKE RIDGE TERRACE
Legal description (Township, Range & Section)
Lot Size 22,647 Sq. Ft. Number of Bedrooms 3
BLK 3 LT 4A
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(N all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) 0
Septic Tank
0
Upgrade
(w/wo ADU)
Holding Tank
ElRenewal
ElDuplex
(D) El
Privy
❑
Multiple Dwellings ❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
NONE Distance: NA
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
C&M ENGINEERING
(5lgnature of property owner or authorized agent)
Permit/Rush Fees: Z Z Waiver Fees:
17
Date of Payment: & Z Date of Payment:
Receipt Number: 3 -5- c V Receipt Number:
Permit No. 0 S P 2 %/ Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
C&M ENGINEERING SERVICES
Ph: 907-854-5558
Municipality of Anchorage
Onsite Water & Wastewater Program
4700 Elmore Rd Anchorage, Ak 99507
RE: Proposed Septic System for Lake Ridge Terrace Block 3 Lot 4A
Dear Reviewer,
The above referenced property is currently served by an older septic system with a leaking tank that
needs to be replaced. The owner is seeking COSA after the tank is replaced.
Our review of available documentation and field investigation show that this project will not adversely
impact any nearby Wells, Wastewater disposal systems, replacement disposal sites, or drainage flowing
onto and off of the subject property.
As shown on the plan, the tank will be greater than 10’ from the house foundation.
The tank will be of MOA approved construction.
The tank must be covered with a minimum of 2” moa approved insulation and 3’ of cover or a minimum of
4’ of cover without insulation.
The repair must be performed by a moa certified installer in accordance with MOA requirements.
If groundwater is encountered during excavation of the tank hole, an alternate tank type may be required.
Repair of the proposed system will not negatively impact adjacent lots.
Upon completion of the installation, a record drawing will be submitted showing the location of the new
tank, leach field, well, and other applicable features.
Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854-
5558 or by email cgbalzarini@gmail.com with any questions or concerns.
Sincerely,
Charles Balzarini, PE
4/23/24
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241076, Curtis Townsend, 05/09/24
CHARLES G BALZARINI
CE-13854REG
IST EREDPROFE S S I O N A L E N GINEER
4/23/24
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241076, Curtis Townsend, 05/09/24
09/05/1996 10:15 9076941211
S AND S ENGINEERING
PAGE 02
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QGREA'I'ER ANCHORAGE AREA BORCJGH
Department3330°f EnvironmentaIc Street Ouality
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE
FROM WELl
INSIDE LENGTH
NUMBER OF q
INSIDE WIDTH LIQUID DEPTH .LIQUID CAPACITY /<:::~ GALLONS,
SEEPAGE ~ 7~-~"4
NUMBER OF PITS ~, DIAMETER--
d~ /
LINING MATERIAL CRIB SIZE:
BUILDING FOUNDATION2~,
OR WIDTH ~,
DIAMETER
NEAREST LOT LINE J/
ADDITIONAL ABSORPTION
LENGTHY/DEPTH
DEPTH ~ DISTANCE FROM: WELL
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA)
.SQ. FT.
WELL:
TYPE
BUILDING
CESSPOOL
APPROVED
CONSTRUCTION
NEAREST ~¢
LOT LINE
OTHER SOURCES
DISAPPROVED
£7-~ </' OEPTH
NEAREST SEPTIC
SEWER LINE TANK
REMARKS
DISTANCE FROM:
SEEPAGE
SYSTEM
DISTANCES:
INSTALLED BY:
PIPE MATERIAL;
LOT SLOPE:
REMARKS:
DIAGRAM OF SYSTEM
F'E;F.:M I T' N I:]l.
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e-al Descrl tlon: Lot Block 3. Subdivision ~/O~/~-~D~E ~
Th~s ~orm ~epor ~ ~-~ '
Depth
Feet
/~'-- ~
Soll Cha~,zcteristics
Was Ground Viater Encountered? ~_ ' ~/~'
If .Yes, At khat 'Depth
Location Sketch
Reading J Date
, Gz'oss Time Net Time Depth To H20 Net DrOp
6;1.5" , /m ~ /,,~ z~/~ " Y~ ',
,~ ~/~ .3 ~/ff Y~ '~
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~212 ............
Proposed I,nstal~tion: Seepage Pit ~ Drain Field
Depth Of I:nlet Dep~h T8 B~'ttom 0~' Pit Or T~enc~~- ' '- '
COM~TS: ?~?..r~_7~ A ~r~'~~Z' ~_~,.~- ~~
Test Performed By:
Data Certified By:j~F~ Date:
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COSA Checklist_June 2022
COSA Checklist
Legal Description: Parcel ID:
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes go to bottom of effective.
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Adequacy test date
Results Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
Comments/Deficiencies:
COSA Checklist_June 2022
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F.ENGINEER’S COMMENTS
G.CERTIFICATION & 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 Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Phone
Engineer’s Printed Name Date
C&M ENGINEERING
CHARLES BALZARINI, PE 8/10/24
i
1 LOT 1
\ PLAT #2015-66
�T
N
cO
O
/LOT
5A
BLOCK 3 N
U, 100'
O RAC
LOT 12A
BLOCK 3
LOT 2
I PLAT #2015-66
O
cn
JAMES
(N 89°53'00" W
(2.93')
POWER POLE
/ 4u
4 /
MH
SEPTIC TANK LID
WELL
MAILBOX
411
0
CONCRETE
BRICK PAVERS
X19.0'
�4u
/
ESMT. PROHIBITING
VEHICULAR
_1'
ACCESS
Tb
NEW GLENN
HWY
/
/
4u
/
4u
PP
�
ASPLS MORTGAGE LOCATION SURVEY NOTES:
NO TITLE REPORT WAS PERFORMED FOR THIS SURVEY, EASEMENTS SHOWN PER THE
RECORD PLAT. THERE MAY BE ADDITIONAL EASEMENTS NOT SHOWN HEREON. THIS
MORTGAGE LOCATION SURVEY HAS BEEN PREPARED IN ACCORDANCE WITH ASPLS
MORTGAGE LOCATION SURVEY STANDARDS. IT IS A REPRESENTATION OF THE
CONDITIONS THAT WERE FOUND AT THE TIME OF THE SURVEY. THIS SURVEY DOES
NOT CONSTITUTE A BOUNDARY SURVEY AND IS SUBJECT TO ANY INACCURACIES THAT
A SUBSEQUENT BOUNDARY SURVEY MAY DISCLOSE. THE INFORMATION CONTAINED IN
THIS DRAWING SHALL NOT BE USED TO ESTABLISH ANY FENCE, STRUCTURE, OR
OTHER IMPROVEMENTS. UNLESS GROSS NEGLIGENCE IS DISCOVERED, THE LIABILITY
EXTENT OF THE PREPARER SHALL BE LIMITED TO THE AMOUNT OF FEES COLLECTED
FOR SERVICES IN PREPARATION OF THIS PRODUCT.
LEGEND
O RECORD DATA PER PLAT #71-293
FOUND CONCRETE R.O.W. MONUMENT
O FOUND 1/2" REBAR, NO CAP
GRAVEL DRIVEWAY
EDGE OF ASPHALT
— E E — OVERHEAD UTILITIES
P
POWER POLE
SEPTIC PIPE
MH
SEPTIC TANK LID
WELL
MAILBOX
DECK
0
CONCRETE
BRICK PAVERS
0' 30' 60'
SCALE: V= 30 FEET
(11"x17")
_"F A�gsl
j *•••49TH...... •:*
J
-Ryan G. Johnson;
r�+,••No. 192159 ,•�
8f29/202.4••S;
AS—BUILT OF:
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.# ~-~'\ -~/;z~-C'~
1. GENERAL INFORMATION
Complete !egal description
Lot 4A; Block
Lake Ridqe Terrace
Location (site address or directions)
17822 James Way
Property owner :, Joe Owens
Mailing address..' P.O. Box 772633
Lending agency
Mailing address'
Eaqle River, AK
Eagle River,
Day phone 694-1602
AK 99577
Day phone
,Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well XXX
Community well
Public water
NOTE:
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 s & s ENGINEERING
i~0.~4 F. ag;~ F.;,~r ;.,~p ~.,~,,J ',..;~. =C,.4 Phone ~ ~ - ~ c~ ?~]
Address Eagle River, Alaska 99577 - ,-
EngineeCssignature '-)/"~/~''~- .~.-x,----- 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'~ work.
72-025 (Rev. 1/91) Back MOA ~21
Municipality of Anchorage ~',_41~\
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744~U~Op^Lir~O~C~O~O~
Health Authority Approval Checklist ENVIRONIHEN~ALSERVJCF..SDJVi$10&
Legal Description:
A. WELL DATA
Well type
Log present ((~N)
Total depth
Sanitary seal ~)'N)
Date of test
I
Static water level lea
Well production q. ~
AUG 02 996
¢,~.oc~ S;L,~ Parcel I.D.:
RECEIVED
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed '7 ~ ?- ~ - 1 o
Cased to liE, Casing height (above ground)
Wires properly protected (~'N) ¥~
FROM WELL LOG
AT INSPECTION
-/
I
g.p.m, g.p.m.
WATER SAMPLE RESULTS:
Coliform C) Nitrate
O, I o Other bacteria 0
Date of sample:
Collected by:
B. ~HOLDING TANK DATA
Date installed .~/"77 Tank size
Foundation cleanout (~N) ,,{'¢.
Date of Pumping qf
C. ABSORPTION FIELD DATA ~
Date installed ~/7~/ '
Lepgth.~'z. ~ m") = ~z' Width,
Eff~btive absorption area "~"/
Date of a~'equacy test "7 -~"~-~
/ooo
Depression (Y~ /,,Jo
Pumper ,,~ ~, ~,)~e,,4 r_.
Number of Compartments
High water alarm (Y~ /Jo
Soil rating (g.p.d./fF or ft2/bdrm) 2e5 ~,//~. System type -T-~z~4c,4
Gravel thickness below pipe C Total depth
Monitoring Tube present (~N) ~ <~ Depression over field (Y~ /'J o
Results (l~/Fail) 1¢A5¢ For -~ bedrooms
Fluid depth in absorption field before test (in.); I I Immediately after-~ffo gal. water added (in.):
-2N'~
Fluid depth (ins) Minutes later: 72.~ ,~.J Absorption rate
= .g.p.d.
Peroxide treatment (past 12 months) (Y/N) t,/~e ~4~,~1 If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N)
~ig~ w~ *Datum
.Cyete'C~sted
E, SEPARATION DISTANCES
~__ept-"~ho,lding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
SEPARATION DISTANCES FROM WELL ON LOT TO:
Io~+
;2~I P
SEPARATION DISTANCES FROMi~-~'(~HOLDING TANK ON LOTTO:
Foundation lO i + Property line I o ~ -~ Absorption field
Water main/service line I o Surface water/drainage I¢oI ~- Wells on adjacent lots
On adjacent lots
On adjacent lots Io o
Public sewer manhole/cleanout
Lift station /~/A
loc?-{--
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Surface water
Curtain drain
Building foundation
I
Water main/service line I o -+
F. ENGINEER'S CERTIFICATION
Driveway, parking/vehicle storage area
Wells on adjacent lots
I certi~ that I have determined thru field inspections and rewew of Municipal records th~~, ~s are
* conformance with MOA H~ gui¢lines in effect on this date.
Signatur
~:~ ROBERT C; C.OWAN
Date ~ /~/ ~6
HAA Fee $~
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
RIGHT OF WAY BRANCH
Juli 2, 1996
Re:
Letter of Non-Objection for
Septic System Encroachment
New Glenn Highway Frontage Road
R/W ID #210.105
Mr. Joe Owens
P.O. Box 772638
Eagle River, Al( 99§77
Dear Mr. Owens:
The Department of Transportation and Public Facilities has no objection to the
encroachment of your septic system into approximately one foot of the right of way of the
Frontage Road on the west side of the New Glenn Highway.
It is understood that the encroachment will have no adverse effects or incur any costs or
liability to the State of Alaska. You will be responsible for adherence to the following items:
The right of way shall be occupied for the purpose stated above and for no other
purpose or purposes, without the written consent of the State, and that you will not
use the right of way for any purpose in violation of any law. municipal ordinance or
regulation.
The owner shail adjust or relocate the encroachment without cost or Liability to the
State if, at any time, or from time to time, the use or safety of the highway within
which the encroachment exists requires that the encroachment be adjusted or
relocated.
The encroachment shall be constructed and maintained by the owner in such a
manner that the highway, and all of its appurtenances or facilities including, but not
limited to, all drainage facilities, pipes, culverts, and ditches, and their safety shall not
be impaired in any way by the construction or maintenance.
The owner shall hold and save the State, its officers, agents and employees,
harmless from liability of any nature or kind, including costs and expenses, for or on
account of any or all suits or damages of any character whatsoever resulting from
injuries or damages sustained by any person or persons or property by virtue of the
encroachment permitted herein.
Mr. Owens
-2- July 2, ~996
The owner shall not place additional improvements within the right of way, and, if at
anv time in the future, the existing encroachment is destroyed, removed or rebuilt for
any reason whatsoever, it shall net again be placed within the right of way unless
authorized by separate agreement.
This letter of non-objection is subject to any applicable federal law, regulation, or
policy and procedure memorandum of the Federal Highway Administration.
Nothing in the transfer of use or any rights granted to the owner under this -
agreement shatl be construed to have granted to the owner any right to convey,
assign, ~ i~ ~ ~o transfer a~y rights in said property without prior approval by
the State.
If any provisions or covenants of this Letter of Non-Objection are violated, then this Letter
shall be revoked and null and void if said violation is not corrected after the owner has
received written notification by the State of said violation or noncompliance, and has had a
reasonable time to correct said violation to conform to this agreement.
This Letter of Non-Objection will be revocable in the event that the right of way ceases to
be used or is abandoned, and the provisions of this agreement may be in writing altered,
changed, or amended by the mutual consent of the parties hereto. The State, however,
reserves the right to terminate this agreement by ninety (90) days written notice if said
property is needed for highway purposes.
Please sign the acknowledgment below and return this letter to our office for the non-
objection to be valid.
Sincerely,
Right of Way Agent
cc: Bill Mowt, Maintenance & Operations, Anchorage
ACKNOWLEDGMENT OF RECEIPT AND UNDERSTANDING:
JOE'JDWENS DATE
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Anchorage,•. Cc
24S-339•',
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
GENERAL INFORMATION
(a)
Application Date
/!
Legal Description (include lot, block, subdivision, section,~wnship, ~g~)
Location (address or directions)
(b> Applicant Name ~ /LO ~/~/¢~.~z.,~) Telephone: Home
ApplicantAddres~rs /~' ,~'-'- ,¢¢~-~..¢~ ?~¢?~.y..~
(c) Applicant is (check one): Lending Institution []; Owner/builder ~; Buyer []; Other [] (explain);
(d) Lending Institution /~'~,-~-~"
Address ~~-
(e) Real Estate Company and Agent
Address
.~.e_l.~e~p h o n e
(f) 4~il-the HAA to the following address:
TYPE OF RESIDENCE
Single-Family, S' Multi-Family []
Number of Bedrooms *, %'
Other
WATER SUPPLY
Well, J~' Community [] Public []
Individual
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, j~ Public [] Community [] Holding Tank []
Note: If community well system, must have written ~0nfi~'~n~tion from the State Department of Environmental Conservation
attesting to the lega. lity and status. ' ~ ~
Page I of 2 72-025 (11/84)
'ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DA iA 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.
$ & $ ENGINEERING
Name of Firm
SRB 196X
Address
EAGLE RIVER, Al(, ¥V517
Date
Telephone
DHEP APPROVAL C/~'-~') ~ /'° ~' .~,
Approved ,0r ~.~-~e'ed room s by (~'i'~ ~'/-'~; ~ ~: ~'" '" ~-' ~'~ Date
Approved ~ Disapprove8 Conditional
Terms of Conditidnal Approval
CAUTION
The Muncipality of Anchorage Department of Health~ ~'n~tI ~"n)vironmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requ, ir, ements. Employees of DHEP 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.
Page 2 of 2
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: L.o'F
Well Classification
Well Log Present ~N)
Total Depth lol ~ Cased to
Static Water Level
Casing Height Abc~ve Ground
Electrical Wiring in Conduit J~N)
Separation Distances from Well:
To~Holding Tank on Lot / ~O¢
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Dat~C~m~ ere d
C/ ','~Depth of Grouting
Pump Set At
/1~~ Sanitary Seal on Casing
Depression Around Wellhead (Y~
If A, B, C, D.E.C. Approved (Y/N)
Yield
; On Adjoining Lots
; On Adjoining Lots
?~./"A To Nearest Public Sewer
/"/;?',~' ' ' TO Nearest Sewer Service Line on Lot
; Date
Comments ~,'~1~ J~ xl I ~-.4~
'" '
B. ~I't~TANK DATA
Date Installed <~/~" Size {~O ¢/1~, No. of Compartments
Standpipes (~) Air-tight Caps (~N)
Depression over Tank (Y~)
Pu m ping/Maintenance Contract on File (Y/N~.i//~ ~///~.
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
TO Property Line
TO Water Main/Service Line
Course ~:
Foundation Cleanout (YN~
Date Last Pumped
· for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~:~/
Width of Field ~ t
Square Feet of Absorption Area
Depression over Field (Y/(~
Results of Last ,Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
~/~,-/F.../ Type of System Design
Length of Field ~"VV ~ -
Depth of Field
Gravel Bed Thickness
Standpipes Present (~N)
Date of Last Adequacy Test
· /'~2(:~/ To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
~ /~' "¢" TO Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons /~.///'~
'Itl
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Oodes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and H.AA guidelines in effect on the date of this inspection.
~ , S & S ENGINEERING Date /~"'/'~ .~"/ ~
~ignea ____. ~;'
SR B 196X (2/ ~o
Company ..... MOA No. o,-- ~ ~
e.A~LE RIVER, AK 99577
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
Q "
MUNICIPALITY OF ANCHORAGE
~ DEPARTMENT OF HEALTH & ENVl RONMENTAL PROTECTION
) 825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER PHONE
MAIEING
P~OPE~T? ~ESIDENT (If differ~ from ebove) PHONE
2. BUYERU - PHONE
3, LEND BQI~STITUTIO~ PHONE
MAI LIN G' ADDR ESS
4. REALTOR/AGENT ~ I PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE O rj
~ SINGLE FAMILY
[] MULTIPLE FAMILY
?. WATER. 8/IJPPLY [~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
NUMBER OF BEDROOMS
[] One [] Four
[] Two [] Five
[] Three [] Six
[] Other
* ATTACH WELL LOG. A well log is requ'ired for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM ,~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
**If individual/on-site, give installation date /~' ~ 7
If system is over two (2) vears old an adequacy test is required
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
DATE RECEIVED
INSPECTION APPOINTMENTS
'IME TIME TIME
DATE DATE DATE
INSPECTOR
DIRECTIONS:
INSPECTOR
INSPECTOR
1. TYPE OF RESIDENCE
SINGLE FAMILY
MULTIPLE FAMILY
2. WATER SUPPLY
INDIVIDUAL
E] COMMUNITY
PUBLIC UTILITY
Connection Verified
3. Sf?~/AGE DISPOSAL SYSTEM
EZ]INDIVIDUAL/ON -SITE
E~PUBLIC UTILITY
Connection Verified
[~]Septic Tank or EJHolding Tank
Size: ../~) ¢-~ If Tank is homemade
give dimensions:
TYPE OF TANK
TOTALABSORPTION AREA
NUMBER OF BEDROOMS
E~ ONE [] THREE [] FIVE
[] TWO [] FOUR [] SIX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATEINSTALLED
INSTALLER
SOILS RATING
MANUFACTURER
[] OTHER
4. DISTANCES Septic/Rolding Tank Absorption Area Sewer Line I Nearest Lot Line
I
WELL TO:
Absorl:,tion Area to nearest Lot Line
5. COMMENTS
DATE
LEGAt. DESCRIPTION
~ APPROVED FOR -~ BEDROOMS
[Z~ CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
BY (Title)
72-010 IRev, 3/78)
%,Tmrlifi�b Nn-1 n frivig
by
A & 1, DRMLING COM PANY
BOX 97, EAGLE RIVER, ALASKA 99577 a TELEPHONE 694-2588
' - t J-00
_;,�:(,j (,�/ 1, ri,
OWNER OF LAND -%, � I �✓, i,`dcYF-K DEPTH OF WELL
ADDRESS STATIC LEVEL OF WATER FT
LEGAL DESCRIPTION- Z-14 DRAW DOWN FT.
1-7 7.
DATE - Started Ended GALS. PER HR
PERMIT NUMBER 77171 KIND OF CASING
KIND OF FORMATION:
From —'Ft. to Ft. From Ft. to Ft.
I -- From Ft. to Ft. From Ft. toFt.
�14 —i From Ft. to Ft.
From Ft. to —'.Ft.
From Ft. to Ft. 77�4t5 From Ft. to Ft.
From Ft. to Ft RL-F, /133 15 /)"?0 c- e From Ft. toFt
From Z) Ft. to Ft. 6WEe,., From Ft. to Ft.
From Ft. to d Ft. J 'From Ft. to Ft.
From Ft. to - Ft. F1 fe- 7 /Q_ c I%,- From Ft. to Ft.
From Ft. to Ft. From —Ft. to Ft.
From Ft. to Ft. From Ft. to Ft.
From Ft. to Ft. From Ft. to Ft.
From Ft. to Ft. From Ft. to Ft.
From Ft. to Ft. From Ft. to Ft.
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MISCL. INFORMATION:
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DRILLER'S NAME
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QnHfi�b lnAhng Toy
by
A & II_, DRMMN& AA`VI11A NY
BOX 97, EAGLE RIVER, ALASKA 99577 o TELEPHONE 694-2588
OWNER OF LAND ? 1 14 C NC tC DEPTH OF WELL (� B
ADDRESS STATIC LEVEL OF WATER FT.
LEGAL DESCRIPTION 4/4 64k C'?W DRAW DOWN FT. D {
DATE - Started !-, r %l ' l7 -7 Ended 6 1' i `i GALS. PER HR
PERMIT NUMBER % 7 1 -7 1 KIND OF CASING to 1 -0
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