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HomeMy WebLinkAboutT12N R4W SEC 10 LT 52A (BLM)
HEFTY DRILLING
Well Water - it's naturally betted
3540 AKULA DRIVE TELEPHONE:
ANCHORAGE, ALASKA 99516 (907) 345-0593
Date Drilled : 6-24-93
Static Water Level 45 . Feet
Draw Down N/A Feet
Norm Burgess
8936 Gloralee
Anch. Ak 99502
Gallons Per Minute 12
Total Feet of Casing 140
Type Material Drilled:
0 ft.
138 ft.
to
to
to
138 ft. Clay
140 ft. Fine gravel W H20
to
to
to
to
to
to
3540 AKULA DPJVE
ANC~0RA~, Al( 99515
(907) 345-0593 ~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW930166
DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES
OWNER NAME:BURGESS NORMAN W &
OWNER ADDRESS:8848 GLORALEE ST
ANCHORAGE, ALASKA 99502
PAGE 1 OF 1
DATE ISSUED: 6/21/93
EXPIRATION DATE: 6/21/94
PARCEL ID:01121362
LEGAL DESCRIPTION: T12N R4W SEC 10 LT 52A (BLM)
LOT SIZE: 21428 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVIS~
DATE:
.LOT
Flou s£
R.0. ~'. LOT ~/]
LOT
s2 A
HOUSE
JE~/£LL LAKF
LOT ~/~
D.I.R S£~ER '
BLM LOT ..c2A, SEC I0, TIZN~
-SIT~c PLAN
..SCALE: I'''=
NOTE: THIS IS NoT
A Su~VEyEb PLAT.
ALL LOCATIONS
/~RE A?P RoX IM~TE'.
Tom Fink,
Mayor
vtunic p lity of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
June 16, 1993
Ted Moore, P.E.
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
Re: Waiver Request For T12N R4W Section 10 BLM Lot 52A, Health
Authority Number HA930266, P.I.D. 011-213-62
Dear Mr. Moore:
Your request for waiver of the required separation distance of
75 feet between a single family well to a public sewer line has
been denied. The requested separation distance is 38 feet.
As stated in the memorandum dated January 3, 19851 from the
Alaska Department of Environmental Conservation, section 3,
paragraph a), "Consider how much of a waiver is requested (what
% of the separation needs to be waived)." The subject waiver is
requesting approximately a 50% reduction in the required
separation distance of 75 feet. This is an unwarranted
reduction in the required separation distance when considering
that there is adequate area on the subject lot to construct a
well and maintain the required separation distance from the
public sewer line in question.'
It should also be noted that the subject well was drilled
without a permit from this office. Had the property owner
applied for a permit when the well was drilled in 1991, we would
have required that all separation distances be satisfied.
If you have any questions of the above,
phone.
Daniel J. Roth
Civil Engineer
On-Site Services
please contact me by
/~6hn Sm~hh, P.E.
~Prog ra~f Manager
On-Site Services
#220
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR# ~q.~.~ PID# 011-213-62
Date Received: May 27r 1993
Legal Description: T12N R4W Section 10 Lot 52A
Engineer: Ted Moore, P. E., Flattop Technical Services
14530 Echo Street, Anchoraqe, Alaska 99516
Applicant: Norman W. Burqess
Waiver Requested: WEll on property to be 38 feet from an
along east side of the property.
8" sanitary sewer
HA# ~[3~ Permit
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:
List Conditions or
Reasons
Waiver is NOT Granted:
for above: ~F
Date:
Name of R~vi~wer
Rec ~: 24729/8089 Amount: $ 590.00 Date Paid: 5-27-93
STATE OF ~J~SKA
DEP~Tb~EHT OF NATU~AJ~ I~ESOII~CES
DIVISION OF GEOLOGICAL AND GEOPHYSICAL SURVEYS
WATER WELL RECORD
LOCATION OF W-ELL t-.L.:'V ' F' ~ - '
BOROUGH SUBDIVISION LOT BLOCK SECTION QTRS TOWNSHIP RANGE MERIDIAN
ON E]E
Os
DIRECTIONS:
WELL
OWNER:
WELL DEPTH: DATE OF COMPLETION:
F~ASU~ING
POINT:
~"l~tOp of easing Depth of hole: /~an ft
Oground surface Oother: Depth of easing: /~S' ft { ~¢ - ~/
BOREHOLE
DATA:
Depth
STATIC WATER LEVEL: '~,~ ft. Date
Material type and color. .. · From TO
~'~, .... )/-~l.;/~/ ~[~[~1~' C ~ t ~1 Oair rotary
'- ~cable tool ~other:
/ ~ ]~ ~ .~/~(C~~ /(~ ~(~ /(~... ,7,/ /~)1 USE OF WELL: ~domestic ~irrigation ~monitor
/ .,' ~publi6 supply ~other:
~, /~ /0 ~
/.?., . . / C~SING: Sg~ck-up,~Ott ft. Diam: ~ t/
. ~, .. ~ IR,5' I~-'
/ WELL INTAKE: ~ opon end
· ,,"',,.'I,V (4,~ ~..t L.~. [~..or~l-~m)IL:.~~ I~/ 0 perforated ~open hole
!/3;~/J~/~ ~A'~¢/'2~-'~' ~ /,~& /~/' Depths of openings: to ft
SC~EN TYPE: Diam: -in
Slot/Mesh Size: Length: ft
Set Between and ft
- G~VEL PACK TYPE:
Vol~e used: pepth to top:
GROUT TYPE: Vol~e:
Depth: from .ft to __ft
~S: P~PING LEaL ~D yIELD:
MAY ~ 7 1993 /6Of~ .after ~ h=s p~pln~ 'lO ~m
~",,,~a]c~pality of A'nohora~e P~ INTAKE DEPTH:~ft ' Horsepower:
. DeDt. Health & Human Services Date P~p Installed ~ -~- ~ · · .
CONTeSTeR INFECTION: WATER ~HEMISTRY S~LE TAKEN?, ~yes ~no
nil ~TA~,., ~,,~11 ~,.~/ :~, Well d~'sinfected upon Complet~'6n? ~es ~no
R~gistered Business Name
Signature of Authorized Representative ~
Date
PLEASE MAIL WHITE COPY OF LOG WITHIN 45
DAYS TO:
DGGS
PO BOX 77-2116
EAGLE'RIVER, AK. 9957.7
THEODORE F. MOORE, P.E.
PH: (907) 345-1355
OP T EHNICA.L .SE
CIVIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS
14530 ECHO ST.
May 27, 1993 ANCHORAGE, ALASKA 99516
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
RE: BLM Lot 52A, Section 10, T12N, R4W, S.M., Well - Sewer separation distance waiver
Dear S~rs:
By means of this letter we are requesting issuance of a separation distance waiver allowing the existing
well on the subject lot to be 38 feet from an 8" sanitary sewer which runs along the east side of the lot.
We are also applying for a HAA certificate and a well permit, since we cannot find any evidence that an
on-site well permit was ever issued by your office. A site plan, copy of the driller's log, copy of the
sewer as-built, and water sample test results are also enclosed to assist you in yom' review. For your
infol~ation, the as-built property survey describes this lot as BLM Lot 52A (P85-277), Lakehm'st S/D.
According to the chiller's log the well was drilled on 8/5/91 by All Alaska Well Drilling and has a total
depth of 138 feet and a yield of 10 gpm with the pump set at 135 feet. On May 10, 1993 we conducted a
yield test on this well. The initial static water level stood at 40 feet below the top of the casing. Steady
pumping of 552 gallons of water from the well at the maximum pump output of 8.1 gpm caused the water
level to be drawn down to the level of the pump intake. After the well had recovered for only 5 minutes
we were able to pump an additional 172 gallons of water from the well at the maximum pump output
without the water level being drawn back down any lower than 131 feet. Based on our test data we
determined that the yield of the well is 6 gpm, which is more than adequate for M.O.A. approval of a three
bedroom residence. Water samples collected on May 5 were satisfactory, showing 0 coliform or other
bacteria per 100 mi., and undetected nitrates.
The Gloralee Street Lateral to C-4 Trunk sanitary sewer was installed in 1974 and runs 10 feet west of
the east property line of Lot 52A, in what is now designated as a utility easement. A relevant portion of
the AWWU sew~er as-built is enclosed. The sewer line is 8 inch diameter Class 2 ductile iron pipe,
buried approximately 10 feet below ground level. This type of pipe was designed to be used for drinking
water and is similar to the more commonly used Class 50 D.I.P. used for sanitary sewers, except that it is
lined on the inside with cement to provide additional corrosion protection.
The following is a breakdown of how waiver analysis points could be assigned using D.E.C. SCRO's
1985 "Separation Distance Waiver Guidelines".
Category Points
Distance to aquifer (aquifer depth 135' - sewer depth 10' = 125')
Soil so~ption (well log reports predominantly silt between 10' and 135')
Soil type (predominantly soil with perc rate slower than 50 rain/inch)
Water table gradient (assume 0%, parallel with ground surface)
Horizontal ~paration (38 feet~
Total
7.1
3.5
3.0
2.9
0.8
17.3
Based on this point assignment there does not appear to be any threat of contamination. Further
mitigating factors include: (1) the aquifer is confined/artesian, meaning that contamination originating in
the mediate vicinity would not be able to make its way into the aquifer, and (2) the sewer line was
constructed to a high standard Class 2 ductile iron pipe, and has special corrosion protection, gasketed
joints and was pressure tested before being placed in service. Additional tests for inorganic contaminants
were conducted on water samples collected by the owner in August of 1991 (results enclosed).
For the above reasons, it is my professional opinion that the requested waiver can be granted without
concem as to potential contamination of the subject well by effluent leaking from the portion of the sewer
line which passes closer than 75 feet from it. Please give me a cai if you have any questions on this
analysis.
cc: Norman Burgess
Sincerely,
Ted Moore. P.E.
LoT $ I
House
L ~
R.o.~',
LOT -IA
HOUSE
LOT 3A
JE~ELL LAKE
~VEL
, -~ LOT
D.I.R S£~VE R
BLN1 LOT 521~,
.SITE- PLAN
l:)A-r E
NOTE: THIS IS NOT
A SuRVE'tEb 'PLAT.
ARE APP RoX ~M/V1-E..
~~MMERCIALTESTING & ENGINEERING CO.
Chemlab Ref,~ :93.1960-1
Client Sample ID :BL~I L52A
Matrix :WATER
LAKEHURST s/D GARAGE ROSE BIB
5633 8 STREET
ANCHORAGE, AK 99518
TEL: (907) 562-2343
lAX: (907) 561-5301
Client Name :FLATTOP TECHNICAL SRV
Ordered By :T.F, MOORE'.~
Project Name
Project~ : ~ - :
PWSID :UA
,WORK Order :65686
Report Completed :05/07/93
Collected :05/05/93 @ 15:00 hrs.
Received :05/05/93 @ 15:40 hrs.
Technical Director :STEPHEN, C. F~DE
Released By
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: T~F. MOORE.
QC Allowable Ext, Anal
Parameter Results Qual. Units Method Limits Date Date Init
See Special Instructions Above UA = Unavailable
See Sample Remarks Above NA = Not Analyzed
Undetected, Reporte~ value is the practical quantification ;/imito LT = L~:~ss Than
Secondary dilu~ion~ G~' = Greater ~han
~SGS Member of the SGS Group (Soci~t~ G~n~rale de Surveillance)
ENVIRONMENTAL SERVICES IN ALASKA COLORADO. UTAH. LLINOIS. OHIO, ~AARYLAND. WEST VIRGINIA. NEW JERSEY SOUTH CAROLINA
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (997) 561-5301
ANEL¥SIS REPOR! E! 3ANELE gox WORHorde~t 37388
Pate Report Printed: AUG 29 91 e 15:32
Client Sample ID;WELL HEAD
PWSID :UA
Collected AUG L6
Received AUG 16 91 @ 14:10 h~s.
Pre{e~ved with :AS REQUIRED
Client Na~ :BURGESS, NORMAN
Client Aoct :BURGNC
BPO { PO t NONE RECEIVED
Ordered By :NORMAN BURGESS
Ar~lysls Comploted :AUG 26 91 Send Reports to:
Laboratory Supo=visox. ;S[E~NEN C. ED~ , ~ i)BURUESS, NOR~AW
Chemlab Roi t: 914193 Lab Sapl ID: 1 ~at~ix: MAIEH
Allowable
Pala~aeter TeateO Result Units ~ethod Lll~lto
PRIVATE I~DI¥IDUAL WATER n/a n/a
ALUMIHH~ 0.17 ~/1 EPA 200.7'ICP
ARSENIC HD(O.02~?~/ ~/1 EPA 200.?'ICP
BARIUId 0.014 n~/1 EPA 200.7'ICP
CADNIU~ ND(O.02$) n~/1 EPA 200.?'ICP
CALCIUH 10 n~/1 EPA 200.?'ICP
CUROHILP~ RD(O.OI$) n~/l EPA 200.?'ICP
COPPER ND(O~JL~ n~/1 EPA 200.?'ICP
IRON ~0.26/ n~/1 EPA 200.?'ICP
LEAD HD(O.02S) ~g/1 EPA 200.7'ICP
~AGNESIUM 5.8 n~/1 EPA 200.7'ICP
MANGANESE 0.019 n~/1 EPA 200.7'ICP
PHOSPHORUS ND(O.S) n~/1 EPA 200.?'ICP
POZASSIUM ND(2) mR/1 EPA 200.?'ICP
SILICON 3.4 n~/1 EPA 200.?'ICP
SILVER ND(O.OI3) ~/i EPA 200.7"ICP
SODIUI4 36 ~g/1 EPA 200.?'ICP
ZINC ND(O.OS) ~g/1 EPA 200.?'ICP
NIIP~YE-W RD(O.IO) ~/1 EPA 3S3,2 iQ
CHLORIDE $,$ n~/1 EPA 325.3
SULFATE 3.6. n~/1 EPA 375.4
SOLIDS, lOYAL DISSOLVED 220 rna/1 SH2OgE
HARDNESS as cae03 49 mR/1 RWEOgA
ALKALINITY as Cae03 124 n~/1 EPA 310.1
CONDUCIIVIIY 25S u~ho{/cm EPA 120.1
, pH ,? 8.33 unrra EPA 150.1
IOIlL COLIFORM 0 col/lO0 ~1 SM908
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. # (~)1
HAA #
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent N, ,4.
Address
No-' ~,'~ ~ ~ r'~'~--¢~ Day phone
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
Individual well ~-~
Community well
Public water
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:
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 inves!!gation and inspection, the on-site water
sul~ply 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 ~'/~ f'/~f 7'~c~ n'~ c~ /
Address /"/5- ~ 0 ~c~ .~./ /~c~or~/¢ ..
Engineer's signature ¢/-'~ ~ ~
Phone
/~ ¢¢~-'/~'
Date
DHHS SIGNATURE
Approved for ~¢
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
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.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Parcel I.D.
Well type p m ,/a f'~_ If A, B, or C, attach ADEC letter. ADEC water system number /¥, ~.
Log present (Y/N) Y' Date completed ~' / ~ ?/q :~ Driller /'/¢~/'~,
Total depth I.yo ' Cased to
Sanitary seal (Y/N) Y'
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG
I ¥O ' Casing height ~Jo"
Wires properly protected (Y/N) 'r'
INSPECTION (N.//. - New
AT
IZ. .g.p.m. g.p.m.
M_nh:
SEPA~ATION~ISTANCESFR~)MWELLTO: an~d. ~dl,.~ff Ca~[~ ~,.,;t~ ¢o~¢.~/~.
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
N.A. ( (>~, lic 5'~o.,~); On adjacent lots N,
N, /I-. ; On adjacent lots /~,
7~' ---¢ Public sewer manhole/cleanout
Petroleum tank
Nona
WATER SAMPLE RESULTS:
Coliform (~ c~(//O©,"h~
Date of sample: ~"/~ ~/"~ '~
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Nitrate ~ ~2,!~e/~
Collected by:
Tank size
Foundation cleanout (Y/N)
Other bacteria
Compartments
Depression (Y/N)
Alarm tested (Y/N)
Pumper
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 (3/93)* Front CONTINUED ON BACK PAGE
C, LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA N, ~-.
Date installed
Length
Total absorption area
Date of adequacy test
Width
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
.Cycles tested
On adjacent lots
Soil rating (GPD/FF)
Gravel thickness
Cleanout present (Y/N)
Results (pass/fail)
Surface water
System type
Total depth
Depression over field (Y/N)
for
Bedrooms
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
After test
If yes, give date
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
E. ENGINEER'S CERTIFICATION
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots Properly 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 !n.~..~e.~C~!r~ the date of this inspection.
Signature %~ ~ ~ ' ' ..... ''
Engineer's Name ~*Eo¢o¢, F./~°0~ ~ ~::~ ~'~
H~ Fee $ t~ .O( h Waiver Fee $
Date of Payment ~.- ~ ~ - ~ % Date of Payment
Receipt Number ~ ~ ~ ~°1 1%~ Receipt Number
72-026 (3/93)* Back
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.# ~ ~ - ~"~ ~,~-[~'-.~ HAA# ~ ~o~,~,(,--~ ,.,~(~
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent N, A,
Address
Day phone
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
Individual well /
Community well
Public water
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:
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
Engineer's signature
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.
NameofFirm ~1~ ~¢-¢? 7-e~ ~ ,~ ; c~-[ _~er~'~ ~e~r Phone ~'5
Address /Y~Zo ¢c~o ~/_, ~ncXor¢~(,. ~
~~ ~ ~ Date
DHHS SIGNATURE
Approved for
Disapproved.
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By: 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
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: J~*~ ~-oT 52~A $~¢ lo, TVZN, ~',Jur Parcel I.D.
A. WELL DATA
Well type PR~vA-~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) ~/ Date completed '7lB Jell Driller AL~-
Total depth 13~'' Cased to 13~' / Casing height
Sanitary seal (Y/N) 7 Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
Date of test '7/~]~l
Static water level 2. S
we,, f,ow ,o g.p.m.
Pump level I ~-~ I~'
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot N,A, ;On adjacent lots N,~,
Absorption field on lot N.~- ; On adjacent lots
Public sewer manhole/cleanout
Public sewer main~ ;3g" ~-
Sewer service line ~ ~-5"
WATER SAMPLE RESULTS:
Coliform ~ co! //oo ~.¢_. Nitrate
Date of sample: ,,5'-/,~c"/? .~
Petroleum tank
~.,¢4~'e~-/'~'( Other bacteria Non~-
Collected by: F(~/-/o/~ 7'ec~.
B. SEPTIC/HOLDING TANK DATA N, A, (._P~,
Date installed Tank size
Compartments
Cleanouts (Y/N)
Foundation cleanout (Y/N)
Depression (Y/N)
High water alarm (Y/N)
Alarm tested (Y/N)
Date of pumping
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
On adjacent lots
Foundation
To property line
Absorption field ' Water main/service line
Surface water/drainage
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Well on lot
D, ABSORPTION FIELD DATA
Date installed
Length Width
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 Surface water
Soil rating
Gravel thickness
Cleanouts present (Y/N)
Date of adequacy test
for
Well on lot
If yes, give date
To building foundation
On adjacent lots
Surface water
Curtain drain
E, ENGINEER'S CERTIFICATION
System type
Total depth
bedrooms
On adjacent lots Property line
To existing or abandoned system on lot
Cutbank Water main/service line
Driveway, parking/vehicle storage area
HAA Fee $ / 7
Date of Payment
Receipt Number
72~026 (Rev. 3/91 ) Back MOA 21
Waiver Fee: $ ,~--~g3 ¢(J7~
Date of Payment '--5~'- 2-~--?~
Receipt Number '~ 7~,7~ ~ ~/~',~"~ ~)
Engineer's Name
Date /v?~.,y
Signature ~.-~~ ~. ~
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
07x02/93 09:11 CTCE ENUIRONMENTAL LAB SERUICES ~ 5451355
NO. 493 5)[
Chemlab Ref.% ~93o3089-~
client Sample ID ~L52A, SEC 10
Matrix ;WATER
T12N
EAST HOSE BIB
FAX: (9(17) 56t-5:~0~
Client Name :FLATTOP T~?,CHNICAL SRV
Ordered By
Project Name :
Project~ :
~SID :UA
WORK Order :6773;!
Report Completed : 07/01/93
Collected :06/29/93 @ 12.'30 h~
Received. :06/29/93
Technical Director:S~-C, EDJ5
Released ~y : .~,~/Y~3',~,.,.-~~'
Sample Remarks: ROUT~N~ BA~IPLE COLLECTED bY: CHRIS,
QC Allowable Ext. Anal
Parameter Results Qual U~its Method Limits Date Date InJ
Nttrate-N 0.10 U mg/L EPA 353,2/300.0 10 06/30 L[
See Special Instructions Above UA = Unavailabl~
See Sample Remarks Above NA ~ Not: Ar[alyzed
Undetected, Reported value i~ the practical quantification limit. GT = 5ess Than
Secondary dilution. GT = Greater ~han
~ ~"~ Member of the 8~ Group ($001~,¢ GCnsr.le de Survei,lance)
LOT
Flou $ £
R.o.u. LOT '7/J
GLOI~^L£E
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HOUSE
LOT
SA
LAKE
Nr~
LoT ~A
CLASS
D.I.R SEk/£ R
BL~ LoT $2A, ~gd Id),
.SITE PLAN
3CALE: I''= 3D'
'bA-TE s/cJ3
NOTE: THIS IS NoT
A SuRVEyED PLAT.
ALL LocATIONS
iRE A?PRoX tMATE..