HomeMy WebLinkAboutLAKE RIDGE TERRACE BLK 2 LT 6Lake Ridg
Terrace
Block
Lot 6
#051.-315-21
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.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. ~'/' ~/~-' ~...I HAA#
Expiration Date: / [- <~ - O /
1. GENERAL INFORMATION
. Complete legal des~iption 'Lol"~ <J:~ot. jz~. ~ LA./~--~-q~I/3G~- ~'-~--f"~A-~_.. "~/~
Lo~tion (site address or directions) Ig~b
Current Property owner(s) "~Ot-'l ~----f~=:~,,J
Ma,ing address
Lending agency
Dayphone ~,~(,,,-- I.~
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested. HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: ~
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class .~
Public Water System
Well
[]
[]
[]
[]
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 5 by an independent professional civil
engineer registered in the Slate of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties sewed 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 private or Class C we!l and may be reissued with
new water sample results less than 30 days old. (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 Authodfy 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 stn~cture 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(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name~
Engineer's Printed
bedrooms.
,~'~";,' A "..',~.'t
bedroo~s~ with the following stipulations:
DSD SIGNATURE
~ ApprmJed for:
Disapproved.
Conditional approval for
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ~ - ~ - 0 1
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage. AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-79O4
HEALTH AUTHORITY APPROVAL CHECKLIST
A, WELL DATA
well t~pe~?_~ V'~-~'
Date completed
Total depth ~:~'{' ft.
If A, B, or C provide PWSID # '"- ' Well Log (Y/N)
Sanitary seal (Y/N) ~'~ Wires property protected (Y/N)
Cased ~o ~/~.. ~Casing height (above ground) /~ 4" in.
FROM WELL LOG
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform ~ c~lonles/100 mi.
g.p.m.
Nitrate 0-'~" 'mg./L
AT INSPECTION
Other bacteria O colonies/100 mi.
Data of sample:
!
B. SEPTIC/HOLDING TANK DATA
Taqk size '~0~" gal...' Number of Compa~ments
F~.';J~lation cta~out (Y/N) ~<J~ Depression over tank (Y/N)
D:ata of pumping '~/~;/~ / Pumper ~'--~'
High water alaml (Y/N) /*,,Z//~-*
[
Absorption rata >=
C. ABSORPTION FIELD DATA'
Dat~ installed I &~& ~' , ' Soil rating (g.p.d./ft= or ~/bdrm) ~/A/~
~'Le.~ ' ~' .. ~th ~' ft.
~e, d.pth_~ ft. .. a~,o,,,on.e ~/~ · Mo.~., ~,~, _~
Date of adequacy te.~/~ ~O) Results(Pass/Fail) ~r;,,5'
~ f
Fluid depth in absoq3tion field before tast~in. Water added/~el.
Elapsed Time: ~O min. Final fiuid depth ~) in.
Any rejuvenation Ireat~ent (past 12 mo.) (Y/N & type)
System type ~ I ~
:Itl~'Grevel below pipe ~ / ft.
Depression over field /4//~
For ..~ bedrooms
New depth~.~n.
~ g.p.d.
If yes, give date.
O. LIFT S'rATION
Date installed
eval ~
'Pump on" I in.
Datum
Size in gallons.
'Pump off' level at
Cycles tested
Manhole/Access (Y/N)
in. High water alarm level at in.
Meets alarm & circuit requirements?
Public sewer main ,~',/~
.~l~epflc een~ce line ~-~'
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: ~
Sep.c tanU~ on lot_~ '*' · ' on adjacent ~c~
Absorption field on lot "~ ~ ''P' On adjacent lots
Public sewer manhote/cleanout
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~' ~ Property line ~ ~ Absorption fiald
Watarmain t~/~- - Watersewicelino ~/0 /4' Sudacewater
Wells on adjacent lots /(~7 /~-
SEPARATION DISTANCE FRoMABsORPTION FIELD ON LOTTO:
Prope~e/line ,/~) ~-P" Building foundation //~7
Curtain drain '~/&~'V ~A-,~/'~ Wells ~n adjacent lots
Fo COMMENTS
O. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems ere/n
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name /~O/J~-~.T' C. COv,/~,~
Oat, '~/~/o /
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
300.
s'/,/o /
· Waiver Fee $
Date of Payment
Receipt Number
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. # O 5"1 - 3 !,F- - A. I
1. GENERAL INFORMATION
Complete legal description
Lo~ 6;
HAA # ~ ~'~ (:~ --,~
B! o~k '~2::,~ Laker idge; Terrace
Location (site address or directions)
18136 James Way
Anchorage, AK
696-1041
:, roperty owner :. Richard & Norma Floyd
Mailiflg addres~ ..... p~p. Box 770256 Eagle River,
Day phone
AK 99577
.'L. endin, g agency
"..Mailing adOress
Day phone
A~'ent
Address
Kathi Olmstead/ Remax of Eagle River
Day phone
694-4200
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
XXX
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.. ~ ~ ,. .
xxx
TYPE O F WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Co mmunity on-site
public sewer -
NOTE: If Community WasteWater Syster~, provide written Confirmation from State ADEC
attesting to the legality and status Of system.
72-025 (Rev, I/91) Front MOA#21
5. STATEMENT OF INSPECTION BY ENGINEER.
' As certified by my seal affixed heret° 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 hereinl 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 ENGINEEEING Phone.
17034 Eagle River Loop Roa~l NO. ~
Address :;.::.~;e [liver, Abska 9~577
EngineeCs signature ~~ ~. ~ ~ Date
- ' _
6. DHHS SIGNATURE
' ~ Approved for ~ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
~'~ ;' ~.,'i ,"
';,The Mu'~icilSality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Ap,preval Certificates based only upon the representations given in paragraph 5 above by an independent
professk~nal en§!nee( registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending ir~$titutions,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) Bacl< MOA#21
MUNic, it'~LITY
[NVI~ONMENT^L_iL...~. SERVICES,~ DIVI$1~
Municipality of Anchorage -
DEPARTMENT OF HEALTH & HUMAN SERVICEb~
Environme.talServices Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (9
Health Authority Approval Checklist
Legal Description: LO ~ G (~ ~c-*< ~ L~,i.../,~,t)~'L Parcel I.D.:
Date completed I ~/G 7
Cased to ~/~ *";' ~:'~ o p,,~ Casing height (above ground)
Wires properly protected (~)N)
A. WELL DATA
Well type ~ i ~/4 T ~- If A, B, or C, attach ADEC letter. ADEC water system'number
Log present
O
depth
Total
Sanitary seal (~N).
FROM WELL LOG
~ qf, '7
Date of test
Static water level
Well production tJ / ~ g.p.m.
AT INSPECTION
7
g.p.m.
WATER SAMPLE RESULTS:
Coliform O Nitrate
Date of sample: "~-/ t ~ / ~ 7
B.~IOLDING TANK DATA
Date installed ! ~ ~' 7 Tank size ! co o
0 ~ ( Other bacteria O
Collected by:
S & S ENGINEERING
;7054, Eag;e River Loop ~:oad Nm 204
Eagle River, Alaska 99577
Number of Compartments / Cleanouts (~/N) ¥ ~ J
Foundation cleanout (Y/N~
0
Date of Pumping q / ~i{ ~, Lc
C. ABsO'RPTiON FIELD DATA' ~:
Depression (Y,~
Pumper ,3',~. I~,~,~?~
High water alarm (Y/~'~ ~' ~
Date installed ! dl (,' 7 ' .... :~ Soil rating (g.p.d./fF or ft2/bdrm) System type
Length'· ".. Wid,.th . ¢' 6 Gravel thickness below pipe 4' Total depth,
Effective absorption area .'"' t)//.c Monitoring Tube present (~/N). V~-.f Depression over field (Y/I~ ~ 0
Date of adequacy test ~ / :z¢ / ~ 7 Results~Fail) /~'¢ 3'5 For '-'J* bedrooms
Fluid depth in absorption field before test (in.);
Fluid depth ';~ ~ (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N) N ¢,'~
Immediately after ~/-¢~'gal. water added (in.): 2) /~ '/~'"
Absorption rate = ~ ~"0 /* _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*
Cycle_s~r~~
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level *.¢3.t~'~"~'~*~ "Pump off" level at*
*Datum
F.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Se}.~holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM ~___T_~HOLDING TANK ON LOT TO:
Foundation $" -)- Propertyline $-" '~ Absorption field
Water main/service line to -~- Surface water/drainage ~"O ./L Wells on adjacent lots
)00
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ) O -/- Building foundation lo -w
Surface water -Y- ~-o '+
Curtain drain /v,,,~6 ,~,~ ow
~ I~ i7',~.(.~/J ?,¢tO,~ ;FO
ENGINEER'S CERTIFICATION
Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots / o o C~-
I certify that I have determined thru field inspections and review of Municipal record&~C~t~,h...~....o~ms are
tn conformance w/th MOA NAA guidelines in effect on this date.
Y '
Signature ?~'7 ~' ~~
Date ~ / ~6 / I 7
HAA Fee $ .-~-z>, ~
.)
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Lot 6; Block 2; Lak~ridg~ T~rrac~ Subdivision~
Location (site address or directions) 18136 James Way
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
~e.b~d F£nyd
P.0.Box 770256
Day phone
Earql¢ Riv~, Ak. 99577
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
NOTE:
×X
Public sewer
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.
Phone' ~ ~d~lq9
Name of Firm
$ & $ ENGINEERING
Address 17034 Ea~_le River Loop Road Ne_. ~1~_
Eagle River, Alaska 99577
Engineer's signature
DHHS SIGNATURE
ior-r-
__ Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date //- 'm/- ¢ /
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesyto purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA ~21
(~ Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L-,~r [., ¢'~-¢--~/-- '~,V.-~. ~,~,¢-- '¢~.¢_r.¢. Parcel I.D.
A. WELL DATA
Well type
Log present (Y~)
Total depth
Sanitary seal
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed l '~/~, '7 Driller
Cased to ~-~¢.~ ¢-o4_~/__ Casing height
Wires properly protected (~/N) ~/
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
~q ul
g.p.m.
AT INSPECTION
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
WATER SAMPLE RESULTS:
Coliform 0 4"~c4/1~-~, Nitrate
Date of sample: ~ -'[-~ -~1 t
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts ~'~'N)
High water alarm (Y,{~,
Date of pumping
Other bacteria ,~J-~ ¢'J ~
$ & $ ENGINEERIN~
Eqle River, Alaska ~577
Tank size t C)c~c:> Compartments
Foundation cleanout (YZ~ ~ Depression (Y~.-~
Alarm tested (Y/N)
Pumper .~.~,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot '~ '5'
To property line ~c~ v¥
Surface water/drainage
72-026 (Rev. 7/91) Front
On adjacent lots lc) o Foundation
Absorption field ~' ~,u Water main/service line
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
Manufacturer
"Pump on" level at
High water alarm level ~
Meets MOA electr~
STANCE FROM LIFT STATION TO:
On adjacent lots
Manhole~
"Pump off" level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed ~ ~ L~'I
Length"~l~ ~)' Width~
Total absorption area
Depression over field (Y~g))
Results~fail)
Peroxide treatment (past 12 months)
Soil rating O ~zL. .System type
Gravel thicknessl'~ ~' ~
Total depth
Cleanouts present(C~)'N)
Date of adequacy test '21 -
for "~r~ ¢, ¢¢--~
I(,'~,1~.[ If yes, give date
bedrooms
SEPARATION DISTANCE~..~_~.,ABSORPTION FIELD TO:~ Y~rro
Well on lot O On adjacent lots JO~;;'/''~r ertyline
To building foundation ¢"~ * To existing or abandoned system on lot
On adjacent lots ~Z::) ~'~ ¢utbank "-JLA Water main/service line
Surface water ~c)~ /F-~FA'u'mCcP Driveway, parking/vehicle storage area
Curtain drain
· ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
HAA Fee $ \-~ O,,(.~LT.) Waiver Fee: $
Date of Payment \ ~ ~ \ - c~ / Date of Payment
Receipt Number L,g,,~\ ~(,o / Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Loc~tio~ :(address o/' directions)
(b)" P'rop.erty Owner/~'/e~-u,'~ ~'~/'~/¢ ~u~/ Telephone: Home ~G ~ ~ Business
~ailin~Address'/~/~ J~ ~ ./ ~ /~.~
(c)' Le~di"g,l,nstitution' . '¢¢~¢ ~- ~, Telephone
Mailing,ACdress.
(d) Real Esiate Company and Agent ~¢~ ~¢ ~ ~¢~ ~
Address '~-- I~ ~
~elephone ¢ ~q ~o ~
(e) Mail the HAA to the followina address: or: Check here ~ if hold for pick up.
List contact person and day phone number below·
2. TYPE OF RESIDENCE
Single-Family J~
Number of Bedrooms
WATER SUPPLY . ...
Individual Well R] Community [] Public []
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 [~ Public [] Community [] Holding Tank [] '
. Noie: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status. ' ' - -- ' ' ' ' '
Page 1 of 2 72-025 fRev 8/86) Front
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA 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.
Name of Firm /¢E'C .~ .~¢ Telephone
Address [~o /,~ ~$~-o'1 ~ ,,,~~,,e_ ,,~
Date
6. DHHS APPROVAL '.
Approved for ~ bedrooms by
' :- APproved ~ Disapproved Conditional
Terms of Conditional Approval
CAUTION
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.
Page 2 of 2 72-025 fRev. 81861 Back
MUN C PA' T OF ^NC.ORAGE
'-; ~-~'Ot:/,,NCr4 .~ DEPARTMENT OF H~ALTH & HUMAN SERVICES
~0~ ~ ~ ~9~7 OF ON-SITE SEWER264.4744AND WATER FACILITY
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lo~ation (~ddres~ o~'~ir~tions)
(c) Len;in~'¢nstitbtio'n.¢~2 ~"~ Telephone
Mailing Address' ' ': . ,-- -
Address ~mb/~' ' ~ ~
Telephone ~ ~ - ~ ~
(e)Mail the HAA to the followine address: or: Check here~ if hold for pick up.
List contact person and day phone number below.
2. TYPE OF RESIDENCE '
Single-Family I~ ,~ ,/,..;,! '.'. ~ ',', '. '.' .'
Number of Bedrooms
,,,
.,
3. WATER SUPPLY . . - -..
Individual Well J~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status. .,i.: ;..; -
4. SEWAGE DISPOSAL
Onsite ~ Public [] Community [] Holding Tank []
Note:.lf co'mmunity well system, must have written confirmat, ion from the State Department of Envircnmental Conservation
attesting to the legality and status.
72-025 fRev 8/861 Front
Page 1 of 2
/-%
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4744
Legal Description:
Well Classification
Well Log Present (Y/~)
Total Depth ~¢' Cased to ~¢~/r,~ c~
Static Water Level ~' ~' '~'
/.~'
Date Completed ~/~ ? Yield
Depth of Grouting ~'~- £,',~ ~ '~ ,
Pump Set At
Sanitary Seal on Casing ~N)
Depression Around Wellhead (Y/~)
Casing Height Above Ground
Electrical Wiring in Conduit
Separation Distances from Well:
To Septic/Holding Tank on Lot
If A, B, C, D.E.C. Approved (Y/N)
To Nearest Edge of Absorption Field on Lot
To Nearest Public 8ewer Line ,~o,~ ,~
Cleanout/Manhole ~,t.,~,~ ~.
Water Sample Collected by ~' /~ ' ~
Water Sample Test Results ~ ~ ~¢~ - ~'
Comments ~ ~u~ ~ ~,~ ~ ~Y/
; On Adjoining Lots
/~o i On Adjoining Lots ,>-" ~' ,, /
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
;Date ///~'/~'?'
B. SEPTIC/HOLDING TANK DATA
Date Installed / ¢/~' ?
Standpipes ~)N)
Depression over Tank (Y/¢
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Welt'; , ? $- /
To Property Line: '~ ~ '.:'~ ':-.~
To Water Main/SeryiceLi0e '" '~-~-["
Course ' - -
Size /¢ ~0 No. of Compartments
Air-tight Caps ~N) Foundation Cleanout
Date Last Pumped //~/~JC',~c'E' ?.
,A.///~/- ; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
72 026 IRev 8/86) Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ?¢¢ 7
Width of Field
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 ~ o~.¢
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/~)
Date of Last Adequacy Test ///~'//~' ?'
~' 'h - ).-
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present) ,~'
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments .//
Dimensions /
Manhole/
/~...~p Off"Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test, Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have ch.ea~ed, verified, ol' conformed to all MOA and HAA guidelines in effect on the date of this inspection.
//~,// 7
Signed ~.,~~ u~----~// Date / ~"
Company ~' -'~ ~ ',~fC~d~ ~ MOA No. ~? -~.2 ~/
Receipt No. /C~ O / 000 ~
Date of Payment
Amount:
Page 2 of 2
72-026/Rev 8/861 Back
BILLY e (geNE) McGOWEN ///'~1~
Rent-A-Can l'oilet Co.
POST OFFICE BOX 770433
EAGLE RIVER, ALASKA 99577-O433
INC.
~PHO N E 694-9202
3443
All accounts due and payable by the 20th of the month. Past due balances are
subject to 11/~ % service charge per month until paid,
CUSTOMER'S ORDER NO. [ LOCATION ~:.~,~ .... ¥ ~.1-,-~. ~;~.',' ;- ', , ,~ previous BALANCE
~UNICIP/ ,ITY OF ANCHORAGE
ENVlRONME~ TAL S~RVICE~ OIVI~ION
ALASKA I1UIROIqmi FITAL COrlTROL SI I4LIICeS, Inc.
I~nclineerinc~ &- I~nuironmenlal Studies
MUNICIPALITY OF ANCHO~Agj~
November 10, E~.:.~I~NMENTAL SERVICES DIVISION
Municipality of Anchorage
Department of Health & Human Services
825 L Street
Anchorage, AK. 99501
1987
RE: Lot 6, Block 2, Lake Ridge Terrace Subdivision
Attached are the documents for the Health Authority for the subject property.
The on-site system and well was installed in 1967. The builder of the property
was Mr. James Polyefco. Contact with Mr. Polyefco and one of the owners of the
property, Ms. Kuentzel, indicate that at the time the system was installed there
was an inspection. Jim Alien, from DEC, had not been on the job at that time.
He suspects that Mr. Bruce Adams had done the inspection. Mr. Adams has left
the state to work with the U.S. Public Health Service. Kyle Cherry replaced him
after 1970. A search of ADEC files does not indicate that there was anything
available. A check of the old G.A.H.D. files and MOA files does not show
anything either for this lot. The lending institute has nothing in their files.
This appears to be the only information available on this lot.
On May 3, 1972 Joe Blair collected a water sample for a C.M.O.R inspection and
on August 3, 1972 a typed request of C.M.O.R. approval was made. This was at
the time that the Kuentzels were leaving Alaska and the house was being rented
by a military family for several years. There is some information on the
attached C.M.R.O. inspection.
The C.M.R.O. inspection shows the disposal field to be a seepage pit and
drainfield. However, the builder says that he installed a log crib. Mrs.
Kuentzel had told the G.A.A.B. inspector that there was a seepage pit and
drainfield but upon questioning she says that she only remembers a seepage pit.
I spoke to one of her sons and he says that all he can remember beyond the
septic tank was a big hole in the ground with the men working in it. That would
indicate to me that the system is probably a log crib as reported by Mr.
Polyefco. The crib was the most common absorption system used in that area.
At the time the system was installed the required distance was a lake to a crib
would have been 25 feet. The Manual of Septic Tank Practices shows that a
distance between a seepage pit and a stream to be 50 feet but it does not
address a lake. In talking with Susan Oswald there was a discrepancy when the
G.A.A.B. regulation was passed in 1968. The Borough required 50 foot separation
distance and the State only required 25. T~e crib is over 80 fete
pxisting lake surface. The septic tank is also in excess of 50 feet from the
lake surface. Therefore, at the time of installation the system met all
applicable codes.
I hope this is sufficent information to allow the approval of the system. If
you have any questions please let me know.
Sincerely,
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343
5633 B Street
Anchorage, Alaska 99518
Drinking water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
,~' PRIVATE WATER SYSTEM
Phone No.
Mailing Address
City State Zip Code
Mo. Day Year
SAMPLE TYPE:
I~ Routine
Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
) E] Treated Water
[] Untreated Water
SAMPLE
NO. L, OCATION
3 [ J
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
'~ Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results, Please send
new sample via special delivery mail,
Date Received
Time Received
Analytical Method:
,/0x/o
Membrane Filter
* No. of coloniesll00 mi.
Lab Ref. No. Result*
]
Analyst
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS Membrane Filter: Direct Count
O Coilform/100ml
BEFORE
COLLECTING SAMPLE
Verification: LTB BGB
Final Membrane F~er Results ~ ~
lime:
C/oilform/100ml
a.m.
TNTC = Too Numberous To Count
OB = Other Bacteria
[-"ART I OF 2
REMAINDER TO FOLLOW'
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. "
F~'~-~ 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ~ ~
~'~'BIo''T--/,~ FEDERAL TAX ID # 92'0040440 ~ ~
P.O. BE ,'96650
ANCHORAGE, ALASKA 99519-6650
(907) 343-4200
TONY KNOWLES,
MA YOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
November 24, 1987
Alaska Environmental Control
Services, Inc.
1200 West 33 Avenue, Suite B
Anchorage, Alaska 99503
Subject: Lot 6 Block 2 Lake Ridge Terrace Subdivision
Dear Dr. Reid:
Per our conversation ~of November 23, 1987, this office will
waive that portion of the conditional approval relating to
determining the crib size. As you have verified that the
system is adequate for the number of bedrooms and you will
provide data concerning the presence or absence of ground
water, we feel nothing further need be done.
If there are any further questions, please call this office
at 343-4744.
Since~elv,
Daniel N. Belles
On-site Services
DNB.ljw
cc: Gus Andress, P.E;, Manager
On-site Services/Water Quality
ALASKA BiIUIROFIIT1EITAL COFITIROL SI [ UICeS, IrlC.
~n§ineerin§ F~ [nuJronm~nlal $1uaks
Municipality of Anchorage
Department of Health & Human Services
825 L Street
Anchorage, AK. 99501
Attn: Dan Bolles
Re:
December 1, 1987
MUNICIPALITY OF ANCHOP~kGE
DEPT, OF HEALTH &
ENViRONMENTAl PROTECTION
L;c,-, 1 1987
Lot 6, Block 2, Lake Ridge Terrace Subdivision RECEIVED
Dear Dan:
Per the conditional on the Health Authority for the subject property on November
24 we installed a series of testholes on tile subject property to check water
levels. I have sketched them on the attached drawing. TH#1 was west of the
system area. The test hole was dry to 11 feet but at 12 we hit water. The
soils were a red volcanic cinder like soil. The size ranged from pea gravel to
sand. At 11 feet the soils were hard packed and water was about I foot under
this layer. I dug another hole over where I thought the crib would be, TH #2.
There was water at -2.5 feet. It was in a course sandy gravel which was black
and it smelled of sewerage. The gravel started at I foot below ground. The
~ater levels in the system hole was 0.8 feet above the ~akn_w~_.l~y~ ~ ~.
final w~r_r_r_r~ TH #1 was O.~.~fee.~.~e.lo.~h~.2~ke~ leve~. ~t~.~ppe~rs ~h_e~s~s~t~
bottom to be around 7 ~e~ be~.~w:gr~g~d..~ev.e!,.
There was a considerable amount of mud in TH #1 after drilli~K. It was.
questionable if the mud reflected a true water level. The water levels dropped
to 5.5 feet below ground and stopped, The third TH was dug, closer to the house
than the others, It was dry to -10,5 feet. The soils were a coarse rock. The
relative elevations between TH #1 and TH #8 are the same. I feel confident that
the water we hit in TH #1 is in a seam at -12.0 feet below'ground level and does
not reflect true water levels in that our other hole which is 8 feet away and at
the same elevation was dry at 10,5 feet. The system appears to be slightly more
than 4 feet from the ground water levels which would be between 11.5 to 12.0
feet.
I would like to caution you that the MOA Public Works Department changed the
outlet structure of the lake several years ago. See attached photograph. This
has raised the lake level by about 2 feet which has flooded part of this lot.
jRay Mann and the Mayor was notified of potential problems but no action was
/~taken to drain the lake to the proper level. The recent heavy snow has caused
the lake level to raise,
of today.
Approved by:
It has not affected the water level in this system~as
.-.- '~,~ .-""J ~1-~,' .. ·
, ~T~I~TIO~- .~ ~. ~.~:..: ~... ..
_~? ~,,~ ~N~- ~C~DING ' ~NCT,' ~ASKA. AND.
W( O, ~LAP ~ ENCROACH ~ ~ . I ~
~ A~[ Ho RoadwaYS, uTlUTv LIN~ OR ,OTH[~ YISBLE ~~