HomeMy WebLinkAboutSAMPSON ESTATES BLK 2 LT 5Sampson
Estates
Block 2
Lot 5
#051-053-56
Y MUNICIPALITY OF ANCHORAGE
p DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 LStreet -Anchorage, Alaska 99501 Telephone 264.4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
'NEW
Thomas Flodin
68
)GRADE
MAILING ADDRESS
P.O. Box 671514 Chugiak, Ak. 99567
LEGAL DESCRIPTION
Sampson Estates L. B. 2 Sec. 3 Township 15N. Range 1W
LOCATION
NO. OF BEDROOMS
Delilah Circle
Four 4
Well \\
Absorption area
Dwelling
PERMIT NO.
Uy
DISTANCE TO:
G:A'h rnAn1T'
15t
F z
w F
Manufacturer _
►'1G� 0"Cx� e, (.LYM1
Material i j
N
No. of compartments
N
Liq. capacity in gallons
Inside length
Width
Liquid depth
j
IF HOMEMADE:
U y
z
DISTANCE TO:
Well
Dwelling
PERMIT NO.
= z F
Manufacturer
Material
Liquid capacity in gallons
in
DISTANCE TO:
Well -
Foundation
Nearest lot line
PERMIT NO.
�'SCsi` �61
w=
�O/-�
JE z
No. of lines
Length of each li ,
Total length of lines
Trench width
Distance between lines
Z w
a_�
I -+
q121
r inches
Q b
Top of the to finish grade /
Material beneath the
Total effective absorption area
®7_1
inches
-V
Length
Width
Depth -
PERMIT NO.
w
f7
Type of crib
Crib diameter
Crib depth
Total effective absorption area
as
LU
LU N
Well
Building foundation
Nearest lot line
DISTANCE TO:
Class
Depth
Driller
Distance to.lot line
PERMIT NO.
J
J
W
Building foundation
Sewer line
Septic tank
Absorption area(s)
DISTANCE TO:
r
OTHER,r
- �^''
PIPE MATERIALS
Approved P.V.C.
SO] LTEST RATING
243 bedroom
_
A
-
INSTALLER
Hamann Construction, Inc.
,
r
REMARKS
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,
.I
4
4 A
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Ll
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,gyp
O n 47
q
144
`J J
APPROVED DATE LEGAL
S ice(
Lot 5; Block 2 Sampson Lstates f� r
111 ,0_ 11101
Listed below are the options available to you in 71esignirig your septic
system. Choo�e the option that best fits your site.
ISSUED
> 75 FT, REQUIRES
MULTIPLE
RUNS
(NOT EXCEEDING
75 FT. EACH)
** GRAVEL
LENGTH
** TANK MUST
HAVE
AT LEAST
TWO
COMPARTMENTS
I certithat:
1, I am familiar
with the re�uirements
{or
on~site
s as set
State
Alaska.
Wrth by
the
of
(MOA>
and
the
o[
2. I will
install
the Qstem
in
accordance
with all
MOA
c�dss
a:d re�ulati�ns,
design
this
and in
pompliance
with the
crit—�ria
o,
permit.
W
Alaska
�or the set back
3. I will
adhere
all MOA
and
@tate o{
requirements
disposal
distances
[rom
any exishng
well, wastewater,
system
or public
sewera�e
system
on
or any
adjacent or
nearby
lot,
4. I u:dersta:�
that this
is valid !or
a maximum
of 4
bedrooms and
ps!rmit
any enlargement
will require
an addiiional
permit.
ISSUED
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
LEI
SOILS LOG
ki iii' IV
PERCOLATION
TEST
t4wco 4./7a az4ci.46
9 4 � �,cL
10
11 m� WAS GROUND WATER
ENCOUNTERED?
12
13
14
OF A4
16
1 '4 TH m"y
+ 1
coo oo °eo�oe� .*odd
®(§
STE
EN E. FLODIN e
1 0.4209E °� �'u�t�y�19°%0
0°0°
0.'0.e.
IF YES, AT WHAT
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
a®
r 8'S
4t®v
I
q.
k:q
3"
NONE
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W J■■■�� .��
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1
. s
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8'! NS'
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fI(I
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eo
-
. •
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■■'iii■
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■ENER■■■■■
■on■
ONES
off9E111641MNo�
t4wco 4./7a az4ci.46
9 4 � �,cL
10
11 m� WAS GROUND WATER
ENCOUNTERED?
12
13
14
OF A4
16
1 '4 TH m"y
+ 1
coo oo °eo�oe� .*odd
®(§
STE
EN E. FLODIN e
1 0.4209E °� �'u�t�y�19°%0
0°0°
0.'0.e.
IF YES, AT WHAT
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
a®
r 8'S
4t®v
I
q.
k:q
3"
n
% +
1
8'! NS'
®
fI(I
Ili% "
eo
......... ..
20 ®� feSSIOVa\
PERCOLATION RATE C _ 93 (minutes/inch)
TEST RUN BETWEEN FT AND FT
//►�
COMMENTS /�th lv&�to
Anru e 47,,%e l &*4- -2®K& cit r i e len s cl a r! ,
PERFORMED BY: 51 this/."L CERTIFIEDBY:I DA
72-008 (6/79)
II Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
051-053-56
Parcel I.D. COSA Q 1000 q q
Expiration Date:
1. GENERAL INFORMATION
Complete legal description Sampson Estates, Block 2, Lot 5
Location (site address) 24056 Delilah Circle
Current Property owner(s) Thomas Flodin Day phone 355-3388
Mailing address 24056 Delilah Circle
Lending agency Day phone
Mailing address
Owen Strong 351-4368
Real Estate Agent Day phone
Mailing Address Prudentlal/Vista of Eagle River
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
ElIndividual
On-site
tilC
Individual Water Storage
❑
Individual Holding Tank
❑ .
Community Class C Well
Community On-site
❑
Public Water System
❑ '
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given In paragraph 4 by an Independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also Issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my. investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further 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.
NorthRim Engineering 694-7028
Name of Firm P.D. box 770724 Phone
Address
Engineer's Printed Name Date _
4/20/^10
•. ...........'• a1
storan W. E 9• ,_•
5. DSD SIGNATURE '0 '•. :a/L�/
/ eEm�O��0FE5S%v
JG Approved for ,� bedrooms. 6�Latie:s�
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X Arsenic Advisory
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: V Original Certificate Date: �-- 2 '5 "/ 0
(R., 11105)
Municipality of Anchorage
\� Development Services Department^
Building Safety Division
-- On -Site Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Sampson Estates, Block 2, Lot 5 Parcel ID:051-053-56
A. WELL DATA
Well type _ If A, B, or C provide PWSID # _ Well Log (YIN)
Date completed _ Sanitary seal (YIN) _ Wires properly protected (YIN)
Total depth ft. Cased to ft. Casing heighVabove ground) in.
FROM WELL LOG AT INS6TION
Date of test
Static water level
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate 0. 90Smg/L
Arsenic: x15 ug/L date of sample:j�/1 1/10
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Anchorage Tank/Steel
Tank size 1250 gal Number of Compartments 2
Foundation cleanout (YIN) Y Depression over tank (YIN) N
Date of pumping 10/20/09 Pumper JR's
C. ABSORPTION FIELD DATA
Other bacteria o colonies/100 mL
Collected by: /t%•✓
Date installed
• S S
Cleanouts (YIN) Y
High water alarm (YIN) N
Date installed 8/8/85 Soil rating (g.p.d./f? or ft2/bdrm) 243 System type Trench
Length 45&47 ft, Width 3 ft. Gravel below pipe 6 ft.
Total depth 9.5 ft. Eff. absorption area 1104 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 4/19/10 Results (Pass/Fail) PaSS For 4 bedrooms
Fluid depth in absorption field before test _M in. Water added,6p gal. . New depths in.
Elapsed Time: 1 PChin. Final Fluid depth _a)L in. Absorption rate >=Ann g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) unk If yes, give date
D. LIFT STATION
Date installed no
"Pump on" level at no in.
Datum no
Size in gallons no Manhole/Access (Y/N) no
'Pump off" level at no in. High water alarm level at no in.
Cycles tested no Meets alar & circuit requirements? no
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot no On adjacent lots no
Absorption field on lot no On adjacent lots no
Public sewer main no Public sewer manhole/cleanout NA
Sewer /septic service line no Holding tank NA
Animal containment areas no Manure/animal excrete storage areas no
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5 + Property line 10' + Absorption field 10' +
Water main 10'+ Water service line 10' + Surface water 100' +
Wells on adjacent lots 150' +
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 101+ Water main 10'+
Water Service line 10' + Surface water 100' + Driveway. parking/vehicle storage 25' +
Curtain drain NA Wells on adjacent lots 15n' +
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steve Eng
Date 4/20/10
COSA Fee $ / I v
Date of Payment Y Ido / O
Receipt Number 3 So 3 C
(Rev. 11/05)
Waiver Fee $ _
Date of Payment
Receipt Number,
IR
Srcran V. Erg
rEE c:Sp
"6k -W I K.
E'80FESi"• •-�„�
Northrim Eng
Attn: Steve Eng
17237 Bear Paw Circle
Eagle River, AK 99577
907-694-7028
Fax: 907-694-7026
Client Sample ID:
Sampling Location:
Client Project:
Sample Matrix:
COC #:
PWS#:
Residual Chlorine:
Comments:
Sampson Estates g2 LS
Sampson Estates 82 LS
Drinking Water
Lab#: A1004387-OIA
SP-Analytica, Inc. -Anchorage
4307 Arctic Blvd.
Anchorage, AK 99503
Phone: 907-258-2155
Fax: 907-258-6634
Report Date:
5/21/2010
Receipt Date:
4/29/2010
Sample Date:
4/29/2010
Sample Time.
11:00:00AM
Collected By:
Steve
Flag Definitions:
MRL = Method Reporting Limit
h1CL = Maximum Contaminant Limit
B = Presenlalso in Method Blank
H = Exceeds Regulatory Limit
M = Matrix Interference
1= Estimated Value
D = Lost to Dilution
'• = RL higher than MCL; target not detected
TNC = Too Numerous to Count - result rejected
CF = Connuent Growth - result rejected
TCNG = Turbid Culture No Growth - rejected
Analysis Method
Prep Prep Analysis
Parameter Result
Units Flags
MRL
MCL Method Date Date Analyst
4500-NO3E (Aqueous) - Nitrate+Nitrite Pres
Test was conducted by. Analytica - Anchorage
Nitrate -Nitrite as Nitrogen 0.925
mg/L
0.50
10 5/7/2010 5!7/2010 KM
Lab#: A1004387 -01B
Analysis Method
Prep Prep Analysis
Parameter Result
Units Flags
MRL
AICL Method Date Date Analyst
92238 -PA (Aqueous) - Coliforms in DW
Test was conducted by: Analytica - Anchorage
li. Coli Pass
PASS/FAIL
1.0
1 4/29/2010 4/29/2010 CW
Total Coliform Pass
PASS/FAIL
1.0
1 4/29/2010 4/29/2010 CW
Lab#: A1004387.OIC
Analysis Method Prep Prep Analysis
Parameter Result Units Flags MRL MCL Method Date Date Analyst
200.8/200.8 (Aqueous) - Family Well Water I Test was conducted by: Analytica - Thornton
Arsenic 0.845 ug/L 0.15 10 200.8 5/17/2010 5/19/2010 MO
Page 3 of 3
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SC -ALA •c 11- 40
A 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
Application Date 1 1
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
5•')_mi'>v �' �°=7�if��� '!L' Ot'l � f -i/ L�-;i /->L=«.;.- Irl" ri;v.0.
(b) Applicant Name R ane?.S f- Lv/Ii Telephone: Home 66 '?'50 Business
Applicant Address 7 &V C'
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder K ; Buyer ® ; Other Cl (explain);
(d) Lending Institution
Telephone
Com° /IV _,�
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
2. TYPE OF RESIDENCE
Single-Family'p,. Multi -Family ® Other
Number of Bedrooms :nU (?,
3. WATER SUPPLY
Individual Well ® Community'p, Public 0
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 K Public ® Community ® Holding Tank 11
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 n 1/84)
Pagel of 2
ENGINEERING FIRM PROVIDING . _JPECTI®NS, TESTS, FIDE SEARCH, DATE .a9fD 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
fromfhe 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. / �{
�_ Telephone -;;2- ,
Name of Firm L c>i7iF/ I �!%<iT,i�i7 i :�
Address
� s f/V p
b
�� OOOO OOOB ��
l''
e oo �,
p 0 ,
o°
y000 Seo %o 0 acoo0 0 000,9 -an
,� Is- v'o 5oo00000°00000000
D
o STEVEN Engineer's Seal
V F.N F . FI -O D'\ °
9 o u ty Es
°°
0.0
q � '✓
A � UE�S0:U3`•113�"� O
DHLP APPROVAL. /////// / /// / /%
4 n /J`-�12.4",1,e , " � /7/(T1_ i,- Date
Approved for " "`' t bedrooms by
Approved G�f Disap Koved — Cont i9 onal
Terms of Conditional Approval _
CAUTION
The Muncipality of Anchorage Department of Health and Environmental 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 requirements. 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
72-025 111/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
Q � a{ 1 1 3 ✓ � �
CHECKLIST FEBRUARY 1984
9861,91330 ✓11 Legal Description: 4� 1
n/1r, Srs_e ,3 r T%�R7 iC 3w 6;I
N0110310dd 1V1N3WN0SIAN3
A. WELL DATA T H11V3H d0 'ld3a
HJYd0HONV 90 A111Vd101Nf1W
Well Classification C- If A, B, C, D.E.C. Approved (Y/N) U�5
Well Log Present (Y/N) yS Date Completed Yield
Total Depth Cased to Depth of Grouting
Static Water Level Pump Set At
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot 2G /-7'-- ;On Adjoining Lots
To Nearest Edge of Absorption Field on Lot 2-5-0 f ; On Adjoining Lots 20 f
To Nearest Public Sewer Line To Nearest Public Sewer
Cleanout/Manhole 'y _14 - To Nearest Sewer Service Line on Lot
Water Sample Collected by S h= n 'OE i PU 216,,Lm1G Date
Water Sample Test Results 54975P4c-7Z'2-�l�—
Comments coL/rzC�oO 90OiTit°i��T� G�sfi2 �,�trri��� 1�
B. SEPTIC/Ids TANK DATA
Date Installed__G_- Size �Z �� No. of Compartments
Standpipes (Y/N) ` &S Air -tight Caps (Y/N) YL, S Foundation Cleanout (Y/N) `4�� S
Depression over Tank (Y/N) &)o Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ilk
for
Holding Tank High -Water Alarm (Y/N) 6 / /9- Temporary Holding Tank Permit (Y/N) /,54
Separation Distances from Septic/Holding Tank:
To Water -Supply WellZ •5 l� f To Building Foundation
To Property Line
To Water Main/Service Line
Course
Comments
Page 1 of 2
72-026(11/84)
To Disposal Field
�7�
— To Stream, Pond, Lake, or Major Drainage
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 2-4-. dj- Type of System Design
Date Installed �5� Length of Field `%Z
Width of Field 36111 Depth of Field 16) /
Gravel Bed Thickness 79
Square Feet of Absorption Area O Standpipes Present (Y/N)
Depression over Field (Y/N) Date of Last Adequacy Test
Results of Last Adequacy Test
Separation Distance from Absorption Field
To Water -Supply Well ZSf�j t To Property Line /G a
To Building Foundation To Existing or Abandoned System on
Lot Iwo L) On Adjoining Lots / S U f
To Water Main/Service Line 520 7� To Cutbank (if present) 5--G7 -/-
To Stream/Pond/Lake/or Major Drainage Course /VU`t2
To Driveway, Parking Area, or Vehicle Storage Area �U
Comments
D. LIFT STATION N/
Date Installed l
Size in Gallons
"Pump On" Level at
High Water Alarm Level at _
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
** Check Permitted Bedroom Rating Against HAA Request **
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
I certify that I he ecked, verified, or co f med to all MOA and HAA guidelines in effect on the date of this inspection.
C ��
Signed_ 2' �Y -<4-� bate It
Company o�Y1 ri</ R✓G�JLtr 5 MOA No.!rf 5
Receipt No ,�Ar,& L( OLOO
Date of Payment l P_- c) -g5
Amount: $ 00
Page 2 of 2
72-026 (11/84)
�ayda tl
Engineer's Seal
a°ooa o oot+°.o ooeoe e -
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