HomeMy WebLinkAboutSAMPSON ESTATES BLK 3 LT 9ampson
I sta
Block 3
Lot 9
#051-811-35
,, Municipality of Anchorage Page / ~of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Address:
Phone: ~ ~
LEGAL D~:'SCRIPTION ' ....
Lot: Block: Subdivision:
Range:
/5- ~ ~-~ -~
WELL: fr'z~"~r [] New [] Upgrade
Cased To:
lassification (Private~ A,B,C):
PID Number:
ABSORPTION FIELD __-----
-'~ Deep Trench I~ Shallow Trench ~ Bed [] Mound E] Other
Total Depth from original grade:
Gravel depth beneath pipe
:ill added above or'g' g : ' ,.~
co,-~ Ft.
Number of lines: ~ between lines:
~ 4' ¢/,3 ~,~..~ Ft.
3e material:
Total absorption area:
/--/~ SQ, Ft. /'~"~'~-~ ~"~' ~
//~/'~ Ft. /~-'~ Ft.
Date Drilled: Static Water Level: Installer:
~riller:
Pump Set at: Casing Height Above Ground:
,.¢-. 7 GPM /.2,E' Ft.
:rom
SEPARATION DISTANCES
Station
To
Sewer Ltnes
Surface
Water
Lot
Line
Foundation
Curtain
Drain
Remarks:
TANK
lied:
~ Septic [] Holding [] S.T.E.P.
~nufacturer: Capacity in gallons:
Number of Compartments:
/laterial:
£ ~..~ /
LIFT STATION
Size in gallons: ~lenufacturer:
"Pump on" level at: "Pump off" level at: High water alarm at:
, Make & Model ectrical Inspections performed by:
BENCH MARK
and Description:
Assumed Elevation:
Inspections performed by:
Dates: 1st ??~w/~f
2nd_ ~/"~/'~'
Department of Health and Human Services approval
Reviewed and approved by: ~'~' ~'~ [~ Date: ?/~-~//2/
Loub/. i;J er~ ~
CE-6736
72-013 (1/91) MOA 25
Permit No.
Page ~ ,of ~
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
SCALE /i
:XIST
SAHPSBN ])RIVE
PID No.:
TANK
HSE
oW~LL
UPGRA[IEi
FIELB
ELEVAT~DNS'I
BED EAST END = q/'/ ?~o ~,~.
GROUND e TE~T HOLE 2
~ATE~ TABLE~= ~3-~
· BENCHHARK (]~DP. DF REAR DECK)=''t~'~ .......
CLEANDUT = o! '
NDN[TDR = ot
72q)13 A (2/91) MOA 25
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW910284
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES
OWNER NAME:STEPHENS WILLIAM H &
OWNER ADDRESS:22537 SAMPSON DR
ANCHORAGE, ALASKA 99516
DATE ISSUED: 9/11/91
EXPIRATION DATE: 9/11/92
PARCEL ID:05181135
LEGAL DESCRIPTION: SAMPSON ESTATES BLK 3 LT 9
LOT SIZE: 40121 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD 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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS
RECEIVED BY:._--
Louis Butera, P.E.
Registered Civil Engineer
August 30, 1991
John Smith, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Sampson Estates, Lot 9 Block 3
Narrative
Dear Mr. Smith,
The proposed septic upgrade will have very limited impact on adjacent properties for the
following reasons:
1. The area has large lots allowing sufficient room for septic sites.
2. Immediate neighboring septic systems are all +30' distance and are installed.
3. Reserve space is adequate, due to large lot size and neighboring well locations
favoring upgrades.
4. Drainage will not be effected and is not a major consideration in our design.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
I~O. Box 773294 o Eagle River, Alaska 99577 - Telephone (907) 694-5195 · Fax (907) 694-3297
lO' Mr/z.. ~t4~.
UNDER HO CIRCUbISTAflC~S SHOULD AN AS-BUiLT BE US£O FOR CO;qS~RUO~ON OR FOR EsT~USHIN~ BOUHD~Y OR FENCE ' U$~ DISTANCES PREVAIL O~R SCAUNO. REPRODUC~ON MAY CAUSE ERRORS IN
~-BUiLT . , · NO CORHERS..SET [ 0 . FOUND RtBAR ~c ~ ~ ~U~
RE~HCA~ ~-BUlLT. ~, NO CORNERS SET ~ ~ ASSUMED ~V. ~CHN~ U~K ~NCE ~ WOOD
~0~
~[ RESPOHSlelU~ OF mE eUI~ER OR ELA~ ~ FENCES, ~LLS, SEP~O CLEANOUT~, ~_,.
O~O~ TO ~R1FY pROPOSED BUILDING GRADE R SIlO XIMA~E LOCAHUH.
Prepered by
~~"~ -**~'~%" Robert E. Johns, Jr. ~ Assoc.~..'~':
h~y ~lfy ~ot I hay*
s:o~,: 1" = 50' I ?~ .....
d~bed hereon, end
Im~evemente whown _ , .......... ~ ..... . '' ' ~Chee['~ b~ ..
'~'-'" "" '"~'" '~' ~7':::~ ;:: ::: .~ ~-~I "~
p~p~y Ilnel ond do not orM: ~0Hb
,er th=m thole whown ~k:~r . ~ V°'~ LOT 9, BLOCK 3, SAHPS08 ESTATES
not ~hown hereon.
EAGLE RIVER
ENGINEERING SERVICES
P. O. Box 773294
EAGLE RIVER, ALASKA 99577
Phone 694-5195
JosSampson Estates, Lot 9
SHEET NO.
Blk 3 91-110
OF
CALCULATED BY g ~B, DATE 08/29/9'1
CHECKED BY DATE
SCALE
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL: LOT 9 BLOCK 3, Sampson Estates
GENERAL
1. The well and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of Health
and State Department of Environmental Conservation requirements.
4. All soil tests are advisory to the design and are to be verified or modified in the
field by the engineer.
5. All excavations and depths are advisory and are to be verified or modified in the
field by the contractor to meet Municipality of Anchorage, Department of
Environmental Conservation requirements.
6. It is the responsibility of the owner to obtain all necessary permits or easements
and to locate any adjacent multi-family wells.
7. The excavation is to be exactly in the area shown on the site plan, any deviation
requires engineer approval.
8. It is always recommended that a surveyor locate the nearest lot line position and
the location of any easements.
Bo
BED
i.
6.
7.
8.
The bed is to follow the natural land contour to maintain uniform total depth of
the bed bottom.
The bottom of the bed shall be level, plus or minus 1.5".
The total depth of the bed excavation is not to exceed 4.5' at any point.
The sewer line is to replace the existing sewer line that leads to the existing pit
to be connected into the existing leach line to allow effluent overflow to the
upgrade leachfield.
The bed gravel is to be covered with typar fabric material.
Soil or combination of soil and extruded board insulation to a depth of 3' or
equivalent is to be placed over the leachfield.
The area over the bed is to be finish graded to prevent ponding of surface water
runoff.
The septic tank and leachfield must not be closer than 100' to any existing private
well, 150' to any Class "C" well, or 200 feet to any community well.
RECOMMENDED LEACHFIELD DIMENSIONS:
TOTAL DEPTH = 3.5' GRAVEL DEPTH = 6" below pipe
BED LENGTH = 15' BED WIDTH = 12'
SOIL RATING = 0.8 GPD/ft2 BEDROOM CAPACITY = 3
SEPTIC TANK SIZE = 1,000 gallons existing
NOTE: Over excavate to 4.5'. Replace with 1' sandy pit run, then 6" of sewer rock.
Twenty-four (24) hours notice required for all inspections.
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20-
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street. Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
(ENGINEE~F~'S SEALi: ~
DATE PERFORMED:' ;I!~? ' ~ '~ '
.5,,¢/'/,~0/'1 ~, ~07'~. ]J~-'~ Township, Range, Section:
.- SLOPE
~IL:TY 5..4NP,
775,~/ P/~ 5£¢ S
SITE PLAN
I
N
WAS GROUND WATER
ENCOUNTERED? j~,~5' .
L
IF YES, AT WHAT / O
DEPTH? /~ P
E
Depth (o Water After ,.. ,' _ /
Monitoring? y.w/.r /~'.. Dale:
Gross Net Depth to Net
Reading Date Time Time Water Drop
/ ~'/-~-~/'7~' ~,-;~,,~-,~,,~. /,,,~,,,5 .~, / ~ ~ ~
PERCOLATION RATE Z~, /
TEST RUN BETWEEN ~ FT AND ~ FT
COMMENTS
__ (minutes/inch) PERC HOLE DIAMETER .
~.~_r ~ ~'~--~~RT,F~ THAT ~H,s ~EST WAS ,ERFOR~ED IN
PERFORMED BY: /_~ ~/~
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4185)
A
4 P.~. Box 773294
Eagle River, Ak. 99577
Legal:
Owner: _~ ~,~ ~t .¢,- Date:
IType o.f test:
ri Well Flow Test 1:3 Septic Test Only J~ Well & Septic Test ri Other:
Meter Monitor Well Tank GPM PSI Remarks'
Time Reading Level Level Level
it:~,~ ~-/o ~' ~" ~' I1~
lt,.~ 20 ~/¢ 7~% ~ 9~ 1/7
~ ~, 0"
lO MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME · PHONE I [~NEW
LEGAL DESCRIPTION
'P~'S Absorption area , Dwelling PERMIT NO.
DISTANCE TO:
~__~ ~ Manufacturer &m~ M ate r ial, s~j. _ No. of compartments
[Liq. cap~gallons IF HOMEMADE: Inside length Width Liquid depth
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in gallons
Q Well Foundation ~ Nearest lot line ~ PERMIT NO.
~ DISTANCE TO: ~0~
~ ~ ~ Top of tile to finish orade Material Beneath tile Total effective absorption
Length Width Depth PERMIT NO,
~ ~ T~pe of crib Crib depth
m Well Building foundation Nearest lot line
m DISTANCE TO:
~ Class~/n~,~_ ,.--;~, Depth ~ ~ i~ Driller Distance to lot line PERMITNO.
~ ~ DISTANCE TO: Building fou~t~o~ Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
REMARKS ~ ~
~'~ W~LU HAS Nor ~ INSF~. ~ ,, ],
"
APPenD / / DATE LEGAL ~
........
DEPARTI~IENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET.~ ANCHORAGE, AK 99501
264-472()
F:'ERM I T Iq[);
.DATE ISSUED:
APP[:.. I CAN'1":
ADDRESS:
'CONTAC'T' PNONE
LEGAL DESCRIP:
LOT SIZE:
MAX -BEDROOMS
8 504 3 3
SKAGGS CONSTRUCTION
P. L'). BOX 6'70690
CHUGIAK... AK 9956'7
688-~83 1
SUBDIVISION: SAMPSON ESTATES
SECTION: 3 TOWNSHIP: 15N
40000 (SQ.. FT. OR A(]RE~) ·
3
LOT: 9 BLOCK: 3
RANBE: 1W
L. isted beIow are the eptiens available tc~ yr]Lt irt designing y(DUP septic
system.. Choose the option that best fits your site.
DEF:"T'N 'TO PIPE BO'T'TOM (FT.) 3.5 ~'~
GRAVEL DEPTH (F"]"~) 0.5
TOTAl_ DEPTH (FT.) 4'. 0
GRAVEL WIDTH (FT.) 27.0
GRAVELr LENGTN (FT.) 54.0
GRAVEL VOLLIME (CU.YDS.) 54.0
TANK SIZE (GAL. S) 1-,000.0 'e*
SOIL RATING (SQ.FT. /BR) 324.
*~' DEF'TH TO F'IPE BOTTOM-< 4.0 FT. MAY REQLJIRE A LIFT STATION
*~* .TANK MUST HAVE AT LEAST TWO COMFARTMEN[S
I certify t'hat:
].. I am familiar with the requirements Iccp en-site sewers and wells as set
IF: A
T Ff E N
W]]LL.
EL. ECTRICAL WORK MUST BE DONE By A I.~ICENSED ELEC;TRICIAN.
S I GNED --'Zi
Forth by the Municipality of Anchorage (MOA) and the State oF Alaska.
t will ~ns'Lall the system in accordance with all MOA codes and regulations,
and in compliance with th'e design cPiteria of this per. mit. ·
I wiI1 adhere to all MOA and State of Alaska requirements f'~r- the set back
distan'ces from any existing well,, wastewater disposal system c~P public
se~.~erage system on this or any adjacent er. nearby lot.
I under, stand that this permit is valid for a ma>.'imum of' 3 bedrooms and
any enlargement will require an additional permit.
LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUIL. DING CODES,
(].) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (~2~~ AS-BUIL.TS
NOT BE AF'PROVED WI'[HOUT AN ELECTRICAL INSPECTION ~ REPORT; AND (3) THE
?.O. B~..'X 6650
ANCHORAGE, ALASKA 99502-0650
~.907) 264-~t 11
TON'; ,K ~,,"O WLES
DEPART,~IENT OF HEALTH & HUMAN SERVICES
January 10, 1986
TO: Permit Applicant
Subject: Permit # 850433
Lot 9 Block 3 Sampson Estates Subdivision
A permit issued by this Department for an individual well and/or on-site
sewer system has expired as of December 31, 1985.
Permits are issued on a calendar year basis by authority of Municipal
Ordinance. A new permit must be obtained from this Department for any
well and/or on-site sewer system not installed by the expiration date.
If you have drilled the well, a well log needs to be sent, to this
Department for documentation of the installation and to close the permit.
If a private engineer inspected the installation of the on-site sewer system
the original as-built inspection report(three part form) must be sent to
this office for review and approval,and for documentation.
If there are any further questions, please call this office at 264-4720.
Sincerely,
Susan E. Oswalt
Program Manager
On-site Services
SEO/ljw
enc: Copy of Permit
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAl PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
SOl LS LOG
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
4
5
6
7
8
10
12
14
16
17
18
19
2O
COMMENTS
PERFORMED BY:
72-008 (6/79)
SLOPE
SITE PLAN
WAS GROUND WATER ~¢.~ ~
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~"~ (minutes/inch)
'Z'~'~ FT AND ~ FT
TEST RUN BETWIEEN
.-t
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 05~-8~ 1-35
GENERAL INFORMATION
Complete legal description
Location (site address)
Expiration Date:
Sampson Estates S/D, Block 3, Lot 9
22537 Sampson Drive, Chugiak, Alaska
Current Property owner(s)
Mailing address
Edward and Ruth Cunlippe
Day phone (360) 601-2759
=
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone
Joe Lowndes, Keller Williams Real Estate Day phone 317-4830
11901 Business Blvd. #105, Eagle River, Alaska 99577
Unless otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class ~ Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual .Holding Tank []
Community On-~ite []
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, I vedfy 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.
Name of Firm Douglas T. Kenley, P.E.
Address 9806 E. Northstar Circle, Palmer, AK 99645
Engineer's Printed Name
Douglas T. Kenley
DSD SIGNATURE
~/Approved for '~
Disapproved.
Conditional approval for
bedrooms.
Phone (907) 746-1073
Date [|'['[[
bedrooms, with the following stipulations:
Attachments: COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
(Rev. 11/05)
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date: //'~
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
........ 4700 Elmore Road .
P.O. B6~( 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL*CHECKLIST
A. WFJ-L DATA
Data completed &~0~s
Total depth 140 ft.
Date of test
Static wata~ level
Well production
~ Gstates ~, abck. 3~ L~-9 PameJ ID:. 051.811-35
If A,. B, or C provide PWSID # . .
Sanitary seal (Y/N) Y
Cased to . !40 ff.
FROM WELL LOG
WATER SAMPLE RESULTS:
~/~o fL
5~ g.p.m.
Coliform 0 colonies/100 mL Nitrate 5-27 mg/L
of sam-le lo/21/11
~-~el3ic: ND ug/L data p :..
Well Log (Y/N) . Y
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
10/21111 '.
127:6 ff.
Y
iN,
3.5 g.p.m.
Collected by:
F. Kenley
B. SE~ TANK DATA
Tank Type/Material , Septic/Steel
Tanks~e 100o gal.
Feundation cleano~t (Y/N)
Date of pumping
Date installed 9/14/91'
Number of Compartments. 2 ,* ~ Cleanouts (Y/N) Y ~
Depression over tank (Y/iN) ~ High water alarm (Y/N) N
1.0/31/2011 Pumper JRs Pumping'
Date installed:'9~16~. .1.' ~ Soil rating (g.p.d./ft2 or ft~/bdrm)
0.8 system type Bed
Length 28 fL Width
Total depth 4.5 ff. Eft. absorption area
Date of adequacy test 10/21/11
Fluid depth in absorption field before test 0
Elapsed Time: 15 min. Final fluid depth 0
Any rejuvenation treatment (past 12 mo.) (YIN & type)
18 fL Gravel below pipe ,5 ff.
fi2 Monitoring tube Y Depression over field~ N
Results (Pass/Fail) · Pass .* ' * For 3 bedreoms
in. Water adde~l 603 gal. New depth 0 in.
in. Absorption rate >= 450 g.p,d,
N
If yes, give data ..'--
LIFT STATION
"Pump on" level at in.
SEPARATION DISTANCES
SEPARATION DISTANCES FROM,WELL ,,,ON LOT TO:
Septic tank/lift station on lot 100+ ft.
Absorption field on lot 100+ ft.
Public sewer main N/A
Sewer Iseptic service line 25+ ff.
Animal containment areas 50+ ft.
Size in gallons Manhole/Access (Y/N)
"Pump off" leve! at ,' a er alarm level at
CyCles te~tad Meets alarm & circuit requirements?
On adjacent lots 100+ 'fl:.
On adjacent lots 100+ ft.
Public sewer manhole/cleanout N/A
Holding tank N/A
Manure/animal excrete storage areas 100+ ft.
SEPARA:I:ION .DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: -
Absemaon 5+fi;
Surface watel' 100+ ft.
Building foundation 10+ ft.
Surface water t00+ ft.
Wells'on adjacent lots 100+ ft.
Water main 1 0-1- ft.
Building~ 5+ft~ Propertyline lO*fL
Water main 10+.,ft~. Water service line 10+ ff.
Wells on _adjacent lots 100+ ft.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO-
Property line 10+ ff.
Water Service line 10+ ft.
Curtain drain None known
in.
F. COMMENTS
Municipality of Anchorage
Community Development Department
Development Services 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
Nitrate Advisory
Certificate of On-Site Systems Approval # 111428
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 3, Lot 9 of
Sampson Estates subdivision. This inspection revealed a nitrate
concentration of 5.27 milligrams per liter (mg/L) was reported for the
property's well water sample. The Environmental Protection Agency (EPA)
has established a maximum contaminant level (MCL) of 10.0 mg/L for
public drinking water systems. While private wells are not subject to this
regulation, EPA standards are based on existing health information and can
therefore be used to gauge the relative quality of water from private wells.
Please see the attached "Nitrate Fact Sheet" for important information
regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
SGS Ref.# 1115226001
Client Name Douglas Kenley P.E. Printed Date/Time 10/28/2011 16:00
Project Name/# Sampson Est SD BK3 LT9 Collected Date/Time 10/21/2011 15:35
Client Sample lD Hose Bib Received Date/Time 10/21/2011 17:27
Matrix Drinking Water Technical Director Stel~hen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container 1D Limits Date Date Init
Metals by ICP/MS
Arsenic
ND 5.00 ug/L EP200.8 C (<10) 10/24/11 10/27/11 NRB
Waters Department
Total Nitrate/Nitrit¢-N
5.27 0.100 mg/L SM20 4500NO3-F B (<10) 10/27/I1 AYC
Microbiology Laboratory
Colony Count 0
Fecal Coliform 0
Total Coliform 0
col/100mL SM20 9222B A (<200) 10/21/11 DLC
col/100mL SM20 9222B A (<l) 10/21/11 DLC
col/100mL SM20 9222B A (<1) 10/21/I1 DLC
UNDER NO CIRCUMSTANCES SHOULD AN AS-BUILT BE USED FOR CONS~UCTION OR FOR ESTABUSHING BOUNDARY OR FENCE lINES
THE ~URVEYOR TAKE~ RESPONSIBlUTY FOR THE INITIAL TRANSACTION ONLY ~ND ASSUMEs FINANCIAL EABIMTY ONLY FOR THE COST OF THE SURVEY
USTED DISTANCES PREVAIL OVER SCAENG. REPRODUCTION MAY CAUSE ERRORS IN SCALE.
[] AS--BUILT... NO COP~~-- · SeT REaM m,mm~ DRAINAGE ~
RE. CERTIFICATION AS-BUILT. '~ . NO CORNERS SET FOUND REBAR C C C WOOD FENCE ~
[~1 PLOT PLAN . , . AS-BUILT... LOT SURVEY , . ~ TgP~I~^?HY ASSUMED ELEV. X X X. CHAIN liNK FENCE ~
I,PLOT PLANS & LOT ~UR~ NOTE:
ASPHALT
CONCRETE;
WOOD DECK
IT I$ 31~E RESPONSlBIU~if OF THE BUILDER OR OWNER, PRIOR TO
CONSTRUO31ON, TO VERIFY PROPOSED BUILDING GRADE RELATIVE
TO RNI~HED ~RADE AND UTIUTY CONNECTIONS AND TO DETERMINE
THE ID~IS3~J~ICE O~ ANY EASF. MEJ~TS, COVENANTS OR RESTRICTIONS
DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT.
LOt I
REcIRTIRCAIlONA~'~IJS'T PLOTA~.BUILTPLAN I ~.~::.1
~ h~v ..r~ ~ha~ ~ hay. I '""
· u .r~e.y~<l the property drown I
~u~d <1~ hereon, grad
the Imp~v~m~t. ~hown.
~hemon are within th~.
=v~Hop m- ~neroeoh on
ad~oent proper~y, except
am Indlooted hereon. ."
on the reoorcled plot,
are not Ihown he~eon.
ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE
SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS. SIDEWALKS, DRIVEWAYS.
ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW
MAY:~PREVENT SOME IMPROVEMENTS. FROM BEING SEEN AND LOCATED.
,~ Prepared by
Robert E. Johns, Jr. & Assoc.
Profea~ional Land Survey0m
,, [Drown b)~ REJ
Scale:
Dote Surveyed,'. 10t24/Ii
bate Drawn: 10/21./,11.
Lc,el O.crlptl~: ~0:'11-374
LOT 9
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw 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
. ~piration Date: I/,, [o~
1. GENE~ INFORMATION
~mplete legaldescdption zct~ ~1¢~. ~'¢~ ~f~/~ ~,' ~/~"~/'~
Lo~tion (site address) ~-~ ~ ~ ~ ~'~ ~Z~7/~ ~' ~/~
Current Property owner(s)
Mailing address
Lending agency
,Z,~*"7 ~,','~ ~' ,*/"/~¢""? ~',~ ~ Day phone ~,~,F- ¢?,¢,'¢',F
~',o, ~,x 77~9'-/ E,~:- "~rr~'~. A[ 975'77
Day phone
Mailing address
Real Estate Agent
Day phone.
Mailing Address
Unless otherwise requested, COSA 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 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. Cedificates 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
Se
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 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.
Name of Firm
Address .'~P~ ~
Engineer's Printed Name /~.....,?/,.~ ~ ~'. ,/~.~/~/.-f Date ~".'Z.'] · ~'
DSD ~,~NATU RE
Approved for ~'
Disapproved.
Conditional approval for
~.'.~.."; .-'~ I.. *l.} · '*. ,~
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By:,
Original Certificate Date: lo I(~ I°~'
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Waler & Wastewater Program
4700 Bragaw 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: ~/,'/~, /~/,~Z-'J'~ ..~,~.,,~.,~ ~'~-~-~,/~.< ~'./~) Parcel ID:
WELL DATA
Well type
Date completed
Total depth /,;,'0 ft.
Date of test
Static water level
Well production
If A, B, or C provide PWSID #
Sanitary seal (Y/N)
Cased to /~O fl.
FROM WELL LOG
ft.
g.p.m.
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
/.~l L, ft.
g.p.m.
Do
WATER SAMPLE RESULTS:
Coliform . 0 colonies/100 mL
A~senic: ~,'~ mg/]
SEPTIC/HOLDING TANK DATA
Nitrate /.~,~ mg/L Other bacteria o colonles/100 mL
Date of sample: ~/~,t'/'~, Collected by:. H',~,, ,,~, ~/,~ ~
Tank size /~,~',o gal. Number of Compartments
Depression over tank (Y/N)
Foundation cleanout (Y/N)
Date of pumping
C. ABSORPTION FIELD DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N) ,,~/.,//~
Length ~.~'7
Total depth v'? fi.
Date of adequacy test
Pumper
Data installed ~'//.~/£5' SO ratng ~o~r"~~. -~'~ ~/
ft. Width ~ ~' ~.
Eft. absorption area ft= Monit~ing tu~ )/
Flu~ depth in abs~tion fi~d ~f~e I~t ~ in. Water add~ ~F ~l.
Elaps~ Time: ~ min. Final fluid depth ~ In. Ab~rpt~n rate >=
Any rejuvenation ~eatment (~t 12 mo.) (Y/N & ~) ~
System type ~'~ rz~///~ ~
Gravel below pipe · · J'~ fl.
Depression over field /f/
For 3 bedrooms
New depth .-~ ~/~ in.
~/b-,~ g.p.d.
If yes, give date ~
D. LIFT STATION
Date installed Size in gallons
'Pump on' level at __ in. 'Pump o~ level at .
gatum~ Cycles tested.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot /,~' Y' ..~'
Absorption field on lot
Public sewer main
Sewer/septic service line
Animal containment areas
Manhole/Access (Y/N)
' er a arm level at
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excreta storaga areas
SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK ON LOT TO:
Building foundation ~, /"/ Propertyline ?~/~.J' Absorption field ,~((.
Watermain ~.~,/,~ Water service line r~'-,g ~'Y' Surface water /~',~ /- ,.,~/'"
Wells on adjacent lots ?~' ~' /7~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Propertyline / ~,/'~// ~. Building foundation /7,/..?? f/~ Watermain /,~.,/~'
Water Service line ,~C'/ ~'Z' Surface water /~'/o ~-/~ Driveway, parking/vehicle storage ..-?~'.
Curtain drain t-~, ~ ~,, ~ Y' Wells on adjacent lots /~']~ ~
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the alx)ve systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name
Date ~' '7,."] · ~
Waiver Fee $
Date of Payment
Receipt Number
SGS Ref.# 1065560001
Client Name Douglas Kenley P.E.
Project Name/# Lan'y Grant
Client Sample ID Lt 9/13k 3 Sampson Est.
Matrix Drinking Water
All Dates/Times are Alaska Standard Time
Printed Date/Time 10/04/2006 11:59
Collected Date/Time 09/1~2006 13:25
Received Dateffime 09/18.'2006 15:20
Technical Director Stephen C. Ede
PWSID 0
Samlalc Remarks:
AIIovable Prep Anab~i$
paramete~ Results POL Uniu Method Container ID Limita Date Date Init
Arsenic
ND ~.00 ug/L EP200.8
C (~I0) 09/26/06 10103/06 WAW
Waters Department
Nitrate-N 1.83 0.100 mg/L. EPA 353.2 B f<10) 09/19/06 AIR
Microbiology Laboratory
Total Coliform 0 co[/100mL Slvl/0 9222B A (<11 09/18/06 TLF
d o.
a.~-BU~T.. · ~0 C~t~'~$ .~ o FOU~O IL~.~,R ~ ~ FI~C~
CO~Sll~UCl~, TO ~ r · .... a,~O ETC, ARE SHOWN IN ~HEiR APPR~M ..... ¢ ·
OF ANY EAS~41~, COVenANTS OR SOME: IMPRO~MENI~ FROM BEING SEEN AND LOCATED.
~121-S
Prepared by
Robert E. Johns, Jr. &Assoc.
Professional Land Surveyors
~.OIl: ]" m 50! EEJ
B-06
LOT 9, BLOCK 3, SAMPSON ESTATES
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.# 051 811 35
1. GENERAL INFORMATION
Complete legal description
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA #
sampson Estates, Lot 9 Block 3
T15N R1W Section 3
Location (site address or directions) 22537 Sampson Drive, Eagle River
Property owner William FT. & R~m T,..g~-ephmns Dayphone (602) 451-1589
Mailing address c/o ~ecutive K~agement, 2020 Abbott Rd., #5, A~chorage, AK 99507
Lending agency
Mailing address
P;~cific B]~ka Mortqaqe Day phone 258-7534
2600 Denali , Suite 702, Anchorage, AK 99503
Agent
Address
N/A Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY: .:
X
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
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 th'at roy
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 verifythat based on the information obtained from
the Municipality of Anchorage flies 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.
99577
Phone 694-5195
Name of Firm Eagle River Engineering Services
Address P.O. Box 773294, Eagle River, AK
Engineer's signature ~
Date
DHHS SIGNATURE
Approved for 7~'/¢--~ ~)bedrooms.
Disapproved.
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: ~,~' y x~/~ .~ 3"~,,~.~,~,,,' zCJ-,~,, Parcel I.D. ~5)
A. WELL DATA
Well type/~r/~''~ ~--
If A, B, or C, attach ADEC letter. ADEC water system number ~'~,'/'~
/V' Date completed ~' - D-,~ - ,~..c- Driller
Log present (Y/N)
Total depth //-/"~ /
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
Cased to //¢",~" Casing height
/V Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
.5- g.p.m. ~ ?
/3 ,~' ¢'//2 '
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot /~'¢'"
Absorption field on lot /~'&"
Public sewer main ~'/,~
Ptrbt+e sewer service line
g.p.m.
z
;~>
om ~
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
Collected by:
Other bacteria ,,~
B. SEPTIC/HOLDING TANK DAT~A
Date installed //~.P'~"- Tank size
Cleanouts (Y/N) ~ Foundation cleanout (Y/N)
High water alarm (Y/N) 1,3/,~
Date of pumping ' -5-~-~ ~/'~/
Compartments ~'~
Depression (Y/N)
Alarm tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ,/-~- ~ On adjacent lots
To property line ;7.¢, / Absorption field /.5-
Foundation ~'
Water main/service line
Surface water/drainage
72-0~6 (Rev. 3/91)Front MOA21 CONTINUED ON BACK PAGE
c. UFT ST^T O.
Date installed ~*'.
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
· "Pump off" level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed /,¢~'///~' ¢/
Soil
rating
Length ~'2:/ --~' ' Width ,-~2,,~//¢· ' Gravel thickness
Total absorption area /.?..?~ ~-
Depression over field (Y/N)
Results (pass/fail) ~
Peroxide treatment (past 12 months) (Y/N)
~.2. ~'/¢,~¢,?/~'System type
Total depth
Cleanouts present (Y/N) ~
Date of adequacy test
for
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /¢~' ¢ On adjacent lots ~'/¢¢' - Property line z./'¢
To building foundation /~'"
To existing or abandoned §ystem on lot
On adjacent lots /- 3,> ' Cutbank /¢/.4 Water mmn(serwce hne
Surface water ,~'/,4 Driveway, parking/vehicle st~age area ¢-/o
/
Curtain drain /v/,4. /-
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, er conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name ~ .5 ,,¢',.~/~.-,-~
Date
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (997) 562-2343 FAX: (907) 561-5301
ANALYSIS REPORT BY SAMPLB for WORKordert 37279
Date Report Printed: AUG 16 91 ~ 16:47
Client Sample ID:LAB RE[ tAA899~ SA~P30N 9/3
PWSID :UA
Collestod AUG 15 91 ! 16:10
Received AUG 14 91 t 14:10
PraeozYed with :AS REQUIRED
Analysis Collated :AUG 16 91
Laboratory Sup~vi~j. STEP~N C. EDE
Client Name
Client lcct :EAGLERP
BPO t PO t NONE RECEIVED
Req I
Ordered By :LOU
Send Reports to:
2)
Chemlab Roi l: 914131 Lab Smpl ID: I ~trix: WATER
Allowable
Parameter Tested Reeult Units Wethod Limits
NITRAT~-N 1.0 ag/1 EPA 353.2 10
~nsple ROUTINE SII4PL[ COLLECTED BI:
Remrks:
Teats Performed
~ono Detected
got lnslyzed
· 8we ~pecial Instructions Aboxe
** See Sample Remarks Above
LT-~ees ~han, GT-G~oater ~han
UA-Unavailable
~SG-~ Member of the SGS Group (Soci~t~ G~n~rale de Surveillance)
,%
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 .2../~'/<~ ~'
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant NameT"~-~) ~'¢/,,Z"~77'&UC"rtoCCf'elephone: Home 74"-,&-' ZT,]I Business ~--
ApplicantAddress P,.O, I'~o~ 2E2_"¢' , P,~Lh'~'t~ , ,gK.
(c) Applicant is (check one): Lending Institution []'; Owner/builder uyer []; Other [] (explain);
(d)
Lending Institution
Address.
Alaska Pacific Mortage Telephone 694-7780
(e) Real Estate Company andAgent RE/MAX of Eagle River - Jim Montague
Address PO Ro~ 772R4Q; ~gl~ ~';'~r~"~ A~ 99R77
Telephon~ 694-4.200
(f) Mail the HAA to the following address:
RE/MAX of Eaqle River
Attn: Jim Montague
PO Box 772849
TYPE OF RESIDENCE
Single-Familyy Multi-Family []
Number of Bedrooms 3
Other
WATER SUPPLY ·
Individual Well Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
4. SEWAGE. DISPOSAL
Onsite~ Public [] Community[] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 {~1/84)
Page 1 of 2
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 He,alth
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adeqbate
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 (~O/ZLU//~ ,,~.,~,5~2(..,, //,~(.., Telephone
Address ¢¢~7~'C~ ~O~i,~J~¢.-% p~P-f~ .~,V~) , ~1.,~)~-.
Date ,~, ° 5 ° ~
· Approved for ~¢-~'-~ bedrooms .~e
Approved ,)~ . Disapproved Conditional "-, /
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
institutiens 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 (11/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: ,L.L'"") "J"'
WELL DATA
Well Classification pi2, J V~:) ")"E If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) _Y_E~__ Date Completed ~ ° Z,O, ~ ~' Yield
Total Depth ~/..0 ~'~ Cased to
Static Water Level / 2.0
2F'T:
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
Depth of Grouting
Pump Set At ./,~'~'
Sanitary Seal on Casing (y/N)
Depression Around Wellhead (Y/N)
/~.Z J~'T', ; On Adjoining Lots ~ ,/O~:~ ic'T
To Nearest Edge of Absorption Field on Lot / O ~ rT'~,; On Adjoining Lots "7~/~ 0 F 7'
To Nearest Public Sewer Line /%//,~) To Nearest Public Sewer
Cleanout/Manhole /D/~ To Nearest Sewer Service Line on Lot ~'~
Water Sample Collected by 7'4:2~ ,~'/v,~"/7_//v)/~/k,( ; Date ~ ' '-~ ' ~ ~'
Water Sample Test Results 5~ '7'/.-~ ~-,~]C.. 7"'0/'~ .'~
Comments /~ ~ ~;'
B. SEPTIC/HOLDING TANK DATA
Date Installed ~ "I,-,~ * ,~' Size /O C~::;~ No. of Compartments ~
Standpipes (Y/N) ,Y~' -~ Air-tight Caps (Y/N) ~__ Foundation Cleanout (Y/N) ~-~---
Depression over Tank (Y/N) N.E:)
Pu m ping/Maintenance Contract on File (Y/~,~ ~J/,~.
Holding Tank High-Water Alarm (Y/N) !
Separation Distances from Septic/Holding Tank:
To Water-Supply Well / 2-~__.. ~' ¢T'¢
To Property Line / ~' ~
To Water Main/Service Line /(u¢/~
Course ~
Comments /~ZO/',,/~_
Date Last Pumped
· for
Temporary Holding Tank Permit (Y/N)
To Building Foundation /.~. /~' To
TO DisPosal Field /:~' '~ T,
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata .~ :2.,~- ~'~., ~ ,~D,/2_M Type of System Design
Date Installed ,~ ~ I,.~ ' ~-~,-~' Length of Field -'.'.'.'.'.'.'.'.'~-~' ~""~',
Width of Field 2, ~/ FT~ Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area / .~'.~' ~ ..Cc:j).
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well /O~¢, ~'~'~
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 ~J Of'C/_/:=
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line /~
To Existing or Abandoned System on
; On Adjoining Lots -/- ..~ O ~' 'T
To Cutbank (if present) A//~
D. LIFT STATION ~'/~O'T' f.,J,.5-~/:2>
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Per/~tted Be¢om Rating Against HAA Request **
I certify that' bOCa/cc cheCJ~d, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed //~,~// "" ~ Date ~,,~ ~=
Company ~ ¢~' MOANo. ~¢~' Z/~
Receipt No. ,3q%-~ ~ ~
Dateof Payment ~ S-! ~-~0
Page 2 of 2
72-026 {11/84)