HomeMy WebLinkAboutSAMPSON ESTATES BLK 3 LT 15Sampson
Estates
Block 3
Lot 15
#051-811-41
Municipality of Anchorage Page 1 of 2
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
Permit Number: SW 930446 PID Number: 051-811-41
Name:
M M & M Contracting
Address:
P. 0. Box 670495, Chugiak Ak.9956
Phone: No. of Bedrooms:
688-1236 1 3
LEGAL DESCRIPTION
Lot: Block: Subdivision:
15 3 Sampson Estates
Township:
Range:
Section:
T15N
R1W
NW4 Sec. 3
WELL: E:kNew ❑ Upgrade
Classification (Private, A,B,C):
Total Depth:
Cased To:
Indiv.
183' Ft.
183 Ft.
Driller:
Date Drilled:
Static Water Level:
Sullivan Water Wells
10/93
158 Ft.
Yield
I Pump Set at:
Casing Height Above Ground:
lO GPM
Unk Ft
2' Ft.
Wastewater System: ❑ New ❑ Upgrade
ABSORPTION FIELD
M Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other
Soil Rating:
Total Depth from original grade:
0.97 wei hte§�D/S .Ft.
varies, 11-17.5'
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
varies, 4.5-10.5Ft
7.0' Ft.
Fill added above original grade:
Gravel length:
None Ft.
36' Ft.
Gravel width:
Number of lines:
Distance between lines:
3.0FL
1
-- Ft.
Total absorption area:
Pipe material:
504 SO. Ft.
HDPE ASTM; D3034 A
Installer:
Date installed:
M M & M Contr.
Oct. 1993
TANK
SEPARATION DISTANCES
X Septic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer:
Capacity in gallons:
Anch. Tank
1000
From
Tank
Field
Station
Tank
Sewer Lines
Material:
Number of Compartments:
Well
101.5
105.0
--
--
84'
Step'
9
Surface
LIFT STATION
Water
+100
+100
--
--
+100
Lot
Size in gallons:
Manufacturer:
Line
57.51
62.0
1
--
54
"Pump on" level at:
"Pump off' level at:
High water alarm at:
Foundation
17.5
21.0
--
--
--
Curtain
Pump Make & Model
Electrical Inspections performed by:
Drain
+10 0
+10 0
--
--
+100
BENCH MARK
Remarks:
Location and Description:
Assumed Elevation:
100.0
"4
4�
/�y 1#d
Inspections performed by: Constructing Engr'spates: 1Stll/13/9�'
11/13 9 HENRY H. WILSON
p / 1732—E kk
Final ,%���
Department of Healt d H ervices approval ®�SSIDNA��
®®®®®
Reviewed and approved by: Date:`
72-013 (Rev. 9/91) MOA 25
MI
WASTEWATER ABSORPTION SYSTEM
LOT 15 BLOCK 3 SAMPSON ESTATES SUBDIVISI❑N
PERMIT # SW 930446 PID # 05111841
55.'
W
43.0
SCALES I" = 20'
SEWER ROCK
36'
BOTTOM OF TEST HOLE Ho.1
MM & M CONTRACTING
P❑ BOX 670495
CHUGIAK, AK, 99567
HT
V
CONSTRUCTING ENGINEERS
9601 BUDDY WERNER DR HC83 BOX 192A MYRTLE DR
ANCHORAGE, AK, 99516 EAGLE RIVER, AK, 99577
346-2000 694-9098
DATE! 3-17-94 DRAWING #
NOT TO SCALE AS -BUILT
SPRING
ENDS"
i
?
GRADE i0 HE
ORIGINAL
AND
FINISHED
E
99.8
UNCLASSIFIED FILL (TRENCH EX)
32.5'
o
FILTER FABRIC
w
ow
2 94.1
2 HD INSULAT II
95.2
o0
I— 5
1000 GALLON
STEEL SEPTIC
93.9
2-CDNPARTMElIT
'
TANK
SEWER ROCK
36'
BOTTOM OF TEST HOLE Ho.1
MM & M CONTRACTING
P❑ BOX 670495
CHUGIAK, AK, 99567
HT
V
CONSTRUCTING ENGINEERS
9601 BUDDY WERNER DR HC83 BOX 192A MYRTLE DR
ANCHORAGE, AK, 99516 EAGLE RIVER, AK, 99577
346-2000 694-9098
DATE! 3-17-94 DRAWING #
NOT TO SCALE AS -BUILT
MMM
CONTRACTING
INC.
P.O. Box 670495 • Chugiak, Ak. 99567 • (907) 688-1236 or 373-7176
March 2, 1994
Mr. Robinson
Department of Health & Human Services
Municipality of Anchorage
825 "L" street
Anchorage, Alaska 99502-0650
MAR 71994
Mwntcipahly of Anchorage
Dept. Health & Human Services
RE: Health Authority Approval on Lot 2 Block 1 Sampson Estates
Dr. Mr. Robinson
After our conversation yesterday I spoke with Chuck Landers of Construction
Engineers. He advised me that he would have the elevations of the inverts to your
office no later than Monday March 7th.
I also spoke with Paul Myers about the monitoring tube. He believes he did install
one and that the Fire Department knocked it over during the fire. We had to fix
some of the cleanouts, but forgot about the monitoring tube.
We will no later than May 15th find & repair the monitoring tube or install a new
one. We understand your concerns and apologize for not taking care of this
sooner.
We appreciate your giving us the time to take care of this.
Sincerely,
Arleen Myers
Sec/Treas
tDrilling'
` log
by
DOG Co, dbe q,
SULLIVANELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 o TELEPHONE 688.2769
t
'NER OF LAND T� / / i (-4 l c 'J'66.�r ''6
t DESCRII'TION -tbl� l �. _, %ii¢�Yi1.fJ..J s
Started Ended
..._
:iT NUM13ER
-i OF FORMATIOM
DEPTH OF WELL IFS c -
STATIC
STATIC LEVEL OF WATER FT. .. / 61
DRAW DOWN FT. .f/.
GALS. PER HR --
KIND OF CASING
Ft. s'i ,, JG. ( G
From....o..
rt. to--- -
--Ft. —
Ft. to i
,• L1 t- 0 0z .6 g,:zzL__-.
From
Ft. to-
--.Ft,
f '7� `�
From
Ft. to—Ft,
n _ Ft. to__.L>' .Ft• —
c$,JJJ it e.pf6.1�.�-_
From -17C
to�.-..-Ft
to�l-p Ff.
d-eR r k>���
to�, te7' Ft.
From
etttlLFt. ,
Ft. to
Ft.
rom, Ft. to -Ft.
From
Ft tnFt.
Ft. to—�Ft.
From
Ft, tom
17t.�
rom
Ft
94_....x.....- .._..
FromFt,
to
- -Ft. -
.
rOm.--.._...._—Ft.
to--LFt.
From
__FI, to
Ff.
rom _Ft.
Ft -
Ff. to. . W
From
Ft. to
-Ft.
rom
"�
rom Ft. to Ft; -•
From
ft to
Ft: r
:om Ft, to Ft.
From
Ft, tom.__—Ft.
•Ft.
4m Ft. to Ft.
From
Ft. to._..
---- .._
om Ft, to� Ft•
From
Ft. to
-Ft. --
Ft, to
From
Ft. to
Ft.
rom -Ft,
..
From
Ft to.�.
Ft ;,
eom Ft. to Ft.
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 WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW930446 DATE ISSUED:10/22/93
DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC. EXPIRATION DATE:10/22/94
OWNER NAME:M M & M CONTRACTING INC
OWNER ADDRESS:P.O. BOX 670485
CHUGIAK, AK 99567
PARCEL ID:05181141
LEGAL DESCRIPTION: SAMPSON ESTATES BLK 3 LT 15
LOT SIZE: 40109 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY:
DATE: L �3
DATE: lok-
r'i7; 'MK. JUiiN SMl'I H DAFE: MARCH 31, 1994
MANAC PR ON STIR SERVIC,RR Ito P.M.
MLN4 1C1PAL= OF Ajv*CHQrLAVE
RE: Lo'f 1s BLOCIC3 SA IT'S 3 t;GrATEs
DE.�F'r Alla. SASI'1'1.1: •
In our e11ar r �m•�r52L'2 ! dwrlier t�3ay at approximately 1 1:l S you stated that the only reason you would not sign
rile Health tl,ttutority Approval for ale above referenced lot was that there was a perceived error in the paper worx,
'there v«as nothing wrong with the :septic system or. the water. T Advised ymi that M M Rr, M ContrAGting wAq the
uwitw ur d10 pruptaLy auulFad put iet llas 54;VUU eysstaiu Mid ,h i we umlcu to luruw wliat'u`Fa axavt pruUlvuF wass bu
that we could help solve it. 1, also, advised ,you that if we did not get this Health Authority Approval today or
tom0now that wo might loose. our buyers for this home, bccauaw, if we could not otos:. ;;. the a; ,day ar ;a that
their interest rate would increase,
y ou woula not tc11 me what the perceived error in the paper work is. You rctused to put to tvndng what the problem
Yntl refiled to llt tri wPfi%v that ym.1 wolild not toll me what the problem wBS. Y91j stated that yrnt wanted t4
talk to the engineer. ivir. Hank Wilson and would not sign off unur you had. I called you again a few minutes later to
Advi4P. ynit thAt Mr. Wilson wA4 Ant of stAte nn vRcAti4n. YMr AVAIn 4bFtP,r1 that yell WAtrid not 48n the TieAtth
Authority Appiuvai w►thuut fust 4Pe ig with Mr,19d6a1L
ASr. Paul Myers tried to call you at 1:38 and lett a measagc. lip, then called Mr. Bob ilaker and alloainad to luta that
as the septic and water had been approved we could not understand why for a minor technicality (a perceived
problem) in tl:c paps: wort: that the Heg& Atdhority Approval could not be sued now and the problem if any
to
taken care of as soon as possible. The main point being that the septic and water are ok, as verified by an �r��
insppr•.tlnn by the muturipality yesterday. An approval shoedrl not be tFelrl up fora tn+nnti trclFCFieAlity m
work that could be resolved. We think this is unusual.
Mr. Myers also explained to 1�1r. Bal+xr that if this hoose sale m at ire 4.1 mately $100.100 over the next N d with4l 1114 11dXt day 01 &o yem,
buyers will loose their locked in interest rate which will Bost them approximately
atld that the cur=t intxcascd rate may make them unable to gtlahty far this ltomc. Tllcn, tocLed in ruts is 6-875 and
the current rate is 13.375 which is a ditierenae of 1.5 %, which amounts to quite a bit on a home costing close to
�j71�4i0,0
AYlnrn MyArS,
aewTrea�,
uv: 141r. Bob Baer
wa
40 dol.Htvn —.—�— ��—•-- ��—:ggySS3W
9ieVSk1FN Nk7l-IV .� �� _ — ..# )(Vj
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Td WdSZ:t70 1766T 1£ 'aeW
82F -T899 : 'ON 3NOHd DNI UdiN0O WWW WONA
P.O. Box.670495 • Chugiek, Ak. 99567 • (907) 668.1236 or 373-71705
TO: "Mit. JOHN SMITH LHIE: MARCH 31. 1994
MANAOPR ON SlTr% SFRVr('.FR ISO P.M.
IvIIJ13ICIPaLiTi' Di• it►rCi1('ii�r+vS
RE; LOT 15 ALOCK 3 SANIM10t4 ESTATES
DE.1P, r 4R. SbIMI:
Ln our t. rror cenv.nation earlier today at approximately 1115 you stated that the oily reason Tvu would not sign
rho Health Ami kority approval for the above referenced lot was that mere was a perceived error in the paper work.
There wns nothing wrong with the septic. syAtem or the water. I Advised yon that M M r@ M Contracting wAs the
urruw ui aLU NnuNCtly lulu lead NULuI Ili: MVUU syA0111 laid uutl wC licetled iu nnvw what Cie Cnaui piuinCru was su
that we could help solve it. I, also, advised you thatifwe did not got" Health Authority Approval today or
tomorrow that we might loo9c our buytr8 for this hom.., 5:.cauac, if we could not close in the next day or ao that
their interest rate would increase.
You would not tell me what the perceived error in the paper work is. you reAmil to put 1i writing what the problem
is. You refused to put in writing that y 9q would not trZ rrr, what the problem was. You stated that you wanted to
halt w lite enguteer Mr. hank Wilson and would not sign ofiuntd you itad.. i called you again a few minutes later to
Advise you that Mr. Willson was fait of state nn vacation. Bran Again stated that yrnn would not sign the Health
Authority Apt}ioval wdlsvld lk-st Dpe"Is with Mr.,%T6011.
Mr. Paul Myers tried to call you at L•32 and left a message. He then called 1Kr. Dob Aakor and oxplainod to him "t
as the septic and water had been approved we could not understand why for a minor technicality (a perceived
problem) in the paper work that the Health Authority Approval could not be signed now and the problem if any
taken care of as soon as possible. The main point being that the septic and water are ok, as verified by an onsite
insper.%tien by the muntVality yesterday. An approval should nut be lwld rip for a minor technicaW in thn P"r
work that could be resolved. We think this is unusual.
Mr. Myers also explained W Mr, SAker that ,if this Iwusa sale cannot be closed within Ilia i"t flay ix &0 die dw
buyers will loose their locked in interest rate which will cost them approximately $100,000 over the next 30 years,
and that tho current inomascd roto may make them unable to quality for this home. Thorc ioekcd in rata is 6.575 and
the current rate is 8.375 which is a dltlerence of 1.5 °/a, which amounts to quite a bit on a home costing close to
1ao'�I.
ii Arleen Myers,
I 1CW nreaY.
Co. Mr, Bob Batu'
_
IM 3NOHd .A� XVI _Q . �� � .# XVd
NOUV001 � ••.�,s�—:NQIAtl907
wane ,G� '':01
�.
s39Vd # % �:�w11 �ltla /� V=4
----
Id Wd6Z:b0 P66T i£ 'apw
BEFT889 : 'ON 3NOHd
ONIlOU81NOO WWW :.WObd
Alikunicipant � POU H 6-650
-� ANCHORAGE, ALASKA 99502 0650
(907) 264-411 1
(I
TONY Y.NO'NLES.
+� MAYOR
DEPARTMENT OF 14EALTH AND ENVIRONMENTAL PROTECTION
Permit 4: 840334
January 31, 1985
TO: Permit Applicant
SUBJECT: Lot 15 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,
1984.
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
and the yellow copy 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,
Keith E. Bandt Supe visor
p
Environmental Engineering Program
KEB/ljw
enc: Copy of Permit
SWP/057
PERMIT NO:
DATE ISSUED
.APPLICANT
ADDRESS:
CONTACT PHONE
r-1 U r -J I IZ- I F' F:f L_ I -Ir &-e in �', F=1 r-4 C�: " L -_l Fe F=1 9_3
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTIO;4
325 L STREET, ANCHORAGE, AK '9_9501
264-4 0
840234
05/lL'84
BRYAN ROFF
% S&S ENGINEERING
EAGLE RIVER., AK 99577
6942979
LEGAL DESCRIP: SUBDIVISION: SAMPSON EST. LOT: 15
SECTION: 3 TOWNSHIP: 15N RANGE: IW
LOT SIZE: 40105 1,*SQ. FT. OR ACRE'S')
MAX BEDROOMS: 3 1
BLOCK: 3
LISTED BELL 14 ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR SEPTIC
SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR SITE.
- - - - - - - - - - - - - - - - --- - --- - - - - - - - - - - - - - - - - - - -
� FEC -a
DEPTH TO PIPE BOTTOM (FT.) 3.0
GRAVEL DEPTH (FT.) 0.5
TOTAL DEPTH (FT.) 3
,.5
GRAVEL WIDTH (FT.) 19.0
GRAVEL LENGTH (FT.) 36.0
GRAVEL VOLUME (CU.YDS. ) 25.3
TANK SIZE (GALS) :1,000.0
SOIL RATING (SQ, FT. ,JBR)
DEPTH TO PIPE BOTTOM -,- 3.'.5 FT. REQUIRES INSULATION
DEPTH TO PIPE BOTTOM -C 4.0 FT. MAY REQUIRE A LIFT STATION
TANK MUST HAVE AT LEAST TWO COMPARTMENTS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
I CERTIFY THAT:
1. 1 AM FAMILIAR WITH THE REQUIREMENTS FOP ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE (MOA) AND THE STATE OF ALASKA.
2. 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS,
AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT.
3. 1 WILL ADHERE TO ALL NOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK
DISTANCES FROM ANY EXISTING WELL, WASTE14ATER DISPOSAL SYSTEM OR PUBLIC
SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT.
4. 1 UNDERSTAND THAT -THIS PERMIT IS VALID FOR A MAXIMUM OF 3. BEDROOMS AND
ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT.
IF A LIFT STATION 15 INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
'i" HEN (1> FIN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS -BU ILTS
.WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
.ELECTRICAL WORK MUST BE DONE BY A, LICENSED ELECTRICIAN.
S I GNED
APPLICA
ISSUED
vf) DATE:
NT: BRYA 9 F
BY DATE:
�
SOILS LOG
MUNICIPALITY OF ANCHORAGE
j • ac DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST C/
PERFORMED FOR: �- ����Ex KA R\ DATE PERFORMED:
LEGAL DESCRIPTION: Is– 6-3 �L� I%��er 0`i 2k –r
DEPTH(J SLOPE SITE PLAN
�-Zs �i (� f �
ikm) (G)
s ( L�-�( SAN4 Y &P-gv'vL
(6P)
CSR r� v E L A S F�Nl D
(vrm)
S F LT Y SprN t�' Y WAS GROUND WATER S
C7 F–P v e– L e ENCO NT RED? LO %
E
I YE AT WHAT %
- ; "t4`t: e,,: EPTH?
6:, Imo. gR�37� e'y�L`n
COMMENTS
sV
PERFORMED BY:
72-008 (6/79) _.
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE
TEST RUN BETWEEN """ FT
Municipality of Anchorage .n a
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program «;
4700 Bregaw 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
Parcel I.D. O S 1- Sl 1- Y/- peV
1. GENERAL.INFORMATION
Complete'legaf description
COSA # 060 1 9 R
Expiration Date: tR - / 7 - o 6
Sa.a�r.a o�rsrare.# L.r /t XocA 3
Location•(sfte address), /e
- .I.' t:.::.;.,
Current Propei(y'oWner(s) it/e..c� �oreiol
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone
X44
rw�i
Qcs.�aa7iyl Worr (4tfl"e'r") Day phone 4!�ryY-gyl8
fJ2-
Pc'fc ��NI/H
Day phone q07- 2_16r- 9/36
7-S zs- e- /o? .wee ft;c 99re�
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
A�T
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site 1T
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. 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 andlor 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 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 �ysti0� uS Eti,�i�c Phone
Address 7.000 E. !i//eec �.�rtt�s X/c .4k- 914 f'
Engineer's Printed Name M9?ZZ4zA`, Date
5. DSD SIGNATURE
f/ Approved for .3 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date:_Z % _Q
(Rev. 77005)
Municipality of Anchorage e
• Development Services Department
Building Safety Division
On -Site Water & 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: 107- /s 011y E > �"/�oN eOr Parcel 0:4t1- S//- 4fl-�
A. WELL DATA
Well type �'' *;rc
Date completed fo-f
Total depth 41—ft.
Date of test
Static water level
Well production
If A, B, or C provide PWSID # d4t
Sanitary seal (YIN)
Cased to 11 -3 -ft.
FROM WELL LOG
/v -4 3
to
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate 00n' mg/'C
Arsenic: t/D ug/L date of sample: #_2,'X, 06
B. SEPTICIHOLDING TANK DATA
TankType/Material STce-I
Tank size 14:10o gal. Number of Compartments 2
Well Log (YIN) Ye --s
Wires properly protected (YIN) Ye -S
Casing height (above ground) 24/ in.
AT INSPECTION
4-y-ar
163 ft.
K. ')� g.p.m.
Other bacteria 41 colonies/100 mL
Collected by: Z:� /a'!;✓w"* ',
Date installed //-,?I
Cleanouts (YIN)
2 -
Foundation
Foundation cleanout (YIN) Lr_,�L Depression over tank (YIN) High water alarm (Y/N) N'4
~'q-zl-or r TiC )..* s.
Date of pumping _ . Pumper p
........:.
C. ABSOf PTION FIELD DATA
Date installed •//�-'„Soil rating (g.p.d./ftZ or ft2/bdrm) 4.4% System type T`+e-,4
Length 3 6 ' ft. Width 3 ft. Gravel below pipe 7 ft.
Total depth 11 ft. Eff. absorption araaS W Monitoring tube 1ks Depression over field 416,
Date of adequacy test 01- Y et Results (Pass/Fail) P10 -4J For 3 bedrooms
Fluid depth in absorption field before test s/ in. Water added] Qa gal. New depth .Sf in.
Elapsed Time: 0 min. Final fluid depth S2L_ in. Absorption rate >= qry g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) A'"" ) If yes, give date _y4
D. LIFT STATION114 -
Date ins /�' Size in gallons Man efA�cess I(YIN)
'Pump vel at _ in. p off" leve7at High water al evel at m.
atum Cycles to els alarm & circuit r uirements7
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot /0�' S On adjacent lots
Absorption field on lot 105-
Public
vsPublic sewer main AIA
Sewer /septic service line = Si
Animal containment areas "t/ao' -
On adjacent lots
t/GT�J
t /tae ,
Public sewer manhole/cleanout ✓A
Holding tank *t 4
Manure/animal excrete storage areas ^r�D
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 17 s Property line T7.f Absorption field 7 ,
Water main N-4 Water service line t/G Surface water
Wells on adjacent lots '714
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
i
Property line 4rx Building foundation ;L,/ Water main �A
Water Service line */90 Surface water
Curtain drain a✓q Wells on adjacent lots '/40 '
F. COMMENTS
Zmf 772;.i is .s 1te"
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 *770C..., T it'/+iwG:.,'
Date S/6 -04r
COSA Fee $ 4430
Date of Payment - / % -
Receipt Number 0
(Rev. 17/05)
Driveway, parking/vehicle storage 10
Waiver Fee $
Date of Payment
Receipt Number
497a
-�Z441
to: 907-343-7997 From: hattheu J Hardini, PE
05-16-06;12:17 ;
SGS Ref. a:
1062333
Cl;ent Name:
Mat -Su Test lab
Project Name:
Sampson Est LIS, B3
Cr.entsample ID:
Sampson Est LIS, S3
Matrix:
Drinking Water
rl3 ar6'11�7
P9 2/ 2 05/16/06 4:30 ps
;607 661 5301 # 2/ 2
SGS Environmental Services Inc
200 W. Potter Drive
Anchorage, AK 99518
Tel: (207) 682.2343
Fax (907) S61-5301
All dates/times are Alaska Standard Time
Printed Oetarl'ims: '06/18/0s 11:80
Collected DateMma: 04/27/06 13:40
Received DaleMme: 05/11/06 15:50
Technical Director. � Stephen EiA
Released
Allowable Prep Analysts
Parameter Results POL Units Method Llrr,its Data Date Ink
Nitrate 0.28 0.10 mg*g EPA 300.0 10.00 05/12/06 05/12108 e!r
May 16 06 06:50a Mat -Su Test Lab, LLC 907-745-3010
P.1
SGS Environmental Services Inc
200 W. Potter Drive
Anchorage, AK 99518
Tel (907) 562-2343
Fax (907) 561-5301
SGS Ref. It.
1062172009
All dates/times are Alaska Standard Time
Client Name:
Matsu Test Lab
Printed Data/Tlme: 05115106 15:40
Project Name:
61209 Olympus
Collected DateJTlme: 0427106 10:45
Client Semple ID:
61209 Olympus
Received Daterrime: 05/02106 230
Madr
Drhtldng Water
TecrMicat D(rector�phen e ,
PVVSID
Rebased . .I�/��/
6ampte Remarks:
Allowable Prep Analysis
Parameter Results POL Units Method Limns Date Date Init
Arsenic ND 5.00 U91L 200.8 10.00 05104!06 05/10106 sol
�e►ds-k,L
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. HAA # 0 gnu RiS
Expiration Date: ► 2 -Z % — 05-
1. GENERAL INF.ORMA riblT'�';..
Complete legalxL6scripholi61r-i^-s..r_ '5757�s 1.7 /S' lg/o�E 3
Location (site addrtA5S'(5gyGonsp
' ••, iscar•�r c+ � ' ,
Current Property,owtm.gs)-•,' -0 ./ Day phone'
Mailing address
Lending agency _tVe_11s (Aed VZ1 toj Day phone
Mailing address /Soo �✓ Bus... gJrd, yti
Real Estate Agent /.ivy I�.:,./ie/ Day phone
Mailing Address _ 4me-Zo!!:%e 9s9�-03
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well t['
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
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 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority 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 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 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 verify that my investigation,
based on procedures outlined in the Health Authority 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 ��Y"'�s /�✓� Phone 907-393-d-28*1
Address Z.000 e. ?rY/ore Ak '?
Engineer's Printed Name-eT>lc.,, 7Z:: i1+1�W;1 Date
5. DSD SIGNATURE
Approved for �� bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
bedrooms, with the following stipulations:
'RV-- ....'cy'��
0
ATERAND
tNQCTFIe/ATrn
: m=
'' PROG•R,q
_'
Maintenance Agreements
Supplemental Engineer's Report
Other
ey:Original Certificate Date: C1
17
(Rev 0IM2)
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) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Goi /S sh,e" 3 SWAG mo e�r'rr_s Parcel ID: OSI-
A. WELL DATA
Well type 'Lf. ✓e>, If A. B, or C provide PWSID # i✓�
Well Log (YIN) ye -t
Date completed l�-'13 Sanitary seal (Y/N)
Wires properly protected (Y/N) Ye -5
Total depth _8'3 ft. Cased to �" ft.
Casing height (above ground) Zy" in.
FROM WELL LOG
AT INSPECTION
Date of test /0-93
Static water level /r8
Well production /0 g.p.m.
b• 9 -
p.m -WATER SAMPLE RESULTS:
Coliform colonies/100 ml. Nitrate 3•y-2 mg./I.
Other bacteria - 4�5.l colonies/100 ml.
Arsenic: _ mg./I. Date of sample:
by: ,t/ 41o1.1,;,,
B. SEPTICIHOLDING TANK DATA
Tank Type/Material fry
Date installed [ l 43
Tank size /��' geC, ',• .. Number of Compartments 2
Cleanouts (Y/N)
Foundation,cleahout Qt'". Depression over tank (Y/N) �2 High water alarm (YIN) _N.9
Dale ofpumpiap gn2h4Pr Pumper
C. ABSORPTION F1BLD DATA .
Date installed L + Soil rating (g.p.d.W or ft2/bdrm) 0.9% System type Testi
Length 3 ft. Width 3 ft. Gravel belowi
a ��► P Pe t;7_ ft.
Total depttr ft. We EH. absorption area 2± -ft: Monitoring tube Yc) Depression over field _ o
Date of adequacy test _?-,Y-or Results (Pass/Fail) .&S For 3 bedrooms
Fluid depth in absorption field before test J/_ in. Water added 09gal. New depth S -r in.
Elapsed Time: �_'o min. Final fluid depth �:/ in. Absorption rate >= Se g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) /moo ru_04. 0_) If yes, give date
D. LIFT STATION 1114 -
Date -installed V 4 -
Dale installed
'Pump on' I at
M
E. SEPARATION DISTANCES
)ns annu'wn
level at n. High er alarm level
ad eels alarm t: c' it requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot _/ d( f
Absorption field on lot to
Public sewer main /144
On adjacent lots 4/do
On adjacent lots
Public sewer manhole/cleanout /✓A
Sewer /septic service line 2 SS" Holding tank Alel9
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: �i
Building foundation / % t Property line S7 S Absorption field /
Water main —Aq - Water service line '` /o 1 Surface water
Wells on adjacent lots * y,00
'f' /00 f
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
r
Property line 4K 2 Building foundation A / Water main y�
i
Water Service line -F!O Surface water 4140 ' Driveway, parking/vehicle storage
Curtain drain _� Wells on adjacent lots -A /o o
F. COMMENTS
e,,4
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name /''f/7r4e^l
Date 9-/S -es-
HAA
os
HAA Fee $ 4-3 0
Date of Payment 61— - O S
Receipt Number
(Rev. 12101) 67 V
Waiver Fee $
Date of Payment
Receipt Number
*; 49 DI
d
rrsr
F,1
l
Dtufntiu5
Dtalthew I Nardint, P.E. email: matto olympusengineering.com
PO Dox 876901 Phone: 907-373-6289
Wasilla AK 99654 Fax: 815.612-0719
Lep-al Description: Sampson Estates Lot 15 Block 3
22529 Sarah Circle (MOA PID 051-81141-000)
3 Bedroom Residence Well and Septic Adequacy Test Date: 9/4/05
Report Date: 9/16/05
Septic Adequacy Test Results: Pass for 3 Bedroom
Well Information: Depth 183', 6" Steel Casing, Static Water Level 163 BTC
Nater Samples Taken: 9/7/05; PASS (Coliform, Nitrate/Nitrite)
Well Flow Test Results: Pass for 3 Bedroom, 6.2 Gallons per Minute (GPI%I) pump
capacity/Well Flow Rate
Introduction
Records Attained from MOA Indicate that the system is comprised of Deep Trench System. The well
wiring is protected in conduit, and the grade is sloped away to allow for drainage or surface water. No
improvements are required to the well.
Well Flow Test
The test, conducted on 9/4/05, measured the static water level of the well at 163' below top of casing
prior to the beginning of the test. A total draw down of 4 feet was observed after 15 minutes of
pumping, at this time the water level had stabilized. Water was initially produced at an average flow
rate of 6.2 GPM. After the water had stabilized at a level of 167', a flow rate of 6.2 gallons per minute
was maintained for the remainder of the test. Observations and measurements made after the flow of
water had stopped determined that the well had a recovery rate that was greater than the established flow
rate of 6.2 GPM. This flow rate is the maximum that can be established with the installed pump.
A total of 1543 gallons was produced over a 4.1 hour period, with a continuous flow rate of
approximately 6.2 GPM. The well had recovered to a static level of 163' within 15 minutes after the test
ended.
Septic Adequacy Test
As stated above, MOA records reflect a Deep Trench design of the septic system. The monitor tube for
the system showed a total depth of 194". The observed layout and depths of the septic system tubes are
consistent with the parameters of a Deep Trench design. This report tests only the performance of the
septic system, and does not verify any construction methods, or system sizes or materials.
The capacity of the septic system was tested utilizing the observations taken both at the time of the test
and following the test to monitor the recovery of the system. Water was added to the After Tank
Cleanout, and a rise in the water level in the monitor tube of 4" was recorded. A total of 613 gallons
were added into the septic system. 1 hour after the addition of water had ended the monitor tube had
returned to its original level. This indicates that the water that was added was absorbed into the
surrounding soil The observed acceptance of 613 gallons of water exceeds the minimum 450 gallons
required for a 3 bedroom residence.
In summary, the Well and Septic Systems located at Lot 15 Block 3 Sampson Estates (22529 Sarah
Circle) have passed adequacy for the usage of a 3 Bedroom Single Family Residence at this time.
It should be noted that these results are not indicative of future performance of the system, and reflect
performance at the time of the test. This test also does not verify construction methods or compliance of
any materials used in the construction of the system.
Well and Septic Adequacy Test performed and certified by:
September
166,, 2005 /
Matthew J. Nardini
CE -10322 AK
Mat -Su Test Lab 9077453010 09/09/05 12t40pm P. 001
mat -Su
Test Lab of Alaska
Water Quality Testing
TM
Mlle 3.2 Palmer-Wasiila Hwy.
P.O. Box 2749
Midtown Community Business Park
Palmer, Ak. 99945
Plane: (907) 745-3006
Email: matsutes4"_rooershsa.com
Fax: (907) 746-3010
Client: Olympus Engineering
Date Arrived: 98/05
Report Date: 98/05
Sample Date: 91=5
Atm.:
Sample Time: 1100
Client ID: Lot 15 Block 3 Sampson
Collected By: WN
PWSID #:
Source:
M.S.T.L.#: 51715
Sample Matrix:
Comments:
Method Parameter Units
Results MDL Date Prepared
Date Analyzed MCL
SM 4500-NO3-E Nitrate -N mg/L
3.42 0.50 9/8/05
9/8/05 10.0
SM 4500-NO3-E Nitrite -N mg/L
0.13 0.05 9/8/05
9/8/05 1.0
Total Nitrate/Nit6te mg/L
3.42 0.50 9/8/05
9/8/05 10.0
Legend: MRL - Method Report Level
MCL =Max. Contaminate Level '
B = Present In Method Blank
E e Estknated Value
H -Above MCL
D a Lost to Dilution
Rte Ld By Jon Paul Campbell
Lab Manager
ra
`0p5 CURVE LENGTH RADIUS
SARAH CIR, C1 40.77 50.00
• C1 i N,,-3. V4�0'S7
\fx�ST�Noo���f ,� 22a.Sp
0' TELECOMM �RqD,
4
1AY WELL
6 ELEC. ESMT.
`\5.3 amt ° / 1
I
ZN vy t\NM�S� W
RPS,; �j. ��6y u I
a
f�`•C�
NI
Za
scoot vrwrs 1.3
N
a�
N I
N v I
I
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\ I
' I
I
// 10' TELECOMM R ELEC ESMT.
--f----------------
`2� S89°55'08'W 126.20
Vertical control is assumed relative.
Horizontal control per recorded pro -� -----
No
No property corners found or set this survey .
v
0
0
0
1 herby certify the followine described properly.LOT 15.
EILK 9 , SAMPSON ESTATES , BLS
Anchorage Recording PregincL, Alaska, •has been p.
. O; surveyed by me, or at my direction, and that the lx.
Al'improvements situated thereon are within the
properly lines and de not overlap or encroach on the ASSOC.
!' , proprrty lying adjacent thrrelo. That no improvements
on lbe property lying adjncer,t thereto encroach on the P.O. BOX 0084
/premises in question and I, -gal there are no roadways, ANCHORAGE, AK 99523
/ Iransmission lines, or othe:-' visible easements on said Tele. 907) 526-6050
properly, except as Indical.•d hereon. Fax 907) 562-6040
4 nonny r. BURNER The information hereon Is :Yor the use of lending ins-
L-a4a' titutioas specifically to shnw'any conflicts between DAT);;
existing structures and pini.l.ed lot lines or easements 04-22-97
�oESssroN�L�P i and is not to be used for positioning additional SCALL:
structures or fencelines. f:asements of Record, Other 1" = 40'
than those shown on 'Lha recorded plat, are not _ GRID; NW 16130
shown hereon.
= ` 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/ ' 8 /{— ¢/ HAA # �G r�
1
-(�yh9_
:<
I., GENERAL INFORMATION `
Complete legal description -_ + oro v5 SOL hPSv../
FSS•
Location (site address or directions)
Co�+roc-rA�7-
J �( Mt= l t� LSA �NSiES`i
Property owner Day phone
Mailing address
Lending agency NDay phone
JA
Mailing address A
Agent ToT�J�9 - (2��e,,Y gaP� �A-�� Day phone
Address — -7,24 �� i i S AvE . AjoU-+ +
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: `+
S. STATEMENT OF INSPECTION BY ENGINEER.
As certi f ied 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
a.ncitype of firucture indicated herein.1 f1.artherverify that based on the information obtained from
the Municipality of Anchorage file, ant, born my inve � i gatior. and inspection, the on-site water
supply and/or was'cewaicr disposal sy i( is in com fiance v. itis all Municipal and State codes,
ordinances, and regulations in effect on the dot of this inspection.
Alaska Water i Phone .337-61 / 7
9
Name of Firm �;� • '41ntnr-
13h7 B kriclon r.
Address / Ar c . AK gg "
L::ngineer's signature / Af L)ato �� r
Goth_`or
C J w5
LG ° 1 f reYA.Gar' , "
6. I;tHHS SIGNATURE f>`,l CE -7453 0 �6d
of _IV
_. Approved for _ f bedrooms.
_ Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
Amm
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 orderto 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 M
MUNICIPALITY OF ANCh
ENVIRONMENTAL SERVICES D,
Municipality of Anchorage APR 0 2 1997
DEPARTMENT OF HEALTH & HUMAN SERVICE E C E I V E D
Environmental Services Division
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Legal Description:
A. WELL DATA
Well type P V t
Log present (Y/N)
Health Authority Approval Checklist
�A.-I9So a I
LoT tS , gK3 _ Parcel LD.:
0151- 8/l- 4t-000
If A, B, or C, attach ADEC letter. ADEC water system number t
`.I t'S
Date completed ►O / R 3
Total depth I a3' Cased to I `a '2� /
Casing height (above ground) 2 Q
Sanitary seal (Y/N) Wires properly protected (Y/N) yds
Date of test
Static water level
FROM WELL LOG
tID/93
/5S
AT INSPECTION
3/z2�Lq7
/65'
Well production I D g.p.m. • g g•p•m•
Fbr2 wil-4 onn.`j
WATER SAMPLE RESULTS: t Foca- a;c DeA%Ajoov-j 6-oaO wAa-(J-'
Coliform Nitrate s 3� M h Other bacteria
Date of sample: 3/�/cIj Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed It �q 3 Tank size I OOL) Number of Compartments Z Cleanouts (Y/N) S
Foundation cleanout (Y/N) Depression (Y/N) NO High water alarm (Y/N) N to
Date of Pumping wiz; 96 Pumper J • 125
q
C. ABSORPTION FIELD DATA
Date installed ///93 Soil rating (g.p.d./ft2 orjl!4;fm) • 9 *7 System type 712P—JGt1
Length 3 Width 3 Gravel thickness below pipe -7 Total depth 16 a �n
Effective absorption area Sb 4' Monitoring Tube present (Y/N) Y Depression over field (Y/N) �2)
Date of adequacy test 3 A-21/27 Results (Pass/Fail) p S For 3 bedrooms
36.5 885 IVIG k
Fluid depth in absorption field before test (in.); . Immediately after_ gal. water added (in.): 4 9
Fluid depth 4l /4 (ins) Minutes later: t 2 Absorption rate = y 4 5D g.p•d•
Peroxide treatment (past 12 months) (Y/N) t`' a Nf If yes, give date nl
72-026(Rev.3/96)' # Rvoti 44.0 ( c.)S �o T?f+�SE 'R1o^1 A. 19; 7'0 +!$S, tuE�CT'
445 6-^-L4-OZ oa( ..t (i2aDutfD A I
D. LIFT STATION —�
Date installed
Manhole/Access (Y/N)
High water alarm le I�
�.6gCles tested
E. SEPARATION DISTANCES
Size
on" level
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
7
Septic/holding tank on lot 101-5
Absorption field on lot 1 O 5' }
Public sewer main r�j
Sewer /septic service line
j 4 -
On adjacent lots
On adjacent lots
"Pump off" level at*
--� 100
Public sewer manhole/cleanout
Lift station N IA
tJ Ia
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation I "' 5 Property line 5-7• sr Absorption field %
Water main/service line �=- t0 Surface water/drainage �:-ItXJ Wells on adjacent lots �IOO
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 62 / ± Building foundation 21 r
i
Surface water > /DO
Curtain drain N°tJf:— V -,J
F. ENGINEER'S CERTIFICATION
l certify that l
in conforman
Water main/service line to /
i�
Driveway, parking/vehicle storage area 60
_ Wells on adjacent lots too
inspections and review of Municipal recc
?s in effect on this date.
are
Signature L� °�p aac roo a0oe
Engineer's NamCoal'-5� < <,,, e froy A.
CE -7453 all
V Gd -,v°'
Date 4' t Vit. ,;�&Dave 994na ' i\.
HAA Fee $ 6V Waiver Fee $ _
Date of Payment Z IAL,7 7 Date of Payment
Receipt Number 7�-1 Z( 6ZI Receipt Number
72-026 (Rev. 3/96)*
6
AFI�-%2-1997 08:55 CT&E ESI ANCHORAGE
" m
O
' Z
O L A CT&E Environmental Services Inc-
rs'iSI.IOSI/'v1Ys0®!.1/rg�elOSSSA
CT&E Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSiD
971464003
ATS Water & Wastewater Services
N/A
Lnt 15,13k 3, Sampson Est.
DriWdng Water
Sample Remarks:
Sample collected by: Games
Corrected report: Samples were an, within hold time.
907 561 5301 P.04/04
Client PO//
Printed Date/Time 04/02/97 08:34
Collected Date/Tkne 03/26/97 09:30
Received Date/Time 03/26/97.15:25
Technical Director. Stephen C. Ede
Released By
ALtuable Prep Anatysis
Parameter Results P9L units Method Limits Date: Date lni'
Nitrate -N 7.32 0.100 W/L SM18 4500-NO3F 10 max 03/27/97 JBL
TotaL Coliform 0 Col/100mL SM18 92228 03/Z7/97 R,W,
Tnroi 0 c
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE Auk
• '� DEPARTMENT OF HEALTH & HUMAN SERVICES Mim
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
051-811-41
HAA #
1�1 Aokt\(0 \SLI
1. GENERAL INFORMATION
Complete legal description Lot 15, Block 3, Sampson Estates
Location (site address or directions)
Sarah Circle
Chugiak, Alaska
Property owner M, M & M Contracting Day phone 688-1236
Mailing address P. O Box 670495 Chugiak Alaska 99567
Lending agency
Mailing address.
Agent
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well XX
Community well
Public water
Day phone
Day phone
0 S
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XX
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) Frani MOA #21
5.
CQ
In
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm Constructing Engineers Phone 346-2000/694-9098
9601 Buddy Werner Drive HC83 Box 192A Myrtle Drive
Address Anchnran,P 4A14ska'1 4 Qg.51 6 Fagle River, Alaska 99577,
Engineer's signature
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
Additional Comments
bedrooms.
Date I(—
z/61-
bedrooms,
l6
bedrooms, with the following stipulations:
wT11n
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. 1/81) Back MOA N21
Legal Description
A. Well Data
Municipality of Anchorage
Department of Health and Human Services 44
HEALTH AUTHORITY APPROVAL CHECKLIST
Lot 15, Bk 3 Sampson Parcell.D.- 051-811-41
Estates
Well type Ind,
Log present (Y/N) _ Y
Total depth 1331
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump levell
SEPARATION
Septic/holding tank
Absorption field on
Public sewer main
Sewer service line
WATER SAMPLE R
Coliform 0
Date of sample:
A, B, or C, attach ADEC letter. ADEC water system number
Datecompleted 10/93 Driller Sullivan water wells
Cased to 183' Casing height 21
Wires properly protected (Y/N) Y
FROM WELL LOG
10/93
AT INSPECTION
158'
1^ 9.p -m. 9 -p.m
Unk.
FROM WELL TO:
lot 101.5 ; On adjacent lots +100'
105, ; On adjacent lots +100,
4-10 n ' Public sewer manhole/cleanout +100'
84' Petroleum tank +100"
ULTS:
3/22/94 Nitrate 2.34
22, 1994
B. SEPTIC/HOLDING TANK DATA
3/9/94 Other bacteria 0 3/22/94
Collected by: Constructing Engineers
Date installed 111/93 Tank size 1000 gal. Compartments 2
Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression (Y/N) Y - to be
graded spring 1994
High water alarm (Y/N) N /A Alarm tested (Y/N)
Date of pumping New system Pumper --
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on tot .5 On adjacent lots 101 +100' Foundation 17.5'
To property line 57.5' Absorption field 7' Water main/service line 60'
Surface water/drainage +100'
rt-026(3=)•Front CONTINUED ON BACK PAGE
C. LIFT STATION N/A
Date irlstaf
Size in gallons
Vent(Y/N)
High water alarm level _
Meets MOA electrical codes
SEPARATION DIST'Xt`NCE FROM LIFT STATION TO:
On adjacent lots
D. ABSORPTION FIELD DATA
Manufacturer
Manhole/Ac Y/N)
"Pump off" Level at
Cycles tested
Surface water
Weighted average
Date installed 11/93 Soil rating (GPD/Ft2) 0.97 System type Trench
Length 3 6 ' Width 31
Total absorption area 504
Gravel thickness 7' Total depth varies, 11' to
17. 5'
Cleanout present (Y/N) Y Depression over field (Y/N) e
graded spr.-94-
Date of adequacy test New system Results (pass/fail) for Bedrooms
Water level in absorption field before test pI/ n After test
Peroxide treatment (past 12 months) (Y/N) N/A If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 105.0'
To building foundation 21.01
On adjacent lots +100, Property line 62'
To existing or abandoned system on lot N/A
On adjacent lots +100, Cutbank +100, Water main/service line 6 0 '
Surface water +100' Driveway, parking/vehicle storage area 50 '
Curtain drain +100'
E. ENGINEER'S CERTIFICATION
l certify that l have checked, verified, or conformed to all MOA and HAA guidelines in
Signature
Constructing Engineers
Engineer'sNamee 9601 Buddy Werner Drive. Anch. Ak
Date /Z
HAA Fee $ �nt1 0. ) __ Waiver Fee $ _
Date of Payment �- �� �lil Date of Payment
Receipt Number Receipt Number.
72-025 (3/93)• Back
�,Pqf this inspection.
Commercial Testing & Engineering Co.
i
4 Environmental Laboratory Services o—mm %7.7.�m��� �
SINCE 1906
LABORATORY ANALYSIS REPORT
CT&ERef.#
94.1002-1
Client Sample ID
SARAH CIR M M & M L15 B3
Matrix
WATER
Client Name
CONSTRUCTING ENGINEERS
Ordered By
LANDERS
ProjectName
@13:00 his.
Project#
PWSID
UA
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: S. OSWALT.
QC
Parameter Results Qual Units
-------------------------- ---------- -
Nitrate -N 2.34 mg/L
WORK Order
76433
Printed Date
03/14/94
@14:25 his.
Collected Date
03/09/94
@ 11:15 his.
Received Date
03/09/94
@13:00 his.
Technical Director STEPHEN C. EDE
Released By:
Allowable Ext. Anal
Method Limits Date Date Init
-----------------------------------------
EPA 353.2/300.0 10 03/11/94 CMR
* See Special Instructions Above UA=Unavailable
** See Sample Remarks Above NA=Not Analyzed
U= Undetected, Reportedvalue is thepractical quantification limit. LT= Less Than
o D=Secondary dilution. GT= Greater Than
V
O
N
LL 5633 B Street, Anchorage, AK 99518-1600 — Tel: (907) 562-2343 Faz: (907) 561-5301
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