HomeMy WebLinkAboutSHANE LEE ESTATES BLK 2 LT 2Shane Lee
Estates
Block 2
Lot 2
#014-061-74
,jr W 21031 9p Anchwagg NNGH 6, Pump Ar 9072430742 11
MumCIPAU-11Y OF ANCHORAGE 1 OVA"
Dewe; cpnnanl Services Departiment Phone: 907-343-7904
On -SAP, Water & 'Nashwatr SelAn 1 Far 907043j997
Pump hnstaflation Lorg
"NeV -T)H31mg F,�-rzyp.tt Date of Issue:
Pa eft Edci.xfificativ-n Nuitiber- 0 Iq -Qb I -7`-i
Legal Desm-[pvion --f—BlEwAl Lot Frapert,r Owner Name & Address*
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?Vn1P 11INWICr NMWL�:.. ANCHORACEF VVELL & PUMP SERVICE
7640 King Skyet
Anchorage, AK 9LI518
PH! (907) 24S-0740
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A,ttentimn: Tho } ump mWershW! i-Ism]
"Id.tion, logic OnsiWAMin 30 days of pump installation.
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MINIMUM DISTANCE BETWEEN A WELL. AND ANY ON—SI'T'E _;EbaAGE D I `=,PI i:_:AL. M•4'_ I EI I I
100 FEET FOR A PRI % ATE WELL i_1R 200 FEET FOR H PUBLIC WEL.1.....
WELL LOS ARE F:Ei!UIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN :?:4t DAYS
OF THE WELL COMPLETION.
PECIFICATIONS AND CONSTRUCTION DIA>;t?'l=M ARE A''r'AIL_i=1Bl._E TO IN' ----'URE PROPER
I NiSTiI__LAT I ON.
DEF- @_ ' II✓' FR-, a =a 0-1 1 "=r - N -.._a E: �:
7: f='r_'R—l'IF`T' THAT
L: I 1=11'1 FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELL1 _', AS SET
FORTH H BY 'THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL STAI_I_ T'HE SYSTEM ll` WITH THE: CODES.
DES.
APPLICANT EDWIN F:I NdN•dEF:
0-1 1Eri i 9 � ® �
_ '` �i � � '� ��r°
a`a I:- FA a-,9 a µ
DEPARM IEN'dT•
OF HEALTH AN[)
ENVIRONMENTAL
r'E? ITEC T I OPS
25 .1_•
STREET, ANCHORAGE.-
AK. ,= 95C -9a
PE'F�rll-r
h1o. 7-f"190 )
API-.LIC;AN•dT
EDWIN F:IhIN'aER
8:_--,:1Wi
WELL.SLEY CT
L_OC Hl I i -INS
LEGAL.
L2 B2 SHANE I-E:E
ESTATE'
LOT
"IZE c_,G�Et[�=i!I-IIiF?F: FEET
MINIMUM DISTANCE BETWEEN A WELL. AND ANY ON—SI'T'E _;EbaAGE D I `=,PI i:_:AL. M•4'_ I EI I I
100 FEET FOR A PRI % ATE WELL i_1R 200 FEET FOR H PUBLIC WEL.1.....
WELL LOS ARE F:Ei!UIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN :?:4t DAYS
OF THE WELL COMPLETION.
PECIFICATIONS AND CONSTRUCTION DIA>;t?'l=M ARE A''r'AIL_i=1Bl._E TO IN' ----'URE PROPER
I NiSTiI__LAT I ON.
DEF- @_ ' II✓' FR-, a =a 0-1 1 "=r - N -.._a E: �:
7: f='r_'R—l'IF`T' THAT
L: I 1=11'1 FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELL1 _', AS SET
FORTH H BY 'THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL STAI_I_ T'HE SYSTEM ll` WITH THE: CODES.
DES.
APPLICANT EDWIN F:I NdN•dEF:
MUNICIPALITY
®F ANCHORAGE _---
Development Services Department
Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 014-061-74 q
Expiration Date:
1. GENERAL INFORMATION
Complete legal description SHANE LEE ESTATES BLK 2 LT 2
Location (site address) 6731 TIFFANY TERRACE, ANCH AK
Current property owner(s) JERUE JANELLE H 50% & SOLBOS MATTHEW W 50% Day phone
Mailing address SAME
Real estate agent
2. TYPE OF DWELLING:
El Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Private Septic
❑
Water Storage ❑
Holding Tank
❑
Community Well ❑
Community
❑
Public Water System ❑
Public Sewer
0
Waiver request for:
Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the
engineer.
COSA Fee $ '7 —I g- RLI SI"�
Waiver Fee $
Date of Payment 1
Date of Payment
Receipt Number —0I 3 �� S
Receipt Number
COSA # _ 0-� C.21139 b
Waiver #
5. 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864
Address 4661 NATRONA AVE ANCH AK
Engineer's Printed Name MIKE N ANDERSON, P.E. Date 7-12-21
6. DSDSIGNATURESIGNATURE
, System #1 Approved for 3
System #2 Approved for
Disapproved
Conditional approval for
O i� 41 X'
/ 49TH �6
bedrooms j• • :• • • • • • d
�•MICHAEL N. ANDERSON
bedrooms
PR
bedrooms, with the following stipulations: ®��.aa>�•`
WASTp�yVATER
O PROGKAM—
C) ;:z
1�
By: - CC�� t��a-'i'l�� �7
Original Certificate Date. ! �y 202 f
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineers work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
COSA Checklist
Legal Description: SHANE LEE ESTATES BLK 2 LT 2
If more than 1 septic system on lot: COSA Checklist # _of
A. WELL DATA
❑Q Well log is filed with Onsite (or attached)
Date drilled 1117176
Total depth 60 ft
Cased to +40' ft
Q Sanitary seal is functioning correctly
❑� Wires are properly protected
Casing height (above ground) 30" in.
Date of flow test for COSA 6n5iz1
Static water level at beginning of test 20 ft.
Comments
B. TANK DATA
Age of tank(s) _ years
Tank type/material
Measured operating fluid level in septic tank _
❑ Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA
Which system tested (date installed)
❑ ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A —pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective _
Parcel ID: 014-061-74
Structure served by this system
Well production at time of test 5+ gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes X No
F111 Coliform bacteria is Negative
Nitrate 0.705 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L 0 Arsenic less than MRL (ND)
Collected by MNA
Date of Sample 6125121
C9MI11f3111RAUc1111iN]J
❑ Required maintenance completed
Age of lift station _ years
Lift station material
Comments:
Adequacy test date
Results ❑ Pass For _ bedrooms
Fluid depth prior to test 36 in
Water added _ gal
New depth _ in
Elapsed time _ min
❑ Code -required soil cover over field
Final fluid depth _in
❑ System presoaked
Absorption rate _ gpd
(Required if vacant for greater than 30 days prior to
Any rejuvenation treatment (past 12 months) _
date of test)
If yes, enter date
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100'
[3Yes if No _ ft ❑ Yes if No X50 + ft
Neighboring Tank > 100' ❑� Yes if No _ ft Private Sewer/Septic Line > 25' ❑✓ Yes if No _ ft
Absorption Field on Lot > 100' ❑✓ Yes if No _ ft Holding Tank > 100' 0 Yes if No _ ft
Neighboring Absorption Fields > 100' Animal Containment > 50' ❑� Yes if No _ ft
❑Q Yes if No _ ft
'50'+ Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑ Yes if No _ ft Yes if No _ ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑ Yes if No _ ft Surface Water > 100' ❑ Yes if No _ ft
Property Line > 5'
❑ Yes
if No
_ ft
Wells on Adjacent Lots:
Absorption Field > 5'
❑ Yes
if No
_ ft
Private Wells > 100' ❑ Yes if No _ ft
Water Main > 10'
❑ Yes
if No
_ ft
Community Wells > 200' ❑ Yes if No _ ft
Water Service Line > 10'
❑ Yes
if No
_ ft
If septic tank is under driveway comment below
From Absorption Field on
Lot to: (Please enter distances
if
less than required)
Building Foundation > 10'
❑ Yes
if No
_ ft
If absorption field is under driveway comment below
Property Line > 10'
❑ Yes
if No
_ ft
Wells on Adjacent Lots:
Water Main > 10'
❑ Yes
if No
_ ft
Private Wells > 100' ❑ Yes if No _ ft
Water Service Line > 10'
Surface Water > 100'
❑ Yes if No _ ft Community Wells > 200' ❑ Yes if No _ ft
❑ Yes if No _ ft
F. ENGINEER'S COMMENTS
" approved during construction, pre 1983
G. ENGINEER'S CERTIFICATION
I certify that / 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.
COSA Checklist yellow sheet
......
.. A117 y�
* 4,9TH
po MIC14AE "t5` ANDERSON : ✓
• CE 9 9 j
Municipality of Anchorage
On -Site Water & Wastewater Program
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL - 2014
Parcel I.D. 014-061-74 Expiration Date:
1. GENERAL INFORMATION
Complete legal description SHANE LEE ESTATES S/D; BLOCK 2, LOT 2
Location (site address) 6731 TIFFANY TERRACE, ANCHORAGE, AK, 99507
Current Property owner(s) ROBERT & CANDIE ANTKOWIAK Day phone
Mailing address
Real Estate Agent
6731 TIFFANY TERRACE, ANCHORAGE, AK, 99507
YVAN CORBIN W/ KELLER WILLIAMS Day phone
2. TYPE OF DWELLING:
Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
331-7370
301-0875
TYPE OF WASTEWATER DISPOSAL:
Individual Well
0
Individual On-site
❑
Individual Water Storape
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
0
W aiverefariance request for
Received by: Date:A/
^�
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $
Date of Payment
Receipt Number 0-730ZG C�
COSA# 0SGI r l2Z /
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
Distance: -
5. 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 alt applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm
GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 `ANCHORAGE, AK, 99507
Engineer's Printed Name
Engineers Comments:
JEFFREY A. GARNESS, P.E.
In conducting this evaluation, GEG, UD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSO Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person orpady is not authorized, nor will it confer any legal right whatsoever.
6. DSD SIGNATURE
System #1 Approved for 3 bedrooms.
System #2 Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following
Phone
337-6179
Date 1;/�1// 0
fAIV6��rlf,
OF
NZ,
ON-SITE
WATER AND
o ASTEWATER
W
o^
Original Certificate Date: —
The(Wni9partly�61'Anchorage Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTCHMENTS:
COSA Checklist Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
'R.� lana» l
If more than 1 septic system is on the lot:
COSA Checklist # of_
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description:
SHANE LEE ESTATES S/D; BLOCK 2, LOT 2
Parcel ID: 014-061-74
A. WELL DATA 'ASSUMED BASED UPON SURROUNDING WELL LOGS.
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES
Date completed 1/17/1978 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth 60 ft. Cased to '40+ ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 1/17/1978 5/9/2014
Static water level 22 ft. 18
Well production 10 g.p.m. 5.33+
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml
Arsenic:N12 ug./L.
B. SEPTIC/HOLDING TANK DATA
Nitrate'}� mg./L. Collected by:
Date of sample: 5/9/2014
Tank Type/Material
Tank size gal. Number of Compartments _
Foundation cleanout (Y/N) Depression over tank (Y/N) _
Date of pumping
C. ABSORPTION FIELD DATA
Pumper
9.p -m.
Ltd.
PUBLIC SEWER
Date installed
Cleanouts (Y/N)
High water alarm
Date installed Soil rating (g.p.d./ftor ft2/bdr _ System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption ea ft' Monitoring tube_ Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absor ' n field before test _ in. Water added _gal. New depth in.
Elapsed T —min. Final fluid depth in. Absorption rate >= g.p.d.
y rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date'installed Size in gallons
"Pump on" level at in. "Pump off' level a�
Cycles
Manhole/Access
a er alarm level at in.
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot NIA On adjacent lots N/A
Absorption field on lot N/A On adjacent lots NIA
Public sewer main *50'+ Public sewer manhole/cleanout '501+
Sewer /septic service line 25'+ Holding tank N/A
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation - Property line_
Water main Water service
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION
Property line
Water service
F. COMMENTS
Surface water
Wells on adjacent lots
'APPROVED AT TIME OF CONSTRUCTION ( PRE 1983)
G. ENGINEER'S CERTIFICATION
I certify that 1 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 N�10
me JEFFREY A. GARNESS
Date Srlyy
(Rev. 10112112)
Absorption fielc
Surface water.
TO:
Water main
Driveway, parking/vehicle storage
?ROFESSI��
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q EXISTING
o�
N HOUSE
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'2
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251
1
WELL
28.34'
a
0
UNDER NO CIRCUMSTANCES SHOULD AN AS -BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES.
THE SURVEYOR TAKES RESPONSIBILITY
DISTANCES FOR THE
PREVA
IL OVER SCALING ONLY AN CAUSE ASSUME IAL ISCALL
LABILITY Y FOR THE COST OF THE SURVEY.
LISTE
REPR
LOT SURVEY SURVEY TYPE SYMBOLS
FOUNDATION AS -BUILT SET REBAR DRAINAGE ASPHALT
RNAL STRUCTURE AS-VULT G FOUND RESAR G e WOOD FENS '"A CONCRETE
PLOT PIAN ... As-WLT ... LOT SURLY ... T OORASNY ® ASSUMED ELEV. X X M METAL FENCE ® WOOD DECK
S- T . ND SET 0 RE ARCATION AS- T ... NO CORNERS SBI
NOTE:
OT PLANS & LOT SURVEYS
IS THE RESPONSIBILITY OF THE BUILDER OR OWT4ER, PRIOR TO ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE Q L at!
INSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE SHOWN. FENCES, WELLS SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS,
FINISHED GRADE AND UTILITY. CONNECTIONS AND TO DETERMINE ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY, SNOW
E EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED.
IICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. ALL DISTANCES ARE RECORD UNLESS OTHERVASE NOTED.
Prepared by
tVEY CERITFlCATION '.**r,��tit��
�P�� pF /,i+iii Robert E. Johns, Jr. & Assoc.
�,�'w '••••• i Professional Land Surveyors
.,..
ra.. as ecw Aver. re arae 1700 Brink Drive.
rena «.Nrwr a a >M Ne anr.AP-l; �. ANCHORAGE. ALASKA 99504
eaa w•ia .wrwe..l array
,ri0jrr e,°^Ar .r myatr '� ar t� AP 4L •• �* Scale: „ , Rec. Lot S.F. Rec. Plat Fla No.
_L __
At .... 48th_ t 1
JDA174N AS -BUILT /r / Drawn by: Checked bSMK
.n E. AAvr r. o„ey .,ey ewt t Data Surveyed: K
05/21 /14 REJ
�.Nen�rt'Wien aisw lw•h.
ROBE R JOH'••, JR. •, +
. AF Dote Drawn: 05!23/ 14 Grld. 2034 w.o. 14-196
o J•T
L•SSTRUCTURE AS-BUILT••�, off ••.,• Legal Description:
",.d;a.A�,A.nyI ii ed •... .........
....••ora Lot 2 Block 2
.ie.ae Mwnrlle.. tlr Iran .iii p"ofaesiona) �'S��
a wr. fir._____.. SHANE LEE ESTATES
Municipality of Anchorage
Pipe Types
AB
Acrylonitrile-Butadiene-Stynene
AC
Asbestos Concrete
CC
Concrete Cylinder
Cl
Cast Iron
CM_._Getwgated.
Metal
CN
Concrete
CU
Copper
DI
Ductile Iron
GI
Galvanized Iron
MLC
Mortar Lined Concrete
PE
Polyethylene
PWT In Plant Flow Channels
PV
Polyvinylchloride
RC
Reinforced Concrete
RE
Relined
-RP
Techite
ST
Steel
TN
Tunnel
UNK
Unknown
VC
Vitrified Clay
WS
Wood Stave
WSP
Welded Steel
NP
No Print
Private System
0 960 300 600 '
Feet --=�`"•
Map Created: 05/11/2009 - -
Grid Numberli
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E STATE pCtAT� (j
3125 EAVr 72RD AVENUE
ANCHORAGE. ALASKA Y/DOT
SUBSURFACE EXPLORATION
Shift Report of Operations
L oPWLR Elden Pederson PROjEET 'lksRn'Subdiy'ialms'L'oi'4 -Block I ,
Domestic Water Well
2. TYPE OP EXPLORATION
S. CONYWACTOR WESTEFffJ STATES ASSOMTES EOUIPMENTNAME 22W
A. CONTRACT NO. NOLC N0. -
/. /uRFACC ELCVATION WEATHER
961'111
Of FTN•/LOIN /RIFT DEPTH.END 1NIFT DEPTH DRtLLEO 77��++
1. PERMAFROITENCOUNTEREo: FROM TO
T. WATER LEVEL DATE A SHIFT
..
Herb TIME DISTRIBUTION HOURS
RIG HOURS
GRILL C% fNp RN p11tLL FITNINO
NOTARY DRILL FULL CASINO
Don SOON TRUE% /TANODY
HELPER
TRUCK WELDING
/up CINE PUMPING
/• ` CASING SAG
1/. SOILS LOG.
arc
TYPE
DEPTHS
AMO LE
SITNIP•ICC
MATERIALS AND REMARKS
TOTAL—LNOTN
NO.
LENGTH
FROM TO
1
10'6'.'
0
7'
Sandy gravel.
2
7,211
17'8"
7
12
Silty sand and gravel.
3.
.7'o"
2418"
12
• 26
Sand gravel very bard packed. No crater.
4
3000„
26
47
San and gravxocks. . Hard packed. ome s
,51411
3
710"
37'0"
47
65
Sandy gravel. Very hard with rocks.i.nter-
bedded. No water.
6
387"
42'7"
63
76
'Sandy clayl'tight.
7
7'7"
50'2"
76
89
Very tight hard packed sandy clay gravel
t -rocks intarbedded.
8
8'8"
$8'10
89
96
Coarse gravels stater bearing.
9
7'7"
6619"
Test !xi'1cd 12 gpm:rur 40 minutes. No
10
11"
771611
drawdoun, Water clearing, Water level 28' f
11
419"
82131,
surface elevation. Set pump and pumped 12 gp
, 1D„
B-713"
Water clear in three hours.
DRILLER INSPECTOR '
13
811011
961111' 1
rva
m.
• %Cell w%In SA:�`Si''ISwN�yws'
�c 5`J 7-I2n/4 R3 w, S
012 - 66164 35*, 6
w 63 - M9 4°730, 8
�tA 4r5% S
-STg �/STATNS
H JC�
7126 EALT 72Hp AVENUE
ANCHORAGE. ALASKA 09707
SUBSURFACE EXPLORATION
NEwavner: Russel + KgFbleen Deu9lgsSShifi Report of Operations,
. 0411
OWNER
Elden Pederson PROJECT Da bdivisIon - Zo-t 2, 81ock 1
!,
Q. TYPE OF EXPLORATION Domestic Water Well
ST STE:iPi STATES ASSOCIATES 22V
.L CONTRACTOR EDUtPMfiNT NAME
., CONTRACT MO. HOLE N •
S. SURFACE €LEVATION WEATHER
OCPTH•GEOtM SHIFT DEPTH.EHD SHIFT • DEPTH ORILLCO 10614"
C PERMAFROST ENCOUN TEACO: FROM To
7. WATER LEVEL DATES SHIrT January 19Zf ,
a..1
• ' . TIME DISTRIBUTION HOURS
DEPTHS
RIG HOURS '
Herb
_
TO TIL
SAMPLE
No.
pRILL ER
CHURN DRILL
PISHING
MATERIALS AND REMARKS
Np.
• ROTARY DRILL -PULL.
CASINO'
FROM
70
Den
•COM TRUCK
STANOHY
1010
HELPER
-
10
Sandy gravel
2
• TRUCK
WELDING
�'•� MHni of Ail CAO,"
ye
30
SURGING
PUMPING
3
18'.6
S. CASMIG).OG
iG. SOILS LOG.. .
30
5L
IF=
TYPE
DEPTHS
'
TO TIL
SAMPLE
No.
TTPE
SAMPLE
MATERIALS AND REMARKS
Np.
IENGTN
LENGTH
FROM
70
I
1010
0
10
Sandy gravel
2
710
17-0
10
30
Tight sand and gravel
3
7'2
24-2
31-2
-
30
5L
Very hard packed sand and gravel
4
7,O
51
64
Tight cemented sand and gravel w/small rod
5
710
3812
64
75
Tight sandy clay
6 •
710
4502
511411
_r,8,0
641911
75
-•100
106
-
100
106 I
Tight sand and gravel.
Very hand cemented hardpan.
Coarse gravel - water bearing.
7
612
8
6,8N
9
619"
ro ,T1"0
v5.911U
!
1
Test tailing 32 gpm for 40 minutes. No draw
down. Water level 34 feet from eleva
11
6'11"
8218
surface
13
5, 8„
4 ,1„
Set pump. Pumped 12 gpm.
Water clear in two hours.
14
:-
3+'
r I^+t
:'TnCv.n
3
pr•:L;,ER
INSPECTOR
AAR4w PUMP Sit WER SERU3CEr LLC
P.O.: Sax 110496 - t� 1 '
Art0orage, AK 89537 §e' P�
ONCO: (907) 34&9365 - FaK,(907) 93$8976 P
Eagle River! (907) 622.9335
No. 9454
�) CUS7YMF-9 J498tTE
L 3 < J
YVOILF 0.§TE
w£t1.IJF.0.TH
eWL
j}ILC1jINFiEO.
�uxndEgiH
SRLFSpEgSQV /^ _
/nt:a�pti
.... ... ... _5,_
.y
'ia..f.. ✓ire,-.. 1�, c-c'.n'�.��' 1'�e°��;:y!C'-5..._�'"-;
__:,_._ ,_....._.__
_....;
LABOR
HOURS
RATE
AMOUNT
TOTAL
s
TOTAL LABOR
kMIIX171E1Eb+6Y
0&TE.Q01AR TOTAL
:LABOR
PAY THIS AMOUNT sa s
Thank You
&1GNAYtIRE
(I Hereby Acknowledge the Sodsfectory domplefion of the Above Desorlbedwork end:egreaitlet If eSoVe work tsiwt paid for in 90 days I agree to avow Aerow
PumPa
Well Sertiae, "Gtherght to remote unpah, fonequitahA-h and dtar.P:f"AAbor slresdy PerWmed 6 labor to YEmove unpatJ for eGtapohd rt)
TERMS:. ACCOUNTS)PAYAOLE AT 10TRDF R10tdadi FQLLOW[Na PURCHASE.
SEwOE CHARGEAir RATEDF I,'G%6 PER. F4eNTH WILL 9E SiHARGE6 9N 13VEROUE ACOQUNTS.
S Let?
3 Zy L
Ds:flmail-attachment.googieusercontent.coMattachmentlu/O/Tui=2&ik=a1 badcl666&view=aft&th=13... 1/1
p MUNICIPALITY OF ANCHORAGE `fid
• DEPARTMENT OF HEALTH & HUMAN SERVICES (y}
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. # CJ 1j, - r'(-- t -- -7 HAA # L1
1. GENERAL INFORMATION t j
Complete legal description
Mar �, 5 ka,o
L� 2
F 4c 2
( �� 1
Location site address or directions) c ��
Property owner t4F vOLOS Day phone
Mailing addressG-+ V'rUP
�9 i
Lending agency Nor446Inppt m g -L& k Day phone
Mailing address Ute, .Z 000'
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
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.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE' it community wastewater system, provide wrttten confirmation from Stare 11oeu
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. 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 h �''� �" r [ `lt-, l— Phone 0- W-
Address
Engineer's signature b'_- -� �,%'L" " Date
6. DHHS SIGNATURE
1 L Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
bedrooms, with the following stipulations:
By:
�-� Date
Zt-
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 (Bev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: P-/2 a"", , `rams Parcel I.D. 0 f q .C6/._ 7 l
I_1Mh'144 N 97_A CA
Well type F If A, B, or C, attach ADEC letter. ADEC water system number "/_
Log present (Y/N) Date completed I//7`/ 7- Driller H
Total depth Z10 Cased to to -e-, Casing height—
Sanitary
eight
Sanitary seal (Y/N) Wires properly protected (Y/N) \7/
FROM WELL LOG AT INSPECTION
Date of test 717'� l<S�9 3 MUNICIPALITY OF ANCHORAGE
ENVIKUNMENTAL SERVICES DIVISION
Static water level d4.G
Well flow O g.p.m. RECEIVED
.p.m.
Pump level �dZ7 %3°y�°e"I RECEI V E®
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot y11_\ ; On adjacent lots 1111A
Absorption field on lot N/4 ; On adjacent lots N/4
Public sewer main ' !
Sewer service line
WATER SAMPLE RESULTS:
Public sewer manhole/cleanout > /u -o
Petroleum tank NG D
Coliform J % Nitrate Oo -�9 Other bacteria �1
Date of sample: / L �� Collected by: 0, 1,� 4-
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts(Y/N)
High water alarm (Y/N)
Date of pumping
N1/4,
Tan(((k size
Foundation cleanout (Y/N)
Compartments
Depression (Y/N)
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surface water/drainage
72-026 (Rev. 7/91) Front
On adjacent lots
Absorption field
Foundation
watermaiMerviceline
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
— Manufacturer
Manhole/Access (Y/N) _
"Pump off" level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA
Date installed
Length Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Surface water
Soil rating System type -
-Gravel thickness Total depth
Cleanouts present(Y/N)
Date of adequacy test
for
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot On adjacent lots Property line
To building foundation To existing or abandoned system on lot
On adjacent lots Cutbank Water main/service line
Surface water Driveway, parking/vehicle storage area
Curtain drain
bedrooms
E. ENGINEER'S CERTIFICATION
1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name _6 (D W -e 1,1 —
Date a« --t
ov
HAA Fee $ /7-0 Waiver Fee: $
Date of Payment JIB Date of Payment
Receipt Number cam? 5��i %" ���%�� Receipt Number
72-026 (Rev. 3/91) Back MOA 21
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
.5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS RESULTS for INVOICE # 62026
Chemlab Ref A 93.0012 Sample ( J. liatxix: PLATER
Client Semple ID 2/2 SHANE LEE
PP;SIG UA
Collected 01/04/93 B. 13:00 hrs.
Received 01/04/93 6 14:00 hrs.
Preserved with
Analysis: Completed 01/06/93
Laboratory Supexvisgx S"1EPHE}! C. E
Client Name :TOBBEN SPURfLAND, P.E.
Client Acct :TOBBENS
BPO# PO# :NONY RECEIVED
Reg#
Ordered By
Send Reports to:
1)TOBBEN SPURELAND, P.E.
P.eleased By .r'y �: 2)
_ i
Pasarnetex Results Units Hpthod Allowable Limits
- --------------------------------------------------------------- n
NI'PRATE-t! 0.26 M/1 EPA 353.2/300.0 10
:;ample ROUTINE SAIRLE COLLECTED BY: STUART.
Remarks:
=juvi=pIuFIITests PerfoxmedsN See Special Instructions Above
iii)- tiaazc Accac Gcft - 0-- ----lc Remarks A6—
?lA� lleic }�k�aly�ail L'li-LaeH Than,. G'i,G�eater Tiiin
UAB -Unavailable
1160MGS Member of the SGS Group (Societe Generale de Surveillance)
Time
APPLIC`',NT FILLS
OUT UPPER HAI' `ONLY
Time
Proper[y'Owner
Pauline J. Linnell/Lyle D. Linnell
Phone
272!8926
Mailing Address
6731 Tiffany Terrace Anchorage Zip Code 99507
344-5846
Buyer
Brett Evans
Inspector
Address
Field Notes:
Zip Code
Lending Institution
Colonial Mortgage
ENVIR-) +'.f..,'.. '...U:'_, -TION
Phone
701 East Tudor Road
RECEIVED
562-2181
Address
( ) DISAPPROVED
Zip Code
( ) CONDITIONAL APPROVAL'
Realty Co. a Agent
Gold Panner Realty
Phone
1577 C Street
99501
Well To Absorption Area
Address
Septic Tank Size
Zip Code
Legal Description
Lot 2 Block 2 Shane Lee Estates Subdivision
Street Location
6731 Tiffany Terrace
Type of Residence
Private engineer is domng
the
XKSingle Family
El Multiple Family
No. of Bedrooms three
inspections.
❑ Other
Water Supply
3tkIndividual
ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975.
❑ Community
For wells drilled prior to that date, give well depth (attach log
if available).
❑ Public Utility
Sewer Disposal
❑ Individual
Year Individual Installed:
�}
{Public Utility
When Connected to Public Utility: ef
r
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes:
MUNICIPALITY OF ANCHORAGE
DEPT. C'P ;- ' �.T' q
ENVIR-) +'.f..,'.. '...U:'_, -TION
RECEIVED
() APPROVED BEDROOMS
`CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
DATE' ��
BY
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
Septic Tank Size
Well to Tank
72023 (3182)
ALASKA �i dROURTAL COnTnOL Sekd'US, InC.
Engineering & 6nuironmental Studies
February 8, 1983
Municipality of Anchorage
Department of Health & Environmental Protection
825 L. Street
Anchorage, Ak. 99501
Re: Health Authority
On February 7, 1983 our company collected a water sample from the house
located on Lot 2 Block 2 Shane Lee Subdivision. The property owner is
Mr, Stone. The water analysis was satisfactory.
The well has a seal and the casing stands approximately 3 feet above the
ground. The electrial wires are completely enclosed in conduit. All
standpipes are capped.
A copy of the report is attached.®® A4.
11
�"�`i✓ seoeG �tl Li ��
e ea oe
Sincerely,j,e •• ol4e y
[¢g ePaPtl v"GOOD 6.0L40-70'
v�3 e e rases °o •.e .a...e a AJ
Leroy C. Reid Jr., PhD Lero . Reid, Jr.
President ��u�`oee 0. 2231-E
pe•t to reo•a't',. V�m9
ROFESS%
1200 West 33rd Auenue, Suite B • Anchoroge, Alaska 99503 9 (907) 276-1361
�. MUNICIPALITY OF ANCHORAG-9:,
DEPARTML OF HEALTH AND ENVIRONMEN L PROTECTION
825 L Street, AnchoraaP. Alaska 99501
264-4720
#1: Time 9:30 a.m. #2: Time
Date Received: February 14, 1978
#3: Time
Date 2-16-78 Thursday Date - Date
Insp Pratt Insp 4vo7 Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
1. Lending Institution Request: First National Bank of Anchorage
Mailing Address: Post Office Box 4-2090 99509 Phone:
2. Property Owner: Sebring Builders 3PAoBO69 344-3069
Mailing Address: Star Route A Box 1540C 99507
3. Legal Description: Lot 2 Block 2 Shane Lee Estates Subdivision
4: Single Family Residence: (x) Number of Bedrooms: Three
Multiple Family Residence: ( ) Number of Bedrooms:
5. Well System: Individual Well (x) Community/Public System ( )
Permit # �j __),N'k0 Depth of Well n C__�' Well Log on File �)
Construction nr a LCS• Bacterial Analysis 2=1
o
6. Sewage Disposal System: On-site System ( ) Public Utility (x)
Permit # Installed Installer
Septic Tank Size Manufacturer
Absorption Area Soils Rate Material
7. Distances: Well to Septic Tank to Absorption Area
to Sewer Line Nearest Lot line Absorption Area
to Nearest Lot Line
'~ ag"e ` Two
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 2 Block 2 Shane Lee Estates Subdivison
Comments:
Affadavit Attached: ( ) Letter Attached: ( )
Approved: V c
Date:
Disapproved:
Date:
Department Worksheet:
— --
(plus postage)
RECEIPT FOR CERTIFIED MAIL-30t�
•
POSTMARK
SENT TO - OR DATE
- SII LO
STREET AND NO. -I
co
P.O., STATE AND ZIP CODE
I
SERVICES FOR ADDITIONAL FEES _
-
JPTIONAL
toom and 1. Shows ith whdate delivered ............ 15¢
RETURN,! Wdelivery to addressee only ............ 550
RECEIPT ' p, Shows to whom, date and where delivered .. 35¢ i
With delivery to addressee only ..........�.
- SERVICES 50d
...................... I ................ ............ .= —
� DELIVER TO ADDRESSEE ONLY
__ .
SPECIAL DELIVERY (extra fee required) ••�••�����••• �� "" ""
0-
Z '
PS Form NO INSURANCE COVERAGE PROVIDED— (See other side)
3800 NOT FOR INTERNATIONAL MAIL GPO:197a O-460-743
Apr. 1971
J I
MUNICIPALITY OF ANCHORAG
Department of Health and Environmental Protection
o % 825 L Street, Anchorage, Alaska 99501
264-4720
�f
equest for Approval of Individual Sewer and Water Facilities
1. Property Owner:
Mailing Address:
C_/ V, _j
Phone: .f Aif 3C G�
2. Name of Buyer:
Mailing Address: Phone:
3.
M
5.
Lending Institution:
Mailing Address:
Realtor/Agent:
Mailing Address:
Legal Description:
0
a
Phone:
Phone:
Street Location: ! IPW
6. Single Family Residence: Number of Bedrooms:
Multiple Family Residence: ( ) Number of Bedrooms:
7. Water Supply: *Individual Well Public/Community System ( )
If Individual Well, well depth
If Community System, name of system
8. Sewage Disposal -System: *90n -site System ( ) Public System (�
If On-site System, date of installation:
*NOTE: A well log is required on ALL wells drilled since 6/75.
**If on-site sewer system is over two(2) years old, an adequacy
test is required by this department.
� fes, of S2s_oo M +_- accompany each request before processing
can be initiated.
3/77