HomeMy WebLinkAboutDON JACK LT 2Don Jack
Lot 2
#020-092-60
Municipality of Anchorage Page 1 of 3
Development Services Department
On-site Water and wastewater Program
4700 South Bragaw Stmt
P.O. Box 196650 Anchorage. AK 99519-6650
www.d.anchorage.ek.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number. SWO30508 PID Number. 020-09260
wna.
Dane Bandell Wastewater System: New
A00aee:
13771 Venus WayAnchorage, AK 99515 ABSORPTION FIELD
Prolw rAn6ar of senoune
345 4016 Feurfdl 5' Wide Trench
LEGAL DESCRIPTION 'a`� ° T""� "°" ° a "
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BENCH MARK
Garage Slab
Inspections performed by: AH Dates: 1a 6/8/04
2ne 619104
Department of Vealth and Human Services appr�o�v"alb
Reviewed and approved by. ate: ��4M:M ,
(Ree, l e _� _-.T_
100.0 FL
Engineer's Stamp
49th
MICHAEL E. ANDERSON
, No. CE -4191
Don Jack
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SEPARATION DISTANCES
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To Sep IC
Fran Tank
Absorption
Field
Lin
Station
Holding iWrNne
Tank Seune
Sow
Anchorage Tank 1250
well>100'
>100'
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>25'
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>100'
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BENCH MARK
Garage Slab
Inspections performed by: AH Dates: 1a 6/8/04
2ne 619104
Department of Vealth and Human Services appr�o�v"alb
Reviewed and approved by. ate: ��4M:M ,
(Ree, l e _� _-.T_
100.0 FL
Engineer's Stamp
49th
MICHAEL E. ANDERSON
, No. CE -4191
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Municipality of Anchorage Page 3 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 995196655 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number. SW030508
TBM
PID No. 020-092.60
V = U
PROFILE AS -BUILT
Scale: 1' - 20'
r PINE DRILLING
Rick Mystrom
Mayor
FAX N0. : 907 345 0102 Dec. 06 2004 11:09RM P1
Municipality of Anchorage
Department of Health and Human Services
825'L' Street
P.O. Box 196650 Anchorage, Alaska 99519650
htt0•lMn w.ei.anchorsge.akus
Permit Number: #SW 030508 Date of Issue: 12-29 03
Date Started: 4 4 Date Completed: 0-6-Q4
Legal Description: Don Jack Lot 2
Property Owner Name & Address: Dane Bandell
13711 Venus Way
Parcel Identification Number: 020-092-60
Is well located at approved permit location? ® Yes ❑ No
Borehole Data: Depth (ft) Method of Drilling ® air rotary ❑ cable tool
Soil Type, Thickness & Water Strata From To
Casing type: steel
Stick up 0 2 Wall Thickness:,W inches
gravellyslit 2 43 Diameter: _6 inches Depth: 5.0 feet
Bedrock 43 346 Liner TYpt:
Diameter. inches Depth; feet
Casing stickup above ground: 2 feet
Static water level (from ground level): §Zfeet
Pumping level.-944feet after
2 hours pumping .6 Spm
Recovery Rate:,5 gpm
Method of Testing:r8 } IiR
Well Intake Opening Type:
❑ Open End ❑ Open Hole
® Screened Start 5-3 feet Stopped 5,Q feet
❑ perforations Start feet Stopped feet
Grout Type: bentonite # 8 , Volume: I
Depth: Start p fcct Stoppcd 10+foot
Pump: Intake Depth feet
Pump size hp Brand Name
Well Disinfected Upon Completion? ® Yes ❑ No
Method of Disinfection: Oha&2 tablets
Comments:
Well Driller Alpine Drilling a Enterprises
PO Box 110496
Anchorage Alaska 99511
Attention: The well driller shall provide a well log to the property owner within 30 days of completion and the property
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MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water& Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM / WATER SUPPLY PERMIT
Initial
Date Issued: Dec 29, 2003
Expiration Date: Dec 28, 2004
Permit Number: SW030508 Parcel ID: 020-092-60
Legal DescriptionZODon Jack Lot 2 v
Design Engineer: 0014 Anderson Engineering Site Address: 16435 Betty Street
Owner Name: Dane Bandell Lot Size: 49524 SO. FT.
Owner Address: 13771 Venus Way Total Bedrooms: 4 Permit Bedrooms: 4
Anchorage , AK 99515 -
This permit is for the construction of:
❑✓ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑✓ Private Well ❑ Water Storage
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 DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
5. The following special provisions.
Monitor test hole in spring to determine seasonal high water level
Received By:
Issued By:
Date:
lZ—�O—U3
Date: 1 2—,2, -1' Q 3
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
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 020.092.60 Permit Number SW O 30 S0$
Property owner(s) Dane Bandeli Day phone 345.4016
Mailing address (1)13771 Venus Way Anchorage, AK 99515
Mailing address (2) Zip Code
Legal description (Lot, Block & Sub'd.) Lot 2, Don Jack Subdivision
Legal description (Section, Township & Range) 1 o!A 3S R6 ' -tA sA
Lot Size 49,521 —Acrese)
Number of Bedrooms Four (4)
THIS APPLICATION IS FOR:
Sewer Only ❑ Well Only ❑
Sewer and Well ® Water Storage ❑
Sewer Upgrade ❑
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is In accordance with applicable Municipal Codes.
E
(Signature of property owner or authorized agent)
Permit Fees: 5 6 Waiver Fees:
Date of Payment:
!2 -ZZ -03
Date of Payment:
Receipt Number: &k'q O Receipt Number:
(Rev. 17100)
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 FAX
MEMORANDUM
DATE: May 28, 204
TO: Joe Goodall
FROM: Mike Anderson, P.E.
SUBJECT: Lot 2, Don Jack Subdivision
SW030608
Revised Well Location
The well location has been moved at the owner's request to eliminate a visual conflict
with the new house. The revised Site Plan and Area Plan are attached for your review.
The new well location does not conflict with septic systems in the area.
Please let me know if you have additional questions.
OMe
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ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 FAX
December 22, 2003
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject: Lot 2, Don Jack Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of Lot 2, Don Jack Subdivision intends to construct a four-bedroom home on
the lot. We are therefore requesting a permit be issued for the construction of a new
well and septic system to serve the new home. The attached Site Plan and backup
documentation identify the location and configuration of the well and proposed septic
system and alternate site. The locations of wells on the adjacent lots are also shown.
No conflicts exist between the well and septic system on this lot and on adjacent
properties. Contour lines are shown indicating the current drainage patterns. These
patterns will be maintained after construction.
A test hole placed on the lot in the area of the new absorption trench completed by
Brian Harten, P.E. indicated gravel with sile with a percolation rates of less than 5
minutes per inch. Groundwater was found in the monitor tube at 12' during excavation
and rose to 7.5' monitoring period in mid March. We are therefore proposing to place a
new 1,250 -gallon septic tank along with a 70' long by 5' wide by 2' effective depth
absorption trench to collect and treat the sewage generated in the house. The bottom
of the trench will be 3' below the surface and 4.5' above the groundwater table. A
minimum of 3' of cover will be placed atop the trench and 4' atop the new septic tank.
The ground surface on the lot slopes at shallow grades from east to west toward Betty
Street. The absorption trench will be constructed parallel with the slope of the ground
surface as much as possible in conformance with Municipal requirements. The new
septic system will be constructed a minimum of 100' from the well on the lot and on
adjacent lots. It will also be constructed a minimum of 100' from any surface water in
the area.
Lot 2, Don Jack Subdivision
December 22, 2003
Page Two
If the system is constructed in accordance with our design the following statements
apply:
The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
2. The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
3. The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
4. The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
Mr��; tiu
MICHAEL E. ANDERSON
:y No. CE -4381 _j
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LOT 2, DON JACK SUBDIVISION
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Four Bedroom House 5' Wide Trench System
Perc. Rate: <5 Min./Inch 1,250 Gallon Septic Tank
Application Rate: 1.2 GPD/SF 2' Drainfield Rock
4 Bedrooms X 150 GPD/1.2 GPD/SF (A lication Rate) = 500 SF Absorption Area
500 SF/5 LF (Width)' .7(Red. Factor) = 70 LF Trench Length
THEREFORE: Construct a 70' Long x 5' Wide x 2' Effective Depth Absorption Trench.
Flow Line Elevation in Trench to be 1' Below Original Ground Surface. Total Depth to be
3' Below Existing Ground. Provide 4' Cover Over Septic Tank and 3' Cover Over
Absorption Trench.
6"
6"
2'0"
Natural
Backfill
5'
Geotextile
Fabric
4" Perforated
PVC (Holes Down)
Drainfield Rock
TYPICAL 5' WIDE TRENCH SEC I IOf'
(NO SCALE)
NOTE: Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock.
Minimum 4' Separation From Groundwater.
Minimum 100' Separation From Well.
Minimum 100' Separation From Surface Water or Streams.
Municipality of Anchorage
4:PV"6:�a's�gA�j.#
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Services Department
Safety wsion
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Building
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47DO South Bragaw SL
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P.O. Box 196650 Anchorage• AK 9951966650
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• 1AN T. HARTEN �w
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(907) 343-7904
CE -10068 •: ��`"�
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Soils Log- Percolation Test
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Performed For: -
Legal Description:L.or 7 Z�.a T..�u_S 3'ur Township,
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THIS TEST WAS
PERFORMEDBY: ��ta_1 1-. r:.2_Ti�•�._ r'�C£RTIFYTY.AT
GEINEFFCT ON THIS DATE. DATE: o
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P=-RFOR?•IED IN ACCORDANCE VATH
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ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 2, DON JACK SUBDIVISION
GENERAL:
The scope of this project includes the procurement and placement of a new
1,250 -gallon septic tank at the location shown on the Site Plan. Work also
includes the construction of a new 70' long X 5' wide X 2' effective depth
absorption trench at the location also shown on the Site Plan. The
distribution line in the trench will be placed at V below the existing ground
surface. Total depth of the trench will be 3' below the existing ground
surface. The new septic tank and absorption trench must be placed a
minimum of 100' from the well on this and adjacent lots.
2. Construction shall be in accordance with the approved site plan, design
drawings, Municipal Permit with any special provisions or conditions, and all
applicable State and Municipal Wastewater Disposal Regulations.
3. The Contractor shall be responsible for obtaining all underground utility
locates and for the layout of the septic system and verification of the location
of all lot lines. The Contractor must also verify the location of wells in the
area and assure that the separation distances are met.
4. Unless specifically agreed otherwise, the contractor shall be responsible for
final grading areas subsequently depressed from soil settling. Property
owner shall be responsible for revegetation of affected areas unless
specifically agreed otherwise.
5. Contractors installing wastewater disposal systems must be certified by the
Municipal Department of Health and Human Services for system installations.
Owners installing their own systems must receive prior approval from
D.H.H.S. before beginning system installation.
SEPTIC TANK INSTALLATION
A new 1,250 -gallon septic tank must be procured from an approved source
and installed at the location shown.
2. A septic tank is to be constructed by a certified septic tank manufacturer.
Construction shall include two 4" cleanouts for pumping access.
3. The septic tank shall be sufficiently bedded to prevent settling or shifting of
the tank.
Lot 2, Don Jack Subdivision
December 20, 2003
Page 2 of 3
4. All standpipes on the septic tank shall extend a minimum of 12 inches above
final grade.
5. Tanks installed without 4' of cover shall have a minimum of 2" of direct burial
insulation.
6. A foundation cleanout shall be installed one to four feet from the building
foundation. Two cleanouts are required between the tank and the drainfield.
7. Final grading over the tank shall be such that a positive slope exists away
from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown on the design.
The bottom of the trench shall be within 2" of level.
2. Distribution piping must be placed level with perforations down atop a level
bed of drainfield rock. Rock should then be placed over the pipe to provide a
minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between the drainfield rock
and the natural soil backfill.
4. Monitor tubes must be 4" in diameter and installed at the locations shown on
the design. The portion below ground must be perforated.
5. Contractor shall verify the septic tank and drainfield are a minimum 100' away
from any private water wells in the area, 150' from a Class "C" Well or 200'
from any community well.
6. Direct bury insulation must be placed over the distribution system if less than
3' of backfill depth is available. Finish grade over the trench must be
mounded to prevent settlement or depressions.
7. Grade area surrounding the absorption trench to drain away.
8. A minimum 2' of accepting soil is required below the drainfield rock for a 5'
wide trench. Contractor shall verify this condition prior to placement of the
rock. All pockets of unacceptable materials must be removed and replaced.
MATERIAL SPECIFICATIONS:
Septic tanks must be constructed by a Municipally approved septic tank
manufacturer.
Lot 2, Don Jack Subdivision
December 20, 2003
Page 3 of 3
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated and
solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and ASTM D2662
or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow
Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Fernco, or equal).
5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed
between the final drain rock layer and the native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing the
#200 sieve.
INSPECTIONS:
Municipal Ordinance requires a minimum of two inspections. These inspections
must be conducted under the supervision of a professional engineer registered
in the State of Alaska. The first inspection must be conducted after the
excavation of trenches, beds or pits and before the installation of any gravel. A
septic tank may be set in place, but may not be backfilled.
The second inspection must be conducted after the placement of the geotextile
fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No
backfill should be in place at the time of inspection.
Contractor shall provide a copy of all field survey layout and construction notes
for use in preparing the certified as -built of the completed system.
MUMCMAUTY OF
Development Services Department /
On -Site Water & Wastewater Section
Parcel I.D. 020.092.60
Certificate -of On -Site Systems Approval
1. GENERAL INFORMATION
Complete legal description
DON JACK LOT 2
Phone: 907-343-7904
Fax: 907-343-7997
Expiration Date: q -3d 20W
Location (site address) 16435 BETTY CIRCLE, ANCHORAGE, AK 99516
Current property owner(s) CHRISTOPHER MORNET
Mailing address
Real estate agent
Day phone
16435 BETTY CIRCLE, ANCHORAGE, AK 99516
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
SVAX67aftyI_i��MI11=1NAVA
Private Well
Private Septic
Water Storage
❑
Community Well
❑
Public Water System
❑
Day phone
TYPE OF WASTEWATER DISPOSAL:
Private Septic
Holding Tank
❑
Community
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ sg--D' C4!R^sv Waiver Fee $
Date of Payment & /;'Pr/P6'-L6
Receipt Number - ®oqg?y
COSA # ®sc *DO lP-
Date of Payment
Receipt Number
Waiver #
COVID-19
25% DISCOUNT APPLIED
4
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 oh 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 FIRST WATER CONSULTING Prone 907-350-9566
{
Address 13030 SUES WAY, ANCHORAGE, AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 6/20/20
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year; quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject toOF Aj ^I,,,11
these various and dynamic characteristics and are outside the control of the evaluator of the P� ' •��
well and septic system. Therefore, any estimate of how long a system will function satisfactory���+
for current or future occupants or guarantee that no unseen encroachments, deficiencies or rI
discrepancies exist can be given by First Water Consulting & FWCs *Jtv
.. ..
6. DSD SIGNATURE v ...`::
Curtis Huffman
System #1 Approved for bedrooms�,. CE 128991
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
By
Original Certificate; Date: &- d —26 2D
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 engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
Legal Description: DON JACK LOT 2
If more than 1 septic system on lot: COSA Checklist # _of
A. WELL DATA
® Well log is filed with Onsite (or attached)
Date drilled 6/6/2004
Total depth 346 ft
Cased to 50 ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 6/9/2020
Static water level at beginning of test 49 ft.
Well production at time of test 4.2 gpm
Comments
B. TANK DATA
Age of tank(s) 16 years
Tank type/material SEPTIC / STEEL
Measured operating fluid level in septic tank 49"
® Standpipes/foundation cleanout per record drawing
Date of pumping 6/9/2020
D. ABSORPTION FIELD DATA
Which system tested (date installed) 6/8/2004
® ALL standpipes present per record drawing
Total measured depth from grade 7.7 ft (max)
Measured depth to pipe invert from grade 6.0 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective APPROX. 1.7' INTO THE 2' ED.
® Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
Parcel ID: 020-092-60
Structure served by this system
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ® Nc
® Coliform bacteria is Negative
Nitrate mg/L ® Nitrate less than MRL (ND)
Arsenic ug/L ® Arsenic less than MRL (ND)
FW[:S
Collected by
Date of Sample 6/10/2020
C. LIFT STATION
❑ Required maintenance completed
Age of lift station _ years
Lift station material
Comments:
Adequacy test date 6/9/2020
Results �J Pass For 4 bedrooms
Fluid depth prior to test 0 in
Water added 600 gal
New depth 0 in
Elapsed time <1 min
Final fluid depth 0 in
Absorption rate 600 gpd
Any rejuvenation treatment (past 12 months) N
If yes; enter date
FWcs
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'
® Yes
if No
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' ® Yes
if No
® Yes
if No
ft
ft
If septic tank is under driveway comment below
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® Yes
if No
ft
® Yes
if No
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 _
Property Line > 5'
® Yes
if No
ft
Wells on Adjacent Lots:
® Yes
Absorption Field > 5'
® Yes
if No
ft
Private Wells > 100'
® Yes if No
Water Main > 10'
® Yes
if No
ft
Community Wells > 200'
® Yes if No .
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'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that 1 have determined through field inspections and review ,S,. it�. • • ��
of Municipal records that the above systems are in conformance '••.��
with MOA COSA guidelines in effect on this date. ; : . 7H ... ,':
�� • '. Curtis Huffman f
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Municipality of Anchorage
On-Site Water and Wastewater Program '�i It _,, .e.
(907) 343-7904 , /i �,���1 i
C'. ETY
/4 Se ty
Certificate of On-Site Systems Approval \�
thQ�-
Parcel I.D. 020-092-60 Expiration Date: I —2C I
1. GENERAL INFORMATION
Complete legal description Don Jack Lot 2
Location (site address) 16435 Betty Street
Current Property owner(s) Lisa & Michael Gray Day phone
Mailing address 16435 Betty Street Anchorage, AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING:
❑ Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Q Individual 0
Individual Water Storage ❑ Holding Tank 0
Community Class Well ❑ Community 0
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: Date: Ilan( t7
COSA to be released to the engineer niess otherwise requested by the engineer.
COSA Fee $ (p — Waiver Fee $
Date of Payment /b//I//'9 Date of Payment
Receipt Number 651396 Receipt Number
COSA# Q 5Q -/L.IgD Waiver#
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 all applicable Municipal and State codes, ordinances,and regulations in effect at
the time of installation.
In conducting an adequacy test, I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations.The reported results describe 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 soil
condition,ground water 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 this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone Date 10/18/2017
A
4 OF Lq.4�1�+
6. DSD SIGNATURE , / •""5" ' 6
System #1 Approved for i bedrooms j Steven•1. �Mn.rie: 'S
CE-8149 ;�.:/
System #2 Approved for bedrooms '
s •, �e �
4
Disapproved I�11'` OFEs9.00'�
Conditional approval for bedrooms, with the following stipulations:
,ti-okkk
III
yQQ`.,`�� OF AN (4
=� o�-s\��o �'%
0�%� RA
PRof' �
• 0,0,,
*F6tv► SERv\��S
Original Certificate Date: i(r) - L5---1
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 engineer's work.
•
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory _
Well Flow Advisory Other •
COSA blue sheet r
If more than 1 septic system is on the lot:
COSA Checklist# 1 of 1
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: Don Jack Lot 2 Parcel ID: 020-092-60
A. WELL DATA
Well type Private If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed 6/6/2004 Sanitary seal (YIN) Y Wires properly protected (Y/N) Y
Total depth 346 ft. Cased to 50 ft. Casing height (above ground) lin.
FROM WELL LOG AT INSPECTION
Date of test 6/6/2004 10/10/2017
Static water level 52 ft. 53 ft.
Well production 0.5 g.p.m. 4.0 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate ND mg/L
Arsenic ND ug/L Date of sample: 10/10/2017 Collected by: PES
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 6/8/2004
Tank size 1250 gal. , Number of Compartments 2 Cleanouts(Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N/A
Date of pumping
7/11/2017 Pumper McDonald's Pumping Service
C. ABSORPTION FIELD DATA
Date installed 6/8/2004 Soil rating (g.p.d./ft2 or ft2/bdrm) 1.2 gpd/sf System type trench
Length 70 ft. Width 5 ft. Gravel below pipe 2 ft.
Total depth 7.8 ft. Eff. absorption area 500 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 10/10/2017 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test DRY in. Water added 650 gal. New depth 2 in.
Elapsed Time: 180 min. Final fluid depth DRY in. Absorption rate >= 600+ g.p.d.
N
Any rejuvenation treatment(past 12 mo.) (Y/N &type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100+ On adjacent lots 100+
Absorption field on lot 100+ On adjacent lots 100+
Public sewer main 75+ Public sewer manhole/cleanout 100+
Sewer/septic service line 25+ Holding tank 100+
Animal containment areas 50+ Manure/animal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line 5+ Absorption field 5+
Water main 10+ Water service line 10+ Surface water 100+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 10+
Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+
Curtain drain 50+ Wells on adjacent lots 100+
F. COMMENTS
G. ENGINEER'S CERTIFICATIONct,OF ALI 4 k
I certify that I have determined through field inspections and de C0:• 1; �,�
review of Municipal records that the above systems are in # •! %' *�40
conformance with MOA COSA guidelines in effect on this date.` ,w•••• P
Engineer's Printed Name Steven Pannone ":Sleveri k*'aririone: e
Date
10/18/2017 ����yy• CE-8149 . i
k
COSA canary sheet_2-6-15.doc
Municipality of Anchorage d
On -Site Water &Wastewater Program
(907)343-7904
b102 9 0 JdW
CERTIFICATE OF ON-SITE SYSTEMMI-OP", Pgtp
Parcel I.D. 020-092-60 Expiration Date: CJ�� Z//_
1. GENERAL INFORMATION
Complete legal description DON JACK S/D; LOT 2
Location (site address) 16435 BETTY STREET, ANCHORAGE, AK, 99516
Current Property owner(s) GEOFFREY LUNDFELT Day phone
Mailing address
Real Estate Agent
16435 BETTY STREET, ANCHORAGE, AK, 99516
JENNIFER SCHULENBERG WI REMAX Day phone
2. TYPE OF DWELLING:
0 Single Family (wlwo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY:
360-8912
229-4319
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
I_I
Public Water System
❑
Public Sewer
❑
WaivenVariance request for: Distance:
Received by: Date: r C
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5ab Waiver Fee $
Date of Payment S�iDI �� Date of Payment
Receipt Number 043"316 Receipt Number
COSA #C_ IW/6 � Waiver #
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. /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
GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE,
Engineer's Printed Name
Engineefs Comments:
JEFFREY A. GARNESS, P.E.
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD 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 am 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 MCA 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 or party is not authorized, nor will it confer any legal right whatsoever.
6. DSD SIGNATURE
-32
I%
System #1
Approved for
bedrooms.
_
System #2
Approved for
bedrooms.
Disapproved.
Phone
337-6179
99507
Date i S r4
oo600p�0
P:.4
T
.
I
�Q � ff�ey�i G rness:' G
° ICE -79 3 �O
Conditional approval for bedrooms, with the following stipulations:
OF
O i
Jam' ON-SITE �� r
WATER AND r"
J� WASTEWATER o1
Original Certificate Date: :f �2
The Municipality or Anchoxe Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approvai (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 f/ Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
tri— ivnni
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: DON JACK S/D; LOT 2 Parcel ID: 020-092-60
'BEDROCK @ 43'. "24" ABOVE ACTUAL GRADE. WELL IS PROTECTED BY RETAINING WALL AND EXTENDS
A. WELL DATA 12"+ABOVE ARTIFICIAL GRADE AT RETAINING WALL. "'WELL HYDROFRACTU RED AFTER INSTALLATION.
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES
Date completed 6/6/2004 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth 346 ft. Cased to `50 ft. Casing height (above ground) *10+ in.
FROM WELL LOG AT INSPECTION jZf 4 -l' -
Date of test
Static water level
6/6/2004
52 ft.
Well production 0.5
WATER SAMPLE RESULTS:
Coliform O colonies/100 ml.
Arsenic: mug./L.
B. SEPTICIHOLDING TANK DATA
4/1 812 01 4
g.p.m. ...4.85+ g.p.m.
Nitrate N� mg./L.
Date of sample: 4/18/2014
Collected by: GEG, Ltd.
Tank Type/Material SEPTICISTEEL Date installed 6/8/2004
Tank size 1250 gal. Number of Compartments 3 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) NIA
Date of pumping 2/4/2014 Pumper A+ HOME SERVICES
C. ABSORPTION FIELD DATA 'BELOwEXISTING GRADE
Date installed 6/8/2004 Soil rating .p.d./ or ft2/bdrm) 1_2 System type TRENCH
Length 70 ft. Width 5 ft. Gravel below pipe 2 ft.
Total depth '7.8 ft. Eff, absorption area 500 ft2 Monitoring tube YES Depression over field " NO
Date of adequacy test 4/18/2014 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 3 in. Water added 680 gal. New depth"4 in.
Elapsed Time: = min. Final fluid depth"4 in. Absorption rate >= 600+ g,p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date
"LAST 605 GALLONS CAUSED NO RISE IN LIQUID LEVEL. 100% ABSORPTION.
D. LIFT STATION
Date installed
"Pump on" level at in.
Size in gallons Manhole/Access (Y/N)
"Pump off"level at we er alarm level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots
Absorption field on lot 100'+ On adjacent lots
100'+
100'+
Public sewer main N/A Public sewer manholelcleanout N/A
Sewer /septic service line 25'+ Holding tank NIA
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main NIA Water service line 101+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main N/A
Water service line 104 Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date
(Rev. 10112/12)
Municipality of Anchorage
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
FOR A SINGLE FAMILY DWELLING
Parcell.D. 020-092-60 COSA#�L'/�1�13
1. GENERAL INFORMATION Expiration Date:
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
DON JACK S/D; LOT 2
16435 BETTY STREET * ANCHORAGE. AK * 99516
DANE BANDELL Day phone
16435 BETTY STREET * ANCHORAGE, AK * 99516
Day phone
NANCY BERGH POLLOCK W/ PRUDENTIAL Day phone
529-8940
563-5500
3801 CENTERPOINT DRIVE, #200 * ANCHORAGE, AK * 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
E
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
N
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 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 samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my
investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. i further verify that based on the
information obtained from the Municipality of Anchorage files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD 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 or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
VGNApproved for —4— bedrooms.
Disapproved.
Phone
337-6179
Date
6 11 IZ
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Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
l✓ Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Nitrate Advisory Other
By: lit/:oma %
(Rev. 11105)
ON-SITE
WATER AND
WASTEWATER
PROGRAM
Original Certificate Date: ( — 5 , /2
Municipality of Anchorage
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: DON JACK S/D; LOT 2 Parcel ID: 020-092-60
*BEDROCK AT 43'. **WELL WAS HYDROFRACTURED AFTER INSTALLATION. ***24+" ABOVE ACTUAL GRADE. WELL IS
A. WELL DATA
PROTECTED BY RETAINING WALL AND EXTENDS 12+" ABOVE ARTIFICIAL GRADE CREATED BY RETAINING WALL.
Well type PRIVATE If A, B, or C provide PWSID# N A
Date completed 6/6/2004 Sanitary seal (Y/N) YES
Total depth 346 ft. Cased to *50 ft.
FROM WELL LOG
Date of test 6/6/2004
Static water level 52 ft.
Well production 0.5 —
9 -p.m -
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml.
Arsenic: IND ug./L.
B. SEPTIC/HOLDING TANK DATA
Nitrate ND mg./L.
Well Log (Y/N) YES
Wires properly protected (YIN) YES
Casing height (above ground) ***24+ in.
AT INSPECTION
Date of sample: 5/23/2012
Tank Type/Material SEPTIC/STEEL
5/25/2012
31 ft,
**5.63
Collected by: GEG, Ltd.
Date installed 6/8/2004
Tank size 1250 gal. Number of Compartments E Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/Nf) NO c High water alarm (Y/N) N/A
Date of pumping Pumper n C 5+ p e S
C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE
Date installed 6/8/2004 Soil rating .p.d./ r ft2/bdrm) 1_2 System type TRENCH
Length 70 ft. Width 5 ft. Gravel below pipe 2 ft.
Total depth *7.8 ft. Eff. absorption area 500 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 5/25/2012 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 1_5 in. Water added 930 gal. New depth **2 in.
Elapsed Time: **– min. Final fluid depth **2 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date
**LAST 690 GALLONS CAUSED NO RISE IN LIQUID LEVEL.
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YIN
"Pump on" level at in. "Pump off' level High water alarm level at
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main N/A
Sewer /septic service line 25'+
Public sewer manhole/cleanout N/A
Holding tank
F1
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
G. -ENGINEER'S CERTIFICATION_ off` . • gSQ4o
1 certify that 1 have determined through field inspections and a : 4 �ao0�
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this ....... • . • ,
date. Qp f rey Garness. 0
Engineer's Printed Na7 e JEFFREY A. GARNESS 04� C 3
It 12.•'�co�o
Date �earrna «ton°� o
COSA Fee $ `Y `Z G
Date of Payment
Receipt Number
(Rev. 11105)
Waiver Fee $
Date of Payment
Receipt Number
SGS
SGS Ref.#
1121808001
Client Name
Garness Engineering Group, Ltd
Project Name/H
Don Jack Lott
Client Sample ID
Don Jack Lot2
Matrix
Drinking Water
Printed Dateflime
Collected Date/Time
Received Date/Time
Technical Director
05/31/2012 16:22
05/23/2012 16:00
05/23/2012 16:34
Stephen C. Ede
Parameter
Results
LOQ
Units
Method
Container ID
Allowable
Limits
Prep Analysis
Date Date
In@
Private Individual Analysis
Magnesium
10200
50.0
ug/L
EP200.8
C
05/29/12 05/29/12
NRB
Manganese
4.41
1.00
ug/L
EP200.8
C
(<50)
05/29/12 05/29/12
NRB
Nickel
ND
2.00
ug/L
EP20Q8
C
(<100)
05/29/12 05/29/12
NRB
OH Alkalinity
ND
10.0
mg/L
SM21 2320B
D
05/26/12
AYC
pH
7.90
0.100
pH units
SM21 4500-H B
D
(6.5-8.5)
05/26/12
AYC
Selenium
ND
5.00
ug/L
EP200.8
C
(<50)
05/29/12 05/29/12
NRB
Silver
ND
1.00
ug/L
EP200.8
C
(<100)
05/29/12 05/29/12
NRB
Sodium
11000
500
ug/L
EP200.8
C
(<250000)
05/29/12 05/29/12
NRB
Sulfate
12.9
0.100
mg/L
EPA 300.0
D
(<250)
05/30/12 05/31/12
SDP
Total Dissolved Solids
155
10.0
mg/L
SM21 2540C
D
(<500)
05/27/12
AYC
Zinc
6.15
5.00
ug/L
EP200.8
C
(<5000)
05/29/12 05/29/12
NRB
Arsenic ND 5.00 ug/L EP200.8 C (<10) 05/29/12 05/29/12 NRB
Thallium ND 1.00 ug/L EP200.8 C (<2) 05/29/12 05/29/12 NRB
a
SGS ReLN
1121808001
LOQ
Units
Client Name
Garness Engineering Group, Ltd
Printed Date/Time
05/31/2012 16:22
Project Name/9
Don Jack Lott
Collected Date/Time
05/23/2012 16:00
Client Sample ID
Don Jack Lot2
Received Date/Time
05/23/2012 16:34
Matrix
Drinking Water
Technical Director
Stephen C. Ede
Sample Remarks:
Parameter
Results
LOQ
Units
Method Container ID
Allowable Prep Analysis
Limits Date Date
Init
Metals by ICP/MS
AYC
Aluminum
ND
20.0
ug/L
EP200.8
C
Hardness as CaCO3
127
5.00
mg/L
SM21 2340B
C
05/29/12 05/29/12
NRB
Waters Department
(<6)
05/29/12 05/29/12
NRB
Barium
35.5
3.00
ug/L
Total Nitrate/Nitrite-N
ND
0.100
mg/L
SM21 4500NO3-F
B
05/30/12
AYC
Microbiology Laboratory
EP200.8
C
(<5)
05/29/12 05/29/12
NRB
Calcium
34300
E. Coli
Negative
1
100mL
SM21 9223B
A
05/23/12
DLC
Total Coliform
Negative
1
100ml,
SM21 9223B
A
05/23/12
DLC
Private Individual Analysis
Alkalinity
134
10.0
mg/L
SM21 2320B
D
05/26/12
AYC
Aluminum
ND
20.0
ug/L
EP200.8
C
05/29/12 05/29/12
NRB
Antimony
ND
1.00
ug/L
EP200.8
C
(<6)
05/29/12 05/29/12
NRB
Barium
35.5
3.00
ug/L
EP200.8
C
(<2000)
05/29/12 05/29/12
NRB
Cadmium
ND
0.500
ug/L
EP200.8
C
(<5)
05/29/12 05/29/12
NRB
Calcium
34300
500
ug/L
EP200.8
C
05/29/12 05/29/12
NRB
Chloride
1.78
0.100
mg/L
EPA 300.0
D
(<250)
05/30/12 05/31/12
SDP
Chromium
ND
2.00
ug/L
EP200.8
C
(<100)
05/29/12 05/29/12
NRB
CO3 Alkalinity
ND
10.0
mg/L
SN 21 2320B
D
05/26/12
AYC
Conductivity
291
1.00
umhos/cm
SM212510B
D
05/26/12
AYC
Copper
24.7
1.00
ug/L
EP200.8
C
(<1300)
05/29/12 05/29/12
NRB
Fluoride
ND
0.100
mg/L
EPA 300.0
D
(<2)
05/30/12 05/31/12
SDP
HCO3 Alkalinity
134
10.0
mg/L
SM21 2320B
D
05/26/12
AYC
Iron
ND
250
ug/L
EP200.8
C
(<300)
05/29/12 05/29/12
NRB
Lead
0.219
0.200
ug/L
EP200.8
C
(<15)
05/29/12 05/29/12
NRB
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