HomeMy WebLinkAboutSCIMITAR #2 BLK 2 LT 22imi'l'ar'
Block
Lot 22
#051 - 132-40
]~ND ENGINEERING, INC.
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907) 696-6111 / FAX (907) 696-8111
March 2, 2004
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
RE: AMENDED INSPECTION REPORT SW000138
SCIMITAR #2, BLOCK 2, LOT 22
Gentlemen:
After review, of the referenced property's.inspection report that was sub.mitted in
June 2000, it was discovered that portions of the report contained incorrect
information. The attached amended On-Site Wastewate. r Disposal System
and/or Well Inspection Report corrects these errors and omissions. The system
is functioning .proper. ly and was installe.d per the referenced permit and in
accordance with municipal and state requirements. If you have any questions,
please contact me at 696-6111 / FAX 696-8111.
Respectfully,
~D Engineering, Inc.
Attachments: HAA Documents
Amended Inspection Report
Water Analysis
As-Built Survey
O
Municipality of Anchorage
Development Services Department
Building Safety Division ~ ~'
On-Site Water and Wastewater Program, 4700 S. Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page of
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SWO00138 PID Number: 0.51-1 3Z-40
Name: Wastewater System: [] New [] Upgrade
Harold Crocker
Address:
Z0017 Tulwar Drive Chugiak, AK. 99567 ABSORPTION FIELD
Phone: Number of Bedrooms:
"~ . - ? [] Deep Trench [] Shallow Trench [] Bed [] Mound [] Other:
68R-0206
Soil Rating: Total Depth from original grade:
LEGAL DESCRIPTION 1.2 GPD/Ft2 8.5 Fto
Block: Lot: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe:
Z 27_ Scimitar #Z 4.21 Ft. 4.3 Ft.
Township: Range: Section: Fill added above odginal grade: Gravel Length:
1.11 Ft. 45 Ft.
Gravel width: Number of lines: Distance between lines:
Well: [] New [] Upgrade ? Ft. 1 Ft.
Classification (Private, A, B, C): Total Depth: Cased to: Total absorption area: Pipe Material:
Private-Existing Ft. Ft. 387 F~ D3034 & F810
Ddller: Date Drilled: Static Water Level: Installer: Date Installed:
Ft. Walker Const, 06/13/00
Yield: { Pump Set at: Casing Height Above Ground: TAN K
GPMI Ft. Ft.
SEPARATION DISTANCES [] Septic [] Holding [] S.T.E.P. [] Other:
T~ To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity:
Tank Field Station Tank Sewer Line Anchorage Tank 1000 Gal.
Material: Number of Compartments:
wel, 1 00'+ 1 00'+ NA NA 25'+ Steel 2
Su.aceWater 100'+ 100'+ NA NA ~ ~ LIFT STATION
Lot Une 5'+ 1 0'+ NA NA Ga,.
Foundation 5'+ 1 0'+ NA NA "Pump on" level at: "Pump off' level at: in, High water alarm at:
in. in.
Curtain Drain NA *5 0'+ NA NA Pump Make & Model Electrical Inspections performed by:
AMENDED INSPECTION REPORT BENCH MARK
Location and Description:
Tank insulated & *none known. Door threshold
Assumed Elevation:
100
Engineer's Stamp
Inspections performed by: KND Engineering,_ _. Inc. Dates: lst6/13/00
2nd 6/14/00
Development Services Department Approval
Reviewed and approved by: ,~/~'...~"/ ~/, ~°~ate: 3-/13- 0
AS-BUILT SYSTEM DETAILS/SITE PLAN Per. It: swoooI38
SCI~IT^R #2, BLK2, L22 PI~051-132-40
B-C=68.4'
g-D=51.3' i
A-E=67.2' m FINAL GRA~E ~ m
B-E=84,2' ~ : ~-=
A-F=56.U ' ~ ~
~~ RE~8~S ~! ....................................... ~ ' ~e sr~ CHUGIAK, LANO LANG AK. mm ~ ma~:99567 KMO ~Q ~ ENGINEERING 20441 PTARMIGAN BLVD.
~O0017.DWG' ~' 00017 (007)696-6111/Y~ (007)808-8111
Municipality of Anchorage Page 'of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage. Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number:. ~W'~(~ I~ PID Number: (~1 -
"'~: ~ ~,~ ~Wastewater System: ~New D Upgrade
~: ~00}~ ~~ ABSORPTION FIELD
.,o..~ (~q~-~oo I"~'~"-': ~.....~. ~,,ow,,.~
LEGAL DESCRIPTION SoilRafing: I, ~ G.O~q Ft lTo~lDepth~modgi.lg~d.:
SEPARATION DISTANCES ~s,¢= = Holding
Water ~'~ ~ -- % LI~ STATION
Lot
,o-,,o. /o'~ /o'+ -- -~"""-'-'~ I'-'~~''"''''''~'~
Remarks: NO ~0~ ~.UY~GI'~ BENCH MARK
ENGINEER~
mnspe~ions pedo~ed by: ~ Dates: ls~ .m.,.===,r~l
Depa~me~l of Hea~ and~a~Se~ices approval
AS-BUILT SYSTEM DETAILS/SITE PLAN Perm~ S~/000138
SCIMITAR If2, BLK2, L22 PID#051-132-40
' i \
,
~i ! ~:' f''':::~7':''~':y. ..... . .. . l? - / ~
i i
~ SCALt, t- = 50' °~ELL
A-C=45,3' ~ ~
B-C=68.4'
A-D=51,3'
A-E=67.~' m ORIGINAL GRADE
A-F:56.1' - -~ oo GA ·
B-G=109.6'~~~ ~
~ ~ ~ ~ PREPARE~ FBR, SCALD
....... C~GIAK, AK, 99567
m~ IANO ~KUD 20441 PT~IG~ BL~.
~s~o ~ m~ LANe ~m 6/22/00 ~G~ R~R, ~ 99577-8736
~m~.owo ~ oom~ (~o~)~-~.V~
MUNICIPALITY OF ANCHORAGE
Department of Health end Human Services
On-Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: May 31,2000
Expiration Date: May 31, 2001
Permit Number: SW000138
Legal Description: SCIMITAR #2 BLK 2 LT 22
Design Engineer: 0070 KND Engineering
Owner Name: c/o KND Engineering
Owner Address: 20441 Ptarmigan Blvd.
Eagle River, AK 99577-
Parcel ID: 051-132-40
Site Address: 020017 TULWAR DR
Lot Size: 42753 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
r~ Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
construction must be in accordance with:
1. The attached epproved design.
2. Ail 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 caIling
(907) 343-4744 ( 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.
Date:
Date:
~]'k~p ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-6111/FAX (907)696-8111
May25,2000
Municipality of Anchorage
Dept. of Health & Human Services
On-Site Services Section
P. O. Box 196650
Anchorage, Alaska 99519-6650
Subject: Sewer Upgrade - Scimitar #2, B2, Lot 22
Gentlemen:
The owner has requested that we obtain a permit to upgrade the referenced
property's septic field, which has been determined to be in failure. On May 12, 2000
we dug one testhole for the proposed system. The results of the test are attached.
The general slope of this lot is from east to west at a grade of approximately 3 - 7%.
We have designed our system utilizing the testhole we excavated for the existing 3-
bedroom house. Although the other soil stratas were not percolated, the material
appears to be significantly the same as the percolated strata. The lot is served by an
individual well. We propose to install a 2' wide deep trench. Water was not
encountered during the excavation or monitoring.
There are no public or private wells within 200' of our proposed system location
except as noted. There is no surface water within 100' of the proposed system and
there are no known curtain drains within 50'. We do not expect there to be any
adverse effect on adjadent lots by the development of this system. If you have any
questions, please contact me at 696-6111/FAX 696-8111.
Respectfully submitted,
~( l-~I 'Z) Engineering
Kenneth M. Duffus, P.E.
attachments:
On-Site Well and Sewer Application
Wastewater Absorption System Details/Site Plan
Soils Log/Percolation Test
WELL
& WASTEWATER DISPOSAL SYSTEM
SCIMITAR ~E, BE, LEE
21
D
BETAILS/SITE PLAN
!
27
~ ~ 00017.0WG
DESIGN DETAILS
3 ~DRM X 150 GPI) = 450 GPI)
450 GPI)/1.;' GPO PER SQ. FT. (1.67 HIN/IN.)= 375 SQ. FT
375/(;"(V) X 6'(D) (6.0 GRAVEL) = 31.;'5 FT. TRENCH
USE I TRENCH -
Tot~t dep'th oF sys'tem Is 9.0' From orlolnc~t Qro. de.
Total dep'th oF or,vet betow dlstribu'tlon pipe Is 6.0'
NDTES~
1. USE 1000 GALLON SEPTIC TANK. INSULATE TANK IF <4' CGVER.
INSULATE TRENCHES ~/ITH ;" HI) I)URIAL FGAM.
3. CONTRACTOR ~/ILL ENSURE HAXIMUH ;'7. SLOPE INTO SEPTIC TAME.
ADDITIONAL FILL ~/ILL I~E ADDED OVER SYSTEM TD ACHIEVE
HIN. 3' COVER IF REQUIRED.
PREPARED FOR,
JOE PERDZZI
;'0017 TULl/AR
CHUGIAK, ALASKA 99567
JAS
KMD
05/18/00
NW1261
00017
Semite, 1'= 100'
~D ENGINEERING
20441 PTARMIGAN BLVD.
gAGLE RP/ER, AK 99577-8736
PAGE 1 OF 2
~/ASTE~,/ATER DISPBSAL SYSTEM
SCIMITAR #2, B2, L22
DETAILS
K
D
IDI
/
'SEPTIC
0
9o,( F~E
O
¢:
¢
· ~0017 TULVAR
CHUGIAK, ALASKA 99567
~ kiNG
Stogie, 1'= 20'
]~) ENGII~EERING
20441 PTARMIGAN BLVD.
EAGLE RICER, AK 99577-8736
(907)696-6111/FA~ I907)696-8111
PAGE 2 DF 3
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
SOILS PERCOLATION TEST
Performed for:
Tom Reich
.Date Performed: 5/12/00
Project:.
Scimitar #2 Block 2, Lot 22
TEST HOLE # 00-1
16-
17-
18-
Depth
(Feet)
ORG - brown, moist
I
G P- loose, gray I
w/cobbles to 2'
SW - frae sand
GW/SWIsandy gravels, loose
B.O.H,
HOLE PRESOAKED
PRIOR TO TEST
SEE ATTACHED SITE PLAN
FOR HOLE LOCATION
Was Ground water encountered? NO What depth? NA
Depth to water after monitoring? NO Date? 5/19/00
Reading Date Gross Net Depth to Net
Time Time Water Drop
1 5/12/00 1:00 9"
2 1:10 10rain 29/16" 67/16
3 * 1:I1 9"
4 1'.21 10min 211/16" 65/16"
5 * 1..22 9-
6 1'.32 10min 214/16" 62/16"
7 * 1..33 9'
8 1:43 10 rain 3" 6-
9 * 1:44 9"
I0 1'.54 I0 rain 3" 6"
11 * 1'.55 9"
12 2:05 10 rain 3" 6"
· Water Added
19-
2O-
Percolation Rate 1,67 (min/in) Perc Hole Diameter
Test Run Between ~1 feet and ~ feet
I, Kenneth M. Duffus, certify that this test was performed in accordance with all State and Municipal guidelines in
effect on this date.
MUNICIPALITY OF ANCHORAGE
Hea~'~ and Environmental Prote~'%~n
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
279-2511, x 224, 225
INSP~-CIION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCAT,oN__C' ' too
MA,UNG ADDRrSS__C~C lt~
LEGAL L'[SCRIPTION._L ~ Z ~ '~
.HONE J,,9 r'/ ?:~e7
SEPTIC TANK:
DISTANCE
,NS,UE LENaTH.
TILE DRAIN FIELD:"~z~ ~
, , , TOTAL
NUMBER OF
INSIDE WIDTtl .... LIQUID DEnTil __ t. IOUlD CAPACITY/~ALLONS.
ABSORPTION AREA t~)~-O. SO. !T. LEI',I(;TH O[ EACH LI~;E tjx'0 !
~ ~ DEPTH OF FILTER
DEP~I,: TOP OF TILE TO FI/~ISl, GRAD[ __-.~_ _k?_-_-. k~_AT_[ ~_!_AL? [_,[_~,EATH TILE __~,C)___IN ABOVE TILE-
SEEPAGE PIT:
Log Crib Rings
BUILDING FOUNDATION
DIAMETER --OR WIDTtt LENGTH DEPTH
Crib Size: DIAMETER___DEPTH DISTANCE FROM: WELL
TOTAL EFFECTIVE
NEAREST LOT LINE __ ABSORPTION AREA (WALL AREA)
SQ. FT.
Well ~- .
Class: ~-~Ac) Dept'h.
Well.Distance To: Lot L~.ine - J
Bldg. Sewer Sine.
Pipe Materz-'---~ls: ~Ot~
9 of Bedrooms:
Installer: ~j~ ~.
Remarks: %~% ~ ~c
I I
- ,i_SON WELL DRILLli,o
1305 W. 45TH STREET
ANCHORAGE, ALASKA 99503
PHONE 272.9343
DRILLING LOG
Well Owner [[~" '~r~ ~, 't~ 'i" ~ " Useof V,'ell '
Location (address of: Township, Range, Section, if known; or distance main road_L t~'~
Size of casing ¢" .Depth of llole
Static water level I O't ft. (above)
Screen ( ); Perforated (
Describe screen or perforation
Well pumping test at ,ra~' gallons per (hour)
of drawdown from static level.
Date of completion ,'~ ~7'' o ~", 'l 't
.~' .H'.q feet Cased to J [' '1 feet
(b. elow) land surface. Finish of well (check one) open end ( ,- );
DEPT. O~ ~*L O- ~
(minute) for 'g hours wit~-- ~'l~ '((. ft.
.RECEIVED
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
.TO It~ · OC('tl'~1~ ...... ; ,:,., ', .... '. ,:. , I i .,, '.'.
.TO
TO Y~',~[' '-q b ..... , ~,. /.q /,,..';i,;./ /, ..~:
.TO
.TO I
.TO
PERMIT NO.
APPLICANT
LOCATION
LEGAL
iEip~--S I TE
( 77651
LT.
I C I PAL I T%~ OF RI'-,ICHORRGE
DEPARTMENT ~HEALTH AND ENVIRONMENTAL P~.L. OTECTION
825 ~1 ~TREET~ RNCHORRGE~ AK. ~--~
279-2511
SE~ER PERt~ I T
BI. il5 E.R.
LOT SIZE
6949~87
4~560 SQUARE FEET
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 4
SOIL RATING (SQ FT/BR)= 85
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
DEPTH= /) LENGTH= :3:5 GRAVEL DEPTH=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
RE(~UIRED SEPT!C TANK SIZE= I 250 'GALLONS
......... PACKAGE PLANT OPT I Ot~l
PACKAGE PLANT MAY BE INSTALLED AT THE PERMXTTEE"S OPTION SUBJECT TO THE
FCLLOWING CONDITIONS:
EITHER A CLASS I OR II NSF APPROVED PLANT MAY BE INSTALLED.
A CONTINUOUS MAINTENANCE AGREEMENT IS REQUIRED. IF A MAINTENANCE
AGREEMENT IS NOT KEPT CURRENT YOU MAY BE REQUIRED TO ENLARGE THE SOIL
ABSORPTION SYSTEM AND/OR YOU MAY BE SUBJECT TO PROSECUTION.
TWO ( 2 > INSPECT IONS ARE RE(~U I RED
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND BPPROVRL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR R PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL,
OTHER REQUIREMENTS MAY BPPL¥. SPECIFICATIONS AND CONSTRUCTION DIAGRRMS BRE
AVAILABLE TO INSURE PROPER INSTALLATION.
PEAr'11 T EXP I RES DECEI"IBER :3:1,,. I /)77
I CERTIFY THRT
l: I AM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND HELLS RS SET
FORTH BY THE MUNICIPALITY OF BNCHORRGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES,
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
' '~IGNED: __~]OAZ~_i~-~.__~_.._.~3_...Zq~h.~'_~/~-~__ .............. APPLICANT DEAN CONST
V3. 0
'~'~' 0 Er E GEO.'~".CHNICAL ~' DEVELr~MENT CO.
Russell Oyster
694-2774
Soils ~. Foundations
Box 90, Davis St., Eagle River, Alaska 99577
6~4-2774 or 688-2280
SOIL LOG
Performed for: Name: D~'~q/u'~ ~o~v,~7-,c.~¢7-/o,~ Tel. No.
Ead ~71is
688-2280
Land Development
Nalllng Address:
Legal Description: /~-~; ~z~,
Death (feet) ·
0
So11 ~h~racter1$ttcs
2
3
5
?
8
~9
lO
11 ,
12
13
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit
Comments:
No '/~-" If yes,~ what depth
':i.
Drain Field
Perfomed by:
Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
GENERAL INFORMATION
Complete legal description
Location (site address)
Scimitar #2 Block 2 Lot 22
Expiration Date:
· 20017 Tulwar Drive, Chugiak, AK 99567
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Dean & Trudy Burgoyne Day phone
20017 Tulwar Drive, Chugiak, AK 99E67
Day phone
Real Estate Agent Charlene Moss Realty, Inc.
Mailing Address .. 179 E. Nelsen Ave., Wasilla, AK 996%
Unless~otherwise re,,,.quested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
-3, TYpEOF WATER SdgPLY:
Individual. Well []
Individual Water StOrage []
Community Class ~ Well []
Public Water System []
Day phone 357-x4147
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period 6f 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 Pannone Engineering Services, LLC Phone 272-82:1.8
Address P.O. Box :1.oo2~.7, Anchorage, AK
Engineer's Printed Name Steven R. Pannone, P.E. Date 6/27//.(
Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guidelines & 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. PES can therefore not provide any warranty for future
performance nor give any estimate of how long the system will continue to meet the operational
requirements of the 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. DSO SIGNATURE
t.-"
¢ OF'-
4e ~\x.~ ....... c. ·
........
bedrooms.-
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments: COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:, "~- ~-//
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: .. Scimitar #2 Block 2 Lot 22 Parcel ID:..
WELL DATA
Well type P
Date completed 8_1~,1~.n77
Total depth 28,. ft.
If A, B, or C provide PWSID # .....
Sanitary seal (Y/N) Y
Cased to ~.n,. ft.
FROM WELL LOG
Date of test 8121',~77
Static water level =.o9
Well production 6.zr
WATER SAMPLE RESULTS:
Coliform ~ colonies/lO0 mL
Arsenic: /~b ug/I
B. SEPTIC/HOLDING TANK DATA
g.p.m.
Nitrate~ ,/'3~m~g/L
.Date of sample:
Well Log (Y/N) Y
Wires propedy protected (Y/N) Y
Casing height (above ground) =2+
AT INSPECTION
6/2M2oa~
in.
Collected by: Laura Pannone
Tank Type/Material. Anchorage Tank Steel
Tank size zooe gal.
Foundation cleanout (Y/N) Y
Date of pumping
ABSORPTION FIELD DATA
Date installed
Number of Compartments _2
Depression over tank (Y/N) N
Pumper Sanitary Pumpers
Cleanouts (Y/N) Y
High water alarm (Y/N) NIA
Date installed 61=/,120o0 Soil rating (g.p.d./~ or ~/bdrm) .=.2
Length /`~; ft. Width 2 ft.
Total depth e,2_~ ft. Eft. absorption area 8387_ft2 Monitoring tube Y
System type Deep Trench
Gravel below pipe /,.~
Depression over field N
Date of adequacY test ~
Fluid depth in absorption field before test ..Dry in.
Elapsed Time: ~_5 min. Final fluid depth Dry in.
AnY rejuvenation treatment (past 12 mo.) (Y/N & type) _ N
Results (Pass/Fail).,,.,pass
For 3 bedrooms
Water added.~65 gal. New depth/, in.
Absorption rate >=/,no+ g.p.d.
If yes, give date _
D. LIFT STATION
Date installed
"Pump on" level at ~ in.
Datum
E. SEPARATION DISTANCES
Size in gallonS~
"Pump off" level .~~
Cycles ~,~r ~
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot ~oo+
Absorption field on lot ~oo+
Public sewer main NIA
Sewer/septic service line 25+
Animal containment areas
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots ~.oo+
On adjacent lots ~oo+
Public sewer manhole/cleanout N/A
Holding tank ~.oo+
Manure/animal excrete storage areas ~.oo+
in.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
BDilding foundation ~.e+ Property line ~.o+ Absorption field
Water main N/A Water service line 25+ Surface water
Wells on adjacent lots ~oo+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~.o,
Water Service line 2=i+
Curtain drain None Known
Building foundation ~.o+
Surface water ~.oe+
Wells on adjacent lots
Water main N/A
Driveway, parking/vehicle storage 5o+
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
Date
Steven R. Pannone, P.E.
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
SGS Ref.# 1112731001
Client Name Pannone Eng. Srv. Printed Date/Time 06/29/2011 9:36
Project Name/# Scimitar 2 B2L22 Collected Date/Time 06/24/2011 12:30
Client Sample ID Scimitar 2 B2L22 Received Date/Time 06/24/2011 14:15
Matrix Drinking Water Technical Director Stel~hen C. Ede
PWSID 0
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic
ND 5.00 ug/L EP200.8 C (<10) 06/27/11 06/28/11 NRB
Waters Department
Total Nitrate/Nitrite-N 0.255 0.100 mg/L SM20 4500NO3-F B (<I0) 06/27/11 AYC
Microbiology Laborator~r
E. Coli
Total Coliform
Negative I 100mL SM20 9223B A 06/24/11 SDP
Ne~:ative 1 100mL SM20 9223B A 06/24/I1 SDP
OLLOWlNG D~$ORIBED PROP'ERTYr
-I~3lOATED. IT [S THE RES~NSIBtLITY OF THE
~N~ TO D~ERM, tNE THE EXISTENCE OF ANY
o~EMENTS~ COVENANTS,. OR RESTRICTIONS
~,ilCH DO NOT ~EAR ON THE RE~D~ ~BBI*
SiON PL$~. UNDER NO C~ROUMS~AN:CES $~
{L/DATA H~EON BE US~ FOR CONSTRUCTION
= FENCE LtNES~ O~ FOR EST~LISHiN6 ~ND~
Municipality of Anchorage
Development Services .Department
Building Safety Division
On-Sita Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel LD, 051-1R2-40
1. GENERAL INFORMATION
Complete legal description
Expiration Date: ~ - / O - O /'~
~;cimltar #2: Rlnck 2: Lot 22
Location (site address or directions) ;)0017 Tulwnr Drive Chu_nlnk: AK 99567
Current Property owner(s) Harold Crocker
Day phone~
Mailing address
same a~ above
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
e
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: _3_
3. TYPE OF WAFER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] Individual Holding tank []
[] Community On-site []
[] Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of 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 re~su!ts.__(C_ertlf.icates may be reissued for a period of up to one
year with valid water samples.) Certificates are valid for one year for properties ~d b~'-Clas~ '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-sita water supply and/or wastewater disposal system is(ara) 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 Ihe Municipality of Anchorage files and from my investigation and
Inspection, the on-site water supply and/or wastewater disposal system is(ara) in compliance with all
applicable Municipal and State codes, ordinances, and regulations In effect at the time of installation.
Name of Firm _.KND ENGINEERING; INC.
Phone
Address 20441 Ptarmlgan Blvd.: Eagle River: AK 99~77
Engineer's Printed Name Kenneth M. Duffus
Da~ 03/0~/2004
Engineer's Comments:
This Investigation was completed In compliance with
ADEC and MOA regulations. The assessment of the
condition of the well and septic applies only to the
conditions as of the day tested. The fiow 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 and the water usage
of the family being served by the system. The operational
life of all well and septic systems are subject to these
various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system.
Therefore, KND can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can KND guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
5. DSD SIGNATURE
~ Approved for '~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
x
: WASTEWATER
A '-. ..'. ,--,
Maintenance Agreements %'~-~'~I~.~,'
Supplemental Engineer's Report
Other
Original Certificate
Municipality of Anchorage
Development Services Department
Building Safety DIv~ion
On-Site Water & Wastowater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www,cLanchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
SCIMITAR #2. Block 2. Lot 22
Legal Description:
WEII DATA
Well type..,~
D,~te completod ~/~/19~ Sanitary seal (Y/N)Y
Total depth Z84 ft. Cased to 1S4 ft.
FROM WELL LOG
If A, B, or C provide PWSID #
Date of tea 8/2/77
Static water level 1 09 ft.
Well production 6.4 g.p.m
Parcel ID: 051-1 3Z-40
WATER SAMPLE RESULTS:
Coliform
Well Log (Y/N) y
Wires properly protected (Y/N)
Caeing height (above ground)
AT INSPECTION
15~ ft.
7. S 1 g.p.m.
A~senic: NA mg./t. Date of sample: "./=.~W Collected by: ~LEDgJDP~J~
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material ate installed ~Tank size 1000 gal.
Number of Compartments ~, Cleanouts (Y/N) .~
Foundation deanout (Y/N) Y Depression over tank (Y/N) H High water alarm (Y/N) N
Date of pumping Z/Z6/04 Pumper SANITARY
C. ABSORPTION FIELD DATA
Date installed 6/14/0~ Soil rating (g.p.d./~orl~fodrm) I.Z System type ~
Length 4S IL Width ~ fl. Gravel below pipe 4.3 It.
Total depth 8.5 ft. Eft. absorption area 387 ~ Monitoring tube Y Depression over field N
Date of adequacy test~ Results (Pass/Fall) PASS For ~ bedrooms
Fluid depth in absorption field before tesL0~ in. Water added 520 gal New depth O.S in.
Elapsed Time: S min. Final fluid depth_0__/,d~ in. Absorption rate >= 4S0+ g.p.d.
Any rejuvenation tmatmem (past 12 mo.) (YiN & type) N If yes, give date
0 colonlesJlO0 mI.Nltrate _O.~.~.~rng./t.Other bacteria 0 colonies/lO0 mi.
D. LIFT STATION
Date installed Size in gallons
"Pump on' level at__ in. 'Pump off' level at
Datum. Cycles tested.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lilt station on lot 100'+
Absorption fietd on lot 100'.1.
Public sewer main
Sewer/septic sewice line 25'+
Manhole/Access (Y/N)
in. High water alarm level at
Meets atarm & cirouit raquimments?.
On adjacent lots I 0 0' +
On adjacent lots 1 0 0' +
Public sewer manhole/cleanout
Holding tank 1 0 0' +
100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~'+ Property line ~ ' 't' Absorption field ~ ' ~-
Water main 10'+ Watersewicellne 1 0'+ Surl~acewatar 1 00'-I'
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation 1 O' +
Surface water 1 00 ' +
Wells on adjacent lots 1 00 ' +
Water main 1 0' +
Driveway, parking/~mhicte storage 1 0 ' 4-
in.
Property line 10'+
Water Sen, ice line 10'+
Curtain drain 50'+
F. COMMENTS
ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Munt'~pal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Kenneth M. Duffu~
Data
HAA Fee
Date of Payment
Receipt Number
(Rev. 12/Ol)
Waiver Fee $
Date of Payment
Receipt Number
SGS Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Sample Remarks:
1040964001
KND Engineering
Scimitar #2, B2~ L2'7-
Scimitar #2, B2~ L2
Drinking Water
All Dates/Times are Alaska Standard Time
Printed Date/Time 03/02/2004 7:50
Collected DatdTime 02/26/2004 14:00
Received DatdTime 02~26/2004 15:30
Technical Vlrect~,~,.~. ,~.~./rn c. £de
PQL
Urals Method
Wa~ers Department
Nhm~N
Allowable Prep Analysis
Container ID limits Date Da~e Inlt
0.150 0.100 mgtL EPA 300.0 B (<-I0) 02/27/04 JIB
Microblology Laboratory
Total Coliform 0 col/100mL $MI8 9222B A (<=1) 02//6/04 DKC
ASBUILT
b~WA~U & A~SOCIATES I~ SLiT{VEYING 694-o82q
I HEREBY CERTIFY .THAT I HAVE SURVEYED THE ~E'
FOLLOWING DESCRIBED PROPERTY~ ~-~/
INDIOA~. IT IS THE RES~NSIBILI~ OF THE ~"4~
~ ~ D~EEMINE THE ~ISTENCE OF ANY GRID: ~.-.: ....... ,~ ~ ~' ..
E~EMENTS, COVENANTS, OR RESTRI~IONS .~'~ "~~~
WHI~ ~ NOT ~EAR ~ THE RE~D~ ~1- ~'~
VISION P~T. UND~ NO CIRCUMSTANCES S~
~;, .. -,- ..
OF FENCE LIN~ OR FOR EST~LISHING ~ND- DRAWN=
ARY LINES.
Municipality of Anchorage
Dep.artment of Health and Human Serv'iees
· : '* . .~ ::..Divisionof Environment.al Services : :. ,' ·
' :..:-..-~ '. On-Site Services Section .825 'L Street Room 502 · :.: ".
..... '?::' -'?,'P.O.,Box .196650'- Anchorage. AK,99519-6650 .... " . :- ~..
~,- r, ' ..... . ..,., ~;-.., L .;', ~ - ,.. www.c .anchorage.ak. us: - .......... . ....~ ...
· ~,~ :.-. -_ L :' : · .... , ...... -. · ..'" -.~:".~":'i,.u,"¢ (907)'343-4744': ................. . ,,-. - - ,.-, ..: :." . .,
' CERTIfiCATE' OF HEALTi:I AUTHORITY AIGPRO /AL FOR A SINGLE FAMILY DWELLING
- ~' "~".~_ '? ''t,, ....... - ............ ,.,~'-~ ~-,. ,-~ -'~:..; ..... ,-... , '
ParcelI.D.' 051-132-40 ...... ./ ,,~ ...:-, ~:.~ ,:: .,,1:~. ,#'/,,/-/~
· -".. ' '*;' : .' Expiration Date:
1.';"GEN~*~I'INFOR~'~O~.-...~ ,.~,, ,. .L ..... ..:..:. _..: ....... ' ' ','.. :', :.?' ~ .: ," ..... ,' - -" r:'~:,'., ..... . . ..
· . Comp ete: egal'descnpbon ,' ,Scimitar #2.Lot,22.' BIock,2, * - : - * . ·
,~: *Location'(s~te address.,or d~rectlons)'* 20017 Tulwar Chuglak. AK 9~567
~. Current Property owne:(s) Chrla~and'Tom Rlech , ' Day phone .
' " ....... '- ~'7 :" ".'."~ ' '":' ":' '
· . ~ ' . ~Ma~hn¢l address' .', ~, ' * 20017 Tulwar, Chuolak. AK- 9956
· Leno~ng agency ¢, ..... :, .~ Day phone .'. '..' '*, ' -
: Maili6d address: . . . ' ........... ~ ......
" y ..........
ReaI Estat6 Agent - Joe, Pero~zi/Remax E.R. · Da ne ~'.
Mailing Address
Unl~ss otherwis~'requested, HAA will be held by DHHS for pickup. HAA picked up by:
2." NUMBER OF BEDROOMS: ................. 3-: ........... :'. ............................
3. ~TYPE OF, WATER SUPPLY: . , TYPE OF WASTEWATER DISPOSAL:
Individual Well :. .......... ' -: .......... [] ...... : ........ Individual On-site - ' · :.'"
Individuai Wate~'.st6rage ...... [] :_ .......... IndMdual Holding ta~k . [] ,'
Community Class Well , [] Community On-site" []
..... Public Water Sys~em ............... I~1 ............ Public Sewer ..... . ..... I~" ,
The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Certificates of Health
Authority ·Approval (HAA) based only upon the'representations given in paragraph 5 by an 'independent
professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are
required for the transfer of titJe (except between, spouses) on properties served by~a single family on-site
wastewater disposal and/or water,supply system. DHHS also issues HAAs upon request to home owners.
Certificates of Health Authority Approval are valid for 90 days from the date of issue f6i' properties served by- a
pdvate or Class C well and may be reissued with new water sample results less than 30 days 0Id. 'Certificates
are valid for one year for properties served by Class A or B wells or a public water sy~-{em.'The M.u~icipality
Anchorage is not responsible for errors or omissions in the professional engineer's w~rk~ ., ~: _
STATEMENT OF INSPECTION BY ENGINEER "~
As certified by my seal affixed hereto ,and as ~of.the validation date shown below, I venfy, that.my
,investigation. based on procedures outlined in the Health.Authority Approval Guidelines,=fur'ithis Health
Authority Approval application shows that the on-site water'supply and/or:wastewater dislSosal, system is
safe, functional and adequate for the number_of bedrooms and type of structure indicated herein. I further
verify that .based on .ti). e ~informafion obtained ;from'the: Municipality ~of Anchorage 'files .'and from my.
.investigation and,inspection,.ithe'on:site water supply ,~nd/or Wastewater.dispo~l system is in Compliance
~.. ' with all~applicable',Municipa!~nd.LState codes ' ordin, an~es ~andzregulations:lfi;effect .atithe time; of
" *'installation., '-~':"'"'"~'*':'' '"" ~'~'~"~'""" ~*'~"'"'-;'
......, . .~.., :,.:.` ,. . ~. ** . ~~.~--~,
6. DHHS SIGNATURE ~ ...... . .. ·
.L~,'Approved for/*'-'~ ": bedrooms.:_ '=.._=_.:: _..~
i§approved.':'.. -, - ..... "' ' "-'-:' . ': .'
~, .......... IJ... ...... .~ .~... ~ . ~ ... .~ . .'"!.* .~.:.;~.
· '. - Conditional approval for :~...- bedrooms, w~th the following stipulations:...
- .Attachment .~,,.. · .*
r.- - HAA checklist ~'~ . .',
· ~.epti¢System Adwsory
-'-- Well Elow Adv. is~ry.
Expiration Date: '? ~'"~ -
· :.. Maintenance Ag,c.~ments · Supplemental Engineer's Report
: Othei' .......
Original Certificate Datei
Reissue Date:
Municipality of Anchorage . ~
Department of Health and Human Servic~ C [ IV [ D
Division of Environmental Services '
On-Site Services Section 825 'L' Street Room 502 ~U~ 20 [~X)0
P.O. Box 196650 Anchorage, AK 99519-6650
www. cLanchorage.ak.us
(907) 343-4744 I~N. JNICIPAUI¥ Ot ~.,'~.
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Scimitar #2 Lot 22. Block 2
A. WELL DATA
Pamel I.D.:. 0..~ I - I ~2'/*] 0
Well type private
IfA, B, or C provide PWSID # __
Well Log yes
Date complete~ Sanitary seal yea
Wires propedy protected yes
Total depth 284 ft
Date of test
Static water level
Well production
Cased to 154
FROM WELL LOG
81211 977
10~ It
6,4 g.p.m
WATER SAMPLE RESULTS:
ft Casing height (above ground) 29 in.
AT INSPECTION
~.~/~"~ ~ I,~ g.p.m
Coliform 0 colonies/100 mi Nitrate 0.696 mgll
Other bacteria O colonies/100 mi
Date of sample: ~ Collected by: KND Engineering
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Steel
Date Install~ Tanksize 1000 gal Number of Compartments2
Cleanouts yes Foundation cleanout yes Depression over tank no High water alarm
Date of pumpina 6/1312000 Pumper JR PumDina
C. ABSORPTION FIELD DATA
Date Installe ~d_~ Soil rating
(g.p.d./~ or ~/bd~ System type deed trench
Length 31,25
Total depth...9 fl
ft Width 2 ff Gravel below pipe 6 It
Effective absorption area 375 ft2 Monitoring tube ¥e$ Depression ever field
· .~of adequacy test Results (Pass/Fail)
bedrooms
Fluid d~st in Water
added~h
· Elapsed Time: min FIn~._~~___~ in Absorption rate >=
~nt (past 12 mo.) (Y/N & type) ~ If yes, give date
in.
g.p.d.
~ON 'Size in gallo ~ '
Date in ,,s, ta~ ~~water alarm level at
Me~~n'ts?
'Pump on' level at _
Datum ~ Cycles tested
E. E'~J'~PARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots .,2 0 0 ' +
Absorption field on lot 100'+
On adjacent ors, 2 0 0 ' +
Public sewer main 100'+
Public sewer manholelcleanout I 0 0 ' +
Sewer/septic service line 100'+
Holding tank .,1 0 0 ' +
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10'+ - Property line 1 0 ' +
Absorption field 1 0 ' +
Water main 10'+
Drainage 100'+
Water service ne. 1 0 ' + Surface water 1 0 0' +
Wells on adjacent lots ~ )Dd~'-e~"-~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+
Building foundation ~ 0 ' + Water main I o ' +
Water Service line 10'+
Curtain drain 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
tn
Surface water. 1 0 0 ' '1- Driveway. parkingNehicle storage
Wells on adjacent lots
I certify that I 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.
Engineers P,nted .ame
HAA Fee $. (-3) ~ ~- ~
Date of Payment
Receipt Number
(~ev. lt/99)
Waiver Fee $
Date of Payment
Receipt Number
CT&£ Ref-# 100322t001 Client PO#
L"licn! Name ]~D Eagittaeriag Printed Date/'J'hne 06/26/20~0 16:01
Project Namem Scimitar #2 B2 L22 Colle~ Date/Time 06/21/2000 14:45
Client Sample ID Scimitar/~2 B2 t.22 R~celveG D~te/Tlme 0(~21/2000 t6.'~
Marrtx Drinking Waxer Technk'nl Director Stephcn C, F. de
AttO.abLe Prep Anatyoi$
#ltrmte-a 0.696 0.$00 leg/k EPA300.O (<10) 06/21/00
Total cotlfom
Q COL/100.,L ~18 922.2. 06/21/00
MUNICIPALITY OF ANCHORAGE
-' DEPARTMENT OF HEALTH & HUMAN SERVICES ' = ............" '
DIVISION OF ENVIRONMENTAL SERVICES ~ I~)..) ~:~
I,~.~
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVALr- -
OF ON-SITE SEWER AND WATER FACILITY
2644744
· .. App,cat,onD ,te
(a) Legal~scription (include lot. block, subdivision, section, township, range) ~
Location (address or directions)
(b) Pro- erty Owner (~c"~/'I~ °'~L ~'-"~-' ; ~t~*'~-"Telep hone: Ho me Business
Mailing Address .[[ ~~
(c) Lendinglnstit~tion ~ ~-~..'~phone
Mailing Address -
(d) Real ~te comPany and Agent ~ ~J~.~~c~. /~.~~
Address ~- ~ ~J ~ ~ ~~/~ ~~
Telephone ~ ~ ~- -~--~ ~
(e) Mail the HAA ~o the followino address: o~ Check here ~. If hold for pick up,
List conta~ pemon and day phone number below.
170~4 Eagl,, Riv~' Loop Road No. 204
E~gle River, Alaska ~577 .:,-' ..
2. TYPE OF RESIDENCE · Single. FamilyA
. . Number of Bedrooms
3. WATER SUPPLY
Communityn Publicr'l
Individual Well.~
· .,,[ttl.llX~\ .
Note: If community well system, must have written confirmMion from the State Department of Environmental Conservation
attesting to the legality and status. *..*. * ..
SEWAGE DISPOSAL .':2 :'
Onsite]i~ Public I-] Community I"1 *Holding Tank
Note: If c~mmunity well s~'stem, must have written confirmation from the State Department of Environmental Conservation
attesting lo the legality an~ status. ' ' ' "' ' ".:.." .~ :. · ·
Page I of 2
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe. functional and adequate
for the number of bedrooms and type of structure indicated herein, I further verify that based on the information obtained
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.
S & $ ENGINEERING
Name of Firm -~--. 0_ ,~t.~ ~ ~ u__~ .,_ ....
Address E~gle River, Aleska 99577 .
Date
Telephone
6. DHHSAPPROVAL
Approved for ~ bedrooms by
..... ~'PProved '~l~. "~* ' Disapproved
;Terms of Conditional ~pproval
Conditional
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
certificate~ 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.
MuNtCIPALIT( OF ANCHORA~uIrUNiCIPALITY OF ANC'HORAGE (MOA)
[NVtI~O,,qM~.NTAL SE[~VtCE$ DIV~.~A~LTH AUTHORITY APPROVAL (HAA)
WELL DATA
NOV ! 8 19B7
RECEIVED
CHECKLIST - FEBRUARY 1984
264-4744
Legal Description:
Well Classification
Well Log Present(~N)
Total Depth '~- ~
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit(~N)
Separation Distances from Well:
If A, B, C, D.E.C. Approved (Y/N) I'~/,&''''
Date Completed '~//~'"//'/"/ Yield
Depth of Grouting ~-
Pump Set At L.) ~ ·
Sanitary Seal on Casing (~N) ~/
Depression Around Wellhead (Y/~ ~
Cased to [ ~*"'~rj
To Septic/Pl~kJ;,,~ Tank on Lot I r;'.'.~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ' ~'"C',~; ; On Adjoining Lots
To Nearest Public Sewer Line l'3/A, To Nearest Public Sewer
Cleanout/Manhole ~.3/~, To Nearest Sewer Service Line on
Water Sample Collected by ~P ~ ~ '~::>,~', t~.)~:::~_~.-..I,-..~. ; Date ~ \ ~
Water Sample Test Results ~--~/'~ % ~-'z~. f~."'F'~ ~ ~ '~-~,"~'~,.~'~L~ ,~.
Comments ~ ~ ~. ~,~"'L..L~ ~ '~,~::~--/~ "~--~:~.~"~.-J~
B. SEPTI~G TANK DATA
Date Installed ~'x/~,/~? Size I,?~0
Standpipes (~N) y Air-tight Caps~N)
Depression over Tank (Y.~ t
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/H.e~._ing Tank:
To Water-Supply Well ~ (;~(~
To Property Line ~ ~,~ Ij~
To Water Main/Sen/ice Line I c::, I..~.-
Course ~ c::'C:> I..~._.
No. of Compartments
Foundation Cleanout (Y~
Date Last Pumped
:,or
Temporary Holding Tank Permit (Y/N)
Comments
To Building Foundation c:::) . . ....
To Disposal Field ~ ~
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y~;~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot ~/,~
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design ,'"'~--.'~--~---~
Length of Field ~ i
Depth of Fie~d ' Lc:~;'' .
Gravel Bed Thickness ~" ~
Standpipes Presentd~N) ~/
Date of Last Adequacy Test ' tt -- [~ ~5"/
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots '~c:> ~--~-'
To Cutbank (if present) ~-
LIFT STATION
Dat~ . Dimensions
Size in Gallons~'"'-~. Manhole/Access (Y/N)
"Pump On" Level at ~ "Pump Off*' Level at
High Water Alarm Level at ~ Vent (Y/N)
Tested for ~ ~cles during
Electrical Codes (Y/N)
Comments
Adequacy Test. Meets MOA
Page 2 of 2
** Check Permitted Bedroom Rating Against HAA Request **
I ce~ f~ t~ ~l~lt~--~l~lf~j~d, verified, or conformed to all M.OA and HAA guidelines in effect on lhe date of this inspection.
Sion~134,~ Eagle RlY~ L~ R~d No. 2~ Date .
Company MOA No.
Date of Payment
CHEMICAL & GEOLOGICAL LABORATORIES OF .4LASKA, INC.
-.ze:,~"~ 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
~ FEDERAL TAX ID # 92-0040440
Client. PC= : V~,~.L Req I:
Client Sc.~l II~: L22, B2 SCIMITAR, tt-13-87, 12~5
$~r~le Res'si : HiY,' 13 87
~red By :
To:
17034 [AO[Z I~IVG ~ RD., t~4
FJ, CLE RIVE, At. 99577
In.,r~ct.
~,,e~llb ~e~ ~: 8343 lib ~1 ID: I Eltclx: Wirer
Far~eter Tested R~lt/gnits Methc~ Limits
~I~A~-{{ 0.24 ~,q 10
Time
Date
/'"%MUNICIPALITY OF ANCHORAGr-~
DEPARTML. o OF HEALTH AND ENVIRONMEN i. PROTECTION
' ' 825 L Street, Anchoraam. Alaska 99501
264-4720
Date Received: January 6, 1978
1!: ~0~a/m. ,2: Time' ~ ~..~n~ ~3: Time ~
Insp ~h~z/~llers Insp Insp ~
RE~H~ST.~OR ~PPROV~ OF I~DIVIDUhh ~E~R ~D ~TER ~CI~I~I~S w~ll hand carry
1. Lending Institution Request: United Bank Alaska % Mary Forester
Mailing Address: 645 G Street 99501 Phone: 278-9526
2. Property Owner:
Mailing Address:
Dave Deans Phone: 694-9387
Box 115 Chickaloon Street 99577
3. Legal Description: Lot 22 Block 2 Scimitar Subdivision
4: Single Family Residence: (x)
Multiple Family Residence: ( )
Number of Bedrooms: Four
Number of Bedrooms:
Se
Well System:
Permit #
Construction
Individual Well
Depth of Well
6. Sewage Disposal System:
(x) Community/Public System ( )
284' Well Log on File (x)
Bacterial Analysis '~*£-~{~-~
On-site System (x) Public Utility ( )
Permit #
Septic Tank Size
Absorption Area
Installed 1977 Installe~
~..~-~ Manufacturer
Soils Rate Material
Distances: Well to Septic Tank %~ ~
to Sewer Line % \~ Nearest Lot line
to Nearest Lot Line qr ~O
to Absorption Area 1'2.~o
Absorption Area
~Pag~ Two ,- ''
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 22 Block 2 Scimitar Subdivision
Comments:
Affadavit Attached~~
Approved:
Disapproved:
Letter Attached: ( )
Date:
Department Worksheet:
s)L"oe)~-,O ~::o~o, ltYW 1VNOI/YKU]LNI WOJ 10N
--'(TJQIAOBd 3~¥B]AOg ]~NVBflS#! ON 008: lzG! 'J~V
(a3elsod snltd ,)OC--'IIYW 031:II.LU3::) HO.-I J. dlq:)31
'r;e~artmen't.'!of Health and Environmental Protection.~){~n~.'
825 L Street, Anchorage, Alaska 99501
264-4720
' --~eque~t fo~, ~Ap~roval of Individual Sewer and Water Facilities · ~.~.,.~ ~, i.~ .
ro erty er:
Mailing Address:
Name of Buyer:
Mailing Address:
Phone:
Phone:
Mailing Address: ~-~ ~ ~ Phone:
4. Realtor/Agent:
Mailing Address:
Phone:
Se
Legal Description:
Street Location:
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 ~31~
Sewage Disposal System: *~n-site System (~"Public System ( )
If On-site System, date of installation: 8 I~!~~
*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.
A fee of $25.00 must accompany each request before processing
can be initiated.
3/77