HomeMy WebLinkAboutCHUGACH PARK ESTATES BLK 1 LT 4Chugach Park
Estates
Block i
Lot 4
#051-471-01
Parcel Identification Number:
Date of Issue
0-5'_ 411_(}/
Legal Description Property Owner Name & Address
24149 Platsek Stan Hardman
Pump Installation Date: 4-16-18
11 Pump intake Depth Below Top of Well Casing: 510
U Pump manufacturer's Name: F&VV
UPump Model: 41`07G10305
UPump Size: 1
11 Pitless Adapter Burial Depth: 10
PhJessAdapter installer: Unknown
Disinfected Upon Completion? N yes 0 no
�
Method of Disinfection: Chlorine 50 PPM
Comments: PitkessManufacturer: Martinson
Well #2, 600' Deep, Closest to Driveway
11 Pump Installers Name: Sullivan Water Wells
feet
feet
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Well Drilling Permit Number: S%V
Parcel Identification Number:
Legal Description Property Owner Name & Address
24149 Platsek Stan Hardman
Pump 16'stallation Date: 4-16-18
11 Pump Intake Depth Below Top of Well Casing: 410
UPump manufacturer's Name: F&VV
UPump Size: 1
UPit|essAdapter Burial Depth: 10
PidessAdapter Installer: Unknown
Disinfected Upon Completion? M yes F-1 no
UMethod ufDisinfection: Chlorine 5OPPM
Comments: PitlesManufacturer: Martinson
Well #1, 464' Deep, Closest to House
UPump Installers Name: Sullivan Water Wells
feet
hp
feet
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
%AUNICIPALITY OF ANCHORAGE
r \,
// • DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
II ENVIRONMENTAL ENGINEERING DIVISION
825 L Street • Anchorage, Alaska 99501 Telephone 264-4720
ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE � NEW
/
C•Q LJJAG
L
333-410 iAOUPGRADE
MAILING ADDRESS
P• D. 6ox 4-Bs 6 ,/%/vcNoQs7GE, Au• 99� 09
LEGAL DESCRIPTION
Lo7-4 / 45'tAe. /. C,-/06.4C,A PARC L�Ti4TES
LOCATION
NO. OF BEDROOMS
Well
Absorp;oyrea/
Dwelling r
PERMIT NO.
U Y
DISTANCE TO:
y,
Z 3
—
Z
WF
Manufacturer
50A15F7- T�cysr/c
Material
F1A5E4eZ ss
No. of compartments
2
to
Liq, capacity in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
Zi0I
b Y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
—10Z
=?H
Manufacturer
Material
Liquid capacity in gallons
D
m=
DISTANCE TO:
Well
Foundation
jg
Nearest lot Itn
7
PEHMI T NO.
—IME
No, of lines
Length of each line
Total len th of lines
Trench width
Distance between lines
2 Inches
<H
Top finish
Material beneath tile
Total eflective absorption area
o
of tile to grade
"
-S
2 inches
.x-00 �W. FT.
Length
Width
Depth
PERMIT NO.
W
Q ii-
Type of crib
Crib diameter
Crib depth
Total effective absorption area
W 1
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
DISTANCE T0:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS 4we•I VlvE', ¢� �ly�
D,CA/t/ UNE.
3
4'
1
SOIL TEST RATING
45-60.fr /P,,2,
INSTALLER
//0W11f A.-1C�CK�ON
a
?+'
VF
L
REMARKS
S
to.
............
Tit
c
M
...: ..: .k:...�
Rsyi Earl P. Ellis W
eI
APPHUVED DATE LEGAL
1317P /,, C$#Iez X-
4(, IZZ IdKit`
72-013 (Rev. 3/78)
\ - MUNI C I PF11L I TY OF= nNCHORFiGE
DEPARTMENT C"`"EALTH AND ENVIRONMENTAL r"" ECTION /tea
825 'L oTREET. ANCHORAGE. AK. 99:.11..
264-4720 OC
WELL n N E> O N -SITE SEWER P E R M I T
PERMIT NO. C 780362 )
APPLICANT GERALD A LUSK P.O. BOX 4-856 99509 333-4043
LOCATION
LEGAL L4 B 1 CHUGACH PARK ESTATES' LOT SIZE 54400 SQUARE FEET
TYPE OF SOIL ABSORBTION SYSTEM I5: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING CSO FT/BR)= 85
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
C>EF?THa 10 L-ENiCTH- 22 GRAVEL- DEPTH= 5
THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH I5 THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION CIN FEET).
REinU I REQ SEFm*T I C -rnNK S I ZE= 1000 Ont-L_ONS
PERMIT APPLICA14T HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
--- TWO <:22> I NSPECT I IONS F'lRE REQU I REE ---
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELL; OR
150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F='ERM I T EXP I RES [7ECEME3ER 31 . 1 <-;17'O
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IPJ 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 3 BEDROOMS.
SIGNED:----------
APPLICANT
_--1=__APPLICANT GERALD A LUSK
ISSUEDBY�-i �C `_ =--DATE �_��__ a a _ V V3. 2
' 0 & E GEO i 'HNI CAL & DEVEL(, MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688.2280
Russell Oyster
6942774
Soils Et Foundations
SOIL LOG
Earl F//is
688.2280
Land Development
Performed for: Name: e�xz'b LtlSK Tel. No.
Mailing Address:l-SS"G
Legal OescrlpNon:_loT -se, Rik. Gids-qcew %J e'e ESii9TF5
Depth (feet) Soil -Characteristics
0
1 ML
2
3
4
5
6
7
8
9
10
11
12
"Y -P I
CGE441 f /A�sE �s�/G•�.
13
G3drreA� Of ,�.T
14
15
M
Ground Water Encountered: Yes No f If yess what depth
Proposed Installation: Seepage Pit Drain Field
Comments:
N� ' -44E
Performed by: �� ��-C �- �i�-l�'� Date: ?9 7%'
0 & E GEO'~COHNI CAL & DEVEL'- MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russel Oyster
694.2774
Soils Et Foundations
SOIL LOG
Earl Ellis
688-2280
Land Development
Performed for: Name: ZC-,C /</0eP /A/ --S Tel. No. o/k8- 30/0
Mailing Address: .5-R, 7/4(57 , 0110G14-<, 996r-77
Legal Description: /or �LK. /, ('y0e,4cN ,4,eAe ES7,1rFS
Depth (feet)
BE
Soil Characteristics
1 ML 5/LT To Sail Z7J�SP�/3.�2,
2
3 '
4 G P S;VA10 3/ L72�7c/EL
i
5 eveeC.E.s 9, /jodcorES
?o S'V Laose, T..Q.
6 e -'4e V^/
7
D
9
10
11
12
13
14 Se7-7MfIf A c Pr
15
16
Ground Water Encountered: Yes No l' If yes, what depth
Proposed Installation: Seepage Pit Drain Field
Comments:
Performed
rES �qr�
'rgu
F107- P14AI
Alo RACE
(k,ertl ith
by.
A & L DRILLING COMPANY
BOX 97, EAGLE RIVER, ALASKA 99577 • TELEPHONE 694-2588
OWNER OF LAND ('ECAc D < ✓C&l DEPTH OF WELL A60
ADDRESS
LEGAL DESCRIPTION ��� / CV✓�6y (if7
DATE. Started acbj Ended 'S- 271
PERMIT NUMBER 4? D 3C, d
KIND OF FORMATION:
STATIC LEVEL OF WATER FT. 110
DRAW DOWN FT
GALS. PER IIR aS
KIND OF CASING 6 P 0,0
From _t'LFt. to / Ft.—D1�'i4Y.iQ" From Ft.
CS
From � FL to_�Ft. .�F^i 0 �iA'a✓e� r13 A"`�rom Ft.
FromFLto'70 Ft. Mf/,'1049�
From �_FI. toJ ± a_Ft. C«t7' G('if✓a c
FromFt. to-L4tL to—L4'Ft. S/<
From Ft. to Ft.
Froin—Ft. to Ft
From FL to Ft
From 1{.}=FL to /yJ Ft. �Y�iX'�?✓�`'L
From
Ft to
Ft.
From /�Fl. to a ro Ft.
rw�'a'i
J !<
From
Ft. to
Ft.
From c2J0 Ff. tooi_r/ Ft.
C4_I?1' GACA✓et re2,r.44XlFrom
Ft.to
Ft.
Froma�y Ft. to d" Ft.
a_ceXo<aG
From
Ft. to
Ft.
From afO Ft. to Sex Ft,
pC<<r <<S+cTCv.fn
From
Fl. to
Ft.
From 310 Ft. to 3*r Ft.
Lli' cccK Sado
From
Ft. to
Ft.
From 325- Ft. to Ft.
&depc #t a✓� GJMCT�
'wiser
'from
Sir'
Ft. to
Ft.
From -74!r' Ft. toFt.
bfot'Ac K 10410
From
Ft. to
Ft.
94S'
From 4 �o Ft. to Ft.
'164tac/c retu71460
aotYFr
From
Ft. to
Ft.
From IVT� Ft. to 44 4- Ft.64t 3'o -to
From Ft. to Ft.
From Ft. to Ft.
AIISCL. INFORMATION:
Gas.'o 411 -rp r/A< G " cAr..✓c .
From Fl.
From Ft. to Ft.
From Ft.
DRILLER'S NAME � —X--
by.
a
A & L DRILLING COMPANY L�
LOX 97, EAGLE RIVER, ALASKA 99577 • TELE►HONE 694-2589
OWNEROFLAND Ig5rpG.0 <✓SK
ADDRESS
DEPTH OF WELL
r
411,11 00
STATIC LEVEL OF WATER FT. r2 90 r
LEGAL DESCRIPTION Z `� 6�K
/
CWaCAC H 1*ek
lt� sTDRAW DOWN FT
DATE, • Started Z
Ended
��
GALS. PER HR
PERMIT NUMBER % �� a KIND OF CASING 6 x' o e9
KIND OF FORMATION:
FromFt. to 19
00F!!✓C-0:e—
From
Ft. to
Ft.
From SIC Ft. to SF r Ft.
Ai= eoCK Qecye,,"
76?'From
FromFl. to -7,5- Ft.
SA,Jd 614..r7e
i-- ITOCXO0�"
°'From
Ft. to
Ft.
From Ft. to _Ql Ft.YX164OA-J
From Ft. to Ft.
F From
Ft. to
Ft.
From rd S Ft. to/6r Ft.
S/<r
From
Ft. to
Ft.
From Ft. to Ft.
From14:rFt. to /RO Ft.
.5fl. 7 A 6.P/✓Cc
Ft.
From
Ft. to
Ft
Ft. to
Ft
From/10 Ft. to t`7 Ft.
S /c
Froin—Ft.
to
Ft.
From lCi r Ft. to -2-3 Ft.
C/<7_
iQA t C
From
Ft. to
Ft.
From a 3a Ft. to-2_Ft.
Cep 7' 4:
6Q'f✓EZ
From
Ft. to
Ft.
From c4 of Ft. to?zk' Ff
A60A6c K
From
Ft. to
Ft.
From 3 /,? Ft. to --:4-100 Ft.
4EOR-1 K
From
Ft. to
Ft.
From O2 Ft. to 'Ur Ft.
RcoRceiG SOc1D
From
Ft. to
Ft.
From SIC Ft. to SF r Ft.
Ai= eoCK Qecye,,"
76?'From
Ft. to
Ft.
From�Ft.to (-00 Ft
dzaVeee `fd "d
From
Ft. to
Ft.
From Ft. to Ft.
From
Ft. to
Ft.
From Ft. to Fl.
From
Ft. to
Ft.
From Ft. to Ft.
From
Ft. to
Ft.
From Ft. to Ft.
From
Ft. to
Ft
NIISCL. INFORMATION:
// '/ 'T'o TrA< L
P 13
DRILLER'S NAME I �'"
Trrttfxrd Urliltrtg ung
by
A & L DRILLING COMPANY
BOX 97, EAGLE RIVER, ALASKA 99577 • TELEPHONE 694-2588
OWNER OF LAND GEQA< a [ u s K
ADDRESS
LEGAL DESCRIPTION I !'duG.rc/f P41e ofr
DATE • Started Ended
PERMIT NUMBER _%E 0
DEPTH OF WELL
STATIC LEVEL OF WATER FT.
DRAW DOWN FT
GALS. PER HR /-2
S
KIND OF CASING 6 o
KIND OF FORMATION:
From 19 Ft. to 02 Ft. From Fl. to Ft.
From 2Ft. to'/? Ft. S4� 4 ,t 40e.L44 From Ft. to Ft.
From Ft. to -3 Fl. 9^70 From Ft. to Ft.
From Ft. to Ft. + 00ou<40ECS
From -?F- ' Ft. to 2` Ft. 4DZQ1412
5
From � /
Ft. to -6 -T --Ft. S'4n,,0 f G'e'4'•*�"
Fromer Ft. to--Le—Ft. ly' 74eO IW-�
From (f'8* Ft. tol j b Ft. &.606* -
From//? Ft. to13?'Ft. /i9CDOd�
From 138 Fl.tolll Ft. C<AJ'�f l4/✓mac
From142 Ft. toZ 5"4 Ft. S/47-
From
t.T
From /t6 Ft. to12C_Ft. 9 G'PA ufc
From/73_Ft. to L?0' Ft.
From Ft. to 9 r Ft. S/�
From 19 r Ft. to a ] Ft.'" S/< i Sz GQa�t
i
From o%FI. to (9'47 FL Dt�>' r64��Et
rR
From�Ft. to FL 6r.0 0cK
NIISCL. INFORMATION:
Fran
Ft. to
Ft
From
Ft. to
Ft
From
Ft. to
Ft.
Fran
Ft. to
Fl.
From
Ft. to
FL
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From Ft. to Ft.
From Ft. to Ft.
DRILLERSNAME �� {
I=
Oct
r'`� r1 rt74 p child;
S. LEGAL DESCRIPTION
L o -Flock
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
A
BM L Strwt - Anchorage, Alaska 98501
NUMBER OF BEDROOMS
ENVIRONMENTAL ENGINEERING DIVISION
❑ One ❑ Four ❑ Other
Talephom 264.4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all Pas" on page 1. Imaegleb requwb will not he Processed. P1 allow ten 110) days for procuring.
7. PRO OWNER
7. WATERS PPLY
PHONE
M� I�1�q DORESS
715 olc y6 F
C•/K SIAX S5 S'6 7
OPERTY RESIDENT W diflnent from above)
!
since June 1975. For wells drilled prior to that date, give well
0 gt
depth (attach log if available.)
S. SEWAGE DISPOSAL SYSTEM
i BUYER -
T4
9D
PHONE
IMAtLING ADDRESS
if system is over two (2) years old an adequacy test is required
If
LENDING IT TIO
by this Department.
PHONE
MAILING ADDRESS
901
W, No, 4, i -4-9-0
♦ REALTOR/AGENT
PHONE
MAILING AOORESS
S. LEGAL DESCRIPTION
L o -Flock
G H cl Awle rbp6ey
STREET LOCATION
S. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
SINGLE FAMILY
❑ One ❑ Four ❑ Other
❑ Two ❑ Five
❑ MULTIPLE FAMILY
Three ❑ Six
7. WATERS PPLY
INDIVIDUAL'
' ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
S. SEWAGE DISPOSAL SYSTEM
9D
ealfindividual/on•site,give installation date ga .
if system is over two (2) years old an adequacy test is required
If
❑ PUBLIC UTILITY
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCES G CAN BE INITIATEDQ
72-010(3l78) 0 a, r -
fall" 1
M
THIS SIDE FOR OFFICIAL USE ONLY
INSPECTION APPOINTMENTS
DATE RECEIVED
TIME
TIME
TIME
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE
LJ SINGLE FAMILY
❑ MULTIPLE FAMILY
OF BEDROOMS
/NUMBER
❑ ONE � THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
(�/ INDIVIDUAL
ID COMMUNITY
1:1 PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL O
DATE DRILLED l/
LJ
LOG RECEIVED (/
3 AGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE
❑PUBLIC UTILITY
Co action Verified
PERMIT NUMBER
DATEINSTALLED
INSTALLER
SOILS RATING
optic Tank or ❑ Holding Tank
Size: 19 50 Tank is homemade
give dimensions:
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic Holding enk
Absorption Area
r Lim
rest Lot Lim
AbrorptionArm to nmrmt Lot Lina
5 COMMENTS
APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
BY ITiNaI
LE AL ES RI ION
rz-utu Inev. a//r31
Parcel I.D. 051-471
Municipality of Anchorage s
On -Site Water and Wastewater Program
(907) 343-7904 s A E r '
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
1. GENERAL INFORMATION
Expiration Date: 3 ` 1 1� -/ 3
Complete legal description CHUGACH PARK ESTATES BLOCK 1 LOT 4
Location (site address) 24149 PLATSEK DRIVE CHUGIAK AK 99567
Current Property owner(s) MICHAEL & JOYCE ANDERSEN Day phone
Mailing address
Real Estate Agent
PO BOX 671562 CHUGIAK AK 99567
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Received by: Date:
i —
COSA to be released to the engineer, unless otth6r*is�v!�quested by the engineer.
COSA Fee $ f 9th Waiver Fee $
Date of Payment Cil/Op Date of Payment
Receipt Number "a Receipt Number
COSA # 6S Ci%o2 /9W 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.
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 12/10/2012
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 flow and absorption rates may change due to subsurface
conditions that may not be observed from the surface, changes inland 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 fife 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,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen _ '4
encroachments, deficiencies or discrepancies exist.'
6. DSD SIGNATURE
System #1 Approved for, bedrooms.
L-71
The
System #2 Approved for. bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
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.
ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
M A J, I sheet 9-t-:2 6.c
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: CHUGACH PARK ESTATES BLOCK 1 LOT 4 Parcel ID: 051-471.01
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID #
Date completed 5128 & 51251978 Sanitary seal (YIN) Y
Total depth 460' & 600 ft. Cased to 225'&244 ft.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate ND mg/L
Arsenic: ND ug/L Date of sample: 1213112
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC I FIBERGLASS
Tank size 1250 gal. Number of Compartments 2
Foundation cleanout (YIN) Y` Depression over tank (YIN) N
Date of pumping 11129/12 Pumper JRs
C. ABSORPTION FIELD DATA
Well Log (YIN) Y
Wires properly protected (YIN) Y
Casing height (above ground) 12+ in.
AT INSPECTION
1213112
190'&453 ft.
0.25 & 0.049 g.p.m.
Collected by: ARCTERRA
Date installed 61311978
Cleanouts (YIN) Y
High water alarm (YIN) N
Date installed 613178 Soil rating (g.p.d./ft2 or ftZ/bdrm) 85 System type TRENCH
Length 24 ft. Width 6 ft. Gravel below pipe 6 ft.
Total depth 9 ft. Eff. absorption area 288 ftZ Monitoring tube Y Depression over field N
Date of adequacy test 121312012 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 840 gal. New depth 42 in.
Elapsed Time: 10 min. Final Fluid depth 0 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date
FROM WELL LOG
Date of test
5128178 & 5125/78
Static water level
190' & 240 ft.
Well production
0.41 & 0.16 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate ND mg/L
Arsenic: ND ug/L Date of sample: 1213112
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC I FIBERGLASS
Tank size 1250 gal. Number of Compartments 2
Foundation cleanout (YIN) Y` Depression over tank (YIN) N
Date of pumping 11129/12 Pumper JRs
C. ABSORPTION FIELD DATA
Well Log (YIN) Y
Wires properly protected (YIN) Y
Casing height (above ground) 12+ in.
AT INSPECTION
1213112
190'&453 ft.
0.25 & 0.049 g.p.m.
Collected by: ARCTERRA
Date installed 61311978
Cleanouts (YIN) Y
High water alarm (YIN) N
Date installed 613178 Soil rating (g.p.d./ft2 or ftZ/bdrm) 85 System type TRENCH
Length 24 ft. Width 6 ft. Gravel below pipe 6 ft.
Total depth 9 ft. Eff. absorption area 288 ftZ Monitoring tube Y Depression over field N
Date of adequacy test 121312012 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 840 gal. New depth 42 in.
Elapsed Time: 10 min. Final Fluid depth 0 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at _ in.
Datum
Size in gallons
"Pump off"level at —in.
Cycles tested
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100'+
Absorption field on lot 100'+
Public sewer main 75'+
Sewer /septic service line 25'+
Animal containment areas 50'+
SEPTIC/HOLDING TANK ON LOT TO:
Manhole/Access (Y/N) _
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout 100'+
Holding tank 100'+
Manure/animal excrete storage areas 100'+
Building foundation 54 Property line 54 Absorption field 54
Water main 104 Water service line 104 Surface water 1004
Wells on adjacent lots 1004
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 104
Curtain drain 50'+ (NONE KNOWN) Wells on adjacent lots 1004
F. COMMENTS
500 -gallon water storage located in crawl space. `FCO located in crawl space.
G. ENGINEER'S CERTIFICATION
I certify that t 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 KENNETH M. DUFFUS
Date 1211012012
COSA brown sheet 9-1-12.doc
o" - C" AL �
za ati i
p, \ LK T14C
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in.
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
F�,d 410"
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-471-01 HAA # 60 -AIA -
Expiration Date: 9 — / S" O
1. GENERAL INFORMATION
Complete legal description rhugach Park Estates, R1, 14
Location (site address or directions) 24149 Plastek Drive, rht giak, AK 99567
Current Property owner(s) Rill Voss Day phone ARR-5206
Mailing address _POB 670471, Chugiak, AK 99567
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: -1
3. TYPE OF WATER SUPPLY:
Individual Well
N
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer El
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional
civil engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the
transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal
and/or water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health
Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well
and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one
year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or
a public water system. The Municipality of Anchorage Is not responsible for errors or omissions in the
professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my
investigation, based on procedures outlined in the Health Authority Approval Guidelines for this
application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional
and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
Inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all
applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation.
Name of KND FNGINFFRING Inr-'• 1 6964319
• .. .Ti a .. : i wI ll •1
Engineer's Printed Name Kenneth M_ Duffus Date 6/10/05
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 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 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 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
WATER AND
PROGRAM
R;'
_.
Attachments:
IAA Checklist X Maintenance Agreements J'J',�/Im
H
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: �f ` / �� Original Certificate Date: r � (o,��
R
Municipality of Anchorage
Development Services Department
Building Safety Division
Orr -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519.6650
www.d.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description* Chugach Park Estates B7, L4 ParcellD: 051-471-01
A. WELL DATA
Well type private If A, B, or C provide PWSID #
Date completed ,5/28/78 & 5/25/78 Sanitary seal (Y/N)Y—
Well Log (Y/N) Y
Wires property protected (Y/N),Y_
Total depth 460' & 600 ft. Cased to 225' & 244 ft Casing height (above ground) +_ _
FROM WELL LOG
Data of test
Static water level tnnl R 24n ft.
Well production 2s gnr, 6 1n g.p.h.
WATER SAMPLE RESULTS:
AT INSPECTION
6/3/05
log, a asn ft.
g.p.h.
Coltfonn _Pcolonies/100 ml.N rate .0rJQ1ng.A.Other bacteria 0 colonies/100 ml.
Arsenic: .NA mg.A. Date of sample: 6/3/05 Collected by: KND Engineering, Inc.
B. SEPTICIHOLDING TANK DATA
Tank Type/Material SEPTIC/FIBERrl ASS Date installed 6/3/1978 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) ri
Date of pumping 6/3/OS Pumper JR's
C. ABSORPTION FIELD DATA
Date installed 6/3/78 Soil rating (g.p.d.Ate or fe/bdrm) JU System type TRENCH
Length 34 ft. Width 6 ft. Gravel below pipe 6 ft.
Total depth ))'_ ft. Eff. absorption area nLfe Monitoring tube Y Depression over field N
Date of adequacy test 6/3/05 Results (Pass/Fail) PASS For I— bedrooms
Fluid depth In absorption field before test 0 (dW in. Water addedA,QQ gal. New depth 41.4 in.
Elapsed Time: _0 min. Final fluid depth 16.2 in. Absorption rate >= 4SO+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N 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 Masts alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/QR station on lot 100'+
Absorption field on lot 100'+
Public sewer main 75'+
Sewer /septic service line 25'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout 100'+
Holding tank 100'+
SEPARATION DISTANCES FROM 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'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water 100'+ Driveway, parking/vehide storage 10'+
Curtain drain SO'+ Wells on adjacent lots 10 0'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above in
-'* - -%%1
+ E OF '4( %J
•(
s
p systems are
conformance with MOA HAA guidelines in effect on this date.
,. ,.....,
.. - '`�.5��+
}+'�
W7 A
Engineer's Printed Name Kenneth M. Duffus
Date 6/10/05
t %A. lc.ee.x M. wit ,?
HAA Fee
Date of Payment Q ��
Receipt Number
(Rev. 12/01)
Waiver Fee $
Date of Payment
Receipt Number
RECER'tIFICATIOR 10/22-91 '
ASBUILT-NO CORNERS SET THIS DATE.
IRVARD S
1 HEREBY CERTIFY -THAT I HAVE SURVEYED THE
SCALE,
FOLLOWING DESCRIBED PROPERTY1
:' 1"`5Q'
Chugach Park.Eatataa 3ubd.,Lot 49Blk. 1
DATE;AND
THAT NO ENTS -IST EXCEPT AS
INDICATED. RESPONSSIIBILITY.
i
IT ISTt OF THE
10-229 1
OWNER TO DETERMINE THE EXISTENCE OF ANY
GRIDt
WHICH. DO NOT APPEAR 0(17HE RESTRICTIONS
SUsoi-
� 1160,1161
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
FBt
ANY DATA HEREON BE USED FOR CONSTRUCTIOM
24-38
OFFENCE LINES, OR FOR ESTABLISHING BOUND-.
ARY LINES.
DRAWNs
DMS
`1
�'It�� OF• At �r
i
r o);• CJTH
Too", µ..k S.w.,a
• U 6918
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES ,t
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 94519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # 0—Sl — X111 — 01
1. GENERAL INFORMATION
HAA# �1n�1\hllfrin
Complete legal description Loi 4; BCock 1; Chugach Pahk Est.ateb
Location (site address or directions) 24149 Chugach Palk Vtive.
Property owner Jenny f AC °¢¢n Lush Day phone
Mailin� address P� 0. Sox 0• ak, AtaAka
Lending agency
Mailing add
Day phone
AgentVi_nginia Koh4,iefd REIMAX OF EAGLE RIVER Day phone 694-4200
Address t4Ano Contort j/i0ld Vnivo Ecqle Rivet AlrrAbrr 99577
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well XX
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72a251R".191) F,w.t MoAni
S. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I furtherverify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm Phone 7
5 & 5 ENGINEERING
Address 17na4 Eanle River Loop Road No.204
Eagle River, Alaska 99577
Engineer's signature Date ID - u- `'t
I.-111WC ITA0l 14
_X_ Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments ; lLusf A -i o./ zpizle/r -;tzJH ALi, Y/»
MpArm, FA
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-=(R..1/91) 8. MOAR21
Municipality of Anchorage AiL
Department of Health & Human Services 40111IENWW
HEALTH AUTHORITY APPROVAL CHECKLIST CUB
Legal Description: 6,400, PAey- Parcel I.D. 4V-
Es-rwres
A. WELL DATA
Well type &JJwe, If A, B, or C, attach ADEC letter. ADEC water system number
Logpresent&N) J Date completed-/SV75 Driller 'A•l LDCt-o,".t/n
Total depth o' Cased to 22 S'4' 243 a Casing height
Sanitary seal1&N) y Wires properly protected (WN) 4_
FROM WELL LOG
Date of test 5-29 -78 S -ZS -fig
Static water level
Well flow 2S.o t0.o g•p•sl�s•
Pump level JIL uK-
SEPARATION DISTANCES FROM WELL TO: ,
AT INSPECTION MUNICIPALITY Of ANCHORAGE
at- % .11-2ENVIRONMENTAL3ERVICES DIVISION
9 -t'1 -°l\ h-'L'I-xi
l
_moo' tee., OCT 8 1991
t.'EIYED
Septic/holding tank on lot \ ��} ; On adjacent lots I Ca1i-
Absorption field on lot (� o I ; On adjacent lots t no '+
Public sewer main "tl� Public sewer manhole/cleanout
Sewerserviceline 2S tr Petroleum tank ZS
WATER SAMPLE RESULTS:
Coliform o (INitrate A (o•to) Other bacteria
le: 01-9 -9 t `t -'5 C> �t Collected b 5 3 5 ENGINEERING
Date of sample: Y: 17634 Eagle Rive -10613 R—A No 204
Eagle River, Alaska 99577
B. SEPTIC/HOLDING TANK DATA
Date installed (. -'3 -`i al Tank size - -t tri C> Compartments Z-
Cleanoutso/N) Foundation cleanout (YS) Depression (YQ
High water alarm (YA Af Alarm tested (Y/N) 'J/4
Date of pumping A-2.'1-Ct ` Pumper��- L�SSPooI_
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Wells) on lot too �� On adjacent lots t co Ir- Foundation 5
To property line In1�- Absorptionfield 5 r r Water main/service line tot+
Surface water/drainage %oo I'
72-026 (Rev. 7M) From CONTINUED ON BACK PAGE
C. LIFT STATION
Date Installed
Size In gallons
Vent(Y/N)
High water alarm levet
Meets MOA electrical
SEPARATION-17STA?
MR
on lot
—Manufacturer
Manhole/Access (Y/N)
"Pump on" level at dump off" level at
Cycles tested
FROM LIFT STATION TO:
On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date Installed'
Soil rating as i4a- — System type r
Length k Width l�k
Gravel thickness Lok Total depth- 9
Total absorption area 2g0
P
Cleanouts present (�/N J
Depression over field (YA9,
Date 9 t1 1
of adequacy test - -Ci
Results fail) PAce-r-
for arg- %) ' bedrooms
Peroxide treatment (past 12 months) (Ya A/a^IF_
IzAaa ^ If yes, give date -- 11JJX
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellonlottooka- Onadjacenttots Icoky Propertyline tok+
To building foundation to ~
To existing or abandoned system on lot 'l�A
On adjacent lots 'So" Cutbank
"(ld Water mai n/service line inka-
Surface water foo s�
Driveway, parking/vehicle storage area ZS v'
Curtain drain JS�A 1
E. ENGINEER'S CERTIFICATION,
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect oil the date of this inspection.
S& S ENGINEERING
Signature 100P Read Ne.Z00
j yA� v^ y• '�9��d
/�
1?03 t Eagle My"
`
0'*:49TH �;t+ • yr
'
Engineers Name
EaglaRiver,Alaska 99577V.
,,,
.00DateTleo
qJMAFER.P•E•
" `tom
HAA Fee $ % 7e,
Waiver Fee: $
Date of Payment % y
Date of Payment
Receipt Number a3���tG ��
Receipt Number
72-020 (R". 3/91) 8"k MOA 21
October 7, 1991
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVILENGINEERS
(907) 6942979
FAX 694.1211
HEALTH
APPROVALSNORITV
V.Lagini.a Lee Koh6ietd
RE/MAX OF EAGLE RIVER
16600 Centea6-ieLd Drive
Eagte Riven, Ataaka 99577
MAI+NETENs ONS
REFERENCE: Lot 4; Btock 1; Chugach Pank Eatatea;
Dean MA. Koh6iefd,
SEWERS WATER
At your Aequeat a 6tow teat was peA6onmed on .the M 1 weP,t (went weft)
INSPECTION
aenving the u6enenced pnopenty on September 17, 1991. The static
schen tevet was meaaured in the weGt at 300 6t. below the top o6 the
weft caatng. A meteA was connected to the wsten aystem prion to the
hotding tank and the 6tow turned on butt. A6ten one hour and ji6ty
ENGINEERING STUDIES
minutea the water tevet waa drawn down to the p=p (440 6t.). The pump
ANDREPORTS
was then ahut o66 and the water tevet was attowed to recover 6or
approx4matety 20 m.inutea. At that time the pump was turned on again
and the water tevet waa drawn back down to the pump white the water
quantity waa metered. TUA pnoceaa was repeated three times with
WELLINSPECTION
con6i6tent neautU. Faom th.ia teat we have bound the weft to currentty
S FLOW TEST
produce. appaox,imatefy 13 gatCona pen hour (GPH).
Ataoat yowl. requeat a 6tow teat was pen6ormed on the 0 2 wett (Eaat
we ti Aehv.ing the ae6eneneed property on September 27, 1991. The
SITE PLANS
atatie uateA tevet waa meaamed .in the weft at 188 6t. beCow the top o6
the wetC caa.ing. A meteA was connected to the water ayatem prior to
the hotding tank and the 6tow turned on 6utC. A6ten one hour and 6orty
m.inutea the watelt tevet mu drawn down to the pump (502 6t). The pump
ROAD DESIGN
ma then shut o66 and the water tevet waa attowed to LecoveA bon
appnoximate.ty 20 minutea. At that time the pump was turned on again
and the water. tevet drawn back down to the pump white the water
quantity was metered. Th" proeeaa waa repeated three times with
cona.i.atent reautta. Faom thi.a teat we have bound the weft to eunnentty
SOILTEST
produce 7 GPH.
Thebe 6tow natea ane not guaranteed to remain constant, subsequent
vantatiom can occur.
PERCOLATION
TEST
16 we may be o6 6wLther behv.ice, pteaae contact us.
S.ineeneCy,
STRUCTURALS
MECHANICAL
INSPECTIONS
ROGER J. SHAFE P.E.
RLS/gm
ON SITE
WASTEWATER
DISPOSALSVSTEM
DESIGN
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577