HomeMy WebLinkAboutHILLCREST BLK 8 LT 5Hillcrest
Block 8
Lot 5
#016-271-44
T
Gk
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT •
On -Site Water and Wastewater Section
www.muni.org/onsite -
or, �. to Water A Wastewater Section certified contractor performing the well de3Z&4
Z,CSC� Sign
, ((l� rjLP�
�1D 1 i�(,I' W F.GI Se N rU,o
Well devrnmissionmg date C) _1 I $I 25
907-343-7904
Fax: 343-7997
Method of decommissioning: AMC 15.55.O6OL1 a. ❑ b. �] C.9
Location Use the space below to provide a drawing of the property showing the following items:
North arrow
Decommissioned well location
Location of other water wells on the property
Twe separate swing tie distances for each well shown on the drawing
Mote- The swing -tie distances shall be measured from either permanent structures or the property corners
QjDevelciKient ServicesV1 uilding Safety\On She Water and Wastewatafforms\Client Forms\Wall Decommisioning form.doc
MUNICIPALITY OF ANCHORAGE
Development Services Department `' Phone: 907-343-7904
On -Site Water & Wastewater Section --' Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 016 27144
iwe] =1kil=1:7_1a1ill 491IN �i FIN 0to] ill
1
Expiration Date: 3-12--2672 0
Complete legal description HILLCREST BLOCK 8 LOT 5
Location (site address) 200 CONTRARY COURT
Current property owner(s) EULIN CONTRERAS
Mailing address
Real estate agent
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
❑
Water Storage
❑
Holding Tank,.,
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for:
Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee Waiver Fee $
Date of Payment Date of Payment
Receipt Number Receipt Number
COSA # Q AJC /�l/���e 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 C&M ENGINEERING Phone 8545558
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI Date 12/05/2019
TH
*. TH •.* r
6. DSD IGNATURE �...••••••
System #1 Approved for bedrooms % ... . .. '. " . .
CHARLES G BALZARIHf
System #2 Approved for bedrooms ���9F��* CE -13854 • . % ;�
Disapproved �i�iFOPROFEVC P���-=�
Conditional approval for bedrooms, with the following stipulations:
lltttl((((l((
-S/%
By: �.., `- Original Certificate Date: j �- i Z
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 Checklist blue sheet
Legal Description: Hillcrest Block 8 Lot 5
If more than 1 septic system on lot: COSA Checklist # 1 of 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled unk
Total depth 50 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 11/26119
Static water level at beginning of test 13 ft.
Comments
B. TANK DATA
Age of tank(s) years
Tank type/material
❑ Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA
Which system tested (date installed)
❑ ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of drainfield. If not, state
depth into effective
❑ 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:
COSA Checklist yellow sheet
Parcel ID: 016 271 44
Structure served by this system 1
Well production at time of test 4.6 gpm
Water storage tank volume - gallons
Well disinfected for coliform test? ❑ Yes ❑ N
❑ Coliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic 19.8 ug/L ❑ Arsenic less than MRL (ND)
Collected by C&M ENGINEERING
Date of Sample 11/22( (
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date
Results ❑ Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
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'
na
if No
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
❑✓ Yes
if No ft
Neighboring Tank > 100' QYes
if No
ft
Private Sewer/Septic Line > 25' [Z] Yes
if No ft
Absorption Field on Lot > 100' ❑Yes
if No na
ft
Holding Tank > 100' ❑✓ Yes
if No ft
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' ❑✓ Yes
if No ft
❑✓ Yes
if No
ft
ft
Community Wells > 200'
❑ Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' QYes
if No
ft
[Z] Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
❑ Yes
if No
ft
Surface Water > 100'
❑ Yes if No ft
Property Line > 5'
❑Yes
if No
ft
Driveway/Parking > 0'
❑ Yes if No, comment
Absorption Field > 5'
F-1 Yes
if No
ft
Wells on Adjacent Lots:
❑ Yes if No ft
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 ft
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
❑ Yes
if No
ft
Driveway/Parking > 0'
❑ Yes if No, comment
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 ft
Surface Water > 100'
❑ Yes
if No
ft
F. ENGINEER'S COMMENTS
home is served by well and public sewer, no on-site septic system.
G. ENGINEER'S CERTIFICATION
l 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. 12/05/19
COSA Checklist yellow sheet
OF ALgskl
os TM
o CHARLES G BALZARIM 0
•• CE -13854 • `���
t��F0pROFESSTPN .
DEVELOPMENT SERVICES DEPARTMENTIT
( `�
On -Site Water and wastewater Section
www.muni.org/onsite - ~
Arsenic Advisory
Certificate of On -Site Systems Approval # OSC191586
Subdivision: Hillcrest, Block 8, Lot 5
907-343-7904
Fax: 343-7997
A water sample revealed an arsenic concentration of 19.8 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. information on arsenic is available from the On -Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Municipality of Anchorage
• -� Development Services Department
Building Safety Division
On -Site Water and Wastewater Program s ..
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ek.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 4W HAA # b5nal rq
Expiration Date: — 02 O 5-
1. GENERAL INFORMATION
Complete legal description { �(4C k.. L 4
Location (site address or directions) _ /�F n fr4r% tou rf�
Current Property owner(s) ADA( #"AII, 411 Day phone 34 i— 703(3
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
S
00-4.
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
13❑
Individual Holding tank
❑
❑ Community On-site
❑
❑ Public Sewer
to
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of
Address
Engineer's Printed Name ��fC✓E G�16
5. DSD SIGNATURE
Approved for 3
Disapproved.
Conditional approval for
bedrooms.
Phone
Date% OS
Of�A�L�t0
r os_
Steven %.E,g
�'. PE 6156 : V
. w
(' •'�•.......�. i�.C.
bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: ae&42 W. 70a"'t' Original Certificate Date: g '.21 0,S
(Rev 01103)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water &Wastewater Program
4700 South Bragaw St.
P.O. Box 1W650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ,�&'rP.Cf A O!'f 4.%r.4r Parcel Ib:
A. WELL DATA
Well type jP
Date completed ,�_k
Total depth _i6 ft.
If A. B, or C provide PWSID # _
Sanitary seal (YIN)
Cased to _1—oft.
Well Log (YIN) V
Wires properly protected (YIN)
Casing height (above ground) /O in.
FROM WELL LOG AT INSPECTION
Date of test
Static Waterlevel ft. �Z/ ft.
Well production g.p.m. o g.p.m.
WATER SAMPLE RESULTS:
Coliform _–colonies/100 ml. Nitrate 6. S mg.A.
Arsenic: mg./I. Date of sample: �12Z 050
B. SEPTICIHOLDING TANK DATA P0464LIC- SE646A
Tank Type/Material
Tank size al. Number of Compartme
Foundation cl out (Y/N) Depression over nk (YIN)
Data of pufiping Pumper
C. ABSORPTION FIELD DATA #PIlBLtG S6•,iFG
Date installed ,rcw,it rating (g p.d./f:2 or ftp/bdrm) _
Length .. ft/ «
Total de/bsor"pbon
Date of aFluid deElapsed
Width
Eff. absorption area ft,
Results (F
field before test _ in.
Final fluid depth
Other bacteria 0 colonies/100 ml.
Collected by: A0% omli9'
Date installed
Cleanouts (YIN)
High water alarm /N)
System type
Gravel below pipe
tube Depression c
For
added_ gal.
Absorption rate
ft.
!r field
_ bedrooms
depth_ in.
g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access /(Y/N)"Pump on" vel at _ in. "Pump oel at in. High water alarm in.
Datum Cycles t sled Meets alarm 8 circments?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
7s'*
Sewer /septic service line �5 rfi
On adjacent lots /dd ''f'
On adjacent lots /OD i'r'
i
Public sewer manhole/cleanout
Holding tank _qLA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PIJ&4c. tfACR
Building foundation Property line Absorption field
Water main Water servic7re
Surface water
Wells on ad' ant lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: tV &/C ,sfW�i2
Property line
Water Serv' line
Curtain ain
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Building foundati _
Surface Ovate
Wells on djacent lots
Water main
Driveway, parkingivehjp a storage
* /4 J'` \ *
1 certify that 1 have determined through (relit inspections and ....: .. S
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date. / ♦ 4r�
g
Engineer's Printed Name S7Gr(45 EN� I+f t Fil 056 • .��
Date ZAR -710S ` ; \\����t►p ~.'
HAA Fee $ �.�7 • dD
Date of Payment T
Receipt Number JI`I D�
(Rev. 12101)
Waiver Fee S
Date of Payment
Receipt Number
Hat -Su Teat Lab a07741Sa3012 06/24/M C6r67pm P. ooh
Mat-su Test Lab of Alaska
We 3.2 P&IMOFVlasilla Hwy
kli0town Corrtminity eusfnose Park
P.O. Dox 2749
Palmer, Masks 99645
Phone: 7453605 Fax: 746.3010
Drinking Water Analysis Report
Total Collforrn Bacteria
a_pplicable): t
Paid:
'rhtts' Section to -bo bompieted by Sample
0.311
Legal Description of Property: rc c l L s V
Sample Site Location: )5auC.,-- f Delivered to Lab By: �s�-. 4,Zg
0 r: k.tchen sink. bathroom sink, ootwie hese bib) p
Time Sampled: %G3Q Date Sampled:b Z Sampled by: cl
Sample Type: Routine Treated] Untreated:E1Repeat Sample #:
This Section to Be Completed by Lab
Analysis Results:
rsfactory
satisfactory
[]Sample too long in transit (greater than 30 hrs.)
•Recim3t resample.
Cooy Sent to State Yes : Ni
Chromonenic/Fluorogenic Method Results:
Total Coliform Present (P)/Absent (A) '� J Lab I.D. #:
E. Coli Present (P)/Absent (A)
Date Received: � ,31. Time Received: (�!'Is' Received by: `n4 t✓
Date Test t3eyun:-- /�1�Time Test Begun: —L43Q Analyst: , )
Date Completed: �� Time Completed: /Lr�S Analyst:
Refer to Back Side for Instructions
Jun 23 05 03:41p nLOSKIt RIM (007)74C-0222 P.1
/r\Mateaft Test
Lab of Alaska
cry—uVVater Quality Testing
Mlle 72 Palmer-Wasilla Hwy.
Midtown Community Business Park
Phase; (907) 745.7005 Emall: mobeutacUUDai`rvxfershsa rom
Client: North Rini Engineering
17237 Bear Paw Circle
Eagle River, AL 59577
Ann.:
Client ID: Lot 5 Black 8 Hd:creast
PWSID p:
Source:
W.S.T.1-4: 51459
Sample Matrix.
Comments:
i
P.O. Box 2742
Palmer, Ak. 99045
Fax: (90T)745-7010
Date Arrived 622!05
Report Dare: C23105
Sample Date: 602M
Sample Time: 1030
Ccliected Dy SC
ketrod Parameter Units Results MDL Date Prepared Date Analyzed MCL II
SM 4!00-NO3-E N3rate-N
M91
<MDL
0.50
623!05
623105
10.0
SM 4500-NO3-E N:trito-N
mg'L
eMDL
0.05
6123105
623105
1.0
Total Nitrate/Nitri.e
mg/L
<MDL
C.50
623105
6!23!05
10.0
Legwd: MRL • 6lcdiod Report Level
MCL • Max. Conlan nate Level
D - Present In Method Blank
E - Estimated Value
M =Above MCL
D o Loat ioDilution
Revbrt6d By Jon Paul Camptiell
Lab Manager
LOT 5, BLOCK 8 HAS
8,410 SQ -FT. OF AREA
Y CONTRARY COURT
a
N89'55'52"E 60.00'
Scale
Legal Uescrlption
FOR DON HANNA
7/20/05
7/20/05
1" = 30'
�
•moo '
vu I
. Vr•
Dlock 8
NO
O
15.8
' 18.0
Z
00
O
op$
L�
O
00
O
Vo
0
IIILLCREST
9300 VanguardDrive, Suite 203
N
s
Field Dook
SUBDIVISION
2
O
214
x
Q
Ln
-a
VI
t.11
xa8
A
WELL 1
NEIN9NCE 4
V
FENCE ar
r�
POWER
l— I
N89'55'51"E 60.00'
—0-4 O0
i�
Y
a
G
10' UTILITY ESMT j
r
GRAPHIC SCALE: I Inch = 30 Feet
1s � b I's 30 Bo
1 hereby certify that the property described hereon has been surveyed
by me, or at my direction, and that the Improvements situated thereon
are within the property lines and do not overlap or encroach on the
property lying adjacent thereto unless otherwise shown. That no
improvements on the property lying adjacent thereto encroach on the
premises in question and that there are no roadways, transmission
lines or other easements on said property except as shown.
It Is the responsibility of the owner or builder, prior to construction,
to verify proposed building grade relative to finish grade and utility
connections and to determine the existence of any easements, covenants,
or restrictions which do not appear on the recorded subdivision plat.
\ Listed distances prevail over scaling.
Reproduction may cause distortion.
OF q4 14
QS
*; 49L
CHARLES E. FORGES : iI
LS -7326 : Z
/1IP�0lgssiono���� �
Scale
Legal Uescrlption
FOR DON HANNA
7/20/05
7/20/05
1" = 30'
Lot 5
Dlock 8
LanMark
Grid
As -built
Engineering r sureeYing. Inc.
2432
2400658
IIILLCREST
9300 VanguardDrive, Suite 203
Drawn by
Field Dook
SUBDIVISION
Anchorage, Alaska 99507
(907) 582-8050
D.L.N(
214
1 hereby certify that the property described hereon has been surveyed
by me, or at my direction, and that the Improvements situated thereon
are within the property lines and do not overlap or encroach on the
property lying adjacent thereto unless otherwise shown. That no
improvements on the property lying adjacent thereto encroach on the
premises in question and that there are no roadways, transmission
lines or other easements on said property except as shown.
It Is the responsibility of the owner or builder, prior to construction,
to verify proposed building grade relative to finish grade and utility
connections and to determine the existence of any easements, covenants,
or restrictions which do not appear on the recorded subdivision plat.
\ Listed distances prevail over scaling.
Reproduction may cause distortion.
OF q4 14
QS
*; 49L
CHARLES E. FORGES : iI
LS -7326 : Z
/1IP�0lgssiono���� �