HomeMy WebLinkAboutSCIMITAR #1 BLK 3 LT 5imitor
Block 3
Lot .5
#051-132-35
NAME
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
MAILING ADDRESS,~O~ ~i~Vl~ ~ ~f-~¥%~4'_ PHONE
LOCAT,ON
SEPTIC TANK:
DISTANCE
FROM WELL
INSIDE LENGTH
MANUFACTURER
INSIDE WIDTH
MATERIAL
NUMBER OF
COMPARTMENTS ~-'
LIQUID DEPTH
IIQUID CAPACITY. /Z,.~"'~ ,GALLONS.
SEEPAGE PIT:
NUMBER OF PITS I DIAMETER ~'~'! ORWIDTH /21~ LENGTH /2,/ DEPTH ~!
E'INING MATERIAL ~e~ CRIB SIZE= DIAMETER ~' DEPTH ~ * DISTANCE FROM:
~ t TOTAL EFFECTIVE
BUILDING FOUNDATION ~' 0 NEAREST LOT LINE [~l ABSORPTION AREA (WALL AREA)
WELL {~,.,t - I
SQ. FT.
ADDITIONAL ABSORPTION
WELL=
TYPE ~'/J'17/~ ~~'~ CONSTRUCTION O~t' ~f~ J~;/ DEPTH
BUILDING .,). ~,~ C.~ NEAREST NEAREST SEPTIC I
FOUNDATION ,~o0~ . LOT LINE SEWER LINE TANK ~'
CESSPOOL
OTHER SOURCES
APPROVED DISAPPROVED REMARKS
DISTANCE FROM:
SEEPAGE ~/-KC/
SYSTEM
DISTANCES:
DIAGRAM OF SYSTEM
INSTALLED BY: ~tL~
PIPE MATERIAL=
LOT sLOPE:
REMARKS:
Form No. EQ4331
APPROV~"~?~ /k
/G.A.A.B.
· 4,.
D~ OF FORMATION:
,L'~)G OF DRILLING by A & L DRILLING COM.PAN~Y '' '.
GREATER ANCHORAGE: AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99.503
TELEPHONE 274-4561
SEWAGE DISPOSAL SYSTEM ,-- APPLICATION AND PEP, M~T
PERMIT NO. _
NAME OF APPLICANT ~/~/~//~ ~-J" /~//~//~¢
INSTALLATION LOCATION /~'~.JT~--~. ~ ' ~'~/~
LEGAL DESCRIPTION
INSTALLATION OF: SEPTIC TANK
TYPE ANO SIZE OP FACILITY TO BE .SERVED
FINANCED THROUGH
SEEPAGE PIT_ , DRAIN FIELD OTHER
TO BE INSTALLED BY
FINAL, INSPECTION: 2.4 HOUR NOTICE I~EQUIRED, BACKFILLING OF' ANY SYSTEM WITI-IOU% FINAL. INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILl. BE SUBJECT TO PROSECUTION.
SePTiC TANK SlZ--~_ '~.~ TYPE ~-~- SEEPAGE AREA SIZE
MININIUM DISTANCES, REQUIREMENTS DIAGRAm4 Of SYSTEIVI
FOUNDATION TO sePtiC TANK ~
FOUNDATION TO SEEPAGE PIT <2~ ~) /
SEPTIC ~rANK TO SEEPAGE Pit WALL /~F /
SEPTIC TANK ____.~ SEEPAGE PIT~"~) /
. DRAIN FIELD
., DRAIN FIELD
TO NEAREST LOT LINE.
WELL TO SEPT,C T^N~
DRAIN FIELD
~¥ATER MAIN 'TO SEP'FIC TANK
DRAIN FIELD
, ALSO CONSIDER AREA WELLS.
_, SEEPAGE PIT_ /¢~
GRAVEL BACKFILL
CONFORM TO 13CROUCH REGULATION. REGARDING INSTALLATION.
I CERTIFY TEtAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE: AREA BOROUGH ORDINANCE NO. 213-68 AND THAT THE ABOVE
DA T; ~/~/~ APPLICANT'. SIGNATURE '1' ~
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. o5~.-z32-3,:;
GENERAL INFORMATION
Complete legal description
Location (site address)
Scimitar #z Block 3 Lot 5
Expiration Date:
· 9842 Tulwar Drive, Chugiak, AK 99567
Current Property owner(s)
Mailing address
Lending agency
Mailing address
SASCO 2oo7-WF2 US Bank Natl Assoc
3/+76 Stateview Blvd, Ft. Mill, SC 297~5
Day phone
Day phone
Real Estate Agent. Elizabeth MacMullen Day phone .. 77~-~8:[~
Mailing Address ReMax Dynamic of the Valley emacCi)mtaonline.net
UnleSS othe~rwise: requested, COSA will be held by DSD for pickup.
2,~ ~NUMBER OF BEDROOMS:
3. TYPEOF WATER'SUPPLy:
IndMdua 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 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 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 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 272-82z8
Address P.O. Box :too2~-7, Anchorage, AK qqs~o
Engineer's Printed Name Steven R. Pannone, P.E. Date 8/8/z~
Engineers Comments: In conducting an adequacy test, ! attempt to provide a thorough, conscientious engineering analysis of the system in
accordance w/th 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. DSD SIGNATURE
~ Approved for '? bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
By:
(Rev. 11/05)
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'
Scimitar #=. Block =1 Lot ~
If A, B, 'or C provide PWSID # ~
Sanitary seal (Y/N)Y
Cased to 3.04 ft.
FROM WELL LOG
8121', q-/~
g.p.m.
Nitrate C~t ~'"C~ mg/L
Date of sample:
Legal Description:
A. WELL DATA
Well type _.P
Date completed 81',13.n7~
Total depth 270 ft.
Date of test
Static water level 78
Well production
WATER SAMPLE RESULTS:
Coliform ~ colonies/100 mL
Arsenic: ~) ug/I
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Greer Steel
Tank size 3.=So gal.
Foundation cleanout (Y/N) Y
Date of pumping 81~1~,o3.3.
C. ABSORPTION FIELD DATA
Number of Compartments
Parcel ID:
Depression over tank (Y/N) _N
Pumper JR's Pumping
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 3.2+
AT INSPECTION
81812o3.3.
76~ ft.
6.6 g.p.m.
Collected by: Laura Pannone
Date installed
Cleanouts (Y/N) Y
High water alarm (Y/N) NIA
Date installed C#2lJlC~7=~ Soil rating (g.p.d./~ or f[7/bdrm) 85
Length 3.2 ff. Width 3.2 ff.
Total depth 8_=5 ft. Eft. absorption area 288 ft2 Monitoring tube Y
Date of adequacy test 81812o3.~. · Results (Pass/Fail) Pass
System type Locj Crib
Gravel below pipe 6
Depression over field N
For 3 bedrooms
Fluid depth in absorption field before test Dry in.
Elapsed Time: 2_0_0 min. Final fluid depth Dry in.
Any rejuvenation treatment (past 12 mo.) (YiN & type) N
in.
Water added46~ gal. New depth_~ in.
Absorption rate >= 4So+ g.p.d.
If yes, give date
LIFT STATION
Date installed
"Pump on" level at ~
Datum
in.
E. SEPARATION DISTANCES.
Size ~
"Pump ofi"~
Cycles~i~te(~ ~ -
in.
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 5o+
Absorption field on lot 9~ Waived Ao/7/86
Public sewer main 75+
Sewer/septic service line 2~+
On adjacent lots ~.oo+
On adjacent lots ~.oo+
Public sewer manhole/cleanout =oo+
Holding tank ~.oo+
Animal containment areas ~.oo+
Manure/animal excrete storage areas ~.eo+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 6 Property line ~.o+
Water main ~.o+ Water service line ~.o+
Absorption field ~.o+
Surface water ~.oo+
Wells on adjacent lots *,oo+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~.o+ Building foundation =o+ Water main ~.o+ *
Water Service line .,o+
Surface water .,oo+
Driveway, parking/vehicle storage ~.o+
Curtain drain None Known Wells on adjacent lots ~.oo+
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 Steven R. Pannone, P.E.
Date '~l~t[{
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
........
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Community Development Department
Development Services Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Nitrate Advisory
Certificate of On-Site Systems Approval # 111305
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 3, Lot 5 of
Scimitar # 1 subdivision. This inspection revealed a nitrate concentration of
9.29 milligrams per liter (mg/L) was reported for the property's well water
sample. The Environmental Protection Agency (EPA) has established a
maximum contaminant level (MCL) of 10.0 mg/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. Please see the
attached "Nitrate Fact Sheet" for important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
S GS .......
SGS Ref.# 1113674001
Client Name Pannone Eng. Srv. Printed Date/Time 08/11/2011 15:59
Project Name/# Scimitar #1 Collected Date/Time 08/08/2011 11:00
Client Sample ID B3 Lot 5 Received Date/Time 08/08/2011 12:05
Matrix Drinking Water Technical Director Stephen 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) 08/08/11 08/09/1t NRB
Waters Department
Total Nitrate/Nitrite-N 9.29 0.100 mg/L SM20 4500NO3-F B (<10) 08/09/11 AYC
Microbiology Laboratory
E. C01i
Total Coliform
Negative 1 100mL SM20 9223B A 08/08/11 DLC
Negative 1 100mL SM20 9223B A 08/08/11 DLC
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.munLorg/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEF1S APPROVAL
FOE A SINGLE FAHILY DWELLING
1, GENERAL INFORMATION
cos
Expiration Date:
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
SCIMITAR S~D #1; LOT 5~ BLOCK
19842 TULWAR DRIVE * CNUGIAK~ AK 99567
MARK SPILLER Day phone c,/o AGENT
19842 TULWAR DRIVE * CHUGIAKI AK 99567
Day phone
ROLF MILTON w//REMAX (C,/O LYN~-I~E) Dayphone 694-4804
16600 CENTERFILED DRIVE '~ E,R. AK 99577
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ~r~
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 ara required for the transfer
of title (except between spouses) for properties served by a single-fatuity on-site wastewater disposal and/or
water supply system. DSD also Issues COSAs upon request to homeowners. Cedificates of On-Site Systems
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors'or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seat 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 GARNESS ENGINEERING GROUP. Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK ggs07
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Phone 337-6179
Date
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results deecdbed the performance of the
system undor the conditions encountered at the time of tho test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems dopend ou the local soils condition, groundwater levels that may
fluctuate dudng the year, and the water usage of the family being sen/ed by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory lest
results do not guarantee future perfom'~anca of the system, nor do they guarantee that
there are no hidden defects or enc~'cacflments. GEG, LTD. can therefore nE prevido
any warranty or future estimate of how long the syslem will continue to meet the
operational requirements ~f the ADEC or MOA DSD. The content of this report is for
the s~e benefit of the owner listed above. Any reliance upon or use ~f this report by any
other person or parly is nut authorized, nor will it confer any legal fight whatsoever.
5. DSD SIGNATURE
J/ Approved for
bedrooms.
Disapproved.
Conditional approval for
Attachments:
COSA'Checklist
Septic System Advisory
...'
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Reort
Other
bedrooms, with the fllowing stipulations:
...... ..
By:
Well Flow Advisory
Nitrate Advisory
Odginal Certificate Date: '~ - I ~-- 0(.~'
Municipality of Anchorage
Development Services Department
Building Safety Divisk~
On-Site Water & Wastewate~ Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS /~PPROVAL CHECKLIST
LegalDescfipflon: SCIMITAR S/D ~11; LOT 5~ BLOCK
WELL DATA
Well type PRIVAI[ If A, B, or C provide PVVSID# .
Data completed 8/2/197,3 Sanitary seal (Y/N) YES
Total depfft 270 ,ft. Cased to 104' ft.
FROM WELL LOG
Data of test 8/2/197`3
Static water level 78 ft.
Well production 4.`3 g.p.m.
WATER SAMPLE RESULTS:
N/A
Coliform 0 colonies/100 mi.
Arsenic: <5.0 ug.lL.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL
Tank size 1250 gal. Number of Compartments 2
Foundation deanout (Y/N) YES Depression over tank (Y/N) NO
Date of pumping 10/16/2005 Pumper
C. ABSORPTION FIELD DATA
Date installed 9//1973
Length 12 ft.
Nitrate 9.02 mgJL.
Data of sample: `3/`3/2005
Soil rating (g.p.d./ft~or~-~ 85
Width 12 ft.
Parcel ID: ~ 5"t-
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
82 ff.
0.55 g.p.m.
YES
YES
12+ ,in.
Other bacteria 1 colonies/lO0 mi.
Collec~cl by: GEG Ltd.
Data Installed 9/197`3
Cleanou~s (Y/N) YES
High water alarm (Y/N) N/A
JR's
Total depth 12.s fl. Eft. absorption area 288 ft' Monitoring tube YES,
Date of adequacy test 3/3/2006 Results (Pass/Fail) PASS
Fluid depth in absorption field before tost DRY. in. Watar added 1567 gal.
Elapsed Time: - min. Final fluid depth DRY in. Absorption rata >=
Any rejuvenation treatment (past 12 mo.) (YIN & type)
System type CRIB
Gravel below pipe 6 ff.
Daprassion over field NO
For 3 bedrooms
New depth DRY In.
450+ g.p.d.
NONE KNOWN If yes, give data -
D. LIFT STATION
D. ate installed Size in gallons ~
Pump on" level at in. 'Pump n. High water alarm level at in.
~Datum Cycles tested Meets alarm & circuit requirements?.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot *.~0' On adjacent lots 100'+
Absorption field on lot **95' On adjacent lots 100'+
Public sewer main N/A Public sewer manhole/cieanout N/A
Sewer/septic service line 25'+
Holding tank N/A
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+Absorption field. 5'+
Water main N//A Water service line 10°+ Sulface water. 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+
Water service line 10'+
Cuttein drain NONE KNOWN
Building foundation 10'+
Surface water 100'+
Wells on adjacent lots 100'+
WAIVER ~ WR 86-145
F. COMMENTS
· 9/1975 INSTALL DATE.
G. ENGINEER'S CERTIFICATION
Water main N/A
Driveway, parkinghmhicte storage
I certify that I have determined through field inspections end
review of Municipal records that the above systems em in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
10'+
COSA Fee S
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
/
/
ASBUILT
I HEP, EEY CEI~TIFY THAT I HAVE SURVEYE0 THE
FOLLOWING DESCRIBED PROPERTY,
AND THAT NO ENC3~OACHMENTS EXISTEXCEPT AS
INDICATED, IT IS THE RESPONSIBILITY OF THE
OWNE]R TO DETER~41NE THE EXISTENCE OF ANY
EASEMENTS, COVENHNTS, OR RESTRICTIONS
WHICH DO NOT ~J3PEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOUU
ANY DATA HEi~EON BE USED FOR CONSTRUCTION
OF FENCE LINE-~ OR FOR ESTABLISHING BOUND-
ARY LINES.
DATE~
GRID=
DRAWN,
SGS ReF.#
Client Name
Project Name/#
Client Sample ID
Matrix
1061089001
Gamess Engineering Group, Lid.
Scimitar SD Lot $ Block 3
Scimitar SD Lot 5 Block 3
Drinking Walcr
All Date~Times are Alaska Standard Time
ertntrd Date,'TIme 03/10/2006 14::20
Collected Date~I'ime 03/03/2006 12:30
Received Dare, Time 03/03/2006 14::27
Technical Director Stephen C. Ede
P%%'SID 0
Sample Remarks:
Allowable Prep Analysis
parameter Results POL Units Mcthod Container ID Limils Date Date Init
Metalo by TCP/MS
Arsenic ND 5.00 · ug/L EP200.$ C (<~.10) 03106106 03/08/06 SCL
Waters DepaFtment
Nitrale-N 9,02 0.100 mg/L EPA 353.2 B (<=10)
03/03/06 JC
l.ttcrobioloc.:.:.:.~ Laboratory
TotalColi~rm I OB, NoColi coffl00mL S~{209222B A (<-I) 03/03106 TLF
'Tmn~poded .
SGS/cT&E ENVIRONMENTAL SERVICES 'Ta g07-582-23~317 '~. .' L
Fax: g07-581.53~1'
" "'"' .....
Ddnklng Water Analysl§ R'eportTor Total CohfOrm Bec[eTa .'. '~ O
MUST BE COMPLETED BY WATER SUPPEER .
[] P~BUC WA~ER ~'ST~I4 n~l _ I
"'"" ~ '::.:.i '*'''
SAMPLE TYPE:'
[] Ri'~'at
(refer ~o lab no.
[] Special Pur~so '
[] TmatedWater '
· [] Untreated Water
)
'.9
[] RUSH SAMPLE
Phofle f.
F~X #: '
Form # FW- 0053 12/t7/0~
Reported By:.
~sesinas61V~lK..Gmu~ata~oub,~-,OCX:tJMEN3~OR~ Form 121703~ds
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.¢i.anehorage, ak.us
(907) 343-7904
Water Well Advisory
Health Authority Approval # 060079
During a recent Health Authority Approval on-site inspection and test of the
potable water supply well on Block 3, Lot 5 of Scimitar #1 subdivision, the
well's productivity was determined to be 0.55 gallons per minute. The
minimum well productivity required by this Department (AMC 15.55) for a
3-bedroom residence is 0.31 gallons per minute. Although the subject well
currently exceeds this minimum requirement, all parties concerned are
advised that the production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering lawns and
gardens may be required.
This advisory must be attached to all copies ofthe subject Health Authority
Approval.
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
Nitrate Advisory
Certificate of On-Site Systems Approval # 060079
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 3, Lot 5 of
Scimitar#1 subdivision. This inspection revealed a nitrate concentration of
9.02 milligrams per liter (mg/L) was reported for the property's well water
sample. The Environmental Protection Agency (EPA) has established a
maximum contaminant level (MCL) of 10.0 mg/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. Please see the
attached "Nitrate Fact Sheet" for important information regarding nitrate.
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
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650,
www. ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. d2,'5"/ - / ~ ~ - ~,5"'"
Expiration Date: ./I / _,c,~/~t~
1. GENERAL INFORMATION
. Location (site address or directions)
Mailing address
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Un/ess 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 ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ~
D~ Individual Holding tank
[] Community On-site [-]
D 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 end/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 cf
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage flies and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with ail applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm .~-'.,4~ ,~,,/,~,~ ,,~'..~x/l.,~-.~,m..,~,~. ...~--~.
Address J,~ ~.,'~,/
Engineer's Printed Name ~.~',4,~-,.~.~.~_~c-~- ~ /'~/~.~.,,-~
5. DSD SIGNATURE
, ~ Approved for
Disapproved.
Conditional approval for
Phone
Date
bedrooms, with the following stipulations:
Additional Comments
By:
Attachments:
HAA Checklist X
' Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Municipality of Anchorage
Development Services Department
Building Safety O~sion
On-Site Water & Wastewater Program
4700 South 8ragaw St.
P.O. Box lg6650 Ancbemge, AK 99519-6650
www.ci.anchomge.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST ·
Legal Description:
A. WELL DATA
Well type 7'.e'~//~z'
Date completed ?/.q/~'..~
Total depm .,~'4~ ft.
IfA, B, or C provide PWSID #
Sanita~/seald~N) y'~',~
Cased to/K~ %` lt.
Parcel ID:~- ~.%~"
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform t~ coldnies/lO0 mi.
Arsenic: ,~,//.4 mg./L
B, SEPTIC/HOLDING TANK OATA
Tank Type/Material _
Wall Log~'4 )
Wires pmpady protacted~)
Casing height (above ground) ,/,~ in.
ATINSPECTION
Nitzato ~. ~ mg./I. Other bacteria ~ colonies/lO0 mi.
Date of sample: :F//?/*¥ Collected by: '~*,.~r J~a,-#,~
Date installed
Tank size ~ gal. . Number of Compartments ~ Cleanouts4~]~N)
c~eanout(~).--,~r--~, Depression over tank (Y~) ~ High water alarm
Foundation
Date of pumping .~./,~/?/¢~?/'~ Pumper ~'-~="~
C. ABSORPTION FIELD DATA
Date installed ~'~/'~.~ Soil rating (g.p.d./ftz or~)
Length /~.. It. Width /.~_ ft.
Total depth ~ ft. Eft. absorption area .,~l"~ Monitoring tube
Date of adequacy test ~///~-/,' Resu~atl)
Fluid depth in absorption field before test ~ in. Water added ~.~Z~gal.
Elapsed Time: ~ min. Final fluid depth ~¢~ in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y~& type)
System type
Gravel below pipe ~ ft.
Depression over field
For ;~ bedrooms
New depth {~'in.
,,~'2s"'~ g.p.d.
If yes,' give date
LiFT STATION
Date installed
'Pump on' level at __
Datum
Size in gallons /'/~'/~_~~)
in. *Pum~__in. High water alarm level at
~- .,.,,.,,'""Cycles tested Meets alarm & circuit requirements?
in.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
· l~Septic tank/lift station on lot -7..~ '
· -,~Absorption field on lot ¢~,,~" /
Public sewer main 7' ~'~" ·
Sewer/septic service line ,~ A' ~'
On adjacent lots - ~'/'~'¢~ ·
On adjacent lots .,~,-,~ '
Public sewer manhole/cleanout
Holding tank ~/.~,,,~ ·
SEPARATION DISTANCES FROM SEPTICII-1OL=I~4~ TANK ON LOT TO: * · ·
Building foundation r',, ' Property line ~' Absorption field /,,'.,. /
Water main -./- /L.~ ' Water service line */~ ' Surface water ..~/~¢~ '
Walls on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line o"' ~ ' Building foundation /-',P' ' Water main 'P/,.~ '
Water Service line ~ / ~ ' Surface water /./¢~ · . D~mway. parking/vehicle storage '/'/~' ·
Curtain drain '/' 0"¢)' Wells on adjacent lots
F. COMMENTS
O.E. =,. E..'S C..T,.C AT, O.
I ~v ~n~through field inspections
~~i~l ~s ~at the abov~ystems am in
H~ F~ S ~ Wg~r F~ $
Date of P~ment ~/Z,/.~ Da, of P~ent
R~i~ Numar ~ [~ ~ R~i~ Numar
(R.. 1~01) '- ~f
Municipality of Anchorage
Development Services Department
Building Safc~y Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage, ak.us
(907) 343-7904
WATER WELL ADVISORY FOR
HEALTH AUTHORITY APPROVAL #HA04-0364
Legal Description: Scimitar #1 Subdivision, Block 3, Lot 5
PID # 051-132-35
During a recent Health Authority Approval an on-site inspection and test of the potable water
well supply on this lot was determined to be 0.65 gallons per minute. The minimum well
productivity required by DIIIIS MOA AMC 15.55 for a 3 bedroom residence is 0.312 gallons
per minute. Although the subject well currently exceeds this minimum requirement, all parties
concerned are advised that the production capacity of the well may fluctuate. Restriction of non-
critical water uses, such as, washing cars and watering lawns and gardens may be required.
This advisory must be attached to all copies of the subdivision Health Authority Approval
Certificate.
If there are any further questions regarding this advisory, please call the On-Site Services
Program at 3434744.
ASBUILT
I HEREBy CERTIFY .THAT I HAVE SURVEYED THff I SCALE:
FOLLOWING DESCRIBED PROPERTY, . '11
AND THAT NO ENCROACHMENTS EXISTEXCEPT AS | .j...3~'~/~/
INDICATED. IT IS THE RESPONSIBILITY OF THE ~- f~/~/
SEWARD & ASSOCIATES LAND SURVEYING 69&-0829
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID:
DRAWN~
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANy DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES.
07-21-04 03:Z9~ FR0~-CT&E ESI, $(;$ EN¥ SEI~VICE$
90T5615~01
T-ZH P.0Z/OZ F-4Z?
SGS Ref.~
C1knt Name
ProJ.t Name#
Client SampJe ID
Matrix
Sample Remarks:
1044346001
Ea~Je River Engineering
Scimitar #1 B3, 13
Scimitar fll B3, L~
Di'inkinS Water
All Dates/Times are Alaska Standard Time
hinted Deterl'Ime 07/22~004 11:23
Collected Dare,rime 07/19/'2004 10:00
Received Date/Time 07/19~04 14:25
T.hnJcll Dl~~.fft ~j~lk = Kde
Nitrate-N
Re,alta
430
P~L
Units Mclh~
ms/L EPA 300.0
Allowable Prep Analyaia
Comaine~ ID [.~ Date Dale
B (<'~i0) 07/19/04
t4ic~:ob't olm~' l. abor&r, ozy
TotalColifon'n 0 col/100mL SM209222B A (<'~1) 07119/04 DK
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
CERTIFICATE OF HEALTH AUTHORITy... APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) 198/,2 Tu'lwar Drive
HAA# HA O/O/ O '
Expiration D~te: 7" ~ G - 6) I
Lot 5, Block 37 Scimitar Subdivision #1
Ch~iak. AK 99567
Current Propertyowner(s) Ed Laffert¥ Dayphone 688-7790
Mailing address PO Box 670785, ChuF, iak, AK 99267 '~
Lending agency
Day phone
Mailing address
Real Estate Agent
Sharon Minsch/Rema×
Day phone 694-4?Rf)
Mailing Address 16601 Cqnterf'ield Dr.:
Unless otherwise requested, HAA will be held by DSD for p~ckup.
2. NUMBER OF BEDROOMS: 3
99577
3. TYPE OF WATER 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 Cedificates 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. Ce~ficates 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 samj31e results less than 30 days cid. (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 fcr 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 vefi['! 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 rind type of structure indicated herein. I fudher vedfy that based on the information obtained from the
Municipality of Anchorage files and from my investigatlon and inspection, the on-site water suppIy 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.
Phone' G q"( -,)- ~
$ & $ ENGINEERING
Eagle RDero Alaska ~29577
Name of Firm
Address
Engineer's Printed Name;R°bert C. Cowan, P.E.
bedrooms·
DSD SIGNATURE
~ Approved for '~
Disapproved.
Conditional approval for
Date /,-//Iq/o/
.4/o>? .... A '..~ ,"?,~,
¢~ %-~.,.: .,.%.%'
bedrooms, with the following stipulations:
,,',t ~'
6 '~Or
~"~:';" ON ,91TE
~'~. WATERAND .'
Additional Comments
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow 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 Sou~ Bragaw St.
P.O. Box 196650 Anchm'~ge, A~ ~351G-6650
www.cLanc~orage.ak.us .
(907) 343-7g04
HEALTH AUTHORITY APPROVAL CHECKLIST
.4. WELL DATA
Well t~/pa ~___¢~ If A, B, or C provide PWSID # __
FROM WELL LOG
Date of test ~.~
stets: ,~ter id,~'T'O / ".
Well production '~' ~' g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi.
Data of sample: '¢~//~/
/
Well Log (Y/N)
Wkes properly protected (Y/N)
C, ash~ heght (above oro~nd) ,/~ ~n.
AT INSPECTION
/~.o fl.
Nitrate ~"t.r' rno./L Other bacteria "7. colonies/100 mi.
B. SEI~FIC/HOLDING TANK DATA
Tank Type/Material'~
Tank size/~'~ gal. Number of Compartments
Date of pumping I0 ! I ~11/0 (~
Date installed ¢/9 3
Depression over tank (Y,I~ ~) High wata' alarm (Y/N) /%///'I'
Pumper 5 ~9.-. / r/~ .4-y
C. ABSORPTION .R~'U3 DATA
Length I ~. ft. Width I ~ fl.
Totel depth I,~'~ fl. Eft. absorptton ama ~ Mon~be /~'~
Date of adequacy test 4//~/0/ Results(Pus/Fail) ~'],~
Flu. dep. b.,o. te,,. a in. W..edd g.I.
Elapsed Tkne:_~gr~min. Final fluid depth ,~in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type)_/~/~/~',~q//Z4/,A/ If yes, give date
System type
Gravel below pipe ~o ft.
Depression over field
For 5 bedrooms
New depth ~ in.
D. UFT STATION
"Pump on" level at __ ~.~D~"Pump off' level at in.
Datum / Cycles tested
E. SEPARATION DISTANCES
Manhole/Access {Y/N) .
High water alarm level at
Meets alarm & circuit reCluimments?
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tantdllf~e~t~ on lot
Absorption field on Iol
Public sewer main /V'/,~
CC'.*.'C;/septic sewice line
On adjacent lots
On adjacent lots
Buildingfoundafion ~' ~
Water main Y~/A
Wells on adjacentlets /~/~"
/crc)
/Or'O /.~
Public sm~er manhole/deanout
Helding tank ~ /~'
!
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Property line ~' ~' Absorption field
Water service line / ~) t.,. Surface water
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
O
/
Property line Building foundation ~:) Water main ~//,~l-
Water Service line /0/-v- Surface water ~' O~/'~- Driveway, parking/vehicle storage
Curtain drain ~ Wells on adjacent lets ~'gP~) ~
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field in~pactions and
review of Municipal records that the above systems ate in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printad Name /~,~,'~.7-' ~'. CO~,H,,J
Dale ~/1 "l/O I
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
Waiver Fee $
Data of Payment
Receipt Number
MUNICIPALITY OF ANCHOP~.GE.
MEMORANDUM
WATER WELL ADVISORY
HEALTH AUTHORITY APPROVAL NO._~_~J_~ O
During a recent Health Authority Approval on-site inspect%on
and test of the potable water supply well on Lot
Block ~ of S¢i,~ ;~W ~ / Subdivision, the well's
productivity was ~etermined to be ~.~ ga!l~ns pe~ minute.
The minimum well productivity require~ by this Department
'(~C 15.55) for a 3 bedroom residence is (D,'~ gallons
per minute. Although the subject well currently exceeds this
minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory mumt be attached to all copies ~f the subject
Health Authority Apprcva!.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
03-//~. ~'-- '.
HAA #
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER "OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev, 1/91) Fronl MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER.
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or, wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
.
Name of Firm i,.~ ~ .... ~ ~,~ ~o~,~ ~ -~-/~
Address ~. ~ox xz~4, Eagle ~, ~ ~7~4 Phone
Engineer's signature
DHHS SIGNATURE
~ Approved for ~D bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Note: The well for this property meets existing State and Municipal Codes.
There are nitr~.tes present. It is s,,g?~p~ ~'h~P p~r~ ~ng b~
performed to insure- the wells continued suitability. Current nitrate
concentratioh is 8,--85 ,,~s/~' ~=^ -- ' g/1
More information on nitrates is available from the On-site Services Program,
DHHS, -343-4744.
Additional Comments
By:
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 DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025(Rev. 1/91) Back MOAfCZl
MUN¢.IPALITY C)F AN(..H(JF, AL~t:
ENVIRONMENTAL SERVICE8 DIVISION
Municipality of Anchorage OCT 1 5 1997
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L "'
otreet, Room 502 · Anchorage, Alaska 99501 (907) -
Health Authority Approval Checklist
Legal Description: iot.¢- /'/~'/,7,/,g ~'~*/~,/-/~,- ;g-/ Parcel I.D.:
A. WELL DATA
Well type
Log present (Y/N) AJ
Total depth
Sanitary seal (Y/N)
Date of test
/
Static water level /
/
Well production
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to /"72 / Casing height (above ground) ' /~ /'
FROM WELL LOG
Nitrate
WATER SAMPLE RESULTS:
Coliform /
Date of sample:
g.p.m.
Wires properly protected (Y/N)
AT INSPECTION
/o -- I -/-? 7
g.p,m.
~;~, ~ '"~,"~ Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~'"/? :] Tank size
Foundation cteanout (Y/N) ~
Date of Pumping
/~ .<;-~' Number of Compartments ,~L Cleanouts (Y/N)
Depression (Y/N) /V' High water alarm (Y/N) /V J4
Pumper 0-' ¢'~ ~'
C. ABSORPTION FIELD DATA
Date installed /'2 ~ ~
Length /,~ ' Width
Effective absorption area ,,'2. ~',~
Date of adequacy test ,~"~'~--
Fluid depth in absorption field before test (in.);
Soil rating (g~or fF/bdrm)
Gravel thickness below pipe
Monitoring Tube present (Y/N) /v-
Results (Pass/Fail) _,,,~ ','~'J
,¢?$- System type
~' / Total depth /'/,~
Depression over field (Y/N)
For ."~
Immediately after z./,,,~, gal. water added (in.):
Fluid depth ~ (ins) Minutes later:
Absorption rate =
· t~ z¢,~-~ .g.p.d.
Peroxide treatment (past 12 months) (Y/N)
If yes, give date
bedrooms
72-026 (Rev. 3/96)*
D. LIFT STATION % /¢/A
Date installed
Manhole/Access (Y/N)
High water alarm level at* "~
Cycles tested
Size in gallons
"Pump on" level at*
*Datum
"Pump off" level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot '~5"/ d~'''~'~''- /5',~¢f')On adjacent lots
Absorption field on lot ~'¢~'- /(cc "
Public sewer main
Sewer/septic service line
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
/
Foundation ~ Property line f/o"
Water main/service line
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line f"/,~ / Building foundation
Surface water "-/,' ¢
Cur[ain drain /V/x-i-
ENGINEER'S CERTIFICATION
/~.~;~'-/4,.~_) On adjacent lots .~-/,~,~,"
Public sewer manhole/cleanout .,,~//2/¢
Absorption field /d"
Wells on adjacent lots '~/,~ ~* '~
Water main/service line
Driveway, parking/vehicle storage area. '//
Wells on adjacent lots '~- ,'¢¢~"
I certify that I have determined thru field inspections and review of Municipal
in conformance with MOA HAA guidelines in effect on this date.
S,gnature
Engineer's Name ~¢'~-,,-.~' ~ ,~.~.
Date /~' - /,¢' - ~ ?
HAA Fee $.
Date of Payment _
Receipt Number
72-026 (Rev. 3/96)*
Y
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
MEMORANDUM
WATER WELL ADVISORY
HEALTH AUTHORITY APPROVAL
During a recent Health Authority Approval on-site inspection
and test of tl~e potable water supply well on Lot ~
Block 3 of ,~'~ ~/ ~ Subdivision, the well's
productivity was determined to be ,~ gallons per minute.
The minimum well productivity required by this Department
(AMC 15.55) for a 3 bedroom residence is ~/ gallons
per minute. Although the subject well currently exceeds this
minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory must be attached to all copies of the subject
Health Authority Approval.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICl-'S
DIVISION OF ENVIRONMENTAL SERVICES
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date "~¢'~'/¢ ¢~
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner
Mailing Address ~'/--~'
(c) Lending Institution
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
Telephone: Home ~2~;~¢.- '~¢,'~'/-~ B. usiness
Telephone
(e) Mail the HAA to the followina address: or: Check here~, if hold for pick up.
List contact person and day phone number below.
S & S ENGINEERING
17634-Eagle ~;.¢er Le.p Read Ne. _2~
Eagle River, Alaska 99577
TYPE OF RESIDENCE
Single-Family~-
Number of Bedrooms
WATER SUPPLY
Individual Well.~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite ~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 , 72-025 fRev 8/86t Froni
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 flies and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all MunicipaJ and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm Telephone ~ ,~--~'~/4~.~.~.~.~.~.~.~.~7~
Address a-.u ~.,_ ,.,~.
/ /
Approved for ~ bedrooms by
Approved ..)(, Disapproved Conditional
Terms of Conditional Approval
CAUTION
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.
Page 2 of 2
72-025 fRev 8/86} Back
WELL DATA
Well Classification
Well Log Presentd~N)
Total Depth ~_~"~d;~ / Cased to
Static Water Level ~ / '
Casing Height Above Ground / ~''-~"
Electrical Wiring in Conduit 4~N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ~--~
~,~t.~IClPALITY OF ANCHORAGE (MOA)
~C'~'O~ ..x'I~L~ALTH AUTHORITY APPROVAE (HAA)
¢~~b~ %1 ~ Legal Descri~ion: ~
t I"~1~\ ",/I '~O,~ If A, B, C, D.E.C. Approved (Y/N)
Date Completed 'i~ .-'~- '~ Yield
Depth of Grouting ~--
Pump Set At O,~-.
Sanitary Seal on Casin~)
Depression Around Wellhead (Y/~
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer /~
Cleanout/Manhole r3/P' To Nearest Sewer Service Line on Lot r~
Water Sample Collected by '¢~'~ ~'-.~l/~l~:W2-~4;-~d- _; Date '~t_~"~} - ~
Water Sample Test Results ~~ ¢~_ ~ ~; ~ ~~
Comments~ ~~¢~ ~ ~ b~ /~~o~, ~ ~~
B. SEPTIC/HOLdING TANK DATA
Date Installed ~;~¢
Standpipes~-l)/N) _ ~ Air-tight Caps
Depression over Tank (Y/~I~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/lffot~i¢~ Tank:
To Water-Supply Well "~o /
To Property Line
To Water Main/Service Line ,/
Course / c~¢:;,
Size /"~-¢"--¢2 No. of Compartments
Foundation Cleanout (Y/,I~
,/Date Last Pumped
/,J
; for
Temporary Holding Tank Permit (Y/N) /~/,'~
To Building Foundation
To Disposal Field
/O/
To Stream, Pond, Lake, or Major Drainage
Comments ..~/~'¢ ~:>~ Pblt'~11°/i'~J~
Page 1 of 2
72-026 (Rev ~86~ Front
C, ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ ~ ~ ~ "~ .-~
Width of Field
Type of System Design
Length of Field
Depth of Field /
Gravel Bed Thickness ~' /
Square Feet of Absorption Area ¢_.~-~t~ ¢:' Standpipes Presentd~N)
Depression over Field (Y/,~p /~ Date of Last Adequacy Test
Separation Distance from Absor~pti~f1'~'i~~' ~'~ I~ //'x~ ~-'1
To Water-Supply Well (~ ~z~._ .+ ' -I" /-/2~ ':Fo Property Line
To Existing or Abandoned System on
To Water Main/Service Line _ / c, /¢~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
; On Adjoining Lots
To Cutbank (if present)
LIFT STATION
Date I~
Size in Gallons '"------.-
''Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
um~,,,~ ,.~,~e.?.~uu~ing Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request ** ~
I certify that I have checked, verified, or conformed to alIM2A and HAA guidelines in effect on the date of this inspection.
Signed .~ & S ENGINEERING Date ~.,?/'~ ~ /,¢¢P
~ 17034 Eagle Ri~er L~p Road No, 2~ /¢, .~ / -
u°mpan~a~vo,.,~77 MOA'No. ~d ~< ~
Receipt NO. ~_b~'O ~
Date of Payment 7--~ '7~"'~'
Amount: $ ,/.,3~ .---0~
Page 2 of 2
72 026 IRev 8/86~ Back
TO BE COMPLETED BY WATER SUPPLIER
~PRIVATE WATER SYSTEM
Name
S & S ENGINEERING
17034 E,~gle R/vet Leop
Mailing Eal{~i~Riv'er, Alaska W)$77
Phone NO.
City State Zip Code
Mo. Day Year
SAMPLE TYPE:
__~ Routine
[~ Check Sample (for routine sample
with lab ref. no. ,
[-I Special Purpose :
) [] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
'4 I
Time Collected
Collected By
TO BF COMPLETED BY LABORATORY
Anal~ shows this Water SAMPLE to be:
L~ Satisfactory
[] Unsatisfactory
[] Sampletoo long in transit; sample should~
i not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received .r-,) ~ ,~/__/;/2'
Time Received / ,~O~
Analytical Method: Membrane Filter
* No. of colonies/100 mi. '
Lab Ref. No.
I
I
Result* Analyst
I-FI '
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
Membrane Filter. Direct Count
Verification: LTB
Final Membrane FilteY/Results
Reported By f ~,~*-~.~/~
TNTC = Too Numberous To Count
OB = Other Bacteria ~
BGB
Date
Time:
CoilformllOOml
CoilformllOOml
OLO CAL ALA K , NC.
5633 B STREET ANCHORAGE, ALASkA99518 ~ELEPHONE(907) 5~2-2343 ~
FEDERAL TAX ID 0 92-0040440 ~
ANALYSIS REPORT BY SA[~LZ for Work Order ~ 8040
Date Report Printed: JUL 26 88 @ 10:06
Client Sample ID:L5, B3, SCIMITAR
PWSID :UA
Collected JUL 20 88 @ 15:50 hxs.
Received JUL 21 88 @ 15:00
Preserved with :4 DEG. C
Analysis Completed :JUt 25 88
Client Name : S & S ENGINEERING
Client Acct: SNSENGP
P.O.~[ NONE REC'D
Ordered Ey : R.3.S.
Send Reports to:
Laboratory Supervisor. :STEPHEN C. EDE
Special
Instruct:
Chemlab ge£ ~: 1896 Lab Smpl ID: 3 Matrix: Water
Allowable
Parameter Tested Result/Units Method Limits
NITRATE-N 1.5 mg/1 EPA 353.2 10
Sample ROUTINE SA}4PLE.
Remarks: SAMPLE COLLECTED BY R.J.S,
I Tests Performed ' See Special Instructions Above UA-Unavailable
ND- None Detected '* See Sample Remarks Above
NA= Not Analyzed nX-Less Than, GT=Greater Than
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERI"IFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
GENERAL INFORMATION
(a)
(b)
(c)
(d)
Legal Description (include lot, block, subdivision, section, townshi~.~,ange)
Location (address or directions)
ApplicantName~, ~ ~k_ Telephone:Home ~ ~7-- Business ~ .....
Applicant is (check /bu Other B (explain);
): en ' g s' ' ; 'd~;BuyerB;
Lending Institution ~"~
Address
(e) Real Estate Company and Agent
. Telepho~)e
Address
T¢l(~phone
(f)-" ~alYtl~ HAA to the following address:
2. TYPE OF RESIDENCE
Single-Famil,y~ Multi-Family [] Other
Number of Bedr~ ~oms ~.'
WATER SUPPLY
Individual Well¢~ Community E~I Public L~
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAl.
Onsit?/~ Public [] Community [] Holding 'Yank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11,84)
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
Address
ENGINEERING ~reto and as of the vahdatlon date shown below I verify that my nvesti~ati ....... ~ ~;:
~"~"'y ~pprova, snows mm me on s'te water supply and/or wastewater d,sposal svstem is .~f. , ....... t%all[~
.......... u,,ona, and adequ~t,~
the number of bedrooms and type of structure indicated herein. I fudher verify that based on the information obtained
~~B~. Telephone _ ~- ~¢ F¢'
DHEP APPROVAL
Approved ~"~'~
Disapproved - Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska, The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data bofore a certificate is issued. Tile Municipality of Anchorage is not responsible for errors or omissions in tile
professional engineer's work.
Page 2 of 2
72-o25 (11/84)
D
Well Classification __
Well Log Present (Y,(~
Total Depth
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit ~N)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description: ~-,_~ ~ ~-~
If A, B, C, D.E.C, Approved (Y/N) ..
Date Completed ,, , Yield
Cased to __ ~d.¢ ~) ~':~ DeBth of Grouting ~
/~, k, .... / ~ Pump Set At ~ lc.
/~
Sanitary Seal on Casing ~N)
Depression Around Wellhead (Y~
Separation Distances from Well: ¢-¢~,,~.~_ ..~_~t¢-¢~,~,6~.¢- ~.¢-
To Septic/l".l~ld~g Tank on Lot ~z(7..-h '~ ~y "
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ~'~ ; On Adjoining Lots
To Nearest Public Sewer Line 't~4'//'~,z~ To Nearest Public Sewer
Cleanout/Manhole ~ ('¢' To Nearest Sewer Service Line on Lot
Water Sample Oollected by _ '~"~ ~d"¢"~ ~'~JC~'~t'J~'~'~'~'~( ,Date__
Water Sample Test Results _ ,_,%~
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed.
Standpipes (~(~N) Air-tight Caps ~;~N)
Depression over Tank (Y~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) /w',/'~
Separation Distances from Septic/Holding Tank:
Size / k 5'0 No. of Compartments
To Water-Supply Well __
To Property Line
To Water Main/Service Line
Course
./0/ ¢-
. Foundation Cleanout
Date Last Pumped _..
t¢ / k ;for
Temporary Holding Tank Permit
To Building Foundation
T - ¢
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
72-026(11/84)
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
'To Water-Supply Well
'To Building Foundation
Lot
'Fo 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
Depth of Field ~
Gravel Bed Thickness
Standpipes Present
[)ate of Last Adequacy Test
To Property Line __ /(..
To Existing or Abandoned System on
; On Adjoining Lots -..%,¢ !
To Cutbank (if present) ~.
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify t ha~l&a~l~;t~[~.~i~(~or conformed to all MO/& and/UAA guidelines in effect on the date of this inspection.
Signed ~.l~_l~ '10,r.¥ Dat ~'/~.- ~"
Company ~_.~,_~~, AK 99.~77 M CA No. '
ReceiptNo. ~'~0(_..~ t OOI ?
Date of Payment '~ ¢'1'3 ¢' ~
Amount: $ ~ ~"¢-
Page 2 of 2
72-O26 (11/84)
DEPARTMENT OF HEALTH & HUMAN SERVICES
P,O. BOX 6650
ANCHORAGE, AI_ASKA 99502-0650
(907) 264-4111
TONY KNOW£ES.
MA YOf~
October 7, 1986
Robert A. Shafer, P.E.
S & S Engineering
SRB 196-X
Eagle River, Alaska 99577
Subject: Lot 5 Block 3 Scimitar Subdivision
Waiver Request, WR86-143
Dear Mr. Shafer:
Your request for a waiver of th~100 foot separation required
between the seepage pit and well on the subject lot has been
granted. The required distance has been waived to 95 feet.
The existing 75 foot well-to-septic tank separation is "grand-
fathered" under regulations in effect at the time of installation.
The seepage pit-to-well waiver is valid for the existing three
bedroom single family dwelling only.
Sincerely,
Stephen S. Morris
Civil Engineer
On-site Services
SSM/ljw
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUC'rURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
ROBERT A. SFIAFER
September 28, 1986
CIVIL ENGINEER
694-2979
Municipality of Anchorage
Department of Health and Human Services
825 L Street
Anchorage, Alaska 99501
ATTENTION: Steve Morris
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
.SEP 2 91986
RECEIVED
REFERENCE: Lot 5; Block 3; Scimitar
Dear Steve,
Request you approve the attached Health Authority Approval application
and grant a waiver to the horizontal separation distance between the
private well and a seepage pit at 95 feet. The on-site wastewater disposal
system was installed in 1973 prior to a change in Borough and State
codes, therefore, the septic tank installed at a distance of 75 feet
was in accordance with the code that existed at that time, however,
the seepage pit falls short of the prescribed distance by 5 feet. The
Greater Anchorage Area Borough accepted the installation at that time.
Attached for your review is a site plan, waiver review work sheet, and
well log. Based upon the risk analysis as shown on the attached work
sheet it is our opinion that the horizontal separation distances prescribed
by 18AAC72.021 are not necessary in this case.
If we~
Sincerely,
uovide additional information, please contact us.
~FER, P. E.
SRB 196X EAGLE RIVER, ALASKA 99577
SCALE
NW 1261
North Municipality Area Reference Map--lB
30
38 ~)]>- 40
50
39
0 ¢OPYR~GH? IgC5 J~IR