HomeMy WebLinkAboutNORTH WOODS UNIT 3 BLK 12 LT 9North Woods
#3
Block 12
Lot 9
#051-732-18
(Rev ub/u2/18)
Municipality of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE
WASTEWATER INSPECTION REPORT
Permit Number: OSP201205
PID Number: 051-732-18
Dwelling: W Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑® Upgrade
Name
Nadine Thompson
ABSORPTION FIELD
❑ Deep Trench ❑Wide Trench E] Bed ound
Site Address
23055 Green Garden Drive
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth fr original grade
3
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision
Block Lot
North Woods Unit 3
12 9
Fill added above original gre,
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Holding
Sewer
Total a orption area
Number of trenches
Dist. between trenches
From
Tank
Field
ft Stat
Lift
Tank
Line
Ftz
Fl.
Well
n/a
I
TANK 9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Infiltrator
Capacity
1094 Gal.
Surface water
100'+
Material
Number of compartments
Lot Line
5.0'+
NA
Plastic
2
Foundation
7,5'I
LIFT STATION
Manufacturer
Capacity
Remarks
Gal.
Alarm location
Electrical installed by
PIPE MATERIAL House to tank 3034 Tank to 3034
drainfield
Installer
Whitters
Drainfield CO/MT 3034
Inspector Pannone Engineering
BENCH MARK (Assumed elevation) 350.3 ft
Inspectio v, 7/30/2020
7/30/2020
Location and description
3rd 7/31/2020
2nd
4",
NW Bottom House Trim
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
OF Akq6,
Conditional Approval:
Date
��
:.4 T�
/ L �_ -
Steven R. Ponnone
`��¢
Septic Sy
P . CE 8149
^ste
Appro L
i Date 9'-11-2000
Note: this approval does not include well permit requirements.
(Rev ub/u2/18)
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PANNONE ENG SVC LLC (C.t. io8s�
P.O. BOX 1807 PALh,�ER, AK 99645
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REVISIONS
DATE
8/5/2020
RECORD DRAWING
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P.I.D. NO
051-732-18
DRAWN ACP
PERIAIT N0.
WATERLOO, IN 46793
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PANNONE ENG SVC LLC (C.1. 1088).
P.O. BOX, 1807 PA5JER, AK 9964.5
""`.....
�E`OF A(q''i
REVISIONS
DATE
8/5/2020
RECORD DRAWING
PHONE (907) 745-8200 FAX (907; 745-8201
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NORTH WOODS UNIT 3 B12 L9
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P.I.D. NO
051-732-18
DRAWN ACP
2745 COUNTY ROAD 19
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WATERLOO, IN 46793c
OSP201205
SITE PLAN
SITE: 23055 GREEN GARDEN DRIVE
b " ~ ' �{
SHEET
CHUGIAK, AK
nn
2 OF 3
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://vvww.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP201205
Work Type: SepticTank Upgrade
Tax Code Number: 05173218000
Site Legal Address: NORTH WOODS UNIT 3 BLK 12 LT 9 G:1459
Site Mailing Address: 23055 GREEN GARDEN DR, Chugiak
Owner: THOMPSON NADINE A
Design Engineer: PANNONE ENGINEERING SERVICES
This permit is for the construction of:
Effective Date
Expiration Date
S,
„ 1,�„�y£'.,+3h f kms.
r; f,
Department
Lot Size in Sq Ft
Total Bedrooms:
7/7/2020
7/7/2021
27858
❑ Disposal Field ✓❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By:
Issued By: '
Date: 7//,, ` 4 �,
Date: 7 7 Z6 a D
UNIMPALIT OF ANCHORAGE
P �Y
Community Development Department � Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWERIWELL PERMIT APPLICATION
Parcel I.D. 051-732-18
Property owner(s) Nadine Thompson Day phone
Mailing address 2745 County Road 19 Waterloo, IN 46793
Site address 23055 Green Garden Drive Chugiak, AK 99567
Legal description (Sub'd., Block & Lot) North Woods Unit 3 B12 L9
Legal description (Township, Range & Section)
Lot Size 27,858 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF)
❑X
(w/wo ADU)
Septic Tank
MUpgrade
❑X
Duplex (D)
ElHolding
Tank
F-1Renewal
❑
Multiple Dwellings
❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: $ Waiver Fees:
Date of Payment: (5 7-61ZO Date of Payment:
Receipt Number: O78g3G- Receipt Number:
Permit No. Q5P2.01 Z05 Waiver No.
Permit App_-'-:. :....:c:
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201205, Rebecca Carroll, 07/07/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201205, Rebecca Carroll, 07/07/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201205, Rebecca Carroll, 07/07/20
~ JNICIPALITY OF ANCHORAGE
K°� St B3 01
\ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street • Anchorage, Alaska 99501 Telephone 2644720
ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION
REPORT
NAME
PHONE
"NEW
S}L+ S%
eVe.t Q9gS
Q3
GESS 28❑UPGRADE
MAILING ADDREC)
PA'(.
BO
LEGAL DESCRIPTION
Noh�N°°ds D� li 9
LOCATION
NO.OF BEDROOMS 3
a5 �c'irS rte 1'—
J
DISTANCE TO:
WeiW welt
Absorption area
Dwelling /
PERM
T NO.1
�N/d 4 el
COY
IUs L
weir
2
Manufacturer
Materials ['
No. off ompartments
w�
mc
H
Liq. capacity in gallons
((JJ
IF HOMEMADE;
Inside length
Width
Liquid depth
d Y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
. oz
_ z F
Manufacturer
Material
Liquid capacity in gallons
D
DISTANCE TO:
Well
W cll
Foundati n
Nearest lot line
PE(�iM1T
NO. ,W
rilb
IU t
VLJAA 11r
lines
Length of each line
Total length ; �ines
Trench width
Distance betsvtynflines
241 12—
/
C77inchesf
Im
tile to finish grade -
Materialbeneath lila
Total effective absorption step
H7 �A per.
inches
6 3 []
Length
Width
Depth
PERMIT NO.
W
U
a f
wd
Type of crib
Crib diameter
Crib depth
Total effective absorption area
UJ
a
DISTANCE TO:
Well
Building foundation
Nearest lot line
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
i
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption steals)
OTHER
S
PIPE MATERIALS
pvc•
o
;
SOIL TEST RATING
140 n'/b
INSTALLER
SK " -35
REMARKS
EXe*"✓a e M ✓ [ O✓ems
r7lere is / %r -f '4t /ews7'
'o
Over eijf)re led
co
re
}
1
R
APPROVED 61 DATE LEGAL
6-l1-83 Norte wopdsJI: 6•I�
�-'9
72-013 (Rev. 3/78)
►15Pec4td by '(� a�
,,�NNICIPALITY OF ANCHORAGE o
Department Health and Environment, otection
825' L Street, Anchorage, AK. .99501
�• } 264-4720
Permit # * * * HANDWRITTEN PERMIT
W/OR ON-SITE SEWER PERMIT
Applicant: a Mailing Address:
Location: iU Cr"r AWo0 S Phone Number: _
Legal Description: L -/ r► Z N or'�^ d
Woo P
Type of Soil Absorption System Is:
Trench: Drainfield: u/
Maximum Number of Bedrooms:_
ze: a 0 0 0 a' —
Seepage Bed: `Holding Tank:
Soil Rating(sq.ft/br) / v
1. 5 'Twp.- •c —
The Required Size of the Soil Absorption System Is:
DEPTH � LENGTH . GRAVEL DEPTH 6 J. WIDTH 3
The length dimension is the length(in 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(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE _ ( O 0 0 GALLONS
Permit applicant 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(2) INSPECTIONS ARE REQUIRED
Backfilling of any system without final inspection and approval by this departmen
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 fee
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper.installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 3 3
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 in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more tha 3 bedrooms.' (�(�
Signed: L. e . Issued by: �J 'Q_Q'
Applit
Date:
SWP/024(1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L Street, Amhaa9a, Alaska 99501 2644720
SOILS LOG - PERCOLATION TEST
SOILS LOG
❑ PERCOLATION
TEST
syy���"yy�� r
PERFORMED FOR: �S DATEPERFORMED: AA L3
LEGAL DESCRIPTION:I�,7�1-�C�J�./ E3IL..L�Il ID LO� 1
PERFORMED
72008 (6/79)
WAS GROUND WATER _ No
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
PERCOLATION RATE
TEST RUN BETWEEN
MUMCIPALITY OF ANCHORAGE
i
Development Services Department - Phone: 907-343-7904
On -Site Water & Wastewater Section �-Fax: 907-343-7997
Parcel I.D. 051-732-18
Certificate of On -Site Systems Approval . �
Expiration Date:3�2
1. GENERAL INFORMATION
Complete legal description Northwoods Unit 3 B12 L9
Location (site address) 23055 Green Garden Drive
Current property owner(s) Nadine Thompson Day phone
Mailing address 2745 County Rd Waterloo, IN 46793
Real estate agent
2. TYPE OF DWELLING:
Fx� Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DiSPOSAL:
Private Well
❑
Private Septic
0
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 $ l a, SQ U)U 16 '-, Waiver Fee $ _
Date of Payment /2020 Date of Payment
Receipt Number 0 8 7 28 E Receipt Number,
V
COSA # S C2 d'l Lf ( 5 Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures
outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or
wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated
herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA
COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time
of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on
the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of. the evaluator of this system. All systems eventually fail and satisfactory test results do not
guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot
provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole
benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly
recommends buyers hire their own engineer to evaluate this report.
Name of Firm Pannone Engineering Services
Address P.O. Box 1807 Palmer, AK 99645
Engineer's Printed Name Steven R. Pannone P.E.
6. DSD SIGNATURE
Phone (907) 745-8200
Date `7.0- L',
OF
System #1 Approved for bedrooms � ' 'Stever: Pa r'•*onncne �
kig, %C v1.�o �
System #2 Approved for bedrooms r � � - Lu
Disapproved ' ,0FESSIOI
pp y��
Conditional approval for bedrooms, with the following stipulations:
'111))))))1)''
� p
Original Certificate Date: 0 2 �ZCi2U
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
COSA Checklist
Legal Description: Northwoods Unit 3 B12 L9 Parcel ID: 051-732-18
If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Comments Community Well
B. TANK DATA
Age of tank (S) 7130120 years
Tank type/material 5ap'� `'
Measured operating fluid level in septic tank n/a
Q Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA Bed
Which system tested (date installed) 8/11/83
V ALL standpipes present per record drawing
Total measured depth from grade 5.3 ft (max)
Measured depth to pipe invert from grade 4.8 ft (min)
❑ N/A — pressurized field
FR Monitor tubes go to bottom of effective. If not, state
depth into effective
N Code -required soil cover over field
❑® System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced 1000 gallons
Comments/Deficiencies: Located Bed Installed CO's and MT.
COSA Checklist yellow sheet
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by
Date of Sample
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 8/312020
Results 0 Pass For 3 bedrooms
Fluid depth prior to test 0 in
Water added 450 gal
New depth 0 in
Elapsed time 120 min
Final fluid depth 0 in
Absorption rate >450 gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
NO
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well
Septic Tank/Lift Station on Lot > 100'
❑
Yes
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
❑ Yes
if No ft
Neighboring Tank > 100' ❑ Yes
if No
ft
Private Sewer/Septic Line > 25' ❑ Yes
if No ft
Absorption Field on Lot > 100' ❑ Yes
if No
ft
Holding Tank > 100' ❑ Yes
if No ft
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' ❑ Yes
if No ft
❑ Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑ Yes
if No
ft
0 Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' (❑ Yes if No 7.5 ft Surface Water > 100' ❑✓ Yes if No ft
Property Line > 5'
❑
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
❑✓
Yes
if No
ft
Private Wells > 100' ✓❑ Yes if No
Water Main > 10'
✓❑
Yes
if No
ft
Community Wells > 200'✓❑ Yes if No
Water Service Line > 10'
✓❑
Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' ❑ Yes if No 5.0 ft If absorption field is under driveway comment below
Property Line > 10'
0
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
ED
Yes
if No
ft
Private Wells > 100' ❑✓ Yes if No
Water Service Line > 10'
❑✓
Yes
if No
ft
Community Wells > 200' Q Yes if No
Surface Water > 100'✓❑
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that l 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.
COSA Checklist yellow sheet
�������
OF Al-
49H..
:. ......
Stever R [Jannor)e-
CE 8149
Ile
ft
ft
ft
ft
ASBUILT—NO CORNE , RS SET THIS DATE.
/ HEREBY CERTIFY THAT | HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY-
AND
INDICATED. IT IS THE RESPONSIBILITY OF THEOWNER TO DETERMINE THE EXISTENCE OF ANYEASEMENTST COVENANTS, OR RESTRICTIONSWHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. UNDER NO CIRCUMSTANCES SHOULDANY DATA HEREON BE USED FOR CONSTRUCTIONOF FENCE LINES, OR FOR ESTABLISHING BOUNDARY LINES.
S.UJ&RD ASSOCIATES LAND
SURVEYING 694-082
D R A7W!N:
\ Municipality of Anchorage
•. Development Services Department
Building Safety Division J
On-Site Water and Wastewater Program
4700 Bragaw Street s A IT,
P.O. Box 196650
Anchorage. AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. COSA# NP021015
Expiration Date: C-1-0-7—
Complete
-1-D7
Complete legal description
WPr'�1 tVoeds
1r-3 Lo%- 9 i Rock—
Location (site address) -2
3 06 &Me
-t" C CL4eUn Dr-.
Current Property owner(s)
0 e i�9a.n
Day phone
317 - (0861
Mailing address -P.O- -RQ>( X0.2770,
fincG, •. t)K
9`)9_3o -,A -7-7o
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
01�
Individual Water Storage
❑
Individual Holding Tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
al
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite 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 Onsite 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 Onsite 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. l 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 Eagle River Engineering Services
Suite
Address Fagle 13w;AK995=
Engineers Printed Names her R. X ood
F���9L1;L•ii�1:��
✓ Approved for __ bedrooms.
Disapproved.
Phone V111- T115
Date 5/_76/y6
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: ���� ,,/ G/ Original Certificate Date: �e
)Rev. 11105)
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) 3437904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: -nee-1hw0,^dV- # 3 , Lof 1. G.tk /a- Parcel ID: 0,5/ - :Z .3 Z — 1i
A. WELL DATA
Well type A
Date completed
Total depth ft.
Date of test
Static water level
Well production
WATER SAMPLE
Coliform
mg/l
If A, B, or C provide PWSID # 2�1 Qo t
Sanitary seal (Y/N) _
Cased to ft.
FROM WELL LOG
g.p.m.
iies/100 mL Nitrate mg/L
B. SEPTICMOLDING TANK DATA
Well Log (Y/N)
Wires properly
Casing he
jgMTabove ground) in.
ft.
Other bacteria oolonies/100 mL
Date of sample: _ Collected by:
Tank Type/Material s-ca-r'e- / S -1--A P Date installed tlOf ll,100 3 `
Tank size 1 000 gal. Number of Compartments J -L._ Cleanouts ON) V&.4—
Foundation cleanout! N) Depression over tank (YQ �21Q High water alarm (Y& tit o
Date of pumping 511510fo Pumper 7y' , s :13AMPi2
5
C. ABSORPTION FIELD DATA
Date installed x/ 11 f Sl3 Soil rating (g.p.d.e or 140 System type 99,00-1
Length 3S ft. Width 19, ft. Gravel below pipe 0.5 ft.
Total depth r R Eff. absorption area feag_W Monitoring tube +a" Depression over field -Aa
Date of adequacy test Mom Results ®'Faiq . For _-J_ bedrooms
Fluid depth In absorption field before test _0 _ in. Water added].0 gal. New depth� in.
Elapsed Time: _LS- min. Final fluid depth 0 in. Absorption rate >= 4 So g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y)U& type) r "gnc /, moow} If yes, give date n/C_
D. LIFT STATION
Date installed
"Pump on" level at —in.
Datum
Size in gallons
'Pump ott" level at_ in.
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic-serilike line
containment areas
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit
On adjacent kris
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 46 Property line 't 5" Absorption field y S'
Water main *IDS Water service line tto' Surface water Inn'
Wells on adjacent lots -rtno
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line '--It) ' Building foundation * S ' Water main +"I n '
Water Service line r l o , Surface water + 100' Driveway, parkinglvehide storage 50
Curtain drain + 50 ' Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that 1 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 UhriS- 42ke r 9 • Wood i cidtl47bPttERIt
Date 51 Z 611e, CE. � ,
COSA Fee $ � 3 D
Date of Payment 5-26–n6
Receipt Number O 33
(Rev. I IM)
Waiver Fee $
Date of Payment
Receipt Number
• �,ysr 69•si
ASBUILT-NO CORNERS SET THIS DATE.
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
Q/ao�.v�s'�facP.avr-zu-to�'��.f'/z
AND THAT NO ENCROACHMENTir&IST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TD DETERMINE THE EXISTENCE OF ANY
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 aOUND-
ARY LINES.
SEWARD & E
SCALE yo
GRID,
414%1 -*%s9
11141f 6
s%
Oqwlaluiaaal
Al
.... .....
r i (g,
1h r n
FBr1 oua. Mark E.w,.d ' 1
dl9'JdA,'jJ
DRAWN=
.Off
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. k 05-1 132-' � a HAA N 114 96'05'2 2
1. GENERAL INFORMATION
Complete legal description Lot 9; Block 12; North woods" Subdivision 3
Location (site address or directions)
23055 Green Garden
Chugiak, AK
Property owner Estate of Dotty Prowse Day phone
Mailing address c/o Remax of Eagle River 16600 Centerfield Dr. Eagle River, AK
Lending agency
Day phone
Mailing address
Agent Virginia Kohfield/ Remax of Eagle River Day phone 694-4200
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY: '
Individual well
Community well XXX
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 XXX
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 (R«. 1/70 Hoed MOA 621
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 f urther 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 FirmS & S ENGINEERING Phone G� y — d 9 20
77034 a Eag River Loop oa o.
Address Eagle River, Alaska 99577
Engineer's signature � `fir Date ) -Lja (9 C
6. DHHS SIGNATURE
Approved for --:3 bedrooms.
Disapproved.
Conditional approval for
Additional Comments
By.
r
,,I R0:jRT,C.IFO'MA:+, ; c
• C°-seo1 / `'
min •� ' f�` !.
bedrooms, with the following stipulations:
Date / 2 - M — 9�
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 courtesyto purchasers of homes
and their tending 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.
72-075 IA". 1M) Swk MOA 021
iwAICIPAtItY of ANCMORNoti
ENVIRONMENTAL SERVICES DIVISION
Municipality of Anchorage DEC 0_�s 19
DEPARTMENT OF HEALTH & HUMAN SERVICES R C /' E V96
Environmental Services Division
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health `Authority ((Approval Checklist
Legal Description: L—ftroi t)L4-1Z ljt -tI \Loni3 Parcell.D.: 6U 732
A. WELL DATA
Well type If A, B, or C, attach ADEC letter. ADEC water system number
Log present (YM)
Total depth
Sanitary seal (YM)
Date of test
Date completed
Cased to
FROM WELL LOG
Casing height (above ground)''
i
Wires properly protected (YM)
i
..AT INSPECTION
Static water level /
Well production / g.p.m.
WATER SAMPLE RESULTS:
Coliform Nitrate
Tff- C�
B. SEPTIC/HOLDING TANK DATA
Collected by:
Other bacteria
Date installed �- P3 Tank size OoO Number of Compartments Z CleanouMON)-
Foundation cleanout &I Y Depression (Y Q r' High water alarm (YM) �J14
Date of Pumping /.? -.2 - 71 Pumper Tl- f✓M/"-) 4
C. ABSORPTION FIELD DATA
Date Installed / `/ d 3 Soil rating (g.p.d./M or Witidrm) IVB / System type .61-'Q
Length Sr ' Width /9-1 Gravel thiclmess below pipe G Total depth 3.5- f
Effective absorption area 636 Monitoring Tube present JVN►_y _ Depression over field (Y&__d_-)
Date of adequacy test //'1J -i6 Res all) 64S For 3 bedrooms
Fluid depth in absorption field betore test (in.); O ' Immediately atter gal. water added (in.): G `
Fluid depth 6 (ins) Minutes later: Absorption rate = y4 0 t g.p.d.
Peradde treatment (past 12 months) (Ya Al • +JC /"? / ✓Ld If yes, give date ~/•
72-026 (Rev. 3/98)•
D. LIFT STATION
Date installed
Manhole/Access(Y/N)
High water alarm level at' _
Cyel sed
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
'Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
On adjacent lots
On adjacent lots.
Public sewer manhole/cleanout
Sewer /senfie serV ce linf a Lift station
SEPARATION DISTANCES FRO SEPTI OLDING TANK ON LOT TO:
Foundation
S r f
off" level at'
Property line /o 1%4- Absorption field GI '
Water main/service line /o r f Surface water/drainage /-)v el- Wells on adjacent lots Zoo I -A
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line /0 Building foundation S Water maintservice line /o i
Surface water /Do r� Driveway. parking/vehicle storage area Jo It
Curtain drain .w'o tif, Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
I certNy that I have determined thru field inspections and review of Municipal records
in conformance w , HAAHA guide nes In effect on this date.
Signature 7
Engineer's Name /► J 6 t.t r C . Co u,qv i
Data
HAA Fee $ 3 %
Date of Payment
Receipt Number
72-026 (Rev. 3/96)'
Waiver Fee $
Date of Payment
Receipt Number
'tad r t
=�4
ROGERr C. COWAN �?
CE-8C°O1
=�4
('*11
r�,
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date May 27, 1986
t. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 9, Block 12, Northwoods #3 T15N, R1W, Sec.4
Location (address or directions)
Green Garden St.
(b) Applicant Name Dorothy Prowse Telephone: Home688-4119 Business 862-6207
Applicant Address SR3-208 Chugiak, AK 99567
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builderU; Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution Alaska Pacific Mortgage Telephone 694-7780
Address POB 100420 Anchorage AK 99501 Carol Sherrod
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
pickup by engineer
2. TYPE OF RESIDENCE
Single-FamilyU Multi -Family❑ Other
Number of Bedrooms
3. WATER SUPPLY
Individual Well ❑ CommunityU Public ❑
Note: If community well system, must have written confirmation from the Stale Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite M Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must havewritten confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025(11,84)
n
5. 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. l 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 FirmTelephone
—�ENGINEERING SERVICES
Address FdGL"IVER AK -995
Date P. 0. BOX 773294
694.5195
Z.
Engineer's Seal
�. lovis A. 6W ra
�. e1 GE 6736
v`� PiOFC$Sh:w.. i
J /
6. DHEP APPROY�LA_
CCf.
Approved for 1,� �� bedrooms by � --�Zf•Z1T _
Approved Disapprov Conditio _
Terms of Conditional Approval
CAUTION
Date �K )
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 before a certificate Is issued. The Municipality of Anchorage Is not responsible for errors or omissions in the
professional engineers work.
Page 2 of 2
72-025 (11/84)
MLRJIUFALITY OF ANO40R MUNICIPALITY OF ANCHORAGE (MO
DEPT. OF HEALTH 8
ENVIRONMENTAL PROTEC710N HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1994
MAY 2 71986 264-4729
Legal Description:
RECEIVED.
y
A. WELL DATA
Well Classification fi - N r fz wnoc(/ If A, B. C, D.E.C. Approved (Y/N) Y
Well Log Present (Y/N) Date Completed
Total Depth
Static Water Level
Cased to
Casing Height Above Ground _
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot _
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole —
Water Sample Collected by
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
Depth of Grouting _
Pump Set At
Yield
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
_ ; On Adjoining Lots
On Adjoining Lots —
—To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
Date Installed SAF 3 Size ,54/ No. of Compartments a
Standpipes (Y/N) y Air -tight Caps (Y/N) i Foundation Cleanout (Y/N) y
Depression over Tank (Y/N) y Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) 1446 ; for
Holding Tank High -Water Alarm (Y/N) A-"4 Temporary Holding Tank Permit (Y/N) !!Z4
Separation Distances from Septic/Holding Tank:
To Water -Supply Well fa°° r To Building Foundation
To Property Line r(o To Disposal Field F I
To Water Main/Service Line +/v To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
72-026(11164)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata �� ¢�'B/e Type of System Design
Date Installed 5 & 3 Length of Field 3S
Width of Field Depth of Field 3 y
Gravel Bed Thickness 6
Square Feet of Absorption Area 3 Standpipes Present (Y/N) _Y
Depression over Field (Y/N) Al Date of Last Adequacy Test
Results of Last Adequacy Test . Abr.. A A- — 3 Jtr C'
Separation Distance from Absorption Field:
To Water -Supply Well To Property Line
To Building Foundation 5 / To Existing or Abandoned System on
Lot tiZ-- ; On Adjoining Lots — 3�
To Water Main/Service Line r& To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course Izw
To Driveway, Parking Area, or Vehicle Storage Area
Comments 127e i Jfi. T« b♦ r /.✓rfc /4.0/ /z+ 6. /✓.T,
D. LIFT STATION N1
Date Installed
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
'• Check Permitted Bedroom Rating Against HAA Request '•
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed — Date 7
Company — CiPGu^ MOA No.
Receipt No. _1%f ck8,1
Date of Payment s'
Amount: $ ics .cb
Page 2 of 2
71-026 11 UK
.:.. `........_ ;...
;: Iv�'•�>
Engineer's Seal
t
;u,.,..%./.fes. ,...•
•... • ..
(+;�1
Louis A. Cutara
C <r,S, cssr�5
EAGLE RIVER ENGINEERING SERVICES
Lou Buten P.E.
P.O. x
Eagle River,
Alaskalaska 9 9
9577
Telephone (907) 694-5195
May 27, 1986
Mr. Steve Morris
Civil Engineer, On-site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
REP: Lot X9, Blk 12, Northwood. #t3
Dear Mr. Morris:
The enclosed application is submitted for issuance of Health
Authority Approval for a 3 bedroom home on the above referenced lot.
As the home is located in Northwoods subdivision the required
installation of ground water monitors was provided. The enclosed site
plan shows the position of the monitors with relation to the absorbtion
bed. We are pleased to report that there was no water within 4' of the
bottom of the bed at any time during the monitoring period 5/15/86-5/23/
The adequacy test demonstrated that the bed absorbtion rate is adequate
for a 3 bedroom home. The monitor tubes are left in place for future
inspections. This report applies to the observed conditions on this dat
only.
If there are any questions or if additional information is
required please feel free to contact me at 694-5195.
Sincerely,
Lou Butera, P.E.
Encl: HAA application
site plan
EAGLE RIV!")
ENGINEERING SERVICES INC.
P. O. Box 773294
EAGLE RIVER. ALASKA 99577
Phone 694.5195
JOB L07` 5 �''// /2 /1/, waw(i 93
SHEET NO. OF
CALCULATED BY DATE 'S� 2S/ff
CHECKED BY DATE
SCALE
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-
APPLIC^^T FILLS
OUT UPPER HAL' ALY
Properly owner JkUP+_l /S�r('S
Phone
Mailing Address100..
k— Zip Code 9eJ
Buyer
Date
Address
Inspector
Zip Code
Lending Institution
Inspector
Phone
Address -
Zip Code
-iLa'AcL(LUCI e- k k- s", L
Realty Co. d Agent
TH
DEPT. N H`_PRO 1.
ENVIRO�v1LNTAL ROTEC110N
Phone
Address
Zip Code
RECEIVED
Legal Description
��.. 9+ ��•� ��
/ /��f� r pAnse ZrT
3) APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
'
Street Location
( ) CONDITIO L APPROVAL'
DATE
Type Residence
BY
Ingle Family
Soils Rating
❑ Multiple Family
No. of Bedrooms
Well To Absorption Area
❑ Other
Septic Tank Size
Water Supply
Well to Tank
❑ Individual
ATTACH WELL LOG. A well log Is required for all wells drilled since June 1975.
C/Community
For wells drilled prior to that date• give well depth (attach log if available).
❑ Public Utility
Sewer Disposal
IR Individual
Year Individual Installed:
❑ Public Utility
When Connected to Public Utility:
❑ Holding Tank
'
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes:
MUNICIPALITY OF ANCHORAGE
-iLa'AcL(LUCI e- k k- s", L
TH
DEPT. N H`_PRO 1.
ENVIRO�v1LNTAL ROTEC110N
SEP 7 ist�,�
RECEIVED
3) APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIO L APPROVAL'
DATE
BY
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
Septic Tank Size
Well to Tank
rxon OM
