HomeMy WebLinkAboutNORTON PARK #2 BLK 4 LT 6Norton Park
#2
Block 4
Lot 6
#016-211-58
Municipality
of
Anchorage
March 26, 1986
i^'
P.O. B%,^ 196650
ANCHORAGE. ALASKA 99519-6650
(907) 2644111
TONY KNOWLES.
MA Yon
DEPARTMENT OF HEALTH 6 HUMAN SERVICES
Tobben Spurkland, P.E.
203 West 15th Avenue "C" Suite 203
Anchorage, Alaska 99501
Subject: Lot 6 Block 4 Norton Park Subdivision
Waiver Request, WR86-018
Dear Mr. Spurkland:
It is apparent from Kyle Cherry's project plan approval that the State
Department of Environmental Conservation (DEC) was aware that the Norton
Park LID 82 would not meet the minimum separation requirements to the
well on the subject property. As you have noted, the project drawings
clearly show the separation distance between the well and the sewer at less
than the required minimum. A waiver is implied in the DEC project approval.
The 75 foot separation distance required between the sewer line and the well
on the subject property is therefore considered waived to 19 feet.
Sincerely,
Stephen S. Morris
Civil Engineer
On-site Services
SSM/ljw
0
• . Municipality
of
Anchorage
February 26, 1986
P.O. BCPA 196650
ANCHORAGE, ALASKA 99519-6650
(907) 2644111
TONY KNO WLES.
MAYOR
DEPARTMENT OF HEALTH 6 HUMAN SERVICES
Tobben Spurkland, P.E.
203 West 15 Avenue, C Suite 203
Anchorage, Alaska 99501
Subject: Lot 6 Block 4 Norton Park Subdivision
Waiver Request, WR86-018
Dear Mr. Spurkland:
This Department has reviewed your request for a waiver of the 75 foot well
to sewer line separation distance requirement specified in 18 AAC 72.021.
Your request was for a waiver to 19 feet. Based on available information,
the required separation cannot be waived. It has not been demonstrated that
a lesser distance is clearly justified in this case.
This decision may be appealed through the State of Alaska. If you have
questions regarding this appeal procedure, please call the State Department
of Environmental Conservation at 274-2533.
Sincerely,
Stephen S. Morris
Civil Engineer
On-site Services
SSM/ljw
TO F �.
U o
M
SUBJECT7- �, �, �/� rt -.,_i (i2�/L S/O '642 --DATES
MESSAGEi
SIGNED.L.t�.�
REPLY
i
t
SIGNED DATE
aed�04S 472 SEND PARTS I AND 3 INTACT . POLY PAK ISO SETS) 4P472
PART 3 WILL BE RETURNED WITH REPLY.
DETACH AND FILE FOR FOLLOW-UP
MUNICIPALITY OF ANCHORAGE
O
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 016-211-58-000
Expiration Date: 1/12/2024
Legal description NORTON PARK #2 BILK 4 LT 6
Site address 310 W 123RD AVE Anchorage AK 99515
Current property owner(s) MCGUIRE TAMARA L
X The On-site system(s) is/are approved for 2 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
Original Certificate Date: 10/12/2023
chis Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory X
Other
COSA ApprovaLiune 2022
MV UNMPAUTY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 016-211-58
Complete legal description NORTON PARK #2 BLOCK 4, LOT 6
Location (site address) 310 WEST 123RD AVENUE, ANCHORAGE, AK 99515
Current property owner(s) TAMARA L MCGUIRE Day phone
2. ON-SITE SYSTEMS SIZED FOR 2 BEDROOMS
3. TYPE OF WATER SUPPLY: ® Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ® Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ Z yo Waiver Fee $
Date of Payment�-
COSA# CSC 3MY
Date of Payment
Waiver #
COSA Applicafion.doc
COSA Checklist WELL ONLY.docx
COSA Checklist
Legal Description: NORTON PARK #2 BLOCK 4, LOT 6 Parcel ID: 016-211-58
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled *PRE 1975 Total depth *76 ft
Cased to *76 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 9/26/2023
Static water level at beginning of test 14 ft.
Well production at time of test 6+ gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic 46.0 & ND W/ RO ug/L Arsenic less than MRL
(ND)
Collected by Date 9/26/23 & 9/28/23
Comments *UNKNOWN / PER MOA RECORDS. Second water samples on 9/28/23 were taken from inside the house that
showed ND for arsenic after Reverse Osmosis system at kitchen sink & negative coli from upper faucet.
B. TANK DATA – PUBLIC SEWER
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA - PUBLIC SEWER
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes go to bottom of effective.
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Adequacy test date
Results Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
Comments/Deficiencies:
COSA Checklist WELL ONLY.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No NA ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No NA ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No *19 ft
Community Sewer Manhole/Cleanout > 100’
Yes if No *61 ft
Private Sewer/Septic Line > 25’ Yes if No *10+ ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
*PER WR86-018 &/OR MOA DOCUMENTS
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 10/10/2023
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
10/10/23
Arsenic Advisory
Certificate of On -Site Systems Approval # OSC231374
Subdivision: Norton Park #2, Block: 4, Lot: 6
A water sample revealed an arsenic concentration of 46 micrograms per liter (ug/L).
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. information on arsenic is available from the On -Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Marling Address �P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org
Parcell.D.
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
016-211-56
1. GENERAL INFORMATION
Complete legal description Norton Park No. 2, Block 4, Lot 6
COSA#
Expiration Date: f ��
Location (site address) 310 West 123rd Avenue Anchorage, AK 99516
Current Property owner(s) Chad and Gretchen Stiteler
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
310 West 123rd Avenue Anchorage, AK 99516
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:. Three (3)
3. TYPE OF WATER SUPPLY:
Individual Well
✓❑
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Day phone
Day phone
Day phone
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 Anderson Engineering Phone 522-7773
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
5- DSD SIGNATURE
1� Approved for bedrooms.
Disapproved.
Date 7/9/2012
�!*�R;B�
,AM OE�;�(9etr
'F'... r
� ;�,';enMaAa, E AivoarsoN � w
CE:4381
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: AX Original Certificate Date: 7 '` 9-12
(Rev. 11105)
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Lot 6, Block 4, Norton Park Subdivision No. 2
A. WELL DATA
Well type Private If A, B, or C provide PWSID #
Date completed Pre 1975 Sanitary seal (Y/N) Y
Total depth 76' ft. Cased to 76" ft.
FROM WELL LOG
Date of test
Static water level ft.
Well production 9 -
p.m -WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mL Nitrate NO mg/L
Arsenic: 36_5 ug/I Date of sample: 6/12i2012
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material AWwU sewer system
Tank size gal. Number of Compartments_
Foundation cleanout (Y/N) _ Depression over tank (Y/N) _
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Parcel ID: 016-211-58
Well Log (YIN) N
Wires properly protected (Y/N) Y
Casing height (above ground) >18 in.
AT INSPECTION
6/18/2012
25.1 ft.
6.5 g.p.m.
Collected by: J. Berkram
Date installed
Cleanouts(Y/N)�
High water alarm (Y/N)
Date installed Soil rating (g.p.d./ft2 or ftzlbdrm) System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption area _ft' Monitoring tube _ Depression over field _
Date of adequacy test Results (Pass/Fail) For _ bedrooms
Fluid depth in absorption field before test in. Water added_ gal. New depth in.
Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons
"Pump on" level at_ in. "Pump off' level at _ in.
Datum Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Manhole/Access (YIN)
High water alarm level at
Meets alarm & circuit requirements?
Septic tank/lift station on lot N/A On adjacent lots N/A
Absorption field on lot NIA On adjacent lots N/A
Public sewer main 19— Public sewer manhole/cleanout 61"•
Sewer /septic service line >10' Holding tank NIA
Animal containment areas >50' Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line _ Absorption field
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundation Water main
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
F. COMMENTS:Information From Previous COSA "Waiver No. WR86-0165
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 Michael E. Anderson, P.E.
Date 7/9/2012
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
in.
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
MEMORANDUM
DATE: July 15, 2012
TO: Jeff Poet
FROM: Mike Anderson, P.E.MEAI
SUBJECT: Lot 6, Block 4, Norton Park Subdivision No. 2
COSA
No log is available for the well on Lot 6, Block 4, Norton Park Subdivision No. 2. A
COSA was approved in 2006 however based on information from previous inspections
which indicated the well was 76' deep with casing the entire depth. The water test at
that time indicated little or no nitrate content. A recent water sample did not detect any
evidence of nitrate/nitrite content. It is apparent no contamination is entering the
aquifer serving the home through the well casing. We therefore request the COSA be
approved without further inspection of the well casing.
Municipality of Anchorage
QP
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
Arsenic Advisory
Certificate of On -Site Systems Approval # 121267
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 4, Lot 6 of
Norton Park #2 Subdivision. This inspection revealed an arsenic
concentration of 36.5 micrograms per liter (ug/L) for the property's well
water sample. The Environmental Protection Agency (EPA) has established
a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water
systems. While private wells are not subject to this regulation, EPA
standards are based on existing health information and can therefore be used
to gauge the relative quality of water from private wells. Information on
arsenic is available from the On -Site Water and Wastewater Program
website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
r
Municipality of Anchorage
Development Services Department
Building Safety Division _
On -Site Water 8 Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519519
-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. G( ei-.-w-58 COSA# DlpOg(vf
1. GENERAL INFORMATION Expiration Date: / D — 3 - O
1
i
Complete legal description _NORTON PARK S/D A2; LOT 6. BLOCK 4
Location (site address) 310 E. 123t�rd,, AVE. • ANCHORAGE. AK 99515-3355
Current Property owner(s) MICHAEL � HOLIDAY HY Day phone C/O AGENT
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
310 E. 123rd AVE. • ANCHORAGE. AK
Day phone
ROBERT DELUCIA w/ PRUDENTIAL J.W. Day phone 250-8795
310 E. 123rd AVE. + ANCHORAGE. AK
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 2
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
❑
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
0
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 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 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 seal affixed hereto and as of the validation date shown below, 1 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 tiles 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. Phone
Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
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 described 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 sails condition, groundwater levels that may
nuctuato 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 the system. Satisfactory test
results Oo not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benerit 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 2- bedrooms.
Disapproved.
337-6179
Date b o6
Conditional approval for bedrooms, with the flowing stipulations:
Attachments:
COSA Checklist L/
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Reort
Other
fir- ...,; •��;,
ON-SITE
WATER AN
WASTEWATER
MOURAM •1 00
By: jo- Original Certificate Date: 3
/Pn, I'M%
Municipality of Anchorage
Development Services Department
J BUllding Safety DNMion a .
Onsite Water & Wastewater Program
47W Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.oVansite
(907) 3437904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: NORTON PARK S/D #2: LOr 6. BLOCK 4 Parcel ID: D /4 —.211- S8
A. WELL DATA *PER PREVIOUS HAA'S IN
Well type PLUVATE If A, S, or C provide PWSID# N/A
Data completed PRE 1975 Sanitary seal (YIN YES
Total depth +76 ft. Cased m •76 ft.
FROM WELL LOG
Date of test
Static water level ft.
Well production g.p.m.
WATER SAMPLE RESULTS:
Collform _0 colonies/100 ml.
Arsenic: 29,(l=ugJL.
B. SEPTICIHOLDING TANK DATA
Tank Type/Material
Nitrate QkI mgA.
MOA RECORDS
Well Log (Y/N) NO
Wires property protected (Y/N) YES
Casing height (above ground) 16+ in.
AT INSPECTION
6/6/06
22 R.
5.9 g.p m.
Other bacteria _ n colonies/100 ml.
Date of sample: 6/6/06 Co((ected by: CEG. Ltd.
Tank size gal. Number of
Date
(Y/N)
Foundation cleanout (Y/N) s on over tank (YIN) _ High water alarm (Y/N)
D, a of p ng Pumper
C. ABSORPTION FIELD DATA
Date installed
Length R.
PUBLIC SEWER
Soil rating (g.p.dAeor ft'/bdnn)_ System type
Width R Gravel below pipe
Total depth R. Eff. absorption area ft' Monitoring tube ression over field
iDateLdepth
quacy test R all) For bedrooms
in abso ora teat—
ore
est _ in. Water added _gal. New depth _in.
sed Tsoe: _min. Final fluid depth _ in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (YM & MV) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/
"Pump on" level at _in. "Pump High water alarm level at in.
Cycles tested Meets alarm 5 circuit requirements? -
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tanklliR station on lot N/A
On adjacent lots N/A
Absorption field on lot N/A
On adjacent kits N/A
Public sewer main X19'
Public sewer manhole/cleanout '61
Sewer /septic service line •'� 0'+
Holding tank N/A
Animal containment areas 500+
Manuretan" excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING
TANK ON LOT TO: _
Building foundation Property line
Water mein
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Water service line
F. COMMENTS
0. ENGINEER'S CERTIFICATION
Building
Wells on adjacent lots
Surface water
Driveway, parkingivehicle storage
I certify that I have detem9ned through field inspections and * ! ! 't
review of Municipal records that the above systems are in ....... ... .............
conformance with MOA COSH guldellnes in effect on this
date. y meas
Engineer's Printed Name JEFFREY A GARNESS �� CE -7 53
. b�
Date b zr�ob �•4v._.
COSA Fee S 41 '30 . o O Waiver Fee $ _
Date of Payment 6 /a 1./0 Date of Payment
Receipt Number a j q s Receipt Number
QW. I"M
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
mvw.muni.org/onsite
(907)343-7904
Arsenic Advisory
Certificate of On -Site Systems Approval # 060261
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 4, Lot 6 of
Norton Park #2 Subdivision. This inspection revealed an arsenic
concentration of 28.6 micrograms per liter (ug/L) for the property's well
water sample. The Environmental Protection Agency (EPA) has established
a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water
systems. While private wells are not subject to this regulation, EPA
standards are based on existing health information and can therefore be used
to gauge the relative quality of water from private wells. Information on
arsenic is available from the On -Site Water and Wastewater Program
website (www.muni.or onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
■r 06/21/2006 09:19
r.
I IM
■
■
■
Lot 7
0
If)
LO
v
0
v
0
0
O
iA
'9072432081 FRED WALATKA & ASSO PAGE 01
E. 123rd Avo.
— — — — 8301 F
0 0
c� tq
EAST 83.00
Wei
i _POO
L
t b b Lot 5
.$ 2SbMF'e"wb b
$t b
is
7s o
4. o
DECK O
O
A LOT 6 z SCALE: 1'= 30'
swEo
-------------
10' Screening Easement
—
14 10' Utility Easement
EAST 83.00
Huffman Rd
Gfired
EASEMENTS OF RECORD, OTHER THAN `.
THOSE SHOWN ON THE RECORDED Fb 06.4, pg4u
PLAT ARr;,NOT SHOWN HEREON.
0
w
AS -BUILT NO CORNERS SET THIS DATE
I hereby certify that I have performed a Mortgagees Inspection
of the following described property: LOT 6. BLOCK 4
NORTON PARK ADDITION UNIT No.2
� b
Mchont" Recoromg Precinc% Alaska, and that the
Improvemards
10;
Novated thereon are within the property pees
and do not overlap or encroach on pie property ying
adjacent thereto. that no Improvements on the property tying
adjacent thereto encroach on the premises in
!
quw6on and
that there are no roadways, transmission Anes or other
visible easements an said property except as Indicated
hereon.
"i
Dated at MMorege. Alaska
the @th dayof June 2006
ar
—
FRED WALATKA 6 ASSOCIATES
BE
(607-248.1666) Engineers and Surveyors
I&
!E4��Sl
SCS ReLN
1062864001
Client Name
Garness Engineering Group, Ltd.
Project Name/R
Norton Park 2 Lot 6 Blk 4
Client Sample ID
Norton Park 2 Lot 6 Blk 4
Matti:
Drinking Water
Sample Remarks:
All Dates/rimes arc Alaska Standard Time
Printed Date/rime
06/152006 13:30
Collected Datefrime
06/062006 11:45
Received Date/Time
06/062006 14:06
Technical Director
Stephen C. Ede
Allowable Prep Analysis
Parameter Results PQL Units Method Contaitm ID Limits Date Date Init
Nitrate -N ND 0.100 mg/L EPA 353.2 B 06/06/06 ALR
Nitrite -N ND 0.100 mg/L EPA 353.2 B 06!06/06 ALR
Metals Department
Hardness as CaCO3 ND
Private Individual Analvsia
Aluminum
ND
Antimony
ND
Arsenic
28.6
Barium
ND
Cadmium
ND
Calcium
ND
Chromium
ND
Copper
10.0
Iron
ND
Lead
0.347
Magnesium
273
Manganese
26.3
Phosphorus
ND
Chloride
7.43
Fluoride
ND
Potassium
ND
Selenium
ND
Sodium
124000
Silicon
11500
Silver
ND
Thallium
ND
Sulfate
1.07
5.00 mg/L SM202340B C 06/07/06 06/09/06 SCL
20.0
ug/L
EP200.8
C
06/07/06 06/09/06
SCL
1.00
ug/L
EP200.8
C
(<6)
06/07/06 06/09/06
SCL
• 5.00
ug/L
EP200.8
C
(<10)
06107/06 06/09/06
SCL
3.00
ug/L
EP200.8
C
(<2000)
06/07/06 06/09/06
SCL
0.500
ug/L
EP200.8
C
(<5)
06/07/06 06/09/06
SCL
500
ug/L
EP200.8
C
06/07/06 06/09/06
SCL
1.00
ug/L
EP200.8
C
(<I00)
06/07/06 06/09/06
SCL
1.00
ug/L
EP200.8
C
(<1300)
06/07/06 06109/06
SCL
250
ug/L
EP200.8
C
(<300)
0107/06 06/09/06
SCL
0.200
ug/L
EP200.8
C
(<15)
0107/06 06/09/06
SCL
50.0
ug/L
EP200.8
C
06/07/06 06109/06
SCL
1.00
ug/L.
EP200.8
C
(<50)
0107106 06/09/06
SCL
200
ug/L
EP200.8
C
06/07/06 06/09/06
SCL
0.100
mg/L
EPA 300.0
B
(<250)
06/07/06 06107/06
DSH
0.100
mg/L
EPA 300.0
B
(<l)
0107/06 06/07/06
DSH
500
ug/L.
EP200.8
C
06/07/06 06/09106
SCL
5.00
ug/L
EP200.8
C
(<50)
0107/06 06109/06
SCL
500
ug/L
EP200.8
C
(<250000)
06107/06 06/09/06
SCL
200
ug/L
EP200II
C
0107/06 06/09/06
SCL
1.00
ug/L
EP200.8
C
(<I00)
06/07/06 06/09/06
SCL
1.00
ug/L
EP200.8
C
(Q)
06/07/06 06/09/06
SCL
0.100
mg/L
EPA 300.0
B
(<250)
06/07/06 06107/06
DSH
SCS ReEN
1062861001
All Dales/Times are Alaska Standard Time
Client Name
Ganness Engineering Group, Ltd.
Printed Date/time
06/15/2006 13:30
Project Name/#
Norton Park 2 Lot 6 Blk 4
Collected Date/time
06/06/2006 11:45
Client Sample ID
Norton Park 2 Lot 6 Blk 4
Received Date fime
06/062006 14:06
Matrix
Drinking Water
Technical Director
Stephen C. Ede
Allowable Prep Analysis
Parameter Results PQL Units Method Container ID Limits Date Date Init
Private Individual Analvsis
Total Dissolved Solids
Zinc
Nickel
HCO3 Alkalinity
CO3 Alkalinity
OH Alkalinity
Conductivity
PH
Alkalinity
Total Coliform
306
10.0
mg/L
SM20 2540C
D
(<500)
06/08/06
KP
ND
5.00
ug/L
EP200.8
C
(<5000)
06/07/06 06/09/06
SCL
ND
2.00
ug/L
EP200.8
C
(<I00)
06/07/06 06/09/06
SCL
252
40.0
mg/L
SM20 23208
D
06/06/06
XZ
ND
40.0
mg/L
SM20 2320B
D
06/06/06
XZ
ND
40.0
mg/L
SM20 23208
D
06/06/06
XZ
470
1.00
umhos/cm
SM202510B
D
06/06/06
CRY
8.00
0.100
pll units
EPA 150.1
D
(6.5-8.5)
06/06/06
CRY
252
40.0
mg/L
SM20 2320B
D
06/06/06
XZ
0
coU100mL
SM20 9222B
A
(<I)
06/06/06
TLF
GARNESS ENGINEERING GROUP, Ltd.
CONSULTANTS 8 GENERAL CONTRACTORS
June 30, 2006
Municipality of Anchorage
Development Service Department
Building Safety Division
On -Site Water & Wastewater Program
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: COSA for Norton Park Subdivision 42; Lot 6, Block 4.
To whom it may concern:
A site visit was performed on 6/6/2006 to perform a well adequacy test to obtain a COSA from
your department. During our research of the property a well log was not found. Per previous
HAA's the well was drilled prior to 1975 and has a total depth and is cased to 76 feet. As -built
documentation of the sewer main that runs along W. 123 Avenue was found and was installed in
4/8/1975. This drawing shows that our well was in existence when the sewer main was installed.
Attached are several well logs from adjacent properties that show casing depths of over 40 feet.
Based on this information it is assumed the casing depth of the well on the referenced property is
over 40 feet.
-Norton Park Subdivision; Lot 7, Block 4: Total casing 60 feet.
-Norton Park Subdivision; Lot 8, Block 4: Total casing 61 feet.
-Norton Park Subdivision; Lot 6, Block 1: Total casing 380 feet. Perforated from 78-85 feet.
-Norton Park Subdivision; Lot 16: Total casing 109 feet.
-Norton Park Subdivision; Lot IA, Block 2: Total casing 64 feet.
If you have any questions, please contact us at 337-6179. Thank you for your assistance.
.E., M.S.
3701 E. Tudor Road, Suite 101 ' Anchorage, AK 99507
Ph: (907) 337-6179' Fax: (907) 338-3246 • Website: gamessengineering.com
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W. HUFFMAN RD. _ _ _E. HUFFMANRD.—
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296
SEE OVERVIEW MAP 1' '310 312
324 COPYRIGHT 2003 JAR
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W. HUFFMAN RD. _ _ _E. HUFFMANRD.—
ORCHD:—__—_-------_--WEST.4P CAST -- 1 O
GR 2730 SW 114, SECT. 19. T12N R3W
296
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324 COPYRIGHT 2003 JAR
• l'
(907) 243.2282
KENJOHNSON
001
MUNICIPALITY OF ANCHORAGE
KEN'S COMPANY EWRONMENNTAL PROTECTION
WATER WELL DRILLING
PUMP SALES 8 SERVICE FED 2
30 YEARS ALASKA DRILLING 3 3 LINDEN DRIVE
KJ ' ALASKA 99502
March 60 1984
AL1AN KLATT
S.R.A. BOX 171
Anchorage, Alaska 99575 ( 274- 4457) ( 344- 2088 )
Res Lot 1 A Blk. 2 Norton Park Subd.
0 it
to' 3 ft
3ftto6ft
6 it
to
12 ft -
12 ft
to
35 ft
35 ft
to
38 ft
38 ft
to
39 ft
39 ft
to
1 ft
41'ft
to
43•ft
43 St
toS1
ft
51 ft
to
64 ft
64 ft
to
64-4. ft
64-4 ft to85 •ft
WATER WELL LO
Frozen brown silt -with organics
Brown silt & med. gravel
Course grave a brow* silt
Course gravel and gray silt ( tight )
Same with more gray silt
Same with slight weep H2o no good.-.
Course gravel and gray silt
Same with more silt
Med. gray t clay
Course grav and gray silt
Some water bearing fine grav & sand ( med. )
one GPM with 12 ft head
Clay
Set 060 Slot screen with 5 inch tail pipe and K packer-
( See DRAWING FOR DETAILS )
Over night Static water level 20-6 from Ground Level
No Sand came in while setting screen
Surge 5 min. and bail out I # inches sand
Surge 10 min. -Bail out 8 inches sand
Surge 15 min Bail out i ft .
Surge 30 min 2 ft. Sand.. Material indicates no more surging.'
Test bail
100% drawdown
Reoovers At 1.5 GPM
Set test pump.
Well Yields 2.0 GPM
with draw down to 60 ft.
Total depth 85 fte.
Top of K packer 60-2 inches .*GL
Total 6 inccasing 64 ft 5 inches
18 ft 3 in. of 5 in# tail pipe on screen bottom
Bottom of screen 66 ft.
Top of screen 60 ft.
Three ft of screen exposed to formation .66 ft to 63 ft.
( See drawing )
ti
3U
W
F,I
RET LOT 7 BLK 4 NORTON PARK SUBD. ( 321 123rd )
0 ft to 8 ft
8 ft to 11 ft
11 ft to 18 ft
18 ft to 22 ft
22 ft to 33 ft
33 ft to 34 ft
34 ft to 40 ft
40 ft to 44 ft
44 ft to 48 ft
48 ft to 58 ft
58 ft
TOTAL CASING 60 Ft.
Static water level
Pump set at 53 ft
Time GPM Water
NATER WELL LOG
Brown silt with some course gravel
Course grav with some brown silt
Course grav & gray silt
Same with courser grav ( tight )
Same with cobbles
Course grav & gray silt ( 1' open )
Same with trace of clay
hied. grav with dark gray clay ( 2' open )
Weep in H2O overnite.. 14' static GL
Bail dry.. poor recovery..
Course grav & gray silt ( dry )
Clean med. grav & sand.. Water bearing..
Static water level 14 ft. 0 in TOC..
Test bailed at 10 GPM
Drawdown to 45 ft. Good recovery
Bottom stable..( left 1 ft in casing )
SEE TEST PUMP DATA BELOW..
14 ft 0 in. TOC
1402
KEN'S
COMPANY
WATER
WELL DRILLING
11
36
PUMP SALES
& SERVICE
38
82
30 YEARS
ALASKA DRILLING
3163 LINDEN DRIVE
KEN JOHN
KEN JOHN SON
ANCHORAGE, ALASKA 99502
OCTOBER 11, 1985
DON DEARMOUN
13140 SPECKING
AVE.
ANCHORAGE, ALASKA 99516
( 562-7653)
( HM 345-4506 )
RET LOT 7 BLK 4 NORTON PARK SUBD. ( 321 123rd )
0 ft to 8 ft
8 ft to 11 ft
11 ft to 18 ft
18 ft to 22 ft
22 ft to 33 ft
33 ft to 34 ft
34 ft to 40 ft
40 ft to 44 ft
44 ft to 48 ft
48 ft to 58 ft
58 ft
TOTAL CASING 60 Ft.
Static water level
Pump set at 53 ft
Time GPM Water
NATER WELL LOG
Brown silt with some course gravel
Course grav with some brown silt
Course grav & gray silt
Same with courser grav ( tight )
Same with cobbles
Course grav & gray silt ( 1' open )
Same with trace of clay
hied. grav with dark gray clay ( 2' open )
Weep in H2O overnite.. 14' static GL
Bail dry.. poor recovery..
Course grav & gray silt ( dry )
Clean med. grav & sand.. Water bearing..
Static water level 14 ft. 0 in TOC..
Test bailed at 10 GPM
Drawdown to 45 ft. Good recovery
Bottom stable..( left 1 ft in casing )
SEE TEST PUMP DATA BELOW..
14 ft 0 in. TOC
1402
7.5
•.
1414
11
36
1420
11
38
1425
10+
38-6
Recovery
One min. 33 ft
two min 29 ft
three min 26 ft
four min 23 ft
five min 20-9
level REMARKS
Clean
Dirty ..Clearing
Light cloudy , trace of sand
Clear
Clean & clear
Installed 1/3 HP Fairbanks morse
Mod 383310 Submersible at 55 ft.
)IUNICIPALTTy OF ANC)40401
DEPT. OF HEALTH s'
ENVIRONMENTAL PROTECTION
FES 0 31986
RECEIVED
LOCATION OF WELL
FM
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
DIVISION OF MINING & WATER MGMT
WATER WELL RECORD
BOROUGH
aU DIVISION
Qan�-
t
BLOCK
SECTION OTRS
SECTION
TOWNSHIP
ON
OS
RANGE
OE
OW
MERIDIAN
LOCATION/SKETCH:
(."3.\R e r_Lr L�
WELL OWNER:
DEPTHS MEASURED FROM:Masing top Oground surface
WELL DEPTH: / DATE OF COMPLETION
Depth of hole: it —••��•"" "�—�.
Depth of casing:_: tr t i� l i ��l • 9 +
BORgHOLE .DATA: Depth /
Material Type and Color' From To..
} •
1 Iyi+Gl —Gl
®
2
DEPTH TO STATIC WATER LEVEL:
1t below Atop of casing 13 ground surface
�%A d+✓�!
^,Date:
G
METHOD OF DRILLING: b air rotary O cable toot
O other
i
/
J;$
-Sir
USE OF WELL: %0 domestic O irrigation O monitor
O public supply O other
GT
..�+.•--.e%[� l/stl,.i,�
.
CASING STICK-UP: 2 }L Diam: -i in. tout
Casing type: in. t0 _&I ft
i
WELL INTAKE OPENING TYPE: open end O screened
O perforated O open hole
Depths of openings: to it
SCREEN TYPE: Diam: in.
Slot/Mash Size: Length: IT
• �.. _._..•—. ... :.....,
GRAVEL PACK TYPE: _.
Volume used: Depth to top:
RECEIVED
GROUT TYPE: Volume:
Depth: from It to it
JAN 9 Ick'
DEVELoOPMENT METH .A
u "C'ily 577711M
OBpLIHGafth Y.. Human Sirvices
617—
PUMPING LEVEL AND YIELD:
1t atter / hrs pumping Qpm
PUMP INTAKE DEPTH: It Horsepower:
WELL DISINFECTED UPON COMPLETION? AYES O NO
CONTRACTOR INFORMATION:
REMARKS:
ar-R l'1�1r�i dr/..moi ra�*r�
Rep st rr 0 business Na a
bignature o utnonzea'esp�iveatl;i e
PLEASE MAIL WHITE COPY OF LOG TO:
DNR/DIVISION OF MINING & WATER MGMT
PO BOX 107005
ANCHORAGE AK 99510.7005
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ADL I*DLAq
VATER "LL D:1ILLlw"'L9 IAM
13809
Aron
IIse of well,
or distant
8tatio water level toot (above)(belov) land snrfsoo. riniob of well (oheek
woe) open owseroen ( ): Perforated ( ). N ��• -- OG/0655�5
cowwwaparte _
pail pe 4 ka tast ot�cnn perlh��r eAlauu Yor aware rrl,
_fee of drasdosn fsm otatio level
flerarks .
&Npw in Iwo, iii .rarer uww " .♦ waw v-
grdrisd trimee a td Nuxvleana. _
to
... to _l
Si to.. "
to
DEPT. OF HEALTH 6
:e ENVIRONMENTAL PROTECTION
ad HAR ' 1086
to REGE WED
to
610
to
to
MUNICIPALITY OF ANCHORAGE
O 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 l.D.MC'11--:a 11-dzR HAA# -iCy)w�-��1•(-
GENERAL INFORMATION
Complete legal description Le F 6� 81c c tc '/ NorkA Part: 4Wn vr2
Location (site address or directions) 310 W. 123rd ave
Property owner 41Scc Cacr/rS E Toe Full Day phone
776- S"6/9
Mailing address
P•o. "36x
30L!Z F•Ctna;
741—, 99611
Lending agency
Pre -ser
morf 4,f (kOw'y
494.%v) Day phone S-63 -777
Mailing address
3000 "A"
S><� S«,Fe toz
AACAOrepf A -k 99603
Agent H• h- Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
E
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.
72-0251Rw. 1/911 front MOA 021
S. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I Iurtherverify 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 EtaF/o/r Tech n'rcal SPrvt' cel Phone 3 S's- r 3s5 -
Address /HS30
Ectio V.
A^ chor�f4
Al< 99516'
Engineer's signature
��
m""�
Date OCA 5 er 16 199s
6. DHHS SIGNATURE
Approved for
Disapproved.
AM
�' .� •' ... - c A
40 ... ............... .
j--Tz'..e
V
r
bedrooms.
Conditional approval for
Additional Comments
•
�.nl �• FY
a 4 ix Y Y G
bedrooms, with the following stipulations:
Date /'0 • /
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 engineers work.
72425 (A.. 1/91) 8. k MOA qt
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: t—of!:} Wky Na46n Park #Z Parcel
A. WELL DATA
Well type Prevalti If A. B. or C. attach ADEC letter. ADEC water system number
Log present (Y/N) N Date completed pre—(97r
Total depth 76' Cased to 76' Casing height (above ground) 2'
Sanitary seal (Y/1) Y
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS
g.p.m.
Wires properly protected (Y/N)
AT INSPECTION o 0
Coliform _Q rof//oam'e Nitrate L o. /neo%Q Other bacteria IVany cmarw
Date of sample: 10/re/9s. /0/1`3/9t Collcctcdby: F/af/a/, Tir6 Svc
B. SEPfIC/HOLDLNGTANK DATA N.A. (P.tslic Sewer)
Date installed Tank size Number of Compartments Cleanouts (Y/N)
Foundation cleanout (Y/N) Depression (Y/N) High water alarm (Y/N)
Date of Pumping Pumper
C. ABSORPTION FIELD DATA N. A. ( Pub he Seeger,
Date installed Soil rating (g.p.d.M2 or ft'/bdrm) System type
Length Width Gravel thickness below pipe Total depth
Effective absorption area Monitoring Tube prcscnt(Y/N)_ Depression over field (Y/N)
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before test (in.); Immediately after_ gal. water added (in.):
Fluid depth Minutes later: (in.) Absorption rate a ¢.p.d.
Peroxide treatment (past 12 months) (Y/N) If yes, give date
D. LIFT STATION N. A.
Date installed
INanholc/Acccss (Y/I)
High water alarm level at"
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/Itolding tank on lot N. A. C Pub Ice Ceauer� ; On adjacent lots
Absorption field on lot — ; On adjacent lots
"Pump off' level at*
Public sewer main I9 I�Op.o:id /zd/£6,� Public sewer manholc/cleanout 60
Sewcr /septic service line >fo' Per p ewemw HAA'r Lift station
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
Foundation
Property line — Absorption field
—
Water main/service line — Surface water/drainage — Wells on adjacent lots =
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation
Surface water
Curtain dmin
F. ENGINEER'S CERTIFICATION
Water main/scrvicc litre
Driveway, parking/vchicle storage area
Wells on adjacent lots
J certify that l have determined thru field inspections and review ofAlunicipal records
in conformance with A10A lU4 guidelines in effect on this date.
Signature J�.1.-eG,t,
Engineer's Name 'iAeoe(ore F. l-Ttio
Date Oc{yber /6. /99,r-
HAA
99f
HAA Fee S 300 //
Date of Payment it) 1 b A15-
Receipt
1SReceipt Numbers //,,
Rev. 8/95 OSS: haa.wk.doc 6
Waiver Fee S
Date of Payment
Receipt Number
are
..................
THEODOf.E F. MOORE
CE -3589
MUNICIPALITY OF ANCHORAGE i.
• DEPARTMENT OF HEALTH & HUMAN SERVICES
I { Division of Environmental Services " • ' 1
On -Site Services Section ,
P O. Box 196650 .Anchora a Alaska 99519-6650
CERTIFICATE OF HEALTH A(J ORITYr=
'%' APPROVAUFOR A'SINGLE FAMILY DWELLING
4 ParcellD # t HAA# ShZlqL\h�t`ln
1 GENERAL INFORMATION
r . Complete legal description" LoT'.6. BLK.'4�
Location (site addressor directions), 310 = W, 123 r°I AVE
"
ORA 6E Al .
Property owner TODD" �AcoI35oN ` Day phone 272 -5451
Mailing address 310 1U.`'123'dA✓f`� Arycf/ AI< " g951S
Lending agency Ak `'u oME ` MORTGAGE yphone
Mailing addressP D [Sox /9685 i4 " P , ;4-k. 99s,9
Agent
Day phone
Address ;
Unless otherwise requested, HAA will be held for pickup.
} it �i, :a: � ,. n• is ". ' -` . , .
. rr
2
NUMBER OF BEDROOMS: 2
3.. TYPE OF WATER SUPPLY:
,> _
Individual well.
41
'Community well
Public water
If e wimen confirmation from State ADEC attest'
NOTE: inc to he le a ityand system, at srofis
Ing g ystem _
4" TYPE OF WASTEWATER DISPOSAL
Individual on site
_ ;.Holding tank. , r
Community on site7:7t \"
`Publicseweri'
NOTE:-- If community wastewatersystem, provide written confirmation from State ADEC
attesting to fhe legality and status of system.
rxanm«.uv{t Fw! Mwm
J
5. STATEMENT„OF INSPECTION BY'ENGINEER \
As certified by my seal affixed hereto and as of the validation date shownbelow, 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; functwnat and adequate for the number of bedrooms
and type of structure indicatetl herein. I furtherverifythat based on the information obtained from
_ the Municipality,of Anchorage files and from mytlnvestigation and inspection, the on site water
supply and/or wastewater,disposal
• pp y system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection
Name of Firm FLA i TO TEGN S✓c5. Phone S45'--13657
'Address 14530 ECHO ST ANGN. Ak 995f6
;Engineers signature
T � t._ Y -� Date &a/ 210 199Y
r.......„ .........:..::... �' �;' P
i=? .........? a
I r I
_0! 1:THEODORE F..R100RE ;�-:t�/_.
._ ... '
d y4y �•i C t
3539 ... - -t•,
6. ” DHHS SIGNATURE
�• Approved for .bedrooms.•'
Disapproved
Conditional approval for bedrooms, with the following stipulations:
7
a
• Additional Comments
' By. Date )
ItlTlr
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
sati .. Y not
andtheirlendinginstitutionsinordertosatis certain federala'dstate requirements. Employees
conduct inspections or analyze data before a certificate is issued The Municipali of Anchorage tsknot
responsible for errors or omissions in the professional engineers work i ,
72-=ta«.1v1i 6.k uOAm
�.. tris _.....
® Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LOT (,� BLk 4 NORTON PARk Parcel I.D.
A. Well Data
Weti type PRIVATE If A, B, or C, attach ADEC letter. ADEC water system number N.A .
Log present (Y/N) N Date completed PRE 1975 Driller V NkNownl
Total depth 7(0 Cased to 76 Casing height 2 '
Sanitary seal (Y/N) y Wires property protected (Y/N)
Date of test
Static water level
Well flow
Pump levelt
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
t
gllsl94
1-7
7 3.,q
is
Ec
O m
Z
Septic tholding tank on lot N .A . ; On adjacent lots N .A .
Absorption field on lot N . A . ; On adjacent lots
Public sewer main 19, * Public sewer manhole/cleanout (00 ,
Sewer service line >lo' PER PREviouS NAA's Petroleum tank NordE OBSERVED
WATER SAMPLE RESULTS: )r WAIVER APPROVED 3/26/uo
Coliform O col /loom.( Nitrate L o. / mu/X Otherbacteria none rogorf�c-C
Date of sample: 1+11514 Collected by: FLATTOP TECH 5✓C5.
B. SEPTIC/HOLDING TANK DATA N./}, ( A w wct Sequel)
Date installed
Tank size Compartments
Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (YM)
High water alarm (Y/N) Alarm tested (YM)
Date of pumping Pumper
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK TO:
Well(s) on lot
On adjacent lots Foundation
To property line Absorption field Water main/service line
Surface water/drainage
72-M rWA•Fmnt CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on' level at "Pune off" Level at
High water alarm levet Cycles tested
Meets MOA electrical codes (YIN)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots Surface water,
D. ABSORPTION FIELD DATA N.A. Sewer�
Date installed Soil rating (GPD/Ft) System type
Length Width Gravel thickness Total depth
Total absorption area Cleanout present (Y/N) Depression over field (Y/N)
Date of adequacy test Results (pass/fail) for Bedrooms
Water levet In absorption field before test After test
Peroxide treatment (past 12 months) (YM) if yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot On adjacent lots Property tine
To building foundation
To existing or abandoned system on lot
On adjacent lots Cutbank Water maintserviice line
Surface water Driveway, parkingivehicle storage area
Curtain drain
E. ENGINEERS CERTIFICATION
I cer* that I have checked, verified. or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
OF A i tr r
Signature
Engineer's Name TheocPorY F. moon
Date 4er71 20 r99Y
HAA Fee $ 300
Date of Payment'
Receipt Number
72-M C&W)• Bade
T11EODCnE F, BOOR:
CE -3549
°')a..�••"."..•• moo:
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALANCHORAGE
DEPARTMENT OF HEALTH
b HUMAN SERVICES ti1�
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. # 616— 2 �� J HAA # f�L_
1. GENERAL INFORMATION
Complete legal description
Lot 6; Bock 4; Nocton PoAk Add. Unit 2
Location (site address or directions) 310 East 1234d Avenue
Property owner H.U.D. #111-031895 Day phone
Mailing address
Lending agency
Mailing address
Day phone
Agent Sandy ASSOCIATED BROKERS Day phone 563-3333
J).q AnnhgAirna Ab. 22SO3
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: el
3 `�
3. TYPE OF WATER SUPPLY:
Individual well Xx
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer Xx
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(Ra.1191) front M0A.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 Phone
5 & 5 ENGINEERING
Address
River, Alaska 99577
Engineer's signature
6. DFIkiS SIGNATURE
LY _ Approved for �r 3 bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Date
No. lIS7•E
bedrooms, with the following stipulations:
By:
. ,. Date I'—
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.
naa(n...iA» 8• MOA.:i
4 Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:AAL2-Nc,A-t1rfoel�ArKA z Parcel I.D.
A. WELL DATA
Well type 6t*,JsFs�J4 If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) 10 o Date completed -- Pie I q q 65- Drillery f(
Total depth b Cased to -4 Casing height 12 � +
Sanitary seat (Y/N) V Wires properly protected (Y/N) u
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
�3 J:LiiNI►1�]I��IiJ.Lc:101111iiolky, *4111111][93
p.m.
AT INSPECTION
Septic/holding tank on lot WA ; On adjacent lots 4r) '-f
Absorption field on lot � �' A ; On adjacent lots no /+
Public sewer main i5 Public sewer manhole/cleanout 100
Public sewer service line (� ,t Petroleum tank ►J 0 0 e- (�iJO W /J
WATER SAMPLE RESULTS: � �
Coliform SRI�''�A er-1 Nitrate 6A I&C:lW!1 — Other bacteria Z Gro
Date of sample:=0 2 - `1 j Collected by:
B. SEPTIC/HOLDING TANK DATA J)"fiG Se"J)Cr
Date installed
Cleanouts(Y/N)
High water alarm (Y/N)
Date of pumping
Tank size
Foundation cleanout (Y/N)
SEPARATION DISTANCES FROM SEP C/F
Wells) on lot On adjac
ToproPertyline 'Absorption
Surface water/drainage
Compartments
Depression (Y/N)
Alarm tested (Y/N)
OLDING TANK TO:
lots Foundation
main/service line
nose(R«.M)Fwl MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installe
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical copi (Y/
SEPARATION DISTANCE FROM LI
Well on lot
D. ABSORPTION FIELD DATA
Manufacturer
_ Manhole/Access (Y/N)
'Pump off' level at
Cycles tested
TATION TO:
On cent lots .
Surface water
Date Ins lied
Soil rating System type
Length Width
Gravel thickness Total depth
Total absorption ea
Cleanouts present (Y/N)
Depression over field /N)
Date of adequacy test
Results (pass/fail)
for bedrooms
Peroxide treatment (Past 12 mogtn
(1{ f) If yes, give date
SEPARATION DISTANCE FROM AB RPTION FIELD TO:
Well on lot
Ona ' cent lots Property line
To building foundation
To existing or abandoned system on lot
On adjacent lots
Cutbank Watermain/service line
Surface water
Driveway, p king/vehicle storage area
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified,
or conformed to all MOA and HAA guidelines In effect on the date of this Inspection.
Signature S V S Sh"111LE81MG j
rx
17034 Eaalo RiverLoop Road No, 204
r. r
Engineer's NaTI. I R*
Date
e
f�
HAA Fee $ (
Date of Payment 1 S q
Receipt Number
72-M (R". a'91)auk MOA 21
Waiver Fee: $ —
Date of Payment
Receipt Number
.. .........
'aM e,
obA. Shaf•••.�••'f
No. W74
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 i $ /st"
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
L0t_ jCA NQS EG I G T 12N. R 3 Vfi
Location (address or directions)
__310_W/ 12a rA "JA . A 1C Q4' 5iS
(b) Applicant Name Telephone: Home Business 64^2-7 5
Applicant Address 1!j (3 O sPr�kIM_9
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder De; Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
ILO WD
2. TYPE OF RESIDENCE
Single -Family Multi -Family ❑ Other
Number of Bedrooms 2-
3. WATER SUPPLY
Individual Well Community ❑ Public ❑
Note: It community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ❑ PublicX 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 ube41
%
5. ENGINEERING FIRM PROVIE�A INSPECTIONS, TESTS, FILE SEARCH, �`A AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and Inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm / e 6�Z� —SPOT-
� Telephone —per -3
',�, • F• `l�sfl00
ll
Engineers Seal
r.......
��•s P 2225-E •� a-
JU,l _ 2.,. 1971
,..
.•"••" a
i M.`L
6. DHEP APPROVAL
Approved for bedrooms by `�--� """� Date
Approved Disapproved Conditional
Terms of Conditional Approval
CAUTION
3 - 26 —S:o
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 engineer's work.
Page 2 of 2
72 025 (11184)
MUNICIPAUTY 1XANO: ;'!AGE
n DEPT. OF HEALTH a
MUNICIPALITY OF ANCHORAGE (MOA) :f*lWNMENTAL MTE ,rJN
HEALTH AUTHORITY APPROVAL (HAA) E E B 0 31986
CHECKLIST - FEBRUARY 1884
264-4720�+ �••
Legal Description:
cription: I -O T (o PA
r (3 '=[fes— 0 I�j) I
fes- Q gg-
A. WELL DATA
Well Classification _P_ E S If A, B. C. D.E.C. Approved (Y/N) u��
Well Log Present (Y/N) lt`0 Date Completed �eLc 1476 Yield CPN �J rT DD
Total Depth % Cased to 76, Depth of Grouting No"r_-`'
Static Water Level 07 D Pump Set At
Casing Height Above Ground o2 Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
Depression Around Wellhead (Y/N)
N
To Septic/Holding Tank on Lot KLA ; On Adjoining Lots N/s�
To Nearest Edge of Absorption Field on Lot N On Adjoining Lots
To Nearest Public Sewer Line �L7� To Nearest Public Sewer
Cleanout/Manhole —,�_lo T) To Nearest Sewer Service Line on Lot )'10
Water Sample Collected by T S ; Date /�/ y/& -G
Water Sample Test Results
Comments
G 4
B. SEPTIC/HOLDING TANK DATA N0 N C
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Size
_ Air -tight Caps (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High -Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well _
To Property Line
To Water Main/Service Line
Course
Comments
Page 1 of 2
72-026t11,841
No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
C. ABSORPTION FIELD DATA (qO N C
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION N O N LZ -
Date
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present(Y/N)
Date of Last Adequacy Test .
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
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
Icertify that Ihave checked,verifi ,or conformed to all MOAand HAAquidelines ineffectonthedateof this inspection
Signed Date
Company MOA No.
Receipt No. `10(03% /t ^'+�
Date of Payment — ^ ��` • ! r 11,
Amount: $ 6 0� * ; ^ T_`I Engineer's Seal
%..�!�•�i c ^ i
rr.�. 0.�222�-E
Page 2 of 2 fil
,.4
72-026 411,84)