The URL can be used to link to this page

Home My WebLink AboutSAMPSON ESTATES BLK 3 LT 5Sarnpson Estates Block 3 Lot 5 #051-811-31 Jan.4, 2021 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: Septic Permit Legal: SAMPSON ESTATES BLK 3 LT 5 To whom it may concern: This is a request for a septic tank permit on the above referenced lot. The new tank is closer than 10 feet from the building foundation but outside the building bear area. The bottom elevation of the tank is 7.5 and the bottom of the foundation is 4 feet with a proposed 8 feet between the two therefore no structural impact to either of the systems. The granting of this tank permit will not impact any of the surrounding neighbors. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201509, Rebecca Carroll, 01/08/21 MUNICIPALITY OF ANCHORAGE 72-013 DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-0720 ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME • PHONE EW 1 SHASTA GOht 7� aG!/o A/ �'%/�!/i�/I ❑UPGRADE MAILING ADDRESS 71'o - 7 7 -7 6 9/ LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS %.fe rr L r C k 3 DISTANCE TO: Well i.,eD f Absorptionarea Dwelling / PERMIT NO. O le 40356 6Z Manufacturer /��E,� 6: Material No. of compartments N,a S Tee-/ Liq, capacity in gallons IF HOMEMADE: Inside length Width Liquid depth .ov tj Y DISTANCE TO: Well Dwelling PERMIT NO. I .102 0 f Manufacturer Material Liquid capacity in gallons w= DISTANCE TO: Well S.FC G f Foundation / Nearest lot line PEHMIT NO. 9E W Z No. of lines/ Length of each line / Total length of lines Trench width Distance bet n lines s_ W .'Z inches N C f.. Top of tile to finish grade Material beneath the 79 Total eflectve absorption area inches fs Length Width Depth PERMIT NO. i W i F Type of crib Crib diameter Crib depth Total effective absorption area I rn DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERMIT NO. J 3 DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER ' PIPE MATERIALS i 1A roved 4-CTM IWC SOIL TEST RATIN /?,Y,/ w _,., INSTALLER s A/,x4 i REMARKS TI � Cl to g r.. ...... •a: 4( FiOR GE Aff IT I" : '• OF HEA o• N 2225-E DEPT. :� yII , O ECT ON TO`2 e AJiL�,-00 • 1(�Ot I l APPROVED DAE LEGAL `//z�974- % 72-013 fRev. 3/78) 'Ai1 MIJM I C I O SIL I Tyr• F AtJCH¢RFIGE DEPARTMENT CP^4EALTH AND ENVIRONMENTAL I )TECTION 825 L STREET, ANCHORAGE, AK 99501 . 264-4720 GM—S I TE 'SEWEF2 PERMIT NO: DATE ISSUED: APPLICANT ADDRESS: CONTACT PHONE 840396 05/29/84 SHASTA CONSTRUCTION BOX 7732 EAGLE RIVER, AK 99577 694-4961 .96 WELL PEFZMIT LEGAL DESCR.IP: dSIIBDIVISION: SAMPSON ESTATES LOT: 5 BLOCK: 3 SECTION: 3 TOWNSHIP: 15N RANGE: 1W LOT SIZE: 43560 (SQ.FT. OR ACRES) MAX BEDROOMS: 3 i LISTED BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR SEPTIC SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR -SITE. — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — TFZEt.FCH BEI' W. E>FZFFV I tJ DEPTH TO PIPE BOTTOM (FT.) 4.0 4.0 4.0' GRAVEL DEPTH (FT.) 6.5 0.5 3.5 TOTAL DEPTH (FT.) 10.5 4.5 7.5 GRAVEL WIDTH (FT.) 2.5 21.0 5.0' GRAVEL LENGTH (FT.) 45.0 42.0 63.0 GRAVEL VOLUME (CU. YDS. ) 29.1 32.6 46.6 TANK SIZE <GALS) 1,000.0 ** 1,000.0 ** 10000.0'** .SOIL RATING (SQ. FT. /BR) 194 193 194' ** TANK MUST HAVE AT LEAST TWO—COMPARTMENTS — — — — — — — — — — — ( — — — -- ,I CERTIFY THAT: I 1. I'AM FAMILIAR'WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELLS'AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE (MOA) AND THE STATE OF ALASKA. 2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS, AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. 3. I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL SYSTEM OR,PUBLIC SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR. NEARBY LOT. 4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 3 BEDROOMS AND ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT. i IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, 'THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS !WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3)'THE ELECTRICAL WORK MUST BE DONE BY A.LICENSED ELECTRICIAN.• i SIGNEDDATE: ---------- APPLICANT: SHASTA CONSTRUCTION ISSUED BY �{. DATE: -------- ----- �'+ ^ 'K SO ILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 1 625 L. Street, Anchorage, Alaska 99501 2644720 SOILS LOG - PERCOLATION TEST PERFORMEDFOR: 5144.tt^ �o'rs�'7`-rs.G'f-/ DATE PERFORMED: In4y LEGAL DESCRIPTION: Gf ��/�` SG..,�n Sln •SN be/&" %%$-/j/ Ae/ i SGG 3 1 2- 3 3- a ii 1 Net 4 �o Time Time 5- Drop 6- 67 � ■I■■EMSM009 / 7- 5:79 ■I■UE■■■■■N /� i l SP'GP) 8 81 ■0Y.■■■■■■1, 9 10 11 12 13 14 15 rt h,/G ,6 01 17- �ti e..lwV ski 18 ....... ....• •r 19 /(^ •• ••2225-E • �� AJNE 25,1971 41 COMMENTS SLOPE SITE PLAN ■■■■■■M■■■. Date Gross Net Depth to Net Time Time Water Drop S��T�rc/ � ■I■■EMSM009 / 5:79 ■I■UE■■■■■N /� i ■r,,,M M■■■■■M ■0Y.■■■■■■1, ■II■__M■■■■■■11 NMENEENEW ■■■■RN■■■■ Reading Date Gross Net Depth to Net Time Time Water Drop S��T�rc/ � /`• / 5:79 /C w.,; /� i 4-10 ?4AL PERCOLATION RATE �/'^ (minutes/inch) /Is- _11✓1I q TEST RUN BETWEEN S FT AND 6 FT a/- AJk 0% C /'AfPrc ts./r zn,6�_* lAet44. A/ -Sr< �r✓/ns sT or�'." o PERFORMED 9Y: L 6i. 7E.^ CERTIFIED 72.006 (6/79) O i >- DATE: ST $1l— D u I MUNICIPALITY OF ANCHORA Development Services Department On -Site Water & Wastewater Section Parcel I.D. 051-811-31 1 Certificate of On -Site Systems Approval Expiration Date: _q' GENERAL INFORMATION Complete legal description SAMPSON ESTATES BLK 3 LT 5 Location (site address) 22679 SAMPSON DR, CHUGIAK AK Current property owner(s) BEN & BARBARA EATON Dav Dhone Mailing address 20610 DAVID AVE, EAGLE RIVER AK Real estate agent 2. TYPE OF DWELLING: 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 Private Well El Private Septic rx� Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer [] Waiver request for: Distanc Received by: Date: CASA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 550 Waiver Fee $ Date of Payment12-0/ - Zi Date of Payment Receipt Number 6730 1 �/ Receipt Number COSA # OSC211022 Waiver # C Phone: 907-343-7904 Fax: 907-343-7997 DISPOSAL: 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify t on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this on-site water supply and/or wastewater disposal system is (are) safe, functional and a bedrooms and type of structure indicated herein. i further verify that based on the info Municipality of Anchorage files and from my investigation and inspection, the on-site wate disposal system is (are) in compliance with all applicable Municipal and State codes, ord effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify Name of Firm MIKE N ANDERSON, P.E. Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. 6. DSD SIGNATURE System #1 Approved for 3 bedrooms System #2 Approved for bedrooms Disapproved 3t my investigation, based pplication, shows that the aquate for the number of nation obtained from the supply and/or wastewater ances, and regulations in e information submitted. Phone 72;-8864 Date 1-15J21 Conditional approval for bedrooms, with the following stipulati nn'�lti��,1�4 R C J/JJ��O �Kx B Original Certificate Da -2- The 2 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approv (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. T e Municipality of Anchorage is not responsible for errors or omissions in the professional engineers work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet 1 �• f.�,• 4ICi-AXt d N. C 9 •U 49z Conditional approval for bedrooms, with the following stipulati nn'�lti��,1�4 R C J/JJ��O �Kx B Original Certificate Da -2- The 2 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approv (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. T e Municipality of Anchorage is not responsible for errors or omissions in the professional engineers work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet • Legal Description: SAMPSON ESTATES BLK 3 LT 5 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA Well log is filed with Onsite (or attached) Date drilled 6116184 Total depth 140 ft Cased to 140 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 30"+ in. Date of flow test for COSA 12122/20 Static water level at beginning of test 121 Comments B. TANK DATA Age of tank(s) 2020 years Tank type/material ft. Measured operating fluid level in septic tank NEW ❑ Standpipes/foundation cleanout per record drawing Date of pumping * new plastic septic tank installed D. ABSORPTION FIELD DATA Which system tested (date installed) 1984 ❑ ALL standpipes present per record drawing Total measured depth from grade 10.5 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A— pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced 0 gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel Structure served by this Well production at time of test Water storage tank volume 0 Well disinfected for coliform to Al Coliform bacteria is Negati, Nitrate 7.63 mg/L ❑ Nitr Arsenic ug/L ❑ Ars Collected by MNA Date of Sample 12122!20 ID: 051-811-31 _g pm gallons ❑ Yes IN No less than MRL (ND) less than MRL (ND) C. LIFT STATION ❑ Required maintenance com' feted I Age of lift station years Lift station material Comments: i I Adequacy test date 12122120 Results ✓❑ Pass For 3 bedrooms Fluid depth prior to test 35 i in Water added 450+ gal New depth 48 in Elapsed time 1440 min Final fluid depth 35 in Absorption rate 450+ gpd Any rejuvenation treatment (pt 12 months) If yes, enter date 1", 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' Community Sewer Manho Absorption Field on Lot > 100' M✓ Yes if No ft Neighboring Absorption Fields > 100' M✓ Yes if Na ft Community Sewer Main > 75' MYes if No ft if No ft 1014 . • .tom • • i r• •..r.r...e.r,. �� 70 Private Sewer/Septic Line > 25 Holding Tank > 100' Animal Containment > 50' Manure/Animal Excreta Storagf From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' P/ Yes if No ft Surface Water > 100' Property Line > 5'Q Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' M✓ Yes if No ft Private Wells > 100' Water Main > 10' f-,71Yes if No ft Community Wells > 200' Water Service Line > 10' M✓ Yes if No ft If septic tank is under drive\ From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' 2]Yes if No ft If absorption field is under d Property Line > 10' ✓M Yes if No ft Wells on Adjacent Lots: Water Main > 10' ✓M Yes if No ft Private Wells > 100' Water Service Line > 10' MYes if No ft Community Wells> 200' Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION / 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 anout > 100' [j✓ Yes if No ft Q Yes if No ft 0Yes if No ft 0 Yes if No ft � > 100' dQ Yes if No ft M/ Yes if No ft ✓Q Yes if No ft Q Yes if No ft mment below way comment below U Yes if No ft Yes if No ft 7 Yes if No ft Neighboring Tank > 100' M✓ Yes • h1FC N. AhDFRSGf,' , `' if No ft 1014 . • .tom • • i r• •..r.r...e.r,. �� 70 Private Sewer/Septic Line > 25 Holding Tank > 100' Animal Containment > 50' Manure/Animal Excreta Storagf From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' P/ Yes if No ft Surface Water > 100' Property Line > 5'Q Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' M✓ Yes if No ft Private Wells > 100' Water Main > 10' f-,71Yes if No ft Community Wells > 200' Water Service Line > 10' M✓ Yes if No ft If septic tank is under drive\ From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' 2]Yes if No ft If absorption field is under d Property Line > 10' ✓M Yes if No ft Wells on Adjacent Lots: Water Main > 10' ✓M Yes if No ft Private Wells > 100' Water Service Line > 10' MYes if No ft Community Wells> 200' Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION / 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 anout > 100' [j✓ Yes if No ft Q Yes if No ft 0Yes if No ft 0 Yes if No ft � > 100' dQ Yes if No ft M/ Yes if No ft ✓Q Yes if No ft Q Yes if No ft mment below way comment below U Yes if No ft Yes if No ft • h1FC N. AhDFRSGf,' , `' From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' 2]Yes if No ft If absorption field is under d Property Line > 10' ✓M Yes if No ft Wells on Adjacent Lots: Water Main > 10' ✓M Yes if No ft Private Wells > 100' Water Service Line > 10' MYes if No ft Community Wells> 200' Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION / 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 anout > 100' [j✓ Yes if No ft Q Yes if No ft 0Yes if No ft 0 Yes if No ft � > 100' dQ Yes if No ft M/ Yes if No ft ✓Q Yes if No ft Q Yes if No ft mment below way comment below U Yes if No ft Yes if No ft • h1FC N. AhDFRSGf,' , `' F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION / 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 anout > 100' [j✓ Yes if No ft Q Yes if No ft 0Yes if No ft 0 Yes if No ft � > 100' dQ Yes if No ft M/ Yes if No ft ✓Q Yes if No ft Q Yes if No ft mment below way comment below U Yes if No ft Yes if No ft � > 100' dQ Yes if No ft M/ Yes if No ft ✓Q Yes if No ft Q Yes if No ft mment below way comment below U Yes if No ft Yes if No ft • h1FC N. AhDFRSGf,' , `' SAW S400 /fro ° SHANEP HOLT 10 L_E,A ,..cey oo vA°foAOR E AS-BU/LT SURVEY f"=30' NO CCRNERS SET THIS DATE 1 HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY OF THE FOLLOWING DESCRIBED PROPERTY LOTS, A! OCX 3, SAMPSON ESTI, TES FHEe;FCRVAnoN'EREWISFOR THE USE OP LEN NG mSnNn.NS SPEOFraurro SHOWA.HY ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE mrruCTS BEtvrEEN�lSnNG SrReCNRaeNDPurTFDLOTu, 'ESaYGOR EaSENExTs: avm5 VISIBLE IMPROVEMENTS SITUATED THEREON ARE RgTHIN rcor ro eE usEOFa+ROgnanvGADDmava: sn?uCTUREs. rm?RorEnru:rs, oRPENCEuxES THE PROPERTY LIVES AND NO VISIBLEENCROACHMENTS EASEYENrS Cr FECYu+D C.R arHERk'GHTS pF v/Av, aRaYV E'+nrYNOrCNTNERECORDRAr AFEr:orsHaAv/HEREav, cN:.Ess r:orco EXISTOTHER THAN NOTED, NOMe FENCEUIESW71JAYR iEaRcur TxSORa:r.Nc azErrorro eE usEo roDEraur;E DATED ATANCHORAGE,ALASKA THIS 15TH DAYOF PFOPERl/UNE5 GR Po51nON ALWliaNallMR.ROVcrAENrS J,NJA.4Y 7DZI NIYPAMG S'.0WYHEREQV MAYBE AFRROK!.YATE DUE rO EXCES51VE 510IVaYaUI ICE, IfPLrIANpSURVFYINL 93L9C•RPVCR111, OPoVf 74655, FB 210-%.1.193-40 ANCJroucFaK sssLr I'li trate Advisory Certificate of On -Site Systems Approval # OSC211022 Subdivision: Sampson Estates B 3 L 5 A water sample revealed a nitrate concentration of 7.63 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. Mailing Address P O Box 196650:* Anchorage, Alaska 99519 6650 * wwwmun� org � From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening, or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Mailing Address P O� Box 196650 *Anchorage, Alaska 99519 6650 *www muni arg� � � From: 3ohnn To: mnanderson58(@amaii.com Subject: Well camera inspection Date: Thursday, January 21, 2021 11:51:26 AM ivI i ke We camera inspected the well at 22679 Sampson Dr. and found no leaks, brakes or cracks in well casing down to 70' also the pitless adapter is a good brass one and has no signs of leaks. Thanks Johnny Kay Hefty Drilling, Inc. Sent from my iPhone Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program S A, l l . 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 1?.5/- 811-3/ 1. GENERAL INFORMATION Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing Address COSA# Hrrt%�[rW. Expiration Date: f ( — /s -1-O ro en F54a-�.c S L. 5 9, ;�a(e-7r) Day phone Day phone -93(0 rr%(� nw(Alnfl Rtc1 C� Day phone_( cl N - 9 tis 11411 Olil r-rbri hl,tn, ..Fngtir_:R;VtA A4,—' i 17qS-7-1 V v Unless otherwise mquested, 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 [.K Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ 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 7n§ineer registere m he Stale o as _a e i rca—Tes of n- i e ys ems Approval are required r6rt a transfer title (except between spouses) for properties served by a single-family on-site wastewater disposal arid/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 Eagle River Engineering Services Phone - 10421 VFVV HO., fc°i LI - Sr 9 s ue 201 Address EagloRive; AK 995= Engineer's Printed Name / lir-A:hO r ICZ- tz0ood1 Date g 4 1) 5. DSD SIGNATURE l/'� Approved for 3 bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: COSA Checklist X Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory By: �,.� / — Original Certificate Date: i S �o �A )Rw. 77105) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: '1 -pson ES -In -k S L9 R 3 Parcel ID: 0 6/- I S /l '3 A. WELL DATA Well type �icr%c Date completed /C/g y If A, B, or C provide PWSID # Sanitary seal (9N) `L Total depth ,J civ ft. Cased to 14-0 ft. FROM WELL LOG Date of test fo 1 to l g 4 Static water level _VVI lcncryn ft. Well production 15 g.p.m. WATER SAMPLE RESULTS: Coliform _ff colonies/100 mL Nitrate 5.11 mg/L Arsenic: Or ug/L date of sample: 7 aS/GG B. SEPTIC/HOLDING TANK DATA Well Log 1,k Wires properly protected (Qj�N) � Casing height (above ground) 6 in. AT INSPECTION 1 11 ft. g.p.m. Other bacteria .E7 colonies/100 mL I Collected by: rI r�rLa.�1-Arri�r TankType/Material st.g:i'c/ gft.p Date installed Ig Y4 Tank size 4 006 gal. Number of Compartments Cleanouts (SNN) (,2 Foundation cleanout 0N) Chia. Depression over tank (YO -Z20 High water alarm (YQ -7,7o Date of pumping // �5 Pumper C. ABSORPTION FIELD DATA Date installed _194 Soil rating (g.p.d./ft2 o /bdr ) 1 q'/ System type ±rtri cJ , i Length qS ft. Width ;t. -1 ft. Gravel below pipe (0-5, ft. I Total depth c ft. Eft. absorption area SgSft2 Monitoring tube jAc S Depression over field pfd Date of adequacy test -7 JdbJQ(� Results as Fail) Pass T For _'-3 bedrooms I Fluid depth in absorption field before test _($_ in. Water added -Lo gal. New depth_/_$_ in. Elapsed Time: I Q min. Final fluid depth Imo_ in. Absorption rate >_ q S O I g.p.d. Any rejuvenation treatment (past 12 mo.) (Ydg & type) ,.-+cru /—.,n« a-, If yes, give date �— D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN) "Pump on" level at_ in. 'Pump off" levelM in.�1 FHijh water alarm level at in. Datum Cycles tested I� Meets alar 8 circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 'r' 100 On adjacent lots 4 Absorption field on lot t 100 Public sewer main f 100' On adjacent lots r Public sewer manholelcleanout +100, Sewer /septic service line t a5 ' Holding tank Animal containment areas t- 100 ' Manure/animal excrete storage areas + Inc) ' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation t S ' Property line * 5 Absorption field a ' Water main +10, Water service line +10, Surface water -I I00 Wells on adjacent lots t 100 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line t ICS ' Building foundation + 10 Water main + 1 u Water Service line +10 Surface water f (Q0 Driveway. parking/vehicle storage i 70 " Curtain drain 4 SO Wells on adjacent lots 4/00,-1 F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and ?' 4 review of Municipal records that the above systems are in >k conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name f lnri sJQ2V ar (a 1Md�4, R CUM Date % 04- 10 COSA Fee S Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage • Development Services Department Building Safety Division / On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 060362 1 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 3, Lot 5 of Sampson Estates subdivision. This inspection revealed a nitrate concentration of 5.71 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L !for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. SGS ReEO 1064215001 Client Name Eagle River Engineering Project Nsme/M Sampson Estates Lot 5 Block 3 Client Sample ID Sampson Estates Lot 5 Block 3 hlatria Drinking Water PWSID 0 Sample Remarks: All Dates/17mes are Alaska Standard Time Printed Date/rime 08/03/20061 13:33 Collected Date rime 07/2512006111:20 11.20 Received Date?ime 07/25/2006116:55 Technical Director Stephen C. Ede Allowable PrepAnalysis Parametef Results PQL Units Method ContaineriD Limits Date I Date )nit Metals by ICP/MS Arsenic ND 5.00 ugIL EP200.8 C (<10) 0728/06 08/02/06 Mli Waters Department Nitrate -N Microbiology Laboratory Total Coliform 5.71 0.100 mg/L EPA 353.2 0 col/IOOmL. SM209222D D (<10) A (<I) 0726/06 ALR 0725/06 TLF rt { 41` v / x 2LC- � f Sri R= )30 AF�a k J1� H•.0 jLaV /' "•<i a4 s. 1— f! f' Y4 ?>t f`3 /o ��- � L J n ' e surveyed the following described property: ---o 7 5" av/Is, H � f< 7 -/e: -N Afu SM Anchorage Recording Precinct, Alaska, and that thments - e improveit I situated on are within the overlap or encroacheon the property lying adjacroperty ent thereto, rthat no improvements on progeny lying adjacent thereto encroach on the premises in questwn and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. _Lx Dated at Eagle River, Alaska this day of JQ 4 . IyP( ROB[Ri C. JOI INSON ;& SCALE: Registered Land Surveyor No. W -LS I �f D.)x :7-0.156, Fagle River, Alaska 99577 Phone (907)bti4-2543 e,'c'2%�SZZ.L>9 ll c � +k H.uer p%0. nj L Y tr,l �r �I I _l v I hereby certify that 1 have surveyed the'following described property:_ Lo 7 4' , B/o, . � I _ N A fiu • I -jr AnchuragetuatRecording Precinct, Alaska, and that the improve. ments sied thereon are within the property lines and du not overlap or encroach on the property lying adjacent thereto, that no improvements on property Whig adjacent thereto encroach on the premises in question and tat there are no roadways, transmission lines or other visible easements on said property except as indicated heron. Dated at Eagle River. Alaska this ZB' - day of J. OV NOBERT C. 1O11NSON s , SCALE: Registered Land Surveyor No. tMLS I— � B.,x 77-0456, Eagle River, Alaska 99577 Phone(907)694-2543 r •. j 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 3/25/86 1 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Sampson Estates T15N R3W Sec. Location (address or directions) Sampson Drive I (b) Applicant Name Al Romazewski Telephone: Home N/A Business 694-4200 Applicant Address P.0 Box 772849, Eagle River AK 99577 1 (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ❑ ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution N/A Telephone Address (e) Real Estate Company and Agent Al Romazewski / RE—Max Address P.0 Box 772849, Ea17le River, Alaska 99577 Telephone 694-4200 (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single-Familyp Multi -Family[] Other Number of Bedrooms 3 3. WATER SUPPLY Individual Well ® Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite EI Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 P1,eq 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of lhevalidation 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 cen, r All NEERlIXSERV1GES— Telephone Address EAGLE RIVER, AK 99577 . BOX 773294 Date 3,tr4sa P. 69"195 19 DHEP APPROVAL r �J 7 Approved for l.n n v , bedrooms by _ Date Approved Disapprov Conditional Terms of Conditio I Approval CAUTION The Muncipalily 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 (Iuss) _ MUNIGPALITY OF ANCHORAGE DEPT. OF HEALTH b • � - MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) MAR 2 61986 CHECKLIST - FEBRUARY 1984 2644720 3KgEIVED Legal Description: Zot S s �d tuN 464r)"V %/Tn. ,e3w Sec. 3 I A. WELL DATA Well Classification ��/r/ATF If A. B, C, D.E.C. Approved (Y/N) IV14 I Well Log Present (Y/N) Date Completed 17"" S4 ^ Yield / 1 - Total Total Depth /y'/ r Cased to / yo Depth of Grouting N,L7 I Static Water Level „117 9 f Pump Set At .-75-1 I Casing Height Above Ground ;I Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) % Depression Around Wellhead (Y/N) N Separation Distances from Well To Septic/Holding Tank on Lot *lee, ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot �/� ; On Adjoining Lots Y�cJ To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole VIA To Nearest Sewer Service Line on Lot •� S Water Sample Collected by t<S 4` Date 7��s Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installedy Size �� G'� No. of Compartments E Standpipes (Y/N) i Air -tight Caps (Y/N) % Foundation Cleanout (Y/N) Depression over Tank (Y/N) N Date Last Pumped �� Pumping/Maintenance Contract on File (Y/N) n/11:1- ; for Holding Tank High -Water Alarm (Y/N) /L,- W Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: i To Water -Supply Well '�'" To Building Foundation To Property Line to To Disposal Field b I To Water Main/Service Line ��" To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026(11r84) r�1 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 1,9y 0�le Type of System Design Date Installed 6��y Length of Field S3'� Width of Field So Depth of Field �y Gravel Bed Thickness d r� Square Feet of Absorption Area Standpipes Present (Y/N) i Depression over Field (Y/N) All Date of Last Adequacy Test IZIA He•2 - Gr -p Results of Last Adequacy Test Szs fri AIo t hte�l u, f '/ 3/-zufXC Separation Distance from Absorption Field: To Water -Supply Well To Property Line To Building Foundation �L Lot Ala- -e -To Water Main/Service Line >/o To Stream/Pond/Lake/or Major Drainage Course On Adjoining Lots •n _ To Existing or Abandoned System on t3o' —To Cutbank (if present) V/ To Driveway, Parking Area, or Vehicle Storage Area Comments Seim%rc JXS* i.�S Y+ /* e K ew. )' SYS lei /Ye ver 4Je e/, 0 D. LIFT STATION N� 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 IcertifythatIhav checked,verified, or conformed toall MOAandHAAguidelinesineffectonthedateofthis inspection. Signed Date 21 2r�� CompanyMOA No. Receipt No. 3-n C?9O Date of Payment 3 - a L'4�?, Amount: $ 1.O C2 Page 2 of 2 72-026111,84) CN. CC67U6 Engineer's Seal