HomeMy WebLinkAboutMANN BLK 2 LT 5AARQnn
Block 2
Lot §A
#020-04! -29
Municipality of Anchorage ...::!
Development Services Department .~r_
Building Safety DMsion ~
On-Site Water and Wastewater Pr~ram. 4700 S. Bragaw SL
P.O. Box 19~650 A~chorage. AK 99519-6650 Page t~ of
www.d.ancr~'age.ak.us (907) ~kl-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: ~ (.A) O '2., O I ~5 C:, PID Number:. ~ '30 - O ~ I - Z. c~
~'"~: ~D~.[ ~ ~>~::z~.~/~..~ ["~[..rf'. Wastewatersystem: I-INew ~"Upgrade
{~0'~o t~--~'~,~l-,~-(-h ~', ~' ABSORPTION FIELD
LEGAL DESCRIPTION ~'~"'* i~, 1~ o,,o~,' T°'"°'~"'"~""~*~, O
~,S'-/.o,,. °"' "'*': t,, T q--
Well: [] New [] Upgrade ~ .~"0 r,. 'Z... ,,"0 t..~.
~. ~,,. TAN K
SEPARATION DISTANCES I~Sep~c [] Holding [] S.T.E.P. [] OUter:,
Tank Field Staffon TankSe,,er Une ~c[ ~' 'V3 ~D- .
s~.w.,, too ~1/~o"/- ~/' LIFT STATION
¥
,._. /xx'-''':
"'"~': BENCH MARK
Engine~r',.~f~o
· ,..~--% OF ,Al'"t '
· ,..--.t,.~... ..... ..'/~ L I
,,,,..
Inspectionspefformedby:~J/l~CN~rl, l q/*~ Dates: 1" 7/./'~',''Z4: '"~--' "~ '~'
~.~ · MICHAEL N. ANDERSCN
Development Services Departmeat Approval f~'. CE~
Reviewed and approved by: /') .~'/.,"~ / ~.~ ~')~' Date: I -- ~- 0 '~ '~ ~'?..~.;, .~,~., ~,~,
Permit No. SW020136
Page
2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENV1RONblENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744
On-Site Wastewoter Disposal S~stem and/or Well Inspection Report
Legal Description: LOT 5A, BLOCK 2, MANN SUBDIVISION PID No.: 020-041-29
VACANT LAND
' ' '" - / BENCH
I
I
MARK A B GRND- PIPE
ELEV. ~ ELEV.
CO1 25 2 102 94.7
CO2 37 22 98.8 91.1
TCOI 42 26 98.5
TCO2 51 35 92.8
CO3 53 37 92,8 86.1
CO4 73 55 88.9 85.2 ~
CO5 140 117 87.5 85.2 100' W[~ ~IUS
CO6 92 78 89.1 83.3 ~
CO7 152 132 85.5 83.3
MTI 81 63 88,4
MT2 127 II0 85.8 ~
DiV. 95 76 87.6 84.6 SCALE: 1"=50'
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: May 31,2002
Expiration Date: May 31, 2003
Permit Number: SW020136
Legal Description: MANN BLK 2 LT 5A
Design Engineer: 0088 Anderson Construction & Eng'g
Owner Name: Paul Huber
Owner Address: 16030 Elizabeth St.
Anchorage. AK 99516-0000
Parcel ID: 020-041-29
Site Address: 016030 ELIZABETH ST
Lot Size: 44992 SQ. FT.
Total Bedrooms: 5 Permit Bedrooms: 5
This permit is for the construction of:
~ Disposal Field [] Septic Tank [] Hotding Tank [] Privy
[] Private Well
[] WaterStorage
Ail construction must be in accordance with:
1. The attached approved design.
2. Ail requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By: ~
Date:
.Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWEPJWELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
Permit Number
Propertyowner(s) ~ ~'~41 ~.~(o¥-¢' Dayphone
Mailingaddress(1) / ~ ~,0 ~--"-- i// ;zo[7cI~,, ~---~/" .,~,c~,~t.
Mailing address (2).
Legal description (Lot, Block & Sub'd.)
Legal description (Section, Township & Range)
LotSize [ V,f
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub' []
Swimming Pool []
Therapy Pool []
Zip Code
Number of Bedrooms
Well Only []
Water Storage []
Jacuzzi []
Water Softening Unit []
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit Fees:
Date of Payment:
Receipt Number:
(Rev. 12/00)
0~o lid
Waiver Fees:
Date of Payment:
Receipt Number:
Michael N. Anderson, P.E.
Civil/Structural Engineering
4640 Shoshoni Avenue
Anchorage, Alaska 99516
Phone 345-3377
Fax 345-1391
May 20, 2002
Municipality of Anchorage
Department of Health and tluman Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Re: Lot 5A B2 Mann Subd.
To Whom it may concern:
This is a request for a septic permit for the above residence. The owner is add a full basement to the
existing two story residence this spring. The peres was completed in the rear of the lot at the toe of the
elevation change along the west property line. The soils were consistent in both of the holes with two
feet of silty sand then clean sand and gravel then water at 10 feet. A total depth of 11 feet was
excavated and the water stabilized after the 7day monitoring period at 8 feet. The pert rate was 1
minute per inch with over 70 percent clean sand. The new trenches will be a 5 wide with 2 feet
effective in two 66 foot trenches, excavated below the top silty material.
All the ground slopes to the west as the plan shows. This new system will not affect the future
development of the neighboring properties or shadow out any neighboring septic replacement areas due
to the developed wells and septics in the area.
If you have any question please call me at 345-3377
Michael N. Anderson, P.E.
~MOUND OVER
DESIGN CRITERIA: ~ ~-~-GRAOE
5 BDRM X 150 = 750 GPD -I'__ OR ,~ ~'~' ~-/-FILTER FABRIC
~ u ~ ! ~ INSU~TION
SOILS = 750/0.8 = 940 SQ ~ REQ'D . __
t ML
940/5'.70 = 152' .~,~
TRENCH: _~ sw
4' DEEP -- -
2' EFFECTIVE CP I s.o' ~DRA)N ROCK
5.0' WIDE
132' LONG
[XISTINC HOUSE ~/~ ~ 100' ~IUS
~ -- ~ EXISTING WELL
~ ~ I00' ~IUS
o -O'~ALLEY ROAD
-EAST I 6 2ND AVENUE-
PAUL AND SUZE~E HUBER ~ ~ ,* .... ,~ -
MANN SUBDIVISION
MICHAEL S. ANDERSON, P.E.
4640 SI[OSHONI DRIVE ~;~'. C~.e,~9 ..~
(907) 345-3377 / FAX (907) 345-1391
SCA~: 1"=200' APRIL 26,
EXISTING WELL
TOP OF 25~ SLOPE
~ ~LL
/~ tjHOUSE ~ISTIN( ~ :~- I
~ HOUSE
~ WELL
O WELL
PAUL AND SUZETTE HUBER ~..
LOT SA, BLOCK g
MANN SUnDI~SION
(907) 345-3377 / F~ (907) 345-1391
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street. Anchorage. Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DE,CRIPTION:
ml' [_.
5-
6
?
8
9
10.--
t2-
13-
14-
16
17
18
19
ENCOUNTERED?
IF YESo AT WHAT /~t* SL
DEPTH? pO
E
20
PERCOLATION RATE f' ~ (m~nuteumcnl PERC HOLE DLAMETER ~
TEST RUN EETWEEN ~-"~'"' FT AND '~'~' FT
PERFORMED BY: (~"/~ ~ ~ ~ -'~ J ~" $'~ I CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE ~--'/'~ ~
Munlcil~tty et Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L' Street. Anchorage, Alaska 99502-0650
SOILS LOG ~ PERCOLATION TEST
PERFORMED ~OR:
LEGAL DESCRIPTION: L ~'",/~ 6~..
1
*.' 49T_~q f--~
~; MICHAEL N AND[RSON ~ i
OATE PERFORMED: ~~/~ ~
Tow~hiD. Range, S~on:
WA~ GROUND WATER
ENCOUNTERED?
IF YES. AT WHAT
PEPS?
13.
14-
15-
16-
17-
18-
19-
20-
"OMMENTS G4.~O
__ Immutes~J~l PERC HOLE. DIAMETER
TEST RUN BETWEEJN '~ FT AND
PE.FORMED"¥: ~, .-~,,.-('J.. ,/,-,,,,,~ , C£.TIF. TH,~;.TH,ST.TW^.ERFORM£D,N
ACCOROANCE- WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATK DATF'
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWEPJVVELL SUBMITTAL COMMENT SHEET
To: NL~CHAEL N. ANDERSON
Legal description: MANN SUB3;bV'J:S~:ON BLOCK 2 LOT 5A
The attached paper~vork has been reviewed and is being returned for the following reasons:
[] Original signature or stamp missing on
[] Calculation error in design.
[] Additional soils information needed. ML LAYER WAS NOT PERCED AND Z'l' APPEARS THE
ABSORP'r;~oN 'I'~ENCH MT.~HT BE 11,,I J./e?
[] Water monitoring results inadequat, e.
[] · Discrepancy'in information submitted. NE'~'HER SO~L5 TEST _~ATCHES THE PROFILE
____~EW OF THE bESZ~N OF THE ABSORPT'J;ON 'FRENCH.
[] Topographic information missing or inadequate,
[] Incomplete; missing
[] Incomplete; missing
[] Additional adequacy test information needed.
[] Water sample unacceptable.
[] Measured/propceed distances/dimensions missing.
[] Locations of all soils, percolation and water monitoring tests not shown.
[] Proposed system too deep for soils information submitted.
[] Well log required.
[] Omission in narrative.
[] Insufficient fill over tank or field.
[] Other.
Name of reviewer:, bAN
Date: 5/28/02
Please supply the necessary information and re-submit your request.
LEAVE THIS FORM ATTACHED TO THE PAPERWORK
i~ MUNICIPALITY OF ANCHORAGE
· DEPARTMENT OF HEALTH & ENVIRONMENTAl. PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street o Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
[] UPGRADE
LEGAL DESCRIPTION
~ ~ DISTANCE TO; ., J ~[0~ D~lhng~
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
Q Well t Foundation Nearest lot
~. DISTANCE TO: ~-[00 ~ ~0 f
Y
~ NO. of lines Length of each line Total of lines Trench
length
Distance
k ~ ~ Top of tde to finish fade Material beneath tile
~k~ bdeplh / Total eff~ti~
~ OI~NCE TO: Near
o
Building foundatio ~ Sewer llne Septic rank Absorption area(s)
OTHER
SOl L TEST RAIl NG ,~ v
INSTALLER
REMARKS
72-013 (~v. 3/78)
rquN T C z PAL Z TV OF' AFICHO .F:IGE ~-"~/
DEPARTMENT ~"~ HEALTH AND ENVIRONME!!TAL/~:OTECTION"'~
825 'L- STREET, ANCHORAGE, AL 99o01
2~4-4720
ON-- ZTE
RPPLZCRNT DARRELL ARNOLD SAR BX 472-B RNCH ~7
LOCRTZON ,ELZZRBETH
LEGAL LT. 5 BL~. 2 ~RN~I ~/P W ~/2 LOT ~ZE 44~ ~QURRE FEET
TYPE 0F'SOIL ABSORPTION SYSTEM IS:- TRENCH':. ..,.~.t ' / :.i '.' ,
MRNIMUM'NUMBER 0F:BED~00MS = ~ SOIL R~TING (SQ FT/DR)= 125
THE REQUIRED 'DI~E OF T~E ~OIL"RB~ORPTZON SYSTEM :ID:'. ~' % ' ~J '
DEPTH=' ~ ' .-LENGTH= ~D GRAVEL DEPTH=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR ~RRIN~IELD.
THE DEPTH OD A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SORFRCE OF THE
GROUND. R~D THE DOTTO~ OD THE EXCAVATION (IN FEET).
,?,','THERE"IS ~.10 ~ET WIDTH FOR ~ICHES.
' "THE GRRVE~~tIM~DEPTH OF GRAVEL 8ETWEEN THE OUTFALL PIPE
AND THE BOTTOH O~ THE ENCAVATION (IN FEET).
PERMIT APPLICANT HAS'THE RESPONSIBI~LI~'TO. INFORM THIS DEPARTMENT DURING THE
INSTALLATIO~i INSPECTIONS OF 8N~ WELLS 'AdJH~ENT TO THIS PROPERT~ 8ND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. --
T)dO ( ~ .', INSPECT I 0~$ F~RE REQU I RED
BAC)~?ILLING OF ANY SYSTEM WITHOUT FINAL I)~SPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
lO0 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPO~I THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SE~ER LINE IS ~5 FEET AND
TO A COMMUNITY SEWER LINE IS ~5 FEET.
fELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS M~ 8PPL~. SPECI~IC~TION~ AND CONSTRUCTION DIAGRAMS 8RE
HVHILABLE TO INSURE PROPER INSTHLLHTION.
PER~IT EXPIRES DECE~IBER ~l~ IDA1
I CERTIFY THAT
l: I AM FAMILIAR PlITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITV OF ANCHORAGE.
2: I WILL I~ISTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLRRGEMEFIT IF THE
RESIDENCE IS REMODELED TO I~ICLUDE MORE THAN ~ BEDROOMS.
V4. 0
4
5
6
'~7
8
9
10
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Stt'eet, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
-'0. )
13 c, tA
PERCOLATION
TEST
SITE PLAN
12
13
14
15
16
17-
18-
19-
WAS GROUND WATER
ENCOUNTERED, ~ IS
P
IF YES. AT WHAT I E
PERCOLATION RATE
(minules/inch)
TEST RUN EETWEEN FT AND , FT
72.008 (6/79) ·
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 020-041-29 Expiration Date:
1. GENERAL INFORMATION
Complete legal description Mann Block 2 Lot 5A
Location (site address) 16030 Elizabeth St, Anchorage, AK 99516
Current property owner(s) Michael D Rhodes Day phone
Mailing address
Real estate agent
(907)223-8025
16030 Elizabeth St, Anchorage, AK 99516
2. TYPE OF DWELLING:
❑■ Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 5
Day phone _
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Q
Private Septic
❑■
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 55 O
Date of Payment 5 a 3 a 0 a121
Receipt Number 0 0 � 6 2 IJ
COSA # D 3 C�2 2 1 'l
Date:
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
Distance:
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Engineering (M.J.) Phone (907) 522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503
Engineer's Printed Name Benjamin Schiller, P.E. Date 5/16/2022
6. IGNATURE
System #1 Approved for 5
System #2 Approved for
Disapproved
Conditional approval for
bedrooms
bedrooms
•q� 1
/*:49TH •*
• ;ems
r• Benjarrt&Schiller
f,Q��srF9. 5%16%222
pROFESSIQO .�
bedrooms, with the following stipulations:
WATER A N n m
Original Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
COSA Checklist
Legal Description: Mann Block 2 Lot 5A Parcel ID: 020=041-29
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
0 Well log is filed with Onsite (or attached)
Date drilled 4/12/81
Total depth 115 ft
Cased to 33 ft
❑Q Sanitary seal is functioning correctly
❑o Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 5/9/22
Static water level at beginning of test 20.7 ft.
Comments
B. TANK DATA
Age of tank(s) 19 years
Tank type/material Septic / Steel
Measured operating fluid level in septic tank 49
Q Standpipes/foundation cleanout per record drawing
Date of pumping Alaska Quality Septic 9/23/21
D. ABSORPTION FIELD DATA Shallow Trench
Which system tested (date installed) 7/4/2002
0 ALL standpipes present per record drawing
Total measured depth from grade 3.2/5.5 ft (max)
Measured depth to pipe invert from grade 2.6/3,ift (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective •6/1.9
n Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced _ iallons
Well production at time of test 2.6 gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate 0.383 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date of Sample 5/3/2022
STATION
❑ Require inti
Age of lift station
Lift station material
Comments:
nance completed
vears
Adequacy test date 5/9/22
Results Q Pass For 5 bedrooms
Fluid depth prior to test 0 / 0 in
Water added 753 gal
New depth 8 / 0 in
Elapsed time 1440 min
Final fluid depth 0 / 0 in
Absorption rate '750 gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
Comments/Deficiencies: Trenches listed east / west. East absorption field has grade difference between co/mt.
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to (Please enter distances if less than required or if community well)
✓M
Yes
Septic Tank/Lift Station on Lot > 100'
ft
Surface Water > 100'
Community Sewer Manhole/Cleanout > 100'
Property Line > 5'✓0
Yes
r Yes
if No
ft
M Yes
if No
ft
Neighboring Tank > 100' M✓ Yes
if No
ft
Private Sewer/Septic Line > 25' F7/1 Yes
if No
ft
Absorption Field on Lot > 100' M✓ Yes
if No
ft
Holding Tank > 100' Yes
if No
ft
Neighboring Absorption Fields > 100'
Water Service Line > 10'
�✓
Animal Containment > 50' ❑✓ Yes
if No
ft
✓v Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' M✓ Yes
if No
ft
0 Yes
if No
ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
✓M
Yes
if No
ft
Surface Water > 100'
Q✓ Yes if No ft
Property Line > 5'✓0
Yes
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
Q✓
Yes
if No
ft
Private Wells > 100'
Yes if No ft
Water Main > 10'
ft
Yes
if No
ft
Community Wells > 200'
✓0 Yes if No ft
Water Service Line > 10'
�✓
Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
Q
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
Yes
if No
ft
Private Wells > 100' U✓ Yes if No ft
Water Service Line > 10'
F✓
Yes
if No
ft
Community Wells > 200' 0 Yes if No ft
Surface Water > 100'
✓I
Yes
if No
ft
F. ENGINEER'S COMMENTS
AW OF k.,q
G. ENGINEER'S CERTIFICATION Ape
I certify that 1 have determined through field inspections and review —
of Municipal records that the above systems are in conformance with `' • • ' t°' ' ' '"
MOA COSA guidelines in effect on this date. ®. ......... 0�
Benjarrchiller id
�'�`•• CE 12592 1%
5/16/22. �.�.w
PROFESStO���-
COSA Checklist yellow sheet
• /�� 8 a •
•
Municipality of Anchorag../ ' r °` 8`
On-Site Water and Wastewater Program ( DEC 2 7 Lli I `{9,ii I
(907) 343-7904 s.+r ETV
Certificate of On-Site Systems Appro1Q s
Parcel I.D. 020-041-29 Expiration Date: 3_2-d
1. GENERAL INFORMATION
Complete legal description Mann Subdivision Block 2 Lot 5A
Location (site address) 16030 Elizabeth St
Current Property owner(s) Joseph & Kathleen Conroy Day phone
Mailing address 16030 Elizabeth St. Anchorage, AK 99516
Real Estate Agent Ken Jelinek Day phone 907-6944292
2. TYPE OF DWELLING:
Q Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 5
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by:r(1/4 ,t4/ (0 /jlY) Date: /9-, 8//2
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ Waiver Fee $
Date of Payment /d9.0f/ - Date of Payment
Receipt Number 07204D Receipt Number
COSA# CSG 0/571, Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Forge Engineering Phone 577-7773
Address PO Box 240773, Anchorage, AK 99524
Engineer's Printed Name Benjamin Schiller, PE Date 12/26/17
A PC •• � •`Q'f54}
;
6. DSD SIGNATURE , 1. ....... f
System#1 Approved for bedrooms 3,.• Be* in Schiller • I:�
System#2 Approved for bedrooms �� <`�gti . CE.125°2 .•,��/
Disapproved l\
Conditional approval for bedrooms, with the following stipulations:
S' '( O�FF,k„
hyo..
ON-SITE,
WATER AND �'
`-' WASTEWAI ER
PROGRAM
'VrSERV\C '
-101111111C1----- ,j�_ Original Certificate Date: 11- 2 17
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
•
COSA blue sheet_c c
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description:
Mann Sub, Block 2 Lot 5A Parcel ID: 020-041 -29
A. WELL DATA
Well type Private If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed 4/1 2/81 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 1 15 ft. Cased to 33 ft. Casing height (above ground) >18 in.
FROM WELL LOG AT INSPECTION
Date of test 4/12/81 12/20/17
Static water level 28 ft. 57.3 ft
Well production 2.5 g.p.m. 2.4 g p m
WATER SAMPLE RESULTS:
Coliform
ND colonies/100 mL Nitrate 0.225 mg/L
Arsenic ND ug/L Date of sample: 12/18/17 Collected by: Forge Engineering
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 7/4/02
Tank size 1 500 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 12/29/17 Pumper A+ Home Services
C. ABSORPTION FIELD DATA
Date installed 7/4/02 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.8 gpd/sf. System type 5-Wide
Length 67 / 72 ft Width 5 ft. Gravel below pipe 2 ft.
Total depth 5 ft. Eff. absorption area 992 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 12/20/17 Results (Pass/Fail) Pass For 5 bedrooms
Fluid depth in absorption field before test 0/0 in. Water added 750 gal. New depth 0/0 in.
Elapsed Time: 0 min. Final fluid depth 0/0 in. Absorption rate >= 150 g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access(Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot >100 On adjacent lots 100
Absorption field on lot >100' On adjacent lots �100'
Public sewer main X75' Public sewer manhole/cleanout >100'
>25' >75'
Sewer/septic service line Holding tank
Animal containment areas >50' Manure/animal excrete storage areas >100'
SEPTIC/HOLDING TANK ON LOT TO:
>5' >5' >5'
Building foundation Property line Absorption field
Water main
>10' Water service line >10' Surface water >100'
Wells on adjacent lots >100'
ABSORPTION FIELD ON LOT TO:
>10' >10'
Property line >10' Building foundation Water main 1
Water Service line 1�, Surface water 100'
Driveway, parking/vehicle storage >10'
Curtain drain None Noted Wells on adjacent lots >100'
F. COMMENTS
G. ENGINEER'S CERTIFICATION ~`"`\kk,
I certify that I have determined through field inspections and �i�Q:•'• `4.•�•.1,40
review of Municipal records that the above systems are in 0*'.49mt i\ :* /
conformance with MOA COSA guidelines in effect on this date. .. ..
Engineer's Printed Name
Benjamin Schiller, PE :• .. r. it
it
Date 12/26/17 . 8e " in Schiller : ff
lk.• CE 12 ...$1<,-.11
� er
� �'°ROFES tOH1';. '
COSA brown sheet_10-10-12.doc
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650
~~¢t 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. f-'9'LO - Off ¢ "' Z ~'
GENERAL INFORMATION
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address.
Expiration Date:
I~t// ~-,~ ~or~ Day phone
Lending agency
Day phone
Mailing address
Real Estate Agent
Mailin~t Address ~ , ,.;:,
unless.~fhe rwise requested, ~OSA... will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: '~'' ~
Day phone
3.. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ..... .'," I~ Individual' On-site ~
Individual Water Storage [] Individual Holding Tank []
Community Class Well [] Community On-site []
Public Water System [] Public SeWer []
L I II
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 System's 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 propedies 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
.5.
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, function.~l ,and adequate
for the number of bedrooms and type of structure indicated herein. I further vedfy that based o0 the information
obtained frem,.the Municipality of Anchorage files and from my investigation and inspection, th~
suppl~-a.,~d~0~ ~astewater disposal system is(are) in compliance with all applicable Municipal and S~te
ordi~h~si' and regulations in effect at the time of installation . ·
Phone "~ ~f ~'- "~ ~ "~ ~
Name of Firm
Address
Engineer's Printed Name
DSD SIGNATURE
!,/'"" Approved for ~"
Disapproved,
Conditional approval for
Date /¢"/~-'i¢//~
6 ~ MICHAEL N. ANDERSON
· ~. ~. ,, CE- 9469
·
bedrooms, with the following stipulations:
Attachments:.
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other ~.
Original Certificate Date:
(Rev. 11105)
MunicilJality of Anchorage
DeVelopment Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore 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:
A. WELL DATA
Well type
Date completed
Total depth t/~- ft.
Date of test
Static water level
Well production
IfA, B, or C provide PWSID # /
Sanitary seal (Y/N). y
Cased to ! t ~- ft.
FROM WELL LOG
.,
2.Y~-5 'f g.p.m.
ParcellD: C~"z.O--OH/
Well Log (Y/N) ~'
Wires properly protected (Y/N)
casing height (above ground)
AT INSPECTION
~-~. O g.p.m.
WATER SAMPLE RESULTS:
Coliform __~__._colonies/100 mL
' Arsenic: __~ ug/L' 'date of sample: .
B, SEPTIC/HOLDING TANK DATA
Tank Type/Material '% {-~' {,
Nitrate O~ I O~,..mg/L
Tank size /FO0 gal. Number of.Compartments
Foundation cleanout (Y/N) ¥ Depression over tank (Y/N)
Other bacteria .~___'colonies/lO0 mL
Collected by: /t,¢/,~ ~
Date installed 7/,f,/~ ~
Cleanouts (Y/N) ~
High water alarm (Y/N) ~
~ Date of pumping. ~///~ '//t::) Pumper
. C. ABSORPTION FIELD DATA
Date installed' '7/~//~ ~.
Length I ~
Total depth ~,O ft.
Date of adequacy test
Fluid depth in absorption field before test ¢ "/.,' in.
Elapsed Time: ~.~40 min. Final fluid depth ¢
Any rejuvenation treatment (past 12 mo.) (WN & type)
Soil rating (g.p.d./ft2 or ft2/bdrm) ~..0, ~
ft. Width 5 "' ft.
Eft. absorption area q~fO ft2 Monitoring tube .
~/'zt/e Results (Pass/Fail) tDos~.
Water added ~oo ~al.
__ in. Absorption rate >=
System type .~ ~' ~ ,~ ~.h.
Gravel below pipe 'Z,O ft.
¥ Depression over field ~
For 5'- bedrooms
New depth [~o in.
?SD ~ g.p.d.
If yes, give date
D. LIFT STATION
Date installed Size in gallons
"Pump on" level at ~~ High water alarm level at
Dat~33-----''~ Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
in,
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot /CID/'/'-
Absorption field on lot ! g0 ¢ ~
· Public sewer main ,/o~
Sewer/septic service line I ~;~' ~'-
Animal containment areas .. /'(~ t +
SEPARATION DISTANCES FROM SEPTIC/I=I~I;131NG TANK ON LOT TO:
Building foundation..."z. 0 ~ 1c` Property line. ! (~O
Water main ~/V/j~ Water service line /
· Wells on adjacent lots ! oo ~3L
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 'Z0
Water Service line t c~ c; ~.~--
Curtain drain
F. COMMENTS
Building foundation
Surface water ~ ~,~
Wells on adjacent lots
On adjacent lots. /t2~) 5/.
On adjacent lots . fO0 / ~L
Public sewer manhole/cleanout !C~
Holding tank ~/~.,
Manure/animal excrete storage areas
Absorption field ;¢ O '/'-
Surface water ! Oo ~'~
Water main
Driveway, parking/vehicle storage
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 /~fl ~,~[/~ ~vl ~ ~, 4~ ~
Date ~/~/tO
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
SGS
SGS Reft# I 104226001
Client Name Mike N. Anderson, P.E. Printed Date/Time 08/24/2010 8:36
Project Name/# Elizabeth St / ~ O ~ /9 Collected Date/Time 08/17/2010 16:00
Client Sample ID Elizabeth St Received Date/Time 08/17/2010 16:55
Matrix Drinking Water Technical Director Stephen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic
ND 5.00 ug/L EP200.8 C (<10) 08/18/10 08/19/10 KDC
Waters Department
Total Nitrate/Nitrite-N 0.102 0.100 mg/L SM20 4500NO3-F B (<10) 08/18/10 AYC
Microbiology Laboratory
E. Coli Negative 1 100mL SM20 9223B A 08/17/10 SDP
Total Coliform Negative I 100mL SM20 9223B A 08/17/10 SDP
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.munLorg/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
Location (site address)
Current Property owner(s)
Mailing address
COSA#
Expiration Date: L/.. -. / O - O 7
1. GENERAL INFORMATION
Complete legal description
Lending agency
Mailing address
Dayphone
Real Estate Agent
Mailing Address
Dayphone
· . Unless o!herwise reques!ed, COSA will be held by DSD for pickup,
2. NUMBER OF BEDROOMS: ~'
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
[]
[]
.0
[]
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 COS,As upon request to homeowners. Certifmates 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 sb'ucture 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.
Address
Engineer's Printed Name
Phone
Date
5. DSD SIGNATURE
Approved for ~ bedrooms.
Disapproved.
Conditional approval for
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
(Rev,
X
Arsenic Advisory
Maintenance .,~greements
Supplemental Engineer's Report
Other
Original Certificate Date: / -- / 0 - (.2 7
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Watae & Westawater Program
4700 Bragaw Street
P.O. Box 196650
Ancherage, AK 99519-6650
www.muni.crg/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Totaldepth f(~" ft.
ParcellD: ¢%0- c,/-(I- ~
IfA, B, or C provide PWSID # __
Sanitary seal (Y/N)
Casedto (t~- ft.
Well Lng (Y/N) ~
Wires proper~y protected (Y/N) ~'
Casing height (above g.:)und) ~'
in.
FROM WELL LOG
Da~e of test '~/~/~, ~
Static water level "4.--~ ft.
Well production ".- Y'?--- g.p.m.
WATER SAMPLE RESULTS:
Coliform ~ colonies/100 mL
.au~enic: ._~ mo/}
B. $£1~'l~HOl.~llqG 'T.~K DATA
Tank Tl~laterial ~.~ ~--.t' [ o
AT INSPECTION
Nitrate CO,
Date of sample:
Other bacteria, ¢ colonies/100 mL
Tank size C~-~o gal.
Foundation cleanout (Y/N) *?'
Date of pumping ( 4' ~'/fo"
C. ABSOEPTION FIELD DATA
Date installed 7/~t/0/'"' Soil rating {g.p.dJft' or ft2/bdrm)
Length / 'T' ~, ~.~7'" Width ~'. 0
, Number of Compartments 'z...
· Depressto~ over tank (Y/N)
Cleansers (Y/N) y
High water alarm (Y/N) J
/~ ~ System type ~" t~, 4 .~
fl. Gravel below plpa ' ~ ~ D ft.
Totaldeptb I'~? ft. Eff. absoq)tionarea e~fO ~t2 Monitcringtube Y' Depreselon over field I~
Date of adequacy test t~../~ufOU Results(Pass/Fail) P~6G For ~ bedrooms
o"
Fluid depth In absorption r~e,d before test Water added/~U gal. New depth /'~ "in.~
ElapsadTime: ~h'~Omin. Finalfluiddepth LR" c~4ff.'x4. Abscrptionrate >= T~;o '1L-, gp.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) ~ , If yes, give date
D. UFT STATION
Date installed Size in gallons Manhole/Access~
'Pump on' level at in. 'Pum~e,~'---~ High wator alarm level at
Dat~um Cycles tested Meets alarm & circuit require~ents?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
. Septic tanlc~'~'t on lot /C~
Absorption field on lot /
Public sewer main '~_~
Sewer/septic service line
Animal containment areas /
On adjacent lots
On adjacent lots
Public sewer manhote/deanoul /
Holding tank /V
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTI~G TANK ON LOT TO:
Building foundation 'Z O w .~ Prope~ line ~ O ~ Absorption field
Water main ~"/,'~ Water service line ! u e I¥, Surface water
Wails on adjacent lots /ay ~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line '~ o I ~ Building foundation / O o I~
WatorSewiceline /Or It~ Surface water /c,g~'(--
Curtain drain rv~/,'~, Walls on adjacent lots / u a r.(..
Water main FL'/'~,
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name yv'/, .,~,: ~./~,r.~tl ~L"~¢ ~'o,
COSA Fee $.
Data of Payment
Receipt Number
(Rev. 11/05)
Date of Payment
Receipt Number
tn.
oo 'o~/
/vI,, oo, Eo ,,o /v
'~1~ ¢ 'la./ ,ol
0
SGS Re(.#
Client Name
Project Name/#
Client Sample ID
Matrix
1067211001
Mike lq. Anderson, P.E.
Kitchen Sink 16030 Elizabeth
Kitchen Sink 16030 Elizabeth
Drinking Water
All Dates/Times are Alaska Standard Time
Printed Dale/Time 12/27/2006 13:30
Collected Date/Time 12/I 1/2006 14:00
Received Date/Time 12/I 1/2006 14:36
Technical Director Stephen C. Ede
Sample Remarks:
353.2 - The MS for Nitrite recovered above thc QC criteria. Thc hatch LCS is within QC limits.
Allowable Prep Analysis
Parameter Results PQL Units Method Container ID Limits Date Date Init
Nitrate.N 0104 0.100 mg/L EPA 353.2 C 12/11/06 .IDS
Nitr/te-N ND 0.100 mg/L EPA 353.2 C 12/I 1/06 JDS
Metals Department
I {ardne$$ as CeCO3 162 -5.00 mg/L SM20 2340B B 12/13/06 12/20/06 Tie.
Private Xndividual Analysis
Aluminum ND 20.0 ugfl.. EP200.8 B 12/13/06 12t'20/06 TK
Antimony ND 1.00 ugtL EP200.8 B (<6) 12/13/06 12/20/06 TK
Arsenic ND -5.00 ug/L EP200.8 B {<10) 12/13/06 12/20/06 TK
Bar/urn .50.5 3.00 ug/L EP200.8 B (<2000) 12/13/06 12/20/06 TK
Cadmium lqD 0.500 ug/L EP200.8 B (<5) 12/13/06 12/20106 TI(
Calcium 36200 $00 ug/L EP200.8 B 12/13/06 12?20/06 TK
Chromium ND 1.00 ug/L EP200.8 B (<100) 12/13/06 12/20/06 TK
Copper -59.3 1.00 ug/L EP200.8 B {<1300) 12/13/06 12/20/06 TK
Iron ND 230 ug/L EP200.8 B {<300) 12/13/06 12/20/06 TK
Lead ND 0.200 ug/L EP200.8 B (<15) 12/13/06 12/20/06 TK
~.{agnesium 17300 -50.0 ug/L EP200.8 B 12/13/06 12/20/06 TK
Manganese I-5.6 1.00 ug/L EP200.8 B (<-50) 12/13/06 12720/06 TK
Phosphorus ND 200 ug/L EP200.8 B 12/13/06 12/20/06 TK
Chloride 8.49 0.100 mg/L EPA300.0 C (<250) 12/21/06 12/22/06 JDS
Fluoride 0.316 0.100 mg/L EPA300.0 C (<2} 12/21/06 12/'22/06 JDS
Potassium ND -500 ug/L EP200.8 B 12/13/06 12/20/06 TK
Selenium ND -5.00 ug/L EP200.8 B (<:-50) 12/13/06 12/20/06 TK
Sodium 26000 -500 ug/L EP200.8 B (<2-50000) 12/13/06 12/20/06 TK
Silicon 6840 200 ug/L EP200.8 B 12/13/06 12/20/06 TK
Silver ND 1.00 ug/L EP200.8 B (<100) 12/13/06 12/20/06 TK
Sulfate 27.8 0.100 mg/L EPA300.0 C (<250) 12/21/06 12/22/06 JDS
Thallium ND 1.00 ug~ EP200.8 B (<2) 12/13/06 12/'20/06 TK
$GS Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
1067211001
Mike N. Andcrson, P.E.
Kitchen Sink 16030 Elizabeth
Kitchen Sink 16030 Elizabeth
Drinking Water
All Dates/Times are Alaska Standard Time
Printed Date/Time 12/27/2006 13:30
Collected Date/Time 12/I 1/2006 14:00
Received Date/Time 12/11/2006 14:36
Technical Director Stephen C. Ede
Allowable Prep Analysis
parameter Resulta PQL UniLs Method Container ID Limits Date Date Init
Private Xndividual Analysis
Total Dissolved Solids 23:$ 10.0 mg/L SM20 2540C A (~-~ O0 ) 12/18/06 ACF
Zinc 7.54 5.00 ug/L EP200.8 B (<.SO00) 12/13/06 12/20/06 TK
Nickel ND 2.00 ug/L EP200.8 B (<100) 12/13/06 12/20/06 TK
HCO3 Alkalinity 178 10.0 mg/L SM20 2320B A 12/13/06 PLW
CO3 Alkalinity ND 10.0 mg/L SM20 2320B A 12/13/06 PLW
OH Alkalinity ND 10.0 mg/L SM20 2320B A 12/13/06 PLW
Conductivity 350 1.00 umhos/cm SM20 2510B A 12/I 1/06 XZ
pi[ 8.21 0.100 pl[ units EPA 150.1 A (6.5-8.5) 12/11/06 XZ
Alkalinity 178 10.0 mg/L SM20 2320B A 12/13/06 PLW
TotalColiform 0 col/100mL SM209222B D (<1) 12/11/06 DPT
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Se~ices
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. # /~'-~'") - r'~-\ \ _~c-~ HAA #
1. GENERAL INFORMATION
Complet~ legal description
LoT'
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: -'~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
lng t? the legality and status of system.
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.
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 applicati6n 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 "~'._('~j~., ,"[~-[~.k.~ 'j3. j=~ Phone. P--?~ -~S~ / ~
Address , ~;::~-0:~ ~ i ~-,L~t if r~.~ '..'5
Engineer's signature ~ ~'~°/'~ Date ~'/'~ct77
DHHS SIGNATURE
Approved for J~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date ¢-/7-
The Municipality of Anc'h'orage 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 satisf7 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.
t,~UN~CIPALITY OF ANCHORAGE
[;-T,d2Oh~[ENTAL SERVICES DIVISION
Municipality of Anchorage oep 0 2 1997
DEPARTMENT OF HEALTH&HUMAN SERVICES~. ~.~V E D ~
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907)
Health Authority Approval Checklist
Legal Description: ~ Parcel I.D.:
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal
Date of test
Static water level
Well production
//~ / c--ed to
FROM WELL LOG
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
(
Casing height (above ground)
Wires properh/protected (Y/N) X
AT INSPECTION
WATER SAMPLE RESULTS:
Coflfon, n Nitrate Other bacteria
B. SEPTIC/HOlDING TANK DATA
Datetnstalled */~///~1 I
Foundation cieanout (Y/N)
Date of Pumping
+
Tank size l~ Number of Compartments ~ Cleanouts (Y/N) .
7 Depression (y/N) N High water alarm (y/N)
Pumper
C. ABSORPTION FIElD DATA
Dam installed r:~4/~/~' ' Soil rating ~ or ftYedrm) /,.-~
Length /~ ~'~/ Width [].~-.*~. Gravel thickness below pipe
Effective absorption ama ~) 7~ Monitoring Tube present (y/N) y
System type ~'",,(.x~.~ ¢'~1
/ Tote~ depth 7 //~ ~ ~"/=~
Depm~ion ~r field ~) ~
For ~ .~d~
Fluid depth in absorption field be~re test (in.); .~/~.:~ Immediately aftor, ~,~ /
~gal. water added (in.): :~.
~'-'" ' =" -:'~OAbeo~on rats
Fluid depth _~(ins) Minutes later: = _ g.p.d.
Peroxide treatment (past 12 months) (Y/N) /~ If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STA13ON
Date installed
Size in gallons
Manhole/Access (Y/N)
"Pump on" level at'
'Pump off" level at*
High water alarm level at*
*Datum
Cycles tested
E. SEPARA11ON DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On ~diacent lots
On adjacent lots
Public sewer manhole/cleanout
Uti station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation /~1 f Property line ,,~/D I Absorption field
Water maln/senace line .%. ,,,q-~ t Surface water/drainage /~/o Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line ~/0/
Surlace water
Curlaln drain ~'J/O
Building foundation ~ ~ / Water main/service line .~> ~ ~ I
Driveway, pe~tdngNehicle storage area JO ~
Wells on adjacent lots ~> /.~ O
F.
ENGINEER'S CERTIFICATION ,, - ' '' '
I certify that I have de~ermined thru field inspeotfons and review of Municipal recocds that the above syste~ are
in conformance with MOA HAA guidelines in effect on this date.
stone ra
Date ~ ll
72-026 (Rev. 3/96)'
Waiver Fee $
Date of Payment
Receipt Number
MUN~C~PALIW Or ANCHORAGE ~2 O ~'F/ 2¢'--
~EPART~ENT Or.EALT. & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CE"Tlr,CATE Or,NSP~CT,ON fOR HEALT. AUTHORITY APPROVAL H~g- ~/~-~'
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date _
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a)
(b)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Properly Owner ~,~.~-- Telephone; Home Business
Mailing Address
(C) Lend:ng Inst,tution __(~.~?~___~_~'~' ~'~ ~'"~_e_.z.~ Te:ephone
Mai~ing Address
Telephone ~' I~
(e) Mail the HAA to the followino address: or: Cheek here ~ if hold for pick up
TYPE OF RESIDENCE
Single-Family/~
Number of Bedrooms
WATER SUPPLY
Individual Well ~. Community [] Public I-I
Note: I!community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite ~ Public [] Community ['"] Holding Tank []
Note: If community well system, must have written confirmation Irom the State Department of Environmental Conservation
attesting to the legality and status.
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. . , . /v/S/ON
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUAR~ 1984,
264-4744
Leg_al Description: ,.L.{3~' ~1 r~... ~,
Well Classific~ti0n '" ~__. F~
Well Log Present ~Y]I~) ~"
Total Depth 113" Cased to
Static Water Level :' ' ·
Casing Height Above Ground
Electrical Wiring in Conduit ~WN)
~paration Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field
To Nearest Public Sewer Line
CleanouVManhole N
Water ~mple Collected by
If A. B..C, D,.E.C, ,~pproved (Y/N)
Date Completed ~ 2./~J'/ Y~eld
Depth of Grouting, I~ O J~ E
Pump Set At .~e ~/p ,.'~/
Sanitary Seal on Casing (Y/N) ~
Depression Around Wellhead (WN), ~
Water Sample Test Results
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
Date ~'/Z. gl/~ ~,,
Comments
B, SEPTIC/HOLDING TANK DATA
Date Insta,,ed "~ % J~ IC'..] Size I 0~:) No. of Compartments
Standpipes (Y/N) ~"~-.~ Air-tight Caps (Y/N)
Depression over Tank (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 ~ D~
Foundation Cleano. ut (Y/N)
Date Last Pumped '//'='c/aa
:for
Temporary Holding Tank Permit (Y/N)
To B.uilding Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed I ~ ~/
Width of Field ''
Square Feet of Absorption Area
Depression over Fi.eld (Y/N)
Results of L~st Adequacy Test -~.,~
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 · ~..O
.To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
';
Separation Distance from Absorption Field:_]
To Water-Supply Well' ' / ~.eg:) -r
To Building Foundation ~ ~
Lot ~" ~'~ O ~/~'
TO Water Main/Service Line ~/(~
To Stream/Pond/[ake~or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments -' - · '.:
HoN ' ' "
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Co'mr~ents ' ' "
** Check Permitted Bedroom Rating Against HAA Request ** ' '
I certify thatJ have checked, verified, or~lonformed to all MOA and HAA guidelines in effect on the date of this inspection.
S~gned Date ¢ ~-~' ~ ~
Company / --' MOA NO --r ' ~ ~'
Receipt No. /_~'~
Date of Payment
Page 2 of 2
,F~. 203 W. 15Ih AVE "C" SUITE 203
ANCHORAGE, ALASKA 99501
TELEPHONE: (907) 279.3916
RESIDENTIAL WELL INSPECTION
LEGAL=
Lot 5A, Block 2, Mann Subdivision
LOCATION:
OWNER:
TYPE OF WELL=
WELL LOG AVAILABLE=
16030 Elisabeth Street
Randy & Jane Johnston
Residential, Single Family
Yes
INSTALLATION REQUIREMENTS MET=Yes
WELL YIELD FROM WELL LOG=
PUMP YIELD FROM TEST:
7 gallons per minute
DATE OF INSPECTION=
April 20, 1988
TEST PROCEDURE: Well was pumped at a constant rate while the
drawdown was monitored with an acoustic probe. At the beginning
of the test water level was found at less than 24 feet below top
of casing. At a pumping rate of 7 gallons per minute the 'well
run dry after 70 minutes of pumping. A total of 330 gallons were
pumped. The well recovery rate was monitored for two hours.
50% recovery took place in 30 minutes, 100% recovery in less
· than 2 hours.
TEST FOR E.COLI AND TOTAL NITROGEN: Water was tested for E.Coli
and total nitrates on April 22, 1988
E.Coli 0. Total Nitrates mg/1. (None Detected)
''Max. allowable Total Nitrates 10mg/1.
TEST RESULTS= This well meets the requirements of the
Municipality of Anchorage.
THIS WELL WILL PRODUCE MORE THAN 3 GALLONS PER MINUTE FOR MORE
THAN FOUR HOURS
The Municipal requirement for well flow is 150 gallons of water
per bedroom per day. This well exceed this requirement. The
assessment of the condition of the well applies only to the
conditions as of the day tested. The flow rate may change due to
subsurface conditions that may not be observed from the surface,
and changes in the land use and other factors that may impact the
aquifer feeding the well.
~', 203 W. 15~h AVE "C" SUITE 203
ANCHORAGE. ALASKA 99501
TELEPHONE: (907) 279-3916
SEPTIC SYSTEM ADEQUACY TEST
LEGAL%
LOCATION:
OWNERs
RESIDENCE:
WELL:
SEPTIC SYSTEM:
Lot 5A, Mann Subdivision
16030
Randy & Jane Johnston
Three Bedroom Single Family
Onsite, Single Family
FROM MUNICIPAL RECORDS:
TANK: Greer Steel, 1000 gal. Two Comp.
ABSORPTION.SYSTEM: Trench -
ABSORPTION AREA: 378 sq.-ft.
SOIL RATINGs 125
INSTALLATION DATE: September 1981
DATE OF LAST PUMPING: April 25, 1988 Isaac's
DATE OF TEST:
April 20, 1988
TEST PROCEDURE: System was inspected and measured. Tank was
found with two feet of cover and 54 inches of liquid. Cleanout
to trench could not be found. Trench sump was six feet deep and
had a liquid depth of 30 inches.
330 gallons of clean water were added to the trench while the
water levels in the tank and the sump were monitored. The levels
both rose 4;5 inches. The infiltration rate was monitored for
three hours. 'During the first 30 minutes the levels dropped 1.5
inches. After three hours the levels were within .5 inches of
the levels Prior to test.
On May 23, 1988 the end of the trench was exposed. Water level
was found approximately 12 inches below invert bf distribution
pipe. Ten feet from sump a testhole indicated gravel and sandy
materials to a depth of ten feet. No indication of ground water.
Distribution pipe was found with.the holes up, the rock was
clean with no build up of sludge. The elevation of the end of
the distribution pipe was three inches below tank water level.
Normally the water level in a 1000 gallon tank is 49 inches.
This distribution pipe must have an adverse grade. When water
was added to the tank it immediately flowed to the sump and then
into the gravel.
The tank was exposed and it was found that the front end of
the tank had settled and in the process broken the pipe to the
trench. The tank was leveled and the pipe repaired. A foundation
clean out was installed and the clean out to the trench replaced
and extended to above surface.
Tcbben Spurkland P.E.
TEST RESULTz This system meets the code requirements of
the Health and Social Services Department of the Municipality of
Anchorage.
NOTE The operational life of all septic systems depends on
local soil conditions, groundwater levels that may fluctuate
during the year, and the water usage of'the family being served
by the system. These conditions are outside the control of the
evaluator of this septic system.
th~