HomeMy WebLinkAboutBIRCHWOOD SOUTH BLK 1 LT 4BBirchwood
South
Block 1
Lot 4B
#051-294-31
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On -Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WATER SUPPLY PERMIT
Upgrade
Permit Number: SW980408
Legal Description: BIRCHWOOD SOUTH BLK 1 LT 4B
Design Engineer: 0003 S & S Engineering
Owner Name: Greg Stevenson
Owner Address: PO Box 671032
Chugiak , AK 99567-5536
Date Issued: Oct 15, 1998
Expiration Date: Oct 15, 1999
Parcel ID: 051-294-31
Site Address: 019137 MONASTERY DR
Lot Size: 54450 SQ. FT.
Total Bedrooms: 2 Permit Bedrooms: 2
This permit is for the construction of:
❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy
All construction must be in accordance with:
1. The attached approved design.
❑ Private Well ❑✓ Water Storage
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 ( 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.
5. The following special provisions.
If the existing well is taken out of service and the sole source of water becomes the water storage system, the well
shall be properly decomissioned as per AMC 15.55.
Received By:
Z' �
Date
/0it.%67Y
tiy '�p '
Issued By��O��LU� Date: �78
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
s&s�
,ineepunq
ROBERT C. COWAN, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
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17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
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GALLON OUTLET/DRAIN FILL
CAPACITY DIAMETER HEIGHT SPECIFICATION OPENING PART NO.
35 Horizontal 20" 29" (Length) 3/4" 5" 60318
65 Vertical 23" 39" 1-1/411 8" 60213
100 Vertical 23" 63" 2" 8" 40803 ;
120 Mini Bulk 38" 29" 2" 5" 40318 ;
165 Vertical 31" 55" 2" 16" 40281
210 Pickup 6011/51" 28" 2" 8" 40300
220 Mini Bulk 42" 42" 2" 5" 40320
300 Vertical 36" 78" 2" 16" 40213
325 Pickup 62" 32" 2" 8" 40160
*325 Horizontal 38" 68" (Length) 2" 16" 40217 t
425 Pickup 65" 37" 2" 8" 40102
550 Vertical 67" 42" 2" 16" 40023 .r
1000 Vertical 64" 79" 2" 16" 40152
1100 Vertical 87" 51" 2" 0 `t
1550 Vertical 87" 65 2" 16" 4 �*
2500 Vertical 95" 89" 2" 16" 40051 1; �
**3000 Vertical 95" 107" 311/2" 16" 40063 i ' X
5000 Vertical 102" 152" 311/2" 16" 40164 ►
* Optional bands for 325 Horizontal (2) Part No. 60478'''
** Part number & outlet/drain specification may vary depending upon manufacturing location.
bT " ilabiil4,pay'via a o a ing location. Please conte es i,
er S vice or you Norm tr!r specific details.
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– MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
\ 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
\ ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAMEV
PHONE
__J
KNEW
UPGRADE
MAILM A ,SS�,., -ver S-_.,.,7
�/ �/
LEGAL DESCRIPTION �
11U4 �►vVOb SIJ 1 rl o-4— e—
-- --- -
LOCX-1h N
NO.OFBEDROOMS
DISTANCE TO:
ell
Absorption aa
Dwelling
PERMIT NO.
V
a Z
Q
M f
Ma I/
No. of czartments
UJ ~
to
Liq. &ciyK' gallons
UU
IF HOMEMADE:
Inside length
Width
Liquid depth
° z
DISTANCE TO:
Well
Dwelling
PERMIT NO.
_
_ F
__ ___ __ ___ _______
Manufacturer
__ _ _
Material
Liquid capacity in gallons
O
DISTANCE TO:
Well
Foundation
Neare t limi�
PERMIT NO.
w=
LL z
H Z w-
No. of line
Length e h line
- -—inches
Total lengt f lines
Trenc id
Distance between lines
HTop
of tile to finish rade
Material ben ath the
Total effec ' e abs r area
eJ I
❑
Eh inches
Length
Width
Depth
PE R74 17-N 0.
w
Q H
as
Type of crib
Crib diameter
Crib depth
Total effective absorption area
w
W
DISTANCE TO:
Well
Building foundation
Nearest lot line
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
•
PIPE MATERIALS
SOIL TEST RATIN
�' A lf7—
INSTA ER
-
—
-
REMARKS
14
ago war"�'11 at-,X0'/w
I
72-013 (Rev. 3/78)
11;
MUNICIPALITY OF ANCHORAGE
Department Health and Environmental rotection
825 L Street, Anchorage, AK. V9501
264-4720
Permit # HANDWR 1 TTEN PERMIT # # #
? WELL AND/OR ON-SITE SEWER PERMIT
Applicant: Vo-'A- 0_'�L� Mailing Address : po P) &'z
Location: Phone Number:
Legal Description: �1 �� / ��-�,P.�a art_-���� > Lot Size:
Type of Soil Absorption System Is:
Trench: Drainfield: _ Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: a Soil Rating(sq.ft/br) �•.`�
The Required Size of the Soil Absorption System Is:'
DEPTH LENGTH -L GRAVEL DEPTH WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOtD!'M) TANK SIZE = 1�� GALLONS * #
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* # * TWO(2) INSPECTIONS ARE REQUIRED # # #
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
# # # PERMIT EXPIRES DECEMBER 31, 1 9 3 3
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more thath3 bedrooms.
Signed: Issued by:
Applic `�—�—
Date:
SWP/024 (1/81)
U��p"l 1 10 1:K'7`1�I -*r 1--r." H::n F--- 1:70 P4 co FA TV Fl C3 EZ
DEPARTMENT D. HEALTH AND ENVIRONMENTAL |..dTECTION
825 'L' STREET, ANCHORAGE, HK 99501
264-4720 : ANCHORAGE 694-2131 : EAGLE RIVER
I., P"A_5 X -lF EZ On E" 01 FEE 6z L-A C- -- L_ L_ F— EZ F -.'Ir -1 I "IF
PERMIT NO. 831096-
APPLICANT:
]1096RPPLICONT: GREGORY YHNCE PHONE: 688-3001
ADDRESS: PO BOX 154].-
EAGLE
54�ER6LE RIVER, HK 99577
LEGAL DESCRIPTION —SUODIYISION: EKLUTNR BIRCHWOOD BLOCK: 1 LOT: 4B
LOT SIZE 0 SQ.FT. TOWNSHIP: - RANGE: - SECTION: --
MAXIMUM
MHXIMUM NUM8ER OF BEDROOMS = 2 SOIL RATING = 125 125 125 (SQ.FT./BR)
LISTED BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR SEPTIC
SYSTEM. CHOOSE THE OPTION THAT DEST FITS YOUR SITE.
..... ... ..... _________... ..... .....
________________________
][����
WIDTH = 2.5 FT.
LENGTH = 42.0 FT. .
TOTAL DEPTH = 7.0 FT.
GRAVEL DEPTH = ],0 FT.
GRAVEL VOLUME = 13.6 CU.YDS.
TANK SIZE = 1,00w0 GALLONS (TWO COMPARTMENT TANK)
E-7 IC -u [--il 0 To.. C -i V-4
WIDTH = 14.0 FT
LENGT|| = 28.0 FT.
TOTAL DEPTH = 5.0 FT. '
GRAVEL DEPTH = 0,5 FT.
GRAVEL VOLUME = 14.5 CU.YDS.
TANK SIZE = 1,000.0 GALLONS (TWO COMPARTMENT TANK)
���E:: �1. r -4 � 1 r= L.- E -.a 1--'-u EE I P=i r4
WIDTH = 5.0 FT.
LENGTH = 25.0 FT.
TOTAL DEPT|{ = C.0 FT.
GRAVEL DEPTH = 2.0 FT.
GRAVEL VOLUME = 1G.2 CU.YDS. ,
TANK SIZE = 1,000.0 GALLONS (TWO COMPARTMENT TANK)
... ..... .... ... __..... ..... ..... ..... ..... ____... ... ..... ..... ______________
I CERTIFY THAT: `
1. I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE AND THE STATE OF ALASKA.
2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES AND HAVE RECEIVED
R COPY OF THE CODE SUMMARY AND DIAGRAM ATTACHMENTS WHICH IS PART OF THIS.
PERMIT.
a, I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 2 BEDROOMS.
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM PERSONNEL DURING
THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND
THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
IF O LIFT STATION IS INSTALLED, AN ELECTRICAL PERMIT AND INSPECTION MUST
BE OBTAINED. RS-BUILTS CANNOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION
REPORT. THE ELECTRICAL WORK MUST BE DONE BY D LICENSED ELECTRICIAN.
SIGNED
.. ..... .... .... ..... ..... ..... .���������
APPLICANT: GREGORY YRNCE '
ISSUED � BY: DATE: 12/12/8]
�
1-1 LJ t4 I C::- I F- c-1 L_ I IF 1-e Cl F::" ��m_-_ " o-1 pe- " ol� F= -
DEPARTMENT L HEALTH AND ENVIRONMENTAL JTECTION M
825 'L' STREET, ANCHORAGE, HK. 99501 �&^~
�-
264-4720
t4EF-I t- F:J"Cm '_EF=t4E=F-! �F=F21*11IF
PERMIT NO. ( 830332 )
APPLICANT GREGORY H. \ANCE P.O. BOX 1542, EAGLE RIVER 694-9889
LOCATION
LEGAL LOT 4B BIRCHWOOD SOUTH SUB LOT SIZE 999qqQ cm=~- -EET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH VA, L, S TC< XL- «&/�
MAXIMUM NUMBER OF BEDROOMS = 5 SOIL RATING
��3��� '
"�o\�"� -- � ��'
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
E> EO FO IF Vi= JL AL L_ E= F4 Ci IF VA= 7z AL C3 FO Fl 11 K L_4�
^7ww,o*Q to'
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD.
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE 15 NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
I Re -FEC, 1E ���C--l�� ������S=.
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
___ IF t4 g_-1 < 2" _--o �������l e7D r-4.:-7. �F;;_'FE �E:�U I F -F= C-0
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND
TO H COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
��F--* 1-13: IF . F=, 11 F 'E7 e---. �������� ��� ���31,
I CERTIFY THAT
1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
]: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 5 BEDROOMS.
SIGNED:Aor_.-'A'v GREGORY A.
HNCE
ISSUED B DATE -0 Y4�0
. °�+__�_~�___-���--------�r-��-37- _��
501 LS I.OG
MUNICIPALITY OF ANCHORAGE
• �r DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION f PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: ,.,.�\ DATE PERFORMED: 1_t_
LEGAL DESCRIPTION: t,tit}' �'i ^� lii l f j L Ds L�C)T- v
SLOPE
SITE PLAN
DEPTH 'r - . r 1 "I �) /.
(FEET)
1
3
6-
7 7
f
i4 -
9
14
15
Reading
Date Gross Net Depth to
Net
Time��T�/ne Water
Drop
~ e�
11
_.
WAS GROUND WATER S
=�,` ENCOUNTERED? j-- L �- - - - - —
O
T
P12 - - --- - - -
IF YES, AT WHATif E
DEPTH?
13
••
� N NN t1
-
a arca ye ► : - —
—
t
Q''i0FES
(•f
_—
14
15
Reading
Date Gross Net Depth to
Net
Time��T�/ne Water
Drop
~ e�
11
_.
WAS GROUND WATER S
=�,` ENCOUNTERED? j-- L �- - - - - —
O
T
P12 - - --- - - -
IF YES, AT WHATif E
DEPTH?
13
••
14
15
Reading
Date Gross Net Depth to
Net
Time��T�/ne Water
Drop
~ e�
•�A,�r+694*6
:d►
T
••
� N NN t1
-
a arca ye ► : - —
—
t
Q''i0FES
20 41
---- -•......-
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND LF��
COMMENTS
f,e ���✓r ,�1_n,�;,�s «/�:�//� ���,r,�,� cF iir/�s:IL�_c �,���Pri�,cl ,d�r.�,� ,r/�r ro c�c�ss:-�L�r.�1 �-�'TN .
PERFORMED BY: \ ` l t� 1 'f i i� j+- - _CERTIFIED BY: ��� DATE:
72-008 (6/79)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological a Geophysical Surveys
Drilling Permit No. _
LOCATION OF WELL (Please complete either la, Ib or Ic.) A.D.L. No.
!I.o� Borough Subdivision Lot Block I� '/4gtrs. Section No. TownshipN^ Rong• E0 Meridian
—
11 Anc) I3�chwo d ,� 1 �ar�of—of� sU W�
I Ic�IDISTANCE
AND DIRECTION FROM ROAD fNTERSECTtONS 3. OWNER OF WELL: Mr. Greg Vance
Address: Monastery Rd .
Eagle River, Ak.
Street Address and Area of Well Location
2. WLLL LOG
M oterlal Type
----- ---
1
r- �----- I31 u e clay ------
If
Feel
Feel Below
Surface
Top Bottom
40 1 235
-_ T�IUNICIPALII OF
DEPT. -1
M
4. WE{ I, ¢=PTH: (final) 3. RATE OF 9p�APLETIO�
C i / — f t._� —
6. E3 Cd Is too, ' Rotary Driven Dug
Auger E3Jetted u Bored 0 Other:
7.USK"ri� Domestic Public supply O Industry _—
Irrigation Recharge U Commerical
Test Well Other:
E. CASING E] Threaded W.Ided 1 7
diem.In. toft. Depth Weight_7 _Ibs./ft.
diem.— -- — In. to ft. Depth Stickup___ __ ft.
9. FINISH OF WELL:
rype Diameter:—_------
SIotlMesh Size:-- Length:__ __—__
Set between ft. and ft.
Backfilling _--- __— Gravel pack
10. STATIC WATER LEVEL: —_ �ft.
�] Above or O Below land surface Date
Equipment used:
I I . PUMPING LEVEL below land surface and YIELD
—,—fI. after ---hrs. pumpingg. p. m.
ft. after hrs, pumping g.p.m.
12. GROUTING Well Grouted: Yes -0 No —
Material: ❑Neat Cement Other:
13.PUM0 (if available)
Length of Drop Pipe —ft. capacity-- g. p.m
yE)r'Subm. Jet Centrifical Other
14. REMARKS: Production Of 30 GPH
16. WATER WELL CONTRACTORS CERTIFICATION: —
tS. Water Temperature _.
This well was drilled under my jurisdiction and this report Is true to the best of my knowledge and belief;
T and T Drilling
Registered Businesr, Nome Contract License Number
Address I'umi; installed by Magnuson Dri11 in AA 53P5
a O F El C
:iignod '. In .0 . Bo_ x 710504 Ea Fle River, Ak . Oate �--- May 15, 1984
Authorized Representative
Form 02-WWR (II/BI) Copy Distribution: WHITE - State DGGS, PINK -Driller, CANARY- Customer
Municipality of Anchorage
On -Site Water and Wastewater Program
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 051-294-31
1. GENERAL INFORMATION
Expiration Date: -S',-)Q i 5:::.
Complete legal description Birchwood South Block 1 Lot 4B
Location (site address) 19137 Monastery Drive Chugiak AK
Current Property owner(s) Jilka Renee Day phone 854-3660
Mailing address same
Real Estate Agent Owner Day phone 854-3660
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class C Well
Public Water System
2
TYPE OF WASTEWATER DISPOSAL:
®
Individual
❑
Holding Tank
❑
❑
Community
❑
❑
Public Sewer
❑
Received by:,�a.� Date:
COSA to be released to the engineer, unless othervvi5/e requested by the engineer.
COSA Fee $ 62_(,— Date:
Date of Payment ! P-! I's /I S Date of Payment
Receipt Number 08 L-1? � Receipt Number
COSA # C)5 C_t S (Pl y 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 _NorthRim Engineering Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng Date IJA* 03s2s
Ug
m g�e M
e.
6. DSD SIGNATURE
System #1 Approved for bedrooms. ,4
System #2 Approved for bedrooms. f2/�r%1'S
Disapproved. '/
Conditional approval for bedrooms, with the following stipulations:
0
OF AN�y>7,p�
za s
WATER AN
=o WASTEr
Original Certificate Date: 1 3 ^IS�
The Municipality of Anchorage Devlopment 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
Septic System Advisory
Well Flow Advisory
COSA blue sheet 9-142.doc
X
Nitrate Advisory
Arsenic Advisory
Other
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:/go-A 00-0 S d uTjff t8/ L !:�.8 Parcel
A. WELL DATA
Well type F_ If A, B, or C provide PWSID #
Date completed Sanitary seal (Y/N)
Total depth 6JQ ft. Cased to 0+ ft.
FROM WELL LOG
Date of test -7/607
Static water level LSO ft.
Well production O• a7 g. P. m
WATER SAMPLE RESULTS:
Coliform ,_colonies/100mL Nitrate 40. 5 mg/L
Arsenic 4_ ug/L Date of sample: 1 Z1,r t S
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material :Sz:!!PTyTZ_S.:�n5aL
Tank size 00 0' gal. Number of Compartments Z
Well Log (Y/N)
Wires properly protected (Y/N) T
Casing height (above ground) 12 in.
AT INSPECTION
g ft.
�. g.p.m.'�
,Ar //66' GA/ -".J 5To9-461-55 7A- 4 k
Collected by:
Date installed 4.Ges
Cleanouts(Y/N)
Foundation cleanout (YIN)___�L Depression over tank (Y/N
y)) /t� High water alarm (Y/N) V
Date of pumping Z / qPumper T %z
C. ABSORPTION FIELD DATA
Date installed l f E3 Soil rating (g.p.d./ft2 or ftZ/bdrm) / Z s System type TZfit C/�
Length 3 y2 ft. Width 3 ft. Gravel below pipe — ft.
Total depth ? ft. Eff, absorption area Z 56 ftZ Monitoring tube _X_ Depression over field __&/
Date of adequacy test 2441- Results (Pass/Fail) —fazes Foro� bedrooms
Fluid depth in absorption field before test _( in. Water added & 66 gal. New depth & in.
Elapsed Time: C Z6 min. Final fluid depth Q in. Absorption rate >= _F0 G g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) 'Al 0 If yes, give date
D. LIFT STATION A/4
Date installed Size in gallons
"Pump on" level at in. "Pump off' level at
Datum Cycles tested
E. SEPARATION DISTANCES
WELL ON LOT TO:
.r)c
Septic tank/lift station on lot %4'
Absorption field on lot fF 6,
Manhole/Access(Y/N)
in. High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots e'On "7-
On
7 -
On adjacent lots !O 0 '*
Public sewer main Zd 6 f Public sewer manhole/cleanout /G6` `t
Sewer /septic service line 2 5 r� Holding tank /D 0 +�
Animal containment areas Sd ' Manure/animal excrete storage areas Ida
SEPTIC/HOLDING TANK ON LOT TO:
i
Building foundation S , f Property line el a Absorption field
Water main
110-
Wells
f
Wells on adjacent lots 1t
Water service line /LJ -- Surface water lea, -/-
in.
ABSORPTION FIELD ON LOT TO:
Property line /6 t Building foundation .� Water main �6
Water Service line 1� 1" Surface water Driveway, parking/vehicle storage ID rIe-
Curtain drain k'VkAldc hW Wells on adjacent lots Zffz `1
IAlIl lirili5l:4?U&9
,rK)41yf12 P</i I140A rfc-15
G. ENGINEER'S CERTIFICATION
1 certify that f 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
Date /a�Z 7/15
COSA yellow sheet_2-6-15.doc
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
Water Well Advisory
Certificate of On -Site Systems Approval (COSA) 4 OSC151672
During a recent COSA on-site inspection and test of the potable water
supply well on Block 1, Lot 4B of Birchwood South subdivision, the well's
productivity was determined to be 0.1 gallons per minute. The minimum
well productivity required by this Department (AMC 15.55) for a 2 -bedroom
residence is 0.2 gallons per minute. All parties concerned are advised that
the production capacity of the well may fluctuate. Restriction of non-critical
water uses such as washing cars and watering lawns and gardens may be
required.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
IQ
Tle.'A" B/,2CHWOOP SOOT/-/
LOT 4A
/65-00
Z OT 49
I
53
56
1-OSC/nf/1/
/6500 r
11rI0IVA5TERY 49A? VE {'
S89'S0'OD"E
w OF A
4S 41
%••.,�yio . As—Quit?
* 49 L►S ;
•..«.......4� «�•.Y.•••••, !.o/ 48 Bir�hwoad S� fh Subdi<•isian
T. g Dim ricf A/�chorrlg� LioS.��
No. 4]675 JAMES B. RODGERS
: Pa"'/
���Fc•~••••. ••••• o'JRegr'slered Land Surveyor
1 �"o%tssioyAt��� r SRA Box 1616 G
�1���•,�,��► Anchorcge, Alosko 99507 (907)345-0927
nnte I Sr.ole I Drwn. b✓ I F. H. I Grid Sheol
MUNICIPALITY OF ANCHORAGE ARL
• '� DEPARTMENT OF HEALTH & HUMAN SERVICES AECM
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. # 0 S'1 _ a 11'q - 3 1 HAA # OiL32Jl1LVhn
1. GENERAL INFORMATION
Complete legal description Lot 4B, Block 1, Birchwood South S/D
Location (site address or directions) 10137 Monastary Drive
Property owner Greg Stevenson Day phon�RR-55 6
Mailing address PO Box 671032, Chugiak, AK 99567
)
Lending agency
Mailing address
Day phone
Agent Remax of Eagle River/Brook Stiltner Day phone 694-4200
Address 16600 Centerfield Dr., Suite 201, Eagle River, AK 99577
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 2
3. TYPE OF WATER SUPPLY:
Individual well XXX
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 xxx
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev.1/91) Front MOA821
5. STATEMENT OF INSPECTION BY ENGINEER
r..
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 furtherverify 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 S & S ENGINEERING Phone
17034 Eagle River Loop Road No. 204
Address Eagle River, Alaska 99577_
Engineer's signature
6. DH/l�S SIGNATURE
vApproved for Ltij bedrooms.
Disapproved.
Conditional approval for
Additional Comments
By:
MITIC',
6 g y --x97%
Date / 9.- // o / R V
.��•CF,,0r
11%1 ROBERT C. COWAN e �Q
G'�: CE . 8801
vlF
9r 'h.
t� 4 • ...........:
i._
bedrooms, with the following stipulations:
Date 1 Z ZZ 7C)
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.
72-025 (Rev. 1/91) Back MOA 7121
RECEIVED
Municipality of Anchorage DEC 10 1998
DEPARTMENT OF HEALTH & HUMAN SERVICEh%NICIPALITY OF ANCH
Environmental Services Division ENVIRONMENTAL SERVICES
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: LOT H t3 SouTt4 Parcel I.D.: 0 s / — a'0� y — 3�
A. WELL DATA
Well type /04 / v 4- T IL If A, B, or C, attach ADEC letter. ADEC water system number
Log present &N) Y &, f Date completed 7/ F11
Total depth 600 Cased to ly o /� Casing height (above ground) /f
Sanitary seal aN) _l 6,S Wires properly protected/N) Y
FROM WELL LOG AT INSPECTION
Date of test
Static water level 1 5-0
Well production 01 7 g.p.m. YO D
_%_ )100 FALLOW w19 -;r -t4 STeR4 It T9NK irSTALt- OLq ��� °l$ 'd
WATER SAMPLE RESULTS: Pt R "' r 1i S wO1$ e `4 0 g
Coliform 0 Nitrate 0-1 Other bacteria
Date of samle: Collected by.
p ' *I A Y � �� ��i rr °I g S & S ENGINEERING
17034 liagle Rive.. Loop Read No. 204
B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99577
Date installed ► 4 V 3 Tank size i 0 0 U Number of Compartments �2- Cleanouts (ON) V f 1
Foundation cleanout'If /N) V it S Depression (Y/IM A' 0 High water alarm (Y/&
Date of Pumping /0 3 g Pumper _T
C. ABSORPTION FIELD DATA
Date installed I Soil rating (g.p.d./ft2 or 2/bdr a S System type
Length 3 Width 3 Gravel thickness below pipe �` Total depth g
2
Effective absorption area s6 L1 Monitoring Tube present aN) Y# --J Depression over field (Y(@ Na
Date of adequacy test / ° S 9 Y Resultsass ail) 104-5S For oZ bedrooms
Fluid depth in absorption field before test (in.); 0'4- Y Immediately after 300 gal. water added (in.): 6 �x
Fluid depth DAY (ins) Minutes later: 1 o Absorption rate = 3 0 0 � g.p.d.
Peroxide treatment (past 12 months) (Y/N) N 0v 4- k .-i oa,✓ If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested'
E. SEPARATION DISTANCES
"Pump on_"
*Datum
Size in gallons
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
qoc- u/}44w) '
Septic/holding tank on lot -74 (WNiv4A �R On adjacent lots
Absorption field on lot g6 �'Y'�4 �°�� On adjacent lots / 00
Public sewer main
N / p Public sewer manhole/cleanout N 14
Sewer /septic service line a
Lift station )a /y
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation { Property line S Absorption field S
Water main/service line /0 Surface water/drainage /00 it Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line / o f Building foundation o Water main/service line
Surface water
/ o o '4 -
Curtain drain N c N t K ov° "' 4
F. ENGINEER'S CERTIFICATION
Driveway, parking/vehicle storage area
_ Wells on adjacent lots / o o �4-
I certify that 1 have determined thru field inspections and review of Municipal
in conformance with
�M�OA 11-AA/guidelines in effect on this date.
Signature
Engineer's Name /t�3��4 r �e�✓�^�
r
Date
HAA Fee $ F2 ®b ' Waiver Fee $
Date of Payment ) Z D Date of Payment
Receipt Number 6-7 Receipt Number
72-026 (Rev. 3/96)*
ROBERT C. CO%
CE -8801
aZV,—Z�.::..-%;
01
10 4
e{
ns are
12/21/98 14:24 FAX 1 907 561 5301 C'F&E ENV, ANC
Z002
CT&E Environmental Services Inc.
Zwtk 1
1 sbmtory Division iii i�/yiva�►ri�� ����►iriyiii�s
200 W. Potter Drive
drinking Water Analysis Report for Total Coliform Bacteria Anchorage, AK 99515-1605
Tel: (907) 562-2343
REM INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE Fax: (907) 561-5301
MUST BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY
,Analysis shows this Water SAMPLE to be:
0 PUBLIC WATER SYSTEM I.D. # X Satisfactory
R PRIVATE WATER SYSTEM ❑ Unsatisfactory
7Sendesults Send Invoice ❑ Sample over 30 hours old, results may
be unreliable
Ram
and omp�m m _°°'�" 11Sample too long in transit; sample should
co 9not be over 48 hours old at examination
to indican reliable results. Please send
new sample via special delivery mail.
moxis law Date Received
ry Time Received _
o Nd am& C]S,.d Invoice Analysis Began
SAIAM DATE: Fiq
MaMb
Wawa I
p Routine
ofRapt" Swnple.Qiir roadwe sale
Ualowf. no.
v spo" impose
lis LCIC11"
N 1$ 7LK I 9IAr-}./w10 �C-
p Tr"dsd W Saar
Uoreaied Water
Tl` Cited
comemA DY
Analytical Method: j( IMee 1ma�Gilter
• Numher of colonies/ 100 ml.
Result* Analyst
987282
Qom C.
r1� 1.s
CD �`' -
.nth Fbks Jun 11
Faxed
pele- Time:
Client nodiied of unsatisfactory results:
Phoned ax
ned Spoke with Faxed
Time:
BACM]IOLOMAL WATER ANALYSIS RECORD
y1�pa)� Rpolt: Tori Ceoren
E. Cod
Q C81081e4100 ml
er: pireeCor
I
LTV DIGS COIF
0yrpdomCenfrrwoon
F1ruwss�niterrwDt Coliferm/100ml
RWM* 1111111 Time D (:Of hrs
Comm"Mts:
TNTC—Too Nttatrro-u TO Count
O8—OtherBaaerid
Member of the SCIS Group (soeibt6 Gin6rale de Survailiancel
URAL
NEW JERSEY, OHIO, WEST VIRGINIA
FACLMN M ALASM CALIFORNIA, FLORWAI ILLINOIS, MARYLAND. MICHIGAN, MISSOURI,
DEC -15-1998 00:40 ME ESI ANCHORAGE
ALCT&E Environmental Service$ ln:
CT&E Ref.#
Client Name
project Name/#
Client Sample ID
Matrix
Ordered By
PWSw
987149001
S & S Engineering
N/A
Ut 4B 131k 1 Birchwood SD
Drinking Water
0
9075615301 P.01/01
Client PO#
printed Date/Time 12/15/98 00:26
Collected Date/Time 12/09/98 19:30
Received Date/Time 12/10/98 11:20
Technical Director: Stephen C. Ede
Released By ]A, „_ j Q , „ A
Allowable Prep analysis
FUL Units Method Limits DatDate Init
Parameter Resut�
SM18 92228 12/10/98 KAP
Totat Coliform{ 10 max 12/10/98 12/10/98 SCL
Nitrate•N
0.100 U 0.100 mg/L EPA 300.0
K;
TOTAL P.01
PARCEL: 051-294-31-000-96 CARD: 01 OF 01 RESIDENTIAL SINGLE FAMILY
STATUS: RENUMBERED TO/FROM: - - - - 1
------------------------------------------------------------------------------
STEVENSON GREG P & CARRIE D BIRCHWOOD SOUTH
BLK 1 LT 4B
19137 MONASTERY DRIVE
0
EAGLE RIVER
AK 99577
9248 SITE 19137 MONASTERY
DR
------------------------------------------------------------------------------
LOT SIZE:
54,450
---DATE CHANGED---
----DEED
CHANGED ----
ZONE : R7SL
OWNER : 12/19/89
BOOK
1977 PAGE: 0717
TAX DIST: 022
ADDRESS: 05/24/91
DATE
12/12/89
GRID
HRA # 000000
PLAT
830420
NOTES
----------------------------------ASSESSMENT
HISTORY
--------------------------
---
LAND-- --BUILDING- ---TOTAL---
FINAL VALUE
1993:
21,000 51,300
72,300
FINAL VALUE
1994:
33,400 53,500
86,900
--EXEMPTION---
FINAL VALUE
1995:
25,300 53,500
78,800
-----TYPE-----
EXEMPT VALUE
1995:
0 0
0
STATE EXEMPT 1995: 0
FINAL VALUE 1995: 78,800
-COMM COUNCIL-
CHUGIAK
L
�A
DEPT. OF ENVIRONMENTAL CONSERVATION
WESTERN/ANCHORAGE DISTRICT OFFICE
555 CORDOVA STREET
ANCHORAGE, ALASKA 99501
August 7, 1995
Louis Butera
Eagle River Engineering Services
P.O. Box 773294
Eagle River, Alaska 99577
SUBJECT: Lot 56A Monastery Road
9521 -DW -161-140
Dear Mr. Butera:
TONY KNOWLES, GOVERNOR
(907) 269-5720
RECEIVED
AUG 1 41995
M1i,,;;;.patIty or Huurwrage
Dept. Health & Human Services
We have carefully reviewed your letter of July 21, 1995, received July 24, 1995, on the subject
project. The land owner, Greg Stevenson, on July 27, 1995, verbally requested that the existing
private well be kept in service.
We agreed to this provided we receive detailed engineering plans of this system that assure us
that there is no possibility of a cross connection to the Class C system and that this system is in
fact a viable functioning system. (Department regulations call for the abandonment of any well
no longer in service. This is necessary to avoid the possibility of the well being forgotten and
becoming a potential source of contamination to the aquifer.) The plans must be sealed by a
registered engineer. We would also need acknowledgement by the Municipality of Anchorage
Department of Health and Human Services (DHHS) that maintaining the existence of this private
well is acceptable to them. (Within the Municipality, private wells are regulated by DHHS). We
verbally notified your office of this on July 27, 1995.
We will hold your request to fill the well in abeyance pending completion of the project and
approval of the as-builts. We have researched your request in the meantime, however, and have
concluded that while this method of abandonment was approved in the eighties, it does not
conform to present regulations. Please contact me if you have any questions on this.
Cordially,
oug Stark
District Engineer
cc: MOA Health Department
Greg Stevenson, Owner
DS/pt
MUNICIPALITY OF ANCHORAGE
• -� Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # t�S ' �� �ti - 2 HAA #
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 413• Mock 1 • Bikchwood South Subdivi4ion
Location (address or directions)
19137 Monabtany Dkive, Chugiak.,
(b) Property owner k(U DX1.11-032917- -2-0 3 Telephone: (home) Business 271-2792
Mailing Address, 605 WeSt 4th Avenue, Anchorage Afz 99501
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent ASSOCIATED BROKERS ATTN • Sandy
Telephone 563-
(e) Mail the HAA to the following address: (or check here XX if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
17034 Eagle River Leet, Rand No 004
!eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family R Number of bedrooms 2
3. WATER SUPPLY
Individual Well f Community ❑ Public ❑
Note: If community well.system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site V( 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.
72-025 (Rev. 7/88) Page 1 of 2
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of'this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional.and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage 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. G
Name of Firm Telephone 6
S & S ENGINEE1Rsr��...
Address 17024 Eagle River Loop k",: --
Eagle River,
Date
b N'
0 PNn V ASIP1::.k"
6. DHHS APPROVAL J
Approved for bedrooms by ate
Approved Disapproved Conditional
Terms of Conditional Approval
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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.
72-025 (Rev. 7/88) Back Page 2 of 2
fifONICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: o�_1Irc.(1w�o�
Sootk
A. WELL DATA,3,`
Well Classification yi d u c.4 1 If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) Date Completed `1T8 Yield
i 1 $ -e Sy
Total Depth 600 Cased to J 00 Depth of Grouting
Static Water Level 1 5 D Pump Set At L)
Casing Height Above Ground t + Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
Depression Around Wellhead (Y/N)
To Septic/Holding Tank on Lot 'k 1 b ; On Adjoining Lots / o o f
To Nearest Edge of Absorption Field on Lot )F6( ; On Adjoining Lots too �t
To Nearest Public Sewer Line M 1 To Nearest Public Sewer Cleanout/Manhole A)IA
To Nearest Sewer Service Line on Lot ,� 5 �t
Water Sample Collected by 6-4 5 G /N�e. r 1 N q ; Date // " 0q_ 9 J
Water Sample Test Results -'s4ti 5 fAC. 0- r!q -- Z !nc tfejPr AN � Nit✓tAtcS
Comments 'K- 5e 1'
a pq i9�.�1e� 6-�or�0,Jfg1 �enAV-AtvN I,�AJuer
c Ate -d NovPymcr 10 , l q 84,
B. SEPTIC/HOLDING TANK DATA
Date Installed I —8.3 Size I (900No. of Compartments
Standpipes (Y/N) Y Air -tight Caps (Y/N) Foundation Cleanout (Y/N) —1
Depression over Tank (Y/N) ISI Date Last Pumped I — ( 8 T 8
Pumping/Maintenance Contact on File (Y/N)
;for
Holding Tank High -Water Alarm (Y/N) A)Temporary Holding Tank Permit (Y/N) AWA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well b To Building Foundation
To Property Line
(b "r
To Water Main/Service Line 10 �t
To Stream, Pond, Lake or Major Drainage Course
To Disposal Field 6-
,+
Comments tAN1l Aovvn Aed /04 . 715C�SSADo� 00kmQIto
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 1 , Lir? Type of System Design l r2 enJc;tA
Date Installed /1- 235 Length of Field
Width of Field 3 6 �Depth of Field
Gravel Bed Thickness
Iq I
Square Feet of Absortion Area 'a b Statndpipes Present (Y/N) I
Depression over Field (Y/N) N) Date of Last Adequacy Test
Results of Last Adequacy Test S f Gto ✓ ti - d V oo rw\
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well * 4S (Q To Property Line
To Building Foundation t S �t To Existing or Abandoned System on
Lot A) /6 ; On Adjoining Lots 100 t
To Water Main/Service Line to f To Cutback (if present)
i
To Stream, Pond, Lake, or Major Drainage Course / bD I
To Driveway, Parking Area, or Vehicle Storage Areaa 0 �t I
Comments *- .SSA
ee I! Ac_Aed t�oLZON11 nr dAl S�2Are,t WWIuca7Ld
�] n \)C- vvr� e V, 4 o. t! R4.
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA 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.
I certify that I have checked, verified, or conformed to all MOA and HAA guide
inspection.
Signed S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Company — agie R pr, /Alaska 99577
Date
MOA No. �D
Receipt No. -,I-/ S-,3 7
Date of Payment //
Amount: $ Z 0L
Receipt No.
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
�' . e� .� �++��s,�`my h"T'i NdFim"+:.gi.f. p m.r• c S.: r...i .y,.. �... .. _ ... - .. i z „i.. �...ry....-x.e.....
A 4 W •.
�r.1?:v ��i+...r��'hOt:'haiJ�e�L���iC'k!G`N�•].Cd.^W�ti��i.1\. n.) 1..J'i.. �ft l:A..l �4i ivy f .i.'i.::Cct.�..�.+V.�7'Y F.r.;:.i ..L-�'l .i :fif '^t.Ge•;'.J_N'.:�V i.. N..l� � .u. e4....1 .,.h.n �n.t-.Y•...L.%�l.. i. �.✓1 `�::.�1 w�i �.
A /
O 6 0
� SK
BILL SHEFFIELD, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION Telephone: (907)
Address:
ANCHORAGE/WESTERN DISTRICT OFFICE
i 437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501 274-2533
November 20, 1984
Arctic Engineers, Inc.
1506 West 36th Avenue
Anchorage, Alaska
SUBJECT: Waiver Horizontal Separation between Well and Septic Tank,
Lot 4 B, Birchwood South S/D
(8521 -WA -064)
Dear -Mr. Hanley
The Department has reviewed the subject waiver request and hereby waives
the horizontal separation between the well and septic tank to 76 feet
and well to absorption system to 86 feet on the subject property for a
2 bedroom single family residence only.
BEE/dd
Sincerely,
/rruce E. Erickson
District Engineer
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343 5633 B Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
BACTERIOLOGICAL WATER ANALYSIS RECORD ��eIgq
tljib
READ INSTRUCTIONS Membrane Filter: Direct Count n Collform/100ml
BEFORE
COLLECTING SAMPLE
Verification: L
BGB
Final Membrane Filter Results D Collform/100ml
Reported By 5;, te 1 LIC-)
Time- � � a.m.
p.m.
TNTC = Too Numberous To Count
OB = Other Bacteria
PART ONE OF TWO
REMAINDER TO FOLLOW
TO BE COMPLETED BY WATER SUPPLIER
TO BE COMPLETED BY LABORATORY
❑ PUBLIC WATER SYSTEM I.D.#
Analysis shows this Water SAMPLE to be:
A PRIVATE WATER SYSTEM
Satisfactory
❑ Unsatisfactory
Name Phone No.
S & S ENGINEERING
❑ Sample too long in transit; sample should
not be over 30 hours old at examination
17034 agie raver oop Roado. 04
Mailing Address
Eagle River, Alaska 99577
to indicate reliable results. Please send
new sample via special delivery mail.
^ q
City State Zip Code
SAMPLE DATE: Z yil
Date Received � _
Mo. Day Year
Time Received z � n—
SAMPLE TYPE:
Analytical Method: Membrane Filter
n Routine
❑ Check Sample (for routine sample
with lab ref. no. ) ❑
Treated Water
No. of colonies/100 ml.
❑ Special Purpose ❑
Untreated Water
SAMPLE
Time Collected
Lab Ref. No. Result* Analyst
NO. LOCATION
..g�,1 (����ti�axf I
Collected B
9�;7 F
1 � �
mss--
-
1 1 m
2
m
3
1 m
4
I
m
5
BACTERIOLOGICAL WATER ANALYSIS RECORD ��eIgq
tljib
READ INSTRUCTIONS Membrane Filter: Direct Count n Collform/100ml
BEFORE
COLLECTING SAMPLE
Verification: L
BGB
Final Membrane Filter Results D Collform/100ml
Reported By 5;, te 1 LIC-)
Time- � � a.m.
p.m.
TNTC = Too Numberous To Count
OB = Other Bacteria
PART ONE OF TWO
REMAINDER TO FOLLOW
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 8 STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
\ FEDERAL TAX ID p 92.0040440
ANALYSIS REPORT BY SAMPLE for Work Ozdex t 18166
Date Report Printed: NOV 13 39 @ 19.0''
Cllent Sample ID:LOT 4 "b" - BIRCHWOOD SOUTH, SO Cdier.t Nemo 3 & S PNGR
PWSTD 111A Client Acct SNSENGP
Collected NOV 9 89 @ 11:40 his. 11.0 # NONE RECETVFD
Recelved NOV 9 89 @ 1?:00 his. Req
Preserved With :AS REQUIRED Ordered By S & S ENGRS
Analysis Completed :NOV 10 89 Send Reports to:
Labc.ratoxv 3upecv14or :STEPHEN C. EDE 115 5 S ENGR
Released by Ile
Special
Tnstruct:
Cnemlab Ref #: 3476 Lab �mpl 107 1 Matrix: WATEP,
Allowable
Parametex Tested Revilt Unary Method Limits
------------
NITRATE-N ND(0.101 mu/11 EPA S53.2 10
Sample ROUTINE SAMPLE. 3AA4PLE COLLECTED Bf R.D.J.
R enia x ks :
---'----I Tests-Peiiorriod- ,n See Specia] Instructions Abol!e UA-llnavailaotF
ND- Non -1 Detected See 3fomple Ramatks Above
N1'- Not kn&llyzod iii -Les; Than, Cl-Giiater T�,&ii
T k.
b,.
DOC Co. dba
SULLI"N WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 • TELEPHONE 688.2759
OWNER OF LAND ,� F s C'n�� DEPTH OF WELL 400 `
ADDRESS STATIC LEVEL OF WATER FT.
LEGAL DESCRIPTION 4a7- A3 jjLK l 13t4otrlwU-00 lrljdO DRAW DOWN FT.
DATE • Started �� Ended GALS. PEAiV `3P'$
PERMIT NUMBER ��� KIND OF CASING 6
KIND.OFFOI �� A'f'ION:--�------�""
From Ft. to` Ft. r"A/tl -A "J'644- From-- Ft. to Ft.
FromFt. to Z LD Ft. Ed oCC 6,fee4 004 From_ Ft. to Ft.
From Ft. to Ft.Je-o :'cam From Ft. to Ft.
From `300 Ft.to;2`O Ft. dad'e°dGt �,R6r".l __ From Ft. to Ft_
From`) Ft. to 6 00 Ft. 4Z OIO tr e ``/� u 44,<; 2 Froin -----Ft. to Ft
77
From Ft. to Ft. Jlelr' ALOK6-J K14 From Ft. to—. Ft.
From_ Ft. to Ft. From—. Ft. to Ft.^
From Ft. to Ft. From Ft. to Ft.
From Ft. to Ft. From Ft. to Ft.
+'tU1Y
From Ft. to Ft. From Ft0 -
OF
EtVYIRONMEN ,
From Ft. to Ft. From Ft. to „tj 10N
From Ft. to Ft. From—Ft *V-" t.
From Ft. to Ft. FromD. Ft.
From Ft. to Ft. From Ft. to—u
From Ft. to Ft. From Ft. to Ft. —
From Ft. to Ft. From Ft. to Ft.
From Ft. to Ft. From Ft. to Ft
MISCL. INFORMATION:
1 li
JAJ F14
I3✓C
(` r
DRILLER'S NAME
t MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date 10 _ l % 15 9
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (addret}s'or directions)
/�
� / tW A., ��C 11 n ..te r
(b) Applicants Name V��(r' s Telephone - Home `f- husiness
Applicants Address_ P_ Q, j�px �, �{ 3 F_.A(,L G _P i V LZ
(c) Applicant is (check one) Lending Institution ; Owner/builder;
Buyer 1__:] ; Other F� (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Co. & Agent N E
Address
Telephone
(f) Mail the HAA to the following address:
2. Type of Residence
Single -Family Multi -Family
Number of Bedrooms ,`r �
3. Water Supply
Other (describe)
Individual Well P�' Community El Public M
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 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]
5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein. 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 regula-
tions in effect on the date of this inspection.
Name of Firm AQc T (C F N (tp S
n
Address L,y � 6 y- P_ .A v\-)
Date -22--LZ
(ENGINEER SEAL)
6. DHEP Approval
Approved for bedrooms
Approved ?; Disapproved
Terms of Conditional Approval
Telephone <�� I - U L
i
By �� /" (, Date
Conditional
CAUTION
or ro
• 4..u..... e• .• e. .
S Si ey E. rk .�
CE -15 (14 go
00
\N 00
® OF��S19N�6'�
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS 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 REQUIRE-
MENTS. 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.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 21 7-19-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
A. WELL LATA Legal Description: A -r u a Aig" M&,
Well Classification INDIVIOLM If A, B, cr C, D.E.C. Approved(Y/N) N
Well Log Present (Y/N) Date Completed - 1 1- Yield Y�
Total Depth Cased to L4 L.{ Depth of Grouting /a
Static Water Level Appoo,( 237,.E Pump Set At 2 3 1
Casing Height Above Ground Z L{ Iff Sanitary Seal on Casing (Y,/N)
Electrical Wiring in Conduit (Y/N) y Depression Around Wellhead (Y/N)
Separation Distances from Well: oe
To Septic/Holding Tank on Lot 1) 6 C_- On Adjoining Lots 2 QQ t
To Nearest Edge of Absorption Field on Lot6, ; On Adjoining Lots 20Q �f
To Nearest Public Sewer Line To Nearest Public Sewer_
Cleanout/Manhole H /A To Nearest Sewer Service Line on Lot -��—
Water Sample Collected By Date l O
Water Sample Test Results
Comments
B. SEPT�IC�LDING�TANK�MTA�
Date Installed Size t -5[2Q-_ No. of Compartments 2
Standpipes (Y/N) '1� Air -tight Caps (YM) Foundation Cleanout (Y/N)
Depression over Tank (Y/N) Date Last Pumped may/,cam
Pumping/Maintenance Contract on File (Y,; for
Holding Tank High -Water Alarm (Y/N) �/A Temporary Holding Tank Permit
Separation Distances from"Septic�iolding Tank:
00,
To Water -Supply Well % To Building Foundation (�-
To Property Line �� to �{ To Disposal Field
To Water Main/Service Line ��f To Stream, Pond, Lake, cr Major Drainage
Course
Comments _
Receipt # SDS IL( 0j
Date Paid: ja-3-�U
Amount: LJ g ,ap
[Page 1 of 21
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata J 2 Type of System Design T12F^JC-H
Date Installed I (_ g'l Length of Field 3
Width of Field R 0-2r -t- Depth of Field �-(-
Gravel Bed Thickness
Square Feet of Absorption Area !2S6 C ?- Standpipes Present (YM)
Depression over Field (Y/N) �_ Date of Last Adequacy Test N, /A
Results of Last Adequacy Test N %A
Separation Distance from Absorption Field:
To Water -Supply Well To Property Line(_(' 0 +
To Building Foundation' �-F To Existing or Abandoned System on
Lot t ZAS On Adjoining Lots 2Cjj �.F
To Water Main/Service Line 3o f To Cutbank(if present)/ To Stream/Pond/Lake/or Major Drainage Course -,�
To Driveway, Parking Area, or Vehicle Storage Area 2 n
Comments
D. LIFT STATION
Date Installed Dimensions
Size in Gallons Manhole/Access (YM)
"Pump On" Level at
High Water Alarm Level at
"Pump Off" Level at
Vent (YM)
Tested for Pumping Cycles during Adequacy Test.. Meets MOA
Electrical Codes(Y/N)
Comments
** Check Permitted Bedroan Rating Against HAA Request **
I certify that I have
on the date of ,this 1
Signed
Company
KB1/d5/s
(Page 2 of 21
verified, or, conformed to all MOA HAA Guidelines in effect
--- --- ----
Date -
MOA No.
-b OF AZ"-%%
.• S . !t
: !!
2-15-84
N
TQC? 'A ei,ecyw000 Sov ri-/ 5-3
B9 °.5.0'00 fit/
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Lor 4A I nor 48
0
0 0 56
7
0
0
0
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Faunrf %B" ecbor
OF A \�
.. GG
'�'�V •.Mt...
4,5,
i •�+'l �`
James R. Rodp«1'
♦ 's� ti No. 4367$
f f o
h``O � •........ • • ANO r
'11Z
/ or
yr e s
27-•
5ea1�c �r
'
000
L�
QL
o�
&ID,2(vE
s,69,6-,0,
00
I
15 Ff IE,�CD/)] ¢E�CGJ, CQSC/�1C/9/
As - 3011- 7
1. of �'B, Birch/vocd ,5 oufh Subdi<is ion
Anchor��L�c ,(�ecordiny Ofs•fr•icf, Ai�cho�'c>9c f'l,/oS.�� �
JAMES B. RODGERS
Regislered Land Surveyor
SRA Box 1618 G
Anchorage, Aiaska 99507 (907)345-0927
Dole Sco/s Drwn, by F. B. Grid Sheet
S F-J D 0 0 BILL SHEFFIELD, GOVERNOR
F L4SK
DEPT. OF ENVIRONMENTAL CONSERVATION Telephone: (907)
Address:
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
November 20, 1984
Arctic Engineers, Inc.
1506 West 36th Avenue
Anchorage, Alaska
274-2533
SUBJECT: Waiver Horizontal Separation between Well and Septic Tank,
Lot 4 B, Birchwood South S/D
(8521 -WA -064)
Dear Mr. Hanley
The Department has reviewed the subject waiver request and hereby waives
the horizontal separation between the well and septic tank to 76 feet
and well to absorption system to 86 feet on the subject property for a
2 bedroom single family residence only.
BEE/dd
Sincerely,
rucErickson
District Engineer
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562.2343 ANCHORAGE INDUSTRIAL CENTER1`
5633 B Street
�„b....a Fac-'
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED B WATER SUPPLIER
TO BE OMPLETED BY LABORATORY
(') See In on back
A clysis shows this Water SAMPLE to be:
WATER SYSTEM:
j I.D. NO.
Satisfactory
//!�
�?(7 (� f% N (/ry l sr I `�U OI
Unsatisfactory
ElSample too long in transit; sample should
Water System Name Phone No.
i
�_ /� �-3
�.
not.be over 30 hours old at examination to
inc�lcate reliable results. Please send new
Mailing Address
4r—ALARA 7,=-7
sample via special delivery mail.
City State Zip Cada
p
DATE: Ul
Date Received
SAMPLE
Mo. Day Yew
Time. Received
Analytical Method:
SAMPLE TYPE: {,
® Routine !
;0 Fermentation Tube
❑ Check Sample (for routine sample ❑ Treated Water
►
I
JjMembrane Filter
with lab ref. no._
❑ Special Purpose �l Untreated Water
i
SAMPLE Time Collected
NO. LOCATION Collected
Lab Ref. No. Result' Analyst
f
m
FTI
3
m
4 l__
I ED
.No. of colonies/ 100 ml or No of Pow— portions
06 1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev. 1983
READ INSTRUCTIONS Membrane Filter. Direct Count Collform1100m1
Verification: LTB BGB
Final Membrane Filter ResultsCollform1100ml
� —
BEFORE_ Reported By r�" I�{�I� 1.�1n�1 Dale
Time: a. M.
P.M.
COLLECTING SAMPLE TNTC = Too Numerous To Count