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HomeMy WebLinkAboutMICA'S MEADOW LT 3Mica's Mecidow Lot 3 #075 - 091 - 21 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW930461 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:BROCKWAY DANA & OWNER ADDRESS:1611 WEST 15TH AVENUE ANCHORAGE, ALASKA 99504 PARCEL ID:07509121 LEGAL DESCRIPTION: MICA'S MEADOW LT 3 LOT SIZE: 18050 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: PAGE 1 OF 1 DATE ISSUED:11/02/93 EXPIRATION DATE:11/02/94 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED ANDCLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: 1. PROVIDE COPY OF WELL LOG WITHIN THIRTY (30) DAYS AFTER COMPLETION OF WELL. 2. LOT WILL BE CONNECTED TO PUBLIC SEWER. RECEIVED BY: DATE: ISSUED BY: C�4� DATE: //- 10 C.i1141 CONTR TEL C:702-P'77-1ES -7 -- t 25 93 10 20 flo . 004 P .01 t.f..1A /DX) teN.IL t 11:1 taai4L/412.L..6, •,...— C)f (4)7- 44/‘C4k-,5 (- r ;co •-••••••••.• 81,419 1 LQ -1. (.•)1), Loi srua iThdJ :U11 Ub:18 8U'vER CuH81RUCTION 307 7832392 P.01 miCl s ak ` oLi) 4 3 ``1 Lumnuirta in 1201 Ramona St. 49$15 ANCTSORAGE, ALASKA 344-7/14 SIX INCH WATER WELL DRILLED AUT TO THE DEPTH OF 91 feet. DRILLED AT THE RATE or 112(:.00 PER FOOT. Steel casing seated to 91 ft. PROPERTY OWNER Mr. Paul. Sulver 783-2312 275-4761 333-967: LOCATION OF WELL SITE GI-ray/00d, AK Lt. );IA. Sub. DRILLER Bernie Claus of Pampart Drilling Works WELL LOG: 0 - 16' Silty sandy wet clay.` 16 - 112' hardpan. A wet cemented gravel_. 42 - 85' A sandy gravel with L0%v clay. 6.5 - 91' Water bearing fine sand going into a vod water bearing fine gravel. Water recovery is back up to within 3) feet of surface. Water production is 15 gpm+. 1/2 horse submersible punt should be installed about 10 feet off bottom. $2,000.00 has been paid on this Water Well. (Paul Sulver.) Cost of drilling 9!25.00 per ft. x 91 feet x 11)0.0) reset up cost. $25.00 for one muni aproved well oap/seal.. • To ta.LT-42,3c,.0'.J(a • COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLE'T'ION OF $AID DRILLING. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF 1100.00 THANK YOU VERY MUCH. ATE Dec. 5. 1993 BER CLAUS OF RAM f3XtRT ILL G Municipality of Anchorage On -Site Water & Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 075-091-21 1. GENERAL INFORMATION Complete legal description Location (site address) Current Property owner(s) Mailing address Real Estate Agent MICA'S MEADOW LOT 3 Expiration Date: 129 MICA'S MEADOW WAY *GIRDWOOD, AK ALISON REIN Day phone 244-9186 129 MICA'S MEADOW WAY *GIRDWOOD, AK JACKIE MOSER • 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 Well Public Water System WaiverNariance request for N/A • 3 Day phone 783-1910 TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site Public Sewer • Distance: — Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: (//a -//(o COSA Fee $ 5 Date of Payment Receipt Number 0(Db5G COSA # Waiver Fee $ Date of Payment Receipt Number 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 GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 *ANCHORAGE, AK, 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: - In conducting this evaluation, GEG provided an engineering evaluation of the welt and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of /he system/s on the datels of the evaluation. Separation distances were measured fo readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational tiled all wells and septic systems depend on a variety ofve/lab/es including, but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), qualify of construction (materials and workmanship), and the water usage of (Isa ''& utilizing the system's. These conditions can vary, and are outside the control of GEG. Satisfactory fest results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the cumenl systems fail. The content of this report is for the sole benefit of the person/party who relained GEG. Reliance upon the information provided in this report by any other person or party, including but not limited to subsequent propedy purchasers, is not authorized. In short, GEG disavows any legal duty to anyone other than the person/party who paid for this report. 6. DSD SIGNATURE System #1 Approved for bedrooms. System #2 Approved for bedrooms. Disapproved. Conditional approval for Date <ibeIlla bedrooms, with the following stipulations: \QP\\� C,S;• 0.00. S- ON S1TR WATER AND^ By: e ' t/v 2 z 0 PROGRAM_ 0p44 k�{ G�� l Original Certificate Date: S / v(-,, The Municipality or Anchorage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the represenatations 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. ATTCHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory (Rev. 10/12/12) 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: MICA'S MEADOW; LOT 3 Parcel ID: 075-091-21 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 12/5/1993 Sanitary seal (YIN) YES Wires properly protected (YIN) YES Total depth 91 ft. Cased to 91 ft Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 12/5/1993 4/6/2016 Static water level X30 ft. 42.2 ft. Well production 15+ g.p.m. 7.8+ g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate 0' LI ¥mg /L NDC5 Arsenic: ug./L....e Date of sample: 4/6/2016 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Collected by: GEG. Ltd. PUBLIC SEWER Date installed Tank size gal. - Number of Compartments _ Cleanouts (Y/N) Foundation cleanout (YIN) Depression over tank (Y/N) _ High water alarm Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft2or ft2/bdr System type Length ft. Width ft. Gravel below pipe ft Total depth ft. Eff. absorption - -a_ ft2 Monitoring tube Depression over field Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth imabsor. Q field before test _ in. Water added _gal. New depth _in Elapsed Tip min. Final fluid depth in. Absorption rate >= g.p.d. 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 - High water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A On adjacent lots 100'+ Absorption field on lot N/A On adjacent lots 100'+ Public sewer main 75 + Public sewer manhole/cleanout 100'+ Sewer /septic service line 25'+ Holding tank 75'+ Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER Building foundation Property line Absorption field Water main Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIE • e ' OT TO: Water service line Surface water Property line Bu' oundation Water main Water service line Surface water Driveway, parking/vehicle skit -age drain Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and 37 review of Municipal records that the above systems are in Q JRel Q conformance with MOA COSA guidelines in effect on this date. l �: v rnessr QO Engineer's Printed Name JEFFREY A. GARNESS "QUOS f CE- E,of L pre,. •' •>�'.l5 its.... "1 Date ithoi Id �eai'roo� (Rev. 11/05) if Private .Grjye Access kstrit t° serve Lots jr Z i'.3. >� M r -1- 3'x7101.o.f. 1 ifi 2- -- „se • ,N One starM ft) 14138.37f zf” g ,, ps ido g s tri t• t. -3 - Ward. . f 30? 1sr; h N3 75li 5 g 19.94 14 MI -BUILT No CORNERS sETTHIS DATE 1 hereby certify that 1 have performed a Mgrtaea i tn*pectlo et the tolbwing des��crb1�aed property: 1- o r 4 (HIca's ..Cadow 1 EASEMENTS op REcono. OTHER THAN THOSE SHOWN ON THE RECORDED (,qnT ectH PLAT ARE NOT SHOWN HEAEON. Anchorage Recording precinct, Alaska. end Met ih improvements situated (hereon We MI* the property lines an do_n_1 overlap_ or _encroach on the property frog polacer reto, ingj poiRrproyemsnls on proppe�rty lying edjac,gl Iherel encroach on the Pawning 111 queilloir and mitt than? lire p roadways, transmission pops or othgr ylsble pgaemenls on sal properly except as Indicated hereon. Dated q AA �orage. Araske this 1 of ?ate 02481 ase MED WA d ASSOCIATE! 1 Engineers and Suryeyors Parcel I.D. 1. Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING D'i5- p41 -t/ GENERAL INFORMATION Complete legal description Lot 3; Mica IS Meadow Location (site address) COSA# 0/01-111-1 Expiration Date: / — /8- 0 g Current Property owner(s) Jake & Beth Slot/elty Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 129 mica's Mstititto We1/4,13 Day phone 7834217 PTPx 1U/pLJ g1iLthM Aw 99T7 -11p1,914 Day phone Shamee Epley / Remax Alyeska PO Box 1029 Girdwood, AK 99587 Day phone 7831995 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: ❑✓ Individual On-site ❑ ❑ Individual Holding Tank ❑ ❑ Community On-site 0 ❑ Public Sewer The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) In compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm S & S Engineering Address 15861 S. Birchwod Loop C. giak 9956 •4 Engineer's Printed Name r > , e/ 5. DSD SIGNATURE Approved for Disapproved. By: 3 bedrooms. 1 Phone 694-2979 Date ..... ....r... I eft A. share • re•.. No. t 1,37.2• ; •. cps Conditional approval for bedrooms, with the following stipulations: i1( u7/, ���u` sc.( OF444t �QP_ cy% WATER AND . m: : WAS IEWAIER : PROGRAM o••• -• . l e70? Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other (Rev..,,/0S) Original Certificate Date: / 0 -12 ^ n 7 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 995198650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Ler 3; rr h LAS //ILRtOto A. WELL D� Well type' 11-' If A, B, or C provide PWSID # Date completed 45/45 Sanitary seat) Total depth 91 ft. Cased to CI ( I ft. FROM WELL LOG Date of test (2/6/"1'5 Static water level ,.iSo ft. Well production /6 g.p.m. WATER SAMPLE RESULTS: / Cdorm if I ies/100 L i m Nitrate 0'31° f g/L Otherbacteria 1 colonies/100 ml So S F�Yo/& t/K.x Parcel ID: O.46 — 109F2( "YES Wires Properly protectec�N) '/E3 it Casing height (above ground) 18 + in. AT INSPECT Weil L ft. 11.8 g.p.m. coon m��/) +-. Arsenic: mg/I Date of sample: R�,y/� T Collected by. c t2 5uc eSEe.- B. SEPTIC/HOLDING TANK DMA Tank Type/Material Tank sine Date Installed gal. Number of Compartments Cleanouts (YN) s • n over tank (YIN) _ High water alarm (Y/N) Foundation cleanout (WN) Date of Pumper C. ABSORPTION FIELD DAT 0SL/ C_. ez Date installed Length Total depth _ ft. Eft. absorption area _ft2 Date of adequacy test R Fluid depth in absorption field bef ' = st _ in. Elapsed Time: Final fluid depth Soil rating (g.p.d./ft2 or ft1/bdrm) ft. Width Any tion treatment (past 12 mo.) (WN & type) Mon' System type ft. G ss/Fail) Water added_ gal. in. Absorption rate >_ If yes, give date ow pipe ft. Depression over field For _ bedrooms New depth_ In. g.p.d. D. LIFT STATION 4 Date installed • - Size in gallons Manhole/Access (V/ `.Pump on level at _ in. "Pump off" I High water alarm level at Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCEM WELL ON LOT TO: Septic tank/Idt station on lot _ U13L1C On adjacent lots On adjacent lots Absorption field on lot Public sewer main Sewer /septic service line e2^J f Animal containment areas $O 4 - in. Public sewer manhole/cleanout Holding tank /Cr Manure/animal excrete storage areas jap SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: j�u$ac sZ tsr`ot Building foundation Property line Water main Water se Wells on ad'a SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: P a L Property line Building foundation Water main Surface wa Wells on adjacent lots Absorption Surface water Water Service line Curtain drain F. COMMENTS Driveway, parking/vehicle storage G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records at above syste are i. conformance with MOA CO gu' s i/elject�r s da Engineer's Printed Name/iL/a, `1! Date l� 1) o COSA Fee $ l Waiver Fee $ Date of Payment /0//6/0•9 Date of Payment Receipt Number 0 5 0 3 Receipt Number (Rev. 11/05) tnc t AE % i ....:..."1.114.• M A. Show. 1457-! • SGS Ref.# Client Name Project Name/N Client Sample ID Matrix PWSID 1075054001 S R S Engineering L3 MICA's Meadow L3 MICA's Meadow Drinking Water All Dates/Times are Alaska Standard Time Printed Date/Time 10/12/2007 Collected Date/time Received Date/time Technical Director 09/24/2007 16:40 09/25/2007 10:30 Stephen C. Ede Sample Remarks: Parameter Results PQL Allowable Prep Analysis Units Method Container ID Limits Date Date mit Metals by ICP/MS Arsenic Waters Department Total Nitratc/Nitritc-N Microbiology Laboratory Total Coliform ND 5.00 ug/L EP200.8 C (<10) 10/03/0710/10/07 MII 0.364 0.100 mg/L SM204500NO3-1' D (<10) 09/26/07 IDS 1013, No Coli coUI OOmL 5M20 922213 A (<1) 09/25/07 SDP ( cf3ff t� l� r� 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 1)15 nOcii-2/ HAA # 0500276 Expiration Date: G% - 2 7 - 0.5� 1. GENERAL INFORMATION Complete legal description Lot 3: Mica's Meadow Subdivision Location (site address or directions) Mile 1.1 At yeikn Highway Ci rdvnnd Current Property owner(s) David Bauer Day phone 350-3803 Mailing address PO Box 307 Girdwood, AK 99587 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System 3 TYPE OF WASTEWATER DISPOSAL: 0 Individual On-site0 Individual Holding tank Community On-site Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health Authority 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 Health Authority 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 S & S Engineering Address Engineer's Printed Name Robert A. Shafer 5. DSD SIGNATURE ✓ Approved for 3 bedrooms. Disapproved. Conditional approval for Phone 694-2979 bedrooms, with the following stipulations: Additional Comments .�ih tvaltY�OF, 4: WATR AND Attachments: I -IAA Checklist X Septic System Advisory Well Flow Advisory BY: li9V fa '1 (Rev 01/03) Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: G-z7-os- Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTHfAUTHORITY APPROVAL CHECKLIST • Legal Description: f• -DT 3; Micas 01‘4460g, Parcel ID: 075-101/ -2f A. WELL Well type IV fFib If A, B, or C provide PWSIID # = Well Log l) \1E5 Date completed 1215/Q 3 • Sanitary seal('/N) TES Wires properly protectedeN) yts Total depth Cr ft. Cased to III ft. Casing height (above ground) f EA' in. FROM WELL LOG AT INSPECTION Date of test ) 2/ 5/95 6/16/mS Static water level do I I ft. it ft. Well production 15 g.p.m. 'T•? g.p.m. WATER SAMPLE RESULTS: Coliform O colonies/100 ml. Nitrate 0• mg./l. Other bacteria " colonies/100 ml. Arsenic: aI P mg./I. Date of sample: 4/10105 Collected by: 54 S Eni*/4.n6e) itsV B. SEPTIC/HOLDING TANK DATA �t9Btrt c, E, . Tank Type/Material Date installed Tank size gal. Number of Compartments _ Cleanouts High water alarm (Y/N) Foundation cleanout (Y/N) Date of pu Depression over Pumper C. ABSORPTION FIELD DATA )'U6UL %'CY .z.. Date installed Soil rating (g.p.d./ft2 or ft2/bdrm) _ System type Length ft. Width ft. Gravel bel.. - ft. Total depth _ ft. Eff. absorption area ft2 Monitorin • Depression over field _ Date of adequacy test Result ' - s Fail) For _ bedrooms Fluid depth in absorption field befor- - _ in. Water added_ gal. New depth_ in. Elapsed Time: is' . Final fluid depth _ in. Absorption rate >= Any r-' ation treatment (past 12 mo.) (Y/N & type) If yes, give date g.p.d. D. LIFT STATION Date installed Size in gallons Manhole/Access Y 'Pump on level at _ in. 'Pump off" level igh water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot?'131-11.- SEtt.9f E- On adjacent lots r 081,1c. 3E4.0M. Absorption field on lot U PA On adjacent lots A.) l* r Public sewer main IS I+ Public sewer manholelcleanout i'� 4- Sewer /septic service line a s r+ Holding tank Nn SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: {Foe Ll i_, Building foundation Property line Water main W Wells on Absorption fie Surface water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: iF198L�1L Property line Water Service line Curtain dra F. COMMENTS Building foundation Surface water G. ENGINEER'S CERTIFICATION ells on adjacent lots 1 certify that I have determined through field inspections and review of Municipal records th= - -bove systems are i conformance with MOA H'•uid= i es irye ton r. •ate. Engineer's Printed Na a ati' '7 672Y, c Date Water main Drive HAA Fee $ 14.30 - Waiver Fee $ Date of Payment tp/a3%acy Date of Payment Receipt Number IDci9DI iq cf\ Receipt Number (Rev. 12/01) 06-16-05 09:32AM FROM-CTLE ESI, SCS ENV SERVICES 9075615301 T-096 P.02/04 F-574 SGS Refit Client Name Project Name/N Client Sample ID Matrlt 1053312001 S & S Engineering Lot 3. Mice Meadow Lot 3, Micas Meadow Drinking Water An Dates/Times are Alaska Standard Time Printed Date/Time 06/15/2005 14:57 Collected Date/Time 06/10/2005 14:56 Received Date/time 06/10/2005 15:43 Technical Director Stephen C. Ede Sample Remarks: Parameter Results pot Units AOowable Prep Analytic Method ConainerID Unita Dare Date IA RaSri Department Nitrite -N 0.504 $iarobtology Laboratory Total Colltorm • 0 0.100 mg/L EPA 300.0 8 (a10) 06/11/05 1113 coV100mL SM2092228 A (a1) 06/10/05 T1F 06-16-05 09:33%0 FROM-CTLE (SI, SCS ENV SERVICES 9015615301 SOSICT&E ENVIRONMENTAL SERVICES Drinking Water Analysis Report for Total Coliform Bacteria . NAD METRUCTONa ON MOSE EOE WORE =ACME SAMPLE MUST BE COMPLETED BY WATER SUPPLIER (]niut 3V(InMUM w TE WATEll MEN ❑ Bee Rae p Sad WC i Win cthhECTION: I.L.iI Ir.MatIns.• z8 /0 . p aspilins T-096 P.03/04 F-514 200 W. POTTER OWE • ANCHORAGE. ALASKA 00512 Tot 001.582-2343 Fax: 007-5814301 tab MI No. 1053312`i Ns bms we ems Isc....env limiallotess hagAi... Ff eat w Dais SAMPLE TYPE: ❑ Routine. Repeat Semple (refer to lab no, 0 apodal Purpose ee±.a.n JvStrFPtams T+r.wlr So Lad Mr E7darlla a coMaeloi 0 Trated YFetsr Unnoatod Wabr 1 lee TO ■E COMPLETED BY LABORATORY Bamoh ReceMnm Date L tb-n5 • T it (5Y . Tamp: D.Ovay Method: Racelyed By: ❑ Baripla Darr hen a1} RNAs trey M anralsas ❑ 411 Nora Woke P:rRomeo L.saar ❑ num !AMPLE Pham N: • .. fax ..::.:a...+ Baelerleho(al Wahr AmMh Reeore Awabar erg /750 • wwE1kM Memo ff—Mombrono F wo 61%10-MUO (WA) onto -woo 04 Son Tat anemic MEM■IMIM SILTS RESULTS: DMorACane vNlW= war.: { r,., 4mAaarlaort eanl to /OEQ • ANC FOx all DarallLn: WA la age Phaetd D food Q Lamm span el.c — D....T,Iic ( JT -or /O : Ge al flea lee TM no Nee See .-.........wr wcv rnmaimennvadCall form 1217035 Fen FIN- 00S3 12/17103 Prfvgfe .Drjye Access #stn1 t° serve Lots 1,2 e3 t4+l to —2— r—a.mwape —1_ 3'x7' u,. D. ff dommiMi r /y38°379Zl"F 76 toxic. Elec.gsthlt• —3 — Weft Dec .N a 9 2 30? 1 De 3± 3 1 N 35e59r45ng. EASEMENTS OF RECORD. OTHER THAN THOSE SHOWN ON THE RECORDED I -Amigo PLAT ARE NOT SHOWN HEREON. 1'4 99.1+ AB -BUILT 319 NO CORNERS SET THIS DATE 1 hereby certify that 1 have performed a Mgrlg¢,gee s Inapectlo of the following des�"cread property 1- c t 1� /Mica's MCaCLOW Anchorage Recording Precinct,Aleaka. end Mei Ih Improvements !Homed Thereon ere yrlgrin the properly Ones an 40 not overlap or encroach on the properly lying pdjacer Thereto, lhgl pc. Improyemenls ort proppeefly lying edjac;gl therel encroach on Ihp premises Iq (luasdon and 1641 there qre p roadways, transmiaelon Fines or olhgr ylsble ega;menla an ?al properly except as Indicated hereon. Dales at Anchorage. Alaska pile 10111 • d c( °� 0 n (907) 248.1866 Engineers and SurveyorsASSOCIATE: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 _ 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel ID # C»`-)--CIA1- HAA # L i n `q ( n 1. GENERAL INFORMATION Complete legal description Lot 3; Micah Meadow G.L'Ldwood, AK Location (site address or directions) A.Cyeeiza Hwy. G,Lndwood, AK Property owner Steve Li ttLq Day phone Mailing address. C/O Judy We.2ch Reae. E4tate P.O, Box 307 Gindwood, AK 99587 Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well Public water XXX NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer xxx 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 MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature S & S ENGINEER! r/U34 Eagle Riv Eagle River, A Road No. 204 577 Phone (69Y— 2-97 6. DHHS SIGNATURE (Approved for 3 bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: By Date /3/9 Additional Comments Date CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a 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.-0751nOv. 1/91) Berg ".7A 421 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: i - cT 3 /1) C 1 S MQZ>ftA SA) Parcel I.D. A. Well Data Well type P21 VA T6— If A, B, or C, attach ADEC letter. ADEC water system number Log presen( Total depth Sanitary seal Date of test Static water level Well flow Pump levell S J�, Date completed R./ S/ `J.7 Cased to FROM WELL LOG �zIS113 UK SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot P/CLI Absorption field on lot ^N_M Public sewer main / Sewer service line .N//4 Driller 0000,4,r Casing height / Wires properly protected((] VN) YDS g.p.m. AT INSPECTION C/2-')/ 11- 1%2/ct_/nJ6 .3?' m 6,/g.p.m. rri ; On adjacent lots /�ciilcr ; On adjacent lots A-YA Public sewer manhole/cleanout /00'7" WATER SAMPLE RESULTS: Coliform 0 //00/14"---- Nitrate Date of sample: 512-7/14- O, m zz m zi tip m T < Z m n fn X 00 2 Petroleum tank NvN6 /Gaud`-/ B. SEPTIC/HOLDING TANK DATA pc)4 1_ / Date installed Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) High water alarm (Y/N) Al- tested (Y/N) Date of pumping Other bacteria // o U Collected by: �—� ANG %age IN Tank size Compart Pumper SEPARATION DISTANCES FROM IC/HOLDING TANK TO: Well(s) on lot On adjacent Tots Foundation To propert Absorption field Water main/service line S ' .ce water/drainage 72-026 (3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Ala -)E Date installed Manufacturer Size iri gallons Manhole/Access (Y/N Vent (Y/N) "Pump on" level at Pump off" Level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTAN - OM LIFT STATION TO: VVe11 S . . On adjacent tots Surface water D. ABSORPTION FIELD DATA Fu/3 C( c S[-= c„)c= ,2 Date installed Soil rating (GPD/Ft2) System type Length Width Gravel thickness Total depth Total absorption area Cleanout present (Y/N) Depress '• - over field (Y/N) Date of adequacy test Results (pass/fail) for Bedrooms Water level in absorption field before test fter test Peroxide treatment (past 12 months) (Y/N) If yes, give date SEPARATION DISTANCE FROM ABSORPTION FI TO: Well on lot On acent lots Property line To building foundation To existing or abandoned system on lot On adjacent Tots Cutbank Water main/service line Surface wate Driveway, parking/vehicle storage area Cu drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or c Signature Engineers Nameag34 Date rmed to all MOA and HAA guidelines in effect On'?ji' 'l1�! Iver Loop Road No.204 ver, a +rrF 0 HAA Fee$ (f) C) Date of Payment - -9)( Date of Payment Receipt Number —9 3"( (`f )Pat, Receipt Number 72-026 (3/93)' Back td;of this inspection. Waiver Fee $ SINCE 1908 Commercial Testing & Engineering Co. Environmental Laboratory Services ��&2, o©o 00002o7000z,,,,— o o2iro„,7,— Jo LABORATORY ANALYSIS REPORT CT&ERef.# 94.2583-1 Client Sample ID L3 MICA'S MEADOW S/D Matrix WATER Client Name S & S ENGINEERING Ordered By Project Name Project# PWSID UA WORK Order Printed Date Collected Date Received Date 78892 06/01/94 @ 14:13 hrs. 05/27/94 @ 12:40 hrs. 05/27/94 @ 16:00 hrs. Technical Director STEPHEN C. EDE Released By: - - -------------------------------------------------------- - Sample Remarks: ROUTINE SAMPLE COLLECTED BY: S.S. c. QC Allowable Ext. Anal Parameter Results Qual Units Method Limits Date Date Init ------------------------------------------------------------------------------------ - Nitrate -N 0.17 mg/L EPA 353.2/300.0 10 05/-31/94 CMR * See Special Instructions Above UA = Unavailable ** See Sample Remarks Above NA=Not Analyzed U= Undetected, Reported value is the practical quantification limit. LT= Less Than VS =o D= Secondary dilution. GT= Greater Than o a u. 5633 B Street, Anchorage, AK 99518-1600 — Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, 01-1I0, UTAH, WEST VIRGINIA S.%CE COMMERCIAL TESTING & ENGINEERING CO. ENVIRONMENTAL LABORATORY SERVICES Drinking Water Analysis Report for Total Coliform Bacteria nc ,, s 5,7.==r R.E,4D INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE TEL (50i) ;z 23343 FAX: (907) 5615301 MUST BE COMPLETED BY WA 1 ER SUPPLIER ❑ PUBLIC WATER SYSTEM LD. PRIVATE WATER SYSTEM ❑ Send Results 0 Send Invoice -.S E /NEE1j (k)6 0 Send lnvoice Watc Systci NnneCompan V NL -Ie ConzaC ram, rnonc lumber tax :\tamper M.a•_igAdttess C:.y S:a:e Zip Coat ❑ Send Results 0 Send lnvoice Co.^..pa-,y Naac Ccn:act ramc Ma•_,g Adan ay Stat_ z..:p Cocc SAMPLE DA 1 E: SAMPLE TYPE: XRoutine to Ise 21? Month Day q14 Year 0 Treated Water O Repeat Sample (for routine sample 0 Untreated Water with lab ref. no. ) O Special Purpose SAMPLE LOCATION Loj .3, /vas �1 Time Collected Collected By Please t9—^.t TO BE COMPLE1hD BY LABORATORY Analysis shows this Water SAMPLE to be: Satisfactory ❑ Unsatisfactory ❑ Sample over 30 hours old, results may be unreliable ❑ Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample via speci delivery mail. 2-7/a Date Received Time Received Analysis Began MAY 2 7 1994 Analytical Method: iS Membrane Filter 0 ? MO -MUG * Number of colonies/100 mi. Lab Ref. No. Result* Analyst 4.2_.1_ l/ 1 dI Sent to A.D.E.C. (Atichl Fbks Jun C Faxed Date: Time: - Client notified of unsatisfactory results: Phoned Spoke �+ith Faxed Date: Time: Comments: BACTERIOLOGICAL WATER ANALYSIS RECORD DEMO-MUGResult: Total Coliform E. Cali Membrane Filter: Direct Count CD Colonies/100 ml Verification: LTB BGB COLIFIRM Fecal Coliform Confirmation Final Membrane Flter Results Coliform/100 ml C// -� IAY 8 1994 / hrs Reported By DateMAY Time 7�C7 r;\1 C = TOO .\ Jmcpi, To Ccitt U3 = O:rc BcCvia rSGS Member of the SGS Group (Societe de S GeneraleSurveillance) urveil,�nc=_) ENVIRONMENTAL SERV/CES IN ALASKA. COLORADO. UTAH. I .O-1O. MARYLAND. l =ST VIRGINIA. NEV:' JERSEY. SOUTH C:,-.OLUN. C. LIFT STATION /V ONE P2.56.-.WT-- Date 2csL 7 Date installed Manufacturer Size in gallons Manhole/Access (Y/N Vent (Y/N) "Pump on" level at Pump off" Level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTAN - "'OM LIFT STATION TO: Well • • • On adjacent lots Surface water : c1/ C C D. ABSORPTION FIELD DATA Date installed Soil rating (GPD/Ft2) Length Width Total absorption area Cleanout present (Y/N) Depress '• - over field (Y/N) Date of adequacy test Results (pass/fail) for Bedrooms Water level in absorption field before test fter test Peroxide treatment (past 12 months) (Y/N) If yes, give date Gravel thickness System type Total depth SEPARATION DISTANCE FROM ABSORPTION FI • TO: Well on lot To building foundation On adjacent Tots Surface wate C acent lots Cutbank Property line To existing or abandoned system on lot Water main/service line Driveway, parking/vehicle storage area drain E. ENGINEERS CERTIFICATION I certify that 1 have checked, verified, or rmed to all MOA and HM guidelines in effec :On? Engineer's Name�eo34 9 Date HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)' Back 06 9(()) to pf this inspection. Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: 1.—oT 3 /11/CIS / Q LJ SP Parcel I.D. A. Well Data Well type P/ I ✓!f} 7-6—✓ If A, B, or C, attach ADEC letter. ADEC water system number N/14 Log presen (Y ) 1 E S Date completed /Z/S7,'7 Driller gA4.444,crkIUL/N6, ittlics Total depth l' 1 Cased to G/ / ' Casing height / / fi Sanitary seal '/) TkJ Wires properly protected({] VN) YS FROM WELL LOG AT INSPECTION 4- _3()r /Jr (O g.p.m. , / g.p.m. lr o D 0 m O vK < T Z ® CX oc Enc ; On adjacent lots /-2c./3c_r c .SL"wevC_ z° m Date of test Static water level Well flow Pump levell UK SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot P/CLI Absorption field on lot N/M . LJrz Public sewer main /S r4— ; On adjacent lots N/M Public sewer manhole/cleanout /00(7" Sewer service line zS Petroleum tank No WATER SAMPLE RESULTS: Coliform 0 Nitrate O 1 ri Other bacteria // U U/ Date of sample: 512.7 /'74- Collected by: S`11 - B. ` B. SEPTIC/HOLDING TANK DATA pU/3L( (. Date installed Tank size Compart Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) High water alarm (Y/N) A Date of pumping tested (Y/N) Pumper SEPARATION DISTANCES FROM IC/HOLDING TANK TO: Well(s) on lot On adjacent lots Foundation To propert - Absorption field Water main/service line S e water/drainage 72-026 (3/93)6 Front CONTINUED ON BACK PAGE 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address S S ENGINEER! 1/034 Eagle Riv Eagle River, Al Road No. 204 577 Phone (4.9Y— 2979 Engineer's signature Date �,3A. `7 6. DHHS SIGNATURE (Approved for 3 bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: By Additional Comments CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a 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) 5),c4 .'OA M21 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. K711 - HAA # \ADPRI(nfa.iln 1. GENERAL INFORMATION Complete legal description Lot 3; M.i.ca6 Meadow GiAdwood, AK Location (site address or directions) A2yuka Hwy. Gindwood, AK Property owner Steve LLttLq Day phone Mailing address C/0 Judy welch Real Ebtate P.O, Box. .307 G.i.ndwood, AK 99587 Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3 XXX NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer XXX 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 MOA 121