HomeMy WebLinkAboutSAMPSON ESTATES BLK 1 LT 11Sampson Estates
Lot 11
Block 1
#051-053-59
MunicipalitY 0f Anchorage Page 1 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. BoX 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: Sw990232 PIDNumber: n~l-n~'~-~
Name:
MM&M Contracting Wastewater System: x~ New [] Upgrade '
Address:
P.O. BOX 670495 Chugiak, AK ABSORPTION FIELD
Phone: 688-12 3 6 I NO' of Bedrooms: .
Three ~DeepTrench [] Shallow Trench [] Bed [3 Mound [] Other
LEGAL DESCRIPTi ON so,, Rating: Total Depth from original grade:
· 7 GPD/Sq,. Ft. 1 0
' . Subdivision: . Depth to pipe bottom from original grade: Gravel depth beneath pipe
Lot I 1 Block: I Sampson Estates 4 Ft. .6 Ft.
Township: I Range: I Section: Fill added above original grade: Gravel length:
· 1 .5 Ft. 65 Ft.
Number of lines: J Distance between lines:
WELL: :N~ New CI Upgrade Gravelwidth: 3 . Ft. 1 I -- Ft.
Classification (Private. A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Private 201 FL 201 Ft. 780 SO. Ft ASTM D3034 Pvc
Driller:. Date Drilled: Static Water Level: Installer. Date installed:
Su'llivan Water '1 0/7/99 1 35 Ft. ,MM&M Contractin~ 1,0/22-25/99
· I Pump Set at: I Casing Height Above Ground:
,ie,d: 50 ~P~, Ft. I ' ' 2 Ft. TANK
SEPARATION DISTANCES ~Septic [] Holding - '[] S.T.E.P.
TO Septic Absorption Lift HOlding Public/PrivateManufacturer:. Capacity in gallons:
From Tank Field SU.0n Tank ~run. Anchorage Tank I r 000
Well- > 100 ' > 100 ' N/A N/A N/A Uaterial~tee1 Number of Compartments:
TWO
Su,aC~water >100' >l 00' N/A N/A ~/A LIFT STATION - ~/A
Lot Size in gallons: I Manufacturer.
Line > 5 ' > 1 0 ' N/A N/A N/A
>10' N/A N/'A' N/A "Pump on" level at: I'Pump°ff"levelat:'II High water alarm at:'
Foundation
>5'
Curtain Pump Make & Model J Electrical Inspections performed by:.
Drain None t'roted )n T.ot.
Remarks: ~-" Insulation. Over Septic BENCH MARK
Location and Description:
Tank· Front Entrance Deck
I Assumed Elevation:
Reviewed and approved by: ~/~.~ Date- /
72-013 (Re~. 9/91) MOA ~5
Municipality of Anchorage Page 2 of 3
DEPARTMENT OF HEALTH AND 'HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 - Anchorage, AK 99519-6650 - 343-4744
On-Site Wastewater DispOsal System or Well Inspection Report
Permit Number SW990232
'1
PLAN AS-BUILT
SCALE 1" = 40'
PID NO. 051-053-59
Municipality of Anchorage Page 3 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, AK 99519-6650 - 343-4744
On-Site Wastewater Disposal System or Well Inspection Report
,,,,~ermit Number SW990232
PID No..051-053-59
98.0
94.5 ~11sG~!!°O~a~ 94.3
I I 6 ' 11 !'
97.8
/
Geotextile Fab'ri
Drainfield Rock
65'
87.6
93.8
~OM
:"COUNTRY REALTY
PHONE NO. : 9076881310 Jan.
06 2000 08:13AM P2
by
DOC C~. dba
SULLIVAN ATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 9~$67 - ;FELEPHONE 688-2759
PERMCr I~U~BER ~ff Oc~.~i Date of Issue '7 - ~ c./. ?
Is,well located at approve.d i~errnit location? L~es O No
.Method of Drilling: ~r ;otary I-I cable tool
Depth of well: c~ /
"¢~.~-'~ inches
,~ /, feet
feet
Casing TYlJe.~Wall Thickness
.- /t
Diameter___ ~ .in. ches, depth
Liner Type: __~ ~ ~ ~
Ca~ing Stickup Above Ground: ~
~atic Water Level (from. ground level): _
Pumping level: feet after · hrs, pumping .~__gpm
Recover Rate: ~ gpm
Method of Testing: ~Li ~
Well Intake Opening Type: ~~pen End I~ Open Hole
~ S.cre.e.ne.d; Start .. feet Stopp.ed feet
12:1 '~erfo'rationsSta r~ feet, S~opi~ed, feet
De~th: frpm (.,) feet, to ~ feet
Pump Ih. take Depth: feet
Pump Size hp Brand Name
Well Disi.nfected Upon Completion? i~i~s ['~ No
Commen{s;
BORE HOLE DATA
DEPTH
Driller's Name ..
ATTENTION: It is the responsibility of the property owner td submit a copy of the well Icg to the proper authori~i, l~l;Jr~i6ipaiit~
of Anchorage: D~partment of Health' & Rurnan Services and/or'Department of Environmental Conservation.' Mat~d'B~ough:
Department ofRe c e i v e d T i m e;<J a n. 6,°~ 8:17AM
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 WASTEWATER DISPOSAL SYSTEM I WATER SUPPLY PERMIT
Initial
Date Issued: Jul 29, 1999
Expiration Date: Jul 28, 2000
Permit Number: SW990232
Legal Description: SAMPSON ESTATES BLK 1 LT 11
Design Engineer: 0014 Anderson Engineering
Owner Name: MM & M Contracting
Owner Address: PO Box 670495
Chugiak, AK 99567-0000
Parcel ID: 051-053-59
Site Address:
Lot Size: 63891 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
r~ Disposal Field r~ septic Tank [] Holding Tank [~ Privy
Private Well
water Storage
All construction must be in accordance with:
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
(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.
Date: '~/-'~ / ~
July 11, 1999
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 11, Block I, Sampson Estates Subdivision
Septic System Design
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of Lot 11, Block I, Sampson Estates Subdivision intends to
construct a three bedroom home on the lot. We are therefore requesting a
permit be issued to construct a septic system' and well on the lot to serve
the home. The attached site plan and backup documentation describe the
proposed system and the location of the proposed well.
The testholes placed on the lot revealed poorly graded gravel with a
percolation rate of 2 minutes per inch. Silty gravel was also found with a
percolation rate of 21 minutes per inch. We have therefore averaged the
percoation rate for the design of the absorption trench and utilized an
application rate of .7 gallons per day per square foot. No groundwater was
encountered during excavation nor was any noted during the monitoring
period.. We have therefore designed a deep absorption trench with 6' of
gravel beneath the distribution pipe. The pipe will be placed at 3' below
the surface. Total depth of the system will be 9'.
The ground surface of the lot slopes from the south to the north at varying
grades. The absorption trench will be placed in an area with a slope of 6%
or less. The trench will be constructed perpendicular to the slope in
accordance with Municipal criteria. The ground slope uphill from the
location of the absorption trench is extremely steep, but should not
impact the trench.
I'ot 11, Block I, Sampson Estates Subdivision
July 11, 1999
Page Two
If the system is constructed as designed the following statements apply:
The system, if constructed as.designed, will have no adverse impact
on the wells in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact
on existing septic systems in the area or those to be constructed in
the future.
So
The system, if constructed as designed, will have no adverse
impact on reserved space, either surface or subsurface, on any lots
located in the area.
4. The system, if constructed as designed, will have no adverse impact
on drainage patterns in the area. The current drainage pattern will
be maintained.
.!
I':'
Lo~ 11, Sampson Ests. Subd.
~-~El:--r NO. OF
\\ CAI. Ct,P..AT~-O 8Y
0 JISC3~..~ B'~ D~.TE
-.
:. / 0
.. . .. ~
. ~'. ,
'. ~o ~ "
u )--3 ,~u ,u0 o
: ~ '
~.. .' ..
. ~.. . -. ~Nt'
· ' {~ ' ..
· 55' Long X 3.'.
" wide X 6' Ef~
· Depth Absor
Trench
SITE PLAN
.:'
SCALE 1" = 40'
)tic Ta . }., ~ [ \
Bedroo~ '
~Propos~d
! (~ Well
,,/
LOT 11, BLOCK 1, SAMPSON ESTATES
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Three Bedroom System
Parc. Rate: 2 to 21 Min./Inch
Application Rate: .7 GPD/SF (Avg.)
Deep Trench System
.1,000 Gal. Septic Tank
6' Drainfield Rock
3 Bedrooms X 150 GPD / .7 GPD/SF = 642.9 SF of Absorption Area
642.9 SF/12 SF/ LF of Trench = 53.6 LF Trnch Length
Therefore: Construct a Deep Absorption Trench System With One Lateral
55' in Length with 6' of Drainfield Rock Beneath the Lateral.
Distribution Pipe in Trench Placed at 3' Below the Original Ground
Surface. Total Depth to be 9' From Original Ground Surface.
.Natural
Backfill
': ! I
Geotextile
Fabric
4" Perforated
PVC (Slots Down)
Drainfield
Rock
NOTE:
TYPICAL DEEP TRENCH SECTION
Grade Area Over /ranch to urain Away. ~ ~..'._~
Minimum 4' From Groundwater. ~? ~
Maintain 10' Separation From Lot Line. ~ ~'~.~.-~..~.,~
PERFORMED FOR:
LEGAL DESCRIPTION:
4
5
6
7
8
9
10
11
-12
15
16
'17
18
19
20-
COMMENTS
MM&M-
LT 11,
Municipality ot Anchorage.
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street. Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
Contracting
BLK 1, Sampson
i~sts. =Sut~a.
· " '-" SLOPE
WAS GROUND WATER
ENCOUNTERED?
¸' L
IF YES. AT WHAT ~
O
DEPTH? '--"~' p
SITE PLAN
N
Reading Date Gross Net Depth to Net
Time Time v~ ~4 ~. Wat~' Drop
I;~ · ~1, ~ /o~ 6. o
PERCOLATION RATE ~ (minutes/tach) PERC HOLE DIAMETER
TEST RUN.BETWEEN '"~ FT AND--3% 'FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE
PERFORMED FOR:
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST '" "-'-' -- '*~" '~ ~'
f~'~d~-
LEGAL DESCRIPTION: L~' 1 1,
3
13
14
BLK 3
WAS GROUND WATER [I
ENCOUNTERED?
S
IF YES, AT WHAT O
DEPTH? p
E
Reading Date Gross Net' Oel~th to Net
Time Time Wate~ Drop
16-
17
18
19'
PERCOLATION RATE , '~"/ '
TEST RUN .BETWEEN ~&
, . -.(minutes/inch) PERC HOLE DIAMETER __
Fl' AND ""? FT
~/~'~-- / /
COMMENTS
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DAT~ DAT~
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 11, BLOCK 1, SAMPSON ESTATES SUBDIVISION
GENERAL:
1. The scope of this project includes the procurement and
placement of a new 1,000 gallon septic tank. It also
includes the construction of a new 55' long x 3' wide x 6'
effective depth absorption trench at the location shown on
the attached Site Plan. Total depth of the trench is 9' with
the distribution pipe placed at 3' below the surface.
2. Construction shall be in accordance with the approved site
plan, design drawings, Municipal Permit with any special
provisions or conditions, and all applicable State and
Municipal Wastewater Disposal Regulations.
3. The Contractor shall be responsible for obtaining all
underground utility locates and for the layout of the septic
system and verification of the location of all lot lines.
4. Unless specifically agreed otherwise, the contractor shall
be responsible for final grading areas subsequently
depressed from soil settling. Property owner shall be
responsible for revegetation of affected areas unless
specifically agreed otherwise.
5. Contractors installing wastewater disposal systems must
be certified by the Municipal Department of Health and
Human Services for system installations. Owners installing
their own systems must receive prior approval from D.H.H.S.
before beginning system installation.
SEPTIC TANK INSTALLATION
The 1,000 gallon septic tank must be procured from an
approved source and installed at the location shown on the
plans.
· ' Lot 11, Block 1, Sampson Estates
July 11, 1999
Page 2
2. A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts
for pumping access.
3. The septic tank shall be sufficiently
settling or shifting of the tank.
bedded to prevent
4. All standpipes on the septic tank shall extend a minimum of
12 inches above final grade.
5. Tanks installed without 4' of cover shall have a minimum of
2" of direct burial insulation.
6. A foundation cleanout shall be installed one to four feet
from the building foundation. Two cleanouts are required
between the tank and the drainfield.
7. Final grading over the tank shall be such that a positive
slope exists away from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown
on the design. The bottom of the trench shall be within 2"
of level.
2. Distribution piping must be placed level with perforations
down atop a level bed of drainfield rock. Rock should then
be placed over the pipe to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between
the drainfield rock and the natural soil backfill.
Monitor tubes must be 4" in diameter and installed at the
locations shown on the design. The portion below ground
must be perforated.
5. Contractor shall verify the septic tank and drainfield are a
minimum 100' away from any private water wells in the
area, 150' from a Class "C" Well or 200' from any community
well.
Lot 11, Block 1, Sampson Estates
July 11, 1999
Page 3
6. Direct bury insulation must be placed over the distribution
system if less than 3' of backfill depth is available. Finish
grade over the trench must be mounded to prevent
settlement or depressions.
7. Grade area surrounding the absorption trenches to drain
away.
8. A minimum 2' of accepting soil is required below the
drainfield rock for a 5' wide trench. Contractor shall verify
this condition prior to placement of the rock. All pockets of
unacceptable materials must be removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a Municipally approved
septic tank manufacturer.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C.
(perforated and solid), ASTM F810 or H.D.P.E. (perforated,
but not solid) and ASTM D2662 or A.B.S. (perforated and
solid).
3. Insulation shall be at least 2" thick extruded direct burial
polystyrene (Dow Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted
watertight couplings (Caulder, Fernco, or equal).
with
5. A permeable geotextile fabric (Typar, Mirafi or equal)must
be installed between the final drain rock layer and the
native soil layer.
6. All drain rock shall be ..5" to 2.5" in diameter with less than
3% passing the #200 sieve.
'' Lot 11, Block 1, Sampson Estates
July 11, 1999
Page 4
INSPECTIONS:
A minimum of two inspections are required by Municipal
Ordinance. These inspections must be conducted under the
supervision of a professional engineer registered in the State
of Alaska. The first inspection must be conducted after the
excavation of trenches, beds 'or pits and before the installation
of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement
of the geotextile fabric, gravel, distribution piping,
standpipes, cleanouts and insulation. No backfill should be in
place at the time of inspection.
Contractor shall provide a copy of all field survey layout and
construction notes for use in preparing the certified as-built
of the completed system.
•
• 6< v
, -� Municipality of Anchorage e.
On-Site Water and Wastewater Program <
(907)343-7904 5 A, = Y
•
Certificate of On-Site Systems Approval
Parcel I.D. 051-053-59 Expiration Date: 13c9 I (�
1. GENERAL INFORMATION
Complete legal description Sampson Estates, Block 1 Lot 11
Location (site address) 22244 Sampson Dr.
Current Property owner(s) Michael & Kendal Kruse Day phone
Mailing address 12201 E Lady Slipper, Palmer, AK 99645
Real Estate Agent Day phone
2. TYPE OF DWELLING:
0 Single Family(w/wo ADU)
❑ Duplex
❑ Multiple Dwellings(Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well 0 Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer El
WaiverNariance request for: Distance:
Received by: (i Ma I I Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 2-`O Waiver Fee $
Date of Payment t 0/2-C"/ I A7 Date of Payment
Receipt Number 0 3 S / D Receipt Number
n ^
COSA# ns - ( ( �� 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.
In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations.The reported results describe the performance of the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil
condition,ground water levels that may fluctuate during the year,and the water usage of the family being served by the system.These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system.The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 745-8200
Address P.O. Box 1807, Palmer, AK 99645
Engineer's Printed Name Steven R. Pannone Date 10/26/18
�oa�o\
4;• '• Ar 4$t
4 • i` •A�y/`
6. DSD SIGNATURE ii INF •• s • •••• I
40
System#1 Approved for bedrooms ti Steven f2.'f�onnone•• 's
E-8149 v
System#2 Approved for bedrooms fid t •��,�
Disapproved $ Nk1 �R•?I Dy4o
�A\'Na��7
Conditional approval for bedrooms, with the following stipulations:
\G\QPti\t y �; A„It. .
'C
ON-SITE c
WATER AND m,
WASTCWATER o
;-c...\ PROGRAM ��
Ooh` -
'SER\l1 -
BY: `"^—(— ill D3 Original Certificate Date: 1 `--/
The Municipality of Anchorage Development Services Division(DSO) issues Certificates of On-Site Systems Approval (COSA)based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic is
Well Flow Advisory Other (, rwt.IC
COSA blue sheet_f . c
If more than 1 septic system is on the lot:
COSA Checklist# 1 of 1
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: Sampson Estates Block 1 Lot 11 Parcel ID:051-053-59
A. WELL DATA
Well type Private If A, B,or C provide PWSID# Well Log(Y/N) Y
Date completed 10/7/99 Sanitary seal (Y/N) Y Wires properly protected(Y/N) Y
Total depth 202 ft. Cased to 201 ft. Casing height(above ground) 47 in.
FROM WELL LOG AT INSPECTION
Date of test 10/7/99 10/12/18
Static water level 135 ft. 138.9 ft.
Well production 50 g.p.m. 2.1 g.p.m.
WATER SAMPLE RESULTS:
Coliform Neg colonies/100 mL Nitrate 2.36 mg/L
Arsenic ND ug/L Date of sample: 10/12/18 Collected by: PES
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic / Steel Date installed 10/22/99
Tank size 1000 gal. Number of Compartments 2 Cleanouts(Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank(Y/N) N High water alarm(Y/N) N/A
Date of pumping 10/5/18 Pumper JR's
C. ABSORPTION FIELD DATA
Date installed 10/25/99 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.7FGPD/sf System type Deep Trench
Length 65 ft. Width 3 ft. Gravel below pipe 6 ft.
Total depth 10 ft. Eff. absorption area 780 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 10/12/18 Results(Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 45 in. Water added 450 gal. New depth 47 in.
Elapsed Time: 150 min. Final fluid depth 45 in. Absorption rate >= 450 9 p d
None Known
Any rejuvenation treatment(past 12 mo.)(Y/N&type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access(Y/N)
"Pump on"level at in. "Pump off"level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100 + On adjacent lots 100'+
Absorption field on lot 1001+ On adjacent lots 1001+
Public sewer main 75'+ Public sewer manhole/cleanout 1001+
Sewer/septic service line 25'+ Holding tank 1001+
Animal containment areas 50 + Manure/animal excrete storage areas 100'+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5 + Absorption field 5'+
Water main 101+ Water service line 101+ Surface water 100'+
Wells on adjacent lots 100 +
ABSORPTION FIELD ON LOT TO:
Property line 101+ Building foundation 10�+ Water main 101+
*
Water Service line 101+ Surface water 100 + Driveway,parking/vehicle storage 0
Curtain drain 50'+ Wells on adjacent lots 100 +
F. COMMENTS
Presoaked with 2000 gallons
Survey on File *Barrier placed to prevent being driven upon
G. ENGINEER'S CERTIFICATION ` F AOtl
� O 'kk
I certify that t have determined through field inspections and x..17 `fir •'F.y"i
review of Municipal records that the above systems are in 0*:49 . /\ 'Jr'r
conformance with MOA COSA guidelines in effect on this date. /-•--`VP p--•• -�•- f
Engineer's Printed Name Steven R. Pannone -,......•._ .
9 .Steven onnone. d
04,-..
lCE-8149 jDate /goo Z6, � $;. .�
COSA canary sheet_2-6-15.doc
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw SL.
P.O. Box 1966'50 Anchorage, AK 99519-6650
,. www. cLanchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE'FAMILY DWELLING
HA # Oul
Parcel I.D. 05t-053-59 . .
Expiration Date: C:[ .. I L~ --O ~
1. GENE~L INFORMATION
Complete legal description Lot tt, Block 1, Sampson Estates Subdivision
Location (site address or dire~ions) ~ Sampson Drive
Current Property owner(s)
Mailing address ~
Lending agency
Steve and Melody Russell
~)~44 Sampson Drive Chu.qiak, AK 99567
Day phone 689.1812
Day phone
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise'requeSted, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: Three
Day phone
e
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
CommUnity Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:.
I~ Individual On-site
[] Individual Holding tank
[] Community On-site
[] Public Sewer
The Municipality of Anchorage Development serviCes Dep~rtment (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health/~uthofity 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 less than 30 days old. (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.
STATEMENT oF INSPECTION BY ENGINEER '
As certified by my seal affiX:ed 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 0{'
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 code~, ordinances,
and regulations in effect at the time of installation.
Name of Firm Anderson Enqineerin.q Phone 522.7773
Address P.O. Box 240773 Anchoraqe, AK 99524
Engineer's printed Name Michael E. Anderson, P.E.
DSD.SIGNATURE i ·
Approved for ~.~ bedrooms.
Disapproved.
Conditional approval fOr
Date 6/712004 ...
bedroOms, With the following stipulations:
Additional Comments
OU-SiTE
E~'; WAr,RAND :m
~ ..[ WASTEWATER : .
~ ~ PROG~M. ~ .
.....
Attachments:
HAA Checklist
SePtic System Advisory
Well Flow AdVisory
X
Maintenance Agreements ..
iSupp[emental Engineer's Report
Other
original Certificate Date:
(Rev..t 2/00)
: Municipality of Anchorage
Development ServiceS Department
Building SafetY DivisiOn .
On-Site Water & Wastewater Program
i !i ~: ' ' 4700 South Bragaw St. · '"
:. ~ , · P.O. Box 196650 AnchOrage/AK 99519-6650
' ~:: ! '~ 'www' .bi.anchorage.ak.'Us ·
'~ . ~'! (907) 343-7904 · ~ ·
:HEALTH AUTHORITYAPPROVAL CHEC"KLi 3T
Legals,DesCription: . Lot 11, Block 1, Sampson Estates Subdivision
A. 'WELL DATA ..... .
Well tYpe Private '; "ifA?B, or C pr°~ide :PwsID #
Date completed 10/711999 Sanitary seal (Y/N)_Y
Total dePths, .20t ff. Cased to ;1201
· ! i. : -FROM WELL LOG
".Date bf te§t t0/711999
stati~ ' ,~ .
water level 135 L ft.
Well production ' i 50 g.p.m.
I;,, ! ,'.i ' ' i ~ '~ ;:
WATER SAMPLE RESULTS:
' ' r,I >t ' ' ' ' ' m mg./I.;
Coliform r0 colonies/100ml. Nit te .,1.43
Date of sample: 5/2812004 Collected by:'- TLK .
ID: 051.053.59
· Wel
Wires
Y
(Y/N) Y
hove grOund). 2;
Casing in,
ATINSPECTIONI'
51281201~4 J, iJ
138.3~, · , ltl;
Othle~'Ib~cteria i'0, colonies/100 mi.
B. SEPTIC/HOLDING TANK DATA - ~ ~ ' .
Tank Type/Material Septic/Steel · i' ;": '; .....; Date installed 10122/1999 '
"!" ',;il' , ' " :. ' ' " ': ' Cleanouts(WN) Y
Tanks~ze , t 000 gal..~ , Number of Compartments 2
Foundabon cleanout (Y/N) Y Depression over tank (YIN)~ N High water alarm (Y/N) N
Dat~' of pur~'pJB~l 5122-/2004 : pumper':JRs Pumpin,q ': i ;i [ i" . ·
:'1 : ,; : ! , : ' !" ' ; '-. ; ~ ' ; .... ! i ' ·
C. ABSORPTION FIELD DATA . ' ! ~' ' 'i' : '~ .i ' . ~ ,. " '
Date installed t0125fl999 · Soil rating (g.P.d./ft2 orft2/bdrm) ~,7 GPDISF 8yst( m tpe Deep Trench '
Length.6S~".,: '~ ft. .: .' ,. ,Width,3' :i i '~ .... ~ :,:,;'ff... ...-.- Gr~v¢:l below Pipe 6 -. ft.
Total depth '10 ft. '~ ! :Eft. absorption are,a 780 ft ;. , Monitoring tube Y Depression over field N
T :.!j ~ : [ir ' . ; .' -:. ' '~ .'.I'II ,, , · "'!.' . ;. ' ' 'l·~rJ:lJ ::' ' ' '
Date of ad6quacy test $12812004 :' ' , :' !Results (Pass/Fail) Pass' ,i J, [ ::, . '. For 3 bedrooms
Fluid depth/n absorpbon field before test 41 m: :", ,,,. ']' .'Water added452 ga. ' J, ~ ! · New depth54.5 in
i :ElaP{edTime:175min.. Final fluid depth 47.5in. , ..~ · ;Absorption rate'->=450 .' g.p.d.
', ~ ~ · .' : .'. ' '; i: ;..~, ~ ... :' I ' f ;' "-'~" ~ '
i Any rejuvenation treatment (past 12 mo.) (Y/N & tYpe) N ~' ~- ~ I t lf yes, aive date
. .. : I . . ; . -'. .':1 ,' ....~. , '"-71 t-
: ! ; :. ', · , , . ; ~ ~ .
D. LIFT STATION i'. .~,, ,
Date installed Size in gallons ; Manhoie/Access iY/N}
- -"Pump on" level at in. "pump off level at ~n. H!gh water alarm level at in.
Datum Cycles tested ": · ·Meets alarm & circuit requirements?=
E. SEPARATION DISTANCES :
SEPARATION DISTANCES FROM WELL ON LOT TO:~ ! . i
Septic tank/lift station on lot >100' 'On adjacent lots >100'
.Absorption field on lot '>100' ~On adjacent lots >100'
Public sewer main NIA .Public sewer manhole/Cleanout NIA'
Sewer/septic Service line >25' .',H°lding tank NIA
- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: ·' ,
Building foundation >5' Property line >5' Absorption field >5'
Water main NIA Water service line' >10' Surfacb Water >100'
,Wells on adjacent lots· >100' t
SEPARATION DISTANCE FROM ABSORPTION FIELD,, ON LOT TO: -'-
_Property line >10' Building foundation >10' Water main ,>10' - .
Water Service line >10' Surface water >100' Driveway, parkingNehicle storage >25'
Curtain drain None Noted Wells on adjacent lots ' >100' i ,
I certify that,I have determined through field inspections and ~.. ,...'., .4.~..h...).!,.
review of Mu. icipa/'rocO~d~ tha~ the above syste,~s are inl:: '~TJ;,";'~
Engineer's Printed Name MichaelE. Anderson, P.E. . iife,,,/~., ,~,
· ' ~' ~ ' ',Waiver Fee $, "' ~''' ;''
HAAFee $. '~.
· ': ,~i' g'" '7-" 0 7' '!~' ' ;:~ "''~ :'~ ;:' ~ ":'"::
Date of Payment " ' :Date of Payment *' - .... .,
i' 'Receipt Number
:
.Re~eiptNumbffr i ...~'~'~ /-7/. /
(Re~,. '12/00) 'i; '! I
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
MEMORANDUM
DATE:
TO:
FROM:
SUBJECT:
June 14, 2004
Jeff Poet
Mike Anderson, P.E.
Lot 11, Block l, Sampson Estates Subdivision
Certificate of Health Authority Approval
The broken septic system vent Lot 11, Block 1, Sampson Estates Subdivision has been
repaired. The property is now eligible for the Certificate of Health Authority Approval.
Please let me know if you have additional questions.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www. ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWEPJVVELL SUBMITTAL COMMENT SHEET
To: Mike Anderson
Legal description: Sampson Block :1 Lot :1:1
The attached paperwork has been reviewed and is being returned for the following reasons:
[-'1 Original signature or stamp missing on
I--] Calculation error in design.
[--I Additional soils information needed.
I-1 Water monitoring results inadequate..__
[--I Discrepancy in information submitted. __
r-] Topographic information missing or inadequate. ~
J-1 Incomplete; missing
['-] Incomplete; missing
[--I Additional adequacy test information needed. __
[--] Water sample unacceptable.
[--I Measured/proposed distances/dimensions missing..__
["-I Locations of all soils, percolation and water monitoring tests not shown.
J--1 Proposed system too deep for soils information submitted..
I"-] Well log required..__
[--I Omission in narrative.__
[--I Insufficient fill over tank or field.
I~ Other. Broken CO needs reapired
Name of reviewer: ,Tell
Date: 6-10-04
Please supply the necessary information and re-submit your request.
LEA VE THIS FORM ATTACHED TO THE PAPERWORK
ASBUILT
'e
I NF.I~EBY CERTIFY ,TttAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY,
INDIOA~D. tT 18 THE RES~NSlBILI~ OF THE
~N~ ~ D~ERHINE TH~ ~ISTEN~E OF ANY
E~EM~NTS, COVENANTS, OR RKSTRICTIDNS
WHICH DO HOT ~PEAE ON THE REC~D~
VISION P~T, UN,ER NO CIRCUMSTANCES
~Y ~ATA N~t4 aE USE~ FOR CONSTRUCTION
OF FENCE LINE8~ OR FO~ E~LISHiN8 ~N~-
AEY LINES,
0
:::3
0
.~..
m
Parcel I.D. #
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
051 -053-'59
GENERAL INFORMATION
Complete'legal description
HAA #
Lot 11, Block 1, Sampson ... Estates
Location (site address or directions)
Property owner
Mailing address
Lending agency
Maiiin. g address
Agent
Address
MM&M Contractinq . Day phone 688-1236
P.O. Box 670495 Chu~iakr AK 99567
Day p'hone
Day phone
e
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: Three (3)
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
XXX
NOTE:
If community well system, pro'vide written confirmation from State ADEC attest-
ing to the legality and status of system.
XXX
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community;on-si~e
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 MOA#21
STATEMENT OF 'INSPECTION iBY ENGINEER ' ~' :. --.-
As certified bYmy seal affixed hereto and as of the validation date shown beloW,'l 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 forthe number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorag.e files :and from my investigation and inspection, the on-site water
supply and/or wastewater disposal syste~ is in compliance With all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm Anderson Engineering Phone 522-7773 ' : ~'
Address P.O. Box 240773 Anchorage, AK 99524~i'~:'i''! ~ ' ,!
Se
'Engineer,s'signature ~t.4~ ~
'=Date '1/15/90;
DHHs SIGNATURE
~ Approved ~°r
~' DisapprOved.'
Conditional
b~rooms, With th% following stipulations:
'bedrooms.
approval for
Additional Comments
Date
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 ab0~,e 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-(~(Rev. 1/91) Back MOAit21
'or C, attach ADEC letter. ADEC water, system, nu ,rn, ber .' .
'Cased to :.zui ~ i i . Casing gr~una)
~" ~ !.: ' '~ Wires.prop (Y/N),
.;:: i~:~.,.- i' ,. :'-AT'INSPECTIbN !;:il '
· ~A. WELL DATA
Well typ~ Private
:i: pre,Tent
(Y/N)
..Total dePth
Sanitary seal (Y/N)
Date of test '
~.Staticwaterlevel: ~i .... ~i · i~ ,
'" '
Well production ' '-'
,WATER SAMPLE RESULTS:";
, !i0 ,~ : I ~i ~, !- [I Nitn~le 'I i..; 41 Other bacteria'. -
Colifo -
. ........ ] i~': ;~ . ~ . ,
"Date installed., 1 0/Z~/99 Tanks~ze':l ~ 000 Numberpf Compa~nenm ~ '~ no~s
,.. Foundation cleanout ~)'~ '.
I
~. ~ . ' , I=, , .., ~ ~ .
.: - , , .r ~ I · ~ ~,~
ABSORPTION FIELD DATA , , , ; :
Date ~nstalled 1 0 / 2 5 / 9 9 '
; Dateo~adequa~tKt ~ ~ [tonsil; Resul
; Ruid depth in ~bso~tion;,eld (i'n.);
Lffer: . gal~ wateradded ~n.
; Fluid depth :~ ~ :: (i~)Migutesilate~2 ~ ~; ' ~t ic ie = , : i q.I
Peroxide treatment (p~t 12 mogths) ~)
72-~6 (Rev. ~96)* '. ~ ,
;I.p.m.
Trench
N'
bedrooms
D. LIFT STATION - None on Lot
Date installed Size in gallons
Manhole/Access (Y/N) "Pump on" level at*
High water alarm level at* *Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
~Pump off" level at*
HAAFee $. ~ O-o ,~TO
Date of Payment I//~/~
Receipt Number ~' 2.. ~' "/~, 7,~
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
Septic/holding tank on lot > 1 0 0 ' On adjacent lots > 1 0 0 '
Absorption field on lot > 1 0 0 '
On adjacent lots > 1 0 0 '
Public sewer main N/2~ Public sewer manhole/cleanout
Sewer/septic service line > 2 5 ' Lift station h~/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation :, .~ ~ Prope~ line > 5 ' Absorption field. > 5 '
Water mai~sewice line > 1 0 ' Suda~ water/drainage > 1 0 0 ' Wells on adjacent Io~ > 1
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Prope~ line > 1 0 ' Building foundation > 1 0 ~ Water m~sewice line
Surface water > 1 0 0' ~Hveway, pa~in~ehicle storage area
Cu~ain drain Hone '~b~ nn T,~ 'Wells on adja~ntlots >1 00 '
ENGINEER'S CERTIFICA~ON
..I ~ that I have dete~in~ ~ field insp~tions and review of Munic[p~ m~rd~~~e~ .
~n confo~an~ ~ MOA H~ guidelines in effect on ~is date. ~ ~