HomeMy WebLinkAboutEAGLE RIVER HEIGHTS BLK 2 LT 10ogle River
Height
Lo1'
10
lock 2
050- ; 81
-31
www.sullivanwaterwells.com
Pump Installation Log
Well Drilling Permit Number: SW Date of Issue
Parcel Identification Number:
Legal Description Property Owner Name & Address
Eagle River Heights Block 2 Lot 10 Christopher A Hagge
10231 Wildwood Street Eagle River, AK 99577
Pump Installation Date:
6-9-20
Pump Intake Depth Below Top of Well Casing:
90 feet
Pump manufacturer’s Name:
F&W
Pump Model:
4F07P05305S
Pump Size:
1/2 hp
Pitless Adapter Burial Depth:
10 feet
Pitless Adapter Installer:
Unknown
Disinfected Upon Completion?
yes no
Method of Disinfection:
Chlorine 50 PPM
Comments:
Pitless Manufacturer: Unknown
Pump Installers Name:
Sullivan Water Wells
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
· MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage. Alaska 99501 Telephone 2644720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHONE
[~] UPGRADE
IWe,I I Absorpt,on area D.Iling PERMIT NO.
DISTANCE TO: t ~ /
~ Z Manufacturer ~ A T~ ~ ~ ~ ~ [ O~
~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
~= DISTANCE TO: Well ~OO ~ Foundatlon/~ ~ Nearest lot ,i.e PEHM~
No. oflines / ~3 ~ ~3 I ~ ~ inch~ Total~lf~ti~e rptionarea
OTHER
PIPE MATERIALS
SOl L TEST RATING / . . ~ ~i J,~
REMARKS :j~"~-~ ~
~.. ~ 5:~ ~,, ,~ ':
· ~*: .... -::,~-
72-013 {Rev. 3/78)
MUPI I C I pAL I TY OF ANCt-IOF4P~SE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET~ ANCHORAGE, AK' 99501
26474720
ON--SITE SEWER ~ WELL PERMIT
PERMIT NO:
DATE ISSUED:
850227
APPLICANT~
ADDRESS:
CONTACT PHONE:
LEGAL DESCRIP:
LOT SIZE:
MAX £:EDROOMS:
CRAIG SNUMWAY
P.O. BOX 1481
EAGLE RIVER, AK
694-4150
SUBDIVISION: NA
SECTION: 7
99577
Lot 10 ~lock 2.Eagle River Heights Subdivision~
LOT: NA BLOC~.:
TOWNSHIP: IqN RANCE: 1W
10874 (GQ.FT. OR ACRES)'
5
Listed below are the options available to you
sys~tem. Choose the option that b[-~st fits your
DEPTH TO PIPE BOTTOM (FT.) 4.0 4.0 4.0
GRAVEL DEPTH (FT.) 8.0 0.5 3.5
TOTAL D'EF'TH (FT.) 12.0 4.5 7.5
'GRAVEL WIDTH (FT.) '2.5 ~0.0 5.0
GRAVEL LENGTH (FT.) 51.0 5~.0 54..0
GRAVEL V0LUME (CU.YDS.) ~ 28.2 40.0
TANK'SIZE (GALS) 1,000.0 ** 1,000.0 ~* 1,000.0
SOIL RATING (SQ. FT. /BR) 165 165 165
in d~igqing your ~eptis
site..
TANK MUST HAVE AT LEAST TWO COMPARTMENTS
certify that:
1. I am familiar with the requirements for
3.
4m
on-site sowers and weiis as s~t
forth by the Municipality o~ Anchorage (MOA) and the State of Alaska.
I will install the system in accordance with all MOA codes and rogulations,
and in compliance with the design criteria o£ this permit.
I will adher~ to all' MOA and State of Alaska requiremonts ~or tho s~t back
distances ~rom any existing woll'~ wastewater disposal system er public
sewerage system on this or any adjacent or nearby lot. .
I understand that this permit is valid for a m~ximum of 3 bedrooms and
any enlargement will require an additional permit.
IF. A LIFT STATION IS INSTALLED IN A~ AREA COVERED BY MO~ BUILDING .CO~,
THEN (1) AN ELECTRICAL PERMIT AND .I~]~SPECTIOW MUST B~.'.O£1TAINED; (2) AS-BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSFECTIO~ REPORT; A~D .(3) T~3
ELECTRICAL WORK MUST BE DONE B~ A LICENSED ELECTRIC IAPC..
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
925 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
PERFORMED FOR:
DATE PERPORMED= 5-,/~,s~/~-s'
LEGAL DESCRIPTION:
SLOPE
SITE PLAN
I
4
5-
6
7
8
10
WAS GROUND WATER ~O SL
11 ENCOUNTERED? O
P
E
IF YES, AT WHAT
DEPTH?
13-
14-
15-
16
17
18
19
20-
Gross Net Depth to Net
Reading Date Time Time Water Drop
~-~" (minutes/inch)
~ PT AND .5" PT
PERCOLATION RATE
TEST RUN BETWEEN
CERTIFIED BY: _~~;~ DATE:~
72-008 {6/79)
WATER WELL RECORD
STATE OF.ALASKA
DEPARTMENT OF NATURAL RESOURE$
Division of Geolog[co! 8t Geoph¥$1cel Surveys
ft.
Test Well 0 Other:
lo /()~ ft. Oepth Weight -~ Ibi./ft,
..~,,,,,.~ Or...,
o,,-.., o ..,.. ,... ...,..
o.,.:.//- //- ~ ~
•
•t Municipality of Anchorage
On-Site Water and Wastewater Program Mil I i
(907) 343-7904 s x F E T Y
Certificate of On-Site Systems Approval
Parcel I.D. 050-281-31 Expiration Date: J 2 7
1. GENERAL INFORMATION
Complete legal description Eagle River Heights. Block 2, Lot 10.
Location (site address) 10231 Wildwood Street.
Current Property owner(s) Phyllis Carter Day phone
Mailing address 10231 Wildwood Street. Eagle River, AK. 99577.
Real Estate Agent Day phone
2. TYPE OF DWELLING:
E Single Family (w/wo ADU)
❑ Duplex
E Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Q.0
Received 120Date:
COSA to be released to the engineer, unless otherwise request y t e engineer.
COSA Fee $ IL(0 Waiver Fee $
Date of Payment q-g`17' Date of Payment
Receipt Number (92 t cp /I Receipt Number
COSA# a sr_ f '71 `7 l (' 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) 272-8218
Address P.Q. Box 100217, Anchorage Ak. 99510
(2-----
Engineer's
'?/Engineer's Printed Name Steven R Pannone Date 94/2017
pF ALA l>11
...eco..
co.C ..'s �tq
*: 49: s ‘ •.*%l
6. DSD SIGNATURE --- F
System #1 Approved for bedrooms f ...Steven R.�l onnone: Air
T . CE-6149 .•��
System #2 Approved for bedrooms } q.r"._, •' ��
Disapproved ��li`;OFESSC
Conditional approval for bedrooms, with the following stipulations:
omw1\�`�{3sUTYf(jkr/fir
N-Sirs .
o pm
F�'A ER m
(---------- -- .,a 6/ , 7 .2
By: \ `.,^J Original Certificate Date: 1 ^/ ( 7
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet_F. - • ,.
If more than 1 septic system is on the lot:
COSA Checklist# 1 of r
Structure served by this system '
Certificate of On-Site Systems Approval Checklist
Legal Description Eagle River Heights. Block 2, Lot 10. Parcel ID: 050-281 -31
A. WELL DATA
Well type Private If A. B. or C provide PWSID # Well Log (YIN) Y
Date completed
6/1/1985 Sanitary seal (YIN) Y Wires properly protected (Y/N) Y
Total depth
110 ft Cased to 107 ftCasing height (above ground) 18+
Ill
FROM WELL LOG AT INSPECTION
Date of test 6/1/1985 7/12/2016
Static water level 86 ft. 59 ft.
.2+
Well production 8 g p m 7 g_p.m.
WATER SAMPLE RESULTS: p .' •
Coliform Neg colonies/100 mL Nitrat- _�- _Y►g&
Arsenic ND ug/L Date of sample: 8/9/2017 Collected by: PES
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 7/3/1985
Tank size 1000 gal Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (YIN) N High water alarm (Y/N) N
Date of pumping 8/8/2017 Pumper JR's Pumping
C. ABSORPTION FIELD DATA
Date installed 7/31/1985 Soil rating (g.p.d.1ft2 or ft2/bdrm) 165 SF/bdrm System type Deep Trench
Length 33 ft. Width 2.5 ft. Gravel below pipe 8 ft.
Total depth 1 3 ft. Elf absorption area 528 ft' Monitoring tube Y Depression over field N
Date of adequacy test 7/1212016Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 61 in. Water added 501 gal. New depth 72 in.
Elapsed Time: 380 min. Final fluid depth 61 in. Absorption rate >= 450+ g p d
No
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes. give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YIN)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm& circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100+ On adjacent lots 100+
Absorption field on lot 100+ On adjacent lots 100+
Public sewer main 75+ Public sewer manhole/cleanout 100+
Sewer/septic service line 25+ Holding tank 100+
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 10+ Water service line 10+ Surface water 100+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 10+
Water Service line 0+ Surface water 100+ Driveway, parking/vehicle storage 10+
Curtain drain 50+ Wells on adjacent lots 100+
F. COMMENTS
Survey on file.
G. ENGINEER'S CERTIFICATION ���,�NIVIN
I certify that I have determined through field inspections and rrg'�P•• �) •'�• ''#
review of Municipal records that the above systems are in *. Ti-I d\ *
conformance with MOA COSA guidelines in effect on this date. r� •'
Engineer's Printed Name Steven Pannone ---1 :Sieveri W2..Pannone •
Date 9/$12017 +� 4,�. CE-8149 'xv
i<AithES.9.04:217'
<\\t��-"b-
COSA canary sheet_2-6-15.doc
3:O4
V311(t
• Municipality of Ancho
On-Site Water and Wastewater Prog
(907)343-7904
Parcel I.D. 050-281-31
Certificate of On -Site Systems
AUG 0 3 2016
Expiration Date: / I - P- ( to
1. GENERAL INFORMATION
Complete legal description Eagle River Heights. Block 2, Lot 10.
Location (site address) 10231 Wildwood Street.
Current Property owner(s) Katherine Means Day phone
Mailing address 10231 Wildwood Street. Eagle River, AK. 99577.
Real Estate Agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wc 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 Q Individual rX_1
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water Syste ❑ Public Sewer ❑
WaiverNariance request for:
Received by: Date: (0
COSA to be released to the enginee7,nless otherwise requested by the engineer.
COSA Fee $ rJa� Waiver Fee $
Date of Payment B/Slay Date of Payment
Receipt Number 0f5J C G Receipt Number
COSA # O 6Gl (0l3 43 Waiver #
5. STATEMENT OF INSPECTION BWF_NGII R,vk,4
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 Onsite 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) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone
6. DSD SIGNATURE �+
JSystem #1 Approved for J bedrooms
System #2 Approved for _ bedrooms
Disapproved
Date 7/13/2016
Conditional approval for bedrooms, with the following stipulations;
By: 1 ! Original Certificate Date: _)_R_1 C.
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet ! '. I. c
If more than 1 septic system is on the lot:
COSA Checklist # + of +
Structure served by this system +
Certificate of On -Site Systems Approval Checklist
Eagle River Heights: Block 2, Lot 1.0. 050-281-3'1
Legal Description: g g Parcel ID:
A. WELL DATA
Well type Private If A, B, or C provide PWSID # Well Log (YIN) Y
Date completed 6/1 /1985 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 110 ft. Cased to 107 ft. Casing height (above ground) 18+ in.
FROM WELL LOG AT INSPECTION
Date of test 6/1/1985 7/12/2016
Static water level 86 ft. 59 ft
Well production 8 g.p.m. 7.2+ g p m- —
WATER SAMPLE RESULTS:
Coliform L_J�colonies/100 mL Nitrate q. (03 m_g/L
Arsenic A ug/L Date of sample: -711 >, 1LO I G Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SeptlC/Steel Date installed 7/3/1985
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
Date of pumping 6/23/2016 Pumper JR'S Pumping
C. ABSORPTION FIELD -DATA
Date installed 7/31/1985 Soil rating (g.p.d./ft2 or ft2/bdrm) 165 SF/bdnn System type Deep Trench
Length 33 -ft. Width 2.5 ft. Gravel below pipe 8 fit.
Total depth 9.6 ft. _ ,. Eff. absorption area 528 fe Monitoring tube Y Depression over field N
Date of adequacy, tost ,7/12/2016 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 21 in. Water added 501 gal. New depth 52 in.
Elapsed Time: 380 mina Final fluid depth 21 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) No 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 levet-at in.'
- Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES .
WELL ON LOT TO:
Septic tankAift station on lot 100+ On adjacent lots 100+
Absorption field on lot 100+ On adjacent lots 100+
Public sewer main 75+ Public sewer manhole/cleanout 100+
Sewer /septic service line 25± Holding tank 100+ ;•
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 .10+ Water service line 10+ Surface water 100+
a
Wells on adjacent lots- 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 10+,
Water Service line 10+ Surface water 100+ - _ Driveway, parking/vehiclestorage 10+
Curtain drain 50+ Wells on adjacent lots 100+ '
F. COMMENTS
Survey on file.
G. ENGINEER'S CERTIFICATION
certify that I have determined through field inspections and -
review of Municipal records that the above systems are in
conformance with AdOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven Pannone
Date 7/13/2016
COSA canary sheet 2-6-15.doc
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
Parcel I.D. 050-281-31
t. GENERAL INFORMATION
Complete legal description
Expiration Date:
Eagle River Heights Subdivision, Lot 10, Block 2
Location (site address) 10231 Wildwood Street Eagle River, AK 99577
Current Property owner(s) Patrick Lorentz and Tina Martin
Mailing address 3910 Crosson Anchorage, AK 99517
Day phone 440-1928
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailin'g Address
Unless otherwise requested~ COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER sUpPLY:
Individual Well []
Individual Water Storage []
Community Class ~ Well []
Public Water System []
Three (3)
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding Tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues 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 Anderson Engineering
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
DSD SIGNATURE
~" Approved for
Disapproved.
Conditional approval for
bedrOoms.
Phone 522-7773
Date 3/16/2011
bedrooms, with the following stipulations:
Attachments: COSA Checklist
Septic System Advisory
Well Flow Advisory
N7 AdvlS°~,
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: -~//~ {/] I
(Rev. 11/05)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Road
P.O. Box lg6650
Anchorage, Al( 99507
www.muni.org/onsite
(g07) 343-7g04
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Eagle River Heights Subdivision, Lot 10, Block 2
Parcel ID: 050-281-31
A. WELL DATA
Well type Private
Date completed 6/1/85
Total depth 107 ft.
IfA, B, or C provide PWSID #~
Sanitary seal (Y/N) Y
Cased to 107 ft.
FROM WELL LOG
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) >18 in.
AT INSPECTION
3/2/2011
83.7
6.2
Date of test 5/1/85
Static water level 88 ft.
Well production 8 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mL Nitrate 1.97 mg/L
Arsenic: N/D ug/I Date of sample: 12/13/2010
SEPTIC/HOLDING TANK DATA
Other bacteria
Collected by:
g.p.m.
0 colonies/100 mL
A. Harala
'~ank Type/Material Septic/Steel
Tank si.z.~.....1,000 gal. :Number of Compartments Two
Fouddation cleanout (Y/N) Y Depression over tank (Y/N) N
Date of pumping 31112011~r',t ~"'°~q.~umper N_o Sludge Noted in Tank
·
ABSORPTION FIELD DAI. A * '
Date installed 7/31/85 Soil rating (g.p.d./~ or ~/bdrm) 165 SF/BDRM
Length 33 ft. Width 2.5 ft.
Total depth 12 fl:. Eft. absorption area 528 ft2 Monitoring tube
Date of adequacy test 3/2/2011 Results (Pass/Fail) Pass
Fluid depth in absorption field before test 32.4
Elapsed Time: 1,052 min. Final fluid depth 31
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Date installed 7/31/85
Cleanouts (Y/N)
High water alarm (Y/N)
Y
N
System type Deep Trench
Gravel below pipe .......8 ft.
Y Depression over field .. N
For 3 bedrooms
in. Water added 510 gal. New depth 36.7 in.
in. Absorption rate >= 450 g.p.d.
N If yes, give date
LIFT STATION
Date installed
"Pump on" level at~
Datum
in
E. SEPARATION DISTANCES
Size in gallons
"Pump off' level at
Cycles tested
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot>100'
Absorption field on lot >100' ·
Public sewer main N/A
Sewer/septic service line >25'
Animal containment areas >~0'
Manhole/Access (Y/N)
High water alarm level at
in.
Meets alarm & circuit requirements?
On adjacent lots >100'
On adjacent lots >1oo'
Public sewer manholelcleanout
Holding tank N/A ~
Manure/animal excrete storage areas
N/A
>100'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5' Property line >5'
Water main N/A Water service line >1o'
Wells on adjacent lots >1oo'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line >1o'
Water Service line >1o'
Curtain drain None Noted
COMMENTS:
Absorption field >5'
Surface water >1oo'
Building foundation >1o'
Surface water >1oo'
Wells on adjacent lots >1oo'
Water main >10'
Driveway, parking/vehicle storage >25'
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Michael E. Anderson, P.E.
Date 3/16/2011
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
fl, o-
Waiver Fee $
Date of Payment
Receipt Number
' UND~ No QR~MST~S" ~ ~ AN AS-B~LT 8E U~ F~ C ~S~c~'~ ~ F~ EST~I~ 8~1 rD~Y ~ ~ UN~.
. US~ DIST~ PREVNL O~ ~NG. ~LY ~O A~MES ~N~Q~ U~IU~ ~Y I
L~ ~ SURLY ~E ~ ~ ~BOLS
PLOT PLANS · LOT SUR~YS ~ ~O~:. ' ' , '
IT IS ~E RESPONSIBIU~ ~' ~E BUlkieR OR O~ER, PRI~ TO ~NLY ~O~ IMPRO~MEN~ ABO~ROUND AND ~B~ ~ BE
C~S~UC~ON, TO ~RIFY PROPO~D B JILDING ~RAOE RELA~ ~ HO~J ~N~S, ~, ~P~C C~, ~W~KS,
TO ~NI~ED GRADE AND U~U~ ~NEC I~S AND TO DE~RMINE ~ TC., ARE SHO~ IN ~EIR APPROXI~A~ LOCA~ON, ~LY. ~OW
~E EXIS~NCE OF ANY EA~M~, COM~N~ ~ R~S~IC~ONS ~AY PR~NT'SOM~ IMPRO~MEN~ ~ BEING ~ ~O LOCA~D.
~1~ DO NOT APPE~ ~ ~E RECOrDeD ~BDI~ON P~T. ~LL DISTANCES ARE RECORD UNLESS OTHER~SE
' _~.~m ~ Prepared by
~o,~ i.~ ~. ~/ ~ obert E. J°hns~ Jr. ~ Assoc.
'~ "g~ ~T~ Professidnal Lan'~ Surveyors
MEMORANDUM
DATE:
March 18, 2011
TO:
Jeff Poet
FROM:
Mike Anderson, P.E.
SUBJECT:
Lot 10, Block 2, Eagle River Heights Subdivision
Certificate of On Site System Approval (COSA)
The house on the subject lot has been in foreclosure status and empty for nearly a
year. The water samples were taken in December as the seller was certain a sale
was imminent. That sale fell through and a new buyer has now emerged. We have
therefore applied for the COSA to transfer the property. The house has remained
vacant since the original water samples were taken. The sample results show only a
small nitrate content and no arsenic or coliform. We are confident a retest would
produce the same results. We therefore request the original water sample results be
acceptable for the COSA.
.. ..... ,~/ .., ............. ~""~,,.~,~-- · ...... MUNICIPALITY OF ANCHORAGE .......... '/'~'.
.... · r?:,~- .~?:~-~--tp:-.::.~-.f ~?. ° '~". ' · - ;' *,.-- ......... '~
- .v-~,~.. 2 "" ~=~'' ~'~:: '" .;?: ~ ~:~ D~ARTME~ OF H~L~ & HUMAN SERVICES ;fi ~
....... " ~' ~¢~1f;~;'¢*' .:r.t~%r~ ~ ~r~ ~ BOX 1~ ' Anchoraoe?A aska J,~51~ ~ ~
.:':,.~,~(~;~.~-~J;g,G~;.J~,._~'.:'~..;.;~'~.~ ~ "~',' '.~_~-' ~...'~__'~-. .....
rzr ~.X~ t ...~.:'~:..': .Z.~.~.,.] ~ ' Day phone
[ .,,..~..,- ,~,, ...... ; ina to the leoahty of system... ~ .............
As certified ~3~,'m~'s~al'a~xed h~r~i0 and as of the validation date shown'below, I verify that my
investigation of this Healt'~t' Authority Approval application shows that the.o.n-site water supply
and/or wastewater disp~)sal system is safe, functional and adequate for the nu~n~.b~'~:6f b~drooms
and.type of str~ct~'e'i_ndi~ated herein. I further verifythat based on the information. obtained from
the Municipality'.of Anchorage ~iles and from my Investigation and Inspection, the (~'~::site water
- -'."supply and/or wastewater dlsposa system s In comp ance w th all MunicipaJ and Sta'ta~c~d~:
:- ordmances,:and:regulations in effe~-t on the date of this'insp~ctior~. = ......
"· : "'-' :::~:/"' !":'"-'~%'$ & S ENGINEERING ~ :.
' . ..:, Name of Firm-. '
i ' '.;' Addre~':" x'.. ' ~Rl. wr. Al,lc~tgS'.'.'.'.'.'.'.'.~7 .- "~'..
............. '' ': :'..
. . .........._ ......
,.,_ ..... . , ,, .. ...... . ~::,,..
....... - ,- ~ ~'-,- · · =~.~?~ ~sG ~ .
.. .... ., ,., ...... .?, ..~?. .~., ...... , .... , ~ .~i~ ~ .....,,., ....,~..
· -' -':.~ .'-- '.'~[.' ~ . ~ ::;~'~,:::~:, '' '-,',?,'' · · -. *
' · ;- '~.--i~/~ .-~'- ~','*~'d'*~q'~l~"'~ll'*;",~'"','',;' ;' , : :. , ' ' ·
': ,': ',' ': :~;¢? ,'~--'~;':;-'~ndttional :~pr~al for; ;' . ._ ~r~ms,:with ·the,following ~pulnbons:i:,h~,..
. .. ~..~ ~' . ......... :,,'-'..
~ , ~ t::'l.~ ,-:.,~:~,~ .... ~ .~,,~-~*,.~,..~ -.:- ~:~-*= . . .;..,.~,, , .....
. .... ~_~ Munlc~l~,~ncho~ge ~ent of H~I~ and Hu~n ~1~
. - : ~::~pp~?a~,~~ only u~n ~ mp~n~tions glen In ~g~ph 5 ~ve by an inde~dent *: :..' .
; ';andt~lrm~naln~l~lno~erto~tis~in~emlands~te~ulm~.Emolov~ofDHH~donot__._ _,., _ ~ ,.. ~ _ _....__,.__ _ _ _= __ ._. :_____ _ ..... ·
condu~ I~ons ~[,anal~e ~ ~fom a ~fl~te ~ I~u~. ,~e .Mumc~li~.of Anchorage b not . ~ ::; .
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Z~'//~?,/' ~-~/~-~' ~ ~c"~%/g Parcel I.D. ~ ~ Z ~/
A. Well Da~
~/V~ ~ If A, B, or C, a~ach ADEC le~er. ADEC water system number
Well
~pe
Log present ~) ~
g / oo0
Date completed' ~"~ / --o~,-~ Driller~-'*C ~-'/~",/,~; ..~c.
Total depth /'~:2,0c'' ~7Z.
Sanitary seal (Y/N) .~
Cased to
FROM WELL LOG
Date of test ~ '"/--~"~
Static water level ~' ,~'
Well flow (~
Pump level1 c/'/~ /~
/'~'~ ~ Casing height
Wires properly protected (Y/N)
g.p.m,
AT INSPECTION ~ r- z~ ,--
7 g.p.m.
e,, .Z,,o,-.,,
SEPARATION DISTANCES FROM WELL TO:
Septic..~Jd{~.g ~'ank on lot
Absorption field on lot ~/~:~ '/-'~'
Public sewer main
Sewer service line
7J7' '
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
.Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
Date of sample: ~ ~'-~ 0 - ~.(.--
'79 /'~3/,// Other bacteria
Collected by: , ~' ~-- ~/ .~
O
B. SEPTIC/I-h~LD;NC TANK DATA
,'7~'~'~/~'~-.o~'-' /4:74~ 0o. /; Compartments '
Datelnstalled ~,'~: n,. - .. Tank size
· "/' '*' '/ ' ~/ Depression (Y/N)
Cleanouts (~/N).' ; '% ~,~ Fpundation cleanout (Y/N)
H gh wa~r'alarm ~/N) ':;*"N , ~r~?d Alarm tested (Y/N)
' '' '"':":;' '" ."t..' / ~ 2~ --9,~-' Pumper c'7'/~
Date of pumping 7' ' ¢' .. -
SEPAR~'I01'~ DIS'I;~NCES FROM SEPTIC~ ;C',.~:;:C TANK TO:
Well(s) on ~"". :"/'~ '~""~/.On adjacent lots
TO prope~ line ')'~' ~/' Abso~tion field
Surface water/drainage /~ ~ ~ ~
.Foundation
Water main/service line
CONTINUED ON BACK PAGE
72-026 ~J/93)° Fro~t
C. UFT STATION
Date installed
Size In gallons
Vent (Y/N) /'~//~ 'Pump on' level at
High water alarm level /~/',//
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (y/N)
"Pump o,' Level'at -/'~/,.,'~
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:,
Well on lot /"/// On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed' .-~ _ _~/,~ ~'2,.~ Soil rating (GPD/FF) ~'~' "('-'~/~ ~ System type
Length i' ~-~ ,~. ~dth ,,~ O ,,',~ . Gravelthickness. ¢~C~,,/'/. Total depth
Total absorption area ,.~zO=' ZJz~ Cleanout present (Y/N)
~' ~ Results (pass/fail)
Date of adequacy test
Water level In absorption field before test
Peroxide treatment (past 12 months) ~
'/~ ~"'~("(' for
.~ f ~/"'~ '~ r~{~l-L3l''~If yes. give date
Depression over field (y/N)
~ ,Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO: ; .
We,,on,ot- //O //. Onad acent,ots "
Property line
To buiIding foundation ~ "~ ~ To existing ~r abandoned system on lot
On adjacent lots "~ ~ ~' "'//'~', Cutbank ,,~///'/'~' Water main/service line
Surface water
Curtain drain
/¢
Driveway, parking/vehicle storage area -/4:~ .~..-~'.
E. ENGINEER'S CERTIFICATION
I certify that ! have checked, verified, or conformed to all MOA and HAA guidelines in eff~ fate of thi~ i'nspecbbn.
Signature ~'~ ~"' ~"~/~--.- '~~
Engineer'sName /~,OZ~,,tT C. (.-~'#~J '
Date 7//0 / ~.~'* '~'~'~.~,.. CE-8801 ~.~-'~
', ,
HAA Fee $ ~. ~ Waiver Fee $
Date of Payment ~_[~/,~:2,~ ---'-" ' 'Data'Of Payment
Receipt Number .t/Of~::~(~"_//~'~P/~/ Receipt Number
72-026 (3/93)' Back
15:23 C[~RCIAL TESTIN~ ~ 9~769~1211 N0.810 ~2
CT&E Env~ronmenta! Services In¢,
Laboratow Divilion
Laboratory Analysis Report
Natrix #A?gR
Collected Date 0;/10/95 W 1~:15 hrl.
Xnit
................ 0~/03/~5 c~.
~lCtate-~ 1.7~ D .~/~ EPA 353,2 10.
. 8econd~ry dilution.
200 W. Potter Drive, Anchorage, AK 99518-1605 -- Tel: (907) 562-2343 Fax: (907) 561.5301
ENVIRONMENTAL FACIL~IE$ IN ALASKA. CALIFORNIA, ;LORIOA. ILUNOI$, MARYLAND. MICHIGAN, MIS$OUR{. N[W JERSEY, OHIO, WEST ~tRGINIA
~/EY5/95 13:2~ (X~RCIAL TESTING ~ 9076941211 N0.810
"m~' '~+CT~E;Enwronmental Services mc _...t~'/~'~'='~'/~//~'~
W. Potter Drive
A~chorage. AK 99518-1605
Drinking Water Analysis Report for Total Coliform Bacteria 2oD
EEAD lh'$TJ~ C'CTIO.YS ON I~EFERS£ SIDE BEFORE COLLECTING sAMPL£ Tel: (907} 862.2343
Wax: (907) 501,5301
13 Srnd lnvoice
Month Doy Year
S..\M PLE TYPE:
t.31~ Routioe O Treated ~Yater
0 Repeat Sample (fo~ routine sample O Untreated Water
~,i h lab re£ no._ ,)
O Special Purpose ~ime Collected
SA$~LE LOCATION Collected By
Analysis shows ~is Water SA,M~LE to b~:
Satisfactory
Unsatisfactory
0 Sample over 30 hours old, r~ults may
~ umcllabX~
$ample too long in .an{h sample should
not be over 48 hours old at exam nut on
~o indicate reliable rcsul~, please ~cnd
~ew ,ample via special delivc~ mail.
Date Received ~ I ~
Annly{i~ B~lau _
Aaa ~icnl Method: ~ M¢~b~n~ Filter
' MMO-b~G
· Number of colonies/100 mL
Lab !1c£ No. Result*
Analyst
Sea! Io A.D.£;C. ~ Fbks J~a []
. Fazed
Cli(nt noticed ofunsatimfaCtO~' result:
BACTERIOLOGICAL WATI~R AI~ALYSIS RECORD
MMO-MUG Resuli: Total Coliform _
Membrane Filirr: Direct Count __
Yerification: LTB
Fecol Coliform conr~rmltion __
I~ ~.~,~ Metal:er of the $ G S Group ($o¢iate G&nerale de Surveille ncc)
.... ,.,*, c-~',,,?,~¢ ~N &I&~XA CAUFOnNIA, FLORIDA. ILLINOIS, {~A;tylJkNO. M~CH~GAN MI$SOURI~ NEW JERSEY. OHIO. wEST VIRGINI~
Parcel I.D. tt
1.
MUNICIPALI:TY O'F ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Se~ices
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAAIt ~~L'~ O~ ~ IC~ LA ~'1./3
GENERAL INFORMATION
Complete legal description
Lot 10; Block
Location (site address or direction~) 1025! ~it.c~uood
Property owner
Mailing address
Lending agency
Mailing address
#281507
2.~5 East 8th
Day phone
Anchoraq¢, Ak. 99503
Day phone
Agent Pc~ ,lohr~on ALL STAR REALTY Day'phone
. Address ~07 Ea6~ Tudo~ Rd, #5~ Anchorage. Ak. 99~;08
Unless otherwise requested, HAA will be held for pickup.
561-7827
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
........ - Individual well
Community .well
Public water
NOTE: If community well system, provide written confirmation from S~tate ADEC attest-
ing to the legality and status of system.
4. TYPE OFWASTEWATER DISPOSAL: .- .
-', · : '". :-'~ Individual on-site XX . ·
.-, ? ~-:. ,-.. .~:,~ Holding tank-
· ,. , ,:.:.~_. ~_'._.. __~.~
· Community on-site
· ..... '- .~ ......... Public sewer · ·
NOTE: community wastewater system, provide written confirmation from State ADEC ,,; :.:':'
~attesting to the legality and status of system.
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that r~y
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
$ & .5 ENGINEERING
17034 Eagle R[ve~' L~p Road
Eagle River, Alaska ~5~7
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
Phone
bedrooms, with the following stipulations:
Additional Comments
By: ~
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 ~oes this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal~n~ 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.
Municipality of Anchorage .
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ,Z~'~,tc) :,~-,_ ~/~.:,,~,~/~ ~..._,-~' Pl,~J,~'J'~,Parc. el liD.
A. WELL DATA
Well type ~ If A, B, or C, attach ADEC letter.
Log present (Y/N) I.1 x
Totaldepth I ,o f~ Cased to
Sanitary seal (Y/N) h
Date of tesi '
Static water level
Well flow
Pump level ~
ADEC water system number
Date completed Ir' ~-~;{-~- Driller /~t~'"~.'~/'~-.
FROM WELL LOG
'
SEPARATION DISTANCE~ FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main '
Public sewe[ servlce line
WATER SAMPLE RESULTS:
Coli,orm
Date of sample: __,1 0 ~
I (~) "~ Casing height
Wires properly protected (Y/N)
g,p.m.
AT INSPECTION /~UNtCIPAUI'Y OF ANQ-IORAGE
~/' ~ 2- .q' ' ~ON~N~A~ S~WC~S DmS~O~
m ~ I OCT t 1 1991
· .'
uN" g'] CEIVED
; On adjacent lots
; On adjacent lots
?P~blic sewer manhole/cleanout
Petroleum tank /~O.
Nitrate :-'~A. . f'c~ Other bactm:ia
/ ~ ~.~. I Collected by: ~ ~ ~
SEPTIC/HOLDING TANK DATA
Date installed -7 - ~ I - ~ ~" Tank size ,/ ~"P ~ _~ [
Cleanouts (Y/N) t1 Foundation cleanout (Y/N) {~
High water alarm (Y/N) f.)/~ Alarm tested (Y/N)
Date of p~mping'_ ~- 2b'q:!
Compartments ~---
Depression (Y/N) ~)
Surface water/drainage
SEPARATION DISTANCES FRO'M SEPTIC/HOLDING TANK TO:
Well(s) onlot .~ ~ · On adjacentlots t ~ Foundation
To property line ! ~ '/' Absorption field ~' Water main/service line
CONTINUED ON BACK PAGE
C LIFT STATION
%%% ....... Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "I~vel'at ' Pump off" level at
High water alarm level . Cycles tested
Meets MOA electrical codes (Y/ ~ ' ' · ~ .....
"SEPARATION DISTANCE FROM LI TO:
Well on Io~ . 0n adjac~ts -
D. ABSORPTION FIE'D DA,TA
Gravel thickness
Total abso;ption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment.(past 12 months) (Y/N)
. Cleanouts present (Y/N)
Date of ad, equ_acy test
for
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellonlot t'l ~ ' On adjacent lots / ~ ·
· - '/'
To building foundation ~-- ~. To existing or abandor~ed system on
/
On adjacent lots ~--~O '~- Cutbank /"-) ~ Watermain/serviceline
/
Surface water ~ ~ Driveway, parking/vehicle storage area
Curtain d~-ainl ~ [~ .............
E. ENGINEER's CERTIFICATION
I certify that I have checked, vedfied, or conformed to all MOA and HAA guidelines in effecJ, o,z~e~e~ of this inspection
Si"nature $ & $ ENGINEERING '
Engineers Name ~a~r, River, Alaska .5~ ~
ua~e _ - - ~ -~' L' .
, , ,
H~ Fee $ / ~ '~
Waiver Fee: $
Date of Payment /~'~/-~/ Date of Payment "
Receipt Number ~ ~ I ~ ~-- ~// Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
AllLY$IS l~Ol[! B! $AMPL! fez ~l:ozdezl 38512
Date Repots Pointed: SEP 24 91 e 09:59
Client ~amplo ID:LIO B 2 1151!
P~GID :UA
Collected OEP 20 91 t 09:40 h~s.
~ocotvod SIP 20 91 I 12:10
Pzosozvod vith :AS
Client lam :$ i S
BPO ! PO ! NO~ llCIIV~O
~oq !
O~dozed By :BOB
Analysts Completed :OEP 23 91 Ser~l lepoztl to:
Labocatoty SupozvitoI~EPHEI C. EDE 1)3 & $
Chealab ~of E: 914960 Lab ~,pl lO: 7 Jhtztz: WATER
Allowable
~azaMtez Tested ~esult Unite Method LiMAs
IlT[ATE-I 1.8 ~/1 EPA 353.2 10
Sample [OlrII~ ~AMPLE COLLE~ED BI: ~.D.J.
~aMzks:
Testl Pet~ozMd ' See Special IP~t~ucttone Above UA-Unavailable
None Ostecte~ ** See ~am~le ~oziazks Above
lot Analyzed LT-Less Than, GT-Groate~ Than
~S~S Member Of the SGS Group (Soci&t~ G6n~rale de Surveillance)
5C --L LABORATORY I ..
CHEMICAL & GEOLOGICA ,.
A DI~7$10N OF COMMERCIAL TESTING & ENGINEERING CO.
~pRiYATE WATER sySTEM
Drinking Water Analysis Report lor Total CoMorm Bacteria
TO BE coMPLETED BY LABORATORY
SAMPLE TYPE:
F~ TTaeted Water
FI Untreated Water
31me Collected
Col..ted
Analye~ shows 1.~1s Water sAMPLE to be:
,~,,t~slac'torY
Unsatistactory
Sample too long In transit; eample shoukl
not be over :30 hours oki at examinat~n
to '~ate reliable results please send
I~ewl~d~emple vla special darh'e~/me 1.
Analytical Method: Membrane Filter
· No. o! colonles~lO0 mL
Ret, No~ Reautt'
55?7 5
Routine
CheCk Sample [tor/outlne sample
with lab vel no.~--- --
SpeCial purpoaa
BACTERIOLOGICAL WATER ANALYSTS RECORD
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
O ~Coflfetm/1oomt
TI, FI'C = .Too Numerous To count .....
c3~ = Other Bacteria
CO~ CO0 O000000000000000000O
pART ONE OF T~dO
REMAttlDER 1'O FOLLO~t
ooooooooooo'o-o~oooooo
.~g: g0 [g-01,-tggl
~ MUNICIPALITY OF ANCHORAGE ~ ~
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION"
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 10 Block 27 Eagle River Heights TI4N R1W Sec.7
Location (address or directions) Wildwood Road
(b) Applicant Name Mar}, Shumway Telephone:Home 694-4158 Business 694-4158
Applicant Address POB 1/481 Ea~le River AK. 99577
(c) Applicant is (.check one): Lending Institution []; Owner/builder; Buyer []; Other [] (explain);
(d) Lending Institution Alaska Mutual Bank Telephone
Address Eagle River Alaska 99577
(e) Real Estate Company and Agent Vista- David Gallup
Address Diamond Blvd. Anchorage, AK ~0~
~elephone 344-9603
(f) Mail the HAA to the following address:
Pickup by applicant
694-9571
TYPE OF RESIDENCE
Single-Family ~K3 Multi-Family []
Number of Bedrooms 3
Other
WATER SUPPLY
Individual Well~] Communit~ [] Publicr'l
Note: If community well system, must have written confirmation from the Stale Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite~] Public r-I Community[] Holding Tank []
Note: Il community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2
ENGiNEERiNG FIRM PROVIDINL, ~SPECTIONS, TESTS, FILE SEARCH, DA', 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.
Name of Firm Telephone
A~'~ ~.~'n.~-~[-~:~.~r..~5 ~.~ EAGLE RIVER ENGINEERING 5:RVICE~
Address R ~'~ :~ ..... ~ ~IVEH, AK 9~J~ 7
Date ///~/~ ~ ~V~~J:~" ' P- 0' ~9X 7737~'~
~ 694-5195
6, DHEPAPPROVAL'." ' ' -'/~~
· .'",- :-,i(1" '
, ,Approved , .,~ ',, .., Disapproveo" Conditional
Terms of Cbnditional Approval
'/
II ~1 I~,~
CAUTION
The Muncipatity of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval c~rtificates based solety upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work·
Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal D~cription: ' ~'
_
WELL DATA
Well Classification ~'~/~,',4 T~_- If A. B. C. D.E.C. Approved (Y/N)
Well Log Present (Y/N) ~' Date Completed ~'/I /~.,~" Yield
Total Depth //~' Cased to
Static Water Level ~' ~ /
Casing Height Above Ground ,'~ /
Electrical Wiring in Conduit (Y/N)
.Y
Depth of Grouting /z:'//
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wetlhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot ~/,~O '~
To Nearest Edge of Absorption Field on Lot //~ /
To Nearest Public Sewer Line ~ 'r/;o /
; On Adjoining Lots
; On Adjoining Lots ~-/~"~
To Nearest Public Sewer
CleanouVManhole
Water Sample Collected by
Water Sample Test Results
Comments
'~'/u,, ~ To Nearest Sewer Service Line on Lot
/~.~._~/~ ~-.2¢~ ~--~5~¢~',,',~ ;Date ~/~
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) /~ Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well /~ *'
To Property Line /~'
To Water Main/Service Line
Course
Size /~'4~:~ ~/ No. of Compartments ~
/Y' Foundation Cleanout (Y/N)
Date Last Pumped ,'q-"~' ¢~'
; for ~
Temporary Holding Tank Permit (Y/N)
To Building Foundation ~"/
To Disposal Field ~ x
To Stream. Pond, Lake. or Major Drainage
Comments
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72-026{11~84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width ~f Field '~'
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Length of Field -~..~ '/
Depth of Field /..,3
Gravel Bed Thickness
Standpipes Present (Y/N) ,,t,,
Date of Last Adequacy Test ~"~
Separation Distance Irom Absorption Field:
To Water-Supply Well
To Building Foundation ~- /
Lot
To Water Main/Sen/ice Line. ~'~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots _~o /
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
Company
Receipt No.
Date of Payment
Amount: $
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection,
Date
MOA No.
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