HomeMy WebLinkAboutT15N R1W SEC 8 LT 212T15N RIW
Sec 8
Lot
212
#051-154-41
) MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
MA,L,NG ADORES¢' x 135' ; ¢'
LEGAL DESCRIPTION
LOCATION NO, OF BEDROOMS~
~ DISTANOETO: ]Well ]Absorptionare~ f Dwelling PERMITNO.
~ ~ Manufacturer
No. of compartments
Liq.i~ gallons IF HOMEMADE: Inside length WidthTM Liquid depth
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
~_~O ~ ~ Manufacturer Material Liquid capacity in gallons
~ DISTANCE TO: Well ,~0 ~ Foundation~ ~ Nearest lot line ~¢ l~ PERMITNO,¢
No. oflines ~ Length ~f~a~ ~e Total le tb of I'nes Trench wid~ Distance between lines
Total effecti e a o~ ion
~ Topoftiletofinisbgrade ~ , Materialbene~thtge ~ inches ,~[~
~ Length 'Width Depth PERMIT NO.'
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
m DISTANCE TO:
Classr ~'~ Depth Driller Distance to lot line PERMIT
NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
INSTALLER ~ ~ ,
Rev. 3/78)
t1".1 t._I It'-~ ][ C: :I: P F-t L :I: T T' C, IF !-~ 1'-.! ,:: H ~-::~ IF~.' I-q "3 E / ~. 825 '"L STREET., Ai'.,ICH~RAGE, AK.
. ELL ,NC.
PE:,:.!:I~T NO. ,:: 8~0_-..':~± )
RPFLICP,NT CLYDE J GILBREATH F'¢~ BFOg..',
LC :P,'I ION ..............
LEG. AL T±51'..!R±W '=;8 L2±2 LOT SIZE ~L~'.~9 SOUARE FEET
TYPE OF SOIL P,BSORPTION SYSTEM IS: TRENCH
HAXIMUM NUtdBER OF BEDROOMS = 4 SOIL RATING (SQ F'T,ZBR)= 306
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEN IS:
[. E~.F TI.II-- ::L~-_::', IbEi"-.i~t3TH= ::L2F_~ GF.'~/R'..."EI._ DEF'TH= ~";
THE LENGTH DIMENSIOli IS THE LENGTH (IN FEET:) OF THE TRENCH OR [)RRINFIEL. D.
THE DEPTH OF P, 'FRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF 'THE
GF.:OUND AND THE BOTTOM OF THE EXCAVP'TION (IN FEET)·
THERE tS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
P,ND THE BOTTOM OF THE EXCP,VATION (IN FEET).
i~."lE~l.T-~ U ]: F.:EE:.., .--"~;.EF=" T ][ C: TI:=II'-.I t-::.' $ T ZE= ::IL25~Z,
PERMIT APPLICANT HP'S 'THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE
Ii",IS"FRLLP,TIrZ~N INSPECTIONS OF ANY WELLS ADJRC:ENT TO THIS F'ROPERT~' .P,ND TF.IE
, ~. -..,: ~ ,,,,,
NUMBER OF RE-IE. ENEE_, THAT THE WELL I.,.IILL _ER,E. ~ /
...... "rl..~i,:~ ,:: 2 ) I 1'4"~PiC:T I ,3~"-.!:5 R~:E RE C-:., MI :I: ~:EiD .........
BACKFILLING OF P,N',r' S'T'STEM WITHOUT FINAL INSPECTION P'ND P'PPROVP,L BY THIS
[)EPARTMENT WILL BE SUBJECT TO PROSECUTION·
MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
±00 FEET FOR P, PRIVRTE WELL OR :L50 TO 20~0 FEET FROM R PUBLIC .WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTP'NCE FROM A PRIVATE NELL TO P, PRI'¢ATE SE!4ER LINE IS 25 FEE;]''
TO R COMF1UNITY SEWER LINE IS 7'5 FEET.
WEL. L LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN -:;0 DAYS
OF ].'HE WELL COMPLETION.
OTHER REQUIREMENTS MAY P'PPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS P'RE
AVP'ILP,BLE TO INSURE PROPER INSTALLRTION.
I CERTIFY THP,T
±: I AM FAMILIAR WITFI THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALl_ THE S'¢STEM IN ACCORDANCE WITH THE CODES.
3: I UNDERSTAND THAT THE ON-SITE SEWER ~'¢STEM MRV REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLLIDE MORE THAN 4 BEDROOMS.
RPF'L~CRNT ~ CLYE:'E J G I LBRERTH
ISSLIED B~ .............. : ................ ~-- b -~ [ o ',/4. e
i~
<Permit #: 820908
January 31, 1983
TO: Permit Applicant
Subject: TL5N R1W ' ~ '
Se¢.t]on 8 Lot 212
A permit issued by this department for an individual well
and/or on-site sewer system has expired as of December 31,
1982.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drllled the well, a well log needs to be sent
to this department for documentation of the installation
date and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, please have them send us the as-builts
for our files and documentation.
If there are any further questions, please call this office
at 264-4720.
Sincerel~
Robert C. Pratt, R.S.
Acting Program Manager
Sewer and Water Program
RCP/ljw
enc: Copy of Permit
SWP/057
MUNICIPALITY OF ANCHORAGE
Department ~ Health and Environmenta
' . '825 ~ Street, Anchorage, AK.
Permit % ~(~O% * * * HANDWRITTEN PERMIT * *
' ~ ~ ~ ~'~rf~/n Mailing Address:
Appel ~c ant ~ /¢/f ~
Lo:cation: , ~P.
ne:gal Description:
Type of Soil Abs~rption System Is:
Trench: ~/ Drain field:
Maximum Number of Bedrooms:
The Required Size of
DEPTH _/L)/ . LENGTH ?~,~ '
Phone Number:
Seepage Bed: __ Holding Tank:
Soil Rating(sq.ft/br)
the Soil $ubsorption System Is:
. GRAVEL DEPTH
The length dimension is the length(in feet) of the trench or drainfield. The
~epth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
Th'e gravel depth is the minimum depth of gravel between the outfatl pipe and
the bottom of the eXcavation(in feet).
* * REQUIRED SEPTIC'(HOLDING) TANK SIZE = .,/~C] GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED* * *
Backfilling of any system without final inspection and approval by this departmen.
wiIi be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 fee'
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private Well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are ~
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 1 9 8 2 '* * *
I certify that:
(1) I am familiar with %he requirements for on-site sewers
set forth by the Municipality of Anchorage.
(2) I will install the.system in accordance with codes.
(3) I :understand that the on-site sewer
the residence is remodeled
Signe~:
Applicant
and wells as
system may require enlargement if
to include more that 3 bedrooms.
Date:
SWP/024 (1/81)
/01 .t~ ~'~ . ORAV~ ~P~ _..~ -----
d~nm~0n ~ ~e l~h(tn fee~) o~ the t~ench or ~a~t~ld.
~th Of a ~ench Or pit ~ ~he d[st~n~ ~t~en hhe S~ of ~he
~tt~ of ~he e~c~atLon(~ fee~}. ~ere L~ no set w~dth ~o~ ~I~
g~av~ d~th ~ ~ha m~ depth of grave~ ~t~n ~ha ou~a~
~alkation tn~i~s of any ~L[~ a~jaden~ ~o tht~ p~r~y ~d t~
r~do~es ~hat th~ ~ will s~va,
~Eill~g of ~y ~ymt~ wtt~uc ~hai ins~tton ~d a~roval by ~te de~u~
_ ~LL. ~ dist~ ~ a p~fvat~ w~ll to a p~iva~
~t ~ Cet~ ~o ~his de~r~nt wLthtn 30 days of the ~[
cer~key ~h~t;
(1} I ~ ~ilta~ Wkth the r~ic~n~ for on-si~e ~rs and ~i~
~t ~octh by t~ ~al/ty of ~raqe.
I will in.ail t~ eyst~ in ~cOrd~ vi~ a~.
t~ res~eno~s ~~ to f~lu~e ~re that ]
8W~/024 (~Sl)
[] SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
82B L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION:
PERCOLATION
TEST
SLOPE ITE PLAN
2
3
4
5-
6-
7
8
9
10
11
12-
13-
14-
15-
16
17
18
19
20-
Ho.
COMMENTS
PERFORMED BY: 1~, .... ~RB 196X
PH, 694-2979
72-008 (6/79)
ENCOUNTERED?
IF YES, AT WHAT E
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
TEST RUN BETWEEN ~ FT AND ~ ' FT
ilS�ffl fes\'\`. ;.t ,;�,t��vp' � Y t I ,)(•�,('
WA, . WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ Geophysic01 Surveys
Lot a~ooh p ..................
DIgTANCE AND DIRECTION FROM ROAO
INT ERSECTIONB
~treel AddreBi grid Arco of Well Locution
WELL LOG Feet Below
B~e~ a~ ~e. ~e& 217 ~5
~UNICIPALI~ OF ANCHO~A~
DSPT. O~ H~ALTH
S OWNER OF WELL:
6 ~ Coble tool ~ Orlven ~Oug
Q ~r ~'t~d ~ ~or~
~ Test Well ~ Other;
a, CAS, : ~ T~d ~Welded
diem ........ ~ in to fl Oopth Weight 17 lbs
• -� Municipality of Anchorage
On -Site Water and Wastewater Program 2'
(907) 343-7904 sg,.
CERTIFICATE OF ON-SITE SYSTEMS APPRO
wo �?
a JUN0 2 't016
Parcel I.D. 051-154-41 Expiration Date: �-
1. GENERAL INFORMATION °L 6 s 5
Complete legal description T15N, R1X, Sec 3: Lot 212
Location (site address) _19616 Scenic Dr, ChuQiak, AK
Current Property owner(s) DAN AND NANCY MCKEWIN Day phone
Mailing address
Real Estate Agent
19616 Scenic Dr, Chuoiak, AK
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
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
❑
Waiver/Variance request for: Distance:
Received by: 441 )h: Date: 4i / 6P
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $_ . Q ® Waiver Fee $
Date of Payment Date of Payment
Receipt Number ZO/ ,?®3 Receipt Number
COSA# ()5'C16 ®20 ? 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 nunl.ber 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 MIKE N ANDERSON P.C. Phone 727-8864
Address 4661 NATRONA AVE.
Engineer's Printed Name MIKE N ANDERSON, PE Date 06/2/16
6. DSD SIGNATURE
System #1 Approved for
System #2 Approved for
Disapproved.
3 bedrooms.
bedrooms.
a'
d r°49T,
MICHAEL No ANDERSCtq cs
CE/ 9 G9
��Q9•C�
�(2�i�J.°/.0
Conditional approval for bedrooms, with the following stipulations:
By � - Original Certificate Dater L —�
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 10-10.12 doc
• 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: T151 RiN, Sec S. Lot 212 Parcel ID: 051-154-41
A. WELL DATA
Well type Private
Date completed 61311983
Total depth 265 ft.
Date of test
Static water level
Well production
If A, B, or C provide PWSID # _ Well Log (Y/N)
Sanitary seal (Y/N) Y
Cased to 48 ft.
FROM WELL LOG
61311983
UNKNOWN ft.
WATER SAMPLE RESULTS: 1
Wires properly protected (Y/N) Y
Casing height (above ground) 18"+
Coliform NEG colonies/100 mL Nitrate 0.552 mg/L
AT INSPECTION
512012016
24 ft.
2+ g.p.m.
Arsenic: ND ug/L Date of sample: 5/1912016 Collected by: Mike Anderson
B. SEPTICIHOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL
Tank size 1000 gal. Number of Compartments 2
Foundation cleanout (Y/N) Y Depression over tank (YIN) N
Date installed 71811983
Cleanouts (Y/N)
High water alarm (Y/N) NA
Date of pumping 10.26.15 Pumper Sanitary Pumpers
C. ABSORPTION FIELD DATA —1985 SYSTEM TESTED
Date installed 71811983 Soil rating (g.p.d./ftZ 0c306 System type _WIDE TRENCH
Length 139 ft. Width 5 ft. Gravel below pipe 3.0 ft.
//,, S�
Total depth 5ft. Eff. absorption area 1198 fe Monitoring tube Y Depression over field N
Date of a0equacy test 512012016 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 22 in. Water added 500+ gal. New depth 30 in.
Elapsed Time: 500+ min. Final fluid depth 25 in. Absorption rate >= 500+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) UNKNOWN If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at
Datum
in.
Size in gallons Manhole/Access (Y/N) _
"Pump off"level at in.High water alarm level at
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100'+
Absorption field on lot 1001+
Public sewer main 754
Sewer /septic service line 501+
Animal containment areas 1001+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 51+
in.
On adjacent lots 1001+
On adjacent lots 1001+
Public sewer manhole/cleanout 1001+
Holding tank M
Manure/animal excrete storage areas 100'+
Absorption field 5'+
Water main 1001+ Water service line 101+ Surface water 100'+
Wells on adjacent lots 1001+
ABSORPTION FIELD ON LOT TO:
Property line 101+ Building foundation 101+ Water main -"TW im 0 r ,_
Water Service line 101+ Surface water 1001+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+(None Known) Wells on adjacent lots 1001+
F. COMMENTS
* MEASURED AT THE END OF THE TRENCH/MT
G. ENGINEER'S CERTIFICATION
I certify that l 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 MIKE N. ANDERSON, PE
Date 061212016
COSA canary sheet 2-6-15.doc
OF**°4°s1!
A[ 1
.. .ir
..Y,,..,.,...........
7e •. MICHAU4 ANDERSON*ft-
CE%9
Fat
Municipality of Anchora
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
r
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Z
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-15LI- y I COSA# UP nrz
Expiration Date: 1-12-0-7
1. GENERAL INFORMATION
Complete legal description f/Silk r/jV SaC• F, /-o f /-?
Location (site address) _/94/1,
Current Property owner(s) lfe4, cf Day phone e§Af-
Mailing address PO. fnr 67/5''6 &,.4'/e !,'9.SY_ 7
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual On-site
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
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 Phone
Address !2pe)E �• i/^its 5�� ��ir..^/rrr, f 9>l�/_��
Engineer's Printed Name 7` Date 1b ' I ( • 66D
IY•
5. DSD SIGNATURE 1'r2 .ST.tZ"ZY
Approved for bedrooms. tff''r•• o Ziiu19
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
i
Additional Comments
.0., OFA
4
WASTEWATER
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: �t_Original Certificate Date: 10— 1% Ow
(Rev. 11105)
Municipality of Anchorage ...
!� Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 198850
Anchorage, AK 99519-8850
www.muni.orglonsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: r/ --/V . If /N 5ee. 'F /-a 7-e 1 la Parcel ID:6 s / — / -)/ -.44 /
A. WELL DATA
Well type pri i,,? !e If A, B, or C provide PWSID #
Date completed l/9/P3 Sanitary seal (Y/N)-j/
Total depth AL f ft. Cased to
FROM WELL LOG
Date of test G /3 /83
Static water level cf � kn n zu n ft.
Well production O' S 9—
p.m-WATER SAMPLE RESULTS:
Coliform oolonies/100 mL Nitrate 0.3" mg/L
NO
Arsenic: $ mg/I Date of sample: f u/t/o el
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material 5!54 b 6 f 5 /G c
Tank size /Dao gal, Number of Compartments
Well Log (Y/N) Y
Wires properly protected (Y/N) 'L_
Casing height (above ground) a y in.
AT INSPECTION
9� • P ft.
/. 9—
p.m-
Other bacteria O colonies/100 mL
Collected by. F�cd fire /e y
Date installed 711P F3
Cleanouts(Y/N) y
Foundation cleanout (YIN) _�/ Depression over tank (Y/N) Al High water alarm (Y/N) dYi9
Date of pumping /01y/G! Pumper
C. ABSORPTION FIELD DATA /
Date Installed 741/9 Soil rating (g.p.dJft2 or ft2/bdrm) 306 System type Cdr d a firnc h
Length 19q ft. Width 3" ft. Gravel below pipe 1:7 ft.
Total depth _]kYA J-4-
ft. Eff. absorption area f/9�ft2 Monitoring tube i Depression over field Al
Date of adequacy test /D/3 le6 Results (Pass/Fail) /+s5 For 3 bedrooms
Fluid depth in absorption field before test _ in. Water added fV gal. New depth %/ �in.
Elapsed Time: /Oj//min. Final fluid depth 19 in. Absorption rate >= '/SA g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) N
If yes, give date
D. LIFT STATION
Date installed
`Pump on" level at _ in.
E. SEPARATION DISTANCES
Size in gallons
"Pump off" level at
Cycles tested
Manhole/Access (YIN)
at in.
Meets alar & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot /o�% 'i ft On adjacent lots
Absorption field on lot // v f Jor
Public sewer main HSA
Sewer /septic service line -:� St iT
Animal containment areas
/co r //.-
On
t
On adjacent lots / o o t FT
Public sewer manhole/deanout
Holding tank AV -22
Manure/animal excrete storage areas /o o t 1'7-
SEPARATION
'r
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5 > f �' Property line 3 n t fT Absorption field I/ Lr
Water main //'/A Water service line Surface water on f i
Wells on adjacent lots / o o t //
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line -4-0 f Lt Building foundation o't tf Water main IV1/%'
Water Service line /c'o r " Surface water Driveway, parking/vehicle storage
No�•c K^awn /OGt
Curtain drain s, cxr s t Wells on adjacent lots f'r
F. COMMENTS
G. ENGINEER'S CERTIFICATION b�p• •••��'f�
I certify that I have determined through field inspections and s!• .*49TH
• • • , • .. - . •; �
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date. •P
Engineer's Printed Name J Ge4t 1e—" r/. `CE1176
1
Date
COSA Fee $ Y3D 4 /-Is- 12"V -
Date of Payment 1-10&
Receipt Number?y
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
ASBUILT
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
cor ziz fcr, � >is�v�iw
AND THAT NO ENCROACHMI<NTS EXIST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONSTRUCTION
OFFENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES.
SEWARD h ASSOCIATES LAND SURVEYING 694 -
SCALE:
� OFAL
DATE:
o' � 9`rfi`1
T „�
GRID.{y
�
so* Mark S..rd
I Duw
FB:
DRAWN:
�
Axa 7kw'r�
14
wqiE�Jl
SCS Ret#
1065956001
Client Name
Douglas Kenley P.G.
Project Name/#
Daw
Client Sample ID
T15N RI W Sec 8 Lot 212
Matrix
Drinking Water
All Dates/rimes are Alaska Standard Time
Printed Date/rime
10/132006 10:06
Collected Date/time
10/032006 18:00
Received Date/time
10/042006 9:05
Technical Director
Stephen C. Ede
Sample Rcmmks:
ICP/MS
Arsenic
Parameter
Allowable
Results PQI. Units hiedwd Container ID Limits
Ptcp
Date
Analysis
Date [nit
Metals by
ICP/MS
Arsenic
Waters Department
Nitrate -N
Microbiolocy
Laboratory
Total Colirotm
ND 5.00
0.342 0.100
0
ug/L EP200.8
mg/L EPA 353.2
C (<10) 10/05/06 10/11106 TK
0 (<I0)
col/100mL SM209222D A (<I)
10/04/06 ALR
10/04106 DPT
DEPARTMENT OF HEALTH & HUMAN SERvI( ~
Division of Environmental serViCes ~., ,' '; ~.:;
On-Site ServiCes Sec < ,.
196650 Anch°ragel AlaSka 9951! "~ :' ~ ; "~: '~ ~'' r
IE.ICATE.OF HEALTH
~MILY
nity well '.,'
IJu'blid Water '
c~mmunity well system,-~rovide written confirmation from State ADEC attest-
to the legality and status of system.
DISPOSA
'~':~- -, unity on-site
Public sewer
NOTE:- If community wastewater system, provide written cony
attesting to the legality and status Of system.'-;
tion fr~)m State ADEC
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.
,-u.. %=, .qg
Name of Firm ~'~' "'~ ......
~:,,'~,i ~'~arm:gan mva. Phone /~ ¢'~ - ,/~///
Address E~;;,I~ ~f;'er. AK 99577-8736
Engineer's signature
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
"'he Munic'pahty 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 pu rchasem of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or 8missions in the professional engineer's work.
72-025 (Rev, 1/91) Back MOA~21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907) 343-4744
Health Authority Approval Checklist
Legal Description: L=/':~I2 ~,~ ~ 7'/d'/V,~ I ~/ Parcel I.D.:
A. WELL DATA
Well type //,~/
Log present (Y/N)
Total depth .~. ~ ~'"
Sanitary seal (Y/N)
Date of test
Static water level
Well production
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed G/3/~' ~
Cased to. /'/~' / Casing height (above ground)
FROM WELL LOG
.
WATER SAMPLE RESULTS:
Coliform
!
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed 1/~'/~°,~ Tank size
~ /
Foundation cleanout (Y/N) y
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
/ /
Length /.~ / Width
Effective absorption area
Wires properly protected (Y/N)
Date of adequacY test
AT INSPECTION
£:~.~ ,
Nitrate
4~),/z// Other bacteria
C~llected by:
/
/~ Number of Compartments ~ Cleanouts (Y/N) .
Depression (WN)
Pumper
Soil rating (g.p.d./fF or ff~/bdrm) .~, ~f' ystem type
~ ~ Gravel thickness below pipe
~ Monitoring Tube present (Y/N). ~/
· ,~' /' Total depth ~,~
· . Depression over field (Y/N)
For ,~ bedrooms
Fluid depth in absorption field before test (in.); ~ Immediately after//..r~TJgal, water added (in.): _~_~
Fluid depth __~__ (ins) Minutes later: /~ ~v~.'~ Absorption rate = /-/~"~ '+ g.p.d.
Peroxide treatment (past 12 months) (Y/N) ~JD If yes, give date ~
72-026 (Rev. 3/96)*
D. LIFT STATION
High water alarm level at* ~ *DatumS., J ,
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot /
Public sewer main.
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station . ,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation .5'~ ~4- . Property line /C) ~ ~ Absorp?on f e, d
Water main/service line ,.5"'43 '
+ Surface water/drainage _/DO' ~
SEPARATION DISTANCE FROM ABSORPTION FIELD, ON LOTTO:
Property line / C)' '+ Building fpundation ,~) / -~
Surface water. /~C~ ' ~-
Curtain drain lDO ~ '~'
F. ENGINEER'S CERTIFICATION
Wells on adjacent lots
Wa!er main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots / D O ~ ~
in conformance with MOA HAA guidelines in effect on this date.
Signature ~. ~ ~,~...~
Engineer's Name ~ Erlg~eri~g // ~, ~
n~*~ * ~/ /~/ EageRJver A~ go;~** ~ t.~'~
.
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $,
Date,~f Payment
Receipt Number
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)
(b)
(c)
(d)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directior~) ,.~
, _
~ ~ ~.., ~-~~ ~__~-/~
Applicant Name ~~~;~ne~e ~-~ Business ~~
): ding Institution ~; Owner/builder~; Buyer ~; Other ~ (explain);
Lending Institution ~L.Z.,~/_ ~/.~..~_ Telephone
(e)
Address ~
Real Estate Company and Ageni
Address
Telephone
(f) ~f~e HAA to the following ~ddress: --
TYPE OF RESIDENCE
Single-Family ~ Multi-Family L~ Other
Number of Bedrooms
WATER SUPPLY
Individual Well¢~' Community [] Public []
Note: If corem unity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite~ Public [] Community l'-I Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2
72-025 (11/84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, fu nctional 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.
..... ~ Telephone ~ ~ ~ ~- ~ ~
Address ~ /¢~ ~. /~ ~
Approved __ [.,--'- .__ Disapprov~ -~-~--~_ Conditional
Terms of Conditional Approval
CAtJTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely 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
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE (MOA) DEPT. OF HEALTH &
HEALTH AUTHORITY APPROVAL (HAA) ENVIRONMENTAL PROTECTION
CHECKLIST - FEBRUARY 1984
264-4720 LJ~-0 0 2 1~~
Legal Description: ~ 'Z..~ ~,~---~-~ae~ ~ I%
WELL DATA
Well Classification
Well Log Present
Total Depth '~J~'.~'
Static Water Level
Casing Height Above Ground
Electrical Wirlng in Conduit ~'N)
Separation Distances from Well:
To Septic/J;~g Tank on Lot
~' ~[~' If A, B, C, D.E.C. Approved (Y/N)
Date Completed (,p - ~. ~5'~ Yield
Cased to _ Z.~-~/,/' Depth of Grouting '--'--
Pump Set At
Sanitary Seal on Casing ~/N)
Depression Around Wellhead (Y~'
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ~ ~="~ ' '~ ; On Adjoining Lots
To Nearest Public Sewer Line ?/~ To Nearest Public Sewer
Cleanout/Manhole ¢5,/~, To Nearest Sewer Service Line on Lot _
Water Sample Collected by _.'~-~ '~ ~ (~',-~,,[¢,,..~=:¢:::~¢~4,,,-~..~ ; Date
Water Sample Test Results ~,e,-.1-~,¥F-~ ~
Comments ]
B. SEPTIC~G TANK DATA
Date Installed
Standpipes (~N) Air-tight Caps ~N)
Depression over Tank (Y/4~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/~ol¢ih~ Tank:
To Water-Supply Well
To Property Line [,¢,. ~-~--
To Water Main/Service Line
Course . //
Comments
Size ~ No. of Compartments ~
Foundation Cle a n o u t~i~ N~.....~-
Date Last Pumped _ _~\~
, for _ ~
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ - ~- IE,'~
Width of Field Loc:~
To Water-Supply Well
To Building Foundation
Lot
Square Feet of Absorption Area
Depression over Field
Results of Last Adequacy Test
Separation Distance from Absorption Field:
~"~'fl:~/~'t'""' Type of System Design
Length of Field
Depth of Field (_~ ~"1
Gravel Bed Thickness
Standpipes Present
Date of Last Adequacy Test
To Water Main/Service Line L ~=, ~ ,~
To Stream/Pond/Lake/or Major Drainage Course
To Property Line ,\ ~-~ t N
To Existing or Abandoned System on
; On Adjoining Lots '~%'P
To Cutbank i(if present)
To Driveway, Pa~qg Area, or Vehicle Storage Area ~:'~ ~"~-
Comments .~L'~t,Jrc~-~'¢~, '~"n~.~ ~~~~ ~ ~ ~~
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)
"l~ump Off" Level at
/,~ Vent (Y/N)
~l~/'~'~1'~ Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check, . ,.~/.~__P.ermi/tt~-.¢/ /. Bedroom Rating Against HAA Request **
I certify
t~ n~e~, verified, or conformed to all MOA~nd HAA guidelines in effect o~ the date of this inspection,
Signed ~ ~ Date ///~ ~/~
Receipt NO. ~ ~L[ I q ~
Date of Payment J~- ~-~ ~ ~
Amount: $ ~ ~
Page 2 of 2
72~026 (11/84)
