HomeMy WebLinkAboutHANSON ACRES #1 BLK 1 LT 15Hanson Acres #1
Block 1
Lot 15
#009-294-09
MUNICIPALITY OF
Development Services Department
On -Site Water & Wastewater Section
Parcel I.D. 009-294-09
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Expiration Date:
Phone: 907-343-7904
Fax: 907-343-7997
2-! (9 ZE)
Complete legal description Hanson Acres #1, Block 1, Lot 15
Location (site address) 5902 Cordova Street Anchorage, AK
Current property owner(s) Fedor Martynyuk Day phone
Mailing address
Real estate agent
3992 W Rayne Ave, Wasilla, AK 99623
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
El
Private Septic
❑
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
El
Waiver request for:
Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 550- 0 0
Date of Payment 1 o 125 0y'l
Receipt Number 0_1 2550
COSA # OSG (° cj l c)
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
6. 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Engineering Phone 907-522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage AK 99503
Engineer's Printed Name Michael E. Anderson, P.E. Date 10/24/19
6. D R SIGNATURE
_T_System #1 Approved for _LL bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
By: I
OF Ah
V�
J � 1
Original Certificate Date: I I_S t -/
The Municipality of Anchorage Development Services Divis`lon (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
X Nitrate Advisory
Arsenic Advisory
Other
Legal Description: Hanson Acres #1, Block 1, Lot 15
If more than 1 septic system on lot: COSA Checklist #
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled Unknown
Total depth 82.5* ft
Cased to '40** ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) '12 in.
Date of flow test for COSA 10/22/2019
Parcel ID: 009-294-09
of Structure served by this system
Well production at time of test 4.3 gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic 5.65 ug/L ❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date of Sample 10/21/2019
Static water level at beginning of test 18.5 ft.
Comments *Well depth per inspection from Arrow Pump & Well. **Assumed per adjacent lot well information.
B. TANK DATA
Age of tank(s) years
Tank type/material Public Sewer
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA Public Sewer
Which system tested (date installed)
❑ ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date
Results ❑ Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
E. SEPARATION DISTANCES - No septic system on lot. Public sewer.
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
❑✓
Yes
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
❑✓ Yes
if No ft
Neighboring Tank > 100' ❑✓ Yes
if No
ft
Private Sewer/Septic Line > 25' ✓0 Yes
if No ft
Absorption Field on Lot > 100' ❑ Yes
if No
ft
Holding Tank > 100' Yes
if No ft
Neighboring Absorption Fields > 100'
❑ Yes if No ft
Water Main > 10'
Animal Containment > 50' ❑✓ Yes
if No ft
✓❑ Yes
if No
ft
[]Yes if No ft
Water Service Line > 10'
El
Yes
if No
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway
Community Sewer Main > 75' ❑✓ Yes
if No
ft
✓❑ Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required) - No septic system on lot. Public sewer.
Building Foundations > 10'
❑✓
Yes
if No
ft
Surface Water > 100'
® Yes if No ft
Property Line > 5'
✓❑
Yes
if No
ft
Wells on Adjacent Lots:
ft
Absorption Field > 5'
❑✓
Yes
if No
ft
Private Wells > 100'
❑ Yes if No ft
Water Main > 10'
0
Yes
if No
ft
Community Wells > 200'
[]Yes if No ft
Water Service Line > 10'
El
Yes
if No
ft
If septic tank is under driveway
comment below
From Absorption Field on Lot to: (Please enter distances if less than required) - No septic system on lot. Public sewer.
Building Foundation > 10'
❑ Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
❑ Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
❑ Yes
if No
ft
Private Wells > 100' ® Yes if No ft
Water Service Line > 10'
❑ Yes
if No
ft
Community Wells > 200' ❑ Yes if No ft
Surface Water > 100'
❑ Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
l 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.
COSA Checklist yellow sheet
OF
�® ............. '..
I �'s •e �
49th G zT
Vglrp ipsiiA 3431 it3t4R.[ [Of! R11�R31
"4bw Ate'
........ Alt tpltti.. 4*9 .......
0% MICHAEL E. ANDERSON o' 4
No. CE -4381 ,E
10/25/19
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & 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
APPROVTV___�
FOR A SINGLE FAMILY DWELLING
Parcel I.D.Odal-,Qq`r 7_0q COSA# HA CA 01
1. GENERAL INFORMATION Expiration Date: 3
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
*.
HANSON ACRES S/D• BLOCK 1, LOT 15
5902 CORDOVA ST • ANCHORAGE. AK • 99518
BRIAN HARPER Day phone 376-8384
5902 CORDOVA ST • ANCHORAGE, AK • 99518
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 1
3. TYPE OF WATER SUPPLY:
Individual Well
0
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
❑
Individual Holding tank
❑
Community On-site
❑
Public Sewer
N
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 samples. (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 INSPECTIO14 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 riles and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 s ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date
Engineer's Comments:
In conducting this evaluation, GEG, VD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described 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 soils condition, groundwater 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 the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTO. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
S. DSD SIGNATURE
_L,-"� Approved for -1 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the fllowing
Attachments:
COSA Checklist
Septic System Advisory
Well Flow
(Rw 1115)
P�\ZY.OF',q14
�C'
r
WATER AND
PROGRAM
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:_O�
\ Municipality of Anchorage
l Development Services Department
�4Building Safety Division
On -Site Water & 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 CHECKLIST
Legal Description: HANSON ACRES N1; BLOCK 1, LOT 15 Parcel ID:
A. WELL DATA "PRE -1972 PER HOMEOWNER. ""PER INSPECTION BY AAROW PUMP AND WELL 5/12/09.
""ASSUMED PER PREVIOUS HAA AND SURROUNDING WELL LOGS. SEE ATTACHED.
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) NO _
Date completed 'UNKNOWN Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth ""82.5 ft. Cased to'""40'+ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of lest 5/11/2009
Static water level NLx'o jN ft. 18 ft.
—v
Well production g.p.m. 8.4 g.p.m.
WATER SAMP E RESULTS:
Coliform colonies/100 ml.
Arsenic: 1• bug./L.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal Number of Compartments _
Foundation cleanout (Y/N) _ Depression over tank (Y/N)
Nitrate t.1D mg./L. Other bacteria colonies/100 ml.
Date of sample: 5/11/2009 Collected by: GEG Ltd.
/%9
PUBLIC SEWER
Date of pumping
C. ABSORPTION FIELD DATA
Date installed
Length ft.
Total depth ft. Eff.
Date of adequacy test
Date installed
Cleanouts (Y/N) _
High water alarm
Soil rating (g.p.d./ft'or ft'/bd System type
Width ft. Gravel below pipe ft.
bsorptio ea_ ft' Monitoring tube_ Depression over field
Results (Pass/Fail) For bedrooms
Fluid dep=—min.
before test _ in. Water added gal. New depth _in.
ElapsedFinal fluid depth _ in. Absorption rate >= g.p.d.
y 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"High water alarm level
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots N/A
Absorption field on lot N/A On adjacent lots N/A
Public sewer main 75'+
Sewer /septic service line 25'+
Animal containment areas 50'+
Public sewer manhole/cleanout 100'
Holding tank N/A
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line Absorption
Water main
Wells on adjacent lots
Water service line Surface
SEPARATION DISTANCE FROM ABSORPTION
Property line B +rtgtound
Water service line Surface water
Wells on adjacent tots
F. COMMENTS
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 JEFFREY A. GARNESS
Date
TO:
Water main
Driveway, parking/vehicle storage
COSAFeeS LIM Waiver Fee $
Date of Payment 5A? g Lo q Date of Payment
Receipt Number C) i yU Receipt Number
(Rev. 11105)
LOT 16
N '`5013
�
Njo°58x6
r
fence Ga��
\ wwwh ed
ad (Very poor condition)
o ock
0
J;;
LpSmoker
�CSV/
0
y
\ �0i
J
LOT 15
Well
/
i/<Y\ .2DCi
� N5`P te°'' '\ /
�Ql
`Go
Chain fink lanca—�, Well
,rib
�y�yti LOT 14
*-:49TH*
.. r •off
Fred Wa'atka .*E-,
>' No.3255•S
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED Fb 09-2, pg 23.24
PLAT ARE NOT SHOWN HEREON. BE
TO 3Dvc!
OSSV 'E V>IIV-VM Q3dJ
R \
wood fenrb \
poor condition
SCALE: 1"-- 30'
AS -BUILT NO CORNERS SET THIS DATE
I hereby ceNfy Mat I Dave pwfomred a stortgagee s mspe w
of the tolbvring described property: LOT 13. BLOCK 1.
HANSON ACRFS SUBDIVISION
Anchorage Recording Precinct Alaska. and that the
improvements situated thereon are within the property lines
and do not overlap or encroach on Me Property Ming
adjacent thereto, that no ImprovemertU on the property Mira
adjacent thereto encroach on the premises in question and
that there are no roadways, Uwwmlasion fines or other
visible easements on said property except as Indicated
hereon.
Dated at Anchorage. Alaska
this 14tH day of Adrll .2009
FRED WALATKA a ASSOCIATES
Engineers and Surveyors
(907-246-1666)
180ZEVZL06 6p:01 600Z/LT/90
10:09A FPOt1:
AAROW PUMP & WER SERVICE, LLC
P.O. Box 110496
Anchorage, AK 99511
Office: (907) 346-9355 • Fax (907) 333-8976
Eagle River: (907) 622-9335
70:3383246
P.1/1
C HWOOCE
N° 08338
CUSTOMER JOB SITE
f rrG� aro<r ��IO�- ro r 010ya
J
iC D
-� -O
• WELL DEPTIr !
SWL I
CPIOR =N D_
--
-MP
►UDEPTH
ERSON
r"a VN.
QUANTITY
DESCRIPTION//
PRICE
AMOUNT
PeaIIQboJC
or 14A rfe de-
GLABOR
LABOR
HOURS
RATE
AMOUNT
TOTAL MATERIAL
TOTAL LABOR
WORK ORDERED BY
DATE COMP.
TOTAL
LABOR
PAY THIS AMOUNT
Thank You
SIGNATURE
(I Hereby Acknowledge the Satisfactory Completion o1 the Above Described Work and agree that If above work Is not paid for In 90 days 1 agree to allow Aarow
Pump d Well Service, L.L.C. the right to remove unpaid for equipment and charge for labor already performed E labor to remove unpaid for equipment.)
TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE.
SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS.
tri
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date/
(a) Leg 1 Descr ption nclude loft, block, subdivision, section, �t
Location (address r directions) -
s"50"-- i )/"v/a-
hip, range)
(b) Applicants Name 2i �ii'� Telephone - Home Business
Applicants Address
(c) Applicant is (check one) Lending Institution
Buyer ; Other (explain);
Owner/builder ;
(d) Lending Institution Telephone
Address
(e) Real Estate Co. & Agent
Address
Telephone
(f) Mail the HAA to the following address:
2. Type of Residence
Single -Family Multi -Family Other (describe)
Number of Bedrooms
3. Water Supply`
Individual Well Communityr Public
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Onsite E= PubliFisystem,
Community Holding Tank
yNote; If communit w,must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
pr_
5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows tha8,,the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein. I further, verify that,
based on the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspecto�
Name of Firm
Address 7 vsf% `�/� ��G�•
Date
(ENGINEER SEAL)
b. DHEP Approval
Approved for .iit,7 bedrooms By
e
Approved m Disapproved
Terms of Conditiona3,Approval
Telephone
14t
T. ai -2*i,
Conditional
D,Dlo R. Me ell w
No.2065•Ga �0
. �d
'0n..- . 47..00 ". �..0
l
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 21 7-14-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
MUNICIPALITY of ANCHORAGE
DEPT. OF NE L11111 TION
IWIRONMENTAI
JEC03 '
Legal Description:/�ti�f
O
A. WELL DATA
Well Classification If A, B, C, D.E.C. Approve (Y )
Well Log Present (� Date Completed �— Yield
Total Depth Cased to `�� -_14_ Depth of Grouting
Static Water Level Pump Set At
Casing Height Above Ground ��' Sanitary Seal on Casinj 1)
Electrical Wiring in Condui (�f i) Depression Around Wellhead ( 11
Separation Distances from Well:
To Septic/Holding Tank on Lot /��� ; On Adjoining Lots /Go
i
To Nearest Edge of Absorption Field on Lot-+ ; On Adjoining Lots
To Nearest Public Sewer Line �'� To Nearest Public Sewer
Cleanout/Manhole +100 To Nearest Sewer Service Line on Lot t Z�
Water Sample Collected by
Date
Water Sample Test Results
Comments
lfe4q- Fob ANO Ho2q: �5VPMArlo/J u . "cc
B. SEPTIC/HOLDING TANK DATA
Date Installed Size
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
Comments
Page 1 of 2
72-026(11/84)
No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
�0
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well
To Building Foundation
I nT
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course _
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
On Adjoining Lots
To Cutbank (if present)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** 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.
Signed Date 1501 311 005-
Company
05Company 5 i E Pel 5 MOA No.
Receipt No. �J (p
Date of Payment I ; -_3z5 'AW�� OF �A��@��
Amount: $•� ' n� "•,' "
Engineer's Seal
�� /_�
"9T r d
Page 2 of 2
72-026 (11/84)
Na 2P55 -E
pROFESSION.+�
Location:
BESSE, EPPS & POTTS
2220 EAST 88 AVENUE
ANCHORAGE, AK 99507
(907) 349-6451
WATER WELL TEST
Date: /Z •-..J
Subdivision: /,z
Lot: i
Block:
Client's Name:
GPM
GALLONS
VOLUME
GALL DNC S
TOTAL VOLUME:
Address:
D
In
6
J 3
Tester:������
1 1
6
p
n1
D
O Z
Initial Reading on Meter:
o
d v
,2
m
TIME
GPM
GALLONS
VOLUME
GALL DNC S
TOTAL VOLUME:
D
In
6
J 3
ac 7
�
6
U
o
d v
,2
'3
/
6a
'
2 O
4
/ S
NOTES:
Pra.li we i i on Rab-: GPn 21-11our Capacity Callcns
s7A7E OF ALASKA BILL SHEFFIELD, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501 274-2533
December 2, 1985
Besse, Epps & Potts
2220 East 88th Avenue
Anchorage, Alaska 99507
SUBJECT: Grandfathered Horizontal Separation between Well and
Community Sewer, Lot 15, Block 1, Hansen Acres Addition
#1 Subdivision, Anchorage, Alaska (8621—WA-087)
Dear Sir:
The Department has reviewed the subject Grandfather request and
hereby approves the horizontal separation between the well and
community sewer to 80 feet on the subject property only.
Any future expansions will require further review from this
office.
Sincerely,
Michael P. Lewis
Environmental Engineer
MPL:pkk
NORTHERN TESTING LABORATORIES,
INC.
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99701
907-479-3115
6957 OLD SEWARD HIGHWAY, SUITE 101 ANCHORAGE, ALASKA 99502
909-349.8623
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY CLIENT
❑ PUBLIC WATER SYSTEM I.D. #
N PRIVATE WATER SYSTEM
NAME �/f�
Mailin Address J
City State Zip Code
SAMPLE DATE: —//— i8 ,;f:S Phone
Mo. Day. Year
Purchase Order No.
SAMPLE TYPE:
Routine 'Treated Water
/❑`Special Purpose ❑`Untreated Water
❑ Check Sample (for original contaminated
sample with lab reference no. )
Sample Time
No. Location J Collected Collected by �boratorry Ref. No.
4) &Z
SCP 1 11
2
0
4 _
5 _
6 _
7
8
9 _
10
Signature of Representative
FOR LABORATORY USE ONLY
CASH CHARGE PREPAID TRANSMITTAL SPECIAL INSTRUCTIONS MAIL
HOLD FOR
PICKUP
�wealw�
TO BE COMPLETED BY LABORATORY
Lv1
Received at: Anch. ❑Fbks.
Date Received // /r/— d76
Time Received LJ/jV5
Next Sample Due
COMMENTS:
SATISFACTORY
0
UNSATISFACTORY
U
RESAMPLE
R
OTHER BACTERIA
OB
TOO NUMEROUS
TNTC
TO COUNT
Direct
- varfieation Final
Count
LSB
BGB Resutt•
Comments
Mo) of Tot #' lonies pef)00 mis.
orted by
Date
Time /S
May 12, 1969
Mr. Dan Rapalee
Veterans Administration
P. 0. Box 1399
Anchorage, Alaska 99501
SUBJECT: Sewer and *mater
for Individual Home on
Lot 15, Block 1, Hanson
Acres Subdivision
Dear Mr. Rapalee:
This Department has checked the files concerning the
subject residence and the sewer and water systems are
still approved as before.
A recent water sample was satisfactory.
Sincerely,
DAVID R. L. DUNCAN, M. D.
Medical Director
BY.
Rolf R. Strickland, R. S.
Sanitarian
RFS/srr
VA
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
i- tram?.of person requesting approval Audie Moore
2. rta, of property.owner Glen W. Kiehl
3. Legal descriptior� (5902 Cordova) Lot 15, Blk 1, Hansen Acres
4, Number of ledr,00ms in house
5. Water Analysis:
a, Bacterial OK
purchaser: Theodore Braiterman
b. Detergent
6. Well data:
a. Type drilled ,
b. Depth 94'
c, Casing Size
d, Distance from well to closest existing or proposed:
h
1. Sewer line
2. Septic tank
3. Seepage Area
4, Cesspool'
5. Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
7. Sewage disposal system,
a. Age of system
b. Septic tank capacity in gallons 1000 gal septic & cesspool,
c. Name of septic tank manufacturer
1. If "home made" show diagram on reverse side of this form.
d; Disposal field or seepage pit size and type
1. Distance to property line to house foundation
e, Percolation. Test results
f. Percolation Test performed by
-9- Use the reverse side of this form to show diagram. Diagram should include
the following information: property lines;•well location, house location,
septic tank location, disposal area location, location of percolation test,
and direction of ground slope.
9. The information on this form is true and correct to the best of my knowledge.
Signature of Applicant Date Signed
TO BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL
he above described sanitary facilities are hereby approved, subject to the
'following conditions:
Conditions:— NOM
The above described sanitary facilities are disapproved for the following
reasons:
12-30-68
ig ature o f#sea.;; ` Date
David B. Harkness, sanitarian
Approval is valid for one year following, the date of approval.
CPJ:cw