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HomeMy WebLinkAboutPROSPECT HEIGHTS #5 BLK 1 LT 2Onsite File Prospect Heights #5 Block 1 Lot 2 #015-135-02 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: C)~ _o~k_~ ~ °_-b PID Number: ,(~ ~ .z.)._ I Name: ~ ,~ ~ ~ Wastewater System: ~New D Upgrade ~ ~o¢~ ~[/~ ~ ~ ABSORPTION FIELD Phone: No.o~drooms: ~Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other Total Depth from original grade: LEGAL DESCRIPTION Soil Rating: ~'~ GPD/Sq. Ft. Lot: ~ Block: ~ ~ ~ ~Subdivisi°n: Depth to pipe bottom from original,de: Ft. Gravel depth beneath pipe ~ Ft. Township: Range: ~ection: Fill added above original grade: Gravel length: O ~,. ~ ~. Number of lines: Dis[ance be~n lines: WELL: ~New ~ Upgrade Gravel width: ~ Ft. I Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: Date Drilled: Static Water Level: InsJaJler: ~ Date installed: Pump Se~: Casing Height Above Ground: ~'~'~: ~ ~.~ ~D ~,. ~ ~,. TANK SEPARATION DISTANCES ~s~¢ic ~ Ho~i~ ~ S.T.E.~. From Tank Field Station Tank S .... Lines ~C~ ~ ~ Material: Number of Co~rtments: Surface Water N~ ~ LIFT STATION Lot SiZ~a~ Line ~¢~ ~ ' Fo.ndation '~ ~ 1 ~ . "Pump on" level a~ "Pump off" level at: High waler alarm at: CUDrainrtain ~ ~ ~ Pump Make & Model Ele~ nspections performed by: Remarks: CX~ ~;i~ ~~~, BENCH MARK Location and Description: I ~ ~O: ~ P~ I Assumed Elevation: ENGINEER'~ SEAL Inspections performed by: ~ ~ Dates:lst I°tt~q~ 4:? : Department of Health and Human Services approval 'it,';~ CE-7760 Reviewed and approved by: Date: ~ '/~-~¢ ~ Permit No. Legal Descri Page ~- of ~ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report ~tion: [2~--r. JK IH~ ~/ /.-~ / ~ I PID No.: 0+00 0+10 T-rTr- 0+20 0+80 ............ 1+00 1+10 --.ST 1! -- CO2 -- CO3 MT MARK W. PEARSON CE - 7760 STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES · DIVISION OF WATER WATER WELL RECORD LOCATION OF WELL : "': .... ' '~' BOROUGH -~'~ SUBDIVISION* . LOT' BLOCK SECTION QTRS SECTION TOVVNSHIP RANGE MERIDIAN LOCATION/SKETCH: WELL OWNER: // DEPTHS MEASURED FROM:l-lcasing top r-lground s Jrface WELL DEPTH: // DATE OF COMPLETION Depth of hole: ~_~) ~ ft BOREHOLE DATA: Dep :h Depth of casing: /~,// ft t/'O /?~::2 / Material Type and Color From To DEPTH TO STATIC WATER LEVEL: ~'.7>~ - ~ ~ ~; /_? ~' ft be,ow J~ top of casing [] grou.d surface METHOD OF DRILLING: ~ air rotary [] cable tool ~~_ ~ ? -~ ~ publio ~upplv D other ~ CASING STICK-UP:· ~ft. Dial: ~ in. to/~/ft ~~~~ :~ WELL INTAKE OPENING TYPE: ~ open end ~ screened ~ ~ ~ /'Z~ Q pedorated ~ open hole ~_~. . / ~ y ; ~ ~ Depths of openings: to ft SCREEN TYPE: ~. Diam: in, SIoUMesh Size: Length:. ft Volume used: Depth [o lop: ~. GROUT TYPE: ~.. Volume: ~-- ~e Depth: from ft to ft ~'~ ~'~,- D~ELOPMENT M~HOD: ~o~9 : o.~ Duration: ~ ~ OeV"-- PuMpING L~EL AND YIELD: ~ 7 ft after ~/ hrs pumping ~ gpm PUMP INTAKE DEPTH: ~ ft Horsepower: WELL DISINFECTED UPON COMPL~ION? ~.YES ~ NO CONT~CTOR INFORMAT~N: REMARKS: e~~ ;gi.%t~re~/Bu,s :lmu / /. Signature of Authorized Respres~ative Date PLEASE MAIL WHITE COPY OF LOG.~O: DNR/DIVISION OF WATER PO BOX 772116 '~' EAGLE RIVER AK 99577-2116 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930423 DESIGN ENGINEER:MOUNTAIN ENGINEERING OWNER NAME:ONEY JOHN ANTHONY & OWNER ADDRESS:2631 W 100TH AVE ANCHORAGE, AK 99515 DATE ISSUED:10/ll/93 EXPIRATION DATE:lO~il~94 PARCEL ID:01513502 LEGAL DESCRIPTION: PROSPECT HEIGHTS #5 BLK 2 1 LT LOT SIZE: 87402 (SQ. FT.) NUMBER OF BEDROOMS: 5 THIS PERMIT: 5 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS RECEIVED BY:~ MOUNTAIN ENGINEERING 3868 Shannon Circle Anchorage, Alaska 99508 (907) 562-1500 Project Scope: Legal Description: Date of Report: .~?'..;q:, OF 4?%- ..';'.- On-Site Septic System & Well Design Prospe~ Heights Addition No. 5, Blo~ 1, Lot September 29, 1993 DESIGN CRITERIA This permit request is for a new septic system and well on the above referenced lot. The proposed home is a five (5) bedroom single family home. Two test holes were excavated at locations indicated on the attached site plan. Percolation rates were 3.3 min/inch in test hole #1, and 7.7 min/inch in test hole #2. Water was not encountered during the testing, and the monitoring tubes were dry at the end of the ground water monitoring period. Based on five bedrooms, the daily design flow is 5 X 150, or 750 gallons/day. The application rate for test hole #1 will be 1.2 Gal/Day/SF. The required area is thus 750/1.2, or 625 SF. With gravel depth below the pipe of 8 FT, the length of trench required will be 625/16 or 39 FT, rounded to 40 FT. The topography on the lot in the area of the proposed septic system slopes at approximately 5% to the east. ?/ k ~ ~etu~oZ Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16- 17 18 19 2O -- ,~ll O ~.~..~ C~ SLOPE WAS GROUND WATER ENCOUNTER ED? SITE PLAN S L IF YES, AT WHAT ~ O DEPTH? p E flepth to Water After Monitoring? ~ I~,,T~¢.,. Date: Re~ding Date Gross Net Depth ton ~ Net Time Time Water. (~ ~ wc~,) Drop / PERCOLATION RATE ~,"~ (minutes/inch) PERC HOLE DIAMETER TEST RDN BETWEEN ~:' FTAND '~- FT PERFORMED BY: ~;~,,,"~'~4'~ ~1/~.4"~ I 'V~-.."~-, '~e'~'~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THiS DATE. DATE: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: -' '.:(ENGINEERS:SEAL) :' t . f/iZRK W P~AReON ,..% CE - 7760 TownshJp, Range, Section: 1 2 3 4 5 6 7 8 9 10. 11 12 13 14 15. 16 17 18 19 20. SLOPE SITE PLAN WASGROUND WATER ENCOUNTERED? -I N S IF YES, AT WHAT L DEPTH? ~ O · p E Depth to Water ADer. Alonitoring? NC~'"~-. Dale: Reading Date Gross Net Depth to Net Time Time Water Drop I PERCOLATION RATE ~'~ ~'" (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN (~ FT AND '~ FT COMMENTS ~ ~ ~0 . /~:~F ~-,¢~r~ ~_~ ~/~ ~ ~/.~ ~ q~ PERFORMED BY: ~~ ~~3 , ~ r~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~]1 ~[~ MUNICIPALITY OF ANCHORAGE i Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section \� -`� Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 015.135.02 1. GENERAL INFORMATION Expiration Date: 0 CA 1 I a ©2 V Complete legal description PROSPECT HEIGHTS #5 BLOCK 1, LOT 2 Location (site address) 10001 ZERMATT CIRCLE, ANCHORAGE, AK 99507 Current property owner(s) GREGORY & LINDA SAMORAJSKI Day phone Mailing address Real estate agent PO BOX 32478, JUNEAU, AK 99803 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 5 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic, Water Storage ❑ Holding Tank: ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ J�J�O t4 I k Waiver Fee $ Date of Payment [a[;k 26 Date of Payment Receipt Number p'��� Receipt Number COSA # Waiver # COVID-l9 2570 DISCOUNT APPLIED 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY. ANCHORAGE. AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 6/19/2020 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & FkS ' 6. DSD SIGNATURE System #1 Approved for System #2 Approved for Disapproved Conditional approval for 5 bedrooms bedrooms ..OF �� -49 i •,,k t/� .- • Curtis Huffman CE 128991 FOPROFE S10* bedrooms, with the following stipulations: `��`� OF '' ` f,, WATER AND WAST' -'w' F o..; r,.nr r, AM' _eo T SERV By:17MTi'r� �c��unc�riginal Certificate' Date: ! 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 X Septic System Advisory Arsenic Advisory Well Flow Advisory Other A� COSA Checklist Legal Description: PROSPECT HEIGHTS #5 BLOCK 1, LOT 2 Parcel ID: 015-135-02 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA Well log is filed with Onsite (or attached) Date drilled 10/20/1993 Total depth 307 ft Cased to 141 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 6/8/2020 Static water level at beginning of test 129 ft. Well production at time of test 3.3+ gpm Water storage tank volume NA gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate 5.61 mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date of Sample 6/8/2020 Comments __________________________________________________________________________________ B. TANK DATA Age of tank(s) 27 years Tank type/material SEPTIC / STEEL Measured operating fluid level in septic tank 51” Standpipes/foundation cleanout per record drawing Date of pumping 6/8/2020 C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: SEE MOA TANK ADVISORY D. ABSORPTION FIELD DATA Which system tested (date installed) 10/24/1993 ALL standpipes present per record drawing Total measured depth from grade 12.2 ft (max) Measured depth to pipe invert from grade 5.4 ft (min) N/A – pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective 6.8’ INTO THE 7’ ED Code-required soil cover over field System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Adequacy test date 6/8/2020 Results Pass For 5 bedrooms Fluid depth prior to test 57 in Water added 750 gal New depth 75 in Elapsed time 1440 min Final fluid depth 47 in Absorption rate 750 gpd Any rejuvenation treatment (past 12 months) N If yes, enter date Comments/Deficiencies: E. SEPARATION DISTANCES 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 if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Property Line > 5’ Yes if No ft Absorption Field > 5’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ 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) Building Foundation > 10’ Yes if No ft Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No F. ENGINEER’S 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. 6/22/2020 MUNICIPALITY OF ANCHORAGE    DEVELOPMENT SERVICES DEPARTMENT    907‐343‐7904  On‐Site Water and Wastewater Section                                                                                           Fax: 343‐7997  www.muni.org/onsite         Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org      Nitrate Advisory   Certificate of On‐Site Systems Approval # OSC201274  Subdivision: Prospect Heights #5, Block: 1, Lot: 2  A water sample revealed a nitrate concentration of 5.61 milligrams per liter (mg/L).   The  Environmental  Protection  Agency  (EPA)  has  established  a  maximum  contaminant level (MCL) of 10.0 mg/L for public drinking water systems.  While  private wells are not subject to this regulation, EPA standards are based on existing  health information and can therefore be used to gauge the relative quality of water  from private wells.  Since nitrates are known to slowly increase, we recommend  you monitor the water quality.  Please see the attached “Nitrate Fact Sheet” for  important information regarding nitrate.  This advisory must be attached to all copies of the subject Certificate of On‐Site  Systems Approval.                                 Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org  Nitrate Fact Sheet  From Northern Testing Laboratories, Inc.  Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water.  Nitrate  is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.  SOURCE:  Nitrate is a major component of fertilizer and wastewater.  Often the nitrate is in the form of  ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the  oxidized form known as nitrate.  Sources of nitrate from wastewater include urea, ammonia cleaners,  food solids, and bacterial cells.  It may also result from the breakdown of organic matter buried in the soil.  TOXICITY:  Nitrate is generally not toxic to adults or children over the age of two or three years, but is  associated with a potentially fatal infant disease called methemoglobinemia.  In the digestive system of  young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood  stream.  There it combines with the hemoglobin and interferes with the ability of the blood to carry  oxygen.  For this reason, methemoglobinemia is referred to as “blue baby” disease.  The EPA limits the  concentration of nitrate in public drinking water supplies to 10 mg/L.  The standard has been lowered  from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.  TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home  water treatment systems such as softening or iron filtration does not readily remove nitrate.  The best  method for limiting nitrate in well water is source control.  This can include avoiding overdosing of  fertilizer near the well and maintaining good separation distances between septic tank leach fields and  the well.  A special anion exchange filter that contains a medi a with a strong affinity for negatively charged  ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.  TESTING:  Nitrate analysis is usually done by one of the several  “wet  chemical”  methods  using  a  spectrophotometer to read the final color endpoint.  Specific ion electrodes also can be used to detect  the activity of nitrate in water.  This laboratory uses several different wet chemical methods approved  under the public water supply laboratory certification program.  They also have test kits available, which  the laboratory uses to perform an inexpensive “screening test”, and with which the homeowner can  monitor the change in nitrate levels from their well.  They recommend comparing the test kit results  against a certified analysis from the lab occasionally to verify the accuracy of the kit.  We recommend  using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.          MUNICIPALITY OF ANCHORAGE    DEVELOPMENT SERVICES DEPARTMENT    907‐343‐7904  On‐Site Water and Wastewater Section                                                                                           Fax: 343‐7997  www.muni.org/onsite         Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org      Septic Tank Advisory   Certificate of On‐Site Systems Approval # OSC201274  Subdivision:  Prospect Heights #5  Block:1, Lot: 2  The septic tank for this property is 27 years old.  The average life for a steel septic  tank is 20 years. Typical replacement costs range from $7,000 to $11,000.   This advisory must be attached to all copies of the subject Certificate of On‐Site  Systems Approval.               This is an example of what the metal of a 30 year old steel tank MAY look like.      �N�0� 25' 0 O I � to co O CV Q � / O / O G LU O I U O � O U O � O Q M W co N I / / 25' WELL lV I I 0 25' 50' — — —-ZERMATT AVENUE — — o co co S 89053'25" W 216.80' i 4 u Sal : �o LS -14837 = fit x EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED SUBDIVISION PLAT (82-313) ARE NOT SHOWN HEREON THIS DOCUMENT DOES NOT CONSTITUTE BOUNDARY SURVEYAND IS SUBJECT TO ANY INACCURACIES THATA SUBSEQUENT BOUNDARY SURVEY MAY DISCLOSE. UNDER NO CIRCUMSTANCES SHOULD ANY OF THE DATA HEREON BE USED FOR CONSTRUCTION OF FENCES, IMPROVEMENTS, OR FOR ESTABLISHING PROPERTY BOUNDARIES. NO CORNERS SET THIS DATE I SCALE 1" = 50' t N LOT 4 AS -BUILT I HEREBY CERTIFY THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY: LOT 2, BLOCK 1, PROSPECT HEIGHTS SUBDIVISION ADDITION No. 5 ANCHORAGE RECORDING DISTRICT, ALASKAAND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST EXCEPTAS INDICATED. DATED THIS 24th DAY OF JUNE, 2020, ATANCHORAGE, ALASKA. FIXED HEIGHT, LLC Land Surveying Services 907.290.8949 WWW. FIXEDHEIGHT COM JOB # 20124 Parcel I.D. # MUNICIPALITY OF ANCHORAGE 'UI~I~LITY OF ANCHO~GE DEPARTMENT OF HEALTH & HUMAN SERVICES ENV Division of Environmental Services ~1" On-Site Services Section ~ 5 0 1997 P.O. Box 196650 Anchorage, AlaSka 99519-6650 RECEIVED CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Day phone ~/~'7~" Lending agency /~f ~/q' Day phone /'"/~- Mailing address /v~ ),or'- Agent '-~z~q'¢--'~l (~"r~ ,/'~ ~ Dayphone ~,~-~-~/ Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~- TYPE OF WATER SUPPLY: Individual well ~' Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~25 {Rev. 1/91} Front MOA *Y21 · 5. STATEMENT OF INSPECTION BY ENGINEER. As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of~ds inspection. A~a~a Water ~ Name of Firm Wsstewa~erServbes // I pk~,~,~ :~'7~/'7~ 847, B,oo~r~dcJe D,. - z/ Address ,~ ~¢.¢~,¢50;;~-~///' / Engineer's signature ~__.~/~~~] _ -' Y APproved for ~' bedrooms. -.. Disapproved. Conditional approval for bedrooms, with the following stipulations; Additional Comments By: Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent profe-~ona! engineer recJistered in the State of Alaska. The DHHS does th s as a courtesy to purchasers of homes and their lending institut ons in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-O25(Rev. 1/91) Back MOACY21 MUNICIPALITY Oj= ANCHORAGE Municipality of Anchorage ENVIRONMENTAL SERVICES DIVI~ DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division tIJJN ~ 0 1997 825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 J ECEIVE Health Authority Approval Checklist Legal Description: A. WELL DATA Parcel I.D.: Well type ~'kl'-~'~ If A. B, or C, attach ADEC letter. ADEC water system number L0g present (Y/N, X'~S Date completed Total depth ¢ 0 7 Cased to I ~ [ Sanitary, seal (Y/N) X~t(~5~ Casing height (above ground) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test / O/~tO///~ ~ /2-.~/~ '~ Static water level 1 3 ~ / 2 o~ Well production WATER SAMPLE RESULTS: Coliform ¢ Nitrate Date of sample: ~ B. SEPTIC/HOLDING TANK DATA Foundation cleanout (Y/N) y Depression (Y/N) AdO Date of Pumping &/~.~J/a] ~'* Pumper C. ABSORPTION FIELD DATA Date installed I Length 4-~'-1 Width Effective absorption area Date of adequacy test Number of Compartments 2- Cleanouts (Y/N) High water alarm (Y/N) Soil rating (g.p.d./ft2 or ft2/bdrm) ?* ~'~ Gravel thickness below pipe 7 System type Total depth Monitoring Tube present(Y/N) y Depression over field (Y/N) Results (Pass/Fail) ]2'~"~ For ~-' bedrooms Fluid depth in absorption field before test (in.); 4gOo ~" Immediately afie~ ~. gal. water added (in.): Fluid depth 44~ it (ins.) Minutes later: [ &~ ~) Absorption rate = ~' 7~-/'~ g.p.d. Peroxide treatment (past 12 months) (Y/N) NOr~ ~otda/~ttyes, g~ve' date PJ/4F- Size m gallons Manhole/Access (Y/N) ~ High water alarm level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot ! o~J(' / / Absorption field on lot Public sewer main t~ ~/septic service line · On adjacent lots : On adjacent lots i O0 / + lO0t + Public sewer manhole/cleanout Lift station P'J/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation [ J ! Property line Absorption field Water main/service line a,Q-~-' 14''' Surface water/drainage /OO (/- Wells on adjacent lots' SEPARATION DISTANCE FROM A~RPTION FIELD ON LOT TO: Building foundation j _ Water main/service line ~ ~ ''p' Surface water Curtain drain /00 i I/'" Driveway, parking/vehicle storage area ~'~) ! '~'- Wells on adjacent lots /O~-) / '~- Property. tine F. ENGINEER'S CERTIFICATION ~(. ~ X ?,.~'?~-.%'~] Signature Engineer's Nam~ [/ ~ ~~ ................................................................................................... .... . .... HAA Fee $ ~,~ Date of Payment Receipt Number C3~6~ ~9_¢ Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number ~ Facsimile Transmittal Alaska Water & Wastewater Consulting Engineers If¸ Attention: From: Jeffrey A. Garness, P.E., M.S. Comment(s): '1 S oF'F-, Reply requested: ;~ Yes if] No 8471 Brookridge Drive * Anchorage, Alaska 99504 * Phone: (907) 337-6179 * Fax: (907) 338-3246 ~ ur~-~-l~'¢ iY: 4~ CT&E ESI ANCHORAGE CT&E Environmen'ml Services Inc, Clhmt Name Client $1~mple Matrix Ordered By 97~24001 AK Wa~er & W~te~ater Serviee~ 10001 Zen'nat Circle Hose Bibb Drinking Water S~uaple ge~arks: N[trste-H pQL 3,14 Client Primed Date/Time 06/26197 14:~I Colleci~fl Date/Time 06124197 Received Date/Time 06/~/97 1~:20 Technical Director; Stephen C. Ede O.SOO mg/k ~fl18 4500-~03; 10 mx 06/~6/97 SW~8 922zB 06724/9~ AbDN, "-' E'f~ ~.JA 7' T : ~ ~MUNI~!PA~IT¥ OF..ANCHORAGE :- HEALTH & ~. ~.:'-;: :- '".? P.O;:Box~.196650 Alaska;-,:99519.-.6650. ij:-i::?:, i, ' '' CERT F CATE OF HEALTH AUTHORITY ~ APPROVAl" FOR:A-SINGLE'FAMILY:DWELLING Par~e;' i.D.#· ~"~,/_~_ ?..~Z.,'~F'~'i":!:'"'-~!:!~"~.:~':i:.'i.:::;?i.?.':.~ :'GENERAL iNFORMATION: Complete.legal des~Hption).'L~2 Location (siteaddr~ss0r~dir~ti0~)' :-)'~'~0'(~'1~,._ zermatt Property owner i' "Whit'.ehead ' A'. John~'~: M~rci":L'i'~Oay phone Mailing ' '" Mailing address ;:":: i';! Address '_ '2,' NUMBER OF BEDROOMS: ~.3,. ': TYPE OF WATER SUPPLY: ! : ..: _ Individual' we'll:: ' Agent The Peterson Group Day pm Unless.otherwise requested, HAA will. be held for pickup. 5 · Community well · .,., '.;i. NOTE: '.If community wellsYStem, 'P~°vide,,:~Written)c~nfirn~atiOn from Stat~ :i :'i','-'.i-""~ : ' ing to. the legalit~/ an'd ~iatu~:~f s~i~rn. , 4. :TYPE OF WASTEWATER DISPOSAL:-- . ?~!:'-~ ',., .~ i:,...: --~., Individual:on-site. ~itY.:on-site ',. i. -.' ~lOTE:',¢ : :'lf comm u n attesting B¥¢ENGI; gation~0fYtl tyl of uate for the number'bf bed'i;~b~n~ on the informatiOn Obtained ~om )ection, · Municipal and .~ SIGNATURE - ' ':!i~-::.' A'l~'~'oved for-- Disapproved. Conditional a Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Y If A, B, or C, attach ADEC letter. ADEC water system number Date completed I°[¢-.~IC~ '~ Driller At p~v~.. Cased to I ~ I Casing height ~._ Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot {-~ L~- Absorption field on lot (~ Public sewer main ~ Sewer service line ~ g.p.m. AT INSPECTION MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION g.p.r~., ] 'J t994 RECEIVED ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ¢ Date of sample: L~J~--I~'~ B. SEPTIC/HOLDING TANK DATA Date installed ~ OIC°rl~ Cleanouts (Y/N) ¥ High water alarm (Y/N) Date of pumping Nitrate c[ (o Other bacteria ~ Collected by: ~CP/,,.~ ~) ~c~,,~[~x~¢, ~v~.~, Tanksize {1~"O~ Compartments ~-- Foundation cleanout (Y/N) ~ Depression (Y/N) Alarm tested (Y/N) ~ ~"~'~( ~,~'"~¢-~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot { ?---~1- On adjacent lots Kt~'-v-~ Foundation ( J To property line ~.3C~ Absorption field [~-- i Water main/service line Surface water/drainage ~e~... 72-o26 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) __ ~ __~ump on" level at High water alarm level Meets MOA electrical codes (Y/N)~ SEPARATION DISTANCE FROM LIi~ STATION TO: Well on lot ~)n adjacent lots Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Surface water. D. ABSORPTION FIELD DATA Date installed H21,?..~i..~. o~ Soil rating (GPD/Ft Length . L'{'"7~F / Width Gravel thickness Total absorption area ~-c~ ,~r?.- Cleanout present (Y/N) ~1' System type ~ I Total depth ( Depression over field (Y/N) Date of adequacy test ~-.',~ 1~"~c'~'~1 Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Results (pass/fail) .-.-- for After test If yes, give date Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot t ~ To building foundation On adjacent lots Surface water Curtain drain On adjacent lots IN~.o~,--~ Property line To existing or abandoned system on lot Cutbank ~,9-v~- Water main/service line Driveway, parking/vehicle storage area ~ i E. ENGINEER'S CERTIFICATION n£ormed to a// MOA and HAA guide/ines in effect ~.th-e:date..of is inspection. or co I certify that I have checked, verified, ~' . ~,:;' .~. ,' ::. ~,~' .', ~,~. Signature~' Engineer's Name ~Y~ Date I,,~1 IOI C[~ HAft, Fee $ ,~00 Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number