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HomeMy WebLinkAboutEAGLE RIVER HEIGHTS BLK 3 LT 14A1-1Onsite File Eagle River Heights Block 3 Lot 14A1-1 #050-271-66 Certified Drilling Log OWNER OF LAND: Dennis Albert ADDRESS: 10322 Chain of Rock St. Eagle River, AK 99577 LEGAL DESCRIPTION Eagle River Heights Block 3 Lot 14A1-1 DATE: 10-1-20 PERMIT NUMBER: OSP201396 DATE OF ISSUE: 9-23-20 TAX IDENTIFICATION NUMBER 05027166000 Is well located at approved permit location: Yes No Method of Drilling: air rotary cable tool Depth of Well: 164 Casing Type: Steel Wall thickness .250 inches Diameter: 6 inches, depth 164 feet Liner type Static Water Level: 100 feet Recovery Rate 8 gpm gph Method of Testing Air Well Intake Opening Type: open end open hole Screened Start feet Stopped Perforations Start feet Stopped Grout Type: Bentonite Volume: 50 lbs Depth: from 2 feet, to 42 feet Well Disinfected Upon Completion: yes no Method of Disinfection: Chlorine 50 PPM Comments: Bore Hole Data Depth From To 0 2 Casing Stickup 2 4 Overburden 4 22 Silty Sand & Gravel 22 60 Hardpan 60 71 Tight Silty Sand & Gravel Wet 71 135 Hardpan & Cobbles 135 144 Silt & Sand w/ Some Gravel Water 144 163 Tight Silty Sand & Gravel 163 164 Sand & Gravel Drillers Name: Cole Sullivan ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. MatSu Borough: Department of Environmental Conservation. www.sullivanwaterwells.com Pump Installation Log Well Drilling Permit Number: SW OSP201396 Date of Issue 9-23-20 Parcel Identification Number: 05027166000 Legal Description Property Owner Name & Address Eagle River Heights Block 3 Lot 14A1-1 Dennis Albert 10322 Chain of Rock St. Eagle River, AK 99577 Pump Installation Date: 10-12-20 Pump Intake Depth Below Top of Well Casing: 130 feet Pump manufacturer’s Name: Dempster Pump Model: Unknown Pump Size: 1/2 hp Pitless Adapter Burial Depth: 10 feet Pitless Adapter Installer: PCN Disinfected Upon Completion? yes no Method of Disinfection: Chlorine 50 PPM Comments: Pitless Manufacturer: Martinson NOTES: This pump system was reused from old well. 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 Community Development Department On -Site Water & Wastewater Program 4700 Elmore St. ■ P.O. Box 196650 ■ Anchorage, AK 99507-6650 0 www.muni.org onsje_ ■ (907) 343-7904 Well Decommissioning Lo Legal Address: Subdivision /6W Block Lot I 1 T R �T— Section ` Lot On-site Water & Wastewater Program certified contractor performing the well decommissioning — Name: Signature Company: LjJ(r l MA'�'V' MZeZ115- Well decommissioning date: V 1 Z-/Zo Method of decommissioning: AMC 15:55.0601-1 a. ❑ b. ❑ c. Location: Use the space below to provide a drawing of the property showing the following items; • North Arrow • Decommissioned well, • Other water wells on the property, • Two separate swing -tie distances for each well shown in the drawing, Note: The swing -tie distances shall be measured from either permanent structures of property corners. N _ 14 S pry MUNICIPALITY OF ANCHORAGE On -Sit$ Mter & wastowat,er Program PQ Box 1 HMO 4700 Ekrnwe teed Anchorage, Xask$ 995 550 ph4ft' (9Q7) 343-794A Fax; (9Q1} 345.7997 hStpl wu_rnuni.urgeansRE3 Permit Number; OSP201396 Mork Type, '."fell Upgrade On -Site Wafter System Permit Effective Date; Expiration Date: Tac Code Number- 05027136000 Site Le -gal Address: EAGLE RIVER HEIGHTS ELK 3 LT 14A1-1 G_01}52 Site Mailing Address; 18322 CHAIN OF ROCK ST, E=agle River Owner: ALBERT DENNIS LEE Design Engi neer: FIRST WATER WN SU LT1N G This permit is for the constructlon of 9f2312021 Lot Size In S€1 Ft: 20342 Till Bedrooms: 4 ❑ Disposal Field ❑ Septic Tank ❑ Holding Teak 13 Privy (21 Private well ❑ Water Storage Al r construction sha rI be In aoeorda n r~e wIth: 1- The attached approved design- 2- All requirements specified in Anchorag a M un ici p@1 code Chapters 16.55 and 15.65 and the Sate of Alaska Wastewater Disposal Regulations (18AAD72) and Drinking Water Regu[ations (I8 AC80) 3. The wastewater cede requires inbpet�t�.Ons during the installation- Tho engineer shall notify tha Devaloproent Servic*9 Department per AMC15. 65. Provide notipr tion bycaIlli ng J907) 3.4�-7904 (24f7)- 4- From October 15 to April 15, a subsuftce soil absorptlorl system under construction during freezing weather shall be $ilher: a. OpRned and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: To clo" this perrO please submit: 1. Well Log 2. Pump Install Log B. Water sample results 4. Well Dacommissioning 1-og Recelved By; Date: 9123/2020 Issued By: � Date' MUN ICIPALITY OF ANCHORtA 'R t' U5.IGE �4� Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 050-271-66 Property owner(s) DENNIS LEE ALBERT Day phone 9072304891 Mailing address 1661 THUJA STREET, ANCHORAGE, AK 99507 Site address 10322 CHANI OF ROCK STREET, EAGLE RIVER, AK 99577 Legal description (Sub'd., Block & Lot) EAGLE RIVER HEIGHTS B3, LOT 14A1-1 Legal description (Township, Range & Section) Lot Size 20,342 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 29 (w/wo AD U) Septic Tank ❑ Upgrade © Duplex (D) ElHolding Tank ❑ Renewal ElMultiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: $ ? X8.75 QV 1 D 1� Date of Payment: C1 10:Z -A.0 Receipt Number: 512 205 Permit No. O5 P,20 1-� (o -Waiver-Fetes: R (; Jl )01.-Z5 CO v10 Date of Payment: L,Z320 Receipt Number: 213270 Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc 13030 Sues Way, Anchorage, AK 99516 907-350 -9566 / firstwaterAK@gmail.com September 20, 2020 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: WELL UPGRADE PERMIT LEGAL: EAGLE RIVER HEIGHTS BLOCK 3, LOT 14A1-1 PHYSICAL: 10322 CHAIN OF ROCK STREET, EAGLE RIVER The owner has requested that we obtain a well permit to upgrade the existing aged well on the above referenced lot. Cole Sullivan recently scoped the well and found the casing in poor condition. We propose to drill the well 15’ northward of the existing well to maintain 25’+ to the existing sewer service line to serve the existing 4-bedroom residence. A mix of public, private water and sewer serves the lot and area. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201396, Deb Wockenfuss, 09/23/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201396, Deb Wockenfuss, 09/23/20 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 050-271-66 Certificate of On -Site Systems Approval Expiration Date: 12-6-22 Legal description Eagle river Heights Block 3 Lot 14A1-1 Site address 10322 Chain of Rock St. Eagle River Current property owner(s) Micha Sarah Ellington X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for Comments or advisories: bedrooms, with the following stipulations: c.� BY: `"-��`-� � Original Certificate Date: 1 2 -Z - This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 MUHMPAU Y OF AHCHORQGIE ��y; 4 Development Services Department -_7 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 050-271-66 Complete legal description EAGLE RIVER HEIGHTS BLOCK 3, LOT 14A1-1 Location (site address) 10322 CHAIN OF ROCK STEET, EAGLE RIVER AK 99577 Current property owner(s) MICHA & SARAH ELLINGTON Day phone 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS 3. TYPE OF WATER SUPPLY: ® Private Well ❑ Private Well servin dwellin g--2 — g - units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ® Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ 2-G Date of Payment COSA # 0.�) G Waiver Fee $ Date of Payment Waiver # COSA Application—July 2022 copy.doc r Legal Description: EAGLE RIVER HEIGHTS BLOCK 3 LOT 14A1-1 Parcel ID: 050-271-66 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA ® Well log is filed with Onsite (or attached) Water storage tank volume NA gallons Date drilled 10/1/2020 Total depth 164 ft Well disinfected for coliform test? ❑ Yes ® No Cased to 164 ft ® Coliform bacteria is Negative ® Sanitary seal is functioning correctly Nitrate 0.445 mg/L ❑ Nitrate less than MRL (ND) ® Wires are properly protected Arsenic ug/L ® Arsenic less than MRL (ND) Casing height (above ground) 24+ in. FWIN Date of flow test for COSA 8/25/2022 Collected by Static water level at beginning of test 94 ft. Date 8/25/2022 Well production at time of test 5+ gpm Comments ATTACHED IS THE SULLIVAN DATA — WELL LOG DECOMMISSION NOT FOUND IN MOA FILEM B. TANK DATA C. LIFT STATION Measured operating fluid level in septic tank ❑ Required maintenance completed Date of pumping NA — PUBLIC SEWER Age of lift station years ❑ Required maintenance completed, if AWWTS Lift station material Comments: Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) NA - PUBLIC ❑ 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. ❑ Per record drawings, field is insulated. ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: COSA Checklist—July 2022 copy.docx Adequacy test date Results ❑ Pass Fluid depth prior to test _ in Water added _ gal New fluid depth _ in Elapsed time _ min Final fluid depth _ in Absorption rate _ gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) _ in Effective depth used _ in Effective depth remaining _ in E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft 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' ® Yes if No ft Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' ® Yes if No ft ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ®Yes if No ft N Yes if No ft ❑ N/A — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft Tank to Property Line > 5' ❑ Yes if No ft Wells on Adjacent Lots: Field to Property Line > 10' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft Water Main > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft F. ENGINEER'S COMMENTS If tank or field is under driveway comment below G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Engineer's Printed Name CURTIS HUFFMAN, PE Date 8/2912022 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 or NO 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 COSA Checklist—July 2022 copy.docx AMW _,� 11 r��g�P• 7 *:49TM *�rJ /;1011 Curtis Huffman CE 128991 8/29/22 l�,` PROFESSIONS' MUMMPALITY OF A 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. 050-271-66 1. GENERAL INFORMATION Expiration Date: Z-4z6A, Complete legal description EAGLE RIVER HEIGHTS BLOCK 3, LOT 14A1-1 Location (site address) 10322 CHAIN OF ROCK STREET, EAGLE RIVER, AK 99577 Current property owner(s) DENNIS LEE ALBERT Mailing address Real estate agent 1661 THUJA, ANCHORAGE, AK 99507 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone Day phone 3. NUMBER OF BEDROOMS: 4 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 $ d �C�� I ®" i c1 Waiver Fee $ Date of Payment I l I ) 0, CQ. Date of Payment Receipt Number 0,9 1 Receipt Number COSA # OS C ) �'-� q 6 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. 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 9951.6 Engineer's Printed Name CURTIS HUFFMAN, PE Date 8/31/2020 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 & fWfS ' 6. DSD SIGNATURE System #1 Approved for _�f_ bedrooms System #2 Approved for Disapproved Conditional approval for bedrooms bedrooms, with the fol 4 sail meg.• -49 TH r% . .. ....1M:.... • Curtis Huffman ����G�`�TF,p• •C$ 12891 /31/ 0p OF `l,F� PROFESSIONI`�.� )Wig( Q?I,ulations. ON-SITE �G WATER AND V,fAST- 4 z� PROGRAM Q1�1 By: Original Certificate Date: 2�i The Municipality of Anchora 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 Checklist Legal Description: EAGLE RIVER HEIGHTS BLOCK 3, LOT 14A1-1 Parcel ID: 050-271-66 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 10/1/2020 Total depth 164 ft Cased to 164 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 24 in. Date of flow test for COSA NA – NEW WELL Static water level at beginning of test 100 ft. Well production at time of test 8 gpm Water storage tank volume NA gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate 0.302 mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by SULLIVAN Date of Sample 10/20/2020 Comments B. TANK DATA - NA Age of tank(s) years Tank type/material Measured operating fluid level in septic tank Standpipes/foundation cleanout per record drawing Date of pumping C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA - NA 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 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 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 NA ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No NA 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 Excret a 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. 11/4/2020 Municipality of Anchorage -� Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 0.0 -a 1. GENEjtAL',INFORMATION Comp?e"IegaldE'scriptioP' �a• Location (site addressor directions) HAA # OOY09 Expiration Date: // — -7, 3 — D ,S Current. Propertyowner(s)IP�( Mailing address',,;.�''c f `. Lending agency Day phone e<j%—gy %c Day phone Mailing address // /I� Real Estate Agent Fck' K" ken Day phone'b 7 9 �y c Mailing Address ptUT"tel ✓ Unless otherwise requested, HAA 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 Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (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 Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number 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 Address Firm 41664 Frri Phone _K 94/- 77}24 17d37 9eCe- P< O e - Engineer's Printed Name sSTF_VG r4S Date &/ 7/d -r _; c OF AL .��. • S. DSD SIGNATURE ✓ Approved for 4 bedrooms. Disapproved. Steven W. E PE 6256 Conditional approval for bedrooms, with the following stipulations: Additional Comments Note: The well for this property meets existing State and Alunicipal Codes. There are nitrates present. It is suggested that periodic testing be performed to insure the wells continued suitability. Current nitrate concentration is 5.42 mg/l. EPA maximum concentration is 10.0 mgA. Afore Information on nitrates is available from the On -Site Services Program, at 343-7904. Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: rJ - 3' 0 Jr (Rw 0IM2) Municipality of Anchorage • Development Services Department Building Safety Division s < On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL 1CHECKLIST' Legal Description: �Ewc M6 t xr�( �, �T /4/4'%Parcel ID: 0 SO 2 '7%� G (, A. WELL DATA Well type If A, B, or C provide PWSID # _ Well Log (YIN) /y Date completed %q75 Sanitary seal (YIN) Wires properly protected (YIN) _ Total depth ,2D—o ft. Cased to _�ft. r Casing height (above ground) in. FROM WELL LOG AT INSPECTION Date of test k6tG S Static water level ft. 5?, s ft. Well production g.p.m. 465 g.p.m. WATER SAMPLE RESULTS: Coliform__(2—colonies/100 ml. Nitrate 5 mg./l. Other bacteria colonies/100 ml. Arsenic: mg./I. Date of samplers Collected by: d,44,41 B. SEPTICIHOLDING TANK DATA j'vB� (C SEw Tank Type/Material Date installed Tank size gal. Number of C/over ments _ Cleanouts (YIN) Foundation snout (YIN) _ Depressiotank (YIN) _ High water alarm (Y/ Date of pGmping Tper C. ABSORPTION FIELD DATA Pv51_1C ISfc�R Date installed Soil rating (g.pAA2 or felbdrm) Length _ ft. Width Total depth Date of ade Fluid depth Any ft. Eff. absorption area ft, y test Results absorption field before test_ in. min. Final fluid depth ion treatment (past 12 mo.) (YIN & pe) . in System type ft. Gravel below pipet ft. ng tube _ Depression Forms Water added_ gal. N Absorption rate >= If yes, give date depth_ in. M. D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) `Pump on" level a in. `Pump off* level at in. High water alarm level at in. Datum Cycles tested Meets alarm & circuit requir entsl E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO Septic tank/lift station on lot On adjacent lots f do ��- Absorption field on lot On adjacent lots 4 - Public Public sewer main 7 f Public sewer manhole/cleanout /Calf- Sewer Carf- Sewer /septic service line 4 f Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PuRuC Soa JeA Building foundation Property line Absorption field Water main Water service ne Surface water Wells on a 'scent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: /'dBL/c SAZ4X Property/eline Water S Curtain drain F. COMMENTS G. ENGINEER'S CERTIFICATION Building foundation Surface water Wells on adj acr lots I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name _ S T= ✓r �it/ 6' Date—P& ��OS HAA Fee $ 4'3 Date of Payment 9— g ' Receipt Number 7(p% (Rev. 12101) Water main Driveway, parking/vehicle store Waiver Fee $ Date of Payment Receipt Number ' 0497rM �. PE 62.56 . V ��UFiS:'��:•t . -FENCE ON ADJACENT LO' CONSTRUCTED BY ADJACENT LOT OWNERS I S 24 b6, WATER WEL Nog 'III u. 2 -STORY i o ®g�VLEANOE}� WIITTHSLOFT �g1V�— 241=e owN CLEO 58. Tt£CY to 7 41'19" £ N 2p2.81 W N pi Ix�....•J .. , o ~' CONCRETE WA .T I W O N z GRAVEL PAD �.5' '8 LOT 14A2'BLOCK 3 Z ]42' EAGLE RIVER HEIGHTS SUED. GAlog z 1101.27. 19e.7e — — S 89.67140" E 1 SCA LEGEND FOUND PRIMARY !.-NUMENT O. FOUND PRIMARY NUMENT • FOUND 5/8' REE '.•W/ 1 1/4' 0.1' ABOVE GROUND O FOUND REBAR v—■ 8 FOOT 1 •H FENCE ASBUILT SURVE iOF LOT 14A1, BLOCK 3 EAGLE RIVFR HEIGHTS SUBDIVISION 0 CORNERS SET THIS DATE BY AMTEC, INC. 111E INFORMATION HEREI IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY T{' SHOW ANY CONFLISTS BETWEEN E%I NO STRUCTURES AND PLATTED LOT LINES OR EASEMENTS 1.0 IS NOT TO BE USED FOR POSITIONING ATIONAL STRUCTURES OR FENCEUNES. 1 HEREBY CERTIFY THAT I AM PROPL . ' REGISTERED AND LICENSED 10 PRACTICE LAND SURVEYING IN THE : .TE OF ALASKA, THAT THIS AS - BUILT IS TRUE AND CORRECT AND TI IE ARE NO ENCROACIIMENTS OTIIER THAN THE ONES SHOWN IIEFII 1 FLOYD A. TETPON, PLS 923 S DATE 8 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, A~aska 99519-6650 (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SI NGLE FAMILLY DWELLING 1. GENERAL INFORMATION Completelegaldescription EAGLE RIVER HEIGHTS SUBDIVISION: LOT 14A-1. BLOCK Location (site address or directions) 10522 CHAIN OF ROCK STREET Property owner DON SHERSHEN Mailing address 10322 CHAIN-OF ROOK ST. Lending agency Mailing address Day phone (907) EAGLE RIVER. AK 99577 Day phone Agent DEBBIE LEWIS W./ REMAX PROPERTIES Day phone (907) 99577 Address 16600 CENTERFIELD DR, EAGLE RIVER. AK 99577. Unless otherwise requested, HAA will be held fo pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual well xx Community well Public water NOTE: If community well system, provide wdtten confirmation from State ADEC attest- ing to the legality and status of system. 4, TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding Tank Community on-site Public sewer NOTE: XX If community wastewater system, provide wdtten confirmation from State ADEC ing to the legality and status of system. 72-025 [Rev. 1/91)Front MOA #21 Computer Version 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I vedfy that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewatar 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,~ d State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ALASKAVyAT'=~&'V~/A~TE~E'~ ' '~/ CONSULTANTS, INC. Phone (907) 337-6179 Address 6901DEBARi~fROAD.~U~/2~B~N~CHORAGE.ALASKA 99504 / Engineer'sS/gnature k__ ~//~V//~ /''~ Date ' - ALASKA WATER & WASTEWATER CONSULTANTS, INC. SHALL BE PAID $800.00 AT, OR PRIOR TO, CLOSING FOR THE ENGINEERING 'SERVICES PROVIDED. 6. DHHS SIGNATURE ~ Approved for 4 bedrooms Disapproved Conditional approval for bedrooms, with the foil_ owing stipulations: Additional Comments Date The Municipality of Anchorege 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 purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 Computer Vemion RECEIVED Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES ~:~,~, 5 Environmental Services Division · ~.~.., 1 825 %" Street Rm 502 Anchorage, Alaska 99501 (907) 343-47N~U4N[¢ipAUT¥ ~vI~ONMENTAL Health Authority Approval Checklist Legal Description: EAGLE RIVER HEIGHTS S/D; LOT 14A-1, BLOCK 3 Parcel I.D.: 050-271-65 A. WELL DATA Well Type PRIVATE If A, B, or C, attach ADEC letter. ADEC water system number N/A Log present (Y/N) NO Date completed Total depth U.K. Cased to 40'+ Sanitary seal (Y/N) YES APPROX. 1975 Casing height (above ground) Wires properly protected (Y/N) 18"+ YES FROM WELL LOG Date of test x~c''?V~'~''/' / Static water level 65' Well production f/ g.p.m. 4.8 AT INSPECTION 2/,3/2000 g.p.m. WATER SAMPLE RESULTS: Coliform 0 Date of sample: Nitrate 4.12 mg/L Other bacteda 0 2/3/2000 Collected by: A.W.W.C., INC. B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER Date installed Tank size. Numberof~s (Y/N) - Foundation cleanout (Y/N) ~Dep~oon ~). High water alarm (Y/N). D~~ Pumper C. ABSORPTION FIELD DATA PUBLIC SEWER Date installed Soil rating (g.p.d./ft2 or ft2/bdrm) System tyPe Width Gravel thickness below pipe ~Dfaf~ Length Effective absorption area__ __ Monitoring T~mO' n over field (Y/N)_ __ Date of adequacy test ~Fail)~__ For Bedrooms ;;:ii; ::pp:: in absorption~i:.); _ _' ~lm m[is:t:i;canft::te= gal. water added (in.): ~ent (past 12 months) (YIN) If yes, give date 72-026 (Rev. 3/96)* Computer Vemion D, LIFT sTATION ~ Data installed ~"- Manhole/Access (Y/N) /~p~"~e at--Pump off" level at* High wa~ *Datum · E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot N/A Absorption field on lot N/A Public sewer main 75'+ Sewer/septic service line 10'+ (SEE ATFCHED LEIIER) On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout. 100'+ Lift station N/A SEPARATION DISTANCES FROM sEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER Foundation. Property line Surface water/drainage Wells on adjacent lots SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO: P U B LI C Property line Building foundation ~r-maTh-/~rvice line Sur[ace water ~g/vehicleDriveway, storage area ~ Wells on adjacent lots F. ENGINEER's CERTIEICA~ of Municipa, I/recorc~/ ~[t t~ a Sign at u re c..~.~,~,~'~'' Na / t/ Engineer's Date ~ field inspections and review ,e systems are in conformance ! on this date. JEFFREY A. GARNESS HAA Fee $ Date of Payment Receipt Number ~ ~/':~' 72-026 (Rev. 3/96)* Computer Version Waiver Fee $ Date of Payment Receipt Number Rick Mystrom. Mayor Municipality of Anchorage Department of Health and Human Services @25 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 http://www.ci.anchorage.ak.us March 2, 2000 Jeffrey Gamess Alaska Water & Wastewater Consultants, Inc. Subject: Waiver Request for Eagle River Heights Subdivision, Lot 14A-l, Block 3 Waiver Request #WR000006 Parcel ID #050-271-63 HA000048 Dear Mr. Gamess: Your request for a waiver of the required 25 feet horizontal separation from the sewer service line to private ~vell has been approved. The approved separation distance is 10.0 feet. This waiver approval applies to the existing sewer service line to private well separation only. Any furore upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-4744. Sincerely, Daniel J. Roth Civil Engineer On-Site Water Quality Program MUNICIPALITY OF ANCHORAGE Department of Health & Human Services On-Site Services Waiver Review Worksheet WR# WR000006 PID# 050-271-63 HA# HA000048 Date Received: February 15, 2000 Legal Description: Eagle River Heights, Lot 14A-1, Block :~ Engineer: Alaska Water & Wastewater Consultants 6901 Debarr Road, Suite 2B, Anchorage, AK 99504 Permit~ Applicant: Don Shershen Waiver Requested: A 10 feet separation distance waiver from the well to the sewer service line. Criteria: 1. Geology Points: '/' / '- B. Soil Sorption -"~o ~ C. Permeability 2o O 3 2.9 O ~o D. WaterTable Gradient i/O / E. Horizontal Separation Tota,: 141. 2- 2. Special Conditions: 3. Other: Waiver is Granted: ~ Waiver is not Granted: List Conditions or Reasons for above: Name of Reviewer Rec#: 0000 Amount: $0.00 Date Paid: February 15, 2000 ALASI WATER & WASTEWATER February 14, 2000 Municipality of Anchorage Department of Health & Human Services Division o f Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref: Waiver Request and Health Authority Approval for Eagle River Heights Subdivision, Lot 14A-l, Block 3 To whom it may concern: The existing 4 bedroom house is served by public sewer and a private well. We request you issue a Health Authority Approval and grant a 10 feet separation distance waiver from the well to the sewer service line. As can be seen on the attached As-built Survey, the well is 10+ feet from the sewer service line. There is no well log for this property; but the static water level was at 63 feet below the top of the casing on 2/3/2000 so it is assumed that the casing is to at least that depth. Attached is a well log for the neighboring well (Lot 14A-2, Blk 3, Eagle River Heights S/D) which is approximately 70 feet southwest of the referenced well. Its appears on the well log that there are confining clay lenses that protect the aquifer. The sewer service line is under the asphalt driveway which if effluent was to surface it would be evident and swift action would be taken. Attached is also the A.W.W.U. connect card. It is not documented what type of piping was used for the sewer service line. Recent water sample results indicated nitrate levels of 4.12 mg/L, no coliform bacteria, and 0 other bacteria. Based upon the aforementioned facts, it appears that there is minimal risk associated with the 10+foot separation distance and request that your department grant the requested waiver and issue a Health Authority Approval on the referenced property. If.y°u h~:e any 5I Presi~[el~ ions, please contact us at 337-6179. Thank you for your assistance. !., M.S. 6901 Debarr Road, Suite 2B - Anchorage, AK 99504 - Ph: (907)337-6179 ~ Fax: (907)338-3246 ~E~O~EI~UL',ED COMPLET ~: I DATE I~ iTl-DWELLING NO. APT$ i Original WR% PID% Date Received: Legal Description: Engineer: MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Wgiver Review Worksheet HA# Permit Applicant: Waiver Requested: Criteria: t. Geology: Points: A. Water Table B. Soil Sorption C. Permeability ~ D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: . List Conditions or,Reasons Waiver is NOT Granted: for above: '.Date: Rec ~: Amount: By: $ Name of Reviewer Date Paid: