HomeMy WebLinkAboutCOTTONWOOD HEIGHTS BLK 2 LT 6Cottonwood
Heights
Block 2
Lot 6
#051-431-06
11/47
ocipAtir, MUNICIPALITY OF ANCHORAGE
a•O ...,�: of �»r n C
.
\ On-Site Water& Wastewater Program \o :
EPL#7A1
MUNICIPALITY OF ANCHORAGE
( fr.A.;
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section �" - Fax: 907-343-7997
Emergency Tank
Replacement
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 051 431 06
Property owner(s) Waldo Holden Day phone 854-8577
Mailing address 16241 Parkview Drive
Site address 16241 Parkview Drive
Legal description (Sub'd., Block & Lot) Cottonwood Heights Block 2 Lot 6
Legal description (Township, Range & Section)
Lot Size 47,480 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field ❑ Initial ❑ Single Family (SF) ❑
Septic Tank ❑ Upgrade ❑ (w/wo ADU)
Duplex (D) ❑
Holding Tank ❑ Renewal ❑
Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well n
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.
C&M Engineering
(Signature of property owner or authorized agent)
Permit/Rush Fees: o7a.`J�I Waiver Fees:
Date of Payment: I/LI6 (q Date of Payment:
Receipt Number: (1210C)0 Receipt Number:
Permit No. 05 P/91030 Waiver No.
G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
C&M ENGINEERING SERVICES
Ph: 907-854-5558
Municipality of Anchorage
Onsite Water & Wastewater Program
4700 Elmore Rd Anchorage, Ak 99507
04/03/2019
RE: Proposed Septic System Modification for Cottonwood Heights Block 2 Lot 6
Dear Reviewer,
The above referenced property is currently served by an older 3 bedroom septic system. The 1000 gallon
tank has failed and is in need of immediate replacement.
We are proposing that the existing tank be replaced with a new 1250 gallon (minimum) tank constructed
and installed in accordance with MOA requirements. A polyethylene or advanced coated tank is
recommended.
As shown on the plan, the tank will be greater than 10’ from the house foundation.
The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover.
The repair shall be performed by a moa certified installer in accordance with MOA requirements.
The engineer will inspect the tank before backfilling.
Repair of the proposed system will not negatively impact adjacent lots.
Upon completion of the installation, a record drawing will be submitted showing the location of the new
tank, leachfield, well, and other applicable features.
Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854-
5558 or by email cgbalzarini@gmail.com with any questions or concerns.
Sincerely,
Charles Balzarini, PE (04/03/19)
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191080, Deb Wockenfuss, 04/11/19
Municipality of Anchorage Page of
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: PID Number: 051 — D(O
Name: ` Y ,7
►v
Wastewater System: ElNew L1Upgrade
Address:�Or �JO ���G`
ABSORPTION FIELD
Phone:
Phone:
No. of Be rooms:
70
Deep Trench ❑Shallow Trench ❑Bed ❑Mound ❑Other
LEGALDESCRIPTION
DESCRIPTION
Soil Rating: p�� �
6e 6ZPD/S
Total Depth from original grade:
10'
-A . Ft.
Lot: Block: Subdivision: //
Depth to pipe bottom frorrYorigina grade:
f
Gravel depth beneath pipe
c�
Ft.
Ft.
Township:
Range: �\ , '
Section:
Fill added above original grade:
Gravel length:
�
Ft.
Ft.
WELL: ❑New Upgrade
Gravel width:
Number of lines:
I
Distancebetweenlines:
I
Ft.
Ft.
Classification (Private, A,B,C):
Total Depth:
I
Cased To:
To:
1
Total absor ton area: to
�O�
Pipe material: a
���� ��.
OO Ft.
J Ft.
SQ. Ft.
- ( �t
Driller:
M -W
Date Drilled:
LZ.3O
Static Water Level:
l3
Installer. \�
1�( �
Date installed:
�-r _T5
• S
Ft.
Yield:Pump
14,GPM
Set at:
Casing Height Above Ground:
TANK
1 (0� Ft.
Ft.
SEPARATION DISTANCES
Septic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption Lift
Holding
Public/Private
Manufacturer: ?435 7
�9�ir.�+�'�
Capacity in gallons: ��O
From
Tank
Field Station
Tank
Sewer Lines
Well
' 5t)
tav� R/A
�t /l
`/°�(-'`,
;IIA
'4�l
Material: ►n 8_V�
Number of Compartments:
Surface
�DD�.
Nlti
11
[
t
LIFT STATION ►.ilk.
Water
C�c.t/ `
Com/
6
Lot
/JO f
, /X
Size in gallons:
Manufacturer:
Line
Foundation
Z"J�� 5
,�i1V71h`
3?j,5` x
N
/ A
"Pump on" level at:
"Pump off' level at:
High water alarm at:
Curtain
r 1
IV
Pump Make & Model
Electrical Inspections performed by:
Drain
Remarks:
BENCH MARK
Location and Description:
Assumed Elevation:
Ft
ENGIN)kER.'.S SEAL
4V Goo 00
or 62 ° ; ;
®8®
49 T o
Inspections performed by: Dates: 1st
°Ds'°°°°eeeaa-pppff°O
�O B
2nd
G°°� °®. o�°°°°voe°o° mo
AZ
®� a J. David Norton o
Department of Health and Human Services approval
�o CE 6253 0 10
�B�e9op�°cppe°�"9010 ��
See `tqZ C051� YZf2AIM( , 7��"W
ROFESSI���,
Reviewed and approved by: Date:
�R
72-013 (Rev. 9/91) MOA 25
Permit No
Page of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650-0 Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: U)T �,, BLOCK 2 C070tQ \ 00D {-I EIl�NI' ID No.: 00:51- 431 " Ola
Q
4 i
�4�
Q i
I
I iw
I NN
L
j I .J
WATER Ulf e °
ITRENGN T`f PE
DRla.IN FI'�L.1�
I'
1500 CAL, 5EP1"1C
TANK I ENC
'4&rt EAL
AW
.�►
Ey, ISTIN& MOD
FRAME HOUSE000090000000 of
ova RHA>`1G/ ��Se J. David Norton
3P�' ite J'�'• CE 6253'010 �®
• . 0*0 AV
QCs
RHA, N6 ( *`,t�OFES
72-013 A (Rev. 9/91) MOA 25
I'ii�,M1T No. MAGE OF
I
I
I
I
2
i
SEE Dr=TAIL"A
ATC'ACHED -7
yG✓�w Asa 38' I
zee\
28
SEPTIC SITE PLAN F09 f
LOT G 5LK 2., C,oT 0w\M00Q M I�HTS SUgD.
LOCATF—P WITHIN SEC,29, T,ISN, F� IVI, S.M.
MUWCIPkLIT"f GRIP NW 15G
DATE: 12.-10-92- SCALE: 111=G0'
PRAWN PAY ; J,C, WK -,W e TROWEL DRA'FTIW&
®F At ®�
� C,2 e 9 �®
izbootee, of
•e..•a•••••s••°e •• ,
* tate
J. David Norton
CE 6253Op
a• ��®
A 0 Ef E GEOTECHNI CAL & DEVELOPMENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694.2774 or 688-2280
Russell ovster Earl Ellis
6942774 SOIL LOG 688-2280
Soils Et Foundations Land Development
Performed for: Name: Tel . No.
Mailing Address:./ -f -0-,6,=x 5;.r4d7
legal Description: La'r 6, &Y-& 2, 60; 7--cfi KIC60
Depth (feetl_ foil Characteristics
0
T 10,Al
1
2
3
4
5.
6
- "V
8
9
10
12
13
14 &0 - '7 7A9 47,4— lv6z-67
15 RECEIVED
16
DEC 10 1992
Municipality of Anchorage
Ground Water Encountered: Yes No, l" If yes s what depth,_ t' Health & Human Services
Proposed Installation: Seepage Pit Drain Field
Comments
L1117Performed by: �,/! I % ,/, �� Date: 7
M -W DRILLING, Inc.
P.O. Box 10-378 • 10300 Old Seward Highway
(907) 349-8535
ANCHORAGE, ALASKA 99511
DRILLING LOG
Well Owner TERRY JORGENSEN Use of Well Domestic
Location (address of: Township, Range, Section, if known; or distance main road_
Lot 6, Block 2 Cottonwood Hts., ChuAiak
r
Size of casing 6" Depth of Hole 160 feet Cased to.,. 159 feet
Static water level 134 ft, ( (below) land surface. Finish of well (check one) open end ( XXX ;
Screen ( ) ; Perforated
Describe screen or perforation None
Well pumping test at 10 gallons per (MIRL) (minute) for—1 hours with 100% ,
of drawdown from static level.
Date of completion np r Lzmher 30 1983
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
-a—TO 2
-2—TO 2 3
?a—TO—r 77
27 TO 81
81 TO 123
123 TO 135
135 TO 141
___L4_ _-TO 150
150 TOS
TO
TO
TO
—TO-
O
-TO-
TO
0
0
Gravelly Clan
1 —CUSTOMER
C:) F-_ r-4 0-4 �F H H_ lE_
DEPARTMENT L HEALTH HND ENVIRONMENTAL . .OTECTION
- 825 'L' STREET, ANCHORAGE, HK 99501
264-472(,--1
PERMIT NO. ( 811182 )
APPLICANT JAMES TERRY JORGENSEN
LOCATION ER
LEGAL LT 6 BLK 2 COTTONWOOD SID
PO BX 329 CHUGIFIK 19 cq ch q 1(1 688-2237
LOT SIZE 45000 SQUARE FEET
MINIMUM DISTANCE BETWEEN H WELL HND ANY ON—SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE 15 25 FEET AND
TO H COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
K K IT! lvl I -T- ��Flr4;?E="v ����PlE3EEFF_'."
'I CERTIFY THAT
\`1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELLS AS SET
� FORTH BY THE MUNICIPALITY OF ANCHORAGE.
�
. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
SIGNED:
........................................
CH JAMES TE
�
M -W DRILLING, Inc. MVN|c|p4ca(o�Awc"ge^Gc
� p.o.Box ^-lc/o ° /3locInternational Airport nq9E�T. o1 x�;! u
�
(907)274-4611ENV! Rom';Vcx��
' xmcnDnxsE. ALASKA 99509
DRILLING LOG
Well Owner-
I.ocubou <uddroxo of: Township, Range, Section, if known; or 8ixtuucc ouubn zo
Depth o{ Bole foet (�uuo6to____-__-_-feot
Size of cuaiug-__-L�__ ap
Stotic water level -_______ft. (above) (below) land surface. Finish of well (check one) open end ( )�
Screen ( Perforated ( ).
Describe screen or porforuti --
.nll pumping test ut_____-guDouu per (hour) (minute) Yor-_--____'huurm with t
of druvv6ovru from static level. /\
o�+
Date of completion
Depth bufeet from
ground surloce
'___-�__-�0-------'
�
TO-
TO-
-TO-
TO------
TO-
WELL LOG
Give details of formations penetrated,
O-_----'TO__----
__-TO_-----
GhedatuJanfformatiuoapeuetcate6' size of material, color and hardness
�
«.
0
Municipality of Anchorage o
Development Services Department 1211110 -1
Building Safety Division .:
On -Site Water and Wastewater Program `
4700 Bragaw Street "
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051431-1)62 COSA # 0`4 OL416
Expiration Date: 3— 19-09
1. GENERAL INFORMATION
Complete legal description 1^_ O 7- Mo R I kYlyd Q drS BL -O Ck, 0 L a 7-C
Location (site address) 1C -2W 1 211,6 , 12—WL/ 6'1,1+k--
Current Property owner(s) _5 TF�%'/i�A) F5i21 a iC.•W Day phone 6941'4C 5"2
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
1_
Day phone
Dayphone Zdy—/930
TYPE OF WASTEWATER DISPOSAL:
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineers work.
Individual On-site
,B
❑
Individual Holding tank
❑
❑
Community On-site
❑
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineers work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below. I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system Is(are) in compliance with all applicable Municipal and Stale codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm A/es i- 1 A %zip, z5,24
AddressE2 Sot -77 7.2y
Engineer's Printed Name S%Et/E Ea_JC
5. DSD SIGNATURE
_AZ Approved for _: bedrooms.
Disapproved.
Phone .PU- 7 ce 6
Date
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: 14 Original Certificate Date:--/ 7
VRw. I IM51
Municipality of Anchorage "
Development Services Department '
Building Safety Division <
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 198850
Anchorage, AK 99519-8850
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:0.6 LAnLaoJ *S 62 L,g- Parcel ID: 6_52— !A 3 /.� 0 G
A. WELL DATA
Well type —?— If A, B, or C provide PWSID # _
Date completed N30/�3 Sanitary seal (YM) 4
Total depth �ft. Cased to _LELft.
FROM WELL LOG
Date of test /Z/Jo Z d3
Static water level
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform —0_colonies/100 mL Nitrate "M91L
Arsenic: OIL", 4W Date of sample:/! 27 0 7
B. SEPTICIHOLDING TANK DATA
Well Log (YM)
Wires properly protected (Y/N)
Casing height (above ground) _in.
AT INSPECTION
! ? 07
S g.p.m.
Other bacteria d colonies/100 mL
Collected by:w- .t
Tank TypelMaterial ANC, r axrL Irr'e Date installed o%2111)
Tank size gal. Number of Compartments Z Cleanouts (Y/N)
� N
Foundation cleanout (Y/N)Y Depression over tan -k (YIN) � High water alarm (Y/N)
Date of pumping 511,&? Pumper _.1%Z f
C. ABSORPTION FIELD DATA
Date installed /'0� 7- 8 Soil rating (9*A-#f2ft2/bdrm) Ps System type T%z�CH
Length � 3 ft. Width y ft. Gravel below pipe 6 ft.
Total depth/0 ft. Eff. absorption areas4(5 ft2 Monitoring tube ,- Depression over field N
Date of adequacy lest Z 7/07 Results (Pass/Fail) ?,*" For 3 bedrooms
Fluid depth in absorption field before test 0 In. Water added gal. New depth -Z_ in.
Elapsed Time:, min. Final fluid depth _0 in. Absorption rate >= .SO 0 g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) _ r/^/!C If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
'Pump on' Iev t _ in. `Pump off"X at _ in. High water alar vel at in.
Datum Cycles t ed Meets a & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:'R
Septic tank/lift station on lot
Absorption field on tot /00 "7'
Public sewer main 64
i
Sewer /septic service line lead t
Animal containment areas /OD �4
On adjacent lots 1D0 /f'
On adjacent lots -1-/J 6'f
Public sewer manhole/cleanout AV -,4 -
Holding tank 1,1414
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
/ r
Building foundation 'f' Property line l—rf Absorption field S `
Water main Water service line Id rt Surface water d o f
Wells on adjacent lots /d d rt
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ZO v?�" Building foundation zS rr Water main Nlo'`f
r
Water Service line ea/ v')4 Surface water /a �i �f Driveway, parking/vehicle storage Zf �
Curtain drain tiI✓K Wells on adjacent lots ed'f
F. COMMENTS
G. ENGINEER'S CERTIFICATION .�E•OF
I certify that I have determined through held inspections and���ps�y all,
review of Municipal records that the above systems are in /
conformance with MOA COSA guidelines in effect on this date. are..
Engineer's Printed Name QST G C+U� d, nit: Steven W. Erg
s�. PE 6:56
Date $ F9� '�•... .
COSA Fee $ 3t� Waiver Fee $
Dale of Payment %? O % Date of Payment
Receipt Number 103D�c1 Receipt Number
(Rev. 11/05)
WELL IJEcosKr�ISr�ou�Q a�
/ WELL ~
/ JO
2.0' X 28.3'
CANT
1Rl—
WOOD
RES] NC
7.9' X 6.7'
SHED
LOT 5
/ WELL
LOT 6
1.09 ACRES
GRAVEL.
DRIVE
SEPTIC /
OUTS-(\�
10�
SERVICE
4J42
X 4.7'
CANT
x I
1
PATIO + I
X 16.1' 1
+
DECK J1
+
HAINUNK I
FENCE
y
F
0
10' UTILITY
EASEMANT
PLOT PLAN _ AS BUILT X SCALE 1' --50' GRID NW 756 Project No. 07-213
Lan &Associates t InC. 11500 Daryl Avenue, Anchorage. Alaska
9 (907) 522-6476 Phone
Registered Land Surveyors (907) 522-4625 Fox
kglanglsOalaska.net / jclonglsOalasko.net
I hereby certify that 1 have surveyed the following described property:
LOT 6, BLOCK 2, COTTONWOOD HEIGHTS SUBDIVISION (PLAT No.71-291)
Anchorage Recording District, Alaska, and that the Improvements sifuat thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
no Improvements on the property lying adjacent thereto encroach on the surveyed
promises and that there are no roadways, transmission lines or other visible
easements on sold property except as Indicated hereon.
Dated this the tR Day of DQ,m..r=,ra-- _, 704 , at Anchorage, Alaska
99515-3049
H Is the responsibility of the owner to determins the existence of any easements, 'Vppo�o '
covenants. or restrictions which do not aoaear an the rennrrleA enh,adwtnn MM
Dec 19 07 08:03a
axvr oa
taus t eie -
Jim Sullivan
907
ARCTIC PUMP & WELL INC.
Jim Sullivan
PO Box 770197
Eagle River, AK 99577
(907)688-2510
(907) 258-2510
arwavci net
Pump Installation Log
Well Drilling Permit Number: SW
Parcel Identification Number:
Date of Issue:
Leal Description:Cotiouicood ZITS Property Owner Name R Address:
Loeb Remax Of H.gIe Ricer
Block:2
Pump Installation Date: 12/19/2007
Pump Intake Depth Below Top of Well Casing: Feet
Pump Manufacturer's Name: Pump Model:
Pump Size: hp
Pitless Adapter Burial Depth: feet
Pitless Adapter Ihlanufaeturer's Name:
Pitless Adapter Installer: Arctic Pump & Well, Inc.
Well Disinfected Upon Completion? Yes
Method of Disinfection: Chlorine
Comments:
Well permanently decommissioned by procedure I 5.55.060L.c.
Pump Installer Name:
Arctic Pump & Well, Inc.
Arctic Pump & Well, Inc.
Pagel of
P.1
Municipality of Anchorage
/-
Development Services Department
Building Safety Division
Onsite Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. bsl-y31-ur HAA# b5Q3-4G
Expiration Date: I / — Is—os-
1.
$—DS
1. GENERAL INFORMATION
Complete legal description Lot 6, Block 2, Cottonwood Heights Subdivision
Location (site address or directions) 16241 Parksville Drive, Chugiak, Alaska
Current Property owner(s) James and Lynda Jorgensen Day phone 696-7037
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone
Audrey Mason Day phone 694-4200,242-77T7
16600 Centerfield Dr., #201. Eagle River, Alaska 99577
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
El
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
El
Individual Holding tank
❑
Community On-site
❑
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 engineers 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 Firm Douglas T. Kenley Phone (907) 746-1073
Address 9960 E. Puffin Dr., Palmer, Alaska 99645
Engineer's Printed Name Douglas T. Kenley Dater
1 OF
i •. 1LR
9(
.........
5. DSD SIGNATURE I' CE8175
Approved for 3 bedrooms.
Disapproved. ��! ••
�.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: Original Certificate Date:S�8— o y
(Rw 01102)
Municipality of Anchorage
• �` �, Development Services Department
Building Safety Division
On -Ste Water 8 Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 995196650
www.muni.orgionske
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 8 Block 2 Cottorevood Heights Subdivision Parcel ID: (9 s—/- y 3 / - 0&
A. WELL DATA
Well type P^" If A. B, or C provide PWSID # _
Date completed " Sanitary seal (Y/N) Y
Total depth 190 ft. Cased to 159 ft.
FROM WELL LOG
Date of teat 12/30/83
Static water level 134 R.
Well production 10 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate 3.39 mg.A.
Arsenic: WA mg.A. Date of sample: 7-24106
B. SEPTICIHOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL
Tank size 1500 gal. Number of Compartments 2
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 27 In.
AT INSPECTION
7/24105
134.8 ft.
4.7 g.p.m.
Other bacteria 0 oolonies/100 ml.
Collected by: FRED KENLEY
Date instaaed 10/78
Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y' Depression over tank (YIN) N High water alarm (YIN) WA
Date of pumping 10/16104 Pumper SANITARY PUMPERS
C. ABSORPTION FIELD DATA
Date installed 10178 Soil rating (g.p.d.W or fe/bdrm)SS System type TRENCH
Length 456* R. Width 4 ft. Gravel below pipe 6 ft.
Total depth 510 R. ER. absorption area540 R2 Monitoring tube Y«� Depression over held
Date of adequacy test 724/05 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test o in. Water added525 gal. New depth In.
Elapsed Time: 70 min. Final fluid depth u in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N 8 type) N If yes, give date —
D. LIFT STATION
Date installed
'Pump on' level at _ In.
Size in gallons Manhole/Accew (YIN)
Pumpofr _a%vra r alarm level at
Cycles tested Meeh alarm 8 circuit requirements?
In.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank -lift station on lot 153+ FT On adjacent lots 100+ FT
Absorption field on lot 108+ FT On adjacent lots 100• FT
Public sewer main N/A Pudic sewer manhole/cleanout N/A
Sewer /septic service line 25+ FT Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 22+ FT Property line 104 FT Absorption field 10 FT**
Water main N/A Water service line 25+ FT Surface water 100+ FT
Wells on adjacent lots 100+ FT
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10 FT Building foundation 33+ FT Water main N/A
Water Service line 25+ FT Surface water 100+ FT Driveway, parking/"hide smrage 35+ FT
Curtain drain NOm a'O'n Io exist Wells on adjacent lots 100+ It
F. COMMENTS
'Foundation dean -out Is Imide the house; ••Fran previous Inspection report & HAA; ***anew 1.1Q" MT Installed 7/12105.
G. ENGINEER'S CERTIFICATION
1 cerW that I have determined through field inspections and
review of Municipal records that the above systems are in
oontormance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Douglas T. Kenley
Date 10-1-05—
HAA
-1-0S
HAA Fee 11 Waiver Fee S _
Date of Paymentf'2��'� Date of Payment
Receipt Number Receipt Number
(Rev. 121(11)
PERMIT No.
PAGE of
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1
MUNICIPALITY OF ANCHORAGE
• '� DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I. D. # 0'r/ -L43 1 —0 �` HAA # Q-� 1r, -) `)
1. GENERAL INFORMATION
Complete legal description•? �, 61 .�w �• C-te�
Location (site address or directions)
Property ownerJc,:Day phone 6F1�
Mailing address 1",�J, 4>0x -SL`/ C, __rrlIi�fc- It<
Lending agency �io,�vv<<n( 9;014.-z_ Z!& 2 Day phone ?527-34-1.31-1
Mailing address Pry. Qom 16!76zS Ahj'i 4L ` 5t-ki zs '
Agent - az� 04Day phone ?gZy
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. 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.
4. 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.
72-025 (Rev. 1/91) Front MOA #21
S. 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 furtherverify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
. p �O of30
Name of Firm R'� t Phone Z(°`S
Address 8 ,5� Z A, l4 0044 C, A 99 Sol
Engineer's signature
6. DHHS SIGNATURE
X Approved for
Disapproved.
Conditional approval for
Additional Comments
By:
bedrooms.
11 ITIC
Date 1 I
/2. /C) z
ttOF A
•.� p
k� ••a0 000 �4
a
• 0
A,MTtu i''
gym. ji-M__ 4�i
CB 453
�'$►4W
bedrooms, with the following stipulations:
Date Z- 11
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their tending 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
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: IALIJ Parcel I.D. OS/ -/ 31-G4
e,s _S/10
A. WELL DATA
Well type®M�If A, B, or C, attach ADEC letter. ADEC water system number
Wj,b_ ►a13e)�l3 1'I/I'
Log present (Y/N) Date completed Driller v kJ
Total depth Cased to 1 1 Casing height t
Sanitary seal (Y/N) TCS Wires properly protected (Y/N)
m
FROM WELL LOG C AT INSPECTION
i l z3 1
�6� - rl t!5 o z
Date of test
�
j it M m
Static water level f 0 r3 rl rQ
/IM y O
Well flow "( �� g.p.m. 1-11.5 9.11 �o � z
Pump level z�� m r`v N o
® <
SEPARATION DISTANCES FROM WELL TO:`n m
0
Septic/holding tank on lot �2 � � ; On adjacent lots
Absorption field on lot On adjacent lots -
Public sewer main i�!)� Public sewer manhole/cleanout
Sewer service line Petroleum tank
WATER SAMPLE RESULTS:
Coliform Nitrate Other bacteria
Date of sample: Collected by: �°�iw�s►s-�.J jMltT'fJ s GM �K4*(
a v�J
B. SEPTIC/HOLDING TANK DATA
Date installed hL ���%8 Tank size �SQ� C4,* Compartments Z
Cleanouts(Y/N) Ve-5 oundation cleanout (Y/N) Nrn S Depression (Y/N)
High waier alarm (Y/N.) Alarm tested (Y/N) A16
1
Date of •pum.ping hi J Z Pumper J /2S
,� JT T
SEPARATON DISTANCES FROM. SEPTIC/HOLDING TANK TO:
Wells) on lot- I On adjacent lots Foundation
f!
To property line �d Absorption field 16 Water main/service line
Surface water/drainage A0
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION f
Date installed Manufacturer
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
Manhole/Access (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
On adjacent lots
"Pump off" level at
Cycles tested
Date installed / Soil rating'&l#-T-( CirA hz�
b
Length Width y Gravgl thickness—
�
_ Surface water
8�
System type
Total depth �� r
Total absorption area T1.
Cleanouts present (Y/N) I
Depression over field (Y/N) Mo Date of adequacy test 1 be t w_
Results (pass/fail) Auss for _'__3 bedrooms
Peroxide treatment (past 12 months) (Y/N) Aho If yes, give date AJ/
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot On adjacent lots %l9 r
) �/� Property line
To building foundation To existing or abandoned system on lot
On adjacent lots Cutbank Water main/service line
Surface water Driveway, parking/vehicle storage area
Curtain drain A)t.
lfa'
'E. ENGINEER'S CERTIFICATION
1 certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
OF 4�.q,�®g
Signature • 'y
i
Engineer's Nametooled
J '�• �Oo'', ®""�" •""'•*"•.
Date ; J. DWA Noma+ v,®
CE 623300 1000
0 • a4'�
HAA Fee $ / %V ° CTV
Date of Payment //— z' `~g z---
Receipt Number 71,P)
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number