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Home My WebLink AboutALPINE VILLAGE BLK 3 LT 10PERMIT NO. DEP~RTMENT~ HE~LTH fiND ENVIRONMENT~L ;OTECTION 825 'E' STREET, flNCHORflGE, RK. 99581 264-4720 [.~ELL F'EF:~-I IT ( 8~029~ ) RF'PLICRNT LOCRTION LEGRL COLONY BUILDERS INC LiO B3 RLPINE VILLRGE 1407 W 4?TH #2 99503 LOT SIZE 562-53~9 999999 SQURRE FEET 'MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS ±00 FEET FOR 8 PRIVRTE WELL OR ±50 TO 200 FEET FROM R PUBLIC WELL DEPENDING ~ UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTRNCE FROM ~ PRIV8TE WELL TO 8 PRIV8TE SEWER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. i WELL LOGS 8RE REQUIRED 8ND MUST BE RETURNED TO THE DEPRRTMENT WITHIN 30 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS M8Y 8PPLY. SPECIFIC8TIONS 8ND CONSTRUCTION DIRGRRMS RRE RVRIL~BLE TO INSURE PROPER INSTBLLBTION. F' E E: f-1 I T' E ::-=: P I F.: E $ [:, E C: E r-1 E: E F.: _~'-: :L .. 2L L:~. :_=.: _--< I CERTIFY THBT t: I RM FRMIL. IRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS 8ND HELLS RS SET FORTH BY THE MUNICIPBLITY OF 8NCHOR8GE. 2: I WILL INSTBLL THE SYSTEM IN 8CCORDBNCE WITH THE CODES. SIGNED: RPPLICRNT COLONY BUILDERS INC I :,.=,LtE[., BY_ V4. 0 MUNU LUTYOF HCHORGE n � 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. 014-133-28-000 Legal description ALPINE VILLAGE BLK 3 LT 10 Site address 7341 BASEL ST Anchorage AK 99507 Current property owner(s) KRIZMAN WILLIAM A Expiration Date: 9/14/2023 X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 6/14/2023 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 MUMMPAUTY OF ANCHORAGE Development Services Department - ' 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. 014-133-28 Complete legal description Alpine Village Block 3 Lot 10 Location (Site address) 7341 Basel Street, Anchorage, AK 99507 Current property owner(s)William Krizman 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone (907) 565-9787 3. TYPE OF WATER SUPPLY: ®❑ Private Well ❑ Private Well serving 2 dwelling 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 C TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age - See advisory if 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide T nre 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 $ P Waiver Fee $ Date of Payment Lt to-- _ Date of Payment COSA # 0 S C % -�, l 19 0 Waiver # COSA Application—June 2022 Legal Description: Alpine Village Block 3 Lot 10 Parcel ID: 014-133-28 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) Date drilled 6/2/83 Total depth 120 ft Cased to 120 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA 6/6/23 Static water level at beginning of test 22.3 ft. Comments B. TANK DATA 1Gtea ed operating fluid level in septic tank Date of pumping ❑ Required maintenance comp if AWWTS Comments: D. ABSORPTION FIELD DATA ich system tested (date installed) ❑ ALL s dpipes present per record drawing Total measured from grade ft (max) Measured depth to pipe inv doe grade ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulate . ❑ 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 N/A gallons N/A date Any rejuvenation treatment (past 12 months) N/A If yes, enter date Well production at time of test 5.4 gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate 0.669 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by Forge Engineering Date 5/24/23 C. LIFT STATION LJe fired maintenance completed Age of lift station years Lift station material Comments: 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 orption rate > gpd FIELD S US — POST RECOVERY Effective depth (p ecord drawings) in Effective depth used Effective depth remaining in Comments/Deficiencies: Property is Served by city Sewer. COSA Checklist June 2022 E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) ❑ Yes Septic Tank/Lift Station on Lot > 100' F-1 Yes if No NSA ft Community Sewer Manhole/Cleanout > 100' if No ft Field to Property Line? 10' 0 Yes if No ft Neighboring Tank > 100' ❑ Yes if No NSA ft Private Sewer/Septic Line > 25' ❑ Yes if No 19' ft Absorption Field on Lot > 100' ❑ Yes if No NSA ft Holding Tank > 100' 0 Yes if No ft Neighboring Absorption Fields > 100' NSA Animal Containment > 50' Q Yes if No ft ❑ Yes if No ft Community Sewer Main > 75' Yes if No ft Manure/Animal Excreta Storage > 100' ❑ 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) BuUdin_g Foundations > 10' ❑ Yes if No ft Tank to Property Line --1 -----❑Yes if No ft Field to Property Line? 10' ❑Yes if No Water Main > 10' ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft F. ENGINEER'S COMMENTS #WR900018 Surface Water > 100' Wells on Adjacent Lots: Private Wells > 100' Community Wel'ss r, ❑ Yes if No ft ❑ Yes if No ft 2Y es if No ft 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 Forge Engineering Engineer's Printed Name COSA Checklist June 2022 Benjamin Schiller, P.E. Phone (907) 522-7773 Date 6/7/23 *:49TM •* ' BenjarrSchiller % CE 12592 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address"or dii'ectiO.ns) (b) Property owner'" ;~/)Z/,f~__, ,.';, Addi;ess Mailing . :~ '', , (c) Lending Id'st, it:~.t, jqn .... - ' Mailing Address ' ' Telephone · (home) Telephone Business (d) Real Estate Company and Agent Address ~_~d6 d'P~eY'e/¢v'e Telephone oZ'2~;---,.27¢ / (e) Mail the HAA to the following address: (or check here,J!~, if hold for pick up.) List contact person and day phone number below: TYPE OF RESIDENCE Single-Family [~ Number of bedrooms WATER SUPPLY Individual Well,j~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. SEWAGE DISPOSAL ,_ On-site [] Public/~' Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional end adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm .,~"-~J" ~ Telephone Address /¢) ~ ~o.6~ /~c~ c/?j-.,~y,_ Approved for c,4 bedrooms/.~-~'/~~ Approved [,~"""'~D i sa p pro ved Conditional Terms of Conditional Approval Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph 5 above by an independentprofessional 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. 7/88) Back Page 2 of 2 A. WELL DATA Well Classification Well Log Present (~N) Total Depth /?..O i MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) .¥~C.~, F~I~[-EI~-~!~BRUARY 1984 ~CtPAL~ ' ~ ~ ' .~ ~,[. S~_~.V ~c~-S ~ ~44 Legal De~oription: D~te Oompleted ~/~ Oased to /~ Depth of Grouting If A, B, C, D.E.C. Approved (Y/N) Yield $'~.~.~,'~. Static Water Level /5" ~ Casing Height Above Ground ,/ Electrical Wiring in Condu t~N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot ! Pump Set At Sanitary Seal on CasingS) Depression Around Wellhead (Y~) ;On Adjoining Lots A///~ ; On Adjoining Lots To Nearest Public Sewer Line ,~-/" To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments t~.~.~ ¢...~?z_ To Nearest Public Sewer Cleanout/Manhole /?~ ;Date B. SEPTIC/HOLDING TANK DATA Date Installed Size No. of Compartments StandPipes (Y/N) Air-tight Caps (Y/N) Founda~(Y/N) Depression over Tank (Y/N) ______ Date Last Pu_,,.~d _ __ Pumping/Maintenan.ce Contact on File (Y/N) ~ Holding ,Tank High-Water Alarm (Y/N) ____ T~a115orary~Holding Tank Permit (Y/N) SEPARATION' DISTANCES FRoM SEPTIC/H~I.~G TANK: To W~ater-Supply Well ~.-. ..-" To Building Foundation To Property Line ' To Water Main/Service To Stream, Pond,.~.~? Major Drainage Course Com men.~", . To Disposal Field 72-026 (Rev. 7/88) Front Page 10 fr 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Type of System Design __ Length of Field Depth of Field __ Gravel Bed Thickness Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION Statnd (Y/N) Dat, Adequacy Test To Water-Supply Well To Building Foundation Lot To Water Main/Service To Stream, Pond, Lak~ Major Drainage Course To Driveway, Par~ Area, or Vehicle Stor. age Area Comments / To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) D. LIFT STATION ~ Date Installed Size in Gallons ~_~.):anhole/Access (Y/N) "Pump On" Level at "Pump Off" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical~s (Y/N) Comments **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines MOA No. ~ 0/9 -OFT...- Receipt No. Date of Payment Amount: $ / s~i,a~e'W~-'~ta the date of this ~~h~tr's Seal f;:':::', Receipt No. Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 · (907) 561-5040 ! SHEET NO, CALCULATED BY CHECKED BY OF DATE SCALE PRODUCT204-1 ~l~, Croton. Ma'~ 01471. CHEMICAL & GEOLOGICAL'LABORATORIES OF ALASKA, INC. 5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343 FEDERAL TAX I,D. #92-0040440 Date Report P~in'ted: APE 30 90 ~ 10:29 Cti~nt Sample Ig:LIIJ, B9 ALPINE VILLkGE Co]l.~cted A~ 25 90 ~ i7:30 ~ec~v~d A?R 26 90 ~ 10:00 h~, P.~ese~ved with :AS REQUiRgD Client Nam~ : A E C S Cli~i~ Aect : AMECSRP ?.0.~ NO~[ ~ECEiVED O~d~red By : L. REID Ana].ysls Completed :AP~ 27 90 Send ~epo~t~ to; Laboratory Supe,;vi~ol~, ::~TEPHEN C. EDE 1)k E C S Speclal ) n~tIuct: Sh~,r~lab Bef ~: 901070 Lab Smpt I[:': ]. ~a~:i.×: WATZt~. ,~liow~b~, NIT{{A'~E.N ND(O, lO) mg/i EPA 353,2 16 S~',',pl e ~OUTINE 2A~%E ilmf,a~s: 5A}~?LC COLLECTED ~¥ L. ?J]!D. i~one D~tected "Se~ ~Jample Re~arks Above Not Analvze,~ L3'~ ~s~ Than, (;l',=Cze~ter Than CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.,.~ : TELEPHONE (907) 562-2343 5633 B Street · Anchorage, Alaska 99518 ~ Drinking Water Analysis Report for Total Coliform Bacteria . TO BE COMPLETEI~ BY WATER SUPPLIER [] PUBLIC WATER SYSTEM I.D.# I I' I I I I [] PRIVATE WATER SYSTEM ALASKA ENVIRONMENTAL Na,~eCONTROL SERVI(~,, ~NC. P. O. BOX 240668 Mailing Address ANCHORAGE, AK 99524-0668 State Zip Code Mo. Day Year City SAMPLE DATE: SAMPLE TYPE: /1~ Routine Check Sample (for routine sample with lab ref. no. .) . [] Special Purpose SAMPLE NO. LOCATION · [] Treated Water ~' Untreated Water Time Collected Collected By TO BE COMPLETED BY LABORATORY s YaSiS shows this Wate~ SAMPLE to be: tisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mall, Date Received Time Received Analytical Method: Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Result* Analyst READ INSTRUCTIONs BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD Membrafle Filter:. Direct Count (~ Verification: LTB BGB Final Membrane Filter Results Reported By ,~_.,~__ ~__~...~ _.~:~.. ~--~__o~..Date Time: / TNTC = Too Numberous To Count OB -- Other Bacteria Collform/100ml Collform/lOOml PART ONE OF TWO REMAINDER TO FOLLOW ACHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER [] PUBLIC WATER SYSTEM I.D.# ~ PRIVATE WATER SYSTEM Name Madin~ Address City SAMPLE DATE: 3---,00-1~; ? Phone No. $~ate Mo. Day Year Zip Code SAMPLE TYPE: Routine Check Sample (for routine sample with lab ref. no. [] Special Purpose .) [] Treated Water [] Untreated Water SAMPLE NO. . I . I LOCATION Time Collected Collected By TO BE COMPLETED BY LABORATORY tis shows this Water SAMPLE to, be: is factory [] Unsatisfactory [] sample too long in transit; sample should -,not'Be over 30 hours old at examination to indicate reliable results. Please send new'sample via special delivery mail. /F Time Received Analytical Method: Membrane Filter No. of colonies/100 mi. Lab kef. No. Result* FTq FTq FT5 Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Ti'4TC BACTERIOLOGICAL WATER ANALYSIS RECORD , Membrane Filter: Direct Count · C'"') Verification: LTB Final Membrane Filter Results Reported 8~ = Too l~'umberous To Count _BGB Date Time: ORE OF TWO REMAII',ff3ER TO ~'OLLOW' OB - Other Bacteria Collform/100ml Collform/lOOml aomo p.m.:. '1 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. FEDEFIAL TAX ID # g2.0040440 ANALYSIS REPORT BY SAMPLE for Work Order g 17515 Date Report Printed: OCT 18 89 @ 17:33 Client Sample ID:LT. gO BK. 3 ~L~INE VILLAGE PWSID :UA Collected OCT 13 89 ~ [4:30 hrs. Received OCT 13 89 @ iL:00 his. Preserved with :~S REQUIRED Analysis Completed :OCT 16 89 Client Name : CORWIN & ASSOC Client Acct: CORWINP P.O.~ NONE RECEIVED Ordered By : BRUCE CORWIN Send Reports to: Labozatory Supezvi~o: jSTEPHEN C. ED~ L)CORWIN & ASSOC Special Instruct: Chemlab Re£ ~: 8031 Lab.Smpl ID: 5 Matrix: WATER Allowable Parameter Tested Result/Units Method Limits NITRATE-N 0.18 ms/! EPA 353.2 Sample COLLECTED BY KRESS Remarks: i Tests Per£ormed See Special Instructions Above UA=Unavailable ND- None Detected "See Sample Remazks Above NAr Not Analyzed LT=Less Than, GT=Greater Than Municipality of Anchorage Department of Health and Human Services Tom Fink, 825 "L" Street Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 May 25, 1990 Lee Reid, P.E. Alaska Environmental Control Services, Inc. PO Box 240668 Anchorage, Alaska 99524-0668 Subject: Waiver Request for Lot 10 Block 3 Alpine Village S/D Waiver Request #WR900018, PID#014-133-18, HAA ~HA900191 Dear Mr. Reid: Your request for a waiver of the required 25 foot separation of a private well to private sewer line has been approved. The approved separation distance is 19 feet. This waiver approval applies to the existing well and private sewer line only. Any future upgrade will require all separation distances be met or another approval from this department. S ince~.e?ly, /~-~ Concur: ~/ ~ Robert W. Robinson ~J~n SmitH/, P.E. Civil Engineer P~ogram Manager On-site Services On-site Services RWR/ljm ALASKA FIUII OFIITI FITAL COnTI OL $ gUlC $, Inc. MuN/CIPAL/1Y 01= ANC~*bDRAGE ' E~qv~ONN~EN-[AL SERVICES D[VtSION P. O. Box 240668 Anchorage, AK 99524-0668 (907) 279-5553 *** FAX (907) 276-8706 May 18, 1990 RECEIVED Municipality of Anchorage Department of Health & Human Services 825 L Street, Fifth Floor Anchorage, AK 99501 RE: Lot 10, Block 3, Alpine Village Subdivision Application for Waiver On October 24, 1989, a Health Authority (HAA) was issued by the MOA showing the distance between the private sewer line and the private well at 25 feet. See attached. On April 25, 1990, I was asked by Alaska Housing Finance Corporation's agent to prepare a new HAA. I found that the cleanout for the private sewer is 19 feet from the well instead of 25 feet. The records at the AWWU indicate the private sewer was installed on May 18, 1983. The well was drilled on June 2, 1983. From the plot of the AWWU records it appears that the private sewer line is between 19 and 25 feet from the well. See sketch. Prior to January 1, 1983, there was no know separation requirement between a well and a private sewer line. The separation used was for any source of contamination which was 10 feet. The 1983 regulation requires 25 feet separation distance between a private well and a private sewer line. The ground slope is 11% from the house to Lucern Avenue. The sewer line is about 8 feet deep and is constructed of ductile iron pipe. The soils, from ground level to 69 feet deep, are "clay and gravel" There ts 2 gpm of water between 69-73 feet. The well is cased to 120 feet. This water source at 120 feet is a confined aquifer with sufficient head to raise the static water level to 15 feet below ground level. There is no evidence of upward leakage around the casing. The soils are dry. Because this well is artesian the work done by Le Grande is not applicable as he only addresses water table wells. Since the ADEC scoring system is based on water table wells, it is not applicable in this case. Bacteriological tests on October 13, 1989, and April 25, 1990, showed no coliform bacteria. The nitrates were 0.18 and Not Detected on the respective dates. The ductile iron pipes are generally sealed either with Tyseal joints or Romac type couplings which give watertight seals. Were the couplings to leak, the odds of penetration into the aquifer are nigh impossible as the aquifer is under pressure. Based on the ground slope of 11%, the flow would be downslope and parallel to the well. Probably it would be confined to the disturbed soil in the construction trench. For the flow through the ground to reach the we].] it would take about $6 years, See calculations. Therefore, based upon the evidence available, there would be no health danger occurring if the distance between the well and the private sewer line were to remain at 19 feet. It is therefore requested that the distance between the well and private sewer line be moved to 19 feet. LCR/sr ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ^LASKA 99503 (907) 561-5040 JOB SHEET NO. CALCULATED BY cHECKED BY SCA,E / '= 30 DATE DATE ! PROOUCT 2~4-1 ~ I~, GMS), a~ 01471. MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lOt, block, subdivision, section, township, range) Location (address or directions) (b) Property owner /~ Mailing Address (c) Lending Institution ~t//~ Mailing Address - / (d) Real Estate Company and Agent ~:~ ' '~(~' ~'~ r~ '~ ~: C Telephone · (home) Telephone Business Telephone (e) Mail the HAA to the following address: (or check here'~.'I,, if hold for pick up.) List contact person and day phone number below: 2, TYPE OF RESIDENCE Single-Family ~" Number of bedrooms -~ 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site [] Public~]" Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 ~ ,to ~; e6ed leAo~ddv leUO!1!Puoo ~,o swJ~.L leUO!t!puoo peAo~dd~s!O ~ peAo~ddv I~eS s,Jeeu!6u3 ,..~,~.\'~ . ~;~--~,,,' MUNICIPALITY OF ANCHORAGE (MOA) ~'~'i~.~.~'~'v~'.~ Health Authority Approval (HAA) ~°~' ~ ~ CHECKLIST - FEBRUARY 1984 (~.~ ~ '~ 343-4744 A. WELL DATA C assmcat on Well Log Present (Y/N) Y Date Completed ~/~ Total Depth ]~O~ Cased to ~' Depth of Grouting ~ ~.O~ ~ Static water Level /~ ~ Casing Height Above Ground /(~" ~ Electrical Wiring in Conduit (Y/N) Y' SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot N /~ / To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line 7~<,-' Legal Description: LOT !O ILl ~ AL P I H. E L LA(E If A, B, C, D.E.C. Approved (Y/N) Yield Pump Set At U'LI LI,!OG2Li Sanitary Seal on Casing (Y/N) y Depression Around Wellhead (Y/N) ~ · On Adjoining Lots ~/,~ ' / ~//~ ;On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments L-o~T -~'~,"v¢c./ / ;Date B, SEPTIC/HOLDING TANK DATA /A Date In, lied Size ~k~ ! No. of Compartments Standpip~k(Y/N) Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Depression ~r Tank (Y/N) .... Date Last Pumped _ PumPing/Maint'e~ance Contact on File.(Y/N) .... ; for Holding Tank High~ater Alarm (Y/N) ____ Temporary Holding Tank Permit (Y/N) SEPARATION DISTA'N~ES FROM SEPTIC/HOLDING TANK: To Water-Supply Well ~. To Building Foundation To Property Line 'X~ To Disposal Field To Water Main/Service Line ~ To Stream, Pond, Lake or Major Dra't~,age Course Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils RatiNn AbsorPtion Strata Type of System Design Date Installed~ Length of Field Width of Field ~ Depth of Field Gravel Bed Thickness Square Feet of Absorti~Area _ __ _ Statndpipes Present (Y/N) Depression over Field (Y%__ __ Date of Last Adequacy Test Results of Last Adequacy Te~ SEPARATION DISTANCE FROr~SORPTION FIELD: To Water-Supply Well ~ To Property Line __ To Building Foundation ',~ To Existing or Abandoned System on Lot ~ On Adjoining Lots To Water Main/Service Line To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Size in G_al.l.0ns . % "Pump_On" Level at % High Water Alarm Level at",,..,~ Tested for '~ ~l~erntr~ eMnOtsA Elect rical Cod es (Y/N) '~ Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitt~j~Bedroom/~/a. ting Against HAA Request** I certify that !/h/a~/b//~.t' ;cke~'~fied, or conformed to all MOA and' inspection. ///~,~,/~/,-.~.~z ................ Signed //// Company ~5/.>~¢'/.,~ /_//~?~'~ / ~ ~, Date MOA NO. 3es ~n effect on the date of this Receipt No. Waiver Fee: $ Date of Payment Engineer's Seal 72-028 (Rev. 7/88) Back Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria PRIVATE WATER SYSTEM Name Mailin~ Address City SAMPLE DATE: Phone No. State Zip Code Mo. Day Year SAMPLE TYPE: Routine Check Sample (for routine sample with lab ref. no. [] Special Purpose SAMPLE NO. LOCATION 2 I Ac-?t J - [] Treated Water CI Untreated Water Time Collected Collected By J. READ INSTRUCTIONS BEFORE COLLECTING SAMPLE TO BE COMPLETED BY LABORATORY SatiS shows this Water SAMPLE to be: isfactory [] Unsatisfactory [] Sar~ple too long in transit; sample should not'be over 30 hours old at examination to indicate reliable results. Please send new,sample via special delivery mail. Date Received [ D -/,.~--~ . Time Received / Analytical Method: Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Result* flTq I-I71 Analyst Membrane Filter: Direct Count ~ .Verification: LTB B~B 'Final Membrane Filter Results Repoded Time: pART ONE OF TV/O BIDER TO ~'OLLOW TNTC = Too Numberous To Count OB - Other Bacteria Collform/100ml CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ~"'~k 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order 8 17515 Date Report Printed: OCT 18 89 @ 17:33 Client Sample ID:LT. lO BK. PWSID :UA Collected OCT 13 89 @ 14:30 Received OCT 13 89 @ 15:00 Pzesexved with :AS REQUIRED 3 ALPINE VILLAGE '~' Client Name : CORWIN & ASSOC Client Acct: CORWINP h]:s. P.O.~ NONE RECEIVED ha:s. geq { O~dered By : BRUCE CORWlN Analysis Completed :OCT 16 89 Send Reports to: Labo~atozy Supez¥isoz ,:STEPHEN C. EDE _ 1)CORWIN & ASSOC ReleasedBy :~~~. ~ 2) Special Instzuct: Chemlab Ref ): 8031 Lab Smpl ID: 5 Matrix: WATER Allowable Parameter Tested Result/Units Method Limits NITRATE-N 0.18 mg/1 EPA 353.2 10 Sample COLLECTED BY KRESS Remaxks: 1 Tests Performed ' See Special Instructions Above UA=Unavailable ND- None Detected "See Sample Remarks Above NA= Not Analyzed LT=Less Than, GT=Greater Than APPLIC NT FILLS OUT UPPERHA ' ONLY Lending Institution ":) 1 '<' ~: [~ '~ ..... " Street Locati~ {~.,~ .. ~-,,. ..... Type of Resl~nce Single Family Multiple Family No. of Bedrooms ~ Other Water Supply Individual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975. r~ Community For wells drilled prior to that date, give well depth (attach log if available). ~ Public Utility Sewer Disposal ~' Public Utility ~ ~ When Connected to Public Utility: /~' Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspect(;~ /~ ......... v ~ ANCHO~E. Field ~U~l~r~" ' -' . ENVIrONMeNTAL pgoTECTION ~} APPROVED BEDHOO~8 'CONDITIONS OF APPHOVAL ( } DIGAPPHOVED ( ) CONDITIONAL APPROVAL* Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received Well to Tnnk Septic T~k Size 72-023 (3182) CHEMICAL & Gl LOGICAL LABORATORIES ? ALASKA', INC. -' TELEPHONE (9CJ~7) 562-2343 ANCHORAGE IN~US:I:RIAL CENTER_ '" . . :. /~ 5633 B S!r~et Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED:BY WATER SUPPLIER WATER SYSTEM: Water System Name NO. Mailing Address City Mo. Day .. SAMPLE TYPE: [] Routine [] Check Sample (for routine Umple with lab ref. no. [] Special Purpose Phone No. State Zip Code Year SAMPLE NO. 1 Time , Oolleoted LOCATION , COlteoted By Rev. 1978 TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: J~atisfactory [] Unsatisfactory [] Sample too.19ng n transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. Date Received ~/ ~:~ ~ / ~ 1' Time Received ./ ~,,"", i..~' ~_ Analytical Method: [] Fermentation Tube .J~Me~'brane Filter Lab Ref. No. Result* ,I *No of colomes/lO0 mi. os, No, of Positive portions. Analyst BACTERtOLOG ~AL WATER ANAL¥SI~ RECORD READ INSTRUCTIONS BEFORE COLLECTING SAM PLE Date Collect~l Source Data RKIIvIcl Time Received -- p.m. Lab. NO. I~'elumPt lye 10mi 10mi 10mi 10mi 10mi 1.0mi 0.1mi 24 Hours 48 Hours Confirmatory 24 Hours =' 48 Houri '~ EMB Broth 24 houri: .Multiple Tube Report: Membrane FIIter~ Direct Count Verification: LTB Final Membrane Filter Relplti Report. By <*~'.'~ Broth 48 houri: 10mi Tubes politlw/'rotal 1Omi Portions Coliform/lOOml BGB Collform/100ml ibm,