HomeMy WebLinkAboutBENITO BLK 2 LT 5��So-a`�a-o�
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BOX 337,0
PALNIER,`A',_ASKA 9%45 / YOUR P O NUMBER.' 1@
TELEPHONE 745-4071 s f S / •C= �, '
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DEPTH e.
rpt( f y i�CA31N ,'N IORMATIO IN FT. CASIIJ FORM. C10N IN FT. CA6INATION;
101 201
1 i ► 202
; 309=203:_
.. ' 204 , w• u, :,•,
104
i ....
a ..,106r:•2i
106 M w.r- 4Wn r.ww, '.
107 - 207 .. .«+tb►.
,ti 7 103 206 ww
t 6 . 109 209—
'-210—
__110—
_112-
09
110 210
1 10 ' 111 211 FS
t 11 112 212:1'
7t 1 ... 113 213
W p 16 -.1. 111 214
•' gg 16 . 11 b 216
116 216 u
217
7 f— p~ Ili 216 y
? 119 220
120 ...a .
221
y; 121 222-
222—
T7
22121 -
t. 1� 123 214
° ; K ff
1 226 a. ray
yir�? 3166 316 Z�
i22727
1126-
229
1 r.
—129--
-230-
9
129 229
y 230
30 130231
131 282 fC
y ua: 1 132 233
u
134 iss
;r 6.
6 iso _ 23a
d — 137 236
,9134
139 ��
140 240
241y
40. • • 141
41 142. r
242.. rte?+
✓c _ 42 —1-1 .
143 24i
246
246 P
146 247 •'-
1 ... ,., ... �'.;
249 —4
146 249-
-250--
160-
252--
12
49 — c ,
149 260' `
1b0
t 0 181 261 v h
r - 1 1 102 263--
-163-
254-
256'
63
I2
l d 103 264 .. �?
({ 206 1.
106
1� 2 j
e
e 107 Zai
(� ISO 2a9 Y 3
9 160 280 r
( 0 261
(1 1a4 — 262
�; (Z-163---283 < .
(1 264 ;t
(1 165---268 s ...`
(�--too--266 ;.
(i 167 287 i,...
l 1 16i_269-
-270--
--170-
271
289 1 't
Z69 �+
169 N
(i -170 270
1 -171_272--
-273
271 }
272 _j ; •'TM`iW
f'i t "171 a.
4 ' 173
276
174
Tti 174— 178 ZT6
T6 M6 27T'
76 -177
i. 77 27d
17 6 2
179. 280
r �' 7i -. 1d0III
—261-
-262-
1
y il: d2 "-�C
5 263
i3' AA 11 1dS 184- `A•:
63 194—
284
i�16a
ltd - 297 s..
M.
a7'. ld6 Z66 `
ld9 269 ? a
as. 190 290
W : 291 is
191 292 . +;
191
�1 293
�. 9d. 293
294
14 _ 198 196
r
90 296 a.
—19e
ii • o7 397 298 y'
+;# - 196
�r 96 199 299 u •.
k
TOTAL DEPTH OF WELL - FT.
FT.
PERFORATED DE PT.H -
;Z
A'.
Municipality of Anchorage,
AWW
Department of Health and Human Services
Tom Fink, 825 "L" Street
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
January 18, 1994
Lewis F. Crumb
17225 Big Horn Circle
Eagle River, Alaska 99577
Subject: Lot 5 Block 2 Benito Subdivision
Permit #SW930003, PID #050-272-07
CJI'1h5
The subject permit, issued January 14, 1993 by this office for a
single family well and/or on-site wastewater system, has
expired as of January 14, 1994.
A new permit must be obtained from this office for a well
and/or on-site wastewater system NOT installed by the
expiration date.
If you have drilled the well, a well log must be sent to
this office for documentation of the installation and to
close the permit.
If a licensed Professional Engineer has inspected the
installation of the on-site wastewater system, the original
as -built inspection report must be sent to this office for
review, approval and documentation. All inspection reports
must be submitted within 30 days of construction completion.
When applying for a new permit, the fees are: $320.00 for an
on-site wastewater permit; $120.00 for a well permit and
$440.00 for a combined on-site wastewater and well permit.
If you have any questi
Sin erely,
On-site
n Smith, P. E.
ogram M ager
S rvices
enc: Copy of Permit
s, please call this office at 343-4744.
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM PERMIT
PERMIT NUMBER:SW930003 DATE ISSUED: 1/14/93
DESIGN ENGINEER:DUMMY COMPANY EXPIRATION DATE: 1/14/94
OWNER NAME:CRUMB LEWIS F
OWNER ADDRESS:17226 BIG HORN CIR
EAGLE RIVER, AK 99577
PARCEL ID:05027207
LEGAL DESCRIPTION: BENITO BLK 2 LT 5
LOT SIZE: 27526 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
THE WELL MUST BE LOCATED OUTSIDE OF THE REQUIRED 100 FT.
SETBACK FRON THE SEWER MANHOLE IN THE CUL-DE-SAC, /
RECEIVED BY: -
DATE:
DATE:
ISSUED B, ':
Jan 12. 1993 04 : 35PM FROM ECRFLER COMPHN I ES
TEL No.9t7r-563-4418
111 219,r
Lot 5 Block 2 Benito Subdivision
To whom it may Wncerrl
1, Law CrUMb, am the owner of trot 5 Block 2 Banito SID.
TO 19073762103 P•02
Jan 12,93 16:03 No.009 P.02
I give perrrtission for a well and land use permit to be issuBd on the above tot to
Grandpre Custom Homes and ()ary Smith.
"inCerrly,,
-'Lew Co urnb
TT -4(,T.- I
by
a
M
LOT G
----
Sb�=5b�?fa"� 12b
u
?Rovesarr� w
0
0
Mr'
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\ t
� 2.ok14�S GNr
4z 4.L
432.0
• 1.5' Moor dvwwt..A
CT`(Ptae6.)
.✓_/� H &V -Sb'- ZS" W - 224.23
0
tT15M- roP oc SSV409- W
iAA.WROVL 6 - s1., 452 80
�f S!
Lo -r S
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O
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B
uo r a.
qyz 2
LoT 2 LOT 3
4.07.E MKtPTI Wo ZLW4, I.o U -nu r` F.As ��•tr
4o t 3 P(Zc� POs is p la-►.sv 5'curr� n� G Pst�-►� t r
PLOT PLAN X AS BUILT SCALE 1"� 4c�` GRID NW S2 JOB No. `�Z-Z3'L
lKsmastoa , Luz � G 1 George Bell Circle
a � a v Anchorage, Alaksa 99515 (907) 345-6476
I Hereby certify that I have surveyed the following described property: �����
Lot _5, Block 2 — E5I2M ITO S1J&21 V(S10{�I jam = C,']_ ,s�► .
;;
A&JQbCYJL�._ Recording District, Alaska, and that the improvements situated .`�,.� .; -,.?
thereon aro within the property lines and do not encroach onto the property
adjacent thereto; that no improvements on the property lying adjacent thereto AV te3 •••.M. w.>� • :►��
encroach on the surveyed premises and that there are no roadways, transmission 49
�r•rr•r•.%I•,•• .r• •..�•.•
linea or other visible easements on. said property except as indicated hereon. � � �
ti, O..r .. r ....,�
Dated this the �� Day of ��2, 19 93 , at Anchorage, Alaska Kennan Lang r
�,�•.• LS - 5202
Ar
It is the responsibility of the owner to determine the existence of any easements,�•.••••r..••»••
4F
covenants, or, restrictions which do not appear on the recorded subdivision plat. �� �40*'
• Municipality of Anchorage G �L'`z
On -Site Water and Wastewater Program rt
(907) 343-7904 s A E, r s
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 050-272-07
1. GENERAL INFORMATION
Complete legal description BENITO BLOCK 2, LOT 5
pe,a-s S v -e-
Expiration Date: 7- a a - /S
Location (site address) 17226 BIGHORN CIRCLE EAGLE RIVER, AK 99577'
Current Property owner(s) BRETT ROSS & STEFFANIE COUNTRYMAN Day phone
Mailing address
Real Estate Agent
16512 CHAROLETTE DAY DRIVE, LAPINE, OR 97739
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual
IZ
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
WaiverNariance request for:,
COSA to be released to the engineer, unless
COSA Fee
Date of Payment
Receipt Number
COSA# 0 5 Ci 1!4 L
Date:
Waiver Fee $
Date of Payment
Receipt Number
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.
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 4/17/2015
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 inland use, local soil characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system. 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, -
ArcTerra can not give any estimate of how long a _�`�
system will function satisfactory for current or future r O A \
occupants or can ArcTerra guarantee that no unseen v L
encroachments, deficiencies or discrepancies exist. *�'�.� ���
4�T tt
6. DSD SIGNATURE r -
-A KENNETH k. u4ee a/
System #1 Approved for bedrooms. , e $4' Air
System #2 Approved for bedrooms. 1 iD ° rE SfoN�
'Ae
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
OF
WATER AND
By: Original Certificate Date:
The ni ' lit of orage 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 blue sheet 10-10-12Am
If more than 1 septic system is on the lot:
COSA Checklist # of _
Structure served by this system _
Certificate of On -Site Systems Approval Checklist
Legal Description: BENITO BLOCK 2. LOT 5 Parcel ID: 050.27207
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID #
Date completed 3/911993 Sanitary seal (Y/N) Y
Total depth 90 ft. Cased to 90 ft.
FROM WELL LOG
Date of test 3/211993
Static water level 80 ft.
Well production 10 g.p.m.
WATER SAMPLE RESULTS:
))""
Colifornt colonies/100 mL Nitrate ?3 mg/L
Arsenic: AID ug/L Date of sample:
B. SEPTIC/HOLDING TANK DATA — PUBLIC SEWER
Tank Type/Material
Tank size _ gal. Number of Compartments
Foundation cleanout (Y/N) Depression over tank (YIN)
Date of pumping
C. ABSORPTION FIELD DATA
Pumper
Well Log (Y/N) N
Wires properly protected (Y/N) Y
Casing height (above ground) 24+ in.
AT INSPECTION
9/4/2014
ft.
8.2 9—
PIM-
Collected by: ARCTERRA
Date installed
Cieanouts (Y/N)
High water alarm (Y/N)
Date installed _ Soil rating (g.p.d.te or ft2/bdrm) _ System type
Length ft. Width ft. Gravel below pipe . ft.
Total depth ft. Eff. absorption area ft2 Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) _ For bedrooms
Fluid depth in absorption field before test in.
Elapsed Time: _min. Final fluid depth _ in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Water added gal. New depth_ in.
Absorption rate >_
If yes, give date
...
D. LIFT STATION
Date installed
"Pump on" level at _ in.
Datum
Size in gallons
"Pump off' level at _ in.
Cycles tested
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot NA
Absorption field on lot NA
Public sewer main 75'+
Sewer /septic service line 25'+
Animal containment areas 50'+
SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation
Water main
Property line
Water service line
Wells on adjacent lots
ABSORPTION FIELD ON LOT TO: PUBLIC SEWER
Property line
Water Service line
Curtain drain
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Manhole/Access (Y/N) _
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots NA
On adjacent lots NA
Public sewer manhole/cleanout 1001+
Holding tank NA
Manure/animal excrete storage areas 100'+
Absorption fief
Surface water
Building foundation Water main
Surface water
Wells on adjacent lots
Driveway, parking/vehicle storage
l certify that l have determined through field inspections and review of
Municipal records that the above systems are in conformance with MOA
COSA guidelines in effect on this date.
Engineer's Printed Name KENNETH M. DUFFUS
Date 4117/2015
COSA canary sheet-6-15.doc
41W OF AZ
10, 44TH*
in.
$ KnENNErre a. n /6
_SCS
SGS Ref.#
1151407001
Client Name
AroTerra Engineering and Surveying
Project Name/#
Benito B2, L5
Client Sample ID
Spigot
Matrix
Drinking Water
Sample Remarks:
Parameter Results
Metals by ICP/MS
Arsenic
Waters Department
Total Nitrate/Nitrite-N
Microbiology Laboratory
E. Coli
Total Coliform
Printed Date/Time
04/21/2015 14:39
Collected Date/Time
04/10/2015 14:40
Received Date/Time
04/10/2015 16:55
Technical Director
Stephen C. Ede
Allowable Prep Analysis
LOQ Units Method Container ID Limits Date Date Init
ND 5.00
1.23 0.100
Negative 1
Negative 1
ug/L EP200.8
C (<10) 04/13/15 04/13/15 ACF
mg/L SM214500NO3-F B (<10)
100mL SM219223B A
100mL SM219223B A
04/20/15 SLC
04/10/15 MEV I
04/10/15 MEV
• '� Municipality of Anchorage
On -Site Water and Wastewater Program
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 050-272-07 Expiration Date: / �)_ - -2 �-
1. GENERAL INFORMATION
Complete legal description BENITO BLOCK2, LOT 5
Location (site address) 17226 BIGHORN CIRCLE EAGLE RIVER AK 99577
Current Property owner(s) BRETT ROSS & STEFFANIE COUNTRYMAN Day phone
Mailing address
Real Estate Agent
16512 CHAROLETTE DAY DRIVE. LAPINE. OR 97739
Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
F-1DuplexIiLDB�� SAFETY
664SPECTI `9N FEE PAID
❑ Multiple Dwellings (Single Family and/or Duplex)
SEP 16 2J14
3. NUMBER OF BEDROOMS: 4
AMOUNT: $
4. TYPE OF WATER SUPPLY:
TYPE OF Wrr
�P0SAL:
Individual Well ®
Individual
Individual Water Storage ❑
Holding Tank
❑
Community Class _ Wall ❑
Community
❑
Public Water System ❑
Public Sewer
❑
WaiverNariance request for:
Distance:
Received by: zlol�_
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5�24
Waiver Fee $
Date of Payment�� ��{ (�_
Date of Payment
IV
Receipt Number C757Sci-n
Receipt Number
COSA4 oe�jq ILISI/
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.
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 9/16/2014
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 inland use, local soil characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system. 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,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
i
�F
occupants or can ArcTerra guarantee that no unseen
I ,�� Sy 1
encroachments, deficiencies or discrepancies exist. T ,
o: !
6, DSD SIGNATURE
L-1/ System #1 Approved for ___q_ bedrooms.
System #2 Approved for bedrooms.
Disapproved.
?�
KEN r Lr IH \1 DGFFd, /
�Ror:;ssloh'° w
Conditional approval for bedrooms, with the following stipulations:
OF
WASTEWATER o1
By: a Original Certificate Date:
The uni al chorage 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
COSAbluesh et_141412.dm
If more than 1 septic system is on the lot:
COSA Checklist # of _
Structure served by this system _
Certificate of On -Site Systems Approval Checklist
Legal Description: BENITO BLOCK 2, LOT 5 Parcel ID: 050.272.07
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID #
Date completed 31911993 Sanitary seal (Y/N) Y
Total depth 90 ft. Cased to 90 ft.
FROM WELL LOG
Date of test 3/211993
Static water level So ft.
Well production 10 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate 1.47 mg/L
Arsenic: ND ug/L Date of sample: 9/4/2014
B. SEPTIC/HOLDING TANK DATA - PUBLIC SEWER
Tank Type/Material
Tank size _ gal. Number of Compartments
Foundation cleanout (Y/N) Depression over tank (Y/N)
Date of pumping
C. ABSORPTION FIELD DATA
Date installed
Length
Total depth ft.
Pumper
Soil rating (g.p.d./ft2 or ftZ/bdrm) _
ft. Width ft.
Well Log (Y/N)#- Y
Wires properly protected (Y/N) Y
Casing height (above ground) 24+ in.
AT INSPECTION
9/4/2014
ft.
g.p.m.
Collected by: ARCTERRA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
System type
Gravel below pipe
Eff. absorption area fe Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail)
Fluid depth in absorption field before test in.
Elapsed Time: _min. Final fluid depth in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) _
Water added al.
Absorption rate >=
ft.
For bedrooms
New depth_ in.
If yes, give date
.M
D. LIFT STATION
Date installed
"Pump on" level at _ in.
Datum
Size in gallons
"Pump off' level at _ in.
Cycles tested
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot NA
Absorption field on lot NA
Public sewer main 75'+
Sewer /septic service line 251+
Animal containment areas 501+
SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation
Water main
Property line
Water service line
Wells on adjacent lots
ABSORPTION FIELD ON LOT TO: PUBLIC SEWER
Property line
Water Service line
Curtain drain
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Manhole/Access (Y/N) _
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots NA
On adjacent lots NA
Public sewer manhole/cleanout 100'+
Holding tank NA
Manure/animal excrete storage areas 100'+
Absorption fie
Surface water
Building foundation Water main
Surface water
Wells on adjacent lots
Driveway, parking/vehicle storage
I certify that t have determined through field inspections and review of
Municipal records that the above systems are in conformance with MOA
COSA guidelines in effect on this date.
Engineer's Printed Name KENNETH M. DUFFUS
Date 0911612014
COSA brown sheet_10-10-12.doc
4 q TH
'P KENA'F"TH M. D L W /
178 Aw
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�\ Municipality of Anchorage
1 Development Services Department
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. _ � -07 � 'U` COSA # 66 b4Lf!SI
Expiration Date: - O G
1. GENERAL INFORMATION L L p
Complete legal description Ben I -1 U S R a I
Location (site address) 1-72aU RI n Horn IY rLA
Current Property owner(s) Smii hlci&CtU Day phone I - Mailing address �Q RUX 9R , j2�h�X I PAI -k, Ak 077�'
Lending agency Day phone
Mailing address r
Real Estate Agent -Ev&, ( a K o v. Day phone _ (o 7 (o
Mailing Address -j(0(03!5 ,D 0yfi 1, 0L n►. 2K jkK q7`i7-
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: _
3. TYPE OF WATER SUPPLY:
Individual Well [1j
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
51
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
ungineerregisteredtTthe-State-ofWaska-Gertificate5W On-SRLSystems-Approvat-are7egatru"onho-n?Tste7-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 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 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.
Name of Firm
Eagle River Engineering Services Phone �D N-5135—
.
Address /Eagle River. AK99=
Engineer's Printed Name `hyl f)D{'1RX 12 Wood • Date •.q I .a - o(r)
5. DSD SIGNATURE
Approved for _ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the follow
Attachments:
COSA Checklist X Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory Other
By 41 dmf/1 Original Certificate Date: 0
(R". 11105(
Municipality of Anchorage
' Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Bf' Yl � to L � B D Parcel I D: n S �%' -' 7Z- D -7
A. WELL DATA
Well type P&Y 0,A-9, If A, B. or C provide PWSID # _
Date completed 3 q 3 Sanitary seal &N)
Total depth ft. Cased to Afl—ft.
FROM WELL LOG
Date of test f�
Static water level X h ft.
Well production 10 g.p.m.
WATER SAMPLE RESULTS:
Coliform ,colonies/100 mL Nitrate l -as mg/L
Arsenic: 0 J? ug/L date of sample: -O (4.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal. Number of Compartments_,
Foundation cleanout (Y/N) _ Depression over tank (Y/N)
Date of pumping
C. ABSORPTION FIELD DATA
Date installed
Length ft.
Total depth _ ft.
Date of adequacy test _
Fluid depth in absor ' 1
Elapsed T' min.
Pumper
Soil rating (g.p.d./ft2 or I
Width
Eft, absorptionW4ed- ft
Well Log ON)
Wires properly protected Y )
Casing height (above ground) n.
AT INSPECTION
f- g.p.m.
Other bacteria _4 colonies/100 mL
Collected by: Chckrup tSso k2ari t'11
Date installed
Cleanouts (Y/N)
High water alarm
System type
ft. Gravel below pipe
Monitoring tube _
Results (Pass/Fail)
before test _ in. Water added_ gal.
Final fluid depth _ in.
treatment (past 12 mo.) (Y/N & type)
Depression over field _
For_ bedrooms
New depth in.
Absorption rate >= I g.p,d,
If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at _in. 'Pump off" atm�_ in. \�� G,� Hiy�tatacate a at in.
Datum s ed Meets alarm & circuit requirements?
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot t 100'
Absorption field on lot, 4 1C>
Public sewer main A I x),
Sewer /septic service line { a C
Animal containment areas + 1 W
On adjacent lots 4 1 n(�,
On adjacent lots ' IDD,
Public sewer manhole/cleanout +AW
Holding tank "I -1q,
Manurelanimal excrete storage areas fi IUY
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line Absorption field
Water main Water service line Surfac,w
Wells on adjacent lots �� ET`
SEPARATION DISTANCE FROM ABSORPTION CT LD ON LOT T
Property line ng foundation Water main
Water Service Ii Surface water Driveway, parking/vehicle storage
m drain Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that 1 have determined through field inspections and &V AAM
review of Municipal records that the above systems are in *'
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name f hr i Slo0 !? Y. �. YVt7 WERR
CE:
Date—SP 12fl-M %f _/0 o� 66 2 (o ..
COSA Fee $ CW /
Date of Payment q/la" D6
Receipt Number 8 Oa3
(Rev. 11105)
Waiver Fee $
Date of Payment
Receipt Number
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ANALYT
GROUP
Eagle River Engineering
Attn: Christopher Wood
10421 VFW Rd. Ste. 201
Eagle River, AK 99577
907-694-5195
Fax:
Client Sample ID: Benito Lot 5, Block 2
Sampling Location: Benito Lot 5, Block 2
Client Project: Miscellaneous DW Testing
Sample Matrix: Aqueous
COC a:
PWS#:
Residual Chlorine:
Comments:
Analytica International, Inc.
5761 Silverado Way, Unit N
Anchorage, AK 99518
Phone: 907-258-2155
Fax: 907-258 6634
Report Date: 9/8/2006
Receipt Date: 8/22/2006
Sample Date: 8/22/1006
Sample Time: 2:15:OOPM
Collected By: CB
Flag Definitions:
MRL = Method Reppoorting Limit
MCL — Maximum C ontammant Limit
B - Present also in Method Blank
FI - Exceeds Regulatory Limit
M - Matrix Interference
J- Estimated Value
D - Lost to Dilution
•• - RL higher than MCL; target not detected
Analysis Method
I
Parameter Result
Units
Flags MRL
Prep Prep Analysis
MCL Method Date Date Analyst
200.7/200.7 (Aqueous) - Family Well Water 111
Test was conducted by. Analytica - Thornton
Magnesium8.79
mg/L
0.10
200.7 9/1/20069/1/2006 CC
Manganese <MRL
mg/L
0.0100
0.05 200.7 9/1/2006 P/1/2006 CC
Sodium 5.07
mg/L
3.0
200.7 9/I/2006 P/1/2006 CC
200.8/200.8 (Aqueous) - Family Well Water III
Test was conducted by: Analytica - Thornton
Arsenic 0.298
ug/L
0.15
/0 200.8 9/5/2006 J/6/2006 KLS
Lab#: A0608280-OID
Analysis Method
Parameter Result
Units
Flags MRL
Prep Prep Analysis
MCL Method Date Date Analyst
150.1 / 150.1 (Aqueous) - PH
Test was conducted by: Analytica -Anchorage
PH 6.9
pH
0.0
150.1 8/22/2006 8/22/2006 AJ
2330B (Aqueous) - Langelier Index
Test was conducted by.-Analytica'- Anchorage
Langelier lndcx/Corrosivity -0.93
%
-1.0
8/30/2006 9/1/2006 KP
2320B/23208 (Aqueous) - Total Alkalinity
Test was conducted by. Analytica'-Anchorage
Alkalinity, Total 85.0
mg/L
4.0
2320B 8/26/2006 8/26/2006 AJ
2540C/2540C (Aqueous) - TDS
CaCO3
Test was conducted by: Analytical - Anchorage
Total Dissolved Solids 173
mg/L
20
Soo 2540C 8/25/2006 8/25/2006 AJ
Reported by: Krissy Plett, Page 2 of 3
Laboratory Project Manager
- Membrane Filtration MF Test was
Bacteria, Other <MRL
i
Analytica International, Inc.
1.0
5761 Silverado Way, Unit N
Total Coliform <MRL
Anchorage, AK 99518
1.0
/ 8222006 8222006 PL
Phone: 907-258-2155
ANALYTICA
GROUP
Fax: 907-258-6634
Eagle River Engineering
Report Date: 9/8/2006
Attn: Christopher Wood
Receipt Date: 822/2006
Parameter Result
10421 VFW Rd. Ste. 201
Sample Date: 8222006,
Eagle River, AK 99577
Sample Time: 2:15:OOPM
907-694-5195
Collected By: CB
Fax:
Nitrate as N 1.25
mg/L
Floe Definitions:
Client Sample ID: Benito Lot 5, Block 2
MRL - Method MCL - Maximum C Reppoorting Limit
ntaminant Limit
Sampling Location: Benito Lot 5, Block 2
B - Present also in Method Blank
Client Project: Miscellaneous DW Testing
11— Exceeds Regulatory Limit
Sample Matrix: Aqueous
COC #'
M - Matrix Interference
PWS#:
J - Estimated Value
Residual Chlorine:
D — Lost to Dilution
Comments:
•' - RL higher than MCL; target not detected
LabH: A0608280-OIA
Sample Comment: AX 1821
Analysis M1lethod
Parameter
Method Date Date Analyst
- Membrane Filtration MF Test was
Bacteria, Other <MRL
CFU/IOOmL
1.0
-- ----•-- ..�........�...... -,.,.,..,.,...ate
8222006 8222006 PL
Total Coliform <MRL
CFU/IOOmL
1.0
/ 8222006 8222006 PL
Lab#: A0608280-OIB
Analysis Method
Parameter Result
Units Flags
MRL
Prep Prep Analysis
MCL Method Date Date Analyst
4500-NO3E (Aqueous) - Nitrate
Test was conducted by. Analytica - Anchorage
Nitrate as N 1.25
mg/L
0.50
/0 8282006 8282006 AJ
Lab#: A0608280 -OIC
Parameter
MOB (Aqueous) - Total
Result Units
I ardness, Total 140 mg/L
200.7200.7 (Aqueous) - Family Well Water III
Calcium
Iron
Reported by: Krissy Plett,
Laboratory Project Manager
41.6 mg/L
<MRL mg/L
MRL
LO
0.10
0.050
Page 1 of
Prep Prep Analysis
MCL Method Date Date
Test was conducted by: Analytica - Thornton
9/82006 9/82006 CC
Test was conducted by: Analytica - Thornton
200.7 9/12006 9/12006 CC
0.3 200.7 9/12006 9/12006 CC
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. # f( - ala- QI HAA # � °� � � gjp 04,
1. GENERAL INFORMATION
Complete legal description Lot 5; Stock 2; Beni& Subdi.vi4ion
Location (site address or directions) 17226 Big Honn Cikc2e
Eagte Riven, AK
Property owner Gany Smith Day phone
Mailing address
Lending agency uay pnone
Mailing address
Agent _
Address
Unless otherwise requested, HAA will be held for pickup.
'2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3
XXX
Day phone
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 XXX v
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1191) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I 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.
Name of Firm S & S ENGINEERING
Address Eagle River,
Engineer's signature
6. DHHS SIGNATURE
Approved for A bedrooms.
Disapproved.
Conditional approval for
Additional Comments
By:
Phone j
Date
bedrooms, with the following stipulations:
DateV-17-1-9 3
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 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) Beck MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description. 1—dT C 1 Z ?JI;' Sb Parcel I.D. O 6-6 — a 72- - o 7
A. WELL DATA
Well type �� KI If A, B, or C, attach ADEC letter. ADEC water system number
Log present&N) Date completed '; - 0� ' T5 Driller M D c r�
Total depth Cased to 9 Casing height lZ
Sanitary seal �I) Wires properly protected (SYN)
Date of test
FROM WELL LOG
AT INSPECTION
Lt✓ss Tek �
Static water level
a\
—
Well flow
\O.O
g.p.m. g.p.m.
r"
is
Pump level
•�•
OO
to (J
a
SEPARATION DISTANCES
FROM WE LTO:
m
Septic/holding tank on lot
On adjacent lots
W
rn
a 0
\�
Q
Absorption field on lot
~ �'
oi]
; On adjacent lots
y
n
TZ
Public sewer main
��
Public sewer manhole/cleanout
Sewer service line
�'`� t�
Petroleum tank ZS
WATER SAMPLE RESULTS:
Coliform Nitrate 1 a Other bacteria
�� ' �-'� '�3 Collected b S & S ENGINEERING
17 024 Eag11* River Leep Read No. 204
Date of sample: y:
Eagle River, Alaska 99577
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size
Foundation cleanout (Y/N)
SEPARATION DISTANCES FROM
Well(s) on lot
To property li
_Sufface water/drainage
72-026 (Rev. (Rev. 7/91) Front
Compartments
Alarm tested (Y/N
LDING TANK TO:
On adjacent lots
bsorption field
Depression (Y/N
Foundation
"rater main/service line
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed .
Size in gallons
Vent (Y/N) _
"Pump on" level at
High water alarm level
Meets MOA electrical codes
SEPARA
on lot
Manufacturer
Manhole/Access (Y/N)
�umpoff'-'el at
ANCE FROM LIFT STATION TO:
On adjacent lots
D. ABSORPTION FIELD DATA
Date installed
Length Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Cycles tested
Soil rating
—Gravel thickness
Cleanouts present
Surface water
System type
T�depth
Date ota6equacv test
SEPARATION DISTANCE FROM ABSWTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
If yes, give date
_On adjacent lots Property line_
To existing or abandoned system on lot
Cutbank Water main/service line.
bedrooms
Surface er Driveway, parking/vehicle storage area
Cu in drain
E. ENGINEER'S, CERTIFICATION
1 certify that I have ch ed, verifi d, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
y34
A 5$fl
c+y� v3
Signature
_ a �-
t
17034 Eagle River Loop Road No.
u
Enginee a ZQ4
ry Alaska a 9577
»C ra at
�
Date
A,jp¢ . i
'i ,• _ soy%;l
r ac3.r
HAA Fee Waiver Fee: $
Date of Payment 3' Z^
Date of Payment
2 �5_ ��J�
Receipt Number Receipt Number
72-026 (Rev. 3/91) Back MOA 21
05/27/93 11:50 CT&E EN•)IRGNhiENTAL LAB SERVICES;
AINCQ I90d
Chemlab Ref.#
Client Sample ID
Matrix
ENVIRONMENTAL LABORATORY SERVICES
:93.2363-1
:L5, 82, DENITO S/D
WATER
RDORT of ANALYSIS
NCI. 921 ipL1l
6833 E STREET
ANCHORAOE, AK 99518
TF'_ ;997 562.2343
FAQ:: (907) 551.5301
Client Name %S & S ENGINEERING
WORN Order
:66448
Ordered BY ;R. SHAMR
Report Completed
s05/27/9
Project Name .
Collected
105/24/93
@ 10:30 hr:
Project#
Received
:OS/24/93
@ 16:15 hr:
PWSID :U,4
Terhnical Director
Released By
sSTEP C. EDE
Sample Remarks ; ROUTINE: SAMPLE CO:,,Ll'.CTED BY: PAY,
QC Allowable Ext.., Anal
Parameter Rest t� Ual. Onit,el M�tt""A Limits %kite Date Init
--
---•--------_....__.._._..__... ._ ._ _ _..._._. w_......._.__......�__ ___.._....._._......-._.-�___-_
Nitrate -N ^1. i8 1&91L, ETA 353.2/300.0 10 45/26 Li..
s=t=QmwasamFas:7=sacam=5l="It= Y-_zc====U•Z
* See Special Instructions Above UA = Unavailable
See Sample Pemarks Above NP. Not Analyzed
U a [Undetected, Reported venue is the practical quantification limit. LT = Less Than
D s Secondary dilution. GT Greater Than
Member of the SO$ Group (SD661:6 Gtlntml6 do Surveillance,
ENVIRQNtv1ENTAL SERVICFS IN ALASKA, COLORADO. UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTIi CAROLINA
