HomeMy WebLinkAboutROLLING HILLS ESTATES BLK C LT 1Rolling Hill
Estates
Block C
Lot I
#011-072-11
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP201204 Effective Date:
Work Type: SepticTank Upgrade Expiration Date:
�t»ent
i
Dcpa rtment
7/7/2020
7/7/2021
Tax Code Number: 01107211000
Site Legal Address: ROLLING HILLS ESTATES BLK C LT 1 G:2124
Site Mailing Address: 5108 W 72ND AVE, Anchorage
Owner: KING CLIFFORD W Lot Size in Sq Ft: 15566
Design Engineer: GARNESS ENGINEERING GROUP LTD Total Bedrooms: 4
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received B
Issued By:
y: / Date:
Date:
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Fax: 907- 343-7997
On -Site Water & Wastewater Program
Mayor Dan Sullivan
On -Site Sewer/Well Permit Application
For A Single Family Dwelling
Parcel I.D. 011-072-11
Property owner(s) CLIFFORD KING
Mailing address 5108 WEST 72ND AVENUE *ANCHORAGE, AK 99522
Site address 5108 WEST 72ND AVENUE `ANCHORAGE, AK 99522
Day phone 907-947-6465
Legal description (Sub'd, Block & Lot) ROLLING HILLS ESTATES; BLOCK C, LOT 1
Legal description (Township, Section & Range)
Lot Size
Single Family (SF)
APPLICATION IS FOR:
(w/wo ADU)
(® all that apply)
Duplex (D)
Absorption Field
❑
Septic Tank
(SF and/or D)
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
Sq. Ft. Number of Bedrooms
APPLICATION IS AN:
Initial ❑
Upgrade
Renewal ❑
THIS APPLICATION INCLUDES A VARIANCE/ WAIVER REQUEST FOR:
N/A
TYPE OF DEWELLING:
Single Family (SF)
(w/wo ADU)
Duplex (D)
❑
Multiple Dwellings
❑
(SF and/or D)
Distance: -
I certify that the above information is correct.. I further certify that this is in accordance with
applicable Municipal codes.
GARNESS ENGINEERING GROUP, Ltd.
(Signature of property owner or authorized agent)
Permit/Rush Fees: / 616. 7-6-
Waiver Fees:
Date of Payment: 61�Av Date of Payment:
Receipt Number: r�03176 Cr Receipt Number:
Permit No. ®Sr 2�)?-� Waiver No.
(Rev. 0 t 111)
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201204, Rebecca Carroll, 07/07/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201204, Rebecca Carroll, 07/07/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201204, Rebecca Carroll, 07/07/20
MUNICIPALITY OF ANCHORAGE , ~:
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
NAME
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
JPHONE _J~_N EW
MAILING ADDRESS
LEGAL DESCRIPTION
Well
IF HOMEMADE:
LOCATION ~
DISTANCE TO:
Manufacturer ~2
Liq. capacity in gallons
,tion area Iling
Inside length ~ Width
Dwelling
DISTANCE TO:
Manufacturer
NO. OFBEDROOMS ~.~
PERMIT NO.
Liquid depth ~ [~
PERMIT NO.
DISTANCE TO:
No. of lines ~..
Well
Length of each line
Top of tile to finish grade
Length
Type of crib
DISTANCE TO:
Depth
DISTANCE TO: Building foundation
I Material
Foundation ~ Nearest lot line
~ O Trench
Total length of lines
\pt
Material beneath tile
Depth
capacity in gallons
PERMIT NO..,-] ~O~S(~
inches Distance between lines
inches
Total effective absorption area
PERMIT NO.
Crib depth
Building foundation
Driller
Sewer line
Total effective absorption area
Nearest lot line .
Distance to lot line PERMIT NO. ~. ~.~.~
Septio tank I Absorption areals
OTHER
PIPE MATERIALS
SOl L T EST RATING
NSTALLER
REMARKS
DATE LEGAL
DEF'ARTMENT OF HEALTH AND ENVIRONMENTAL PROTECT
- 825 '"L'" STREET., ANCHOR, AGE, AK.
~' ,, ;264-4720 ~ V ~ -~ ~., ,'
L--IELI_ R[--IE:. ,_~1'-.t--"_=. T TE
HFFLI..ANT ROY HLINT 6_-'.':44 AIR QUARD
LOCATION ?2ND RVE,.-"BA I LEY
LEGAL I_:'L E:LK C F.:OLLII"~G HILLS EST LOT .=,I~E /L._,'.t.:t,:, 'SQUARE FEET
- ""- ' ' 0 '-' '"~ TF..ENUH
TYPE OF SOIL HBz, ORBTI_N =~'_,TEfl IS: ' '-'
.=,S. F [,, BR.)=
' ' E, EDROEIM_, = 4
MAX I MUM NUMBEF.. OF ' ' ' - '= =,U I L RFIT I NG ,:' '-" "'" ' '
THE REQ_IRED SIZE OF THE SOIL RBSORPTI~']N :,Y=,TEI'I IS:
£".:. ES F" T H = 21_2 L. EI'4,3 TH= g-a.: ¢=_-;
G " R '
THE LENGTH DIMENSION IS THE LEN.~TH (IN FEET) OF TFIE tREN..H CF. DRRI. NFIEL. D.
THE DEPTH OF A TRENCH ~F. PIT IS THE DI=,TRN~.E BETWEEN THE =,I. FFId~.E OF THE
GROUND RND THE BOTTOM ElF THE EF.,CRVRTION 4IN FEET.'-'.
' ~"RENCHE=,.
THERE IS NO SET wIr~TH FOR ' '
THE GRR',,,'EL DEPTH IS THE MINIMUM 'DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE E>4CAYATION (IN FEET:).
RE_,FUN_,IBILIT"r' TO INFr'IRM THIS [:,EPARTMENT DURING THE
'' I-*. 2"~- ,- . ,.--.
F'ERMIT AFFLI..ANT HAS THE - ,
IN_-,~HLL. FfTIJN IN_,PECTIUN=, OF RNY WELLS ADJACENT TO THIS PF. LPEF..1 ¢ AND THE
NLIME:ER OF RESIDENCES THAT THE WELL W~LL SERVE.
. .
....... TI---lO ,: 2 ':. I l%t_.F
BACKFILLING OF ANY =,T..,TEM WITHOUT. FINAL INSPECTION AND RPPRO',/RL B'T' THIS
P F..U=.EL. UTI L N.
DEF'RRTMENT WILL BE SUBJECT TEl ,--,-,-
MINIMI_IM DIz, TANE. E BETWEEN R WELL AN[:, RNY ON-SITE SEWAGE DI._,FLI_,HL :-.,-r=,I'EM IS
i08 FEET FUR R PR I ',,,'ATE WELL.; OF..
,3 "11 '
:;L5¢.~ TO 2ElO FEET FROM R F'UBLIC WELL [:,EF'ENDII"4G UFLN THE TYPE OF F.E:LIC 1.4EL. L
WELL LOGS ARE REQUIRED AND MU:,T BE RETIJRNED TEl THE DEPF.IRTMENT WITHIN 2~E.4 DAYS
OF THE WELL COf'IF'LETION;
OTHER REQUIREMENTS MR'T' APPLY. SPECIFICATIONS AI'.,ID CuNmTRUL. TIUN [.IR.~F..HM=, RF4:E
AYRILABLE TO INSURE FF.LPEF.. INSTALLATION.
I CERTIFY THAT
t: I AM FAMILIAR WI~THE REQUIREMENTS FOR ON-SITE SEWERS FIND WELLS RS SET
FORTH BY THE MUNICIF_-'RLITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3..: I UNDERSTAND THFIT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF T'HE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
.........
U
y.T r�l LL -11N% -7'r A IN%'..
.'.t *XNCHORAGE
MUNICIPALITY
f.• DEPT. -OF IV-AITH &
..-ENVIRONMENTA
DRILLING LOG t
(ROY -'i4,:`::AI TINIT VAT, G.. - TOTER' JAMES A. UUNT FAV ED
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"'"' "~'x:-'MUNICIPALITY OIF ANCHORAGE
DRILLING LOG
Cased
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Municipality of Anchorage
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.
1. GENERAL INFORMATION
COSA #
Expiration Date:
Complete legal description Rolling Hills Estates Block C Lot
Location (site address) ~
~o8West :?Avenue Anchora e AK
Current Property owner(s). Patrick & Terri Lemons Day phone ..77o-~7z7
Mailing address
Lending agency
Mailing address
5~o8 West 72nd Avenue, Anchorage, AK q9~o2
Day phone
Real Estate Agent
Mailing Address
Unless othe~, ise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: .._4_
?
TYPE OF WATER SUPPLY:
IndiVidual Well ' []
IndiVidual Water Storage []
Community Class Well []
Public Water System []
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site 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 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 Pannone Engineering Services, LLC Phone 272-82~.8
Address P.O. Box moo2m7, Anchorage, AK qgqlO
Engineer's Printed Name Steven R. Pannone, P.E. Date
Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions
encountered at the time of the test, and separation distances measured to readily identifiable features.
The operational life of all wells and septic systems depend on the local soil condition, ground water
levels that may fluctuate during the year, and the water usage of the family being served by the svstem
'Ih.esoe condlt,ons are. ou?de the control of the evaluator of this system. Ail systems eventually fail and ~
sans~actory test results do not guarantee future performance of the system, nor do thev euarantee that ~
there are no h~dden defects or encroachments. PES can therefore not provide any warranty for future ~......-'.~..~'~2~
performance nor g~ve any estimate of how long the system will continue to meet the operational _ ~
r,equire ,ments o,.f the MOA DSD. The content of this report is for the sole benefit of the owner listed -~-~~n';'~'~';i"i
aoove. ~,ny renance upon or use of this report by any other person or party is not authorized nor will it '~'~.., ~o. EC ~149
confer any legal right whatsoever ~'~
- ' '*i '" ...... '"~ '
5. DSD SIGNATURE
~/" Approved for ~ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: / ~- //~'-///
Municipality of Anchorage
Development Services Department
Building Sefety Division
On-Site Water & Westewater Program
4700 Bragew 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:
A. WELL DATA
Well type P
Date completed ',:zl',l',q78
Total depth =o~ ft.
Rolling Hills Estates Block C Lot =
Date of test
Static water level
Well production ~;
WATER SAMPLE RESULTS:
h
Coliform N~?-~ colonies/100 mL
Arsenic: ~.~ ug/I
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Sunset Fiberglass
Parcel ID: o~-o72-~
If A, B, or C provide PWSID # ~ Well Log (Y/N) Y
Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Cased to ~oo.8 ft. Casing height (above ground) :t2
FROM WELL LOG AT INSPECTION
=.:zl~/z978 "o/zrl:zo',',
6~; ff. 7z ff.
g.p.m, a.z g.p.m.
Nitrate ~) mg/L
Date of sample: aol~.12oa=.
Number of Compartments _~
Depression over tank (Y/N) _N
Pumper A+ Home Services
Tank size z=5o gal.
Foundation cleanout (Y/N) Y
Date of pumping aol?l~,o.,.,
C. ABSORPTION FIELD DATA
Date installed ?1=.o1=.~78 Soil rating
(g.p.d./ft2 or ~/bdrm) =1~o
Collected by: Laura Pannone
Date installed 7/~o1~q78
Cleanouts (Y/N) Y
High water alarm (Y/N) N
Length aoz ft. Width :12" ft.
Total depth ~-3 ft. Eft. absorption area z6:t6 ft2 Monitoring tube Y
Date of adequacy test :m/~./2ozz Results (Pass/Fail) Pass
Fluid depth in absorption field before test =.~8 in.
Elapsed Time: .~.zrzro min. Final fluid depth ~..~8 in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) .. N
System type Deep Trench
Gravel below pipe 8
Depression over field N
For .~ bedrooms
in.
Water added6:/o gal. New depth3.Q in.
Absorption rate >= 6oo+ g.p.d.
If yes, give date
LIFT STATION
Date installed Siz~,
"Pump on" level at ~ in. "Pump.
Datum Cyc~
E. SEPARATION DISTANCES
',~vel at ~ in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 92' Waived
Absorption field on lot
Public sewer main ~.oo+
Sewer/septic service line
Animal containment areas ~.oo*
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
Building foundation ~o+
Water main
Wells on adjacent lots
Property line ~o+
Water service line 25+
On adjacent lots ~.oo.
On adjacent lots ~.oo+
Public sewer manhole/cleanout ~oo+
Holding t~nk ~oo+
Manure/animal excrete storage areas ~.oo+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Absorption field 5+
Surface water ~oo+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation ~.o+
Surface water [oo+
Wells on adjacent lots ~.oo+
Property line ~.o+
Water Service line 50+
Curtain drain None Known
F. COMMENTS
Water main 50+
Driveway, parking/vehicle storage
lO+
Fenced back yard ~o' from well.
in.
G. ENGINEER'S CERTIFICATION ~,~'~.,,,?,~.,,,,~/~
I cedi~ that I have dete~ned through field inspections and
review a ve are ;
confo~ ance w~h MOA COSA guidelines in effect on this date.
~~~ ...... ~ .... ~,,-~,,~
~.~St~ R. Ponnone:~=
EngineeCs Printed Name Steven R. Pannone, P.E.
Date ~ol71~o1~
COSA Fee $.
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
SGS Ref.# 1114845001
Client Name Pannone Eng. Srv. Printed Date/Time 10/I 1/2011 13:50
Project Name/# Rolling Hills Est Bk C Lt 1 Collected Date/Time 10/04/2011 13:40
Client Sample ID Roling Hills Est Bk C Lt 1 Received Date/Time 10/04/2011 14:30
Matrix Drinking Water Technical Director Stephen C. Ede
PWSID 0
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic ND 5.00 ug/L EP200.8 C (<10) 10/05/11 10/09/11 NRB
Waters Department
TotaINitrate/Nitrite-N ND 0.100 mg/L SM204500NO3-F B (<10) 10/10/11 AYC
Microbiology Laboratory
E. Coli Negative 1 100mL SM20 9223B A 10/04/11 DLC
Total Coliform Negative 1 100mL SM20 9223B A 10/04/11 DLC
2 of 4
HOME SERVICES , INC.
7501. E. 140th Avenue
****+ Anchorage, Alaska 99516
345-1890
CUSTOMER
5108 W- 72'"t. Avenu-e
Anchorage, AK 99502
INVOICE #
41073
Block
DATE
Lot
DESCRIPTION
AMOUNT
770-3717
o?no ~oo ~atto.~, ~ ~tan~, ,~,, Z,S
,.. TOTAL
REMARKS '" "' ·
[~,~ Gallons
~, Septio ~ Leach Area _ Holding Tank
[] PROBLEM AREA -- CALL FOR MORE INFORMATION
[] _ NEEDS TO BE DONE AGAIN IN 6 MONTHS
~/Good Shape [] Sludge buildup on bottom
[] Jim cap missing or [] Cut standpipe to 1' above ground
needs replacing
Standpipes 3~('/~ime
[] Floater on top
[] Needs Septictrine
Parcel I.D. 011.072-11
Municipality o.f Anchorage
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
COSA#
1. GENERAL INFORMATION
Complete legal description Rollinq Hills Estates, block C, Lot 1
Location (site address) 5108 West 72~ Ave. Anchora.qe, AK 99502
Current Property owner(s) Matthew Fitzqerald
Mailing address
Lending agency
Mailing address
Real Estate Agent Daran Donald~eller W~lliams Realty
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
4
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class Well []
Public Water System []
Day phone 206-292-3822
Day phone
Day phone 865-6500
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding Tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of.Naska. 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 end 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 certitied by my seal affixed hereto and as of the validation date shown below, I vedfy that my Investigation,
based on procedures outJined 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 vedfy 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 Pannone EnqineeHnq Services, LLC Phone 272-8218
Address P.O. Box 102954, Anchomqe, AK 99510
Engineer's Pdnted Name. Steven R. Pannone, P.E. Date ~,.t ,//"~
Engineers Comments: In conducting an adequacy test, I att~mp! to provide a thorough, conscientious engineering analysis of thc system in
accordance with MOA DSD Guidelines & Regulations. Thc reported r~ults &scribe thc p~rformance of the system under thc conditions
encountered at thc time of the tc~, and separation distances m~sured to ~adily identitlablc features.
Thc operational life of all wells and soptic syst cms depend on the local soil condition, ground water
levels that may fluctuate during thc ycan, and thc water usage of thc family being served by the system.
These conditions sro outside the control of the evaluator ofthis system. All systems eventually fail and
satisfactory test results do not guarantee future performance of the system, nor do they guarantee [hat
there are no hidden defects or encroachments. PES can therefore not provide any warranty for future
performance nor give any estimate of how long the system will continue to meet the operational
requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed
above. Any reliance upon or use of this report by any other person or party is not authorized nor will it
confer any legal fight whatsoover.
5. DSD SIGNATURE
[// Approved for q bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COS~ Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
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.munl.org/onsita
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Rolling Hilb Estates, Block C lot I
Parcel ID: 011-072..11
WELL DATA
Well type private If A, B, or C provide PWSID # Well Log (Y/N) Y
Date compl(~ted 17./111978 Sanitary seal (Y/N)Y Wires properly protected (Y/N) Y
Totaldepth 101 ft. Casedto 100.8 ft. Casing height (above ground) 24 in.
FROM WELL LOG AT iNSPECTION
Date of test t2/5/1978 6/13/2008
Static water level 65 ft. 7t
Well production 15 wit00% drawdown g.p.m. '1.4 gp.m.
WATER SAMPLE RESULTS:
Coliform ,--~--~olonies/1 O0 m L
Arsenic: 538 mg/i
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Sunset Fiberglass
:~' Tank size. ~.1250 gal. Number of Compartments 2
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
Date of PumPing 6/13/2008 Pumper A* Home Servlces
C. ABSORPTION FIELD DATA
Date of sample: .6/13/08
Other bacterla--'~"~, coloniesll00 mL
Collected by: :Laura Pennone
Date installed 71t011978
Cleanouts (Y/N) Y
High water alarm (Y/N) N
Water added600 gal. New depthdrv in.
Absorption rat~ >= 600+ g.p.d.
If yes, give date
Date installed 711011978 Soil rating (g.p.d,/ft:z Or ~/bdrm) 3'10 , System ,type ,Deep Trench
Length 101 f~. W dth 32" ft. Gravel below pipe 8
Total d~pth'.13 ft. Eft. absorption area 1615 ft= Monitoring tube Y Depression over field _N
Date of adequacy test 6/13/2008 Results (Pass/Fail) P For 4 bedrooms
Fluid depth in absorption field before test d_~ in.
Elapsed Time: 4~i min. Final fluid depth dry in.
Any rejuvenation treatment (past 12 mo.) (YIN & type) N
D. LIFT STATION
Date installed Size In~
'Pump on" level at in. 'Pump of
Datum C~lo~
E. SEPARATION DISTANCES
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tan~ift station*on lot 92'*
Absorption field on lot '104'*
Public sewermain foG+
Sewer/septic service line 50+
Animal containment areas *10o+***
On adjacent lots fOG+
On adjacent lots fOG+
Public sewer manhole/cleanout 'loG*
Holding tank *lOG+
Manure/animal excrete storage areas *loG*
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation
Water main 50*
Wells on adjacent lots *loG+
Proper~y line *10+
Water service line 5O+
Absorption field 8'
Surface water *lOG+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line lo+
Water Service line
Curtain drain
F. COMMENTS
Building foundation 30'
Surface water *100+
Wells on adjacent lots *10G+
Water main 50+
Driveway, parking/vehicle storage fO+
*MOA waiver qranted for well separation inside of 10G' on 9/6/1988, **Per feb 1998 COSA, *"*Fenced Yard 10' from well
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven R. Psnnone, P,E,
Date
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11~5)
· . ~o... t '..Gee
Waiver F~ $
Date of Pa~ent
Receipt Number
SGS Ref.# 108626900 I
Client Name Pannone Eng. Srv. Printed Date/Time 11/21/2008 9:12
Project Name/# LI,BC,Rolling Hills Estates Collected Date/Time 11/13/2008 10:15
Client Sample ID LI,BC,Rolling llills Estates Received Date/Time I 1/13/2008 10:40
Matrix Drinking Water Technical Director Stephen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results POL Units Mcthod Container ID Limits Date Date Init
Waters Department
Total Nit~te/Ni~ite-N
ND 0.100 mg/L SM20 4500NO3-F B (<10) I 1/14/08 JDZ
I~LLcrobiolo~l¥ Laborato~r.
Colony Count 0
Total Coliform 0
Fecal Coliform 0
col/100mL SM20 9222B A (<200)
col/100mL SM20 9222B A (<1)
col/100mL SM20 9222B A (<1)
11/13/08 DLC
11/13/08 DLC
11/13/08 DLC
Municipality of Anchorage
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. 011-072-11
COSA #
Expiration Date:
1. GENERAL INFORMATION
Complete legal description RoIlinq Hills Estates, block C, Lot 1
Location (site address) 5108 West 72"d Ave. Anchoraqe, AK 99502
Current Property owner(s) Matthew Fitzqersld
Day phone 206-292-3822
Mailing address
Lending agency
Day phone
Mailing address
Real Estate Agent
Daran Donald/Keller Williams Realty
Day phone 865-6500
Mailing Address
Unless otherwise requested, COSA will De held by DSD for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class ~ Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individua~ On-site []
Individual Holding Tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site 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 fcra period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or i~ wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions In the professiona! engineer's work.
Municipality of Anchorage
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. 011-072-11
1. GENERAL INFORMATION
Complete legal description
Rollinq Hills Estates, block C, Lot 1
COSA #
Expiration Date:
Location (site address) 5108 West 72"~ Ave. Anchorage, AK 99502
Current Property owner(s) Matthew Fitzqerald
Day phone 206-292-3822
Mailing address
Lending agency
Day phone
Mailing address
Real Estate Agent
Daren Donald/Keller Williams Realt7
Day phone 865-6500
Mailing Address
Unless otherwise requested, COSA will I~e held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage [-I
Community Class __We~l []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding Tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site 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 professiona! 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 Cerlificate 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 cf 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(ara) in compliance with a!l applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Enqineer~nq Services, LLC Phone 272-8218
Address P.O. Box 102954, Anchoraqe, AK99510
Engineer's Printed Name Steven R. Pannone, P.E. Date
Engineers Comments: In conducting an adequacy teaL, I attempt to provide a thorough, conselcntious engineering analysis of the system in
accordance with hie^ DSD Guidelines &: Regulatlona. The reported rcsuhs dcsor[bc thc performanca of the system under thc conditions
encountered at the time of the test, and separation distances measured lo readily identifiable features.
The operational life of all wells and septic systems depend on the local soil condition, Bound water
levels Ihat may fluctuate during thc year, and thc water usage of thc family being served by th= system.
These conditions arc outsldc thc control of thc cvaluator of this system. All systems eventually fail and
satisfactory test results do not guarantee future performance of the system, nor do they guarantee fha:
there arc no hidden defects or encroachments. PES can therefore not provide any warranty fur future
performance nor give any estimate of how long the system will continue to meet the operational
requirements of thc MOA DSD. The content of this report is for the sole benefit of the owner listed
above. Any reliance upon or use of this report by any other person or party is not authorized nor will it
confer any legal right whatsoever.
5. DSD SIGNATURE
~ Approved for ~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
ON-SITE
WATER ANR
WASTEWATER
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: 7 - ~ ' O ~'
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 outl!ned 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 a!l applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Enqineednq Services, LLC Phone 272-8218
Address P.O. Box 102954, Anchoraqe, AK 99510
Engineer's Printed Name Stgven R Pannone, P.E. Date ~;/'~//~2~
Engineers Comments: In conducting an adequacy test, I aHempt lo provide a thorough, conscientious engineering anal).sis of the system in
accordance with MO^ DSD Guldc]incs & Regulations. Thc reported results deso~[bc the performance of Ibc system under thc conditions
cncountcrcd at thc time of thc test, and separation distanco$ measured lo readily identifiable features.
The operational life of all wells and septic systems depend on the local soil condition, ~Tound water
levels that may fluctuate during Ibc year, and the water usage of thc family being served by the system.
These conditions are outside Ihe control of the evalualor of this syslem..Ail systems evcotually fall and
satisfactory test results do not guarantee future performance of the system, nor do they guarantee tha:
there arc no hidden defects or encroachments. PES can therefore not provide any warranty for future
performance nor give any estimate of how long thc system will continue to meet the operational
requirements of the MOA DSD. Thc content of this report is for the sole benefit of thc owner listed
above. Any reliance upon or use of this report by any other person or party is not authorized not wil~ it
confer any legal right whatsoever.
~L
Ir~ Approved for ~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
,,,',;.\x, .-' -...
~'~ .- ON-SITE
~'=~ ~ WATFR ANn
: . WASTEWATER
-~ '<,,3~ - - · -
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
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:
A. WELL DATA
Well type private
Date completed 12/111978
Total depth 101 ft.
Rolling Hills Estates. Block C lot I
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform ~ colonies/lOOmL
Arsenic:
B. SEPTIC/HOLDING TANK DATA
If A, B, or C provide PWSID #
Sanitary seal (Y/N) Y
Cased to 1003 ft.
FROM WELL LOG
12/5/1978
'
g.p.m
Parcel ID: 011-072-11
;
Well Log (Y/N) y
: Wires properly protected (Y/N) Y
Casing height (above ground) 24 in.
; AT INSPECTION
611312008
Tank Type/Material
Tank size 1250 gal..
Foundation cleanout (y/N) Y
Date of pumping 6/13/2008
ABSORPTION FIELD DATA
71 ft.
1.4 gp.m.
~ bacteria '"~ colonies/lO0 mL
Nitrate ~/~L~) mg/L Other
Date of'sample: 6113108 ~ Collected by: Laura Pannone
Sunset Fiberglass
Number of Compartments
Depression over tank [Y/N)
Pumper A* Home Services
Date Installed 7110/1978
Cleanouts (y/N) Y
High water alarm (Y/N) N
Date installed ?I1011978 Soil rating (g.p.d.~' or ft2/bdrm) ~110 System type Deep Trench
Length 101 ft. Width .~2; ' ff. Gravel belowpipe 8
Total depth 13 ft. Eft. absorption area 1~15 ft2 Monitoring tube Y Depression over field _N
Date of adequacy test 6/13/2008 Results [Pass/Fail) p For 4_ bedrooms
Fluid depth In absorption field before test dry in.'
Elapsed Time: 428 min. Final fluid depth .~ in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type). N
Water added60._~0 gat. New depthdrv in.
Absorption rate >= 600+ g.p.d.
If yes, give date
D. LIFT STATION
Date installed
'Pump on" level at __ in. ~Pump.o
Datum
E. SEPARATION DISTANCES
vel at in.
Manhole/Access (Y/N)
High water alarm levet at
Meets alarm & circuit requirements?
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 92'*
Absorption field on lot 104'**
Public sewer main 100+
On adjacentlots 100+
On adjacent lots 100+
Public sewer manhole/cleanout
100+
Sewer/septic service line 50+ Holding tank 100+
Animal containment areas 100+"* Manure/animal excrete storage areas 100+
SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK ON LOT TO:
Building foundation 18'
Water main 50+
Property line 10+
Water service line 50+
Absorption field 8'
Surface water 100+
Wells on adjacent lots 100+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Fe
Property line 10+
Water Service line $0+
Curtain drain nla
COMMENTS
Building foundation 30'
Surface water 100+
Wells on adjacent lots 100+
Water main
Driveway, parking/vehicle storage
*MOA waiver qranted for well separation inside of 100' on 9/611988, *'Per feb 1998 COSA, "*Fenced Yard 10' from well
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven R. Pannone, P.E.
Date
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
~..,,:'[,.'~%11'.;~ ~F Ii~CODD, OTHER THAN
T,'-..~SE .t, HOWN GN TI.~ l~'Cr'JTOr,f.1
· ;T, .,w~! NOT SI.I.I.I~WN
SGS Ref.#
Client ,Name
Project Name/#
Client Sample ID
Matrix
1082749001
Pnnnone Eng. Sty.
Rolling Hills Est BIkC Loll
5108 W. 72nd Ave.
DrinkinR Water
All Daler,/Times are Alaska Standard Time
printed Date/Time 0~/27/2008 8:37
Collecled Date/Time 06/13/2008 I 1:30
Received Date/Time 06/13/2008 12:30
Technical Director Slephen C. Ede
PWSID 0
Sample Remarks:
Allowable Prep Analysis
Pardmcter Results POL Units Etethod Container ID Limits D~Ie Date Init
Hetals I~ff ZCP/H~
Arsenic
5.Sg $.00
ug/L EP200.8 C (<10) 06/17/0g 06119/08 NRB
Waters De,ar tment
Total Nitrnte/Nit~ite-N
ND 0.100 mg/L SM204500NO3-F B (<10) 06/26/08 JDZ
Hicrobioloc.~, I,~borato:~'
Colon>, Counl 0
Total Coliform 0
Fecal Colt foml 0
col/100mL SM20 9222B A (<200)
col/100mL SM20 9222B A (<11
col/100mL SM20 9222B A (<1)
0~13/08 DLC
0~13/08 DLC
0~13/08 DLC
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, # O I I -- O 7~L.-- I I
1. GENERAL INFORMATION .......
Com,p e:t,e legal description Lo'T' [ '~ V. ~._
Location (site address
Property owner
Mailing address
Lending agency
Day phone 5&t'/'',~ ? '''/ ' '~!
Day phone
Mailing address
Agent '"~;
Address
Day phone -- -"' '
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
comm'uhitY well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding
C¢
Public ~,;
attesting to the legality anc Sfatus of system.
Stat6
72-025 (Rev. 1/91 ) Front MOA #21
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. fbncti°nal add adequate for the number of bedrooms
and type of structure indicated herein. I furti~e'r V~rify that based on the information obtained from
the Municipality of Anchorage files andfrom my, investigation and inspection, the on-site WaterI~
sUpply and/or wastewater disp'osalSystem i~.in ~0mpliance ?ith all Municipal and State codes;~ '"'
ordinances, and regulations in effect on the date of this inspection.
NameofFirm "-~'~-~ ~::~.~,'J'¢-[4~" ~;~'~" Phone
I
Address ~% ~ :./~ ~'~ ~ ~ ' '
Date
Engineer's signatt~re
. DHHS SIGNATURE
'~- Approved for
/
Disapproved.
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
By:
Additional Comments
The Munioipali~ of Anchorage Department of Health and Human Services (DHH$) issues Health Authority
Approval Oertificme$ based only upon the representations given in paragraph § above by an independent
professional engineer registered in the 8tare of Alaska, The DHH$ does this as a oourtesy to pLirohasers of homes
and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not
Cdnduct inspections or analYzedat~ of AnchOrage is not
responsible for errors or omiSSions in the Pr°f~ssi°r~llengi~r's ~ork::
72-025(Rev, I/91) Back MOA#21
MUnicipality of Anchorage
[3epartment of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well ~pe
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Cased to
Date of test
Static water level
Well flow
Pump level1
Parcel I.D.
If A, B, or C, attach ADEC letter, ADEC water system number
Date completed )~. , 7~ ;?5 Driller
~ O I Casing height
Wires properly protected (Y/N) y
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~-"~:'~
Absorption field on lot ~ ~:)~
Public sewer main '~ !~
Sewer service tine ~ ~/~
g.p.m.
AT INSPECTION
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~
Date of sample: 2. ~
Nitrate
N ~ Other bacteria
Collected by: ~ ~ .~
B. SEPTIC/HOLDING TANK DATA
Date installed '7/I O / '7~ Tank s~ze I ~.. ~ t.~ Compartments ~-
Cleanouts (Y/N) ~/ Foundation cleanout (Y/N) Y Depression (Y/N)
High water alarm (Y/N) ~t/~. Alarm tested (Y/N) }"¢//~r~:
Date of pumping ~/t~ / '~ ~/ Pumper 1 ~ o,. ~ ~. '~,,~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~'"/"~ On adjacent lots > t ~
To property line .~ i i~ Absorption field (~
Surface wateddrainage
72-026 (3,93,* Front
Foundation 1 8
Water main/service line .'> .~'~
//t.j~/, ~/~,/...~.,~..//~y~:(/ ¢/~/~8¢¢'~ONTINUED ON BACK PAGE
C. LIFT STATION ~',,,~/^
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed -7/! 6> /
Length 1 (,,OI
Total absorption area
Date of adequacy test
Soil rating (GPD/Ft2) ~
Width ~_~ ' Gravel thickness
~ ~ I ~ Cleanout present (Y/N) ~
/~g /~'~ t~ Results (pass/fail) ~
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
System type
Total depth
Depression over field (Y/N)
for
After test ~
If yes. give date
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~ ~) ~'/
To building foundation
On adjacent lots ~ ~ ~
Surface water ~' ! ~,~
Curtain drain ~',1 I0
On adjacent lots ~ / ~ Property line
To existing or abandoned system on lot
Cutbank ~'~I ~ ~ ~' Water main/service line
Driveway, parking/vehicle storage area ~> I ~
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect 5n the date of this inspection.
Engineer's Name '~'13 d r-'~_...[~,...~ ~ ~ · :~::~
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
CT&ERef.#
Client Sample ID
Matrix
ClientName
Ordered By
ProjectName
Project#
PWSID
Sample Remarks:
Parameter
Commercial Testing & Engineering Co.
Environmental Laboratory Services ~jj~e-~r~-~r~-J,JJ~e'~'~'~'~e'~e'J~
LABORATORY ANALYSIS REPORT
94.0867-1
L1 B C ROLLING HILLS
WATER
TOBBEN SPURKLAND, P.E.
TOBBEN SPURKLAND
UA
RO~ SAMPLE COLLECTED BY: T.S.
WORK Order 76183
Printed Date 03/02/94 ~ 14:30 hrs.
CollectedDate 02/28/94 ~ 14:30 hrs.
Received Date 02/28/94 ~ 15:00 hrs.
Technical Director STEPHEN C. EDE
ReleasedBy: ~~" ~
QC
Results Qual Units
Allowable Ext. Anal
Method Limits Date Date
Init
Nitrate-N
0.10 U mg/L EPA 353.2/300.0 10
03/02/94 LLH
* See Special Instructions Above
** See Sample Remarks Above
U = Undetected, Reported value is the practical quantification limit.
D = Secondary dilution.
UA = Unavailable
NA = Not Analyzed
LT = Less 3ban
GT = Greater Than
5633 B Street, Anchorage, AK 99518-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH &, HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERT, F,OATE OF,NSPEOT'ON FOR HE^'T. AUTHOR,TY ^PPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Descrip.ti.on (include lot, block, subdivision, section, township, range)
· Location (address er directions)
:7¢:-¢'
(b) Property Owner/~'/-~_ ~/I/.~/i.?;$ Telephone: Hom. e
' Mailing Address -:~."~-~:::~ ~,,~-~.~//~g),~E~-. ~/~ ~/ /
(c) Lendinglnstitution ~ ~/'~~ Telephone
Mailing Address ~ / ~ ~ ~
(d) Reat Estate Company and A~ent- ~ ~, ~
Address //~/ ~ -2~ ~~ ~
Telephone ~- 7~'~/
Business
(e)
Mail the HAA to the followina address: or: Check here f-I, 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~L Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite~. 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.
Page 1 of 2 72-025 fRev 8/861 Front
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peufmqo uo!le~Jolu! aql uo pas~q jeqj XlpeA Jeqpnj I 'u!eJsq pe~eolpul eJnjonJls ~o edXl pue s~ooJpeq ~o Jeq~mu aql Jo1
ejenbepe pue leUmlounl 'e~es s! ~ejsXs lesods!p Je~MelSeM Jo/pue Xlddns JeleM elfs-uo eql Jeql SMOqS JeAoJddv
~lleaH mql ~o uolleS!JSaAU! X~ leqJ XlpeA I 'MOleq UMOqS elep uo!jepfleA eql ~0 S~ pue oleJe~ pexf~je lees X~ Xq pe!l!Pao sV
MUNICIPALITY OF ANCHORAGE (MO~',i
~.~,c~O~NG.~,LTH AUTHORITY APPROVAL (HAA)
.,.,~a~?/~U . ~C~ CHECKLIST- FEBRUARY 1984
~ ~ ~ . 264-4720
~0~"
~-~9~ ~ Legal Description: ~'/
~% ~/~
WELL DATA ~¢d¢
Well Classification "/~/~/M/"~'~)~'~ Ii A, B, C, D.E.C. Approved (Y/N)
Well Log Present, N) / Date Completed /~'~"- ~ Yield
Total Depth /42 / Cased to //4:~O.E / Depth of Grouting
Static Water Level ~ ¢~"/ Pump Set At
Casing Height Above Ground /~ 4/// Sanitary Seal on Casingl~N)
Electrical Wiring in Conduit~N) Depression Around Wellhead (Ye
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Fie~
To Nearest Public Sewer Line Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
;Date ~Z-- ,~--'~ --~'/,~'
Comments
6-7¢ //
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes~N) Air-tight Caps')
Depression over Tank (Yi~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well 7~' '~;Z-- /
Size /~--'~O No. of Compartments
Foundation Cleanout~Xl)
Date Last Pumped ~'''~¢~Z'-'~'¢~'
~/)4 ;for ,,~/~4
Temporary Holding Tank Permit (Y/N)
To Property Line /O
To Water Main/Service Line
Course /01)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page I of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot ,'~/
To Water Main/Service Line
Type of System Design
Length of Field /O/
Depth of Field / ~
Gravel Bed Thickness ~' ~
Standpipes PresentON)
Date of Last Adequacy Test
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area ?O
To Property Line
Comments
To Existing or Abandoned System on
; On Adjoining Lots /~
To Cutbank (if present) /
LIFT STATION
"Pump On" Level at ~ "Pump Off" Level at
High Water Alarm Level at ~ Vent (Y/N)
Tested for ~-,,,,~mping Cycles during Adequacy Test. Meets MOA
CommentsElectrical Codes (Y/N) ~~~
** Check Permitted Bedroom Rating Against HAA Request **
I certify that ~v/ch,~e~ verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection:
Signed ~-4.¢...------f~. ~ Date
Company /4,~-.5 MOA NO.
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
Tom Fink,
Mayor
Municipality of Anchorage
Department of Health and Human services
825 "L." Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
April 6, 1988
Alan C. Wien
Engineering Technician
Alaska Environmental Control Services, Inc.
1200 West 33rd Avenue, Suite B
Anchorage, Alaska 99503
Subject: Waiver Request For Lot 1 Block C Rolling Hills Estates
Waiver Request Number WR88-011
Dear Mr. Wien:
Your request for waiver of the required 100 foot separation
from a private well to a private septic tank for the subject
lot has been approved. This separation has been waived to 90
feet.
Points supporting this approval are: i) The Water Well appears
to be supplied by a confined aquifer and has solid casing to
this aquifer, 2) the house that stands between the septic tank
and well should act as a barrier to protect the well from any
surface contamination that may originate from the tank.
This approval applies to the existing well to. septic tank
only. Any future upgrade to either will require all separation
distances be met or another approval from this department.
Sincerely,
Daniel J. Roth
civil Engineer
On-Site Services
cc: Gus Andress, P.E., Manager
On-Site Services/Water Quality Programs
ALASKA enUlROllmenTAL CO ITROL $1 RUlCi $,
I~nclineerincI F., I~nuironmental Studies
InC.
March 25, 1988
Municipality of Anchorage
Department of Health & Human Services
825 L Street
Anchorage, AK, 99501
Re: Lot 1, Block C, Rolling Hills Estates Subdivision
Waiver Request - Well to Tank
Our Health Authority inspection shows the septic tank cleanout pipe to be 92
feet from the well. The well was not in when the sewer system was installed,
however, the sewer asbuilt contains a waiver of 90 feet from proposed well to
tank and approved by Les Buckholtz of the MOA.
The tank is a 1250 gallon Sunset Plastic tank. The well depth is 101 feet and
cased to the bottom. On 2/29/88, a well flow test showed static level at 72
feet and a yield of 2.3 GPM with a 20 foot drawdown to the pump level.
The house is located between the two.
the north which is away from the well.
satisfactory.
Surface drainage from the tank is towards
Water samples taken 2/29/88 are
We request that you grant a current waiver of the separation distance.
If you have any questions, please call.
Sincerely,
Alan C. Wien
Engineering Technician
Approved by:
ALASKA ENVIROI~MENTAL
CONTROL SERVICES, INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
SHEET NO.
CALCULATED BY
CHECKED BY
SCALF
OF
DATE
I I
FEDERAL TAX ID # 92-0040440
ANALTSIS REPOR~ 8Y SAM?gE £or Work Order ~ 5397
Date Report Printed: I~AR 3 88 8 i1:01
Client Sample ID:Lt, BLK C ROLLING HILLS EST.
PWSID :UA
Collected FEB 29 88 8 16:20 hrs.
Received FEB 29 88 8 16:47
Preserved with :NONE
Client Name : AECS
Client Acct : AKECSRP
P.O.~ NONE REC'D
Req $
Ordered By :
Analysis Completed :~AR 2 88 Send Reports to:
I)AECS
Laboratory Supervisor~_.~_~_~__~:STEPHEN C. EDE
Released By :
Special
Instruct:
Chemlab Ref $: 9237 Lab Smpl ID: 1 Matrix: Water
Allowable
Parameter Tested Result/Units Method Limits
NITRATE-N ND(O.iO) mu/1 EPA 353.2 IO
Sample ROUTINE SAMPLE.
Remarks: SAMPLE COLLECTED BY A. WEIN,
Tests Performed ~ See Special Instructions Above UA=Unavailable
None Detected ** See Sample Remarks Above
Not Analyzed LT=Less Than, GT=Gzeatez Than
.~ ~/IUINI~.IYALII y (DF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT. OF t~ALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECr~ONMENTAL i.:FiOEECTION
825 L Street - Anchorage, Alaska 99501
MAR 1 6 I97g
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 284-4720 RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be processed. Please allow ten (10) days for processing.
1. P~PERT~ OWNER PHONE
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE
3. LENDING INSTITUTION
MAILING ADDBESS
4. REALTOR/AGENT I PHONE
1
MAILING ADDRESS
5. LEGAL DESCJ~IPTION
STREET LOCATION
o.0 Lc.
6. TYPE OF RESIDENCE
/~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One ~ Four
[] Two [] Five
[] Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.}
8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
**If individual/on-site, give installation date ~("y ~/ Jc~.~ ~
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78) ~
THIS SIDE FOR OFFICIAL USE ONL,
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
1. TYPE OF RESIDENCE NUMBER DF BEDROOMS
[~SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [~ FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[~/INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified_ LOG RECEIVED
[] INDIVIDUAL/ON -SITE
DATE INSTALLED ~/ .
[]PUBLIC UTILITY S L?R
Connection Verified IN TAL
[]Septic Tank or [--]Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF ~1~ ~ MAN
TOTAL AB~p~AR EA MATERI~
INearest Lot Line
I
Absorption Area to nearest Lot Line
[] APPROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must a,,e~ompany certificate)
H
~_~-E)ISAPPROVED I~ //
DATE ~/ ~ -~ "~ ~ BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-66~0
www.muni.org/onsite
(9071 343-7904
CERTIFICATE OF ON-SITE SYSTEM S APPROVAL CHECKLIST
Legal Description: .. Rollino Hills Estates, BI~ck C I~t 1
A. WELL DATA
Parcel ID: 01f-072.11
Well type Private
Date completed 12]111978
Total depth 101 ft.
Date of test
Static water level
Well production
If A, B, or C provide PWSID #
Sanitary seal '(Y/N) Y
Cased to 10018 ft.
FROM WELL LOG
:
. /.c d ·
g.p.m.
Casing height (above ground)
: AT INSPECTION
6/1312005
71 ft.
1.4 g.p.m.
Well Log (Y/N) y
Wires properly protected (Y/N) y
24 in.
WATER SAMPLE RESULTS:
Coliform ~ .colonies/100mL
Arsenic: _~'; <~mg/1
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Sunset Fiber,lass
Tank size 1250 gal..
Foundation cleanout (Y/N) Y
Date of pumping 6/13/2008
Co ABSORPTION FIELD DATA
Nitrate !/~l)p mg/L Other bacteria '~colonies/100 mL
Date of sample: 6/13/08 Collected by: Laura Pannone
Number of Compartments _2
Depression ~ver tank (Y/N) J~
Pumper A+ Home $e~/Ices
Date installed 711011978
Cleanouts (Y/N) Y
High water alarm (Y/N) N
Water added650 gal. New depthdrv in.
Absorption rate >= 600+ g.p.d.
If yes, give date
Date installed 7/10/1978 Soil rating (g.p.d.~ft2 or ff2/bdrm) :[110 System type Deep Trench
Length 101 ft. Width .32" ft. Gravel belowpipe 8
Total depth 13 ft. Eft. absorption area 1616 f~ Monitoring tube Y Depression over field N
Date of adequacy test 6/13/2008 Results (Pass/Fail) P For_4 bedrooms
Fluid depth in absorption field before test dry In.'
Elapsed Time: 428 min. Final fluid depth dry in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N
D. LIFT STATION ~/~,,,
Date installed
"Pump on" level at __ in. "Pump~
Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL
Septic tank/lift station on lot 92'*
Absorption field on lot 104'**
Public sewer main 100+
Sewer/septic service line 50+
Animal containment areas 100+***
?
vel at
3N LOT TO:
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?.
On adjacent lots 100+
On adjacent lots 100+
Public sewer manhole/cleanout 100+
Holding tank 100+
Manure/animal excrete storage areas
100*
SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK ON LOT TO:
Building foundation 18' Property ne 10+ Absorption field 8'
Water main 50+ Water service line 50+ Surface water 100+
Wells on adjacent lots 100+
Water Service line 50+
Curtain drain
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Propertyline '10+ Buildingfoundat[on 30'
Surface ~water 100+
Wells onladjacent lots 100*
Water main 50+
Driveway. parkingNehicle storage. 10+
F. COMMENTS
'MOA waiver .(:!ranted for well separation in side of 100' on 9/611988, *'Per feb 1998 COSA, *"Fenced Yard 10' from well
G. ENGINEER'S CERTIFICATION
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
I cerlify that I have determined through field inspections and
review of Municipal records that the above systems are In
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven R. Pann~ne, P.E.
Date
Waiver Fee $
Date of Pa~ent
Receipt Number
,..,.:,~,4.~,~r.~ hi: IF. CO,D, I~THffli THAN
D-..~E SHOWN ON TNI~
· :T, ..a~-_. NOi' SHOWN