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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Heallh Division 0
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
N.,~..Z~/~ ~ ~ /~ ~.~ / ~? . DISTANCES
A~ /0/~ ~/ ~ar~ ~ ~'~7~ TANK FIELD WELL
Phone(s) Permil No. Bedrooms WELL
- ,~/~t~ ~ .2 FOUNDATION
Township, Range, Section
AS-BUILT DIAGRAM (Show location of Well, septic system, properly lines, foundation,
'~/ ~/~ /~ ]/d ~ ~/ -- driveway, water bodies, etc.)
TANKS - U
SEPTIC ~ HOLDING
~ Capacity in gallons /~
Manulacturer
Material NO, el Compadments
TYPE OF SYSTEM /
~TRENCH ~ BED ~ W. ~ OTHER
Depth to pipe bottom Item T~al~th from original grade
original grade F~/ FT
.
Fill added above original grade ~Gravel depth benealh pipe
Gravel length Gravel width
ET FT
Total absorption area Distance between lines
., ,1 /
S0 FT
Insteller ~ Date installed
WELLS
~ PRIVATE ~ OTHER fldentifv)
~ / ENGINEER'S SEAL
inspections Pedormed by:
Municipal and ,tale guidelines in ellec, on~s date:
72-01;3 (3/85)
. ,;:~ -~!~ · "- ...... , , . · . WATER WELL RECORD .
: : · , · >:~-~ .... ~.,,,~. ..... : ......... .~..,.-_,:- -.,. ,.~ .... - ,., · .- .,,, :.DEPARTMENT OF NATURAL RESOURES.~'
.r..~.: LOCATION~'OF,:WEL'E' ~ (PI~;~ ' ' ' I~:~b ;~ 'lc~ ) ~;:'"'~ ;~';:~';':'~'~';'::::'~'': ........
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
MAI LING ADDRESS
LEGAL DESCRIPTION
LOCATION
DISTANCE TO:
Menufacturer~, )"¢ ~
Inside length
IF HOMEMADE: ......
Well Dwelling
DISTANCE TO:
Manufacturer
Liq. cape(
F o u ndat io~ 0~'
Well
DISTANCE TO:
No. of lines / Length of eacl~ line._,
/
Total length of linis'
Material benea~ftile
Depth
Dwelling/~ O/~ i'~,
Material~'F&& /
W dth ......
Material
Nearest let line 4 t
Trenc~ widt~ inches
inches
PHONE
~¢b~ 0 ~ 7o
[~]NEW
[~)UPGRADE
NO. OF BEDROOMS
PERMIT NO. , , ,
/-/~,, d~r, #eh
No. of compartments ~
Liquid depth
PERMIT NO.
Liquid capacity in gallons
Top of tile to finish grade,~_ / _ ~ i
Length Width
Crib diameter
Well
DISTANCE TO:
Depth
Building foundation
PERMIT N~O, . , ~
Distance between lines,(~..
Total effective absorption area
3 '7 q ,£/~
PERMIT NO,
Type of crib Crib depth Total effective absorption area
Building foundation Nearest lot line
Class Driller Distance to lot line PERMIT NO.
DISTANCE TO: Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALSp V C:
SOIL TEST RATING
12 ~-
INSTALLER
APPROVED
DATE
LEGAL
./
72-013 (Rev. 3/78)
MUNICIPALITY OF ANCHORAGE
? Health and Environmenta
~ Street, Anchorage, AK.
Department 7rotection
825 ~9501
264-4720
* * * HANDWRITTEN PERMIT * ~ ~
Permit ~(~,~}~./rC~ WELL AND~J~ ON-SITE SEWER PERMIT
Applicant: ,,. ~/-~/' ()/?/~/~'-~3,~// Mailing Address:
Phone Number: ~L~-~3J
Location:
Legal Description: ~,~--) .~'~.g./]d~--~ ~7~')/~:~&~"~-~ Size:
Type of Soil Absorption System Is:
Trench: ;,~-' Drainfield:
Maximum Number of Bedrooms: ~
Seepage Bed: Holding Tank:
Soil aating(sq.ft/br) ~
The Required Size of the Soil Absorption System Is:
DEPTH /? LENGTH /c/ . GRAVEL DEPTH //~ WIDTH
The length dimension is the length(~n feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTtC~Ot;B~Bf~TANK SIZE = /~>C~) GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * ~
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31~ 1 9 8 S * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
to include more th.a,th bedrooms. Issued by:~~-~
Date:
the. eside is emodeled
X~P~ant
SWP/024(1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED FOR:
DATE PERFORMED: '~t_-- ~.Q:~ '- (~:~'~
LEGAL DESCRIPTION:
3
5
6
7
8
9
10
11
12
13
'~' ,.~'14
15
16
17
18
19
2O
SLOPE SITE PLAN
WAS GROUND WATER ~,'t ~:) S
ENCOUNTERED? ~
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
COMMENTS ~/ L% t) tN L ""~ ~'~- ~ ~ C
TEST RUN BETWEEN FT AND
72-008 (6/79)
CERTIFIED BY:
ALASKA ENVIRONMENTAL
CONTROL SERVK ', INC.
1220 West 25th Avert, Suite B
ANCHORAGE, ALASKA 99503
276-~361 · 279-29~.7
(
[V~-W DRILLING, Inc.
Box 10-378 * 10300 Old Seward Highway
(907) 349-8535
ANCHORAGE, ALASKA 99511
DRILLING LOG
Well Owner CI.^J~i ,c. Tl~4f~.~,.LT,7~I,~": Use of Well Doraest:tc'
Location (address of: Township, Range, Section, if known; or distance main road !~t 6 Tract 5 Siaflcer.'~:..~
Size of casing fi''' Depth of Hole
Static water level
Screen ( ); Perforated (
5~ feet Cased to 53.2 feet
(below) land surface. Finish of well (check one) open end ( xx
).
Describe screen or perforation ~k:a'te
Well pumping test at rfc gallons per ~6}:
of drawdown from static level.
(minute) for 1 hours with 10~'/~
Date of completion July 13; 198~
WELL LOG
Depth in feet from
ground surface
0 .TO. 2
Give details of formations penetrated, size of material, color and har6lness
2 .TO. 4
50
.TO.
TO
.TO
.TO.
.TO.
.TO
.TO
.TO.
TO
~TO
.TO
Brown clav mud Kravel
NW1NA C~-ttfied
C_~.~_~_--_te iMM_._ ~f ~
3--CONTRACTOR
61 F. ' \
•- Municipality of Anchorage ti �°P=
t
On-Site Water and Wastewater Program o��
(907) 343-7904 a JUN 0 Iw r (.1 IAA a
.may
��
si
Certificate of On-Site Systems Approva c : e g`AV%.\
Parcel I.D. 015-281 -48 Expiration Date: 61-2,3-/7
1. GENERAL INFORMATION
Complete legal description Siefker #3 Tract 5 Lot 6
Location (site address) 3740 Cleo Avenue
Current Property owner(s) Scott & Julie Duby Day phone
Mailing address 3740 Cleo Avenue Anchorage, AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING:
H Single Family (w/wo ADU)
❑ Duplex
n Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well H Individual H
Individual Water Storage Holding Tank ❑
Community Class Well n Community n
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received b1 I CS jjDate:
COSA to be released to the engineer, unless otherwise requested by the en . r.
COSA Fee $ 5a , Waiver Fee $
Date of Payment 4,/ -71/7 Date of Payment
Receipt Number U c165-3 _ Receipt Number
COSA# 3�5C / 1 aas 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.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and 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 system.These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system. nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone Date 6/7/2017
'6. OFAt, '
1
6. DSD SIGNATURE g -• --
•••• �' - 1P• • • • 0
it System #1 Approved for bedrooms %Steven R. Pannone .
r CE-8149 ��
System #2 Approved for bedrooms 9 ' �
.
Disapproved illgf \\Or-ES P •
Conditional approval for bedrooms, with the following stipulations:
\-C•( OF h/ •
ON-SITE cG:
WATER AND
rt WASTEWATER
•
PROGRAM
By / (" ' Original Certificate Date:
The Municipality of Anchorage 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 •
• ' ' • 3,-4
,
COSA blue sheet_c
If more than 1 septic system is on the lot:
COSA Checklist# 1 of 1
Structure served by this system '
Certificate of On-Site Systems Approval Checklist
Legal Description Siefker #3 Tract 5 Lot 6 Parcel ID 015-281-48
A. WELL DATA
Well type Private If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed 3/6/1990 Sanitary seal (Y/N) Y Wires properly protected (YIN) Y
Total depth 113 ft Cased to 113 ft. Casing height (above ground) 24+ in.
FROM WELL LOG AT INSPECTION
Date of test 3/6/1990 5/23/2017
Static water level 32 ft. 48 ft.
Well production 15 g p m 5 g p m.
WATER SAMPLE RESULTS.
Coliform NEG colonies/100 mL Nitrate ND mg/L
Arsenic ND ug/L Date of sample: 5/23/201 7 Collected by: PES
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 6/10/1983
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 5/19/2017 Pumper A+ Home Services
C. ABSORPTION FIELD DATA
Date installed 6/10/1983 Soil rating (g.p.d./ft2 or ft2/bdrm) 125 SF/BDRM System type Trench
Length 41 ft. Width 5 ft. Gravel below pipe 3.5 ft.
Total depth 8 s_i i 5 ft. Eff. absorption area 379 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 5/23/2017 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test DRY in. Water added 450 gal. New depth DRY in.
Elapsed Time: 90 min Final fluid depth DRY in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo ) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off" level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 86* On adjacent lots 100+
Absorption field on lot 100+ On adjacent lots 100+
Public sewer main 75+ Public sewer manhole/cleanout 100+
Sewer/septic service line 25+ Holding tank 100+
Animal containment areas 50+ Manure/animal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line 5+ Absorption field 5+
Water main 10+ Water service line 10+ Surface water 100+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 10+
Water Service line 10+ Surface water 100+ **
Driveway, parking/vehicle storage
Curtain drain 50+ Wells on adjacent lots 100+
F. COMMENTS
Survey on file. *Waiver on file #WR890067. Tank has 2" of insulation over top.
**Partially under driveway, trench insulated for driveway.
G. ENGINEER'S CERTIFICATION ..+� OF AL.•Ak
I certify that I have determined through field inspections and j�%.P �)� ...*9
����
review of Municipal records that the above systems are in r*. 49 TH / ' •.* 9
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven Pannone • �� Pannone:
Date 6/7/2017 liars. CE-8149 . '0%
+�li. Aois�icP� �
COSA canary sheet_2-6-15.doc
CLEO AVENUE
0
``' b
r7
ill L
E,
S89° 57' 40"E 84.00'
Os:
CV _ N. oda.. ...
--• -15.9' . :. ....:.....:
�1 45.2'
flEXISTING HOUSE � .
, �
el
C 45.2'
O 1 s.-nii i 31#1 C
O I.......,..X..,,..,..,. O
04 CA
LOT 5 .— A '
x W LOT 7
OO
NI- I
F._
• x CONCRETE BLOCK
° RETAINING WALL
O
Z x to
x
LOT 6, TRACT 5,
SIEFKER SUBDIVISION x
x NO. 3
x
— —
J
10' UTILITY EASEMENT _ _ X
--- X ' X -- -- X --- -- X f- X
N89° 57'40"W 84.00' 1 -- -
44Qoaappp
,„,,:„<„,c,..............:.<11/4.5,,1111
. : V LOTS LOT B
10-
e, 4 s °ao
'.• 49TH i`.. %�0V
g....
d.,.. .€44....,
m •. STEVEN CALLA AN • o D
PQO e• •'• r_L _-1 034 .•••4 Q0
'4OJr°fe•ssi•o•n0\ \''4� NOTE:
"ppaa�a THIS DRAWING SHALL NOT BE MODIFIED FOR USE AS A PLOT PLAN
WITHOUT THE EXPRESSED WRITTEN CONSENT OF LCG LANTECH.
ORDERED BY: JULIE AND SCOTT DUBY PARCEL No.015-281-45-000 SURVEY CERTIFICATION:LCG LANTECH.INC HAS CONDUCTED A PHYSICAL SURVEY OF
THE PROPERTY AS SHOWN ON THIS DRAWING AND CERTIFIES THAT THE
LEGAL DESCRIPTION: ADDRESS- 3740 CLEO AVE. IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO
ENCROACHMENTS EXIST OTHER THAN NOTED
AS-BUILT
EXCLUSIONARY NOTE:IT IS THE OWNERS'RESPONSIBILITY TO DETERMINE THE
LOT 6, TRACT 5, EXISTENCE OF ANY EASEMENTS,COVENANTS.RESTRICTIONS OR RIGHT-OF-WAY
TAKINGS WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. UNDER NO
SIEFKER SUBDIVISION NO. 3 CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION,FOR
ESTABLISHING PROPERTY LINES,OR FOR PLOT-PLAN PURPOSES.
LEGEND:
25x0 H Street SEPTIC STANDPIPE 0.... ea=fen: ..........
Anchorage, Alaska 99501rre Overhang Asphalt
.y WATER WELLyy�d Deck.r` Concrete
\ } Survey Department FENCE —X—X— - -
Phone 562-5291 DRAWN DATE: 6120117 WORK ORDER: 17043
"tom~. Inc Mainline DRAWN BY: AP PLAT: 70-90
e Phone 243-8985 CHECKED BY: SC GRID: SW2735
SCALE: 1"=20' FB/PG:68/18 REF:89L266
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address ~r d~rectLoe~s) , ~.~: ', , ..
(b)
Property owner ,' h:/'/~-% ~-
Mailing Address '° '
Telephone: (home)
Business
(c)
Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent
Address
Telephone
(e)
Mail the HAA to the following address: (or check here~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family..~ Number of bedrooms
3. WATER SUPPLY
Individual Well~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site I~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
leAoJdd¥ leUOR!puo0 Jo sLu.,e/
leUO!t!puoo 'pe^oJddes!O //~" pe^o~dd¥
7~/~~ /'/ /' '" ~q SLUOOJpeq ----~-- JO, pe^oJddv
A. WELL DATA
Well ~Classification
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authorily Approval (HAA)
CHECKLIST- FEBRUARY 1984
343-4744
Legal Description: Z'¢/
If A, B, C, D.E.C. Approved (Y/N) /4///~¢
Date Completed -~,/~.,/¢,'~ Yield /J'-,/';/¢,*-~ ·
//,3 Depth of Grouting '
Pump Set At //o
Sanitary Seal on Casing ~/~N)
Depression Around Wellhead (Y¢~'
Well Log Present~"~)/N)
Total Depth //.3 Cased to ....
Static Water Level .~-~ ~
Casing Height Above Ground
Electrical Wiring in Conduit ~N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by / ,
Water Sample Test Results /2)0 c-'/:
Comments ~-'~,,~ "/Lo f,¥-¢-/_?
; On Adjoining Lots
/<2~ ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
/
B. SEPTIC/HOLDING TANK DATA
Date Installed ~//'~¢/~'~ Size /~¢¢
Standpipes ~'~N) Air-tight Capsc/~N)
Depression over Tank (Y/~
Pumping/Maintenance Contact on File (Y/N)
Holding Tank HighrWater Aiarti~ (Y/N)
SEPARATIONO!S.TANOES:~FRbM SEPT C/HOLD NG TANK:
To Water-Supply Well , < , ~-~¢'~ .. '
To Propert~ Lin~- ....
No. of Compartments
Foundation Cleanout
Date Last Pumped ,~ --/¢ ~'~¢
;for
Temporary Holding Tank Permit (Y/N)
To Water M~'i~/S'erv~e:Li"n'e '. ,' ::.; "-Z-F.'-¢ /
To Stream, pbnd; ,17~k~ or Major Drainage Course .~/¢¢
Comments ~'~-~-%-, ~ /lac .~ ~c~'[ /**Jul>/z~ ~'~'~z/ ~o,.~ //~.* C/~ ~.~
72-026 (Rev. 7/88) Fron~ Page 1 of 2
To Disposal Field
/
To Building Foundation /~'~
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area ,~¢
Depression over Field (Y/6i'
Results of Last Adequacy Test /¢¢/~? '~¢ ~-~
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well /'¢¢-
To Building Foundation ./~) (*'
Lot ~,/L J~-~.t.,~z4/6
To Water Main/Service Line ~'.J'- ',~
Type of System Design
Length of Field z// /
Depth of Field ¢¢"'J' --//.,)~
Gravel Bed Thickness c//Z "'
Statndpipes Present (~'.~)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots //~ ~- ·
To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date I n S'~....._ Dimensions
Size in Gallons ~ Manhole/Access (Y/N~. ~'~'
"Pump On" Level at ~ ~ ~) / _ "~.m..~Of-f~evel at
High Water Alarm Level at -""---~~ Vent (Y/N) _
Tested for ¢.~-'~/ %~ Pumping Cycles during Adequacy Test.
Meets MOA Electrical Codes ~ /
Comments ~..--"'~ '
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
Signed
Company
Date
MOA No.
Receipt No. ~ / '~ -~-~ /(~'7/d~/
Date of Payment , ,.~ '--/~-~-~,~"~'~ '
Amount: $ / /fP'
eeee ee % ~ ~nglneer s ~eal
Receipt No.
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
Tom Fink,
Mayor
unicipality of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
March 16, 1990
Leroy C. Reid
Alaska Environmental
Control Services, Inc.
PO Box 240668
Anchorage, Alaska 99524-0668
Subject:
Waiver Request for Lot 6 Tract 5 Siefker Subdivision #3
Waiver Request ~WR890067, PID ~015-281-48,
Permit 9SW900032
Dear Mr. Reid:
Your request for waiver of the required 100 foot separation of
a septic system to a private well has been approved. The
approved separation distance is 86 feet from well to septic
tank on the subject lot.
This waiver approval applies to the existing septic system to
well separation 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
C°ncuri~ ~
On-site Services
ljm:#6
Tom Fink,
Mayor
Department of Health and Human Services
$25 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
February 9, 1990
Leroy C. Reid, P.E.
Alaska Environmental Control Services, Inc.
P.O. Box 240668
Anchorage, Alaska 99524-0668
Re: Waiver Application WR890067, Lot 6 Tract 5 Siefker ~13
Subdivision, P.I.N. 01528148
Dear Dr. Reid:
This office has completed its evaluation of the subject waiver request. Based
on our review, the waiver of the required 100 feet separation distance between
the proposed well and the existing septic tank is approved. The approval is
for a separation distance of 85 feet.
Because this waiver is being approved prior to completion of the well, it is
understood that the following conditions must be met for this waiver to remain
valid:
When the new well is constructed the septic tank shall be exposed to
verify tank integrity, the presence of water tight couplings, and
manhole gaskets. As an alternative to exposing the septic tank, you
may through the analysis of well logs from adjacent wells, provide
documentation which supports the conclusion that the aquifer
supplying the new well is confined and slopes away from the well
towards the septic tank.
The well shall be constructed with solid casing to a depth no less
than 80 feet.
Should either of the above conditions not be met within 120 days from the date
of issuance of this waiver, the waiver will become void.
This waiver approval applies only to the separation distance between the
existing septic tank and the proposed well. Any future upgrade to either will
require all separation distances be met or another approval from this office.
Sincerely,
Daniel J. Roth
Civil Engineer
On-Site Services
Program Manager
On-Site Services
Municipality Anchorage
Department of Health and Human Services
Tom Fink, 825 "L" Street
Mayor P.O. Box 196650 Anchorage, Alaska 99519-8650
January 30, 1990
Leroy C. Reid, PhD, P.E.
Alaska Environmental Control
Services, Inc.
P.O. Box 240668
Anchorage, Alaska 99524-0668
Subject: Request for Separation Distance Waiver
Lot 6, Tract 5, Siefker No. 3
Dear Dr. Reid:
This office has completed its evaluation of the subject request
for waiver of the required 100 ft. separation distance between
an existing septic tank and a proposed well location. The
request was for a separation distance of 85 ft.
The request for waiver was evaluated in accordance with the
Alaska Department of Environmental. Conservation (ADEC) waiver
review guidelines. Our evaluation of the supporting
documentation, which accompanied the request, yielded a total of
10.9 points. In accordance with ADEC waiver guidelines, a
minimum of 16 points is required for issuance of a waiver unless
the presence of special construction techniques and/or
mitigative factors is documented. Therefore the request for
waiver is denied.
Resolution of the separation distance deficiency may be pursued
by any of the following three alternatives:
You may prepare and submit additional supporting
documentation which supports the assignment of 16 or
more points in accordance with the ADEC waiver review
guidelines.
Kids Are Our Future
Dr. Leroy Reid
January 30, 1990
Page Two
2 o
You may prepare an engineering report that documents
special construction techniques and/or the presence of
mitigative measures or factors which support the
issuance of the waiver. Such a report must conclude
that there is a negligible possibility or probability
of the wastewater system serving as a point source of
contamination to the well. This conclusion must be
supported by an appropriate engineering analysis.
You may relocate the offending well or wastewater
system.
If you have any questions, please call me at 343-4744.
Sincerely, ~
PJ~ha~a~Er; On-site Services
cc: Dan Roth, Civil Engineer, On-site Services
I
..- eFIUIRO ITIE FITAL COFITROL S( RUIC $, Ii'lC.
~n~in¢¢rincI ~ ~nuironmcntd $1udics
" P. O. Box Z40668
'G . r, %~ ~ '~, ~Anchorage,AK 99524-0668
.:~,. -J+, (907) 279-5553 *** FAX (909) 276-8706
November 14, 1989
Department of Health & Human Services
~unictpa]ity of Anchorage
P. O. Box 196650
Anchorage, AK 99519-6650
RE: Lot 6, Tract 5, Siefker #3
WR 890055
Geatlemen:
On February 15, 1989, a waiver request was made to allow the
septic tank to remain 91 feet fram the we].l. On February
24, the waiver was issued. See the attached letter. Since
then, the lending institution has decided that it will aot
lend money on this house unless the well is moved to outside
the utility easement.
The well can be moved and not impact the ne:[ghbor's system,
Lot 7, if it is moved to the location shown on the attached
site p]an. This will place it exactly 100 feet from the;
edge of the neighbor's septic tank (Lot 7) and 100 feet from
the edge of the existing 5 feot wide drainfield, on this
lot. The distance to the septic tank on this lot will be
reduced from 91 feet to 85 feet.
The tank is only 6 years old, so it still should be in good
repair. The house has bean vacant since the Health
Authority was issued on February 27, 1989.
In my prefessional opinion I do not think that tthe issuance
of a new distance waiver of an additional 6 feet will create
a health hazard. I therefore request that you issue a new
waiver.
LCR/sr
Sincerely yours,
Leroy C. Reid, Jr.
PhD, PE, DEE
President
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4?44
Parcel I.D. Ct ...
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property owner
Mailing Address
·'Telephone: (home)
Business
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent ~/'~'~'~'/;~'
Address
Telephone
(e) Mail the HAA to the following address: (or check here (~, if hold for pick up.)
List contact person and day phone number below:
-
2. TYPE OF RESIDENCE
Single-Family I~ Number of bedrooms --~
3. WATER SUPPLY
Individual Well [~
Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 {Rev. 7/88) Page 1 of 2
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, Iverifythat myinvestJgation of this
Health Authority Approval 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 further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
NameofFirm ~'~"~-' '~' ' Telephone ¢~'~) 2 ~'~'- ,.~"'5'-5'-3
6. DHHS APPROVAL
Approved for ~
bedrooms~~/C~
Approved ~ Disapproved Conditional
Terms of Conditional Approval
Date
The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph S 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. TheMunicipalityofAnchorageisnot responsible for errors or omissions
in the professional engineer's work,
72-025 (Rev. 7/88) Back Page 2 of 2
A. WELL DATA
Well Classification
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST- FEBRUARY 1984
343-4744
Legal Description:
Well Log ,Present
Date Completed
If A, B, C, D.E.C. Approved (Y/N) ~
'~-,/,~---~2'~ Yield 0-2 ~','~-/~r 4,l~'~
Total Deptti~'l '~ Cased to L~Cw
Static Water Level ~
Casing Height Above Ground / ~'¢-~
Electrical Wiring in Conduit ~N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot ~, / '
Depth of Grouting _ /,.,//(~
Pump Set At /'~"/( ~
Sanitary Seal on Casing (~)
Depression Around Wellhead (Y(~_
,..~/:¢.Y/i~.TM) ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot /{/o¢C/.- .
, On Adjoining Lots
To Nearest Public Sewer Line /t,,/~ To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by ~ ~~ ~,~,~. ;Date C~~ ~
Water Sample Test Results ~c~ ~ ~~5 ~,~ ,
Comments ~1( ~1~ '~ ~'~-~ ~ ~ ~ ~.'~
B. SEPTIC/HOLDING TANK DATA
Date Installed ¢'-/¢~ *>~ ze/~¢ ~a4. No. of Compartments
Standpipes ~N) Air-tight Caps ~) Foundation Cleanout (Y~
Depression over Tank (Y/~)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Date Last Pumped ~_//~ ~v~ /,¢/t~C5
Temporary Holding Tank Permit (Y/N) /?//~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-sUpply Well '~:~// ' ~'¢
To Property Line ~ '?'/~ z"
To Water Main/Service Line ~.,.5'" ~
To Stream, Pond,, bake Or Major Drainage Course
To Building Foundation
To Disposal Field
Comment~
72-026 (Rev, 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ -{¢_.;1~ ~.-.~
Width of Field ~
Square Feet of Absortion Area ¢-~' '
Depression over Field (Y,~
Results of Last Adequacy Test /¢dd-fl..c~,¢~._- '" '
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well ,/(:~ ry.._
To Building Foundation /'C_.~
Lot L-~CkKr~ccc'rl ;On Adjoining Lots
To Water Main/Service Line ~"/+'- To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course /~:::~(..2"
To Driveway, Parking Area, or Vehicle Storage Area ~ ¢''\~
Comments '7"-,E~c.f/ ,,,J.~ ~.'r'~ /¢~
Type of System Design
Length of Field ~ / '
Depth of Field ~'.
Gravel Bed Thickness
Statndpipes Present (~N)
Date of Last Adequacy Test
k.
To Existing or Abandoned System on
aTION
lied
Size in G~
"Pump On" Level at ~
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
~,~ Vent (Y/N)
~"'"~ ~mping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection..4
Signed
Company
Date
MOA No. '¢~['
Receipt No
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back Page 2 of 2
Tom Fink,
Mayor
' ' 'it
un c pai y of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
February 24, 1989
Lee Reid, P.E.
Alaska Environmental Control
Services, Inc.
1412 West 33 Avenue
Anchorage, Alaska 99503
Subject: Waiver Request for Lot 6 Tract 5 Siefker Subdivision ~3
Waiver Request #WR890055, HA890006
Dear Mr. Reid:
Your request for waiver of the required 100 foot separation of
a septic tank to a private well has been approved. The
approved separation distance is 91 feet.
This waiver approval applies to the existing septic system to
well separation only. Any future upgrade to either will
require all separation distances be met or another approval
from this department.
Sin ely,
/ ·
Civil Engineer
On-site Services
RWR/ljw 96
ALASKA eFIUIROI meF1TAL COFITROL SeRUlCe$, IrlC.
I~n~]in~¢ria~ 6 I~nuir0nm~nld $1udies
MLu") lc i i:::,a :1. i ty (::)'f: An c I'a(::~ rag e
]}el::)ar'trn~:~l"~t o'f: Hea:l.'l:h and t...lum~n Ser"vices
825 L.. S'~:reet, Su:i. te 502
Ar'u]l"~or'age, Al< 9950.t.
A"FTIxl: I}an R(::)t h
I:;;E:: Lot 6, Tra(:::t
F:'r"om the I..lealth Autl'~or":Lty :J.l"lSl::U~c'l~imr'i, ~.~e find the separatiorl
distance from well 'E:(:~ s~ptic tar)l.:: ~(:~ be 91 feei;. The t~nl.::
was :Lr'Jstal].ed ,;](..u'l(.>~ .'L()~ 19~:'.$~ ar'icj is a 1C)0C) gallon steel,
c:o~Jlpart~er'Jt tal]k,, Nater tight c:oLq::)].~el"~ shoL~].d be Ol] inlet
and outlet': piping:, ,)
'T'l-le well was c:lr"illed July 13, 1983. Or'l Fel::H'"uary 9, 1989, a
zl. hour flow test shQwed statlc level at 46 feet, '7.2 gpm
with a tc:)tal drawdown c)f :];5 feei-.,. Thls area is not known
f(::)r any bedrc)ck al:)ov(~.., 1(])(]) feet, se casir'lg should extend
be].o~ Ii.)..]. feet. Surface slope :i.s to the east, southeast.
Water samples are satisfactory.
W(.:+;, r"£.):,'.::luest that y(:)u gF"al]i] a waiver mf 9.1. fee't: fc)r well tm
s e j::)t .'J.. (::: t ~t r~ k ,,
I'F yi::)L.i have ai'/y C:IL(est.i.c:,I"IS, i:.)lease call.
ACW / s r
S i n c:: e r e 1 y
Alan C. W.ier'~
Tec:hnician
1412 W6s~. 331~Ch AV61lU6 e Ancho~aqe, ~kJ&sk& 99503 · (907) 279-5553
ALASKA ENVIRONMENTAL
CONTROL SERVICES, INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
SHEET NO OF
CHECKED BY DATE
SCALE
!
~ ii! .... .... :i ...... ~ .......
I
................ ! .......... ~ i .... i i;. ~..! ! ......... i i ...... i ........ i
' ' ' ' ' ' .i. ~ .... ~ ~ i, ' ~ i i."i'., i.i.'"' .."~.'.'"'.'.....~'
APPLI( NT FILLS OUT UPPER HA[ONLY
Zip Code
Zip Code
Phone
Lending Inslitution
Address / ,?" ,.,' .;'~ 'i ''q / :'
Zip Code
Realty Co. & Agent
Address
Legal Description
Street Locatio~
Zip Code
Phone
Phone
Type of Flcsidence
~-'S~'n~ le Family
E~ Multiple Family
[] Otber
No. of Bedrooms
Water S~.pply
...F%-Iffdividual
[] Community
[] Public Utility
ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975.
For wells drilled prior Io that date, give well depth (attach Icg if available).
Sewer D~iSposal
E~¢~'ndividual
[] Public Utility
[] Holding Tank
Year Individual Installed: .' r
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED,
Time Time Time
Date Date Date
Inspector Inspector Inspector
Time
Inspector
MUNICIPALITY OF ANCHORAGi
Field Notes:
-- ^PPROVED BEDROOMS
) DISAPPROVED
) CONDITIOFI,¢4. ASPROVAL'
DEPt. OF I'!E/",L/'il &
I'=NVIRONMENi'AL PROT/CTIOh
RECEIVED
'CONDITIONS OF APPROVAl.
Soils Rating
72.023 (3182)
Date Sewer Installed
Well To Absorption Area
Well to Tankl"'~,('
Well Log Received
Septic Tank Size / <:¢'""~2
Torn Fink,
Mayor
A ur ieip lity Ar ¢lxQr e
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
February 24, 1989
Lee Reid, P.E.
Alaska Environmental Control
Services, Inc.
1412 West 33 Avenue
Anchorage, Alaska 99503
Subject: Waiver Request for Lot 6 Tract 5 Siefker Subdivision ~3
Waiver Request #WR890055, HA890006
Dear Mr. Reid:
Your request for waiver of the required 100 foot separation of
a septic tank to a private well has been approved. The
approved separation distance is 91 feet.
This waiver approval applies to the existing septic system to
w'~ll separation only. Any future upgrade to either will
require all separation distances be met or another approval
from this department.
Civil Engineer
On-site Services
RWR/ljw #6
".F ih ' ',
' ALASKA r IIUIROFImEFITAL COFII'ROL SERUICES, IFlC.
o ~'~~En~ine~rincl ~' EnuJronmenlel $~udi.
February 15, 1989
MLInicipality of Anchorage
Department of Health and Human Services
8~ L Street, Suite 502
Anchorage, AK 99501
ATTN: Dan Roth
RE: Lot 6, Tract 5, Siefker #3
From the Health Authmrity inspection, we find the separation
distance from well to septic tank. to be 91 feet. The tank
was installed June 10, 1983, and is a 1000 gallon steel, 2
compartment tank. Water tight couplers shQuld be on inlet
and outlet piping.
The well was drilled July 13, 198~. On February 9, 1989, a
4 hour flow test showed static level at 46 feet, 7.2 gpm
with a total draWdown of ~O feet. This area is not known
for any bedrock above-lF~F~ feet, so casing should extend
below 81 feet. Surface slope is to the east, southeast.
Water samples are satisfactory. '
We request that you grant a waiver of 91 feet for well to
septic tank· ~.
If you have any questions, please call.
ACW/sr
Sincerely
Alan C. Wien
Senior Engineering
Technician
1412 ~Ve~c 331~0 ~v~riu6 · ,~ncho~,~q~. ~[,~sk& 99~03 · (907} 279-~53
A ¥~ ~_O_E
EXCLU$10N
rosponslblllly~lo delerrnino the
existence oJ
ENQINEI~I~IB, I~[,.ANNEI:II~,
440W~$T BEN$ON BbVO.
ANCHORAGE, ALASKA 99503 562.5291
NOT[: It It the contra~
0/~" I~ Iii BA fl 0 0
MONUMENT ~ ~
PK N~ll ~
IRON PIP~ (~
~o EL,~VS,, DATUM
ALASKA e lUIROFlme[1lAL CO[1TROL SeRUICeS, Itl[
Enqin~¢rin~ $ [~n~ironm~ntol Slu(~i¢$
P. O. Box 240668
Anchorage, Al( 99524-0668
(90'/) 2'/9-5558 *** FAX (90'/) 2'/6-8'/06
January 81, 1990
MEMO
TO: John Smith
FROM: Dr. Leroy C. Reid, Jr.
SUBJECT: Well waiver, Lot 6, Tract 5,
Siefker Subdivision #2
Using Darcy's equations and soil permeabilities, I have
calculated the possible conditions for the waiver of 85 feet
from the well to the septic tank. In addition, I used the
well log from Lot '/ as a possible real case.
My conclusions are as follow:
1. It will take between 1.7 and 17 years for the water
to flow from a leaking tank to the first aquifer at 50
feet below ground. The literature does not support
bacteria living this long in water. Also, the
literature shows bacteria not being able 'to travel this
far. See attachments.
2. If the new well's log was the same as the Lot 7
well, the water from the septic tank would still not
reach the well. The radius of influence would be about
1 foot. It would flow vertically. Under full flow
conditions (tank leaks all water) it would take 2 days
for the water to flow that far. Normally, 2-3 feet of
soil will remove all bacteria from a stream of water.
3. The granting of the waiver for a well to septic
tank distance of 85 feet will not create a health
Attachments:
Table
Table B.1
3 well logs