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HomeMy WebLinkAboutNORTON PARK #3 BLK 1 LT 8 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. December 31, !.979 Paul Klatt Star Route A Bo:{ 1.71. Anchorage, Alaska 99507 Permit {~ 790014 Subject: Lot 2 [~]ock 1 Norton Park Subdivision i!3 A permit issued by this department fer well and/or sewer system has expired. Permits are issued ena calendar year basis, as :stated en the permiu, by authority ef Municipal ordinance. If you have drilled tile well, a '.,,ell leg should be sent to this department to decument the inshaliation date. If an enginee~ has inspected tine installation ef eh-site sewer system, please inave them send us the as-bui!ts for our files. If there are any further questions, please co~.ntact this office at 264--4720. Sincerely, Les N. Buchhoiz, R.S ..... Senior Environme~:ea i LNB/1 j w e~.c: Copy o~ Permit Dotten Drilling Co. BOX 10056 JOHN'S ROAD ANCHORAGE, ALASKA ~,gso2 PHONE 344-1952 February 27, 1979 Mr. I~aul Klatt Xlatt Road Anchorage, Alask~ 99502 For drilling 85' o~' 6" water well ~ $19.00 ~er ft. on lot 8, blk. 1~ ~or'ton Park SB ~1615.00 THANK YOU. KLt::IT-I" F'FIIJ L.. :l.;:?. ]: L..CIT 8 [?,LK ~l. NORTON F't:qI~:K ',Fi;RF:I FI E:O',='=2 ::L;:?::I. M I tq I I'"tLIf"t [:, ]: .'..li;'['FINCE [FJETI,.IEEN I:1 I.,.I[ELL. FIf.,t[) RP',t"¢ I:)h.t-:~i; I "rF; SEI.,.IFIGE [::, l .'i~;F:'O:~;F:ll. %'.d%TEM :1: l~:.lCl FLEET F'OR F:I PRI'v'FITE b]E:LL.; CfR :'t.50 ]]:3 ;2[?:II.Z1 I::[.'l:[!]' [::'ROM F:IF'IJE~LIC I,.IELL [)EF'EN[)iNG IJF'OI'.d THE "["~"PE: O[:: [::'1..1[~I[.. :(1::: ].,IEI..[ kl[i!:L.L LOCi~:.'; I:::IRE REm.';R.J!RE[:, FIN[) P'IUE;T [3E RETIJRI'.,IE:[)TO THE I}EF'I::It~:TM[~:NT I.,.I:IiTH!N :!j:l~!~ I'::,F~'T':~!; OF: THE I,.IEI..L. COiqPI...ET]iON. O'I"HER REki:!LI I R[i~}'IEi"dT:~, I'"lFi"r' F:II::'F'L.k'. :!~;F'EC: I I:: .T. CFIT ]: O{",l'.':i; FIN[:' CClt",I:~!;T[;?.UCT :[ Oiq [:, 3:1:::l(31:~:FIf"lti~; FP,,'I::I I L.FI[~U...E TO Z NE',liRE PROPER ]: 1",I'.:4;TFILL. I::IT I ON. ): CERT I F"~" ]'NFI]" :?.: I FIM F'FIMII...II':IR Iq:!:TH THE RI:B]:!I..IIREMENT:.li: FOR ON"~'%ITE [::'OR"I"H [.3¥ 'T'Hli~ MlJi'.,I I C I PI:SlL I T"? OF:' FtI-,ICHI]IRI':IG[!!:. ;;::: I WILL. IN::]';TFI[..I.. TIdE :~;"r':E;'TEi:I'"I If',! [::IC:I.~::I])I:;?.[:'t"':I['~{C[~:: I.,.IITI't THE COI}E~;. .................................................................... I:'IPF'I~. :[ CFIi'-,IT KL. FITT F'F:II. JL. Certificate of On -Site Systems Approval Parcel 1.9- 016-211-72 Legal description Norton Park #3 Block 1 lot 8 Site address 321 W.123rd Ave Anchorage, Ak Current property owner(s) Scott & Molly Cunfer Expiration Date: 12-26-22 X The On-site system(s) is/are approved fer 2 bedrooms Conditional approval for Comments or advisories: _ bedrooms, with the following stipulations: By. Original Certificate Date`? — za> Zd�Z This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory X Other COSA Approval_June 2022 ;,. HO MUNI C I PAL11Y Of A �,= _._RA�$E Development Services Department T Phone: 907-343-7904 On -Site Water & Wastewater SectionFax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 016-211-72 Complete legal description Norton Park #3 Blk 1 Lot 8 Location (site address) 321 W. 123rd Ave. Anchorage, AK 99515 Current property owner(s) Scott & Molly Cunfer Day phone 2. ON-SITE SYSTEMS SIZED FOR 2 BEDROOMS 3. TYPE OF WATER SUPPLY: x Private Well Private Well serving 2 dwelling units _-- ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank x❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ ur-i 1� Date of Payment 9/A3 /110 /�91 COSA # QS C 291 L/? 0 0q 5_0S C7 Waiver Fee $ Date of Payment Waiver # COSA Application June 2022 Legal Description: Norton Park #3 Block 1 Lot 8 Parcel ID: 016-211-72 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 2/79 _Total depth 85 ft Cased to 85 ft ❑✓ Sanitary seal is functioning correctly © Wires are properly protected Casing height (above ground) 19 in. Date of flow test for COSA 9/19/22 Static water level at beginning of test 25 ft. Comments TANK DATA Measu _ operating fluid level in septic tank _ Date of pum ❑ Required main nce completed, if AWWTS Comments: Well production at time of test 5.3 qpm Water storage tank volume - gallons Well disinfected for coliform test? ❑ Yes./❑ No ® Coliform bacteria is Negative Nitrate mg/L ® Nitrate less than MRL (ND) Arsenic 15.7 ug/L ❑ Arsenic less than MRL (ND) Collected by ArcTerra Consulting Date 9/14/22 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA PUBLIC SEWER Which system tested (date installed) ❑ ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: COSA Checklist June 2022 Adequacy test date Results n Pass Fluid depth prior to test in Water added gal Now fluid depth in Flaps time min Final fluid h in Absorption rate gpd FIELD STATUS — PO ECOVERY Effective depth (per record ings) Effective depth used in Effective depth remaining in In E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100' ❑Yes if No NA ft ❑ Yes if No 78* ft Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25' ❑X Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No NA ft Holding Tank > 100' © Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' ❑X Yes if No ft 0 Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑ Yes if No 78* ft 0 Yes if No ❑ N/A — Served by Community Well (not on lot) or Public Water rom SepticlHolding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Fou 10' F] Yes if No ft Surface Water > 100' ❑Yes if No Tank to Property Line > 5' Field to Property Line > 10' ❑ Yes Water Main > 10' ❑ Yes Water Service Line > 10' ❑ Yes F. ENGINEER'S COMMENTS if No ft Wells on Adjacent Lots: if No ells > 100' if No ft��Pr�ivate IIs > 200' if No ft If tank or field is under drivE MOA records state distances were permitted at time of installation ❑ Yes if No _ ❑ Yes if No _ went below ft ILI ft ft G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Areterra Consulting Phone (907)-696-6111 Engineer's Printed Name Kenneth Duffus Date %/zr�LL. Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. COSA Checklist June 2022 Arsenic Advisory Certificate of On -Site Systems Approval # OSC221472 Subdivision: Norton Park #3, Block, 1 Lot 8 A water sample revealed an arsenic concentration of 15.7 micrograms per liter (ug/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. information on arsenic is available from the On -Site Water and Wastewater Program website (www.muni.org/onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. Mallin Address P O Box 196650 * /anchorage, Alaska 99519 6650 *www muni org ; DEPARTMENT OF HEALTH & HUMAN sERV cEs : Division of Environmental Se~ices On-Site Se~ices Section :~" ~. ~t~ ~ ,~ 0700 P.O. Box 196650 Anchorage,'Alaska 99519-6650 ' CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ParcelI.D. ff ~(~~ ; : : : : ''' HAAff~ 1. GENERAL INFORMATION Complete legal description ~[- ~ ~/~'~ No~,~ '~r~ ~ ' Location (site address or directiOns) Property owner Mailing address Lending agency Mailing address_ Agent Address Day phone ¢, Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WA'rER SUPPLY: NOTE: Individual well ~- Community well Public water 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 tank Cc mmunity on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. . , 72-025 (Rev, 1/91) Front MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by r0y,.seal affixed hereto and as Ofrthe validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater dispOsal system is safe, functional and adequate for the number of bedrooms ..a.nd type of structure indicated herein. I further verifythat based on the information obtained from · the Municipality of Anchorage files and from my investigation and inspection, the o n-site water supply and/or wastewater disposal system is in compliance .with all Municipal and State codes, ordinances,.and regulations in effect on the date of this inspection, Name of Firm Address Engineer's signature DHHS SIGNATURE ~/" Approved for Disapproved. Phone Date Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations g~ven in paragraph 5 above by an independent professional engineer registered in the State Of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Re~.1/91) Back MOA¢21 Legal Description: A. WIgLL DATA Well type fir ~ Log present (Y/N) Total depth Smfitmy seal (Y/N) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SEI~VIC~S 825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 34~¢,7~-~-f 0,~ . .: If A, B, or C, attach ADEC letter. ADEC water system unmber Date completed Cased to FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform Date of sample: 6"//7/ 9 7 B. SEPTIC/HOLDING TANK DATA Date installed Foundation cleanout (Y/lq) __ Date of Pumping C. ABSORPTION FIELD DATA Date installed Length Width Effective absorption area Date of adequacy test g.p.m. Nitrate Casing height (above ground). '~ t" Wires properly protected (Y/N) AT INSPECTION 6"{/71 9 7 ~. c,, -/- g.p.m. Fluid depth in absorption field before test (in.); Fluid depth (ins.) Minutes later: Peroxide treatment (past 12 months) (Y/N) Tank size Depression (YFN) Pumper Soil rating (g.p.d,/ft2 or fQfodrm) Gravel thickness below pipe __ Mouitoriug Tube present(Y/N) Results (Pass/Fail) Immediately after Absorption rate = If yes, give date < o; / mq/.~ Other bacteria None r'e~o Collectcdby: /~/~t/-/-q? 7-<cA -~c Nmnber of Compartments .___ Cleanouts (Y/N)__ High water alarm (Y/N) System type __ Total depth Depression over field (Y/N) __ For bedrooms __ gal. water added (in.): g.p.d. D. LIFF STATION t~, fir. Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tmflc on lot /x/./5. ~ ,4t~tx-~ ~ 5'e~e,'~ Onadjacent lots At, ,4. Absorption field on lot N'. ,4. ; On adjacent lots tV. Public sewer main 7~ ' Public sewer manhole/cleanout~' 7~ ' Sewer/septic service line ~ 2 ,~-' Lift station /v'. SEP~ON DIST~CES ~OM SE~C~OLDING T~K ON LO~ TO: ~. ~. Building foundation Prope~ line Abso~tion field Water m~semice line S~ace water/&~nage Wells on adjacent lots SEP~ON DIST~CE ~OM ~SO~ON ~ELD ON LOT TO: M.A. B~l~ng fo~tion Prope~ Line Water m~iffse~ce line Surface water Driveway, p~kin~vehicle storage area Cu~n ~n Wells on adjacent lots F. ENG~ER'S CERT~CATION I certi~ that I h~e determined thmfield inspections and review ofMuniccal reco~ ~fh~l~tff~a~ove ~stem, are in conformance with MOA ~ guidelines in effect on this date. ~:}~'~" ~'~. Engtneer sName .... /~o~ ~ ~oo~ ~ :gEn lneeGng-Se~Here. I-IAA Fee $ .T G'c~ ~ Date of Payment Receipt Number (5~7V (0 / ~~ Rev. 8/95 eSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number 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. fl _(~)__~b - '~ / \ ~ --1 ,~ 1. GENERAL INFORMATION Completelegaldescription /-c,/' ~/ ~'(c,¢~ // A/c~r/¢,~ /~r-/¢ ~/~ Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent /~1, ,~. Address J~cc~/ /m/~f-h Day phone DIo~/t~ ¢~n~' " Day phone ~ ~t//na~ce3 Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~. ~ TYPE OF WATER SUPPLY: Individual well ~ Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public"sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1t91) Front MOAIf21 'H JOiA speeu!bue leUO!SS@~oJd eql u! SUOiSS!LUO JO 9JO JiB JOJ elq!suodseJ ~,ou s! ebeJoqouv ,to /q!ledp!unlAI eql 'penss! s! e),eo!Hpeo e eJojeq e],ep ezXleUe JO suoBoedsu! ],9npuo3 ~ou op SH HQ jo seeXoldLU3 'slueuueJ!nbeJ e~e~s pue leJepej u!eMeo/gs!),es o~ JepJo u! suolln~Bsu! bu!puel ~!eq~ pue seu~oq jo sJeseqoJnd o~ XseMnoo e se s!q], seop SH HQ eqj_ 'e>lSel¥ jo @~e~S eq~ u! peJe~S¢SeJ Jeeu¢Sue leuo!sse,~oJd luepuedepu! ue Xq e^oqe 9 qdeJI3~Jed u! ue^!6 suoBe),ueseJdeJ eq~ uodn ~luo paseq se~,eo!j!Meo le^oJdd¥ /qpoq~n¥ q~leeH senss! (SHHQ) seoFues ueLunH pue q~leeH ~o lueLu~edeQ ebeJoqouv jo X~!led!o!unl/N eqJ. s~ueLuLUoo leUOB!pP¥ :suoRelndp, s 13U!MOIIOJ eq~ H],IM 'su~ooJpeq ~oJ leAo~dde leUOB!puoo 'peAo~ddes!Q ~oj pe^o~ddv ~ :II::In.L~'N 9IS SHHa "9 '9 Legal Description: /oT Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST NoRToN YARI~ ¢'Z Parcel I.D. A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) _ IfA, B, orC, attach ADEC letter. ADEC water system number Date completed '8/7~ Driller DO'rT&N Cased to ¢¢~ Casing height 20 Wires properly protected (Y/N) ~' FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: g.p.m. Septic/holding tank on lot N.~, Absorption field on lot ~,A. Public sewer main 7~ Sewer service line ~ 25' ; On adjacent lots ~,~, ; On adjacent lots N,A. Public sewer manhole/cleanout 70° Petroleum tank NoNF. OSCE,eV'E b WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Nitrate Tank size Foundation cleanout (Y/N) Collected by: Sevue~') Date of pumping Other bacteria ~ cc,[ / ¢c~,,~.,~... F~A'r TO? T~c~ Compartments Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on'lot To property line Surface water/drainage On adjacent lots -Absorption field Foundation Water main/service line 72-026 (Rev. 7/91) Fronl CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested On adjacent lots Soil rating Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA Date installed Length Width Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain E. ENGINEER'S CERTIFICATION Surface water Gravel thickness Cleanouts present (Y/N) Date of adequacy test for If yes, give date System type Total depth bedrooms On adjacent lots Property line To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. blOT~: No ¢~,"d(en'..r (oa ;z ot. vc~f,xbl~ c~n,~ affrdler Lr no {o~qen 'tn ~..l'~,oe.f-c bc_.o,.~o, er (c.,,~v of:? tJ . ., ,f Signature ?~.~- ~ ~ ,e,~' OF Engineer'sName Thcvocxcor¢ ~, ~or~ ~&;, ~ ,'~ v '~ ~,,TH~ODORE F. MOORE ,0 ~2~..',, CE- 358,9 ,,"~ Waiver Fee: $ HAA Fee $ / Date of Payment Receipt Number Date of Payment Receipt Number