HomeMy WebLinkAboutPETERS CREEK BLK 3 LT 10 MUNICIPALITY OF ANCHORAGE
DE iTMENT OF HEALTH AND HUMAN SER~, -:S
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name
Address
I Perm t No. of
LEGAL DESCRIPTION
Township, Range, Section
TANKS
' SEPTIC [] HOLDING
Manulacturer Capacdy m gmlons
Material No. of Compartments
TYPE OF SYSTEM
~ TRENCH [~ BED ~ W. DRAIN [] OTHER
Depth to p~pe bottom from Total depth from original grade
or,g,nalgrade 2'S FI '~
Fdl added above original grade Gravel depth beneath p~pe
Gravel length
Total absorphon area
~J~. SQFT
lestaller
WELLS
Gravel width
Distance between hnes
/A
Pipe material
Date Installed
FT
~PRIVATE
Classdication (A,B,C)
[] OTHER (Identify)
Total Depth J Cased to
I
FT
FT
Installel
DISTANCES
WELL
SEPTIC
TANK
I
ABSORPTION
FIELD WELL
LOT LINE
FOUNDATION
AS-BUILT DIAGRAM (Show Iocahon of well, septic system, property hnes, foundabon,
driveway, water bodies, etc.)
REMARKS:
Scale:
Date:
Municipal and Stale g~ifl~~ this date:
certily thai Ihis inspection was pedormed
- o.--¢'.-~-t.,.~.. (¢,~-t-4,/"~.(" ' Date:
Health Department Approval:
72~013 (3/85)
DIF.:PAR'I"MENT OF HEAL..TH AND EIqVIRONMEIq'TAL PI:~OTECTION
825 I_ STREET, ANCH[)RAGE, Al< 99'501
264-4'72C)
85()601
)9 / 18/85
A F:'I='I... I CAtq'T:
ADDRESS:
[::ONI"AC'T PHONE
I..,E=.GAI.... DESCR I F':
LOT' S I Z E:
MAX BEDROOMS:
S&S ENGINEEIRtlqG
SR BOX 196X
EAGLE RIVER, AK:
694-'2979
99577
SLIBDIVISION: F'E]ERS CREEK
SE[.',"[' I ON: 10. T'OWNSH I P:
6'7()0 (SQ. Fl". GR ACRES)
4
LOT: lC) BLOCK: 3
:L5N RANGE: 1W
L..is'!'ed below are the opt:i, ons available 'Lo you in designing your septic:
system. Choose the'. option that be~t 'f:i. ts your site. /
DEF':'TH 'T'O PIF'E BOTT'OM (F:'T.)
GRAVE:L,. DEF:'I"H (F'T,)
TO'T'AI ....DEPTH (F"T.)
GRAVI.::ZL WIDTH (F::T.)
GRAVliF. I .... LENG'I"H (F"t",)
GF~AVE:L VOLLIME: (CU. YDS. )
]"ANI< SI ZE (GAI...S)
!3[]IL. I'"'((.YT'ING (SQ. F'I",, /BIR)
2.5 **
0.5
3.0
.1.6. ()
52.0
t9.0
250. () *~
85
..x- DEF"I"H ]"0 F'II.::'[:.: BOT'TOM < 3.5 FT. REQLJIIRES INSUL. ATION
.~* DE.F:']"H TO F:'II::>E BOTTOM < 4.0 FI". MAY REQUIIRE A LIFT STATION
** TANK MUST HAVE!: A'l" I...EAST 'T'WO [,OMFAfx[MEN[S
! cer'tit'y that:
] ....I aiTl {ami].iar w:i'Lh the requiremenCs t'c)r' c}n-s:i, te sewers and we].].~ as set
~'or'th by the Mur~:[c:il:~al:i. ty o~' (4ncl"~or'age (MOA) and' the State o~' Alasl.::a.
2, I w:i. ll :i. nstall 'Lhe system in accordance with all MOA codes and regulat:ions,
and in compliar~ce with the desigr.i [:pJ,'[~PJ.a of this per'mit,
3. I will adhere to all MOA and State of Alaska requir'ements .for' the set back'
d:i. stances {'rom ar'w existing well, wastewater disposal, system of public
sewefage system on this of any acl.jac:erlt cm nearby lo{.
4, I undePstand t. hat this per'mit :i.s raj. id ¢ofa maximum o[ 4 bedr'ooms arid
ally en].~l-gE~lllef'it w~ll PeqLlipe an additiona. 1 per'mit,
IF:' A I....IF:'T' STATION IS .£N,.:~1AI...I....EDIN AN AREA COVERED BY MOA BUILDING (..,ODI=.,:~,
. . . (,,:.. AS-BU I I.../T'S
'THEIq (1) AN IEL. ECTRICAI... F:'E~:RMZT AND INSF'ECTIOIxl MUST' BE [:)BT'AI'IqED~ '"'~
NOT BE ~F:I::'ROVE:D W]:THOUT AN ELECTRICAL.. INSPECTION RE:F:'OFCr~ AND (3) TFIE
AI:::'PL.. I CANT': ~ ~:~xl~E]::~ I NG
Ntunicipa ity
Anchorage
2644
MA
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Permit ~: 840931
January 31, 1985
TO: Permit Applicant
SUBJECT: Lot 10 Block 3 Peters Creek Subdivision
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1984.
Permits are issued on a calendar year basis by authority
of Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system not
installed by the expiration date.
If you have drilled the well, a well log needs to be sent
to this Department for documentation of the installation
and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, the original as-built inspection report
and the yellow copy must be sent to this office for review
and approval, and for documentation.
If there are any further questions, please call this office
at 264-4720.
Sincerely,
Keith E. Bandt, SupeYvisor
Environmental Engineering Program
KEB/ljw
enc: Copy of Permit
SWP/057
DEPARTMIE:N'T OF::' I'"IE(:.fl...'T'H AND ENVIROIqldE"NTAI... I:::'ROTECTION
825 L S'I"Fi:IEIE'I", AI~ICHORAGI!i~:, A.K 995() :t.
264-4720
CI~ Ih,,.ll ........ ¢."i?~; X 'l" IEEE '.E3 Eli"_": IP, J lEE F;;,". ;[Ek: It..,t,lt IE".:E It.._. 11 ....... F::" EE IF::;?. IP"ll ]1[ 'T'
P ER M I 'T IqO:
DATE ISSUED:
84. () 93.1.
11/0 1 ?84
A F" F:' L... I C A N '1':
A D D R E S S:
CONTACT F'HONE:
C/(] S &. S ENG'G ART SAI...ES
SRB :1.96X
E.AGI...E RIVER., Al< 99577
694-2979
I_lEGAI....DIESCF~ I P ::
L.. 0'1" S I Z E ::
MA),' BEDROOMS:
SUBD ]: V I S I ON :: F'ETIEF~S CREIEK
SErCT I ON: 1() TOWI',ISH I F:': :[!.'.51',1
6700 (SQ,, FrT. (]E:;: ACRE']S)
4
L..OT: 1.0 BI._OC?,K: 3
RANC~IE: 1W
L.i,:sted below ar'e the opt ions ava :i. ]. ab l e 'Lo you in design:i, ng your' sept:i.c:
system., Cl"toch'ir, e 'Lhe ot::ition that l]est fi'L.~:~ your'
DEi.:.F:'"FH 'T'C) F:'IPIE BOTTOM (F:"I",,)
G IR A V E I_ D E: F"'"t" H ( F T. )
TOTAl .... DEF:"TH (1'"""'t",,)
GI:~AVEt.. WIDTH (F"F,)
GFi:AVEI .... I....li."]',IGTH (F::'T..)
GRAVEL, V[II...LIME (CU,, YDS. )
"1"(..11',11.::: SIZ'E ((SAI_S)
SC)II... RATIIqG (SQ, F:'T, /BR)
· ~.+~. DEF:'TH TO F:' I F"E BOTTOM < 3.5 F:'T ,, REQ. U I RES I IqSLII...A'T' I ON ~
~..~. DEF:'TH TC) F' I I:::'E BO'I"T(")M < 4.0 I'.-."1", MAY REQU.I: RE' A L. I FT ST'A.T I ON
· ~ TAI',II< MLJS'T' HAVE AT L..tE:AS] .... r'w0 COMF:'AF;'.TMIENTS
I ,::::er'i:.ify i'..l")a'L:
1, I arn fam:i, liar' w:L'LIq the r'eclu:i, pements for' on.....'..':;:i, te set~6.,r',.:; and t~(.:.:.:l:l.s as set
f'or'tl"~ by the Municipality of Anchor'age (MOA) and the ~::~f..~:.t.(~.:.:, of Alasl.::a
,::..":'.. I w.i. ]. ]. instal 1 'l:.he *::~vs+..., ... ,..em in ac:copdance v~:i. th al 1 MOA c:odes and r'egulat:i, or'is.,.
and in cc')mp ]. :i.¢.~r~c:e v,;i'Lh 'Llqe desiqn (::r' iter' :i.a of th:i.s per'mi'L.
sewt::.:.:page system ,.':.~n 't:.hJ.'~!il oP o.r'ly ~..:tdjl..'..'t(:::E..q"l'l:. c:,r' ne:ar'by lot,,
4, I uncleps'Lar~d that 'Ll'~J.s per,,qtJ, i:. :i.s val:J.d f(::)r' a ~lO.~.,'J. ll'iLUfi £:)f /4 bedr'ooms and
any en].ar'ge.,mer'~t t,,~i:Ll r'equ:i, pe an addi't:.:i, or'~al I:~e.r'm:Lt,
.., (' ..... 1 ] ,.,l~.~lI[.),l iS~,,,.5'I~I,.,]AL.t...L.[, IN All AId,..A
THEN .1> A)4 ELEC~A~.JF:ERM:[T A)4D '.I:I4,~F'IECTIC)I4 MU,ST BE OB]"AINEED; (2.) A,S..-.E, UIL.',"S
I/~II...l .... NO'I" BE ~I>F:'F~VE~D ~II'I'HOLFT AN ELIE:CTF:~ZC~L. ZNSF'ECTIEU~I REF:'OR'T'=; AND (3) THIE
I...1_1....[., I t~.l.t..,~L NOI'.~ST ~N~. LY ~ L.].L, EN,::ED Ei....L:.L, 11.,IC.I. AI,t..
:' :: '~"" :' ' '~ :", v C~"" ,' ' " .:~ ~ .... ~
S ]'. GNED ' DATtE :: '
AFF I.....I.C.,AII1 ~~ S IE. NG (:~ AlmxT ..~AI...E:.,::~
V / . y/ /
................................................... %.%... :.%.:.: ~: ................... : ........................................................................ , ................................
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
~ .5'/~/-7 5'~0 t,/t ¢
2
5
6
7
8
9
10
11
12
13
JND WATER
NCOUNTERED? C 5 I~_
O
P
IF YES, AT WHAT ~ ( E
DEPTH?
14
15
16
ae~'t 3,. 8h~le~ ~'
N~, ~'~?'~:
17
18
19
~ SOl LS
LOG
[] PERCOLATION
TEST
DATE PERFORMED:
SITE PLAN
Gross Net Depth to Net
Reading Date Time 'rime Water Drop
PERCOLATION RATE (minutes/inch)
.... TEST RUN BETWEEN FT AND FT
co.,,..,,.~.-.-s /4/~ I¢/~ ~,...4 ~o,,..~.,.~ .~ !., ,.
72-008 (6/79)
DEPARTMEIqT OF: HEAL:TH AND ENVIROI',IMENTAI .... F'F~OTEI]TION
82'.5 I... S'I"REEI" ~, ANCFfORAGE, Al'::: 9950:1.
2.64-4720
F"'ERM I T Iq[:}:
DATE ISSUED:
840876
10/:1.2/84
APF::'L. I CANT:
ADDRESS:
CONTAC]" PHONE":
AL. BERT L. VAN OF~NLJM
F:' 0 BOX 77()788
I?]AGL~E I"i'IVER:, AK 9"7577
694-92.4 1
I...EGAI .... DE".SCR I P:
L 0 T S I Z I'.:'::
SLIBD I V I S I oN: PIE:TIERS CREI:?.K
SECT I ON: .1. () 'I"[]WNSI.-I I F::' :. :L ()N
105CK) (SQ. FT.. OR AC;RES)
LOT: 10
RANGE:: 1N
BLOCI<: 3
]: cer'T..i¢¥ +_hat:
:1... I am .ramil:i.a~- with the r'equ:i.t-ements Ceil" cm-si'l:.e se~,~el-'....'-¢ and wells as set
¢or'th by 'f. he Flunicipality of Anchor'age (MOA) and 'Ehe State of Alaska..
2. .T. will :Lns~tall the system in ac:c(:~r'danc:e wi'Lb ail MOA c,c~des and r'egula'f..ior'~.i~,
arid in compliance ~,~J.'f..h the des:Lq.n cr'it, er':La of tl"~J.s per'mit,
3, I wi].], adhePe to all MOA and State (:~' Alaska r'equit-emer'l'l:.s ~'c)l" the set back
cli s t a,/~: e.=..; ~ir' o m a n y e x :i. s t. i n g w~, w a s t ewat e r' d i sp o s a 1 s ys t em ~.:.) r' pub 1 .i. c
se~.e, eage system on 't'..his g,'~lz'f¥ a)::ljacent of near'by lc.rt.. ~ /
, · .................. : .......................... [z .......... ~ .......................... %: .................................................... 7" ....... 7'
AF:'F:'LICANT: AL. BERT' I .... VAN ORNUM ' /
'MUNICIPALITY OF ANCHORAGE
a T,ll
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Parcel I.D. 051-115-10
1
Certificate of On -Site Systems Approval
Expiration Date: 1/ ^ 2 s -20 ?0
GENERAL INFORMATION
Complete legal description PETERS CREEK BLK 3 LT 10
Location (site address) 21111 Four Wheel Dr
Current property owner(s) KELLER MARY
Mailing address
Real estate agent
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
Day phone 242-4330
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
Z
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
El
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $
Date of Payment
I
Receipt Number 05z'37b
COSA # 0 S C 2 013 00
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures Outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm North Rim Eng. Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng Date
497E' `4
a�
a
Jr*
: 49 TM :�,t4♦t
1
It
6. DSD SIGNATURE f..`y�t`V� .I�' coo
System #1 Approved for bedrooms 4♦f,T
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
"���1J)))lllllllt,
By: - V''`'t� Original Certificate Date: 7 q--2dZo
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
COSA Checklist blue sheet
COSA Checklist
Legal Description: PETERS CREEK BLK 3 LT 10
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Comments Public Water
B. TANK DATA
Age of tank(s) 8 years
Tank type/material °GSGe1
Measured operating fluid level in septic tank 50
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 10/3/19
D. ABSORPTION FIELD DATA 10/23/85
Which system tested (date installed)
❑ ALL standpipes present per record drawing
Total measured depth from grade 3 ft (max)
Measured depth to pipe invert from grade 2.5 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
Parcel ID: 051-115-10
Structure served by this system
Well production at time of test gpm
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 ug/L ❑ Arsenic less than MRL (ND)
Collected by
Date of Sample
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 4/23/20
Results✓� Pass For 4 bedrooms
Fluid depth prior to test 0 in
Water added 600 gal
New depth 4 in
Elapsed time 60 min
Final fluid depth 0 in
Absorption rate 600 gpd
Any rejuvenation treatment (past 12 months) unk
If yes, enter date
E. SEPARATION DISTANCES
From Private Well oOLot to: (Please enter distances if less than required or ifmmmunitywell)
Septic Tank/Lift Station onLot �>1OO'
21
Yes
Community Sewer Manhole/Cleanout �>1O0'
F�Yea
ifNoft
Absorption Field �>5'
E-1YesifNoft
Yea
Neighboring Tank �>1OO' El Yes
ifNoft
Private Wells �>1O0' C�Yee ifNoft
Private Sewer/Septic Line �>25[-lYes
ifNoft
Absorption Field onLot 1OO' [:lYea
ifNoft
Holding Tank >�1OO' Fl Yes
ifNoft
Neighboring Absorption Fields > 100`
Yes
if No
Animal Containment >50' �� Yes
if ft
Yea
if No
�
-
----
Manure/Animal Excreta Storage >1OO'
{�onnnnunityGavverK4ain�>75' F-1 Yes
if No
- Yes
ifNoft
From Septic/Holding Tank DOLot to: (Please enter distances if less than required)
Building Foundations �>1O' [D Yes ifNoft Surface Water �>1OO' FV Yes ifNoft
PropeTtyLine b'
21
Yes
ifNoft
Wells on Adjacent Lots:
Absorption Field �>5'
Yea
ifNoft
Private Wells �>1O0' C�Yee ifNoft
Water Main �>1O'
k1Yes
Yes
ifNoft
Community Wells �>2OO' MYeo ifNoft
Water Service Line �>1O`
P1
Yes
if No
!fseptic tank iaunder driveway comment below
From /\bSorohoO Field on Lot to: (Fqouse enter distances ifless than required)
Building Foundation �>1O'
M'Yes
ifNoft
If absorption field iaunder driveway comment below
Property Line 1O'
Yee
ifNoft
Wells onAdjacent Lots:
Water Main �>1O'
k1Yes
ifNoft
Private Wells �>1OO' Yea ifNoft
Water Service Line �>1O'
LHYes
ifNoft
Community Wells >2OO` C1Yee ifNoft
Surface VVatar�>1OO'
Yea
ifNoft
F.ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
/ certify that / have determined through field inspections endnaview/
of Municipal records that the above systems are in conformance with
&404COGA guidelinesin effect onthis date.
C0SAChecklist yellow sheet
A Cpl III T
I HEREBY CERTIFY -THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
AND THAT ,NO FNCROACWkNTS EXIST D(CEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONS*rRUCTION
OFFENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES.
SCALE:
DATE
GRID:
FB:
OE"U'," C-' -APPYWA-LU) 1,4MviJ JUt1VtX1A6 b94-U82L)
Duane Mw, Scwwd
L S — S
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