HomeMy WebLinkAboutPETERS GATE BLK 2 LT 2Peters Gate
Block 2
Lot 2
#051-541-14
91
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Well Lo
ermit .INTu mer; #SW 494242 Late of Issue 121 twoq Parcel Identification Number: 951-641-14
Tate Started: 1/412010 Late Completed: 111112010 Is well located at approved permit location? 'des %lig
Property Description PETERS GATE Loft 2 Block 2 Section: Tmm: Range:
Property Owner Name & Address: BILL HAY ARD
PO BOX 32316 JUNEAU, AK 99843
Borehole Data:
Depth
Method of Drilling air rotary ,. -; cable tool
Soil Type, Thickness &Water Strata
From
To
Casing type:
Casing Stickup
4
3
Wall thickness 0 25 inches
Overburden
3
6
Diameter 6 inches Total: 96 feet
Lister type:
Sift Gravel Clay
6
19
Diameter inches Depth: feet
Bedrock Rotten
j
19
61
Casing stick-up alcove ground: _.3 .feet
i Black Bedrock
fit
905
Static Water Level (from top of casing) 25 feet
Gray & White Bedrock
145
118
Pumping Level. feet after
White Bedrock
118
129
1 hours pumping ._ gptn
Recovery Rate 1 gPm
Tan & Gray Bedrock Soft
121
124
Method of Testing: Air
Gray & White Bedrock Soft
124
159
Well Intake Opening Type
Black & White Bedrock Soft
159
163
i?pe't2 End Open t3ole
Gray Bedrock
163
165Screened
Start feet Stopped feet
.. �
Gray tt White Bedrock Soft
165
980
Perforations Start feet Stopped feet
Green Bedrock
180
984
Grout Type: Bentonite dry granular Volume: 404 Pounds
Depth _: 80_..._. Start 4 feet Stepped 84 feet
Gray Bedrock
984
234
Pump intake Depth: feet
Gray Bedrock Soft
234
305
Green Bedrock
305
355
Pump size: HP brand name
Gray Bedrock
355
395
Well disinfected upon Completion? X' Yes No
Method of disinfection CHLORINE 50 PPM
Green Bedrock
395
410
_
C'omnients, AS PER MOA REQUIREMENTS, OVERSIZE
Gra Bedrock
Gray
410
544
BOREHOLE AND GROUT TO 84`
Water Sample Results:
Arsenic:
ugll
Well Driller:
_...: __.
Cole Sullivan
%titrates
mg1l
Sullivan Water Wells
Total Coliform Bacteria
colonies/100mL
--------
P.O. Box 670272
Chugiak,,AK 99567
Other bacteria:
col/ 1 UilmL
{907) 688-2759
Attention: The property owner shall provide
this log to DSII (onsite) and IBNR within 30 day's of completion.
ARCTIC PUMP & WELL INC.
Jim Sullivan
PO Box 770197
Eagle River, AK 99577
9 ^< (907) 688-2510
(907) 243-2282
7,
Well Drilling Permit Number: sw09O242
Parcel Identification Number: 051-541-14
Date Of Issue: 12/30/2009
Legal Description: Peters gate Property Owner Name Address:
Bill Hayward
Lot: 2 9110 Glacier Highway
Block: 2 Juneau AK 99801-8032
Pump Installaion Date:
Pump Intake Depth Below Top of Well Casing:
Pump Manufacturer's Name
Pump Model:
Pump Size:
Pitless Adapter Burial Depth:
Pitless Adapter Manufacturer's Name
Pitless Adapter Installer:
Well Disinfected Upon Completion?
Method of Disinfection:
Comments:
Pump Installer Name:
Arctic Pump & Well, Inc.
Alonday, Appil 2, 2018
1/13/2009
435 Feet
Franklin
Constant Pressure System: 7SDQP-1.5 HP
1.5 HP
12 Feet
S-50
u/k
Yes
Chlorine
MUNICIPALITY OFANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WATER SUPPLY PERMIT
Upgrade
Date Issued: Dec 30, 2009
Expiration Date: Dec 30, 2010
Permit Number: SW090242 Parcel ID: 051-541-14
Legal Description: PETERS GATE BLK 2 LT 2
Design Engineer: 0000 ZZ - NONE NEEDED Site Address: 024964 SIERRA MESA CIR
Owner Name: WILLIAM C & MALLIA L. Hayward Lot Size: 54014 SO. FT.
Owner Address: PO BOX 32316 Total Bedrooms: 3 Permit Bedrooms: 3
Juneau . AK 99803 -
This permit is for the construction of:
❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑✓ Private Well ❑ Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Date: — 3U— 0`
Issued By:���� / It/, Date: 12 — 3 O' D q
Municipality of Anchorage Page I of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: c5WP11037/ PID Number: oS/574//4
Name:
Wastewater System:EV-Kew ❑ Upgrade
Address:�� �,f9-NU(,fla�L.
ABSORPTION FIELD
Phone:
vU_
No. o Bedrooms:
ep Trench El Shallow Trench I-] Bed ❑Mound El Other
LEGAL DESCRIPTION
Soil Rating:
/ri
Total Depth from original grade:
//-/3,
GPD/S .Ft.
Lot: Block: Subdivision:
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
2
Z-6- 3.% Ft.
8 Ft.
Township:
Range:
Section:
Fill added above original grade:
Gravel length:
C� Ft.
Ft.
eW
WELL: ❑ Upgrade p9
Gravel width:
3.n
Number of lines:
Distance between lines:
N/,r'
z,S— Ft.
Ft.
Classification (P vate, A, B, C): _
Total Depth:
Cased To:
Total absorption area:
Pipe material: �gzlM�.-
/�7✓/Z�C.
/It -0 Ft.
Ft.
376' SQ. Ft.
-'do. G• .f='
Dri er:
Date rilled:
Static Water Level:
2-e.. Ft.
Installer: 1
�1w-/Y1 L�nv7/ �.
Date ins Iled764/7 1�i`�
InA.-
.
Yield:
Pump Set at:
Casing Height Above Ground:
TANK
M GPM
//?.� Ft.
2,i7Ft.
SEPARATION DISTANCES
Rseptic ❑ Holding ❑ S.T.E.P.
To
Septic
AbsorptionLitt
Holding
Private
Manuffacturer:
��`r`'
Capacity in gallons:
/, 90C:7
From
Tank
Field
Station
Tank
Sewer Lines
Well
=/U.
=/35'
=/v 1-
Number of Compartments:
17--
Surface
'
Z/03'
/03'
LIFT STATIONWat
/OZ'
Lotti
,
27 i
�
� � /
Size in gallons:
Manufacturer:
Line
/ "
Foundation
� �
y �
✓'
�'
"Pump on" level at: p off' level at:
High water alarm at:
CurtainN//�"
�
Pump Make & el
Electrical Inspections performed by:
Drain
Remarks:�`� a��,�. Ile -6
BENCH MARK
Location and Description:
oso✓
Assumed Elevation:
p
/04
ENCtIIVLER'S,SEAL
Inspections byL%r�.c- .c.. Dates: 1 st
performed
2nd
Department of Healt d Hum - ervices approval
by: X4`" l ' �- Date:/911
Reviewed and approved
72-013 (Rev. 9/91) MOA 25
Permit No.4�*/,y_✓l Page Z of 3
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit No. 4cl
Page 3 1 of -S
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 0 Anchorage, Alaska 99519-6650 e Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
*7 1+ ve- Joe
Legal Description: AATT-, PID No.: 1051 S41
FROM MMM CONTRACTING PHONE N0. 6881238 Dec. 21 1994 09:42AM P1
` ♦ * ,AMP
by
DOC Co. dba
SULLIVANWATER ''WELLS
P,O, BOX 070272, CHUGIAK, ALASKA 99587 • TELEPHONE 088.2759
OWNER OF LAND / f)EI'TFI OF WELL
ADDRESS , fie) - I / 7r', � � •,.,.. !1 O6 r r�
_ fiATIC' LEVEL OF WATER F'D'./07-
'D'. 7_
LEGAL DESCRIPTION__ l r r� l3�C r�' 4 7 ,-baa fj 7` ^_
DRAW DOWN M , ..
DATE • Started -_ Ended o GALS. PER HR e>� �h 0
PERMIT NUMBER� —��
KIND OF CASING 49:A0
y ,
KIND OF r0I114AT10N:
From
f From Ft. to4.. .Ft.
From._ S2 Ft. to _ . Frurn__ Ft, to
._._.___._Ft,
From Ft. to Ft. Frarztr.,_,,_ ft. to_ Ft.
Froin Ft, to_.__ ------Ft.... 4 r''Yi is Fmm,.,, . ,,,,..Ft. to Ft.
Froin Ft. to :s Ft, `�� `� j` .,. �._ C.
y �i /GFram , �t. tom Ft
Frain`Ft. to Ft. i r� c: �t �� 4, ec"
__ �' FromFf. to_._.. Ft. _
From_ I Ft. to. LLL k.Ft. i i c= {r Jr�C l�(�� �) J ,4 ``' r �!
-1 From Ft. to_, Ft.
From Ft. to Ft. , �iLf�'J� 1107.4 Froin Ft. to_Ft.
From__ -.._.___ ,Ft. tor,._.., .. Ft,_ Froin Ft. to Ft.
From_._____Ft. to Ft. _ �._ ......,.. From—Ft. to—Ft.
From Ft, to Ft. r _._. From Ff. tu.._,._._..,._Ff.
From:. ....Ft, to ---.___----Ft.
From__ rt.to - Ft.
From Ft. toFt.
From Ft. to. - Ft.
From Ft. to Ft. From _ Ft.
From Ft. to— Ft.
From—Ft. toFt.
From_Ft. to_Ft, From Ft. to Ft.
From Ft. to—Ft. From Ft. to Ft
MISCL. INFORMATION:
Post -it'" brand fax transmittal memo 7671 +rot pages I-
CO. o. o. DRILLER'S NAME d __
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW940371
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NAME:GRAY MICHAEL A &
OWNER ADDRESS:206 N 88TH PLACE
MESA, AZ 85207
PARCEL ID:05154114
LEGAL DESCRIPTION: PETERS GATE BLK 2 LT 2
LOT SIZE: 54014 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1
DATE ISSUED: 9/30/94
EXPIRATION DATE: 9/30/95
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 (24 HOURS) .
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY:
DATE: /0/W.Fv
DATE • 30 a
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, ALASKA 99524
September 26, 1994
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject: Lot 2, Block 2, Petersgate Subdivision
Well and Septic System Design
Impacts to Adjacent Properties
Dear On Site Services Engineer:
We hereby request that a permit be issued for the construction of a septic
system and well on the subject property. The location of the system and
well is shown on the attached site plan. In addition, the topography of the
lot and existing drainage pattern is also illustrated on the plan. Soils
encountered during the field study indicate acceptable conditions for an
on.site sytem. No groundwater was encountered in the excavations.
If the system is completed as designed the following statements can be
made:
1. The system, if constructed as designed, will have no adverse impact on
the wells currently in use or to be constructed in the future.
2. The system, if constructed as designed, will have no adverse impact on
existing septic systems in the area or those to be constructed in the
future.
3. The system, if constructed as designed, will have no adverse impact on
reserved space, either surface or subsurface, on any lots located in the
area.
4. The system, if constructed as designed,
drainage patterns in the area.
Sincerely,
Michael E. Anderson, P.E.
will have no„._adW.rse impact on
0
MC
oe
r
1
d
Q
MC
PROOIICT 204.1 Mc• GMW, Mm. 01471. To OMn NO* TOLL FREE I-M22 433
Lot 2, Block 2, Petersgate Subdivision
DESIGN FACTORS:
Three Bedroom Home
Perc. Rate: 4 Min./Inch
Application Rate: 1.2 GPD/SF
SYSTEM REQUIREMENTS:
Deep Trench System
1,000 Gal. Septic Tank
S' Drainfield Rock
3 Bdrms. X 150 GPD / 1.2 GPD/SF = 375 SF of Absorption Area
375 SF / 16 SF/LF = 24 LF of Drainfield Trench
Therefore: Construct a Single Deep Trench Lateral a Minimum of
24' Long. Eight Feet of Drainfield Rock Must Be Placed Beneath the
Distribution Lateral.
NOTE: Maintain 4' Separation from Bottom of System to
Groundwater.
Grade Area Over Trench to Drain Away From Area.
To
i, 000
C- ALL04
AhrrOR-AdL
1 �A
A-CALF1(.4..
6e0j d:T17W'
f to
�z.�.
FAc
�R
m
�l q'
...... ......_.
- f .....
n
1 ? }
.. ..... .. .....
_.
;,
.. j
.. .. .... ..... ... .....
NOTE: Maintain 4' Separation from Bottom of System to
Groundwater.
Grade Area Over Trench to Drain Away From Area.
e �.c Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG - PERCOLATION TEST
)Mid il-,r. t.l 1:. f;'i<.141 X1;1 t• : i
4
PERFORMED FOR: I G DATE PERFORMED zl %
LEGAL DESCRIPTION: LZ,, �2�I ri S/p Township, Range, Section:
SLOPE SITE PLAN
IF
0 4
2
� D /
3
4
5
a
oa
a � •°oma
7 Op
0
8-
17-
0
Net
Time
MENNEENEEN
Net
Drop
10
10-
�.
11
11
/L.'/� 7 t
12
oa
0 0
10.9!r>17 -22t
3
13-
S 3 /5. 0m,
/O
14
14
Q
/ ;V
15
/ /5
Z. L
16-
6
,G 3 Z zy5
170
19 Qe�
0 6
WAS GROUND WAT
ENCOUNTERED?
IF YES, AT WHAT /
DEPTH?
Depth to Water After
Monitoring? l Date:
20
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND 7 FT
COMMENTS
Reading Date Gross
Time
Net
Time
MENNEENEEN
Net
Drop
7 /
Reading Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
7 /
/L.'/� 7 t
wzz-
/O
10.9!r>17 -22t
Z.75"
S 3 /5. 0m,
/O
142 C> 7z;7
Z•G3
/ ;V
O
/ /5
Z. L
,G 3 Z zy5
Z. S
147.
2.8$
PERFORMED BY: /'r &1 ,j I #L THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: c1h, 1'/ Iq�
72-008 (Rev. 4/85)
Qt c r
Municipality of Anchorage <'
i.: u z,zs
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: I f 1 I Cit�%V1�.I�i . � j � YiG, DATE PERFORMED: g 2-Z/
i
LEGAL DESCRIPTION: Ii(i. ri7/
7
DEPTH
F
9
2
10
3
11
4-
.o 0
12
a
5 5
,.
13
."•. a
,b •
4
14-
7
18
19
Township, Range, Section:
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SLOPE
1%
__ A/
S
L
O
P
E
Depth to Water After
Monitoring? Date:
SITE PLAN
2
==mmDepth
8
9
.o Q
10
`4 '
11
12
a
to D
13
."•. a
,b •
4
14-
0
15
15
16
17
18
19
Township, Range, Section:
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SLOPE
1%
__ A/
S
L
O
P
E
Depth to Water After
Monitoring? Date:
SITE PLAN
2
==mmDepth
.
NW®
20 --
PERCOLATION RATE 2� (minutes/inch) PERC HOLE DIAMETER
TEST/RUN BETWEEN /D FT AND FT
COMMENTS Z'e<�Anle– ri/�4
PERFORMED BY:/'► I RTIF THAT THI TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: r Z/�T
72-008 (Rev_ 4/A51
UNW PAU7Y of ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051-541-14
1. GENERAL INFORMATION
Complete legal description PETERS GATE BLOCK 2, LOT 2
Expiration Date: ! / t -P —z) -
Complete
zJ
Location (site address) 24964 SIERRA MESA CIRCLE, CHUGIAK, AK 99567
Current property owner(s) KELLY O'DONNELL & LAUREN FLEMING Day phone
Mailing address
Real estate agent
PO BOX 773285, EAGLE RIVER, AK 99577
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
®
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date:
COSA Fee $ 5 Waiver Fee $
Date of Payment % Date of Payment
Receipt Number. V7 08-3 Receipt Number
COSA # 0 SC x.1131 �?, 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 FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY, ANCHORAGE, AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 5/28/2021
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. 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 in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to AJ
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any estimate of how long a system will function satisfactory g�Q:. • . �9 ���
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting & FWGS *� ..Tl -I
•�* �!
/J ....... /
6. DSD SIGNATURE // • '. • Curtis Huffman .
System #1 Approved forbedrooms ��Fc/sT . ,CE 128991
System #2 Approved for bedrooms
tROF 8 ONt`�'��r
Disapproved
Conditional approval for bedrooms, with the following stipulations:
R N'
y� wPTEI� SER o;z
J o W P AM
�.ck) pROG>;l
�iJJ J `Op
MT
Original Certificate Date: — 1
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
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Other Sec 5 +,tJ �a
Legal Description: PETERS GATE BLOCK 2 LOT 2 Parcel ID: 051-541-14
If more than 1 septic system on lot: COSA Checklist # _of _ Structure served by this system _
A. WELL DATA
® Well log is filed with Onsite (or attached) Water storage tank volume NA gallons
Date drilled 1/11/2010 Well disinfected for coliform test? ❑ Yes ® No
Total depth 500 ft ® Coliform bacteria is Negative
Cased to 96 ft Nitrate mg/L ® Nitrate less than MRL (ND)
® Sanitary seal is functioning correctly Arsenic ug/L ® Arsenic less than MRL (ND)
® Wires are properly protected Fwts
Casing height (above ground) 18+ in. Collected by ,-
Date of flow test for COSA 5/5/2021
Static water level at beginning of test 25 ft. Date of Sample 5/12/2021
Well production at time of test 2.4 gpm
Comments SEE COLE SULLIVAN DECOMMISSIONING LETTER FOR ABANDONED / AGRICULTURAL WELL
B. TANK DATA
Age of tank(s) 27 years
Tank type/material SEPTIC / STEEL
Measured operating fluid level in septic tank 50"
® Standpipes/foundation cleanout per record drawing
Date of pumping 4/27/2021/
D. ABSORPTION FIELD DATA
Which system tested (date installed) 10/6/1994
® ALL standpipes present per record drawing
Total measured depth from grade 13 ft (max)
C. LIFT STATION
❑ Required maintenance completed
Age of lift station _ years
Lift station material
Comments: SEE MOA TANK ADVISORY
Adequacy test date 5/5/2021
Results N Pass For 3 bedrooms
Fluid depth prior to test 53 in
Measured depth to pipe invert from grade 4.8 ft (min) Water added 450 gal
❑ N/A — pressurized field
New depth 71 in
® Monitor tubes go to bottom of effective. If not, state Elapsed time 1320 min
depth into effective 8.2' OF 8' ED
® Code -required soil cover over field Final fluid depth 52 in
❑ System presoaked Absorption rate 450 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N
date of test) If yes, enter date
Gallons introduced gallons
Comments/Deficiencies: AS NOTED PREVIOUSLY IN MOA DOCS — FIELD IS IN THE DRIVEWAY. FRES
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
® Yes if No ft
Wells on Adjacent Lots:
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No
Neighboring Absorption Fields > 100'
Surface Water > 100'
® Yes
Animal Containment > 50' ® Yes
if No
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® Yes
if No
ft
® Yes
if No
ft
ft
ft
ft
ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑ Yes if No *5 ft Surface Water > 100' ❑ Yes if No **88 ft
Property Line > 5'
® Yes if No ft
Wells on Adjacent Lots:
Absorption Field > 5'
® Yes if No ft
Private Wells > 100' ® Yes if No _
Water Main > 10'
® Yes if No ft
Community Wells > 200' ® Yes if No _
Water Service Line > 10'
® Yes if No ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
® Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® Yes
if No
_ ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' ® Yes if No —ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
*PER CODE AT INSTALL. **MOA WAIVERS ISSUED PREVIOUSLY. PER MOA RECORD DOCS & VISUAL
OBSERVATIONS FIELD IN DRIVEWAY APPEARS ADEQUATELY PROTECTED FROM VEHICLES & FROST.
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and review e �Q ! • • • •����
TH
of Municipal records that the above systems are in conformance •."�
with MOA COSA guidelines in effect on this date.: ! . • .':
.... ...........
. Curtis Huffman i
FFG, •. CE 128991N 'due
,• <t`��
t�� pROFE3S10NA -�
ft
ft
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
On -Site Water and Wastewater Section
www.muni.org/onsite
Septic Tank Advisory
Certificate of On -Site Systems Approval #OSC 211312
Subdivision: Peters Gate Block 2 lot 2
907-343-7904
Fax: 343-7997
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this property is 27 years old. Typical replacement costs range from $8,000 to $11,000
This advisory must be attached to all copies of the subject Certificate of On -Site Systems
Approval.
This is an example of what the metal of a 20 -year-old steel tank MAY look like.
�� �, � � � 4 Mailing Address P O Box 196650 *�Anci�orage, Aiaska�99519 6650 *www muni org
Municipality of Anchorage
Community Development Department
On -Site Water & Wastewater Program
4700 Elmore St. m P.O. Box 196650 m Anchorage, AK 99507-6650 my��u,.�.Fi. i, M(907) 343-7904
Legal Address " ` f
Subdivision Block Lot X
T R Section Lot
On-site Water & Wastewater Program certified contractor performing the well decommissioning:
Name
Signature TM
1
Company: �) „Al
i _ moi
Well decommissioning date: P _ Method of decommissioning: AMC 15:55.0601-1 a. ❑ b. ❑ c
Location: Use the space below to provide a drawing of the property showing the following items;
® North Arrow
s Decommissioned well,
w Other water wells on the property,
® Two separate swing -tie distances for each well shown in the drawing,
Note: The swing -tie distances shall be measured from either permanent structures of property corners.
1cad V-1 t. k
Municipality of Anchorage X61 8 9 10 77 `f'
• @
t On-Site Water&Wastewater Program ") _ nX o _L '"
(907)343-7904 r' E; --"-
APR 302018
�yb ti
CERTIFICATE OF ON-SITE SYSTEMS '". c;\
0
01689
Parcel I.D. 051-541-14 Expiration Date: (.L5 15 . 0
1. GENERAL INFORMATION
Complete legal description PETERS GATE S/D; BLOCK 2,LOT 2
Location (site address) 24964 SIERRA MESA CIRCLE, CHUGIAK,AK 99567
Current Property owner(s) WILLIAM & MALIA HAYWARD Day phone 723-7743
Mailing address P.O. BOX 32316,JUNEAU, AK 99803
Real Estate Agent AVA ANDERSON W/SOMERS REALTORS Day phone 360-9890
2. TYPE OF DWELLING:
El Single Family (w/wo ADU)
Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Individual On-site
Individual Water Storage ❑ Individual Holding tank ❑
Community Class Well ❑ Community On-site ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for. SEPTIC TANK TO SURFACE WATER Distance: 88 FEET
Received by: Date: 5/,0
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ � Waiver Fee$ 25
Date of Payment 5/1 / 1-3,, Date of Payment
35`
Receipt Number ��`` lIIS��) Receipt Number Q
COSA# CJ6[ SII 1 (7 Waiver# 65V/g/0(
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the
information obtained from the Municipality of Anchorage files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 *ANCHORAGE,AK, 99507 /2, )//Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date -7�t `2
Engineer's Comments:
In conducting this evaluation,GEG provided an engineering evaluation of the well and/or septic system in accordance with the ..,..,,,,S.14%i,
guidelines and regulations established by the Municipality of Anchorage and industry practices.The reported results describe the � 4 OF .‘1♦
condition of the systems on the date/s of the evaluation.Separation distances were measured to readily identifiable features. �•P • •"" ♦
Hidden defects or encroachments may exist that were not identified during the evaluation.The operational life of all wells and septic =C\• . •••/• 0
systems depend on a variety of variables including,but not limited to,soil conditions,groundwater levels(that may fluctuate during - � 1 ##
the year),quality of constriction(materials and workmanship),and the water usage of the family utilizing the system/s.These �' 9 ,.../1
Ni 4- O.
conditions can vary,and are outside the control of GEG.Satisfactory test results do not guarantee future performance of the / I , „ 0
systems;therefore,GEG makes no warranty(express or implied)regarding the future performance of the well or septic system. 0
GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the /�l`,,, ,,{Y l f . , ,.,�,-
current systems fail.The content of this report is for the sole benefit of the person/party who retained GEG.Reliance upon the 0 � le'if e A''•am s =
information provided in this report by any other person or party,including but not limited to subsequent property purchasers,is not ♦.0j'.I i C -79 3 authorized.In short,GEG disavows any legal duty to anyone other than the person/party who paid for this report. �♦S ,�.�;.-4-.•. i� . F1"."
6. DSD SIGNATURE
♦�*IPROFESS�(it,.S
LICENSE I�Y�,`,�,��
System#1 Approved for 3 bedrooms. #AECC884
System#2 Approved for bedrooms.
Disapproved. c.. °/7 OF AI�1G
Conditional approval for bedrooms, with the following stipulations: .jZ ON-SITE
WATER AND
A WASTEWATCR o
PROGRAM ��
‘-(") o
By: I✓u,�; ,e/ 0,Q3U,1 Original Certificate Date: 7/15/I 8-
The Municipality or Anchorage Develop,emt Services Division(DSD)issues Certificates of On-Site Systems Approval(COSA)based only
upon the represenatations 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. ATTCHMENTS: �(
COSA Checklist /� Nitrate Advisory
•
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
•
(Rev.10/12112)
If more than 1 septic system is on the lot:
COSA Checklist#_of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: PETERS GATE S/D; BLOCK 2, LOT 2 Parcel ID: 051-541-14
A. WELL DATA 1994 WELL IS AN AGRICULTURAL WELL/2009 WELL IS THE WELL SERVING THE HOUSE.
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES
10/1994/ YES/ YES/
Date completed 1/11/2010 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
112'/ 60'-7"/ 18+/
Total depth 500' ft. Cased to 96' ft. Casing height(above ground) 18+ in.
FROM WELL LOG AT INSPECTION
Date of test 1/11/2010 4/5/2018
Static water level 25 ft. 22 ft,
Well production 1.0 g.p.m. *2.7+ g.p.m.
*NOTE:A TOTAL OF 1,198 GALLONS
WATER SAMPLE RESULTS: WAS PUMPED FROM 2010 WELL
OVER A PERIOD OF 332 MINUTES
Coliform NEG. colonies/100 ml. Nitrate ND mg./L. Collected by: GEG, Ltd.
NOTE:WATER SAMPLES FOR AGRICULTURAL
Arsenic: <5 ug./L. Date of sample: 4/5/2018 WELL TAKEN BY SULLIVAN WATER WELL.SEE
ATTACHED RESULTS.
B. SEPTIC/HOLDING TANK DATA *NOTE: 24 YEAR OLD STEEL SEPTIC TANK MAY BE
APPROACHING THE END OF ITS USEFUL LIFE.
Tank Type/Material *STEEL Date installed 10/6/1994
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout(Y/N) YES Depression over tank(Y/N) NO High water alarm (Y/N) N/A
i4)
Date of pumping 9/30/2411rAol1 Pumper JR'S PUMPING
C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE.
Date installed 10/6/1994 Soil rating Il&p.d or ft2/bdrm) 1.2 System type DEEP TRENCH
Length 25 ft. Width 2.5-3.0 ft. Gravel below pipe 8 ft.
Total depth *13-17 ft. Eff. absorption area 375+ ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 4/5/2018 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 63.25 in. Water added 690 gal. New depth 75.5 in.
Elapsed Time: 120 min. Final fluid depth 65.5 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N &type) NO If yes, give date -
*NOTE:THE COVER OVER THE DRAINFIELD IS APPROXIMATELY 8.5 FEET ON THE NORTH END OF THE TRENCH AND
APPROXIMATELY 4.25 FEET OF COVER ON SOUTH END.DRAINFIELD IS INSULATED WITH 2"OF INSULATION ON SOUTH
END AND PER THE OWNER,THE DRAINFIELD WAS INSULATED BY CONTRACTOR WHEN NEW DRIVEWAY WAS INSTALLED.
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at '• .. a er alarm level at in.
- . •• Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ 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 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation *54. Property line 5'+ Absorption field _ 5'+
Water main 10'+ Water service line 10'+ Surface water '*88'
Wells on adjacent lots 100'+
—DRAINFIELD UNDER DRIVEWAY.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: SEE ATTACHED LETTER.
Property line 10'+ Building foundation 10'+ Water main 10'+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage "`0'
Curtain drain NONE KNOWN Wells on adjacent lots "100'+
F. COMMENTS
*MET SEPARATION DISTANCE AT TIME OF INSTALLATION."92 FEET FROM ST1 FOR SEPTIC TANK TO CLOSEST PART OF RIVULET
AND 102 FEET FROM DBL CO'S TO CLOSEST PART OF RIVULET PER MARK SEWARD,RLS ON 4/24/2018-SEE ATTACHED SURVEY.
REQUESTING 88 FOOT SEPARATION DISTANCE WAIVER FOR SEPTIC TANK (SEE ATTACHED) ovas`IRlik IN
G. ENGINEER'S CERTIFICATION ♦.`P .•••• kj
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 r••��•• •• ;
date. •0 r •Y a ess::
Engineer's Printed Name JEFFREY A. GARNESS # .f,, CE-795 �/ ,,
Date Li/3a�/ g '. t-ROFESS\ "4♦
LICENSE RIIll„s101
#AECC884
(Rev. 10/12/12)
--- to r n r
Municipality of Anchorage ^�:� 5;
. dill'
\`— Ucpai ttncnt
P.O. Box 196650 • 4700 Elmore Road
Anchorage, Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997
http://www.muni.orq/Onsite
Development Services Department
On-Site Water and Wastewater Section
**** VARIANCE/WAIVER REVIEW ****
Waiver#: OSV181019 COSA#: OSC181179 Permit#:
PID#: 051-541-14
Legal Description: Peters Gate Block 2 Lot 2
Engineer: Garness Engineering Group
Applicant: William & Malia Hayward
Your request for a waiver of the required 100 feet horizontal separation from the septic tank to
the surface water has been approved. The approved separation distance is 88.0 feet. See
engineer's waiver request letter for justifications.
This waiver approval applies to.the existing septic tank only. Any future upgrade to the on-site
wastewater disposal system will require all separation distances be met or another approval from
this department.
t
Waiver is Granted: X Waiver is not Granted:
Date: 5/0/8 Approved by: Qiite,e_4 6i zne/
Name of Reviewer
**** VARIANCE/WAIVER REVIEW ****
GARNESS ENGINEERING GROUP, Ltd
ENGINEERING SALES CONSULTING
April 27, 2018
Municipality of Anchorage
On-site Water &Wastewater Program
4700 Elmore Roade
Anchorage, Alaska 99507
Phone: (907) 343-7904
Reference: Requesting Waiver from Septic Tank to Surface Water
at Peters Gate S/D; Block 2, Lot 2
To whom it may concern:
During our site visit, it was found that there was a rivulet/drainage swale that is located on the
refenced property. During our site visits for the well flow test and septic adequacy test, there
was lot of snow and the location of the rivulet could not be verified; however, during a recent site
visit to meet the surveyor onsite, the path of the rivulet could be defined and was found to
having running water. We requested Mark Seward, RLS to measure the separation distance
from the closest septic tank pipe to this rivulet and the double cleanout pipe near the beginning
of the drainfield to the rivulet. Mr. Seward has shown these on the attached as-built survey. We
are requesting a 88 foot waiver be granted from the septic tank to the rivulet/surface water. The
following is justification for this waiver:
• The general topography (see attached MOA topo drawing) of the lot in the vicinity of the
septic system runs from North to South. In the event the tank were to overflow, it
appears the overflow would flow southerly over a path exceeding 100 feet of travel from
the septic tank to any surface water.
• The tank is right next to the driveway and near the front entrance of the house. In short,
the septic tank cleanouts are in a very visible area and in the unlikely event of
overflowing sewage, the owners would notice the issue and could resolve it in a rapid
fashion.
• The house has a daylight basement, so flooding of the basement would likely occur
before and overflow event, making an overflow event highly unlikely.
Based upon this information, it is our opinion that there is minimal risk with the granting of this
waiver and request d e waiver be granted. Please do not hesitate to call us at 337-6179 if you
r-e - further inf.r ..n. Thank you for your assistance.
Sincerel ,
Je -y -. ;me s, P. ., M.S.
Preside t
3701 East Tudor Road,Suite 101 *Anchorage,Alaska 99507-1259
Phone: (907)337-6179*Fax: (907)338-3246'Website: www.garnessengineering.com
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ASBUILT SEWARD & ASSOCIATES LAND SURVEYING 694-082A
I HEREBY CERTIFY THAT I HAVE SURVEYED THE E' %
FOLLOWING DESCRIBED PROPERTY: .---
r- 7-0 '_(''
3� �s��
� �r G i —v 'a- /�,e<z DATE. E
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS g e
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID:
EASEMENTS, COVENANTS} OR RESTRICTIONS �� ,2_-Z
WHICH DO NOT APPEAR ON THE RECORDED SUBDI- �
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB`
ANY DATA HEREON BE USED FOR CONSTRUCTION �/� #
OF FENCE LINES, OR FOR ESTABLISHING BOUND- D.2
ARY LINES. �� _ �-^_�
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ASBUILT SEWARD & ASSOCIATES LAND SURVEYING 694-0:29_
I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE: /-:-"/
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FOLLOWING DESCRIBED PROPERTY: ,30 4.7SOF_ 001111AL
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AND THAT NO ENCROACHMENTS EXIST EXCEPT AS
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OWNER TO DETERMINE THE EXISTENCE OF ANY GRID: i I"'b
EASEMENTS, COVENANTS, OR RESTRICTIONS A/ev/Zz 0
WHICH DO NOT APPEAR ON THE RECORDED SUBDI- �0 A-. Duane Merk Wer A.0
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB' s- 4°� .. � Jr
ANY DATA HEREON BE USED FOR CONSTRUCTION �/� 7 #t `1 if
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OF FENCE LINES OR FOR ESTABLISHING BOUND- - " ;.`..`.ter
ARY LINES. DRAWN: - 5"'A.t1�v•,1,.4'' ;
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Page lof5
i
GARNESS ENGINEERING GROUP, Ltd
ENGINEERING SALES CONSULTING
April 23, 2018
Municipality of Anchorage
On-site Water &Wastewater Program
4700 Elmore Roade
Anchorage, Alaska 99507
Phone: (907) 343-7904
Reference: Drainfield under driveway at Peters Gate S/D; Block 2, Lot 2
To whom it may concern:
We have recently performed a well flow test and septic adequacy test on the refenced property
for the purpose of obtaining a COSA. During our site visit, we found that the drainfield is under
the driveway. The septic tank does not appear to be under the drivable surface of the driveway.
The septic standpipes for the drainfield are in the drivable surface, but the owner has taken
measures to protect these from damage by installing a steel domed cover that is placed over
the standpipe (see photos below). According to the inspection report, the south end of the
drainfield was insulated at the time of insulation and according to the homeowner, when the new
driveway for the garage was installed, the contractor installed additional insulation over the
drainfield as well. It appears when the new driveway was installed, additional cover was also
installed. Based upon our field measurements, the North end of the drainfield has approximately
8.5 feet of cover over the top of the drainrock, and there is approximately 4.5 feet of cover over
the top of the drainrock on the South of the trench. Based upon out visual inspection of the
standpipes for the drainfield, there was no indication that the drainfield was frozen or had froze-
up in the past. The owners have also provide us an email statement stating that they have had
no issue with freezing of the septic system (see attached). Based upon this information, it
appears the septic system is functional for its intended purpose.
Please donot hesitate to call us at 337-6179 if you require further information. Thank you for
your assistance.
aS' ,
II
- • • f ; •ess, P.; ., M.S.
Preside
3701 East Tudor Road,Suite 101 *Anchorage,Alaska 99507-1259
Phone: (907)337-6179*Fax: (907)338-3246*Website: www.garnessengineering.com
Page 2 of 5
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Phone: (907)337-6179*Fax: (907)338-3246*Website: www.garnessengineering.com
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Phone: (907)337-6179*Fax: (907)338-3246*Website: www.garnessengineering.com
Page 4 ot 5
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3701 East Tudor Road,Suite 101 *Anchorage,Alaska 99507-1259
Phone: (907)337-6179*Fax: (907)338-3246*Website: www.garnessengineering.com
Nage 5 of 5
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Phone: (907)337-6179*Fax: (907)338-3246*Website: www.garnessengineering.com
From: Malia Hayward
To: Ava Anderson
Cc: )odv Maus;5uliivanwaterwells()hotmail.com;Erica Sourivonq;Sonia Blewett
Subject: Re:2009 MOA Open Well Permit-24964 Sierra Mesa Or
Date: Monday,April 09,2018 3:14:30 PM
Hello Jody,
We have never had the septic freeze up and have had it pumped every year for at least the last
ten years.
Thank you,
Malia
Sent from my iPhone
On Apr 9,2018,at 3:04 PM,Ava Anderson<ava@andersongroupak.com>wrote:
Jody-
I wanted to clarify with you that you are addressing the list of items in your last e-
mail? I presume it is informational&that you do not need anything from us at
this time,please verify.
Items needed from the sellers:
Chip&Malia should be able to write an e-mail regarding the septic and if they
have had any freeze ups. Will an e-mail suffice or do you need something more
formal?
Could Chip&Malia also include in the e-mail which way they would like to
proceed with regards to the well?
Looking forward to hearing from you.
Sincerely,
Ava
® I
On Mon,Apr 9, 2018 at 2:33 PM,Jody Maus yodyngarnessengineering.com>
wrote:
jk
G
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
ox 196650
Anchorage, AK 99519-6650
www.muni.org/onsite 7�
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. o5i-1;4i-i4
1. GENERAL INFORMATION
COSA # („'2 el tO O d 3
Expiration Date: 9 — 8 — O 9
Complete legal description Peters Gate Subdivision Block z Lot z
Location (site address) 24g64 Sierra Mesa Circle Chugiak AK g9567
Current Property owner(s) William & Mallia Hayward Day phone a60-22'AS
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
P O Box 672178 Chugiak AK gg567
Day phone
Malvn Anderson (a) Exit Empower Day phone 16o-zoi3
Fax 117-cn 1
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3_
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ED
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-faAly 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 engineers 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 272-8218
Address P.O. Box iozgsc. Anchorage. AK 995io
Engineer's Printed Name Steven R. Pannone. P.E. Date 6/21oci
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 system
These conditions arc 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 arc 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 right whatsoever.
5. DSD
/SIGNATURE
V Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory_
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date:
Municipality of Anchorage o
Development Services Department °
j 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: Peters Gate Subdivision B21.2 Parcel ID:0 ✓rte
A. WELL DATA
Well type p If A, B. or C provide PWSID N _
Date completed01 1111994 Sanitary seal (Y/N) Y
Total depth 112 ft. Cased to 60 ft.
FROM WELL LOG
Date of test 101111994
Static water level 26 ft.
Well Log (Y/N) Y
Wires property protected (Y/N) Y
Casing height (above ground) 24 In.
AT INSPECTION
121302008
22 ft.
Well production 6 g.p.m. 0.6
WATER SAMPLERES��/��LRP ND (C 1_1DC( LRT
Coliform colonies/100 mL Nitrate 149 lmg/LJ Other bacteria colonies/100 mL
Arsenic: VAP ug/l • Date of sample:(2 %/d9' Collected by: 'y¢s1�% 'N;,,
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Anchorage Tank Steet Date Installed 10112009
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 (YM) NA
Date of pumping 10!32008 Pumper JR's Spetic Pumpers
C. ABSORPTION FIELD DATA
Date installed 10162008 Soil rating (g.p.d./ft2 or ft2 bdrm) L2 System type Deer) Trench
Length 24 ft. Width 3 ft. Gravel below pipe 8 ft.
Total depth 13 ft. Eft. absorption area ,JZ ft2 Monitoring tube Y Depression over field N
Date of adequacy test 12/302008 Results (Pass/Fail) Pass For 2 bedrooms
Fluid depth in absorption field before test ¢4 in. Water added450 gal. New depth66 in.
Elapsed Time: 100 min. Final fluid depth 64 in.
Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
Date installed
`Pump on" level at
(Y/N)
at _ In. Hig m level at
Cycles tested Meets alarm & circuit
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100+
Absorption field on lot 100+
Public sewer main 100+
Sewer/septic service line 25+
Animal containment areas 100+
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 5+ Property line 0+ Absorption field 5+
Water main 25+ Water service line 25+ Surface water _ 100+
Wells on adjacent lots _ 100+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 100+
Water Service line 25+ Surface water 100+ Driveway, parking/vehicle storage 0
Curtain drain 50+ Wells on adjacent lots 100+
F. COMMENTS
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 $ c�"�� ' Waiver Fee $ _
Date of Payment d%% Date of Payment
Receipt Number a'� Receipt Number,
(Rev. 1 Ims) '
0
fen R. Panni
No. CE 8149
13
In.
Municipality of Anchorage ..
• Development Services Department y
/ Building Safety Division `
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchoragc.ak.us
(907)343-7904
Nater Well Advisory
Certificate of On -Site Systems Approval (COSA) # 090003
During a recent COSA on-site inspection and test of the potable water
supply well on Block 2, Lot 2 of Peters Gate subdivision, the well's
productivity was determined to be 0.6 gallons per minute. The minimum
well productivity required by this Department (AMC 15.55) for a 3 -bedroom
residence is 0.31 gallons per minute. Although the subject well currently
exceeds this minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction of non-critical
water uses such as washing cars and watering lawns and gardens may be
required.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
\ Municipality of Anchorage
-� Development Services Department ' I
!�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 �j
Parcel I.D. 051-541-14 COSA # C�ga(�U3
Expiration Date: 3 — I (0 - O 5-
1. GENERAL INFORMATION
Complete legal description Peters Gate Subdivision Block 2 Lot 2
Location (site address) 24964 Sierra Mesa Circle
Current Property owner(s) William C and Mallia L Hayward Day phone 360-2235
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
P.O. Box 672378
Unless otherwise requested, COSA will be held by DSD for pickup.
Day phone
Day phone
2. NUMBER OF BEDROOMS:
3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual On-site
Individual Water Storage
❑
Individual Holding Tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
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 272.8218
Address P.O. Box 102954, Anchorage, AK 99510
Engineer's Printed Name Steven R. Pannone, P.E. Date 1/512009
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 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 arc 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 hIOA 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
L, Approved for q— bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date: 14 - Oct
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: Peters Gate Subdivision 82 L2 Parcel ID: [15-1'
A. WELL DATA
Well type P If A. B, or C provide PWSID N _ Well Log (Y/N) Y
Date completed 101111 Sanitary seal (Y/N) X Wires properly protected (Y/N) Y
Total depth 112 ft. Cased to 60 ft. Casing height (above ground) 24 in.
FROM WELL LOG AT INSPECTION
Date of test 101111994 1213012008
Static water level 26 ft. 22 ft.
Well production 6 g.p.m. 0.6 9 -
p.m -WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate W) mg/L Other bacteria colonies/100 mL
Arsenic: N9 ug/1
Data of sample:( �1�� Collected by: Y¢sN11 N %o
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Anchorage Tank Steel Date installed 101112009
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (YM) N High water alarm (Y/N) NA
Date of pumping 101312008 Pumper JR's Soetic Pumpers
C. ABSORPTION FIELD DATA
Date Installed01L�008 Soil rating (g.p.d./ft2 or ftp bdrm)1.2 System type Deep Trench
Length 24 ft. Width 3 ft. Gravel below pipe 8 ft.
Total depth 13 ft. Eff. absorption area X75 ftZ Monitoring tube Y Depression over field N
Date of adequacy test 1213012008 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 64 In. Water added450 gal. New depth66 in.
Elapsed Time: 100 min. Final fluid depth 64 In. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
Date installed
"Pump on" level at
(Y/N)
at _ in. Hig m level at in.
Cycles tested Meets alarm & circuit
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100+
Absorption field on lot 100+
Public sewer main 100+
On adjacent lots 100+
On adjacent lots 100+
Public sewer manhole/cleanout 100+
Sewer /septic service line 25+ Holding tank 100+
Animal containment areas 100+ Manure/animal excrete storage areas 100+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line 10+ Absorption field 5+
Water main 25+ Water service line 25+ Surface water 100+
Wells on adjacent lots 100+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 100+
Water Service line 25+ Surface water 100+ Driveway, parking/vehicle storage 0
Curtain drain 50+ Wells on adjacent lots 100+
F. COMMENTS
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 $ `�� ' Waiver Fee $
Date of Payment
Receipt Number
(Rev. 11105)
Date of Payment
Receipt Number
.ASleven R •�Pannore, ,llr i
P + No. CE 8149 .e 4�
�y�ass1.: �.
Municipality of Anchorage
• "` Development Services Department
j/ Building Safety Division `
a• arr
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
Nater Well Advisory
Certificate of On -Site Systems Approval (COSA) # 090003
During a recent COSA on-site inspection and test of the potable water
supply well on Block 2, Lot 2 of Peters Gate subdivision, the well's
productivity was determined to be 0.6 gallons per minute. The minimum
well productivity required by this Department (AMC 15.55) for a 3 -bedroom
residence is 0.31 gallons per minute. Although the subject well currently
exceeds this minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction of non-critical
water uses such as washing cars and watering lawns and gardens may be
required.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
Pannone Engineering Services, LLC P.O. Box 102954
Consulting Engineers Anchorage, Alaska.
99510
(907) 272-8218 (907) 272-8218 Fax
February 10, 2009
Municipality of Anchorage
On -Site Department
4700 Elmore Road
Anchorage, Alaska 99507
Subject: Certificate of Onsite Approval
Peters Gate Subdivision Block 2 Lot 2
I am writing in response to your "pink sheet" dated February 5, 2009 concerning a Certificate of
Onsite Approval application for Peters Gate Subdivision Block 2 Lot 2 (24964 Sierra Mesa
Circle). Your comments indicated the code does not allow for soil absorption systems to be
installed under driveways, therefore preventing approval of this system. This letter will provide
an engineer's evaluation of the adequacy of the sewer absorption system to provide service to
the aforementioned property for the foreseeable future.
Pannone Engineering Services (PES) performed a well and septic adequacy test at 24964 Sierra
Mesa Circle on December 30, 2008. The well and septic system were found to be fully
functional and adequate. The site conforms to all Municipal Code requirements save one: a
driveway has been installed over the top of the sewer absorption field. Although this is not
allowed under Municipal code, PES has come to the conclusion that the system will provide
service to the site without any complications pertaining to this violation for the following
reasons:
• The soil absorption system was installed in 1994. The driveway was constructed over
the system in 2003.
• The system has been in operation since 1994 and the owner has reported having no
problems with the drain field.
• The northern (uphill) portion of the field has 8.8 feet of cover above the drain field.
This is an adequate amount to protect from freezing.
• The southern (downhill) portion has 4.8 feet of soil (per investigation) and two inches
of rigid insulation (per record drawing) above the drain field. This is also sufficient to
protect from freezing equating to approximately seven feet of cover.
• Both ends of the drainfield have 4" diameter cleanouts to facilitate thawing if the field
docs freeze.
• The field is covered with an additional two inches of packed snow and ice during the
winter.
• There does not appear to be a good location to move the field to.
• Existing conditions of the field show it to be well within operating levels, with five
feet of liquid in eight feet effective depth of sewer rock.
• The septic tank is not located under the driveway.
Pape 1 of 2
Page 2 of 2
February 26, 2009
Furthermore after a second inspection of the site on February 7, 2009 we concluded that the
driveway could not be abandoned or relocated without losing access to the garage. It is for these
reasons that PES requests that the requirement of the drain field not to be located under a
driveway be waived for this system, and a Certificate of Onsite Approval be issued for Peters
Gate Block 2 Lot 2.
If you have any questions or concerns, please contact me at 227-3522 or 272-8218.
Sincerely,
Steven R. Pannone, P.E.
Civil Engineer
Attachments: (1) Record Drawing
W:\PES Work Files\letters\htoosewalk Bl L3A 001.doc
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Anchor;e Recording Ptedrx Al"ke. and that the im "
conte situated thereon ate within @te property lines and do not
overlap or encroach on the ptopeery 17u+g adjacent theme; that
no �ptortmrnts an pto lyln66 ad`ecent thereto ervcach
on the ptem6ae In qIt nd tftat theta any no roadways.
tratwnimbn ]toes at other visible easements on said poperty
except arindk7ted' hetecn.
Dated a�Mya. ALska
m 70
ROBERT C. JOHNSON �
SCALP: r pa6 aR7ed Land $ury A V7
I� �(`O Boa 7741156, Eagle River, J.l ka 99 77
Phone M, WZ515
/ 2 -
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. # 05 -1S -q-11 y HAA # K A g 4()toq I
1. GENERAL INFORMATION
Complete legal description Ld r Z, Z, 1 t ---r- an s 6
S'v1�DI V1Sio4
Location (site address or directions) 2 4964 S 1 1L4?_4 / V I GZS 4 ILow
Property owner C10 NrrlzA L -1N G Day phone " I Z.3&
Mailing address �� o x 61() 4q� 1�1�11C�1 A i� 9q5��
Lending agency Day phone
Mailing address
Agent /NJ D ^I C Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well X X
Community well
Public water
NOTE: it community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site x` X
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. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I 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.
Name of Firm 4,jA c1L S 0, b i � t5'CT1-i nJ Phone 3 `' 4 - 4G S 1
Address P0. KC X Z-40
Engineer's signature
6. DHHS SIGNATURE
By
G
Approved for F - bedrooms.
Disapproved.
Conditional approval for
Additional Comments
.6t_= 414- 1
Date / Z17-1 /q4
4
TA
ason
S h��1.i`��Od )A•CU bOV b`c`JC�```.s'�7
bedrooms, with the following stipulations:
on
71717
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in orderto 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 (Flw.191) B=11 MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
�-zi `L-- / �T � e<47& Parcel 1. D.
Sa/AVx
A. Well Data
Well type rr,
If A, B, or C, attach ADEC letter. ADEC water system number
�^
Log present (Y/N)
% Date completed /® �'' Driller SU C t 1 V/1
Total depth
Cased to Ga 7 � Casing height
Z-
Sanitary seal (Y/N)
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
Date of test
DLI
$ z
Static water level
Z4,
74r
Well flowO
G g.p.m. gti
~' �
,,, M
Pump levell
()i,4 V— t" 0
0
vi
Il'r7
to rn
(n G
SEPARATION DISTANCES FROM WELL TO:
N
Septicfkuotank
on lot �= / 2-`L - r ; On adjacent lots > -2�e r
Zn
Absorption field on
lot / �5 r ; On adjacent lots , /5g r,, r
Public
/V`4---
/1s
sewer main
Public sewer manhole/cleanout
Sewer service line
= /C2 Petroleum tank N��
WATER SAMPLE RESULTS:
Coliform
Nitrate /U MJ /L Other bacteria
Date of sample:
Collected by:
B. SEPTIC/IG TANK DATA
Date installed o���� Tank size 4 Compartments
Cleanouts (Y/N) r Foundation cleanout (Y/N) K Depression (Y/N)
High water alarm (Y/N)Alarm tested (Y/N) �/✓��F—�"
Date of pumping _ /`" Pumper
SEPARATION DISTANCES FROM SEPTIGG TANK TO:
r �
Well(s) on lot
On adjacent lots > 2 e-' 0 r
Foundation 1 )- /C'
To property line = `%a > Absorption field ~ Water ivi*0/service line - -G7
Surface water/drainage ,y /o t, r
72-026(3/93)'Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
on" level at
Meets MOA el rical codes (Y/N)
SEP ATION DISTANCE FROM LIFT STATION TO:
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
Well on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed A)� Soil rating (GPD/Ft') / 'L System type
Length 2 Width Gravel thickness Total depth
Total absorption area > Cleanout present (Y/N) %� Depression over field (Y/N)
Date of adequacy test � Results (pass/fail) - for -�� Bedrooms
Water level in absorption field before test l� After test
Peroxide treatment (past 12 months) (Y/N) _ If yes, give date ,�—
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
On adjacent lots
Property line
- % i To existing or abandoned system on lot 2100 / Cutbank /V/ Water-aaa+n/service line
Surface water Driveway, parking/vehicle storage area
Curtain drain I✓/�-
E. ENGINEER'S CERTIFICATION
A. i
1 certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines ,n --effect on the pate of this inspection.
HAA Fee $ Waiver Fee $
Date of Payment Date of Payment
Receipt Number Receipt Number.
72-026 (3/93)' Back J r 1 0
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