HomeMy WebLinkAboutMEADOW RIDGE ESTATES BLK 3 LT 8Meadow Ridge
Estates
Block 3
Lot 8
#051-461-29
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 LStreet- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
MAILING ADDRESS
LEGAL DESCRIPTION
PHONE
LOCATION
, Well~2~/?~" ('~ / Material
DISTANCE TO:
Manufacturer
[Liq. capaoity in gallons
DISTANCE TO:
NO. OF BEDROOMS
IF HOMEMADE:
Well
Well /
DISTANCE TO: ])~2~ q~
No, of lines ; Length of each line
I
Inside length
Dwellin9
Foundation / ~) ¢,
Total length of lines
Top of tile to finish grade /
Material
INearest lot line
Trench width
Material beneath tile
Depth
PERMIT NO.
Liquid depth
PERMIT NO.
Liquid capacity in gallons
P E R MIT N O'~ ~ O ~'~(~ ~ q~'
Distance between lines
Length
Type of crib
Crib diameter Crib depth
Well Building foundation
DISTANCE TO:
DISTANCE TO: Building foundation
Total effective absorption
Nearest lot line
/.D:riller ,¢.~_~ ~,) ,~) I Distance to lot line
: f /Lo
Sewer line Septic tank
Total effective absorpti(
OTHER
PIPE MATERIALS
SOl L TEST RATING.
INSTALLER
REMARKS
[~4~rEW
E~UPGRADE
APPROVED DATE
[:'F£F'FtRI"HENT ,_.,- HERLTH RND EN',,,' I F~ONHE1',ITF:IL. r'ROTEC:T ! 0i',1
825 '"L'" :T.',T~?EET., Ft1',ICI..'IOrRFIGE.,
~:IE;,:~-4.72E~
)
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t. '.~ '- FIT I ON
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!.'"r'F'E FIF_ Si;OIL FtE~SCIIRF'TII3N _-..,'~" '""'""-"l.r.:, ~.. I $ ' TF. tEt'.,ICI.-I
;:2 ',4.
SI2.'L RF::E' FEET
HFIXtHI._Ii"I I".!I..II'"IE:EI~t OF BE[:'ROCIi-'iS := ..E: ':.-;I.3tL RFITI1'.,II3 ':;S6! F'T,.'"E~R:)=:
THE F.:EQUIF.':EC, '.ST. ZE OF:' THE SOIL RE~SOF..tF'TION
'±5~3
....... " ~-~ iF :. ~--~ -~. ~_-T b ~:" E.-E_ F" -F .~-I ==. 4.-
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THEF?E.: IS NO E;ET 14IC, TFI F:OR TF.:ENCHE$.
THE I.-.iF.:Ft',,,'EL E:,EF'I"H IS T'NE HINIHUPI C, EPTH OF F" '-'-
.~F..H,E.L BETI4EEN TIE LqI_TFFiLL PIPE
FIN[:, THE BF:'F1T&'I I:~F THE E::'::C:I:1',,,'IaTiI31'.~ '::IN FEET).
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t'.,ILIHE:Er4: LqF RE:~II3, EI',IE:ES THFlt" THE !4ELL. I.,.!IL.L SEF.:',,,'E.
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E:FtCF':F ILL t iqG OF R1'.4'¢ .:Sh'S'"F..:i' I 14.IT THOUT F' 1 I'.41:11_.
[:,EPRRTHEI",t-F t.,.flLL E:E E;UE',JEC:T TO F'F.':OSEE:UTtON.
HINIHI_tH DIS'FRNCE BE'TI.,.IEEI'.,I R I.,.!EL.L FIND RN'¢ ON--SITIE SENRGE DISF'OSFtL S'¢STEH tS
d. CIel FEET FOR R PF;Z',,,'RTE t.,.IEL_L OR ~SE~ TO 2Clei FEET FROPt R F'UBLIC NELL DEPENDING
UPON THE T%'PE OF F'LIBLII3 I.,.!ELL
I"IZt'-,iIHIjH [;,ISI'RNCE FROH Ft F'RI'¢RTE I.,.IEL. L TO A PRIVATE: SEI.4ER I_INE IS 25 FEET AND
TCI F:I I]OI'"IHI_tNZT'T' SEt.,.IER LINE IS 75 FEET.
O]'FIEI;4 REI;~UIREHENTS t"lR'¢ RF'F'L'¢. SPEiE:IFIC:RTIONS Rt'.4D C:ONSTRUC:TIC~N DIRGRRt"IS RRE
Ft',,,'RILRE',L.E TEl INSI_II;'.E F'ROPER INSTI:1LLIaTION.
F' ~E Fi." P""[ '_,T. T' E.E '.'=-:: F" ',f.X IF%: E :'£i; E:> E'E IL~:: E ii"-! E; E: IF::-': 1~7: :!. .... :iL :5" ~;E: .3:
I C:EIE'.T I FY TI--IRT
:ti i RH FRI"!ILiRR I.,.IiTH THE RE,;!UIF.':EHE:NTS FOR ON-E;ITE SEt.qERS RN.[:, ,t,.IELI....:5 RS SET
FORTH B'T' THE I'"IUI',!ICIF'RL. ITh.' OF Rt",ICFIOI;.':FIGE.
2:-': t 14IL. L ilq."STRLL THE E;'-FSTEH it'-,l FICCOR[:,RI'-,IC:E .b.lIi"H TI-IE L-:ODES.
]:: I UNE:,EF.-."E;TFINt~, 'THI::IT THE CIN-$ITE SE!.qER '_-7, "r"_.:; l~ E l'"l HFI"r' I~:EQUII;.':E EP.tL. FIRIiiEHENT IF 'THE
IRESt'E:,EiqE:E IS I:;-:EI"!ODELEL':, TO tNCL. UDE HOF.:E T!-tR1",t ~: E:EDI~:OOHS.
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•/� Municipality of Anchorage g .
On -Site Water and Wastewater Program _-
(907)343-7904 sAr�,v
Certificate of On -Site Systems Approval
Parcel I.D. 051-461-29
1. GENERAL INFORMATION
Expiration Date:
Complete legal description Meadow Ridge Estates, Block 3, Lot 8
Location (site address) 20857 Country View Drive
Current Property owner(s) Gerald & Deborah Hendrickson Day phone
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
0 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:
Individual Well
❑
Individual (]
Individual Water Storage
❑
Holding Tank ❑
Community Class A Well
El
Community ❑
Public Water System
❑
Public Sewer ❑
WaiverNariance request for:
Distance:
Received by r" f �C!(�
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ +i C) n
Date of Payment 5
1
r (' l � - /)
Receipt Number b -1 t�
COSA# RC1 3\\ b�
Waiver Fee $
Date of Payment
Receipt Number
Pff-7Q-a'Fi :3
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 Pannone Engineering Services LLC
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone
Phone (907) 272-8218
Date 09100
6. DSD SIGNATURE """
System #1 Approved for 3 bedrooms even Pannone
System #2 Approved for bedrooms +�} CE -8149r
Disapproved +Ri0FE551 tr
Conditional approval for bedrooms, with the following stipulations:
By: Original Certificate Date: — 7—/3
Theunicipsli of nchorage 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.
ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet r ., ,.
If more than 1 septic system is on the lot:
COSA Checklist # -L_of
Structure served by this system 1
Certificate of On -Site Systems Approval Checklist
Legal Description: Meadow Ridge Estates, Block 3, Lot 8
A. WELL DATA
Well type Class 'A'
Total depth
If A, B, or C provide PWSID # 210401
Parcel ID: 051-461-29
Well Log (Y/N)
Sanitary seal (Y/N) _ Wires properly protected (Y/N)
Cased to ft. Casing height (above ground) in.
LOG AT INSPECTION
Date of test
Static water level ft.
Well production 9 -
p.m -WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic ug/L Date of sample:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/ Steel
ft.
Collected by:
Date installed 4/4/1984
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping ZOf Pumper 'QJMPI,vt--
C. ABSORPTION FIELD DATA
Date installed 4/4/1984 Soil rating (g.p.d./ft2 or ft2/bdrm) 150 sf/br System type Deep Trench
Length 57 ft. Width 4 ft. Gravel below pipe 4 ft.
Total depth 12 ft. Eff. absorption area 456 ftz Monitoring tube Y Depression over field N
Date of adequacy test 1/3/2013 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 467 gal. New depth 0 in.
Elapsed Time: 100 min. Final fluid depth 0 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date
D. LIFT STATION
"Pump on" level at
Datum
Size in gallons
in. 'Pump
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tan i
Absorption field on lot
Public sewer main
lot
Sewer /septic service line
Cycles tested
Animal containment areas
SEPTIC/HOLDING TANK ON LOT TO:
Manhole/Access (Y/N) _
High water alarm level at
Meets alarm & circuit
On adjacent lots
On adjacent lots
manhole/cleanout
Holding tank _
Manure/animal excrete storage areas
Building foundation 5+ Property line 5+
Water main 10+ Water service line 10+
Wells on adjacent lots 200+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+
Water Service line 10+ Surface water 100+
Curtain drain 50+ Wells on adjacent lots 200+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
l 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
Date — <30! OL-
COSA brown sheet 10-10-12.doc
Absorption field 5+
Surface water 100+
Water main 10+
Driveway, parking/vehicle storage 110+
fi
ASSUILT �� �_ SE�TARD & ASSOCIATES 1,6M SURVEYING 694-082a
I HERESY CERTIFY THAT I HAVE SURVEYED THEP—DA
`
FOLLOWING (DESCRIBED PROPERTY-
.9,1!,? 'P "�E.'OF A�-9 9a
AND THAT NO. ENCROACHMENTS EXIii EXCEPT AS�w A'.INDICATED. tT IS THE RESPONSIBI LfTY OF THEOWNER TO DETERMINE THE E:CISTENCE OF ANY EASEMENTS, COVENANTS,: OR RESTRICTIONS/�i/3�2 i9WHICH DO NOT APPEAR ON:THE RECORDED Sam -VISION PLAT..UNDER NO CIRCUMSTANCES SHOULDPANY DATA HEREON BE USED FOR CONSTRUCTIONOFFENCE LIN OR FOR ESTABLISHING BOUND- �' :
ARY LINES.
,4i�1
/\q ,
(J/Il(l{;> I V~I~;(' I~'~I
IX/( )
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 inves~Lgation 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
Address
Engineer's signature
~' " 5 [;.NGINEERING
I ~'034 Eagl~ River L~oop~E~ad No. 204
Ea~Je River, AJasJ~:a'C)~5,~-'"'~ '
DHHS SIGNATURE
~.' Approved for
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
I
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 th is 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~)25 (Rev. 1/91) Back MOA 1~21
~-i'-iV [1 /\ij'FiiC)i:;I'[Y ~\iq'li()V/-\i Ctlt{(?KLi',5i
I t~()M V¥[ I ~ i
!i. 5t:[' I IC/lt(}L !ilN(i i'/xNF. I)~', i ~
I li~lhWmOr ~dmnl
i"l[)nc,''~(,,/vt,' iT/ariJlOIO;cI(DLU/t)LJt
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v'Vdil(';} m! k)i
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C. ABSORPTION FIELD EIATA
Soils Rating in Absorption Strata _/~'c~ ,~
!
Width of Field ~7~/
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test__
Date of Last Adequacy Test
Type of System Design ~7~~
Length of Field ~-7 ~
Depth of Field .~ ~ /
Gravel Bed Thickness ~-/
Standpipes Present (Y/N) F
Separation Distance from Absorption Field:
..
To ~ater-Supply Well .~?_;Z¢_~__ To Property Line ~' ~"
TO Building Foundation /9 ! To nxlst~n] or DJpandoned System cn
Lot ~//~ ... On Adjoining Lots
To Water Main/Service Line /7' To Cutbank(if present)
To Stream/Pond/Lake/or Majo~ Drainage Co, rose
To Driveway, Parking Area, or Vehicle Storage Area
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequac~y Test.
~ets _MOA
Comnents
** Check Permitted Bedroom Rati. ng Against ~51A Request
I certify that I have checked, verified, or confornmd to all MOA HAA Guide!i~ms in effect
on the date of this inspection.
KB1/d5/s
MOA No.
[Page 2 of 2]
2-15-~:4