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HomeMy WebLinkAboutMCMAHON BLK 2 LT 1McMahon
Block
Lot 1
#017-041-23
Municipality of Anchorage Page of Z
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: `)q 1101 1 ci PID Number: nhi -- ini-j \ 5
Name:—�'A
Wastewater System: ) 'New El Upgrade
�o n n�e'er
Address: ZZ0
Cleveland -0-(Z01
ABSORPTION FIELD
Phone: i/
Z
No. o4f8 edrooms:
Deep Trench LJ Shallow Trench 11 Bed El Mound Other
LEGAL DESCRIPTION
Soil Rating:
D' �
Total Depth from original grade:
��' � F'T_
GPD/Sq. . Ft
Lot: Block: Subdivisio�ny
C/ "f cl Am
Depth to pipe bottom from original grade:
3• $ Ft.
Gravel depth beneath pipe
� Ft.
Township:��yy
/G
Range: W
g 3
Section. �J Q
Z8
Fill added above original grade:
4M /-3
Gravel length:
Ft.
T� Ft.
WELL: XNew ❑ Upgrade
Gravel width:
Numberoflines:
/
Distance between lines:
Ft.
Ft.
Classification (Private, A,B,C):
Total Depth:
/01
Cased To:
/0/
Total absorption area:
1
Pipe material: 1P VC,
Yi va+e,
Ft.
Ft.
- , 000 SQ. Ft.
Driller: lite; rdlil n € G14W,
I�IeD
Date grilled:
�
Static Water Level*
7��n
Installers
aAn ,w,ir�- Co.
Date installed:
3�5�I9
Yield:
115
Pump Set at:: Casing Height Above Ground:
ve
00
TANK
GPM
! Ft. ✓ Ft.
SEPARATION DISTANCES
XSeptic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacture
y7 ) 1
(j7 K
Capacity in gallons: /ZSO
From
Tank
Field
Station
Tank
Sewer Lines
��LL1lll
Well
2-S'
/
l30!
N6�
Nd�
aJ��
,VA/�
Material: �L
7
Number of Compartments:
Surface
Water
N�.
�/�
�V
Arm
!V
t`
/V
IV
LIFT STATION
Lotze
/
t0
An,-
Size in �4allons:
Manufacturer:
Line
/ "MQ�
/ �O
/(HVAC
Foundation
5'
0'
✓
n/ -
/V
A m
/(/
AJai
�V
Pump on" level at:
"Pump off' -level at:
High water alarm at:
Curtain/
Drain
���
� '
Am
-
J*+
/V /
Pump Make & Model
"`
Electrical Inspections performed by:
BENCH MARK
Remarks:
Location and Description: `o f/ t/ n !R /Z !/
bi'rck 23' ea,s4 of easf _r -'Y4 o-� Krause
Assumed Elevation: /00
ENGINEER'S SEAL
OF
Dates: 1st
Inspections performed by:
° y .^�
2nd3/khj:10a
000°
Department of Health and Hu a
Services app
Vol.,$.a.baay. a
° EAUSMAN
ARLE V. °
°'
Reviewed and approved by: �' % Date:
CE d 1393
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ww
72-013 (Rev. 9/91) MOA 25
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Permit No.
Page of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
'/� �32-
Legal Description:
i PID No.:
r Co
N 98-
Co Co Ai vi
N9 Z
98)
e theJ %�g111,
in
N9le: No wils win
,41St"riV• �ntij
W"�s er1T lets(
0,v5'oF level
844, it off ' Na vJafer __
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16,
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5'r,
l5'
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s I col
sTZ
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CoZ
25,
16
Dwk!_GII/6-
Go3
26
_ �3co2
Mwl
39'2-71250
Z
A$Z
c
r
39'
�3`
30' GkL, TgNt�
co0 s
G88'1
r
ENGINEER'S SEAL
Nof�
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72-013 A (2/91) MOA 25
co, �!
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FPDI•I FiPIIE ERILLVA'
LOCATION OF WELL
_.. ... ___ Fk< 110. : 907 345 IS'Ll•' Har. 2' 2DOS 11:1314.1 Pl
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
DIVISION OF WATER
WATER WELL RECORD
aoRCUGH sueolm." LOT Ilteat SeCTION nTRs E[crioN TOVNKNIP PAMS 641700 AN
OE
ONI Owl
I
LOCATIONISKETCH: WELL OWNER:
DEPTHS MEASURED FROM:❑caslrg top Oground surface WELL DEPTH: DATE OF COMPLETION
Depth of hole: �9— % ft
!�
BOREHOLE DATA: Depth Depth of casing /_L/ / 5
Material Type and Color From To
'.
DEPTH TO STATIC WATER LEVEL:
f7 0 h below EX4v of casing ❑ Around surface
f Dace
„�•
METHOD OF DRILLING: .0 air rotary O cable tool
❑other
USE OF WELL, 13 domestic ❑irrigation ❑ monitor
z*,r
2,- ❑ pt*& supply O other
_.) C
�"
CASING STICK-UP- 7 . tt. Otam: tn. tozQl h
.�'.��.%IAvac+�✓ :s'Z�fJ
��% Casing type_ in. to YO!—ft
WELL MAKE OPENING TYPE: © open end ❑ screened
13 perforated ❑ open hole
Depths of openings: to h
SCREEN TYPE: Diam: in.
Slot/Mesh Size: lugth: It
GRAVEL PACK TYPE-
YPEVolume
Volumeused: Depth to top:
GROUT TYPE: \ Volum¢:
Depth: from h to h
DEVELOPMENT METHOD -
Duration:
PUMPING LEVEL AND YD:
rsDumDig? _gpm
PUMP INTAKE DEPTH: h Horsepower:
WELL DISINFECTED UPON COMPLETION? MM ❑ NO
CONTRACTOR INFORMA ON' , REMARKS:
PLEASE MAIL WHITE COPY OF LOG:70:
atO tl ! DNRIDNISION OF WATER
PO BOX 772116
EAGLE RIVER AK 99577.2116
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650 FJ/v y3
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW940013
DESIGN ENGINEER:POLARCONSULT
OWNER NAME:HAGMEIER JOHN C & JUDITH A
OWNER ADDRESS:2204 CLEVELAND #201
ANCHORAGE, ALASKA 99517
PARCEL ID:01704123
LEGAL DESCRIPTION: MCMAHON BLK 2 LT
LOT SIZE: 29809 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
1
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
I
DATE ISSUED: 1/26/94
EXPIRATION DATE: 1/26/95
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 OR 343-4681 AFTER BUSINESS 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
ISSUED BY
DATE:ZY
DATE: 2 /- / 4
polarconsult alaska, inc.
ENGINEERS • SURVEYORS • ENERGY CONSULTANTS
January 12, 1994
DHHS, Environmental Services, On-site Services
P.O. Box 196650
Anchorage, Alaska 99519
Attn: Permit Review Officer
Re: Design and Construction Approval for On-site
Sewer System at Lot 1, Block 2, McMahon S/D.
Dear Sir or Madam:
Please accept the following design for review and permitting. The proposed system
does not affect the current use of the adjacent properties and will have minimum future
impact. If you have any questions, please give me a call.
Sincerely,
Matthew Korshin
POLARCONSULT
Attachments:
On-site Sewer/Well Permit Application
Site Plan, Sheet 1 of 4
System Design Calculations, Section, Sheet 2 of 4
Percolation Test, Sheet 3 of 4
Percolation Test, Sheet 4 of 4
4e�Alo $44A Check for Permit Fee
1503 WEST 33RD AVENUE • SUITE 310 • ANCHORAGE, ALASKA 99503
PHONE (907) 258-2420 • TELEFAX (907) 258-2419
PRODUCT 217-1(&*Sh )205-1(PWW) 0. IN., GMMMm. 01471. To OrdffPMTOLL FRE I-MMMO
polarconsult alaska, Inc.
1503 West 33rd Avenue • Suite 310
ANCHORAGE, ALASKA 99503
(907) 258.2420 Fax (907) 258-2419
JOB G / ,B Z /" lcMahon S/29
SHEET NO. OF Z
CALCULATED BY DATE
CHECKED BY DATE
SCALE
PRODUCT 207-1&0sr,aets)20�1(Paaaed)®,[M.Ghon,MM.01471. To Order PHONE TOLL FREE I�00.225d'f80
Of' At"S
�� ° k
0;% GINEER'S ........ 42k
°.° - d
YM �F
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a• •oeeeee ooe• ..�
Z
e Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES ®@ ••® ••••°•®••••
825 "U' Street, Anchorage, Alaska 99502-065039 MW V. AUSMAN °
SOILS LOG — PERCOLATION TEST ���°••� 17�'
r pram -o
PERFORMED FOR: vYtn c� e—le—r DATE PERFORMED:
LEGAL DESCRIPTION:_ Lal 1, 81k 2 11%lcMgiM Township, Range, Section: —r12 -N, R3W, S215
DEPTH SLOPE SITE PLAN
(FEET)
2 1 10.
3-
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
4
4-
■■■EEN■R■■
—
-
—
—
G
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—
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—
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8 min
rnrn
Z
l mril
yrmn.
3'Y'
I"
12-
/6 min
mmimmo■■NI■■
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13-
3
■■■iiiENNEN
14
14-
16
16
17
°; .. _.
'JAA5 +he dc,
18
GOH
NO wo-I
19
20
COMMENTS
WAS GROUND WATER A /C
ENCOUNTERED? NV
IF YES, AT WHAT
DEPTH?
Depthto Water Aflen
Monis _ 1 /1 7/9i
Monitoring? � Date:
■■■■■■■11■■
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
RESD4
■■■EEN■R■■
—
-
—
—
G
■■emmmmlffl
—
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—
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MM=9
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$
0111111111000
min
ONION
.2
la116
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/6 min
mmimmo■■NI■■
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■■■iiiENNEN
■■ICA■■■■■■■
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
RESD4
► 6
—
-
—
—
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O rnin
—
3
—
Z
1/6
"in
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$
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min
/ min
.2
la116
8 min
rnrn
Z
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yrmn.
3'Y'
I"
8
/6 min
3 rrn'n
3
�.
PERCOLATION RATE 8 (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN 7 FT AND Qv FT
PERFORMED BY: J00Arc S a �� I CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: I zz/H
72-008 (Rev. 4/85)
e Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: Jnn Aka rA4 e4—
DATE PER
VF pas
wo 001OV6o0 a as a o a`®a
1ARlL= W. AU3MAN
LEGAL DESCRIPTION: �07 �� /lam Z, MC/ ,AAur_ Township, Range, Section: % 12A1, 93W) SZB
DEPTH SLOPE SITE PLAN
( FEET) I j—TTT"1
2
Date
Gross
Time
3-
Depth to
Water
Net
Drop
PkZD#W-
16
—
4-
4
—
5-
567
16
0 min,
—
t
—
6-
jb
Zmin•
Zmin,
7
I
MIDI.
2 m in,
B�6 ��
3 /b ••
8-
6
(o in.
mil.
101146
I "
9-
91012
10-
1114
12-
13
13-
hy rhi .
'
14-
1415
/(o min-
2 wlin,
l yel I
/ r,
15-
16-
1617
17-
18
18
$oH
N Waite
19
20
COMMENTS
Tl��'Z
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
AD
S
L
O
P
E
Depth to Water After /
Monitoring? Dirl Date: i 94
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PkZD#W-
16
—
—
—
16
0 min,
—
t
—
jb
Zmin•
Zmin,
3
I
MIDI.
2 m in,
B�6 ��
3 /b ••
6
(o in.
mil.
101146
I "
1114
8
hy rhi .
'
/(o min-
2 wlin,
l yel I
/ r,
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND 1 FT
PERFORMED BY: Polaria"+ I CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE 1171,P1
72-008 (Rev. 4/85)
MUMCWAUTY OF
Development Services Department
On -Site Water & Wastewater Section
Phone: 907-343-7904
Fax: 907-343-7997
Certificate of On -Site Systems Approval -y P,
Parcel I.D. 017-041-23 Expiration Date: O Q l (� 7 v2— d
1. GENERAL INFORMATION
Complete legal description MCMAHON BLOCK 2, LOT 1
Location (site address) 3600 MC MAHON AVENUE, ANCHORAGE, AK 99516
Current property owner(s) K.M. & FRANK MEEDS TRUST.... Day phone
Mailing address
Real estate agent
MC MAHON AVENUE, ANCHORAGE. AK 99516
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Private Well
Water Storage
Community Well
Public Water System
4
Day phone
TYPE OF WASTEWATER DISPOSAL:
®
Private Septic
❑
Holding Tank;
❑
❑
Community
❑
❑
Public Sewer.
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5n - Lf ( a •SD Waiver Fee $
Date of Payment (.9 Iq I a-0 Date of Payment
Receipt Number 3()QI57a- Receipt Number
COSA # 05C �26 ia(,05' Waiver #
COVID_ 19
-M� DISCOUNT ApPLIL
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 6/18/2020
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
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
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting & Fks
6. DSD SIGNATURE
/�- System #1 Approved for —1— bedrooms
System #2 Approved for bedrooms
Disapproved
�.�W.... % .........
Curtis Huffman
f �F� CE 128991p •`�AM
PROF SSI H��+` r
Conditional approval for bedrooms, with the following stipulati���((((((f���
C
L
J
WATER AND m
7v;�,ATER o
r--
By: *� ('— Original Certificate ii Date:-/- 17- 20 20
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�r
Legal Description: MCMAHON BLOCK 2 LOT 1 Parcel ID: 017-041-23
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)
Date drilled 4/1/1994
Total depth 101 ft
Cased to 101 ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 24+ in.
Date of flow test for COSA 5/15120
Static water level at beginning of test 79 ft.
Well production at time of test 5.5 gpm
Comments
B. TANK DATA
Age of tank(s) 26 years
Tank type/material SEPTIC / STEEL
Measured operating fluid level in septic tank 50.5"
® Standpipes/foundation cleanout per record drawing
Date of pumping 5/15/2020
D. ABSORPTION FIELD DATA
Which system tested (date installed) 3/15/1994
® ALL standpipes present per record drawing
Total measured depth from grade 14.6 ft (max)
Measured depth to pipe invert from grade 7.6 ft (min)
❑ N/A — pressurized field
® Monitor tubes go to bottom of effective. If not, state
depth into effective
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ® No
® Coliform bacteria is Negative
Nitrate 13.1 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ® Arsenic less than MRL (ND)
Collected by
NES
Date of Sample 6/10/2020 & 7/6/2020
C. LIFT STATION
❑ Required maintenance completed
Age of lift station _ years
Lift station material
Comments: SEE MOA TANK ADVISORY
Adequacy test date 5/15/2020
Results N Pass For 4 bedrooms
Fluid depth prior to test 63 in
Water added 800 gal
New depth 74 in
Elapsed time 1380 min
®Code -required soil cover over field Final fluid depth 60 in—
❑ System presoaked Absorption rate 600 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: NES
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
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No ft
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No ft
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No ft
Neighboring Absorption Fields > 100'
Water Service Line > 10'
® Yes
Animal Containment > 50' ® Yes
if No ft
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ®Yes
if No
ft
® Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
® Yes
if No
ft
Surface Water > 100' ® Yes if No 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 ft
Water Main > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No ft
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
G. ENGINEER'S CERTIFICATION
,••...,...c5'���
1 certify that I have determined through field inspections and review ��Q'•. • r�
of Municipal records that the above systems are in conformance �0j.•� •;'� ��
with MOA COSA guidelines in effect on this date. '.
pl.... .... .. .........
•. .. .... ........:.� �.• Curtis Huffman •;
�c •. CE 128991
�kFlo
lk�,�'�'®�����
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC 0201265
Subdivision: McMahon , Block: 2 , Lot: 1
A water sample revealed a nitrate concentration of 13.1 milligrams per liter
(mg/Q. The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relativequality of water
from private wells. Please see the attached "Nitrate Fact Sheet" for important
information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Ma�l�ng Address P O Box 196650 *Anchorage, Alaska 99519 66501,,_, W mum org
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
^ � Ma�Ung Address P �O Box 196650 *Anchorage, Alaska 99519 6650 * vvuwir muni org ��
Septic 'Tank Advisory
Certificate of On -Site Systems Approval #OSC 201265
Subdivision: McMahon Blk 2 Lot 1
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this property is 26 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.
Municipality of Anchorage _v
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
FORA SINGLE FAMILY DWELLING f
Parcel I.D. 017-041-23 COSA# QS C I a123
Y
1. GENERAL INFORMATION Expiration Date: I ":�), ,,c - %
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
MCMAHON S/D; BLOCK 2, LOT 1
3600 MCMAHON AVENUE * ANCHORAGE, AK * 99516
JULIA DOUGAN Day phone 227-0221
3600 MCMAHON AVENUE * ANCHORAGE, AK * 99516
Day phone
JANELLE PFLEIGER W/ REMAX Day phone 242-0076
110 W. 38TH AVENUE, #100 * ANCHORAGE, AK * 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
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 samples. (Certificates may be reissued fora 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. 1 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
Address 3701 E. TUDOR ROAD, SUITE 101 . ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
in conducting this evaluation, GEG, LID. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance ofthe
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 soils condition, groundwater 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 the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or 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
Approved for bedrooms.
Disapproved.
337-6179
gy,......... ss. ...O
rrC 79 3 � .
profess'%O
�0000o��
2 ON-SITE
-� WATER AND
Conditional approval for bedrooms, with the following stipulations:� PROGRAM
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: _Original Certificate _Date:
(Rev. 11/05)
Municipality of Anchorage
' Development Services Department
Building Safety Division
On -Site Water & Wastewater Program s'
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: MCMAHON S/D; BLOCK 2, LOT 1 Parcel ID: 017-041-23
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A
Date completed 4/1/1994 Sanitary seal (Y/N) YES
Total depth 101 ft. Cased to 101 ft.
FROM WELL LOG
Date of test 4/1/1994
Static water level 70 ft.
Well production 15 g.p.m.
WATER SAMPLE RESULTS:
Coliform O colonies/100 ml.
Arsenic: NQ ug./L.
B. SEPTIC/HOLDING TANK DATA
Nitrate &• .z ?mg./L.
Well Log (Y/N) YES
Wires properly protected (YIN) YES
Casing height (above ground) 24+ in.
AT INSPECTION
6/9/2012
Date of sample: 6/8/2012
Tank Type/Material SEPTIC/STEEL
Wel
7.07+ g.p.m.
Collected by: GEG, Ltd.
Date installed 3/14-15/1994
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (YIN) YES Depression over tank (Y/N) NO High water alarm (YIN) N/A
Date of pumping 12/26/2011 Pumper DENALI PUMPING
C. ABSORPTION FIELD DATA
Date installed 3/14-15/94 Soil rating ( .p.d./ft rft2/bdrm) 0.6
Length 72 ft. Width 2 f
System type TRENCH
Gravel below pipe 7 ft.
Total depth * 13.6 ft. Eff. absorption area 1000 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 6/9/2012 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 53 in.
Water added 600 gal.
New depth
65 in.
Elapsed Time: 120 min. Final fluid depth
55 in. Absorption rate >=
600+
g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date —
D. LIFT STATION
Date installed
"Pump on" level at in.
E. SEPARATION DISTANCES
Size in gallons
"Pump off'
Manhole/Access
water alarm level at
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+
Absorption field on lot 100'+
Public sewer main N/A
Sewer /septic service line 25'+
Animal containment areas 503+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout N/A
Holding tank N/A
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5' Property line 5'+ Absorption field 5'+
Water main
N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
P
10'+
Building foundation
10'+
Water main N/A
Water service line
10'+
Surface water
100'+
Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
t certify that 1 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 JEFFREY A. GARNESS
Date 4 1/ �L1f 2
COSA Fee -S `l g o. — I
Date of Paymentla 0A /
Receipt Number a Lig IY-4
(Rev. 11105)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage e
Community Development Department
Development Services Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
Nitrate Advisory
Certificate of On -Site Systems Approval # 121234
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 2, Lot 1 of
McMahon subdivision. This inspection revealed a nitrate concentration of
8.22 milligrams per liter (mg/L) was reported for the property's well water
sample. The Environmental Protection Agency (EPA) has established a
maximum contaminant level (MCL) of 10.0 mg/L for public drinking water
systems. While private wells are not subject to this regulation, EPA
standards are based on existing health information and can therefore be used
to gauge the relative quality of water from private wells. Please see the
attached "Nitrate Fact Sheet" for important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 017-041-23
1. GENERAL INFORMATION
Complete legal description McMahon Blk 2, Lot 1
;fit,C-lam
HAA # 65 f7IN
Expiration Date: a-20— O,S
Location (site address or directions) 3600 McMahon Dr. GG51to
Current Property owner(s) Estate of Chester Darrell, Jr. Day phone 336-2123
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
c/o Helena Collins, 3600 McMahon Dr.
Ken Jelenek
REMAX Properties
Unless otherwise requested, HAA will be held by DSD forpickup.
2. NUMBER OF
Day phone
Day phone 257-0196
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
El
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 Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health Authority 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 seat affixed hereto and as of the validation date shown below. I verify that my Investigation,
based on procedures outlined In the Health Authority 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 -she 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 Watkins Engineering, Inc. Phone 349-1851
Address P.O. Box 110443, Anchorage, AK 99511-0443
Engineer's Printed Name Cindy W. Ellis Date
6. DSD SIGNATURE
✓ Approved for _—Ik— bedrooms.
Disapproved.
Conditional approval for
Additional Comments
bedrooms, with the followin
3-Z4.os
Note: The well for this property meets existing State and Municipal Codes There are nitrates
present It is suggested that periodic testing he to Insnrn the wells rnntinned sni►ahility.
Current nitrate concentration is 8.28 mg11 EPA maximum concentration Is 10.0 mg&_Mnrn
Information on nitrates is available from the On -Site Services Program, at 143-7004_
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By; Original Certificate Date: -3 " 3 U ` 0 5�
(Rw.o,Az)
Municipality of Anchorage
• Development Services Department
Building Safety Division
On-Sfte Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 198850 Anchorage, AK 99519-850
www.muni.org/onsfte
(907) 343.7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: McMahon, Btk 2, Lw 1 Parcel ID: 017-041-23
A. WELL DATA
Wen typePr+
Date completed 4nim
Total depth 101 ft.
Date of test
Static water level
If A. B, or C provide PWSID S
Sanitary seal (Y/N) Y
Cased to 101 ft,
FROM WELL LOG
4/1/94
70
ft.
Well production 15 9 -p.m.
WATER SAMPLE RESULTS:
Conform 0 colonies/100 mi. Nitrate 8.28 mg.A.
Arsenic: NA mg.A. Date of sample: 3"6m
B. SEPTICIHOLDING TANK DATA
Tank Type/Material •1061
Tank size 1250 gal. Number of Compartments 2
Well Log (Y/N) Y
Wires property protected (Y/N) Y
Casing height (above ground) 24+ In.
AT INSPECTION
3/15/2005
73
7.3
ft.
Other bacteria 0 oolonies/100 ml.
Collected by: Cindy Ellis
Date installed 3/14/94
Cleanouts (Y/N) Y
Foundation cleanout (YIN) Y Depression over tank (Y/N) N High water alarm (YIN) NA
Date of pumping 3/16/05 Pumper A+ Home Services
C. ABSORPTION FIELD DATA
Date Installed 3/14/34
Length 72 ft.
Soil rating (g.p.d.W or f?/bdrm) 0_6
. 1IM1
ft.
System type deep trench
Gravel below pipe 7 ft.
Total depth 13_7 ft. Eff. absorption area 1008 IF Monitoring tube Y Depression over Reid N
Date of adequacy test 3/15/)5 Results (Pass/Fa1Q PASS For 4 bedrooms
Fluid depth in absorption field before test 30.5 in. Water added 997 gal. New depth 47 in.
Elapsed Time: 188 min. Final fluid depth 38_5 in. Absorption rate >= 800 g.p.d.
Any rejuvenation treatment (past 12 mo.) (YAV & type) None known If yes, give date
D. LIFT STATION
Date installed NA
'Pump on' level at _ in.
Datum
E. SEPARATION DISTANCES
Size in gallons Manhole/Access (Y/N)
'Pump ofr level at _ in. High water alarm level at in.
Cycles tested Meeta alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/11111 station on lot 117
Absorption field on lot 190
Public sewer main 100+
Sewer /septic service line 115
On adjacent lots 100+
On adjacent lots too+
Public sewer manhole/cleanout 100*
Holding tank NA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5 Property One 48 Absorption field 5
Water main 100+
Wells on adjacent lots 100*
Water service line 50+ Surface water 100+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 25 Building foundation 13 Water main 100*
Water Service One 50« Surface water 100+
Curtain drain None Wells on adjacent lots 100*
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 car* that ► have determined through field Inspecdons and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Cindy W. Ellis
Date 3-Z4-06
HAA Fee
Date of Payment `814''/05
Receipt Number �5014q
(Rev. 12/01)
Driveway. parldng/vehicle storage 25+
Waiver Fee
Date of Payment
Receipt Number
49TH
10dY YI(:.Ellls
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❑
❑
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MCMAHON AVENUE
N 90000'001IW 1 1 5.00'
a We 17-21"E 145.071
THE INFORAMTION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN
EXISTING STRUCTURES AND PLATTED LOT LINES OR EASEMENTS AND IS HOT TO BE USED FOR POSITIONING ADDITIONAL
STRUCTURES OR FENCELINES.
EASEMENTS OF RECORD. OTHER THAN THOSE SHOWN ON THE RECORDED PUT. ME NOT SHOWN HEREON MLESS INDICATEO)
NOW ANY FENCELINES SHOWN ME LOCATED APPROMWELY AND ME HOT TO BE USED TO DETERMINE PROPERTY LINES
OR LOCATE STRUCTURES.
ANY PAVING SHOWN MAY BE APPROXIWTE DUE TO SNOW CONDITIONS.
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G SHANE A. HOLT.
Ip w LB -691 4 i G
AS -BUILT SURVEY (NO CORNERS SET THIS DATE )
1'•70'
1 HEREBY CERTIFY THAT 1 HAVE FERFORMED A
MORTGAGEE'S INSFECTION OF THE FOLLOWING
DESCRIBED PROPERTY.
LOT 1. BLOCK 2, WNIAHON SUB.
ANCHORAGE RECORDING DISTRICT. ALASKA AND THAT
THE VISIBLE IMPROVEMENTS SITUATED THEREON ME
WITHIN THE PROPERTY LINES AND NO VISIBLE
ENCROACHMENTS EXIST OTHER THAN NOTED.
DATED AT ANCHORAGE, ALASKA THIS 167H.
DAY OF MARCH 2005 .
HOLT LAND SURVEYING BBI. FB 11)40
TEL. 345 5510
MUNICIPALITY OF ANCHORAGE
• '� DEPARTMENT OF HEALTH & HUMAN SERVICES y}
Division of Environmental Services Mei
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. # C� M!1 - X2) HAA # A Q 9
1. GENERAL INFORMATION
Complete legal description LI / 321
!'/271/, R 3 W, Se c. 2- 8
-7%3-0
Location (site address or directions) 5- Car''La'Y- °'F t-tcrro-V✓ "k PC/. ,
ovvld /I C1t1ah'n. Ave.
Property owner 1AnL, m4 ( Q2 Day phone
Mailing address '���L1 �La r Q nrf Q , nL2
Lending agency
Mailing address
Agent
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: ZI
3. TYPE OF WATER SUPPLY:
Individual well X
Community well
Public water
Day phone
Day phone
NOTE: If 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 ——
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 H21
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 —
Address 150
o/Cir(ZWa/-t- Phone ZS8'2520
Engineer's signature
6. DHHS SIGNATURE
Approved for
Disapproved.
M
Conditional approval for
Additional Comments
bedrooms.
Date 5/19
�:I ^70
00 90000000 0 got ijf ea
. •0/e'ea 0 0000 1400
�! EARLE V. AUSAMH ra
�- Cli - 1393
bedrooms, with the following stipulations:
111TIC
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 order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025(Rev.1/91) Back MOAk21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LI , 132 SAD Parcell.D.
A. Well Data
Well type Prl ei4o- If A, B, or C, attach ADEC letter. AD/EC water system number
Log present (Y/N) t Date completed 1///9-fDriller Alplu Drdl/ A 9 &4�_nk-Zs
Total depth !'D/ ?1577-
v
Sanitary seal (Y/N) 1
Cased to /4/ FT Casing height 3 �T
Wires properly protected (Y/N) i/
FROM WELL LOG
Date of test ZM/ A y
Static water level 7o
Well flow 5 9•p•m•
Pump levell
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
/25'
X30'
AT INSPECTION
o
Nod
?
_ g.p.m.
91;
z
r T1
_
0ro
c 1
o
�'
X77
rn
<w
�liV /
o
On adjacent lots
—
+J
On adjacent lots O
Public sewer main No -n4 Public sewer manhole/cleanout Ncr�
Sewer service line Ah Petroleum tank Nrli-p-
WATER SAMPLE RESULTS:
Coliform D Nitrate 6 2�1 �' �Z Other bacteria �
Date of sample: 5-4 / `� Collected by: /111/�ii;t
B. SEPTIC/HOLDING TANK DATA
Date installed 3/ly/9y
Cleanouts(Y/N) Y.
Tank size /I ZSa 6--a/ Compartments Z"
Foundation cleanout (Y/N) y Depression (Y/N)
High water alarm (Y/N) IVIA Alarm tested (Y/N) A1114 -
Date of pumping lAv Tank Pumper IVIA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well's) on lot X25 / On adjacent lots f/�� / Foundation 5
To property line 51 , Absorption field 2-0 / Water main/service line 7�
Surface water/drainage /Vane_
N
72-026(3,93)• Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed / V P_LA__ Manufacturer —
Size in gallons Manhole/Access (Y/N) —
Vent (Y/N) - 'Pump on" level at
High water alarm level =
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA
"Pump off" Level at —
Cycles tested —
Surface water —
Date installed 3/ 9Y Soil rating (GPD/Ft2) �' System type _ ��P nc
Length 72- Width 2 Gravel thickness Notal depth . /D, S
Total absorption area /i ODD Fr /
Z, Cleanout present (Y/N) I Depression over field (Y/N) N
Date of adequacy test /Vol �� %red Results (pass/fall) for
Water level in absorption field before test '
test
Peroxide treatment (past 12 months) (Y/N) Alrne- If yes, give date =
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot J 30'
To building foundation 30
On adjacent lots 56 r
On adjacent lots /00 F=T Property line
To existing or abandoned system on lot /Voll_
r
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Bedrooms
Cutbank N� Water main/service line //vn-e _
Surface water A� Driveway, parking/vehicle storage area 33/
Curtain drain /VU'S e -
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
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HAA Fee $ kW
Date of Payment _� _a:�, - (A 'A
Receipt Number a,�C1D3
72-026 (3/93)' Back
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Waiver Fee $
Date of Payment
Receipt Number
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Signature:,.6!!.<��':..4.4na�'
Engineer's Name
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Date
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HAA Fee $ kW
Date of Payment _� _a:�, - (A 'A
Receipt Number a,�C1D3
72-026 (3/93)' Back
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Waiver Fee $
Date of Payment
Receipt Number