HomeMy WebLinkAboutHIGHLAND TERRACE #2 LT 16Highland
Ter'r'oce
Lo1' 16
050- 31
-01
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 C ~'2
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
DISTANCES
SEPTIC ABSORPTION
Address TANK FIELD WELL
Phone(s)~Il Perm,t~,~) ~'N°'~- ZO ND.z/of Bedrooms WELL //5" / / R ¢
Township, Range, Section
AS-BUILT DIAGRAM (Show Iocatmon of well, septic system, pmpeny Imnes, ioundallon,
~/~ ~ /~ / ~ ~ ~ 7 d ..... ay, water hod ..... tO.)
TANKS i
~ SEPTIC ~ HOLDING __
Ma~rial No. of Compadments
TYPE OF SYSTEM .....
~[TRENCH U BED U W. DRAIN U OTHER ~ SE
or~gina~ grade ~/~ FT ~ FT
Fill added above original grade Gravel depth beneath p~pe ~ -~ . ~
Gravel length Gravel w~dth . /f
Total absorplion area Distance between lines / ~ ~ ~ ~
Number of linesSoil raling Pipe material / ~ ,
Installer Date Installed ; ;;
WELLS
~ PRIVATE ~j~¢ ~ OTHER fldentifv) ED, ~ ~,~o ~,
Instatle~ Date Installed:
REMARKS:
.............................................................................. ~'~'~U NIC~PALtT'Y- OF-ANCa401~ ..........
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
^-1t6 6 990
RECEIVED
_1
N 89'58'0~" E 240,00'
in
No weIl~ /~ dq,!H~tlItftHfl~h~fl/~T.T.T.T.T.T.T.T.T~ ~ ~ ~ Ex~tlng pit
+100' J-- I , ~ ~ Hew tank
15 ~ TH
89'55'00" W 240.00'
No ~','ells +100'
[] - TEb~T HOLE
· - MONITOR TUBE
o - SEWER C LEANOUT
-¢'- - WELL
NO KNOWN CURTAIN DRAINS H+mH+~- PROPOSED LFACHFII~LD
EASEWENT
SEPTIC SITE PLAN
LEGAL: Hig.hland Terrace Subdv. #2 Lot 16
OWNER: Barbara Nachmonn
CONTRACTOR: N~A ~ .5/~ _~
~-0~ ~ ~O-~66[]'~-X~[:F ....... ~ SCALF 1" - 40'
A EAGLE RIVER ENGINEERING SERVICES
P.O. Boz 773294
EAGLE J~/VER, AIC. 99577
(SO7) 694-..-5195 FAX: (90'7) 694-32,97
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL: LOT 16, Highland Terrace
GENERAL
1. The well and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of 'this specification.
3. All materials and workmanship shall meet 'the Anchorage Depar'tment of
Health and State Department Of Environmental Conservation
requirements.
4. All soil tests are advisory to the design and are 'to be verified or
modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified or
modified in the field by the contractor to meet Municipality of
Anchorage, Department of Environmental Conservation requirements.
6. It is the responsibility of the owner to obtain all necessary permits
or easements and to locate any ad3acent multi-family wells.
7. The excavation is 'to be exactly in the area shown on the site plan,
any deviation requires engineer approval.
8. I't is always recommended 'that a surveyor locate the nearest lot line
position and 'the location of any easements.
TRENCH
1. The trench is to follow the natural land contour to maintain uniform
· total depth of the trench bottom.
2. The bettom of the trench shall be level, plus or m:[nus 1.5".
3. The total depth of the trench excavation is not 'to exceed 10' at any
point.
4. The sewer line is to (replace the existing sewer line that leads to
the existing tank. )
5. The trench gravel is to be covered with typar fabric material.
6. Soil. or combination of soil and extruded board insulation to a depth
of 4' or equivalent is to be placed over the leachfield.
?. The area over the trench is to be finish graded to prevent ponding
of surface water runoff.
8. The septic tank and leachfield must not be closer 'than 100' 'to any
existing private well, 150' to any Class "C" well, or 200 feet to
any community well.
RECOMMENDED LEACHFIELD DIMF. NSIONS
TOTAL DEPTH = 10' GRAVEL DEPTH = 7' TRENCH LENGTH = 40' TRENCH WIDTH =30"
Soil Rating = 140
Bedroom Capacity = 4
Septic Tank Size =
1250 gallons
Pump, Excavate, and abandon existing septic tank and pit to MOA code. Mound
soJ.! cover 1' over trench. Insulate flow line under driveway.
"~ SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
PI=-RFORMED FOR:
LEGAL DESCRIPTION: ~-o7L /'~'
SLOPE SITE PLAN
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19-
2O
; GROUND WATER S
ENCOUNTERED? /L'/,~ L
0
IF YES, ATWHAT
TH? ~ ~r
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE 6, cf' (minutes/inch)
TEST RUN BETWEEN ~ FT AND '~ FT
COMMENTS
PERFORMED BY:
Eagle Riv0r Engineerin9 Services
Eagle Rive~ AK 99577
69~5195
CERTIFIED BY: ~~'~ DATE:
S
•i y..d Municipality of Anchorage
On-Site Water and Wastewater Program 4
(907) 343-7904 s 4 (T Y
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 050-312-01 Expiration Date: I Z` / 2 -/ 7
1. GENERAL INFORMATION
Complete legal description HIGHLAND TERRACE#2 LOT 16
Location (site address) 10930 CORRIE WAY, EAGLE RIVER,AK 99577
Current Property owner(s) SHANE &ANNE HARGIS Day phone
Mailing address 10930 CORRIE WAY, EAGLE RIVER,AK 99577
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Individual
Individual Well ® Holding Tank ❑
Individual Water Storage ❑ Community ❑
Community Class Well ❑ Public Sewer El
Public Water System ❑
WaiverNariance request for: Distance:
Received by: � f' Date: g/72/17
COSA to be released to the engineer,unle . othe -- requested by the engineer.
COSA Fee $ 5-Z12 Waiver Fee $
Date of Payment q/5 717 Date of Payment
Receipt Number Receipt Number
COSA# O5C-1-7-1 405- 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.
Name of Firm ARCTERRA CONSULTING,INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER,AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 8/18/2017
THIS COSA DOCUMENT CANNOT BE USED TO TRANSFER TITLE UNLESS ALL VENDORS(ENGINEERING,SURVEYING,CONTRACTORS,ETC...ASSOCIATED
WITH THIS COSA ARE PAID IN FULL AT OR BEFORE CLOSING. Engineers Comments: This investigation was completed in compliance with
ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested.
The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use,
local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the
system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function
satisfactory for current or future occupants or can ArcTerra guarantee that no unseen +-...7.1.\
encroachments,deficiencies or discrepancies exist. . Ar,P OF' 4L�`�1�
���� �� f'7
1
6. DSD SIGNATURE * Tri \
System #1 Approved for ( bedrooms. - ���� �
F NENi`4fil . il
System #2 Approved for bedrooms. +) .-,.5 7�8 v` ,��
Disapproved. \ 't'"o E st, .:,�.
\\_��
Conditional approval for bedrooms, with the following stipulations:
s.,-`k'
....• (.,\
err:,
n Wq A7 AN ;
E
U
W-1 pI�OGR� R/14 o •
-.... :-
Sk.'Rvics- \
___________
_ %� / m
By: f Original Certificate Date: 1 r(2--1 7
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 engineers work.
7. ATTACHMENTS: /
COSA Checklist X Nitrate Advisory • . �'
Septic System Advisory Arsenic A,dysgry . ,
Well Flow Advisory Other • ' •
COSA blue sheet 141a12.doc
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: HIGHLAND TERRACE #2 LOT 16 Parcel ID. 050-312-01
A. WELL DATA - PER MOA RECORDS
Well type PRAT If A, B, or C provide PWSID # Well Log (Y/N) Y
Date completed 6114/1965 Sanitary seal (Y/N) Y Wires properly protected (YIN) Y
Total depth 69 ft. Cased to 31 ft. Casing height (above ground) 18+ in.
FROM WELL LOG AT INSPECTION
Date of test _ - 611411965 8115/2017
Static water level 27 ft. 31 ft.
Well production 6+ g.p.m. 4.6 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate 7•+(S mg/L
Arsenic _ ND ug/L Date of sample: 8/16/17&$111f1T Collected by: ARCTERRA 9a?
OM,/I/
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material _ SEPTIC!STEEL _ _ Date installed 8/10/1990
Tank size 1250 gal. Number of Compartments 2 Cleanouts (YIN) Y
• Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 8/15/17 Pumper JRs
C. ABSORPTION FIELD DATA
Date installed 8111/90 Soil rating (g.p.d./ft2 or ft2/bdrm) 140 System type DEEP TRENCH
Length 40 ft. Width 3 ft. Gravel below pipe 7 . ft.
Total depth 10 ft. (Measured 8/15/17) Eff. absorption area 560 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 8115117 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 0 in. Water added 700 gal. New depth 19 in.
Elapsed Time: _ 1140 min. Final fluid depth 0 in. Absorption rate >= 600 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes. give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YIN)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm &circuit requirements?
E. SEPARATION DISTANCES
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 100'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 51+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+(NONE KNOWN) 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 16.
with MOA COSA guidelines in effect on this date. QF. Ate
' •
• Engineer's Printed Name KENNETH M.DUFFUS ____
17
Date 811812017 * 4 9•
TH
COSA canary sheel_2-6-15.doc
.. KEV,E'TH M.
l116
v Air
111, 'APL's:10,:a�' Air
Municipality of Anchorage .°`_•,.°.�.
t I Development Services Department
Building Safety Division s'AT
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 # OSC 171405
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
16 of Highland Terrace #2 subdivision. This inspection revealed a nitrate
concentration of 7.45 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.
Nitrate Fact Sheet
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.
Municipality of Anchorage
DeveloPment Services Department
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
Parcel I.D. 050-312-01
1. GENERAL INFORMATION
Complete legal description
Location (site address)
COSA#
Expiration Date: ! ~-/~/,~¢
Highland Terrace #2 S/D, Lot 16
10930 Corrie Way, Eagle River. AK
Current Property owner(s) Greg and Theresa Rodgers
Mailing address
Day phone 696-4160
Lending agency
Day phone
Mailing address
Real Estate Agent . ReMax of Eagle River/Audrey Mason
Mailing Address 11525 Old Glenn Hwy., Eagle River, AK 99577
Unless otherWise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 4
Day phone 622-3344
TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class ~ Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
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-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
o
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 Douglas T. Kenley, P.E.
Address 9806 E. Northstar Circle, Palmer, Alaska 99645
Engineer's Printed Name Douglas T. Kenley
DSD SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
Phone (907) 746-1073
Date
bedrooms. ~ .
bedrooms, with the following ~pul~0~
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
By:
(Rev 11/05)
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
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 Descriptio~n:- Highland Terrace #2 S/D, Lot 16
A, WELL DATA
Parcel. ID: 050-312-01
Well type Private
Date completed 6/14/65" Sanitary seal (Y/N)~
Total depth *69 ft. Cased t° 31 ft.
" FROM WELL LOG
Date of test 6/14/1965
IfA, B, or C provide PWSID #~
Y
Well Log (Y/N) Y
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
8/16/2010
Y
23+/- in.
Static water level 27 ft.
34.7
3.2
6+
Well production ,/
WATER SAMPLE RESULTS:
Coliform Negative colonies/100 mL
Arsenic: ND mg/I
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size 1250 gal.
FpU~,~ o~ ,eleanout-.(Y/N ) Y
,, Date of pamping J~l,y.8,.2010
ABSORPtiON F. IECO DATA
Septic/Steel
g.p.m.
Nitrate ~ mg/L
Date of sample: 8/16/1o
Other bacteria
Collected by:
Date installed o8/1t/9o
L~igth~ 40' ff.
~rstal depth lO ' ft.
Date .~)f ad6~lua~y t~st
Number of Compartments 2
Depression over tank (Y/N) N
Pumper JR's Pumping
Soil rating (g.p.d./ft2 or ft2/bdrm) 140
Width 3 ft.
Eft. absorption area 56o fi2 Monitoring tube
o8/16/10 Results (Pass/Fail) Pass
Fluid depth in absorption field before test
Elapsed Time: 3o min. Final fluid depth
colonies/100 mL
F Kenley
g.p.m.
N/A
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Date inStalled 08/10/90
Cleanouts (Y/N) Y
High water alarm (Y/N)
System type Trench
Gravel below pipe 7 ft.
Y DePression over field N
For 4 bedrooms
in. Water added 756 gal. New depth
0 in. Absorption rate >= 6oo
N If yes, give date
in.
g.p.d.
LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
"Pump on" level at~
Datum
in. "Pump off" level at ~ in.
Cycles tested
High water alarm level at
Meets alarm & circuit requirements?.
in.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Sap.tic tank/lift station on lot115 ft.
Absorption field on lot 120+ ft.
On adjacent lots 100+ ft.
On adjacent lots 100+ ft.
Public sewer main N/A
Public sewer manhole/cleanout N/A
Sewer/septic service line 25+ ft.
Holding tank N/A
Animal containment areas 50+ ft.
Manure/animal excrete storage areas *'1oo+ ft.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ ft. Property line 10+ ft. Absorption field 6 ft.
Water main N/A Water service line 25+ ft. Surface water 100+ ft.
Wells on adjacent lots 100+ ft.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10+ ft. Building foundation 60 ft. Water main N/A
Water Service line 25+ ft. Surface water 100+ ft.
Driveway, .parking/vehicle storage 10+ ft.
Curtain drain None known to exist Wells on adjacent lots lOO+ ft.
F. COMMENTS: '1994 Health Authority Approval submitted by S&S Engineering. **There are two dog houses inside the fenced
area that will not be utilized by the Buyer's house dog. The buyer's house dog will have access back and forth from the house to the cement
floored containment area attached to the northwest corner of the house.
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 Douglas T. Kenley
Date'
COSA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Municipality of Anchorage
Development Services Department
Building Safety 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 # 101184
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
16 of Highland Terrace #2 subdivision. This inspection revealed a nitrate
concentration of 6.75 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.
ARCTIC PUMP & WELL INC.
]i~ S~lli~, C?!
PO Box 770197
Eagle River, AK 99577
(907) 688-2510
(907) 258-2510
apw,~gci.net
Pump Installation Log
Well Drilling Permit Number: SW
Parcel Identification Number:
Date of Issue:
Legal Description:Lake Ridge Ter
Lot:5
Block: 10
Property Owner Name & Address:
Kris kinney
PO BX 67O461
(2hn(~i~lc AI~ C}Oq~q7
Pump Installation Date: 8/30/2010
Pump Intake Depth Below Top of Well Casing:
Feet
Pump Manufacturer's Name:
Pump Size:
Pump Model:
hp
Pitless Adapter Burial Depth:
Pitless Adapter Manufacturer's Name:
Pitless Adapter Installer:
feet
Well Disinfected Upon Completion? Yes
Method of Disinfection: Chlorine
Comments:
Well permanently decommissioned by procedurel 5.55.060L.c.
East Well
Pump Installer Name:
Arctic Pump & Well, Inc.
Arctic Pump & Well, Inc.
Page 1 of 1
SGS Ref.# 1104211001
Client Name Douglas Kenley P.E. Printed Date/Time 08/23/2010 17:39
Project Name/# Highland Terrace #2 L 16 Collected Date/Time 08/16/2010 16:15
Client Sample ID Highland Terrace #2 LI6 Received Date/Time 08/17/2010 9:10
Matrix Drinking Water Technical Director Stel~hen C. Ede
Sample Remarks:
4500NO3 - Total Nitrate/Nitrite - MS recovery is outside of QC criteria. Refer to the LCS for accuracy.
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals b~r ICP/MS
Arsenic
ND 5.00 ug/L EP200.8 C (<10) 08/18/10 08/19/10 KDC
Waters Department
Total Nitrate/Nitrite-N 6.75 0.100 mg/L SM20 4500NO3-F B (<10) 08/18/10 AYC
Microbio loc~r Laboratory
E. Coil
Total Coliform
Negative 1 100mL SM20 9223B A 08/17/10 SDP
Ne~;ative 1 100mL SM20 9223B A 08/17/10 SDP
ELEV. (ASSUMED)
PRO~OSE:D EIUILDINO CORNER
B.-rV. (ASSUM[~)
LOT 17A
240.00' N89° 58' 00"E
OWELL I
~, ~ ~ / L. 40.0 . ~~ ;~ >-
LOT 3 ~ U.I ~
5 40.0~
;~ ~- ~ 30'
I
S$9° 58' 00"W 240.00'
LOT 15
UNDER NO CIRCUMSTANCES SHOULD AN AS-BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES.
THE SURVEYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL LIABILITY ONLY FOR THE COST OF THE SURVEY.
LISTED DISTANCES PREVAIL OVER SCALING. REPRODUCTION MAY CAUSE ERRORS IN SCALE.
[] LOT SURVEY SURVEY TYPE SYMBOLS
[][~ FINALFOUNDATIONsmuCTuREAS-BUILTAs-BUILT · SET REBAR ~ ~ DRAINAGE
ASPHALT
rm~ O FOUND REBAR ^ ^ ^ WOOD FENCE I.'~::',=-'q CONCRETE
U PLOT PLAN , . . AS-BUILT , , . LOT SURVEY . . . TOPOGRAPHY
[] AS-BUILT . . . NO CORNERS SET [~ RECERTIFICATION AS-BUILT . . . NO CORNERS SET ~ ASSUMED ELEV. X X X METAL FENCE I,''-'x~','~ I WOOD DECK
PLOT PLANS & LOT SURVEYS NOTE:
IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE
CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS,
TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW
THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED.
WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED.
SURVEY CERTIFICATION _~~... Prepared by
PLO~,,A, ~...~..O...F. 5~.. !~ Robert E. Johns, Jr. & Assoc.
"""~*"~°"~°"""'"'="'""~"~~~_~;,,.,.!~d'~"r':' '~_ ~/ ;~uPr°fessi°nal Land Surveyors
hove found or e~tabllahed all of the Icl corne~'~ 842 E. 12 AVE.
FOUNDATION AS-BUILT ~ .... """~'
howl' RobertpecfonlledE. Jobn~,~n Jr.,As_BuiltherebYsur~eycertifYof thetthe I ~ ~ ,~'~ Dote Surveyed: Drown b~ Checked
,~.,o,,~. th,.,o, o., tho, oil th. ¢~,...=: 9/1/10 REJ ~SWL
~,,AL s~,uc~,~ A~-BU,,~ ~;:%."'... / _. ¢*..-- Leto, De,cri¢io.:
,°.,.~.. °. As_,.,, ..., o, th.o,, th.-,.*,¢ ..............- LOT 16
dime~lim, md inform°tim oS ~Oml hece~ ~. OfessionO\
°z~:~"-',::."~'~'''''u"'-.,,...----' HIGHLAND TERRACE # 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. # _L"-~lEb - %\ ~ - (-bi
1.
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lot 16B~,,High~and T6~ra¢¢ #2
10930 Corrie Way
Eagle ~iu¢% AK
Tgr~sa and Gr¢9 Rodg~s Day phone
10930 CorSe Way
696-4160
Eagle Riv~, AK 99577
Lending agency
Mailing address
Day phone
Agent
Address
Day phone,.
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~
TYPE OF WATER SUPPLY:
Individual well XXX
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XXX
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
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 verifythat based on the information obtained from
the Municipality of Anchorage files and from my inves!i_gation 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 ~Phone
~,rne~:r's signature ~
Approved for z~
Disapproved.
Conditional approval for
DHNS SIGNATURE
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
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 MOA#21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
A. Well Data
Well type ~¢-,~-t ~'~-
Logpresent..l~_ N)~ ?
Total depth -'T ¢2~1 ~
Sanitary seal Y~)
~"I~"//ROM WELL LOG
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~ \cq L¢¢" Driller'~fi'
Cased to -~.~ ~ i ~-~_¢.., Casing height
Wires properly protected ~.JN) ¢
Date of test \
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot \
Public sewer main
g.p.m.
AT INSPEC'f'ION
Sewer service line
MUNICIPAl. II 'r
(.NVIRONMENTAL SERVICES DIVISION
!' r ;'.t I 0 t994
g.p.m:'
RECEIVED
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
Date of sample: '¢' ~'"= -~ ~
B. SEPTIC/HOLDING TANK DATA
Date installed Z~ (/~ ~c~
Cleanouts ~/N) /
High water alarm (Y~))
Date of pumping
Collected by:
Other bacteria
S & $ ENGINEERING
17034 Eagle River Loop
E~gle River, Alaska 99~77
Tank size / ,~ .5~o Compartments
Foundation cteanout (~/N) / Depression (Y~'~
,'-'( Alarm tested (Y/N) 'J//4
/?~ ¢)~ Pumper ]~'~/Z,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To properly line
Surface water/drainage
On adjacent lots
Absorption field
/¢o /4-
/o¢ ~ ~' Foundation
L, ~ Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N) ~.~-~-"~
Vent (Y/N) "Pump on" level at "~ at
High water alarm level ~sted
Meets MOA electrical codes ( ~
SEPARATION DIST~OM LIFT STATION TO:
V~on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed 5> ¢ //¢
Length ,¢c~ i
Total absorption area
Date of adequacy test
Width
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y~
Soil rating (GPD/FF) /'¢~ ¢ System type
~ Gravel thickness '7 / Total depth / ~ /
Cleanout present ~(~/N) / Depression over field (Y/~) . ,~/
Results ~fail) ~¢,,'r~5 for ¢ ~ Bedrooms
I/
~;~ After test
/J' If yes, give date ~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~ oc~
To building foundation
On adjacent lots ~
Sudace water
Curtain drain
On adjacent lots I ~ ~
To existing or abandoned system on lot
Cutbank 'J (''~ Water main/service line
Driveway, parking/vehicle storage area
Propertyline
/o
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or eonformedto~alMIMIM~O~and HAA guidelines in effec.~ on,the date of this inspection.
Signature
~nglneer s ~ame
HAA Fee $ ~O o ~
Date of Payment o,2- /~-'---¢ '%/
Receipt Number ~'~-~-~ -%-~¢
72-026 (3/g3~* Back
Waiver Fee $
Date of Payment
Receipt Number
COMMERCIAL TESTING & ENGINEERING CO.
ENVIRONMENT AL LABORATORY SERVICES
Drinking Water Analysis Report for Total Coliform Bacteria
READ h oeTR OCTIOh S 0/¢ REPTRS£ SIDE BEFORE COLLECTh'¥ G oe,4;'ff pLjz'
5533 B S¥,AEET
ANCHORAGE, AK 99518
TEL: (907) 552.2343
FAX: (907) 551-5301
MUST BE COM?LETED BY WATER SUTPL1ER
[] PUBLIC WATER SYSTESI LD.
~ P~ATE WATER SYSTEb~
~ ~endR~u~ ~ ~endfnvoice
~ SendResd~x ~ Send£nvoice
$,L\{PLE DATE:
5Ionth
S :Ux,qPLE TYPE:
Routine
[] Repeat Sample (for routine sample
with lab ref. no. )
· [] Special Purpose
S &'~2PLE LOCATION
L/ca
Day Year
[] Treated Water
Untreated Water
Time Collected
Collected By
TO BE COM2PLETED BY L>d3OtLATORY
Analysis shows this Water SA-MPLE to be:
Satisfactory
Unsatisfactory
Sample over 30 hours old, resu2u may
be unreliable
Sample too long in transit; sample should
not be over 48 hours old at examination
to ind./cate reliable results. Please send
new sample ',,ia special deliveU. m~!.
Date Received %6i/
Time Received ][/~--'-
Analysis Began
Analytical blethod: ,~Membra:e Filter
/ [] N~{O-MUG
* Number of colones/100 ml.
Lab Ref. No. Result*
Sent to ~D,E.C. ~ch~
FbM
Jun
Client notified of unsatisfactoo' results:
Phoned Spoke ~ith
Analyst
Datc: T/mc:
Faed
Faxed
BACTERIOLOGICAL WATER ANALYSIS RECORD
YD;iO-YFUG Result: Total Coliform
Yrembraae Filter: Direct Count
Verification: LTB
E. CoE
BGB C O LIYI2%?,I
Colonies/100 ml
T,\TC = 7'00 .\'uma. ous 7'0 Count
Fecal CoIiform Confirmation
Final Membrane Filter Results ColiformJl00 mi
ReportedBy_~//~__ Date =_~-~?C_/ Time /7452(51 hfs
ENV;~ON/,',ENTAL SEF\,'ICES !N ALASKA· COU,
PART ONE OF TWO:
REMAINDER TO FOLLOW
SOUTH C~.~I,~
CT&E Ref.~
Client Sample ID :L16B
Matrix :WATER
Commercial Testing & Engineering Co.
Environmental Laboratory Services
REPORT of ANALYSIS 5633 B Street
:94. 0565-3 Anchorage, AK 99518-1600
Tel: (907) 562-2343
HIGHLAND TERR. ~2 Fax: (907) 561-5301
Client Name :S & S ENGINEERING
Ordered By :R. SHAFER
Project Name :
Project~ :
PWSID :UA
WORK Order :75601
Printed Date :02/08/94 @ 09:59 hrs.
Collected Date :02/03/94 @ 15:30 hrs.
Received Date :02/04/94 @ 11:15 hrs.
Technical
Director :STEPH~C. EDE
Released By :.J~~C'~-~
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: RAY.
Qc Allowable Ext. Anal
Parameter Results Qual Units Method Limits Date Date Init
Nitrate-N 1.87 mg/L EPA 353.2/300~0 10 02/07 LLH
* See Special Instructions Above UA = Unavailable
*~ See Sample Remarks Above NA = Not Analyzed
; U = Undetected, Reported value is the practical quantification limit. LT = Less Than
~D = Secondary dilution. GT = Greater Than
Member of the SGS Group {Society5 G~n~rale Oe Surveillance}
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Highland Terrace ~2 Lot 16 T14N R1W Sec. 7
Location (address or directions)
10930 Corrie Way
(b) Property owner Barbara Nac1'-~aan
Mailing Address P.O. Box D Hebo, Or
Telephone: (home)
97122
Business
(c) Lending Institution Cb'LAC Telephone
Mailing Address 460 W. Tudor Anchoraqe, AK 99503
(d) Real Estate Company and Agent Luc/le Frye/Dynamic Real£t¥
Address 501 W. Northern Liqhts
Telephone 279-7611
562-2181
(e) Mail the HAA to the following address: (or check here;~3, if hold for pick up.)
List contact person and day phone number below:
engineer
2. TYPE OF RESIDENCE
Single-FamilyE~ Number of bedrooms 4 "V
3. WATER SUPPLY
Individual Well Z]
Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4, SEWAGE DISPOSAL
On-sitej~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
7~-025 (Re'., 7/88) Page 1 of 2
g to B 8iS~d
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suo!lo@dsu! lonpuoo ~ou op SHHQ 1o see,~oldLU=! 'sluemeJ!nbeJ elelS pub leJepet u!B3,Jeo/~tS]lBS ouepJo u! suoRn),!~su!
bu!puel J!@ql pue secuoq to sJeseqoJnd ol /~selJno3 e se s!ql seep SHHQ eq/ 'e)lsBIV ,to e3,elS eql u! peJe~S!beJ
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'etes s! cuels/~s lesOds!p Jele~elset~ ao/pue ~lddns aelet~ e),!s-uo eLI1 leLI~ $~OqS le^oaddv /~poqlnv q~,l~eH
s!ql,to uoRBI3Rse^u! ~uu 1Bql ~tPe^ I '/~oleq u/~oqs elep uo!lBp!le^ eql to sB pub o~eJeq pex!,t,tB IBes ~tu ,~q Pe!tR~eo sV
NOI.I.'~INEIO4NI QNV ¥.1.¥Q 'H3EIV~S W'll:l 'S.LS~.I. 'SNOIJ.~)~dSNI 9NIQIAO~d INldl4 DNltI~NIDN~! '~
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST- FEBRUARY 1984
MUNICIPALITY OF ANCH~)~I}.~44
I~NVIRONMENTAL SERVICES DIVISION
Legal Description: ,~-~'7~
AUG 1 3 1990
A. WELL DATA
Well Classification hz ~-~ i. R E E I V E D
Well Log Present (Y/N) ~ Date Completed
Total Depth'"'r,~?-' Cased to -~// /3~,~ ,~,
_uepth or Grouting
Static Water Level .:~¢"'~. '
Casing Height Above"Ground /E /'
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot W
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by ,z'='*'.~
Water Sample Test Results ('~Z;;,,~,~, = ,¢
Comments /t/~'/,/ /,..'~v~., /~¢.,," /'2 ~.~ ,','.r
If A, B, C, D.E.C. Approved
_ Yield Z-~¢/-~-~( ~.
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots f/¢~r~"
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
;Date _
B. SEPTIC/HOLDING TANK DATA
Date Installed /?~"-¢ Size/--,z¢
Standpipes (Y/N) ,..v Air-tight Caps (Y/N) _
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped "~
;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
'Fo Disposal Field g
To Water-Supply Well ' ,/'/~'- /
To Property Line ~-~-~ /
To Water Main/Service Line //¢ ~
To Stream, Pond, Lake or Major Drainage Course
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well '",,.2,~o
To Building Foundation ¢'o
Lot ~
To Water Main/Service Line /~/'-~
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field ¢~'¢ '"
Depth of Field /O/
Gravel Bed Thickness '7 /
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line ,~'_5-- /
To Existing or Abandoned System on
; On Adjoining Lots ~_¢'o ~
To Cutback (if present)
z-/d,: '"
/_
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed
Company
Date
MOA No.
Earl0 River Engineerir!g ~qer'.'!cgc
P. O. Box 773294
Eagle Riwr, AK 99577
6~5195
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2