HomeMy WebLinkAboutBROADWATER HEIGHTS TR H LT 10PoadwateP
Height
Tract H
Lot 10
050- 08 !
-54
MUNICIPALITY OF ANCHORAGE
DE ITMENT OF HEALTH AND HUMAN SER' -=S
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name P¢~-"'~~O DISTANCES
Address
[~~ ~~ ~ ~~ ~ TANK FIELD WELL
Phone(s) /~ Perm,t No. lng, of Bedrooms WELL
I LOT LINE
LEGAL DESCRIPTION
[°t X~ · ~ ~. FOUNDATION
Township, Range, Section
~~, ~~ , ~. / ~ , dr,veway, water boO.es, etc., AS-BUILT ~IAGRAM (Showiocat,on of well, septic system, property hnes, ioundabo,,
~SEPTIC ~ HOLDING
'~an.*acturer Oapaclty I" gallons
M~tenal No. gl Compadments
TYPE OF SYSTEM
¢ TRENCH ~ BED ~. DRAIN ~ OTHER ~
Depth to pipe bottom Irom Total depth from original grade % I
Fill added above original grade Grave, depth beneath pipe ~ X ~ ~
-~}~;~TI% n~tl%' Grave; width ~;
,otalabsorptlonarea ~4 SO FI Distance between lines * & FI .....
Number of hnes~ Il S°'I ratmg~ ~ ~ '0 FI P,pe material~~ ~~
WELLS ~'~~- '
I Instatie~ Date Installed:
t
. , InspectionsPed~rmed by: ' '
I S & S ENGINEERING
1703~ ~Jm ~;.V~i-' L~ ~--d ~'- ~= cedily at this in peclion was pedormed according to all
72-013 (3/85)
,, ,
SCALE
F..<x~=' x
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:
2
3
8
9
10
11
12
13
14
15
16
17
18
19
2O
DATE PER FORME~?~*~~ ~-I
Township, Range, Section:-~ , ~,.,), ~_:____~
SLOPE SI~'E PLAN '
ENGINEERING
3
t_
WAS GROUND WATER . I ./'~ \
ENCOUNTERED?
DEPTH? pO
E
Deplh Io Water Alter~
Moniloring? DaLe:
Reading Date Gross Net Depth to Net
Time Time Water Drop
~~ ~~ ~ ~/5' ~ i ....
PERCOLATION RATE q (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN/. , FT/~ID ~ FT
COMMENTS
17034 Eagle RLver Loep Road No. 20~ ~"~//" ~
PERFORMED BY: ...... ~,--[.. ~a= I
IN
DOC Co. (~ba
SULLIVAN WATER WELLS
P. O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OF LAND/)ti,.,; c: ///.fl~q OZ'.S"O.-V DEPTH OF WELL 5;3 C
iESS ~ STATIC LE~ WATER FT.
...... ~ ~ '"''~-. ' ~Z' z"'/~ DRAW D~.
Sta~ed ~ ~./;,: , '/,: , .Ended . <~//a ,/'["/ GA~. PER HR ... ~) /
PE~iT NUMBER -~ ,' ,- ;,; ~ ~, ,. ~ ,~ ~..~
_7/
KIND OF CASING .. tL~.. ~ O e'9
KIND OF FORMATION:
From ~--' Ft. to -~
From " _Ft. to_ ~>
From_
From., ~'
From~Ft. to ~;~'1 Ft._
From~Ft. toY,~, ! _Ft. /~
Fro~ c~ /
From.
From I ~'/ Ft'. to--FL ",'~: .' ~ ·
From~Ft. to/5'7_Ft._ E;' .'
_Ft. to.: i/'"? Ft._;j,~z:.~.'Ot i
Ft. to_ _Ft. ,'~-/' ""
' -
From_.,; t ~/, Ft.
From.~Ft.
From~ ~-
From.. Ft. to__Ft.'_ · ' ,
From "~
From ~ Ft. to_
From_ Ft. to_
From_ Ft. to
From_ Ft. to~
From______Ft. to_
y/./ c,),.,.-~.¢ '7' 7 3r~C,'pd From __
,O" ¢?(,','4 o c ,<
From
'"~,"(:-:<'~"O From_
From ,. Ft. to _ Ft. _
From ~ Ft. to__Ft._
Ft. to ....
Ft. to..
_Ft. to.~
_Ft.
Ft.
_Ft.
Ft.
Ft.
Ft.
Ft.
FL
MISCL. INFORMATION:
c) o ' c/'" 7'
DRILLER'S NAME
PERMIT NO.
DEPARTMENT ~ HEALTH AND ENVIRONMENTAL .... OTECTION
825 "L" STREET., ANCHORAGE, AK. DD501
264-4720
I.qELL F'EF:r"I Z ]'
( 8~0t86 )
APPLICANT
LOCRTION
LEGAL
DALE C. 0L$0N POST OFFICE BOX 1442 9~577 694-2266
SKYLINE DRIVE
L t0 TRACT H BRORDNRTER HEIGHT LOT SIZE 35000 SQUARE FEET
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
t00 FEET FOR A PRIVATE WELL OR t50 TO 200 FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO R PRIVATE SEWER LINE IS 25 FEET AND
TO R COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DRYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY.~ SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
RVRILABL. E TO INSURE PROPER INSTALLATION.
F' E F..: r'l I ]- E2 :=-,.: F' I F~: E S; [:. E C: E r-1 El E R Z=: ~L .. ~L 9 :E: ±
I CERTIFY THAT
i: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
SIGNED:
APPLICANT DALE C. OLSON
ISSUED BY ....
Department
MUNICIPALITY OF ANCHORAGE
~ Health and Environmental
rotection
825 L Street, Anchorage, AK. 99501
264-4720
* * * HANDWRITTEN PERMIT * * *
WELL AND/~-~---O~!-S~TE 8£~12 PERMIT
Applicant: ~ /~ ~ ' 0/S0"% Mailing Address: PO
oca on, u er,
Legal Description:~ L-'/O,'-~-~ //- /'~"O~ J~d~C ~Lot. Size:
Type of Soil Absorption System Is:
Trench: -. Drainfield: .................. Seepage Bed: ..... Holding Tank:
Maximum Number of Bedrooms: Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is:
DEPTH .... LENGTH ........... GRAVEL DEPTH .............. WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 1 * * *
I certify that:
(1) I-am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
Signed..~ ~ J ,~~-~ ~t~=~residence(u~ is remodeled to includelssued by:mere that 3 bedrooms. [--/'~::~? ~c~~~
App 1 ic ant ' '
Date: ~/~h~ { / ~/ ~/
SWP/024 (l/8l)
MUNICIPALITY OF ANCHORAGE
Hea h and Environmental Prote ion
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
279-2511, x 224, 225
................... -J'~-~CTION REPORT ON-SITE'SEWAGE DISPOSAL SYSTEM
LOCATION .__ ' LEGAL DE:SCRIPTION _~L-_..T.I.O '~"2-'"F' d.__
SEPTIC TANK:
DISTANCE ~(~00
FROM WELL
INSI[3E LENGTH
MAN U FAC 'I-U R E R /~-~'---
INSIDE WlDl'H
MA-FE RIAL
LIQUID DEPTH
NUMBER OF
COMPARTMENTS
LIQUID CAPACITY/O~2GALLON$.
TILE DRAIN FIELD:
DISTANCE FROM WELL [~ FOUNDATION NEAREST LOT LINE.
# of Lines DISTANCE BETWEEN LINES ......... TRENCIt WIDTH~/~ IN.
ABBORPTIO~ AREA ....................... S(~. FT. LENGTH OF EACH LINE
DEPTIt OF FILTER
DEPTtt: 7OP OF 'TILE TO l-:ll'qlSti GRADE
TOTAL LENGTH
.OF LINE
TOTAL EFFECTIVE
MATERIAL BENEATH TILE ~ IN. ABOVE TILE ~Z
..... IN.
SEEPAGE PIT:
DI,'-~,MET'ER ____ OR WIDTH
, I" ENGTH_~, DEPTH
Well Distance To: Lot Line
Bldg: Sewer Line:
Pipe Materials:
~ of Bedrooms:
Installer:
Remarks:
Log Crib Rings Crib Size:; DIAMETER ...... DEPTH_ DISTANCE FROM: WELL
TOTAL EFFECTIVE
BUILDING FOUNDATION ..... NEAREST LOT LINE____ ABSORPTION AREA (WALL AREA) SQ. FT.
i/l/ ,,, I
Well
Class: Depth: .... ~.._.~.~., ~
SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF
DRILLED AT THE RATE OF _~._.0_~0_L~__ PER FOOT,
PROPERTY OWNER ...... _S T_ _~.~;_~ ~ ~0_~ _ ~ ~_~
LOCATION OF WELL SITE. Lt, 10 Tract H Broadwater Hights Sub,
D R I L.L. E R Bernie _ Claus .gl._ i~Pa~_~_~g .~rks_
WELL LOG:
,,-.1~-~. ¢~-~:bY...._~ ~..r~_ ¢?:?_~_. s~~, ?~p s~6_~~ _O~:_~
---50' B~ock, A S~entary rock,
~--53' A granular rock sho~g signs of water,
~-.-90~ Se~entary rock,
)..-94~ More signs of water, A granular rock,
-115' Sed.~ent~'y rock~
5-~i7~ Wot area of granular rock,
.7-125' S~Jmentaz~ rock,
Total production of water yieId~ ~.~880 ga~s per 24 ho~ t~e fr~e,
i~ecovery of water ~ cas~: 115 fee~ of water
P~:p :~hould be in;~talled ten feet off bottom~
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF
THANK YOU VERY MUCH.
BERNIE CLAUS OF RAMPART DRILLING WORKS
SERVICE CHARGe:,' F' ~V~% PER MONTI-~-'~ILL
t;'"i:':'t;;i'1"1 t t i'*il t ( ;*"','"';.:'i '.:; )
I':1t:;;'t:;:'1 [ I";F'tN 'l
t I'1:1."1i Il'IN ';;:'1':;' %'1 '1
I i";MHt
f"tHX l lvll ilvl I'-,ti tI'"iF;II;.-i~.' lit;: l;;l';;i )ti~'.l 'll.ll"'J'!!i := ";:;
t::t l:;:'t:::lL':i<]t:;ll:iii-!:] i';;'t t::tt",l t' t"'tFI"/ ~IIF! ]' l"lli:;;"l'l;il I .iCl:) I::11" THt!':/ 1;' I'-.t,:.t 1 :[ "I"T[!!:F:: '" ?i i'~il;;:""t'' '[ [ll"l SI...It!~I..]'EiI::::"I .... I"Ct
l";'l']l t .I"1i,.t [ I'-,tl';i I";I IF,Il';, 'J' 'l 't I'll'.i';:;; ·
· '1 I:.: t'"tHtti;[;i: 1:;;t l]iil .l:;;l':;;';:i :1: I']1;;;' 't' ]' N'::;iF' Ft::'F'l:;t'"',~'l~'l":~ I':'l..l::tl"i"t" I'"tl::t't' I.::ilE; t.N.::,IHI...t..t':.t ....
. I .:, [;.!F[::!I I ]: I:;i'ET:' 'Ir F:' [:~ t"1t:1 T
;.;;' I:;:t I':l"lJ'.l 'j' 'l' I"ll II"il t':;i JvtiF:l I' ~.i"I"F: I",tF:tI"II"';I::' IF!l";i[ [:;T!]"'It:.".t"i'I" ' ":'
I:.;!l':il.i,l:~:l::]"'ii::'l'.,l'T' 'ili::; i"ll"'IT k'l:;:'l:::"r' r':l II~'l;i'F:'l'-l"l" M[,II.I f,tF:l'.r' I!~IF: ~'F:::;! .l :[ [t[~l') "1"[':1 t:.']'.ll..l:;:tt:;h'][~: "t"t..tt!~:
F:'ti;:l'::;il'll'i]'l';;'l I I'lJ"l ';;:i:~'"':!i']'l;:;]'"t I':It'-!1').."'1]ti~, '~"['11.1 I"IFI:'/ l:~l[:;: l'~',l.lE|.]'Ei:(:::"t .... t"O F:'~'.:':';~[!:J''
P'tiFiI'i"lttI"'I i:'t';:;,'lF;li"Jl":t::' I':;:F(I'L,JIF;'I':;iN f::;l L,JI:'I I F~t"~I';'
"1l"1l;1
b. li:': 1 t ! t tt:i";:,
[Ii;" i t'"1i;:: MI'; i I I':1"ti"11';'i 1;;;] i I 1'11'.,t
I t 't 1"'ti::: l'i;'
1';;I',.,'1;;;1 'i i I::tl;;~ll I:;; '1 I"1 'i l"i'::it It,i'l':' I-;'t~'l'ill;':'l;;i'J;i~' J' t"l'::!i"t |:'ti i i;I '1" ]' ['IN
O~ EGED -CHNICAL ~ DEVEL PMENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster Earl Ellis
694-2774 SOIL LOG 688-2280
Soils ~ Foundations Land Development
Perfomed for: Name: ~_~7-~qz/_'/~-/¢ ~;~_,>~z~:~ Tel. No..~.-~,~2~
Ha~ 1 tng Address: ~ ~... ~ to.-~/ ~r~ ~T~~ ~c~. ~:~ "~:
Depth (feet) ,~ol] Charactertstlc~
1
m
6
8
10
11
12
13
Ground Water Encountered: Yes ~
Proposed Installation: Seepage Pit
Comments:
No.__._._. If yes, what depth
Drain Field
Performed by:
Date:
L~epartment of Ll~vi roflllleliLa] ()ual i ty
3330 "C" Street
Anchorage, Alaska 99503
S()II,S 1,0(I
Performed for
Del) th
Feet
11 -
12-
Was ground water encountered? '_~2)
If yes, at what depth? -
Reading
Percolation rate
Date
.Gross Time
minute.
Net Time
Depth to Water' Net Drop
~Proposed installa~]~-n': Seepage Pit_.. Drain Field ........
[}el)th of Inlet .. Depth to bottom of pit or trenci, -__ ¢ ,]~----
,?5
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
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. (~ 5'0- (:~oC'/.--' ..5-z.)/
GENERAL INFORMATION
Complete legal description
Location (site address) /~
Current Property owner(s) ,T(Jc~,
Mailing address
Expiration Date:
I!-
/'LOT'
Day pllaoe, d~'d/-" ~..~/o°'
Lending agency
Day phone
Mailing address
Real Estate Agent
Mailing Address
unless otherwise requested, COSA will be held by DSD for pickup.
NUMBER:OF BEDROOMS:
TYPE OFWATER 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
I
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 System's Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the.professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown belOW, I verify that my. investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm x)~/~Ov-
Address· /')0 '4~'
Engineer's Printed Name
Phone
DSD SIGNATURE
~ Approved for
~./ bedrooms.
Disapproved,
Conditional approval for
t,
bedrooms, ~th the following stipulations:
By:
Attachm'ents:.
COSA Checklist
Septic System Advisory
Well .Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
(Rev. 11105)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Eimore ROad
P.O. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343'7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: ~t~v" , ~ ~. L /'0
~LLDATA -- 2 t~-j'/~
Well type ~ IfA, B, or C provide PWSID ~
Date completed~~/~/ Sanita~seal (Y/N) y
Total depth (~0/~. Cased to ~0 ff.
FROM WELL LOG AT INSPECTION
Sta~c level E.
'.Well produ~ion g/~f~d g.p.m. ~ ~ g.p.m.p72 a
WATER'~AMPLE RESULTS:
~liform~ ~loni~/100mL' Ni~ate ~' 5 mg/L Colle~edby: ~[~/~ ~,
~senic: ~', 3 / ~ ug/L date of sample: .~/~[
SEP~C/HOLDING T~K :DATA
Tank Type/Material ~D ~ Q / ~ ~[ Date installed ~
Tank size/~O 6 gal. , Numar of Compa~ments ~ Cleanouts (WE) ~
F~ndafion deanout (Y/N) ~ Depre~ion over tank (WN) ~ High ~mr alarm (WN) ~
Date of pum~ng ~//~/~( Pumper ~
ABS~PTI~ FIELD DATA
Dateinstall~ ~o/~, ~Soilmfing (g.p.d.~2or~/bdrm)/~ Systemty~ ~/~ ~~
Length ~ ~ fi: Width ~ ff. Gravel below pipe Z ff.
Total depth ~ fi. Eft. abs~ption are~~ Monitoring tube ~ Depression over field .~.
Date of ad~ua~ test ~//~//[ Results(Pass/Fail) ~ For~ b~rooms
Fluid depth in absorption field ~f~e test / ? in. Water additional. New dep~ d in.
Elap~d Time: ~Omin. Final fluid depth J 7 in. Absorption rate >= ~;~O g.p.d.
Any rejuvenation tr~tment (past 12 m0.) (WN & ~pe) ~ [~ If yes, give date
Parcel ID: O,~'0-
Well Log (Y/N)
· Wires properly protected (Y/N)
Casing height (above ground) 2/,// in,/2
D. LIFT STATION
Date installe~,~ Size in gallons., ............Manhole/Access (Y/N)
"Pump on" I "Pump off" level at ~ High water alarm level at
Datum Cycles tested / Meets alarm & circuit requirements?
SEPARATION DISTANCES
in,
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot /~)i~ ?'1~-
Absorption field on lot //'~4:3 · 'f"
Public sewer main ~,/,~
Sewer/septic service line 2 ~' ¢~
Animal containment areas /~ ~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~4:~/P' Property line /
Water main /~/~ Water service line
Wells on.adjacent lots /~'~' ~'~" ,,
SEPARATION'DISTANCE FROM ABSORPTION FIELD ON LOT TO:
On adjacent lots .
On adjacent lots 7
Public sewer manhole/cleanout /~,~-
Holding tank
Manure/animal excrete sterage areas
Date of Payment
Recei~)t NumJ:)er
(Rev. 4/10)
Date of Payment
Receipt Number
Property line /~ /'J~" ~ Building foundation /~, ~'' Water main .,~,~
Water Service line / ~"//"' Surface water //~-/'~ Driveway, parking/vehicle storage'
Curtain drain __~ Wells .on adjacent lots//~ '''~
.F: COMMENTS
-, ,. ~ _?~'-;,~,. '~.
Icertify that/have determined throughfleld inspectionsand
review of Mu~cipal recerds.that, ti3e above systems are in
conformance with MOA COSA guidelines in effec~on this Edte.
· . ~ .
Engineer's Pri~. ed,Name ~
a,e ,. .
COSA Fee $ Waiver Fee $
Absorption field
S. urface w~r /"~
A'NALYTICA
GROUP
NorthRim Eng
Attn: Steve Eng
17237 Bear Paw Circle
Eagle River, AK 99577
907-694-7028
Fax: 907-694-7026
Client Sample ID: ER 2
Sampling Location: Kitchen Sink
Client Project: ER 2
Sample Matrix: Drinking Water
COC #:
PWS#:
Residual Chlorine:
Comments:
SP-Analytica, Inc.-Anchorage
4307 Arctic Blvd.
Anchorage, AK 99503
Phone: 907-258-2155
Fax: 907-258-6634
Report Date: 7/22/2011
Receipt Date: 7/7/2011
Sample Date: 7/7/2011
Sample Time: 11:00:00AM
Collected By: SE
Flag Definitions:
MRL = Method Reporting Limit
MCL = Maximum Contaminant Limit
B = Present also in Method Blank
H = Exceeds Regulatory Limit
M -- Matrix Interference
J = Estimated Value
D = Lost to Dilution
** -- RL higher than MCL; target not detected
TNC = Too Numerous to Count - result rejected
CF = Confluent Growth - result rejected
TCNG = Turbid Culture No Growth - rejected
Lab#: A1107144-01A
Analysis Method Prep Prep Analysis
Parameter Result Units Flags MRL MCL Method Date Date Analyst
4500-NO3E (Aqueous) - Nitrate+Nitrite pres Test was conducted by: Analytica - Anchorage
Nitrate-Nitrite as Nitrogen 5.50 mgFL 2.5 10 7/19/2011 7/19/2011 MC
Lab#: Al 107144-01B
Analysis Method Prep Prep Analysis
Parameter Result Units Flags MRL MCL Method Date Date Analyst
9223B-PA (Aqueous) - Coliforms in DW Test was conducted by: Analytica - Anchorage
E. Coli Pass PASS/FAIL 1.0 1 7/7/2011 7/7/2011 KM
Total Coliform Pass PASS/FAIL 1.0 1 7/7/2011 7/7/2011 KM
Lab#: A1107144-01C
Analysis Method Prep Prep Analysis
Parameter Result Units Flags MRL MCL Method Date Date Analyst
200.8/200.8 (Aqueous) - Family Well Water I
Arsenic 0.313 ug/L
0.15
Test was conducted by: Analytica - Thornton
10 200.8 7/18/2011 7/18/2011 RM
Page 3 of 3
Municipality of Anchorage
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 # 111271
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
10 of Broadwater Heights Tract H subdivision. This inspection revealed a
nitrate concentration of 5.5 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.
Jim Sutl~va~
PO Box 770197
Eagle River, AK 99577
(907) 688-2510
(907) 258-2510
(907) 745-2510
apw~?,,,v, ci.net
Pump Installation Log
Well Drilling Permit Number: SW
Parcel Identification Number:
Date of Issue:
Legal Description: Broadwater
Heights TR H
Lot: 10
Property Owner Name & Address:
Judith Fetherolf
12320 W Skyline Dr
l~'~crl~ l:?~x~r Aid' OC}q'7'7
Pump Installation Date: 8/2/2011
Pump Intake Depth Below Top of Well Casing:
Feet
Pump Manufacturer's Name: Dempster
Pump Model:
Pump Size: hp
Pitless Adapter Burial Depth:6 feet
Pitless Adapter Manufacturer's Name: Martinson
Pitless Adapter Installer: UK
Well Disinfected Upon Completion? Yes
Method of Disinfection: Chlorine
Comments: Casing with no perforations sealed into bedrock and no water
infiltration at 20'
Pump Installer Name:
Arctic Pump & Well, Inc.
Arctic Pump & Well, Inc.
Page 1 of 1
PLAT NO. 71-156
BROADWATER HEIGHTS SUBDIVISION
TRACT H, s?T 10
35,900
$ 89°58'2o"E 11
s 89'~.O"E ~5.oo,'(.,) .....
SEP33C SYSTEM
1 "=40'
FENCE (APX)
LEGEND
(R) RECORD MEASUREMENT PER PLAT NO. 71-1 56
(M) MEASURED DIMENSION THIS SURVEY
BUILDING DETAIL
SCALE: 1'"'"20'
WELL
WELL
AS "BU"iET .....................
-- I HEREBY CERTIFY THAT I HAVE SURVEYED THE
....... PROPERTY DEPICTED ABOVE AND THAT NO
GASTALDI LAND ENCROACHMENTS EXIST EXCEPT AS INDICATED.
SURVEYING, LLC IT IS THE RESPONSIBIUTY OF THE OWNER TO
JEFF A. GASTALDI, R.I..S.DETERMINE THE EXISTENCE OF ANY EASEMENTS.
!2000 F- DOWUNG RD., SUITE 8 COVENANTS OR RESTRICTIONS WHICH DO NOT
ANCHORAGE, ALASKA 99507 APPEAR ON THE RECORDED SUBDIVISION PLAT.
PHONE 248-5454 UNDER NO CIRCUMSTANCES SHOULD ANY DATA
GRID DATE ' HEREON BE USED FOR CONSTRUCTION OR FOR
NW0253 7/27/2011 ESTABMSHING BOUNDARY OR FENCE UNES.
.......... ANCHORAGE RECORDING DISTRICT, ALASKA
F.B, JOB NO,
11-0.3 BHSIOTRH NOTE: NO CORNERS SET THIS DATE.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ~)
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date ¢:~ - ~ ) '" ~:~
GENERAL INFORMATION
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name ~"~,. ,~ Telephone: Home ~L~-'~J'~I~ Business
Applicant Address \'~.;~'7..-~ ~-'~.~L...~J~:.. --'-- ~___~-~_. ?-"~.~,/="~.~--~. ~.~'t~"~"~
Applicant is (check one): Lending Institution []; Owner/builder []; Buyer [] · O.ther [] (explain);
(d) Lending Insbtution Telephone
Address
(e) Real Estate Company and Agent
Address ~~ ~~
Telephone ~ ~
(f) ~the HAA to the following address:
17~ ~gle R~ L~ R~
TYPE OF RESIDENCE
Single-Family.]~-- Multi-Family []
''Number of Bedrooms "~
Other
WATER SUPPLY
Individual Wetl)~ Community [] Public [] ,
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite/~ 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.
Page 1 of 2 72-025 (11;84)
ENGINEERING FIRM PROVIDIN(. SPECTIONS, TESTS, FILE SEARCH, DA'~ ~ND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown betow, I verify that my investigation of this Health
Authority Approval 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 $ & $ ENGINEERINO
17034 Eagle Ri.vet Loop Roaci
Address ,.___~, =,,a,, AI~,.I~n 99577
Date
Telephone
DHEP APPROVAL
Approved for i'¢"A'~-~ ~bedrooms by ~
Approved ~ Disapproved
Terms of Conditional Approval
Conditional
Date
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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.
Page 2 of 2
72-025 (11/84)
WELL DATA
MUNI¢IPAUI"¢ Cjl IO.!OEN3E
DEP~, OF HI^[.tH ~IUNICIPALITY OF ANCHORAGE (MO~i
E~IgONMENTAL PR~t~TH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
SEP 9 2 264-4720
Well Classification )t--~.~l ¢~O/~--t... If A, B, C, D.E.C. A/gproved (Y/N) I'~
We Log Present (Y/~°/~ DateCompeted~t~/~-~ Yiel~~
~ ~ / i~ ~ - .
Total Depth ~t~ ~ Cased to ~ Depth of Grouting
' ~ '
Static Water Level ~ ~ /~ [ Pump Set At
~asing Height Above Gro~n~
Electrical Wiring in Conduit~N)
Separation Distances from Well:
To Septic/bleh3frrg Tank on Lot
Sanitary Seal on Casing ~N)
Depression Around Wellhead (Y(~
~. ¢>¢:~ I ~. ; On Adjoining Lots
To Nearest Edge of Absorption Field o7 Lot \~:~;;;:~) '~ · On Adjoining Lots
To Nearest Public Sewer Line ~/~ To Nearest Public Sewer
H
Cleanout/Manhole~/~ To Nearest Sewer Service Line on
Water Sample Collected by ~ ~ ~1~1~ ;Date
Water Sample Test Results ~~~~~~ ' ~~
Comments ~[~. ~ ~~ ~ ~ ~,~
SEPTIC~HOLDING TANK DATA
Date Installed ~-'~¢"'~1 Size ~¢
Standpipes (~N) Air-tight Caps CN)
Depression over Tank (Y/~¢~)
PumPing/Maintenance Contract on File (Y/N)~!
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/H~'dl~g Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
Comments
No. of Compartments
Foundation Cleanout t(~)N)
Date Last Pumped
;for "'"----
Temporary Holding Tank Permit (Y/N)
To Building Foundation ~,C~ j
To Disposal Field ~, ~ !
To Stream, POnd, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~:~ ~'"Z~,°--' ~;::~"~
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation ~"~
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field
Depth of Field ~'~
Gravel Bed Thickness
Standpipes Presentd~N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots "-~ ~:~
To Cutbank (if present)
Comments
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 Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all rvJOA aFd HAA guidelines in
& $ ENGINEERING
17034 E g ~ ~/~_~
Compa~er, Ai,*k.~5~ MOA No.~ ~7 ~ ~
ReceiptNo. {~~--~ ~
Date of Payment ~ ~-~-~
Amount: $ ~ 00, O~
Page 2 of 2
72-026 (11/84)
effect on the date of this inspection.
L ~ ~ · DA~'E RECEIVED
I NSPECTI ON APPOI NTM ENTS
(~~ TIME
TIME TIME i, ~_~ L~L_~t
DATE DATE ~ ~ DATE
iNSPECTOR INSPECTOI~ ~- ~'~ ~ ~ ~'
' NSPECTOR ¢~ ~ ~HOEAOE
MUNICIPALI~ OF
MUNICIPALITY OF ANCHORAGE ~EPT
) DEPARTMENT OF HEALTH & ENV, RONMENTAL PROT~N~ENTAL-F.,,o.r~CTiON
~ 825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION JAN 7 I981
Telephone 264-4720
nE~E/~IE~
. .UEST FO. APP.OW. O. W*T .
r
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proce~ed. Please allow ten {10) days for processing.
1, PRO~RTY OWNER PHONE
~O~fi~TY ~ ~SI ~fi~l {I f differont from a~ow~ ~ PHO~
PHONE
MAI LIN G ADDR ESS
3, LENDING INSTITUTION / ' ' I' PHONE
MAI LING ADDR ESS
4. REALTOR/AGENT ~ PHONE'
MAI LING A~DRESS ' /
~' I' EGAL DESCRIPTION
S, TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
[] One [] Four
[] Two [] Five
~ Three [] Six
[] Other
7. WATER SUPPLY [] INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTI LITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] I NDIVI DUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank_or [] Holding Tank
Size: ~;1~)~.~ If Tank is homemade
give dimensions:
TYPE OF TANK
TOTAL ABSORPTION AREA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
NUMBER OFBEDROOMS
[] ONE [] THREE
[] TWO [] FOUR
[] FIVE
[] SiX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOILS RATING
MANUFACTURER
MATERIAL
[] OTHER
5. COMMENTS
DATE
[] CONDITIONAL APPROVAL (letter must accompany certificate)
72-010 (Rev. 6/79)
o ~:: S"[" R E E T
A N C.~ lC) R ,fig E, ALASKA 99501
(!') 07) :?.~ ~ 4. ,ri. 1 l !
M P, Y O R
O I}i P..'U i i' i',.4 [!:N l' O F 1.1E A I..!H Al',.! I? E I',,!',,/IqONM !? N 'F/',, I.. PF!OTEC"H O J',,i
1}d.~zt.].a.ry tl, 198t
9 95 '? 7
Subject:: .Lof:. ]~0 'I'rac-[: hi Broadwater' Ne ]..gh'l::s Subditris:i. on
On ,Tanuary 8,, 1981, I ob-hained a w;ater sample for bf:tcterial
analysis al:. the subject: propert:y. It: tis nob required i:o
have tzhe presst]re Lank comple'tel_y drained and re:El!led
before: our sample is drawn. ~le do not: ~est l:he waker ~
system for quanit:y.,
If there are any Eu]':'~:he:~: queshions, please cai.l_
o:[fice, at: 264-4720,,
S i n c e r e 1 y ,,
Rober'l: C Prat::.'[: R S
Assoc iat:e Spec :i.e..].. i,..s'"L
Date..._./%~,~"-~ 19o~/
~o /~~~~~
Address ~o. (_.), ~_.~,_~ ~L c/7
8K 882
,STATEMENT
825 "L" STREET
ANCHORAGE, ALASKA 99501
(907) 264-4111
GEOF~GE M. SULLIVAN,
MAYOF~
[ I: ~P~F~,'i ~.,'IF:N I ()1. IlEAl 1 ~1 AND EN\/II~ONMENYAL Pr~OTECTION
January 12, .].981
Tommy C./Barbara Rhodes
Post Office Box 1442
Eagle River, Alaska 99577
Subject: Lot 10 Tract H Broadwater Heights. Subdivision
Approval for your individual sewer and water facilities
cannot be granted until the following items have been
completed:
(1)
The water analysis report needs to be delivered to
this office from 'the Chem Lab, 5633 B Street,
for our review.
(2) The septic tank pumped with a reciept submitted
to this office.
If there are any further questions, please call this
office at 264-4720.
Sincerely,
Robert C Prat't, R. ~
Associate Specialist
RCP/ljw
CC:
Spokane Mortgage
3201 C Street 99503
Joyce Port
% Area Inc. Realtors
Post Office Box 249 99577
825
Time
Date
Insp
f OF HEALTH AND ENVIRONME~ ,k PROTECTION
L Streetf Anchoraa~. Alaska 99501
,, / ~~~~eceived: Dece~er 28, 1977 '"O~
# 93: Time
~ Date Date
Insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
Lending Institution Request: Coast Mortgage Company
Mailing Address: Post Office Box 1200 99510 Phone: 279-0665
2. Property Owner: Robert L./Maria L. Bell Phone:
Mailing Address: % Cy Barker, 276-0579
3. Legal Description: Lot 10 Tract H Broadwater Heights Subdivision
4:
Single Family Residence: (x)
Multiple Family Residence: ( )
Number of Bedrooms: Two
Number of Bedrooms:
J
Well System:
Permit # ~WW;~. Depth of Well
Construction
Sewage Disposal System:
Individual Well (x) Community/Public System ( )
Well Log on File
On-site System (x) Public Utility (
Permit 9 Installed J~ Installer
Septic Tank Size . ~)~;O Manufacturer ~'
/!
Absorption Area 3 ~ Soils Rate //~ Material ~
Distances: Well to Septic Tank
to Absorption Area /~.
to Sewer Line
Nearest Lot.line
Absorption Area
to Nearest Lot Line
MUNICIPALITY OF ANCHORAGE
DEPAR'[MENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L Street, Anchoraqe, Alaska 99501
2'79-2511, ext. 224, 225
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection: VA
2. Property Owner:J~obert T,. & Ma. ria T,. Bell az~d H.
Mailing Address:
~C
FHA CONV.:~cx:~
LeslieDBurtner Jr. & Judith W. Burtner
Day Phone:
3. Name of Buyer:Tx~my_Clar~_Rhodes and Barbara Elaine Rhodes
Mailing Address:_~;]:i~t_~;Le_ Dr_iv_~e__
4. Narne of Lending Institution: Coast ~ortgage Qqm~y
Mailing Address: P.O. Box 1200, ~cho~e, ~ Phone:~7~066~
5, Name of Realtor or Agent:
Mailing Address: ]~)~ w. 7th Ave. Phone: 276-0~79
6. Legal Description: T,~ lO~~~dwater Heights Subdivision
Location: ~.gl ~ Biv~r¢
Day Phone:.. 694-2.219
Type of Facility to be Inspected: Home
Water' Supply
Type of Supply: Public Utility
If Individual, number of dwellings presently served
If Individual, depth of well ~mdc~own
Sewage Disposal System
Type of System: Public Utility
If Individual, date of installation ~m_tc~own.
one
__ No. Bdrms. 2
Individual Well
Individual (on-site)
Septic
72 003( 3/76)
Page Two
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 10 Trach H Broadwate~ Heights Subdivision
Comments:
Affadavit Attached:~ Letter Attached: ( )
Disapproved: Date:
Department Worksheet: