HomeMy WebLinkAboutTHAYERMOORE HEIGHTS BLK 1 LT 5(e -A
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— Municipality of Anchorage Page I of a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 A Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -.Site Wastewater Disposal System and/or Well Inspection Report
PermitNumber: fq�' ��) a 1�� PID Number: i ISO $ 1 O"7
Name: G I e
(.E N 1 %�2DrnJ E M k¢T I i�
Wastewater System: -,4 New ❑ Upgrade
�vev_a®s��es
Address: YL 5q�°
q��ln i-i1Lt-$IYI� 1]�. .�NGNo Abi
ABSORPTION FIELD
Phone: No. of Bedrooms:
3&1 IF a?� G/ 5 �
—
,Deep Trench ❑Shallow Trench ❑Bed ❑Mound ❑Other
LEGAL DESCRIPTION
Soil Rating:
Total Depth from original grade:
I, a GPD/Sq. Lt,
I 1
Lot: ' Block: .r; Subdivision::
r 1 Nf
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
SI
/HAL/C-72Mo$w. Ll rs
3' Ft.
Ft.
Township:
.�J��
Range: Section:
Fill added above original grade:
7.0 1 Ft.
Gravel length: f
35 Ft.
WE'LL' - New El Upgrade
'
Gravel width:
�.�_
Number of lines:
Distance between lines:
Ft.
_I
Ft.
Classification (Private, A,B,C): —
Total Depth:
Cased To:
Total absorption area
Pipe material: ASTt"A
2r73' Ft.
,703/ Ft.
S(n0 SO. Ft.
GfS ID%FD3o$�—
Driller:
A,-P/"E
Date Drilled:
Static Water Level:
Installer: n
UAYLTt-N S1'.
Date installed:
q4t,-dI�
DR/I.LrNL9
11'30-45
(7Hr Ft.
C.O�e
Yield—
Pump Set at
Casing Height Above Ground:
TANK
O GPM
aOO FL
/aq r Ft.
SEPARATION
DISTANCES
Septic C1 Holding ❑S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer:
'I-AF./K
Capacity in gallons:
la 50
From
Tank
Field
Station
Tank
Sewer Lines
677LSE'D-
Well
104
log,
'
-
I
a5 -7-
Material: —
��-rt:ef_
Number of Compartments:
®�
Surface
l°o-
-�
LIFT STATION
Water
It,ot,-
Lot
t
Size in gallons:
Manufacturer:
Line
I
afo
II
I
Foundation
I J
I I
�-�
rte'
«
—
"Pump on" level at:
ump ofY' level at
High water alarm at:
Curtain
%ION
I<N
1.4
Pump &Model
Electrical Inspections performed by:
Drain
Remarks:
BENCH MARK
v
—
Location and Description:
--- ICJ 0r- `owcR>1.E9'E VEC-IC
SVPno2-r 0 L N T '6 (C0fxnr60.oF tett(
—
Assumed Elevation: /
.b
s,��°ta
� r♦ !•, 1..11 f�µ� •, •,. •'°
/j�f�r✓ f j """
-C`
���� �e���
5 & S ENGINEERING
i 45
34 Eagle RL ates:ls��
Inspections
G°0�". .
performed le Iver, Alaska 99517
2nd
C( :
COWAN
OWAN e isv y
CE
-ssoi
{
Department of Health and Human Services approval
:, vR
Reviewed and approved by: � — Date: /-1_2-
72-013 (Rev. 9/91) MOA 26
Permit No. SW950275 Page _ 2 _ of _ 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
LOT 5, BLOCK 1, THAYERMOORE HTS. 01508107
Legal Description: ____ PID No.: —
72-013 A (lieu. 9/91) MOA 25
100.41
IINAL GRDG
MTl GO4
95.4'
NEW
JST4127
0 GAL
C 'PAN
.'
SR
90.5'
82.5'
Np
US.
A 77.5'
NO WATER FOUND
i�
8-28-95
n
J�
� col
IAT1
/
coa
NEW 1250
AL
A
B
—
SEPTIC TAN
O
FCO 44'
7'
WLLL
ST2
55'
20'
C01
63'
25'
L
T 5
IVM
CO2
67'
27'
����
CO3
74'
47'
C04
66'
-7-64
IL
T 1
o F
ROp�
4.
C04
FCO
C . S�4ppd
7r
y/ z,r.1i'
SCALL 1" = AO'
d T..'•. .Ci a/
72-013 A (lieu. 9/91) MOA 25
Np
US.
i�
j�coz sl
n
� col
IAT1
/
coa
NEW 1250
AL
—
SEPTIC TAN
72-013 A (lieu. 9/91) MOA 25
DEC -11-1995 09:40 BELL HOMES P.02
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
DIVISION OF MINING 8, WATER MGMT
WATER WELL. RECORD
LOCATION OF WELL TM7MDIAN
BOROUGH SUBDIVISION LOT BLOCK SEOTION QTR5 SECTITTIIWN;H—
IP RANNGE
T�arwn+c, _S S OW
LOCATIONISKETCH: WELL OWNER:
��FJVE.D DEC U
WELL DEPTH:
�— DATE OF COMPLETION
DEPTHS MEASURED FROivi:'�casing top Oground surface WELL
of hole: +'T) -a -6, ft
BOREHOLE DATA: Depth Depth of Casing: .9 /
Material Type and Color From To
—� DEPTH TO STATIC WATER LEVEL:
02 ft below R top of casing ❑ ground surface
Date1�/_�U
METHOD OF DRILLING: X air rotary ❑ cable tool
0 Other
USE OF WELL: ,'Es7 domestic CJ irrigation ❑ monitor
O Public supply ❑ �- other_, ._
Jl — .�C—Q• in. taa03ft
CASING STICKUP: ry — ft.�. lam: _
Casing type:_ In. to alt
WELL INTAKE OPENING TYPE: ,;open end - LJ screened
❑ perforated 0 Open hole
/f f `,.r/Q Depths of openings: ==to� ft
lv[��—/ ►�rc SCREEN TYPE:
• y, Slot/Mesh Size: tt
GRAVEL PACK TYPE:
Volume used: Depth to top:
GROUT TYPE! _ volume: ••_ �f,_.
earlo, Depth: from __. ft to � _ ft
DEVELOPMENT M HOD:+�,��_�_
L__ PUMPING LEVEL AND YIELD:
R , C E',�J ft attar 0 hrs pumping P(.•I�uprn
�)C PUMP INTAKE DEPTH: it Horsepower. �-
WELL DISINFECTED UPON COMPLETION? "EJ, YES ❑ NO
CONTRACTOR IN FOR %�TROeptt. Flealttj &'I-turnanntServireB REMARKS:
Id PtUSItt S am ' (/ .
PLEASE MAIL, WHITE COPY OF LOG TO:
�.�,•t.r •%. / •^C ; .f -- �%�' DNRlDIVISION OF MINING &WATER MGMT
3-Ignature o uthorizeedesspresyrttatrve . Date ANCHORAGE BO 1070057005
TOTAL P.02
PAGE 1 OF 1
MUNICIPAL:CTY OF ANCHORAGE
/ S r 7- 26 9�
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW950275 DATE ISSUED: 9/13/95
DESIGN ENGINEERS & S ENGINEERING EXPIRATION DATE: 9/13/96
OWNER NAME:MARTIN GLEN & DARLENE
OWNER ADDRESS:9840 HILLSIDE DR
ANCHORAGE, AK 99516
PARCEL ID:01508107 �o 'C\
LEGAL DESCRIPTION:
THAYERMOORE HEIGHTS BLK 1 LT 5
LOT SIZE: 24741 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL, ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY:
DATE:_ - e_�
DATE%Z� �) _
Eli
HEALTHAUTHORITV
APPROVALS
SEWER & WATER
MAIN h7(TENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
ANDREPORTS
WELL INSPECTION
&FLOW TEST
SITEPLANS
ROADOESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ONSITE
WASTEWATER
DISPOSALSVSTEM
DESIGN
nG
September 5, 1995
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: Lot 5, Block 1, Thayermoore Heights S/D
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
CIVIL ENGINEERS
(907)694-2979
FAX (907) 694-1211
Request you issue a permit to drill a well and install a
septic system to serve the proposed four bedroom house on
the referenced property.
Two test holes were excavated and percolation tests
performed. The approximate location of the test holes are
located on the attached site plan.
At the time of excavation no water was encountered in the
test holes and after seven day ground water monitoring,
the monitoring tubes were found to be dry.
This property has enough area for a future septic upgrade
which can be seen on the attached site plan.
We do not anticipate any adverse effects on neighboring
wells, septic systems or drainage patterns by the
installation of the proposed septic system.
There are no points of contamination within the proposed
well radius which can be seen on the attached site plan.
If you require additional information, please contact us.
Sincerely,
1"�c,�//
Robert C.
RCC/gk
Enclosure
G 11" 11„'
Cowan, P.E.
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
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Municipality of Anchorage
t DEPARTMENT OF HEALTH 1£ HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: 13 E LL- qom 9 _ DATE PER
S- is L o c 14 I
LEGAL DESCRIPTION:/[_TNAY r�l M0^ `£ S � Township, Range, Section:
DEPTH 1, SLOPE _ SITE PLAN
(FEET) 'F -t i i FFJ 1, l- it .I
1 2 Z
-t. `T- 0 R 4r4Nr c 5
2 Z 2
3 O 4
d�'T CrM G�a�?aL w l Sn�n
4
' C3 ftvGt5
5 "9 i
7�//I vKny �,rv�
8
9
10
11
17.
13
d
WAS GROUND WATER N 4
ENCOUNTERED?
IF YES, AT WHAT
wI SAN 0 DEPTH?
_ SJMr'✓ �'�N?vf Depth to Water After uay
�^ Monitoring? Dale:
-r.
14-
15 L
16 `
17
1E
19
20
COMMENT'S c L
S
L
O
P
E
Reading
Date Gross
Time
Net Depth to
Time Water
Net
Drop
-G%7
'Aa
l
.
a 3
11.7i. r
is-"
. I
) Mrd- °i.1j'•.
) .,
'1 6 ..
PERCOLATION RATE / (minutes/inch) PERC HOLE DIAMETER
b` 4 '7a -
TEST RUN BETWEEN FT AND 10"X FT
A ?-dA ___ — ---
S ✓I, S ENGINEERING / w� CERTIFY THAT THI TEST WAS PERFORMED IN
PERFORMED BY: ggl0-R.I,-IO^ O. i114
ACCORDANCE WIT�f%Lt WAgf`E911Z0MAlR *ftL GUIDELINES IN EFFECT ON THIS DATE. DATE: s —
72-008 (Rev. 4/95)
uas Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502.-0650
SOILS LOG - PERCOLATION TEST
PERFORMED FOR:
13b 1, L_NUM/L S_--
Net
Drop
WAS GROUND WATER N
1_07 4Lo eee. /
LEGAL
DESCRIPTION:
L4Y!LhP"d'T 4G —
DEPTH
(FEET)
I'G S T-
11
/
/�"
2
U �
DEPTH?
12
3
4
5
r ``
'
(, rr� RA It1�
6
7
..r
laoah�y (ICA o+iO
9
�-
Township, Ranj
SLOPE
•/�
Net
Drop
WAS GROUND WATER N
10
ENCOUNTERED?
MIN
11
/
/�"
IF YES, AT WHAT s
U �
DEPTH?
12
Depth to Water After n R Id /
13
Monitoring? __r_ Date:
gr�rY
14 5 M SffND
15 (3.J•I4
16
17
18-
19-
Reading
819
DATE P
Section:
SITE PLAN
K
:ER'S SEAL)
A Ai 1
o /
Reading Date Gross
Time
Net Depth to
Time Water
Net
Drop
MIN
3 '/z
/�"
ST_
20PERCOLATION RATE I (minutes/inch) PERC HOLE DIAMETER
,
TEST RUN BETWEEN S FT AND FT
COMMENTS S
PERFORMED 8,5 $ S PN/3INEMNO I �""`0' CERTIFY THAT THIS TEST AS PERFORMED IN
ACCORDANCE 17034
g 9f�LaSTA.T �yG� � P74L' WINES IN EFFECT ON THIS DATE. DATE: G `3~
rarer, A aC 999SSS
72-OOB (Rev. 4/85)
s&s�
?-rneeninG
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
HEALTHAUTHORITY
APPROVALS REFERENCE: Lot 5, Block 1, Thayermoore Heights SID
September 5, 1995
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
CIVIL ENGINEERS
(907)694-2979
FAX(907)694-1211
SEWER&WATER
VFa1Y GA[l1L:
MAIN EXTENSIONS
1. The scope of this project includes the installation of
a 1250 gallon septic tank and leachfield trench to
serve the proposed four bedroom residence located on
SEWER&WATER
the referenced property.
INSPECTION
2. Construction shall be in accordance with the approved
site plan and design drawings, Municipal permit with
any special provisions or conditions, and all
ENGINEERING STUDIES
pp p p applicable State and Municipal Wastewater Disposal
AND REPORTS
Regulations.
3. The contractor shall be responsible for obtaining any
necessary underground utility locates.
WELL INSPECTION
& FLOW TEST
4. Unless specifically agreed otherwise, the property
owner shall be responsible for final grading areas
subsequently depressed from soil settling.
SITE PLANS
5. Contractors installing wastewater disposal systems
must be certified by the Municipal Health Department
for system installations. Owners installing their own
ROADDESIGN
systems must also receive prior approval from the
Municipal Health Department.
SOILTEST
SEPTIC TANK INSTALLATION:
1. A septic tank is to be constructed by a certified
septic tank manufacturer. Construction shall include
PERCOLATION
two 4" cleanouts for pumping access.
TEST
2. The septic tank shall be sufficiently bedded to
prevent settling or shifting of the tank.
STRUCTURAL&
3. All standpipes on the septic tank shall extend a
MECHANICAL
minimum of 12 inches above finalrade.
g
INSPECTIONS
ONSITE
WASTEWATER
DISPOSALSYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP - SUITE 204 - EAGLE RIVER, ALASKA 99577
Page Two
Lot 5, Block 1, Thayermoore Heights S/D
September 5, 1995
Septic tanks installed with less than 4 ft. of cover shall
be insulated.
5. A foundation cleanout shall be installed one to four feet
from the building foundation. in the Line between the tank
and the leachfi.eld there shall be two adjacent cleanouts
(unless an effluent pumping system exists within the septic
tank). These cleanouts shall be located on undisturbed
soil not more than 10 ft. from the tank. The first
cleanout, in line, shall be to clean toward the leachfield.
The second cleanout shall be to clean toward the septic
tank.
Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
1. Excavate the proposed trench to the dimensions shown on the
design. The bottom of the excavation shall be within 2
inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (ruffed -•up) before
gravel (sewer rock) placement.
2. Once the gravel is installed, the distribution pipe is to
be installed level with the perforations faced downward.
Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
3. A silt barrier must- be installed between the final gravel
layer and the native soil backfill. Ensure the silt
barrier covers the entire gravel surface before placing
backfill.
4. Monitor tubes shall be of four (4) inch diameter,
installed approximately in the locations shown on the
design, and extend a minimum of 12 inches above final
grade. The portion of the monitoring tube extending
through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is
equivalent to the effective depth of the gravel as noted on
the design.
Page Three
Lot 5, Block 1, Thayermoore Heights S/D
September 5, 1995
5. Backfill over the final gravel layer must not be less than
twenty-four (24) inches. Insulation must be installed when
the backfill. depth is less than thirty-six ( 36 ) inches.
The finish grade over the trench must be mounded to prevent
the formation of a depression after_ settling.
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Type of Pipe Perforated Solid
Cast
Iron
Yes
Yes
ASTM
D3034
(PVC)
Yes
Yes
ASTM
F810
(HDPE)
Yes
No
ASTM
D2662
(ABS)
Yes
Yes
Use of a type of pipe other than listed above must be
approved by the inspecting engineer..
3. Insulation shall be at least 2" thick extruded direct
burial. polystyrene (Dow Chemical Company Styrofoam HI or
equal).
4. Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N,
or equal) must be installed between the final leachfield
gravel. layer and the native soil backfill.
6. All leachfield gravel (sewer rock) shall be 0.5"-2.5"
screened gravel with less than 3% passing the #200 sieve.
7. When sand is being used as a filter material, its gradation
specifications must conform to current M.O.A. or D.E.C.
requirements.
Page Four
Lot 5, Block 1, Thayermoore Aeights S/D
September 5, 1995
INSPECTIONS:
Typically there will be a minimum of three (3) inspections
required during the installation of the wastewater disposal
system. These inspections will occur as follows:
The first inspection must be conducted after the
excavation of ditches, pits, trenches, or beds and
before the installation of any gravel. A septic tank
may be set in place, but may not be backfilled before
this inspection.
The second inspection must be conducted after the
placement of the silt barrier, gravel, distribution
lines, standpipes, cleanouts, and insulation, but
before the placement of any other backfill.
The final inspection is to occur upon final grading of
the property.
Often there will be more than these 3 inspections required.
Especially with the installation of multiple trenches, sand
filters, pressurized distribution systems, etc. Thus, the
inspecting engineer is to be contacted at :Least 24 hours prior
to the start of construction. If necessary, a pre -construction
meeting will take place on-site. The inspecting engineer will
not coordinate, direct or control in any way the contractors
activities.
The owner shall contract with the contractor to perform the work
outlined in these specifications and plans and in accordance
with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S
Engineering. S & S Engineering shall be the owner's
representative and will. inspect the work as stated above to
document- the contractors activities. Final acceptance of the
contractors work rests with the owner and the M.O.A.
Page Five
Lot 5, Block 1, Thayermoore Heights SID
September 5, 1995
S & S Engineering shall have no liability to the owner or to
others for acts or omissions of the contractor or any other
persons performing work on this project or the failure of the
contractor to carry out the work in accordance with these
construction documents. S & S Engineering's inspecting engineer
will not be responsible for the construction means, methods,
techniques, sequence, procedures or the safety precautions
incident to this project.
CONTRACTOR/INSTALLER
MUNICIPALITY OF ANCHORAGE
o
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 015-081-07-000
Expiration Date:
Legal description THAYERMOORE HEIGHTS BLK 1 LT 5
Site address 9840 HILLSIDE DR Anchorage AK 99507
Current property owner(s) FARNSTROM HANS OLOF
1/17/2024
X The On-site systems) is/are approved for 4 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
0
Original Certificate Date: 10/17/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory X
Tank Age Advisory X Arsenic Advisory
Other
COSA ApprovaUune 2022
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section - Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 01508107000
Complete legal description THAYERMOORE HEIGHTSBLK 1 LT 5
Location (site address) 9840 HILLSIDE DR
Current property owner(s) FARNSTROM HANS
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
Day phone 865-6406
3. TYPE OF WATER SUPPLY: ❑■ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: X Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑■ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 28 yrs -,See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed X Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $/ q_5
Date of Payment lezy 3
COSA # D5G2313$JL57
Waiver Fee $
Date of Payment
Waiver #
COSA Application—June 2022
COSA Checklist
Legal Description: THAYERMOORE HEIGHTSBLK 1 LT 5 Parcel ID: 01508107000
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _
A. WELL DATA
❑■ Well log is filed with Onsite (or attached)
Date drilled 11/30/95 Total depth 203 ft
Cased to 203 ft
❑■ Sanitary seal is functioning correctly
❑■ Wires are properly protected
Casing height (above ground) 48 in.
Date of flow test for COSA 9/8/22
Static water level at beginning of test 170.2 ft.
Comments
B. TANK DATA
Measured operating fluid level in septic tank 49
Date of pumping 9/25/23
❑ Required maintenance completed, if AWWTS
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 9/26/95
❑■ ALL standpipes present per record drawing
Total measured depth from grade 12 ft (max)
Measured depth to pipe invert from grade 4 ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
❑■ Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Well production at time of test 8+ gpm
Water storage tank volume0 gallons
Well disinfected for coliform test? ❑ Yes ❑■ No
❑■ Coliform bacteria is Negative
Nitrate 5.71 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L XArsenic less than MRL (ND)
Collected by NRimEng
Date 9/20/23
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 9/8/22
Results g Pass
Fluid depth prior to test 0
Water added 600 gal
New fluid depth 10 in
Elapsed time 30 min
Final fluid depth 2 in
in
Absorption rate 600 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 96
Effective depth used 2 in
Effective depth remaining 94 in
Comments/Deficiencies: System was rechecked on 9/20/23- no changes
COSA Checklist June 2022
in
E. SEPARATION DISTANCES
From Private Well on Lot to: {Please eater distances if less than required or if community well on lot)
Septic TankiLitt Station on Lot > 100' Community Sewer Ma n h ol eJC leanout> 100'
F■ Yes if No ft ❑■ Yes if No ft
Neighboring Tank > 100'■❑ Yes if No ft Private Se erlSeptic Line > 5' [kYes of No ft
Absorption Field on Lot > 100' ■❑ Yes if No fl Holding Tank > 100' ❑ Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment> 50' Yes if No
n■ Yes if No ft
Manure/An irnaI Excreta Storage > 10 0'
Community Sewer Main > 75' []■ Yes if No, ft Q Yes if No
L1 NIA — Served by Community Well (not on lot) or Public Water
From SeptiliciHoldling Tank and Absorption Field(s) on Lot to. {Please enter distances if less than recuiredj
Building Foundations > 10' Q Yes if No , fl Surface Water > 100' ■I Yes if No
Tank to Property Line > 5'
Field to Property Line > 10'
Water Main > 10`
plater Service Line > 10'
F. ENGINEER'S COMMENTS
F■ Yes
if No ft
■❑ Yes
if No , ft
■ Yes
if No ft
�■] Yes
if No fl
Wells on Adjacent Lots:
Private Wells > 100'■❑ Yes if No
Community Wells > 200' F]■ Yes if No
If tank or field is ander driveway comment below
ft
M
ft
ft
ft
G. CERTIFICATION & 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 Ori -Site Systerr3s Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm NorthRim Engineering Phone
Engineer's Printed Name _ Steve Eng Date
COSA heckfisr June 2022
$4-7028
10113123
411 4�
OF A�Ar
�s1��i
.
�.A.. ; ... Steve Eng . ; ,� 1
`IC' CE 621%
10/13/
BOO MCIPAU Y OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
On -Site Water and Wastewater Section
www.muni.org/onsite
Septic Tank Advisory
Certificate of On -Site Systems Approval # OSC231385
Subdivision: Thayermoore Heights Block:1, Lot: 5
907-343-7904
Fax: 343-7997
The septic tank for this property is 28 years old. The average life of an asphalt
coated steel septic tank is 20 years. Typical replacement costs are $10,000 or more,
not including engineering, surveying or MOA permitting fees.
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 30 year old steel tank MAY look like.
DEVELOPMENT SERVICES DEPARTMENT o
On -Site Water and Wastewater Section
www.muni.org/onsite
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC231385
Subdivision: Thayermoore Heights, Block: 1, Lot: 5
907-343-7904
Fax: 343-7997
A water sample revealed a nitrate concentration of 5.71 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 relative quality of water
from private wells. Since nitrates are known to slowly increase, we recommend
you monitor the water quality. 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
o i tR �..�
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 015-081-07
Legal description Thayermoore Block 1 lot 5
Site address 9840 Hillside Dr Anchorage, Ak
Current property owner(s) Sharon Anderson
Expiration Date: 1-7-2023
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for
Comments or advisories:
bedrooms, with the following stipulations:
By �, C'" l Original Certificate Date: t6— / ^=_
-,rT&vZt%e,,,,
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA ApprovaLiune 2022
GUI MHMPAUTY OF AHCHO
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 01508107000
Complete legal description THAYERMOORE HEIGHTSBLK 1 LT 5
Location (site address) 9840 HILLSIDE DR
t
Current property owner(s) ANDERSON SHARON
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
Day phone 229-6624
3. TYPE OF WATER SUPPLY: ❑N Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑■ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑■ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 27 yrs - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑■ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ S5D Waiver Fee $
Date of Payment Date of Payment
COSA # Waiver #
COSA Applicatlon_June 2022
Legal Description:
COS/ Checklist
THAYERMOORE HEIGHTSBL.K 1 LT 5
Parcel ID: 01508107000
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _
A. WELL DATA
0 Well log is filed with Onsite (or attached)
Date drilled 11/30/95 Total depth 203 ft
Cased to 203 ft
®❑ Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 48 in.
Date of flow test for COSA 9/8/22
Static water level at beginning of test 170.2 ft.
Comments
B. TANK DATA
Measured operating fluid level in septic tank 49
Date of pumping 9/7/22
❑ Required maintenance completed, if AWWTS
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 9/26/95
❑® ALL standpipes present per record drawing
Total measured depth from grade 12 ft (max)
Measured depth to pipe invert from grade 4 ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
0 Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Comments/Deficiencies:
COSA Checklist June 2022
Well production at time of test 8+ gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate 5.79 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by NRimEng
Date 9/23/22
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 918/22
Results 0 Pass
Fluid depth prior to test 0 in
Water added 600 gal
New fluid depth 10 in
Elapsed time 30 min
Final fluid depth 2 in
Absorption rate 600 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 96
Effective depth used 2 in
Effective depth remaining 94 in
in
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100'
Yes
if No ft
Community Sewer Manhole/Cleanout > 100'
Fm� Yes
if No
ft
FE1 Yes
if No ft
Neighboring Tank > 100' Fp] Yes
if No
ft
Private Sewer/Septic Line > 25' Fol Yes
if No ft
Absorption Field on Lot > 100' 0 Yes
if No
ft
Holding Tank > 100' F01 Yes
if No ft
Neighboring Absorption Fields > 100'
Animal Containment > 50' nE❑ Yes
if No ft
Q Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main> 75' [g]Yes
if No
ft
inn❑ Yes
if No ft
M NIA — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10' g Yes if No ft Surface Water> 100' E Yes if No ft
Tank to Property Line > 5'
Yes
if No ft
Field to Property Line > 10'
Q Yes
if No ft
Water Main > 10'
M Yes
if No ft
Water Service Line > 10'
9 Yes
if No ft
F. ENGINEER'S COMMENTS
Wells on Adjacent Lots:
Private Wells > 100'
Community Wells > 200'
Yes if No ft
Yes if No ft
If tank or field is under driveway comment below
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Finu NorthRim Engineering Phone
Engineer's Printed Name - Steve Eng Date
COSA ChecklistJune2022
694-7028
9/20122
Municipality of Anchorage
Development Services Department
/ Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.enchorage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING '
Parcel I.D. D15-081-07 HAA# f% 3 Q ! % T
1. GENERAL INFORMATION Expiration Date: O L?
Complete legal description THAYERMOORE
HEIGHTS
SUBDIVISION: LOT 5.
BLOCK 1
Location (site address or directions) 9840
HILLSIDE
DRIVE • ANCHORAGE.
AK
Current Property owner(s)
Mailing address
Lending agency
Mailing address
GLENN & DARLENE. MARTIN Day phone 346-4889
9840 HILLSIDE DRIVE 'r ANCHORAGE AK 99516
Day phone
Real Estate Agent DIXIE DIXON w/ PRUDENTIAL VISTA Day phone
Mailing address — 4241 `B"'STREET • ANCHORAGE, AK 99503
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
561-3200
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 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 samples. (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.
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $ at, or prior
to closing for the engineering services provided.
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 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-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 ALASKA WATER do WASTEWATER CONSULTANTS, INC. Phone
Address 6901 DEBARR ROAD, SUITE 28 ' ANCHORAGE, AK 99504
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, AKWWC, inc. 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 of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local 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. AKW WC, Inc. can therefore not provide
any warranty or future esfim •ate 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 conter any legal right whatsoever.
5. DSD SIGNATURE
Approved for _ bedrooms.
Disapproved. -
337 -6179
Date aq 03
Conditional approval for bedrooms, with the fllowing stipulations:
ittt(1(((0((Ff/f//�/i
Ja : ON-SITE
WASTEWATER
nonr^_t7/•r9
Attachments: / ��;�A ' • . , , , . • ' • SO�'�`
HAA Checklist t/ Manitenance Agreements ��i�/0�;. c
Septic System Advisory Supplemental Engineer's Reort ���11))llllll
Well Flow Advisory
Other
gy; 'tel LL•" .C�- Original Certificate Date: 5
(Rev. 1=1)
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water & Wastewater Program
4700 South Sragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.d.anchorage.ak.us
(907) 843-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: THAYERMOORE HEIGHTS SUBDIVISION: LOT 5 BLOCK 1 Parcel ID: 015-081-07
A. WELL OATH
Welftype ,I:RNATE If A, B, or C provide PWSID# N/A
Date completed 11 Z3,OZ1995 Sanitary seal (YIN) YES
Total depth 203 ft. Cased to 203 ft.
FROM WELL LOG
Date of test 11/30/1995
Static water level 174 ft.
WeQ'production 10 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0_ colonies/100 ml. Nitrate ILT-7 mg./1..
Well Log (YM) YES
Wires property protected (Y/N) YES
Casing height (above ground) 48 in.
AT INSPECTION
43/2003
174 ft.
6.8+ O.P.M.
Other bacteria D colonies/100 mi.
Arsenic WA mgJC Date of sample: 4/23/
2003 Collected by: AKWWC, INC.
B. SEPTIC/HOLDING TANK JDATA -
Tank Type/Material ,, _ GREER/STEEL Date installed 9/26/1995
Tanksize 1250 . gat. Number of Compartments ? Cieanouts (YIN) YES
Foundationcleanoa(Y/N) SES . ,Depression over tank (YM) -M0 High water alarm (YM) NIA
Date of pumping .,.. 4 i 2003 Pumper CHUGACH PUMPING
C. ABSORPTION FIELD DATA �i ow Exis-N c'cTzn'a
Date inStalled. !4&1995 1995 Soll rating .p.d. r ftlbdrm) 1.22 System type DEEP TRENCH
Length 35 , ,ft. Width 2.5 ft. Gravel below pipe 8 ft.
Total depth012-3 , ft, Bff. absorption area 560 ft' Monitoring tube YES Depression over field NO
Date of adequacy feet $423Z.2003 Results (Pass/FaiqP_,_,,,,,A-5� For 4 bedrooms
Fluid depth in absorptionfiieeld before test 10.5 in. Water added 1S78gal. New depth**� 14.5in.
Elapsed Time: 26 min. Final fluid depth 11.,5_ in. Absorption rate >= 600+ g,p,d.
Any rejuvenation treatment (past 12 mo.) (YM & type) NONE KNOWN If yes, give date
**LIOUID LEVEL 81.5 INCHES BELOW DISTRIBUTION LINE INVERT
D. LIFT STATION
Date installed
"Pump on" level at in.
E. SEPARATION DISTANCES
Size in gallons
High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?,
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
1009+
Absorption field on lot
100'+
Public sewer main
N/A
Sewer /septic service line
25'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout N/A
Holding tank N/A
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 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
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer'sPrinted ame JEFFREY A. GARNESS
Date 4 3
'n AIM&&
...................
e A. ess.
—7953 �e
�A
HAA Fee $ 375 •Waite Fee $ � SC
Date of Payment T:30 -03 Date of Payment 5,110
Receipt Number 3:fG 2 Receipt Number ' N 1_+
(Rev. 12/01) Y Ji
FROM : Fleming Surveying Services FAX NO. : 907-243-4890 Apr. 25 2003 02:45PM P1
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4-28-03; 3:29PM;
J
SCS Ref.#
1032244001
Client Name
AK Water & Wastewater Consultants Inc.
Project Name/q
Thayennoore L5 B1
Client Sample ID
Thayermoore L5 B I
Matrix
Drinking Water
;907 $815301 u 2/ 3
All Dates/Times are Alaska Standard Time
Printed Date/Time 04/28/2003 11:35
Collected Date rime 04/23/2003 16:25
Received Date rime 04/24/2003 11:55
Technical Director,_,,, -Stephen e
Released B�
Sample Remarks: `
Allowable Prep Analysis I
Parameter Results PQL Units Method limits Date Date Init
Waters Department
Nitrate -N 4.27 0.100 mg/L EPA 300.0 ("10) 04/24/03 JS
1
Microbiology Laboratory
Total Coliform 0 coV100mL SM18 9222B («1) 04/24/03 KAP
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section ti
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744 :10`
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING 1�
Parcel I.D. # �'\'1 "l` - S\' ir—n' , 1 t :_ C=(�':
'I. GENERAL INFORMATION
Complete legal description La.t 5; 8, ock 1: Thaye.,,wo>te, ffe,iah.tb
Location (site address or directions) NHN H..?24tide. Dicive.
Property owner
Mailing address
Lending agency
Mailing address
Se.?2 Horne.4
13622 Gu ,"..er)o.t Ci. c2e.
Agent _
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual well XXX
Community well
Public water
Day phone 345-2355
zge, AK 99516
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 XXX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADF-C
attesting to the legality and status of system.
7M25 (Roy. 1/91) Front MOA 421
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 furtherverify 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 F S
Address i -7 6 3`/ )-4c-
Engineer's signature
6. DHHS SIGNATURE
By:
E c'- Phone
Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
UJITIC
Fico --77
Date Z / S i
bedrooms, with the following stipulations:
Date 2 - /S " `r
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72V5 (RV. 1/91) Beck MOA V1
.
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bedrooms, with the following stipulations:
Date 2 - /S " `r
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72V5 (RV. 1/91) Beck MOA V1
Municipality of Anchorage
DEPARTMENT OF HEALTH &HUMAN SERVICES
Environmental Services
825"I-" Street, Room 502 • Anchorage, Alaska 99501• (907) 343-4744
Health Authority Approval Checklist Ice
G0 7 %SLocK / TH YE�Mvo/tE HCrJ. 1 S _c' Si a 7e
Legal Description: $ Parcel LD.:_G
A. WELL DATA o�
Well type I'R1 v 4T t _ If A, B, or C, attach ADEC letter. ADEC water system number —
Log present &N) Y S _ Date completed 1 I / s o
'Fatal depth _ O 3 _ Cased to ;k 0 3 / Casing height (above ground) 3 /
Sanitary seal (Y)_iIz .S _ Wires properly protected Y r S'
FROM WELL LOG AT INSPECTION
Date of test
Static water level
Well production
I 30 As -
17 t/ ,
/p
g.p.n1.
WATER SAMPLE RESULTS:
Coliform _ �— Nitrate 3 T mq /�_ Other bacteria —
Date of sample: _ PZ �L 9!a _ Collected by: _ S & S ENGINEERING
i71S3TEo—te Ftivel'1�p-Road"91s29�
B. LEPTIC�HOLDING TANK DATA s gla River, Alaska 99577
Date installed 10 / 01 r/ °7 S- Tank size I d 5' G Number of Compartments Z_ Cleanouts (9/N)_Y[ S
Foundation cleanout Y'N) yE J Depression (Y& h 0 _ High water alarm (YA ^' J _
Date of Pumping 1"14 `^ 6J Pumper _ —
C. ABSORPTION FIELD DATA
Date installed 9 /a 6 �_ Soil ratingg d. z or ftz/bdrm) System type De L/3 i Ae- c. y
Length 3 S / Width d=s Gravel thickness below pipe _b' Total depth ) 3
Effective absorption area _S 6 O Monitoring Tube present(' IN) Y t S Depression over field (YkD N 0
Date of adequacy test rv14 /" � c✓ _ Results (Pass/Fail) ____ For __---`_bedrooms
Fluid depth in absorption field before test (in.); In�;diatel—y5fier_: gal. water added (in.):
Fluid depth (in=Mit , eter!—__ Absorption rate = ___g.p.d.
Pero�yiatr nt (past 12 months) (YIN) _ __ If yes, give date
D. LIFT STATION
Date installed
Manhole/Access (YIN)
High water alarm level at*
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Sem' lioldiug tank on lot /01 " ; On adjacent lots /
Absorption Feld on lot IV? ; On adjacent lots /
Public sewer main N /9 Public sewer manhole/cleanout
off' level at*
O0 f
i
0 0 �-
Sewer /septic service line 97 t Lilt station N ��
SEPARATION DISTANCES FROM SEPTI^HOLDING TANK ON LOT TO:
Building foundation I Property line Absorption field
Water main/service line NO i- Surface water/drainage /00 t Wells on adjacent lots _
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
N /,q
Jv
Building foundation 16 Water mairlservice line Z/ O /-/--
Surface water /0,) -I- Driveway, parking/vehicle storage area No -/-
Curtain drain do N L Wells on adjacent lots 100 Property line I1
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review ofMitnicipal records
in conformance wit M( HELI guide✓e� a`ffect on this date.
Signature _
r
r;
Engineer's Name 0�¢.Q % C. Co 64,F,/
Date a
HAA Fee $ 6—�- y/ Waiver Fee $ _
Date of Payment 2—Ir L7 Date of Payment
Receipt Number / q (6-6 1r) Receipt Number
Rev. 8/95 OSS: haa.wk.doc
HQGCRT C. COwA!J
'01
are
Ci&E Environmental Services Inc
Laboratory Division -51
Laboratory Analysis Report
Cheml-ab Ref. #:
96.0369-01
Collected:
2/2/96 1415
Client Sample ID:
Lot 5 Blk 1 Thayermoore Hgts
Received:
2/2/96 1445
Matrix:
drinking water
Client P.O.:
Lims Sample ID:
WORK Order:
Client Name:
S&S Engineering
Report Printed:
Ordered By:
R. Cowan
Released By:
Project Name:
1
Project Manager:
t`
VITT
Project #:
Sample Remarks:
Method --Analyte
Nitrate EPA 353
End of Sample
Units QC Qual. Result
mg/L D 3.37
Ext Date Comp.Date Analysis's Init.
2/5/96 2/5/96 BMW
200 W. Potter Drive, Anchorage, AK 99518-1606 Tel: (907) 562-2343 Fax: (907) 561-5301
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