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HomeMy WebLinkAboutTHAYERMOORE HEIGHTS BLK 2 LT 5Block Lot 5 #015-081 - 15 Municipality of Anchorage Page f of '?- DEPARTMENT OF HFALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: __-~W c~¢D'~C)~)',~c~_ _ PID Number: Name: ~UF-- ~1~% -- Wastewater Syste~: Q New ~Upgrade Address: ABSORPTION FIELD Phone: INo olB~oor s: ~Deep Trench ~ Shallow Trench D Bed D Mound D Other LEGAL DESCRIPTION , SoilRating: TolalDeptbfro~or~inalgrade: ~pth to pipe boltom from ~riginal grade: Gravel depth beneath pipe ~ Filladdeda o eoriginal fade: Gravellength: [owoship: Range: S~c,ion: ~,~- ~ ' FL ~,S' Fb WELL: ~t~w B Upgrade Gravel widtb: ~ //Ft Number ollines:~ ~/~OislancebelweonlineS:Ft. Classificatio~ rivale, A,B,C): Total Depth: Cased TO: Total absorption area: / Pipe materia}: ~% Driller: Date Drilled: StaticW~ter Level:Ft. Installer:_F~¢ ~, Date instailed:/¢/¢¢ Yield: GPM IPUmp Set at: Ft. JCasi., HeightAboveGro..e:F, TANK SEPARATION DISTANCES u Septic r~ Holding ~ S.T.E.P. To Septic AbsorpliOn Lift Holding 'ublic/Pdvale Ma faoturer: Well //S' //~ ~ ~ ~,~ Material: ~-- Number of Com~tments: Surface ) ~ ~ ~L,FT STAT,ON Water ~1. ¢0~ ~ Size in gallons: I Manufac~~ ~to ~SI ~0(~ "pUmp on" level ~~ level ~~~rm at: Foundation Ig ' C¢~;~inn ~NF~ ~0~ ,~¢el _]~ctri~llnspect,onsper~r,,~by: Remarks: O&P ~d~¢ ~¢ /¢~) BENCH MARK Location and Description: Inspections performed by: ~o~ River L¢~ Road, ~S' 1 st ~ ~ Department of Health and Human Services approval Reviewed and approved by: ~,-~- ~ Date:.~ 72-013 (Rev. 9/91) MOA 25 Permit No. ~O.~ ?_.- ~. Page of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 1966.50 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposa~ System and/or Well Inspection Report ~o~pt~oo: J--o'r .~ / i2.y-2, / ~m'~,~0~,~ ~c,~. P~D No.: Z3ZSO~'-'~ 79-013 A {Rev 9/91) MOA 95 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW920258 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:KENT STEPHEN H & OWNER ADDRESS:7200 THAYER CIR ANCHORAGE, AK PARCEL ID:01508115 LEGAL DESCRIPTION: THAYERMOORE HEIGHTS BLK 5 2 LT DATE ISSUED: 9/01/92 EXPIRATION DATE: 9/01/93 II', o LOT SIZE: 25200 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK 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 (iSAACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: THIS UPGRADE MUST BE INSTALLED IN ACCORDANCE WITH THE APPROVED ENGINEER'S DESIGN DATED 8~21~92.THE COMBINED LENGTH OF BOTH TRENCHES IN THE UPGRADE SYSTEM MUST NOT BE LESS THAN 95.5 FEET IN LENGTH. RECEIVED BY: -'~,~'~. DATE: ISSUED BY: / . ~_-~3-/~.~--~-- DATE: ROBERTSHAFER P E ROGERSHAFER PE August 24, 1992 CIVILENGINEERS (907) 694 2979 FAX 694 1211 HEALTH AUTHORITY APPROVALS SEWER&WATER MAINEXTENSIONS SEWER&WATER INSPECTION ENGINEERINGSTUDIES ANDREPORTS WELt INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTE WATER OISPOSAL SYSTEM DESIGN Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street Anchorage, AK 99519-6650 REFERENCE: Thayermore Subdivision, Block 2, Lot 5 We request you issue a permit to upgrade the septic system serving the referenced property. An adequacy test was performed on the existing system and the absorption capacity of the system was found to be inadequate. Two test holes were excavated and percolation tests performed. The approximate location of the test holes are located on the attached site plan. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. If you have any questions, or require additional information for your review, please contact us. Sincerely, Roger J-- Sh'afer, P.E. ~JS/JPW/lsu 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 DEPARTMENT OF FIEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 ~.~ ROGEr] ~R ~' I SOILS LOG -- PERCOLATION 'TEST ~% No~~/ 4- 5- 6- 7- 8- 9- 11 13- 14. 15 16- 17,-. 18- 19.- 20- 1 WAS GROUND WATER Vz~r- ENCOUNTERED? $ IF YES, AT WHAT l~[ L DEPTH? Oeplh lo Water Alter ,,. Monitoring? ~/;~ Date: _ Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE . ~L¢._ (minutes/,nchl PERC HOLE DIAME'fER TEST RUN [BETWEEN _~_ FT AND '~ FT COMMENTS PERFORMED BY: S & $ ENGINEERING ~ ~.~'~ 17034 Eagle Rive[" Loop Road NO, ACCORDANCE WiTH A~'~:~V~I~f~.I~'r~IDELiNES IN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST '"~'~1~ LEGAl- DESCRIPTION:LoOT ~.~; b~/~¢. ~.~, Tl~/~v~lv~G~ ~/~ownship, Range, Section: SLOPE 5 6 7 8 9 10 11 13- 15- 16- 17- 18- 19- 2~'- COMMENTS SITE PLAN V~L7 ~-t I) P£Tl,f WAS GROUND WATER ENCOUNTERED?/~Jo S L IF YES, AT WHAT .... O DEPTH? p E Depth to Water After Monilorin9? _ D)X,~ Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE (~ tm~nutes/mch) PERC ROLE DIAMETER TEST RUN BETWEEN '-'~/~'-- FT AND ~/-i/J~- FT PEREORMED BY: $ & s ENGINEERING '~7034 Eagle River Loop I{o~ No. ACCORDANCE WITH A~a~,[[~v~,~[;~/~I[~I~UIDELiNES IN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) CERTIFY THAT THIS TEST WAS PERFORMED IN DATE: NAME MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENFAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL. INSPECTION REPORT MAILING ADDRESS .~ LEGAL. DESCRIPTION K_o -5 131kz_ Th_ / c_moFc LOCATION Well Absorption area Manufacturer Liq. in gallons~ IF HOMEMADE: / Inside DISTANCE TO:LWelt ~' ~-'~wel~ ~g Manufacturer DIS rANCE TO: No. of lines.~/ Length of Top of tile to fini h grade Length rWidd~ Well Building foun¢ a o UPGRADE DISTANCE TO: Class Depth DISTANCE 'FO: Building foundation Sewer line OTHER PIPE MATERIALS INSTALLER c; T REMARI<S NO, OF BEDROOMS Material <~ No, of compartments Wid~ ~ '~' ] Liquid depth PERMIT NO. Material Liquid capacity in gallons Distance between lines Total effective 8bsorption are~J ~tion Nearest lot line PFRMIT NO, of lines Material beneath tile Septic tank -[Absoq~tition alee(s) DATE LEGAL PERMIT NO. DEPFIRTMENT OF' HERL..Tt4 FIN[.', ENVIRONMENTFIL FRO].'EC:TION 825 '"L" STREET, RNCHORI~EiE, BK. 9S~ri 264-4728 818168 ::, RF'F'L I CFINT S'FE',/E I<EN'f' I...OCFIT I ON L. EGRL L5 B2 THR'¢ERMORE B J,.., C:HRIN OF D]'"I-,' ~cI~-L"'~~] -' · :~. !:: . (::, :':')4. - ].:~: ii: :i;~ El LO].' SIZE 25500 SQUFIRE FEE].' T'¢F'E OF' SOIL. FIBSORPTION S'¢STEM IS: 'TRENCH MP]F',IMUM NUI"IE~ER OF BEDROOMS SOIL RRTING (SQ FT?BR) .... 265 'I"HE REQLIIRED SIZE OF' THE SOIL. RBSORPTION S'.r'STEM IS: ].'FIE LENGTH DIMENSION IS THE LENG'FFI (IN FEET) OF' TFIE TRENCN OR DRFIINFIEI...D. · FHE DEPTH OF' R TF.:ENCN OR PIT IS THE DISTRNCE BE'f'WEEI'.,I THE :SURFFICE OF ].'NE GROUND RND THE BOTTOM OF ]"HE E,~.~CRVRTION ,:.'IN FEE]"). ].'HERE IS NO SET I-4IDTFI FOR TRENCHES. THE GRRVEL DEP]"N I:-]; THE MINIMUi'd DEPTN OF GF.'R',/IEL BETHEEN TNE OU].'FF1LL PIPE FIN[:, TNE BOTTOM OF TNE EXC:FI',/Ir:ITION ,.'.IN FEE'r). F'ERi'IIT FIPPLICFINT HFIS "FHE RESPONSIE:IL. IT'.r' TO INFORM TNIS DEPFIR'rMEi".,II" [:,LIRING THE INS-.:TFILLFITION INSPECTIONfS OF' RN'.r' WELLS RD..:rRC:ENT ·FO TNI?S PROPERT'¥' FIND THE NUMBER OF RESIt';,ENCES THRT ]"PIE WELL WILL SERVE. E~RC:}(FILLING OF RN"r' S'T'STEi't I.'.IITHOUT FINRL INSPEC].'I(]N F:IND RF'PRO',/RI.... E:~¥' THIS DEPF~RTi'dENT WILL BE SUBJECT TO PROSECUTIOi",L MINIMUM DISTRI",ICE BETNEEN R WELL RND RN'T' ON-SITE SEF.IFIGE DISF'OSRL S'¢STEr,1 IS :IJF,~O FEET FOR FI F'RIVRTE NELL OR :t..5(~ TO 2E~D FEET FROM FI PUBLIC HELL DEPENDING UPON ·FHE T'¢F'E OF PUBLIC WELL. MIN1HUM [:,IS]"RNC'E FROi'd F:I F'RI',,,'RTE NELL TO R PRI',/RTE SENER LINE IS 25 FEET FIN[:, TO R COi'IMLINI]"'¢ SE!4ER LINE IS 75 I::'EET. HEL. L LOGS FIRE REL]fl. JIRE[:, laND MU:ST E:E RETURNED TO THE [:,EF'RRTMEN]" 14ITHIN OF THE HELL COMF'LETION. O].'HER REI..T.!LIIREIdENT'S MR'¢ RPF'L'T'. SF'ECIFICFITIONS RND COi'4STRUCTION D:(I:'IC~RfrlMS FIRE: FI',,,'RILRBL..E TO INSURE PROPER INSTFILL.BTION. I CERTIF"r' THR'F ::1..: I RM FFIMILIFIR WITH ]"NE REg!I...IIREMENTS FOR ON-SI]'E SE'WERS FIND I.,.IE'I·.LS FIS SE].' FORTH B"r' TFIE HUNICIPh]LI]"'T' OF FINCNORRGE. 2: I WILL INSTFILL TFIE S'¥'S'f'IEM IN FICCORDRNCE WI].'N TFIE CODES. 3:: I LIN[:,ERS,].'RND I'HFIT THE ON-SITE S;EWER S'¢STEM MA"r' REQOIRE ENLFIRC"iEMEN]" IF: 'THE RESI[:'ENC:E IS REi"IODELED TO INCLU[:,E i'"IOR. E ].'HFII",I 2: BE[:,ROOMS. HFFLIL. FIN[ _IE,~ I<Ehl F , C/4:? / Z:.:.;SUED ~:"' ; ( :' ,r(..¢.?.,~. (/), f .~ f'? ...... '.,,/ 1// f,' //'/) ; [ ' r ',,,'4. El 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 PERFORMED FOR: LEGAL DESCRIPTION: 8 10 11 13- 14- 15- 16- 17 18 19 2O COMMENTS DATE PERFORMED: SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? , IF YES/AT WHAT E DEPTH? /.~ Reading Date Gross Net Depth to Time Time Watel' ~/~ Net , O op t~ zo /o Z, Ye 17~ 30 Z,¢d 0 PERCOLATION RATE .'~ (~' (minutes/inch) TEST RUN BETWEEN ~ FT AND -.--.~,=~ FT DATE; 72-008 (6/79) o © (D 0~ o o o o 0 Municipslity of Anchorage Development Services,, Department Building Safety Division On-Site Water & Wastewatei' Program 4700 Etmore Road P.O. Box 196650 Anchorage, AK 995i9-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING O Parcel I.D. 015-081-15 1. GENERAL INFORMATION COSA# 0 Expiration Date: Complete legal description THAYERMOORE HEIGHTS; BLOCK 2, LOT 5 Location (site address) 7200 THAYER CIRCLE * ANCHORAGE, AK * 99507 Current Property owner(s) JEFFREY HAVRILLA Day phone 350-4844 Mailing address 7200 THAYER CIRCLE * ANCHORAGE, AK * 99507 Lending agency Day phone Mailing address BRIAN BRODERICK W/PRUDENTIAL Day phone 3801 CENTERPOINT DRIVE #202 *ANCHORAGE, AK 99503 Real Estate Agent '~ ~M~itiqg..._. address Unless. Otherwise requested, COSA will be held by DSD for pickup. 2.. NUMBEROF BEDROOMS: 4 3. TYPE.OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well · Individual On-site · Individual Water Storage [] Individual Holding tank [] Community Class Well [] Community On-site [] Public Water System [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued 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. STATE~ENT OF INSPECTION BY ENGINEER As certified by my seat affixed hereto and as of the validation date shown below, l verify' that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this appfication, o ..... o ,, ,~, ,,,~ ~,,,-s,,~ water supply. . and/or wastewater dispose!. ~.~v~m~., is (are) ~_.~, functional and adequate for the number of bedrooms and type of structure indicated herein. I furt,Ser verify that based on the on-site water supply and/or wastewater disposal system is(are) in compfiance wit.h afl applicable Municipal and State codes, ordinances, and regulations in effect at the time of instal/afion~ Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Phone Date 557-6179 Engineer's Comments: In conducting this evaluation, GEG, LtD. 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. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any otherperson or party is not authorized, nor will it confer any legal right whatsoever. Approved for bedrooms. Disapproved. . Conditional approval for bedrooms, wroth the following sbpulatmons: COSA ~ ~ecrd,s~ Septic System Advisory Well Flow Advisory By: . ~ .,.':: .~ .~¢C~ ~ .-.h" // (Rev. 11/05) Arsen.c Advisor' Maintenance Agreements Supplemental Engineer's Report Original Certificate Date: Municipality of Anchorage Development Se~ices Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Ac CERTIFICATE OF Legal Description: WELL DATA Well type PRIVATE Date completed Total depth 111 8/5/1981 ON-SITE Date of test Static water level Well production 20 WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi. Arsenic: ND ug./L. SEPTIC/HOLDING TANK DATA SYSTEMS THAYERMOORE HEIGHTS; BLOCK 2, LOT 5 APPROVAL CHECKLIST Parcel ID: 0/,~- *ASSUMED BASED ON SURROUNDING WELL LOGS. SEE A'I-rACHED. IfA, B, or C provide PWSID# N/A Well Log (Y/N) Sanitary seal (Y/N) YES Wires properly protected (Y/N) Cased to *40'+ ft. Casing height (above ground) FROM WELL LOG AT INSPECTION 8/5/1981 10/6/2009 81 .ft. 65 ,ft. g.p.m. 7.57 g.p.m. Nitrate 5.04 mg./L. Date of sample: 6/9/2011 2 Depression over tank (Y/N) NO Pumper. I'BELOW EXISTING GRADEI Soil rating ~)or ft2/bdrm).0.45 Width 3 ft. Tank Type/Material SEPTIC/STEEL Tank size, 1250 gal. Number of Compartments__ Foundation cleanout (Y/N) YES Date of pumping 6/9/2011 ABSORPTION FIELD DATA Date installed 10/2-3/1992 40 & 55.5 Length 95.5 TOTAL ft. YES YES 12+ in. Other bacteria 0 colonies/100 mi. Collected by: GEG Ltd. Date installed 10/2-,.3/1992 Cleanouts (Y/N) YES High water alarm (Y/N) N/A A+ HOME SERVICES * 10.,3(EAST) Total depth *9.8(WEST) ft. Eff. absorption area 1557 fi2 Monitoring tube YES Date of adequacy test *'10/6/2009 Results (Pass/Fail) PASS Fluid depth in absorption field before test 60 in. Water added 710 gal. Elapsed Time: 120 min. Final fluid depth 73 in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE **TESTED WEST TRENCH ONLY. EAST TRENCH System type DUAL TRENCH Gravel below pipe 7 ft. Depression over field. NO For 4 bedrooms New depth 82 in. 6OO+ g.p.d. KNOWN If yes, give date - HAD 70 INCHES OF LIQUID. D. LIFT STATION Date installed "Pump on" level at__ Size in gallons Manhole/Access (Y/_..~LN_~ J in. "Pump off" level_~J--------i~'-----. High water alarm level at .in. E. SEPARATION DISTANCES Cycles tested. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot 100'+ Public sewer main N/A Sewer/septic service line 25'+ Animal containment areas 50'+ 100'+ Meets alarm & circuit requirements? On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout Holding tank N/A Manure/animal excrete storage areas N/A 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main Wells on adjacent lots 5'+ Property line 5'+ N/A Water service line 10'+ 100'+ Absorption field 5'+ Surface water 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water service line 10'+ Surface water 100'+ Curtain drain NONE KNOWN Wells on adjacent lots. 100'+ Water main N/A Driveway, parking/vehicle storage 10'+ 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 COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date COSA Fee $ Date of Payment Receipt Number - Waiver Fee $ Date of Payment Receipt Number (Rev. 11/05) 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 # 111197 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 2, Lot 5 of Thayermoore Heights subdivision. This inspection revealed a nitrate concentration of 5.04 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. .AS BUILT PLOT PLAN . I ttcroby certify that I hay; surveyed the followinS dcscr.i.bed prop~t¥: Lot.,_.%_,Bloc~.~-.~',. ~'~r~uo~Iz~ ~~' ~u~, .... ~ ~ce~'S DiStrict, Alaska, ~d that' th~ improvcm~t: situ~t~ ~reon arc wit~ tk~ proper~y li~cs and d~ no~ encroach onto ~c propcrly adja~cnl ~r~to, that no improv6mcnts on th~ proper~y lyin~ adjaccnt thercto cncroach on th~ surveyed premises a~d t~a~ there ~rc no roadways, transmlsaion lines or o~er visible easements on said propcrty cxccpt as indica~cd hcr6on. Dat,~ t~s thc ~ Day of ~ O~~b~:, 19~Z, at A,choras,, Alaska ti is th~ r~ponsibility of the ow~cr to ~i~rai~ thc existcncc of a=y cascm~n~, covcn~ffts, or r~stricttons which do not appcar on t~c rccordcd subdivision plat. scALE 'I"' ~ GRID 1731 George Bell Circle 99515 JOB No. 9~*%Z-4' 86/10/2011 12:~1 8686778 APLUS HOME SERVICES INC. CUSTOMER · 7501 E. 140th Avenue Anchorage, Alaska 99516 345- 189O Giiiia~ ~iia. 7200 Th~l_~_ Anchorage, AK 99507 INVOICE # PAGE 81 40132 Lot DATE DESCRIPTION AMOUNT 06-09-,i Yump Setaic for adequacy' test.. :. ~165. 346-.4465 .., ' Trak loeat,d 20' from SW e~'ner _ -- l'-aoc receJpt to Cra~e~s REMARKS .... '":' ~ PROBLEM AR~-- CALL FOR MORE INFORMATION EEDS TO BE DONE AGAIN IN 6 MONTHS ood Shape ~ Sludge buildup on bosom ~ Floater on top ~ Jim cap missing or ~ Cut standpipe~o 1' above ground ~ Needs Septlctrine needs replacing Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street ~' P.O. Box 196650 chorege, 995 - 6 0 www.muni.org/onsite ~EET~F~CATE OF ON-SITE SYSTEHS APPrOVaL FOE ~ S~NGLE FAH~LY DWELUNG Parcel I.D. 015-081-15 1..GENERAL INFORMATION cos O ? (3 ,/4--4'-4- Expiration Date: ' ' Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address THAYERMOORE HEIGHTS; BLOCK 2, LOT 5 7200 THAYER CIRCLE * ANCHORAGE~ AK ~' 99507 JEFFREY HAVRILLA Day phone 7200 THAYER CIRCLE * ANCHORAGE, AK * 99507 Day phone 350-4844 Day phone. Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well ~r~ 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 su~)ply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are vaIid 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. 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 fudher vedfy 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 Finn GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD. SUITE 101 * ANCHORAGE. AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Phone 337-6179 Engineer's Comments: In conducting this evaluation. GEG, LtD. 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 rneasurad to readily identifiable features. The operational life of all welts and septic systems depend on the local soils condition, groundwater levels that may fluctuate dudng the year, and the water usage of the family being served by the system. These condilions are outside the control of the evatuator of the systom. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there ara no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or futura estimate of how long the system will continue to meet the operational requirements of lhe 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 authorfzed, nor will It confer any legal right whatsoever. 5. DSD SIGNATURE ' _~'"~' Approved for Disapproved. ~/'. bedrooms. Conditional approval for _ _ · ~jdf~/&. G~ ness.' '% ON-SiTE : WATERAND '~: ~ ~, WASTEWATER; :" ~ ;~.... PROGRAM....~..~? bedrooms, with the fllowing stipulations: ,,,?~/· - ,,, ,(~ ~ _ ,,r~..~ .~,~~ Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineers Report Other //~4~'~ . Original Certificate Date: Municipalit. y 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.orglonsite (907) 343-7904 Legal Description: A. WELL DATA Well type PR~VA'r¢ Date completed 8/5/1981 Total depth 111 ft. CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST THAYERMOORE HEIGHTS; BLOCK 2, LOT 5 Parcel ID: (~)/~""'-' *ASSUMED BASED ON SURROUNDING WELL LOGS. SEE AFl'ACHED. IfA, B, or C provide PWSID# N/A Well Log (Y/N) YES Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Cased to *40'+ ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 8/5/1981 10/'6/2009 . Static water level 81 .fi, 65 ,ft. Well production . 20 .g.p.m. WATER SAMPLE RESULTS: 7.37 ,g.p.m. B. Coliform 0 colonies/100 mi. Nitrate 5.24 mg./L Arsenic: ND ug./L. Date of sample: 10/6/2009 SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1250 gal. Numberof Compartments 2 Foundation cleanout (Y/NI YES Depression over tank (Y/N) NO . colonies/100 ml. Ltd. Other bacteria O Collected by: Date installed 10/2-3/1992 Cleanouts (Y/N) YES High water alarm (Y/N) N/A A+:HOME SERVICES Date installed 10,/2-3/1992 System type 40 & 55.5 Length 95,5 TOTAL ft. 3 ff. Total depth -9.8(w£sT) fi. Eft. absorption are~ 1337 ft~ Monitoring lube YES Date ot' adequacy test ** 10/6/2009 Results (Pass/Fail> PASS Fluid. depth in absorption, field before test 60 ;in. Water added 7'10 9al. Elapsed Time: 120 mtn, Final fluid depth 73 in. Absorption rate >= Any rejuvenation treatmen! (past 12 mo.) (YIN & lype) NONE KNOWN If yes, give date **TESTED WEST TRENCH ONLY..EAST TRENCH HAD 70 INCHES.OF LIQUID. Date of pumpir{g 10/12/2009 Pumper ' C. ABSORPTION FIELD DATA ~*SELOW EXISTING CRAOEI Soil rating ~r ft%drm)0.45 Width DUAL TRENCH Gravel below pipe 7 Depression over field. NO For 4 bedrooms Newdepth 82 tn. 600+ g.p.d. D. LIFT STATION Date instalIed. Size in gallons Manhol~ ...---- 'Pump off" leve..~. H~gh water alarm level at 'Pump on" level at in. ~ ~ ~Cycles tested. Meets alarm & circuit requirements?. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot. 100'+ Public sewer main N/A Sewer/septic service line 25'+ Animal containment areas. 50'+ 100'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout Holding tank N,/A Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Water main N/A Water service line 10'+ We/Is on adjacent lots 100'+ Absorption field. Surface water. N/A 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water service line 10'+ Surface water 100'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ Water main N,/A Driveway, parking/vehicle storage 10'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I ced/fy 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 JEFFREY A. OARNESS Date ,o/~1=~ COSA Fee $ ~'~ Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment, Receipt Number 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 # 090455 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 2, Lot 5 of Thayermoore Heights subdivision. This inspection revealed a nitrate concentration of 5.24 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. SGS Rcf.# Client Nnme Project Name~ Client Sample ID Matrix 1095426001 Gamess Engineering Group, Ltd Thayermore Hts, B2,L5 Thayermore H~ B2,L5 Drinking Water Printed Date/Time Collected Dar e/Time Received Date.,'fime Technical Director 10/19/2009 16:26 10/06/2009 13:00 10/06/2009 14:15 Stephen C. F..de Sample Remarks: POL Units Method Allowable Prep AJ~ysis Container ID Limits Date Date Init Morals ~ ICp/Ms Ars~ic ND 5.00 ug/L EP200.g C (<I0) Waters Department Total NitratWNi~ite.N 5.24 0.100 mg/L SM20 4500NO3-F B (<10) 10113/09 LCE Microbiolo~ Laborato=~ Colony Count Total Coliform Fccal Coliform col/100mL SM20 9222B A (<200) col/100mL SM20 9222B A (<1) col/100mL SM20 9222B A I 0/0(fi09 DLC I 0/0 (~09 DLC 10/06/09 DLC '4 PLOT PLAN _ ' ,.-. ~ ;. -. ' ..... ~,--~- and t~at ~n Improvements stt,,sted tEereon ~re witMn tee property ~cs ~d do not encroach onto tEc ~ropcrty ~ncroach ...... t~ .to.ert~ except ~s Indicated hereon. lines or o~r visible essemen~l ~.-,- ~ ~ ~ I~ ts t~o rcs~onstbllit~ of ~o o~cr to ~tcrmino the existence of any eucmcn~, covc=sn%s, or restrictions which do not nppesr on thc recorded subdivision plat AS BUILT __ ~. ,. SCALE :1 s ~ .. GRID Z4,5'~ JOB No. 1731 George Bell Circle 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. cf 6~13'-- c'5'/ -- / 1. GENERAL INFORMATION Complete legal description 5o_t 5; Block 2~ Th~ayermore Heiqhts Location (site address or directions) __ Property owner Mailing address Lending agency. Mailing address_. 7200 Thayer Circle Anchoraqe, AK 9951--6 Ed & Janet Shellington 7200 THayg~ Circle Vista Mortqaqe Day phone 346-1972 ANchoraqe, _A_~ 995].6 Day phone_562-6444 Agent Address __Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 ~' '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. 72q)25 (Rev. 1/91) Front MOA #2~ 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm s & s ENGINEERING lY034 EagJe River Loop ~oacJ No. Address Eagle River, Alaska Engineer's signature Date DHHS SIGNATURE ~'/ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments 'ho'cC 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. RECEIVED Municipality of Anchorage dUi~ 0 4 DEPARTMENT OF HEALTH & HUMAN SERVICES 'UNtCIPALI~'Y OF AND - Environmental Services Division ~NV~Ot'4~,ENTALS~RVlCI.~ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Lega~ Description: z.-~ 7'- 5'- f¢~.,~c.~ ~- A, WELL DATA Parcel I,I).: Well type eR ~',/~ T ~ Log present ~,/~N) "/ Total aepth _ I1 If A, B, or C, attach ADEC letter. ADEC water system numcer Date completed ~' / 5- / ~ / Cased to ~ 0 -F Casing height (above ground) Sanitary seal ~)N) '1 ~.. J Wires propeny protected (~N',, _ Y ~- J Date of test Static water level Well production WATER SAMPLE RESULTS: FROM WELL LOG g.p.m, AT INSPECTION ~ .q?- Collected by: Coliform O Nitrate Date of sample: B, SEPTIC/HOLDING TANK DATA Date installed I0 /3 /~7. Tanksize Foundation cleanout (~N) Date of Pumping lO / ~ / q 7 _ Pumper ~ 'k f/a,~ ~ J'~..'~ v,,..-.~ Other bacteria S & 5 ENGINEERING Eagle River, Alaska 99577 I ;)-5'-0 Number of Comoar~ments Depression (Y~ ,,,v 0 High water alarm (Y/~ z,/ 0 C, ABSORPTION FIELD DATA Date installed I,b / ~ / ¢1 "& Length ¢~ 5" '/'~ '~ Width Effective absorption area I ~ '.~ ~? Date of adequacy test ~ / ? / ~f ~" Results ~(.~/Fail) Fluid depth in absorution field before test (in,); ~ ' ¥" Fluid depth ~ c, (ins) Minutes later: 3o ~' Soil rating (g.p.d,/fF or fWbdrm) CO. ~¢' ~ Gravel thickness below pipe '7 Total depth ~'~' Monitoring Tube present(~N)'Y'~d' Depression over field (Y~__ _ Systemtype 7 ,¢¢,-,cl/~ J bedrooms ImmediateLy after6;/~al, water added (in.):. {'~ ~ Absorption rate = ~;oO ~ g.p.a, Peroxide treatment (past 12 montes) (Y,(~ 72-026 (Rev, 3/96)* If yes, give date '~' D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pu~ff" level at* High water alarm level at* ~ *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots ! ~ ¢ -/- On adjacent lots / o e -/ Public sewer manhole/cleanout Lift station /¢/// SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~' -;- Property line '¢ ~ Absorption field Water main/service line I ~ ~ Surface water/drainage /~9 ~ ~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Propertyline /O --F Building foundation /O ¥ Water main/service line Surface water / O o Driveway, parking/vehicle storage area Curtain drain /v a ~ ~L. /~/0 ~ ~,/ Wells on adjacent lots / ~) 0 F. ENGINEER'S CERTIFICATION ~.~.,_~,,~ ~ '~ I ceflify that I have determined thru field inspections and review of Municip~g~at ~ ,,~¢ystems are in conformance with MOA HAA -uideli~es in effect on this date ~ ~ ~ ~ % ~ ~ Signature ~ ~ '"~ ~ ;:h :: Date 6 [ ~ [ ~ F ~ ~('., ...... ."~ HAA Fee '$. ~ 4~0, /~ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72~026 (Rev. 3/96)* MAY-O?-1998 16:29 CT&E ESI ANCHORAGE 90?5615501 P.02/03 ~t~ CT&E Envlmnmon~l So. Ices Inc. CT&E Ref.# Client Name Project Name/# Client Sample ID Martin Ordered By PWSID 981949001 S & S Engia~erhig Lot 5 Bk 2 Thayermore Hgt$ Lot 5 Bk 2 Thayer~ore Hgts Driukmg Water 0 Sample Remaxks: Client PO// Printed Date/Thne 03/07/98 15:32 Collected Date/Thue 04/30/98 11:45 Received Datefrhne 04/30/98 12:20 Technical Director: Stepheu C. Ede TOtat Coliform Resutts PQL 100 NL/ NO tOLl unjt~ 0,100 ms/L ~[Io~ab[e PPep Ano[ysis EPA 300,0 30 m~x 05/05/9~ tdV CT&E Environmental Services loc, mrovlmional 4/~0/~, inking Water Analysis Repor~ for Total Coliform Bacteria 2~o w. ,o.., o,iv. Anch0ra~e, AK ~9518.1605 ~ ,~[us-r g~ co~'IPL~D BY WAT~It SUPPLI~K TO B~ CO~P[~D BY LASO~TO~Y d" pUB LIC WAT]F:R S Yb"TEM LDo # ~/PRIVATE WATER SYSTEM I ~ Reu~ine a Rip~ Snmple (f~r mm~na ~m~ ~ Um,~ Wnmr with lob SA~L}~ LOCATION ,. ~ C~I~ ~ / ... .~ .,~/~- ~ ~ople (~ 30 ha~ old, ~uIU m~y Client ,otlfiod of unsotL~lfletotY 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 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLF FAMILY DWELLING F'arcel LD.# ~,,\~ - /~'_~,\- ~2~ HAA# ~-~ Lot 5; Bloc~ 2; Thay~or~ub~vision Location (site address or directions) 7g00 Thay6r CirCe Property owner Mailing address Lending agency Mailing address. St6ve Day phone 7200 Thayer Circle A~¢horage, Alaska Day phone 346-1777 Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: ×X If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system, 4. TYPE OF WASTEWATER DISPOSAL: NOTE: ×X Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. $ & S ENGINEERING 17034 Eagle River Loop Road Eagle River, Alasl~a 99577 Phone Name of Firm Address Engineer's signature DHHS SI(~NATURE ~' Approved for bedrooms. Disapproved. Conditional approval for 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.  Municipality of Anchorage ~ Department of Health & Human Services HEALTH AUTHORITY APPROVAl.. CHECKLIST Legal Description: / O-6 ~, [~'~.~--? / ~-/~-/'////)'/Z~Parce D 4~/ ¥'~--- O oc' /-/ ..%~" A. WELL DATA Well type Log present {~/N) Total depth Sanitary seal ~N) If A, B, or C, attach ADEC letter. ADEC water system number . Y~ ~ [)ate completed 8-~'=c~/ Driller ~"¢//~(~',.) )'~FLO '~, ~c. .Cased to /// ~ Casing height Wires properly protected CN) FROM WELl. LOG AT INSPECTION Date of test ~-~ ! ~-"~ 6-1 ~C~ ~ Static water level ~ ~ ~ ~ Well flow ~O g.p.m. %~O Pump level (~E '~2 '~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tsnk on lot ~ ~ ~ r ; On adjacent lots [ Absorption field on lot //~ / ; On adjacent lots /~O Public sewer main _ ~/A Public sewer manhole/cleanout Sewer se~ice line &% ? Petroleum tank ~ WATER SAMPLE RESULTS: Coliform ~ Nitrate _ Date of sample: / ~-- \'~-- ~ ~ Collected by: Other bacteria B. SFPTIC/HOLDING TANK DATA Date installed __ /~)/-~-/~ ~-~ Tank size //¢,~:t~ O/fi,-. Cor~partments 2__ Cleanouts ~__~1)TVv'O Foundation oleanout ~1) t/'~-~'_ ¢¢~T~P-.~ e p re s,, o n ( y/~_~ High water alarm (Y/~ _ ~d/f4~- Alarm tested (Y/~)~. ~O Date of pumping ~/~/, ~ 7~ . Pumper ~ SE-'PARATION DISTANqES FROM SEPTIC/HOLDING TANK TO Well(s) on lot /) ~t On adjacent lots /0(~ /¢' Foundation To propert~ line '~Eo ' ._Absorptionfield ¢'~.0 ~W _Watermain/serviceline Surface water/drainage /00 ~L 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION ~,.,j/,/~_ Date installed Manufacturer Size in gallons ~ Manhole/Access (Y/N) ~ Vent (Y/N) "Pump ~~ ~vel at High water alarm level ~'"'~ ycles tested _ Meets MOA electrical codes (Y/N) ~ ~ SEPARATION D~ATION TO: ~ Well on lot On adjacent lots Surface water Date installed Length R~,~-~' Width Soil rating L/~, =System type Gravel thickness Total absorption area Depression over field (Y/(~ Results (pass/fail) ~'J.//~ Peroxide treatment (past 12 months) (Y/~)) I ~'-'~ SI'% Cleanouts present (~fN) ~E~ r~o Date of adequacy test ~/~ -~1~ ~, --~ SYS, for ~ bedrooms ~0~ ~d, If yes, give date ~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot [ t ~ To building foundation On adjacent lots o'~S Surface water Curtain drain On adjacent lots / O0 ' '/- Property line ,,20-, O ~''~ z¢-(~ / To existing or abandoned system on lot /- Cutbank /(~) i/_ Water main/service line /00 'f Driveway, parking/vehicle storage area /(~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA ~ of this inspection. Signature Engineer's Name Date S & S ENGINEERING 17034 Eaole River Loo~ Rend Eagle River, Alasl<a 99577 HAA Fee $ / Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAl. TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99516 TELEPHONE (907) 562-2343 FAX:(907) 561-5301 ANALTSlD BSDULTS for INVOICE I 59359 Chemlab RET.# 92.5545 Sample # 1 Matrix: WATER Client Sample ID PWSID : UA Collected : OCT 6 92 @ 20:00 h~a. Received : OC~ 7 92 ~ 15:11 Ara. Preserved with : AN REQUIRED Client Name :3 & S ENGINEERING Client Acct :$NNENOP BPO# : Neq# : Ordered By :R. SHA~ER PO# :NONE RECEIVED Analysis Completed : OCT 9 92 Laboratory Supe~vl&o~.~_~k.~3~$JiEN C. EDE Parameter Results /~ Units Method Allowable Limits Sample ROUTINE SAI4PLE COLLECTED BT: ~omarks: i Tests Performed 3eo Special Inotructlons Above UA-Unavailable ND- None Detected *' See Sample Remarks Above NA- Not Analyzed LT-Less Than, GT-Groater Then ~'~ BG~ Member of the SGS Group (Soci~t~ G~n~rale de Surveillance) 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 GENERAL iNFORMATION (a) (b) (c) (d) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name ._~-~¢~ Applicant Address Applicant is (check one): Lending institution []; Owner/builder/[Zl'; Buyer []; Other ['1 (explain); Telephone: Home .Z~(~-/'7'7? Business .~¢Z-- Lending ,nstitution/4~(-~---"'CP,,"~ &~--~'~,~r /~_~&,/~ Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family/[2~ Multi-Family [] Number ol Bedrooms ,~ Other WATER SUPPLY Individual Well [/~ Community [] Public [] / Note: If commnnitv well system must have written coofirmaticn h'om the State Department of Environmental Conservation attesting to the ~egality and status, 4. 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 PROVIDIh,~ INSPECTIONS, TESTS, FILE SEARCH, D~ .*, AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, [ 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, ~ 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"~,~--~'~' / ~__~__~__~:'T~ Telephone Address ~.~.Z.O ~', ~7~ Date Engineer's Seal DHEP APPROVAL Approved for /'~'~'~/..~,~,) bedrooms by Approved ,.~_ Disapproved Terms of Conditional Approval Conditional 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 purcbasers of homes and their lending institutions in order to satisfy certain federal and state requirements, I--mployees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipalily ol Anchorage is not responsible for errors or omissions in the professional engineer's work, Page 2 of 2 72-025 u 1/84) WELL DATA MUNICIPALITY OF ANCHORAGE (MO/,,~ HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 · MUI~ICIPALi'pf OF DEPT. OF HEALTH & ENvIRONMENTAl PROTECTION ~64-4Z20 LegalDescripeon: ~o~ ~ ~c~ Well Classification '"J:~uc,.q-~ If A, B, C, D.E.C. Approved (Y/N) '"J/.~ Total Depth /// Cased to ',/¢~ Depth of Grouting Static Water Level . ('r2~ Pr Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on LOt Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) · On Ad.oining Lots /¢~(::;,-H F.T. To Nearest Edge of Absorouon Field on Lot J~o--~+ ~ : On Adjo.mng Lots J~d2L~F'T TO Nearest Public Sewer Line .~..j/,A To Nearest Public Sewer Cleanout/Manhole _ ,~/A To Nearest Sewer Service Line on Water Sample Collected by /~.//.~..l~Ll~C~l;~- ~ [~8'~$~'~,.p_C:~e'p?-~ : Date Water Sample Test Besults ~/qCTT,-~F.'~C'TD~'¢ Comments ~--~:~'~:~~~ B, SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) -~ Depression over Tank [Y/N) Pumping/Maintenance Contract on File [Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Seotic/Holding Tank: To Water-Supply Well To Property Line To Water Main/Service Line _ Course ,~-~,/,A Air-t ght Caps (Y/N) Sze /ooo ~ ~'/No. of Compartments Foundation Cleanout (Y/N) Date Last Pur~ 0ea d~/~--~/,.~z ' for Temporary Holding Tank Permit (Y/N) To Building Foundation f/¢ To Disposal Field 1~ To Stream. Pond. Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C, ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ! ~./~l Width of Field ..5-,c~ Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test ~--~.~~ ~r' Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation ~ ~ Lot ~,/~' To Water Main/Service Line 7S-~-~- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Desigr¢"'~ Length of Field I ~ Depth of Field ,~' ~-T' Gravel Bed Thickness "~ ~ Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line _,~CO~- 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 che. e~e, dCv~fdfi~/d, pr conformed to all MOA and HAA guidelines in effect on the date of this inspection, Company ~s F, ~Sl;~ MOA NO. Receipt No. ~ ~ ~ ~ Date of Payment (~- ~ q'~ Amount: $ ~ ~ ~¢' ~4~¢ '%~ Cn Engineer's Seal 2220 I"~23T 88 AVI'~NUE ANCHORAGE, AK 99507 (907) 349-6451 WATER ~7{LL Subdivinion: Lot: _._~<- Block: Address: Initial Reading on Meter: TIME _/: lq___ GALLONS Zk VOLUME G TfYl'AL VOLUM~ NO'f ES: : Time %. Date lb_ -/: nsesc~or -Time Date Inspector Dste ML NICIPALItY OF ANCHORAGE DEP], OF HEALTH & Conditional ApprovJJNVIRONMENTAL PROTECTION D:u ~ 1981 RECEIVED D~t~e~ewer InstaJled Permit No. Septic Tank Size Holding Tank Size Soils Rating Well To Abserption Area Wel Log Received Well to Tank Property Owner Mailing Address Buyer Addrsss Lending 'mtltutlon Address APPLICANT FILLS OUT LOWER HALF ONLY · , , , t.~ Realty Co & Agent Addrsss Street Location Type.~f Residence /rd, Single Family "~ ' I· Multiple Para Jy No. of Bedrooms J Other Phone Phono Watr4r. LSupply ,fl'Individual t· Community · Public Utility Sewa.cje Disposal /ET Individual · Public Utility I-Ioldin~. l'anl~ ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, g~ve well death (attach Icg ' available.~ --_-~7'- Year Individual Installed: When Connected to Public Utilit'~,; NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATE[). "As-Built" [ hereby certify thot o survey of tho following described property ~4~o ~ ~/~ and that tho )mprovements oltuatod thereon wlthln~'the property IIn~ Ond ~'not overlap or encroach entre propert~ adjacent t'horeto~that no improvements on'property lyln~ adjacent thereto encroach ontho prom[so~ in question and that there are no roadway~t transmission JJnos or otho~ vl~JbJo easomont~ on ~ald p~oporty except as Indicated . D~tod at Anchor~g~Al~sko~ this ~ ~doy of,, , / ~ . RACTJNG ENGINEERS & ASSOC. . International Airport Road Anchorage j AJosk~ 9950~ Phone: SEAL Block ;2, ~?hay~';moor~ ~;ul~d.i. vision ~:~J. ce ......... J!ro~i~ t.! . (tho;,'; Lab~ 56~3 , Pitr:,q t .~_ t.>t~-~ thc-, instdll~Jtior't 'of thc on,~site newer system