HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 4 LT 21Zob K
TIME
DATE
INSPECTOR
INSPECTION APPOINTMENTS
TIME
DATE
NSPECTOR
DATE RECEIVED
TIME
DATE
MUNICIPALITY OF ANCHORAGE MUNiCIPALiTY OF ANCHORAGE
DEPARTMENT OF: HEALTH & ENV RONN ENTAL PROTECTIONDEPT'~F?I~ ','.,Lf, l ~?,
82,5 L Street - Anchorage, Alaska 99S01 ~NVIRONM , /. ,.,.'fi_cT~ON
ENVIRONMENTAL SANITATIDN DIVISION APR 3,; 1980
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~ [~'~~
DIRECTIONS: Comoleto ali paris on page 1. Incomplete requests will not be processed. Please allow ten (10) da~s for processing.
1. PROPERTY OWNER
~IAI LING ADDRESS
PHONE
PROPERTY RESIDENT ' f different from above)
,s ,/¢.
PHONE
2. BUYE. R
MAILING ADleR ESS
~ LENDINGI STITUTION
4. REAL,R/AGENT
MAILING ADDRESS
PHONE
'S. LEGAL D~S~.RIPTION
STREET t. OCATION
6. TYPE OF RESIDENCE
NUMBER OF~BEDROOMS
[] One [] Four g] Other
[~ ~"SINGLE FAMILY [] Two [] Five
[] MUL'FiPLE FAMILY ~E]-~ Three [] Six
7, WATEE SUPPLY
~ INDIVIDUAL* ~ ATTACH WELL LOG, Awel log is required for all wells drilled
[] COMMUNITY since June 1975, Eor wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available,)
8. SEWAGE DISPOSAL SYSTEM
~ ~*NDIVIDUAL/ON-SITE'- .YEAR ON-SITE SYSTEM WAS INSTALLED.
~ PUBLIC UTILITY
NOTE: THE INSPECTION FF.E MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev, 6179) ~l
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified i NSTALLER
[]Septic Tank or []Holding Tank
Size:~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELLTO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
~[]~' APPROVED FOR .~ , BEDROOMS
[] CONDITIONAL APPROVAL (letter must ac~ol~pany c~ertificate)
~;]"'~DISAPPROV ED ~ ~
72-01e (Rev. 6/79)
CHEMICAL & G~,.,LOGICAL LABORATORIES ~.-" ALASKA, INC.
' TELEPHONE (907)-279,4014 ANCHORAGE INDUSTRIAL CENTER
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATE. SYSTEM: i--I I I I I -I
I.D. NO.
Water System Name Phone No.
City State Zip Code
SAMPLE DATE: ~ V~ V~I
MO. Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref, no,
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[]Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results, Please send
new sample.
Date Received
Time Received
Analytical Method:
[] Fermentation Tube
[]' Membrane Filter
Lab Ref. No. Result* Analyst
b J ~
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06.1220 (b)
Rev, 1978
BACTERIOLOGICAL WATER ANALYSIS RECORi')
PresumPtive 1Omi ~Ornl lOrnl 1Omi 10_~!, 1,0mi O,lml
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received ____.~.~__
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Approval requested by: ~_~.~_~. ~_~_~
Mailing Address:t~ ~ /~'-'-'-'-'-'-'-'-'~ .~¢.~ -~~._~ .
Property Owner: ~ ~
Mailing Address:
Phone:
Phone:
3. Legal Description:
4. Location:
A. Type,f~-~ B, Depth
C. Construct~on ~/'~,..~..~ ~ .~,,,~-~ D. Bac,ter~al Analys~s .~
7. Sewage Disposal System:~~~ ~' ~- W ~
A. Installed J~/~' B. Installer '
C. Septic Tank: 1. Size
D. Seepage Pit: 1. Absorption Area
E. Disposal Field: Total length of lines
Distances:
A. Well to: Septic tank
Nearest lot line
B. Foundation to septic tank
2. Manufacturer
2. Material
, Absorption area
Other contamination
, Absorption area
C. Absorption area to nearest 'lot line
, Sewer Lines
EQ-034 (1/74) Page 1 of two pages
Page 2 of 'two pages - Request for Approval of Individual S~,,.,er & Water Facilities
Legal Description
Comments .....
Approved~,-~ Disapproved
ApprOval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental
DIAGRAM OF SYSTEM
Date .~-/e-:7_~
Quality
certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
Date
SIGNED
EQ-034 (1/74)
DATE
DEPh ',tENT OF HEALTH AND SOCIAL SEr"ICES
DIVISION OF PUBLIC HEALTH
BACTERIOLOGICAL WATER ANAI.YSIS
Lab. No ....
OFFICE
REPORT RESULTS TO
NAME
~DDRESS
SAMPLE COLLECTED DY ~
DATE COLLECTED T ME COLLECTED
3
Records in this office ind cate this WATER SUPPLY to be of:
Analysis shows this Water SAMPLE to be:
Improve your ~spring Odugwell Dddvenwell Ddrilledwell [~cistern
Division of Public Health, sanitation office for hull~tins, consultation and
D PIsstic Joint Material - Type
GENERAL: Does Water Become Muddy or Discolored?
When?_
Yes ~] No
Diamater ot Wall ~ Depth Feet.
Weg Casing
SANITARIAN'8 REMARKS
Signature _
06-1220
READ INSTRUCTIONS Date Received
24 hours
48 hours
Brilliant Green
REVERSE SIDE
24 hours
48 hours
BEFORE
lNG SAMPLE
EMIl_
-Lactose Broth, 24 hrs,__
-Coliform Density
-MF resu]ts.
-Reported by ~
BACT~ERIOLOGICAL WATER "ANALYSIS RECORD
AGAR
48 hrs.~_ Gram's stain
am
pm
h61B9 /0 �i
4)
• ti vL
Li
•_ ; ; a JUN Mt c' . lily of Anchorage
i
On-Site er and Wastewater Program 4
4- c (907)343-7904 sAFE., .
Ol69Lg�
Certificate of On-Site Systems Approval
Parcel I.D. 015-011-34 Expiration Date: IPTC
�L.
1. GENERAL INFORMATION
Complete legal description Zodiac Manor Alaska, Block 4, Lott/11'
L9tation (site address) 854$ Pluto Drive
Bruce O le 907-903-2778
urrent Property.owper(s) 9 Day phone
Mailing address
., Real Estate Agent Day phone
•
2. T'FP�E.OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well 0 Individual ❑
Individual Water Storage 0 Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer 0
WaiverNariance request for: Distance:
Received by lrrf� Date: b/ x 3 (e7
COSA to be re Based to the engineer,untep otherwise requested by the engineer.
K r se I / /r-1•tJ'1 1-' r, fik
COSA Fee 526.00 Waiver Fee $
Date of Payment (D //44(9'' Date of Payment
Receipt Number 0•9(13-3Receipt Number
COSA# t36(.191 39 Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Crewdson Engineering, LLC Phone 907-280-9493
Address PO Box 671389, Chugiak, AK 99567
Engineer's Printed Name James Crewdson Date 6-9-2017
sOF 11
*. 497 /r •q �/
6. DSD SIGNATURE / '• . %� *. 01
System #1 Approved for bedrooms %�'.J• .s A. rewdson' "•
•
System #2 Approved for bedrooms
J' ' C11527 .4,--
System
Disapproved I OAR P�?+
1 4FESS14N4
Conditional approval for bedrooms, with the following stipulatioAN.)9 C iIoWf
ONSITE
WATER AND �''
•z-..;
WASTEWATER
RROCRAM
By: Original Certificate Date: (c; -/ �, 1 7
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Clue sheet_f c
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: Zodiac Manor Alaska, Block 4. Lot 11 Parcel ID: 015-011-34
A. WELL DATA
Well type Private If A, B. or C provide PWSID # Well Log (YIN) Yes
Date completed 5-12-1974 Sanitary seal (Y/N) Yes Wires properly protected (YIN) Yes
Total depth 124 ft. Cased to 124 ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 5-12-1974 6-6-2017
Static water level 85 ft. 86 ft.
Well production_ 30 g.p.m. _ 9+ g.p.m.
--�. - f sw at hose bib
ATER SAMPLERESULTS:�
Coliform A , colonies/100 mL Nitrate 10 % mg/L (✓-/S-/
II;
Arsenic A r ug/L Date of sample: 6-6,--/?- Collected by: • rewdson Engineering, LLC
B. SEPTIC/HOLDINGTANK DATA
!0'''
Tank Type/Material �tl mate installed
Tank size gal. Number of Comp tte Cleanouts (Y/N)
Foundation cleanout (Y/N) r io over tank (YIN) High water alarm (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2 or ft2/bdrm) System type
Length ft. Width ft. Isigr.afirbelow pipe ft.
Total depth ft. Eff. absorption area ft2 Mipp.4flbe Depression over field
Date of adequacy test Res I Fail) For bedrooms
Fluid depth in absorption field before tes V. Water added gal. New depth in.
Elapsed Time: min. Finuid depth in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
,
D. LIFT STATION
S\
AFL
Date installed Size in gall Si v Manhole/Access (YIN)
"Pump on" level at i �`'I�i$Olevel at in. High water alarm level at in.
NDatum Prr Cyclesletested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO: Note: subject and adjacent lots served by public sewer
Septic tank/lift station on lot NA On adjacent lots 100+
Absorption field on lot NA On adjacent lots 100+
Public sewer main 100+ Public sewer manhole/cleanout 100+
Sewer/septic service line 25+ Holding tank 75+
Animal containment areas 50+ Manure/animal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line toRaAbsorption field
Water main Water service linetoe Surface water
Wells on adjacent lots
J
%...•
ABSORPTION FIELD ON LOT TO: te.is,
Property line Build' on _ Water main
Water Service line face water Driveway, parking/vehicle storage
Curtain drain lb—Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION te. OF........\\.\\,
111
.•Zrgyp,...•... .,• 4q 11
I certify that I have determined through field inspections and g �� iI
review of Municipal records that the above systems are in ;.*'..4g rc y
conformance with MOA COSA guidelines in effect on this date. / .. /
Engineer's Printed Name .lames Crewdson / •,. •• ....
Date �- �j-q_-/ fI • •. -115277 A
sNote: as the engineer of record, I have provided information on 11 9' -
form intended to satisfy MOA COSA requirements only, and 1, S100--C"--
this
it does not include any statements or guarantee regarding the d
/ C /10202C?020 Q}
future life and serviceability of the subject systems. , L t I
COSA canary sheet_2-6-15_CE.pdf
-- _ Al
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�➢ .,� ,Drilling Co..;___F;S c n r; 1/ res USCS Ne.. 12 - -3 -Jo 5+w r 4(..e)
Driller ..D p A. A--; S 5 ti Area 2-3 c t560
4
Well Owner .f.d , /3, (7,11` • s . Use of We11 pA'1 e r
Location (address of: Township, Range, $ Section (if known) ; distance from road:
. i 0 / P / 23PLock ' ;z 1, e )., ,-, hi /,
Size of Casing Depth of Hole /.'{/feet. Cased to /,-.? 9( / feet.
Static water level RC, feet (above) (belki land surface. Finish of well
ii
F. (check one) Open end _
p ( (� : Screen ( ) : Perforated ( ) .
Describe screen or perforations:
Well pumping test at 3P gallons per (hr) (min) for hours with
i? A 6 feet of drawdown from static level.
Remarks 1A 74 '/r r/
Date completed S / 2 . 7 / WELL LOG
__...Depth in feet from Give. details of formations penetrated, size of material,
ground surface color, and hardness.
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d 013, to 6 J ' ' 1 It of. 9P.'.
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