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HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 6 LT 18odi*ak Manor Alaska Block 6 Lot 18 #015-015-16 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 App,catm Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) ' Location (address or directions) (b) Applicant Name J. S fZ ore{ $¢,,P Telephone: Home .~'~"'¢~--¢d'~Z2~'¢- Business Applicant Address ~9~:~,~ v' ¢ (c) Applicant is (check one): Lending Institution [']; Owner/builder ~'; Buyer []; Other [] (explain); (d) Lending Institution 'Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: E'¢,~I [ 34-/~ - 3~,¢2/4- TYPE om" RE,SIDENCE Number of Bedrooms ! . Other WATER SUPPLY Individual Well.~ Community [] Public E] Note: If corn munity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 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, 72-025 (11,84) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE[ SEARCH, DATA AND INFORMATION 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 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 systera is in compliance witl~ all Municipal and State codes, ordinances, and regulations in effect on the date of this iaspection. NameofFirm //~¢,/~1~-/, ,or ~ ¢¢ - /:~,~ r-, Telephone Address -~/~. 7 ~"') ~ Date / ( ./ ~, WATER ~ELL NOTE: This Health Authority Approval inspection merely certifies that the subject water well produced 150 gallons per bedroom per day and that certified laboratory ~ests showed no presence of coliform bacteria in a sample of that water. No warantee or certification is expressed or implied concerning the long term adequacy or safety of the water supply. ON-SITE SEWAGE DISPOSAL SYSTEM NOTE: This Health Authority Approval inspection merely certifies that the subject on-site sewage disposal system accepted at least 150 gallons of water per bedroom per day as determined by methods approved by the Municfpality of Anchorage Department of Heel th and Human Services. No warantee or certification is expressed or implied concerning the long term adequacy of the on-site sewage disposal system. Constrsction data reported on buried system components is from MOA files and was net verified during this inspection. DHEP APPROVAL Approved for _~"~ Approved Disapproved Terms of Conditiona[ Approval bedrooms by _.2~"~/4~' ",~¢~-~.-~,, Date Gonditional CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) .~ HEALTH AUTHORITY APPROVAL (HA/~'~ , , q Wall Classification Well Log Present (Y/N) Total Depth _/4¢3~ Static Water Level ~?¢/ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) ~,~.~' CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: -- If A, B, C, D.E,~. Approved (Y/N) Date Completed ~~ Yield ~ Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Weilhead (Y/N) Separation Distances from Well: T,~Septic/Holding Tank on Lot c~/~_~.~o 'Nearest Edge o, Absorption Fieid on Lot _~ o Nearest Public Sewer CleanoutlManhole [~,~ Water Sample Test Results _ Comments _ ~Z/C ; On Adjoining Lots ; On Adjoining Lots v'~¢// To Nearest Public Sewer __ To Nearest Sewer Service Line on Lot ; Date _ ) SEPT,C/HOLO'"" TANK DA'rA Date Installed - Standpipes (Y/N) Air-tight Caps (Y/N). Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line To Water Main/Service Line Size No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped ; for __ Temporary Holding Tank Permit (Y/N) To Building Foundation ~ ' To Disposal Field To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) 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~ h/av?.~d, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ./'~~ Date ?/j'2 Company _/1./'-/,~ ..~.j ~,~¢ x'*, ~ MOA No. Receipt No. ~/~..)O / ¢ ~ '~'""~-"- Amount: $ ~:~ .-~- Page 2 of 2 72-026 (11/84) '~7 OLD SEWARD HIGL ,/AY ANctlORAGE, ALASKA 99~18 (907)344-8551 ~, . :~ BACTERIOLOGICAL MATER ANALYSIS TO lie COMPLETED BY WATER SUPPLIER DATE COLI.ECTEI) I TIME COLLECTED[ TYPE OF SYSTEM I.D. HO. (PUBLIC 'SYSTEMS) CIRCLE CLASS NAME,,QF SYSTEM ~, TELEPHONE NUMBER S Y,81 E-M ADDRESS, ...... STATE LOCATION W,HERE SAMPLE WAS COLLECTED ' COLLECT~I GNATURE ) ~YPE OF SAgPL~ / C~ECK OHLY OHE THIS COLUmn) ~ DRINKING WATE~ ~CHECK TREA~ENT ZIP CODE []CHLORINATED r-)FILTERED [~UNTREATED OR OTHER ~ RAW SOURCE WATER [] NEW CONSTRUCTION OR REPAIRS . [] OTHER(Specify) '" ,i .- IS THIS SAMPLE A CHECK SAMPLE TO A PREVIOU~S NON-CONFORMING SAMPLE? [ YES [~NO ~ PREVIOUS COLLECTION DATE ANALYSIS REQUESTED (IF OTHER THAN TOTAL COLIFORM) 'SEND REPORT TO:(PRINT £UI:L NAME,ADDRESS AND ZIP CODE ~C~RIOL~ICAL ~TER ANALYSIS RECORD FO~ LAB USE ONLY FOR LAB USE O~LY [] TOTAL COLIFORMS [] FECAL COLIFORMS [~ OTHER [] RESUBMIT SAMPLE Sample rejected because: CHECK ONE OR MORE [] Sample too long in transit. Sample should not be over 30 hours. [] Sample received too late in week []Not in proper container []Leaked out r'l Insufficient information provided. Please read instructions on form. [] Other (Specify) RECEIVED FROM RECeiVED DY .DATE / ~-~--~aTIME AN A LYT Z C.AJ,~JJI~THOD: Ld~J~M[ME M BRA N E FILTER r'] FERMENTATION TUBE Date & Time Started ~ Date& T". Completed. LABORA'rORY RESULTS Analyst ~ ~/}~/~. __ ['] Other Bacteria [] Test uesultahle because: ri confluent Growth [] TNTC ~ SATISFACTORY [] UNSATISFACTORY [] Membrane Filter: Direct Count Verification: LTB Fina) Membrane Filter Results. Reported By ~) Coliform/l~Oml BGB Coliform/lOOml Date Time A.M. P.M. READ SAPIPLE COLLECTION INSTRUCTIONS ON BACK OF FORH Municipality of Anchorage On -Site Water & Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 015-015-16 Expiration Date: 1. GENERAL INFORMATION Complete legal description ZODIAK MANOR BLOCK 6, LOT 18 Location (site address) Current Property owner(s) Mailing address Real Estate Agent 2. TYPE OF DWELLING: 8601 JUPITER DR. JOHN SIGURDSSON Day phone 14712 W SHORELINE WASILLA 99623 Day phone 240-4233 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplei� 'AUG 2 2 zom 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: TYPE -OF WASTEWATEkbISPOSAL: Individual Well Individual On-site ❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well L 1 Community On-site n LJ Public Water System ❑ Public Sewer 0 WaiverNariance request for: neo Distance-= / J Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ G Date of Payment cJ I Receipt Number COSA # Waiver Fee $ Date of Payment Receipt Number 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. l further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site watersupply 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 GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date 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 re Sults described the performance of the o O system under the conditions encountered at the time of the test, and separation o� distances measured to readily identifiable features. The operational life of all wells and ,c c1 1� septic systems depend on the local soils condition, groundwater levels that may Q0� 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 tr : • 9 TFi•�a 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 an warrant or future estimate of how long the system will continue to meet the �"' • . . . . I Y Y 9 Y !%' v ..... ...� operational requirements of the ADEC or MOA DSD. The content of this report is for OO J f y Go r ess.• the sole benefit of the owner listed above. Any reliance upon or use of this report by any y, CE -7 other person or party is not authorized, nor will it confer any legal right whatsoever. kl m �t,% U11t 11 _a°oma 6. DSD SIGNATURE �Yr1 n System #1 Approved for bedrooms. System #2 Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: r DN -SATE' VdATER AND 'NAs-VE WATE Ft Original Certificate Date: 9 -,Z7- / The Municpalitf or AKchorage Develop, emt 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. ATTCHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory (Rev. IV05) Nitrate Advisory Arsenic Advisory Other 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: ZODIAK MANOR, BLOCK 6, LOT 18 ParcellD: 015-015-16 *PER GEG INSPECTION A. WELL DATA **PER ANCHORAGE LIVE CONSTRUCTION DATE Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) >F5 N a Date completed **1972 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth *92+ ft. Cased to 40+ ft. Casing height (above ground) 8.75 in. FROM WELL LOG Date of test �0 Static water level NO Well production —9 P.M. WATER SAMPLE RESULTS: Coliform � colonies/100 ml. Arsenic: NP ug./L. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size gal. Number of Compartments _ Foundation cleanout (Y/N) Nitrate mg./L. Date of sample: 8/7/2014 PUBLIC SEWER Date of C. ABSORPTION FIELD DATA Date installed Pumper PUBLIC SEWER Soil rating (g.p.d./ftor ft2/bdrm) Length ft. Width ft. Total depth ft. Eff. absorption area ft2 Monitoring tube Date of adequacy test Results (PassFFafll AT INSPECTION 8/7/2014 83 ft. 6.14 g.p.m. Collected by: GEG. Ltd. Date installed High water alarm (Y/N) Fluid depth in absorption field before a/ System type _ Gravel below Water added _gal. over field For bedrooms New depth _in. Elapsed Time: Final fluid depth _ in. Absorption rate >= g.p.d. An natio+= on treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N "Pump on" level at in. "Pump ofr level . High water alar level at Cycles tested Meets alar & circuit requirements? E. SEPARATION DISTANCES " SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanknift station on lot NSA On adjacent lots 100'+ Absorption field on lot NSA On adjacent lots 100'+ Public sewer main 50'+ Public sewer manhole/deanout 50'+ Sewer /septic service line 25'+ Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER Building foundation Property line Absorption field Water main Wells on Water service SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Water Water service line Surface water Curtain drain 11ills on adjacent lots 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. Engineers Printed Name JEFFREY A. GARNESS Date bilq)l« (Rev. 11105) 4 PUBLIC SEWER storage DFY. (AISL'MtDi n T atanw T.BI.O[ SOE iulG10 SZ3BALX IC.nll G.11 : 418�IX !7 6.OZ � cfi N SHED \ ��� o 1 t.. yj -aL ' EXISTING '® a HOUSE p, 5 WELL W a V V ,C _U,.._TC.. lx, -r -Ct' IHL NIDA- I .NeACHCN CNLT AN`-lu U AmoJ r1NpAuAL LiA�JI f JNL/ rl" nf ItiVS' n y' -Z vvlir. i. LISTED DISTANCES PREY: IL OVER SCAUNn. REPRODUCTION MAY CAUSE ER -CRS IN SCALE. HLOT SURVEY SUHVgY TYPE a SYMBOLS FWINDAMON AS-BULT SET REBAR DRAIN:,GE ^� ASPHALT ❑ FIN& SIRUCIURE AS-SULT 0 FOUND REBARq�—g CONCRETE ❑ PLOT PLAN ... AS-OULT ... LOT SURVEY ... TOPIXRAPHY WCCA OO II ASSUMED ELEV. -„--TF Fl m. ..ee+ F.2 se nrAn,w .moi,,.. vn ..ro.une m O METAL FENCE ® WOOD DECK PLOT PLANS & LOT SURVEYS IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. SURVEY CERTIFICATION I ®V�`9"�!9!9 PLOT PLAN _a05 OF ,t Psw WVM a aWiltlw m N fM bl t w � � ^,w1s0 V,M ap mNGL w � " ARi4 a> fj FOUNDATION AS-BWL7 '=s+ s asr. = ea+r t. +nLr SrNy ^^-r *ANm..um ., ui. Nt aw ort a n. • , ROBE JOHN o -w �a Ip .,umavee,a mdx >,km em.. oan,lx FINAL STRUCTURE AS-BUILY i� ". +'r •' 411 —5 L Ace.a L boa i„ IeMr artHr Prt 1 ®i ps °• . . ••••• O'°+. .a.• ah,sL.e a, AY'�i ai tlnY .'d Ad w. ale lw .we.e.nea .a.e ,ate Mi._. Y ONLY 'HOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS, ETC.. ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED. ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED. Prepared by Robert E. Johns, Jr, ' Assoc. Prafesslanal Land Surveyors 1700 Brink Drive. ANC:ORACE. ALASKA 8950? i" ® 30C 08122114 JR. ■ Data Dr a 16P REJ h .a hr J AF 233, jW.D. 4-3,1 Lot 18 Bock 6 70niCll KAA►JOP Al ARKA I SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF !( 37 Zeet. _ DRILLED AT THE RATE OF 1619.00 _ PER FOOT. PROPERTY OWNER—S;W,U.. oal Ba dyu. 344-7750 2773485 LOCATION OF WELL SITE_-fA,. 25 Bik. 5 _.Zod taL Suh. i DRILLER t3vuvi p- C1.atw off. P.nmpaiut &&U-) in4_WO&k,6 WELL LOG - 0 ---- 26, OG:0---•-26' si'b y vet. 30% CC,laly.T-- --- -----� 26---69' P=veL. Several, 4mu.U. bmLde-&z. 69--721' Glut aiwj wWL 15% 721.736' SZUty, jarubj. c.tmt m.%th -�. eak4 of patre.L. Some jigm 4 vycteA. 736-137' &ate& bewax4 clean VtaveL pnaducztL 8 �,Pfa uriUh a 30 &o.t ctand a� uratet taL C'04 al.:y. 7/2 Home Sub Pump 6hou-Ld be- .inwtaUed �e. �ee:t og trottam. ble.0 Seat: 1624.00 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF 162627°D0 , — THANK YOU VERY MUCH. BERNIE CLAUS OF RAMPART RIL.LING WORKS DATE- �Gt° 12t1� 7978 .... SERVICE CHARGEOF 1%z% PER MONTil WILL BE ASSESSED ON PAST DUEACCOUNTS.