HomeMy WebLinkAboutPROSPECT HEIGHTS #5 BLK 2 LT 5Prospect
Heights
Block 2
Lot 5
#015-135-13
I I. / 4 u '. 1J ILI; .3Ar_ A14 L..r U V.A UL UJ :_' LL '.- -1 J M il 1_'U i G 141) L, [ 4 -1
.2
d I
A
L
Pump Installation Log
Well Dt-iffing 'Pennit Number- SW__
U
Parcel ldeatirleftfi011 Number,__. -
Legal Desci-iptiotl
1 C�
Date of Issuc-
Pr )eryy Olvilo. Name & Address:
L;
Pump 111.1tallatiorl Date;
puillp intake Depth Below Top of Well feel
urer's Name:
Pump Mallufact
rufrip Model:
Furrip lip
Pitless Adapter Burial Dtpfll: feet
Pitless Adapter Instalkr:
Well Disinfinted Upoll Colllpl(;tion? y U's "E", No
Njethod ot'Dishifectitill:
Comments:
Anchorage Pump & Well Sentice
Pump Installer Name: 330 East 70th Avenue
Anchorage, Alaska 99518
Phone: 907-243-0740
Fax: 907-243-0742
IC196 wee\�
0 15 - ISS- 13
Atte,16011: Thd rpL11,111) jWUZIIICrShall ')[()VidC Ll Pt',MP in.,-'oll-mion ;og to th�.' DSD with -.n 30 days, )?j'L:MP iMUli_,,Itiofl,
Ju. 02,19 01:05p Anchci-nge WeH & PLmp Sai 'n072430742 p.1
Well Drilling Permit'NtiInber:
Pareei Idenbricatiov. _N uraber:__015-- 135- B
-#5 8Z LS
Urap Instal I q ate:
tion
Ptln'P Intake Depth Belovy Top of
Ydd fe e t
PUITIP Al'ar'ftfhcfurt�rls Nam., "7
PUMP Model: C''_r v S Z
purnp Size rhp
Pitless Adapter Burial Drph.. feet
Pitless Adapter :'Manu factjjrej_' s 'lame:
tj Iq
Pffiess Adapter Installer.
Well, Disinfected Upon compledon? Yes 17ii No
Method ofDisinfection-,
Comments -
Pump Installer Dame:
Date of Issue:
Property Owner Naine & Address-
Cerj'v ' 'r- AR&n6z.;j'-;'
Attention:I
.- PUMP it'staiter sfla'l pravicc a rump il:�•tal'j'lli)ll ',Gj-,r re the DSD witl-iin 30days C -f PUM" instajlat'�an.
Development Services bepartivent
Builditiq
Sur'el'y C)!�,fsjorj
On -Site Water & Wastewater Program
4700 Eltre Road
rvj
Mark 89gich
P -G, 8ox 196650
Mayor
Archorcae, AK 99507
�'_IWYMUML2��
(907) 3<i-7904
Pani p Installation Log
Well Drilling Permit'NtiInber:
Pareei Idenbricatiov. _N uraber:__015-- 135- B
-#5 8Z LS
Urap Instal I q ate:
tion
Ptln'P Intake Depth Belovy Top of
Ydd fe e t
PUITIP Al'ar'ftfhcfurt�rls Nam., "7
PUMP Model: C''_r v S Z
purnp Size rhp
Pitless Adapter Burial Drph.. feet
Pitless Adapter :'Manu factjjrej_' s 'lame:
tj Iq
Pffiess Adapter Installer.
Well, Disinfected Upon compledon? Yes 17ii No
Method ofDisinfection-,
Comments -
Pump Installer Dame:
Date of Issue:
Property Owner Naine & Address-
Cerj'v ' 'r- AR&n6z.;j'-;'
Attention:I
.- PUMP it'staiter sfla'l pravicc a rump il:�•tal'j'lli)ll ',Gj-,r re the DSD witl-iin 30days C -f PUM" instajlat'�an.
87/88/2888 18:15 9873453287 HW DRILLING PAG~ 83/83
M-W brilling, ]:nc.
eP.O. Box l10378eAnchomge, AK 99511e
e907-345-4000 · 907-345-3287 Fax*
Job No. 07-~.34
GROUNDWATER WELL AS-BUILT_& LOG
Well Owner. Phil Haws
Legal Description: . Prospect Hel~hts #5~ Block 2,. Lot 5
· 8003. Oney Circle, Anchorage 99507
Use of Well: Domestic
CO NSI~.U~C~ ON
Hole Depth: 4oa' Casing Size: e' Cased To: ~.oo.a?'
Drill Method: Air Rot~r~ Wall: o. ~2uJ' -
Well Completion: Open end X
Screen/Pen'oration description:
Screen Pen'omted
None
Material: A 53 Steel
Perf. Method:
Grout Notes: ( 3 ) Sack{s) of NO. 8 Dentonite granules
Notes:
Disinfected: Yes Method: Chlorine Tablets
Well Development Method Air Surge
Notes:
Static water level (SWL) 92 below top of rasing {TOC~). ~'
Well yield test at ~4. ';allons per minute (GPM) for~._,~' hour(s) wi~/~/~of drawdown (DD) from static leveI[SWL).
Method: Air lift -
Start Date: __ 07/3.6/07 Completion Date: 07/22/07
Pump Inst~ll Date: 07/3.8/07
WELL LOG
Depth in feet
top of caslnl~ Details of formations pene;~ated, size of material, color and misceilaneous details.
0 TO 3 casing stick up
3 TO 3.9 gravel: small, sandy
3.9 To 25 silt: dry
25 TO 78 gravel: ~mall, silbj, sandy
78 TO 96 gravel: small, sandy
96 TO 3.35 bedrock: slltsto~e argillite
3.35 TO 3.55 bedrock: fractured
:[55 TO 3.70 red rock: soft "'
3.70' TO 196 green rock
:[96 TO 240 red and green layers
240' TO 25-'0 black rock and quartz
:250 TO 342 red and [reen layers Intermittently
342 TO 406 fracture zone
TO
TO
TO -U-~AYNEE;-WE9TBERG,
~ t.k:onr, o No. 1000
07/08/2888 18:15 9873453287 M~ DRILLING PAGE 82/83
Pump Installation Log
Well Drilling Per~it ~Number:. SW . Date of Zssne: __
Pnrcel ][deniil]ca~On ~be~ 1~ I ~
Il
~mp ~ke ~ ~ Top efW~ ~s~g: ~0 f~
~mp Mauufac~r'a Nnme~ ~r~ /
Pit]ctsASapter~urlzlDe~: 1~ feet
ArCHon: The pump inatall~r shall pr~dc a pump Installa~ou leg tu the DSD within 30 days of pump iustallat~on.
MUNICIPALITY OF ANCHORAGE
Development Services Departmenl
On-Site Water & Wastewater Program
4700 South Bragaw Streel
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WATER SUPPLY PERMIT
Initial
Date Issued: Jul 16, 2007
Expiration Date: Jul 15, 2008
Permit Number: SW070160
Legal Description: PROSPECT HEIGHTS #5 BLK 2 LT 5
Design Engineer: 0000 ZZ - NONE NEEDED
Owner Name: PAUL HAWS
Owner Address: 8001 ONEY CIRCLE
ANCHORAGE, AK 99516-1141
Parcel ID: 015-135-13
Site Address: 008001 ONEY ClR
Lot Size: 77512 SQ. FT.
Total Bedrooms: 5 Permit Bedrooms: 5
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well
[] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. Ail 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 DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
5, The following special provisions.
-THE INSTALLATION OF A WATER WELL SHALL MEET ALL THE ANCHORAGE MUNICIPAL CODE 15.55.
PLEASE SEE THE ATTACHED SHEET 'PERMIT REQUIREMENTS FOR A DOMESTIC WATER SYSTEM". IF
THERE ARE ANY QUESTIONS PLEASE CALL THE MUNICIPAL ON SITE WATER AND WASTEWATER
PROGRAM AT 907-343-7904.
Municipality of Anchorage
*' '-- :.-'-Development Services .Department.,
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
ON-SITE SEPTIC/VVELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Legal description (Sub'd, Block & Lot) ,~Z,~./,~'~
Legal description (Township, Section & Range)
Lot Size_/~ ~ ~x~____~S(:l. Ft.
Day phone .~.~.~.~._.
Zip Code
Zip Code
Numberof Bedrooms ~'
THIS APPLICATION IS FOR ([~all that apply):
Absorption Field
Septic Tank
Holding Tank
Privy
Private Well
Water Storage
THIS APPLICATION IS AN:
Initial []
Upgrade []
Renewal []
I certify that the above information is correct. I fudher certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or ad~odzed agent)
1
Permit/Rush Fees: / ~-- ~
Date of Payment: '"~//,,:~./~ c~'
Receipt Number. ~':~/Ul
(Rev. 11/05)
Waiver Fees:
Date of Payment:
Receipt Number:
Municipality of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 e Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~ bJ ~,0E.~)sL PID Number:
""~": ~;M ~oa~ Wastewater System: ~w D Upgrade
Phone: ~ ~O~~' D Deep Trench ~allowTrench D Bed D Mound E] Other
Total Depth from original grade:
Township: Range: I Section: Fill added above original grade: Gravel length;
I
WELL: ~w D Upgrade Gravel width: Number of lines:
Oriller: Oat grilled: I~staller~ ~~. DaLai stalled:
SEPARATION DISTANCES ~c a Holding a S.T,E,P.
w~ ~/~o' >/o~ ~ ~ ~ LIFT STATION
~--¢7' / / / "Pump on" level at: "Pu~ High water alarm at:
Fobndation
Remarks: BENCH MARK
Location and Description: ~
Assumed Elevation:
ENGINEER'8 SEAL
Inspections performed by: ~/~ Dates: 1st ~/~¢~>~
Department of Healt~and, Hfin~n ~ces approval
Reviewed
and
approved
by:
72-013 (Rev+ 9/91) MOA 25
35'
Permit No..
Page ~' of ~
ML!nicipality of Anchorage
"DEPARTMENT OF HEAl. TH 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
Legal Description:
z
Permit No. __~ *'~ ~b
Page '~ of '~
Municipality of Anchorage
'DEPARTMENT OF HEALTH 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
1201 Ramona St. 99515 ,A,~cHOR~GE, ALASKA
SIX INCH WAITER WELL DRILLED ............ -OUT TO THE DEPTH OF $~5 feet,
DRILLED At THE RATE OF ~24.00 PER FOOT. Steel. cesi~]g seated out
Mr. Jim Goard ?29-5400 Anchor.~.ge
PROPERTY OWNI:R
to 110
ft.
I,t. 5 Blk. 2 Prospect Heights Sub.
LOCATION OF WELL SITE
DRILLER Bernie
I\L.% C I V
WELt. LOG:
18 - 45' Clean coarse gra, vel. Oept. Health & Human Services
4~ - 98~ Hard-'an, A cemented gr~vel,
98 - 110~ Bedrock, A soft broken rock ~oing into a herd bedrock ~t 110 £t.
35% cls.y binder.
110 - 585' Bedro~k."Ai sed!gen~ry.r0ck with. ,ha{dly_~s.ny ...... water sho,..ing in
crs.cks & fissures in the rock until s little over 400 ft. Then only about
~/2 gvm. By 500 feet the water yield u~as only u? to ]/4 g'-m. !~ater yield
showing a~ain at 570 feet in a ~orous ty-e rock &'mALincresse in yield
with use. But 120 gallons ~er hour is the best this iVell is doin~ ~t this
time. In wetter yea. rs, the Well'will increase in yield ~bout 30%. In dry
years~ this Well will dro~' back somewhet in ~roduction. We. ter recovery is
only b~ck u~ to 200 feet of surface. 1 1/2 horse'~ower submersible pum? shou].d
be installed to about 560 feet.
Charge only for 500 feet of drilling at $24.00 per foot: $~a,O00.O0
# 8 wire in ditch (~00 feet) & Mass '~itless adapter :installed & Muni Well
Cap: ~525.00
$'r INCLUDES ALL ~BOR AND MATERIAL FOR COMPLY'ION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR TNE ~UM OF ~] ~ ~2~.00
~ ~1)~ 0 d O'/ BERNIE C'LAtJS OF R~PAI~I' DRILLING WORKS
_h 1~ ~o~ ..... Thi~ ~ ....
MUNICIPALITY OF ANCHORAGE
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:SW960294
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NAME:JIM GOARD
OWNER ADDRESS:15041 OLD SEWARD HWY.
ANCHORAGE, ALASKA 99516
PAGE 1 OF
DATE ISSUED: 9/12/96
EXPIRATION DATE: 9/12/97
PARCEL ID:01513513
LEGAL DESCRIPTION:
PROSPECT HEIGHTS ~5 BLK
2 LT 5
LOT SIZE: 77512 (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 (iSAAC80) .
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:
September 11, 1996
MuniciPality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 5, Block 2, Prospect Heights Subdivision, Addn. No. 5
Well and Water System Design
Impacts to Adjacent Properties
Dear On Site Services Engineer:
We are hereby applying for a permit to construct a well on the subject lot. The attached
site plan shows the location of the well and the 100' protective radius. Placement of
the well in this location will not conflict with the septic system to be placed on this lot
or those in existence on adjacent lots.
The ground surface on the lot drops from the home site toward the northwest at varying
slopes from 12% to 4%. In the area of the proposed well the surface is fairly flat.
Relative topographic contours are shown on the attached site plan. If the well is
constructed as designed the following statements can be made:
The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on reserved
space, either surface or subsurface, on any lots located in the area.
The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
2
LOCATION MAP
SCALE:
1"= 200'
'~..,' L~e Lois
~ NOTE:
t Iii
SITE PLAN
SCALE 1" = 60'
NO CONFLICTS WITH WELLS OR SEPTIC
SYSTEMS IN THE AREA.
September 11, 1996
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 5, Block 2, Prospect Heights Subdivision, Addn. No. 5
Septic System Design
Impacts to Adjacent Properties
Dear On Site Services Engineer:
We are hereby applying for a permit to construct a septic system on the subject lot.
Two testholes were placed on the lot at the locations shown on the site plan. The
percolation rate was determined to be between 2 and 5 minutes per inch and no
groundwater was noted. We are therefore proposing to place a wide absorption trench
with 4' of effective depth. The distribution lateral will be placed 5.5' below the ground
surface.
The ground surface on the lot drops from the home site toward the northwest at varying
slopes from 12% to 4%. in the area of the proposed absorption trench the surface is
fairly flat. Relative topographic contours are shown on the attached site plan.
Conditions on this lot are ideal for the treatment of septic effluent.
If the system is constructed as designed the following statements can be made:
The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on reserved
sub ' any lots located in the area.
space, either surface or surface, on
The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.I=_.
Attachments
.. J
NOTE:
_SJl'E PLAN
SCALE 1" -- 60'
NO CONFLICTS WITH WELLS OR sr.'PTIC
SYSTEMS IN THE AREA.
SYSTEM PLAN
EN 15
LOT 5, BLOCK 2, PROSPEC'r' HEIGHTS
SUBDIVISION, ADDN. NO.. 5
r)ES~GN FACTORS:
Four Bedroom Home
Perc. Rate: 2 Min./Inch
Application Rate: 1.2 GPD/SF
SYSTEI~ REQUIREMENTS:
Wide Trench System
1,250 Gallon Septic Tank
4' Drainfield Rock
4 Bedrooms X 150 GPD / 1.2 GPD/SF = 500 SF of Absorption Area
500 SF/5 LF X .5 (Red. Factor) = 50 LF L.ength of Trench
Therefore: Construct a Wide Absorption Trench With One Lateral 50' in
Length. Distribution Pipe in Trench Placed at 5.5' Below the Original
Ground Surface.
NOTE:
TYPICAL WIDE TRENCH SECTION
(NO SCALE)
Grade Area Over Trench to Drain Away,
(ENGINEER'S SEAL)
Municipality o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825"-"L Street Anchorage, Alaska 99502-0650 ~ . ~ :;; i, :;~,~,:~ ~, i:::
SOILS LOG -- PERCOI.ATION TES r
fl i~' , "'~'~ .......... ~ {,: ~,,
P~RFORMED FOR: ~ ~
LEGAL DESCRIPTION: LO¢~; ~Z) P~ Township, Range, Section:
9-
5 r WAS GdOU D WA*ER
ENCOUNTERED7
IF YES, AT WHAT
Depth le Water A~r
Gross Net Deptl~ to Net
14 Reading Date Time Time Water Drop
~/,5' /~ y~' z ~/,~"
16 ,~0~ O~ ~H~.O Z:/~ 7"
18 ~N~ Z~J '?
19
20
PERCOLATION FIATE ~__ {minutes/ich) PERC HOLE DIAMETER ~ /~
TEST RUN BETWEEN 7 _ FT AND ~ FT
PERFORMED BY: . -~, ~/,~.~,~ ~..,,Z~ , ~/~, ~'~c~_~E.h~,r~T H AT T Hi/~ T~ST WAS p ER F OR M ED i N
ACCORDANCE WITH ALL STATE AND MUNICiPAl. GUIDELINES IN EFFECT ON THiS DATE 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
LFGAL DESCRIPTION;
OL.
1
2
6
Township, Range, Section:
12
SLOPE
WAS GROUND WATER
ENCOUNTERED?
13
14-
15-
16 - {,~o'ri' o ~v~
~'o
18-
19-
20-
COMMENTS
ENGINEER'S SEAL.)
SITE PLAN
S
IF YES, AT WHAT
DEPTH? PE
Depth to Water Afl, er
Monitoring? /~J"~J ~"
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE /"~' (minutes/tach) PERC HOLE DIAMETER __
TEST RUN BETWEEN /~ ~/2... FT AND '? ///'' FT
ACCORDANCE WITH ALL STA'rE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, DATE:
72-008 (Rev. 4/85)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650
~5,~ ~ Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D: "O[5 -.t~ -I.~
1, GENERAL INFORMATION
COmplete leg al .description
LOcation (site address)
Current Property oWner(s)
Mailing addrSss
Lending agency
Day phone
Mailing address
Real Estate Agent
Mailing Address
Day phone 'Z 50 - O g 3 (~
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: ~
=
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~ Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
Community On-site
Public Sewer
[]
[]
[]
II
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 sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my. investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspegtidn, ,,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.
N~me of Firm
~k
Address ~.0[, I~/.
Engineer's Printed Name.
DSD SIGNATURE
~./" Approved for
Disapproved.
Conditional approval for
bedrooms.
Phone
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
(Rev. 11/05)
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: r'¢~' ~ '-' / jr'
Municipality of Anchorage
Dev~elopment.Services Department
Building Safety Division
on-site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650.
www. muni.org/onsite
(907) 343~7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
LegalDescription: P¢o-~)ec'~ ~1(,-[4T5 ~,5 ~IK. ?.. Lo~5 Pardi ID; O1~-J~
~LL DATA
Well ~ ~;.~ . If ~ B, ~ C ~ovide PWSID ~ --
Date~et~ ' ~ ~1~o~ S~.~al (WN) ~
: .... ; ' ~gs~ ' t~'~
Total depth ~ ff. ~to I~ ff.
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
FROM WELL LOG AT INSPECTION
Static water level ~30 ~JT.. ff. l"{'5 ;~ ~',.~ *ff.
Well production ~, ~PlK g.p.m. I,[ ~B!~~ g.p.m.
WATER SAMPLE RESULTS: ~r~or~ bi~ e~
Coliform Ne(~, coloniesll0OmL Nitrate O,'Z~IZ, mg/L
Arsenic: J~/D ug/L date of sample: ~lzs/ll
Depression over tank (Y/N) Pumper ~,~ ~G
B. SEPTIC/HOLDING TANK~DATA
Tank Type/Material /~lor~t T.~i~ /
Tank size [~'i ~i gal.' Number of Compartments
Foundatior{ cleanout (Y/N)
Date or,pumping Au~q~t' ~
C. ABsO~pTt~'PIELD'DATA
Date installed ~/zS] %, Soil reting (~ or ~/bdrm)
Length ~ fi. Width
Date installed' 7/Z~/
Cleanouts (Y/N)
High water alarm (Y/N)
Total depth'Tr',9, ~. ~'" Eft. absorption area J~00 ftz Monitoring tube .
Date of adequacy test '+lZ{'ll( Results (Pass/Fail)
Fluid depth in absorption field before test ~ in. Water added (~00 gal.
Elapsed Time:/~) min. Final .fluid depth Z.5. in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type) JVoat k~o~
in.
System type Sh~,l[~,a -~.ck
Gravel below pipe ~ ff.
Depression overfield /V'
,For ~, bedrooms
'New depth ~.$,5 in.
(~o0
If yes, give date
g.p.d.
D. LIFT STATION
Date installed
"Pump on" level at ,//~'n.
Datum
:E. SEPARATION DISTANCES
Size in gallons ~ Manhole/Access (Y/N)
"Pump off" level High water alarm level at in.
Cycles tested Meets.alarm & circuit req ?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
I
Absorption field on lot Joe
Public sewer main /V/A,
I
Sewer/septic service line
'r )
Animal containment areas 50
On adjacent lots J0o 4
On adjacent lots Ioo
Public sewer manhole/cleanout
Holding tank /V'['A, ....
Manure/animal excrete stOrage arms
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~ +
main
Wells on adjacent lots 100
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 5 ~ Absorption field
Water service line Surface water
Property line Io '~ Building foundation !o'-~ Water main /V'/A
Water Service line J0~ ~ Surface water J00'~ ('/V. 0..,) Driveway. parking/vehicle storage
Curtain drain 501+ (~/. 0.) Wells on adjacent lots J00
rF~ COMMENTS
, --- OF A
G. ENGINEER S CERTIFICATION ,..,
Date
· "
COSA Fee $
Date'of Payment
Receipt Number
(Rev. 4/10)
Date of Payment
Receipt Number
DRIVE
W 522.15'
80.00'
Z
Z
0
,o0'OC~=~
ZZ
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Divi,'~ion of Environmental Services
(:)n-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL. FOR A SINGLE FAMILY DWELLING
1. GENERAl.. INFORMATION
Complete'legal description ___Lot 5..- B].oc.k 2..-
Location (site address or directions)
Property owner
Mailing address
Jim Gourd
80010ney Circle
Anchoraqe¢ AK
Day p~one 868-5111
C/O Prudential Jack White Real Estate
Lending agency
Mailir!g address
Day phone
Agent
Address
Greq Moore/ Pr__udential Jack White
· Day phone
727-7158
Unless otherwise reqgested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
xx
NOTE:
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
xx
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA#21
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 s~,~r~aisC~f~fr~liahSe with all Municipal and State codes,
ordinances, and regulations,i.n, ef[ect o,n~ th..e date ~th. is inspection.
was~e~ [er c;onsu Itlts, Itt~.
Name of Firm ~n~ ~'Rnr,~ ,t,~ ~ Phone
Address / /~ :h¢~,/~l~' ~4
Engineecssignature ~ /~/ f~ -- Date: //~
Waslewater Consultants, Inc.
Shall be PAID $//~ °-'E-°
or prior to, closing for the
Engineering'Services Provided.
6. DHHS SIGNATURE
~ A.p. proved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments S£1E /¢ Tl'/~ ( H ~D I/" /¢ ~' ~ ~ u., e c c
By:
Date
The Municipality of Ar~chorage Department of'Health and Human Services (DHHS) issues He'aJth 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 DH HS 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
MEMORANDUM
WATER WELL ADVISORY
HEALTH AUTHORITY APPROVAL
During a recent Health Authority Approval on-site inspection
and test of tl~e potable water supply well on Lot ~
Block i of R~£6T~/~ Subdivision, the well's
productivity was determined to be o~ gallons per minute.
The minimum well productivity required by this Department
(AMC 15.55) for a ~ _ bedroom residence is °~ gallons
per minute. Although the subject well currently exceeds this
minimum requirement, ali. parties concerned are advised that the
production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory must be attached to all copies of the subject
Health Authority Approval.
Kt:CI:iV U
Municipality of Anchorage I~OV 1 7 199~
DEPARTMENT OF HEALTH & FtUMAN SERVICES
......
Environmental Services Division ENVIRONMENTAL SERVICES
825 L Street, Room 502, Anchorage, Alaska 99501 · (907)343-4744
Legal Description:
A. WELL DATA
Well type PRIVATE
Log present (Y/N)
Total depth 585'
Sanitary seal (Y/N)
Health Authority Approval Checldist
PROSPECT HEIGHTS, LOT 5, BLOCK 2 Parcel I.D.:
If A, B, or C, attach ADEC letter. ADEC water system number
YES 10/24/96
015-135-13
Date completed
Casedto 110'
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
11/5/99
Date of test
Static water level 200
Well production 2
WATER SAMPLE RESULTS:
Coliform 0
Date of sample: 11/9/99
B, SEPTIC/HOLDING TANK DATA
Date installed 9/23/96 Tank size
Foundation cleanout (Y/N) YES
Date of Pumping 11/5/99
C. ABSORPTION FIELD DATA
Date installed 9/23-25/96
YES
FROM WELL LOG
lO/24/96
YES
135
0.42+
g.p.m, g.p.m.
Nitrate
0.618 mg/L Other bacteria 0
Collected by: A.W.W.C., INC.
1250 Number of Compartments 2 Cleanouts (Y/N). YES
Depression (Y/N) NO High water alarm (Y/N) N/A
Pumper OLD McDONALD'S
Soil rating (g.p.d./fF or~:~' 1.2 System type SHALLOW TRENCH
Length 50' Width 5' Gravel thickness below pipe 4' Total depth
Effective absorption area 500 SO. FI' Monitoring Tube present (Y/N) YES Depression over field (Y/N) NO
Date of adequacy test _ 11/5/99 Results (Pass/Fail). PASS For 4. bedrooms
19.5"
14-.25" Immediately after 754 gal. water added (in.):
60 Absorption rate = 600+ .g,p.d,
NONE KNOWN If yes, give date -
Fluid depth in absorption field before test (in.);
Fluid depth 17.5" (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3~96)*
D. LIFT STATION ~
Date installed Size in gallo
Manhole/Access (Y/N) ~ "Pump off" level at*
High water alarm level at* ~ *Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
1 O0'+ On adjacent lots
100'+
Absorption field on lot
100'+ On adjacent lots 1
Public sewer main N/A
Public sewer manhole/cleanout N/A
Sewer/septic service line
25'+ Lift station N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 5'+
Water main/service line
Property line 5'+ Absorption field
~ NONE
10'+ Surface water/drainage KNOWN Wells on adjacent lots
5~+
100%
10'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Surface water
10'+ Building foundation 1 O' Water main/service line
· ~ Nr~NF ~N~WN Driveway, parking/vehicle storage area
50'+
Curtain drain
NONE KNOWN Wells on adjacent lots 100'+
F. ENGINEER'S CERTIFICATION
I certify that l h/a~etfCr~ ,in
inconforman~ewit~.~l~~
Engineers Namd Y J. I
~ield inspections and review of Municipal
felines in effect on this date.
JEFFRF¥ A. (2ARNESS
Date
Waiver Fee $
Date of Payment
Receipt Number
HAAFee $ ¢'~ (:r'D
Date of Payment //?/'~ /
Receipt Number "~"~'7~
72-026 (Rev. 3/96)*
recor,~'~t ¢~,~.1~..~r ' ms are
:'/f