HomeMy WebLinkAboutSOUTH LAKEWOOD HILLS #1 BLK 3 LT 3South Lakewood
Hills #1
Lot 3
Block 3
#015=0151-16
MUNICIPALITY OF ANCHORAGE
\
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
i ENVIRONMENTAL ENGINEERING DIVISION
i 825 L Street- Anchorage, Alaska 90501 Telephone 264.4720
ON-SITE SEWAGE: DISPOSAL SYST 'M AND/OR WELL INSPECI"ION REPORT
NAMf_�®PHONE ❑ NISW
��PGRADE
MAI LI NG ADDR ESS
h7
LEGAL DESCRIPTION
Lcir 3T 8Lot. k �_ ow TO LAte►_ /ooA N!l..t s
LOCATION /
®l_ voo c> N n N1 i
NO. OF BEDROOMS
Well
DISTANCE TO: Absorption area Dwelling r
�—
PE=RMIT NO.
Q Manufacturer Material
W I_ST
w LIq. capacity in gallons Inside length Width
IF HOMEMADE:
No. of compartments
_
Liquid depth
DISTANCE TO: Well Dwelling
PERMIT NO.
_
OZ Z
___ __
Manufacturer
_____
Material
_
Liquid capacity in gallons
uis
w Z
DISTANCE TO: Well +
(Tj� 1
No. of lines Length of each line
Foundation
(�jd !>°f_
Total length of lines
Nearest lot line
�LP)�7'
Trench width
PERMIT NO.
ale) I{�'(�
Distance between lines
�j ET
T'
-f2 inches
CC I–
O
Top of file to finish grade p^
. 1' /
Material beneath file
p� inches
Total effective abso tion area
!�
�p�p
Length
Width
Depth
PERMIT NO.
w
C7
QH
an°
Type of crib
Crib diameter
Crib depth
Total effective absorption area
an
DISTANCE TO:
Well
Building foundation
Nearest lot line
Class
Depth
Driller
Distance to lot linePERMIT
NO.
M
M
�
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area (s)
OTHER
—
---
e
PIPE MATERIALS
h'4FC
r`
SOIL TEST RATING
INSTALLER
��++
REMARKS
C�
_
....0
-p.49M �*
¢ JUNE 25, 1911LL
ra �
i /ry^rn 4`ro
LEGAL
APPROVEDDATE
e
72-013 (Rev. 3/7,31
R
TA���������–I��A �� ���1 A����
DEPHRTME@T .: HEHLTH HND ENVIRONMENTAL RDTECTION
825 'L' STREET/ ANCHORAGE HK. 99501
264-4720
cmq~0 1XIE on EVE R, 1 YEE & 12"00 owl 1: "0
PERMIT NO. ( 820480 )
HPPLICHMT T SPURKLHND 201 H15 99501 279 3916
LOCATION
{(`\
LEGAL LI BI S LAKE WOf) D LOT SIZE 20000 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MHXlMUM HumER OF BEDROOMS = el SOIL RATING (50 FT/BR)- 105
THE RE0UIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS�
, f j, cy, R_ EVE XN 9:1 X I -U— Z9 TD ������ EAEFF"IFFI= 7A
fit is: I &M L 1 1. too SIT ED 13 EA F I _f X L? ���V yR. C' 1: 721 &= fL. n2 ns AD CA FA L_I _C j I q n:,;
PERMIT APPLICANT HAS THE RESPONSI8ILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES TART THE WELL WILL SERVE.
--- 11 - R4 C) Q7 It 0 ���& RE: C.3 0' X 0 Fa EE F;;:� ;_3 T F4 KE ED
BACKFILLING OF OF HNY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETHEEN R WELL AND ANY ON–SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 209 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTHNCE FROM 8 PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET HND
TO R COI 1MUNlTY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
1044RE lot owl 1: "7- EE 14 Fn X FR LE n3 ED Ili! Cl E! tl 103 FE FA nL, ��to 0:1-1
I CERTIFY THAT
1: I OM FAMILIAR WITH THE REQUIREMENTS FOR ON–SITE SEWERS AND WELLS AS SET
FORTH 8Y THE MUNICIPALITY OF ANCHORAGE
2: 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES,
I: I UNDERSTAND THAT THE ON–SITE SM41R SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUD5rMORE THAN 4 BEDROOMS.
203 W. 15th
E 203
4 ®0 ° ° �uV �J 1 BIALNlrANDO VJ 5o Q. ANCHORAGE, VALASKA IT99601
CONSULTING ENGINEEII `� TELEPHONE: (907) 279-3916
MUNICIPALITY OF ANCHORAGE
[`FFT C" 1T'1 ^.
June 2.1, 1982
Municipality of Anchorage
Department of Health &
Environmental Protection
825 L Street
Anchorage, AK 99501
Subject: Permit No. 820480
Lot 3, Blk. 3, South Lakewood
Gentlemen:
,'-l:!
i "'
.., - M82
RECEIVED
On June 15, 1982, I made the first inspection for the upgrade covered
by this permit. For the full length of the trench (30 feet), the soil
consisted of silt and clay. A test hole was dug in order to do a percolation
test. In three hours the water level dropped 1/2 -inch.
The original soil log for this lot shows 7 feet of well graded sand
over well graded gravel. Five additional testholes were dug on the lot
but the reported soil strata was not found.
In the last test hole a 2 -foot layer of coarse gravel was found. The
system was redesigned based on this soil condition.
Very truly yours,
TOBBEN SPURKLAND, P.E.
lmg
OF Al
>>ti- h9M
2225-F
J NE 25 d91Ji
_t
GRE ER ANCHORAGE AREA BO' UGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
IN REPORT ON-SITE SEWAGE DISPOSAL SYSTEM ��u
NAME 0U U 7nQ h MAILING ADDRESS %/<� I77.7 r14 PH///ONE_3 Z//__ 9 ��
LOCATION _ LEGAL DESCRIPTION L 3 3 s. �4�i Pyae9 /711j6_
SEPTIC TANK:
DISTANCE NUMBER OF
FROM WELL / 07 _ MANUFACTURERS I(h MATERIALCt9k)r-%C l_COMPAR MENTS_�
INSI DF_ LENGTH INSIDE WIDTH— _LIQUID DEPTH LIQUID CAPACITY -?0 GALLONS.
SEEPAGE PIT:
NUMBER OF PITS—/—. DIAMETER --OR WIDTH) -& LENGTH,4e , DEPTH __L 1
LINING MATERIAL0— CRIB SIZE: DIAMETER_ DEPTH _q__ DISTANCE FROM: WELL_.
TOTAL. EFFECTIVE
BUILDING FOUNDATION, NEAREST LOT LINE 7Q . ABSORPTION AREA (WALL AREA) qr_fl�-SQ. FT.
ADDITIONAL ABSORPTION
WELL:C; -�tiblj
TYPE 1(r _CONSTRUCTION
BUILDING -2 9' NEAREST
FOUNDATION LOT LINE _
CESSPOOL
APPROVED
DISTANCES:
OTHER SOURCES
DISAPPROVED
INSTALLED BY: Oto n e✓,
PIPE MATERIAL: 2 C -d
LOT SLOPE:
f790TA1_T17M
Form No. EQ -031
DEPTH
DISTANCE FROM:
NEAREST SEPTIC SEEPAGE
SEWER LINE—,TANK—,SYSTEM
�1
DIAGRAM OF SYSTEM
f
civg
GREATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO,
3330 "C" STREET' ANCHORAGE-, ALASKA 99503
�� )] E TELEPHONE 274-4561
SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT
NAME OF APPLICANT_.✓ )�� %� MAILING ADDRESS -5�:y�PHONE
y �_
INSTALLATION LOCATION -e2 z-�'�✓lll�� ----
LEGAL DESCRIPTION _�--
INSTALLATION OF: SEPTIC TANK ✓ SEEPAGE PIT_ � VAIN FIELD OTHER
TYPE AND SIZE OF FACILITY TO BE SERVED -y✓ r�-���"L�1-.��c- 4L =�'�{T � �`-L1 -
FINANCED THROUGH _ _-- TO BE INSTALLED BY
SOIL TEST RESULTS
-.AN1°
.-�0EI THIS PERMIT IS NOVALID WITHOUT SOIL TEST
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT 1'I1\1TTN/f7Y1THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC TANK 512E-Zr 9-[-1.__ TV PE,..L1-�'�"/ C - EEPAGE A -SIZELCL: TYPE:
MINIMUM OIST'ANC:ES,REQUIREMENTS y49.S ip 0772.S DIAGRAM OF SYSTE&T
FOUNDATION TO SEPTIC TANK - .5
FOUNDATION TO SEEPAGE PIT _6�� (/ DRAIN FIELD -_
SEPTIC TANK TO SEEPAGE PIT WALL -� -
L f
SEPTIC TANK -..6--. SEEPAGE PIT _-�D -, DRAIN FIELD
TO NEARESTLOT LINE. {% S/C9
WELL TO SEPTIC TANK. -a -=.V) _ O SEEPAGE PIT
DRAIN FIELD �y /J ALSO CONSIDER AREA
WELLS.
WATER MAIN TO SEPTIC TANK -F " / SEEPAGE PIT
DRAIN FIELD
SEPTIC l'ANK,,�- SEEPAGE PIT ��� J -. DRAIN FIELD J .,
TO RIVER, LAKE. STREAM.
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
G.A.A.B.
OR
LICENSED DESIGNER
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 2668 AND THAT THE ABOVE
DESCRIBED SYSTEM
/ISSIIN%ACCORDANCE WITH SAID CODE. / /%,/{///¢/�
DATE �1L.-,C--/->1-- APPLICANT'S SIGNATURE �Y_JJJ- -- --
FORM NO. EQ -016 -
GREATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY Case
3330 "C" Street
ANCHORAGE, ALASKA 99503
Performed For )C5„ 7lofrit'�ati _Dated Performed � 73
Legal Description: Lot k_ Bloc—Subdivision 17T_
This Form Reports Soils Log _Percolation Test;_
- Soil Test Must Be Logged To 4' Below Proposed Seepage System —
Depth
Feet Soil Characteristics
Q -s- - S UC)
S S - cl, t'
Was Ground Water Encountered?_ b _
If Yes, At What Depth?
Reading
Date
Gross Time
Net Time
Depth to H2O
Net Drop
reFcuiduiUn KdLL minucc
Proposed Installation: Seepage Pit Drain Field
Depth of Inlet_ __Depth to Bottomof Pit or TrencF--__
COMMENTS: /pS �` �� mer, ch ._ L'�� 7ii/� div- 'f" sr7`�n J[i,ro7n.,:
Test Performed BY1C Date Certified BY:_—_
Date:
EY'tPNS
MUNICIPALITY OF ANCHORAGE
Development Services Department \\ j Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 015-151-16
1. GENERAL INFORMATION
Expiration Date: 7 1 Zn 2
Complete legal description SOUTH LAKEWOOD HILLS #1 BLOCK 3, LOT 3
Location (site address) 6360 WOODMONT DRIVE, ANCHORAGE, AK 99516
Current property owner(s) GREGORY & KRISTINA CLARK Day phone
Mailing address
Real estate agent
6360 WOODMONT DRIVE, ANCHORAGE AK 99516
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
®
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 6:56 X010 S("
Date of Payment �Il3/ad2o
Receipt Number
COSA # 56b
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY ANCHORAGE AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 3/7/2020
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting & FWCS
6. DSD SIGNATURE
System #1 Approved for � bedrooms
System #2 Approved for bedrooms
Disapproved
• , •
• ' Curtis Huffman. .' +
% CE 128991 ,• c4`w`�.+�
/'ROFESSOO .
Conditional approval for bedrooms, with the following stipulations:
.�t�llttttf t((/s,,
WWASTEvVATER
J�
PROGRAM GRA
4�
B r. 1 Original Certificate Date: ^Z�
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
Legal Description: SOUTH LAKEWOOD HILLS #1 BLOCK 3 LOT 3 Parcel ID: 015-151-16
If more than 1 septic system on lot: COSA Checklist # _of
A. WELL DATA
® Well log is filed with Onsite (or attached)
Date drilled 1/1/1974
Total depth 81+ ft (Per acoustic readings)
Cased to 40+ ft (Per MOA docs)
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 10/2/2019
Static water level at beginning of test 68 ft.
Well production at time of test 4.9+ gpm
Comments
B. TANK DATA
Age of tank(s) 46 years
Tank type/material SEPTIC / CONCRETE
Measured operating fluid level in septic tank 107"
® Standpipes/foundation cleanout per record drawing
Date of pumping 1/21/2020
D. ABSORPTION FIELD DATA
Which system tested (date installed) 6/3/1974
® ALL standpipes present per record drawing
Total measured depth from grade 13.3 ft (max)
Measured depth to pipe invert from grade 6.8 ft (min)
❑ N/A — pressurized field (TOP OF CRIB)
Structure served by this system _
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ® No
® Coliform bacteria is Negative
Nitrate mg/L ® Nitrate less than MRL (ND)
Arsenic ug/L ® Arsenic less than MRL (ND)
WES
Collected by
Date of Sample 2/24/2020
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments: A+ pressure cleaned / pumped tank.
Adequacy test date 10/2/2019
Results N Pass For 4 bedrooms
Fluid depth prior to test 41 in
Water added 810 gal
New depth 61 in
❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 1350 min
depth into effective 6.5+/- (PER TOC TO BOC)
® Code -required soil cover over field Final fluid depth 37 in
® System presoaked Absorption rate 600+ and
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N
date of test)
Gallons introduced 2030 gallons If yes, enter date
Comments/Deficiencies: Existing trench was saturated — presoaked and tested crib. F
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
® Yes if No ft
Wells on Adjacent Lots:
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No
Neighboring Absorption Fields > 100'
Surface Water > 100'
® Yes
Animal Containment > 50' ® Yes
if No
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® Yes
if No
ft
® Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ® Yes if No ft Surface Water > 100'
ft
ft
ft
ft
I
® Yes if No ft
Property Line > 5'
® Yes if No ft
Wells on Adjacent Lots:
Absorption Field > 5'
® Yes if No ft
Private Wells > 100' ® Yes if No _
Water Main > 10'
® Yes if No ft
Community Wells > 200' ® Yes if No _
Water Service Line > 10'
® Yes if No ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
® Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® Yes
if No
_ ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' ® Yes if No —ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
l 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.
.. ....•..
.. .... .........�
• Curtis Huffman
r �`G'��,•. CE 128991 ..•4���
M
ft
4? (,c+
LunoDMnt.iT C)A.
r1
trit'
All
Div
Deo
S.f ?
Aftk. t7
3 m®spo
I&'vfeli7cY fi5i,*4*
Pipes visually identified / noted above appear to correspond with MOA record docs (IRs and
the diverter with an apparent CO installed in 2000 per PEG). Diverter / line to crib repaired
& tank jetted / cleaned by A+ Services. - First Water Consulting 3/30/2020
• s+ •a we a• ..wa w.waw�iw�w�r.
f ;• L Robert C -Johnson
!w
rf. • %l a. ttL'i�'5' oo ��
Td �� Fo. a a • �
M d
�+o A
.....�
A5 -BUILT
I hereby Certify that I have surveyed the following described
property- i aT 3. 81- f -e . 3 , s b 4,..
k9FWe, CrP 14& LLs 1-1
5.�. � :... 2?,; r I L M; R 3 u' a SM
Anchorage Recording Precinct, Alaska, and lha the improve-
ments situated thereon are within the property lines and do not
overlap or encroach on the property lying adjacent thereto, that
no improvements on property lying adjacent thereto encroach
on the premises in question and that thea are no roadways,
transmission tints or other visible easements on said property
except as indicated hereon.
Dated at Eagle River, Alaska
this 2`e--- L'' —day of _!vf!1 -., i t a
ROBERT C. JOHNSON
SCALE: Registered Land Surveyor No. 60-L5
Box 77-04%, Eagle River, Alaska 99577
Phone (907) 694.2543
Municipality of Anchorage
Development Services Department
Building Safety Division i
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. COSA# CSL/D 10 I
Expiration Date: 9 - 3- /O
1. GENERAL INFORMATION
Complete legal description Lot 3; Block 3; South Lakewood Hills Subdivision MI
Location (site address) 6=) Woodmont Dr. Anchorage, AK
Current Property owner(s) Bank of America Day phone
Mailing address
Lending agency Day phone
Mailing address
Real Estate Agent KathiOlmstead /Remax Day phone696-2209
Mailing Address
Unless otherwise requested, COSA will be held by DSO for pickup
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
4
TYPE OF WASTEWATER DISPOSAL:
R1
Individual On-site
IZI
❑
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
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 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 SSSEngineering Phone 694-2979
Address 15861 S. Birchwood Loop Ad. Chugiak. AK 99567
Engineer's Printed Name Robed A. Sharer
5. DSD SIGNATURE
✓ Approved for ___�L bedrooms.
Disapproved.
Date
.+
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: -L!• X11 �V I a -e* Original Certificate Date:
6-3-10
(Rev 11.05)
Municipality of Anchorage
• Development Services Department
Building Safety Division
Onsite Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519.6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:r! 04 3 , -'blk3 4' o,'L11 ` 115 *:' Parcel ID: O /S' IS / - / 6
A. WELL DATA
Well type �ak-e If A, B, or C provide PWSID # _
Date completed 1)/ 1111 7q Sanitary seal (Y/N) 4
Total depth Cased to 10 ft. F
FROM W�f LL LOG n
Date of test _ i/1 ]�fb
S1+a♦r iTvM
Static water level ur\�L'4y\ (t. ado
�'I is
Well production 9—
p.m-
WATER SAMPLE RESULTS: j
I l{�
Coliformy coloniesH00 mL Nitrated � `}� mg/L
r
Arsenic: l—qo 0<%9/L k date of sample) 10
S. SEPTICIHOLDING TANK DATA
,I
Tank Type/Material C 60AC fe\-e
Tank size QoOO gal. ! Number of Compartments
Well Log (YIN)
Wires properly protected (YIN) Y
Casing height (above ground) /8 in. t
AT INSPECTION
S o
6 ft.
x
6 . U g.p.m.
Other bacteria 0_colonies/100 mL
Collected by: S4 S C`iryiaePi%rf y
Date installed 6A/-14/
Cieanouts (Y/N)
t
Foundation cleanout (Y/N) Depression over tank
//(Y///N)�n High water alarm (Y/N)
Date of pumping Pumper fC7UrrIP, ) atl/l[ e' S I/ -J C-
C. ABSORPTION FI L DATA
Date installedI ,� 3 Soil rati
Length IL ft.
Total depth IZ ft. Eff. absorpti
I
Date of adequacy test S
ng {g.p.d./ft? ort2 r 'oo
Width IZ ft.
b
System type C'r't
Gravel below pipe _ ft.
on area Z6g ft' Monitoring lube
Results Pas Fail) L.SS
Fluid depth in absorption field before testa O in. Water added E �-gal.
Depression over field _61
For �L bedrooms
New depth in.
Elapsed Time: 170 min.Final fluid depth in. Absorption rate >= w g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) \ If yes, give date
Tt�vv�h !tf\S \�2d ir1 l�5'2. wc�S �W:1C �Z �Je Over Sckur�.Q.
T �ow �.4 xr vti\'v-e. �c.5 5;.v;� h.e.c� ��k 4-o pr•ire,c'stin� cc'.b ,
C2l3 TPrf<c� crr��1 ,o�srF�,
D. LIFT STATION
Date installed u Size in gallons
'Pump on' level at_ in._Pump eftevl
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
r
Septic tank/lift station on lot / oc i
Absorption field on lot .1Qn r4
Public sewer main Ai
r
Sewer /septic service line ZS f
Animal containment areas 501f
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots /yo f
in.
On adjacent lots (Od If
Public sewer manhole/cleanout A11111-
Holding tank /V
Manurelanimal excrete storage areas Ob CF
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation S �f Property line Absorption field f
Water main 1b rf, Water service line /U rfi Surface water /00'r
Wells on adjacent lots 06 17
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line �D �/ Building foundation /ler Water main /O rr
Water Service line Surface water /20 �f Driveway, parkinglvehicle storage /,57 /
Curtain drainAViV/` I N06WWells on adjacent lots led
F. COMMENTS
occ J r
G. ENGINEER'S CERTIFICATION +�•' •» '
I certify that 1 have defermine thro gh field inspectio and
review of Municipal records that f above syst yte.'
conformancewith MOA COS gui fres i 'eff to thiEngineer's Printed Name O' »•» •
i t A.ft
Date s. 14V4 {
COSA Fee $ L / Waiver Fee $
Date of Payment 5 �li Date of Payment
Receipt Number o� s y� Receipt Number
(Rev. 11/05)
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
ww%v.muni.org/onsite
(907)343-7904
Arsenic Advisory
Certificate of On -Site Systems Approval # 101061
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 3, Lot 3 of
South Lake Hills #1 Subdivision. This inspection revealed an arsenic
concentration of 19.5 micrograms per liter (ug/L) for the property's well
water sample. The Environmental Protection Agency (EPA) has established
a maximum contaminant level (MCL) of 10.0 ug/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. information on
arsenic is available from the On -Site Water and Wastewater Program
website (www.muni.or onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
L3 Go
lv c o pNt 01,J -r
fir,.. V'- •=t`4.O'Y\
qt
r ....NM•tl •«.w •.MN•IN
Robert C. Jotnson �w
PF ,.• NO. aCa-5�•�
•N i
AS -BUILT
1 hereby cejjtifYY that 1 have surveyed the following described
property: I- 6T 31 a L K. 3, S o u+ -L
1,Afe we, a p N t L L s sz 1 1
S_.Cf;�-,,z?,r It Ni R ? u,, 5A4
Anchorage Recording Precinct, Alaska, and that theimprove-
ments situated thereon are within the Property lines and do not
overlap or encroach on the property lying adjacent thereto, that
no improvements on property lying adjacent thereto encroach
on the premises in question and that there are no roadways,
transmission lines or other visible easements on said property
except as indicated hereon.
Dated at Eagle River, Alaska
2 D 1�+r a y /K 6�! Z G 1 a
this a of ROBERT C. JOHNSON � tom•
SCALE: Registered Land Surveyor No. 6LS
V-30 Box 77.0456, Eagle River, Alaska 99577
Phone (907) 694-2543
-S -GS,
SCS Ret.N
1102216001
Client Name
S & S Engineering
Project Name/a
L3,133 South Lakewood Bills NI
Client Sample ID
L3,I33 South Lakewood Hills 111
Matrix
Drinking Water
Sample Remarks:
Parameter
Results
LOQ
Metals by ICP/MS
05/19/10 0521/10
SCL
Arsenic
19.5
+ 5.00
Waters Department
0524/10
AYC
Total Nitmtc/Nitrite-N
0.148
0.100
Microbiology Laboratory
E. Coli
Negative
I
Total Coliform
Negative
1
Printed Date/rime 05262010 8:13
Collected Date/Time 05/182010 14:05
Received Date/Time 05/182010 14:30
Technical Director Stephen C. Ede
Allowable Prep Analysis
Units MOW Contaiw ll) Limits Date Date [nit
ug/L
EP200.8
C
(<10)
05/19/10 0521/10
SCL
mg/L
SN1204500NO3-F
13
(<10)
0524/10
AYC
100ml- SM20 92230 A
100ml. SM20 92230 A
05/18/10 DLC
05/18/10 DLC
A4.1nicipality of Anchorage
U 4j Department of Health and Human Services
Division of Environmental Services
On -Site Services Section 825 "L" Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www. ci. anchorage. ak. us
(907)343-4744
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING pp
Parcel I.D. 015-151-16 HAA #af} (Ma6(9
Expiration Date:
GENERAL INFORMATION 3
Complete legal description Lot 3 Block It South Lakewood Hills
Location (site address or directions) 6360 Wood mont Drive
Current Property owner(s) Matt & Maggie
Hansen
Day phone
346-8231
Mailing address 6360 Woodmont Drive,
99516
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DHHS for
pickup. HAA picked up by:
2. NUMBER OF 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 Sever
❑
The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Certificates of Health
Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent
professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required
for the transfer of title (except between spouses) on properties served by a single family on-site wastewater
disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of
Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C
well and may be reissued with new water sample results less than 30 days old. Certificates are valid for Dene year
for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is nct
resconslble for errors or omissions in the professional enginee s •-;•;crk.
Rog.?I, ?)
S STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below. I verify that my investigation
based on procedures outlined in the Health Authority Approval Guidelines for this Health Authority PApprovai
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 Municioality of Anchorage files and from my investigation and inspection, the on-
site water supply and/or wastewater disposal system is in compliance with all applicable Municipal and State
codes. ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Eng Svc Phone 272-8218
Address P.O. Box 102954, Anch, AK 99510
Engineer's Printed Name Steven R. Pannone, P.E. Date 6110/2000
0000�..oeQgo
o..,..z
. ^`-1 ..AN
..o
6. DHHS SIGNATURE o' - J ; '
Approved for bedrooms. ♦ApoY �. ,• ®�,��
Disapproved. ®�®so®oo®ewao®op
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisor/
Maintenance Agreements
Supplemental Engineer s Report x
Other
By: G Original Certificate Date:
Exciration Date:_ C -- q - O d Reissue Date:
�ttcility of Anchorage
Department of Health and Human Services
Division of Environmental Services JUN 12 2000
On -Site Services Section 825 "L" Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650 MUNKAVAuly yr Arv�HvXA h
www.ci.anchorage.ak.us IlpnNMENTALSERVICESINVIT
(907)343-4744
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 3. Block 3 South Lakewood Hills S/D Parcel I.D.: 015-151-16
A. WELL DATA
Well type PRIVATE
Date completed 1/1/1974
If A, B, or C provide PWSID #
Sanitary seal Y
Total depth UNKNOWN ft Cased to 40+ ft
FROM WELL LOG
Date of test 1/1/1974
Static water level UNKNOWN ft
Well production UNKNOWN g.p.m
WATER SAMPLE RESULTS:
Coliform& colonies/100ml Nitrate0a6tlbmg/I
Well Log N
Wires properly protected Y
Casing height (above ground) 18 in.
AT INSPECTION
6/7/2000
73 ft
5.0 g.p.m
Other bacteria -0- colonies/100 ml
Date of sample: 6/7/2000 Collected by: S.R.PANNONE
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material CONCRETE
Date installed 6/3/1974 Tank size 1300 gal Number of Compartments 1
Cleanouts Y Foundation cleanout Y Depression over tank N High water alarm
Date of pumping 5/19/2000 Pumper iSSAACS
C. ABSORPTION FIELD DATA
Date installed 6/3/1974 Soil rating (g.p.d./ft2 or ft2/bdrm) 85 System type CRIB
Length 14 ft Width 12 ft Gravel below pipe 9 ft
Total depth 12.7 fl Effective absorption area 468 ftz Monitoring tube Y Depression over field N
Date of adequacy test 6/7/2000 Results (Pass/Fail) PASS For 4 bedrooms A&.72
Fluid depth in absorption field before test 60 in Water added600 gal. New deptl;*f in.
�oea
Elapsed Time: 1440 min Final fluid depth`sPin Absorption rate >= 600 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
(Rev. 11199)
If yes, give date
D. LIFT STATION
Date installed Size in gallons
"Pump on" level at._ in"Pump off' level at
Datum
E. SEPARATION DISTANCES
Cycles tested
Manhole/Access-
-
in High water alarm level at in
Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 105 On adjacent lots 100+
Absorption field on lot 100+
Public sewer main
Sewer /septic service line 100
On adjacent lots 100+
Public sewer manhole/cleanout N/A
Holding tank 100+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5 Property line 50 Absorption field 25
Water main N/A Water service line 75 Surface water 100+
Drainage 100+ Wells on adjacent lots 100+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 20 Building foundation, 85 Water main N/A
Water Service line 100+ Surface water 100+ Driveway, parking/vehicle storage 35
Curtain drain `60 -� Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
i certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Steven R. Pannone, P.E.
Date 6-10-00
HAA Fee
Date of Payment
Waiver Fee $
Date of Payment
Receipt Number � / �< 44 �'C� Receipt Number
(Rev. 11/99)
d9T11
cc� 'A
;Steven I:.
I'onnone. 41
Prnnnne Engineering Services, LLC P.O. Box 102954
Consulting Engineer Anchorage, Alaska 99510
(907) 272-8218
SEPTIC SYSTEM ADEQUACY TEST
_4s OF q�'
Legal:
Lot 3, Block 3 South Lakewood Hills S/D,
4 `�,o' •:.v s
49TH
Owner:
Mr. Matt & Maggie Hansen
o ♦
..
Residence:
6360 Woodmont Drive, Anch. AK 99516
0........
0 0
No. of Bedrooms:
Four (4)
♦�" :StP P:
Septic System:
Tank Size: 1250 gallons.♦♦#
_* No. CE alas
��: F els ..•�:
♦#Absorption
System Type:
soy op ••••
Absorption System Size: 59'x5'x2Ciib xl4'x9'
Bei. w��o
Absorption Area: 421/468 s.f. Installation Date:
6-17-82/6-3-74Soi1 Rating: 85 sf/br
Date of Pumping:
5-19-00 By: Issaacs
Date of Test:
6-7-00
Test Procedure: System was inspected visually and measured. The tank was found to have 4 feet of
cover. Liquid depth was measured to be 50 inches. The 5 -wide drain field was found to have 31 inches of
cover and a total depth of 55 inches. There was 29 inches of liquid measured in the field's monitor tube.
The 50wide trench was found to be in failure. The original crib was found to be connected to the five wide.
It has 44 inches of cover and there was 60 inches of liquid in the crib. Water was added from the well at a
rate of five gallons per minute (GPM) into the cribs clean-out.. Liquid depths were measured in the monitor
tubes. The liquid levels rose 12 inches in the monitor tubes with the induction of 600 gallons of water into
the drain field. After the water was turned off, the liquid level returned to the original level within 1440
minutes. This system is able to absorb 600 gallons per day. A diverter valve is being installed between the
two fields.
The well was tested in conjunction with the septic system. The static water level in the well was measured
to be 73 feet below the top of the casing. The water level in the well was drawn down to 83 feet below the
top of casing while the pump produced 5.0 GPM. It appears that the well is able to produce greater than 5.0
GPM. The water was tested for bacteria and nitrates. The test results were not available at the time of this
writing, but will be forwarded when received.
TEST RESULTS: This system meets the code and operational requirements of Municipality of Anchorage,
Department of Health and Social Services for a four (4) bedroom house.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the
system in accordance with ADEC and MOA DIMS Guidelines & Regulations. The reported results describe
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 soil condition, ground water 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
this system. All systems eventually fail and satisfactory test results do not guarantee future performance of
the system, nor do they guarantee that there are no hidden defects or encroachments. PES can therefore not
provide any warranty for future performance nor give any estimate of how long the system will continue to
meet the operational requirements of the ADEC or MOA DHHS. The content of this report is for the sole
benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not
authorized nor will it confer any legal right whatsoever.
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.U. #
1. GENERAL INFORMATION
1z4-5
HAA# _ «OBI _-
Complete legal description Lc5T 3�• Soo -r-14 I-AKE. wooer_
9-, LL c s JT
Location (site address or directions) 623 too woc-, moa-T—a)?- -
Property owner Mst4 M&S lou kRQiF� JEA'22P-T+- Day phone
Mailing address6 3/0[ w 501 MON —� "tJ2- I LAAJCA A K
Lending agency _
Mailing address --
Agent —
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: —4-
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
Day phone
Day phone
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank —
Community on-site
Public sewer
t
NOTE: If community wastewater system, provide written confirmation
from State ADEC
attesting to the legality and status of system.
72-025(Rev.1191) Front MOAk21
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 ST_P—v6—�na Q27 A u,uoN0 ' P. E Phone
Address P-o.%oY /412.oz5- 4 An/c(� AK 99S/q
Engineer's signatur Date
6. DHHS SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
I
Steven R. Pannone
J CE -8749
:C....,
Vn«.
� PR0FE—F: ()0"
bedrooms, with the following stipulations:
Date � - 3 - 9s
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval C4rtificates. ased only upon the representations given in paragraph 5 above by an independent
prof@ssional eng`g6et registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and'thefr`dending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA M21
Municipality of Anchorage
ON Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:_ Q3 S•LAKsWgPD /( LS Parcel l.D. ol.S– /Sl -/6 —_
A. Well Data
Well type If A, B, or C, attach ADEC letter. ADEC water system number_
e
Log present (Y/N) >-+o Date completed _may --Driller a Ic,u
Total depth _Ir �o Li (0 --Cased to _ Y 0 Casing height
Sanitary seal (Y/N)
FROM WELL LOG
Date of test 0N1c.00wn
Wires properly protected (Y/N)
Static water level
Well flow—9-P.M.
Pump
Pump levell
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot / o o rt
AT INSPECTION
6uS�*
aj_
°
------
.z.
5-'-'..
>
r r t
3, O
g.p.m. r�31�
r
--
J:
UNl��ov>nJ•
`� -
����
n o
«3
W
ry
cn
(,
e7 ni
aD
( m
On adjacent lots
i v b
Absorption field on lot _moo a -I ; On adjacent lots /00
Public
voPublic sewer main --_Public sewer manhole/cleanout N(A _
Sewer service line _ N —_Petroleum tank _— N rda —_
WATER SAMPLE RESULTS:
Coliform o —
__ C9 -- Other bacteria -- C7)
Date of sample: -a —Z3 —a S —Collected by: _S • 05 w A z -r . —_
S. SEPTIC/HOLDING TANK DATA
Date installed l0J 'i�u Tank size _ l3 0d —_Compartments
Cleanouts (Y/N) _ Y -Foundation cleanout (Y/N) _ ` _Depression (Y/N)
,�I z7
High water alarm (Y/N) —V-- Alarm tested (Y/N) /YM —_
Date of pumping _ L -'L U -9 S- Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
r
Well(s) on lot /CC) —_On adjacent lots _ / oo,f --Foundation -!S-
To
To property line _ Zc�> Absorption field =So ` —_Water main/service line
Surface water/drainage /00 ��--
72.026(9/99)• Front CONTINUED ON BACK PAGE
C. LIFT STATION /
Date installed �` Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
"Pump off" Level at
tested
On adjacent lots Surface water
Date installed Q Z Soil rating (GPD/Ft) /v,5- SF—A Yz- System type L000-rrzalucO
Length -,!5- 4 Width S Gravel thickness Z Total depth S4 "
Total absorption area G(Z Cleanout present (Y/N) Depression over field (Y/N) ti
Date of adequacy test 7Z—ZS--9,S__ Results (pass/fail) SASS for 4 Bedrooms
Water level in absorption field before test ac, " After test
Peroxide treatment (past 12 months) (Y/N) If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /C:?o -_t- On adjacent lots /00 rt Property line
/o /
To building foundation 6 C) To existing or abandoned system on lot Z f
On adjacent lots y 0o * Cutbank "& Water main/service line Nlul
Surface water Z. oc7 Driveway, parking/vehicle storage area / o r t -
Curtain drain V ZA
E. ENGINEER'S CERTIFICATION
I certify that l have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
.F: -�a.� 1. �_✓}`° J} si�r
Signature _
Engineer's Name S7—EVE_,�4 Yf�AA NONE T. El -
Date Z- Z8-95
HAA Fee $ �3 DD 1 OD Waiver Fee $
Date of Payment 'S r/_196.._
Receipt Number 712 ( N,
72-026 (3/93)' Back
y?. x Steven R. Pannon®,f
c�
="' CE -0149
J
Date of Payment
Receipt Number
CT&E Environmental Services Inc.
'AA Laboratory Division ►iosir�iyiiriiuri►iisi��
C. 95.0733-1 �.�oratory Analysis Report
Client
SamSample ID L3 BLK3 S LAKEWOOD
Matrix WATER
Client Name PANNONE ENG SRV. WORK Order 12836
Ordered By Printed Date 02/27/95 N 11:28 hrs.
Project Name Collected Date 02/23/95 M 09:43 hrs.
Projectff Received Date 02/23/95 Q 11:15 hrs.
PWSID UA
Technical Director STEPHEN C. EDE
Released
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: S. OSWALT
*
See Special Instructions Above
QC
= Unavailable
**
Allowable
Ext.
Anal
TV =
Parameter
Results
_________________---______-__
Qual
Units
Method
Limits
Date
Date
Init
Nitrate -N
0.10
U
mg/L
__
EPA 353.2
___
10.
_
_
02/24/95
CMR
*
See Special Instructions Above
UA
= Unavailable
**
See Sample Remarks Above
NA
= Not Analyzed
TV =
Undetected, Reported value is the practical quantification limit.
LT
= Less Than
D,,=
:n
Secondary dilution.
GT
= Greater Than
200 W. Potter Drive, Anchorage, AK 99518.1605 — Tel: (907) 662-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA
--" �-- ----
T,
--- '-------
Time ae
Date —
Dale — _ -
Date
Inspector - Inspector
Inspector
Comment .-��- —
Conditional Approval
pp�
V= '1
MU4CIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
f
EiNVIRONMENTAL PkOTECTION-
U
1981
RECEIVED
by
AL
_
Data s w Installed - Permit No.
Sepllc'Fank Slze
Holding Tank Size
---
Solis Rating --
Well To Absorption Area
Well Log Received
- -
Well to Tank -
APPLICANT FILLS OUT LOINER HALF ONLY
Property Owner D F•(—t R,(=( MT=1
-
-
Mailing Address
Beyr.�F(—
Address -
Lending Institutlon���7—tFkO i1-- —e
Phone—
Address N,->af i � ( -( L.(� -i_. C S 3 / 1119 C! .S d 3—
ReallyCo.&Agent 2( i
Phone
zti:3 3
Address W5 *(. r(C. U1c.S gjzo
Legal Description (,c>
Street Location V� \ Y LbCjo
Typgqof,�..Rasidence. t—�---�-0�—
.�`single Family
❑ Multiple Family No. of Bedrooms
❑ Other
Wa(-r Supply ®—---�—��---
- X Individual ATTACH WELL LOG. A well log Is required for all wells drllled since June
--❑ Community 1975. For wells drilled prior to that date, give well depth (attach log If
�❑ Public Utili�available.)
Sew Disposal
Indlvidual - Year Individual Installed: _ _ -
❑ Public Utility When Connected to Public Utility:__
❑ Holding Tank
NOTE: THE INSPECTION TEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
(Li
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ALASKA CnUIROWnTAL COnTROL SCRUIUS, IX
Engineerinq & Enuironmental Studies
December 4, 1981
Department: of Health & Environmental Protection
825 L. Street
Anchorage, Ak. 99503
Attn: Les Bucholtz
Dear Les:
On December 3, 1981 I .inspected the well and took a water
sample for .loan approval for L3 B3 South Lakewood Hills #l.
The results of the bacterial test for the water is attached.
It was satifactory. The well has a seal and is approximately 1
ft above the ground level.
The sewer system has caps on all standpipes
Sincere
E:
, PhD, PE
L" C. Row, Jr.
- 140. 2251•E .,a
2
«A. 1�J. �(1,V
1220 West 25th Auenue • Anchorage, Alaska 99503 • 907) 276-1361