HomeMy WebLinkAboutNORTH WOODS UNIT 3 BLK 12 LT 4Northwoods #3
Lot 4
Block 12
#051-732-13
Municipality of Anchorage Page 1 of 3
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
Permit Number: SW000423 PID Number: 051-732-13
Name: CINDY RODASKY
Wastewater System: ❑ New ■ Upgrade
Address:
22927 GREEN GARDEN DRIVE CHUGIAK, AK 99567
ABSORPTION FIELD
Phone:
No. of Bedrooms:
(907) 694-1383
4
■ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other
LEGAL DESCRIPTION
Sall Rating:
0.6
Total Depth from original grode:
9.5 — 10.0
GPD/Sq.
Ft. a
Lot: Block: Subdivision:
Depth to pipe bottom from original grade:
G-val depth beneath pipe:
4 12 NORTHWOODS #3
1.34 — 1.84
Ft. 8.16 a,
Township:
Range:
Section:
Fill added above original grade:
Grovel length:
—
—
—
1.0 — 1.5
Ft. 63 Ft.
WELL: ❑ New El Upgrade
Grovel width:
2.5
Number of lines:
1
Dietanca be linea:
—
F<
M
Classification (Private, AB,C): Total Depth:
sed To:
Total absorption area:
Pipe material:
\ Ft
Ft.
1028 So. Pt
ASTM D -3034/F-810
Milan Data DAA:
StaSa Water Level:
I
Installer.
GREEN GENERAL
Data installed:
10/16-17/00
PL
Yeld:
I
Pump Set Al:
Cooing Height Above Ground:
TANK
DPM
Ft.
SEPARATION
DISTANCES
■ Septic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer.
ANCHORAGE TANK
Capacity in gallons:
1250
From
Tank
Field
Station
Tank
Sewer linea
Well
200'+
200'+
—
—
25'+
Motedal. STEEL
Number of compartment:
2
Surface
Water
100+
100'+
—
—
—
LIFT STATION
Lot
5'+
10'+
—
—
—
Size in gallons:
M
Manufacturer.
Line
5'+
10'+
'Pump on' level at: 'Pump off
High water alarm at:
Foundation
—
—
—
Curtain
IPump
Maka
feij;
Electrical Inepecaone performed by:
Drain
NONE KNOWN
Remarks:
BENCH MARK
Location and Deecripb'on:
BACK DOOR THRESHOLD
Assumed eevation:
108.01
pt
ENGINEER'S S
000boo 04
OF
000 �F- <�s�o0
AWWC, INC.
'.
Inspections performed by: Dates: list 10/16/2000
• .. ......• ...,`..*,�. V
2nd 10/17/2000
D
QOA..•...nes5:
0�9, ' E-7953
Department of Health and Human Services approval
, m p
�o
Reviewed and approved by: Date: /4 %Z �'O
�4p"dP • s • a�F ��
rofessioo 0
72-013 Rev. 9/91) MM 25
[SW000423 AS -BUILT DRAWING PARCEL05511732-13 1
OLD
THIS UPGRADE IS
DESIGNED FOR A FOUR
SITE BEDROOM HOUSE.
NEW DRAINFIELD
EXISTING DRAINFIELD USED
AS A RESERVE SITE
NEW 1250 GALLON
SEPTIC TANK
For FG lbJO"p
INSTALLED FLOW DBL2
DIVERTER (FD) DNL1
a'
b .
NOTE: EXISTING SEPTIC TANK
WAS COMPLETELY ABANDONED
E
00 GPO
�lttAff' ' DRAWN BY: Yvl• •• ••, 'y
ALASKA WATER & WASTEWATER C.J.G. SSV
CONSULTANTS, INC SCALE:' Q * 4
:.a
..... ................
6901 DEBARR ROAD, SUITE 2B - ANCHORAGE, AK 99504 - PHONE (907)337-6179 - FAX (90])338-3246 1 = 3D :
PREPARED FOR: PHONE NUMBER:
CINDY RODASKY (907) 694-1383
LEGAL DESCRIPTION:
NORTHWOODS S/D #3; LOT 4, BLOCK 12,
TYPE OF WORK:
AS -BUILT DRAWING OF SEPTIC SYSTEM UPGRADE
2 OF 3 u0 "e r ess;
QQ @ 7953 k,,'
nwe�_ •• cP��
PERMIT NUMBER: AS—BUILT DRAWING PARCEL ID NUMBER:
SW000423 051-732-13
iINN. ueAnE - 10639-106,77
511itIN5U-AiI0N
IR� ISg�forOF
Ai Vf - � 5� ' �--� Af OUll r 02,56
IM7EKf OF PM -
Ai NUrf - 102,03
MC41 N- GPADE-
- 96,40-96,90
NM 1250 6& ON
5�M fANK
DOfTOM OF ffa NCYI
- 66,90(AVG.)
`-if,NERf OF f1lBJl
AiODfLEi- 10198
— FINN. CvpAt7E
5GUffA5f END - 97,59
NOR(FEA5i ENG - 96.46
SOIIIIN'151 END Gf
1i�Ngi WA5IW5U Atv
- IM/ERr Or PIPE
95.06 (AVG.)
DATE:
F
10/20/2000
` �� ♦� DRAWN BY:
ALASKA WATER & WASTLA NVA'r R SCALE: C.J.G.
..... CONSULTANTS, INC.-- -X11,-1
6901 OEBARR ROAD, SUITE 213 • ANCHORAGE, AK 99504 • PHONE (907)337-6179 • FAX (907)3383246 N.T.S.
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
CINDY RODASKY (907) 694-1383 1 3 OF 3
LEGAL DESCRIPTION:
NORTHWOODS S/D #3; LOT 4, BLOCK 12,
TYPE OF WORK:
PROFILE AS—BUILT DRAWING OF SEPTIC SYSTEM UPGRADE
.....
.................
A. Garness;
—7953 `AG
Lrw
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services ❑/l /� I ^ �
On -Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ONSITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Oct 05, 2000
Expiration Date: Oct 05, 2001
Permit Number: SW000423 Parcel ID: 051-732-13
Legal Description: NORTH WOODS UNIT III BLK 12 LT 4
Design Engineer: 0041 AK Water & Wastewater Consulta Site Address: 022927 GREEN GARDEN DR
Owner Name: CINDY RODASKY Lot Size: 27000 SQ. FT.
Owner Address: 22927 GREENGARDEN DRIVE Total Bedrooms: 4 Permit Bedrooms: 4
CHUGAK , AK 99567 -
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. 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 ( 18AAC80 ).
3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 ( 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.
Received By:
Issued By:
Date:
Date: /0 -.r-00
ALASKA WATER F& WASTEWATER
CONSULTANTS. INC.
September 8, 2000
Municipality of Anchorage
Department of Health & Human Services
Division of Environmental Services
On -Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: Septic Upgrade Design for Northwoods Subdivision #3; Lot 4, Block 12.
To whom it may concern: ii
COInmufllTl{
The existing 3 bedroom house is currently served by a mate we l and septic system. The septic
system is in a state of failure and in need of an upgrade. One test hole was excavated on the
northern half of the property. The proposed septic system will be designed within this 30 foot
radius. The homeowner requests we design a system for a four bedroom house. We are proposing
that a 1250 gallon septic tank and a deep trench type drainfield be installed. Comments regarding
the proposed design are summarized as follows:
1. SOILS: See the attached logs which shows the soil classifications, groundwater monitoring,
and the percolation test results. It is our opinion that due to the overall appearance of the soils, an
application rate of 0.6 gallons/day/ft2 should be used.
2. TRENCH DESIGN:
a. Percolation Rate: 15 minutes/inch
b. Allowable Application Rate: 0.6 gallons/day/ft2
c. Number of Bedrooms: 4
d. Design Flow: 600 gallons per day
e. Minimum Absorption Area: 1000 ft2
f Total Depth: 10 feet (max.)
g. Effective Depth: 8 feet
h. Width: 2.5 feet
i. Reduction Factor: N/A
j. Minimum Length: 63 feet long
k. Effective absorption area = 1008 ft2
3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed
upgrade.
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
4. TOPOGRAPHY: The proposed septic area is generally flat; in short, there are no slope
concerns.
I am unaware of any adverse impacts this installation would have on adjacent wells or septic
systems. If you have any questions, please contact me at 337-6179. Thank you for your
assistance.
E., M.S.
NOTE: Attached is a site plan drawing, a design drawing, one soil log, and a 7 page
construction specification letter which are all part of the design package for this septic system.
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
LOT 17, BLOCK 1 J /!
NORTHWOODS S/D / J!
J !!
LOT 16, BLOCK 1
NORTHWOODS S/D
l
l
LOT 15, BLOCK 1
NORTHWOODS S/D
/ It
ALTERNATE
! ! NORTHWOOD$ S/D #3
/ !! LOT 3, BK 12,
1
/ PROPOSED SEPTIC
/ UPGRADE. SEE DESIGN
/ PAGE 2 OF 2 FOR
! DETAILS.
! NORTHWOODS S/D #3
LOT 2, 12,
�T
NORTHWOODS S/D #3
LOT 1, BK 12, I
ALL PROPERTIES SHOWN
ARE SERVED BY A
PUBLIC WATER SYSTEM
z< NORTHWOODS S/D
LOT 7, BK 12,
NORTHWOODS S/D #3
LOT 6, BK 12,
NORTHWOODS S/D #3
LOT 5, BK 12,
. EXISTING SEPTIC
/
/ X
/
/
NORTHWOODS S/D #3
/ LOT 4. BK 14,
-------------
/
/
NORTHWOODS S/D #3 NORTHWOODS S/D #3
r LOT 6, BK 14, LOT 5, BK 14,
I
ALASKA WATER & WASTEWATER
CONSULTANTS, INC
9/8/2000
C.J.G.
PREPARED FOR PHONE NUMBER: IPAGE NUMBER:
CINDY RODASKY (907) 694-13831 1 OF 2
LEGAL DESCRIPTION:
NOTHWOODS S/D #3, LOT 4, BLOCK 12,
OF WORK:
SITE PLAN FOR DESIGN OF SEPTIC SYSTEM UPGRADE
A. bgtness:
-7953 mi
a
..........
llwl zpro fes SIO(It
I
DRAINFIELD.
8
ALTERNATE SITE EXISTING DRAINFIELD TO BE
USED AS A RESERVE SITE.
0
TH#l�
INSTALL FLOW
DIVERTER (FD)
THIS UPGRADE IS
DESIGNED FOR A FOUR
BEDROOM HOUSE.
NOTE: THE CONTRACTOR MUST HAVE THE
SOUTHWESTERN PROPERTY LINE FLAGGED
BY A REGISTERED LAND SURVEYOR PRIOR ..
TO ANY CONSTRUCTION.
Aze
DRAWN BY:
ALASKA WATER & WASTEWATER C.J.G.
CONSULTANTS, INC - - = a=„ SCALE;
6901 DEBARR ROAD SUITE 28 • ANCHORAGE, AK 99504 • PHONE (907)337-6179' FAX (907)3383246 1 = 30
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
CINDY RODASKY (907) 694-1383 2 OF 2
NORTHWOODS S/D #3; LOT 4, BLOCK 12,
OF WORK:
DESIGN OF SEPTIC SYSTEM UPGRADE
OF
V
y Gayness;'•••
CE.953 m�
.... ''i oOj\oG
ALASKA WATER & WASTEWATER CONSULTANTS, INC.
SOIL LOG — PERCOLATION TEST
LEGAL DESCRIPTION: NORTHWOODS SUBDIVISION #3; LOT 4, BLOCK 12
PERFORMED FOR: CINDY RODASKY
DATE PERFORMED: 9/6/2000
DEPTH ���� ORGANICS TEST HOLE 1
(feet) ����-
oo°o
.' o0o GW/SW
2 SOIL CLASSIFICATIONS
5
6
7
8
9
10
11
12
13
14
15
16—al
17
B.O.H.
18-
19-
20—
COMMENTS:
81920COMMENTS:
GM/SM/ML
EBio;=
GW
GP
_
ORG
ML
!%�`;'i+,
9/7/00
GM
9/14/00
CL
Z'
GC
OL
o°° o
op
SW
SP
MH
CH
.!;I.-
3:00
SM
6"
OH
SC
3:30
30
DEPTH TO
GROUNDWATER
DATE
DRY
9/6/00
DRY
9/7/00
DRY
9/14/00
FT. AND
7.0
SITE PLAN
I" -
100'
NORTHWOODS S\#3
LOT 5, BK 12,
TH#1+ n
i
v �
DATE
READING
CLOCK
TIME
I NET TIME
(MINUTES)
WATER LEVEL
I READING
NET DROP
(INCHES)
9/7/00
PERC. HOLE WAS PRESOAKED 4+ HOURS PRIOR TO TESTING
FT. AND
7.0
FT.
1
3:00
—
6"
—
2
3:30
30
3 3/4"
2 1/4"
3
3:30
—
6"
—
4
4:00
30
4"
2"
5
4:00
—
6"
—
6
4:30
30
4"
2"
PERCOLATION RATE
15
(MIN./INCH)
PERC.
HOLE DIA.
6 (INCHES) I
TEST RUN BETWEEN
6.5
FT. AND
7.0
FT.
PERFORMED BY ALASKA WATER & WASTEWATER. I, JEFFREY A. GARNESS, CERTIFY THAT THIS
WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON
DATE:
MUNICIPALITY OF ANCHORAGE(:D
MO $ r $3 L�
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
` 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAMEc
PHON E
EW
cc
�IcVJ
.Se S
�Qj �j�p
❑UPGRADE
MAILING AD KESS
P _
Po Boy, Owcrra. Ar- qq
LEGAL DESCRIPTION
Nor -t woojs 13 lot -le 1 2 Lot -
LOCATION
�—
NO. OF EDR00
DISTANCE TO:
Well Y
Absorption area
Dwelling
1 D
PE MIT NO. 11
vaA A j1A
L)
cc, M /h. 1�.2,(�
�}
q
F -Z
W�
Manufacturer
Giree�
Material
No. of compartments
she
7—
w
Liq. capacity in 6,gallons
10
IF HOMEMADE:
E:
Inside length
Width
Liquid depth
Y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
JC)Z
0 FQ-
Manufacturer
Material
Liquid capacity in gallons
0
-u=
DISTANCE TO:
Well
L.�'nOrt1 1'
Foundation
•� y.
Nearest lot line
ZU
PERMr1T NO. ,
w
{'�tto��'k!!t 7
-j U. Z
No. of lines
Length of each line
Total length of lines
'16
Trench width
Distance be en lines
F z w
12 i2 '24 2 'L
8 i( inches
F
Top of tile to finish grade r
Material beneath tile
Total effe ' e absorption a ea
O
"- 5 rte-
inches
S O
Length
Width
Depth
PER T NO.
LU
(7
a F-
LU
Type of crib
Crib diameter
Crib depth
Total effective absorption area
LU
DISTANCE TO:
Well
Building foundation
Nearest lot line
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
3:
rDISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATINGI
G
INSTALLER
S+e� c S lL� S 9S� a�
Zo
REMARKS
'i
o
0
S+4 crs
I9+io
dJ +e1sJqv�j — a
�/,//64" l=�7~of,"e�f''i
4 Recvc/
1104014( IC�tO !/C.
APPROVED DATE LEGAL
6 /25W Nor h-voud .l1A
11 t_.
o -u is Vsev. 151Id)ff -
I in C-tNY r� A 11a1 1 A /A -C Q
Permit_
Applicant:
Location:
MUNICIPALITY OF ANCHORAGE
Department�f Health and EnvironmentT�Protection
825 Street, Anchorage, AK. j9501
264-4720 4441A -40r,
# # # HANDWRITTEN PERMIT
A�IBAR ON-SITE SEWER PERMIT
Mailing Address:
Legal Description: 4U
Type of Soil Absorption System Is:
Trench:_ Drainfield:
Maximum Number of Bedrooms:
Number:
Lot Size:
f /SK r. l IV St.c y
Seepage Bed: Holding Tank:
Soil Rating(sq.ft/br) (9"0
The Required Size of the Soil Absorption System Is:'
DEPTH LENGTHLS
_ GRAVEL DEPTH / WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE _ GALLONS # #
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve. '
* # * TWO(2) INSPECTIONS ARE REQUIRED # #
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer .line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
# # # PERMIT EXPIRES DECEMBER 31, 1 9 3 3
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more tha 3 bedr o s.
Signed: Issued by:
Applic nt
Date:
SWP/024(1/81) C
r ` ^� ❑ SOILS LOG
1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: =��� �• �J'eA&'"S C0 It 4.2— DATE PERFORMED: rd'. egg
LEGAL DESCRIPTION:~
SLOPE SI E PLAN ?
(FEET)
1
Mt— 5 , �� •TPS«-
2 =�o �-�+— -r5 !gal
3-
4-
5-
6-
7 45 67
8-
91011 9-
10-
11
12-
13-
14-
15-
16-
17-
is-
19 -
20
21314151617181920
COMME
St
�AruA •qtr t•tsa r�@��c.�-b
WAS GROUND WATER S
ENCOUNTERED? L
O
/p Or
OF At
* f49TH : 4
l000® oe am "e�®ee. we
eA a Russell L. Ciys1.r
sG"w No. 4286-E
P
IF YES, AT WHAT - E
DEPTH?
J
❑M
4*
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
0
--
.7 -1/1
._ .
•30
gee 7
2 74„
"-1 3
&6
2 0
��
X4 „
-��
'40
PERCOLATION RATE ! a (minutes/inch)
TEST RUN BETWEEN "� FT AND �, -,b. FT
PERFORMED BY: '^^ CERTIFIED BY:
11
DATE: -4—!.3 %
Certificate of On -Site Systems Approval
Parcel I.D. 051-732-13
Legal description North Woods #3 Block 12 lot 4
Site address 22027 Green Gardens Dr
Current property owner(s) Hawn
Expiration Date: 9-21-2023
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
By:
Original Certificate Date: JD3
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory X Arsenic Advisory
Other
COSA Approval_June 2022
MUNICIPALITY OF ANCHORAGE
I_
Development Services Department �� Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 05173213
Complete legal description NORTH WOODS UNIT 3BLK 12 LT 4
Location (site address) 22927 GREEN GARDEN DR
Current property owner(s) HAWN CATHERINE
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
Day phone 242-5276
3. TYPE OF WATER SUPPLY: ❑ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑■ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑N Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑■ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 22 yrs - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑■ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ 5--6
Date of Payment gLa3 /aria a
COSA # 13 S C a 21(l y
Waiver Fee $
Date of Payment
Waiver #
COSA Application—June 2022
COSA Checklist
Legal Description: NORTH WOODS UNIT 313LK 12 LT 4
Parcel ID: 05173213
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Comments
B. TANK DATA
Measured operating fluid level in septic tank 50
Date of pumping 10/10/22
❑ Required maintenance completed, if AWWTS
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 10/17/00
❑ ALL standpipes present per record drawing
Total measured depth from grade 12 ft (max)
Measured depth to pipe invert from grade 4 ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
F1111 Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced 1000* gallons 9/21/22 date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Well production at time of test gpm
Water storage tank volume 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)
Collected by
Date
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 9/21/22
Results 0 Pass
Fluid depth prior to test 40 in
Water added 600 gal
New fluid depth 50 in
Elapsed time 30 min
Final fluid depth 42 in
Absorption rate 600 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 97.9 in
Effective depth used 42 in
Effective depth remaining 55.9 in
Comments/Deficiencies:* 1000 gallons introduced 9/20/22, 2000 gallons total
COSA Checklist June 2022
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or it community well on lot)
Septic Tank/Lift Station on Lot > 100'
[E Yes if No _ ft
Field to Property Line > 10*
Community Sewer Manhole/Cleanout > 100'
OYes
if No
ft
0 Yes-
if No ft
Neighboring Tank > 100' [] Yes
ifNo_ft
Private Sewer/Septic Line > 25' [] Yes
if No _ ft
Absorption Field on Lot > 100' 0 Yes
if No
ft
Holding Tank ?: 100' []Yes
if No ft
Neighboring Absorption Fields > 100'
Animal Containment > 50* n Yes
if No ft
0 Yes
if No
ft
Manure/Animal Excreta Storage> 100'
Community Sewer Main > 75' []Yes
if No
ft
MYes
if No ft
n N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10' g Yes if No ft Surface Water> 100' FE] Yes if No ft
Tank to Property Line > 5'
[E Yes if No _ ft
Field to Property Line > 10*
rol Yes if No ft
Water Main > 10'
]Yes if No ft
Water Service Line > 10'
@] Yes if No ft
F. ENGINEER'S COMMENTS
* Tank>5'
Wells on Adjacent Lots:
Private Wells > 100'
Community Wells > 200'
1 7W Yes if No ft
ffl Yes if No ft
If tank or field is under driveway comment below
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Finn NorthRim Engineering Phone 694-7028
Engineer*s Printed Name — Steve Eng Date 9/20/22
OF
stow Eng
CE -.0w
2 0 r -j --r d-
COSA ChecklisLJune 2022
Septic Tank Advisory
Certificate of On -Site Systems Approval #OSC 221473
Subdivision: North Woods #4 Block 12 lot 4
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this COSA / property is 22 years old. A leaking septic tank may be a source of contamination to
the aquifer. Typical replacement costs range from $10,000 to $15,000
This advisory must be attached to all copies of the subject Certificate of On -Site Systems
Approval.
This is an example of a 16 -year-old septic tank in failure and should be replaced.
Ma�lmg Address P O Box 196650 *Anchorage, Alaska 99519 6650 *,www muni org
Municipality of Anchorage
Development Services Department _
Building Safety Division
On -Site Water and Wastewater Program
s E„
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FORA SINGLE FAMILY DWELLING
Parcel LD. 051-732-13 COSA # o SC 1,A 1391
22�r G 1
Expiration Date: Ll
1. GENERAL INFORMATION ((}}��
Complete legal description Lot 4, Block 12, Northwoods Sulb viT i n #3
Location (site address) 22927 Green Garden Dr. , Chugiak, Alaska 99567
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Mark & Toni Nelson Day phone (907) 688-2234
22927 Green Garden Dr., Chugiak, Alaska 99567
Day phone
Raney Hardman @ RE/MAX Day phone (907) 440-7257
11525 Old Glenn Hwy., Eagle River, Alaska 99577
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
Individual Water Storage
❑
Individual Holding Tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
®
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water 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 Pinard Engineering Phone (907) 357-3647
Address PO Box 87134.7 Wasilia, Alaska 99687
Engineer's Printed Name Paul E. Pinard, P. E.
5. DSD SIGNATURE '
Approved for 3 bedrooms.
Disapproved:
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: ✓ Original Certificate Date: L3 _a -f - 12—
(Rev. NNS)
VA
D. LIFT STATION NA
Date installed
"Pump on el at _ in.
Datum
Size in gallons
"Pump off"level at _ in.
Cycles tested
E. SEPARATION DISTANCES \
SEPARATION DISTANCES FROM WELL
Septic tankilift station on lot
Absorption Feld on lot
Public sewer main
TO: NA
Manhole/Access (YM)
High water alarm level at in.
Meets alarm S circuit requirements?
adjacent lots
On adjac is
Public sewer ma
Sewer /septic service line Holding tank
Animal containment areas Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 51+ Property line 5 r + Absorption field 51+
Water main 101+ Water service line 10t+ Surface water 100'+
Wells on adjacent lots 200' +
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 101+ Buildin foundation 10' + 1Ar�+o, „� ^ 101+
9
Water Service line 10' + Surface water 1001+
Curtain drainNone Known Wells on adjacent lots 200 1 +
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that t have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Paul E. Pinard, P. E.
Date 8/27/12
COSA Fee $ `G `U.)
Date of Payment 6/a,,
Receipt Number l &dgg
(Rev. 4/10)
Driveway, parking/vehicle storage 10 1 +
Waiver Fee $
Date of Payment
Receipt Number
+9TH •�i
�; l�►ftai9td
798 s°
••
�ti.mo••s•A ,rk
Municipality of Anchorage
• Development 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
Legal Description: Lot 4, Brook 12,_ Northwoods Svhd. #3 Parcel ID: 051-732-13
A. WELL DATA NA
Date
Total depth ft.
If A, B, or C provide PWSID # _
FROM
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Sanitary seal (Y/N)_
Cased to ft.
ft.
9.p -m.
Coliform colonies/100 mL Nitrate mg/L
Arsenic: _ ug/L date of sample:
B. SEPTIC/HOLDING TANK DATA
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground) in.
AT INSPECTION
Collected by:
ft.
9.p -m.
Tank Type/Material Septic/Steel- Dateinstalled 10/16 — 17/2000
Tank size 1250 gal. Number of Compartments 2 Cleanouts (YIN) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (YIN) NA
Date of pumping 8/3/12 Pumper JRs Pumping
C. ABSORPTION FIELD DATA
Date installed 10/16— 7/38il rating (g.p.d./ftz0.6 System type Trench
Length 63 ft. Width 2.5 ft. Gravel below pipeRe.16 ft.
Total depth 10 ft. Eff. absorption area ] D_2_ Monitoring tube Y Depression over Feld N
Date of adequacy test 8/16/12 Results (Pass/Fail) Pass For _3 bedrooms
Fluid depth in absorption field before test 61 in. Water added 600 gal. New depths in.
Elapsed Time:1 385min. Final fluid depth 63 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) None Known If yes, give date
rra nrmlm nom
(AesAmD
ONLY THOSE IMPROVEMENTS ABOVE OR OUND AND VISIBLE WILL BE
CLEANOUTS. SIDEWALKS,
IT IS THE RELATIVE
RADE ANOIFUTLTYPOSED BUILDING CONNECTIONS AND R TOEDETERMI E
ONLY. SNOW
ETC.. SHOWNTINL THERPAPPR APPROXIMATE LOCATION,TIC
IMPROVEMENTSG SEEN AND LN
NO
TONFINSHEDO
OF ANYEASEMENTS,
RECORDED COVENANTSUBDIVISIONS OR ICPLAT-
RECORD UNL.ESSOM
OT'ED.
MER WISE NOTED -
ALL DIS71ONS MAY TANCNT ES SOME
WHICH
Prepared by
a arlRcr
Robert E. Johns, Jr. & Assoc.
•.����
PLANP.•.• •T�"�...... �j
Professional Land Surveyors
r eanna gleAal
1700 Brink Drive.
ANCHORAGE, ALASKA 99504
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-Date Drawn: 8/00
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:,,.,aa.N. X21—s
FlNK STRUCTURE AS -BUILT �'�m ••• t•.` ieI
�I ••••••
Legal DescApttan:
Lot 12 BLOCK 3
I. Rae.t E xn^R'w'.aAr w e,.l , ...............•' es'
NORTH WOODS UNIT 3
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?2
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"�
a EXISTING OQe�
y0' HOUSE (P
O
3
00.
UNDER NO CIRCUMSTANCES SHOULD AN AS -BUILT BE USED FOR CONSTRUCTION OR FOR ESTABUSHING BOUNDARY OR FENCE LINES.
THE SURVEYOR TARES RESPONSIBILITY
FOR THE PREVAIL OVER TRANSACTION
R ONLY
AND ASSUMESON MAY FINANCIAL LIAAUSE ERRORS IUTY IN SCALE.ONLY FOR THE COST OF THE SURVEY.
LIS
CES
LOT SURVEY SURVEY TYPE SYMBOLS
FOUNDATION AS -BUILT
SET REBAR DRAINAGE ASPHALT
flNK SiRUC'NE AS -BUILT ,�
0 FOUND REBAR a -e g WOOD FENCE CONCRETE
PLOT PLAN ... AS -BUILT ... LOT SURVEY ... TW"APNY �J ASSUMED ELEV. �;-=T F METAL FENCE ® WOOD DE(
PLOT PLANS dE LVI aUmvalo
RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO
ONLY THOSE IMPROVEMENTS ABOVE OR OUND AND VISIBLE WILL BE
CLEANOUTS. SIDEWALKS,
IT IS THE RELATIVE
RADE ANOIFUTLTYPOSED BUILDING CONNECTIONS AND R TOEDETERMI E
ONLY. SNOW
ETC.. SHOWNTINL THERPAPPR APPROXIMATE LOCATION,TIC
IMPROVEMENTSG SEEN AND LN
NO
TONFINSHEDO
OF ANYEASEMENTS,
RECORDED COVENANTSUBDIVISIONS OR ICPLAT-
RECORD UNL.ESSOM
OT'ED.
MER WISE NOTED -
ALL DIS71ONS MAY TANCNT ES SOME
WHICH
Prepared by
SURVEY CERTIFICATION �Y�1,+
Robert E. Johns, Jr. & Assoc.
•.����
PLANP.•.• •T�"�...... �j
Professional Land Surveyors
PLOT
mnnr arory �. I e,• oNweaF wry .�•//�^�.
•••
�'a °i"'" "° ,-.. _ , n'aY6 °ee tlia11 -J•:
a1.aw.A a a Bm mi ama
1700 Brink Drive.
ANCHORAGE, ALASKA 99504
m» ane n
rnawae. aw amNA a se.,wa. na» a.w '. T
••'1 ��
Scale: n OI
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K .Plat File No.
ma...a mw as mn.er.
-. • ::/�-1T�yt�r�.. �
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1
Date Surveyed: 8/03112
Drawn 4Y REJ
Checked 6JMK
j... •'A•••••"` ...'�--
FOUNDATION AS -BUILT rrr
I,w<Y u,wY qw
Iww TruTtl m lrRil v+Y a tlr ., • • uu» .n.... '•..;
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hgn,aen a .a., waa - OBER T - HNS, JR
Grid: 12-306
-Date Drawn: 8/00
aeaNu. as '
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O/12
J NW145
:,,.,aa.N. X21—s
FlNK STRUCTURE AS -BUILT �'�m ••• t•.` ieI
�I ••••••
Legal DescApttan:
Lot 12 BLOCK 3
I. Rae.t E xn^R'w'.aAr w e,.l , ...............•' es'
NORTH WOODS UNIT 3
.,.ak �m: w �es�:�•�
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water 8 Wastewater Program
4700 South Bragaw St
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-732-13 HAA#_ O'40G��
A. GENERAL INFORMATION Expiration Date: 3 / — O 5 -
Complete legal description
NORTHWOODS
SUBDIVISION #3; LOT 4,
BLOCK
12,
Location (site address or directions)
22927
GREEN GARDEN DRIVE •:
CHUGIAK
AK 99567
Current; Property owner(s)
Mailing address
Landing agency
Mailing address
Real Estate Agent
Mailing address
CYNTHIA RODASKY
Day phone (907) 694-1383
22927 GREEN GARDEN DRIVE • CHUGIAK, AK 99567
Day phone
RANEY HARDMAN w/ REMAX PROPERTIES Day phone 727-4488
16600 CENTERFIELD DRIVE * EAGLE RIVER, AK. 99577
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
S
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
!
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 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) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. 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 samples. (Certificates may be reissued for a period of up to one year with valid
water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water
system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's
work.
4. STATEMENT OF INSPECTION BY ENGINEER
As ceriffled by my seal affixed hereto and as of the validation date shown below, 1 verify that my
investigation, based on procedures outlined in the Health Authority 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. 1 further verify that based on the
Information obtained from the Municipality of Anchorage files and from my investigation and inspection, the
onsite water supply and/or wastewater disposal system Were) 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.
Address 3701 E. TUDOR ROAD, SURE 101 • ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, Ltd. attempted to provide a thorough,
conscientious engineering analysis of the system In accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered of the time of the test, and separation
distances measured to readily Identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory �test
results do not guarantee future performance of the system, nor do they guarantee
at
there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report Is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party Is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
Phone 337-6179
Date 111 S o
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the flowing stipulations:
-ON-SITE ••':
VATER AND
AUEW9ER
:n
PROGRAM
;� .... •' ;acs
Attachments:
HAA Checklist Manitenance Agreements
Septic System Advisory Supplemental Engineer's Reort
Well Flow Advisory Other
0 L1
By: Original Certificate Date: � � — 3 �
(Rev. 12101)
I Municipality of Anchorage
Development Services Department
Building Safety Division `
Onsite Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519.6650
www.ci.anchorage.ek.us
(907)343-7904 4
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: NORTHWOODS SUBDIVISION #3: LOT 4, BLOCK 12, Parcel ID: 051-732-13
I A. WELL DATA PUBLIC WATER/COMMUNITY
Well type PUBLIC If A, B, or C provide PWSID# 213001 Well Lo
Date completed Sanita Wires properly protected (Y/N)
IslandapTfi� ft. Cased to ft. Casing height (above ground)
I
FROM WELL LOG AT INSPECTION
Date of test
Static water level
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 ml. Nitrate m112111 asteria colonies/100 mi.
I
�. A Date of sample: Collected by:
}
B. SEPTIC/HOLDING TANK DATA ;' I
Tank Type/Matenat STEEL Date installed 10/16-17/2000
t
Tank size 1250 gal Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N)8YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A
Date of pumping 11/1/2004 Pumper JR'S PUMPING
C. ABSORPTION FIELD DATA B Low EXISTING canoe
Date installed 10/16-17/2000 Soil rating OErftl/bdrm) 0_6 System type TRENCH
E
r Length 63 ft. Width 2.5 ft. Gravel below pipe 8.16 ft, 4
Total depth'10.7-11.4 ft. Elf. absorption area 1028 ft' Monitoring tube YES Depression over field NO
Date of adequacy test .11/13/2004 Results (Pass/Fail) PASS For 4 bedrooms
Ff
Fluid depth in absorption field before test 43/39 in. Water added 99144 gal. New depth 65.5/61.5 in, Q
Elapsed Time: 170 min. Final fluid depth62 58in. Absorption rate >= 600+ g,p,d,
Any rejuvenation treatment (past 12 mo:) (YIN & type) ONE KNOWN if yes, give date —
r
Date installed Size in gallons
Manhole/A
"Pump on" level at _in. "Pump off" _in.
High water alarm level at in.
DatumCycles tested
Meets alarm & circuit requirements? -
E. SEPARATION DISTANCES
PUBLIC WATER
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
On adjacent lots _
Absorption field on lot
n ots
Public sewer main
Public sewer manhole/cleanout
Seservice line
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line
5'+ Absorption field 5'+
Water main 10'+ Water service line
10'+ Surface water 100'+
Wells on adjacent lots 200'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation
10'+ Water main 10'+ .
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 200'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION o <' Op
I certify that I have determined through field inspections and * 4
review of Municipal records that the above systems are in " " ' • •' • •
conformance with MOA HAA guidelines in effect on this date.
QO P f Go ess.,
Engineer's Printed Name JEFFREY A. GARNESS
Date If f'!4S/o'f Q's ... •
Oona Prem."tono\
HAA Fee $ Waiver Fee $
Date of Payment bskf Date of Payment
Receipt Number_ b1 50 Aw Receipt Number
(Rev. 12/01)
our oo? 4cl-r P.
.. .. .. Z.O. Oa � .. •e
J,
ra
Frr
k
s f;as4y
-17- a m + 11
r- Dr, /°Gs
AS -MLT
I hereby eft* that F have sumry sd the follywiog d'esp3fd;•':
i+'opys ' 07 oGJG Z .
;. w.eed.s• t:riir- • ...,
!• . i, '
`v�� .%tirr•,� •w� Mc, or ge ReeOYdin Pepcinct`: Alaska {nd that the lmpmve-.
\1 r•'• •. + le menta fdtuatad ti�et4on ate wit}tirt't1i'e p' m Imes and do not
e".9 ••' , C� •_�4:� c� � overt ' or encroach on the Pct'
t +L T- f property iyirig adjaoenlrthFxt0, eh'u'•:,
ti) ?' • ►r �� ^ no improvements on property !yens adjacent t;xielo,.e]pagac}i'.
- V on tha ptetni4Cs' in 9ggaapn and )Cwt there pae i(p roadways:
transnitssion'lhwv or oder visible eaaemenb an aakl,Qlaperty .
•.. u �. OwLpt as in"ted here".
;• P. abcriC. Jahn'on !�}re .r Dated at 6 0 River,'Alaskp .. • ''
,Lo L'ts A Oc.7:• :n. oma'• '
.^h
��s �'`�:•,...•s ••i '.v
SCALE, Y
ROOM Z, )OKNSOhi 7F��
.i �;a.,...,;.,+ljlay_•+,.': �ateredt,atidSury c
Y_,. rypr {do¢ iS' ..
r• Box 77,U% ..+�le RivaR, Alaska
+^.• \ . ♦ .. •.Phone .;lon'T 6�9G•a �,.Y
�k5
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILLY DWELLING
Parcel l.D.# 051-732-13 HAA#f�l�S3
1. GENERAL INFORMATION
Location (site address or directions) 22927 GREEN GARDEN DRIVE CHUGIAK. AK 99567
Property owner CINDY RODA4KY Day phone 907) 694-1363
Mailing address 22927 GREEN GARDEN DRIVE CHUGIAK AK 99567
Lending agency
Mailing
Day phone
Day phone
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
0074
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 xxx
Holding Tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
ing to the legality and status of system.
72-025 (Rev. 1191) Front MOA #21 Computer Version
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $1,970.00 at,
or prior to, closing for the engineering services provided.
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 inspect'bn, the on-site water supply and/or wastewater
disposal system is in compliance with all Muni cip State codes, ordinances, and regulations in effect
on the date of this inspection. 7 /
Name of Firm
Engineer's
Phone _L907) 337-6179
Date
In conducting this evaluation, AWWC, Inc att mto provide a thorough, conscientious engineering analysis of the
system in accordance with ADEC and M A 11% ufdellnes & Regulations. The reported results described the
performance of the system under the conditions encountered at the time of the test, and separation distances
measured to readily identifiable features. The operational life of all wells and septic systems denend
on the local soils condition, ground water levels that may fluctuate during the year, and the
usage of the family being served by the system. These conditions are outside the control c
the evaluator of the system. Satisfactory test results do not guarantee future performance
of the system, nor do they guarantee that there are no hidden defects or encroachments.
AWWC, Inc. can therefore not provide any warranty for future 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 parry is not authorized,
nor will it confer any legal right whatsoever.
6. DHHS SIGNATURE
L-� Approved for I" bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
0
GI/.
Date' �Z�-ao
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of
homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of
DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21 Computer Version
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN
Environmental Services Division
825 "L" Street, Rm 502 Anchorage, Alaska 99501
A % d. W do ® V L tY/
OCT 2 4 2000
SEWQ§§LITY OF ANCHO
(907) 343�744TAL SERVICES
Health Authority Approval Checklist
Legal Description: NORTHWOODS S/D #3: LOT 4, BLOCK 12, Parcel I.D.: 051-732-13
A. WELL DATA
COMMUNITY WATER
Well Type COMMUNITY If A, B, or C, attach ADEC letter. ADEC water system number W++_
Log present (Y/N)
Total depth
Date completed
FROM WELL LOG
height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
Date of test
Static water level
We ct!on g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform
Collected by:
B. SEPTICIHOLDING TANK DATA
Date installed 10/16-17/00 Tank size 1250 Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression (Y/N) NO High water alarm (Y/N) N/A
Date of Pumping NEW Pumper
C. ABSORPTION FIELD DATA
*BELOW FINAL GRADES
Date installed 10/16-17/00 Soil rating ..d./ orN2/bdrm) 0.6 System type TRENCH
Length 63' Width 2.5' Gravel thickness below pipe 8.16' Total depth *10.7'-11.6'
Effective absorption area 1028 SOFT• Monitoring Tube present (YIN) YES Depression over field (Y/N) NO
Date of adequacy test NEW Results (Pass/Fail) — For
Fluid depth in absorption field before test (in.);
Fluid depth — (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96x. Computer Version
Immediately after — gal. water added (in.):
Absorption rate = —
If yes, give date —
Bedrooms
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at'
E. SEPARATION DISTANCES
"Pump
'Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Size in gallons
"Pump off' level at"
COMMUNITY WATER
adjacent lots
lots
Public sewer manhole/cleanout —
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 5'+ Property line 5'+ Absorption field
5"+ _
Water main/service line 10'+ Surface water/drainage 100'+ Wells on adjacent lots 7.00'+ _
SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation
Surface water
Water main/service line 10'+ _
Driveway, parking/vehicle storage area 10'+ _
Curtain drain NONE KNOWN Wells on a
F. ENGINEER'S CERTIFICATI
I certify that I h ve r1b,
h field inspections and review
of Municipal r cord f a systems are in conformance
with MOA H Wide)e on this date.
Signature
Engineer's Name JEFFREY A. GARNESS
HAA Fee $ -) 01--) '
Date of Payment
Receipt Number l ? I I
72-026 (Rev. 3/96)• Computer Verslon
Waiver Fee
Date of Payment
Receipt Number
3�1
MUNICIPALITY OF ANCHORAGE O'S
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner V • ! r • Telephone: Home
Mailing Address
(c) Lending Institution
Telephone
Business
Mailing Address
(d), Real Estate Company and Agent
Address
Telephone
(e) -Ntait-the HAA to the following address: or: Check here, if hold for pick up.
List contact person and day phone number below.
S & S ENGINEERING
17034 Eagle R'wer Loop Road No. 204
"gle River, Alaska
2. TYPE OF RESIDENCE
Single-Family,E5-
Number of Bedrooms
3. WATER SUPPLY
127
Individual Well ❑ Community ❑ Public9_
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (Rev 8/86) Front
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
W
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 system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm S aj 3 EiGINEERING Telephone
Address 17034 Eagle River Loop Road No. 204
Date
Eagle River,
1`57 Z ��
-%,%• *1&%1k
OfF
M
A.
H& 1437-6
DHHS APPROVAL
Approved forbedrooms by Date v
Approved Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
certificates based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in
order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data
before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
Page 2 of 2 72-025 (Rev 8/86) Back
;7�7 -/
A. WELL DATA
ENV1 'C1J0A YC MUNICIPALITY OF ANCHORAGE (MOA)
TH�AUTHORITY APPROVAL (HAA)
aLT - FEBRUARY 1984
�� SERVICES LIST
RF
')1988
CEl VED
Legal Des ription: U''r � 2
�C�2�4�oOS
Well Classification N If A, B, C, D.E.C. Approved (0q) V
Well Log Present (Y/N) Date Completed
Total Depth
Static Water Level
Cased to
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
Depth of Grouting —
Pump Set At
Yield
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
i
To Septic/Holding Tank on Lot ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot �L�' j t ; On Adjoining Lots _
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
Date
Water Sample Test Results
Comments tJQ-,2_- 1p41\3�R� 1
B. SEPTIC/Het--DING TANK DATA
Date Installed L-2-6-0 Size 1 C:_-� No. of Compartments
Standpipes&VN) Air -tight Caps&9N) Foundation Cleanout MN)
Depression over Tank (Y/&V IJ Date Last Pumped
Pumping/Maintenance Contract on File (Y/N)) ; for
Holding Tank High -Water Alarm (Y/N) A_ Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/HekkRq Tank:
1 f
To Water -Supply Well �L�1] To Building Foundation
To Property Line (� t�' To Disposal Field
I
To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course � ( 4 -
Comments -JWc>
Page 1 of 2
72-026 (Rev. 8/86) Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata `�J�/`7� Type of System Design ��fl
Date Installed (Oy1' Length of Field �p
Width of Field Depth of Field 4,0
r
Gravel Bed Thickness o`S
Square Feet of Absorption Area S� �� Standpipes Present/N)
Depression over Field (Y& Date of Last Adequacy Test
Results of Last Adequacy Test
Separation Distance from Absorption Field:
1
To Water -Supply Well �p t� To Property Line
To Building Foundation 2'% To Existing or Abandoned System on
Lot / t'
To Water Main/Service Line 1 ('-
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date FR Iled
Size in Gallons
"Pump On" Level at
High Water Alarm Level at —
Tested for
Electrical Codes (Y/N)
Comments
On Adjoining Lots
� A
To Cutbank (if present)
1 k
b --
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent(Y/N)
Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all OA nd HAA guidelines in effect on the date of this inspection.
Signed S &�ENGiaEEoR-ING Date
Compaf{,034
Eagle River Loap Road No. KIM No. 4r -�
Eagle River, Alaska�/ 7
Receipt No. r�
Date of Payment �' S o
Amount: $ O — Qy
Page 2 of 2
72-026 (Rev. 8/86) Back
STEVE COWPER, GOVERNOR
O
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE 563-6775
3601 C STREET, SUITE 1334
ANCHORAGE, ALASKA 99503
DATE: April 5, 1988
PWSID: 213001
To Whom It May Concern:
According to the records on file in this office, the CHUGIAK
UTILITIES/Northwoods Water System is in compliance with the
State of Alaska Drinking Water Regulations.
Sincerely,
S even W ng, PE
Distric ngineer
SWE:pkk
Time
APPLY;. SVT FILLS OUT C "HALj 'ONLY`
2
Property Owner ? iry%(.:"
{ } i...4.,iY} ;--,t Y GY' t c' r-)
Time
Mailing Address v l< raj
iL7X 1! 4v - Art,.- t o dorr/ 14 --- 1....- Zip Code
Buyer
-_
Address
Zip Code
Lending Institution
-
Phone
Address
Zip Code
Inspector
Realty Co. & Agent
Phone
Address
Zip Code
Soils Rating
Legal Description;
wer Installed
D �
Well To Absorption Area
Well to Tank
Well Log Received
�Ct_� SAVC,4-
Street Location
Type o esidence
ingle Family ..
Multiple Family
No. of Bedrooms ✓
❑ Other
. �•
Water Supply
❑ ylpdividual
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
LeCommunity -.-
For wells drilled prior to that date, give well depth (attach log if available).
❑ Public Utility
Sewer isposal
-
Individual
Year Individual Installed:
❑. Public Utility -
When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes:
( APPROVED BEDROOMS
( ) DISAPPROVED
( ) CONDITIONAL APP V
DATE l
BY:
'CONDITIONS OF APPROVAL
Soils Rating
Date
wer Installed
D �
Well To Absorption Area
Well to Tank
Well Log Received
Septic Tank Size��
A
Time
APPLIcNT FILLS OUT UPPER HAT" ONLY
Property Owner
iyy10+--�flv f(7_..��
Phone
Mailin Address
g
/
q. Zip Code
Buyer
Date
Address
Inspector
Zip Code
Lending Institution
-
Phone
Address
Zip Code
Realty Co. & Agent
(C�) APPROVED BEDROOMS
Phone
Address
Zip Code
( ) CONDITIONAL APPROVAL -
DATE
BY:
Legal Description
o �'j� /0� t� ! f
h
p
'(.���)CX�-'
4C)1/'7
Street Location
f` � �---
Type of Residence
"Allunic?pality of Arch,, ..
"P''I't. of Hav &
Environmental Projection"
Soils Rating
EI,ST�ngle Family
Well To Absorption Area
❑ Multiple Family
No. of Bedrooms-
❑ Other
Well to Tank
Water Supply
❑ Individual -
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
[I -Community
For wells drilled prior to that date, give well depth (attach log if available).
❑ Public Utility
Sewer Disposal
P-16dividual
I C�
Year Individual Installed:
❑ Public Utility
When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes:
(C�) APPROVED BEDROOMS
*CONDITIONS OF APPROVAL -
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL -
DATE
BY:
JUN 2 71983
"Allunic?pality of Arch,, ..
"P''I't. of Hav &
Environmental Projection"
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
Septic Tank Size
Well to Tank
2-023(3182)
Time
APPLNT'
FILLS OUT UPPER HAS ONLY
Property Owner
143 I',,jCi j-] ..e r i 6.,-;4/
G,((Y iC1 f..). ._. -" Phone
Mailing Address
Date
p Code
Buyer
Inspector
Inspector
Address
Zip Code
Lending Institution
JUL 2 11983
Phone
Address
Pro�un° ! aiity of Anc1loj-,gg
Zip Code
�/
Realty Co. & Agent
( APPROVED BEDROOMS
Phone
Address
1/1i
ZipCode
( ) CONDITIONAL AP ROV L'COO(�
Legal Description
DATE
Street Location
BY:
Type of esidence
Soils Rating
ET -Single Family
Well To Absorption Area
❑ Multiple Family
No. of Bedrooms"`.
❑ Other
Septic Tank Size
Water Supply
❑ Individual
-
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
QC mmunity
For wells drilled prior to that date, give well depth (attach log if available).
❑ Public Utility
Sewer Disposal
r ,•-
[-�-Individual
Year Individual Installed:
❑ Public Utility
When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes:
Nip U
JUL 2 11983
/,6
Pro�un° ! aiity of Anc1loj-,gg
J l y
�/
( APPROVED BEDROOMS
'CONDITIONS OF A9R1Rb9PNCientdi Protection"
( ) DISAPPROVED
1/1i
( ) CONDITIONAL AP ROV L'COO(�
DATE
BY:
Soils Rating
Date Sewer I stalled
Well To Absorption Area
Well Log Received
Well to Tank
Septic Tank Size
