HomeMy WebLinkAboutGLEASON LT 2Gleoson
Lot
#015-501-24
Municipality of Anchorage Page ~ of_
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: ~ I (~) I ~'~' PID Number:.
Nem~o~'¢~(.~__....~-'~~.:~O~-- I f-.j~-.~q-, Wastewater System: 'j~,New [] Upgrade
Address: ~,~"'--;~2..~) i~'. [O,~"'JC~,"'"J ~V/ ABSORPTION FIELD
Bedrooms:
Phone: '~ ;~ .-~ ~ Deep Trench D Shallow Trench ed D Mound D Other
Total Depth from original grade:
LEGAL DESCRIPTION S0i~.*tin~: D,~ ¢*~/S,.*t.
Lot: .~ Block:~~Subdivision: )epth to pipe botlom Item origjnal~.~grad~ Ft. Gravel depth beneath pipeo.~ [ Ft.
'Township: ~ Range: Section: Fill added above original grade: Gravel length:
Numb~ lines: Distance betweeu
WELL: D New D Upgrade eravel~:Ml~ ~Z~ ' Ft. ~
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: ~/./" P~p~material:~lO ~
Driller: Date Drilled: Static Water Level:Ft. ~ta~er~ ~~;~~ '~ *Dale insta'led: ~ '--5 -~
Yield: Pump Set at: Casing Height Above Ground:
~,M ~. ~t. TANK
SEPARATION DISTANCES ~eptic u Holding U S.T.E.P.
TO Septic Absorption Lift Holding ~ublic/Private M&nufaoturer: ,Capacity iR gal~s:
From Tank Field , Slation Tank Sewer Lines ~¢~¢~¢m~ -- j~, ~
Well -~ ~ ~ ~ ~ Material:~¢~. _ / ~- Number of Compartments:~
SurfaCewater il~ ]00~ --- ~ ~ LIFT STATION
LineL°t ~t¢ j~/~ ~ ~ ~ Size in gallons: ~anufacturer:~
Foundation ,~/~. ~l, ~' ~ ~ ;;;::~~%:2; e~iY~h water alarm at:
Drain ;~ [
Remarks: p~ Liar' (M ¢% BENCH MARK
~d~~ ,'~¢ ~¢ ] Assumed Elevation: .
inspections performed by: ~ ~ ~&l~ ~ates: Ist_~'~>~l'¢ ..... ~, ¢ ~ .
Department of Health and Human Services approval-,~., ',,
Reviewed and approved by: ~~ ~~ Date: /~2;~ ~;?0~sS~;~'
72-013 (l/gl)MOA 25
Perr,~flt .o. '~'~c)I~) [~>~' .age ~" of ~-' __
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well,Inspection Report
Legal Description:
PID No.:
72-013 A (2/91) MOA25
DOC Co. dba
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688.2759
OWNER OF LAND
ADDRESS / ~
LEGAL DESCRIPTION
DATE - Started
Ended
PERMIT NUMBER
DEl'TH OF ~,NELL
SI'4TIC LEVEL OF WATER FF
i)RA'¢,' DOWN FT.
(;ALS PER HR
KIND OF CASING
KIND OF FORMATION:
From : Ft. to Ft.
From ~./- FL to I . Ft
From Ft. to : _ Ft
From : Ft. to !;' ;i, Ft.
From ii Ft. to 'i~ / Ft.
From / , Ft. to ~.~ Ft
From Ft. to Ft.
From~ Ft. to -. Ft.__
From__Ft. to Ft.
From__Ft. to Ft
From__Ft. to__ Ft
From____Ft. to Ft
From Ft. to__ Ft
From Ft. to_ __Ft
From Ft. to__Ft.
From Ft. to Ft.
From Ft. to.__Ft.
From
From
From
Ft. to Ft.
Ft. to Ft
__ Ft. to___ Ft..
Ft. 1o Fl
Ft. to----Fl
Fl. Io Fl.
__ Fl. 1o__ FI.
Ft. lo Fl.
Ft. lo Ft.
Ft. lo Fl
From Ft, to---Ft
From Ft. to __ Ft.
From .... Ft. to__OOTF . 6A992
--/~e~fi-Hoa/lh & HIJma
From , MUniCipali~o~h~Rot a~e
From Ft. to Ft. Services
From Ft. to_ _Ft,
MISCL INFORMATION:
DRILLER'S NAME
09/25/92 08:5(/ ~'9072652803 NBA Al'I) I T [~001
FAX
To: Roger, S & S Engine~]ng 694-1211
From: Dick Bales, T.D. & Company
Date: September 2.4, 1992
Re~
Lot 2 Gleason
5420 E. 104th Ave.
JoAnn Shore, Owner
In. Jtme t 992, I abandoned the well located in ~e garage of thc above
using stm~dard procedurcs. The purap, con&fit, and pipe w~re remove, d,
filled m~d covered with con_~:rete.
Signed: . ,,
.,, /} i// !
· '."~_e.~a t'.'? c.gx-~..
-.--~-. ........... -g-.~_:__ ~ .................
Dick Bales, T.D. & Company
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF 1
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SWg10187
DESIGN ENGINEER:S & S ENGINEERS
OWNER NAME:DOUBLE HORSESHOE INVESTMENTS
OWNER ADDRESS:5420 E 104TH AV
ANCHORAGE, ALASKA 99503
DATE ISSUED: 7/10/91
EXPIRATION DATE: 7/10/92
PARCEL ID:01550124
LEGAL DESCRIPTION: GLEASON LT 2
LOT SIZE: 22373 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH
INSPECTION. WELL MUST BE ABANDONED IN ACCORDANCE WITH
DNR REQUIREMENTS.
ISSUED BY' ~':~ ,~'~'~ DATE:
July 4, 1991
ROBERT SHAFER, P.E.
ROGER SHAFER
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AN(~ REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Stre~
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: Lot 2; Gleason Subdivision;
Request you issue a permi~ to drill a well and install a septic upgrade
on the referenced property per our design d~ed July 4, 1991.
The existing wastewat~r disposal system appears to consist of a
cesspool. The current well location does not allow a septic upgrade
outside the protective well radius. Therefore, both the existing well
and cesspool are to be abandoned.
The property topography ~ generally flat and we anticipate no drainage
pattern changes. The protective radius of the proposed well cut~ into
the adjacent Lot I; Dogwood. However, ~his is a larger lot and should
not adversely affect any future developments.
If you have any questions or require additional information for your
review, please contact us.
SOIL TEST
A. SHAFER, P.E.
gm
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
SCALE
/---
PERFORMED FOR: ~('¢/~
LEGAL DESCRIPTION: ~--"~--
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
~=~ L'~",/~'~ -~ Ic~ Township, Range, Section:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
SLOPE SITE PLAN
-ER hi O
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, ATWHAT O
DEPTH? p
E
0eplh tO Waler
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ~} _ {minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN __~FT AND . (¢2 FT
COMMENTS /' /
ACCORDANC~ WITH ALL STATE AND MUNICIPAL GUIDELI~Sd'-N E/I/FECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
NHAWTHORNE-ENGINEERING
September 14, 1983
~S"I~'F1 C BOULEVARD
NHAWTHORNE ~ ENGINEERING
7127 Old Seward Highway AN~I~rI~'~GiB,,.ALASKA 99503
An',~,, AK 99502 344 - 4711
Mr. Robert Robinson
Municipality of Anchorage
Department of Health & Environmental Protection
825 L Street
Anchorage, Alaska 99501
Dear Mr. Robinson,
Please consider this my adequacy test report for the existing on-site
waste disposal system on:
Lot 2, Gleason Subdivision
5420 E. 104th
Anchorage, Alaska
Owner: Mr. Norman West
The system consists of one (1) four foot diameter perforated tank.
No septic tank or leach line were observed. Chronological events and
testing are as follows:
First Day, 9:30 A.M., September 12, 1983, arrived at site. Some
laundry had been done that morning by the owners. Testing began at 9:50
A.M. Initial water level below datum equaled 59 inches. Water applied
at 4 GPM for one hour and six minutes and level measurements made at 50
gallon increments. Water level after one hour at 55 inches. Rate change~
to 7½ GPM and water applied until 660 gallons (4 bedroom house) had been
added to the seepage pit. Water level at end of test equaled 50½ inches.
That evening the homeowner reported that water level had dropped
to 69 inches.
Second clay, similar to first day, testing began at 11:30 A.M. Initial
water level at 62 inches. Water applied at 7½ GPM until 650 gallons had
been added to seepage pit with water level measurements made at 50 gallon
increments. Water level at end of test period equaled 51~ inches. Water
level three hours later equaled 65½ inches.
The existing well is approximately 80 feet from the seepage pit.
No other separation distance data or other on-sit~e~ sewer design criteria
may be inferred from this report.
Neil Hawthorne, P.E.
NH/np ~'" ~ % .... ~'~'--:~' ~ ¢ .....~'
MEMORANDUM
91-010 (5/78)
MuniCipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 015-501-24
1. GENERAL INFORMATION
Complete legal description
GLEASON LOT 2
co ^ # 1
Expiration Date: ~/~) ///
Location (site address) 5420 E 104TM AVENUE, ANCHORAGE, AK 99507
Current Property owner(s) !AMES A. ROSE
Day phone
Mailing address
5420 E 104TM AVENUE, ANCHORAGE, AK 99507
Lending agency
Day phone
Mailing address
Real Estate Agent
Heather Estabrook - ReMax
Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class __ Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding Tank E~]
Community On-site
Public Sewer E~
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 pedod 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 fudher 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 ARCTERRA CONSULTING, INC. Phone 868-3792
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date. 04/26/2011
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 inland use, local soil characteristics, groundwater levels that may fluctuate dudng the year and the
water usage of the family being served by the system. 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,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
DSD SIGNATURE
'l_~ Approved for /--'/
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrat~Advisory ¢
/ ' //,, d
(iRe . ~ '
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
MUnicipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw 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: GLEASON LOT 2 Parcel ID: 015-501-24
A.. WELL DATA
Well type PRIVATE If A, B, or C provide PWSlD # __ Well Log (Y/N) 3(
Date completed 10/1_991 Sanitary seal (Y/N) Y Wires properly protected (Y/N) 3(
Total depth 82 ft. Cased to 81 ft. Casing height (above ground) 24 in.
FROM WELL LOG AT INSPECTION
Date of test 10/1991 5/21/2010
Static water level 38 ft. 38 ft.
Well production 50 g.p.m. 7.5 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100mL Nitrate 0.668 mg/L
Arsenic: ND mg/I Date of sample: 04/19/2011 Collected by:. AzcTerra
a. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 9/5/'1991 Tank size 1250 gal.
Number of Compartments _2 Cleanouts (Y/N) 3( Foundation cleanout (Y/N) 3( Depression over tank (Y/N) N
High water alarm (Y/N) N Date of pumping 5/21/10 Pumper McDonalds
C. ABSORPTION FIELD DATA
Date installed 9/5/1991 Soil rating (g.p.d./ft2 or ff2/bdrm) 0.8 System type Bed
Length 32 ft. Width 24 ff. Gravel below pipe 0.5 ft. Total depth 5.25 ft. (Measured 5/21/10)
Eft. absorption area 768 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 5/21/2010 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 1.2 in. Water added 730 gal. New depth 5.4 in.
Elapsed Time: 1440 min. Final fluid depth 1 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N__lf yes, give date ---
LIFT STATION
Date installed
~Pump on" level at__
Datum
in.
E. SEPARATION DISTANCES
Size in gallons
"Pump off' level at __
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot :leO'+
Absorption field on lot :I0(Y+
Public sewer main
Sewer/septic service line 25'+
Animal containment areas 50°+
in.
Manhole/Access (Y/N)
High water alarm level at in.
Meets alarm & circuit requirements?
On adjacent lots :llxY+
On adjacent lots :leO'+
Public sewer manhole/cleanout :1000+
Holding tank :l~Y+
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
llXY+
Building foundation $'+
Water main :lo'+
Wells on adjacent lots :10(Y+
Property line $%
Water service line
Absorption field
Surface water
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line *5'
Building foundation :10'+
Water Service line :10'+ Surface water :10(Y+
Curtain drain 500+ (Nene I(newn)
Water main 3.0'+
F. COMMENTS
Driveway, parking/vehicle storage 3.00+
Wells on adjacent lots 3.1XY+
*MOA #WR070029 (Lot Line Waiver Granted 2007)
G. ENGINEER'S CERTIFICATION
I certify that I have determined through ~eld 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 I(]~NNETI-I M. DUFFUS
Date 04/26/20:ll
COSA Fee $490.00- PAID PREVIOUSLY
Date of Payment 8/17/2010
Receipt Number 03596C
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Parcel I.D.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
015-501-24
GENERAL INFORMATION
Complete legal description
Location (site address)
GLEASON LOT 2
Expiration Date:,
5420 E 104TM AVENUE, ANCHORAGE, AK 99507
Current Property owner(s) ]'AMES A. ROSE Day phone
Mailing address 5420 E 104TM AVENUE, ANCHORAGE, AK 99507
Lending agency Day phone
Mailing address
Real Estate Agent Heather Estabrook - ReMax Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup,
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] 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 ARCTERRA CONSULTING, INC. Phone 868-3792
Address 20z141 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 08/17/2010
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 inland u~e, Iooal soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. 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,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
DSD SIGNATURE
lc'"" Approved for L./L
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ,~ - ~. _~ -- / O
MuBicipa y of Anchorage
Dever t ices Department
Buildings, 'Safety' Division
On-Site Water~ & 'Wa~teWater *Program
4700 Bragaw Street
P.O: Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343-7904
CERTIFrCATE OF ON-SITE SYSTEMS A'PPROVAL CHECKLIST
Legal Description: GLEASON LOT 2
A. WELL- DATA
Parcel ID:
Date of adequacy test 5~t0
Fluid depth in absorption'field before t~=st
Elapsed Time: la,40 min. Final fluid'.depth __
Results (Pass/Fail) Pass For 4 bedrooms
1.2 in. Water added 730 gal. New depth 5A
1 in. Absorption rate >= 600+ g.p;d.
in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N'__? yes, give date
WATER SAMPLE RESULTS:
Coliform NF.G colonies/100mLNitrate 1.02 mg/L
Arsenic: ~ ~ , mg/I Date of sample: 08/09/20~0 Collected. by: A~Te~a
B. SEPTIC/HOL~ TANK DATA
Tank Type/Material S~Steel Date installed 9~99~ Tank size Z~. gal.
Number of Corn partments _2. C[eaneuts (Y/N) ~ Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
High water alarm (Y/N) ,N Date of pumping 5/21/10 Pumper McDonaMs
C, ABSORP'FION' FIELD DATA
Date'instalted9;C3t199I Soil rating (g.p.dJft2 or ft2/bdrm) 0.8 System type Bed
Length 32 ft. 'Width 2/t ff. Gravel below pipe 0.5 ft. Total depth 5.25 ff. (Measured 5/21/10)
Eft. absorption area 768ft2 Monitoring tube Y Depression'over field N__
(Y/N) X
Total depth 82 ft. Cased to 8~1 ff. CaSing height (above ground) 24,in.
F'ROMWELL LOG AT INSPECTION
Date of test Z0/'19~ 5/2~20~0
Static !,water level 38 ft. 38 ft.
Well ~°ducfion ,56 g.p.m, 7.5. g.p.m.
LIFT STATION
Date installed
"Pump on" level at
Datum
E. SEPARATION DISTANCES
Size in gallons
"Pump off" I~vel at
Cycles tested
Manhole/Access (Y/N)
High water alarm level at in.
Meets alarm & circuit-requirements?
SEPARATI'ON DISTANCES FROM WELL ON LOT TO:
Septic tan~lift station on lot 100'+
Absorption field on lot I00'+
Public SeWer main ?5'+.
Animal containment areas 50'+
On adjacent lots 10lY+
On adjacent lots
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundatiOn 5'+
Water main 10%
Wells on adjacent lots.*'/~+
Property line 5'+
Water service,line 10'+
SEPARATION DISTANCE ~FROM ABSORPTI'ON'FIELD ON LOT TO:
Property line '5' Building foundation 10'+
Water Serviceline 10'+ Surface water 100'+
Curtain drain 50'+ (NeaeKnow~}
F. COMMENTS
*MOA- #WR~ (.Lot L~xrm WaJvez Granted 2007)
Absorption field 5'+
Surface water ~00~.+
Water main 10'+
Driveway, parking/vehicle storage. 10'+
Wells on adjacent lots 100'+
G. ENGINEER'S,CERTIFICATION
, certify that l have determined through field inspections and
review of Municipal records that the above systems are
conformance with MOA COSA guidelines, in effect on this date.
Engineer s Pdnted Name KENN~T. M. DtJ'FFUS
COSA Fee $490.00
Date of Payment ~' {~' J 0
Receipt Number ~ .~---~6~' ~
(Rev. 11/05)
Waiver Fee $
Date of Payment
ReceiPt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
015-561-24
Parcel I.D.
1. GENERAL INFORMATION
Complete legal description
cosA#.
Expiration Date:
GLEASON LOT 2
Location (site address) 5420 E. 104TH AVE., ANCHORAGE, AK 99507
Current Property owner(s) THOMAS HAYS & FRIEDA KOPER Day phone
5420 E. 104TH AVE., ANCHORAGE, AK 99507
Mailing address
Lending ag?ncy
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 4
Day phone
KRIS ABEGG I PARAGON PROPERTIES Day phone 349-1200
3111 C Street, Suite 555 Anchorage, AK 99503
3. TYPE OF WATER SUPPLY:
Indi{/idual Well
individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site [~]
individual Holding Tank
Community On-site [~]
Public Sewer
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 end/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 pedod of up to one year with valid water
samples.) Certificates are valid for one year for preporties 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 lype 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 Watkins Engineering, Inc.
Address P.O. Box 110443, Anchorage, AK99511-0443
Engineer's Printed Name Cindy W. Ellis, P.E.
Phone 907-349-1851
Date (t~_ ~ '07
5. DSD SIGNATURE
Approved for , ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date,
(,,- Id-o7
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastawater Prngmm
4700 Bn~sw Street
P.O. Box 196650
Anchorage, AK 99519-6650
~muni.o~g/onslta
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: GL;~ON LOT 2
IfA, 8, orC provide PWSID #
Sanitary ~eal (Y/N) YES
Case<tm 81 ft.
FROM WELL LOG
10/91
38 ft.
50 g.p.m.
Nitrate 1.68 mg/L
Date of ~ample:
A. WELL DATA
Well type PRI
Date completed t0/91
Total depm 82 ft.
Depression over tank (Y/N) NO
Pumper !~"~ Pumping Sandce
Parcel ID: 015-501-24
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Col~n'n 0 .colonies/100 mL
Amenic: <0.005 mg/I
B. SEPllC/HOLDINO TANK DATA
Tank Type/Metaled STEEL SEPI~C TANK
Tlnk eize 1250 gal. Number of Compartments 2
Foundation cMarmut (Y/N) YES
Date of pumping 4/25/07
C. ABSORPTION FIELD DATA
Date in~lalled 9;5/91 Soll rating (g.p.d.~ft~ or ~/txlrm)0.8
Lenglfl 32 It. V~24
We, Log (Y/N) YES
Wtms pro~ee/protected (Y/N) YES
Casing height (.t~ve ground) 24
AT INSPEC~ON
4/25/2007
38 fl.
7.2 , g.p.m.
Other hectada 0 colonieS100 mL
Coflectad by: Roc~ Tminor
Date in/tailed 9/5/91
Cleanouta (Y/N) YES
High water alarm (Y/N) NO
Gravel below pipe
TotaldePth6.1 fl. Eff. absoq~Jonama768, ~ MonltodngtuheYE$ DepmssionoverfleldNO
Date of adequacy test .4/25/2007 Results {F~l$~Fall) .PASS F(x' 4 . bedrooms
Flutddepatineb~xptle~fiek:lheforetast2.375 in. Wataredded768 gal. New dept~ 5.125
Elal~ Time: 60 min. Final ftuid depth 3.375 in. AbsofT)tiDe rate >= 600
Any rejuvenation ~'eatment (past 12 mo,) (Y/N & type) NO . ~f yes, give date.
lt.
g.p.d.
D. LIFT 8'rATION
Date installed NA Size in gallons
'Pump on' level at in. 'Pump off' level at.
Datum. Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic lank/tl~ station on lot 120
Absoq~on field on lot 142'
Public sewer main 100+
Sewer Meptic ~ervice line 110%
Animal containment areas 100+
Manhols/A _,~e__ss (Y/N)
High water alarm level at
Meets ilmm & circuit m~?
On adjacent lots 100'+
On adjacent lots .1.00'+
Public ~ewer manhola/claanout ...I 00+
Holding lank N/A
Manum/animat excrete ~torage areas .10.0+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foun~a*Jon _26'
Sun'ane water, 1.00'+
Wells on edjacem lots 100'+
Absorption field $'+
Surface water 100+
Building foundation .5.+ Property Hne .3~.'
Water main 100+ Water nen4ne line 35+
Wells on adjacent ~ 100+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
~r Sen4ne line 92'
Curtain drain N/A
Water main .1..00+
Pti,away. paddng/va~c~e ~,ge 88'
F. COMMENTS: ' Lot line waiver requested to west property line - -~=__,'~t__ to dght of way f~ Daisy Cir~e.
G. ENGINEER'8 CERTIFICATION
I cerl~y that I have determined thro~h fle/d in.~x~k3~ and
mvtew c2~ Munic~ records that the above systems am in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Pdnted Name..Cino~ W. Ellis, P.E.
Date 7'07
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/o~)
Waiver Fee $
Date of Payment,
Receipt Number
06/13/2007 15~42 3491934 WATKINS ENGR PAGE
Watkins Engineering, Inc.
P.O Box ].10443, Anchorage, AK 99511
(907):349-1851 cwellis@gd.net
June 13, 2007
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater program
P.O. Box 196650
Anchorage, AK 99519-6650
RE: Oleason Lot 2
Request for Lot Uno Waiver
Attention: Jeff Poet
Dear Jeff,
I request a lot line waiver for a 5 ff separation between the dralnfield on the
subject lot and the west lot line. This is adjacent to the right of way for Daisy
Circle, and will not affect the water or wastewater needs for any adjacent lots.
Thank you for consideration of this request. If you need any further Information,
please cell me at 349-1851.
Sincerely,
Clndy W. Elhs, P.E.
President
Mayor Mark BtTfich
Municipality of Ancho agc
6/14/2007
Cindy Ellis
Watkins Engineering, Inc.
Subject:
Waiver Request for Gleason
Waiver Request #WR070029
Parcel ID #015-501-24
HAA# 070185
Lot 2
Dear Engineer,
Your request for a waiver of the required 10 feet horizontal separation from the
absorption field to the property line has been approved. The approved separation distance
is 5.0 feet.
This waiver approval applies to the existing absorption field to property linc separation
only. Any future upgrade to the on-site wastewater disposal system will require all
separation distances be met or another approval from this depaflment.
If there are any further concerns or questions regarding this waiver, please call our office
at 343-7904.
Sincerely,
Jeffrey W. Poet
Engineering Technician
On-Site Water & Wastewater Program
Community, Security, Prosperity
Municipality of Anchorage
Development Services Department
Building Safc~y Division
On-Site Water and Wastcwatcr Pwgram
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorag¢.ak.us
(907) 343-79O4
Waiver Review Worksheet
Wl~; I)?0029 PII3f: 0t~-50t-24
HA#: ~)70185 permit~:
Date Received: 61t 1107
Legal Description: ~
Engineer..~
Applicant: ~r~omas Haves & Frleda Kooer
Waiver Requested: ~i feet seoaratton distance absomtlon field to Dronertv line.
Criteria: Geology Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
Total:
Waiver Is Granted: ~ Waiver is not Granted:
Ust Conditions or Reasons for above:
Rec#: 6-11-~7 Amount: S175.00 Date Paid: 6-11-07
SGS Ref.# 1072372001
Client Name Wa~ins Engineering
Project Name/# Gieason Lot2
Client Sample ID Glcason Lot :2
Matrix Drinking Water
All Dates/TIme~ are Alask~ Standard Time
Printed Date/Time 06/07/2007 16:18
Collected Date/Time 05/25/2007 14:4~
Received DateJTIme 05/25/2007 15:13
Technical Director Stephen C. Ede
PWSID 0
Samvle Remarks:
Allowable Prep Analysis
parameler p.e~tlt* PQL Un/ts Me0~l Container ID Limits l~le Date Init
Arsenic ND 5.00 ug/L EP200.$ C (<10) 06/01/07 06/04/07 TK,
Wate~a Depaz't-aamco
Toal Nitrat~itHtc-N
1.68 0.100 mg/L SM20 4500NO3-F B (<10~ 0f/0~/0? ,1DS
l, Lt crob£oloc~'
Total Coliform
col/100mL SM20 9222B A (<Il
05/25107 DLC
EAST 104TH AVENUE
N 89'57'30" W
139.84'
x
~...-,GRAVE,/. DRI~
34,5
LOT 2
LOT DOES NOT
CLOSE BY 0.16'
AS-BUILT
Lot 2,
Gleoson Subdivision
LAND & CONSTRUCTiON SURVEYORS-PLANNERS-ENGINEER~
440 West Benson Bouleverd. Suite 200 Phone:
Anchorage. Alosko 99503 Fox: 561--6626
~'~ot: 72-193 2537
Wor~ 0,~. 2007L092^ r~/~g: Ref:921.215
SET LATH ALONG
fPROP. LiNE (TYP)
N 89'57 O0 W 139.83'
TR. B
46.9
LOT I
DRAWING IS NOT TO BE MOOIFIED FOR USE AS A PLOT PLAN.
May 31. 2007 ~ro~ B)~ NRB
1'-30' :h,~ed B~ APH
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
G.,~e.as o,~ Subdivision
Lot 2; ~ "~
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
goAmz ~'
.)~l.O,~_e.
5420 ~. 104th Avenue
5420 E. 104th Avenue
Day phone
AnchoJ[aqe¢ AK 99516
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest°
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Fronl MOA #21
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigatioh 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.
Nameof Firm S&SENGINEERING Phone ~ ¢/~- ~¢i'7~
17034 EagJe Eiver Loop Roac~ No. 204
Address Eagle River, Alu, sEa 99577 .~ ~,,
Engineer's signature ,.-~/: ~'¢------ Date C /2~" /~4-
DHHS SIGNATURE
/IV Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date 7- '/
=, - __-~-_ -.-- ..q-,Nil / [.] ~
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certifice.tes based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes
and their lending institut ons 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 engineeCs work.
72-025 (Rev 1/91) Back MOA #21
Municipality of AnChorage
DEPARTMENT OF HEALTH & HUMAN SERVICESt~uN~¢~^~
Environmental Services Division
825"L" Street, Room 502 · Anchorage, Alaska 99501e (907)
Health Authority APproVal Checklist
¢. L ~, /4- ,~ o ,'~ 3-'/1) Parcel I.D.:
Legal Description:
A. WELL DATA
Well type
Log present (~yN)
Total depth
Sanitary seal (~/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed / o / q /
Cased to ~ / Casing height (above ground) ) '/'
' Wires Properly protected C~/N) Y'~'- j'
FROM WELL LOG
Date of test ! o / ¢/ /
Static water level ~ ~
Well production ~ 0
WATER SAMPLE RESULTS:
AT INSPECTION
/
g.pan. ~ o,
Coliform O Nitrate [. '? 3
Date of sample: (o ~ t q / ~1 (.. Collected by:
B.~I'TC~HOLDING TANK DATA
Date inst~led ~ / fi-/~ t Ta~ size } ~6~ O
Fom~dation cle~out ~ Y~ Y ~- Depression ~ /~ o
DateofPumping5/~l/q.6 ~mper /S~/) c ~
C. ABSO~ION ~LD DATA
Date installed cf ~ ~ / Soil rating ~r ~2~,dm) O. ~ System
Length ~ ~ Width' ~ ~ Gravel thckness below pipe O. 5' Tot~ depth
Effective absorption area "'7 6 ~
Date of adequacy test
Other bacteria
Fluid depth in absorption field before test (in.);
g.p.m.
$ & $ ENGINEERING
170~4 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Number of Compartments ~ . Cleanouts ~)'N) Ye. J ~
__ High water alarm (Y, qg) ~ o
6
Monitoring Tube present~/ixD. ¥~-J' Depression over field (Y~P~ /" o
Results (Pass/Fail) t°//£/; For ~t bedrooms
P~'¥ Immecliatelyafter (,1~ gal. wateradded (in.): ~/>'"
Fluid depth o c.-y (ins.) Minutes later: ) 7 Absorption rate = ~ 0 0 q- g.p.d.
Peroxide treatment (past 12 months) (Y/N) t~o..,~i, tOoo~o ~ ffyes, give date '--
D. LIFF STATION
Date installed
Manhole/Access (Y/N)
High water aiarm level at*
Size in gallons
"Pump on" level at*~'~~"Pmnp oW' level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
~S~pti~)holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service tine
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM'~OLDING TANK ON LOT TO:
f
Buildingfoundafion ~- 4- Propertyline ~) $- ~q- Absorption field 3'- /-/-
Water main/service line ,L $' '~- Surface water/drainage. 1o o '~- Wells on adjacent lots lo 0 '-~
SEPARATION DISTANCE FROM ABSORPTION HELD ON LOT TO:
Building fom~dation 'l $' q- Property Line }t O ~ Water main/service line
Surface water ! 0 o /4-- Driveway, parking/vehicle storage area
Curtain drainN0~-'r~ /e,~ocv~' Wells on adjacent lots ! 0 0
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal
Signature n~~d- . ~~
eceipt um er /?xo fw)
Rev. 8/95 O8S: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number
zTr
CT&E Environmental Services Inc.
Laboratory Division g~',a~,~,;~',a~a~'J-~'ar,~-~'~-,a~',~-~-~',~'jffjj~f~jjfjjjjf~f~~
Laboratory Analysis Report
CT&E Ref.#
Client Sample ID
Matrix
PWSID 0
962447.962447002
Lot 2 Gleason S/D
Drinldng Water
Collected Date 06/19/96
Technical Director: Stephen C. Ede
Released By ~ ~' ~
Sample Remarl~:
Nitrate-N
Nitrite-N
Total Coliform
Results OC
Qua l
1.73
0,100 U
0
PQL Uni ts Method
Allowable Prep
Limits 0ate
0.100 mg/L EPA 353.2
0.100 mg/L ~PA 353.2
0 col/lOOmL SM18 9222B
Analysis Init
Date
06/21/96 Elizabeth
06/21/96 Elizabeth
06/I9/96 TAV
U - Undetected
LT - Less than
GT - Greater than
D - Secondary Dilution
J - Below the calibration range
200 W. Potter Drive, Anchorage, AK 99518-1605 -- Tel: (907) 562-2343 Fax: (907) 561-5301
3180 Peger Road, Fairbanks, AK 99709-5471 -- Tel: (907) 474-8656 Fax: (907) 474-9685
ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI. NEW JERSEY, OHIO, WEST VIRGINIA
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Lot 2; Gleason Subdivision
Location (site address or directions) 5420 East 104th, Anchorage, Alaska
Property owner JoAnne Shore Day phone 265-2890
Mailing address 2906 Willow Street, Apartment 7, Anchorage, Alaska 99517
Lending agency
Mailing address
Day phone
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system,
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
xxx
72-025 (Rev 1/91) Fronl MOA~21
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
Address
S & S ENGINEERING
17034 Eagle River Loop Road No, 204
~a*,:e ~iver, Alaska 99577
Engineer's signature
DHHS SIGNATURE
X Approved for ~L~q.z f~.. ~.~/ bedrooms.
Phone
,/
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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.
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: 1...-<:-,1- '~ ~ ~~--~
Parcel I.D.
A. WELL DATA
Well type~¢~ ~/,¢~
Log present~W~F~)
Total depth
If A, B, or C, attach ADEC letter.
-/ Date completed
Cased to
Sanitary seal.N) _ y
ADEC water system number
\ '.~ /'¢'~ L Driller ~L~..~-~
Casing height
Wires properly protected~/N) "7/
FROM WELL LOG
Date of test / c~/'ct [
Static water level -"~-~
Well flow ~'~¢-~
Pump level
g.p.m.
AT INSPECTION
/
SEPARATION DISTANCES FROM WELL TO:
t
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
Date of sample:
'/. t~, ~ ~ ///~ _ Other bacteria
Collected by: ~ ~ ~ ~
B. SEPTIC/HOLDING TANK DATA
Date installed ~ ~ ~ ~ ~
Cleanouts ~¢)'N) V
High water alarm ('C/N)
Date of pumping
Tank size '\"~ ~-L~ Compartments
Foundation cleanout CC/N) ~ Depression (Y~
~ Alarm tested (Y/N)
~/~b~/ ~ :~__~.j Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot \ c>~-~
To property line ~-c~
Surface water/drainage
On adjacent lots
_Absorption field
Jo- Foundation
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed
Length ~'~-~
Total absorption area
Depression over field
ResultS'fail)
Width
Peroxide treatment (past 12 months)
Soil rating
Gravel thickness ~ Total depth
Cleanouts presentd~N)
System type
Date of adequacy test
for ~'
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots [ d---~t -~ Propertyline
To existing or abandoned system on lot
Cutbank r~.//~ Water main/serviceline
Driveway, parking/vehicle storage area _
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
S & $ £NGINEEEING
17034 Eagle River Loop Road
Signature
[~f:lle ~iver, Alaska
Engineer's Name
HAA Fee $ //7¢ Oc)
Waiver Fee: $
Date of Payment ¢/O --¢ ~ ~ ~ ~ , Date of Payment
Receipt Number ~_~.. ~// ¢~/ (~'~5~..~' "~ Receipt Number
~ CHEMff~AL & GEOLOGICAL LABORATORY
...... ,., a DIVISION OF COMM~HGIAL TESTING & ~NGINE~RING CO.
AHCHOqAGE, ALASKA 9951~ TELEP? ONE (907)
A~A[,~$I9 ~T~ f~ I~VOIC[ t 59~48
FAX:
,
$~pl~ kOg/l~E 8A~,E coLLEC%ED BY: J.~,
NA- ~ot A~ly~d ZT-Lw~ Than,