HomeMy WebLinkAboutGRECIAN HILLS BLK 2 LT 7 •
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• Municipality of Anchorage
-` On-Site Water and Wastewater Program •,j t
(907) 343-7904 SAF ETY
Certificate of On-Site Systems Approval
017-073-72
Parcel I.D. Expiration Date: `/ r 1 g
1. GENERAL INFORMATION
Complete legal description Grecian Hills Block 2 Lot 7
Location (site address) 8000 Cox Drive
Current Property owner(s) Abby & Thomas Beltz Day phone
Mailing address 8000 Cox Drive, Anchorage, AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING: �" L ,
0 Single Family (w/wo ADU) vW
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex) 10415 1rill
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well 0 Individual
Individual Water Storage ❑ Holding Tank , ❑
Community Class Well ❑ Communjty ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: altiVilhA OP(//11. Date: b/j f l t
COSA to be released to the engineer,unless otherwise requested by the engineer.
(00
COSA Fee $ 6A V-1.- 31S6o = g 1 Waiver Fee $
Date of Payment 1(3011g Date of Payment
Receipt Number C53(eL Receipt Number
COSA# CC-Z1(1 131'4 Waiver#
5. STATEMENT OF INSPECTION BY'ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. 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 Forge Engineering Phone (907) 522-7773
Address PO Box 240773 Anchorage, AK 99524
Engineer's Printed Name Benjamin Schiller, PE Date 7/30/18
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6. DSD SIGNATURE /
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, System#1 Approved for ,3 bedrooms
'. Benja E. Schiller
System#2 Approved for bedrooms ��fi��srF�4 ,C/3058 2..:.v
,,,17.
Disapproved. itt „PROFES51olo
. ,, , t . ry ANNNNN
Conditional apprdval for bedrooms, with the following stipulations:
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2 W4STEWANO rte-..:
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By: ` ‘ w , Original Certificate Date: 1 — I S.
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineerre isteed in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professiona).engjrleer's work.
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7. ATTACHMENTS: -.11',-‘;:•',%
COSA Checklist X Nitrate Advisory. '
Septic System Advisory Arsenic Advisory''
Well Flow Advisory Other a r-".,: . .,v,,'..
COSA blue sheet r '• .. c
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: Grecian Hills Block 2 Lot 7 Parcel ID:017-073-72
A. WELL DATA
Well type Private If A, B, or C provide PWSID # Well Log (Y/N) Y
Date completed
7/5/09-7/7/09 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 74 ft. Cased to 73.07 ft. Casing height (above ground) 27 in.
FROM WELL LOG AT INSPECTION
Date of test 7/5/09-7/7/09 7/28/18
Static water level +3 ft. 31 .5 ft.
Well production 20 g.p.m. 5.1 g.p.m.
WATER SAMPLE RESULTS:
Coliform Neg colonies/100 mL Nitrate 5.06 mg/L
Arsenic NDug/L Date of sample: 7/16/18 Collected by: Forge Engineering
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material S.T.E.P./SteelDate installed 8/06/14
Tank size 1500gal. Number of Compartments 2 Cleanouts(Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) Y
Date of pumping 2/12/18 Pumper Around the Clock Pumping
C. ABSORPTION FIELD DATA
Date installed 8/08/14 Soil rating (g.p.d./ft2 or ft2/bdrm) 1.0 System type Mound
Length 30 ft. Width 20 ft. Gravel below pipe 0.52 ft
Total depth 4.0 ft. Eff. absorption area 600 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 7/28/18 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 600 gal. New depth 0 in.
Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 450 g p d
None
Any rejuvenation treatment(past 12 mo.) (Y/N &type) If yes, give date
D. LIFT STATION
Date installed 8/06/14 Size in gallons 1500 Manhole/Access (Y/N) Y
-Pump on" level at Timer in. "Pump off level at Timer in. High water alarm level at 51 in.
Datum Bottom Cycles tested *ARM Services Meets alarm &circuit requirements? Yes
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot >100On adjacent lots �100
Absorption field on lot >100On adjacent lots �100
Public sewer main >75' Public sewer manhole/cleanout 100
Sewer/septic service line >25' Holding tank >75'
Animal containment areas >50' Manure/animal excrete storage areas 100
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line >5 Absorption field >5
Water main X10 Water service line �1 Surface water
Wells on adjacent lots >100
ABSORPTION FIELD ON LOT TO:
Property line >10 Building foundation Water main
>10' >100' >10'
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain None Noted Wells on adjacent lots >100'
F. COMMENTS
*See maintenance report from ARM Services.
G. ENGINEER'S CERTIFICATION .`z�7���\ ,
.,.,�oF ACgllil
I certify that I have determined through field inspections and tQ
review of Municipal records that the above systems are in ...co.. 4.4-.1.440
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conformance with MOA COSA guidelines in effect on this date. ,*•49 11-I /\ +r�
Engineer's Printed Name
Benjamin Schiller, PE , ow• ••• _• • • •
Date 7/30/18 �r ': Benja chiller j
�� is •.CE 12592 ••` /
C�Jl• 7/30/18 • •GA
kk PROFESS1r ' l
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COSA brown sheet 10-10-12.doc
ARM Services, LLC
March 13th, 2018
Tom Beltz
8000 Cox Drive
Anchorage AK, 99516
Subject: Quanics Aerocell - Maintenance Report
Mr. Beltz,
We greatly appreciate the opportunity to complete your Quanics system maintenance.
Overall, your system was operating as it was designed (with exception to the deficiencies to
be addressed later in this letter). The media level and condition were inspected, and the
drainfield was found to be dry. The pump and return functions were tested, along with all of
the floats and alarm functions. While onsite, ARM cleaned the pressure filter, stirred the
media, and cleaned the spray nozzles in the aerocell.
The following deficiencies were noted during our inspection:
1. The lift station pump was found to not be working. Per conversation with you, ARM
replaced it while on site.
2. The pump run light on the control panel was inoperable. We recommend this is replaced.
Overall, the system appeared to be in excellent condition. It is our understanding that the
tank was recently pumped. The tank should be pumped once a year. Feel free to contact us to
set up an annual pumping and cleaning schedule with ARM services.
Please don't hesitate to contact me via phone or email with any questions.
Sincerely,
Rob Campbell
Managing Member
24738 Chugiak Drive *Chugiak, AK 99567
Ph: (907) 317-9433 office/fax: (907) 688-9433 Email: ARMServicesAK@outlook.com
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MUNICIPALITY OF ANCHORAGE
ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
THIS MAINTENANCE AND REPAIR AGREEMENT,herein the"AGREEMENT" made and
entered into as of this , Ci Da'fof I) f l IV of 20 Ili',by and between
Amar)44 Papal 044 l //v'^ l t u h al,herein the"OWNER,"and the Municipality of
Anchorage,herein the"MUNICIPALITY",in accordance with Anchorage Municipal Code
(AMC) 15.65.365. In consideration of the mutual covenants contained herein,the parties to this
Agreement agree as follows:
I. Advanced Wastewater Treatment Systems. The Municipality grants permission to the
Owner to utilize and operate an Advanced Wastewater Treatment System(AWWTS),
described as Quantics Aerocell Advanced Treatment System.
located at(legal description)
Grecian Hills Block 2 Lot 7
2. Maintenance,Repairs and Alterations.
(Owner is required to read, understand and initial each section)
Throughout the term of this Agreement,the Owner shall enter into a service agreement
with an AWWTS service and maintenance provider approved by the Municipality or the
manufacturer's representative. The AWWTS shall be maintained in a satisfactory
condition capable of performing as designed and producing treated septic effluent in
accordance with the equipment's approval for operation in the Municipality.
�( It shall be the responsibility of the Owner during the term of this Agreement to pay fox all
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repair(s), maintenance,adjustment(s), replacement costs,and inspection costs. This
includes an annual maintenance fee (typically $.400 to$600).
4) q Owner agrees that only maintenance and repair personnel approved by the Municipality
or the manufacturer's representative will inspect and make any necessary maintenance,
repairs or permitted alterations to the system.
(-4-Di K/Owner acknowledges that regular maintenance of an AWWTS reduces the potential
failure of the system,which could include sewage backup and costly repairs or drainfield
replacement.
(rev. 05/18/2018) Page 1 of 3
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4Owner acknowledges that the Municipality may request records of maintenance and
repairs from the manufacturer's representative or maintenance provider.
Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be
assessed in accordance with AMC 14.60.030.
k, Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS. The Municipality will give at least 24-hour notice.
g)/4/ Owner agrees that any sale or transfer of title of the property will not occur without a new
j/ Certificate of On-Site Systems Approval.
` lq Owner agrees that the AWWTS installation and maintenance requirements as provided
I
by the AWWTS vendor/installer and approved by the Municipality are the governing
guidelines for the construction, maintenance and repair of the Owner's AWWTS.
kr Owner agrees to maintain remote monitoring of the AWWTS as required by the
AWWTS approval.
3. Term. The term of this Agreement shall begin on the date of approval by the
Municipality to operate the installed system,or upon transfer of title, and shall continue
while the AWWTS is operational or until title is transferred.
4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this
Agreement shall in no way constitute a waiver of the provisions, nor in any way affect
the validity of the Agreement or any part hereof, or the right of the Municipality
thereafter to enforce every provision hereof.
5. Amendment. This Agreement shall only be amended by authorized representatives of
the Owner and Municipality. Any attempt to amend this agreement by either an
unauthorized representative or unauthorized means shall be void.
6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be
. brought in the Superior Court for the Third Judicial District of the State of Alaska at
Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the
parties under this Agreement.
7. Severability. Any provisions of this Agreement decreed invalid by a court of competent
jurisdiction shall not invalidate the remaining provisions of the Agreement.
(rev. 05/18/2018) Page 2 of 3
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O'WNE'R:
/ i°
By: . _ (signature) Date: ___72 e1 / 1-g
V,I/1'Y) r, Ayl r( (print name)
STATE OF ALASKA )
)ss.
TI-IIR.D JUDICIAL DISTRICT )
The foregoing instrument was acknowledged before me this 2a day of_Dvty,
201%,by Ska...01‘. £day
V &
NOTARY-PUBLIC FOR.ALASKA STATE OF ALASKA„
My Commission expires: Z,,1n z D.71..-z NOTARY PUBLIC - '1-
Shawn Edens �'C:Y
My Commission Fires Jul 2,2022
MUNICIPALITY:
By: (signature) Da.c:
(print name) Title:
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(rev. 05/18/2018) Page 3 of 3
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OWNE :
By: (signature) Date: 7/2`?, )
Rn1611iac P4r Gtr (print name)
STATE OF ALASKA )
) ss.
THIRD JUDICIAL DISTRICT )
The foregoing instrument was acknowledged before me this 2q day of '�J- ,
201ri,by Skakrr, fdeAte,
NOTARY PUBLIC FOR ALASKA
My Commission expires: ZQ1.3 2 2021- STATE OF ALASKA ,
NOTARY PUBLIC 1)- =
Shawn Edens
My Commission Expires Jul 2,2022
MUNICIPALITY:
By: C � (signature) Date:
(print name) Title:
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(rev. 05/18/2018) Page 3 of 3
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT I a F r��' 907-343-7904
On-Site Water and Wastewater Section Fax: 343-7997
www.muni.org/onsite \�
Nitrate Advisory
Certificate of On-Site Systems Approval # OSC181374
Subdivision: Grecian Hills, Block: 2, Lot: 7
A water sample revealed a nitrate concentration of 5.06 milligrams per liter (mg/L).
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Please see the attached "Nitrate Fact Sheet" for important
information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On-Site
Systems Approval.
Mailing Address: P.0. Box 196650 *Anchorage,Alaska 99519-6650 *www.muni.org
Nitrate Fact Sheet
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids,and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
Mailing Address: P.O.Box 196650*Anchorage,Alaska 99519-6650 *www.muni.org
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONIVIENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
I NAME/~ IPHONE ?yEw
MAILING ADDRES~
LEGAL ~ESCRIPTIO~ I
LOCATION NO. OF BEDROOMS
DISTANC~ TO: Well ~bso~pdon area Dwellin~ PERMIT
~ ~ ~anuf~ctu~er Material ~o. of compartments
~ ~ Liq, capacitv in 9al]ohs Inside length Width Liquid depth
IF HOME.DE:
~OZ~ ~ DISTANCE TO: Well ~t Dwelling ,~l PERMIT NO.
~-~O~" Manufacturer ~ , ,~(.~(.~ ~ Mat eri~
~ ~ DISTANCE TO: Well ~ Foundation Nearest lot line PERMIT NO.
~ ~ ~ No. of lines Length of each line Total length of lines Trench width Distance between lines
~ ~ ~ inches
~ of tile finish Material beneath tile Total effective
Top
to
grade
absorption
area
O inches
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tanE Absorption area(s)
~ DISTANCE TO:
OTHER
PiPE ~ATERIALS
SOIL TEST ~1~
'V. ~[X
INSTALLER
REMARKS I ~
APPROVED DATE LEGAL
72-013 {Rev. 3/78)
JIUI~IIL. II-'/~/.!. I Y UP /4i~lL.l-lUl~,qbl-
Departmen~,.~.~, Health and Environmenta,~.~ ..,2rotection
.... '="' 825 L Street, Anchorage, AK. 99501
' 264-4720
Permit # c~O~/~ HANDWRITTEN PERMIT
W. FJ~L-~_~'c/.~~ S~F=WE==t% PERMITu
Applicant:~~ ~d0-~.U~3~/ Mailing Address: ,'~O
Location: Phone Number: _~
Legal Description:
Type of Soil ~sorption Sys%em Is:
Trench: Drainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is:
DEPTH -- LENGTH _ 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 ~(HOLDING) TANK SIZE = D--Oc~ ~ GALLONS * *
?ermit applicant has the responsibility to inform this department during the
~.nstallation inspections of any wells adjacent to this property and the number
)f residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
~ackfilling of any system without final inspection.and approval by this department
~ill be subject to prosecution.
4inimum 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
Df 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
~nd must be returned to this department within 30 days of the well completion.
)ther requirements may apply. Specifications and construction diagrams are
).vailable to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 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 r~J~i~ remodeled to inslude more that 3 bedrooms.
D a t e: ~//9/~
825 "L" STREET
ANCHORAGE, ALASKA 99501
(907) 264-4111
GEORGE M, SULLIVAN,
MAYOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PRO FECT!O~'4
July 14, 1981
Lynn Manley
% Peoples Bank and Trust
Pouch
~mchorage~ Alaska 995].0
Subject: Lot 7 Block 2 Grecian Hills Subdivision
The soils condition on the subject property is not suitable
for a regular on-site sewer system.
Therefore¢ a holding tank on the property is the only
suitable means for disposal.
If there are any further questions, please call this
office at 264-4720.
Sincerely,
Robert C. Pratt, R.S.
Associate Specialist
RCP/ljw
HEALTH DEPARTMENT ~.
.... 327 EAGLE ST. ANCHORAGE, ALASKA 99501 2~9:2511
'* "~ ' INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEFTiC TANK:
DISTANCE FROM WELL
LIQUID CAPACITY,~
GALLONS.
~.~.~.,~..-~ NUMBER OF /,
MATERIAL ~/.~-, ~ COMPARTMENTS
, DEPTH
INSIDE LENGTH ~ INSIDE WIDTH
SEEPAGE SYSTEM: SEEPAGE PIT:
TILE DRAIN FIELD:
1,OTAL LENGTH
DISTANCE FROM WE~ ~'~ FOUNDATION ~fl'~E'~EST LOT LINE ,
OF
LINES
NUMB __-- ISTANCE B I EACH LINE ----(:~
DEPI~H: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE' IN. ABOVE TILE
WELL: TYPE/~-/~,/'/~/'~;?'~ DEPTH //: / DISTANCE FROM · /- ~ / WATER
, ,BUILDING FOUNDATIO~./~ ~ SAMPLE ~2 NEARESt,
~//'~//~ SEEPAGE ~.j ~j OTHER /~-
LOT LINE /~ /~, SEWERNEARESTLINE / , TANK ~' , SYSTEM , CESSPOOL , SOURCES
DISTANCES:
DATE
DIAGRAM OF SYSTEM
I3 '
, ,''' <-~- _ .
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HEALTH AUTHORITY
HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
case No.
NAME OF
APPLICANT
RESIDENCE ADDRESS ~-, .-~ ~
., SEEPAGE PIT__ , DRAIN FIELD OTHER
ANTICIPATED DATE OF COMPLETION/" ,,~...~,~"~//~-~
PERCOLATION
TEST
RESULTS
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
' , .AS DESCRIBED BELOW. SiZE OF UNIT-lO BE SERVED
.. %KS,ZE.TYPES4 -- SEEPAGE TY,E
APPLICATION TO INSTALL: SEPTIC TANK
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH
DIAGRAM OF SYSTEM
LTH AUTHORITY
OR
NSED DESIGNER
I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the
above described system is in accordance with said code.
DATE 7/~'~/7-~'~ APPUCANTS SIGNATURE
MUMCIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Sectiocn
P.O. Box 196650 Anchorage. Alaska 99519-6650
343-4744
1. GENERAL INFORMATION
Complete legal description
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Lot 7; Block 2: Grecian Hills Subdivision
Location (site add'ress or directions) 8000 cox Drive, Anchorage, Alaska
Property owner
Mailing address
Harry and Patricia Buccili
Day phone 345-1196
Lending agency
Mailing address
Day phone
Agent Ron Clark/FORI~3NE PROPERTIES
Address 3o00 A Street, Anc. hor~g~, Als.~ka 99503
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: .3
TYPE OF WATER SUPPLY:
Individual well ×××
Community well
Public water
NOTE:
Day phone 562-?653
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.
72-025 (Rev. 1/91) Front MOA ¢21
t':'' t
AS certified by my seal at.xed 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
~nd 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 ~nd/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 & S ENGINEERING .
Address 17034 Eaqle River Loon gn~ .~!=. 304
Eagle River, Alaska 99'577
Engineer's signature
Phone
DHHS SIGNATURE
__~ Approved for
Disapproved.
bedrooms.
Conditional apl~roval for
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based dnly upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska, The DHHS does thia 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) ~ack MOA#21
Municipality of Anchorage
Department of Health & Human Services
Ill:Al-TN AUTHORITY AppROVAL CHECKLIST
Legal Description: L~7 '~! ~u(.Cr ~-.~E-<.~At-~ ~¢LcS $/0 Parcel I.D.
A. WELL DATA
Well type ~(ZVJPr-fF_
Log present (Y/O~)
Total depth.
Sanitary seal ~N)
If A, B, or C, attach ADEC letter. ADEC water system number
H~~ ~
Date completed ~¢F0/Z.E -¢-/~o Driller
Cased to /-¢'0 ~,~ Casing height
Wires properly protected (~fN)
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG AT INSPECTION
0( g.p.m, t ¢' I
; On adjacent lots
; On adjacent lots
P.blic sewer manhole/clean~t
Petroleum tank
~ IL.
SEPARATION DISTANCES FROM WELL TO:
.~holding tank on lot
./
Absorption field on lot
Public sewer main
Sewer service line
o
WATER SAMPLE RESULTS:
Coliform (~) Nitrate
Date of sample: ,~-I C~- ~ ~__
~,,(~ r~/~ Other bacteria O
Collected by: '---~ ~ EhS~l~iF-.C__-Z~l'.Y.~
B.=~/HOLDING TANK DATA
Date installed ~)-'~-~(---~ g Tank size c~O(.~ ~./2~_ Compartments
Cleanouts (~N) ¢bl~-- Foundation cleanout (~¢N) :]:~s,o~
~~ ~.~ Depression (Y/~
High water alarm ~N) G' OU~T&~D~:i {'~M. DF_~ (~,~. ~X- Alarm tested (~/N) V~-'~
Date of pumping 6 [°1 o~ ~ Pumper
SEPARATION DISTANCES FROM ~S~./HOLDING TANK TO:
Well(s) on lot . .'~i~
TO property line //0
Surface water/drainage
On adjacent lots
Absorption field
/0(~ re_ Foundation ~_2~
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
.ATIONate ins /D t~ Manufacturer
Size in gallons % Manhole/Access (Y/N)
Vent (Y/N) "Pu~t "Pump off" level at
High water alarm level~ Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
D~~ ~l~///~ System type __
Length ~ Width Total depth
Total absorption area ~
Depression over field (Y/N) ~
Results (pass/fail) ~ for bedrooms
Peroxide treatment (past 12 months) (Y/N) ~ If yes. give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO~'~,~
Well on lot On adjacent lots . . _pro~ _
To building foundation To existing or abandoned system on ~
On adjacent lots Cutbank Water main/service line %
Surface water Driveway, parking/vehicle storage area ~
Curtain drain
On adjacent lots,
Soil rating
Gravel thickness
Cleanouts present (Y/N)
Date of adequacy test
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.
Signature ~ ~ ~ ~m~I~E~N6 ~ ~ - ,,,~ ~ p ~
HAA Fee $ /7~
Date of Payment
Reoeipt Number ¢-'
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET
ANCHORAGE, ALASKA99518 TELEPHONE (907) 562-2343
ANALYSIS RESULTS for INVOICE $ 54944
Chemlab Ref.$ 92.2884 Sample ~ 9 Matrix: WATER
FAX: (907) 561-5301
Client Sample ID
PWSID
Collected
Received
?zesezved with
DRINKING WATER L7 B2 GRECIAN HILLS S/D Client Name :S & S ENGINEERING
UA Client Acct :SNEENGP
JUN 16 92 @ 17:10 h]:s. BPO$ :
JUN 17 92 ~ 16:50 h~s. Req# :
AS REQUIRED O~dexed By :R. SHAEER
PO# :NONE RECEIVED
Analysis Completed : 3UN 20 92 Send Repozts to:
Laboratozy Supe=visoz : STEPHEN C. EDE 1)S & S ENGINEERING
Released By : ~
Paramete~ Results Umite Nethod Allowable Limits
....................................................................................................................................
NITRATE-N 3.0 mE/1 EPA 3E3.2 10
Sample ROUTINE SAMPLE COLLECTED BY: J.W.
Remarks:
1 Tests Per£o~med ' See Special Instructions Above UA=Unavailable
ND~ None Detected '* See Sample Remake Above
NA~ Not Analyzed LT=Less Than, GT=Greater Than
Member of the SGS Group (Soci~t~ GCnCrale de Surveillance)
· ..... / DA~'E RECEIVED
'"f, INSPECTION APPOINTMENTS
~IME ~ ~ TIME TIME. /)
tiP' (~° ~ ~""~ "' o ~'%'~/ 4, o
DATE ~.~ DATE AT /
INSPECTOR G ('~ !"-/U I NSPI~CTC~R I NS P ECTO....P/I
ANCHORAGE
MUNICIPALITY OF ANCHORAGE MuNIcIPALIT'~F
OEPARTMENT OP .EALT. ~ ENV,.ONMENTAL PROTECT'O~;~'~'~Z'~.,O~
ENVI
825 L Street - Anchorage, Alaska 99501
( ,~"~ jl~, ) ENVI RONMENTAL SANITATION DIVISION
Telephone 264-4720
r~ rP EI~/EJ~
DJ RECTIONS: Complete all p~rts on page 1. Incomplete requests will not be processed. Please 811ow ten (10) deys for processing.
1. PROPERTY OWNE~R PHONE
/:~'/~,~,-~
MAILING ADDRE~'S ~" '
PROPERTY RESIDENT (If different from a~ove) PHONE
2. BUYER PHONE
/72~ ~ ~ ~,, ,-, ~ ,'//) '
MAILING ADDRE88
3. ~.ENDINGINSTITUTION J PHONE
I
MAILING ADDRESS
4. REALTOR/'AGENT .,/yZ/,,~ I PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE / NUMBER OF~BEDROOMS
~ One ~ Four ~ Other
~NGLE FAMILY ~ Two ~ Five
~ MULTIPLE FAMILY ~ree ~ Six
7, WATER SUPPLY
A~'--"IN DI VI DUAL*
[] COMMUNITY
[] PUBLIC UTILITY
*ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
.~N DI V I DUAL/ON-SITE*~
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [~ ONE [~ THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[~ INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified
INSTALLER
[~Septic Tank or []Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
PROVEOFOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY
72-010 (Rev. 6/79)
--i' \ ~(/ TIME TIME
DATE~~'/~ / DATE DATE
INSPECTOR INSPECTOR~(~ }~ INSPECTOR
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF i~:'&'~H &
825 L Street - Anchorage, Alaska 99501 ENVI~ONMENh~.L
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720
~l~fi~TIOffiS: Complete all 0arts on Oa~e 1. Ineompl~lo r~quosts will nol bo proe~ssod. Please allo~ ten {10} dags for processing.
1. PROPERTY OWNER PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE
MAILING ADDRESS
3. LENDING INSTITUTION ] PHONE
,
MAI LInG'ADDRESS
4, REALTOR/AGENT .. IPHONE
MAILI~'~ ADDR~S '
5. LEGAL DESCRIPTION
STREET LOO^T' N B 9--
6. TYPE OF RESIDENCE
[~dS'TNG LE FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One [] Four [] Other
E] Two [] Five
~ee [] Six
7l WATER SUPPLY~
~'~'~IVI DUAL*
[] COMMUNITY
[] PUBLIC UTILITY
*ATTACH WELL LOG. Awell Icg is required for all wells drilled
since June 1975, For wells drilled prior to that date, give well
depth (attach Icg if available.)
8. SEWAGE DISPOSAL SYSTEM
[~-"~ V I D UA L/O N-SIT E**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY |
3. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY r~l ONE [] THREE E3 FIVE [~] OTHER
[] MULTIPLE FAMILY [] TWO [~] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] I NDIVI DUAL/ON -SITE DATE INSTALLED
~3PUBLIC UTILITY
Connection Verified INSTALLER
E~Septic Tank or E~'~i'olding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
1
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
> PPROVED BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany cer~ficate)
[] DISAPPROVED
DATE BY
72-010 (Rev. 6/79)