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Home My WebLink AboutCAMPBELL HEIGHTS BLK 4 LT 17A ' WATER WELL RECORD STATE OF ALASKA OEPARTMENT OF NATURAL RESOURES Division of Geologlcol 8, Geop~ysicol Surveys tnchora~ e tl~ts. 17A ~ --of--,~--of-- .~ w~ ~IDIsTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3, OWNER OF WELL: '67th Ave. 1'an till ~6 &4 0 "'i,'"%r':' 0 ,.:,or,. l'&~n till. we% A& 9~ ~ T..tw.t~~ Brown %~'atcr [~nnd & ~r~ve]. 69 70 dl0..6"~5,. ,o 70 ft.O,plh W,l$~l 17 m,./f, I0. $TATIC WATER LEYE~: ~0 ~Above Or .~Below Io~d Clea~d well; cecove~e~ ~os~ of he~d 9uickl3. I~3tten ~ill~n~ Ch. AA 05~? Signed: DaCe: ~'~ ~ C~ ~. PERMIT RPPLICRNT TED MISSIG GEN DEL CHUGIRK c-I~ LOCRTION E g7 TH OFF LK OTIS LEGRL '.LOT l?R BLK 4 CRMPBELL HTS S LOT SIZE g88-~142 7500 SQURRE FEET MINIMUM DISTRNCE BETHEEN A HELL RND RNY OM-SITE E, EHRGE DISPOSRL SYSTEM IS 100 FEET FOR R PRIVRTE HELL OR 150 TO 200 FEET FROH R PUBLIC HELL DEPENDING UPON THE TYPE OF PUBLIC HELL MINIMUM DISTRNCE FROM R PRIVRTE HELL TO 8 PRIVRTE SEHER LINE IS 25 FEET RND TO R COMMUNITY SENER LINE IS 75 FEET. HELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT NITHIN ~0 DRYS OF THE HELL COMPLETIOM. OTHER REOUIREHENTS HRY RF'PLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. PERI"1 I T E.~'P I RES DECEMBER I CERTIFY THRT i: I RM FRHILIRR HITH THE RE~!UIREMENTS FOR ON-SITE SEHERS RND HELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORRGE. 2: I HILL INSTRLL THE SYSTEM IN 8CCORDRNCE HITH THE CODES. V4. 0 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 014-072-77 1. GENERAL INFORMATION Complete legal description Expiration Date: f Campbell Heights, Block 4, Lot 17A Location (site address) 3621 E 67th, Anchorage, AK 99507 Current property owner(s) Abby Klffmeyer Day' phone Mailing address same Real estate agent Day phone 2. TYPE OF DWELLING: [] Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic ❑ Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer"; i Q Waiver request for: ; Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 11 -6j - Date of Payment 6_1V Q //? Receipt Number '?I ty C COSA# 6SC1911gg Waiver Fee $ Date of Payment Receipt Number Waiver # i S. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm Crewdson Engineering LLC Phone 907-280-9493 Address PO Box 671389, Chugiak, AK 99567 Engineer's Printed Name .dames Crewdson Date 5/29/2019 6. DSD SIGNATURE �LAw j. rA '�F q��1 .00 System #1 Approved for a bedrooms y. • ,,�Y..: ,ai5. • • • . System #2 Approved for Disapproved Conditional approval for �/ aures �. Crewdson. bedrooms / 011527 � � 1�`�OFESSI�P�+ _ bedrooms, with the following stipuf�t�l3M��` ,�l��l«ry nc�r��/�, . Original Certificate Date: (v - 7-1 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. i 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist Legal Description: Campbell Heights, Block 4, Lot 17A If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA 0 Well log is filed with Onsite (or attached) Date drilled 3116182 Total depth 70 ft Cased to 70 ft F Sanitary seal is functioning correctly F Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 5123119 Static water level at beginning of test 18 ft. Comments B. TANK DATA Age oftank(s) yearsC Tank type/material `L► Measured operating fl in septic tank ipes/foundation cleanout per record drawing Date of pumping Parcel ID: 014-072-77 Structure served by this system Well production at time of test 2.94 gpm Water storage tank volume none gallons Well -disinfected for coliform test? ❑ Yes X No /%Coliform bacteri Negative r.�.0 Nitrate mg/L ® trate less than MRL (ND) Arsenic_ ug/L "0 Arsenic less than MRL (ND) Collected by Crewdson Engineering LLC �- Date of Sample 5123119 C. LIFT STATIO maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) Adequacy ❑ ALL standpipes present per record drawing eZ Total measured depth from grade ft (maxim nF Measured depth to pipe infrom %rd ft (,in ❑ N/A —pressurized field ❑ Monitor tubes go to bottom of ec state depth into effective ❑ Code -required soil' r over field ❑ Syste soaked fired if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet added New depth _ Elapsed time _ Final fluid depth bedrooms test in _ gal in min in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 10 ' Community Sewer Manhole/Cleanout > 100' U i ft ❑ Yes if No 50} ft Neighbo ' g Ta, 00' es if No ft Private Sewer/Septic Line > 25'[Z] Yes if No ft A s ti i _ 100' ❑ Yes if No ft Holding Tank > 100' ❑✓ Yes if No ft Nei b Absorption Fields > 100' Animal Containment > 50' El Yes if No ft ❑ Yes if No . ft 50+* Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' [1 Yes if No ft ❑✓ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No ft Surface Water > 1 0' Property Line > 5' ❑ Yes if No ftp els n en ts: Absorption Field > 5' ❑ Yes if No ft Priv ells 0' ❑ Y if No ft ❑ Yes if No I ft Water Main > 10' ❑ Yes o ft C unity Wells > 200' ❑ Yes if No ft Water Service Line >,10' Y s if N If septic tank is under driveway comment below From Absorption I o Lot ( e distances if less than required) Building Foundation_ 0' s if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No ft Wells on Adjacent Lots: Water Main > ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft W Service Line > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft Surface Water> 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS *per code at time of installation ..: ��... F A 4.1 G. ENGINEER'S CERTIFICATION ��•' •'•5�� I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with - MOA COSA guidelines in effect on this date. edson r .. ll` ?R�FES50�P COSA Checklist yellow sheet MUNICIPAUTY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION {a) Legal Description (include lot. block, subdivision, section, township, range) Lot 17A, Block 4, Campbell Heights Location (address or directions) 3621 East 67th Avenue, Anchoraqe, Alaska (bi Applicant Name Mike Georq~ Telephone: Home Business 274-8525 Applicant Address 3621 East 67th Avenue (c) Applicant is (check one): Lending Institution I-I; Owner/builder~ Buyer r'l; Other I'1 (explain); ~, (d) Lending Institution {~ ~,~"~'('~ ~ ~'{0~.--~'~-l-~'-'~eephone ' ' Address (e) Real Estate Companyand Agent ~ ~ m~ ~ Telephone (f) Mail the HAA to the following address: 2. ~ ,TYPE OF RESIDENCE Single-Family E'I Mule-Family I-I f ~; Number of Bedrooms" 3 Other WATER SUPPLY Individual Well [~ Community I-I Public I-I Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsitel-1 Public~ Communityl-I Holding Tank CI Note; I! community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page I of 2 72-025(tl ~) 5.' ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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 Irom my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with ail Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm , QUADRA Enqineerirlg'. Irtc, ' Telephone Address 401 E. Fireweed Lane, Anchora~e,'AK 99503 Date Junp 14.' lqR'~ Engineer's Seal Approved for . ,,%~"-~'~'~ bedrooms by /%7 , ~ / ~'~-,'~'Date ~::rmOsV::condition~a ApprovalDisa pprov~/ __ Conditional CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: Lot 17A, MUNICIPALITY OF ANCHORAG.': DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION RECEIVED Block 4 Campbell Heights Anchorage, AK Well Classification Thc1 ~ v~'t~a 1 If A, B, C. D.E.C. Approved (Y/N) Well Log Present (Y/N) ¥ Date Completed Ma Yield Total Depth 7 0 ' Cased to 7 0 ' Depth of Grouting None Static Water Level 2 7 ' Casing Height Above Ground 2 ' Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot None N/A 2 qal/min. Pump Set At 57 ' Sanitary Seal on Casing (Y/N) Y Depression Around Wellhead (Y/N) Sl~qht None ; On Adjoining Lots None None To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by A. Water Sample Test Results Comments ; On Adjoining Lots 13 5 ' To Nearest Public Sewer 6 5 ' To Nearest Sewer Service Line on Lot Harala ;Date June 13~ The depression around the well head must be 65' 1985 - 11:15 AM filled with impervious material and sloped away from the casing. B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course Size No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field X, To Stream, Pond, Lake. or Major Drainage Comments Page I of 2 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (WN) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Sen/ice Line To Stream/Pond/Lake/or Major Drainage Course To Driveway. Parking Area. or Vehicle Storage Area Comments Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Lest Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off*' Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed 7~'~tz~.~.~Date June 14, Company _QUADRA Eng~n~r~n~tOANo. Date of Payment Am ou nt:$ f.~a~~J~,,~ '~,~~~' %~ Engineer's Seal Page 2 of 2 401 ERST FIREWEED LRNE RNCHORRGE, RLRSKR q9503-2197 C~07) ':'7~-3~0 ~TR~RX ,0. (~07) RNCHORRGE · JUNEI:tU · BETHEL · FFIIRBRNKS June 19, 1985 Municipality of Anchorage D.H.E.P. Division of Environmental Health 825 L Street Anchorage, Alaska 99501 CTION JUN 9 .RECEIVED Subject: Lot 17A, Block 4, Campbell Heights Health Authority Approval Gentlemen: The well on the subject property was inspected on June 18, 1985. The depression around the well head was filled in and is now acceptable. The private sewerline emanating from the house is connected and outfalls into the public sewer along 67th Avenue. Sincerely yours, Michael E. Anderson, P.E. MEA/jb Time, Time Date Date ~mmenta ~naltloa~l Approval Date Sewer Install~ Pe~lt No. Septic Tank 81ze Holding Tank Size ~it~ Rating Well To Absorption Area Well L~ Recelv~ Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Prope~y Owner ~'~ ~ /~) Phone Buyer Address Lending laslllu~lon P~oae Addres~ Realty ~. & Agent ~ Phone Address Type~f Residence ~ Single Family J ~ Multiple Family No. of Bedrooms ~ Other ,,' Wate~upply ~ Individual - ~ A~ACH WELL LOG. A well log Is requlr~ for all we~'ls drlll~ since June ~ ~mmunlty 1975. For wells drlJled prior to that date, give well depth (attach log If ~ Public Utility available.} Sewage Disposal . ~ Individual Year Individual Installed: Public Utility When ~n~ected to Public Utitity: ~ Holdln~ Tank I NOT~: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. April 2?, 1982 Theodore J. Missly General Delivery Chugiak, AK 99567 SubJect~ Lot 17A Block 4 Campbell Hts. Approval for the individual sewer and water facilities cannot be granted until the following items have been completed: ~_.3%~well log submitted to this office for our files and review. ~%e depression or pit around the well casing needs to be fi'lled with impervious type soil so that it slopes away from the well casing. ~e water analysis report needs to be aubmitted to this .~.e from the Chem Lab, 5633 B Street, for our review. Please make arrangemen~to o~t~i~T'~ per~ Please notify t~is department for a reinspection when the noted discrepancies have been corrected. If there are any further questions, please call this office at 264-4720. Sincerely, Robert C. Pratt Associate Environmental Specialist RP91/p/EII