HomeMy WebLinkAboutGOLDEN HILLS BLK 2 LT 3 oldcn Hills
Block
Lot 3
#015-122-35
Municipality of Anchorage
On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP221059 PID Number: 015-122-35
Dwelling: X Single Family (SF) [:] with ADU E] Duplex (D) Rm Two Single Family Project: [:] New M Upgrade
Name
Donald & Edna Shugak
ABSORPTION FIELD
R Deep Trench El Wide Trench R Bed E] Mound
Site Address
10180 Curvi St, Anchorage, AK 99507
❑ Other
Phone
907-223-0493
Number of Bedrooms
3
SI 1
Total depth from original grade
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe inv rom original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Golden Hills 2 3
Fill added above original grade
Gravel length
. I-- Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Line -t-,
11istance between lines
Ft.
SEPARATION
DISTANCES
TO
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. betwe enches
From
Tank
Field
Tank
Line
Ft2
Well
>100,
>100'
N/A
N/A
>25
TANK 0 Septic El S.T.E.P. El Holding [I Other
Manufacturer
GREER
Capacity
1000 Gal.
Surface Water
>100'
> 100'
N/A
N/A
Material
PLAT IC
Number of compartments
2
Lot Line
>5'
>10'
N/A
N/A
NA
Foundation
>10'
>10'
N/A
N/A
UFTi UATION
Manufacturer
Capacity
Remarks
Gal.
Alarm location
ElectriGa ed by
Installer
PIPE MATERIAL House to tank D3034 drainfielTank
to dD3034
JR's Septic
Drainfield N/A CO/MT N/A
Inspector JI.Millette IBENCH
MARK (Assumed elevation) 100 ft
n 1�t 5/26122 5/26/22
I rispdatesectio2nd
:
Location and description
3rd 4th lBottom
of Siding
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
..41� . �k
oF
Conditional Approval: Date
Aw
49 TH
WWI .......
.. .. ......
Septic S s
ben'a chiller
—1st
ve
Approved Date
6, CE 12592
vj)r.
5/31/22
AM,
kPROFESSO—
Note: this approval does not include well permit requirements.
k EV v.rrvu 1U)
GOLDEN HILLS, BLOCK 2, LOT 3
PERMIT # OSP201475
PID # 015-122-35
V.J
PROFILE AS -BUILT
(NO SCALE)
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PERMIT # OSP201475 PID # 015-122-35
LOT 2
�EXISTING WELL
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LEGEND
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2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEAN(
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
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MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP221059
Work Type: SepticTank Renewal
Tax Code Number: 01512235000
Site Legal Address: GOLDEN HILLS BLK 2 LT 3 G:2539
Site Mailing Address: 10180 CURVI ST, Anchorage
Owner: SHUGAK DONALD R & EDNA S
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date:
�17�ent
.moo `Sr,
r�
n r,
Department t
3/21/2022
3/21/2023
Lot Size in Sq Ft: 50809
Total Bedrooms: 3
❑ Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Veronica Pope
GE 2022.03.21
Received By: 10:31:26 -08'00'19 Date:
Issued B /
y� Date: 312 f1:2 0,2 ,2,
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 015-122-35
Property owner(s) Donald & Edna Shugak
Mailing address P.O. Box 230608 Anchorage, AK 99523
Site address 10180 Curvi Street Anchorage, AK
Day phone 223-0493
Legal description (Sub'd., Block & Lot) Golden Hills, Block 2, Lot 3
Legal description (Township, Range & Section)
Lot Size 50,809 Sq. Ft. Number of Bedrooms Three (3)
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) ❑X
Septic Tank
RX
Upgrade ❑
(w/wo AD U)
Holding Tank
E]Renewal
❑X
Duplex (D) ❑
Privy
❑
Multiple Dwellings ❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
'
771
(Signature of property owner or authorized agent)
Permit/Rush Fees: V I q 5 Waiver Fees:
Date of Payment: 3 a l I a Date of Payment:
Receipt Number: O W 2,31 b Receipt Number:
Permit No. C S P a a 1 0 5 9 Waiver No.
Permit App_:- ::-.,:c
March 17, 2022
PO BOX 240773
ANCHORAGE, AK 99524
522-7773
677-7766 (FAX)
FORGECIVIL.COM
MOA Development Services, On -Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Golden Hills, Block 2, Lot 3 —18180 Curvi Street
Septic permit renewal
Dear On -Site Services Engineer:
. A/
AW
*: 4 TH •.
..........
Benja m Schiller
�'��, • CE 12592 • i�`4`��
��T�`• . 3/17/22
The permit for the replacement of the septic tank on Block 2 Lot 3, Golden Hills Subdivision has
expired. There have been no substantial changes to this lot or to the surrounding area since the
permit was originally issued. The current design and permit conditions meet all code requirements.
We therefore request the renewal of the permit for the septic tank replacement.
Sincerely,
Benjamin Schiller, PE
11.18.20
MUNICIPALITY
Community Development Department
Development Services Division
On -Site Water & Wastewater Program
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 015-122-35
Property owner(s) Donald & Edna Shugak
Mailing address P.O. Box 230608 Anchorage, AK 99523
Day phone 223-0493
Site address 10180 Curvi Street Anchorage, AK
Legal description (Sub'd., Block & Lot) Golden Hills, Block 2, Lot 3
Legal description (Township, Range & Section)
Lot Size 50,809 Sq. Ft. Number of Bedrooms Three (3)
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑ Initial ❑
Single Family (SF)
❑X
(w/wo AD U)
Septic Tank NUpgrade FX_1
Duplex (D)
❑
Holding Tank F-1Renewal ElMultiple
Dwellings
❑
Privy ❑
(SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: $165,75 Coutp Waiver Fees:
Date of Payment: 11 17 1 a 0 3 Date of Payment:
Receipt Number: d (3 2 3 Receipt Number:
Permit No. 0S (P 20 1 L475 Waiver No.
Permit App_::- : , _.,:c ;
PO BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
November 12, 2020
MOA Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Subject: Golden Hills, Block 2, Lot 3 – 18180 Curvi Street
Septic System Design
Dear On-Site Services Engineer:
The septic tank on the subject property has passed its useful life and must be replaced.. We are
submitting this application for a permit to construct a new septic tank. The attached site plan
identifies the location of the home, the existing well and the proposed and existing septic tank
sites. No conflicts exist between this proposed tank location and any other well or septic system,
whether on this lot or adjacent lots.
The new septic tank will be placed near the same location as the existing tank. Storm water
drainage will not impact this site.
Wells on this and adjacent lots are shown. The new tank will be a minimum of 100’ from all wells
and surface water, and more than 5’ away from the absorption trench. No surface water is within
100’.
Please refer to the attached plan sheet for the septic design. If this design is followed, there will be
no adverse impacts to adjacent properties.
Sincerely,
Michael E. Anderson, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201475, Rebecca Carroll, 11/18/20
EXISTING WELL
1"=50'
DECOMMISSION EXISTING
SEPTIC TANK PER U.P.C.
3 -B D R M HOMENOTE:
NO SLOPES >25% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE
PROPOSED SEPTIC SYSTEM
ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC
SYSTEMS.
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
MH
GOLDEN HILLS, BLOCK 2, LOT 3
CURVI STREET11/13/20 FEET
0 50 100
TEMP TURNAROUND
50' RADIUS10' UTILITY EASEMENTSV
2CO
PLACE NEW 1,000 GALLON
SEPTIC TANK w/20" MANWAY
OUTSIDE 100' WELL RADIUS.
EXISTING ABSORPTION TRENCH
TO REMAIN IN SERVICE.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201475, Rebecca Carroll, 11/18/20
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF I"IEALI'H & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAMJ~--~
MAILING ADDRESS
LEG& DESCRIPTION
~'O~AT'ON ~. C~. ¢.. UI ~%--
' Well
I DISTANCE TO: I /~O '
~ ~ M~turer ~ ~J
~ [Liq. caybt~rballon, IF ~M~ADE:
~ ~,,c~o: Iw~''
~;~ JNo, ofUn.s f JLen~¢~ofelc~Uq%
~~~ish grade
~' ~enath W~dth~
- ~ ~O: Well -
~ lCl~s Depth
_ ~1~;o%..,,~,n-""
j Abs°rpt~l~ar)a
Inside length
Dwelling
Foundation /~..~ I~
Totaf l eh gt h/o~_~n e~
NO. OF B .F~OOMS
[ Dwelling ~,~.¢~_ (, PE I O.
/ ~4~ ~ __ -- NO. of co,~.~tme,lts
JWidth O / ~ ~ Liquid depth
PERMIT NO.
IMaterial Liquid capacity in gallons
ITrench ~ inches
Total eff~lv~b~n area
PERMIT NO.
Tota~ eff~;ive~bsorption are~
Nearest lot tine
Material beneath tile
Depth
Crib depth
Building foundation
Driller
Sewer line
OTHER
PiPE MATERIALS
SOIL 'TEST RATING
INSTALLER,
9.; T I:;~'. E E T., FIi'.,I E:H 0 F..' FI G E., FIK. SL 3 ::[.
[)E:E"I::'FIF~:I'ME[NT ,nr;' HEEI:::~L. TFI FIND EN'v' t FitEd'.,IMET.~"r'FIL, '"[;':',O"f'EC'T'I ON
FIF'F'I...ICFINT SOLO [:,E',,,'EI...OF'hlENT '72,4- EFI'.".T,T i~'T'H F:I'v'E
L. OE:FFr' I ON Cl..ll::::',,,' ]i
L.E[GFII... L..OT ]: E:I...I.::: 2 GOLDEN HILL.:E; Eq...IE:: LOT $I2:E
')"¢F'E OF SOIL FIB$OI:E'.F'T];CiI'.,I S'¢STEf,t
MFt::.:', I i'"lLtI'l i'.,II...IME:EF..: OF
THE[ REI]:!I..IIRE[:, 9IZ'E OF THE SOIL FIBSORF'TIOI'.,I $Y:=';TEM I':T':;:
THE LEi'.,IG'rH DIMENSION IE; THE LENGTH ,:i IN FEET) OF THE 'TF.'.ENCH OR [.':,RRINFIEL. I:).
THE [:,[EpuFFI OF FI TR[:-.NCH OR PIT II.7, THE DI'.'E;'ITIN(.":E BETI.4EEI',,t THE :i~LIRFFICE OF 'THE:
L~iF~:I.)IJI'.,![:, FIN[:, THE E:OTTCIM OF THE E::.::E:Ffl',,,'FYf'ICII'.~ (II'.,l FEET).
TH[ERE' IS NO '.'SETF N IDTH FOR TREI'.,IC:HEE;.
THE GF::I~',,,'EI... DEPTH I'E, THE MIl'.,lINIJhl [:,EF:'TI.-I OF GF~:I::I',,,'EI... E:ETHE%'N THE OIJTFF~L.L. PIPE
FIND TFIE{ E~O'r TOhl OF THE EC:.:;C:F:I',,,'FI'r' ~ ON ( I N F'EIE'T' ).
F:'Et:;i:h11' T RF'F'L I CI::tI'.,FF HR'.-:}: THE REE:;F'C~NS I E: I L I T'T' TO I NFOR'M T'H I :~ .[:'EF'FIRTMENT P l...I F". .1:. NG 'T'HE
I N"-XTFILLF~T :[ 01'.~ :[ I'.,I'.Z-';F'ECT I Ol",t'.:."; OF' FIN'T' klF-"'L.L'.:."; FI[)SFIE:ENT 1'0 TH 1 9: F'F!Cd"-"EF~:'["¢ Fd'.~[:, THE
NLIME:ER OF F.':E'.'.-'.';I[:,ENCES THFtT THE HELL [dILL SEF!',,,'E.
.................. "1'" It,JI E~ ,:'.' ;;::.:" :;:, ]: J'-,J :'~, F' E (E.'. -If"' .'lf: ~:} J'..41 ~.:_::; II::~ r~." EE F--i: F..: 6::., IL.Il
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DEF'FIFi:FMEt",Ff' H I L.L. E:E SIJB..TECT TO F'RO'.:J;ECLIT I ON.
MII'-,III'ILIM [:,ISTSi'.,IC:E E:ETf'klI!:~;EI'.4 R I.,IEI..J_ F:I?.,t[:, FIN"r' ON-SITE ?,EHRGE DIL-qF'OSFIL. L:'i'T'STEZM IE;
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L.IF'CII'4 THE:. T"¢F'E OF F'I...IE:LIE:
i"llNIMIJh~ [:'I:~TRi',ICE: FROI"I R F"F.':I',,,'FITE HEL. L TO FI F'tE:I',/RTE '_=.,El.,.fEi~: L. II',IE I."3 25 FEE::T FIN[)
TO R COI"IMUNZT'-/ :E;EHEF: LII',IE I:E; 75 FEET.
1.4ELL. LOG'.?, RRE F.:EQUIF.':ED FIN[:, i"IUST BE F..'ETUF::NED TO THE [:,EF'FIRThlEI".,IT HITHZN
OF THE I.,.IE/..L. COMF'I...ETI
OTHEI;~'. I~;~'.El:."41..I I F,:'.EMENT'.:.; hlFl'¢ FIPPI...'¢. ::.-7, F'EC I F' ~ C:FFF ;I; ONS RN[:, C:ON'E, TIE:UCT I ON t7.:, I RGF~:Ri"IE; FIRE:
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F'OFi:TH B'~.' THE i','IUN I C: Z F'FIL. I T'./ OF' FINCHORFIEiE.
;2: ~. HILL ]:I'.,ISTFIL. L THE E;"r'STEM IN FIC:C:OF::DFINE:E HITH THE CODES.
2: I UNDEF:%TFINE:, THFtT THE ON-'-.:iiZTE SEI.,.IER 5'.¢::T.,TEr,1 r,lR'¢ RE(T&.IIF,.".E ENL. FIF::GEMEI'.,FI" IF:' THE
I:;;:ESIE:,ENCE: I:.E; F:EMOE:,ELE:E:, TQ INCL. UDE MOF.:E: THFII',I ..E..': BEI.":,ROOMS.
FIPF"L. I C~T ':7, OL..C, DE',,,'ELOF'MENT
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Alaska 99~02 776-2221'
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED FOR: ,-S'("J'~-~ ~,~
LEGAL DESCRIPTION: ~¢"~:~ ~'"
2
3
5
6
7
8
9
0,,,,~ ,~¢/~ ,,,,,r¢~,~ SLOPE SITE PLAN
r--' ri r i i i l
m-L- ! ~ -
,./ !
~_.
lO
11
12
13
------.14
15
16
17
18
19
2O
Earl R. Barnard ," YES, AT WHAT
·
754.E
¢~DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE ~,~¢ --~ (minutes/inch)
TEST RUN BETWEEN '"~*~) FT AND .~' ~ FT
72 008 (7/76)
COOK .T H hE't'
14~:4 E, 27l:h
~%~ct,ur~e ~ A1 a:'}.:',
U9504
2';6-
PROPERTY OWlqER:
LOCATION OP WELL:
DEPTH OP ¥,~DLL: 156'
DRILLING LOG:
STATIC LEVEL:
YIELD:
FORE~;.OST
LO' ,3.
B]~'J~ER:
O .- ~0'
~0 - 40
40 - 60
60 - 77
77 -
1~ -I 1'/
117
117- ~>0
150 - 150
G()l,l,q'::. ,[ZLL~ GU1{1).
brownisl, tirt.¢' clUy~ ::8nd
gravel
gruvc], with zone
x'ock ~ ti,o' (h~d
m:}utJ)' ;'ru,,l~ {.:rr,veL (lkttle cl~y)
90" :L'n:,!:
PROPERTY 0W~ER:
LOCATION 0P VfELL:
DE]P!I)H OF V/ELL:
DRILLING I,OG:
b, [.
TA ~IC LEFEL:
~IELD.
i4,5!4 E. 27t:h Ave,
Anchor~'~e ~
?504
2'/6- 2025
0 -- 50~ 1):pou:~ ~'7'xtv~,~ ~
50 - 40 b:r'c.,wrd:~h ~74,'
40 - 60 r3~cl~ ~rc~zr, 1
60--77 sn~'~r~, grave3
77- 85 ~r,~ui~ rgci,:~ c] ~t,',' (ha2:'4 pan)
~i5 -100 uxx:t,]y :'::t,t: ':ru:vel (ti. Lt]e
O0 -1 i7 xx~re :ll,G~ !o.;:. ::qnd at2~ grr~vell
i17 : ::.nd.)' L' ~"zi:':[ , ~i2 ~
150- i56 e)rn-:, :':2;z tm[
fY1-W DRILLING, Inc.
P.O. Box4-1224 · 13i0C Inte~na[iormlAi~pmt Road
(907) 274-461 ]
ANCHORAGE, ALASKA 99509
DRILLING LOG
Well Owner .......................... Use of Well
Location (address of: Township. Range, Seetion, if known; or clistance main roa& .........
Size of casing. Deplh of Ilole .... feet Cased to .... feet
Static water level _ft. (above)
Screen ( ); Perforated (
Describe screen or perforation
(below) hind surface. Finish of well (check one)
).
open end ( );
Well pumping test at_ __ gallons per (hour)
of drawdown from static }evel.
Date of completion
(minute) for hours with .......
WILl. LOG
Depth in feet from
ground surface Give details of formations )enetratcd, size of material, color and hardness
ft.
...... TO
....... TO __ _
......... TO .....
_TO
TO_ _ _
__TO
TO
...... TO
. TO
..... TO
_ .TO
3 -- CONTRAC'rOR
MUNICIPALITY OF ANCHORAGE
Development Services DepartmentPhone: 907-343-7904
On -Site Water & Wastewater Section r Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 015-122-35
1. GENERAL INFORMATION
Expiration Date: q -N-20- Z
Complete legal description Golden Hills Block 2 Lot 3
Location (site address) 10180 CUryl Street
Current property owner(s) Donald & Edna Shugak Day phone (907) 223-0493
Mailing address PO BOX 230608, Anchorage, AK 99523
Real estate agent
2. TYPE OF DWELLING:
❑■ Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑■
Private Septic
limil
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ .550
Date of Payment 6//_Z z
Receipt Number O 6 3 70D
COSA # Oma, L22. 1 2. 53
Waiver Fee $
Date of Payment
Receipt Number
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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Engineering Phone (907) 522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503
Engineer's Printed Name Benjamin Schiller, P.E. Date 06/01/22
Aw
�-,
6. DSD SIGNATURE —. . .r
System #1 Approved for bedrooms r �. Benjarr . chiller
System #2 Approved for bedrooms ��% CE 12592
Tic
06/01/22 . • '�G
Disapproved t>ki�, PROFiSS10���'r
Conditional approval for bedrooms, with the following stipulations:
llll(((((ffr
O�_S� �o
�M
Joo ROG�A FR �:z..
F
BOriginal Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Legal Description: Golden Hills Block 2 Lot 3
If more than 1 septic system on lot: COSA Checklist # of
Parcel ID: 015-122-35
Structure served by this system
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Well production at time of test 5.8 gpm
Date drilled 9/4/1978 -
Water storage tank volume N/A gallons
Total depth 156 ft
Well disinfected for coliform test? ❑ Yes ❑ No
Cased to 156 ft
❑ Coliform bacteria is Negative
❑ Sanitary seal is functioning correctly
Nitrate 8.68 mg/L ❑ Nitrate less than MRL (ND)
❑ Wires are properly protected
Arsenic 5.0 ug/L ❑ Arsenic less than MRL (ND)
Casing height (above ground) 26 in.
Collected by Forge Engineering
Date of flow test for COSA 11/4/20
Date of Sample 6/1/22
Static water level at beginning of test 80.2 ft.
Comments
B. TANK DATA
Age of tank(s) `1 years
Tank type/material Septic/Plastic
Measured operating fluid level in septic tank NEW
❑ Standpipes/foundation cleanout per record drawing
Date of pumping NEW
D. ABSORPTION FIELD DATA
Which system tested (date installed) 8/24/81
❑ ALL standpipes present per record drawing
Total measured depth from grade 14 ft (max)
Measured depth to pipe invert from grade 4 ft (min)
❑ N/A — pressurized field
no Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced N/_ A gallons
Com ments/Deficiencies:
COSA Checklist yellow sheet
IFT STATION
❑ Requi aintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 11/4/20
Results ❑✓ Pass For 3 bedrooms
Fluid depth prior to test 84 in
Water added 551 gal
New depth 107 in
Elapsed time 1440 min
Final fluid depth 83.5 in
Absorption rate '450 gpd
Any rejuvenation treatment (past 12 months) N/A
If yes, enter date N/A
E. SEPARATION DISTANCES
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' Q✓ Yes if No ft Surface Water > 100' Q Yes if No ft
Property Line > 5'
❑✓ Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
From Private Well on Lot to: (Please enter distances if less than required or if community well)
if No
ft
Septic Tank/Lift Station on Lot > 100'
Water Main > 10'
Q Yes
Community Sewer Manhole/Cleanout > 100'
ft
® Yes
if No
ft
❑✓ Yes
if No
ft
Neighboring Tank > 100' M Yes
if No
ft
Private Sewer/Septic Line > 25' M✓ Yes
if No
ft
Absorption Field on Lot > 100' P/ Yes
if No
ft
Holding Tank > 100' 0✓ Yes
if No
ft
Neighboring Absorption Fields > 100'
Animal Containment > 50' Yes
if No
ft
M Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' Yes
if No
ft
0✓ Yes
if No
ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' Q✓ Yes if No ft Surface Water > 100' Q Yes if No ft
Property Line > 5'
❑✓ Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
Yes
if No
ft
Private Wells > 100' 0 Yes if No ft
Water Main > 10'
Q Yes
if No
ft
Community Wells > 200' Yes if No ft
Water Service Line > 10'
Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' ✓V Yes if No ft If absorption field is under driveway comment below
Property Line > 10'✓0
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
Q
Yes
if No
ft
Private Wells > 100' Q Yes if No ft
Water Service Line > 10'
Yes
if No
ft
Community Wells > 200' Yes if No ft
Surface Water > 100'
Q
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that 1 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.
COSA Checklist yellow sheet
OF
G?.4.9 TH
'
. Benjarr Schiller
CE 12592 • c`�i
. ,
06/01/22
�� PROFESS10N4��'�
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC 221253
Subdivision: Golden Hills Block 2 Lot 3
A water sample revealed a nitrate concentration of 8.68 milligrams per liter (mg/Q.
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.
t
Mailing Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www murn org
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.
Ma�6rg Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org
a �t
Municipality of Anchorage
',Development,Services Department
Building Safety Division
On-Sito Water and Wastewater Program
4700 South Bragaw St. - '~
P.O. Box 196650 Anchorage[AK 99519-6650'
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE.OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D, 015-122-35
!'i F~)RM..A. TION
omplef6,1egal, esc.n, pt~on
2
Loc~t[0'fil'(site'~'(~:e direCtions) . 10180 C[]Ev-[ S'~]mT, ~, .N~ 99516
· , ':.* 'Y;;e-'..'.' ;,' ;, '.'~'.~', .'.. :"'", 3'
~C~enLEro.~_.rty~0wfi~(s) JOANI~ D. JO~80N Day phone
~. ..'. ../ · ...... . ...
':Maili~ig :add~'~ss<.'' -'
Lending agency
Mailing address
'Real Estate Agent
Mailing Address
Expiration Date:_ ~'~ ,-- ! ~.
ANCHORAGE, AK 99516.
Day phone
KATHI J~/ JACK WHITE Day phone 762-7562
3201C Street, Anchcxage, AK 99503
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF VVATER SUPPLY: '
Individual Well
Individual Water Storage
; Community Class __
Public Water System
TYPE OF WASTEWATER DISPOSAL:
I~ Individual On-site J~
r-'l . Individual Holding tank, ['-I
Wellm ~ Community On-site r-I
.,. [] Public Sewer [-I
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for propedies served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water 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.
/"3
' ,' .:.Weli"P~o~d~i0n'''''' ';'~ ~ '3~"i :.:'; {:~,, i g.p.m. ~,,~ ,~ :- , I'
~ ,, ~~',~
~'~ . :: ~' -WATER S~MPLE RESULTS:
i,, .: ~ ~, ?.. r .' lU
' ~"' ;- ; . Cohform ~,,~J~: colonies/100 ml~'~,' .:, ,g./I. : ~;~ { ~,. Ot~er ~te[~~colonies/100
;:~ ' ' .' '' '?,'. '~ '~ q" :'..:;'L~?.' ~ ~ .....' ~ :,~'
' ' ~;', ~'
] ~',' I~ . j~.
N)i~~-- " ' ,,~:
. :~t B. SEPTIC/HOLDING TANK DATA'' :i
~ Tank Type/~atefial : .<~"-t ~ / i , ~.
t '.' :..i;kt:'f.;';*...'.'..;<~;,... . " '
': Tank,size,il't 0F')..gal..'-';, Number ?Compartments
~ ..... ~.:; ~ - -:"~ '.~ ' , = , t , ,
. oundaboncleanout (~//N) -~l , Depress on'over tank
'j"~:' ::'{' .~I"'"'.; " "- ' -,,'-~, ~ '. ~.,' :
I ". -;',,' '.l.,J.¥.. ,' .... ; '~'; '. ~IP*':,I ' I'I
. .D. ate.o.r..p~mp,ng., ~/:It 1!-,~, c/',: ~.umper ~:~.
~..?'::."':;:l,I~;~.i%.. .:::,.;.,;' t' tl i
c, ABSORPTION FIELuu~T~ ~.' i : ii i .
; ,; :i' "~' ...... , .... ;'' r
..'~, I ,= -; ' I:-':* '
! Date !q.~ta~!~d Y/'Z~/.e/.. So,,ating (g.p.d./it'
I '~ ....., ".., - . ' : ....
"Length, t,.,.. I~ ft.- "' Width' '
;t;:,i~ ':' ~:' "'" "~'1! *'' ' " ,'
"': ' ' .*.',!l 2(7/3 ..,
Total depth//J, ~.. ft. · Eft. abSorPtion area ,-~ou
": ii , ' .... ' ,
· I ~I ' : '.~-~,~ '1'-, ;:!i':I I i:, I,
Dateofadequacytest'5`jll/~(j''l~';;. . ~... Results'
· ~' { t ~ i= : ~' : * ,:,; i;!;: l ,, I
Fluid Xp,de, ' - --"" :
h'in absorPtion field before test !:..~ ;in
;:'!'t ;I ! ' ' ' 'i" :
. q t !., ~,,/: ; ~ ', Il. t:;,~ T .
Elapsed Time: ,,'/(=,. min.i' :Final .flUid 'depth .5'...~'
, , . ,.;,l.I,, . '""'
^ny rejuvenaUon treatmeni (Past' 12 m0.)'iY/N & tyP~) i i
"::' ' " ' *'" !
!i:I :, ., ',r' , :
,'.'~ :i:i :';=::i:= 'i::i iii:'!:
' ; ': : ':, .:; ! i :,,, ::
, I..8'86 I.. ':I,,L I., I.O. OOS
J. N3F435V3 ),IIglJ. F} ,0~
Z W'
C
..<
--I
Z
0
c
z
Municipality of Anchorage
Development Services Department:
Building Safety Division.....
On. Site Water & Wastewater Program *
' 4700 South Bragaw St.
P.O. Box 196650 A~chorage.'AK 99519-6650 '
.' www.ci.anchorag e.alLus
(907) ~43-?g04 ,~ -
CERTIFICATE OE HEALTH· ,b,0THOR'I'TY.i ,PPROVAL.
FOR .b, SINGLE FAHILY DWELLING '
GENERAL INFORMATION
-C~m'~)lete legal desCdpUon
Location (site address or dire~ons)
GOLDEN 'HTLL'S' SUBDIVISION; I~(~:r' .3, BLOCK '2 '
10180 CURV1 STREET.* ANcHORAoE~ AK 99516
Current Property owner(s) JERRY KOCER
Day phone' 266-8380
Mailing address
Lending agency ,.
10180 CURV1 STREET * ANCHORAGE, AK 99516
· ' ...... Day phone
Mailing address
Real Estate Agent LORI HACKENBUEGER w/ DYNAMIC PROPERtiES Day phone
Mailing address 3111 "C" ST. ANCHORAGE~ AK. 9950.3
Unle'ss o~hen,Y/se requested, HAA will be held by DSD for plckup.
261-7600
2. NUMBER OFBEDROOMS: 3
3. 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
Community On-site
Public Sewer
The Munlclpality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given In paragraph 5 by an Independent professional civil
engineer registered In the State of AJaska. Cer'dficates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties sewed by a single family on-site wastewater disposal and~or
water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of Issue for prepares sewed by a private or Class C well and may
be reissued with new water sample results less than 30 days old. (CerUficates may be reissued for a period of
up to one year with valid water samples.) Ce~ficates are valid for one year for properties served by Class A or B
welIs or a public water system. The Municipality of Anchorage Is not responsible for errors or omissions In the
professional engineer's work.
Note:Alaska Water and Wastewater Consultants, Inc. shall be pald $ ~:~O at, or prtor [
to closing for the engineering s~fces provfded. ·
I
4. STATEMENT OF INSPECTION BY ENGINEER
As ce~fied by my s~al affixed hereto and as Of the vali~a~on date shown below, I redO/that my
Inves#gation, based on procedures outlined In the Health Authorfty Al~oro~l Guidelines for this applicab'on,
shows that the on-site water supp~' and/or wastewater disposal system is(are) safe, functional and adequate
for the number of bedrooms and ~ of structure indicated herein. I further redly that based on the
Information ob~lned from the Municipality of Anchorage tiles and from rny Inv~sb'gation and Inspection, the
on-site water supply and/or wastewater disposal system Is(are) In compliance ~th all applicable Municipal
and State codes, ordinances, and regulations In effect at the time of installation.
Name of Firm ALASKA WATER &: WASTE-WATER CONSULTANTS, INC. Phone
Addr~)ss 6901 DEBARR ROAD. SUITE 2B * ANCHORAOE, AK 99504
Engineer's Printed Name JEFFREY A. CARNESS. P.E.
Data
337-6179
Engineer's comments:
In conducting this evaluation, AWWC, Inc. attempted to provide e thorough,
consden#ous englnesrlng anal/sis uf the ~Tstern In accordance wlth ADEC and MOA
DSD Guidelines & Regute~foes. The reported resulls dosctfbed the performance of the
syStem under tho conditions encountered at ~he f?'me of the test and separatian
distances measured to resdi~, Iden~fiable features. The operational life of all vPolls and
sapac systems depend on the Iocal sel/s condition, groundwater levels that may.
flucfua~e during the year, and the water usage of the family being served by the system.
These conditk;~s are outside the c~b'ol of the evaluator of the system. ,Sa#sfactcN'y test
results do not guarantee future performance of the s~tem, horde they guarantee that
there are no hlddan defects or encroachments. AWWC, Inc. can therefore not pa~fde
any warranty or future estimate of how long the system will continue to mast the
operational requlremonte of the ADEC ur MOA DSD. The content of this report Is for
the sole benefit of the oymer listecl aboye. Any reliance utx~n or use of this report by any
other peraon or party Is not authorized, nor will It confer any legal right whatscever.
5. DSD SIGNATURE
~ Approved for :~ bedrooms.
Disapproved.
Conditional approval for __
Attachments:
HAA Checldist
Septic System Advisory
Well Flow Advisory
Manitenance Agreements
Supplemental Engineer's Reort
Other
OHglnal Certificate Date: ~ ' ~- O - (::) /
Municipality of Anchorage
Development Services Department
BuDding Si;u~y Division
OmSlte Water & Wastewater Program
4700 6oulh Bmgaw 6L
P.O. Box 196650 Anchorage, AK g9519-6650
VAW/.cl~nc~.ak.us
Legal Description:
A. WELL DATA
Well ~ PmVAT[
Date completed 9/4/78
Toteldepth 156 It.
HEALTH AUTHORITY APPROVAL CHECKLIST
GOLDEN HILLS S/D; LOT 3, BLOCK 2 Parcel ID:
IfA. B, or C provide PWSlD~ N/A
~tO 156 ff.
FROM ~ I LOG
9/4/78
148.5 It.
20 g.p.m.
Date of test
Static water level
Well production
WATER ~sJdPLE RESULTS:
Collfmm 0 co~lles/lO0 mi.
Date of ~ample: 4/30/01
B. SEPTIC/NOLDING TANK DATA
Nti~ate 4.57 mg./L.
Collected by:
Tank l~jq~tedal STEEL
Tankslze 1000 gal. Number of Comparlmante 2
Date of pumping 4/26/01
C. ABSORPTION FIELD DATA
Date Installed
Lenglh 19 lt.
Dapmsskm over t~k (Y/N) NO
Pumper,
B GRADE
rating (g.p.d./ft~or ~)125
Wen Leg (Y/N)
Wlms pmbe~, protected (Y/N)
Caalng height (above ground)
qBl-112-35
YES
YES
AT INSPECTION
4-30-01
80 ff.
5.0+ g.p.m.
Other becte~a o
iNC.
Date Inst~ed 8/24/81
C~anou~ (Y/N). YES
High Water alaml (y/N) N/A
ISACCS PUMPINO
Toteldeplh 13.9 ff. Eff. abso~Uonama 375 tt' Mm~odngtube YES
Date of adeduacy test 4/50/01 Results(Pass/Fall) PASS
Fluid depth In absoq~inn field before test 77.5 In. Water added 600 gal.
Elapsed Time: 9 min. Final tiuld depth 87 In. AI~ late
Any rejuvenation treatment (past 12 mo.) (y/N & type)
IKIZ In.~
System type DEEP TRENCH
Greml below pipe 10 It.
Depression over tield NO
For 3 bedrooms
NONE KNOWN
New deplh 94.51n.
450+ g.p.d.
If y~, ghm date -
D. UFT STATION
Date Installed size In gallons ~ _
"pump on" level at In. "Pump n. High water alarm level at In.
~ Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT~'O:
sepuo m .tauun on et
Ab~un field on lot 100'+
Public sewer main N,/A
Sewer lespllo eswlce line 25'+
On adjacent lots 1 oo'+
On adjacent lots 100'+
Public ~wer manhots/cleanout
Holding tank N/A
N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: *PER 1981 INSPECTION REPORT
Property line 5'+ Absorp~on field. .5'+
Water eswlce line. 25'+ Sur[ace water 100'+
Bulldlng foundal~un 5'+
Water main N/A
We~ on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+
Water service line 25'+
Cultein drain NONE KNOWN
F. COMMENTS
Budding foundaUon 10'+
Surface water 100'+
Wells on adjacentlots 100'+
Water main N,/A
Driveway, paddng/vehlcle steraga 20'+
G. ENGINEERS CERTIFICATION
I certify that I have determined ea'ou~h field ~ and
mvfew of Municipal records glat ~ above systems ere In
conformance with MOA I.ARA guidelines In effect on this date.
Engineers Pdnte(~ Name
Date ~o/
JEPtKEY A. OARNESS
NAa, FeeS -
Oate of Payment ~,/.~/~l
Receipt Number ~'(:::~'8
(t~v.
Waker Fee $
Date of Payment
Receipt Number
"' : ' " e ·
~"'. . ': .~,,,~.~ ~. ? :.
: · · -.... e~ e.~ ~ ,
~' .. '. . '~ . . ~ · ~ , ..
~,. ..... · .... .. ..~ e · ~ ~ ~ ~L.'.
t, .. · t. ~ · .. ~~ .~ .~ . ~. :
· ... · · ~ e, ~-- -' -'- .' · ~ ....... t '
· . . · '. :' ~/~ '""- -- ·---' ' ' I
. · I . ~ .
~: '. I . .; '.. ' ' ~_ '. .
'. :' ' .-- ' . ' '~ OF Ae~ht. .
, .. . . ~.~.~ L~,L~:~I .
. . · . . . ~ ~;~, .. ·
s o~ ~o~. o~ z~ ,. ·. · ~~ZT~:~ · .
AS~E~ . _ ...... - ..... . , ~.e~-. ,.~
-- LOT ~RV~ C~TIFI~,AT,ION' . stsK PI '
~ ~ 'e~oc~' ~ .' . .. ~." · 1' ~'1 .'
· .... ' :.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Strect
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchoragc.ak.us
(907) 343-7904
Waiver Review Worksheet
WR#: WR011)~41 PID~: 01~-122-35 HA#: HA010257 Permit~:
Date Received:
Legal Description: Golden Hills ~;ID. Lot 3. Block 2
Engineer:. Alaska Water and Wastewatar Consultants. Inc,
I~101 Deban' Rd,, Suite 2B Anohoraoe. AK 99504
Applicant: Jen'v Kocer
Waiver Requested: 97 foot separation distance waiver from the well to the aeotlc tank
Cdteda:
Geology
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
Total:
Points:
Waiver is Granted: ,~ Waiver is not Granted:
List Conditions or Reasons for above: ~'J; ~-- ~')r~t"bfE~
Rec~: 59~7 Amount: 625.00
Date Paid:
~/VRIVEI~ RE4~UE$/' N~I~EI~ WROlO~4~I
W/~IV~-R REQUEST F~R O/v-lOT' I~'E~ ~vBLL 7'~ SEPTIC
I~. E. la/. 0.¢'0~ 5. C. iV.
.. Po/t,, rs
/17' 7'
· ' I?O Io ,g~.~£2~- 7.0
gI~JWO 17I-~L
ZI
/.8
IZ8
ALA$1(A WATER $ WASTEWATE
~,, ,,, CONSULTANTS, INC.
June 15, 2001
Municipality of Anchorage
Development Services Department
On-Site Wastewater Program
4700 Bragaw Street
Anchorage, Alaska 99519-6650
Ref: Waiver Request Golden tlills S/D, Lot 3, Block 2. Septic Tank is 97 Feet From the Well.
The existing 3 bedroom house is served by a private well and septic system. During our
evaluation for the purpose of obtaining an MOA health certificate, we measured the separation
distance between the well and the septic tank using a Topcon total station, and determined the
separation distance to be 97.8 feet. To be conservative, we are requesting that you grant a 97.foot.
separation distance .waiver.from the well on the referenced property to its septic tank. The
following items are justification for the waiver:
The lot topography (see the attached topography map) is such that if the septic tank were to
overflow, it is physically impossible for it to migrate to the well over the ground surface. The
other path of contamination is subsurface migration of wastewater should the tank begin to leak.
Attached is drilling logs for the subject lot, and three nearby properties. The well depths varied
from 142 feet to 206 feet deep. Water was encountered no shallower than 109 feet in any of the
wells. The static water level was 80 feet for well on the subject property, and was not noted on
any of the other well logs. All of the drilling logs shmv numerous layers of soils that are clay, or
clay mixtures. Given the depth of the aquifer, and the geological profile, it is reasonable to
assume that the aquifer is adequately protected. Water samples from the subject well indicated
no bacteria and nitrate levels of 4.57 mg/L. Although the nitrate level is moderately elevated, it
is probably not solely related to the 2.8 feet encroachment (given the depth of the aquifer, and the
soil profile). Given the age of the tank (almost 20 years old), it is reasonable to assume that it
will need to be replaced in about 5 years, at which time the appropriate separation distance can be
attained.
Based upon the aforementioned facts, it is our opimon that there ts mtmmal risk assoczated wzth
the 2.3 foot encroachment, and we request the separation distance be waived to 97 feet. If you
tlease contact us at 337-6179. Thank you for your assistance.
have any qu.estion~
E., M.S.
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
I LOT
GOLDO, I HILLS SUB.
! { ! I BE:DROOM HOUSE:
I HILLSIDr' PA~K HILLSIOF pARK I.flLLStDr' pARK
ALASKA h~,~'I'ER & WASTEWATER
JERRY KOCER 266-8580 1 OF 2
GOLDEN HILLS SUBDIVISION; LOT 5, BLOCK 2
SITE PLAN FOR WELL TO SEPTIC TANK WAIVER
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
'1-
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner C h~'/e~ Pfo~,.er, z Day phone
Mailing address
Lending agency /=qr-~-/- ~. T~t-l¢_ -o¢6b~e .qh~,~., Day phone
Mailing address
Agent Pc ¢-~ ~
Address ~¢ 0 0 ¢car ~o~,~ Z/'.~ t¢rmcloor~Vq~
Unless otherwise requested, HAA will be held for pickup,
NUMBER OF BEDROOMS:
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.
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/orwastewaterdisposalsystem is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein, lfurtherverifythatbasedontheinformationobtainedfrom
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 I ~t
Engineer's signature
Phone
Date
D~,$ SIGNATURE
' Approved for
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
~ ~ Date '-"%~- / '~ -¢ ~
[By: /
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer' registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72~)25 (Roy, 1191) Back MOA 1121
Legal Description:
A, WELL DATA
Well type P'¢/-
Log present (Y/N)
Total depth
Sanitary seal (Y/N) _
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAl. CHECKLIST
Y
If A, B, or C, attach ADEC letter.
Date completed
Cased to 15' 3 '
FROM WELL LOG
lC, /,~/
7~'
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
ADEC water system number N,
IC,/~1 Driller /~ - ~-/
Casing height I~-"
Wires properly protected (Y/N) Y
AT INSPECTION MUNICIPALITY OF ANCHORAGE
'-~/86' ( ¢~? ENViRONMENTALSER¥1CE5 DIVISION
"
Septic/holding tank on lot __ [o (.,
Absorption field on lot '-~ loc,'
Public sewer main
Sewer service line
WATER SAMPLE RESULTS:
; On adjacent lots__ ;~ too,
; On adjacent lots >, lc,o,
Public sewer manhole/cleanout N, ~.
Petroleum tank ~C,,~ e ~- e.e,,~
3.~'! r~,,/4,' /--~ Other bacteria
Collected by:
Coliform O ¢~! /~oO ¢4 ..( Nitrate
Date of sample: ~ { it/9~
B. SEPTIC/HOLDING TANK DATA
Date installed ~ { ,~ !
Cleanouts (Y/N) ~
High water alarm (Y/N)
Date of pumping _..6-13/9_~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Tank size IOO~ v~Cfl Compartments ~
_ Foundation cleanout (Y/N) ¥ Depression (Y/N)
h4, A-, Alarm tested (Y/N) N, ~
Pumper ~r ~ Ir~,~,(
Well(s) on lot I Oo' On adjacent lots ?~ lo(.,,, Foundation ~ t o'
To property line ;~ ~o' Absorption field .5-~ Water main/service line ~, ~o'
Surface water/drainage -~ (oo'
N
72-026 (Rev 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION /'4. /J-.
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 19' Width
Total absorption area ¢'
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months)
la.5- r~'/~',-,,~ Systemtype
Gravel thickness Io ' Total depth
Cleanouts present (Y/N)
~ate of adequacy test
for
Soil rating
If yes, give date t,,t, A..
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~, lc,r,, '
To building foundation
On adjacent lots
Surface water ~.
Curtain drain
On adjacent lots ~, too' Property line
To existing or abandoned system on lot
Cutbank Non~ 5¢¢n Water main/service line
Driveway, parking/vehicle storage area ~, :~o '
E. ENGINEER'S CERTIFICATION ~
I certify that I have checked verified, or conformed to all MOA and HAA guidelines in ef~,~tbedate of this inspection.
Engineer's Name %~60 ~¢~ ~. moo ¢(
HAA Fee $ / ,~'d ~ Waiver Fee: $
Date of Payment
Receipt Number
Date of Payment
'~ '~' / 7 Receipt Number
MUNICIPALITY OF ANCHORAGE
DF_PARTMENT 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) Leg.al Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
/o/80 0.u~u i ' '
(b) Applicant Name ~g¢~,' ~W~ Telephone: Home
Applicant Address ~"
(c)
Business ~q&
Applicant is (check one): Lending Institution ¢; Owner/builder []; Buyer []; Other [] (explain);
(d) Lending Institution Telephone
Address
(e)
Real Estate Company and Agent
Address
Telephone
(t) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family ¢ Multi-Family []
Number of Bedrooms '7'~,~
Other
3. WATER SUPPLY '
Individual Well ~ Community [] Public []
Note: If community well system, must have written confi[mation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
, 72-025 (11/84)
Page 1 of 2
ENGINEERING FIRM PROVIDINta ~NSPECTIONS, TESTS, FILE SEARCH, DA'I ~ AND INFORMATION "
As certified by my seal affixed hereto and as of the validation date shown below. I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances,, and regulations in effect on
the daie of this inspection.
Name of Firm ,~fl'~-'v/&/e-.. ,~ ]~s,$no.I;q~,S Telephone ,,.~/d~ lit/t3
Address ~Jh/_ ~/~m/Q'~q
ate 3-
Engineer's Seal
DHEP APPROVA
Approved for
Approved
~,/' ../ '..j
Disapproved-' Conditional
Terms of Conditional Approval
CAUTION
The Muncipal[ty 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
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
284.4,20 RECEIVED
Legal Description: .
MUNICIPALITY' OF ANCHORAGI~
DFpT, OF HEALTH &
ENVIRONMENTAL PROTFC:-,rlON
WELL DATA
Well Classification
Well Log Present (Y/N) '1/'
Total Depth _ ,/~ __ Cased
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
If A, B, C, D.E.C. Approved (y/N)
Date Completed J_O ,,q* ~! Yield
Depth of Grouting ~'
Pump Set At _ fJ/t ~J.~i¢~,'J
Sanitary Seal on Casing (Y/N) ~J
Depression Around Wellhead (Y/N) H
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ~'Oq¢¢' __; On Adjoining Lots
To Nearest Public Sewer Line .... To Nearest Public Sewer
Cleanout/Manhole ~ To Nearest Sewer Service Line on Lot ~'"'~
Water Sample Collected by . "J-~ ; Date
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed ~'2~J"~l __ Size JG¢~ No. of Compartments _
Standpipes (Y/N) _ ~ Air-tight Caps (Y/N) _ ~ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ~ Date Last Pumped 3- 2.Z~'c~,
Pumping/Maintenance Contract on File (Y/N) '- '" ; for
Holding Tank High-Water Alarm (Y/N) ~ Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line .
To Water Main/Service Line
Course
To Building Foundation ¢-.~¢'
To Disposal Field _ .~' '~
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
C, ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~- 24-~ ~
Width of Field ~ '~
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well /(~ "¢'
To Building Foundation
Lot
sc'~e~F,~ Type of System Design
Length of Field I~ ~
Depth of Field J~ /
Gravel Bed Thickness /~)
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Water Main/Service Line ~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots ! 0'~'7~'
To Cutbank (if present)
~O
D. LIFT STATION
Date ~ Dimensions
Size in Gallons % Manhole/Access (Y/N) .
"Pump On" Level at
High Water Alarm Level at ~ Vent,,(Y/N) __
Tested for /~....~~%~ Meets MOA
Electrical Codes (Y/N).~
** Check Permitted Bedroom Rating Against HAA Request **
I certify that. I have chc. cked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~[,~./4_ ~ Date
Company ~ ~ ~Oct~ MOA No. ~ ~-2Z~ .-. _ .......
Receipt No. '~ qq (oq
Date of Payment '~
Amount: $ (o ~8
~,o ~o~o¢,~;~t...=~o ..... ¢,.. ~ Engineer's Seal
72-026 (11/84)
~--· ' '"~ ,~CEIV ED
- . INSPFCTION APPOINTME ~TS
TIME TIME - TIME
DATE __ DATE ~' ~ DATE ,~. //
~ MUNICIPALITY OF ANCHORAGE MUNK:IPALBY OF ANCHORAG~
DEPARTMENT OF HEALTH & ENVIRONMENTAL
~ 825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION AIJG 2 6 198'1
Telephone 264-4720
r~ffrK/~lE~
DIRECTIONS: Complete ~11 parts Oll page 1. IncompJe~e requests will not be p~ocessed, PJease ~llow teo (10) d~y~ for processin9,
1. PROPERTY OWNER , PHONE
Solo DeveZopmenL, ~c. ~ ~ ~ 272-0571
724 ~. ~5~ Avenue, A~ota~e~ A~ 9950~
PROPERTY ~ESIDENT (If different ~ffonq above) PHONE
2. BUYER ' PHONE
~. & ~. ~t~a~ Ca~atd 274-0082
MAILING ADDRESS
16~6 ~oga~, A~c~o~age~ ~
3, LENDING INSTITUTION PHONE
~a~lo~a1 ~a~A o~ Alaska~ Att~: ~ecky; 301 ~, ~o~he~ ~lgh~s 265-2786
MAILING ADDRESS '
~ox 7-025, A~c~o~age, A~ 995~0
4, REALTOR/AGENT PHONE
~oCem Ae~lty, ~c,/~1~11a~ ~, Sch:Lege1 · 272-0571
MAILING ADDRESS
724 g, 15t~ Ave~ue~ A~c~o~age~ AK 99501
LEGAL DESCRIPTION
Lot 3, Block 2, Golden Hills Subdivision #1
STREET LOCATION
Curvf Street
6. TYPE OF RESIDENCE
~ [] SINGLE FAMILY
[] MUI.TIPLE FAMILY
7: WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
-8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE**
[] PUBLIC UTI LI'FY
NUMBER OF BEDROOMS
E~] One [] Four
~] Two [] Five
~ Three E] Six
[] Other
/-z- f ?,/
ATTACH WELL LOG. A well Icg is reauired for all wells drilled
since June 1975. For wells drillea prior [o that date, give well
depth (attach Icg if available.)
1981 YEAR ON-SITE SYSTEM WAS INSTALLED,
r2-3~/-~t ( ~,~'
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PI'iOCESSING CAN BE INITIATED,
72-O10 (Rev. 6/79) I
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
[] INDIVl DUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] I ND1VI DUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY ~-~(~ (
Connection Verified INSTALLER
[]Septic Tank or []Holding Tank
Size: ~/(~)(?~2C__~ 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 ] Nearest Lot Line
1
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
E~'~CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY