HomeMy WebLinkAboutKNIK HEIGHTS BLK K LT 5Knik Heights
Block K
Lot 5
#018-232-18
Municipality of Anchorage
Development Services Department
J4;
Building Safety Division
On -Site Water and Wastewater Program, 4700 Elmore St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page / of -L-
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: VS P 1 0 D 9 PID Number: Dl 19 ^ Z3 Z^ ! 51
Name:
�i to �av �,
Wastewater System: 0 New ®'Upgrade
tf rn.(
Address:
405-5' �cpr.r+(4.
ABSORPTION FIELD
Phone: Number of Bedrooms:
3
I -Peep Trench ❑ Shallow Trench ❑ Bed D Mound ❑ Other:
LEGAL DESCRIPTION
Soil Rating:
1. GPDIFI'
Total Depth from original grade:
tJ/Q Ft.
Block: Lot: //�Subdivision:
I� S F� h I � �T/ h d -s
Depth to pipe bottom from original gratle:
3. Ft.
Gravel tlepth beneath pipe:/
CP e 2 Ft.
Township: Range: Segt
Fill added above original gratle:ravel
Ft.
Length:
r')r
� 4 Q{ rJ Ft.
Well: ❑New ❑ Uravel
a
wit
2 0
Number at lines
islance between lines:
Ft.
l
Ft.
Classification Prinate, A, B. C
Casedto:oto
a sorptire
on aa:
pe aena:
Ft.
Ft.
3 IF Ft'
3 0 3 4/
ner: Dan
aic aer eve:
Ft.
nsaer:
Mi Ar/Ct,,4,.
aensaj /
ie
ump a a: sing eig ove roun :
TANK
GPM
Ft. FL
SEPARATION DISTANCES
Ig Septic ❑ Holding ❑ S.T.E.P. ❑ Other:
To
septic
Absorption
Litt
Holding
ublic/Private
From
Tank
Field
Station
Tank
Sewer Line
An. t t pne
(000 Gal.
Well/
/00 f
/U/7'
%!l�
So rZ
s eria :
uroer o ompm
ar ens:
S er(
Z
Surtacewater
1.00.-
LIFT STATION
Lot Line
7 7pr
Z2�r
Gal.
Foundation
7 (Or
7 zp/
ump on levela:
in.
-pump=eve a:
ig waeraarma:
in.
Curtain Dein
u
�•
ump a e e
ecmca nspechans pe orme y:
Remarks:
C�((����o✓% Cs�sGP
BENCH MARK
V( TLJ
N
[i aae w, est Loil 4/ /
nssurn
FL
•
t7Q
Inspections performed by: MIS �N irlrts... Dates: 16t Mr/111i yPM
`��® ��1)
'2nd 2�4(i/ Lp�
41
�Qs�\��
� ���,.+'°e...
.
Development Services Department Approval
Conditional
49TH •�
Approval Date:
�° • •........
/..�((.........
1:10� MICHAEL N. ANDERSON
CE
-9469 c ``
,��`fOpi
Reviewed and approved by: Dater- �R J
(Rev. 04/06)
,``
®"�®�,�
Permit No. OSP111009 Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744
On—Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: LOT 5, BLK K KNIK HEIGHTS S
MARK
A
B
GRND.
ELEV.
PIPE
ELEV.
FCO
14
16
102.6
98.4
CO2
22
21
103
98
TC01
25
23
103
TCO2
30
27
103
CO3
35
33
102.4
97.5
C04
38
35
102.4
97.5
C05
36
52
100.2
95.2
C06
63
64
99
95.2
MT
58
61
99.4
\\ I �J
\\ I
\ 1\C05 /
\9) /
i
i
ASBUILT
SCALE: 1"=20'
U
PID No.: 018-232-18
BENCH, DOOR SIL
r
TCO 2 1 ORIGINAL GRADE '""■
113 ♦
10 .6 FCO �CO2 TCO, CO3 rC04 100.2 1.•�(� OF q / 414*
Il FCO 98.4 rMTi �CO6 1�P\
I `..C7/S .♦
o I( 9 ♦♦.
FLOI � C,
49tH
FILTER FA IC • . ,
� ................. . %
10
9 .4 1.000 GALLON sEwm nocrc'.MICHAEL
9 STEEL TANK ♦ '. MICHAEL N. ANDERSON.' i
SP
♦ %'•. No C 9459 '�� Aw
9 93 ♦♦. ��' '• • 1
SEPTIC SECTION�• "y.....�..`�.11
N.T.S. 63.0 1 A CrJJ
111 �♦♦
On -Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Nr Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number: OSP111009
Tax Code Number: 01823218000
Work Type: Septic Initial
Permit Effective Dates: February 07, 2011 to February 07, 2012
Design Engineer: ANDERSON CONSTRUCTION & ENGIN
Subdivision: KNIK HEIGHTS
Site Legal Address: KNIK HEIGHTS BLK K LT 5 G:2936
Owner/Address: DAVENPORT SCOTT G & LEAH G
4955 DE ARMOUN ROAD ANCHORAGE AK 995163625
Site Mailing Address: 4955 DE ARMOUN RD, Anchorage Lot Size in Sq Ft: 41600
Total Bedrooms: 3
This permit is for the construction of:
Y Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater
Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80).
3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By:
On -Site Water & Wastewater Program
Mayor Dan Sullivan
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Phone: 907-343-7904
Fax: 907-343-7997
Parcel 1. D. i ? .- D -3D — I�
Property owner(s) C 6 P O�NNt !� ��� Day phone
Mailing address
Site address
Legal description (Sub'd., Block & Lot) F 9 � I'k �� Lt3'
Legal description (Township, Range & Section)
Lot Size 1-1 I, (, D d Sq. Ft. Number of Bedrooms 3
THIS APPLICATION IS FOR:
(® all that apply)
Absorption Field [�<]
Septic Tank
21
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
THIS APPLICATION IS AN:
Initial
Upgrade
❑
Renewal
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
I certify that the above information is correct. I further certify that this application is being made
for a Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees:3�
Date of Payment:
Receipt Number:
Permit No. QS e
GABuilding\On Site\Forms\Client FormsTermit App_01 041 1.doc
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
(Rev. 1/11)
Michael N. Anderson, P.E.
Civil/Structural Engineering & Construction
4661 Natrona Avenue
Anchorage, Alaska 99516
Phone 345-3377
Fax 345-1391
Jan. 21, 2011
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: Knik Heights Subd. Blk K, Lot 5
To Whom it may concern:
This is a request for a new septic permit on the above referenced lot. The test hole excavation consisted of
poorly graded loose sand for the full excavation depth, 17 feet. The perc rate was 2 minutes at elevation 4
feet. The existing system is much deeper and will be abandoned. The slopes are all very shallow, 2 to 3
percent, and drain to the northwest. Due to the lot size, this upgrade will not impact any of the other
neighboring lots as the site plan shows.
Please call me if you have any questions.
Sincerely.-7
Michael N. Anderson, P.E.
DESIGN CRITERIA:
3 BDRM X 150 = 450 GPD
SOILS = 450/1.2 = 375 GPD
375GA/10=38'
(1) TRENCH
9.0' DEEP
5.0' EFFECTIVE
2.0' WIDE
38' LONG
r
EXISTING SEPTIC SEPTIC
PROPOSED DRAINFIELD - , V
(TH#1) o
10 ORG
SP
17
SEPTIC FIELD SECTION
3
-Ij
1
l ,f'
LOT 4
0
Q
0
cr
W
C�
0
z
a
m
I
EXISTING HOUSE
LOT 6A
— — — — — — — — — — — — — — — — — — — — — — — —
— z
PROPERTY LINE --J EXISTING WELL0
J
100' RADIUS, TYP 1 m
m
3 ` Q
o
i
Septic Design Prepared for
SCOTT DAVENPORT
KNIK HEIGHT, BLK K, LOT 5
Anchorage, Alaska
Michael N. Anderson, P.E. DATE:
4661 NATRONA AVENUE DRAWN:
ANCHORAGE, ALASKA 99516
PH. 345-3377 / FAX: 345-1391 SCALE:
ND OVER
'R FABRIC
PIPE
ROCK
IN
•
�F
�•,`•11t�1
E �S ♦♦i
AV
�; •'
49TH %. �0
�.....::....... .... ...........::...0
.. .. ........ .... .....�
2/2/2011 ': MICHAEL N. ANDERSON.:
DJR •����' NoAV
.,CE 469 i
I.
1"=100"' ♦♦
11f�-_SS\,...�
fLAURIE S/D
\ LOT 44A
f
NEIGHBORS FENCE X�
X XIX
X�
PROPERTY LINE �s
� 00 OAF
M
N
N
lcTN�' �A u'�i9
0000
CO ----p
``� DOUBLE CO
< O A i \�\ �\ PROPOSED 1,000
% �\' MT / \\\ i I\ \\ GALLON SEPTIC TANK
\
£ \\ CO i
� r �
\� PROPOSED DRAINFIELD
-------------- - - - - -- EXISTING 100' f ---------------
WELL RADIUS 10
N
' UTILITY EASEMET
S89* -'00"W 220.35' (219.90' R)
BASIS OF BEARING
0
Septic Design Prepared for
SCOTT DAVENPORT ��.•�� OF ,q�����
. �P..•••............. 9S�i
KNIK HEIGHT, BLK K, LOT 5 J
Anchorage, Alaska : 49 TH
i. ......l. ,...... ,:...:i
Michael N. Anderson, P.E. DATE: 2/2/2011 % :MICHAEL N. ANDERSON;=
4661 NATRONA AVENUE DRAWN. DJR �j�,$)*%•. No. C 9 69
ANCHORAGE, ALASKA 99516 �� Z-.1 /(
�
Vj
SCALE: 1 "=30' .... .�
It
PH. 345-3377 / FAX: 345-1391
Performed For:
Legal Description
Depth
1
2
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99507
www.ci.anchorage.ak.us
(907) 343-7904
GINEER18 SEAQ
m s
.4 a-oP P"'S'TT?
1 "
j' a . . R � B9 ew �a Ne•
A, a
"aZ2���
Soils Log - Percolation Test i
S `o t4 t" o`V t n IPt) ✓ Date Performed:
Y/i�'►1 k 174h 'i r7}` —LJF S Township, Range, Section:
(Feet)I a'VX e s
4-
5-
6- S P
7- Z -v0 i �6404e
8 -
Date
Gross Time
9-
Depth to Water
WAS GROUND WATER
dV
ENCOUNTERED?
S
10-
IF YES, AT WHAT DEPTH? L
11-
Depth to Water After/ O
adtn
Monitoring? C/ E
E
12-
Date: (t /
13-
14-
15-
16-
1Z
18-
19-
20-
Site Plan
A1.. z► — !t , L// iG
Reading
Date
Gross Time
Net Time
Depth to Water
Net Drop
YP
Ii wry rc i c L— (minutes/finch) FERC HOLE DIAMETER _ o
TEST RUN BETWEEN _ (. FT AND �_ FT
COMMENTS Z-� icu Z110T ( s
PERFORMED BY: A17/ �- -C �A t Zr y fit I CERTIFY THAT THIS TEST AS
PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
GREP.. ER ANCHORAGE AREA BOR,. cJGN
/j, :,N
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99903
INSPECTION
REPORT ON-SITE
SEWAGE DISPOSAL.
SYSTEM
NAME -�L=��
MAILING ADDRESS—_��3
l/)�`
— PHONE
LOCATION
LEGAL DESCRIPTION
r
SEPTIC TANK:
DISTANCE
FROM WELL/� // �fY
MANUFACTURER iX42A MATERIAL ` _ _ LCA _ ----COMPARTMENTS
NUMBER OF
�\
INSIDE LENGTH INSIDE WIDTH_______.__ LIQUID DEPTH ----LIQUID CAPACITY_/e)L9'C)GALLONS.
TILE DRAIN FIELD:
nn _ TOTAL LENGTH
DISTANCE FROM WELL/�LI)T//4/ FOUNDATION__ O/ NEAREST LOT LINE w- OF LINES —
NUMBER OF LINES— DISTANCE BETWEEN LINES TRENCH WIDTHfX IN. TOTAL EFFECTIVE
ABSORPTION AREA � SQ. FT. LENGTH OF EACH LINE
DEPTH OF FILTER a /
DEPTH: TOP OF TILE TO FINISH GRADE �� ___MATERIAL BENEATH TILE____ ABOVE TILE __._ IN.
WELL:
TYPE __JVp ;�' L14k __ CONSTRUCTION
BUILDING NEAREST NEAREST
FOUNDATION LOT LINE ___ SEWER LINE
CESSPOOL
APPROVED ____-
DISTANCES: ___
OTHER SOURCES
DISAPPROVED
INSTALLED BY:re
SEWER LINE DEPTH:' S
REMARKS
i
PIPE MATERIAL: Led
��_
LOT SLOPE:
REMARKS:
Fn,m F0.037
SEPTIC
TANK
DEPTH
SEEPAGE
SYSTEM -
DIA R
YSTEM_
DIAGRM "SYSTEM
DATE - :x/Y_'-7_7APPROV ED
DISTANCE FROM:
2233 East 72nd A7eaae
---
.� it le:cSS
Itl �r�a is ryidq r.'l���-a :] `:.%I::L ITi
STARTED �� ,z ..............................
.l = E- .-
?r E,
,)-
Arc:xarage, Alaska 99502
.... DiP_,isl OF WELL .................. ::.......................... ._...._....... .
Or E3't1_
- -----. STATICLv9.,s. ';'>;ro FT.— .........
......... DRAW DOWN FT- ....... '............................... =--------------------
_........ GALS. PE -P :3_3. ........... - .............. :----------------- . _
......... .$sIND OF CASY2. .. . .. ........ ...._::::: ............
M4-2612
HIND OF FORMATION:
Rv
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FROM-- ... .................
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"Ono tFs4 is worth a thov,sand of inions"
2204 Cleveland Anchorage, Alaska 99503
Performed For Emmett Boldt Date Performed_?/7H 7
Leaal nescrintion: Lot 5_Block K_ SubdivisionK_n_ik He2ahts__S�zhd�u_ sr.nn
This Form Renorts Soils Loq Yes Percolation Test -------.--
n e n t h
est_____ -
tenth
Feet „ Soi),,Chj't]ras�t�ea int' s _
y�
2 --
Brown Sand
4 ._-_,.. - -- -- -- --- -- - - --
6—
8
Gravelly Sand
10 — (SP)
2---112---
14
4 -_.__-..__ ____ __.__..------_. _.�.__.__.._._._._._..,...-._
BOH
16 18--
20—
Was
8_-
20
Was Ground Water Encountered? NO
If Yes, At what De-,th
Readinq Date Grnss Time
I
Net Time
- --S
Denth to H2O I Net Droni
Percolation Rate Minute
Prnrosed Installation: S e-naae Pit Drain Field
Death of Inlet Del) To Bottorn Of Pit Or Trench
C E N T S : - ],.Z5- s-q,uarP. - eet- _d r axi ag-e , r_er ij_i_�
-- ---- - - 7�- ' ` -- l/
Test Performed By !�f(+c�r�V,�_�cx Data Certified By Const. 'rest Lab
David Paul Date
• Municipality of Anchorage 8
On -Site Water and Wastewater Program s
(907)343-7904 $A LTY
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcell.D. 018-232-18
1. GENERAL INFORMATION
Complete legal description KNIK HEIGHTS BLOCK K LOT 5
Expiration Date:-/
Location (site address) 4955 DE ARMOUN ROAD ANCHORAGE AK 99516
Current Property owner(s) JON R. WYAND Day phone
Mailing address
Real Estate Agent
4955 DE ARMOUN ROAD ANCHORAGE AK 99516
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:
Individual Well
®
Individual
Individual Water Storage
❑
Holding Tank
❑
Community Class _ l,.rel!
❑
Co,;,n,unity
❑
Public Water System
❑
Public Sewer
❑
WaiverNariance request for: Distance:
Received by: gn4 L✓eV z
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5
Date of Payment L4115--
Receipt Number
COSA# 11SC1 f(')(J`S
Date: 1-20-15-
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.
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date
11/11/14
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition
of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface
conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system. The operational life of ail well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseenic; OF ALS�(
encroachments, deficiencies or discrepancies exist. or <�v
6. DSD SIGNATURE
i,/ System #1 Approved for bedrooms.
System #2 Approved for bedrooms.
Disapproved.
P� KENNNE77iS�
`r I6 tt,, DliFkY/ /
,r'/1
`D �� FESSi01`hV
Conditional approval for bedrooms, with the following
All(
OFA
ON-SITE
By: Original Certificate Date:
c�
The n' ' chorage Development Services Division (DSD) issues Certificates of Onsite 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
COSAW.sheet 1410-12dw
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: KNIK HEIGHTS BLOCK K LOT 5 Parcel ID: 018.232.18
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID #
Date completed 511977 Sanitary seal (Y/N) Y
Total depth 264 ft. Cased to 264 ft.
FROM WELL LOG
Date of test 511977
Static water level 140 ft.
Well production 5+ 9 -
p.m -
WATER SAMPLE RESULTS:
Coliform NLG colonies/100 mL Nitrate 2,10 mg/L
Arsenic: Nb ug/L Date of sample: 11/312014
B. SEPTICIHOLDING TANK DATA
Well Log (Y/N)
Wires properly protected (YIN) Y
Casing height (above ground) 12+ in.
AT INSPECTION
1113114
231 ft.
g.p.m.
Collected by: ARCTERRA
Tank Type/Material SEPTIC I STEEL Date installed 2/912011
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 219/14 Pumper ALASKA SEWER & DRAIN
C. ABSORPTION FIELD DATA
Date installed 2/912011 Soil rating (g.p.d./ft2 or ftz/bdrm) 1.2 System type DEEP TRENCH
Length 32 _ft. Width 2 ft. Gravel below pipe 6.2 ft.
Total depth 10.4 ft. (Measured 11/3/14) Eff. absorption area 396 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 11/312014 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 23 in. Water added 130 gal. New depth 56 in.
Elapsed Time: 1350 min. Final fluid depth 22 in. Absorption rate >=450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at _ in.
Datum
E. SEPARATION DISTANCES
WELL ON LOT TO:
Size in gallons
"Pump off' level at _ in.
Cycles tested
Septic tank/lift station on lot 100'+
Absorption field on lot 100'+
Public sewer main 75'+
Sewer /septic service line 25'+
Animal containment areas 50'+
SEPTIC/HOLDING TANK ON LOT TO:
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots 1004
On adjacent lots 1004
Public sewer manhole/cleanout 1004
Holding tank 1004
Manure/animal excrete storage areas 1004
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 101+ Surface water 100'+
Wells on adjacent lots 1004
ABSORPTION FIELD ON LOT TO:
Property line 104 Building foundation 104 Water main 10'+
Water Service line 104 Surface water. 1004 Driveway, parking/vehicle storage 104
Curtain drain 50'+(NONEKNOWN) Wells on adjacent lots 1004
F. COMMENTS
G. ENGINEER'S CERTIFICATION
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.
Engineer's Printed Name KENNETH M. DUFFUS
Date 11110114
COSA brown sheet 10-10-12.doc
OF ALS "A,,
� "A(a TH
in.
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program S A E T Y
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.y(1;'-232 -t COSA# ®SC I k I 0� (P
Expiration Date: S—_
1. GENERAL INFORMATION
Complete legal description I<h r !z 14 h s p Fc L_U
Location (site address) L- 9 sS
Current Property owner(s) S ru 4 t�d Y 'tr n o, + Day phone
Mailing address
Lending agency
Mailing address
Real Estate. Agent
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
9
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
®
Individual On-site
❑
Individual Holding Tank
❑
❑
Community On-site
❑
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my. investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm 1yh r (n e r� N,,�„ 2 rr s �� ID, fi Phone 3 • 33�
Address E (, U t A & I-
Engineer's Printed Name /ul «�a i✓�/ ,�n r,.con
5. DSD SIGNATURE
./ Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
r-
v'f 4 0 F ®i3,' '
j ON-SITE
VMSTEWATER
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date:
(Rev. 11/05)
,o
Municipality of Anchorage ok
Development Services Department<a
u �
Building Safety Division `
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: "I k 1414; i,4j, 61G IF L S Parcel ID: 01V -Z32- / T
A. WELL DATA
Well type Pr%v04.—. If A, B, or C provide PWSID #
Date completed .-5 Sanitary seal (Y/N)
Total depth 2W( ft. Cased to 7-(P4f ft.
FROM WELL LOG
Date -of test
Static water level
Well production S t g.p.m.
Well Log (Y/N) '2z
Wires properly protected (Y/N)
Casing height (above ground) I 'f in.
AT INSPECTION
z Yb ft.
S' *- 9 -
p.m -
WATER SAMPLE RESULTS:
Coliform �2,colonies/100 mL Nitrate &N �'�mg/L Collected by: MN
Arsenic: 4- ug/L date of sample: iZ2 < <= e ' V 6 "" ' 1/=d Lo `'4,t#~''A
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material g ----« ( Date installed 7-1 9� /I f
Tank size i vvD gal. Number of Compartments z Cleanouts (Y/N) Y
Foundation cleanout (Y/N) _ Y Depression over tank (Y/N) High water alarm (Y/N) /
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./e or ftz/bdrm) !, Z System type Q r -r p 4-v e% -G, .
Length 3 'L ft. Width 7.0 ft. Gravel below pipe ft.
Total depth _ to ft. Eff. absorption area '1 fe Monitoring tube V Depression over field M
Date of adequacy test Results (Pass/Fail) i For 3; bedrooms
Fluid depth in absorption field before test .--in. Water added_Ggal. New depth_ in.
Elapsed Time: _e: -"min. Final fluid depth -/_ in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Absorption rate >= / g.p.d.
If yes, give date /
D. LIFT STATION
Date installed
"Pump on" level at in.
E. SEPARATION DISTANCES
Size in gallons
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank4#69te ien on lot /DD ' -f-
Absorption field on lot / D D -f'-
Public sewer main 74 ZA
Sewer /septic service line too ''-
Animal containment areas 100 '*
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots (U 0 1+
On adjacent lots 100`4
Public sewer manhole/cleanout
Holding tank N U .
Manure/animal excrete storage areas 100'-/_
SEPARATION DISTANCES FROM SEPTIC/ham TANK ON LOT TO:
Building foundation 7 ;i D Property line 7 'Z D e Absorption field 2 o ` f -
Water main N''C. Water service line (90 Surface water too
Wells on adjacent lots I v a r +
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 2 y f f- Building foundation z D I -I- Water main N
Water Service line ! 0o ' -� Surface water to a ',L Driveway, parking/vehicle storage 5 D -�
Curtain drain Wells on adjacent lots too 14-
F. COMMENTS
in.
At
G. ENGINEER'S CERTIFICATION r,�.�� •,f°°� a
r •
I certify that I .have determined through field inspections and / �. • � ��,
review of Municipal records that the above systems are in j 9 T ��•
.... ... • 1 • or .. • . I ...
conformance with MOA COSA guidelines in effect on this date. Ff♦
• M►ch:��ANDERSON .
Engineers Printed Name M a �+�• rlA(Ai ,'�j4CE- p 9/ a p,
Date �A r)lI �,�r�,,•• 2///,� // .•� ;;:i
COSA Fee $_015b— LA� Waiver Fee $ .
Date of Payment c�- t f to It ( Date of Payment
Receipt Number Receipt Number
(Rev. 4/10)
I
49
SHANE A. HOLT
LS -6914 -
�p°Jossionsl `»6��
N 89056'00"E 199.90
AS -BUILT SURVEY P' - 40'
NO CORNERS SET THIS DATE
N
11
J
I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY
LOT 5, BLOCK K, KNIK HEIGHTS SUB.
0
Q
0
Ix
z
0
Q
CD
Q
THE INFORMATION HEREON 15 FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS
NOT OF RECO D,OTIER ING THAN THOSEAEARING ON THI RECORD PLATS. OR, ARE FENCENOTS INES.
EASEMENTS OF RECORD, OTHER THAN TH05E APPEARING ON THE RECORD PLAT, ARE NOT SHOWN
HEREON(VNLESSINDILATED)
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
EXIST OTHER THAN NOTED.
SURI/EYORDERED B�
MIKEANDERSON
NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE
DATED AT ANCHORAGE,ALASKA THIS _14TH_
DAY OF
PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS.
_FEBRUARY , 2011.
ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE.
_
8771, _993_744-.3
HOLT LAND SURVEYING
600 TLAND SUHIGH�EW DRIVE
ANCHORAGE,AK 99515
345-5513
SGS Ref.#
1110437001
Client Name
Mike N. Anderson, P.E.
Project Name/#
Scott Davenport
Client Sample ID
4955 Dearmoun Rd
Matrix
Drinking Water
Printed Date/Time
02/16/2011 14:52
Collected Date/Time
02/08/2011 10:40
Received Date/Time
02/08/2011 12:40
Technical Director
Stephen C. Ede
Sample Remarks:
Allowable
Prep Analysis
Parameter
Results LOQ Units
Method Container ID Limits
Date Date Init
Metals by ICP/MS
Arsenic
ND 5.00 ug/L
EP200.8 C (<10)
02/10/11 02/15/11 NRB
Waters Department
Total Nitrate/Nitrite-N
0.576 0.100 mg/L
SM20 450ONO3-F B (<10)
02/09/11 AYC
Microbiology Laboratory
E. Coli Negative 1 100mL SM20 9223B A 02/08/11 DLC
Total Coliform Negative 1 100mL SM20 9223B A 02/08/11 DLC
Municipality of Anchorage
• Development Services'Dep`artment
Building Safety Division,
On-Site Water and Wastewater Program °
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.enchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel l.D. 0I8-23a- W HAA# A D /O.1 1�- :a
Expiration Date:
1. GENERAL INFORMATION
Complete legal description L.oT 'S 1B K 1<1 K t-A l 4C 1-1 F_ 16, H 7-5
Location (site address or directions) 14q;5 7 D,-- A'rwioo-i
Current Property owner(s) Jlavi Pe) I Day phone Ada- 4gg5
Mailing address N g 5 5 i4L 4 V-"A o u H
Lending agency Day phone
Mailing address
Real Estate Agent Nlcknc4 Farris Pe gai t Dayphone .Ib7-01(R
Mailing Address 3leco (2mr-gaJo-
Unless otherwise requested, HAA will be held by DSO for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual On-site f�
Individual Water Storage ❑ Individual Holding tank ❑
Community Class Well ❑ Community On-site ❑
Public Water System ❑ Public Sewer ❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
,
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation,
.based on procedures outlined In the Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. 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 Intoil rh SD r+'�<<n K� ? Phone .774-301 IES
Address 20 ty I 64 W 03 "
Engineer's Printed Name i . S Date
`•� - , ' NGINEER'S
`'..' STAMP
tLGC.•C�•�C,...
5. DSD SIGNATURE
�G Approved for _� bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: (��� It/. 0 Original Certificate Date:
(Rev. 72.100(
Municipality of Anchorage ,,..
• "' Development Services Department
Building Safety Division `
On -Site Water b Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519.6650
www.ciznchorage.ek.us
(907) 3437904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: 1121 'ri 13 k K K N 114 4 G I A H T 5 Parcel ID: 4018-&52- 1$
A. WELL DATA
Well type � If A, B, or C provide PWSID #" /A
Date completed -f 17 Sanitary seal (YIN) _
Total depth -01 ft. Cased to JAL±ft.
FROM WELL LOG
Date of test A4 97-7
Static water level 1140 ft.
Well production .'S-10 g.p.m.
WATER SAMPLE RESULTS:
Coliform _colonies/100mi. Nitrate QUf49.11.
Well Log (Y/N)
Wires property protected (Y/N) _Y
Casing height (above ground) �.Z_in.
AT INSPECTION
241 fl.
6 z_ g.p.m.
Date of sample: O 1 Collected by: S .
B. SEPTICIHOLDING TANK DATA
Other bacteriaj�((/Z colonies/100 mi.
Tank Type/Material 612 a a 2 ST Az E 1 Date installed 7-/ q - 7 7
Tank size f ODo gal. Number of Compartments Cleanouts (YM)
Foundation cleanout (YM) 4- Depression over tank (Y/N) _-q_ High water alarm (Y/N) 14
Date of pumping -r*i %O D Pumper A+
C. ABSORPTION FIELD DATA
Date Installed 719 - 7 7 Soil rating (g.p.d ff or fPlbdrn) it- System type AA44 0 -
Length
Length 3 g fl. Width 2 ft. Gravel below pipe_ ft.
Total depth 1_ ft. Eff. absorption area 17Z0'ft7 Monitoring tube ,,Y Depression over field N
Date of adequacy test - S- O 1 Results (Pass/Fail) -P For S bedrooms
Fluid depth In absorption field before testLio in. Water added 9.6
Qgal. New depth y7iLln.
''II
Elapsed Time: Maltz��r�� _ Final fluid depth 6LO- in. Absorption rate >= 4 5*0 gyA.
Any rejuvenation treatment (past 12 mo.) (Y/N S type) If yes, give date
D. UFT STATION
Date Installed in gallons
"Pump on" level at _ "Pump ofP level at _ in.
Datum _ _ Cydes tested
E. SEPARATION DISTANCES
[QU
water alarm level at
Meets alarm d circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAtft station on lot 1115+ On adjacent lots IOD f
Absorption field on lot 12—Ot
Public sewer main N�A
Sewer /septic service line l t
On adjacent lots 109 0 .1 -
Public sewer manhole/deanout
Holding tank NIA
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
t r
Building foundation 19 Property line 10+ Absorption field R
Water main N/,4- Water service line o2 r Surface water N l 0
Wells on adjacent lots > 1 �
In.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line I D } Building foundation 2> Water main N/R
Water Service line ! 02 Surface water N l O Driveway, parkingivehide storage 60 t
Curtain drain N' O Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name I. S D u f k1 or K aaC
Date 4— 5 D I
HAA Fee $ 3 0 () D O
Date of Payment
Receipt Number
(Rev. 12/00)
Waiver Fee $ _
Date of Payment
Receipt Number
% CE -2225
Io
04-09-01 17:41 FROII-CTE ENVIROAFNTAL 5615301 T-225 P.02/03 F-201
�. CUE Environmental Services Inc.
rr�rrrir�rrrrrrrrrr
CI'&F: RKV
1011688001
Client Name
Tobben Spurkland P.E.
Project NameM
Lot 513k LK Knik
Client Sample ID
Lot 5 Elk K Knik
tllatrix
Dtinkinlo Water
Ordered by
PWSID
0
Sample Remarks
Client POP Pre -Paid Colisr,4
Printed Datetllme 04/09.'2001 16.10
Collected Datefflme 04/05/2001 16:00
Recehed Date/11ute 04/05.2001 16:55
Technical Director Stephen C. Ede
Parameter Results PQI. Unica Atcthed
Waters Department
Narate-N 0.944 0.500 :r18;L EPA 3ti0.0
Microbiology Laboratory
Total Coliform 0 0 coll100mL SN118922213
Allowable Prep Anal}k.;
Limits Date Ikit-- Init
10 max 0,03,01 SCL
0-, 05/01 KAP
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services C -
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # (D 19 e232 163
1. GENERAL INFORMATION
HAA # _�A-A63 k L A �SLD
Complete legal description _'L��I
Location (site address or directions) 41955 'D -e- a-rw,(9uv) 4
Property owner Clow, Day phone
Mailing address
Lending agency Day Day phone
Mailing address
Agent _20� IC, -use. Day phone'''62-1x22__
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: —
3. 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.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site I
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 MOAi121
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and 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 1061;,e4 �p r klA C Phone 974 - zyt t�
Address QO o �it—�ilX5 t.f ;20tp
Engineer's signature Date
6. DHHS SIGNATURE
M
G. 911_1U_i.LZL4l�
9
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
a
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA u21
• Municipality of Anchorage
t Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST LA
Legal Description: o1- `a 13K K )<tA\ 4 F-1[a►t_-S Parcel I.D. O is 0252 is
A. WELL DATA
Well type — If A, B, or C, attach ADEC letter. ADEC water s stem number _ NA
Log present (Y/N) y Date completed�i��71Driller @m ${gam
Total depth 9L Cased to aG !, Casing height ) It
Sanitary seal (Y/N) _x _- Wires properly protected (Y/N)
Public sewer main _ NVQ. _.— Public sewer manhole/cleanout/�
Public sewer service line
WATER SAMPLE RESULTS:
Coliform -- Nitrate __ O
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Petroleum tank
-' Other bacteria f�
Collected by: -
Date installed -/'iQ• 77 Tank size Il7Ab Compartments
Cleanouts (Y/N) % (1) Foundation cleanout (Y/N) Y Depression (Y/N)
High water alarm (Y/N)----Alarm tested (Y/N)
Date of pumping r� �`? r� (= Pia 1 �✓(�
SEPARATION DISTANCES FROM SEPTIC/ISE TANK TO:
Well(s) on lot 1 aG On adjacent lots Foundation (Q
To property line
Surface water/drainage
Absorption field I ) Water main/service line .2 G
Z
72-026 (Rev. 3/91)Front MOA 21 CONTINUED ON BACK PAGE
FROM WELL LOG
AT INSPECTION
q
Date of test
— 19� —
��112
_I
Static water level
W
Well flow00
g.p.m.
g•p.m.
cv
LLJ
Pump level
_ �• _—
Ba 44a WLU
3
SEPARATION DISTANCES
FROM WELL TO:
11 d t
+ w
Septic/he4i4;g tank on lot
; On adjacent lots
1-6 5 ±
( +
Absorption field on lot
_
_ ; On adjacent lots
Public sewer main _ NVQ. _.— Public sewer manhole/cleanout/�
Public sewer service line
WATER SAMPLE RESULTS:
Coliform -- Nitrate __ O
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Petroleum tank
-' Other bacteria f�
Collected by: -
Date installed -/'iQ• 77 Tank size Il7Ab Compartments
Cleanouts (Y/N) % (1) Foundation cleanout (Y/N) Y Depression (Y/N)
High water alarm (Y/N)----Alarm tested (Y/N)
Date of pumping r� �`? r� (= Pia 1 �✓(�
SEPARATION DISTANCES FROM SEPTIC/ISE TANK TO:
Well(s) on lot 1 aG On adjacent lots Foundation (Q
To property line
Surface water/drainage
Absorption field I ) Water main/service line .2 G
Z
72-026 (Rev. 3/91)Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION N1/
Date installed
Size in gallons
Vent(Y/N)
High water alarm level .
"Pump on" level at
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
Date installed i
On adjacent lots
"Pump off' level at
Cycles tested
Surface water _
Soil rating las System type I R–ENGVk
Length Be Width 3� Gravel thickness
Total depth
Total absorption area :3 8o Cleanouts present (Y/N) Y
Depression over field (Y/N) N Date of adequacy test U 10 11 Q f R I
Results (pass/fail) FASS for
Peroxide treatment (Past 12 months) (Y/N) IV If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot I a.6 -F On adjacent lots t o -c> I' Property line
I o +
To building foundation To existing or abandoned system on lot NSA
On adjacent lots 50 Cutbank —Water main/service line .50 �
Surface water /V/A Driveway, parking/vehicle storage area 6o t
Curtain drain NIRA
E. ENGINEER'S CERTIFICATION
bedrooms
I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature ►�s�
Engineer's Name o(obe"ur)Cla�cQ C ��
Date /I R JR 1
HAA Fee $ 70. L Waiver Fee: $
Date of Payment _ Date of Payment
Receipt Number 0 Receipt Number
72-026 IRev3/971 Rack MOA 91
6T51U.0HON0DLYT.
ANCHUkAG['AL�SKA9Y02~3904
(��7>2A8~509�
LEGAL:Lot 5 1.3 K Knik Heights
LOCATION: 4955 De�rmou/� Road
OWNER: Claire Boldt Jones
TYPE QF WELL: Private, Singl� Family
WELL LOG AVAILA8LE:
INSTA.LAT-ION REQUIREMENTS MET:Yes
WELL YIELD FROM WELL LOU -
'j Gallons per Minute
PUMP YIELD FROM TEST:
DATE OF TNSPECTIDN:
5 Gallons per Minute
June 19 1991
TEST PROCEDURE: Well was pumped at a constant rate while the
drawdown was monitored with an acoustic
probe. At the1HNl� i
fee� gp-���casiDg. At y
'�
-�_----
1 t l el did not cnange I tc�tal Df500 gallor's,
�
TEST FOR E.COLI AND TOTAL N[TROGEN: Water was tested for E.Coli
and total nitrogeo on
E.Coli 0. Total NiLrngen 0.73 mg/l.�/
Max. allowable Total Nitrogen 1O mg/l.�^'~
TEST RESULTS: This well meets the requ�remcnts of tho
Municipality of Anchorage.
TKI5 WELL WILL PRODUCE MOR�THAN 3.GALLONSPER MlNL[DE FDR Ml) R1
THONFOUR H0UF�S
The Municipal requirement
for well flow
is 150 gallons
of water
per bedroom per day.
This
wel1 exceed
this requirement.
[he
assessmenL of the
condition
of the
wel)
applies
only to the
conditions as of the
day tested.
The
flow
rate may
change due to
subsurface cond�tions
that
may not be
observed
from
the surface,
and cha�ges in �he land
use
and other
factors
that
may impact the
aqujfer feeding the well.
'
�
�.
�
`
� J
` v
^ /
`
Q5lN.0MUN0DLill 11
ANCH0A8[`ALASKA Y9502'JYV4
(907) 248-509,5
SEPTIC SYSTEM ADEQUACY TEST
LEGAL: Lot 5 Block K Knik Heights
LOCATION: 4955 DeArmoun Road
DWNER: Claire Boldt Jones
RESIDENCE: Single Family, 3 Bedrooms
WELL:
Private, On Site
SEPTIC
SYSTEMx FROH MUNIClPAL RECORDS: 3 8edroom System
TANK: Greer Steel 1000 Gal. Two Comparts.
A8SORPTION SYSTEM: Trench
A0SORPTION A1 ,,E0: 39O Sq. FL.
SOlL R0TING: 125
�
INSTALLATION DATE: 07-19~77
~'��
DATE OF
L0S1' PUMPINGAnd). Cess Pool June 21, 1991
DATE OF
QEST: June I.9 1991
TEST PROCEDUR£:
Systcm was insperted and measured. Tank
was
found
wit.h 3.5 feet of cover and with a liquid level of
49
ind/es.
Tank showpd si(it s of having been severely surcharqed.
Trenc)
clean out was 4.5 feet deep and dry, Trench monitor
tube
was 10
deep with 7 i1.cins, of water.
500 gallons
nf clean water was added to the trench while
the
water
c'. 1, in the tank and the mnnitor tubo were monitored.
The
first �5O
gal]vow; were dumpcd into the foundaLio'l clean out.
1 111s
caused
the wat; r leve] in the tank to, rise 16 inches while
no
rise wa�
nhserved imonitor tube. [ank outlet is blocked
or
broken.
The npxt 350 qallons were dumped jnto the trenc!l
rlean
outAt
the end no charging the water 1,evel in the tank
had
dropped
i1 inrhes while the level in ttie sump had risen 11)
inrh-
esThree
hours later the tank level was 1 inch higher than
at
the stort
whi]e the monitor level had dropped 4 inches, indjcat-
ing that
125 gallon had been absorbed,
Line beHeen
tank and trendt was replaced in, Dean Cnnstruction
from 23`
|991
TEST RESULT:
Thjs system meets the co� e rec!uirements
of
the and Social Servires
0epartment
of the Municipality of Anchorage.
NOTE
The operational life of all szptic systems deoei-Ids on
the
local
soil conditions, groundwater levels that may fiuctuate
juring
the year, and the wuter usage of the family beinw scrved
hy the
system. These conditions are outsiJe the cnntro] of
the
evalua|or
of t1 )is seytic system. We can therefore not qive
anv
estimate
of how lonu tois system will functiol ctory
fi'lr
current
or future occupants.
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING
5633 6 STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS REPORT BY SAMPLE for WORKoxdex# 35402
Date Report Printed: JUN 24 91 @ 10:17
Client Sample IDAS BK KNIK HEIGHTS
PWSID :UA
Collected JUN 19 91 @ 13:45 hrs.
Received JUN 19 91 @ 16:40 hrs.
Preserved with :AS REQUIRED
Analysis Completed :JUN 21 91
Laboratory Supe vieox STEPHEN C. EDE
Released By
Client Name :TOBBEN SPURKLAND, P.E.
Client Acct :TOBBENS
BPO # PO # NONE RECEIVED
Beq #
Ordered By :T. SPURKLAND
Send Reports to:
1)TOBBEN SPURKLAND, P.E.
2)
Chemlab Ref #: 912852 Lab Smpl ID: 1 Matrix: WATER
Allowable
Parameter Tested Result Units Method Limits
---------------------------------------------------------------------------------------------------------------
NITRATE-N 0.73 mg/1 EPA 353.2 10
Sample ROUTINE SAMPLE COLLECTED BY: T. SPURKLAND.
Remarks:
1 Tests Performed See Special Instructions Above UA -Unavailable
ND- None Detected See Sample Remarks Above
NA- Not Analyzed LT -Less Than, GT-Greatex Than
5. LEGAL DESCRIPTION�r ' - }�,`�Ir�
STREET LOCAT N tr
1 WL o I,W\tet
MUNICIPALITY OF ANCHORAGE
6. TYPE OF RESIDENCE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION -
- -
825 L Street - Anchorage, Alaska 99501.
ENVIRONMENTAL ENGINEERING DIVISION
0* ,
❑ MULTIPLE FAMILY
Telephone 264-4720
7. WATER SUPPLY
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS:. Complete all parts on page 'I. Incomplete requests will not be processed. Ple.se.allow ten (10) days for processing. - _ -
1. PROPERTY `
'Mmej
PHONE
3V —CSC)
MAI LING ADDRESS �
L,f %-
-7
PROPERTY RESIDE T (If different fromma above) �
PHONE- - -
2. BUYER
PHONE
MAILING ADDRESS -
PUBLIC UTILITY
3. LENDING INSTITUTION
r -G- A(6' c, �N 01 c kt,ra
PHONE
,9 7
�
MAILING AD RES
G GY u { Sri cL`�2v' VY �1 Vl Ci
4. REALTOR/AGENT
MAILING ADDRESS
PHONE
01' l
5. LEGAL DESCRIPTION�r ' - }�,`�Ir�
STREET LOCAT N tr
1 WL o I,W\tet
`
\ cq� �t v��e
6. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
SINGLE FAMILY
❑ One ❑ Four ❑ Other
❑ : Two ❑ Five ,
❑ MULTIPLE FAMILY
kr Three ❑ Six
7. WATER SUPPLY
:W' INDIVIDUAL* _
' ATTACH WELL LOG. A well log is required for all wells drilled
COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
-depth (attach log if available.)
B. SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE**
'`If individual/on-site, give installation date JLt�
❑
If system is over two (2) years old an adequacs required
PUBLIC UTILITY
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
- -
INSPECTION APPOINTMENTS
DATE RECEIVED - -
TIME
TIME
TIME
DATE
DATE -
DATE
INSPECTOR
INSPECTOR
INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NU BER OF BEDROOMS
❑ ONE THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
117
INSTFlLLER
SOILS RATING
UI/Septic Tank or ❑ Holding Tank
Sizer_ If Tank is homemade
give dimensions:
TYPE OF TANK -
MANUFACTURER _
TOTAL ABSORPTION AREA
MATERIAL
l
4. DISTANCES
WELL T0:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
[CI-- APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE G rX
BY (Title)
LEGAL DESCRIPTION '
72-010 (Rev. 3/78)
