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Home My WebLink AboutELDON BLK 3 LT 2Eldon Block 3 Lot 2 #016-202-1i MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. Municipality of Anchorage •. Development Services Department Building Safety Division " .. On -Site Water & Wastewater Program 4700 South Bragaw SL 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. 016-202-11 HAA# 14W.2b b 1. GENERAL INFORMATION Expiration Date: ✓- f kk — D Complete legal description ELDON SUBDIVISION: LOT 2. BLOCK 3. Community Class Well ❑ Public Water System Location (site address or directions) 610 JACK STREET • ANCHORAGE. AK 99515 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address CLEMENS & COUSTEA Day phone c/o JOHN LEVY w/ DYNAMIC PROPERTIES JOHN LEVY w/ DYNAMIC PROPERTIES Day phone Day phone 261-7520 3111 "C" STREET • ANCHORAGE, AK 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 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 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 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 samples. (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. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid 51 ZCO at, or prior to closing for the engineering services provided. 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. 1 further verify that based on the information obtained from the Municipality of Anchorage rites and from my investigation and inspection, the on-site water supply and/or wastewater disposal system ls(are) In compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone Address 6901 DEBARR ROAD, SUITE 28 ' ANCHORAGE, AK 99504 Engineers Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, AWWC. Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines 8 Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AWWC, Inc. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report Is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party Is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. Conditional approval for 337-6179 Date 2II [11 Z bedrooms, with the fllowing stipulations: Attachments: HAA Checklist Manitenance Agreements Septic System Advisory Supplemental Engineers Reort Well Flow Advisory Other Original Certificate Date: /y Municipality of Anchorage 'r Development Services Department Building Safety Division On-site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 198850 Anchorage, AK 995196650 www.danehorage.ak.us (907)343.7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ELDON SUBDIVISION: LOT 2. BLOCK 3, Parcel ID: 016-202-11 A. WELL DATA Wen" PWATE If A, B, or C provide PWSIDN N/A Date completed 9/12/85 Sanitary seat (Y/N) YES Total depth 132 ft. Cased to 132 ft. FROM WELL LOG Date of test 9/12/85 Static water level 36 ft. Well production 15 g.p.m. Well Log (YM) YES Wires properly protected (YM) YES Casing height (above ground) 12+ In. AT INSPECTION 2/7/2002 40 ft. 8.4 g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 ml. Nitrate 0° ZZ mgJL. Other bacteria _(�_colonies/100 ml. Arsenic: N/A mgJL. Date of sample: 2/7/2002 Collected by: AWWC. INC. B. SEPTIC/HOLDING TANK DATA P U P LI C SEWER Tank Type/Material Date Installed Tank size gal. Number of Compartments __'__4le Foundation cleanout C. ABSORPTION FIELD DATA Date Installed Pumper tank (YM) _ High water alarm (YM) PUPLIC SEWER Soil rating (g.p.dJftbr ftlbdrm) _ Length ft. Width ft. Total depth ft. Elf. absorption area— ft' Monitor Date of adequacy test System type Gravel pe ft. Depression over field For bedrooms Fluid depth in absorption field be est in. Water added _gal. New depth _in. Elap=uvenation : n. Final fluid depth _ In. Absorption rate >= g.p.d. treatment (past 12 mo.) (YM & type) If yes, give date D. LIFT STATION Date installed Size in gallons "Pump on" level at _in. E. SEPARATION DISTANCES High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A Absorption field on lot N/A Public sewer main 75'+ Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Absorption field Water main Surface water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Water Water service line F. COMMENTS G. ENGINEER'S CERTIFICATION Surface Wells on adjacent W I car* that I have determined through field inspections and i review of Municipal records that the above systems are In conformance with MOA HAA guidelines in effect on this date. Engineer's Printed lame JEFFREY A GARNESS Date 2-41 TO Z MAA Fee $ 3 75 7` J /.50 R i eh o ep Date of Payment ;2,J) 6&a. Receipt Number AGRE 615973 3A (Rev. 12MI) Waiver Fee $ Date of Payment Receipt Number parking/vehicle storage s A, ess: —7953 ; ' k ZIL ME E Fft Laboratory niaLSonices,Inc. 200 W. Pottor Drive Drinking Water Analysis Report for Total Coliform Bacteria T,: AK99518-1605 READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE Fax M to nc rnmpiFTED BY WATER SUPPLIER ITO BE COMPLETI O PUBLIC WATER SYSTEM I.D. R A PRIVATE WATER SYSTEM il� Send Results O Seatfwwlce fel se > C`jdT�33a5;3 11,4 G 0 D Seal Rd1), Sod b eice ewn.w- ...-v vc er A v w SAMPLE DATE: go- - Month Day Year SAMPLE TYPE: O Treated Water O Routine O Repeat Sample (for routine sample cL Untreated Water with lab ref. no. ) O Special Purpose Ttma CoHatted Collected By 'Z•3 CSI. r.w P'W SAMPLE LOCATION Fido 1_ al.�k3. Comments: Analysis shows this Water SAMPLE to be: Satisfactory O Unsatisfactory O Sample over 30 hours old, results may be unreliable O Sample too long in transit; sample should not be over30hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received 2 Time Received ♦• S ZU Analysis began T .. Analytical Method: 11Membrane Filter YO 1MMO•MUG e Number ofcolonies/IOOml. Lab Ref. No. Result* Analyst 1020 4 �— Sent to A.D.E.C. Anch Fbks Jun ❑ Faxed Date: Time: Client notified of unsatisfactory 1`4301M: ❑ ❑ Phoned Spoaewlth Fazed Date: Time: BACTERIOLOGICAL WATER ANALYSIS RECORD MMO.MUG Result: Total Collform E. Coli Membrane Filter. DlrectCouot _. Coloalesllooml Verification: LTB BGS COLIFIRM Fecal Coliform Confirmation Colltaratl100 ml Final Membrane Filter Results �j(5D Reported By ate 01---Timebra T.Vrc-TM Mrn--e re C"W of -mweswe IO'd 1015-19S LOG 0.40EW/06e.A040uy 3810 5Z=61 ZO-60-qad FEB -11-02 02:43PM FROM-CTLE ENVIRONIENTAL SRV 9075615301 T-245 P.01/01 F-700 ME Environmental Services Inc. Laboratory Division 200 W. Potter Drive Anchorage, AK 99518 Tel: (907) 562-2343 Fax: (907) 561-5301 CUE Ref. p. 1020756001 Client PON: Na Client Name7 AK Water & Wastewater Cons. Printed Date/Time: 02/11/02 14:40 Project Name: n/a Collected Datemme: 02/07/02 1435 Client Sample ID: Eldon SID; Lot 2, Block 3 Received Dale/Time: 02/07/02 15:20 Matrix Drinking Water Technical Director Stephen Ede PWSID Na Released By n n p Sample Remarks Allowable Prep Analysis Parameter Results POL Units Method Limits Date Date Init Total Coliform (MF) 0 coU100 ml SM92228 02/07/02 KAP Nitrate 0.22 0.2 mqr- EPA 300 10.0 02/07/02 JDT , .�.... . ,. .b%.• le. Ih a It.1 . // T.- 6 ... WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological & GeoORysltol SurveE6 Drilling permit Ne. A.D.L. No, le Svbdl.lelen Lot sleek . I/cre. Ncllen We. Tl.naRlrBorough N� Rust [� YMUIanD T-1OI STANCE AND DIRECTION FROM ROAD INTERSECTION/ $treat Address had Area of Well location , S. OWNER 01 WELL: t. WELL LOO feat Salon Surlesa • rolarlat Trra Ter Dena. a. WELL DEPTNI (float) Z' Zfl. S. DATL OF COMPLETION S-- a_ . 'L 0. ❑Cable tool )0 Salarf ' C) Driven 0061 ❑Auto, ❑1etIN ❑brad ❑OIPorI ?.Use:Onaeue ❑ Pa►110 Snoop ❑ Industry girrlpllm+ ❑ **share* ❑ Doamnlool [3 Test Wall ❑OIMn JO . IO 1 t— S. CA IMO+ ❑ Threaded Wt Wold" dlam. Is. to-ZIta. Depth, Wesal Me./ it, die.. to. to -01. DIP 11NIq �l y//. 1. FINISH 01 WEI��! If r/ TIN: DlamNn+ ep Slat/ es► 1 a: LNolh: Del Pointe% fl W ft. ' bNllltlal heal poll •• 10. STATIC WATER L[VEU—Irp ft. ❑Ab000 or xPoIow load esp" '• Data [eslpnual ote1: . 11.PIf,LNO LEVEL Balsa, IoM Sorhoe and VIICU. �.S' wt. •. after' _It. ofw _hra. pomplof It.MOUTINS Wall Erovied: Q Yes )KNo •_ , material: Onset Comast f otaer: mpump, (it available) NI" Ltodth of Drop p1N 11. oaNelly g.p.m• ❑ Saba. ❑ 101 ❑ CeatritIaol ❑ Other . 14. PC 40 16. WATER WILL CONTRACTORS CERTIFICATION: 16.1'aHr TomNratnro -a ❑ F ❑ c thin oil was dr❑ 617tii )a,11� Ad this esperl is fret to tM b)� �;0yledfe as butt /►/ Ibglala,ed Ovstnioo nt amt Contract Llconat Nam►.r . Add.•r.: Slg.1d: Data• A.1hrinH pueNallna term 02•111iR(11/61) coal Distribution: WNITE•Slal.DOall, FINN•DrOlor. CANARY•CuNMI I n P.01 FES -11-02 06:22 PM LEVY ez34v ATTAP TEFF TALK 7•�' C ,y� r'S,'45 E da.co -9- EASEMENTS OF RECORD. OTHERTHAN THOSE SHOWN ONTHE RECORDED -3 - AS -BUILT NO CORNERS SET THIS DATE I hereby cerbly that 1 have performed a Mortgagee's Inspection of the tottowing described property: 14L0 CK y.• t:.DOA/ SCACDIN/�/✓'J r Anchorage Recording Precinct. Alaska, and that the Improvements situated thereon are within the property lines and do not overlap or encroach on he prop" lyingto ent thereto. that no improvements question orstyo^ 9 and that there ere eno encroach or is a premises property except as Ind ca ed hereon other visible easements on said Dated at Anchorage, Alaska `E N f: 20 this /1 iA day 01 �— FRED WALATKA & ASSOCIATES (907) 248.1666 Engineers and Surveyors r :1 ('10. .ag January 10, 1986 TO: Permit Applicant P.O. 5,jX 6i>50 ANCHORAGE. ALASKA 995020650 (9107) 264-42C 4-4111 70,A1 Y KN04W ItS titA �,.R DEPARTMENT OF HEALTH 8, HUMAN SERVICES Subject: Permit 1850200 Lot 2 Block 3 Eldon Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1985. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system the original as -built inspection report(three part form) must be sent to this office for review and approval,and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Susan E. Oswalt Program Manager On-site Services SEO/ljw enc: Copy of Permit PERMIT NO: DATE ISSUED: APPLICANT: ADDRESS: CONTACT PHONE: TV U psi JE 3C M moo L. X -F "W" M 1=7 ��M 1-1 M17112% qv.�.� D�PARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE� AK 99501 264~4720 850200 05/17/85 HELEN MORGAN 6741 SAMUEL COURT ANCHORAGE. Al::: 99516 562~4005 LEGAL DESCRIP: SUBDIVISION: ELDON SECTION: 19 TOW1Sid IP: 12N LOT SIZE: 10800 (SOFT. OR ACRES) LOT LOCATION: JACK STREm- LOT: 2 RANGE: 3W I certify that: 1� I am f' ami:6iar with the requirementor on~site sewers and wells as set Hyrth by the Municipality csf Anchorage (MO(1) atnd the State oh Alaska. 2^ I will install the^system in accordance with all MOA codes and regulations� and in compliance with the design criteria A this permit. 3" 1 will adhere to all MOA and State o{ Alaska r the set back :;;;distances from any existing well� wastewater disposal system or public sewer this or any adjacent or nearby lot^ SIGNED DATE: ... _..... ..... __.... ..... ... ..... ... APPLICANT: HELEN MORGAN � ISSUED BY -'..... ..... . ..... ..... ~ - , APPLI)'"-~JT FILLS OUT UPPER HAL^'ONLY Time Properly Owner ll E&lv � /]//Gyj� �� Phone r' Mailing Address aZip Code �Z C f�,��---- Buyer �iab(�2�/yloayA�% Address Zlp Code C�'C Lending Institution �/ ..�- �/ Phone .7 Zip Code Address ZZ21 Date Realty Co. & Agent - Phone Address Zip Code Legal Description Street Location Type of Residence° Single Family - El Multiple Family No. of Bedrooms_ ❑ Other Water Supply Individual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.. ❑ Community For wells drilled prior to that date, give well depth (attach log if available). ❑ Public Utility Sewer Disposal ❑ Individual Year Individual Installed: `Public Utility When Connected to Public Utility: / y ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector Field Noses: ( �a_L CfpT O° 11 IT'S a, 1 F n: ,l X L uc',. - ENVIh Jr, -r ,A. .o LIA C��ANQ_ ,'� N 2 1982 RECEIVED ( ) APPROVED BEDROOMS `CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONA APPROVAL` i DATE BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Septic Tank Size Well to Tank 72023 (3182) ALASKA RUIROWnTAL COnTROL SCRUICCS, Inc. Engineering & Enuironmental Studies MUNICIPALITY OF ANCHORAGE PFr'T Or H['t.T'1 . ENVIR,rU.'.:P;,A_'';0 F, (I:.4 1 U ii 2 i- 1982 RECEIVED August 24, 1982 Municipality of Anchorage Department of Health & Environmental Protection 825 L. Street Anchorage, Ak. 99501 Re: Health Authority On August 24, 1982 our company coater sample from the well located on Lot 2 Block 3 Elden Subdivision for a bacterological analysis. The results were acceptable. A copy of the report is enclosed. The well has a sanitary well seal and meets the municipality requirements nts for well construction. 1220 West 25th Auenue 9 Anchorage, Alaska 99503 • (907) 276-1361 CHEMICAL & G1 LOGICAL LABORATORIES F ALASKA, INC. TELEPHONE (907).279.4014 ANCHORAGE INDUSTRIAL CENTER E 274.3364 5633 B Street u roe1C• Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: I I I 2 l6 -IV I.D. NO. Water System Name Phone No. Mailing Address City State Zip Code SAMPLE DATE: ® L-= DfM Mo. Day Year f SAMPLE TYPE: Wet GhfO�'�g��M Routine ) g- I Check Sample (for routine sample with lab ref. no. ► X Treated Water ❑ Special Purpose ❑ Untreated Water SAMPLE Time Collected NO. LOCATION Collected By 2 1 1 3 l 4 I 1 5 TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: `®Satisfactory ❑ Unsatisfactory ❑ Sample too long in transit: sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. Date Received J'/1-dz', Time Received a 2 = Analytical Method: ❑ Fermentation Tube Membrane Filter Lab Ref. �No. Result' Analyst i � m i � m FT -1 J FE tNo, of colonies/ 100 ml. or No. of Positive portions 06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1978 Date Collected sow" READ INSTRUCTIONS a.m. Oat. Received Time Received p.m. Lab. No. Presumptive 1 oml 1 oml 1 oml 1 oml 1 oml 1 Aml 0.1 mt 24 Hours BEFORE 48 Hours Confirmatory 24 Hours 48 Hours EMB Broth 24 hours: Broth 48 hoursr COLLECTING SAMPLE Multiple Tube Report: 20ml Tubes Posltiv./TOW 10ml Portions Membrane Fater: Direct Count Coliform/100ml Verification: LTB BOB Final Membrane Filler Results Coliform/100m1 I Reported By Date Time, a.m. p.m. Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 01 (0 - 2 0 A-11 COSA# 0�1 00 3 q 1. GENERAL INFORMATION Expiration Date: S' Ig — D q Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address ELDON SUBDIVISION* BLOCK 3. LOT 2 610 JACK STREET ' ANCHORAGE. AK ' 99516 SHAWN STOUFF Day phone 350-7557 610 JACK STREET • ANCHORAGE. AK • 99516 Day phone BILL BABYLON W/ PRUDENTIAL JACK WHITE Day phone 351-4762 3801 CENTERPOINT DRIVE, 11200 • ANCHORAGE, AK • 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 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 0 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 samples. (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 rites 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 Finn GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 r ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LID. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines 8 Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily Identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the solo benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Date -2-11 -1 Conditional approval for bedrooms, with the fllowing stipulations: �Gyrness. T79�3 ONSITE WATER AND ; R+= : WASTEWATER PROGRAM c ' //I111)1)Ill Attachments: / COSA Checklisty Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory Other By: AX Original Certificate Date: A- — (R". 1105) r...... . Municipality of Anchorage Development Services Department Building Safety Division On -Site Water 8 Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON—SITE SYSTEMS APPROVAL CHECKLIST Legal Description: ELDON SUBDNISION; BLOCK 3, LOT 2 Parcel to: A. WELL DATA Well type PRNATE If A, B, or C provide PWSID# N/A Date completed 9/12/1985 Sanitary seal (YIN) YES Total depth 132 ft. Cased to 139—ft. FROM WELL LOG Date of test 9/12/1985 Static water level 36 ft. Well production 15 g.p.m. Well Log (YIN) YES Wires properly protected (YIN) YES Casing height (above ground) 12+ in. AT INSPECTION 2/2/2009 29 ft. I 9.4+ g.p.m. WATER SAMPLE RESULTS: Coliform U colonies/100 ml. Nitrate A) 0 mg./L. Other bacteria 0 colonies/100 ml. Arsenic: S.53ug./L. Date of sample: 2/2/2009 Collected by: GEG Ltd. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size gal. Foundation cleanout (YIN) _ Date-omping C. ABSORPTION FIELD DATA Date installed Length ft. Number of Compartments (Y/N)_ Soil rating (g.p.d./Wor ft'/bdrm)_ Width Total depth ft. Eff. absorption area_ ft' Monitoring Date of adequacy test Date installed: High water alarm (YIN PUBLIC SEWER System type / Gravel below pipe_ Depression over field— For—bedrooms ield Forbedrooms Fluid depth in absorption field befor t In. Water added _gal. New depth _in. Elapsed Time: n. Final fluid depth_ in. Absorption rate >_ g.p.d. eluvenation treatment (past 12 mo.) (YIN 8 type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N "Pump on" level at in. 'Pump oft" level at _ . High water alarm level at Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A Absorption field on lot N/A Public sewer main 75'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Sewer /septic service line 25'+ Holding lank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main Property line Absorption Water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Water Water service line Surface water Welts 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 COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date 2117.10oi water parking/vehicle storage fir' ' •�"�,S�p� �,�F-' ... ................ 0 '• f y A. Gorness- PCE oo�t�� •. 79 �J11C'cQ000� Prnrno0�p� c� COSA Fee $ q R d .� Waiver Fee $ Date of Payment Date of Payment Receipt Number t) yS zCl Receipt Number (Rev. 11105)