HomeMy WebLinkAboutSAND LAKE #2 BLK 6 LT 24,,nd Locke
Block 6
Lot
#011-133-13
,,,.,~ IVlUI",II~,Ih'/-.~.LI I y UI- ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
~; 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name
~-F'o ~ ,~ /~ an ~z,y- DISTANCES
Address ___~._ TO SEPTIC ABSORPTION
Phone(s) 2~'~./_ ¢~.¢ Cz~ IPermitN°- No. olBedrooms WELL I
Township, Range, Section
~'¢ c [~ / '~ / 8 ~ / ~ ~ ~ AS-BUILT DIAGRAM (Show Jocat,on o¢ well sep c system, proper~y hnes, foundat,on
driveway, water bodies, etc)
TA. s
~ SEPTIC ~ HOLDING
TYPE
OF SYSTEM
~TRENCH ~ BED ~ W. DRAIN ~ OTHER
Fal added above odgmal grade Gravel depih beneath p~pe ~ %
Total absorption area Distance between lines ~ ~ -~ ~ ~
SO FT FT
I
~ PRIVATE ~ OTHER fldentifv)
Classd~ca~ion (A,B,CJ ~ ~ Total Depth FT Cased to
72-013 13/85) ( / / ~ ~ -
JO!'!N F,' (."'. HIE Y
5;?.00 kJ
AI',tCHC)F:A[3E. ..".~K
[24:3 '"'75 O
SLJ}i)D I V]Z S Z[ 01',1 ~, SAND LAI-:'t:r :1:1:;~:?
: T .: .:..N ~ IO 't"'.3NIqSH ]: F' .~ :i. 2':".N
· 50 (SQ .. F'T ~ O!::;: '" (..,,,. :.c )
L.O"F ."
F,'A Nt'3 E ~
]: c~.~r' 'L J. £'y' ~:ha'L ,",
:i.~ i[ ~;':~!~1 ~'~:'i[fl:i, J, i.:3P b~l.I, I.. '~'.hG? !~G~CtUJ. I'"E~i~(~}:'I"U~,E~ ~ CH" (3iq-'-'sa-i~:.e ~sa~6)ps arid .....
' '
, ~ q' i 'i' h :.~ ..... c, ...... ~.~, = c ....
.......:'..' :1: k,~:i. 1 ]. :[.ns'La.! :!. '~ ........ hm ~iFys!:.(~m~ :i.n a(.,.~..~..n .......... ~,.,~::~.~ r m.~::./- wl't..lq a! il, !"'IOA (,..,,..~,,.: s and i-.(.)N:,iu!a.L :j,c)rH~~.
:5. T ~,,,~:L i 'l adha, r'a:, ~ a]. i MOA ' c:~ ..... -.. _..,
E;(GYb,~(;:H~EtCt6}) !~'Vg;'i'. .......... E'~Q ,:::)r"i 'I' h { E; (:)P ;:;dq¥ .::u.].'l ...... au...L..~!~k" ........... oP FiG;'~d"E)¥' ~r''z,[, ...~
.. -~ .,.J MUNICIPALITY OF ANCHORAGE
' //~,~m',~\\' DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
{~ ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL OESCRIPTION
NO. OF BEDROOMS~
W~ ' Absorption area Dwelling PERMIT N~
DISTANCE TO: ~¢ / // f
h ~ Manufacturer
~ ~~ Materi~¢~ No. ofcompsrtments ~
Liq. c%~t~n ~llons. IF HOMEMADE, Inside length Width Liquid depth
~ Manufacturer .. Material Liquid capacity in gallons
~= % DISTANCE TO: Were ~ /~,' Foundation ~ , Nearest lot line ~ / PERMIT NO.
; ~ ~ f~ Total lengt~of I[ne, ,, Trench width Distance between lines
No. of lines Length o I~ ,¢ ~ / ' ~ inches
P ~ ~ Top of tile to finish grade I Material beneath tile Total effective absorption area~
~ Length Width ~ Depth PERMITNO.
< ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well / ~ ~, Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS ~ /~
SOILTESTRATING / ~ ~ ~1~
REMARK8 I I
~ ~ DATE LEGAL
-013 (Rev. 3/78)
PERMIT NO.
OEPFIRI"MENT L....HERL]'I-I Rt'.,I£:, ENVIRONMENTFIL .,_.OTECTION
8;-25 "'L;: STREET., R.NL-:,HOF..:RGE., RK.
,=:.~, '~'~ -h ..~l
_,EI!..-..E[, F" E F;-:." [-,I Z T'
,' 8tL'-~6::L4 ::,
FFLI .HNF T T r:nN'-:T CO SRF~ E,_i,,
LOC:RTICd'.~ 82ND ~. P.IILCOX
LEGflL L2q. B6 S;FiNr:, LRKE .~2 LOT DIZE
T?F'E OF
:,JIL ~E:'-'~OF:F'TION S'¢STEM I'-q: TF.:ENL-:H
FEET
THE LENG"FFI [:, I MEND I ON I'_-'; THE LENGTH <IN FEET) OF THE TRENCH OR [:,RFINFIEL. D
TFIE DEPTH. OF FI 'TRENCH OF.: PIT ID THE [:,IDTRN'2. E BETHEEN THE DURFRDE OF THE
GF..'s_IND RN[:, THE BOTTOM OF THE ENC:RVRTION. <IN FEET.':,.
THERE IS NO SET I.,.tI[:,TH FOF.: I'F.:ENCHED.
THE GRR',,,'EL ['.,EF'TH ID THE HINIML.IM [:,EF'TH OF ~ '"',' '
L~F..H,,EL BETHEEN THE OUTFRLL PIPE
FINC, THE E;OTTOM OF THE EXCRVRTION <IN. FEET::,.
F'EF.:MIT - "' ' T ....
HFFL_CHNF HR_C; THE REDPOND!BILTT'¢ TO INFOF.:M THIS [:,EPRRI"MENT DLF.'ING THE
INDTRLLRTIIZIN IH--,FE_.TILN.:, L-iF RN'¢ HELL'_:, RE,.TRC:ENT "FEi THID PF-.'OF'EF:T'¢ FIND THE
H_MEEt~: OF F.~E-':qIDENCED THRT THE NELL PJ!L.L ':'EF.",'F
........ T'~.....~C, ":: '-:'-=--". ::" }: P-ISF'EC:T Z C~P-.I"S RF-:E F..': E ~L,.-:.-.~ LI Z F-:E[.-.,
DFUSKFZLLING ClF:. Fff.,l'¢ S'¢STEH NITHOU'F FINFIL INzFEUTION"- ' -' RN[:, ~qPpP.,o',,,~l E:'¢ THIS;
DEPRF.:TMEN. T HILL E:E =,LE, J'EE.T TO F'F.'ZSE.'F:UTION.
MINIMUM [:,ISTRNC:E BETHEEN FI I.,.IELL RND RN'¢ ON-DtTE SEI.,JRGE [:'I:SF'ODRL '.:.;'¢DTEM ItS
Ij.--~R ..... FFET F3F.' F.! F'RIVFFFE HE:LL OR :L._E~" .=,~ T-. 2RFI__ FEET FROM R PUBI._IC: PJELL. [:'EF'ENE, INf':~
LIF'Fff.~. TFIE T'¢F'E OF' F'UBLIL-: FJELL -
MINIMUM F.:,ISTRNC:E FROM R PRI',/RTE HELL TO Ft PRIVR. TE SEHEF.'. LINE tS 25 FEEl' taN. D,
TO FI COMMUNIT'¢ SE~,.IEF;: LINE IS 7.'5 FEET.
HELL_1 _qG':,_ RF.:E REQUIFtE[:, p~.llB, MUST E,E' F. ETLIENE[.' " "' TEl T'HE [:'EPFIF. fTMENT HITFllN 3R DR'C5;
OF THE HELL COMF'LETION. '
CrTHEF.: REQUIREMENTq MFI'¢ RPPL.'T'. '.SF'ECIFIF:RTI~hN,~ RN[:, CONDTF. tUCTION E:,t ..... '" ,-
- - - - HL~RHM= RF.!E
H,H1LHE, L~: T3 INSURE F'F::OPEF.: 1ND"FRLLRTION.
I F' '' "
..ER.~ IF~ THF1T
'±: I FII"I F'RM!LIRR HITH THE F-!EQUtREMENTD FOR ON-SITE DENERD RI'-.IE:, !,.IELL..D F-IS SET
FOF.:TFt E"¢ THE MLNI_-IPRLIT'¢ OF RNCH':F.':RF~E.
3:' I UN[:,ERSTF, ff.~D THRT TFIE OI"~.-'_=ITE DENER D"r'STEM MFI'¢ F.'E[.'JIIIRE ENLRPGEMENT IF ']'HE
r,.E--,IC'EN_.E F. tEHOD'ELEI:) TO INCLUDE HOF.:E THRt",I _'2: E:E[:'F.:OOMD.
MR::-::IMUH NUMBER nF EEr:,F'-nM':; = .'2: DOlL RRTING
· _ - .. . .... :' .,
THE F?.EE.!I..ItF::E[:, SIZE OF THE DOIL -""-"' '' - .... q ,
HE,:,OF.'.FTtUN --,t_TEM ID:
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18,
19-
2O
COMMENTS
PERFORMED BY:
72-008 (6/79)
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
,~ SOILS LOG
[] PERCOLATION
TEST
(~)
DATE PERFORMED:
SLOPE
WAS GROUND WATER ~t~,~. SL
ENCOUNTERED?
'O
P~
IF YES, AT WHAT E
DEPTH?
SITE PLANL~¥_ Z~-~
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND ~ FT
r~.,~,,'~,-~- i-.4 .<-?,f~.... ~ ~< p/.~.~4 ~1~.,..~ /~
CO
U
>
CONSTRUCTION AND OPERATION CERTIFICATE
ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION
PUBLIC WATER SYSTEM
APPROVAL TO CONSTR
Plans for the construction
public water system located
Alaska, submitted in accordance with 18 AAC 80.100
have been reviewed and are
[] approved.
El conditionally approved ,(see attached conditions).
- BY TITLE
DATE
If construction has not started within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED CHANGE ORDERS
~nange (contract order no.
or descriptive reference)
Approved by Date
The "APPROVAL TO OPERATE" section must be completed before any water is made available to
the public.
APPROVAL TO OPERATE
The construction of the
public
water system was completed on (date). The system is hereby
granted interim approval to operate for 90 days following the completion date.
BM
TITLE
DATE
As-built plans submitted during the interim approval period, or an inspection by the Department has
confirmed the system was constructed according to the approved plans. The system is hereby granted
fina!,,approval to operate.
-"' ,t. '~..-: -f
"'BY TITLE DATE
61 F y ,,
•
Municipality of Anchora `�
On-Site Water and Wastewater Progra o- JUL 1 3 2017 : n�L1
(907) 343-7904 $a E
4 ti
t
Certificate of On-Site Systems Approvr. 4/1 6 9 L 9
Parcel I.D. 011-133-13 Expiration Date:
1. GENERAL INFORMATION:
Complete legal description Sand Lake#2; Block 6, Lot 24
Location (site address) 5200 W. 82nd Ave.*Anchorage,AK 99502
Current Property owner(s) Matthew Voit Day phone 441-6084
Mailing address 5200 W. 82nd Ave. *Anchorage,AK 99502
Real Estate Agent Jennifer Flannigan Day phone 350-0881
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
E Duplex
E Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class C Well ® Community ❑
Public Water System ❑ Public Sewer 0
WaiverNariance request Distance:
Received by � Date: —7/19/I 9—
COSA to be rele•.• o the - eer,unless otherwise requested by the engineer.
COSA Fee $ Jo6-66 Waiver Fee $
Date of Payment 91!4/ Date of Payment
Receipt Number a 9/ Q(3 Receipt Number
COSA# 0 6C/7-!2.L, 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: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101-Anchorage, Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date: -#13/f l
�Qa0000
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system o OF A j1�'
in accordance with the guidelines and regulations established by the Municipality of Anchorage and ��•.•..••..••f1 Q,
industry practices. The reported results describe the condition of the system/s on the date/s of the p ' uQ
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or �O • fT �� �0n
encroachments may exist that were not identified during the evaluation. The operational life of all wells Qtr CP,,
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, """' "' " ". .,.,
groundwater levels (that may fluctuate during the year), quality of construction (materials and !U 0
workmanship),and the water usage of the family utilizing the system/s. These conditions can vary,and Q
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the e _ Garn-ss; 0
system/s; therefore, GEG makes no warranty(express or implied) regarding the future performance of Qn .� _ - •'
the well or septic system. GEG makes no representation whether an alternative well or septic system UQ s ' . ' .cgp�
can be installed on the property in the event either of the current systems fail to perform adequately in 44 13. f. '' •cv
the future. The content of this report is for the sole benefit of the person/party that retained GEG to QOPa pr 0 f e s sion°o
perform the evaluation. Reliance upon the information provided in this report by any other person or �':000QQo
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
KSystem #1 Approved for 3 bedrooms
System #2 Approved for bedroomsH.-
,�� � OI A/Vc /
Disapproved
J ON-SITE Gam,
Conditional approval for bedrooms, with the foI
_ wingf;�tY�.Ftat .
c WASTEVVATER o
'c pRCGRfw1 S�
c��
By: `A vw (7 Original Certificate Date: 7- /1-(
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist I Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10-10-12.doc
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. Sand Lake #2; Block 6, Lot 24 Parcel ID: 011-133-13
A. WELL DATA *Now a "private well" under ADEC regulation.
Well type 'c" If A, B, or C provide PWSID# *218660 Well Log (Y/N)
' Date completed Sanitary seal (YIN) Wires properly protected (Y/►
Total depth ft. Cased to ft. Casing hei.. -.ove ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well productio• g p.m g.p.m.
R SAMPLE RESULTS:
Coliform colonies/100 ml. Nitrate i\-)° mg./L. Collected by: GEG. Ltd.
Arsenic-30)` ug./L. Date of sample: 6/28/2017
B. SEPTIC/HOLDING TANK DATA 36 year old steel septic tank is approaching the end of its useful life
Tank Type/Material Septic/Steel Date installed 6/25/1981
Tank size 1000 gal. Number of Compartments 2 Cleanouts (YIN) Yes
Foundation cleanout(Y/N) Yes Depression over tank (Y/N) No High water alarm (YIN) N/A
Date of pumping 8/23/2016 Pumper A+ Home Services
C. ABSORPTION FIELD DATA *Below Existing Grade
Date installed 6/25/1981 Soil rating (g.p.d./ft`or '/bdrm 150 System type Trench
Length 31 .5 ft. Width 5 ft Gravel below pipe **7 ft.
Total depth *11.9+ ft. Eff. absorption area 441 ft` Monitoring tube***Yes Depression over field No
Date of adequacy test 6/28/2017 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 7 in. Water added 726 gal. New depth ****45 in.
Elapsed Time: 120 min. Final fluid depth 30 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment(past 12 mo.) (YIN & type) None Known If yes, give date —
**MT only extends approximately 4.17 feet into 7 feet of effective, however, consistent liquid
level readings were able to be taken throughout test.
***Driven steel pipe ****5" below invert
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YIN)
"Pump on" level at in. "Pump off' level at 'a '• ' a er alarm level at in.
- Cycles tested Meets alarm &circuit requirements? _
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100 + On adjacent lots _ 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main 75 + Public sewer manhole/cleanout 100'+
Sewer/septic service line 25 + Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field Unknown
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line *6 Building foundation 10'+ Water main 10'+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain None Known Wells on adjacent lots 100'+
F. COMMENTS
*Per 1981 inspection report.
�006�04�N,
G. ENGINEER'S CERTIFICATION v .OF A', 'N
/�P Htal.,_ S,771,%
pq001 certify that 1 have determined through field inspections and (� _ 49 - . 7 ,
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 00 9, E 79 3 `pGi
. o
Date 1/130 �4re+;. ' -'f 3/1c7 ,<,,a,
4
OdProfessio�d4�
��0400a6
#AECC884
(Rev. 11/05)
��"'"'""''°r Municipality of Anchorage s.
�t„cnr
::: On-Site Water and Wastewater Program ____________
'� ' P.O. Box 196550 4700 Elmore Road
` Anchorage, Alaska 99519 6650 Phone: (907)343-7904 Fax: (907)343-7997
http:/lwww.muni.org/onsite
44Cn°s"GE
1 (',I)8rtllll'.nI
Review Comments
Engineer: GARNESS ENGINEERING GROUP LTD 7/18/2017
Legal Description: SAND LAKE #2 BLK 6 LT 24
Parcel ID: 01113313000
Permit: OSC171296 WellSeptic
Report Type: COSA Completed By: T.Ecklund
The application has been reviewed and the following comments have been generated. These are to be satisfactorily addressed
prior to MOA approval:
1. Please provide justification for conclusion regarding absorption rate on COSA since the math <450Gallons
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•
• Municipality of Anchorage ,d0.
_ Development Services Department-46
Building Safety Division " T
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Arsenic Advisory
Certificate of On-Site Systems Approval # OSC 171296
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 6, Lot 24 of
Sand Lake 2 Subdivision. This inspection revealed an arsenic concentration
of 32.8 micrograms per liter (ug/L) for the property's well water sample.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/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. Information on arsenic is
available from the On-Site Water and Wastewater Program website
(www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
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
.Z
Parcel I.D. Ott- i33-- 1.~
GENERAL INFORMATION
Complete legal description ';~;~,-,~
Location (Site address) 5'zOO
· /
Current Property owner(s) .~usz,~, ~ ~.~,~ 3,\~ Day phone
~ 5o'~- -
Mailing address
Lending agency
Day phone
Mailing address
Real Estate Agent
Mailing Address
Day phone
Unless othen/vise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: ~
f
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 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 w.~a~er supply and/or wastewater disposal system is (are) safe functional~aod adequate
for the number (~ bed:~°(~r~*~· and type of structure ind cared here n I further verify that based on t~ ififormat on
obtained fr?~'~!~,b~;~Muntc~pallty of Anchorage files and from my investigation and inspection, the brCsi,[e' Water
supply and/~:~S{~water disposal system is(are) in compliance with all applicable Municipal and Stat~C~de~,
ordinances, ~nd regulations in effect at the time of installation. '
Name of Firm -.~ pu ~l. iz_l ~,~
Address '~.0~ '¢', i~'i-X '~VCr, 5f¢, 20'L
Engineer's Printed Name
DSD SIGNATURE
Approved for
Disapproved,
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Attachments: COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
(Rev. 11/05)
Municipality of Anchorage
Development Services Department
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: ~q~ [- ~,P,. ~'~. ~31~ (o Lo~ ~t~ Parcel ID: O II-
A. WELL DATA
Well type ~ If A, B, or C provide PWSID # -" Well Log (Y/N) --
C.t~s$ C,..
Date completed -- Sanitary seal (Y/N) ~ Wires properly protected (Y/N) --
Total depth ~ ft. Cased to ~ ft. Casing height (above ground) ~ in.
FROM WELL LOG AT INSPECTION
Date of test ~ ~
Static water level -- ft. -- ft.
Well production -- g.p.m. -" g.p.m.
Total depth I~, ft.
Date of adequacy test
Fluid depth in absorption field before test 3~ in.
Elapsed Time: ~0~0 min. Final fluid depth ~
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
WATER SAMPLE RESULTS:
Coliform .~colonies/lO0mL Nitrate /V.~ mg/L
Arsenic: ~-':J:,~ Ug/L date of sample: ~/l~/?-Oll
B. SEpTIC/HOLDING TANK DA~TA
Tank Type/Material
Tank size' Iooo gal. Number of Compartments
FoundatiOn cleanout (Y/~I) ~/_ Depression over tank (Y/N) ~
Date of pumping ~[[~17-O[[ Pumper !~,
C. ABSORPTION FIELD DATA
Date installed
Length .31,~ ft. Width ¢ ~ L,~ ff.
Eft. absorption area L[50 ft2 Monitoring tube
~[~]Zotl Results(Pass/Fail)
Water added ~1~) gal.
Date installed (~/25]~J
Cleanouts (Y/N) ~
High water alarm (Y/N)
I J
System type 0~.~
Gravel below pipe
Depression over field
in. Absorption rate >=
fto
For .~ bedrooms
New depth ~'/~ in.
z~?~O g.p.d.
If yes, give date --"
D. LIFT STATION
Date installed
"Pump on" level,~~n.
Datum J
SEPARATION DISTANCES
Size in gallons ~--"~'Manhole/Acc. ess (Y/N) ~
"Pump off" level at ,..-'~n. High water alarm level at ,..-"'"'~ in.
Cycles te~d~'~ Meets a~ments?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer/septic service line ~.~
Animal containment areas
On adjacent lots IOO ~-~
On adjacent lots i00~
Public sewer manhole/cleanout
Holding tank /V'/A
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation
Water main
Wells on adjacent lots
Property line
Water service line I0~+
Absorption field 5' ~
Surface water lO0'+ ~'/V,O,"~
Property line ~5'
Water Service line
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
~ ~ ~ ~' Building foundation ~0' 4.-
lO I.-I' Surface water I. O0' ¥
Curtain drain
COMMENTS
50~ (A/,O,~ Wells on adjacent lots
Water main
Driveway, parking/vehicle storage iD
(Rev. 4/10)
I ceHi~ that I have dete~ined through field inspections and ~ ~". ~,~ ;.~ ~
review of Municipal records that the above systems are in ~. ~ ~ ~
conformance with MOA COSA guidelines in effe~ on this date ~ ' "E~" ,~
Engineer's PrintedName
COSA Fee $ ~ ¢ ~¢: ~ Waiver Fee $
Date of Payment ~//~ >/// Date of Payment
Receipt Number ~¢~ ~ ~ Receipt Number
Municipality of Anchorage
Community Development Department
Development Services Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Arsenic Advisory
Certificate of On-Site Systems Approval # OSC111129
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 6, Lot 24 of
Sand Lake #2 Subdivision. This inspection revealed an arsenic concentration
of 27.8 micrograms per liter (ug/L) for the property's well water sample.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/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. Information on arsenic is
available from the On-Site Water and Wastewater Program website
(www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cLanchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 011-135-15
1. GENERAL INFORMATION
Expiration Date: ~ - 6 - ~)-~...
Completelegaldescription SAND LAKE SUBDIVISION ~2; LOT 24, BLOCK 6
· Location (site address or directions) 5200 W. 82ND AVENUE "' ANCHORAGE, AK
Current Properly owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
CATHY LANDCASTER
Day phone 349-5599
Day phone
MICHELLE COBUEN w/ REAL3Y EXECUTIVF_S Day phone
34-1 W. TUDOR ROAD * ANCHORAGE, AK
261-7355
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 fcr 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.
Municipality of Anchorage
Development Services Department
Bulldlng Sate~ Division
On-SEe Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519.6650
www.ct.eschomge.alcua
¢O7) 343-nm4
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
SAND LAKE; S/D ~2i LOT 24~ BLOCK 6
Parcel ID: 011-133,-13
A. WELL DATA
Well type 'c' If A, B, or C prow*de PWSID~~
ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG
Date of test /
Static wa~r ~1~......,-'''''// fl.
~stk~on g.p.m.
AT INSPECTION
g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi.
Arsenic: N/A mg./L
N;trate .239 mgdl.. Other bacteria
Date of sample: 4/17/2002 Collected by:
4. colonies/100 mi.
AWWC~ INC.
SEPTIC/HOLDING TANK DATA
Tank Type/Material SITEL
Tank size 1000 gal. Number of Compartments 2
Foundation deanout (Y/N) YES Depression over tank (Y/N) NO
Date of pumping 4/17/2002 Pumper
Date installed 6/25/1981
Claanouts (Y/N) YES
High water alarm (Y/N) N/A
A+ HOME/SERVICES
C. ABSORPTION FIELD DATA
Date inslalled e/25,/lg81 Soil rating ~r ft~13drm) 150
Length 31.5 ft. Width UNKNOWN ft.
Total depth 12 ft. Eft. absorption area 450 ft~ Monitortng tuba YES
~ ' Date of adequacy test 4/23/2002 Results (Pass/Fall) PASS
Fluid depth in absorption field before test 0 in. Water added 1176gal
Elapsed Time: 15 min. Final fluid depth 13.5 in.
Any rejuvanaUon treatment (past 12 mo.) (Y/N & type)
Absorption rate >=
NONE KNOWN
System type TRENCH
Gravel below pipe 7 ft.
Depression over field NO
For 3 bedrooms
New depth 24.~in.
450+ g.p.d.
If yes, give date -
~PR--29-02 ~2:09 P~
· ...-.
~..'~r.A,.i.l.l.l.l.l.i'~rJdENTS:OF RECORD, ~ER ~AN
¢: ~SE SH~N ON ~E RECORDED ~ ~Z'I~
~ ~T ARE ~ SH~ HERE~. ~. ~
A~.BUILT
NO CORNERS SET THIS
I hereby certify that I have pe~
of the following described
Anchorage Recording-Precinct,
improvements situated thereon are within th~
do I~ot overlap or encroach on the
thereto, U'mt no Improvements on
encroach on the p~emtse~ In
roadways, transmission II~ei r ~
pr~. ~ty except as ndlcated hereon. .
Dat~l'et Anchorage, Alask~ :
(907) 248-1666
FRED WALATKA & ASSOCIATES
Engineers and Surveyors
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
1. GENERALINFORMATION
Application Date
(a)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name
Applicant Address _~00 CML ~'~-,~; /-)n~/~'~ ~&' ~
(c) Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain);
(d) Lending Institution~~ c~/~' {~ Telephone ~ ~- ~z/7 7
Address ~ ~/ ~ ~'~ , ~ C~ ~
(e) Real Estate Company and Agent
Address ~ / ~
Telephone
~7'¢4¢ ~'a;~ ? Telephone: Home E-~/$~7-'~'~ Business
(f)
Mail the HAA to the following address:
-4?
TYPE OF RESIDENCE
Single-Family [] Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well [] Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
,~'~ ,
attesting to the legality and status. , ,.
SEWAGE DISPOSAL
Onsite [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation fr~m the, State Department of Environmental Conservation
attesting to the legality and status.
Page I of 2 72-025 (11/84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approvai 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
Address
Date ~/
Engineer's Seal
Approved ~. Disapproved Conditional ~
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations 'given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: L o '~' ~ '~'/. ~'/oc ('¢ ~
Well Log Present (Y/N)
Total Depth
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
If A, B, C, D.E.C. Approved (Y/N)
Date Completed Yield
Cased to Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments p ~:C. ('.;¢y-/-c,-r~r¢¢~:/-C ~' ~-~/~C~
SEPTIC/HOLDING TANK DATA
Date Installed ~{~/~1 Size
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well _ ¢¢ ~ ~ ~"¢"~
To Property Line ~(J ~
To Water Main/Service Line '~
Air-tight Caps (Y/N)
No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
; for /4~ ,4-.
Temporary Holding Tank Permit (Y/N)
To Building Foundation~ t 3 ¢ ,C,~,,~ c,~,
To Disposal Field ¢¢ t
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026(1~/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N) N
of Last Adequacy Test
Results
Separation Distance from Absorption Field:
To Water-Supply Well /~ i
To Building Foundation ~'
Lot N,
To Water Main/Service Line ~=,
Type of System Design
Length of Field L~/¢.-6'
Depth of Field 7 ~
Gravel Bed Thickness 7
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Property Line I Ot
To Existing or Abandoned System on
; On Adjoining Lots ¢~: ~ ~
To Cutbank (if present) t,1~,4-.
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ¢r~~ ~.,,~ Date
Company F[~z/'¢°/¢ 7'~/m'~! --.~'¢u'zc.e~lOA No.
Receipt No. 1~ ~ 3 ~
Date of Payment "~ 0,~ [ ~../~';¢ g
Amount: $ V5~ O~:~
Page 2 of 2
72-026 (11t84)
Engineer's Seal
Time
Time
Date Date Date
/--2 7
Inspector Inspector Inspector
Comments Conditional Approval
Date Sewer Installed
Permit No.
Septic Tank Size
Holding Tank Size
Boils Rating Well To Absorption Area Well Log Received
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLY
Property Owner (~//t/~ ~'t'7//.,~'/61~ ~-o~'st~-d
Buyer ~/~ ~~ ,
Phone
Address
Lending Institution
Address
Realty Co. & Agent
Address
Legal Description
Street Location
Phone
Phone
~y p e,~f Residence
.,~ Single Family
[] Multiple Family
[] Other
No. of Bedrooms
Water Supply
[] Individual
~ Community
[] Public Utility
S e W. Cj~ e Disposal
~ Individual
[] Public Utility
[] Holding Tank
ATTACH WELL LOG. A well log is required for all wells drilled since June
1975. For wells drilled prior to that date, give well depth (attach log if
available.)
Year Individual Installed:
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.