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HomeMy WebLinkAboutFORELAND VIEW BLK 1 LT 5Foreland View Block 1 Lot 5 #017-401-46 01 MUNICIPALITY OF ANCHORAGE is 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 NAME PHONE KNE n f r �1 .3'19-3553 1 ❑ UP RADE MAILING ADDRESS 2H'/ De-cr_-P_D✓; ve, q q56 LEGAL DESCRIPTION FD da V;e- r bdv;s,'o S Iccl�� LOCATION N� Ils,'d� NO. OF BEDROOMS 3 DISTANCE TO: Well Ids Absorption area CO' Dwelling Z PERMIT NO. 85-0030 L) .Y Z� Z WaZ Manufacturer i7rre r Material s'1-�P No. of compartments H~Z Liq. capacity in gallons IZSD IF HOMEMADE: Inside length Width Liquid depth Z DISTANCE TO: Well - Dwelling PERMIT NO. = z H Manufacturer Material Liquid capacity in gallons !2 DISTANCE TO: Well r IZS Foundation 'fD� Nearest lot line lOr PERMIT NO. SS���b U.1 LL ZNo, Z w of lines Z Length of each line Total length of lines Trench width Distance between lines 1= 13t 4&1 e5q, 3G inches /01 F Top of tile to finish grade t(� Z rl Malarial beneath the 1 f r{ 8 Total effective absorption area O ! �Q,-Gt-n AVG' /y-22'' inches r 712 5T. W Length Width Depth PERMIT NO. t7 a.F wa Type of crib Crib diameter Crib depth Total effective absorption area w DISTANCE TO: Well _ Building foundation Nearest lot line Classr' Depth Driller Distance to lot line PERMIT NO. u, DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER hnt N6 . 6TH tE PIPE MATERIALS pvc p 'V a SOILTEST RATING � z 37 61Z INSTALLER (� 3 REMARKS O • 6 Agn •.' is •4 ••............ot 4 �Cq NTa• CE -5203 V � ♦ •�'IN.. �l'aROFESSICt,�.m LEGAL t ZA7PDATE 4�0Z 8 qJ �!^e l n'1Ct Vl e -w LS[� 72-0 13 trsev. 317 .Aj owumm i%.; .1 A, . ... .. ..... .Aj owumm MUNICIPALITY OF ANCAGE DEPARTMENT *HEALTH AND ENVIRONMENTAL OOTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 IDC-J—:E3 I _r 1—= E4JER .&: L4E=LL_ F°EFRM I T PERMIT NO: DATE ISSUED: APPLICANT ADDRESS: CONTACT PHONE LEGAL DESCRIP LOT SIZE: MAX BEDROOMS 84029_ O5/04,'84 ROBERT N. POWELL 244 DEERFIELD DR. ANCHORAGE; AK 99515. 349-2553 SUBDIVISION: FORELAND VIEW SECTION: 25 TOWNSHIP: 12N 54816 (SQ. FT. OR ACRES,) LISTED BELOW ARE THE OPTIONS AVAILABLE TO SYSTEM. CHOOSE THE OPTION THAT BEST FITS mss: GRAVEL LENGTH * TANK MUST HAVE LOT: 5 BLOCK: 1 RANGE: 3W YOU IN DESIGNING YOUR SEPTIC: YOUR =ITE. E}FEE U- TRE1'-J1_" DEPTH TO -PIPE BOTTOM (FT.) 4.0 0.5 GRAVEL DEPTH FT.) 4.0 7.5 TOTAL DEPTH (FT.) 8.0 44. 0 'GRAVEL WIDTH <FT.) 2.5 57.0 GRAVEL LENGTH (FT.) 89.0 WW GRAVEL VOLUME (CU. YDS. > 27.0 TANK SIZE (GALS) i, 000.0 W SOIL RATING r SQ: FT. lBR) 237 mss: GRAVEL LENGTH * TANK MUST HAVE LOT: 5 BLOCK: 1 RANGE: 3W YOU IN DESIGNING YOUR SEPTIC: YOUR =ITE. E}FEE U- 14_ CFR n I t -J 4.0 4. 0 0.5 2.5 4.5 7.5 23. 0 5. 0 44. 0 77.0 W» 37.4 57.0 1, 000. 0 xW 1,000.0 w* 220 237 75 FT. REQUIRES MULTIPLE RUNS AT LEAST TWO COMPARTMENTS (NOT EXCEEDING 75 FT. EACH) I "CERTIF', THAT: 1. I AM FAMILIAR WITH THE REQUIREMENT': FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE (MOA) AND THE STATE OF ALASKA. 2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS: AND IN COMPLIANCE WITH THE DESIGN C:R..ITERIA OF THIS. PERMIT. 3. I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL SYSTEM OR. PUBLIC SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT. 4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 3 BEDROOMS AND ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT. IF A LIFT STATION 15 INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (i) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) A=,-BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORt, MUST_BE DONE BY A LICENSED ELECTRICIAN. SIGNED ------------- [NATE: y/ --- 3 - ---- -- -- � �{---- APPLICANT: ROB RT N. POWELL ISSUED BY - GATE:-- PERFORMED LEGAL DESCRIPTI DEPTH (FEET) 1 2 3 4 5 6 7 a 9 10 11 12 13 14 15 16 17 a or D 18- 19- 20 8 1920 a so SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION 825 L. Street, Anchorage, Alaska 99501 264-4720 TEST SOILS LOG — PERCOLATION TEST QC-LANIL ,VL/It-. SILT% 6RAvL_LS q^e'°rea, 111 Of AC,,dlp- JOHN T. LOVETT No. 3512-E nn4•...... =•> 14% L\ eTa 4• A.. �k •• 91d JCHN T. LOVETT No. 3512-E SLOPE DATE PERFORMED: /�-+ '-/4 '-;;:3� 7 SITE PLAN 'NEON PERCOLATION RATE %Y1C/ , IVC �t (minutes/inch) TEST RUN BETWEEN _.YZ_ FT AND - FT mirommomimmiNEE I cryr, e' Y if'{: c'i_ t!'=tr -'—• 1' n INEEMENNEME 1 \rte Ni PY� CERTIFIED BY! DATE: Reading Data Gross Tima Net Time Depth to Water Net Drop mMwwNvmmm INEENEENNE a M1 WAS GROUND WATER S ENCOUNTERED? do L N 12) D P IF YES, AT WHAT E DEPTH? PERCOLATION RATE %Y1C/ , IVC �t (minutes/inch) TEST RUN BETWEEN _.YZ_ FT AND - FT COMMENTS lc"e- cryr, e' Y if'{: c'i_ t!'=tr -'—• 1' n PERFORMED BY: ., O 1 \rte Ni PY� CERTIFIED BY! DATE: Reading Data Gross Tima Net Time Depth to Water Net Drop e^ PERCOLATION RATE %Y1C/ , IVC �t (minutes/inch) TEST RUN BETWEEN _.YZ_ FT AND - FT COMMENTS lc"e- cryr, e' Y if'{: c'i_ t!'=tr -'—• 1' PERFORMED BY: ., O 1 \rte Ni PY� CERTIFIED BY! DATE: • • • WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological & Geophysical Surveys Drilling Permit No. LOCATION OF WELL (Please complete either to, Ib or lc.) A.O.L. No. lel. Borough J Subtliv iE ion Lat Block Ib. I/q gtrs. —of_of—of— Section No. Township N ❑ 6❑ E Range WE] Meridian la DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS Street Address and Area of Well Location 3. OWNER OF WELL Address: 2. WELL LOG FeetBelow Surface M aleriol Type Top eof tom 4. WELL DEPTH:(finol) if. 5. DATE OF COMPLETION 6. 0Cable toolRotary ❑Driven E]Dag ❑ Auger ❑ Jetted ❑ Bored ❑ Other: . - 7. USE: ❑ Domestic Public Supply ❑ Industry ❑ Irrigation Recharge E] commerical Test Wall EJ Other: -' -- =EJThreadedWelded th Weight Ibs./ft. th Stickup ft. ftdia.. --------- INISH OF WELL: Type: Dlamete r+ Slot/Mash Size: Length: Set between ft, and ft. t Backfilling Gravel pack - M(1 EPT ANCHORAG NMENTgL RO 10. STATIC WATER LEVEL) ! ft. ❑ Above or Below land surface Date Equipment used: czM '" aa _---- V I1. PUMPING LEVEL below land surface and YIELD ft. after hrs. pumping g, p, m: ft. after .hrs. pumping g.p.m. l 12.GROUTING Well Grouted: 0 Yes ED No Material: ❑ Neat Cement ❑ Other: 13. PUMP: (if available) HP Length of Drop Pipe ft. capacity g. p.m. ❑ Subm. Jet ❑ Centrificai Other 14. REMARKS: I6. WATER WELL CONTRACTORS CERTIFICATION: I5. Water Temperature _ ° ❑ F ❑ C This well was ori lied under my jurisdiction and this report is true to the best of my knowledge and belief; Rey ste ed Business Name Contract License Number adc Signed a_ ."�— Date _ Authorized Representative farm 02-WWR (II/81) Copy Distribution: WHITE -State DGGS, PINK -Driller, CANARY -Customer Bnwkl Municipality of Anchorage NTG£ $Gi Development Services Department r , Building Safety Division -• On -Site Water and Wastewater Program 4700 Bragaw Street 5A "` 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. 017-401-46 COSA 4 CSC 11 10L)_3 Expiration Date: i4 -3i- 1. ✓'i- 1. GENERAL INFORMATION Complete legal description FORELAND VIEW, LOT 5, BLOCK 1 Location (site address) 13010 TEANNE ROAD, ANCHORAGE, AK 99516 Current Property owner(s) STEVE & MARY KEMPER Day phone Mailing address 13010 JEANNE ROAD, ANCHORAGE, AK 99516 Lending agency Day phone Mailing address Real Estate Agent JENNIFER ZIMMERMAN Day phone Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE -OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site Individual Water Storage ❑ Individual Holding Tank Community Class Well ❑ Community On-site El Public Water System ❑ 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 verity 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 868-3792 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date . 01/12/2011 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 all 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 unseen +� + encroachments, deficiencies or discrepancies exist.f„ 5. DSD SIGNATURE t✓ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Septic System Advisory _ Well Flow Advisory Nitrate Advisory PROGRAM Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: 3 i l (Rev. 11/05) Municipality of Anchorage o #aE • '� Development Services Department Building Safety Division < On -Site Water & Wastewater Program s ^ 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: FORELAND VIEW, LOT 5, BLOCK 1 Parcel ID: 017-401-46 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID # Date completed 3/29/1985 Sanitary seal (YM) Y Total depth 172 ft. Cased to 54 ft. FROM WELL LOG Date of test 3/2911985 Static water level 75 ft. Well production 3.0 g.p.m. WATER SAMPLE RESULTS: Well Log (YM) Y Wires properly protected (Y/N) Y Casing height (above ground) --Min. AT INSPECTION 1/6/2011 Coliform NEG colonies/100mL Nitrate 2.59 mg/L Arsenic: ND mg/l Date of sample: 1/7/2011 Collected by: ArcTerra B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed Z1811985 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (YM) N Date of pumping 1/6/2011 Pumper A+ C. ABSORPTION FIELD DATA Date installed 2/8/1985 Soil rating (g.p.d./e or ff/bdrm)1.58 System type Trench Length 89 ft. Width 3 ft. Gravel below pipe 4 ft. Total depth 10.2 N / 6.9 S ft. (Measured 1/6/11) Eff. absorption area 702 ftZ Monitoring tube Y Depression over field N Date of adequacy test '1/6/2011 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 42/42 in. Water added 740 gal. New depth 48145 in. Elapsed Time: 1140 min. Final fluid depth 42 41 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 Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off" level at _in. High water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanknift station on lot 100'+ Absorption field on lot 100'+ Public sewer main 751+ Sewer/septic service line 251+ Animal containment areas 50'+ On adjacent lots On adjacent lots Public sewer manhole/cleanout 1001+ Holding tank 1004 Manure/animal excrete storage areas 1001+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 51+ Property line 51+ Absorption field 51+ 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 10'+ Building foundation 101+ Water main 10'+ Water Service line 101+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain 50'+ (None Known) Wells on adjacent lots 1001+ 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 KENNETT3 M. DUFFUS Date COSA Fee $490.00 `` Waiver Fee $ _ Date of Payment I 1 Date of Payment Receipt Number n J 1�J Receipt Number (Rev. 11/05) Municipality of Anchorage • "` Development Services Department A . Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ei.anchorage.ak.us (907)343-7904 Septic System Advisory Certificate of On -Site Systems Approval # 111023 During a recent adequacy test on the septic system for Block 1, Lot 5 of Foreland subdivision, 42 inches of standing water was observed in the absorption field. This indicates that approximately 90% of the absorption area is inundated. Although this system passed the adequacy test, the remaining life expectancy may be limited. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval otv. t,u�u�earya to _ . 3G y �� IF a: i ST�.N �jG yes �I 4--4 M• ���� kb � T�[CceMH � I / •� •.I - �. 'CSKT �. .� A74 '-' M� Nl * R=70,0ell' 8• cavy i71 w - X55 L s S(0.S8 • o�rRi� SCa�e: "=do .tW,9AlS0N CYR NO O)URCUMSTARCM 09 D AN AX-BgtT.Wii 'tQIF. 11K7COW qC /d1:F3T/�.l C-BOfiIHIARY OR FOXE UNES. UNDER THE SURVEYOR TAID:S RESPONgwjw FOR 11ff-QA7iAL TRA R'�lA.Y:l1E1DIe S f�All¢& CRI.II� M CJLY "M THE COST OF 71K SURVEY. CAUXjf Ofti.N SOME. \090 tIG1101.MXY': for auncY SURVEY TYPE - ❑ r ATW AS -MILT S'YMB= :. • SET Mzm DRAINAGE © As%I LT � Wfli CR a FOUND RESM 4-�>tOOD FE)iCE "—`r`—"� owcwm 0 OV i 9 11 UETAL f1C i ® MODO DEQ( PLOT PLANS 'tOT SURVM IT IS THE RESPONS- IF1TY OK THE BOLDER OR OWNER. PRIOR TO IT TO VERIFY PROPOSED,EUO-MNG CRADE RICLAI L -=- ONLY THOM 004tOVOAM3 ABOVE GROUND AND VIM" WU-L BE S Ft. qm �•a"�O 6iA'NWi7' >POLY'". DRIVEWAYS, SNOW CONSTRUCTION. TO FINISHED GRADE AND UTILITY AND TO D47EA4INE'. THE EXISTENCE D ANY UTU"fl7.�AN75 OR RE9TR{CTI - O AR[ SHONN HN' T►KDt APPRWMAK E La'AT+a'• ONLY. - itJ�Y FRL4DLTi 4E. Y FROY I=M" O HE AND LOCATED. ARE ;Rw=RQ L7NLE's OTfiE7RWISE NOTED. WHICH DO NOT APPEAR ON 'nit RECORDED :.S IVISIO[: PL:4T..:. Am.. QRsTANGEi y Robert E. Johns, Jr. & Assoc. SURVEY CERMFICAIMroPCr off'+y �.••E :,."`µw •� Q��^ "'"`"` w 1} Professional Land Surveyors •, <••..a+�+r- a• .n..n w w. N.. N V •r Mt f1 $Q E. 12 AVE ANCHORAGE. ALASKA 29M Rsy tni SF. RK Plot F7• Ha I'MMATICH AS -BOLT �. IL O% CNdNd bJi8 2092 3G y 9 T!C IF a: i ST�.N �jG yes �I 4--4 M• ���� kb � T�[CceMH � I / •� •.I - �. 'CSKT �. .� A74 '-' M� Nl * R=70,0ell' 8• cavy i71 w - X55 L s S(0.S8 • o�rRi� SCa�e: "=do .tW,9AlS0N CYR NO O)URCUMSTARCM 09 D AN AX-BgtT.Wii 'tQIF. 11K7COW qC /d1:F3T/�.l C-BOfiIHIARY OR FOXE UNES. UNDER THE SURVEYOR TAID:S RESPONgwjw FOR 11ff-QA7iAL TRA R'�lA.Y:l1E1DIe S f�All¢& CRI.II� M CJLY "M THE COST OF 71K SURVEY. CAUXjf Ofti.N SOME. Usm Dtsmces PAEYAA OYER . Ga tIG1101.MXY': for auncY SURVEY TYPE - ❑ r ATW AS -MILT S'YMB= :. • SET Mzm DRAINAGE © As%I LT ❑ raAL MM=PAa tis -MMT a FOUND RESM 4-�>tOOD FE)iCE "—`r`—"� owcwm ❑ PLOT PLAN -a ... A$T... [GT SWAY... TV0ORAN1v OV i 9 11 UETAL f1C i ® MODO DEQ( PLOT PLANS 'tOT SURVM IT IS THE RESPONS- IF1TY OK THE BOLDER OR OWNER. PRIOR TO IT TO VERIFY PROPOSED,EUO-MNG CRADE RICLAI L -=- ONLY THOM 004tOVOAM3 ABOVE GROUND AND VIM" WU-L BE S Ft. qm �•a"�O 6iA'NWi7' >POLY'". DRIVEWAYS, SNOW CONSTRUCTION. TO FINISHED GRADE AND UTILITY AND TO D47EA4INE'. THE EXISTENCE D ANY UTU"fl7.�AN75 OR RE9TR{CTI - O AR[ SHONN HN' T►KDt APPRWMAK E La'AT+a'• ONLY. - itJ�Y FRL4DLTi 4E. Y FROY I=M" O HE AND LOCATED. ARE ;Rw=RQ L7NLE's OTfiE7RWISE NOTED. WHICH DO NOT APPEAR ON 'nit RECORDED :.S IVISIO[: PL:4T..:. Am.. QRsTANGEi y Robert E. Johns, Jr. & Assoc. SURVEY CERMFICAIMroPCr off'+y �.••E :,."`µw •� Q��^ "'"`"` w 1} Professional Land Surveyors •, <••..a+�+r- a• .n..n w w. N.. N V •r Mt f1 $Q E. 12 AVE ANCHORAGE. ALASKA 29M Rsy tni SF. RK Plot F7• Ha I'MMATICH AS -BOLT �. O% CNdNd bJi8 2092 REJ TMiLJ 4121—$2�.r EST2002 Oft 2841a 22295 FlNAL STRucTLM As—BULT �1•i0' �...;.i^r:w'w.,' 'rte' . ..w. "•' it�c LOT 5 • BLOCK I FOP$LAND VIEW $UBO . 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.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 017-401-46 HAA# r�Jxi 1. GENERAL INFORMATION Expiration Date: I Z u"L Complete legal description FORELAND VIEW S/D; LOT 5, BLOCK 1 Location (site address or directions) 13010 JEANNE ROAD Current Property owner(s) SCOTT FRANCIS Day phone 345-9832 Mailing address 13010 JEANNE ROAD, ANCHORAGE, ALASKA 99,')16 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site 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 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. 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 41 A 1. A WATER & VJAS€E'�NATEI CC SUL`A TS, INC_ Phone Address 6903 DEBARK ROAD, Si' E 2E " aNCiORACE, AK 49604 Engineer's Printed Name if-F-REY A. CARNE' , P.E. Engineer's Comments: In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & 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. AKW WC, 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. 337— n Date 3 Y Disapproved. tttAIV (l Conditional approval for bedrooms, with the fllowina stipulations\\��.. Attachments: HAA Checklist Septic System Advisory Well Flow Advisory By: (Rev. 12IOt)\f WATER AND oRnGRAMNT Manitenance Agreements Supplemental Engineer's Reort Other _ Original Certificate Date: f 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.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: FORELAND VIEW S/D; LOT 5, BLOCK 1 Parcel ID: A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 3/29/85 Sanitary seal (Y/N) YES Total depth 172 ft. Cased to 54 ft. FROM WELL LOG Date of test 3/29/85 Static water level 75 Well production 45 WATER SAMPLE RESULTS: 017-401-46 Well Log (Y/N) YES Wires properly protected (YIN) YES Casing height (above ground) 36 in. AT INSPECTION 8/15/02 76 ft, 3.0+ g.p.m. Coliform 0 colonies/100 ml. Nitrate 2.46 mg./L. Other bacteria 0 colonies/100 ml. Arsenic: N/A mg./L. Date of sample: 8/15/02 Collected by: AKWWC, INC. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size 1250 gal. STEEL Date installed 2/8/85 Number of Compartments E Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (YIN)NE High water alarm (Y/N) N/A Date of pumping 8/14/02 Pumper NORTHLAND PUMPING C. ABSORPTION FIELD DATA *MT ONLY EXTENDS 3'+/— BELOW INVERT IN LOWER TRENCH. NO FUNCTIONAL MT IN UPPER TRENCH. Date installed 2/8/85 Soil rating .p.d./ r ft'/bdrm) 237 System type TRENCH Length 89 ft. Width 3 Gravel below pipe 4.0 ft. Total depth 10.2 ft. Eff. absorption area 702 ft2 Monitoring tube *YES Depression over field NO Date of adequacy test 8/21/02 Results (Pass/Fail) PASS For E bedrooms Fluid depth in absorption field before test E in. Water added 435 gal. New depth 7_5 in. Elapsed Time: 1138 min. Final fluid depth E in. Absorption rate >= 450+ g,p,d, Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date D. LIFT STATION Date installed "Pump on" level at in. Datum .==:::::� E. SEPARATION DISTANCES Size in gallons 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 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Public sewer manhole/cleanout N/A Sewer /septic service line 25'+ Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 3 Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify That !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. QOffre urn s. - Engineer's Printed Name JEFFREY A. GARNESS doo , E 953 mmi �c G Date HAA Fee $ � / S' Waiver Fee $ Date of Payment L6,7_ Date of Payment Receipt Number ✓��5Receipt Number (Rev. 12101) f MUNICIPALITY OF ANCHORAGE AL • i DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section C� P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ✓ 0 3gC� Parcel I.D. # nL7-_41L4r HAA # 1. GENERAL INFORMATION Complete legal description L5 Bl Foreland View Location (site address or directions) 13010 ieanna Road Anchorage, AK 99516 Property owner Ban Haas Day phone 345-1939 Mailing address As above Lending agency i Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: _9 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 x 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 MOA M21 - 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 criterium Alaska Enai neers Phone 349-1 nn� Address Engineer's signaturP//� Date 'JZ 1 A. Johnson, P.E, L.S. 6. DHHS SIGNATURE Approved for bedrooms. An Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 911TIC 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 M21 �' ® Municipality of Anchorage WM Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L5 Bl Foreland View Parcel I.D. 017-401-46 A. Well Data Private Well type Log present(Y/N) If A, B, or C, attach ADEC letter. ADEC water system number completed 3-29-85 Driller Gene Skyles Well drilling Total depth 172' Cased to Sanitary seal (Y/N) Date of test Static water level FROM WELL LOG 3-29-85 75.0' 54' Wires properly protected (Y/N) Well flow 3.0 9.p -m. Pump levell SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 105' Absorption field on lot 125' AT INSPECTION 7-26-94 70.3' 3.83 »n n height 3' u' m 0 Z On adjacent lots 2001+ On adjacent lots 100+' Public sewer main N/A Public sewer manhole/cleanout N/A Sewer service line N/A Petroleum tank WATER SAMPLE RESULTS: Coliform 0 Nitrate 2.5 Other bacteria Date of sample: 7/26/94 Collected by: pkmT B. SEPTIC/HOLDING TANK DATA Date installed 2 -E -8S Tank size , 5g Compartments Cleanouts (Y/N) Y Foundation cleanout (Y/N) y Depression (Y/N) High water alarm (Y/N) N/A Alarm tested (Y/N) t1,A Date of pumping 7 24-94 Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 105' On adjacent lots 140'+ Foundation To property line 6n, Absorption field 101 Water main/service line N/A Surface water/drainage 72-026(3W)•Fmt CONTINUED ON BACK PAGE G m r t� O y 9� O N G LPNz u' m 0 Z On adjacent lots 2001+ On adjacent lots 100+' Public sewer main N/A Public sewer manhole/cleanout N/A Sewer service line N/A Petroleum tank WATER SAMPLE RESULTS: Coliform 0 Nitrate 2.5 Other bacteria Date of sample: 7/26/94 Collected by: pkmT B. SEPTIC/HOLDING TANK DATA Date installed 2 -E -8S Tank size , 5g Compartments Cleanouts (Y/N) Y Foundation cleanout (Y/N) y Depression (Y/N) High water alarm (Y/N) N/A Alarm tested (Y/N) t1,A Date of pumping 7 24-94 Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 105' On adjacent lots 140'+ Foundation To property line 6n, Absorption field 101 Water main/service line N/A Surface water/drainage 72-026(3W)•Fmt CONTINUED ON BACK PAGE C. LIFT STATION Date installed N/A Manufacturer h(/A Size in gallons N/A Manhole/Access (Y/N) NA Vent (Y/N) N/A "Pump on" level atNq/A "Pump off" Level at pA High water alar level N/A Cycles tested N/A Meets MOA electrical codes (Y/N) N/A SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot N/A On adjacent lots N/A Surface water D. ABSORPTION FIELD DATA Date installed 2-8-85 Soil rating (GPD/Ft2) 1-58 System type Tren"h Length 89' Width 3' Gravel thickness Total depth Total absorption area 707 sf Cleanout present (Y/N) v Depression over field (Y/N) N Date of adequacy test 7-25-94 Results (pass/fail) Pates for Bedrooms Water level in absorption field before test o n, After test Peroxide treatment (past 12 months) (Y/N) N If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot, i251 On adjacent lots 4:40 ' I Property line 60' To building foundation 40' To existing or abandoned system on lot p;4A On adjacent lots 100+ Cutbank N/A Water main/service line N/A Surface water 100+ Driveway, parkingtvehicle storage area 3 Curtain drain N/A E. ENGINEER'S CERTIFICATION 1 certify that f have checked, verified, or conformed to all MOA and HAA guidelines in effect on hgdate of this inspection. �� ri 6j•: l *. Signatur ..: Engineers Name Theod re A. Johnson, P.E. , L.S. ®^ PP Theodo chr Date koU l`AFD HAA Fee $ _ Date of Payment Receipt Number 72-026 (3193)' Back cc Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE i DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROSECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 1. GENERAL INFORMATION (a) nclude lot, bl Location (address or directions) Application Date _ I mo-rc.l'1 1 section, township, range) (b) Applicant Name c P2{ f cYaA'Y r QowezP Telephone: Home 34'S' 715 Business �_ � • Applicant Address (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: G Z 2. TYPE OF RESIDENCE Single -Family E -Y Multi-Famil ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well LJCommunity ❑ Public ❑ Telephone Z —b/DO co('s Note: If community well system, must havewritten confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) 5. ENGINEERING FIRM PROVIDIFAISPECTIONS, TESTS, FILE SEARCH, DA•AND INFORMATION 11 As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. r — Name of Firm Telephone J (U1 Address 4i) U,'5 CW . I) % 4 ; Date z i 1' aro, V 1 186 :e J. co, win• �. CE -52`J3 DHEP APPROVAL Approved for bedrooms by2�, LC ate Approved Disapproved Conditional U Terms of Conditional Approval dhep CAUTION neer's Seal 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 72-0?5 (11184) A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) MUNICIF14MALTH /ykpff4$¢}{��Y APPROVAL (HAA) DEPT,ENVI OEN�Rl�RgNMhP T - FEBRUARY 1984 X4720 i_v '' MAR 26 1ttp��Legal Description. e IT : C i �• I r t RECEIVE Well Classification -J1h �.i }f('l1lt: If A, B, C, D.E.C. Approved (Y/N) Well Lo Present Y/N 1,j���°, A( 9 ( ) t-j-� Date Completed `� `I _ � � Yield Total Depth i %L' Cased to > `'l d- Depth of Grouting N lid Static Water Level) `-� '� Pump Set At i `7l' + Casing Height Above Ground Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) +" Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot On Adjoining Lots :�, A To Nearest Edge of Absorption Field on Lot I -�3, ; On Adjoining Lots — '-TC-C To Nearest Public Sewer Line f"!'i To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot A lf`I Water Sample Collected byIYIL_ "r v I , Date L.''I Water Sample Test Results Comments 'I• B. SEPTIC/HOLDING TANK DATA Date Installed f Size No. of Compartments Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (Y/N) Date Last Pumped Pumping/Maintenance Contract on File (Y/N) for Holding Tank High -Water Alarm (Y/N)I�) I- i Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well To Property Line To Water Main/Service Line Course Comments Page 1 of 2 72-026(11 /84) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA s ` Soils Rating in Absorption Strata Z.' � T ype of System Design f ✓ C yr G Date Installed Z– � ' ;'� Length of Field <� i Width of Field Depth of Field _ Gravel Bed Thickness `i'f"- f� Square Feet of Absorption Area Depression over Field (Y/N) — Results of Last Adequacy Test I Z Standpipes Present(Y/N) Date of Last Adequacy Test N v Separation Distance from Absorption Field: To Water -Supply Well f Z To Building Foundation �C'I Lot til!lA To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments QkC-P �to`, D. LIFT STATION x 1 f Date Installed �V I Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments To Property Line To Existing or Abandoned System on On Adjoining Lots To Cutbank (if present) i ir^;r'it Dimensions Manhole/Access (Y/N) Pump Off' Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA " Check Permitted Bedroom Rating Against HAA Request `" I certify that I have checked, verified, or conformed to all MO�Aj and HIAA guidelines in effect on the date of this inspection. Signed LA C� ro,0 q' rT �` ll / Date Company `-OfU 1} 1'1 6�4Q(Q�bA No. Receipt No. C) Date of Payment < 3 Amount: $ (OS, •� F `' ; '11 Engineer's Seal Page 2 of 2 72-026 (11/84) J. Corwin a �4js• .% No. CE -5283 a