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HomeMy WebLinkAboutDAWN VILLAGE BLK 1 LT 2I)awn V io I I age Block 1 Lot 2 #014-061-55 Municipality ®f Anchorage On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval Parcel I. D.014-061-55 1. GENERAL INFORMATION: Complete legal description Dawn Village; Block 1, Lot 2 Location (site address) 6750 Teshlar Drive *Eagle River 99507 Expiration Date: j4 ---r — 2_0 -2—(9 Current Property owner(s) Gerardo Delgado Day phone 907-980-9865 Mailing address Real Estate Agent Nichole Perry Day phone 907-865-6557 2. TYPE OF DWELLING: Z Single Family (w/wo ADU) F71 Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: .4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual 0 Individual Water Storage ❑ Holding Tank E71 Community Class, Well ❑ Community ❑ Public Water System❑15_u�bFicSewer 0 WaiverNariance request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ C� 20 Waiver Fee $ Date of Payment //,2q loogo Date of Payment Receipt Number 6,304 Receipt Number COSA # OScgb (m 3 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 Engineednq 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: Z ho In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells 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 workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fail to perform adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG to perform the evaluation. Reliance upon the information provided in this report by any other person or party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. 6. DSD IGNATURE / System #1 Approved for 4/ bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for �. T 7* f y. Gorn ss.: CE -795 f 4p44ed p��'Z 000G rofessio� —o #AECC884 ��l�lllt4(lt((l(lr� bedrooms, with the following s'f n aticif j <!/rytat vL� M 1 t3 y Original Certificate Date: / `-_7 l 7C) 2_() 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 C Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other Legal Description: DAWN VILLAGE; BLOCK 1, LOT Parcel ID: 014-061-55 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 1977 Total depth 106 ft Cased to 106 ft -may ASSNJ" ` (� Al Sanitary seal is functioning correctly rr FE -1 Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 1/21/20 Static water level at beginning of test 27-1 ft. Comments Age�fANK DATA tank(s) years Tank type7m terial Measured operate fluid level in septic tank ❑ Standpipes/foundafl n cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA Which system tested (date installed) �! ❑ ALL standpipes present per record drawing Total measured depth from grade / ft (max) Measured depth to pipe invert frofn'grade ft (min) ❑ N/A - pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective / ❑ Code -required oil cover over field El System presoaked (Required if vacant for greater than 30 days prior to date of to� tf Gal s introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Well production at time of test 4.7+ gpm �? Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes ❑Q No Coliform bacteria is Negative Nitrate mg/L [,Nitrate less than MRL (N D) Arsenic 10-S ug/L ❑ Arsenic less than MRL (ND) Collected by GEG, LTD. Date of Sample 1/21/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station yea s Lift station material Comments: Adequacy test date Results ❑ Pass For bedrooms Fluid depth prior to test in Water added gal w depth in Elaps time min Final fluid �th Absorption rate\ Any rejuvenation If yes, enter date AWWU SEWER in gpd ent (past 12 months) E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft Property Line > 5' ❑ Yes Septic Tank/Lift Station on Lot > 100' NSA Community Sewer Manhole/Cleanout > 100' *4� ❑ Yes if No ft ❑ Yes if No ft Neighboring Tank > 100'✓❑ Yes if No ft Private Sewer/Septic Line > 25' ❑ Yes if No "UNKNONR! ft Absorption Field on Lot > 100' ❑ Yes if No NSA ft Holding Tank > 100' ❑✓ Yes if No ft Neighboring Absorption Fields > 100' If septic tank is under driveway Animal Containment > 50'✓❑ Yes if No ft ✓❑ Yes if No ft * 34 Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑ Yes if No ft ✓❑ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft Property Line > 5' ❑ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft Water Main > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑ Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No ft Wells on Adjacent Lots: Water Main > 10' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft I 'SCMME N TS SCMMENTS *WR9900078 **NO DISTANCE WAS REQUIRED BY CODE AT TIME OF WELL DRILLING (PRE -1983) Q MU1 i 0060 O G. ENGINEER'S CERTIFICATION o I certify that 1 have determined through field inspections and review ��j�Q ' of Municipal records that the above systems are in conformance with C� g X100 MOA COSH guidelines in effect on this date. � .. COSA Checklist yellow sheet fr*E A. Garne Q E— e� a O sie � ..... 4� fed � �..... \ �o 0 �,professior o #AECC884 �J 3o ® Frontier surveys, LLC Project No: 17-099 Date: June 06th, 2017 NORTH Scale 1" 26' = Ordered By: Laney Stapely Plat: 76-229 Grid: N/A I I LOT 3 I I .I UI ! W z ...i 71 w I N o I a N90' 00' 0011E LL O 125.10' � w o Village Subdivision'' 32.8' ,Dawn Lot 2 of Block 1 n %PAVED DNIVEWAY µ I 8,755 sq.ft. N 3 6750 Teshiar Drive O O 2 Story Wood Framed House 6.6'FA J c o i w/ Attached 2 Car Garage ^ © 0:w g Z Cal I CS W i N !_ I 26.2' O 8.7 o N 25. p 125.05' N90' 00"W 0 LOT 1 Legend: 0 Electric Meter/outside Power 0 Concrete QD Sewer Manhole Gas Meter ® Deck -0- Fence 0 125 25 50 O C/O O Water Well ® Mailbox Feet General Notes: 1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright Law. 2. Exceptingfor gross negligence, the liability forthis survey shall not exceed the cost of preparing this survey. 3. All measurements/setbacks are to the visual/apparent building footprint. 4. Dimensions to property lines are plus/minus 0.1ft. N% %k ♦ � d r 49TH `J'"', ...:� ...........0 09 0 ..::...:..... ......0 . FREDERIC V GNER g PROFESSIONAL SEAL This survey complies with ASPIS Mortgage Location Standards. The survey represents visible improvements and conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the existence of any easements, covenants, or restrictions which do not appear on the record plat. Under no circumstances should this document be used for construction or for establishing a boundary or fence line. As-Bufft Survey of: Lot 2, Block 1 of Dawn Village Subdivision I, Frederic Wagner, hereby certify that I have performed a Mortgage Inspection Survey on the subject property as described above on June 07th, 2017 Frontier Surveys, LLC 4 FRO1pI 650 W. 58th Ave. Suite E Anchorage, Alaska 99518 A"t5Z 907.460.1686 - info@frontlersurveys.com wvuw.frontiersurveys.com MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT tto- 907-343-7904 On -Site water and wastewater Section Fax: 343-7997 www.muni.org/onsite Arsenic Advisory Certificate of On -Site Systems Approval # OSC2O1O28 Subdivision: Dawn Village, Block 1, Lot 2 A water sample revealed an arsenic concentration of 10.3 micrograms per liter (ug/Q. 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. gg ..,. �- � Ma�fing(Address �P 0 Boit 196650 Anchorage, Alaska=99519 6650 4www muni org ���*' s °" a, ;'�z��,>�,�.,.�,� � .:.n�,,. ...�. ��._*�..,.-_x �.-�.�.� .�>a ra c'-�.,.,�s�kv.�T�'�,.�':i. �.v:�. «��zr,�s�„ ,..�i�z�:'. a��- i� , �.r.�.. :�,:.r ��'�''.-s�..-� -,-� '�.a ��z�,✓�s �t Mui nhApality of AncCiLorage � Department of Health and Human Services Tom Fink. 825 "L" Street Mayor P.O. Box 196650 Anchorage, Alaska 99519.6650 March 14, 1988 Mr. Russell A. Douglass 6750 Teshlar Anchorage, Alaska 99507 Re: Health Authority Approval - Lot 2, Block 1, Dawn Village Subdivision Dear Mr. Douglass: In your letter of March 6, you requested that our requirement to have your well sampled and tested semiannually be revised to an annual reggirement. While we believe that testing semiannually would be to.your otan'benefit, annual testing would satisfy the concern of the department. The water sample should be tested for fecal coliform and nitrate. There are several state certified labs in the municipality such as: 1) Chemical and Geological Laboratory - 5633 B Street, 2) Northern Testing Laboratories - 2505 Fairbanits Street, and 3) JML Laboratory - 7127 Old Seward Highway. Please arrange to have the water test results provided to the On-site Services office in this department. Extension of your Health Authority Approval can be handled within the department as a simple updating of the conditions on your existing Health Authority Approval. There will be no charge for this service. Two of the original conditions of approval remain essentially unchanged, and are as follow: 1. The property owner agrees to sign affirmatively on any future petition for a Water Improvement District which would serve the subject property. 2. The property owner agrees to connect to public water service when it becomes available. The final condition of approval, which replaces the original condition requiring public water service by February 15, 19880 is for the annual water test on your well. 3. The property owner will have a water sample from his well collected and analyzed for fecal coliform and nitrate by a state certified laboratory at least once each calendar year. The test results will be provided to the On-site Services Program at the Municipal Department of Health and Human Services. We suggest that you provide these modified conditions of approval to the lending agency handling your home financing. Sincerely, f Robert A. (Bert) Hall Director, Department of Health and Human Services cc: Lee Browning, PE, Manager, Environmental Services �' Mr. Robert A. Hall Director, Dept. of Health and Human Services Municipality of Anchorage P. 0. Box 196650 Anchorage, AK. 99519-6650 Re: Lot 1 Block 2, Dawn Village Subdivision Health Authority Approval (HAA) Dear Mr. Hall: ('1 MAR 0 9 19SB Russ Douglass 6750 Teshlar- Anchorage, AK. 99507 ?larch 6, 1988 I have received your letter of March 2, 1988. I am pleased with the direction you have taken concerning the Health Authority Approval of my water well. First I would like to make a few comments concerning your facts. 1) I too work for a regulatory body. In the past ten years at no time have we "transferred" responsibility for compliance of our regulations to any regulated entity. At times we have shared that responsibility but the ultimate accountability at all times lay with our agency. 2)The HAA issued for my property in 1977 was not complete but was still signed and approved by the Municipality. Even a lending institution would not accept an incomplete HAA and so I find myself in the current situation. 3)Your letter states that Mr. Bruce Erickson of the Alaska Department of Environmental Conservation was contacted on February 16, 1987. I believe there is a typo here and he was actually contacted in 1988 not 1987. Your first and second condition of an HAA are agreeable to me. I applied for a Water Improvement District in 1985 and voted affirmatively when it finally came up. I would have no problem doing so again. I would also want to hook up to city water should it become available and assume this would be required of any subsequent owner of the property. My well has been tested twice in the past ten years once initially (1977) and again in 1985. Under your third condition I would have to test my well the same number of times in one year that was initially adequate for a ten year period. I believe that twice a year is excessive and suggest that once a year is more than adequate. At that rate even if no other wells in the subdivision are tested in the next ten years the total number of well tests will double and the number of tests to my well will rise 500%. �1 Concerning the water analysis I would appreciate receiving information regarding what the water should be analyzed for to meet your requirements. I would also like a listing of State certified laboratories in the Anchorage area. Sincerely Yours, Russell A. Douglass f Municipality of Anchorage Department of Health and Human Services Tom Fina, 825 "L" Street Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650 March 2, 1988 Senator Jan Faiks, President Alaska State Senate Post Office Box V Juneau, Alaska 99811 k4 Re: Lot 2, Block 1, Dawn Village Subdivision Mr. Russ Douglass; Health Authority Approval Dear Senator cs: Thi etter is in response to your inquiry regarding a Health Authority Approval for Russell A. Douglass. We have reviewed the facts relevant to Mr. Douglass' problem and to similar lots in Block 1 and Block 2 of Dawn Village Subdivision. They are as follows: 1. A public sewer line was installed in 1976 under Teshlar Drive fronting Mr. Douglass' property. 2. The majority of the private well permits (including the one for Mr. Douglass' lot) were issued in 1977 subsequent to the construction of the public sewer line. 3. The required setback distance between a private well and a public sewer line or manhole at the time the well permit was issued in 1977 was 50 feet. Mr. Douglass' well was installed only 34 feet from a sewer manhole. Currently, the required separation distance is 100 feet. 4. Due to limited staffing, the municipality does not and has never per- formed field inspections of private wells during the construction phase. Therefore, the responsibility for proper siting of a well is transferred to the permit holder. A copy of the original well permit is attached for your information. 5. The municipality issued a Health Authority Approval for Lot 2, Block 1 on May 9, 1977 at the time of the original sale. Senator Jan Faiks March 2, 1988 Page Two 6. A conditional Health Authority Approval, usually required for refinancing, was issued for Lot 2, Block 1 (Russell Douglass) on February 14, 1985. The terms of condition were: 1) a Water Improvement District (WID) must be successfully petitioned by July 7, 1985, and 2) a public water line must be extended by February 15, 1988. On February 16, 1987, my staff contacted Mr. Bruce Erickson with the Alaska Department of Environmental Conservation (ADEC) regarding Mr. Douglass' and adjacent homeowner's well location problems in the Dawn Village Subdivision. Mr. Erickson reiterated a previous ADEC decision that setback waivers down to the distances required for Mr. Douglass' lot could not be granted. In an effort to alleviate the immediate problem faced by department is willing to issue him a new conditional Approval with the following conditions: 1) the property to sign affirmatively on any future petition for a District, 2) the property owner would connect to pub' becomes available, and 3) the property owner would agr have analyzed (by a state certified lab) water samples well at least two times each year until connection is ma service. The property owner will provide copies of the department. Sincerely, (:?A. (Bert) Hall Director, Department of Health and Human Services RWR112/do Mr. Douglass, this Health Authority owner would agree Water Improvement lic water when it ee to collect and from his private de to public water lab reports to the cc: Representative Virginia Collins, Alaska State Legislature Yvonne Alford, Executive Assistant, Office of the Mayor ., Mussell A. Douglass, Owner Lot 2, Block 1, Dawn Village Subdivision �/ Lee Browning, P.E., Manager, Environmental Services P. O. BOX V JUNEAU, ALASKA 99811 (907) 465.2828 DISTRICT 10 2600 Denali; Suite 501 ANCHORAGE, ALASKA 99503 (907) 276.7943 i 5 i :'� i 1 i i Representative Virginia M. Collins FEB 12 1988 February 6, 1988 Yvonne Alford, Executive Assistant Office of Mayor Tom Fink MUNICIPALITY OF ANCHORAGE P.O. Box P.O. Box 196650 Anchorage, Alaska 99519-6650 Dear Yvonne: MEMBER Community and Regional Affairs Special Committee on Telecommunications Finance Sub -Committee for Labor Anchorage Caucus, House Chair We have been requested to assist a constituent in resolving a situation regarding water wells in the Dawn Village Subdivision. This has not only been a problem for Mr. Douglass, the constituent, but for a number of homeowners in that area. It is our understanding that Max Gifford of Senator Faiks' office has contacted you regarding this, and has forwarded to you copies of Mr. Douglass' correspondence. The most immediate problem Mr. Douglass is facing this year is expiration of his conditional three-year waiver for a Health Authority Approval. The approval is a requirement for his lending institution. I join Senator Faiks in requesting that you look into this situation and inform us of possible action which can be taken to remedy the situation. My office will be glad tp assist you in any way we can. I look forward to hearing from you. Znia Collins Distr Alaska *tau Ecoislaturt FEB 1 1 1988 PRESIDENT JAN FAIKS POST OFFICE BOX V 907-465-3755 JUNEAU, ALASKA 99811 �enute RECEIVED February 4, 1988 FEB 8 1988 Yvonne Alford MAYORS OFFICE Executive Assistant Office of the Mayor P.O. Box 19-6650 Anchorage, Alaska 99519-6650 Dear Yvonne: Here is the matter I discussed with you on the telephone. I fully realize the last thing in the world you need right now is this sort of thing but this is truly a Municipal problem and Senator Faiks would like to help this gentleman resolve his problem. If the matter cannot be resolved expeditiously perhaps Mr. Douglass might accept another three-year waiver and then I would hope the Municipality would use that period of time to settle the well problem. Anyway, if you could go through this and then get me working with someone in the proper Municipal agency I would be most grateful. I really do not want to have to explain to millions of people what the problem is, I just want someone who can make a decision. Thank you. MG/s enclosure Sincer l ,, MaPGiif drd Administrative Assistant OUT of session 3111 C STREET, SUITE 525 ANCHORAGE, ALASKA 99503 907.561.7610 .p o_ Russell A. Douglass 6750 Teshlar Anchorage, AK. 99507 January 21, 1988 Jan Faiks-President Alaska State Senate Pouch V t��N 2 7 150$ Juneau, AK. 99811 J Dear Senator Faiks; In 1985 you received correspondence from Gayle VanAlphen concerning the location of a water well on the property she was trying to sell. Your response to the honorable Tony Knowles December 15, 1985 is attached. The response from the Municipality of Anchorage (HOA) dated February 5, 1985 is also included. My name is Russ Douglass. My property is also located in the area of question. In 1985 I took a second mortgage on my home which required a Health Authority Approval (HAA) from the MOA. As in the VanAlphen case I was issued a conditional three year waiver. The condition was that an application for a Water Improvement District (WID) be made and approved. Since an HAA is only required by the lending institution, but is issued by the MOA/DEC not all of the wells in the subdivision have been surveyed. The files I have indicate at least half of the wells do not meet current code requirements. Since none of them have an HAA the application for a WID was voted down. Those of us with HAA conditionals are now facing relocation of our wells. Attached are two engineering reports which state the wells in their current condition pose no significant health hazard. Also drilling new wells would not significantly decrease the potential for contamination, in fact it would increase the potential by providing additional conduits to the groundwater source. My proposal would be to test a representative number of wells in the subdivision on a regular basis to confirm their serviceability and lack of contamination. Ten water samples have been taken in various wells since the initial tests of all wells were made in 1977 and 1978. None of the samples showed any deterioration in water quality. I feel the MOA/DEC has not accepted enough responsibility for this situation. The wells were not checked for compliance when they were drilled initially. In their correspondence of February 1985 the MOA stated an evaluation of the health risk and their role in the issue would be made. No one at the MOA is aware of any effort in that direction and there is no followup in the files. Both MOA and DEC have been aware that the majority of the wells in the subdivision do not comply with code but they are satisfied to sit back and let someone else do their job. vL My three year waiver expires this year and I assume they will force me to drill a new well. My current well has provided me with adequate and uncontaminated water for over ten years. If I do drill a new well I would not be gaining anything. I may lose quite a bit if the MOA/DEC does decide to crack down on the subdivision and force a WID. Then I would end up with a new well and a 10,000 dollar assessment on my property. I would appreciate any advice or help that you could offer to resolve this situation to the benefit of all parties. Best Regards, � Russell A. Douglass pfit r•1Ur-1 I C 3 1=1L I T*,' C-)F='F1r-AC13F?19C3FEE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 2516 E. TUDOR RD. , ANCHORAGE, AK. 99507 to 276-22:1. I4EL1_ F="FEE F? rpt I T PERMIT NO. C 77007 ? APPLICANT PETERSON CONSTRUCTION SRA BOX 1718X 344-6638 LOCATION TtSHCAR ST LEGAL L2 B1 DAWN VILLAGE LOT SIZE 13000 SQUARE FEET MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F:l'EF?11 Z T=.0fFiL. I r-.- F= 0F? 0r -.1E VIFF F1F; F= F -Z Ca tri 1 *_=__%:s3LwE I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I 1411-L INSTALL THE SYSTEM IPJ ACCORDANCE WITH THE CODES. SIGNED:_1__-�__�___"� ,_-------------------- APPLICANT P5TfERSON CONSTRUCTION 1 �__ A��-„�j.. ISSUED BY_] r���` __!�. 4 — --------------DATE_. / _���_/___— lb 7i MUNICIPALITY OF ANCHORAGE /0"I - DIVISION OF ENVIRON;IENTAL HEALTH DEPARn ENT OF HEALTH AND ENVIROM ENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date Feb (a) Legal Description (include lot, block, subdivision, section, township, range) CTP- sIL -L 1bAwo VSLLA&( Location (address or directions) &-73rO - eSHl.A2 349 -S-Gg6 (b) Applicants Name 2usseLL •DOu6LASS Telephone - Home Business2jq-l433 Applicants Address&770 TFSNCAf- 40cKuti46-c 4r- g4507 (c) Applicant is (check one) Lending Institution ; Owner/fir ; Buyer E'�::j ; Other F::1 (explain); (d) Lending Institutionr•�.—.')Aai_ r:1— Telephone.% 7 `/ Address f-10, n /�Aje-^ i1 (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: e A i \ 1.i11_S 1J ,l.ic�c�-1 2. Type of Residence Single -Family 4� Multi -Family [= Other (describe) Number of Bedrooms 3 3. Water Supply Individual Well r5;z Community Q Public Note: If community well system, must have written 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 21 u i L j L t k% pawN V 2%14 {� I S. 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 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 frcm 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 regula- tions in effect on the date of this inspection. Name of Firm A C S Telephone S6 [' SO YO Address I -L O U W 3 3 d Ave Date /2 (3 I1a'S 6. DEEP Approval Approvew for e4u Approved Terms of Conditional Suarc S 4iUc1(oezA6C- Ar. 4Q a3 o�•ot�- O� A�,�'���� eeeow....c•• 1> C'c"d: /co,.,al ctppoua/ r-}� k3,e-SSD apo /L FE88r �DEc cerZ'.� •y9 Ap2E�uzruN�• wYp wzri��w 3 yoa�s - ......,•• � Ca t - )Y.. /r ' I �1 �J')'oIgo. 225i•E y.,.` < 4r , bedroomsy2FOp°°1`,��;�. Disapproved Conditional FA Z CAUTION LtDate c:R /Y ,QS THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESEST- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTE:RO IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOLES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQULRZ- MENTS. EMPLOYEES OF MEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERROZS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 21 7-19-84 C. ABSORPTION FIELD DATA �t�-b l ►e �e.e��✓' Soils Prating in Absorption Strata Type of System Design Date Installed Length of Field l Width of Field Depth of Field i Square Feet of Absorption Area Depression over Field (YM) Results of Last Adequacy Test. Separation Distance from Absor, To Water -Supply Wall To Building Foundation i To Water To Strea To Gravel Pied Thi ss Sta pes Present (YIN) Adequacy Test To Property Line To Existing cr Abandoned System on On Adjoining Lots To Cutbank(if present) w/or Major Drainage Carie ,Parking Area, or Vehicle Storage Area D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at _ High Water Alarm Level Tested for Electrical Comients Dimensions 9Aroess (YM) Off" Level at / Vent (YM) 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 MOA HAA Guidelines in effect on the date of this peeticn. Signed Date L l�Eb �S op��:OF •A� 40 t many CUnr MOA No.?�s Ml/d5/s 9FC40ruP«v COftJ`*f'.4' t APD"vnl B+s•o Np•h A'DFc. 2-1 t- 15 (e{4ea. ZeQU%&1n& 4 W1 C 460pi""64416", 7F 414.1. 4 W t p H ►wi cow%14&%efr0 lo,3 It 1Feb /98dj [Page 2 of 21 T'd well sh000ld be moveo fo 6aV-044% C04 A. WELL D@►TA MUNICIPALITY of ANCHORAGE DEPT, OF HEALTH & MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PRO, TPgK)N HEAM AUTHORITY APPROVAL ( HAA) FEB 1� -18 CHECKLIST - FEBRUARY 1984 Legal Description: R J U- L ( v Well Classificati to VC•-� If A, B, Cr Cr D.E.C. Approved(Y/N) 6 ,— ra— Well Log Present Y ) Date Completed YieldooP Total Depth7& Cased to Depth of Grouting Static water Level y3 1 O Pump Set At Casing Height Above Ground 41,` ' Sanitary Seal on Casi Y ) Electrical wiring in Conduit Q) Depression Around Wellhead ( ) Separation Distances from Well: To Septic/Holding Tank on Lot Al On Adjoining Lots To Nearest Edge of Abscsption Field cn Lot; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleancut,/Manhole <:�:= To Nearest Sewer Service Line on Lot �? water Sample Collected By ; Data water Sample Test Results • Comments 0 h),A l/ oL1 //e c- Aiu,.La-3 ®..-_,... _ in,,.;..a w _ /I_ -,dL 5ee +rracmep 406 C_ LT2 / L PfA g.S B. SEPTIC/HOLDING TANK DNIA` p/%8LJC-. Date Installed Size No. of Compartments Stan pipes (Y/N) Air -tight Caps (Y/N) Foundation C ut (Y/N) Depression over Tank (Y/N) 1Date Last Pumped Pumping/Maintenance Contract Holding Tank High-water Alar Separation Distances from A To Water Supply Well / To Property Line _ 77:r To Water [Page 1 of 21 Line Holding Tank Permit (Y/N) Tank: To Building Foundation To Disposal Field To Stream, Pond. Lake, or Major Drainage Receipt # 0300t0-1 Date Paid: Amount: LA*� .Op. 2-15-84 STAVE X ALASKA B/LL SNEMELO, GOVERNOR DEPT. OF ENVIRONMENTAI, CONSERVATION SOUTHCENTRAL REGIONAL OFFICE 437 "E" STREET, SUITE 200 ANCHORAGE, ALASKA 99501 February 12, L985 Mr-. Russell A. Douglass 3001 Porcupine Drive Anchorage, Alaska 99501 SUBJECT: Lot 2, Block 1, Dawn Village, Anchorage, Alaska (8521 -WA -099) Dear- MY-. Russell: 274-2533 I have r•e-examined the waiver- request and concur- with the general denial of the waiver. However-, because the system was pr•eviously, appr•oved by the MOA we can provide a temporary 3 year- waiver- provided aIMID is possible and applied for-. The waiver- must stipulate that if the �WID, fails or, is not constructed within 3 years that the system will be upgraded to code. jierely, ��l r•uce E. Erickson District Coordinator, BEE/msm cc: Anchorage/Water, & Wastewater - utility 77 7 BILI SHEFFIELD, GOVERNOR DEPT. OF EN11RONMENTAI, CONSERVATION :' SOUTHCENTRAL REGIONAL OFFICE 437 "E" STREET, SUITE 200 ANCHORAGE, ALASKA 99501 274-2533 February 12, L985 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH d. W. Russell A. Douglass ENVIRONMENTAL PROTECTION 3001 Porcupine Drive Anchorage, Alaska 99501 FEB 151986 SUBJECT: Lot 2, Block 1, Dawn Village, Anchorage, Alaska RECEIVED (8521 -WA -099) Dear- Mr-. Russell: I have r•e-examined the waiver- request and concur with the gener-al denial of the waiver-. However, because the system was previously approved by the MOA we can provide a temporary 3 year- waiver• provided a WID is possible and applied for-. The waiver- must stipulate that if the WID fails or' is not constructed within 3 years that the system will be upgraded to code. Si er•ely, ruce E. Erickson Di str•i ct Coordinator• BEE/msm cc: Anchorage/Water & Wastewater- . Util i ty astewater•.Utility 97A7E U F ALASKA BfLI SHEFffE[D, GOVERNOR DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA 99501 January 28, 1985 Ms. Gwen Turner Alaska Environmental Control Services, Inc. 1200 W. 33rd Avenue, Suite B Anchorage, Alaska 99503 Telephone:(907) Address: 274-2533, SUBJECT: Horizontal Separation Waiver Between Well and Sewer Lines Lot 2, Block 1, Dawn Village Subdivision, Anchorage, Alaska (8521 -WA -099) Dear Ms. Turner: The department has reviewed the subject waiver request and cannot ap- prove the waiver. The report did not show that the separation re- quired by 18 AAC 72.021 was clearly not necessary in this situation. To issue a conditional waiver, first requires submission of proposed corrective measures by your office. Sincerely, eve W. Eng District Engineer SWE/msm _ ALASKA �MIUMMAL COnTROL SEMICCS, InC. Engineerinq 6 Enuironmental Studies February 5, 1985 Department of Health and Environmental Protection 825 L Street Anchorage, Alaska 99501 Legal: Lot 2 Block 1 Dawn Village Subdivision Well Flow Test on Single Family Residence A flow test was performed on the well at the above property on February 5, 1985. The static water level was at 43.1'. Over 700 gallons of water was pumped at a rate of 6.5 gpm with a drawdown of 33.2'. The recovery time was 10 minutes. I consider this well adequate for domestic usage in this 3 bedroom house. Please contact me if you have any questions. Approved: 4 / �y l; 00 lux A •• e .� ici � larc.•C. P.cid, Jr. ••, a• J' ,o. 225I•C s Sincerely, �GG2/12Qif�� Gwen Turner Environmental Scientist 1200 West 33rd Auenue. Suite B • Anchorage. Alaska 99503 • (907) 561.5040 `. MUM- PAUre O. /,Nci IOP.f'.3[ UW. OF H:','11 I is MUNICIPALITY OF ANCHORAGE DV r.0vr.)FNTAI. NJXeCT1CN DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 2510 East Tudor Road, Anchorage, Alaska 99504 276.2221 11 Y 4 1977 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES RECEIVED 1. Type of Inspection: CMRO VA FHA CONY_ 2. Property Owner:rii 7. Type of Facility to be Inspected: I YK (P 3Cky, 1-4 No. Bdrms. 8. Water Supply Type of Supply: Public Utility Individual If Individual, number of dwellings presently served If Individual, depth of well /d6 "' V 9. Sewage Disposal System Type of System: Public Utility X Individual (on-site) If Individual, date of installation 72-003(3/76) SP -4 8r.1 1-7'1'Y 6Ce Day Phone: Mailing Address: ,A t\0 C4_ 3. Name of Buyer: Mailing Address: Day Phone: 4. Name of Lending Institution: /4t kr'_ 1yn%j D e Sci 0 : rt;S Mailing Address: P-1 X11/10 doom%_Phone: Af-r �'bb�G�c'hnseh 5. Name of Realtor or Agent: Mailing Address: Phone: 6. Legal Description: 'faa Q�t2°�'� rdl�w,� U CC'v. "'I'tL . Location: 0 -At "J-2 CoSf-OJ� LOKPOIS 42A LO 7. Type of Facility to be Inspected: I YK (P 3Cky, 1-4 No. Bdrms. 8. Water Supply Type of Supply: Public Utility Individual If Individual, number of dwellings presently served If Individual, depth of well /d6 "' V 9. Sewage Disposal System Type of System: Public Utility X Individual (on-site) If Individual, date of installation 72-003(3/76) I #1: Time MUNICIPALITY OF ANCHORAGE DEPARTMEI"1 OF HEALTH AND ENVIRONMENT PROTECTION 825 _.L Street, Anchorage, Alas..a 99501 279-2511, ext. 224 or 225 Date Received: May 4, 1977 :30 p.m. #2: Time #3: Time Date 5-4-77 Tues Date Date Insp Pratt Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1. Lending Institution Request: Alaska Mutual Savings Bank Hailing Address: Post Office Box 1120 99510 Phone: 274-3561 2. Property Owner: Pederson Construction Mailing Address: Star Route A Box 1718X 99507 Phone: 344-8638 3. Legal Description: Lot 2 Block 1 Dawn Village Subdivision 4: Single Family Residence: (x) j Multiple Family Residence: ( ) Number of Bedrooms: Number of Bedrooms: d 5. Well System: Individual Well (x) Community/Public System ( ) Permit # 77007 Depth of Well 106' Well Log on File ( ) Construction Bacterial Analysis 6. Sewage Disposal System: On-site System ( ) Permit # Installed Septic Tank Size Absorption Area Public Utility jcx) Installer Manufacturer Soils Rate 7. Distances: Well to Septic Tank to Sewer Line to Nearest Lot Line Nearest Lot line Material to Absorption Area Absorption Area Page Tiao Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 2 Block 1 Dawn Village Subdivision Comments: Affadavit Attached: -,L ) Letter Attached: ( ) Approved: � � C. Date: y^� Disapproved: Date: Department Worksheet: i l� � Department of Health and Human Services - 825 "U Street Pick htysrrom. P 0 Box 196650 Anchorage. Alaska 99519-6650 Mawr 1111,7 'h'%ti V. ':] J'lf �iarJgr ;,n ,L5 October 7, 1999 Jetl'Garness, PE Alaska Water R Wastewater Consultants, Inc. 6901 De Barr Road Suite 213 Anchorage, Alaska 99504 Subject Waiver Request for Lot 2 Block I Dawn Village Subdivision Waiver Request OW11990078, PID »014-061-55, HAS HA990468 Dear Mr Garness Your request for a waiver of the required 50 feet horizontal separation from a pubic sewer manhole and public se\%er main has been approved The approved separation distance is 49 feet and 34 feet respectivel} This waiver approval applies to the existing public sewer manhole and public se\\er main to well separation only Any future upgrade to either will require all separation distances be met or another approval from this otlice If there are am• further concerns or questions regarding these waivers, please call our office at 343-4744 Sincerelv, Daniel J Roth Civil Em_ineer On -Site Services Pro_ram 9930 � �r / 3Vc� oi'` � � r ,701 7 /1 re I , G :;:;,_ 7_. ?-/44 Probt/,'`/C or poszrot >G ._eel/c�e�ca.._._e_'t __�rraaG.o/e_. �'<►-r�c�,atq �Jc 6 r-'�y ah. J..�.9� 7I7 _ .{- r / n __..:..... __` _._.. Y..CGa�/.1'..' .(-- L Orval' Alaska Water & Wastewater Consultants, Inc. 6901 Debarr Road, Suite 2-B — Anchorage — Alaska 99504 Phone (907) 337-6179 — Fax (907) 338-3246 September 24, 1999 Municipality of Anchorage Department of Health and Human Services Attn: Dan Roth P.O. Box 196650 Anchorage, AK 99519 RECEIVED SEP 27 1999 Municipality of Anchorage Dept. Health & Human Services REFERENCE: Lot 2; Block 1; Dawn Village Subdivision Waiver of separation distance between well serving reference property and the public sewer main. Dear Mr. Roth, The referenced property is a three bedroom residence served by a private well and by public sewer. Records from your department indicate that the well was permitted and drilled in January, 1977. Per Anchorage Water and Wastewater Utility (AWWU) records, the public sewer was installed in 1976, prior to the existence of the well. Based on our field measurements, the well is 34 feet from the public sewer main, and 50 feet from the sewer manhole. The required separation distance requirements in 1977, between a private well and a sewer main/clean-out was only 50 feet. We are requesting that your department waive the subject separation distance to 34 feet. Justification for the waiver is summarized as follows: 1) The existing encroachment has existed for 22 years with no adverse impact to the aquifer. Recent water samples indicated no bacteria and nitrate levels of .5 mg/L (see attached water analysis) 2) The driller's log for the referenced well indicates that the aquifer is confused by layers of tight sand and gravel and very hard packed sand and gravel (10-30 feet, and 30-51 feet). These confining layers act as a protective barrier between the sewer main and the aquifer. Page Two Waiver request Dawn Village; Lot 2; Block 1 Based upon the facts, it appears that there is minimal risk in granting the subject waiver. information for your review please contact us at 337-6179. LOT 3. BLOCKT' DAWN VIUAGE S/D EXISTING 3 BEDROOM HOUSE I LOT 1. BLOCK 1 DAWN VILLAGE S/D -- \— ----------- I � ALASKA WATER AND WASTEWATER CONSULTANTS, INC. 6901 DEBARR ROAD, SURE 28. ANCHORAGE, AK. 99904 PHONE: (907) 337-6179/FAX: (907) 338-3246 GAL DESCRIPTION: DAWN VILLAGE S/D, LOT 2, BLOCK 1 31E OF WORK: SEPARATION DISTANCE FROM PRIVATE WELL TO PUBLIC SEWER KATHLEEN DOUGLASS (907)349-5696 9/27/99 DRAWN BY:A.C.G. 1 = 30' PAGE. 1 OF 1 I i I i i I APPROXIMATE LOCIn DF PUBUC SEWER MAIN & MMj I �O 4 ����• OF A��S�O 4918 :•yam ...::.......................... .......... 0 .................... -.Jeffrey A. Garness: f� CE -7953 N lA STL STATL �tp� alta RANT sal Avewwt OP Arc,gwAOa. AVMA 90907 SUBSURFACE EXPLORATION I Shift Report of Opentions + nd.n Pederson Darn Subdivision - Lot 2** Block 1 ,. lwlqV.Oa[[f a vn(ig ' la�il Domestic Yater Well ►;elw�.eww STATES ASSWIATFS alY1.Y(«vrWa 22W a�0rf.ae♦ vel, Ryle rl. 1 L W.I.[e aLevaflM wtafw [. en ,�1 Iwly snfw.(ws r.nv sarvet gMlles 10614' a /ears+;�HMfaagl IMM. fl 1. g►vawLaval gave% wIvv JtnOtrl 1977 a TME DISTRIBUTION HOURS RIG HOURS _ Hart gwILL[■ flail,. tW11rgMlL Mawlwl • MNwf gall WLL CAP"* Don gllr flwcr afaN90• MflVlw 7wettr relFrO MllMl IVYIIwI CASING LOO ,.. SOILS LOG. [awLa OePTNS tifi:�a MATERIALS AND REMARKS vefal rt. art Ltwlfw Violet To 1 1010 0 10 Sandy gravel 2 710 17-0 10 30 Tight sand and gavel 3 712 24-2 30 51 Tern hard packed sand and Bawl 4 710 31-2 51 641 Tight cemented sand and gravel r/small rocl 5 710 3812 64 75 Tight sandy clay 6 710 4512 75 100 Tight sand and gavel. 7 612 5114" 100 106 Very turd cemented hardpan. 8 8w 3810 306 Coarse Bawl - rtes beazing. 9 619" 6419^ 10 11'0 75'3" Test bailing 12 gpm for 40 minutes. No da' 11 61120 8218 down. Water level 34 feet from surface sleh 13 5,8. 0401"Set pump. pumped DRILLER 12 gpma Water clear In two hours. INSPECTOR 14 15-2 .1 1,741w I , 1 1 1 i I f MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR#gjQ9nnCiF PID# 014-061-55 HA# HA990468 Permit #' Date Received: Sept 27, 1999 Legal Description: Lot 2 Block 1 Dawn Village Engineer: Jeff Garness, PE Alaska Water & Wastewater rnnaultanta, Tnr_ 6901 De Barr Road Suite 2B Anchorage laaka 995n4 Applicant: Russ/Kathleen Douglass Waiver Requested: Waiver from a private well to the public sewer main of 34 feet: 50 feet from the sewer manhole. Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: Waiver is NOT Granted: List Conditions or Reasons for above: Date: By: Name of Reviewer Rec #: 05317 / Amount: $ 920.00 Date Paid: Sept 27, 1999 WAIVER 14E4114E3T POR Loi 2 A940CR / pRcwAv VIL.L/964 �^. Wfi►vER A/NNOER WRM079 r W13/VER fog ON -Lor 1vF[L. 7-0 ^9LICSic-WFIQ Af.41NoF 34fEET /¢,VD M of So FEE T Sb w ER H/Jta�py— W W W TKA Sfwir? M141a /N 4uES?Iv.v f>�4S %•oF puCT/LE IIPoN PIPE ��N ENTERIu� EXITING THE MrivNcLE, THIJ lioxc TYP/cAtlY DO•vE To ASSuh' coo „0� /} A,16M ZN7r,6K,T-i" VAIMAI HOtT Llktty IdfaxE t..•►' T"EIQ rl6HT, TIME /PE. A PIPS REM� rkq£s ry C4"(4,, MIi1A,0E1? OF 7ME SEWEK L/�vE /S 811 A,G. P •�• rrH CONCRE T1=> 1/HS A TyPICRL L If£ SPAA/ OF 30 yfA)Pf 61ffORt XHVWIN6 POrfAl7/ L t/6uS OF INTEGIPITj� fNlLrt/IL. TMIA•Gs TI-I,aT wlil 40?".rL A.C. PIPE TU f FAIL FASTEe TMR.v NOT /s WlIEA/ TkE SEwen LI,vF_ oorr Max, HgvE Mk{II (LOPE(x 2%>• FHE StVF-I? LIvC Hfis MORE pf 9,vVh0oleT&tv-#77}' TO NAVE q N16kEK SPRIA/G LIe,E (� �2 jFULL> AND STONO FULL OF SE6✓p6E f0/? LOA/6LI? PEIPIODS Of Tl.0 E wHIIH IS (19RROXIvF, rA(E SE w.F, 1. ,A c �. IN TCSCML.Jk ORIvO /N FROM Of T/ -/E Su+9J"E-cr- LOT /S AT SLOPE WHICH W/LL rfwn6,r RitAwlA.1, f/95'T 9AID lean -I° rYF_ S[wER t'vF_� fI(PTY MOST OF THE rl•kE gov0 rHl Sft-n6= NRS 4 SCOuR1MG fFFF_CT WAIICt( PIL4L /{rEI' 7 -Hr; SEwrrj (.►IVC- CtE/!N Aa0 UsS L IkrL i % 0 rORO>'E, . C, SEwFR L /mr TYP1c4l-1 Y w.YFA/ /r DOE'S fAIL� /r wltc vf,=,gK 6 7- TNI TOP or. PIPE WH/CH WILL NOT o9tkow Tl/I• Yri-h16E PASsrwG THrQouG, TO BE IVTJE:)?aF7'E D• TNF_ A, C, PIPE I S oN 9 30 YR, SCHEDkLE Tv 01' B), A. W. w. N. CI-114Nbc/J Oar ►.,t r" j9.1. P. A q.vD OVHrA, CN/9NbE0 Our /s I/v MOST SAS S fauA,p TO tIAVE AI_LOL�Fb LlrTLF_ 77,0 AIo iEVFILt1?NTIVA, of SF--�v AGi= /Iv TO THF_ St•�4�'eu�v/�•.�C. SU/L E vCv t � THr SfwFlp L I,vE H/➢D PREVlOuSLY f, ari.ED ar BRFRK/�I(� OA/ Tyr- Top, f f Tl+E h/ELL /,v QuEfr/OA/ W/9J p/PI[LEO /N TyNUNRY /977 wNE�✓ Ti/e SEWER LINE l-/91 ALREApt/ /4 PLACE, TNS Sk 6 T«T w1 TN /ILL THE IvEL[S cIv T ESf11-,96 Okll/E /pR�+wS FlPom nn/ // 4N/scle AT APP/eor1,wj7-,rLy /Oo fr._eT' D/"LP, MOST OF TI+r_ imvE AF_EA-1 Can sri?a,eTGD BY HEP9 Ar WE jTE*?V STRrES A.TSOr147E5, Tf//S WELL j9PILLEA H65 coA/sr/�u�Te-O ✓FAY FEN/ WELLS /N TNF_ /y, O, R, NEI?B !l9[[s Ou r W W W 000 /1timERo4S L n yE#S OF VER )-lnPd Pne*kED SAI/D naD 6RrIv6L IWO v,00 _Na l' 71G//Y C£AAENTED Sgp/d ANO ovnvF_L /, 1/£ 049E5' A107-MF/v7loA/ s/LT o,p aov rrr L!/Y. j'wO dTAIF/e HoRt rOrllfov wF[L O,?lLlE.Cy GdtiSrlearrrp wE[[S /N DAwN v/LLA(,r SaOt? A,vD ov Tts�lt �1P Dk'/vr ;� 09L.L 0447- NNt+£RouS ° 01YER5 OF S1JuPY &jegVELL v S/LT AND AMRDPn" W///!N /1 % YP/Cf�LL Y 04 /1/ /atPrIZME/4B[E M/9rERlAL, I BE'L/�VE HE"�Pa /S CQMP19A'/NG N/S Us-k';/-/R,� P.4CkrDSs;ao AN/J Gl?pvFL /f}/�rJ �� TlG//r CFA+EN7iG SAvD n/vn GRgvEL // TO //ARoPAV. r9a wE6L /S Cri?ra/AI y 4 CONr�,vf-,o !l,pu/FE.E' w/lift/ /S NuOER pi?rfrwPE /if /A'D/CgTF[7 8Y 7-/-1£ 34 Poor ST/3T/c w4 %CR L EvF<„ 7-11 r- £NCI20ACNHENT or THF SaDJ-EcT w/4 TE r? w LL r0 TA/E SEw61? HJtS EXrSTEp FOO 2 2 eC,4/PS ANO REcFIvT w19TF_14 SAA4PL-C R►ns'uLrs l "vtcAT6 N0 6AcTC-)O/# PkesEniT /�Ntj No N/TR/9TFS OrrE cTApLE, w S. Of A . A E. C S. D. fit! G. {or S. C. OI�'120NThiL f EI°AI?r4T,vN i � X G�/INn TOTOL C ONGL U S'/ ON GRi?Nr Wn/vFR 6.8 OV /. 8 2.9 ova rEn r� ecE N N N h F► W W W W W W 56R6TfCAI coo501L coo O "00 .-C4 44 707 fd Z.3 � �� 6 C4 C4 N C4 N F� PEnMro13,�r S4(9813 WR7-1.1� MoLF GRpolc,vT /tSSNME . O `/o OI�'120NThiL f EI°AI?r4T,vN i � X G�/INn TOTOL C ONGL U S'/ ON GRi?Nr Wn/vFR 6.8 OV /. 8 2.9 10 'd LEPSd99L06 'ON Xdd y lIMMd OOcO[ nH� 66-£�-d�S Alaska Water & Wastewater Consultants, Inc. 6901 Debarr Rd. Suite 213 — Anchorage — Alaska 99504 Phone (907) 337-6179 — Fax (907) 338-3246 September 14, 1999 Municipality of Anchorage Department of Health & Human Services P.O. Box 196650 Anchorage, AK 99519-6650 REFERENCE: Dawn Village Subdivision; Lot 2; Block 1 We performed an adequacy test on the well located on the referenced property on September 9, 1999. On the day of our test, the static level was 37 feet below the top of the casing (B.T.C.). Water was pumped from the well at an average rate of 4.28 gpm for 100 minutes (856 gallons) with a drawdown of 15 feet. Based upon this data it can be concluded that the well will continuously produce at least 4.28 gpm. Water samples were taken on 9/9/99 and analyzed for coliform, nitrates and bacteria. The results were satisfactory, (see attached). After researching MOA files on this property, we learned there is an extensive history regarding the 34 foot separation distance between the well and the public sewer line. Property ownership has not changed since the conditional Health Authority Approval was issued by your department in March, 1988 with specific conditions. l Request you issue a new Conditional Health Authority Approval on the referenced property with the previously approved conditions: 1) Property owner would agree to sign affirmatively on any future petition for a water imporvement district. 2) Property owner would connect to public water when it becomes available 3) Property owner would agree to collect and have analyzed (by a state certified lab) water samples from his private well at least once a year until connection is made to public water service. The property owner will provide copies of the lab report to the depgrtment. If you havA #ny 51&ns or require additional information, please contact us. M.S. u(b ? 8 9 /6, 17 � t ��� Municipality of Anchora! .: ') On-Site Water and Wastewater Program (907) 343-7904 1JuN o 2 201 41:33::7.7L37- Z. r w.S1 �CV Certificate of On-Site Systems Approva O` 6 e L g Parcel I.D. 014-061-55 Expiration Date: a ^ �-- 17 1. GENERAL INFORMATION: Complete legal description DAWN VILLAGE; BLOCK 1, LOT L Location (site address) 6750 Teshlar Drive*Anchorage 99507 Current Property owner(s) Kayla Shearrer Day phone Mailing address Real Estate Agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual ❑ Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer WaiverNariance request f9r` Distance: I Received by: Date: 6 frig(( COSA to be release.,• - -ngineer, •nies of-rwise requested by the engineer. COSA Fee $ 6940 Waiver Fee $ Date of Payment Waft? Date of Payment Receipt Number //�� 0(410 (1 Receipt Number OcJ COSA# 7/0 .09 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 l Engineer's Printed Name: Jeffrey A. Garness Date: 6 f?l 4QOo0 „4Q In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system o �/ in accordance with the guidelines and regulations established by the Municipality of Anchorage and ,c- •..'..�,L��1n industry practices. The reported results describe the condition of the system/s on the date/s of the �O,�Q-.•• .,�00 evaluation. Separation distances were measured to readily identifiable features. Hidden defects or . 45)- i•••••=1, ; V encroachments may exist that were not identified during the evaluation. The operational life of all wells * . , ,r� 0 and septic systems depend upon a variety of variables, including but not limited to, soil conditions, O""”' 'rr`/�j' V groundwater levels (that may fluctuate during the year), quality of construction (materials and J J workmanship),and the water usage of the family utilizing the system/s. These conditions can vary,and a,, � / f� are outside the control of GEG. Satisfactory test results do not guarantee future performance of the Q "...J #r� — G,orness: system/s; therefore, GEG makes no warranty(express or implied) regarding the future performance of QQ 3 d C —7 53 �`a• ( the well or septic system. GEG makes no representation whether an alternative well or septic system Q9 f 74 I•�•.• .\co can be installed on the property in the event either of the current systems fail to perform adequately in It °, 0,• ••. . • \eco the future. The content of this report is for the sole benefit of the person/party that retained GEG to �04 profession�o perform the evaluation. Reliance upon the information provided in this report by any other person or �0400aQo party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. #AECC884 6. DSD SIGNATURE 'L System #1 Approved for bedrooms r System #2 Approved for bedrooms Disapproved \,.. ,,,11\Y CF4 • Conditional approval for bedrooms, with the following s ulatios:�'T �G E . WATER Ago -) 1--r WAs7- . ,� RO�kAM G ��' ",,='n\r:r�r'` B . -y--- --1- Lv Original Certificate Date: [�^ ` 1 7 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 ._ ____ 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: DAWN VILLAGE, BLOCK 1, LOT 2 Parcel ID: 014-061-55 A. WELL DATA Well type PRIVATE If A, B. or C provide PWSID# N/A Well Log (YIN) YES Date completed 1/77 Sanitary seal (Y/N) YES Wires properly protected (YIN) YES Total depth 106 ft. Cased to 106 ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 1/77 5/23/17 Static water level 34 ft. 29.8 ft. Well production 12 g.p.m. 5.3+ g.p.m. WATER SAMPLE RESULTS: Coliform U colonies/100 ml. Nitrate >""i 1 mg./L. Collected by: Arsenic: ie• ug./L Date of sample: 5/23/17 B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER Tank Type/Material Date installed Tank size gal. Number of Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Depression over tank (Y/N) High water alarm Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft`or ft`/bdr • System type Length ft. Width ft. Gravel below pipe ft. Total depth ft Eff. absorptio - ea ft` Monitoring tube _ Depression over field Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in absor• .n field before test in. Water added gal. New depth in. Elapsed T-• e: min Final fluid depth in. Absorption rate >= g.p.d. y rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date - D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN) "Pump on" level at in. "Pump off' level at •• • wa er alarm level at in. e . - • Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO. Septic tank/lift station on lot N/A On adjacent lots 100'+ Absorption field on lot N/A On adjacent lots 100'+ Public sewer main '34' Public sewer manhole/cleanout "49' Sewer/septic service line *'23' Holding tank 75'+ Animal containment areas 50.4- Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Absorption field Water main Water service line Surface water_ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION Fl . 1 LOT TO: Property line B • foundation Water main Water service lin- Surface water Driveway, parking/vehicle storage .in drain Wells on adjacent lots F. COMMENTS *WR990078 **ACCEPTABLE PER CODE AT TIME OF WELL DRILLING(PRE-1983) .., '%»II •44� OF /1(„4•*t G. ENGINEER'S CERTIFICATION 4� •" • ir I certify that I have determined through field inspections and 9 I. tok\ .--...- --#, review of Municipal records that the above systems are in y ,r •• conformance with MOA COSA guidelines in effect on this •• ' ;t�•i date. lig f r: . Garness : 4r; Engineer's Printed Name JEFFREY A. GARNESS 4r �. CE— ' ;'_� Date ! / 44 fROFESS\��. LICENSE �.1iti*1 tS #AECCB84 (Rev 10/12/12) • • Municipality of Anchorage Development Services Department Building Safety Division t 0'4i ;:i 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 171209 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 1, Lot 2 of Dawn Village Subdivision. This inspection revealed an arsenic concentration of 10.8 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. Parcel LD Municipality of Anchorage On -Site Water & Wastewater Program r (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL 014-061-55 1. GENERAL INFORMATION Complete legal description Location (site address) Current Property owner(s) Mailing address Real Estate Agent Expiration Date: _3 VILLAGE SID: BLOCK 1. LOT 2 6750 TESHLAR DRIVE, ANCHORAGE, AK, 99507 NICK BENNETT Day phone 6750 TESHLAR DRIVE, ANCHORAGE, AK, 99507 Day phone 2 2. TYPE OF DWELLING: a n f Single Family (wlwo ADU) ... J I ❑ Duplex JUiJ 2 3 2014 ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: 865-3281 TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual On-site ❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer 0 W aiverNanance request for: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 621(0 - Date of Payment co IzL h/V Jv�._ Receipt Number o O 3 Jp � COSA # DjIN 121117 Waiver Fee $ Date of Payment Receipt Number Waiver # Distance: - 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. 1 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. Address 3701 E. TUDOR ROAD, SUITE 101 `ANCHORAGE, AK, 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, U0.. 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 ofthe system under the conditions encountered at the time ofthe test, and separation distances measured to readily identifiable features The operationaUife ofall 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 them 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 opemh'onal 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 orparty is not authorized, nor will it confer any legal tight whatsoever. 6. DSD SIGNATURE V System #1 Approved for bedrooms. System #2 Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following Phone 337-6179 Date23�� OF IJT47V W ':_>f QE -799¢3 •♦T**fbOF SS/10 �i OF Ay6�� ���. ON-SITE WATER AND 1AIACTrvvATER �^ RRgr,RAM �\ Original Certificate Date: (0 - 3 o -,/,V The Municip6rity of Arfdborage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the represenatations 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. ATTCHMENTS: COSA Checklist Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other 1pa vv19no% 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: DAWN VILLAGE S/D,,BLOCK 11 LOT 2 -Parcel ID: 014-061-55 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 1/1977 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 106 ft. Cased to 106 ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 1/1977 - 6/16/2014 Static water level 34 ft. 25 ft. Well production 12 9.p -m. 4.96+ g.p.m, WATER SAMPLE RESULTS: Coliform.) U colonies/100 ml. NitrateNvo mg./L. Collected by: GEG, Ltd. Arsenic: O . ug./L. Date of sample: 6/16/2014 B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER Tank Type/Material Date installed Tank size gal. Number of Compartments _ Cleanouts (Y/N) Foundation cleanout (Y/N) Depression over tank (Y/N) _ High water alarm Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ftbr Obdr'm System type Length ft. Width ft. Gravel below pipe ft. Total depth ft. Eff. absorption a ft2 Monitoring tube_ Depression over field Date of adequacy test Results (Pass/Fail) For bedrooms Fluid de�thn absorn field before test _ in. Water added _gal. New depth _in. Elapsed —min. Final fluid depth in. Absorption rate >= g.p.d. y rejuvenation treatment (past 12 mo.) (Y/N & type) 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 wa 1.76r 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 N/A On adjacent lots N/A Absorption field on On adjacent lots Public sewer main '34 Public sewer manhole/cleanout .49' Sewer /septic service line "23 Holding tank N/A Animal containment areas 504 Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO. PUBLIC SEWER Building foundation Water main Wells on adjacent lots Property line_ Water service Absorption Surface water. SEPARATION DISTANCE FROM ABSORPTION FIE LOT TO: Property line B oundation Water main Water service line Surface water Driveway, parking/vehicle storage In drain Wells on adjacent lots F. COMMENTS `PER WAIVER #WR990078. `ACCEPTABLE PER CODE AT TIME OF WELL DRILLING ( PRE -1983) . G. ENGINEER'S CERTIFICATION I certify that t 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 Gh 3 bf (Rev. 10112112) 4 ? *V0 ..... ... ...............0 r A. G rness c 4i a 61 3 - ... .� • ��h�:'ROFESSt��i••• Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program f S A E T Y 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite ; (907) 343-7904i1(�� CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 014-o6i-55 COSA #_ 1� Expiration Date:. � �' % �— f 1 1. GENERAL INFORMATION Complete legal description Dawn Village 5/D, Block 1. Lot 2 Location (site address) 67so Teshlar Drive Current Property owner(s) Residential Mortgage LLC Day phone 222-8865 Mailing address ioo Calais Dr. Ste ioo, Anchorage, AK 995o:t Lending agency Day phone Mailing address Real Estate Agent Mary Cox Team / ReMax Properties Day phone 227-3522 Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 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 On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Pannone Engineering Services, LLC Phone 272-8218 Address P.O. Box 100217, Anchorage, AK gggSlo Engineer's Printed Name Steven R. Pannone, P.E. Date 3/11/2o11 Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The reported results describe 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 soil condition, round water levels .,""�, ��Off�� t4 ��5�1� 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 this All ���P................ i �•.•'• �y �� of system. systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that =• 4 _ there are no hidden defects or encroachments. PES can therefore not provide any warranty for future �••••• • ••• ••••• •••• ....I.....� performance nor give any estimate of how long the system will continue to meet the operational requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed °.Steven R. Pannone; above. Any reliance upon or use of this report by any other person or party is not authorized nor will it �1�/ °•.••• No. CE 8149 •.••'�� confer any legal right whatsoever. 1� <� •.., ••°'� ���,,,,;.��.• 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: __ : DRC)G.KAW ; /,I I1gF111 Attachments: COSA Checklist X Arsenic Advisory C Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report. Nitrate Advisory Other By: Original Certificate Date:_ l (Rev. 11/05) 61 :.r / Municipality of Anchorage *A9 Development Services DepartmentBuilding 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 CHECKLIST Legal Description: Dawn village SID, Block i, Lot 2 Parcel ID: 014 -o61 -Sr, A. WELL DATA Well type Private If A, B, or C provide PWSID # Well Log (Y/N) Y Date completed iwi977 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth io6 ft. Cased to io6 ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 1/1/2977 U4/2011 Static water level 34 ft. Well production 12 g.p.m. WATER SAMPLE RESULTS: Coliform Neq... colonies/100 mL Nitrate ND mg/L Arsenic: zi.2 ug/I Date of sample: 2021 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size gal. Number of Compartments _ Foundation cleanout (Y/N) Depression over tank (Y/N) Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ftz or ftz/bdrm) Length ft. Width 24 ft. 6.8+ 9.p -m. Other bacteria Nea colonies/100 mL Collected by: DRM Date installed Cleanouts (Y/N) High water alarm (Y/N) System type ft. Gravel below pipe ft. Total depth ft. Eff. absorption area ftz Monitoring tube Depression over field Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in absorption field before test in. Water added gal. New depth in. Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) 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 tank/lift station on lot zoo+ On adjacent lots ioo+ Absorption field on lot zoo+ On adjacent lots ioo+ Public sewer main 34 * Public sewer manhole/cleanout 49 Sewer /septic service line i3 * Holding tank 3.00+ Animal containment areas So+ Manure/animal excrete storage areas soo+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Absorption field Water main Water service line Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Water main Water Service line Surface water Driveway, parking/vehicle storage Curtain drain Wells on adjacent lots F. COMMENTS * G. ENGINEER'S CERTIFICATION I certify that 1 have determined through held 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 Steven R. Pannone, P.E. Date 3/i1/zozi COSA Fee $_ Date of Payment) S Receipt Number . (Rev. 11/05) Waiver Fee $ _ Date of Payment Receipt Number, �� �" d� 49TH '•: � �. ...........a... Steven R. Pannone�l No. CE 8149 �,79 ,♦♦♦ •. .......... •' SGS Ref.# Client Name Project Name/# Client Sample ID Matrix Sample Remarks: 1110788001 Pannone Eng. Srv. 6750 Teshlar Dr 6750 Teshlar Dr Drinking Water Printed Date/Time Collected Date/Time Received Date/Time Technical Director 03/11/2011 11:10 03/04/2011 15:30 03/04/2011 15:55 Stephen C. Ede Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic 11.3 * 5.00 ug/L EP200.8 C (<10) 03/08/11 03/10/11 SCL Waters Department Total Nitrate/Nitrite-N ND 0.100 mg/L SM20 450ONO3-F B (<10) 03/07/11 AYC Microbiology Laboratory E. Coli Negative 1 100mL, SM20 9223B A 03/04/11 DLC Total Coliform Negative 1 100mL SM20 9223B A 03/04/11 DLC Municipality of Anchorage *A� Community Development DepartmentDevelopment 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 # 111073 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 1, Lot 2 of Dawn Village Subdivision. This inspection revealed an arsenic concentration of 11.3 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 Departments Building Safety Division , Onsite 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. 014-061-55 HAA# !-1 i'1 13 b 2 1. GENERAL INFORMATION Expiration Date: Complete legal description DAWN VILLAGE SUBDIVISION: LOT 2. BLOCK 1 Location•(site address or directions) 6750 TESHLAR CIRCLE " ANCHORAGE AK ' Current Property owner(s) DEANNA NICHOLS Day phone 345-0984 Mailing address 4401 DeAURMOUN ROAD • ANCHORAGE, AK 99516 Lending agency. Day phone Mailing address Real Estate Agent = Day phone Mailing address Unless otherwise requested, HAA will be held by DSD forpickup. 2. NUMBER OF BEDROOMS: 4 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. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $ at, orprior 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, l 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 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 ofinstallation. Name of Firm ALASKA WATER do WASTEWATER CONSULTANTS, INC. Address 6901 DEBARR ROAD, SUITE 28 * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. GARNESS. 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 sorts 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. AKWWC, Inc. can therefore not provide any wairanty 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 4 bedrooms. Disapproved. Phone 337-6179 Date S 03 Conditional approval for bedrooms, with the flknxing stipulations: Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other WATER AND VVAb I LVVATER PROGRAM OP. WENT ?ENT SE`n,,,,�`� By: ! Original Certificate Date: (Rev. 12101) Municipality of Anchorage Development Services Department Building Safety Division On.Sito Water & Wastewater Program 4700 South Bragaw St P.O. Box 196650 Anchorage. AK09519.6650 www.d.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: DAWN VILLAGE SUBDIVISION: LOT 2. BLOCK 1 Parcel JD: 014-061-55 A. WELL DATA Well type PRIATE If & B, or C provide PWSID# NIA Date completed - 1/1977 Sanitary seal(YIN) YES Total depth1� 06 ,.tt. Cased to 106 1 FROM WELL LOG Date of test 1/1977 Statlo waterlevel 34 ft. Well production 12 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Arsenio N/A mgJL. B. SEPTICIHOLDING TANK DATA Nitrate jlj ,mg,ll.. Well Log (YIN) YES Wires properly -protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 5/2/2003 30 ft. 4.11 g.p.m. Other bacteria 0 colonies/100 ml. Date of sample: 5/2/2003 Collected by: AKWWC. INC. PUBLIC SEWER Tank Type/Material Oatednstalled Tank size,:..,.,..,.gal. Number of Compartments , Jga=wtef/ Foundation deanout (Y/N) er ink(YIN). High water alarm (Y/N) ping . Pumper C. ABSORPTION FIELD DATA Date Installed._._ Soil rating (g.p dJftbr ft9bdrm) Length eft. Width ft. System type Gravel below pjpa— ft. Tota► depth ft. Eft. absorption area ft' Monftoring tube �oepression over field Date of adequacy test Resultsal) For bedrooms Fluid depth In absorption field before in. Water added _gal. New depth —in. Elapsed Timet: . Final fluid depth _,_, in. Absorption rate >= g.p.d. treatment (past 12 mo.) (YIN & type) If yes, give date D. LIFT STATION Date installed "Pump on" level at in. 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 tankilift station on lot N/A Absorption field on lot N/A Public sewer main •34' Sewer /septic service line •23' On adjacent lots too'+ On adjacent lots too'+ Public sewer manhole/cleanout •48 Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC S EW E R Building foundation Property line Water main Water Absorption field SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Water Water service line Surface Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are In conformance with MOA HAA guidelines in effect on this date. Engineer's Printed am JEFFREY A. GARNESS Date S 03 y HAA Fee $ Date of Payment 5-103 Receipt Number (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number water parking/vehicle storage of a Garn ss:' �• —79. I1wfe/•_ cc4 APR -30-2003 WED 02:16 PK FAX N0. P. 02 re .our erect RECEIVED SEP 1 51999 1 � :a euwe eew,ex • 4.1 � L 3 i IM— •mil /•�,•, L`{. 1 1 1 h UNDER NO CIRCUlISTANCES SHOLW AN AS -QUILT SE USED POR CONSMWOH OR fOR ESTA$U6fOND OOUNOARY OR PENCE LINES. THE SURVEYOR TAKES RESPONSWIft FOR INC WITW. TRANUC" ONLY AND A•JSUUE7 rMANCIAL UAWLITY ONLY ►CIL THE COST Of *ILC SURVEY. 1 1 U6T40 DISTANCES PREVAIL OVER SCALNIO. MP40UEM UAY CAUSE MRORS IN SCAM LOT Slaw - SuRwy Type SWOOLS id NaATKw u-UAl7 ♦ • REY REANt Z DRAWAOC .' ` • ASPHALT j61 RNIL sTeumw Ai -"T o FOUND MMAR CONCRETE "AT 116M.., e.e-NILt ... SIgIKY ... T4OawNY 'x-"6"0' Wool) " CE 1 ASSUMED CIiY. •�-�(—Ih UETAL FQNCE w000 DICK IPLOT PAN do LOT IT Is THE IICSPONSINUTY Of THE BUILDCR OR OYMCR PRIOR TO ONLY' THOW IUPROVCUEM ABOYP *ROUND AND VISIBLE LNLL BE CONSTRUCTION TO YtrRVY PROPOSED AUDAUNO ORAD•E RELATIVE XHONN• J90NOM 1vA14 SEPTIO CLUNOUM SOCWALKS; D10VZW,4'M TO rMISHED GRADE AND UTILITY C0NNECT10N0 AND TO OCTERUINE CTO., ARE SHOW IN THOR APmw 4MATe LOCA110N. ONLY. $NOW THE EXISTENCE Of ANY CA,704WTS. COVENANTS OR RESTRK:TM MAY PRCVIM SOUL A40ROYMOM FROU OGNO EELN AND LOCATED. WHICH GO NOT APPEAR ON THE RECORDED iUDOARION PLAT. ALL, 014TANCCS ARC MCC O O UNLCaei oT}1ERWISC NOTE . SURVEY CER-nACA-M 'Preparedy sur►IAN •�� *410`411444 Robert E. Johns, Jr. & Assoc. .,,„M„.,,,.•„ .'��P...••• Professional Land Surveyors 1r Irl r ,1 •4 943 E 13 AYE. « w. /4r w U w. MA N y ANCSIMADEAI.ASNA Y:OOI +1M••.M.1 M 64 MLLM�eM.M1.1'1, N« r }f • .[. 7• �I ieda 111 a 30' Rea. Lot i.I. R.c. Pkt R. No. MANDATION Ae-MILT J^f 'r r. .1. ..• «I `..�i`:�..�.-.' Chockld ey. MLJ 4. Ir.••.1+. r11#Ir11Ar. 1. «..w ►.Nr ROB 1�. got* Drum Ql& W.O. ANAL STRUCMRE AS -DUCT ��(•.,R 4121-5 e,I$°;,� 9— 0-1499 2034 99132 [� L .rN L iMN i...rr„«ly M{ 1 ♦ i`�t 1IMNSMWIIM „ M .NnM1■.«I.w/ .MN11 trnl .M -•r WrN. �+e�'L VA.r•••I,er•eIetNe1nr11•-~ �� LOT Deeo2rl�e BLOCK -11 bAVN VILLAGE SUBD(�\ 5M MUNICIPALITY OF ANCHORAGE .i. DEPARTMENT OF HEALTH & HUMAN SERVICES ; Division of Environmental Services On=Site Services Section .•' P.O.'Box196650?`Anchorag*,'Alaska ':•99519-6650; 343-4744 t! r :; CERTIFICATE OF,HEALTH AUTHORITY (' APPROVAL1 L FOR A SINGLE FAMILY DWELLING 1 Parcel IA # _'_01 4 061 55 �` , ,� i It' �_ , HAA # 1 .GENERAL INFORMATION; Complete legal description Lot 2 • Bloc 1 Dayi l age Subdi vi ai on k � wn' 1' Location (site address or directions)67 n °meshl aT S nnnhnra�e7 A :re i 't• ..ir a1 ,r.. y,Y t1i ,,. feat r 1':rr Property,owner, 'Russ t & Kathleen Douglass Day phone 349 5696 '. r• S,U } A. 1 , f .n. - .... 1- t l 1 It t 6750' Mailing address Teshlar Anchorage, AKr 99507 a ::'.Lending agency, Day phone .Mailing address' ' Agent • Day phone Address Unless otherwise 'requested, HAA will be held for pickup 2. NUMBER OF BEDROOMS. 3 TYPE OF, WATER SUPPLY Individual well Community well Public water NOTE: If community' well system, protide written confirmation from State ADEC attest - Ing to the legality and status of system"...' 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer 'xx = • '_... 'i, j:, NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-= (Rw. U91) Fmnt MOA t21 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. If urth6rverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water flIsupply and/or.wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in efl�etsd>ietlW8s[e8of is inspection . Name of Firm -wastewater: onsulta , !•` Phone Address r. INV 11 Engineers signature - = Date �i 1­7 Alaska;Vi�alte� E, F`. Wastewater Consultants, lnC. SWI b6 PAID:$ 560 .or prlorao, closing for the . Engineering :Services )Prov) tom. 6 DHHS SIGNATURE �,ca'�►.., ,;,.�E�� ": Approved . for 3 . _ bedrooms.•" - Disapproved.-7'", Conditional approval for :- ;`bedrooms, ;with the following stipulations: Additional Comments. 'J BY: -Date /& ..; i •ate. ". .. .. CAUTION The Municipality of Anchorage Department of L. Health and Human Services (DHHS) issues Health Authority Approval Certificate§ based only upon the :representations given In paragraph 5 above by an Independent professional engine6e 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-MS m.W.1/91) e.k MOA m .... ..... ... .T._. ..__...... _..._._...._........._..� _ ... .� ..._� _...___M. RECEIVED Municipality of Anchorage SEP 271999 (6 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division MUNICIPALITY OF ANCHO u sE.xvICT s LA (( 825 L Street, Room 502 • Anchorage, Alaska 99501 • (9( !F4 -4744 Health Authority Approval Checklist Legal Description: DAWN VILLAGE: LOT 2. BLOCK 1 Parcel I.D.: 014-061-55 A. WELL DATA Well type PRIVATE If A. B, or C, attach ADEC letter. ADEC water system number d fA Log present (Y/N) YES Date completed t /77 Total depth 106' Cased to 106' Casing height (above groubd) 2'+ Sanitary seal (Y/N) YES Wires properly protected (YM) YES FROM WELL LOG Date of test 1/77 Static water level 34' Well production 12 g.p.m. WATER SAMPLE RESULTS: AT INSPECTION 912129 37 4_7A O.P.M. Coliform n Nitrate n_-5 ma 4l Other bacteria D Date of sample: _4209 Collected by: A.W.W.C.. INC. B. SEPTIC/HOLDING TANK DATA Date installed Foundation cleanout (Y/N) Tank size Number of Compartments _ Depression (Y/N) High water Date of Pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.dA? /bdrm) System type Length Width el thickness below pipe Total depth Effective absorption area Date of adequacy Fluid depth in Tube present (Y/N)Depression over field (YM) Results (Pass/FaIQ For bedrooms field before test (In.); Immediately after gal. water added (in.): Fluid d (ins) Minutes later: Absorption rate • o.p.d. oxide treatment (past 12 months) (YM) If yes, give date 72-026 (Rev. 3196)' D. LIFT STATION Date installed Manhole/Access (YIN) High water alarm level 'Datum Size in at* "Pump off" level at' E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/trolding tank on lot N /A On adjacent lots N/A Absorption field on lot N/A On adjacent lots N/A Public sewer main *34' Public sewer manhole/cleanout •48' Sewer /septic service One •23' station N/A ggLiifftt SEPARATION DISTANCES FROM SEPTIC/HOLDINGTANK ON COTTONED LETTER Foundation Property line Absorption field Water main/service One Surface water/drainage Wells oacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON . Property line=Buildin an Water main/service line Surface wateDriveway, parking/vehicle storage area Curtain dWells on adjacent lots F. I certify that I inconte Signature _ Engineer's NZ Date CERTIFICATION HAA Fee $ Date of Payment_ Receipt Number_ 72-026 (Rev. 3/96)• field inspections and review of Municipal felines in effect on this date. —7953 Waiver Fee $ Date of Payment 2� Receipt Number �✓ % 7 are MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 014-061-55 HAA # "f E0104 IK 1. GENERAL INFORMATION Complete legal description Lot 2; Block 1; Dawn Village Subdivision Location (site address or directions) 6750 Teshlar Anchorage, AK Property owner Kathleen Douglass Day phone 349-5696 Mailing address 6750 Teshlar Anchorage, AK 99507 Lending agency Day phone Mailing address Agent Day phone i i Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 i 3. TYPE OF WATER SUPPLY: Individual well XX Community well I 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 Holding tank Community on-site Public sewer XX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. I'� 72-075 Mw. IA") Font MOA 621 S. 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. l 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 a of this inspection. g WA999 ✓Vi% 1 c. P Name of Firm Wastewater C00:22nfr.. Inn Phone -?27-4171 Address AK Engineer's signature 28 Date REQUEST A CONDITIONAL HEALTH tAUtAORITY A-PMOVAL WITH THE FOLLOWING CONDITIONS: 1. Property owner agrees to sign affirmatively on future petition for a water improvement district. 2. Property owner willconnect to public water when it becomes available. 3. Property owner will collect and analyzed by a state certified lab, water samples from his private well once a year until connect"1 e to public water. property owner will provide copiest11�partment. 6. DHHS SIGNATURE ;v f)46Y A. ow"" Approved for bedrooms. u1 cans= Disapproved. y` Conditional approval for bedrooms, with the Additional Comments By: 4Mlr Date 4c 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 courtesyto purchasersof 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-MMW VYI) B49* MOAAZ Municipality of Anchorage RE C E i V EAUNMA DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division SEP 1? 19 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907). d7AAy OF ANCHORAGE 061RONMENTAL SERWIS OtVMM Health Authority Approval Checklist Legal Description: DAWN VIUAGE, JOT 2_ awci< i Parcel I.D.: 014—nAJ-55 A. WELL DATA Well type PRNATP If A. B, or C. attach ADEC letter. ADEC water system number _NA Log present (Y/N) YES Date completed 1.427 Total depth 106' Cased to lose Casing height (above ground) 2'+ Sanitary seal (YIN) YM Wires properly protected (Y/N) YES FROM WELL LOG Date of test 1.4u Static water level ,34' Well production 12 G.P.M. WATER SAMPLE RESULTS: AT INSPECTION 0.49129 A7 498 9.p.m. Coliform - ,p Nitrate 05 ma.41 Other bacteria 0 Date of sample: 9�9f o9_ Collected by. A.W.W.C.. INC. 8. SEPTIC/HOLDING TANK DATA Date installed Tank size Foundation cleariout (Y/N) Date of pumping C. ABSORPTION FIELD DATA Number of Compartments Depression (YM) High water Pumper Date installed Soil rating (g.p dA? /bdrm) _ Length Width G I thickness below pipe System type Total depth Effective absorption area onitoring Tube present (Y/N) Depression over field (YM) Date of adequacy test Results (Pass/Fall) For bedrooms Fluid depth in a ion field before test (in.); Immediately affer gal. water added (h): Fluid de (ins) Minutes later: Absorption rate . a.p.d. treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)' B yes, give date D. UFT STATION ' Date installed Manhole/Access (Y/N) High water alarm level 'Datum Size In !1 at' _ "Pump off" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septialholding tank on lot N/A On adjacent lots N/A Absorption field on lot N/A On adjacent lots N/A Public sewer main 034@ Public sewer manhole/cleanout 0481 Sewer /septic service One 023 Lift station N/A • SEE ATTACHED LEITER SEPARATION DISTANCES FROM SEPTIC/HOLDINGTANK ON LOTTO: Foundation Property line Absorption field Water maintservice One Surface water/drainage Wells avert lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON F. Property line _ Surface water Curtain drWw ceriffy that 1 in conformar/ Signature. Engineers Date n Water maintservice One Driveway, parking/vehUe storage area _ Welds on adjacent lots inspections and review of Municipal rs in effect on this date. 0 HAA Fee $ 3 OO ' �^ Waiver Fee $ _ Date of Payment / — 7 �/. Date of Payment Receipt Number `"� Receipt Number 72-026 (Rev. 3/96)' 7953 are