HomeMy WebLinkAboutDAWN VILLAGE BLK 2 LT 6Dawn Village
Block
Lot 6
#014-061-44
ES A
TER STATE 0Ct
A�
N
3126 EAST 72NO AVENUE
ANCHORAGE. ALASKA 99507
SUBSURFACE EXPLORATION
Shift Report of Operations
1. OWNER PEDERSON CONSTRUCTION, INC. PROJECT Dawn Subdvision/
2. TYPE OF EXPLORATION 6" domestic water well
3. CONTRACTOR WESTERN STATES ASSOCIATES EQUIPMENT NAME 22W
A. CONTRACT NO. HOLE NO.
S. SURFACE ELEVATION WEATHER
DEPTH -BEGIN SHIFT DEPTH -END SHIFT DEPTH DRILLED
6. PERMAFROST ENCOUNTERED: FROM TO
7. WATER LEVEL DATE A SHIFT
e. TIME DISTRIBUTION HOURS
RIG HOURS
DRILLER CHURN DRILL FISHING
Herb Johnson
ROTARY DRILL PULL CASING
BOOM TRUCK STANDBY
HELPER
TRUCK WELDING
SURGING PUMPING
9• CASING LOG
lo. SOILS LOG.
S12E
TYPE
DEPTHS
SAMPLE
NO.
TYPE
SAMPLE
MATERIALS AND REMARKS -
TOTAL
NO.
LENGTH
LENGTH
FROM TO
1
1110"
1120"
0
43
Fight sand and gravel
2
7'511
18,511
43
83
Tight sand gravel imbedded in clay with some
3
7110"
26'3"
rocks. No water.
4
712"
33'5"
83
89
Water bearing sand and gravel.
5
516"
38'1111
6
416"
43'5"
7
61011
490511
8
7'0"
5615
9
5'9"
6212"
10
1014"
7296"
11
5'8"
7812"
1
5 72
3 9
13
51611
89,3_1,1
12 gallons per minute water , Water level at 19ft from static level
DRILLER Herb Johnson INSPECTOR
jI u r -J I �= ]� 'F-1 1_ x 'F` Ry• r-) F=- r=1 nl t^ F"'a FP: F-1 (3 Er.
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
2016 E. TUDOR RD. , ANCHORAGE, AK. 99507
276-2221
LelEI_L F='EF?1�1 I -r
PERMIT NO. C 77017 )
APPLICANT PETERSON CONSTRUCTION SRA DOX 17188 344-8638
LOCATION TESHCAR ST
LEGAL L6 B2 DAWN VILLAGE LOT SIZE 10000 SQUARE FEET
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIMATE 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--oF=M1 1 I"T "vrraL I F= OF? C)"[=- 04'E1-41<:
I CERTIFY THAT
1: I All FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
SIGNED r___'',__t�i t.-7
-~------ ----------
APPLICANT PETER5bN CONSTRUCTION
i
ISSUED BY__
TE_ZL ��� I -
S 00'01'53•' E 60.00'
10' UTILITY EASEMENT
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•- Municipality of Anchorage =As `o_
On-Site Water and Wastewater Program < &Li i
(907) 343-7904 a MAI' .} 5 .11
Certificate of On-Site Systems Approva << � �`'
O168L9
Parcel I.D. 014-061-44 Expiration Date: 9-23-- (7
1. GENERAL INFORMATION
Complete legal description Dawn Village Block 2 Lot 6
Location (site address) 6711 Teshlar Drive
Current Property owner(s) Weller, Jessica & Schnese, Anthony Day phone
Mailing address 6711 Teshlar Drive Anchorage, AK 99507
Real Estate Agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Q Individual ❑
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer 0
WaiverNariance request for: Distance:
l _
Received b . ii ,a!A 1/ `' - Date: t `—
/ ]�
- /
COSA to be released to the engineer,unless otherwise requested "the engineer.
COSA Fee $ 2-4 -- Waiver Fee $
I
Date of Payment � Z7-4l 1 Date of Payment
Receipt Number OLLi(Pak Receipt Number
COSA# t`0t 2- 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:otltpined 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.
In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and.reguldtions.The reported results describe the performance of the system under the conditions encountered at the time of the test,
and separation distnce5 measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil
condition,ground water 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 this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone Date 5/19/2017
Z.16i OF A�, 1sk1
i
- •
..*TO
6. DSD SIGNATURE
-41 ' f
/ . . . . .r----
System #1 Approved for 3 bedrooms •S'teven R. '•ririone •
System #2 Approved for bedrooms • GE-8149kt,11
Disapproved �ti �OFESSt �4
Conditional approval for bedrooms, with the following stipulations:
nC
•
0\`t'S�SELC•C,
WA,ER SND
�
STEW ATER
PRCORp\\A•
c,
r�y
''ft IT fir".'
By. H... [---4 Original Certificate Date:
5--'2-2--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 X Nitrate Advisory
Septic System Advisory _ Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet2: -
If more than 1 septic system is on the lot:
COSA Checklist# I of 1
Structure served by this system '
Certificate of On-Site Systems Approval Checklist
Legal Description: Dawn Village Block 2 Lot 6 Parcel ID_ 014-061 -44
A. WELL DATA
Well type Private If A. B. or C provide PWSID# Well Log (Y/N) Y
Date completed 1977 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 89 ft Cased to 89 ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test —1977 5/11/2017
Static water level 19 ft 31 ft.
Well production 12 g.p.m. 7.4 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate ND mg/L
Arsenic ND ug/L Date of sample: 5/11/2017 Collected by. PES
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Date installed
Tank size gal Number of Compartments Cleanouts (YIN)
Foundation cleanout N) Depression over tank (Y/N) High water alarm (Y/N)'
Date of pumpin. Pumper
C. ABSORPTION FIELD DATA
Date installed Soil : ing (g.p.d./ft2 or ft2/bdrm) System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption area ft2 Monitoring tube Depression over field
Date of adequac est Results (Pass/Fail) For bedrooms
Fluid depth I, absorption field before test in. Water added gal New depth in
Elapse. ime: 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 (YIN)
"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
WELL ON LOT TO:
Septic tank/lift station on lot 100+ On adjacent lots 100+
Absorption field on lot 100+ On adjacent lots 100+
Public sewer main
* Public sewer manhole/cleanout 100+
Sewer/septic service line ?•54 1 Holding tank 100+
Animal containment areas 50+ Manure/animal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Prope ine Absorption field
Water main W. er service line Surface water
Wells on adjacent lots
ABSORPTION FIELD ON LOT 0:
Property line Building foundation Water main
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
F. COMMENTS
Survey on File. t Welp p(' cW'
G. ENGINEER'S CERTIFICATION ; oF A `kt
I certify that l have determined through field inspections and eco.- `) ••.p���
review of Municipal records that the above systems are in 0*;•49 TH I:. ••*
conformance with MOA COSA guidelines in effect on this date. / •l•••
Engineer's Printed Name Steven Pannone • }even k Pannone
Date
5/19/2017 O�} �. CE-8149
Ik. sssc �r�
Atkx-%,LL41b
COSA canary sheet_2-6-15 doc
LS
I
Municipality of Anchorage
Development Services Department '
Building Safety Division ^ '
\_ On -Site Water and Wastewater Program s
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 014 — 0161— 44 COSA # Q�IQ,,? S 1
Expiration Date: /0—oz
1. GENERAL INFORMATION
Complete legal description Dawn V;Ik5 y Oto_- , a Lo} (o
Location (site address) 16 •11 T"Wo r Drive, Anc 6riag • . A( cmSoT
Current Property owner(s) $coil Sc1nm. ,N �L Day phone a44 — 9100
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone
IEtL1 P12A Day phone
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: .3
3. TYPE OF WATER SUPPLY:
Individual Well z
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ❑
Individual Holding Tank ❑
Community On-site ❑
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site 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 SDgt1_WA(1A6-inE6QJn/G- Phone Pl-3916
Address 203 W, 15 S}r, 20-1, Anc� amme, `1950
Engineer's Printed Name
5. DSD SIGNATURE
I/ Approved for bedrooms.
Disapproved.
Date09
_ of AZ,4
'00
41t �fA
E./s .. -
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By; Original Certificate Date: g —/0
(Rev 11,05)
Municipality of Anchorage
• "' Development Services Department
Building Safety Division '
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 9951M650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Qkjn V&40 elu wo
Parcel ID: 014–OW-44
A. WELL DATA
Well type PjI A.V If A, B, or C provide PWSID # _
Well Log (YIN)
Date completed fL111} Sanitary seal (YIN)
Wires properly protected (YIN)
Total depth Cased Cased to 8_�_fL
Casing height (above ground) {' Ia in.
FROM WELL LOG
AT INSPECTION
Date of test
'i 24 cU
Static water levet li ft.
41 fL
Well production la g.p.M
V•� g.p.m.
WATER SAMPLE RESULTS:
Coliform _colonies/100 mL Nitrate A/0 mg/L
Other bacteria colonies/100 mL
Arsenic. AID mgA Date of sample: ZYlN
Collected by: L Ag5 SC"Q C'VA
B. SEPTICIHOLDING TANK DATA
Tank Type/Material
Date installed
Tank size gal. Number of Compartments=
Cleanouts(YIN)
Foundation cleanout (YIN) — Depression over tank (YIN) =
i
High water alarm (YIN) —
Date of pumping —' Pumper
C. ABSORPTION FIELD DATA ?L,V\;c. S e-jV\
Date installed — Soil rating (g.p.d./ft= or ftz/bdrm)
System type
Length ft. Width --
ft. Gravel below pipe — ft.
Total depth �R .: EH. absorption area — fe 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 me.) (YIN & type)
If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
'Pump on level a in. 'Pump off" level at High water alarm level a in.
Datum Cycles tested Meets alarm & t requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N A
Absorption field on lot NIA
Public sewer main
Sewer /septic service line
is 5501
*151
Animal containment areas Al. O.
On adjacent lots
7 Kao r
On adjacent lots 17
Public sewer manhole/cleanout 11 a
Holding tank
Manure/animal excrete storage areas /V. O.
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. parkingtvehicle storage
Curtain drain Wells on adjacent lots _
F. COMMENTS: 4 Well prMea Ofioc ko lin
G. ENGINEER'S CERTIFICATION ��O.F A,Cgslll
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in 49TH
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name LAZ �tir-'�14nd // r upp; E. �URKLAtiD` ai
Date
COSA Fee $ 'M oo Waiver Fee $
Date of Payment 13L510-1 Date of Payment
Receipt Number 09 38191 Receipt Number
(Rev. 11105)
SCS RCEN
1093652001
Client Name
Spurkland Engineering
Project Name/#
Dawn Village B2,L6
Client Sample ID
Dawn Village B2,L6
Matrix
Drinking Water
Printed Daterrime
08/04/2009 11.19
Collected Date/time
07242009 16:30
Received Datelrime
07242009 16:40
Technical Director
Stephen C. Ede
Samplc Remarks:
Allowable
Prep Analysis
Parameter
Results
pol.
Units
Method Container 11)
Limits
Date Date
Wt
Metals by ICP/MS
Arsenic
ND
5.00
ug/I,
EP200.8
C
(<10)
07/31/09 08/03/09
NRB
Waters Department
Total Nitratc/Nitritc-N
ND
0.100
mg/L
SM20 4500NO3-P
11
(<10)
0728/09
LCC
Microbiology Laboratory
Colony Count
I
col/IOOmL
SN1209222B
A
(<200)
07/24/09
DLC
Total Coliform
0
col/IOOmI,
SM20922211
A
(<I)
07/24,109
DLC
Fecal Coliform
0
col/IOOml,
SN120922211
A
(<I)
07/24,'09
DLC
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water 8 Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPF
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O U-Ouel- 0 L COSA# ��'0,�45
1. GENERAL INFORMATION Expiration Date: 7-2- %- 0 6
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
DAWN VILLAGE SUBDIVISION: LOT 6, BLOCK 2
6711 TESHLAR DRIVE, ANCHORAGE, AK 99507
MATTHEW DEFRASNE Day phone 522-6711
6711 TESHLAR DRIVE, ANCHORAGE, AK 99507
Day phone
TERRIE PISA w/ PRUDENTIAL JACK WHITE Day phone 762-3157
3801 CENTERPOINT DRIVE, ANCHORAGE, AK 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage ❑
Community ClassWell ❑
Public Water System ❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
❑
Individual Holding tank
❑
Community On-site
❑
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an Independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems
Approval are valid for 90 days from the date of Issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions In the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the
information obtained from the Municipality of Anchorage riles 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. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date a,
Engineers Comments:
In conducting this evaluation, GEG, LID. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily Identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to moot 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 -73— bedrooms.
Disapproved.
Conditional approval for bedrooms, with the fllowing stipulations:
• 0�1
J ON-SITE
�:q
WASTEWATER
Attachments: <••., ...•••S��
COSA Checklist C/ Arsenic Advisory ��j�/fill
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Reort
Nitrate Advisory Other
By: Original Certificate Date:
1P.v IIRKI
Municipality of Anchorage
Development Services Department
�J Building Safety Division
OnSlte Water d Wastewater Program
4700 Bragew Street
P.O. Box 1966W
Anchorage, AK 995198850
www.muni.org/onelte
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: DAWN VILLAGE SUBDIVISION; LOT 6. BLOCK 2 Parcel
A. WELL DATA
Well type Rawl If A, B, or C provide PWSID# N/A Well Log (Y/N) YES
Date completed —1977 Sanitary seal (YIN) YES Wires property protected (YM) YES
Total depth 89 ft. Cased to 89 ft. Casing height (above ground) 7 in.
FROM WELL LOG
Date of test ^-1977
Static water level 19
Well production 1
WATER SAMPLE RESULTS:
Coliform _'nD colonies/100 ml.
,
Arsenic: ib ug./L.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal. Number of
Foundation cleanout (YIN) `Beth
AT INSPECTION
2/23/2005
25 ft,
3.62 g.p.m.
Nitrate D,) mg.IL. Other bacteria O colonies/100 ml.
Date of sample: 4/14/2006 Collected by: GEG, Ltd.
PUBLIC SEWER
Date it
martmen Cleanouts (Y/N)
over tank (YIN) _ High water alarm (Y/N)
Pumper
C. ABSORPTION FIELD DATA PUBLIC SEWER
Date installed Soil rating (g.p.d./ft'or ft'/bdnn)_ System type
Length ft. Width ft. Gravel below pipe
Total depth ft. Eff. absorption area _ ft' Monitoring to pression over field
Date of adequacy test ass/Fail) For bedrooms
Fluid depth in ab before test _ in. Water added _gal. New depth _in.
peed Time: _ min. Final Auld depth _ in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N 8 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
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot On adjacent lots 100'+
Absorption field on lot nin
Public sewer main "50'+
Sewer/septic service line "15'
On adjacent lots 100'+
Public sewer manhole/cleanout 100'+
Holding tank
Q
Animal containment areas 50'+ Manurelanimal excrete storage areas 50'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation
Water main
Wells on adiacepH
Property line
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Water service line
F. COMMENTS
Building
Wells on adjacent lots
X��rI;3[��r7;J;i[rl:Iif�iF4=Ir
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date r zs�Gb
Surface water
PUBLIC SEWER
Driveway, parking/vehicle storage
COSA Fee "1 �D - Q)Waiver Fee $
Date of Payment t4la mss,/ i� Date of Payment
� ✓b
Receipt Number l Receipt Number
(Rev. 11105)
U
SGS ReEM
1061846001
Client Name
Garncss Engineering Group, Ltd.
Project Name/N
Lot 6 Block 2 Dawn Village
Client Sample ID
Lot 6 Block 2 Dawn Village
Matrix
Drinking Watcr 4
Sample Remarks:
All Datc%rrimes are Alaska Standard Time
Printed Date/Time 04242006 13:43
Collected Datdrime 04/142006 11:15
Recetsed Datelrime 04/142006 11:29
Technical Director Stephen C. Ede
Parameter
Results
PQL
Units
Method
Conmmm ID
Allowable
Limits
Prep Analysts
Date Date
Init
Metals by ICP/MS
Arsenic
ND
5.00
ug/L
EP200.8
C
(<=10)
04/17/06 0421/06
TK
Waters Department
Nitrate -N
0.106
0.100
mg/L
EPA 353.2
B
(<=10)
04/14/06
ALR
Microbiology Laboratory
Total Coliform 0
coV100mL SM209222B A (<=1) 04/14/06 TLF
Municipality of Anchorage
Development Services Department
L1� Building Safety Division
On -Site Water & Wastewatbr Program
4700 South Bragaw SL
P.O. Box 195650 Anchorage, AK 995196650
www.d.anchoragb.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 014-061-44 HAA#—
1. GENERAL INFORMATION Expiration Date: 10 — / 7 — 016�
Complete legal description DAWN
VILLAGE
SUBDIVISION- LOT
6 BLOCK 2
Location (site address or directions)
6711
TESHIAR DRIVE •
ANCHORAGE AK 99507
Current Property owner(s)
Mailing address
Lending agency
Mailing address
RENEE JO WEBMAN Dayphone_(907) 522-6711
6711 TESHIAR DRIVE • ANCHORAGE AK 99507
Day phone
Real Estate Agent Day phone
Mailing address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
0
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an Independent professional civil
engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of Issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid
water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water
system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's
work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal afxed 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 ts(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
onsite water supply and/or wastewater disposal system is(are) In compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Finn GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 0 ANCHORAGE, AK 99507
Engineers Printed Name JEFFREY A. GARNESS. P.E.
Engineers Comments:
in conducting this evaluation, GEG, Ltd. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines d Regulations. The reported results described the performance of the
system under the conditions encountered at the time ofthe lest, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local sells condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
Those conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG. Ltd. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of lhis report is for
the sole benerit of the ownerlisted above. Any reliance upon or use of this report by any
otherperson orparty Is not authorizad, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
_1z Approved for 3 bedrooms.
Phone 337-6179
Date _L0oS
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
(/ Maintenance Agreements
Supplemental Engineers Report
Other
2
ON-SITE •'•4
��
WASTEWATER •.
o'
By . _j tO&C'r Original Certificate Date.
(Rw.1741)
Municipality of Anchorage ,r
' Development Services Department
Building Safety Division
On -Site Water & Wastewater Program "
4700 South Bntgaw St.
P.O. Box 19665D Anchorage, AK 995196850
www.ci.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: DAWN VILLAGE SUBDIVISION: LOT 6. BLOCK 2 Parcel ID: 014-061-44
A. WELL DATA
Welt type PRNATE If A, B, or C provide PWSID# NIA
Date completed 1977 Sanitary seal (YM) YES
Total depth 89 ft. Cased to 89 ft.
FROM WELL LOG
Date of test –1977
Static water level 19 ft.
Well production 12 g.p.m.
WATER SAMPLE RESULTS:
Well Log (Y/N) YES
Whm property protected (YM) YES
Casing height (above ground) 24+ in.
AT INSPECTION
2/23/05
25 ft.
3.62 g.p.m.
Conform 0 colonies/100 ml. Nitrate 0.10 nVA. Other bacteria 0 colonies/100 mi.
Arsenic: N/A mg jL. Date of sample: 2/23/2005 Collected by: GEG. LtD.
8. SEPTICIHOLDINGTANK DATA PUBLIC SEWER
Tank Type/Material Date Installed
Tank size gal. Number of Compartments _ —XWW Nt
Foundation cleanout
Pumper
(Y/N) _ High water alarm (YM)
C. ABSORPTION FIELD DATA PUBLIC SEWER
Date installed Son rating (g.p.dlfttor ft%dnn)
Length ft. Width ft.
Total depth ft. Eft. absorption area fe Monitorinc
Date of adequacy test
System type
Gravel q2owpl0e ft.
Depression over Geld
For—bedrooms
Fluid depth in absorption field be est = in. Water added _gal. New depth _in.
Elapsed Time: n. Final fluid depth _ in. Absorption rate >w g.p.d.
tuvenetlon treatment (past 12 mo.) (YIN ti type) If yes. give date
D. LIFT STATION
Date Installed
"Pump on" level at in.
E. SEPARATION DISTANCES
Size in gaflons mannF�rn
High water alarm level at in•
Cycles tested Meets alar & circuit requirements?
-
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tanMtft station on lot 100'+
Absorption field on lot N/A
Public sewer main 050'+
Sewer /septic service line 015'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/deanout 100'+
Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation Property line Absorption field
Water main
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO'
Property line
Water service line
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Surface water
Building foundation Water
Wells on adjacent lots
PUBLIC SEWER
parkingfvehide storage
I certify that I have determined through field inspections and t'.•
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effecton this date. I ....... .................
Engineers Printed Name JEFFREY A. GARNESS 0 v 753
�3a.e es<
Date too,
HAA Fee $ �q)N
Date of Payment 3`IS U5
Receipt Number
IRaw. 12JOI)
Waiver Fee $
Date of Payment
Receipt Number
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03-02-05 03:59PM FROM-CUE ESI, SGS ENV SERVICES
—S&I
SCS Ref.N
1050870001
Client Name
Garness Engineering Group, Ltd.
Project Name/N
Dawn Village B2 LOT 6
Client Sample ID
Dawn Village B2 Lot 6
Matrix
Water (Surface, Eft., Ground)
Sample Remarks:
9075615301 T-019 P.02/06 F-691
All Dates?imes are Alaska Standard Time
Printed Date/Time
03/012005 12:54
Collected Date/Time
02232005 10:20
Received Date/Time
02232005 10:33
Technical Director
Stephertc/fde
Released
ParameterResults ARoweble Prep Anatysis
PQL Units Methal ConlalnerlD Lim=n r)arc 1) Init
Watara Department
Nitrate -N 0.100 1.1 0.100
Microbiology Laboratory
Total Coliform 0
mg/L EPA 300.0 II 02/23/05 CAM
coV100mL SM209222B A (o-1) 0223/05 DKC
03-02-05 03:59PN FRN-CT&E ESI, SGS ENV SERVICES 9075615301
SGSICT&E ENVIRONMENTAL SERVICES
Drinking Water Analysis Report for Total Coliform. Bacteria
READ DamucTou DN REVERea slog PEFCRfc COrr-I.EC7M 6AMPLa ..
.MUST BE COMPLETED BY WATER SUPPE.IER '
O PU!�= WAM SYSTEM Of
r
T-019 P.03/06 F-691
'200 W. POTTER DRIVE,
ANCHORAGE, ALASKA 99Sta
Tek 907.562-2313
Fax: 907-561-5301
Lab Rd Na
iosaaro-iq
1111111111
SAMPLE COLLECTION SAMPLE TYPE
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lwa.wwwObr
Reported B� �e� DaWTIme: 2l�°dl0�i iD ' w.a..w�
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Form 0 FW- 0053 12/17103
MUNICIPALITY OF ANCHORAGE Aah—
• 'Y 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
LLLFOR A SINGLE FAMILY DWELLING
Parcel I.D.# � '" D6�.. HAA# 0aciLlnaq 1
1. GENERAL INFORMATION
Complete legal description L�f e. 2 . OQw'R t%/
Location (site (site address or directions) e�5 7/1'
Property owner s ��l 52-
i�itL/,9m UX
- t- - ba phone 3>�-��zvF
Mailing address
Lending agency ppem im- //lam TL �(�� Day phone SU�3 77x(0
l f9 2 C f� t AL
Mailing address •'��ti't' � ��•���_� �_
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, 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
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (R/v.1/91) Front MOA 121
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection. p
Name of Firm 1 A -� �� ,K9_ / -Phone3
Address 74141
Engineer's signature
6. DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for _
Additional Comments
bedrooms.
Date
bedrooms, with the following stipulations:
kt1TIC
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 151) Back MOA 621
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
V; llaq�
Legal Description: f_'dt�� A81k 2 Dawn, Su Parcel I.D. D6/—
A. Well Data
Well type � If A. B, or C, attach ADEC letter. ADEC water system number
Log present (YM) y� Date completed �'" "��'/ Driller li%dk/N A99
Total depth Op9 feG/ Cased to �4 3 ��2 Casing height
Sanitary seal (Y/N) Wires properly protected (Y/N) _� S
Date of test
Static water level
Well flow
Pump levell
FROM WELL LOG
.19
2 , O —
9 -p.m -
AT INSPECTION
MUNICIPAUTY OF ANCHORAGE
ENVIRONMEWAL SERVICES DIVISION
23 / 10 1994
G. D 9-p
SEPARATION DISTANCES FROM WELL TO:
SeptiGholding tank on lot N'y'r�' - ; On adjacent lots
Absorption field on lot //,, HL- ; On adjacent lots
Public sewer main 4-97 Irea / Public sewer manhole/cleanout
Sewer service line Petroleum tank
WATER SAMPLE RESULTS:
Coliform 0/ / Nitrate 49. 110 ` O
"9 r- therbacteria
6
Date of sample: / L1SV Collected by: �Z E •
B. SEPTIC/HOLDING TANK DATA
Date installed;, Tank size
Clean
outs (Y/N)' - r�!-Foundation cleanout (YM)
High water alarm (YM) Alarm t
Date of'pumping . . . mper
SEPARATION DISTANCES FROM SEPTIC/H N
O
TO:
Well(s) on lot adjacent lots
To property line
Surface
Compartments
(Y/N)
(YM)
field Water main/service line
ti.
72-026(3oVi)•Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date Installed Manufacturer
Size in gallons anhole/ ess (YIN)
Vent (Y/N) "Pump on" level at "Pump off" Level at
High water alarm level cies tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE 770n
STATION TO:
Well on lot adjacent lots Surface water,
D. ABSORPTION FIELD DATA
-Date installed Soil rating (GPD/Ftz)
Length Width Gravel thickness
Total absorption area Cleanout present (Y/N)
Date of adequacy test Results pFa
,
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/NVON
SEPARATION DISTANCE FROM ABSOELD
pWm type
Total depth
man over field (YIN)
_After test _
If yes, give date
Well on lot On adjacent lots Property line
To building foundation To existing or abandoned system on lot _
On adjacent lots Cutbank Water main/service line
Surface wate Driveway, parking/vehicle storage area
Curtain drain
E. ENGINEER'S CERTIFICATION
I cen5y chat I have checked, verified, or conformed to all MOA and HAA guidelines in
Signature
Engineer's
Date
A�
is Aix h L}�i
HAA Fee $ 30 a
Date of Payment 6—
Receipt Number
72-026 (393)' Beck
Waiver Fee $ _
Date of Payment
Receipt Number,
Bedrooms
of this inspection.
dr)goEPatooan�!Z
Ice CE -7594 •
'PROFESS,�N�'�
eq COCOMMERCIAL TESTING 8c ENGINEERING CO.
ice. LA_GnATO.=.Y Sc=•.:IC=S
fix-
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to : .��2te re_:L�._ -Ci•_ ice. -"_rte Se��'
Date R ecc!ced
Ti=e Received
?:.alysisB"21 L ,Jil U
Lab Ref. \o. Recd: ?Wti•.st
94.2732 �-7,
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EACTERIOLO GICAL �i' A TER i\'?.LYSIS RECORD
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_.21 CO:::`v^ =
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PART ONE OF TWO: =
REMAINDER TO FOLLOW =
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Ti=e Received
?:.alysisB"21 L ,Jil U
Lab Ref. \o. Recd: ?Wti•.st
94.2732 �-7,
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EACTERIOLO GICAL �i' A TER i\'?.LYSIS RECORD
;._%?O.1:cGRemi:: iC:21 Cc!i;e.^_, -. CCL.'
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PART ONE OF TWO: =
REMAINDER TO FOLLOW =
Commercial Testing & Engineering Co.
Environmental Laboratory Services ss�c��m®,®•c-+-sEsceoce�d-Ea�►recc�-es*cccece-�
SINCE MIA
LABORATORY ANALYSIS REPORT
CTRERef.#
94.2732-1
Client Sample ID
LOT6 BLK2 DAWN SURD
Matrix
WATER
Client Name
PARA -1 ENGINEERING
WORK Order
79153
Ordered By
RUDY PARAOAM
Printed Date
06/08/94
@ 16:15 hrs.
Project Name
CollectedDate
06/06/94
@ 16:20 hrs.
Project#
Received Date
06/06/94
@ 16:40 hrs.
PWSID
UA
Technical Director
STEPHEN
C. EDE
Released By:�---
e Remarks: ROUTINE SAMPLECOLLECTED BY: R.E. PARAOAM, P.E.
QC Allowable Ext. Anal
Parameter Results Qual Units Method Limits Date Date Init
Nitrate -N 0.10 U mg/L EPA 353.2/300.0 10 06/06/94 CMR
' See Special Instructions Above UA=Unavailable
" See Sample Remarks Above - NA=Not Analyzed
U = Undetected, Reported value is the practical quantification limit. LT= Less Than
2 D= Secondary dilution. Gf=Greater Than
0
N
LL 5633 B Street, Anchorage, AK 99516.1600 — Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
� 713 o✓k I
U
5. LEGALpESCRIPTION
D.. _� RECEIVED
+� • ?
INSPECTION APPOINTMENTS
NUMB R UFFIBREMOMS
TIME
❑ One El Four ED Other
TIME
I E
DATE
.1? Three ❑ Six
DATEA
INDIVIDUAL'
' ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1976. For wells drilled prior to that date, give well
INSPECTOR
depth (attach log if available.)
INSPECTOR
f�
1NSPE::6,,,),,
❑ INDIVIDUAL/ON-SITE" YEAR ON-SITE SYSTEM WAS INSTALLED.
NAINICIPAUTY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH &
DEPARTMENT OF HEALTH b ENVIRONMENTAL PROTECTI(SWIRONMENTAL PROTECTION
825 L Street . Anchorage, Atoka 99501
•
JUL 2 4 1981
ENVIRONMENTAL SANITATION DIVISION
Telephone 264.4720 R E C k, � D
WATER AND
REQUEST
FOR APPROVAL OF INDIVIDUAL SEWER FAC
DIRECTIONS- Complete all parts o„ page 1. Incomplete requests will not he Processed. Please allow ten (10) days for processing.
1. P OPERTV OWNE
a W 19ee
PHONE
AILLNG DDRESS
/yz
PROPERTY RESIDENT (If
different from a )
PHONE
BUYER
MAILING ADDRESS
S. LENDINGINSTITUTION,PHONE
MAILING ADDRESS
4. REALTORJAGEN
PHONE
_ 4P
. �-� a� J _ ori
/s`3
MAILING A DR SS
1�
U
5. LEGALpESCRIPTION
STREET LOCATION
9. TYPE OF RESIDENCE
NUMB R UFFIBREMOMS
❑ One El Four ED Other
f L�SINGLE FAMILY
J"
O Two ❑ Five
❑ MULTIPLE FAMILY
.1? Three ❑ Six
7. WATER SUPPLY
INDIVIDUAL'
' ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1976. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
❑ INDIVIDUAL/ON-SITE" YEAR ON-SITE SYSTEM WAS INSTALLED.
"��PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATEDQ
72.010 (Rev. 6/79)
/ ��" 1+:'�4•�-fes. �•�of.,'.v�� .J'. ' `� ..1.
I
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
PEDDIVIDUAL/ON -SITE
PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic Holding Tank
Absorption Area
Sewer Line
Nearest Lot ine
Absorption Area to nearest Lot Line
5. COMMENTS
IK APPROVED FOR _ BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
�6
BY
q;o_�'�
72-010 (Rev. 6/79)
,J
r fiAunicipality
z
of
Anchorage
825 "L" STREET
ANCHORAGE, ALASKA 99501 N tA3L014Q
(907) 264-4111
GEORGE M. SULLIVAN,
MAYOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
July 30, 1981
Howard Young
% Christine Shennum
Century 21 - Shennum Realty
209 West Dimond Boulevard
Anchorage, Alaska 99502
Subject: Lot 6 Block 2 Dawn Village Subdivision
Approval for the individual sewer and water facilities
cannot be granted until the following items have been
completed:
(1) The water analysis report needs to be submitted to
this office from the Chem Lab, 5633 B Street, for
Vour review. I
(2) The depression around the well casing needs to be
filled with impervious type soil so that it slopes
away from the well casing.
Please notify this department for a reinspection when the
noted descrepancy has been corrected. If there are any
further questions, please call this office at 264-4720.
Sincerely,
James S. Roberts
Associate Environmental Specialist
JSR/ljw
cc: Alaska Pacific Bank
Post Office Box 420
99510
r
5. LEGAL DESCRIPTION
L Q2
MUNICIPALITY OF ANCHORAGE
STREET LOCATION Us lf4
�vE (3c6�1C f�ST 4,F 1hKE 07'.% o� E�
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Strees - Anchorage, Alaska 99501
Ae *0
❑ One ❑ Four ❑ Other
A"991
❑ Two ❑ Five
ENVIRONMENTAL ENGINEERING DIVISION
R001Three ❑ Six
7. WATER SUPPLY
Telephone 2644720
�. INDIVIDUAL"
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all para on page 1. Incompis" requests will not be Processed. Plans allow ten (10) days for processing.
1. PROPERTYOWN R
Rser/
depth (attach lag if available.)
PHONE
—84sJ1V
c - ►
❑ INDIVIDUAL/ON-SITE"
*'If individual/on-site, give installation date
3
MAILING ADDRESS
S Rx t147
PUBLIC UTILITY
st)7
PROPERTY RESIDENT (If d[Mmnt from above)
3 —9438
re E w
C4W
2. BUYER
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION
PHONE
ALAQA
&kT UAl
MAILING ADDRESS
M A,►' O
A NON
4 REALTOR/AGENT
�
PHONE
MAILING ADD
r
5. LEGAL DESCRIPTION
L Q2
wN v,ccA6E
STREET LOCATION Us lf4
�vE (3c6�1C f�ST 4,F 1hKE 07'.% o� E�
5 TYPE OF RESIDENCE
NUMBER OF EDR
❑ One ❑ Four ❑ Other
JZ SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
R001Three ❑ Six
7. WATER SUPPLY
�. INDIVIDUAL"
ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach lag if available.)
8. SEWAGE DISPOSAL SYSTEM
❑ INDIVIDUAL/ON-SITE"
*'If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
PUBLIC UTILITY
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATEDL
72-010(3/78)
ro)
THIS SIDE FOR OFFICIAL USE ONL
INSPECTION APPOINTMENTS
DATE RECEIVED
alo la1
TIME
TIME
TIME
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE
O SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearem Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS n
t-4 — 5/
APPROVED FOR 3 BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)