HomeMy WebLinkAboutSHANGRI-LA LT 20Shangr'i La
Lot
20
#020-043-38
Municipality of Anchorage Pag~
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage. AK 99519-6650
w~nn.cl.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number. SW040108 PID Number. .. 020-043-38
Name:
Michelsohn and Daughter Construction~ Inc. Wastewater System: Upgrade
750 W. D~mond Blvd. Anch, AK 99515 ABSORPTION FIELD
522-3375 Four (4) Raised Bed
LEGAL DESCRIPTION ~'~'~
20 Shangri La +2.5
..5' to 7'
Well: New . . ', ,.~,,,.!~: , c-,.,,~,,,~:
~'~-'"?~-"~'~" ·, .. 15 ~. 3
Private 307 ~. 13 F~ 870 Fe ASTM 3034 PVC
AIplne Drilling 6/15/02 ~ ~ 23 F~ Cat's Eye Excavating 16/10-7119/2004
6 ~ F,. 2 ~ .... ~ . ~ . ". TANK
SEPARATION DISTANCEs- STEP
T~To Septic Al3sorptionLift Holding)ublic/Pmeahv.~,,~c~.~e.
Tank Field Station Tank se,~ u~ Anchorage Tank 1,250
~,~ >100' >100' N/A N/A >25' Steel Two (2)
s~,~,w,,, >100' >100' N/A N/A ~/ LIFT STATION
¥
~u,. >10' >10' N/A N/A
BENCH ~ARK
2" insuiafion ~i~¢ed O~er Tank ~
Garage Slab
100.0
Engineer's Stamp
Inspections performed by: AH Dates: 1~ 6110104
·
Department of Health and Human Services approval ~,~\
Reviewed and approved by:. ~.~/./.,/ /~/. "~'~'--D~te:.~"~'-:2.L/,.O~'
m
Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519.6655 - 343-7904
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number:. SW040108
Page 3 of 3
PID No. 020-043-38
B5.4-~
I
2° lnsuL
............... Ge~'t e ~._.~lt t ~ c ..............
Dealn~leld Rock
85.4~
58' (Bed Length)
77.0
~ 05,9
90.4
/
3 O
Dr'alnf'ieid Rock
~ 85.4'
~' Coorse S~nd
;~.5' 5' 5' ;~,5'
PROFILE AS-BUILT
Scale: 1' - 10'
PROJECT #:
PERFORMED FOR:
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT/BUILDING SAFETY DIVISION
ON-SITE WATER AND WASTEWATER PROGRAM
Z.700 SOUTH BRAGAW ANCHORAGE, AK gg,51g
SOILS LOG - PERCOLATION TEST
~i{hetsohn and Oaunhter
DATE PERFORMED:
6/28/200~
TEST HOLE #
Organic ..
Layer - UL
SRty Gravel
with Sand
B0H - &5'
Bedrock
Lot ~0. Shanqrl La Subdivision
] ;LOPE
SITE PLAN
9
18.
WAS GROUNDWATER
ENCOUNTERED9 No
IF YES, WHAT DEPTH9
DEPTH OF WATER None
AFTER MONITORING:
DATE: '//11/200~,
S
L
O
P
E
GROSS NET DEPTH OF NET
READING DATE TIME TIME WATER DROP
Start 6~28 10:35 8'
I 10:/.5 10 Dry 8'
Recharc. le 10:/~6 8'
2 10:56 10 Dry 8"
Recharge 10:5'/ 8'
3 11;0'/ 10 Dry
PERC RATE: 1,Z MIN./INCH PEEL, HOLE DIAMETER: 6"
TEST RUN BETWEEN 2,0 FT, AND 2.5 FT.
COMMENTS: ~r to Percolation Test.
TEST PERFORMED BY: ALAN HARALA I, MICHAEL E. ANDERSON, CERTIFY THAT THIS TEST WAS pERFORMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDELINES ON THIS DATE: '//1/200t,
Apr-~'g-D4 14:4B From-MICHEL$O~ & DAUGHTER CONSTRUCTION gOT52Z337~ T-8N P.~/03 F-34T
Mumc~pa~ of Anchoragel
Depa~e~ of Hea~ and Human ~wlc~
st/ck~p
2
5
307
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Pro, ram
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: May 07, 2004
Expiration Date: May 07, 2005
Permit Number: SW040108
Legal D e scrip rio n ~'Sha~l~'i~__. ~a._L__~_2__O.,
Design Engineer: 0014 Anderson Engineering
Owner Name: Michelsohn and Daughter Construction, h
Owner Address: 750 W. Dimond Blvd.
Anchorage, A 99516-
Parcel ID: 020-043-38
Site Address: 750 W. Dimond Blvd.
Lot Size: 43797 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under consthJction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Issued
Date:
Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWEPJWELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. OEO '* Oq$ '~t~
Permit Number SW
Property owner(s) Michelsohn and Dau.qhter Construction, Inc.
Mailing address (1) 750 W. Dlmond Blvd. Anchoraqe, AK 99516
Mailing address (2)
Legal description (Lot, Block & Sub'd.) Lot 20, Shan,qd La Subdivision
Legal description (Section, Township & Range)
Lot Size 43,797 SF Acres~q. Ft."~
THIS APPLICATION IS FOR:
Sewer Only ~
Sewer and Well []
Sewer Upgrade []
THIS PROPERTY CONTAINS:
Hot Tub []
Swimming Pool []
Therapy Pool []
Day phone 522-3375
.Zip Code
Number of Bedrooms Four (4)
Well Only []
Water Storage []
Jacuzzi []
Water Softening Unit []
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit Fees:
Date of Payment:
Receipt Number:
(Rev. 12/00)
Waiver Fees:
Date of Payment:
Receipt Number:
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
MEMO
DATE: 61112004
TO: Joe Goodall
WITH:
MoA/On-Site Water and Wastewater
FROM:
Mike Andemon
SUBJECT:
Lot 20, Shangri La Subdivision
Septic System Permit No. SW040108
A recent test hole placed on Lot 20, Shangri La Subdivision in the area of the new
absorption sytstem indicated bedrock at a depth of 4.5'. This depth will not allow
placement of a 5' wide absorption trench as originally designed. We are therefore
proposing to install a 15' wide by 58' long raised absorption bed to provide the 6'
separation between the bottom of the bed and the bedrock. Ail organic material will be
removed and between 2' and 3' of coarse clean sand will be placed. The new bed will
then be placed atop the sand bed. The attached details show the location and cross
section of the new bed. Please review the attached design and modify the permit to
allow construction of the elevated bed.
Please let me know if you have additional questions.
LOT 20, SHANGRI LA SUBDIVISION
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Four Bedroom House Raised Bed System
Perc. Rate: 1-5 Min./Inch 1,250 Gallon SepticTank
Application Rate: .7 GPD/SF 2' (Min.) Coame Sand
4 Bedrooms X 150 GPD/.7 GPD/SF (Application Rat'e) = 857 SF Absorption Area
857 SF/15 SF 0/Vidth) = 57.1 LF Bed Length
THEREFORE: Construct a 58' Long x 15' Wide Raised Absorption Bed as Shown Below.
Remove Existing Organic Material and Place 2'-3' of Coame Sand From Approved Soume.
Place Dis~bution Piping at 2' Above Odginal Ground Surface. Provide 2" of Insulation
and 2' of Cover Over Bed. Maintain 100' Separation From Ail Wells in the Area,
__ ExmtJn ~~~==
1'
2" Insulation & 2' Cover (Min.)
/ / ,/ /- / / ,/ ,/ ,/
O O O
Drainfield Rock ~ .
'. ." . ~eanSand.(SeeSpeci§Ca6on.)- .... =
.." .'. '. . "..,....',.* ;.:¢ ... ~ ... .... ...
· .; ;' '?';. · R'~.n~ove.~rga~iC, l~at~dal,6nl~':'-~ .., ,
· -: .:.', ~d6r.~'S~hdPlacerheat',,~.' :..~..~-'.'-'
2,5' 5' 5' 2.5'
NOTE: See Specifications for Clean Coarse Sand.
4"P~' 4
Existing Ground
TYPICAL RAISED BED SECTION
NOTE: Grade Am,a, Surrounding Bed to Drain Away.
Minimum 6 Separation From Bedrock.
Minimum 4' Separation From Groundwater.
Minimum 100' Separation From Wells in the Area.
Minimum 100' Separation From Surface Water or Streams.
Minimum 10' Separation From Water Service Line.
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
for ~rl Ford Date P~o~
~t 20 Shangflla ~ HO~
~p~
~t) SEE A~A~ED
ORG - r~t FOR HOLE LO~ON
W~wateren~te~? ~O ~td~? NA
~p~ ~ water afl~ mom~8? HA
SPISW- bm~ sd~
~ave~y s~
~ Date Gross Net ~t~a~t° Net
T~e T~e ~op
I B/IO/~ 1 ~ 7~
~de~ & ~bbl~ to 2' ~
2 110 10~ 3 8/16' 3 8/16'
3 * 1 11 7*
4 121. 10~ 3 7/16' 3 9/16'
6 132 10~ 3 8/15' 3 8/16'
B I~ 10~ 3 7/16' 3 9/16"
B O.H 9 * 1 ~
10 l~ 10~ 3 8/16' 3 8/16'
11 ' 155
12 205 10~ 3 8/16' 3 8/16'
' Wa~ Ad~
HOLE I'RESOAKED
PRIOR TO TEST
Percohuon Pate,.2,22.. (mm/m) Perc Hole D~ameter ~" I
I
Test Run Betwee~ 2 feet and 3 feet
L Kenneth M Duffus, ¢~ L,f¥ I/tat this test was performed m accordance vath all State and Mumopal guidelines m
effect on II~s date
Apr-2g-04 14:48 From-MICHEL$OF~ & DAUGhtER CONSTRUCTION g075223376 T-884 P.03/03 'F-347
M~nlcipality of Anchorage
Dew~opment Services Departmenl
4700 ,South B,'~gaw b~.
www~u~Lor~a
Soils Log - Percolation Test
lo-
11-
12-
13-
14-
15-
17-
18-
20-
WA3~ AT ~'
DGt~ perfm'me~ ~2D MAY 02
T,~mthlp. Rmga. SecU~ ,'m~. ~ szc 2 ~£
~te ~
i : /i
2G--MAY--02 J~ID 28--ILAY--O2
PR~ TO
R~ng Dqte ~rea. Time I Net 'r, me Inltld Depth
2 8~ 4:~ t0 m~.
4 e~2~2 ~ 1o mb,
6 8~2~2 ~ IO m~ j
I~RCOLA~I RATE .f.0 . (mlnut=s/tno~) K~C IdCY~: DIN, c.~E~ 8 In~_
TeST RUN ~ 3.0 . FT ~ 3.5 FT
p~'(~n~ BY:, C~C ucCeN~J. I C~11rY 1HAT 11~S ~
WAS PE3~ ~ AGGGqDAH~ ~ ALL ~TATE ~ 14U~(3PAL. GU~DE[/N~ IN [T'FE:~'T ON ~S DA~-. DA~: 14 dUNE 02_
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
May 5,2004
Municipality of Anchorage
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject:
Lot 20, Shangd La Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of Lot 20, Shangri La Subdivision intends to construct a four-bedroom home
on the lot. We are therefore requesting a permit be issued for the construction of a new
septic system to serve the new home. A well was previously placed on the lot and is
shown on the attached Site plan. The Site Plan and backup documentation identify the
location and configuration of the proposed septic system and alternate site. Existing
spot elevations and the current drainage pattern are also identified on the Site Plan.
The drainage pattern will be maintained after development of this lot is complete.
Test holes placed on the lot during the subdivision phase indicated gravel with some
silt and sand in the area of the absorption trench. The accepting soils were tested and
found to have percolation rates of I to 5 minutes per inch. No groundwater was found
during excavation but was noted at 8' below the surface during the monitoring period.
Our design includes the placement of a new 1,250-gallon septic tank along with a 60'
long by 5' wide by 3' effective depth absorption trench to collect and treat the sewage
generated in the house. The bottom of the trench will be 4' below the surface to
provide the required separation from the water table. The distribution pipe will be 1'
below the surface. A minimum of 3' of cover will be placed atop the trenches and a
minimum of 4' of cover will be placed atop the new septic tank.
The ground surface on the lot slopes at shallow grades from southeast to northwest as
shown on the Site Plan. The absorption trench will be constructed parallel with the
slope of the ground surface as much as possible in conformance with Municipal
requirements. The new septic system will be constructed a minimum of 100' from the
well on the lot and on adjacent lots. It will also be constructed a minimum of 100' from
Lot 20, Shangri La Subdivlslon
May 5, 2004
Page Two
any surface water in the area. The lot immediately to the west is currently vacant and
no conflicts exist between the new septic system and any wells in the area.
If the system is constructed in accordance with our design the following statements
apply:
The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
I,I
LOT 20, SHANGRI LA
SUBDIVISION
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Four Bedroom House 5' Wide Trench System
Perc. Rate: 5 Min./Inch 1,250 Gallon Septic Tank
Application Rate: 1.2 GPD/SF 3' Drainfield Rock
4 Bedrooms X 150 GPDI1.2 GPD/SF (Application Rate) = 500 SF Absorption Area
500 SF/5 SF ° .58 (Red. Factor) = 58 LF Trench Length
THEREFORE: Construct a 60' Long x 5' Wide x 3' Effective Depth Absorption Trench.
Flow Line Elevation in Trench to be 1' Below Original Ground Surface. Total Depth to be
4' Below Existing Ground. Provide 4' Cover Over Septic Tank and 3' Cover Over
Absorption Trench. Provide 2" of Insulation and 2' of Cover if Necessary.
#
3'0"
ckfill '",
Geotextile
-- Fabdc
4" Perforated
PVC (Holes Down)
-- Drainfield Rock
TYPICAL 5' WIDE TRENCH SECTION
~ - -- '~['~-~c~ ~_.-~-~..~...... ~..
,-~,~.:... ·
NOTE: G~de Area Over Trench ,o Drain Away ,~' ~"~.~-~.~
Minimum 6' Separation From Bedrock. ' ~._~..~.~.
Minimum 4' Separation From Groundwater.
M n mum 100' Sepam~on From Wells in ~e ~ea ~1~['~" ~'~'~
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 20, SHANGRI LA SUBDIVISION
GENERAL:
The scope of this project includes the procurement and placement of a
new 1,250-cjallon septic tank at the location shown on the Site Plan.
Work also includes the construction of a new absorption bed 58' long
X 15' wide also at the location also shown on the Site Plan and at the
configuration shown. The distribution line in the bed will be placed at
2.5' above the existing ground surface. The bottom of the bed will be
2' to 3' above the existing ground level to provide 6' separation from
bedrock. The bed will be raised utilizing coarse clean sand meeting
the specification below. All organic material must be removed to the
underlying soil strata and coarse sand must be placed to raise the bed
to 2' to 3' above the existing ground level. The new bed can then be
constructed atop the coarse sand.
Construction shall be in accordance with the approved site plan,
design drawings, Municipal Permit with any special provisions or
conditions, and all applicable State and Municipal Wastewater
Disposal Regulations.
The Contractor shall be responsible for obtaining all underground utility
locates and for the layout of the septic system and verification of the
location of all lot lines.
Unless specifically agreed otherwise, the contractor shall be
responsible for final grading areas subsequently depressed from soil
settling. Property owner shall be responsible for revegetation of
affected areas unless specifically agreed otherwise.
Contractors installing wastewater disposal systems must be certified
by the Municipal Department of Health and Human Services for
system installations. Owners installing their own systems must receive
prior approval from D.H.H.S. before beginning system installation.
SEPTIC TANK INSTALLATION
1. A new 1,250~jallon septic tank must be procured from an approved
source and installed at the location shown if the existing septic tank is
found to be defective.
2. A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts for pumping
access.
Lot 20, Shangri La Subdivision
June t, 2004
Page 2 of 3
3. The septic tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
4. All standpipes on the septic tank shall extend a minimum of 12 inches
above final grade.
5. Tanks installed without 4' of cover shall have a minimum of 2" of direct
burial insulation.
A foundation cleanout shall be installed one to four feet from the
building foundation. Two cleanouts are required between the tank and
the drainfield.
7. Final grading over the tank shall be such that a positive slope exists
away from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown on the
design. The bottom of the bed shall be within 2" of level.
Distribution piping must be placed level with perforations down atop a
level bed of drainfield rock. Rock should then be placed over the pipe
to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between the drainfield
rock and the natural soil backfill.
4. Monitor tubes must be 4" in diameter and installed at the locations
shown on the design. The portion below ground must be perforated.
Contractor shall verify the septic tank and drainfield are a minimum
100' away from any private water wells in the area, 150' from a Class
"C" Well or 200' from any community well.
Direct bury insulation must be placed over the distribution system if
less than 3' of backfill depth is available. Finish grade over the trench
must be mounded to prevent settlement or depressions.
7. Grade area surrounding the absorption trench to drain away.
A minimum 2' of accepting soil is required below the drainfield rock for
a 5' wide trench. Contractor shall verify this condition prior to
placement of the rock. All pockets of unacceptable materials must be
removed and replaced.
Lot 20, Shangri La Subdivision
June t, 2004
Page 3 of 3
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a municipally approved septic
tank manufacturer.
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated
and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and
ASTM D2662 or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Fernco, or equal).
5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed
between the final drain rock layer and the native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing
the #200 sieve.
COARSESAND:
1. Coarse Sand must be graded as follows:
50% Passing No. 4 Sieve
3% Passing No. 100 Sieve
1% Passing No. 200 Sieve
INSPECTIONS:
Municipal Ordinance requires a minimum of two inspections. These
inspections must be conducted under the supervision of a professional
engineer registered in the State of Alaska. The first inspection must be
conducted after the excavation of trenches, beds or pits and before the
installation of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement of the
geotextile fabric, gravel, distribution piping, standpipes, cleanouts and
insulation. No backfill should be in place at the time of inspection.
Contractor shall provide a copy of all field survey layout and construction
notes for use in preparing the certified as-built of the completed system.
MUNICIPALITY OF ANCHORAGE
Development Sen/ices Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WATER SUPPLY PERMIT
Initial
Date Issued: May 01,2002
Expiration Date: May 01,2003
Permit Number: SW020086
Legal Description: HORACE TR 3B
Design Engineer: 0000 None Required
Owner Name: Anchorage Development & Construction
Owner Address: 9441 Abbott Loop Rd.
Anchorage, AK 99507-
Parcel ID: 020-043-12
Site Address:
Lot Size: 69260 SQ. FT.
Total Bedrooms: 0 Permit Bedrooms: 0
This permit is for the construction of:
[~.~ Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. Ail requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
5. The following special provisions.
~Thls permit ts for proposed,!Shangri-La BIock 1 Lot 20 ~
Received By:
Issued By: ~
Date: ~O Z
· Municipality of Anchorage
Development Services Department
Bu~dlng Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Ancfiorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWEPJVVELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING.
Parcel I.D. b ~ 0
Mailing address (1) ~/
Mailing address (2)
Legal description (Lot, Block
Legal description (Section, Township & Range)
Lot Size I , ..~ Acres/~.
~?;~.~O +-~-~
THIS APPLICATION IS FOR:
Sewer Only []
Sewer and Well []
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Permit Number SW OZOOEg
Zip Code
Number of Bedrooms
Well Only ~'~
Water Storage []
Jacuzzi
Water Softening Unit
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is In accordance with applicable Municipal Codes.
(Signature of p~'operty owner or authorized agent)
Permit Fees:
Date of Payment:
Receipt Number:
(Rev. 12/00)
/ 7o
Waiver Fees:
Date of Payment:
Receipt Number:
)AD
0
Municipality of Anchorage
Development SerVices Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street -'~
P.O. Box 196650 ,' ~ ) ~ ~'
Anchorage, AK 99519-6650 , ,~.~.,,¢~ / Jl .~'
www.muni.org/onsite /'/- /'~' V/~ V,f'
(907) 343-7904 / ~A/?/''
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAHILY DWELLING
Parcel I.D. 020-043-38
1. GENERAL INFORMATION
COSA#
Expiration Date:
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
SHANGRI-LA S/D; LOT 20
16260 LOST HORIZON DRIVE * ANCHORAGE, AK * 99516
THOMAS & ~ BAXTER Day phone 250-1825
16260 LOST HORIZON DRIVE * ANCHORAGE, AK * 99516
Day phone
MARIANNE GRANT W/ PRUDENTIAL Day phone 529-6602
5801 CENTERPOINT DR, #200 * ANCHORAGE, AK * 9950.5
Unless °therwis~ requested, COSA will be held by DSD for pickup.
2. NUMBEROF 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 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 files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with afl 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.
Engineer's 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 & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the 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.
DSD SIGNATURE
Approved for y
Disapproved.
Conditional approval for
bedrooms.
....
~ ~. ON-SITE
~: WATER AND
: WASTEWATER
bedrooms, with the followin9 stipulations: ~ ~,.
'-....'
Attachments: COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
(Rev. 11105)/
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
CERTIFICATE
Legal Description:
WELL DATA
Well type PRIVATE
M:unicipality of Anchorage
Development ServiceS Department
OF
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Buildipg 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
ON-SITE SYSTEMS APPROVAL
SHANGRI-LA S/D; LOT 20
*BEDROCK AT 5'.
If A, B, or C provide PWSID# N/A
Date completed 6/15/2002 Sanitary seal (Y/N). YES
Total depth 307 'ft. Cased to '15 ft.
FROM WELL LOG
6/15/2002
23 ft.
6 g.p.m.
Coliform (~ colonies/t00 mi.
Arsenic: .~_ J~)ug./L,
B. SEP.~C/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL
Tank size 1.250 gal. Number of Compartments
Foundation cleanout (Y/N) YES
Date of pumping 8/23/20,10
C. ABSORPTION FIELD DATA
Date install'ed s/1 o.7/19/2004
Length 58 .ft.
NitrateO, 5OTmg./L.
Date of sample: 8/20/20'10
2
Depression over tank (Y/N) NO
Pumper.
[*BELOW EXISTING ORADEI
Soil rating ~r ft2/bdrm) 0.7
Width 15 ft.
CHECKLIST
Parcel ID: 02 ~"'
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
8/20/2010
33 .ff.
5.18 g.p.m.
YES
'Other bacteria O
Collected by:
YES
24+ in.
__ colonies/100 mi.
GEG Ltd.
Date installed 6/10-7/19/2004
Cleanouts (Y/N) YES
High water alarm (Y/N) N/A
A+ HOME SERVICES
Total depth '4-3.8 ft, Eft..absorption area 870 ft2 Monitoring tube YES
Date of adequacy test 8/20/2010 Results (Pass/Fail) PASS
Fluid depth in absorption field before test 0 in. Water added 600 gal.
Elapsed Time: - min. Final fluid depth 0 in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE
System type BED
Gravel below pipe 0.5 ft.
Depression over field NO
For 4 bedrooms
New depth 0 in.
Absorption rate >= 600+ g.p.d.
KNOWN If yes, give date -
D. LIFT STATION
Date installed
"Pure p on" level at
in.
Size in gallons , Manhole/Access ~
"Pump off" leve_L~. High water alarm level at
Cycles tested. Meets alarm & circuit requirements?
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
100'+
Septic tank/lift station on lot
Absorption field on lot 100'+
Public sewer main N/A
Sewer/septic service line 25'+
Animal containment areas 50'+
in.
On adjacent lots 100'+
On adjacent lots . 100'+
Public sewer manhole/cleanout N/A
Holding tank N/A
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+,
Water main N/A Water service line 10'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Absorption field 5'+
Surface water 100'+
Property line 10'+ Building foundation. 10'+
Water service line 10'+ Surface water 100'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
COMMENTS
Water main N/A
Driveway, parking/vehicle storage 10'+
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
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11105)
Waiver Fee $
Date of Payment
Receipt Number
08/2~72010 ~0~3~ 868~70 ~P~S
A+ HOME SERVICES INC.
CUSTOMER
7501 E. 140th Avenue
AnchorageTAlaska 99516
345-1890
16260 Lo;t ~-Iori=oa
INVOICE #
P~GE 01
38074
Block Lot
DATE DESCRIPTION AMOUNT
0g-23-I0 lhtmp..;; _?ie - :$15.5 ,00
' . - '~ ', ..'; ....... ..,. "'" ",.,'" '2~,::', .............
**** AWWU'; last sehe~le~,n~t~ mereas~ ~g~,, , . ~,~,~ ..... :. ;:'""'
2~0-Ig25 · - ' ' ":":'""' ' '"'"'"
~fl t~-lt--- ~ ~--~ ~ .......
-~, ~ ~ ~.~u~g ~ ~L~C~ , .....,:.,,,,,
T~ I~A" ', " '
~i~ taL~ ~i~ ' . ~
.... . .,.'.. .... ..~..',.. ~ TOTAL ~
;,~ .,~,;',;7.:] ,,~.. ,,',.;~,, ::~'~, ,,
¥:~:?, ' .1' .,,:;,,,,, . ' ....
RE~KS '",:~., 4~.,.,~: ...... :,,
.... ..... ,.......
,, ' ,~ ,~2 ' .'I
.... ,,..
/~ Gallons ~ Septic ~ Leach Ama __ HoldlnO Tank & S~ndpipes/O~me
~ ..o.~...~.- C.LL ~o. ~O.~,.,O.M*;~O.
~ NEEDS TO BE DONE AGAIN IN 6 MONTHS
~ Good Shape ~ Sludge buildup on bosom ~ Floater on top
~ Jim cap missing or ~ Cut standpipe to 1' above ground ~ Needs Septictrine
needs mplacing
SGS Ref.# 1104317001
Client Name Garness Engineering Group, Ltd Printed Date/Time 08/30/2010 9:14
Project Name/# Shungri-La Lot 20 Collected Date/Time 08/20/2010 12:40
Client Sample ID Shungri-La Lot 20 Received Date/Time 08/20/2010 13:40
Matrix Drinking Water Technical Director Steohen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Hardness as CaCO3 163 5.00 mg/L SM20 2340B C 08/23/10 08/24/10 NRB
Waters Department
Total Nitrate/Nitrite-N 0.507 0.100 mg/L SM20 4500NO3-F B 08/23/10 AYC
Microbiology Laboratory ~
E. Coli Negative I 100mL SM20 9223B A 08/20/10 SDP
Total Coliform Negative 1 100mL SM20 9223B A 08/20/10 SDP
Private Individual Analysis
Alkalinity 144 I0.0 mg/L SM20 2320B D 08/20/10 SDP
Aluminum I28 20.0 ug/L EP200.8 C 08/23/10 08/24/10 NRB
Antimony ND 1.00 ug/L EP200.8 C (<6) 08/23/10 08/24/10 NRB
Arsenic ND 5.00 ug/L EP200.8 C (<10) 08/23/10 08/24/10 NRB
Barium 91.6 3.00 ug/L E7200.8 C (<2000) 08/23/10 08/24/10 NRB
Cadmium ND 0.500 ug/L EP200.8 C (<5) 08/23/10 08/24/10 NRB
Calcium 54800 500 ug/L, EP200.8 C 08/23/10 08/24/10 NRB
Chloride 2.8I 0.100 mg/L EPA 300.0 D (<250) 08/21/10 08/21/10 SDP
Chromium ND 2.00 ug/[r EP200.8 C (<100) 08/23/10 08/24/10 NRB
CO3 Alkalinity ND 10.0 mg/L SM20 2320B D 08/20/10 SDP
Conductivity 352 1.00 umhos/cm SM20 2510B D 08/20/10 SDP
Copper 28.6 1.00 ug/L EP200.8 C (<1300) 08/23/10 08/24/10 NRB
Fluoride ND 0.100 mg/L EPA 300.0 D (<2) 08/21/10 08/21/10 SDP
HCO3 Alkalinity 144 10.0 mg/L, SM20 2320B D 08/20/10 SDP
Iron 304 * 250 ug/L EP200.8 C (<300) 08/23/10 08/24/10 NRB
Uniform Residential Appraisal Report
There are 9 comparable properties currently offered for sale in the subject neighborh o ranging in price fr $ 600,000 to $ 750,000
There are 7 comparable sales in the subject nei~lhborhood within the past twelve months ran~ini~ in sale price from $ 600~000 to $ 750~000
FEATURE r SUBJECT COMPARABLE SALE # 1 COMPARABLE SALE # 2 COMPARABLE SALE # 3
Address 16260 Lost Horizon Dr. 16241 Baugh Cir. 5031 Manytell Ave. 16044 Essex Point Cir.
Anchorage, AK 99516-5043 South Anchorage South Anchorage South Anchorage
Proximity to Subject 1.43 miles W 1.43 miles NW 1.40 miles W
; $ 665,00C $ 231.05 sq.ft. 240.53 sq.ft.
Sale Pdce $ 675,00£ $ 213.48 sq.ft. $ 640,000 $ 705 000
Sale Price/Gross Liv. Area $ 305.43 sq.ft $
Data Source(s) AMDS/MLS/MOA DOM=272 AMDS/MLS/MOA DOM=286 AMDS/MLS/MOA DOM=14
Verification Source(s) MOA / Owner/MLS MOA / Owner/MLS MOA / Owner/MLS
VALUE ADJUSTMENTS DESCRIPTION DESCRIPTION +(-) $ Adjustment DESCRIPTION +(-) $ Adjustment DESCRIPTION +(-) $ Adjustment
Sales or Financing Cony. Cony. Conv.
Concessions None None None
Date of Sale/Time . , . 3/31/10 6/2/10 8/19/10
I Location Suburban/Avg+ Suburban/Avg +15,000 Suburban/Avg +15,000 Suburban/AvA+
Leasehold/Fee Simple Fee Simple Fee Simple Fee Simple Fee Simple
Site 43,797sf/1.01ac 32,268 sf +10,000 78,386 sf -10,000 21,196 sf +10,000
View VeW Good/City Avg+/In et/nf +10,000 Avg+/Inf +20,00{: Good/Inlet/Sim
Design (Style) Hillside Ranch 2 Sty+B 2 Sty+B 2 Sty+B
Quality of Construction Good Good Good Good
Actual Age 2004/E2 1998/E6 +4,000 1~999/E6 +4,00C 2004/E4 +2,000
Condition Good Good Good Good
Above Grade Total IBd~s. Baths Total Bdrms. Baths Total Bdrms. Baths Total Bdrms. Baths
RoomOount 5 I (1) 2.5 10 4 3.25 -6,000 10 4 3.5 -6,000 8 4 2.5
Gross Living Area 2,210 sq.ff. 3,115 sq.ft. -36,20£ 2,770 sq.ft. -22,400 2,931 sq.ft. ~28,840
Basement & Finished 2,210 Sq. Ft. 1,414 Sq. Ft. +23,90(: 1,308 Sq. Ft. +27,100 1,070 Sq. Ft. +34,200
Rooms Below Grade 100% 7~)1 100% 41 .75 1100% 301 100% 200 +6,000
Functional Utility Avg+/4 b/r Avg+/5 b/r -8,00C Avg+/4 b/r Avg+/4 b/r
Heating/Conting GFA GFA GFA GFA
Energy Efficient Items Avg+ Avg+ AvA+ Avg+
Garage/Carp0d G3A G3B/Sim G3BFFndm/Inf +3,000 G3A
Porch/Patio/Deck C/E,dk,c/c patio Sim Sim Sim
gas f/p Sim Sim Sim
Custom upgrades Sim · Sim Sim
Net Adjustment (Total) [] + [] - $ 12,700 [] + [] - $ 30,700 [] + [] $ 23,360
Adjusted Sale Price Net Adj. 1.9 % Net Adj. 4.8 % Net Adj. 3.3 %
of Comparables Gross Adi. 17.0 % $ 677,700 Gross Adj. 16.8 % $ 670,700 Gross Adi. 11.5 % $ 728~360
[] did [] did not research the sale or transfer history of the subject property and com'parable sales. If not, explain
My research [] did [] did not reveal any prior sales or transfers of the subject property for the three years prior to the effective date of this appraisal.
Data Source(s) MLS + Owner
My research [] did [] did not reveal any prior sales or transfers of the comparable sa]es for the year prior to the date of sale of the comparable sale.
Data Source(s) MLS
Report the results of the research and analysis of the prior sale or transfer history of the subject pro, petty and comparable sales (report additional prior sales on page 3).
ITEM SUBJECT COMPARABLE SA~.E #1 COMPARABLE SALE #2 COMPARABLE SALE #3
Date of Prior Sale/Transfer None within 3 years No sales activity No sales activity No sales activity
Price of Prior Sale/Transfer N/A in past 1 year ~n past 1 year ~n past 1 year
Data Source(s) MLS/Owner As per MOA As per MOA As per MOA
Effective Date of Data Source(s) 8/1/10 8/1/10 8/1/10 8/1/10
Analysis of prior sale or transfer history of the subject property and comparable sales No sale of subiect within 36 months and no 12 month sale of comps.
It is typical to travel more than 3 miles for comps in the south Anchora,ge market to find similar comparables. Additionally, due to the locations & other amenities, it is
not uncommon to have larger than typ ca net and gross adiustments.
Summary of Sales Comparison Approach $40 per sf above ,grade living area adjustments $30/SF below grade $ 000 per year effective age, $6,000 per ~ll bath, $3,000 per half
bath, respective site size, view, design/style, neighborhood buildup/location, and condition adjustments were also necessar~ to reflect the condition of the sales compared to the subject.
Minor adjustments to reflect parape s ze/u y $8,000perbedroomf~nctiona]uUlityadiustmentsweremade. AJlofthecomparablesrepresentrecentsalesofsimilarage&styehomes
on larger lots in competing S. Anchorage neighborhoods. Afl[er adjustments, the sales analyzed bracket the final value conclusion for the subject property. Please see additional
comparables on forlowing page La,er adjus men s and o der sales were necessar~ due to the large sou h Anchorage ne ghborhood / rnarke~ and lack of inventoW of similar style and b~pe
residences on arger o s A reliable range of comparab es analyzed is about $658,000 to $728,000, with an overaJl adiusted average of about $692,700. Current offer to purchase has
been considered and given weiph n he ana vs s. Concluded value above the mid range due o s gn fican upgrades and built-ins.
Indicated Value b), Sales Comparison Approach $ 700~000
~ Indicated Value by: Sales Comparison Approach $ 700,000 Cost Approach (if developed) $ Income Approach (if developed) $
In final analysis, the direct sales comparison approach is considered to be the most valid indicator of current market value for the subiect. SFR's
are typically not purchased for the income stream, therefore an income model has not been used. Cost approach not completed due to are of
subiect - not applicable, most buyers do not consider this approach.
This appraisal is made [] "as is", [] subject to completion per plans and specifications on the basis of a hypothetical condition that the improvements have been
completed, [] subject to the following repairs or alterations on the basis of a hypothetical cor~dition that the repairs or alterations have been completed, or [] subject to the
following required inspection based on the extraordinary assumption that the condition or defJthency does not require alteration or repair: As Inspected, "As-is". This appraisal report
has been prepared at the request of the client for marketinp purposes and is intended solely for their use. The appraiser is not responsible for any third party use of this report.
Based on a complete visual insl~ection of the interior and exterior areas of the subject property, defined scope of work statement of assumptions and limiting
conditions, and appraiser's certification, my (our) opinion of the market value, as defined, of ~he real property that s the subject of this report is
$ 700,000 ,asof 8/27/2010 , which is the date of inspection and the effective date of this appraisal.
Freddie Mac Form 70 March 2005
Page 2 of 6
Form 1004 -- "WinTOTAL" appraisal software by a la mode, inc. -- 1-800-ALAMODE
Fannie Mae Form 1004 March 2005
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and 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. 020-043-38
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Lot 20, Shan.qrt La Subdivision
HAA # -5-OP?'C
Expiration Date:
Lost Horizon Ddve
Current Property owner(s) Michelsohn & Dauqhter Construction, Inc. Day phone 522-3375
Mailing address 75~ W. Dimond Blvd., Anchors.qe, AK 99516
Lending agency
Day phone
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
Day phone
2. NUMBER OF BEDROOMS:
Four {4)
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
[]
[]
[]
[]
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSO) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 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 sample results less than 30 days old. (Certificates may be reissued for a pedod of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water
system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's
work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage tiles 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 Anderson Engineering
Address P.O. Box 248773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
5. DSD SIGNATURE
~ Approved for Ll~
Disapproved.
Conditional approval for
Phone 522.T/73
Date 5/18/2005
.'%2.'.."
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic Syste'm Advisory
Well Flow Advisory
/_.,u/.
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: 2.'
Municipality of Anchorage
Development Services Department
Bu~lng Safe~ DIv~ion
On-Site Wata~ & W~vater Program
4700 Sot~h Bragaw St,
P.O. Box 196650 Anchorage. AK 99519-6650
www.ci.anchomge, ak.us
(~07) 343-7g04
HEALTH AUTHORITY/ :3PROVAL CHECKLIST
Lot 20. 6h,,~fl La ~ubdlvblon
IfA, B, or C provide PWSID #
FROId WELL LOG
Legal Description:
WEll DATA
Well type Private
Date complate~ ~J15/2002
Total depth 307 fL
Date of test
Static water ~
Well production
WATER SAMPLE RESULTS:
Coliform ~1 colonies/100 mi.
Date of sample: ~/~2005
SEPTIC/HOLDING TANK DATA
Tank Type/Material SeotlctSteet
Tank size t250 gal
Foundation cleanout (Y/N)
Date of pumping
ABSORPTION REID DATA
Parcel ID: 020-043-38
fL
g.p.m.
Well Lng (Y/N) Y
Wires propeW protected (Y/N) Y
Casing height (above ground)
AT INSPECTION
Nitrate 1~6 mg./I.
in.
fL
g.p.m.
Number of Compartments 2
Depression o~mr tank (y/N) N
Other bactarla ID colonieS100 mi.
Pumper Hew Consl~uctlon
Date installed 6/10/2004
Cleanou~ (Y/N) Y
High water alarm (y/N)
Date installed Z/lilt2004 soil rating (g.p.d./ff2 or ft;/tx:lrm) ,? GPD/SF
Total dal~h I fL
Date of adequacy test
Fluid depth in absorption field before test in. Wate~ added gal. New depth
Elapsed TIme: min. Final fluid depth in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N &type) N If yss, give date
System type Raised Bed
ft. 1} fL Gravel below pipe ,9 fL
Eft. absorption area 870~ Monitoring tube Y Depression over field IN
Results (Pasa/Fail) For bedrooms
in.
gp.d.
D, UFT STATION
'Pump on' level at __ in.
Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lilt station on lot >11)0'
A~tion field on lot >ll~r
Public sewer main N~
Sewer/septic sen'ice ~Jne >25*
Size in gallons
'Pump off' level at__
Cymes ~ested
in.
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & cimult requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/clsenout I~A
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >~i' Property #ne >~'
Water main Nf~ Water servee ,ne
Wells on adjacent lots >t1~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line >1~
Water Sewloe line >111~
Curtain drain None Notsd
F. COMMENTS
Building foundation
Surface ~er >1~
Wells on adjacent lots
Absorption field
Surface water
Water main >t~'
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspec~ons and
review of Municipal reoo~s that the above systems ere in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Pdntad Name Mi;llael F_ Ander~mt. P,E
Dat~ ~/1B/2g0$
HAA Fee $ ~'7 ~
Date of Paymont ~"-
Receipt Number ~.. dO/c) j/~ .!
7
Waiver Fee $
Date of Payment
Receipt Number
SGS Ref.#
Client Name
Project Name,°d
Client Sample ID
Matrix
Saml~lc Remarks:
10524:55001
Anderson Engineering
Lot 20 Shan~ri-La
Lot 20 Shang~i La
Drinking Waler
All Dates/Tlmes are Alaska Standard Time
Printed Date/Time 05/13/200~ 8:40
Callected DatWTlme 05/0~2005 15:15
Received Date/Time 05/09,~005 11:3:5
Technical Director Ste~hen C. Ede
£esults
PQL
M~hod
Allowable ~ Azalysis
C~niainer ID Limits Date Da~e Init
Waters Department
Nica~N
1.96 0.100 m~L EPA 300.0 B (<-10~ 05/09/05
Mtcrobiolo~ Laborato=~
Total Colifonu 0 col/100mL SIVI20 9222B A (<-1) 05/09/05 TLF
C
0
o~
O0' 0~,"'