HomeMy WebLinkAboutDORA #2 LT 15Dora #2
Lot 15
#014-251-32
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MUHMpAUTY OF ANCHORAG
trDevelopment Services Department �� Phone: 907-343-7904
On -Site Water & Wastewater Section - Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 014-251-32
1. GENERAL INFORMATION
Complete legal description
Location (site address)
D O RA #2 LT 15
8540 Rosalind St
Current property owner(s)
Mailing address
Real estate agent
TONN NATHANIEL
Thomas
2. TYPE OF DWELLING:
F-1 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
Expiration Date: Jl OQ
Day phone 561-2227
Day phone 561-2227
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
❑
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
FX_1
Waiver request for:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 2 6D 4 165
Date of Payment VAL07.. I
Receipt Number OG 150D
COSA # OS G 2 l 11 aD
Date:
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
Distance:
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm NorthRim Eng.
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng
6. DSD SIGNATURE
System #1 Approved for q bedrooms
System #2 Approved for bedrooms
Disapproved
Phone 694-7028
Date 3/4/20
o�
,`P '�`S�-9�i
r
49Di*
.." . .... .... ....
A
C CE �62% A
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�4 1
Conditional approval for bedrooms, with the following stipulations:
OF A�
CNN
®N -SITE 161)
WATER AND
By:. �UMV Original Certificate Date:- q1, 1 2 0,9 1
- f--T-
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 civilengineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's viork.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist
Legal Description: DORA #2 LT 15 Parcel ID: 014-251-32
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
❑■ Well log is filed with Onsite (or attached)
Date drilled 4/27/81
Total depth 110 ft
Cased to 40+ ft
❑■ Sanitary seal is functioning correctly
❑■ Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 3/31/21
Static water level at beginning of test 39.4 ft.
Comments
B. TANK DATA
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA
Which system tested (date installed)
❑ ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
Well production at time of test 7+ gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes ❑■ No
❑R Coliform bacteria is Negative
Nitrate mg/L ❑■ Nitrate less than MRL (ND)
Arsenic 20.8 ug/L ❑ Arsenic less than MRL (ND)
Collected by NRim Eng
Date of Sample 3/31/21
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date
Results ❑Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
❑ Code -required soil cover over field Final fluid depth in
❑ System presoaked Absorption rate gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months)
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies:
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic TankJLift Station on Lot > 100'
❑ Yes
if No
Community Sewer Manhole/Cleanout > 100'
❑r Yes
if No
ft
0 Yes
if No ft
Neighboring Tank > 100' Q Yes
if No
ft
Private Sewer/Septic Line > 25 0 Yes
if No ft
Absorption Field on Lot > 100' Q Yes
if No
ft
Holding Tank > 100' 0 Yes
if No ft
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' El Yes
if No ft
0 Yes
if No
ft
ft
If septic tank is under driveway
comment below
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' 0 Yes
if No
ft
E] Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
❑ Yes
if No
ft
Surface Water > 100'
❑ Yes if No ft
Property Line > 5'
❑ Yes
if No
ft
Wells on Adjacent Lots:
❑ Yes
Absorption Field > 5'
❑ Yes
if No
ft
Private Wells > 100'
[]Yes if No ft
Water Main > 10'
❑ Yes
if No
ft
Community Wells > 200'
❑ Yes if No ft
Water Service Line > 10'
❑ Yes
if No
ft
If septic tank is under driveway
comment below
From Absorption Field on Lot to: (Please enter distances if loss than required)
Building Foundation > 10'
❑ Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
❑ Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
❑ Yes
if No
ft
Private Wells > 100' ❑ Yes if No ft
Water Service Line > 10'
❑ Yes
if No
ft
Community Wells > 200' ❑ Yes if No ft
Surface Water > 100'
❑ Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that t have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
OFq+++
c+ Steve Eng
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904
On‐Site Water and Wastewater Section Fax: 343‐7997
www.muni.org/onsite
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org
Arsenic Advisory
Certificate of On‐Site Systems Approval # OSC211190
Subdivision: Dora #2, Lot: 15
A water sample revealed an arsenic concentration of 20.8 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Information on arsenic is available from the On‐Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343‐7904.
This advisory must be attached to all copies of the subject Certificate of On‐Site
Systems Approval.
Municipality of Anchorage
• -- Development Services Department :� �• ';
Building Safety Division '
_ On -Site Water 8 Wastewater Program
4700 Bragaw Street
P.O. Box 196650 j
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904 / �ez,
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING f�
Parcell.D. 014-251-32 Cos It ixl�y3
1. GENERAL INFORMATION Expiration Date:��/�
Complete legal description
Location. (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
DORA S/D #2• LOT 15
8540 ROSALIND STREET • ANCHORAGE AK • 99507
BILLY & BRENNA MACON Day phone 884-2504
8540 ROSALIND STREET • ANCHORAGE AK ' 99507
Day phone
RYAN TOLLEFSON W/ PRUDENTIAL Day phone 242-6911
3801 CENTERPOINT DR #200 * ANCHORAGE AK • 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well
0
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Individual On-site
❑
Individual Holding tank
❑
Community On-site
❑
Public Sewer
IN
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 !s(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, SURE 101 • ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date
Engineer's Comments:
to conducting this evaluation, GEG, LtO. attempted to provide a thorough, 406040
conscientious engineering analysis of the system in accordance with ADEC and MOA � Ov OF A
DSD Guidelines & Regulations. The reported results described the performance ofthe p ` ••...... sl�0
system under the conditions encountered of the time o/ the fest, and separation Q
distances measured to readily identifiable features. The operational filo o/all wags and O y
septic systems depend on the local soils condition, groundwater levels that may 0 ...:..... ...............
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
..f . .................
results do not guarantee future performance of the system, nor do they guarantee that Je y rness
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide �O CE -7953 .`
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 profeeetood\
the sole benefit of the ownerlisted above. Any reliance upon or use of this report by any �D�pOpO000
other person or party is not authorized, nor will It confer any legal tight whatsoever.
5. DSD SIGNATURE LI
for �_ bedrooms.
Disapproved
''' `11 OFAI"
Conditional approval for bedrooms, with the fllowing stipUipawng: • • • .. •�q0
Werc:o bNn
Anacnmenis: .1.1
COSA Checklist t/
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other _
By: �l` �/ ti Original Certificate Date:
(Rev. IMS)
Municipality of Anchorage °,
^1 Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage. AK 99519.6650
www.muni.org/onsite
(907) 343.7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: DORA S/D H2; LOT 15 Parcel ID: 0/t -1-7_51-3Z
A. WELL'DATA -BASED ON SURROUNDING WELL LOGS. SEE ATTACHED
Well type PRNATE If A, B, or C provide PWSID# NIA Well Log (YIN) YES
Date completed 4/27/1981 Sanitary seal (YIN) YES Wires properly protected (YIN) YES
Totaldepth 110 ft. Casedto "40'+ ft,
FROM WELL LOG
Date of test 4/27/1981
Static water level 47 ft.
Well production 10 g.p.m.
WATER SAMPLE RESULTS:
Coliform^�� colonies/100 ml.
Arsenic:c:?4 l ug./L.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal. Number of Compartments
Foundation cleanout (Y/N) _ Depression over tank (Y/N)—
Date
Y/N)_Date of pumping Pumper
Casing height (above ground) 12+ in.
AT INSPECTION
11/13/2009
44 ft.
6.59 g.p.m.
Nitrate ��ng./L. Other bacteria colonies/100 ml.
Date of sample: 11/13/200 Collected by: GEG Ltd.
C. ABSORPTION FIELD DATA
Date installed
Length ft.
Total depth ft. EH. s
Date of adequacy test
Fluid depth In asor ' nb
Elapsed _ min.
Soil rating (g.p.d./ft'or
Width
PUBLIC SEWER
Date installed
Cleanouts(Y/N)
High water alarm
System type
Gravel below pipe ft.
ft' Monitoring tube_ Depression over field
Results (Pass/Fail)
field before test _ in. Water added _gal.
For bedrooms
New depth _in.
Final fluid depth _ in. Absorption rate >= g.p.d.
rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N
"Pump on' level at in. "Pump off" leve High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots N/A
Absorption field on lot N/A On adjacent lots N/A
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
'+
Sewer /septic service line 25Holding tank N/A
Animal containment areas 509+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line Absorption
Water main Water service line Surface
Wells on adjacent lots
PUBLIC SEWER
SEPARATION DISTANCE FROM ABSORPTION FIE OT TO:
Property line B ' oundation Water main
Water service lin Surface water Driveway, parking/vehicle storage
drain Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date
COSA Fee S __ y(90.0 O
Date of Payment 111-2 a%
Receipt Number �3y%
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
• Development Services Department 4;
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Arsenic Advisory
Certificate of On -Site Systems Approval # 090431
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Lot 15 of Dora
Subdivision. This inspection revealed an arsenic concentration of 23.3
micrograms per liter (ug/L) for the property's well water sample. The
Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems.
While private wells are not subject to this regulation, EPA standards are
based on existing health information and can therefore be used to gauge the
relative quality of water from private wells. Information on arsenic is
available from the On -Site Water and Wastewater Program website
(www.muni.or /og nsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
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SCS RtE#
Client Name
Project Name/if
Client Sample ID
Matrix
Sample Remarks:
1096209001
Garness Engineering Group, Ltd
Dora 82 L15
Dora M2 L15
Drinking Water
Printed Date/rime
Collected Date/time
Received Date/time
Technical Director
11/202009 8:41
11/132009 12:10
11/132009 15:30
Stephen C. Ede
Allowable Prep Analysis
Parameter Results PQL Units Method Container ID Limits Date Date Init
Metals by ICP/M3
Hardness as CaCO3
Waters Department
Total Nitrate/Nitrite-N
Private Individual Analvsis
Aluminum
Antimony
ej(Arsenic
Barium
Cadmium
Calcium
Chromium
Copper
Imn
Lead
Magnesium
Manganese
Chloride
Fluoride
Selenium
Sodium
Silver
Thallium
Sulfate
Zinc
ND
5.00
mg/L
SM202340B
C
11/1610911/19/09
NRB
ND
0.100
mg/L
SM20 4500NO3-F
B
11/13/09
LCE
ND
20.0
ug/L
EP200.8
C
11/16/0911/19/09
NRB
ND
1.00
ug/L
EP200.8
C
(<6)
11/16/0911119/09
NRB
23.3
• 5.00
ug/L
EP200.8
C
(<10)
11/1610911/19109
NRB
ND
3.00
ug/L
EP200.8
C
(<2000)
11/1610911/19/09
NRB
ND
0.500
ug/L
EP200.8
C
(<5)
11/16/09 11/19/09
NRB
627
500
ug/L
EP200.8
C
11/16/09 11/19/09
NRB
ND
2.00
ug/L
EP200.8
C
(<I00)
11/16/09 11/19/09
NRB
5.81
1.00
ug/L
EP200.8
C
(<1300)
11/16/09 11/19/09
NRB
ND
250
ug/L
EP200.8
C
(<300)
11/16/09 11/19/09
NRB
1.69
0.200
ug/L
EP200.8
C
(<15)
11/16/09 11/19/09
NRB
474
50.0
ug/L
EP200.8
C
11/16/09 11/19/09
NRB
15.8
1.00
ug/L
EP200.8
C
(<50)
11/1610911/19109
NRB
4.33
0.100
mg/L
EPA 300.0
D
(<250)
11/16/09 11/17/09
LCE
ND
0.100
mg/L
EPA 300.0
D
(<2)
11/16/09 11/17/09
LCE
ND
5.00
ug/L
EP200.8
C
(<50)
11/16/09 11/19/09
NRB
96800
500
ug/L
EP200.8
C
(250000)
11/16/09 11/19/09
NRB
ND
1.00
ug/L
EP200.8
C
(<I00)
11/16/09 11/19/09
NRB
ND
1.00
ug/L
EP200.8
C
(<2)
11/16/09 11/19/09
NRB
8.49
0.100
mg(L
EPA 300.0
D
(<250)
11/16/09 11/17/09
LCE
ND
5.00
ug/L
EP200.8
C
(<5000)
II/16/09 11/19/09
NRB
SGS Ref.M
1096209001
Client Name
Gayness Engineering Group, Ltd
Project Name/M
Dora #2 LIS
Client Sample ID
Dora #2 L15
hlstris
Drinking Water
Printed Date/time
Collected Date/Time
Received Date/I7me
Technical Director
11/20/2009 8:41
11/13/2009 12:10
11/13/1009 15:30
Stephen C. Ede
Allowable Prep Analysis
Parameter Results PQL Units Medved Container ID Limits Date Dau IM
PrivatA Individual Analysis
Total Dissolved Solids
Nickel
EICO3 Alkalinity
CO3 Alkalinity
OlI Alkalinity
Conductivity
pl {
Alkalinity
Colony Count
Total Coliform
Fecal Coliform
256
10.0
mg/L
SM202540C
D
(<500)
11/17/09
OLT
NO
2.00
ug/L
EP200.8
C
(<I00)
11/1610911/19/09
NRB
189
10.0
mg/L
SM202320B
D
11/13/09
MPL
NO
10.0
mg/L
SM202320D
D
11/13/09
MPL
NO
10.0
mg1L
SM202320B
D
11/13/09
MPL
398
1.00
umhos/cm
SM202510B
D
11/17/09
OLT
8.00
0.100
piIunits
SM204500416
D
(6.5-8.5)
11/13/09
MPL
189
10.0
mg/L
SM202320B
D
11/13/09
MPL
0
coVI00mL
SM209222D
A
11/13/09
DLC
0
coV100mL
SN1209222B
A
(<I)
11/13/09
DLC
0
coV100mL
SM209222B
A
11/13/09
DLC
Vi o
\ MunicipaIity of Anchorage
Development Services Department �' .•My
Building Safety Division +� A
i On -Site Water and Wastewater Program `
4700 Bragaw Street '
P.O. Box 196650
Anchorage, AK 99519650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O Ili — 2 sI — 3 2 COSA #
Expiration Date:._ I or O
1. GENERAL INFORMATION
Complete legal description 1.411- 1& Do r•a 317 S/Jo
Location (site address) 6 S'Yo SA
2Y0 - 22y0
Current Propertyowner(s) Paul 4 'T -e Pe�frro� Day phone ?Y9 —1Ys'o
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
85—YO 1=y✓w /wet S/: %%i+ff' =41 a 4-k 9'i+S6 7
Day phone
S..;r641_ pr-" denl4a/ Day phone 2 Y -Y7o.T
36th C-tnk�n�,�f Or.
Unless otherwise requested, COSA will be held by DSD for pickup. P l awe !u // R 1p f/o n �C
2. NUMBER OF BEDROOMS:t _ fir' r Ham" `eA14 /wady
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
Individual On-site
❑
Individual Holding tank
❑
Community On-site
❑
Public Sewer
IR
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 engineers 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. l further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations In effect at the time of installation. — -
NameofFirm Flak&,& Technri-af Serw,cti Phone �`1S-f35'S
Address 1 -Yb -30 6cffo dunya., /t•Wl Af1c(lc.) cCC.i Ate 9's'Sl6
Engineer's Printed Name T.SeooPowe Date N&4.112, 2 voC
FTtF[a00-HO
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date: I I Jr
(Rn. 11105)
C
• of
f.� a• J P
iFaf •.e..
#.
5. DSD SIGNATURE
•. •1.1....1.....
L;, ••• ...................
o cat F. uooee ,.'
AApproved for
pp
bedrooms.
,�,
Disapproved.
Conditional approval for
bedrooms, with the following stipulation's: "p
FTtF[a00-HO
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date: I I Jr
(Rn. 11105)
Municipality of Anchorage °,.•__
Development Services Department
Building Safety Division °
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 198850
Anchorage, AK 99519-8850
www.muni.orglonsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: J-0/' f Sy D o o -a TL S /A Parcel I D: O 14 - 2S /- 3 2
A. WELL DATA
Well type -JLV-i If A. B, or C provide PWSID #_
Date completed'�/2.7/B/ Sanitary seal (Y/N)--t
Total depth 1 I U ft. Cased to t o ft.
FROM WELL LOG
Date of test H / t 7 / B /
Static water level 47 ft.
Well production to g.p.m.
WATER SAMPLE RESULTS:
Coliform Q_colonies/100 mL
Arsenic: 12J-00 mgfl
Well Log (YM) r
Wires properly protected (YM) Y
Casing height (above ground) _r�in.
AT INSPECTION
it /t /06'
AU ft.
7.0 -t g.p.m.
Nitrate 410-1 mg1L Other bacteria O colonies/100 mL
Date of sample: JL/—'/404!!r Collected by. mg* klo✓ -r S.,e
B. SEPTIC/HOLDING TANK DATA (M. 4. _ h W U
Tank Type/Material
Tank size gal. Number of Compartments
Stc oer)
Date Installed
Cleanouts (Y/N)
Foundation cleanout (Y/N) _ Depression over tank (YIN) _ High water alarm (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA CN• 4. — h w zi u
Date installed Soil rating (g.p.d./112 or ft2/bdrm)
Length
ft. Width
Sec"e-:)l
System type
ft. Gravel below pipe ft.
Total depth _ ft. Eff. absorption area _ft= Monitoring tube _ Depression over field
Date of adequacy test Results (Pass/Fail) For _ bedrooms
Fluid depth in absorption field before test _ in. Water added_ gal. New depth_ in.
Elapsed Time: _ min. Final fluid depth _ in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (YM & type) If yes, give date
D. LIFT STATION V-A.
Date installed Size in gallons
'Pump on' level at _ in. `Pump Or level at _ in.
Datum
E. SEPARATION DISTANCES
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot /✓• �•
Public sewer main 8 2 r
Manhole/Access (YM)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots N•
On adjacent lots N
Public sewer manhole/cleanout --�— fOS '
Sewer /septic service line 7 z 0 Holding tank N • A.
Animal containment areas N - A. Manure/animal excrete storage areas N• .4.
in.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: (N• A. — ~Wk t tc..r r) -
Building foundation
Water main
Property line
Water service line
Absorption field
Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: CM. A. — +(A -,W44 t t c ✓��J
Property line
Water Service line
Curtain drain _
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Building foundation
Surface water
Welts on adjacent lots
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 I Aew 4mfooY I'= • rt a o .�
Date Ai0 vtm fit / 13- 200K
Water main
Driveway, parking/vehicle storage
COSA Fee $ Y.? 0 a= Waiver Fee $ _
Date of Payment 13 Alv-wg r 6E+• 2-4106 Date of Payment
Receipt Number SS Jqp- Receipt Number,
(Rev. 11/05)
Eur
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-pDCRE F. 11OOR.
^� CE -3539 i
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-SCIS , -
SGS Ref. #:
1066608
Client Name:
Flattop Technical Service
Project Name:
Dora #2 SD, L15
Client Sample ID:
Dora #2 SD, L15
Matrix:
Drinking Water
PWSID
SGS Environmental Services Inc
200 W. Potter Drive
Anchorage, AK 99518
Tel: (907) 562-2343
Fax: (907) 561-5301
All dates/times are Alaska Standard Time .
Printed DatoMme: 11/10/06 16:15
Collected Date/time: 11/01/06 12:45
Received Date/time: 11/01/06 53
Technical Director. �cMphen Eq!>
Released B
Allowable
Prep
Analysis
Parameter
Results
POL Units
Method
Limits
Date
Date
Init
Bacteria
0.00
92228
11/01/06
11/01/06
dpt
Nitrate
ND
0.10 mg/L
EPA 300.0
10.00
11/01/06
11/01/06
azs
Arsenic
19.60
5.00 ug/L
200.8
10.00
11/06106
11/08106
tk
MUNICIPALITY OF ANCHORAGE
1 • 'Yi DEPARTMENT OF HEALTH $ HUMAN SERVICES
Division of Environmental Services
On Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519.6650
(907)3434744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMI !LL/Y DWELLING �l
Parcel I.D. # 014-251-32 HAA # /`� � 0000 3 2 2
1. GENERAL INFORMATION
• • mr.1 -•: 11170170=01• /•C: :/ I •� •
:r,v_,P,n_rtLLowner -J, Day phone
Mailing address F1540 ROSALINO ST_ ANCHORAGE. AK 99S07
Lending agency FHA Day phone
Mailing address
Agent MICHAEL PIKE Day phone, (907) 529-2400
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
4
NOTE: if community well system, provide written confirmation from State ADEC attest -
Ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding Tank
Community on-site
Public sewer xx
NOTE: If community wastewater system, provide written confirmation firm State ADEC
Ing to the legality and status of system.
72-025 (Rev.1191) Front MCA 921 Computer WNW
Note. Alaska Water and Wastewater Consultants, Inc. shall be pald $800.00 at,
or prior to, closing for the engineering services provided.
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation data shown below, I verify that my
Investigation of this Health Authority Approval application shows that the on-site water supply and/or
wastewater disposal system Is safe, functional and adequate for the number of bedrooms and type of
structure indicated herein. l further verify, that based on the information obtained from the Municipality of
Anchorage files and from my Investigatbn and Inapectfpn, the onsite water supply and/or wastewater
disposal system Is in compliance with all Municipal ar>�State codes, ordinances, and regulations In effect
on the date of this inspection. �
Name of Rmt
(907) 337-6179
Engineer's Signature f Date r` o
in conducting Mis evehmSon, AMtW,inC tb p "a thorough, co"scientiaus engin analysis of the
system In accordance wM ADEC and M H Guidelines A Regulations. The reported results described the
performrance of the system under the condiiihns ei>countered at the time of the test and separation distances
measured to readily ldsnt Agbis feetures. The operational ft of all wells and septic systems depend
on the focal soils condition, ground War levels that may fluctuate during the year, and the
usage of the family being served by the system. These candfi ons are outsfde the control c
the evaluator of the system. Satisfactory incl results do not guarantee fixture performance
of the system, nor do vWguarantee fhat there are no hidden deftis or encroachments.
Al*VC, Inc. can therefore not provide any warranty for future estimate of how long Me
system ww7l continue to meet the operabortaf requirements of the ADEC or MOA DHHS.
The content of this report is for the sore benefit of the owner fisted above. Any
reliance upon or use of this report by any other person or party Is not autirorized,
nor will It confer any legal right whatsoever.
6. DHHS SIGNATURE
By:
Approved for 4 bedrooms
Disapproved
Conditional approval for
Additional Comments
bedrooms, with the following stipulations:
The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Health Authority
Approval Certificates based only upon the representaticns 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 cmissicns in the prcfessicnal engineer's work
72-025 (Rev. 1191) e4u* MCA s21 C mputer Vernon
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMM SEMCM t C E I V
On my Sv"L Rm 6o2 Arldlorage, Alaska 9m' Wn 343 474WL 26 am
MAJNCWAuIY OF ANCHORAGE
Health Autt** Appt'oval Cheddist —.."I"WALSWIM NN"'
L"al Damon; DORA /2 SUBDMSION: LOT 15 Parcel I.D.: 014-251-32
A. WELL DATA
Well Type PRIVATE M A, B, or C. atladl ADEC letter ADEC water system number N/A
Log pANNE (YM) Y Date conlpbl l 4/27/8,
Total depth 110, Cased tp 40'+ Casing hdgM (aban gmund) 18'
sanitary sad (YIN) YES Wkes Prop" Plolected MM YES
FROM WELL LOO
Date of tled 4/27/81
sbft water war 47'
Wel productIM 10 g•P•nn•
WATER SAMPLE RESULTS:
AT INSPECTION
7/19/2000
5.4 g.P.m.
Date ofsemple: 7/19/2000 Calected t►Y A.W.W.C.. INC.
B. SEpTIGNOLDM TANK DATA PUBLIC SEWER
Tank stze
C. ABSORPTION FIELD DATA
High water alarm (YM
Date lrumled Sol rating (g pAJl12 or MPodnn) System
Length Width
Date of adequacy test
Fluid depth in absorption Held
Depression over fleld (17M
IFamFor Bedrooms
tmnlamat* atter gd.water added Qm1
Fkdd depth —„ (Ina) Lftme lata Absorption rete •
PAuGilitveatrnent (past 12 monti,$) (Y"
>'aaae pirv. ar�T' omprwira�
Eyes, gIve date
D. LIFT STATION
.:1 -1 1-171177 WOMEN
TTnT`^/_T .. ai;. : it
High water alarm
DISTANCES FROM WELL ON LOT TO:
at•
'Pump ate' level at'
SepildhokIng fart on iot
N/A
On eomd kft
N/A
Adsorption SoM an kit
N/A
On aowd I*
N/A
Pubno sewer mein 50'+ Public sewer menhdaldeenout 50'+
Sawadd"ft sonvice One N/A UR It N/A
SEPARATION DISTANCES FROM SEPTIGHOLDING TANK ON LOTTO.
SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO.
Curtain
F. ENGINEER'S
I ce►Idjr fisetli
afM !re
wilb MOA
MgnatLn
Cfw
Engineers Na
HAA Fee S
A kMpecuonsandrsvlsw
systems are In cordbnnance
on M dads.
Wets on adjacent lots
Web on a
Iris
Reoelpt Number
07-25-00 14:14 FROI+-CTE ENVIROMENTAL
ALME Environmental Services Inc.
CUE RrLN
1003928001
Client Name
AK Water& Wastewater ConsultaanInc.
Project Namem
DORA S/D n2 Lot 15
Clieot Sample ID
DORA SID 02 Lot 15
Matrix
Drinking Water
Ordered By
PWSTD
0
Sample Remarks:
5615301 T-839 P.02/03 F-452
Client PON
Printed Date/rime 07/24/2000 14:44
Collected Date/rime 07/190-000 1145
Reeelved Date/rime 07/19/2000 13.15
Technical Director Stephen C
Released By 0'0,
14
AU&WWe Prep Aralysi;
P,ra nRer Rcsuns PQL Omts Mczod limits Daae Me trot
Waters Department
Nitrate -N 0 S00 U
0.500 mg/L EPA300.0
10 max 07/19100 SCL
Microbiology laboratory
Total Coliform 1013. No Coli coU100mL SMA 92228 07/19100 KAP
MUNICIPALITY OF ANCHORAGE
O DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage. Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # 2111—L6-1-32
1. GENERAL INFORMATION
HAA # &IOZ6C252
Complete legal description Lot 15: Dora Subdivision OZ
Location (site address'or.directions) 8540. Rosalind, Anchorage, Alaska
Property owner
Mailing address
Lending agency
Mailing address
AHFC 532242
WA
Day phone
Day phone
Agent Barbara Vos — CENTURY 21/NEW HORIZONS Day phone 562-6233
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: XX 4 �-
3. TYPE OF WATER SUPPLY:
Individual well XXX
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 XXX
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(R..1A1) FWt MoAR1
iz. VOW WV (ldl •wu)OD-U
•Wom sieau!6ua Ieuo!ssalad eyl ui suo!sslwo jo sjaja jol elq!suodsa
lou sl e6ejoyouV to /4!led!o!unlp ey1 penssi si eleo!l!vao a ejolaq upp ezdleue jo suo!loadsul lonpuoo
lou op SHHO;o saaAoldw3 •sluawal!nbai alels pue lejapal u!evao /Cls!les oliepio u! suo!lnlllsu! 6u!pual xayl pue
sawoylosraseyoindof(savnooeses!ylsaopSHHOsyl•e�lsely;oeieISstllu!paials!6aijaau!Gualeuo!sselad
luepuedapu! ue Aq anoge S ydej6eied ul uan16 suolleluesaidai eyl uodn Aluo paseq saleo!1!va0 IenaddV
Al!joylnv yllEaH sanss! (SHHO) saolniaS uewnH pue ylleaH ;o luawveda0 s6eioyouV to A1!ledlo!unN eyl
NUI111CJ .
:suo!lelnd!is 6u!mollol eyl yl!m 'swoapaq
6_1 ,1 ale0
:A8
sluawwo0 leuo!i!ppV
sol Ienoidde leuotl!puo0
'panaddesia
swoapaq Jo; panoaddy —";'-
3ufI1VNJIS SHHO '9
emleu6ls SJOau!6u3
2 LLS66 e)IfelV'Jan!a 616e3
°I e30£OLl ssappv
'ONIN33NION3 S 8 S
auoyd wj!3 to aweN
•uo!loadsui s!yl to alep eyi uo loa;;a ui suolleln6a pue'saoueuipio
'sapoo elelS pus led!olunlnl Ile yl!m eoue!idwoo ui s! walsAs iesods!p jalemalsem.lo/pue Alddns
is;em ells-uo ayl'uo!loodsu! pue uolle6!isanu! Aw wa; pue sal!; 96ejoyouV;o A4!led!o!unV4 eyl
wwl paulelgo uo!lewjo;ui eyl uo paseq leyl ljuanjayvn; I •ulaay paleolpui ainloruls to edAl pus
swoapaq;o jagwnu ayl.Iol alenbape pus Ieuo!loun;'a;es s! wags (s Iesods!p jalemalsem jo/pus
Alddns jalem ells-uo eyl leyl smogs uo!leolldde IenaddV IlluoylnV ylleaH slyl to uo!le6!isanu!
Aw leyl yuan 1 'molaq umoys elep uo!lepllen ayl to se pus olaay pax!lle pas Aw Aq pa!l!vao sy
u33NION3 AS N01103dSNl d0 1N3W31V1S 'S
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST GDW
//
Legal Description: J-7 E., Z)QRP- S/D Parcel I.D. '32
A. WELL DATA
Well type t V IW'r 117—
If A, B, or C, attach ADEC letter. ADEC water system number
j�
�ES g *-/9 2
�EAt;@v
/� 4
I Ji2(wr.A.
Log presentCY N)
Date completed Driller r�
Total depth r
Cased to qo r Casing height
Sanitary seal &N)
Yt�s Wires properly protected &N) YEf
FROM ELL LOG AT INSPECTION
z
rj
2� f 123'92
Date of test
LLQ
Static water level
y� t 39 t
�'
oma'^,
Well flow
I g.p.m. 6 g.p,�,
O
m
LLJ
k_J
Pump level
(A1C, 6H�+
u_
-;
uJ
SEPARATION DISTANCES
FROM WELL TO: -
Septic/holding lank lot
N��
on
; On adjacent lots
Absorption field on lot
NLA ; On adjacent lots
Public sewer main
r
?S —Publicy sewer manhole/cleanout f
Sewer service line
t/OU
,n�
as t Vu
Petroleum tank oNc
WATER SAMPLE RESULTS:
Coliformcam— ' Nitrate N1 Other bacteria
Date of sample: 1'41'92 Collected by: S 4 S 1=NGrti
B. SEPTIC/HOLDING TANK DATA
Date
Cieanouts(Y/N)
High water alarm (Y/N)
N I/�r - MQNicwFat_ SEwEn
Tank size
Foundation cleanout (Y/N)
Date of pumping
SEPARATION DISTANCES FROM
Well(s) on lot ,L
To property Ii
Surface
—Depression (Y/N)
tested (Y/N)
Pumper
C/HOLDING TANK TO:
adjacent lots
field Water main/service line
r
•
72-026 (Rev. 7191) Front CONTINUED ON BACK
C. LIFT STATION
Date Installed /A -
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N) T
SEPARATION DIST
Well on lot
Manufacturer
Manhole/Access (Y/N)
LIFT STATION TO:
— On adjacent lots
D. ABSORPTION FIELD DATA
Date installed N `
Length Width
i Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
i
level at
Surface water _
Soil rating System type
—Gravel thickness Total d
Cleanouts present (Y/N)
Date of adequacy es(/
for
If yes, give date
He
P
bedrooms
SEPARATION DISTANCE FROM ABSORPTION F}ELJD TO:
Well on lot On ad' en/t lots Pr erty line
To building foundation To existing or abandoned system lot
On adjacent lots Cutbank Water main/service line
Surface water Driveway, parking/vehicle storage area
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
OF AL �h-
S 8 S ENGINEERING. �j�•(P;.••' p ••.;•�S`t!(j+
Signature 17034 Eagle River Loop Road No. 204 • 9 i
Eagle River, Alaska 99577
Engineer's Name '� •��• '•' "'
Date ROGE i HAFER
HAA Fee $ '-f l lCl • U U
Date of Payment
Receipt Number05X3 y�Z
72-028 (R". 3/01) B• k MOA 21 !�
Waiver Fee: $ —
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAG
Department of Health & Human ServiE
ces
~ e . DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D.# n1y-a6I 21A HAA# 1AQ9(11%1A
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 15; Dona Subdivision -OA
Location (address or directions)
8540 Ro4aUnd Staeet, •Anchortaoe
(b)Propertyowner A.H.F.0 # 32242 Telephone: (home) Business
Mailing Address.
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent CENTURY 21INEW HORIZONS ATTN: Stephanie Paszek
Address 2213 East Tudors Road AnchonagP, AYasha 99507
Telephone 561-61233
(e) Mail the HAA to the following address: (or check here Rc if hold for pick up.)
List contact person and day phone number below:
S 8 S ENGINEERING
17034 Eagle River Leop Road No 204
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single-FamilyX2 Number of bedrooms 4
3. WATER SUPPLY
Individual Well 11 Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ❑ Public Rk Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025(Rw. 7/89) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
Date
Telephone 6944— 29 -7?
S & S ENGINEERING
1703A ;:,,Ie River Loop Road No. 204
Eagle River, Alaska 99577
OF gi�Ay,
b�,t 0. SA.fa• t
No. 1457•E l a`'•
6. DHHS APPROVAL
Approved for _4'_ bedrooms by d , W Data
Approved. Disapproved Conditional /
Terms of Conditional Approval
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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
oranalyze 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 (Ree. 7/88) Back Page 2 of 2
01,
oFPa��` MUNICIPALITY OF ANCHORAGE (MOA)
Aga
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: Lel I NnC A s•
A. WELL DATA
Well ClassificationS! rQQ If a EA AA *1 If A, B. C. D.E.C. Approved (Y/N)
Well Log Present (Y/N) !—Date Completed—? i - 1;1 Yield iq. a d M
Total Depths I D, Cased to_qP�t_ Depth of Grouting —
Static Water Level 0 r Pump Set Aty K
Casing Height Above Ground l Z �+ Sanitary Seal on Casing (Y/N) y
Electrical Wiring in Conduit (Y/N) —11 Depression Around Wellhead (Y/N) �J
SEPARATION DISTANCES FROM WELL:
r
To Septic/Holding Tank on Lot A On Adjoining Lots co
r
To Nearest Edge of Absorption Field on Lot AZA ; On Adjoining Lots ( Oct f -
r r
To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole (00 f
r
To Nearest Sewer Service Line on Lot 2'5- f
Water Sample Collected by 4.!_ EA) G t tJPPi IA ;Date — Z O —91)
Water Sample Test Results _- �A I ! 5 fA�foru — RA�i-PrrV�
Comments AAQfJf*r_;pA 'yGWCr
B. SEPTIC/HOLDING TANK DATA
Date Installed e
Standpipes (Y/N) it -ti
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File
Holding Tank High -Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEF
To Water -Supply Well
To Property Line
To Water Main/Service Line
No. of Compartments
Caps(Y/N)
To Stream, Pond, Lake or Major Drainage Course
Comments Jf�IC fOrA �& W c
Foundation Cleanout (Y/N)
Date Last Pumped
;for
-Temporary Holding Tank Permit (Y/N)
TANK:
Building Foundation
72.VM(A". 7/68)F,o l Page 1 of 2
Field
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Square Feet of Absortion Area Statndpipes Present (Y/N)
Depression over Field (Y/N) Date of Last Adequacy Test
Results of Last Adequacy Test
SEPARATION DISTANCE FRO ASO TI N FIELD:
To Water -Supply Well
To Building Foundation "
Lot ; O
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course .
To Driveway, Packing Area, or Vehicle Storage Area
Comments M I W Ir (,0f4 <P k)er/
D. LIFT STATION
Date Installed
Size in Gallons'
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
To Property Line
To Existing or Abandoned System on
)g Lots
Cutback (if present)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at'
Vent(Y/N)
Pumping Cycles during Adequacy Test.
"Check Permitted Bedroom Rating Against HAA Request"
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed S 8• s ENGINEERING
Company 17034 Eagle River Loop Road No. 204
Lagle KIYU, tasks -9%77
Date _01& -0
MOA No. GE IL _ v'-0�'
Receipt No. �a 677 ` c> S / / Receipt No:
Date of Payment —/—g Waiver Fee: $ _
Amount: $ �>O— O Date of Payment
72-M (R".7/88) Back Page 2 of 2
5. LEGAL DES IPTION
DA ERECEIVED
INSPECTION APPOINTMENTS
�Sibu
TIME
TIME
1a� n
TIME
Cl 1 <
6. TYPE OF RESIDENCE
RESIDENCE
t
DATE
I '
DATE
DATE
INSPECTO
INSPECTOR
INSPECTOR
7. WATE�UPPLY
INDIVIDUAL'
' ATTACH WELL LOG. A well log is required for all wells drilled
-uNfU?AUTy OF .NCHORAGE
MUNICIPALITY OF ANCHORAGE
DEPT. OF ! ° cr! &
\ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECJ%WRONMENTAL P..OT;CTION
1 825 L Street • Anchorage, Alaska 88501
•
OC'r 1 6 1981
ENVIRONMENTAL SANITATION DIVISION
\\�
Telephone 2644720 R E C E I�p
REQUEST FOR APPROVAL OF INDIVIDUAL
WATER AND
SEWER FACIL T
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTYOWNER
PHONE
.STE'6U COIUS% UC is c
a
MAILING ADDRESS ��
*�u
0 V/`
PROPERTY RESIDENT (If different from above)
PHONE
2. BUYER
PHONE
oN37-
MAILING ADDRESS
F -A9 os /y0
3. LENDING INSTITUTION 1
PHONE
e
MAILING ADDRESS
4. REALTOR/AGENT
PHONE
MAILINGADDRESS
azaz
5. LEGAL DES IPTION
iv
�Sibu
STREET LOCATION
3�57vo 0 _
` ✓
6. TYPE OF RESIDENCE
RESIDENCE
NUMBER OF,BEDRO MS
Ci SINGLE FAMILY
❑ One Four ❑ Other
❑ Two ': Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATE�UPPLY
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 log if available.)
8. SEWAGE DISPOSAL SYSTEM -
1:1 INDIVIDUAL/ON-SITE"
YEAR ONSITE SYSTEM WAS INSTALLED.
PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72010 ( Rev. 6/79) ) `aa, ! (— 9 4-/
THIS SIDE FOR OFFICIAL USE ONLY .
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLEFAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO :' -.•O,. FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLICUTILITY
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
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
Mi APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate(
❑ DISAPPROVED
DATE /
BY
72010 (Rev. 6/791