HomeMy WebLinkAboutBELLA VISTA #1 LT 17 S75'Vista
Lot 17 $75'
#013-051-23
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & �Nastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 013-051-23
1. GENERAL INFORMATION
Expiration Date: ?,2 3 r?- (
Complete legal description Bella Vista #1 Lot 17 S 75'
Location (site address) 7817 Lumbis Avenue
Current property owner(s) Taylor Davis Day phone
Mailing address
Real estate agent Day phone
2. TYPE OF DWELLING:
Fx_1 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
❑
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
0
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 090
Date of Payment 6zr zz (
Receipt Number OVqOG
Waiver Fee $
Date of Payment
Receipt Number
COSA # 05621 \3 29 Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 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.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MCA
COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time
of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on
the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not
guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot
provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole
benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly
recommends buyers hire their own engineer to evaluate this report.
Name of Firm Pannone Engineering Services
Address P.O. Box 1807 Palmer, AK 99645
Engineer's Printed Name Steven R. Pannone P.E.
6. DSD --� SIGNATURE
System #1 Approved for 3 bedrooms
System #2 Approved for bedrooms
Disapproved
Phone (907) 745-8200
Date
OF A1,4
Conditional approval for bedrooms, with the following stipulations:
Original Certificate Date: 60 ^ 2-3
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
If more than 1 septic system on lot: COSA Checklist # 1 of 1
A. WELL DATA
: ,.. i log is filed with Onsite (or attached)
Date drilled 1975
too
Total depth=-'
epth ')7J ft p ,� "
Cased to 45 ft
FIC Sanitary seal is functioning correctly
Q Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA "°}'°"
Static water level at beginning of test 24.0 ft.
Comments
B. TANK DATA
Age of tank(s) N/A years
Tank type/material
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping Public Sewer
D. ABSORPTION FIELD DATA N/A
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
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
Structure served by this system 1
Well production at time of test 6.27 gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes R No
0 Coliform bacteria is Negative
Nitrate .31 / mg/L ' Nitrate less than MRL (ND)
Arsenic 1,;2-k6 ug/L Arsenic less than MRL (ND)
Collected by PES
Date of Sample
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
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date ___
Septic Tank/Lift Station on Lot > 100'
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
7 Yes
if No rft/
Neighboring Tank > 100'
❑ Yes
if No
ft
Private Sewer/Septic Line > 25' Yes
if No IoJN-ft
Absorption Field on Lot > 100'
p' ;-,A.
❑ Yes
if No
ft
Holding Tank > 100' ❑ Yes
if No NSA ft
Neighboring Absorption Fields
> 1 P0'
Animal Containment > 50' 0 Yes
if No ft
❑✓ Yes
if No
ft
/'
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75'
0 Yes
if No
ft
n 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 > Yes if No ft
Property Line > 5' ❑ Yes if No ft Wells -On Adjacent Lots:
Absorption Field > 5' ❑ Yes if No _eft' J Private Wells > 100' ❑ Yes if No ft
Water Main > 10' E-1 Yes --if No ft Community Wells > 200' ❑ Yes if No ft
Water Service Line >_- `-- ❑ Yes if No ft If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
BuildingFoundation > 10'
_ Yes if No ft If absorption field is under comment below
Property Line > 10' ❑ Yes if No ft Wells on �Adjafe`nt Lots:
Water Main > 10' ❑ Yes if No ft Private Wells > 100'
❑ Yes if No ft
Water Service Line > 10' F-1 Yes if No Community Wells > 200' ❑ Yes if No ft
Surface Water > 100' ❑ Y6s if No ft
F. ENGINEER'S COMMENTS
Lot On Public Sewer (,,,��� W� ��� W CW�3�Gr,y
W
t�V \ (� �. \ori G ti --�i 2 �n rim P 6Wc t c,c� be C a, r, r �{ < ce �-r l �c
/A W, -dle`)7`Z
G. ENGINEER'S CERTIFICATION W OFA k
I certify that 1 have determined through field inspections and review'. 9.
of Municipal records that the above systems are in conformance with 49 �(
MOA COSA guidelines in effect on this date. / r\- ....
. . . . ' .
,X CODE No_ e�,?/� GRlD No_
_,r'P - '7
MUNICIPALITY OF ANCHORAGE — SEWER UTILITY
'ROPERTY= _
Name Addres�
�- /�� f X��. r_urrG��-�� A �`"Acct.o N 2 9
Plat No. Subd.
Lot / _� Block
Residential (9--_ Commerial CD Industrial Q No. of units ;--a �9r�-fifJ/'KGs
:�ON NECT=
Main Tap C:1 On Property Q Permit No.. Size �� T
YP e—
Drawing No. Size Main _" Type Depth at Connect
Insulation C3 Cleanouts Tvpe
Connect Agent 0_�_�,R,8Shspector Date `��' 27,—
Comments
Connect Location ",;2 �
a.SSESSMENTS,
L.I.D. No. Private Dev. No. Subd. Agreement Q No.
Sewer Agreement D No. PT. E. C—) Roll No.
AYE TEST=
Positive C] Negative CD N.S.A. Date
Page No. M.H. No. Billing Cycle
Tested By
Comments
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Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 E!more Road
P.O, Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEHS APPROVAL
FOR A SINGLE FAI','llLY DWELLING
Parcel I.D. 015-051-23
1. GENERAL INFORMATION
COSA# ~ ,J(.~ iii ~1 '~
Expiration Date:
Complete legal description BELLA VISTA S/D #:~; LOT 17, S 75'
Location (site address) 7817 LUMBIS AVENUE * ANCHORAGE, AK * 99518
Current Property owner(s)
Mailing address
STEPHEN & HELEN OBRIEN Day phone
500 W. 36TH AVENUE * ANCHORAGE, AK * 99505
550-5281
Lending agency
Day phone
Mailing address
Real Estate Agent
.... Mai'lit~g ?ddress
, ,Unless Otherwise requested, COSA will be held by DSD forpickup.
2, NUMBER'OF BEDROOMS: 4
3. TYPE 0F WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
LISA CONNOR W,/ PRUDENTIAL JACK WHITE Day phone 244-2015
5801 CENTERPOINT DRIVE, #200 * ANCHORAGE, AK * 99505
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.
STATEMENT OF iNSPECTiON BY ENGINEER
As certified by my seal afl'xed 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,
shot4~ that ..'h,~ nn-~-,'~ ,~,~f,~r -~,,n~h/and/or waste.~ater disposal system is (ar~) ~'~;~,, functional ¢.nd adequate
for the number of bedrooms and type of structure indicated herein. I fu~her verify that based on the
information obtained ,%m the Municipafity of Anchorage files ~nd f~m m,y investig~fio~ and inspection, t,~e
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Phone 337-6179
Address 5701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Date
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 o~ the test, and separation
distances measured to readily identifiable features. The operational life of afl 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 t,ffe 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 ~7L" bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attschments: COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
(~e¥.
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
U~:Rer
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEHS APPROVAL
CHECKLIST
Legal Description: BELLA VISTA $/D #1; LOT 17, S 75' Parcel ID: 013-051-23
WELL DATA *PER GEG INSPECTION. **PER AAROW PUMP AND WELL INSPECTION. SEE ATTACHED.
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) NO
Date completed ,.- 1975 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth *70+ .ft. Cased to **45+ ft. Casing height (above ground) 12+
¸in
FROM WELL LOG AT INSPECTION
Date of test 7/29/2011
Static water level ~x~.~"'~ ft. 52 ft.
Well production ...--" g.p.m. 0.51 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi. Nitrate 0.104 mg./L. Collected by:
Arsenic: ND ug./L.
SEPTIC/HOLDING TANK DATA
Date of sample: 7/29/201 1
GEG, Ltd.
Tank Type/Material
Date installed
Tank size~ gal.
Foundation cleanout (Y/N)_
Date of pumping
ABSORPTION FIELD DATA
Date installed
Length ft.
Total depth .ft.
Date of adequacy test
Fluid depth in~ before test in.
Ela~'''~: --- min'A~y rejuvenation treatment (past ~i:aml~l. li~yi~Pt:type)
IPUBLIC SEWERI
Number of Compartments __ Cleanouts (Y/N)
Depression over tank (Y/N) __ High water alarm,.(.Y./N~.
Pumper
Soil rating (g.p.d./ft2or em type
Width / ft. Gravel below pipe
2 . .
Eft. abs ft Momtonng tube
/ Results (Pass/Fail)
in.
Depression over field__
Water added ~ gal.
Absorption rate >=
If yes, give date
For.__ bedrooms
New depth __in.
g.p.d.
D. LIFT STATION
Date installed
"Pump on" level at,__
in.
E. SEPARATION DISTANCES
Size in gallons Manhole/Access (Y_.(.~ ~
"Pump off" lev~ High water alarm level at
Cycles tested, Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
in.
Septic tank/lift station on lot N/A
Absorption field on lot N/A
Public sewer main 75'-I-
Sewer/septic service line 'i 0'+
Animal containment areas 50'+
On adjacent lots N/A
On adjacent lots N/A
Public sewer manhole/cleanout 100'+
Holding tank N/A
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: iPUBLiC SEWER]
Building foundation Property line Absorption field
Water main Water service line Surface water _.~ /~''~-
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FlEet TO:
line ~ation Water main
Property
Water service line/ Surface water Driveway, parking/vehicle storage
~rain Wells on adjacent lots
F. COMMENTS
*WELL DRILLED
G. ENGINEER'S CERTIFICATION
Prior TO 1985. REQUIRED SEPARATION UNDEFINED AT TIME.
14 tT /j \
JEFFREY A. GARNESS '(~(~ ...
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
Date
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment,
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
Water Well Advisory
Certificate of On-Site Systems Approval (COSA) # 11 1293
During a recent COSA on-site inspection and test of the potable water
supply well on Block , Lot Lot 17 S75' of Bella Vista #1 subdivision,
the well's productivity was determined to be 0.51 gallons per minute. The
minimum well productivity required by this Department (AMC 15.55) for a
4-bedroom residence is 0.41 gallons per minute. Although the subject well
currently exceeds this minimum requirement, all parties concerned are
advised that the production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering lawns and
gardens may be required.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
SGS ReL# 1113475001
Client Name Gamess Engineering Group, Ltd Printed Date/Time 08/03/2011 10:29
Pro. iectName/# BellaVista 1 Lot 17 ! ~ TS' Collected Date/Time 07/29/2011 13:10
Client SampleID BellaVista 1 Lot 17 , 5 1S' Received Date/Time 07/29/2011 13:55
Matrix Drinking Water Technical Director Stel~hen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic ND 5.00 ug/L EP200.8 C (<10) 07/29/11 07/31/11 NRB
Waters Department
Total Nitrate/Nitrite-N 0.104 0.100 mg/L SM20 4500NO3-F B (<10) 08/02/11 AYC
Microbiology Laboratory
E. Coli Negative 1 100mL SM20 9223B A 07/29/11 SDP
Total Coliform Negative 1 100mL SM20 9223B A 07/29/11 SDP
Aarow Pump & Well Service LLC
(907)346-9355
Inspection Report
I ran a camera 45' down the well at 7817 Lumbis Ave and did not find
any holes/cracks in the casing or leaking around the pitless.
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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
www.munl.org/onsite
(907) 343-7904
CEETIFICATE OF ON-SITE SYSTEHS APPROVAL
FOR A SINGLE FAHILY DWELLING
Parcel I.D. OI ~"O~/-~-~
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
COSA"
Expiration Date: //z~/¢.:~-.-
BELl..& VISTA SUBDIVISION #1; LOT 17, S75'
7817 LUMBIS AVENUE * ANCHORAGEf AK 99518
JOSEPH EROVICK Day phone
7817 LUMBIS AVENUE * ANCHORAGEf AK 99518
Day phone
868~3313
Mailing address
Real Estate Agent
Mailing address
KEN McKFAN w./ RFMA)( PROPERTIF<-; Day phone ~76-~761
110 W, ,38th. SUITE; 100 * ANCHORAGE. AK 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBEROF BEDROOMS: 4
3. TYPE OFWATERSUPPLY:
Individual Well [~]
Individual Water Storage
Community Class Well [~
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Sita 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 va#fy that my
investigation, based on procedures outlined in the Ce~ficate 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 atrecture indicated herein. I further verify that based on the
information obtained from the Munidpality 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 tkne of installation.
Name of Finn GARNESS ENGINEERING GROUP. Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE. AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Phone 337-6179
Date /o/,$/o ~,
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provfde e thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The mpo~fed results desctfbed the perfomlance of the
system under the conditions encountered at the t/me 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 dudng the year, and the water usage of the family being sewed 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 pmvfde
any wan'anty 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 repett is for
the sole benefit of the owner listed above. Any reliance upon or us.e of this repcvl by any
other person or party is not authorized, nor will it confer any legal t~ght whatsoever.
5. DSD SIGNATURE
Disapproved.
Conditional approval for __
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
bedrooms, with the fllowing stipulations:
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Reort
Other
Original Certificate Date:
Municipality of Anchorage
Development Se~ices Department
Building Safety DlviMon
On-Site Wate~ & Wastewater Program
4700 Bragaw SUaet
P.O. Box 196650
Anchorage, AK 99519-6650
www.munLo~g/onslte
(907) 343-?g04
C..ERTIFICATE OF ON-SiTE SYSTEHS APPROVAL CHECKLIST
Legal Desc~otion:
WELL DATA
Well type
Date completed
Total deplh 70+.
DELLA VISTA SUBDMSION ~11; LOT 17~ S75'
*SEE A'rrATCHED WELL LOGS
If A, B, or C provide PWSID~ N/A
~~s5 Sar~mry ~ (Y/N) ~S
ff. Casedt~ *40 lt.
Well Leg (Y/N) NO
W~ms property protected (Y/N) ~
Casing height (above ground) 12
Date of test
Statb wate~ level
Well proclucaon
FROM WELL LOG
WATER SAMPLE RESULTS:
B. SEPTIC~HOLDINO TANK DATA
Tank Type/MatedaJ
AT INSPECTION
?/2 /2oo6
67 lt.
1.0 O.p.m.
Date of ~m~ple: 7//21/2006 Collected by: GEG, Ltd.
Date installed ~
Tank ~ize, gal Number of Compmlmen~
Foundation cleano~ ~)~..~~over tank (Y/N) High water alarm (Y/N)
Date Pumper
C. ABSORPTION FIELD DATA
Date instellep Soil ratthg (g.p.d~t~or lt~tx~rm) System type
Length lt. Width lt. Grovel~ lt.
Total depttt ft. Eft. epsoq3Uon area ~ M~g~.~3e,~'''''~ Depression over field
Date of adequacy test ~all) For bedrooms
Fluid dep~ in absorption~ in. Water addad gal New depth in.
Eleps~ Final fluid d~th In. Absorption ra~ >- g.p.d.
uvenatlon Inmtment (past 12 mo.) (Y/N & type) If yes, give date
D. UFT ,STATION
Date installed Size in gallons , ~ Monh~
'Pump on' level at in. 'Pump off' i . High water alarm level et ~
~ Cycles tested Meets alarm & circuit requirements?.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankalff station on lot N/A
Absoq~tion field on lot N/A
Public sewer main 50'+
Sewer/septic sanace line 25'+
Animal containment areas 50'+
On edJacent lots 100'+
On adjacent lots 100'+
Public ~wer manhole/cteanout 50'+
Holding larlk
Manure/animal excrete ~'age areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundaUon Property line Ad0soq~tion field
Wells on '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property I~ Building foundaUon ~ ~
Dfweway, parking/vehicte storage
F. COMMENTS
O. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections emi
review of Municipal recon~ that the al:;ove systems ere in
conformance with MOA COSA guidelines in effect on this
date.
Engineers Printed Name Je.i-eKEY A. GARNESS
cos, Fee s
Data of Payment
Waiver Fee $
Date of Payment
Receipt Number
0'",.: 06~21/~0 "~me: 3:58:58 PM
0'08' l::. 75.00
i;
N 0'08'00"W 75.00'
99S1~ -J.2.9 -2.E)6
III
SGS Ref.#
Client Name
Project Name/#
Client Sample ID
~latrix
1064075001
(;amc'ss Engineering Group, Ltd.
BeUa Vista I LI7 S73
Belle Vista I L 17 S73
Drinking Water
All Date~l'imes are Alaska Standard Time
Printed Date/Time 08/01/2006 13:35
Collected Date/Time 07/21/2006 I0:00
Recelvrd Date~'fime 07/21/2006 13:25
Technical Director Stephen C. Ede
Sanmle Remarks:
Allowable Prep Analysis
Parameter Results PQL Units Method Container ID Limits Dale Date Init
Met:als ~ ICP/MS
Arscnic
ND 5.00
ug/L EP200.8 C (<10) 07125/06 07/31/06 Mil
Waters Department:
Nitrate-N
ND 0.100 mlTdL EPA 353.2 B (<10) 07/21/06 ALR
Microbioloc.[~ Labor a t:oz"~
TotalColifoml 0 col/100mL SM209222B A (<1) 07/21/06 TLF
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date 1-21-85
(a) Legal Description (include lot, block, subdivision, section, township, range)
Belle Vista #1~ Lot 17
Location (address or directions)
78]7 kumbis
344-5986 659-5246
(b) Applicant's Name Fred An~]ebrandt Telephone - Home, Business
Applicants Address 7817 Lumbi$
(c) Appliqant is (check o_ne) L~nding Institution ~--~ ; Owner/builder ~ ;
Buyer ~ ; Other~-~ (explain); . ' ' '
(d) Lending Institution First National Bank Of Alaska Telephone
Address P.O. Box 7Z0, Anchorage, AK 995]0
(e) Real Estate Co. & Agent
Address
(f)
Telephone
Mail the HAA to the following address:
2. T~e of Residence
Single-Family~
Number of Bedrooms
3. Water Supply
Multi-Family~--~
4
Other (describe)
Individual Well ~ Community ~-~ Public .~.
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposml
Onsite ~ Public ~ Community ~. Holding Tank ~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
5. ~n~ineerin~. Firm Providin$ Inspections~ Test..s; 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 ~rith all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm A. W. Murfitt Companv
Telephone 349-7531
Address 8010.King Street, Anchoraqe.=.lAK 99502 .....
Date January 21 ~ 1985 _--,¢_ OF GL ~t~
DHEP A--royal / '~'~ ; Allan W. Murfi~ I~
6. ~V ~ x.~ ~-~ '. ~. ~o~ ' ~
u '"~e'~ ,I . ~o.,7,,-= ..~~ · ·
Approved for droom, ~ ~%~.~~~./~' Date
Approved ~ Disapproved--'~~&*' Condition~
T~ms of Conditional Approval '~O,_~.~-L 7~ ~{--'q~
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOI~LY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR EILRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/eJ/D18
[Page 2 of 2]
7-19-84
ae
0
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
MUNICIPALITY OP ANCI-.fO~AG~
i.3~[. OF r~,.-, ....
ENVIRONMENTAL r' ....... ~,~N
JAN 2 2 I985
.,'~. LL, DATA Legal
RECEIVED
Casing Height Above Ground I foot
Electmical Wiring in Conduit (Y/N).Yes well to
Sepa=ation Distances f=cm W~ll: ground
To Septic/HoldinG Tank on Lot N/A
To Nearest Ed~e of Absc~tton Field on Lot.
To Nearest Public Sewer Line 1 ?~ f~.t ~
Description: Belle Vista,#l, Lot 17
Well Classification Sin.cjle Family If A, B, c~ C, D.E.C. AD~=oved(Y/N) N/A,
Well Log P=esent (Y/N,) No Date _~leted N/A Yield N/A
Sanitary Seal on Casing (¥/N)Yes
Dep~ession A=ound Wellhead (y/N)No
; On Adjoining Lots N/A
. ; On AdjoininG Lots N/A
To Nea=est Public Sewer
Cleancut/Manhole 150 feet T~ Nearest Sewe= Service Line on LOt 28 feet
Water sample Collected. By Cherie M¢Cracken.~te ]-12-85, 4:30 p.m.
Water ~/m. ~~=~~ Sari sfa,ctoF~, , , , , .... ....
Cmos 'ts~3.7. g.a,1/.min. '~i'r-in.q from well to sourqe currently On ~urface-(qround frozen).
Recommend burial in thawed qround in snrin~ (as Der DEH conversation with Susan Oswald
1/22/85). ~'/,uL/x3.L ,u~ ~ ~ C~
,.S. EPT!C/HOLDI. NG TANK DATA N/A c~ ~ ~ ~!
Date Installed , , . Size ,, No. of Ccmpa=tm~nts
Standpipes !Y/N) .... Air-tight Caps (,Y/N) Foundation Cleanout (Y/N) ,
Dap=ession over Tank (Y/N,,) Date Last Pumped , ,,
Pumping/Maintenance Contract on File (Y/N) ; fo~ ........
Holding Tank High-Water Alam (Y/N) Temporary Holding Tank Permit (Y ~/N) , ,
Separation Distances f=cm Septic/Holding Tank:
To Wate=-Supply W~ll
To PTOperty Line ........
TO Wate~ Main/Service Line
Co~
C~nts
To BuildinG Foundation ..........
.... To Disposal Field _
To St=e~n, Pond, Lake, c~ Major D=ainage
[Page 1 of 2]
2-15-84
C. ABSORPTION FIELD DATA N/A
Soils Rating in Absorption Strata
Date Installed
Width of Field
Squa=e Feet of Absorption A=ea
Depression over Field ,!Y/N)
Results of Last Adequacy Test
Separation Distance f=cm Absorption Field:
To Water-Supply Well To PEoperty Line
To Building Foundation
Lot
To Water Main/Se=vice Line
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes P=esent (Y/N)
Date ,of Last Adequacy Test
To Existing or Abandoned System cn
; On Adjoining Lots
To Cutbank ( if present)
To Stream/Pond/Lake/or Major D~ainage Course
To DEiveway, Pa~king A~ea, or Vehicle Storage A=ea
Coa~ents
D. LIFT STATION
Date Installed
SiZ~ in Gallons
"Pump On" Level at
High Water Alarm Level at
Dimensions
Manhole/Access (Y/N),
"Pump Off" Level at
Vent (Y/N)
Tested fo~
Electzical Codes(Y/N)
Pumping Cycles alu=lng Adequacy Test. Meets MOA
Cc~ments
** Check Permitted Bed~ocm Rating A~ainst HAA Request
I certify that I have checked, verified, or confcz~ed to all MOA HAA ~uidelines in effect
on the date of this i~cticn./
Ccmpa~ A, W, M'J;i t~ company
KB1/d5/s
[Page 2 of 2]
-- OF 4 %
:',- I
/ /._-
~A
NO.
4~-~ Allan W. A~urfifl /] ,~' I
2-15-84
Mar~ 8egich
Mayer
On-Site Wc~r & Wc~tcwct~r Pro?cra
4700 Br~cw 5tr~t
Anchor~, ~K
Pump Installation Log
Well Drilling l~ermit
Parcel Identification
Date of Issue:
.Le:ul Description
E~/~g,W~ ~1 L ~7 975'
IJPropert7 Owner Hame & Addr~z:
Pump Lnst'qLadon Date: ..D"'- ~/~-- C)'7
pump h~e pepth BelowTop ofWe~ C~g: ~ feet
~p M~a~rer's Hame: ~ ~
PumpModel: ~ I~ ~
p~p Ske ~ hp
pifless A~pt~rBu~Dep~: ~ fee~
~fles~ Adapt~r ~Ian~a~e~s Name: ~
piflesa Adapt~r Ink'em ~
WeU D~infec:ed Upon Completion? ~Y~ ~ N,)
?iethod of D~infe:~on:
Pump
Attention: The lamp ir.stall< shall provide a pump im',alla~io,~ lo! to tl~ DSD ~rhi.~ .~0 ~Ts of p,---amp in.~alL~tio~.
Anchorage Well/Pump Service
6901 Tanaina Drive · Anchorage, Alaska 99502
Domestic and Industrial Pump Sales and Service ·
· Peerless Deep Well Turbines and Pumps ·
· Hydromatic Waste Water and Sewage Pumps *
· Clack & UWS Water Filtration.and Treatment Products
NAME
ADDRESS r~ ~:~ ~"7
BILLING ADDRESS
BILLING ADDRESS
N-° 2883
JOB P.O. or REF.:
DATE
PHONE
PHONE
] PARTS LABOR & SERVICE
QUAN. NAME QF PART AMQUNT DESCRIPTION AMOUNT
/ / ·/~ ~~~ ~ . ~ I_~ ~ ~ ~ ~~ ~
I TOTAL PARTS fro ~ ~ TOTAL LABOR
TOTAL PARTS
Due and Payable on Receipt of This Invoice -- interest charges begin to accrue 10 days from
linvoice date at the rate of 1~% per month. ' CASH I i CHECK ~['CHARGE I ]
WHITE - Original CANARY - File Copy PINK - Customer
gl: Time
Date
Insp
MUNICIPALITY OF ANCHORAGr
DEPARTME,., OF HEALTH AND ENVIRONMEN, ~
825 L Street, Anchorage. Alaska
264-4720
PROTECTION
Date Received:
Time C~ .. ~D~ ~n~ # 3:
Date
Insp
September 6, 1977
Time
Date
Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
Lending Institution Request: Coast Mortgage Company
Mailing Address: Post Office Box 1200 99510 Phone:
279-0665
Property Owner: Riley Blackmore
Mailing Address:
Phone: 344-6027
3. Legal Description:
Lot 17 Bella Vista #1 Subdivision
'/~17 Lumbis Avenu'e
4: Single Family Residence: (x)
Number of Bedrooms: Three
Multiple Family Residence: ( )
Number of Bedrooms:
e
Well System:
Permit #
Construction
Individual Well (x) Community/Public System ( )
Depth of Well Well Log on File ( )
Bacterial Analysis
?????
Sewage Disposal System:
Permit #
Septic Tank Size
Absorption Area
On-site System ( ) Public Utility'~)
Installed Installer
Manufacturer
Soils Rate Material
Distances: Well to Septic Tank to Absorption Area
to Sewer Line Nearest Lot line Absorption Area
to Nearest Lot Line
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTIdN'~ L :.. ', ~;L, ;. ~ ,T
825 L St_<reet, Anchorage, Alaska 99501
279-2511, ext. 224, 225
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection:
2. Property Owner:
Riley Blackmore
VAxx FHA. _CONV
Mailing ~aoress: ..... .
Day Phone: ,344-6027
Name of Buyer:. Fre____~d M___L.__Ang, lebrandt
Mailing Address: 7e5. u,,~ ~ .... .q .... L~ Day Phone:
337.-1250
4. Name of Lending Institution:
Coast Mortgage Co. ___
Mailing Address:__ p. o_ Rax 1200~ Anc. h.~ra, ge: APhone:
Name of Realtor or Agent: Kathy Jayne~ or Dan Holm.. Area Re~ltqr$
279-0605 _
Mailing Address: Phone:
337 = 9424
6. Legal Description:_
Lot 17~ Bel~a Vista No. 1, Anchorage~ Ak
Location: 7817 Lumbi~ Avenue, Anchora, ge~ Ak
7. Type of Facility to be Inspected: dwe~,ling
8. Water Supply
Type of Supply: Public Utility.
If Individual, number of dwellings presently served
If Individual, depth of well
9. Sewage Disposal System
Type of System: Public Utility_ . _
If Individual, date of installation
No. Bdrms._3
XX
.Individual
one
Individual (on-site)
72-003( 3/76 )
page Two
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 17 Bella Vista Subdivision #1
Comments:
Affadavit Attached: ~
Approved: _(~j' ~..~~
Disapproved:
Letter Attached: ( )
Date:
Date:
Department Worksheet: