HomeMy WebLinkAboutFINCH LT 2DFinch
Lot 20
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WELL SCHEDULE
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ffiAS1 ER CARD
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accuracy: T_/ S, R Sac Other
Local number:
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Local -at: 0
owner or name: L: A '!N; ri, -F R, _r, F, z; r�,' Address:
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(A) 05) (C) .(D) (E) (F) (� (1) Of) (N) (P)
Use of Air cond, Bottliag,,,Camin, Diwater, Power, Fire. Dom, Irrp Med� Ind. P 5, Rec,
water� (S) (T) (U) (V) (W) M W
Stock, Instito Unused, Repressurt, Racharget Demal-F 9, Dessl-othfT, Other
Pot of (A) (D) (G) (H) (0) (P) (R) (7) (U) <:jjj)
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2A7A AVAILABLE: Well d.tao Freq. WIL me&s-: __— El field aquifer char.
70 73F
I _Q�jfi�. Va[CT caLV type:
yes
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7S yes ??E
fk' bpeTturecardsi FS
i�r I �r 79 79
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Mass. 2A fl
MASTER =CARD Depth well: ft 2) F13
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tn
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)4� Power na LP meter no.
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r ---- AccuraCY: 1?
I Z j!�j (source) 6
; 7 7�
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MP; Ft below LSD '�2 Accuracy:
's Method
ve 3 date mined
Data 53 9pM
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mesa: 6 r
Pumping
Drawdown: -ft Accuracl: period Hard. hr&L.6
QUALITY OF S S.1fate Chloride _E _9 a�'
WATER DATA Ito, pp.
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ppm— F D&t P. 2 2
106 I/C7 F I d /141
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twos
�AQUIFER: ' '
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Origi°: ,f Thickness:
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Length of
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AQUIFER:
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ifer
Thickness:
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Length of
aL origin:
s -1-f Jo
Depth to
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,
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54
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Screened:
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GPO 857-700
MUNICIPALITY CH A
Development Services Department
p P Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 050-211-87-000
Expiration Date: 9/20/2023
Legal description FINCH LT 2D
Site address 10711 HIGH BLUFF DR Eagle River AK 99577
Current property owner(s) JONES BETHANI
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
Original Certificate Date: 6/20/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA ApprovdJune 2022
MUNICIPALITY OF ANCHORAGE
Development Services Department - Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 05021187
Complete legal description FINCH LOT 2D
Location (site address) 10711 HIGH BLUFF DR
Current property owner(s) JONES
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
Day phone
3. TYPE OF WATER SUPPLY:❑ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ Waiver Fee $
Date of Payment 0161 �7 Date of Payment
COSA # OG Z 3 �{ Waiver #
COSA Application—June 2022
COSA Checklist_June 2022
COSA Checklist
Legal Description: Parcel ID:
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
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.
Per record drawings, field is insulated.
Monitor tubes go to bottom of effective.
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Adequacy test date
Results Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
Comments/Deficiencies:
COSA Checklist_June 2022
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F.ENGINEER’S COMMENTS
G.CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Phone
Engineer’s Printed Name Date
C&M ENGINEERING
CHARLES BALZARINI, PE 6/9/23
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
Nitrate Advisory
Certificate of On‐Site Systems Approval # OSC221064
Subdivision: Finch, Lot: 2D
A water sample revealed a nitrate concentration of 5.74 milligrams per liter (mg/L).
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/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. Since nitrates are known to slowly increase, we recommend
you monitor the water quality. Please see the attached “Nitrate Fact Sheet” for
important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On‐Site
Systems Approval.
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org
Nitrate Fact Sheet
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as “blue baby” disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a medi a with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several “wet chemical” methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive “screening test”, and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
MUNICIPALITY OF ANCHORAGE
Development Services Department ` v Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 050-211-87
1. GENERAL INFORMATION
Expiration Date: v Py v
Complete legal description Finch, Lot 2D
Location (site address) 10711 High Bluff Drive Eagle River,' AK
Current property owner(s) Jessica Harmelink Day phone 952-807-3431
Mailing address
10711 High Bluff Drive, Eagle River, AK 99577
Real estate agent
Day phone
2. TYPE OF DWELLING:
W Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
3
r
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑■
Private Septic ❑
Water Storage
❑
Holding Tank ❑
Community Well
❑
Community ❑
Public Water System
❑
Public Sewer ❑�
Waiver request for:
Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee�- �U • Gv
Waiver Fee $
Date of Payment CP G ;0 ao
L�a1
Date of Payment
Receipt Number 6 8& 31 D
Receipt Number
QcJC�o
COSA #
Waiver #
COVID-19
2570 DISCOUNT APPLIED
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 Forge Civil Engineering Phone 522-7773
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
6. DSD SIGNATURE
System #1 Approved for 3 bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
cu -S -) i c r - S Ld+-s C-�- q P2Y) j i y 01 . �butt In_.kx IS �Dr k C �a
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Date 6/10/2020
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WATER ANDrn
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PRQnRAM
o�
�JJ/'_ V �SER\X��1��,�
By: ��'.'�'. �CU Original Certificate Date: /19 d�
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
COSA Checklist
Legal Description: Finch, Lot 2D Parcel ID: 050-211-87
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
OR Well log is filed with Onsite (or attached)
Date drilled 1962
Total depth 136 ft
Cased to 135 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) >12 in.
Date of flow test for COSA 6/8/20
Well production at time of test 2.9 gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes FOR Nc
❑ Coliform bacteria is Negative
Nitrate 9.84 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date of Sample 6/3/20
Static water level at beginning of test 122 ft.
Comments ***No arsenic found in well water on COSAs completed in 2016, 2009, 2B06 or 2005. Final results
for this COSA will be forwarded when received.
B. TANK DATA
Age of tank(s) N/A years
Tank type/material Public Sewer
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA Public Sewer
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:
COSA Checklist yellow sheet
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date
Results LiPass 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
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
NA
if No
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
❑✓ Yes
if No ft
Neighboring Tank > 100' ❑✓ Yes
if No
ft
Private Sewer/Septic Line > 25' E✓ Yes
if No ft
Absorption Field on Lot > 100' ❑ Yes
if No NA
ft
Holding Tank > 100' ❑✓ Yes
if No ft
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' ✓❑ Yes
if No ft
❑✓ Yes
if No
ft
ft
If septic tank is under driveway comment below
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ✓❑ Yes
if No
ft
Z Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required) *Lot is served by Public Sewer System
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 less than required) *Lot is served by Public Sewer System
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
The lot is served by a Public Sewer System.
G. ENGINEER'S CERTIFICATION
I certify that l 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.
COSA Checklist yellow sheet
��� OF Ap %
e'
-•49th
° °r ...... •° asu°.We°aua
°n......a°°°°an°°°eun°°°a°°°e°°°°n0`a °
MICHAEL E. ANDERSON
' No. CE -4381 -� 47
����t� 6/19/20 •.•'° c`�Ca�
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
Nitrate Advisory
Certificate of On‐Site Systems Approval # OSC201255
Subdivision: Finch, Lot: 2D
A water sample revealed a nitrate concentration of 9.84 milligrams per liter (mg/L).
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/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. Since nitrates are known to slowly increase, we recommend
you monitor the water quality. Please see the attached “Nitrate Fact Sheet” for
important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On‐Site
Systems Approval.
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org
Nitrate Fact Sheet
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as “blue baby” disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a medi a with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several “wet chemical” methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive “screening test”, and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
SGS Ref.#
1202319001
Client Name
Forge Engineering Inc.
Printed Date/Time
06/25/2020 15:07
Pro,jcct Namc/#
Finch L2D
Collected Date/Time
06/02/2020 15:45
Client Sample ID
Finch L21D
Received Date/"Time
06/03/2020 9:08
Matrix
Drinking Water
"rechnical Director
Stephen C. tide
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 B (<10) 06/05/20 06/22/20 DMM
Waters Department
Total Nitrate/Nitrite-N 9.84 0.200 mg/L SM21 4500NO3-F C (<10) 06/03/20 EWW
Microbiology Laboratory
E. Coli Negative 1 100mL S11v121 9223B A 06/03/20 VAB
Total Coliform Ne,vative 1 100mL SM21 9223B A 06/03/20 VAB
2
4GE •@4'
• �-e Municipality of Anchorage o
On -Site Water and Wastewater Program
(907)343-7904 sA Er,
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 050-211-87
1. GENERAL INFORMATION
Expiration Date:
Complete legal description FINCH LOT 2D
Location (site address) 10711 HIGH BLUFF DRIVE EAGLE RIVER AK 99577
Current Property owner(s) THOMAS R BAKER Day phone
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
12110 BUSINESS BLVD. STE. 6 PMB 430 EAGLE RIVER AK 99577
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
1ndividtaal Well
Individual Water Storage ❑
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual ❑
Holding Tank ❑
Community Class_ Well
❑
Community
❑
_ PullicVhater System
❑ _
Public Sewer
WaiverNariance request for: Distance:
Received by: Date: 9�!p
COSA to be released to the engineer, unless oth is quested by the engineer.
COSA Fee $ S 2%
Date of Payment q —C/'0 (,::;,
Receipt Number t� 0 3g,+��
COSA# 0 C- I ioW
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING. INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 9/14/2016
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition
of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface
conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen OF A \ \
encroachments, deficiencies or discrepancies exist. Lis, ,
6. DSD SIGNATURE
System #1 Approved for ° xs" eT :". F /
y pp 3 bedrooms. us , `r� c�'
System #2 Approved for bedrooms.
ESSoo' �
Disapproved. \ \�`��►
Conditional approval for bedrooms, with the following stipyJ0 44l�W((&,
WATER
BY: �; Original Certificate Date: Q
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of Onsite 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.
ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA bim sheet 0-10.12.dm
If more than 1 septic system is on the lot:
COSA Checklist # _of _
Structure served by this system _
Certificate of On -Site Systems Approval Checklist
Legal Description: FINCH LOT 2D Parcel ID: 050.211.87
A. WELL DATA
Well type PRVT
Date completed 1962
Total depth 136 ft.
Date of test
Static water level
Well production
If A, B, or C provide PWSID #
Sanitary seal (Y/N) Y
Cased to 135 ft.
FROM WELL LOG
1962
122 ft.
9—
p.m-
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate 9.03 mg/L
Arsenic: ND ug/L Date of sample: 911/2016
B. SEPTIC/HOLDING TANK DATA — PUBLIC SEWER
Tank Type/Material
Tank size gal: Number of Compartments
Foundation cleanout (Y/N) Depression over tank (Y/N)
Date of pumping Pumper
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 12+ in.
AT INSPECTION
911/2016
119 ft.
g.p:m.
Collected by: ARCTERRA
Date installed
Cleanouts(Y/N)
High water alarm (Y/N)
C. ABSORPTION FIELD DATA
Date installed Soil rating (g p.d./ftz or fe/bdrm) _ System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption area fl Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) _ For " bedrooms
Fluid depth in absorption field before test _ in. Water added gal. New depth_ in.
Elapsed Time: ._min. Final fluid depth _ in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at _in.
Datum
E. SEPARATION DISTANCES
WELL ON LOT TO:
Size in gallons
"Pump off' level at _ in.
Cycles tested
Manhole/Access (YIN) _
High water alarm level at
Meets alarm & circuit requirements?
Septic tank/lift station on lot NA On adjacent lots
Absorption field on lot NA On adjacent lots
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer /septic service line 251+ Holding tank NA
Animal containment areas 50'+ Manurelanimal excrete storage areas 1001+
SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation Property line _ Absorption feel
Water main Water service line Surface water
Wells on adjacent lots
ABSORPTION FIELD ON LOT TO: PUBLIC SEWER
Property line
Water Service line
Curtain drain
F. COMMENTS
Building foundation
Surface water
Wells on adjacent lots
SEE ATTACHED WELL SCOPING LETTER
Water main
Driveway, parking/vehicle storage
G. ENGINEER'S CERTIFICATION r
�F A`I certify that I have determined through field inspections and review ofTH
Municipal records that the above systems are in conformance with MOA
COSA guidelines in effect on this date.
Engineer's Printed Name KENNETH M. DUFFUS
Date 911412016,
COSA canary sheet 2-e-15.doc
in.
KEFNEPH M. >D . /
., 7118 k'
ssloHc .V
Municipality of Anchorage s ,
Development Services Department
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
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC161417
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
2D of Finch subdivision. This inspection revealed a nitrate concentration of
9.03 milligrams per liter (mg/L) was reported for the property's well water
sample. The Environmental Protection Agency (EPA) has established a
maximum contaminant level (MCL) of 10.0 mg/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. Please see the
attached "Nitrate Fact Sheet" for important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
Nitrate Fact Sheet
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble
in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass
rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is
in the form of ammonia or protein first, which through contact with oxygen and certain
bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from
wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also
result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or
three years, but is associated with a potentially fatal infant disease called
methemoglobinemia. In the digestive system of young children, nitrate converts to
nitrite, which can pass through the intestinal wall into the blood stream. There it
combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The
EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The
standard has been lowered from a previous level of 45 mg/L set by the US Public Health
Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and
other common home water treatment systems such as softening or iron filtration does not
readily remove nitrate. The best method for limiting nitrate in well water is source
control. This can include avoiding overdosing of fertilizer near the well and maintaining
good separation distances between septic tank leach fields and the well. A special anion
exchange filter that contains a media with a strong affinity for negatively charged ions in
water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical"
methods using a spectrophotometer to read the final color endpoint. Specific ion
electrodes also can be used to detect the activity of nitrate in water. This laboratory uses
several different wet chemical methods approved under the public water supply
laboratory certification program. They also have test kits available, which the laboratory
uses to perform an inexpensive "screening test', and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test
kit results against a certified analysis from the lab occasionally to verify the accuracy of
the kit. We recommend using a specially prepared bottle that has been rinsed in
hydrochloric acid for collecting samples.
907 Water Well Services
6630 E 8TH AVE
ANCHORAGE, AK 99504
(907)230-1868
johnnie.nethertonl702@gmalf.com
INVOICE
BILL TO
RE/Max
3350 Midtown Place
Anchorage,Ak 99503
0
•
90 of wiz.
MEBIOEXTYLt COyMERC W. WXTEBXN"DaaWE1L 8ERVICEE
rncEEnIXXTEL
INVOICE # 1255
DATE 09/16/2016
DUE DATE 09/16/2016
TERMS Due on receipt
.17Y` RATES AMOUNT -
1
at 10771 Highbluff Dr. Eagle River, AK 99577 with results 325.00 325.00
Pitiless depth 7 It
S.W.L 116 If
Cased to 130 ft at pumping depth pump obstructs descent.
No cracks breaks or perforations above 130 It or thereafter Pitiless is sealed has
cap and conduit. Casing stickup 18" plus above grade.
All invoices are due on receipt. Subject to a 1.5% interest charge per BALANCE DUE $325.0
month.
Municipality of Anchorage
• -- Development Services Department
Building Safety Division
On -Site Water and 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
FOR A SINGLE FAMILY DWELLING
ParcelI.D. 050-211-87 COSA# oqo3zo
Expiration Date: / � - /.6- - Q q-
1. GENERAL INFORMATION
Complete legal description FINCH SID: LOT 2D
Location (site address) 10711 High Bluff Drive, Eagle River, AK 99577
Current Property owner(s) Jeremy Clarke Day phone907-6221054
Mailing address 10711 High Bluff Drive, Eagle River. AK 99577
Lending agency Day phone
Mailing address
Real Estate Agent
Mailing Address
Day phone
Unless otherwise requested, COSA will be held by DSD for pickup.
. . r'.
2. NUMBER OF BEDROOMS.—
3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well '
®
Individual On-site
❑
Iridividual Water Storage .
s ❑
Individual Holding Tank
❑
Community Class _ Vell
'❑
Community On-site
❑
Public Water System
�)' ❑
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation,
based on procedures outlined In the Certificate of Onsite Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the Information
obtained from the Municipality of Anchorage files and from my investigation and Inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm _ArcTerra Consulting, Inc. Phone 8683792
Address 20441 PTARMIGAN BLVD., EAGLE RIVER AK 99577
Engineer's Printed Name KENNETH M. OUFFUS Date 09/08/2009
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow
and absorption rates may change due to subsurface conditions that may not be observed from the surface,
changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and ArcTena can not ive any estimate of of how long a Zt OF A�
q 1
system will function satisfactory for current or future ,�,�P�.••"'�""••.
occupants or can ArcTerra guarantee that no unseen 4 h ••' •. y
encroachments, deficiencies or discrepancies exist ,% * j4972i '\<*�Ih
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
bedrooms, with the following stipulations:
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
WATER AND
PROGRAM
By: a Original Certificate Date:
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.muni.org/onsite
(907) 343-7904 -
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: FINCH SID: LOT 2D Parcel ID:_ 050-211-87
A. WELL DATA
Well typeRP NATE
Date completed 1"2
Total depth 136 ft
It A, B, or C provide PWSID #
Sanitary seal (YIN) Y
Cased to 135 ft
FROM WELL LOG
Well Log (YIN) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 16 In.
AT INSPECTION
Date of test 1962 8/29/2009
Static water level 122 ft 120 ft.
Well production 8 g.p.m. 2.86+ 9.p -m... .
WATER SAMPLE RESULTS:
Coliform 0 colonies/100mL Nitrate 5.37 mg/L Other bacteria 0 colonies/100 mL
Arsenic: ND mg/I Date of sample: 8128!09 Collected by,ArcTerra
B. SEPTICMOLDING,TANK DATA —PUBLIC SEWER
Tank Type/Matedal ' ` Date installed Tank size gal.
Number of Co' mpartments ' Cleanouts (YM) Joundation cleanout (Y/N) Depression over tank (Y/N)
Nigh water alarm (YM) Date of pumping Pumper
C ABSORPTION FIELD DATA':,
Dale installed Soil rating (g.p.d.e or felbdrm) _System type
Length _ft. ,widtii_ft Gravel below pipe ft Total depth _ ft.
Eff. absorption area _tt� 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.) (YIN & type) If yes, give date
D. LIFT STATION
Date installed Sae in gallons Manhole/Aocess (Y/N)
'Pump on' level at _In. 'Pump off" level at _in. High water alarm level at _in.
Datum Cycles tested Meets alarm 8 circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot NA On adjacent lots NA
Absorption field on lot NA On adjacent lots NA
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer /septic service line 25'+ Holding tank 100'+
Animal containment areas 50'+ Manurelanimal excrete storage areas 1001+
I
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation Property line_ Absorption field
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundation Water main
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
F. COMMENTS
i
OF At %%l
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and 4 '•! ••• �•••
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date. K.e•.rh M, t%
:�• CE 11 •• ��
Engineer's Printed Name Kenneth M. Duffua y� '•.,�%�o
Pff
Date 08/08/2009 OFESSIQN„Z`
COSA Fee $490.00
Date of Payment��/�/D y
Receipt Number /ZLi 'j7-5
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
,.r�I •B y(
• �` Development Services Department,,
/ Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsitc
(907) 343-7904
Nitrate Advisory
Certificate of On -Site Systems Approval # 090320
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
2D of Finch subdivision. This inspection revealed a nitrate concentration of
5.37 milligrams per liter (mg/L) was reported for the property's well water
sample. The Environmental Protection Agency (EPA) has established a
maximum contaminant level (MCL) of 10.0 mg/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. Please see the
attached "Nitrate Fact Sheet" for important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
SCS Ref.#
1094539002
Client Name
ArcTerra Engineering and Surveying
Printed Date/fime
Project Name/N
Water Samples
Collected Date/time
Client Sample ID
Finch Lot 2D
RKelved Date/time
Matrix
Drinking Water
Techaical Director
Sample Remarks:
09/042009 10:33
08282009 15:15
08282009 16:45
Stephen C. Ede
Allowable Prep Analysis
Parameter Results PQL Units Method Contama ID Limits Date Date Init
Metals by ZCP/MS
Arsenic ND 5.00 uglL EP200.8 C (<IO) 08/31/09 09/04/09 NRB
Watera Department
Total Nitr:ac/Nitritc-N 5.37 0.100
Microbiology Laboratory
Colony Count 0
Total Coliform 0
Fecal Coliform 0
mg/L SM204500NO3-F B (<10)
cot/IOOmL SM209222B
coVI00mL SM209222B
col/IOOmL SM209222B
A (<200)
A (q)
A (<I)
09/01/09 RJT
0828109 DLC
0828/09 DLC
08/28/09 DLC
Municipality of Anchorage
Development Services Department
p Building Safety Division p
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
P •�-
, !�^ �W Anchorage, AK 99519-6650 ' 13� itt.r�IY
6 *+� www.muni.org/onsite
r (907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING 11
Parcell.D. 050'all-22 COSA# 010m
1. GENERAL INFORMATION Expiration Date: — 0 �P
Complete legal description FINCH S/D: LOT 2D
Location (site address) 10711 HIGH BLUFF DRIVE • EAGLE RIVER, AK 99577
Current Property owner(s) MICHAEL & KAY CHRISTOPHER Day phone C/OI AGENT
Mailing address 1310 SW. COLLEGE STREET #3 • PORTLAND, OR 97201
Lending agency Day phone
Mailing address
i
Real Estate Agent EVA LOKEN w/PRUDENTIAL Day phone 689.L6476
Mailing address 16635 CENTERFIELD DRIVE • EAGLE RIVER 99577
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well )♦ Individual On-site ❑
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 riles and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
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 d Regulations. The reported results described the performance oftho
system under the conditions encountered at the time of the test, and separation
distances measured to readily Idontiriable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fiuctuato 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 solo benerit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
_1z/ Approved for bedrooms.
Disapproved.
Conditional approval for
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Phone 337-6179
Date 94/06
bedrooms, with the filowing stipulations:
Maintenance Agreements
Supplemental Engineers Reed
Other
WATER AND
.• AS�EOPATER
PROGRAM ;•
.• KV
By: Original Certificate Date: 9-6-06
w_ llmK
i ...
P '•.Je
y A.
ness:
CE—'79/53
/16/0.'_
6oavG
bedrooms, with the filowing stipulations:
Maintenance Agreements
Supplemental Engineers Reed
Other
WATER AND
.• AS�EOPATER
PROGRAM ;•
.• KV
By: Original Certificate Date: 9-6-06
w_ llmK
i
Municipality of Anchorage
• Development Services Department i
Building Safety Division
On-Sks Water b Wastewater Program j
4700 Bragew Street
P.O. Box 196SW
Anchorage, AK 99519 -OM i
www.muni.org/onslts i
(907) 3437904 i
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: FINCH S/D: LOT 2D Parcel to: O 9b -All g %
A. WELL DATA
We9 type PRNATE If A. B, or C provide PWSID# N/A
Date completed 1962 Sanitary seal (YIN) YES
Total depth 135 It. Cased to 135 ft.
FROM WELL LOG
Date of test 1962
Static water level 122 ft.
Well production 8 g.p.m.
WATER SAMPLE RESULTS:
Conform D oolonies/100 ml.
Arsenic: 0 V ugA.
B. SEPTICJHOLDING TANK DATA
Tank Type/Material
Nitrate 4AS mgJL.
Well Log (YIN) I YES
Wires properly protected (YM) YES
Casing height (above ground) 12+ in.
I
AT INSPECTION
8/22/2006
117 ft,
i
3.5 g.p.m.l
I
Other bacteria eoionies/100 ml.
Date of sample: 8/22/2006 Collected by: GEG Ltd.
PUBLIC SEWER
Tank size gal. Number of Compartments —
Foundation cleanout (YIN) — Dsie er tank (YIN) —
Date of g�
C. ABSORPTION FIELD DATA
Date installed
Length ft.
Pumper
Soil rating (g.p.d./ft'or ft%Wrm)—
Width
Total depth ft. Eft. absorption area _ ft'
Date of adequacy test
Date installed
High water alarm (Y/N)
i
System type
Gravel belo pt? ft.
I
Depression over field
—
I
For bedrooms
Fluid depth in absorption field before !! in. Water added —gal. New depth —in.
Elapsed Time: Final fluid depth — in. Absorption rate >= j g.p.d.
i
enation treatment (past 12 mo.) (Y/N & type) If yes, give data
i
D. LIFT STATION
Date installed Size in gallons Manhde/Access (YIN) _
"Pump on" level at _in. "Pump off" leve g water alar level at
Cycles tested Meets alar & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A
Absorption field on lot N/A
Public sewer main 75'+
On adjacent lots 100'+
On adjacent lots
Public sewer manhole/deanout 100'+
Sewer /septic service line 25'+ Holding tank N/A
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
Building foundation Property line Absorption field
Water main
Wells
Water
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundation Water
Water service line Surface
Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspecVorrs 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 `►� P -1b
COSA Fee s %3h • UC) -+ I / _75. 0 Q
Date of Payment /4/06
Receipt Number % 3 ! %
(Rev. 11/05)
Waiver Fee E
water
PUBLIC SEWER
paridngtvehide storage
Date of Payment
Receipt Number
SGS ReEN
1061937001
Client Name
Gamcss Engineering Group, Ltd.
Project Name/H
Finch SD Lot 2D
Client Sample ID
Finch SD Lot 2D
1listrix
Drinking Watcr
All Dateslrimes are Alaska Standard Time
Printed Dale rime
09/012006 13:27
Collected Date rime
0822/2006 11:50
Received Date rime
08232006 15:35
Technical Director
Stephen C. Ede
Sample Remarks:
Allowable Prep I Analysis
Parameter Results PQL Units Method Container ID Limits Date I Date Init
Metals by ICP/MS
Arsenic
Waters Department
Nitratc-N
Microbiology Laboratory
Total Coliform
ND
4.18
0
5.00 ug/L EP200.8
0.100 mg/L GPA 353.2
C (<10) 0824/06 08/31/06 WAW
D (<10) 0828/06 08123/06 ALR
cot/IOOmL SM209222B A (<1)
0823/06 TLF
. 5
Municipality of Anchorage
!<%3/
61
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program , , ,C
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ok.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel l.D. 050 -XI -84 HAA# IJrJOS� �i
Expiration Date: oZ — - o co
1. GENERAL INFORMATION
Complete legal description FINCW S/6 L6T
Location (site addressor directions) /6 78 /K/C61 B_0*= 41045
Current Property owner(s) T8NA14'S16A9 gLTz2 Day phone
Mailing address
Lending agency
Mailing address
Day phone
Real Estate Agent )EVY G a (CEfsI Day phone t9 7'6'U7e
Mailing Address /�.�fJD SAG V/d'T.9 o
unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
19
Individual On-site
❑
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
eIR
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verity 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 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.
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By. Original Certificate Date:
(R" 01A3)
Phone KP41- 747
Name of Firm
7a37 BPer P�✓r
Address01
—
�/
Engineer's Printed Name S%i/F
FSG Date /0�7 dS
p
OF A�gSf+1
. :P..
ow
r. .. .........
5. DSD SIGNATURE
'v, �� Stoven • • Eng �` r
Approved for _
bedrooms. •Jtr •,, PE 6756
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By. Original Certificate Date:
(R" 01A3)
Municipality of Anchorage
Development Services Department
Building Safety Division `
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: F/i tod .C.16 . LQ r ?A Parcel ID: 0S0 -2-//-37
A. WELL DATA
Well type L If A. B, or C provide PWSID # _ Well Log (YIN)
Date completedLf-ej?- Sanitary seal (YIN) Wires properly protected (YIN)
Total depth 13KI ft. Cased to /.3S ft. Casing height (above ground/Pin.
FROM WELL LOG
Date of test /76 e_
Static water level 12z ft.
IN
Well production �g.p.m.
WATER SAMPLE RESULTS:
Coliform 4 colonies/100 ml. Nitrate ?• W mpg../I.
Arsenic: — mg./l. Date of sample: /f)l lolo.S
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size ' gal. Number of Col
Foundation cleano (Y/N) _ Depression
Pursue si!FW
Date of
AT INSPECTION
Wa4o-s-
9-P.M.
Other bacteria 4_ colonies/100 ml.
Collected by:
Date installed
Cleanouts (Y/
(YIN) _ High wat alarm (YIN)
C. ABSORPTION FIELD DATA PJBGtC- SEj.1Fj,5
Date installed Soil rati (g.p.d./ft2 or ft2/bdrm) _
Length ft. Width ft.
Total depth _ ft. Eff. sorption area ft2
Date of adequacy test Results
Fluid depth in absorp ' n field before test— in.
Elapsed Time: min. Final fluid depth
Any rejuvena n treatment (past 12 mo.) (YIN & typv
System type
Gravel below pipe _
Depression over
added_ gal.
Absorption rate >=
ft.
For bedrooms
New epth_ in.
If yes, gi/e date
D. LIFT STATION
Date installed
"Pump on' level at in.
Datum
E. SEPARATION DISTANCES
Size in gallons Manhole/Access (Y/N)
"Pump off" evel in. High water alarm level in.
Cycles teste Meets alarm & circ ' requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 0
Absorption field on lot
Public sewer main ILIO
Sewer /septic service line aZ r?'
On adjacent lots 16o �•
On adjacent lots /LJ n fl,
Public sewer manholelcleanout /a a
Holding tank _W61-14
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK
Building foundation Property line
Water main Water servic/fi—
Wells
on adjacent lots
ON LOT TO: PUBLIC stl�-'64-
Absorption f d
Surfac ater
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: 17UXIfc. Srjd%
Property line Building foundation ater main
Water Service line Surface water Driveway, parking/yal cle storage
Curtain drain Wells on adjacent lots
F. COMMENTS
.N0.
G. ENGINEER'S CERTIFICATION
I certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in�� � — _
conformance with MOA HAA guidelines in effect on this date. if
6� RC Steven W. En/ W
Engineer's Printed Name STFcJ� E.tJG ��sr'•,, PIE 62s6
Date
HAA Fee $ a ' 110 Waiver Fee $
Date of Payment�Oy ?� Date of Payment
Receipt Number 7 6 {iL Receipt Number
(Rev. 12101)
Mat -Su Teat Loo 907745331:.
Mat-fft
We 6.2 F war4Naatlla Mwy.
.Mit43w C.mr. inftf himinsaa Part
Pnf,M: rtlrr3 70-110')S
CbenP North Rim rry inev.nnn
17237 Bear Paw Circle
Eagle River. Ak 00577
Alta -
Client ID: Lot 2D Snch
PW 313 p:
S0=4:
M.S.T..L.Y. 61901
Sarp.e Mat•ix:
Comments
30/la.'e6 M 44pm P. 004
of Alaska
Water Quality Testing
t.tn:V: tZGtt_.uteatlalrl�retxwshsa com
P.O.
t. 99645
7454010
vaso iut•veu. IUi It7/V✓
Report Date: 10/12105
Sample Date. 10/10!05
Sample Time:
Cone&cd By SE
---=e>sa�'
Ye!^x
Paratreiar Unitzl
Rosu!ts MOL Oate Ptepxbo
Dale Ana; --ad 6'CL
Stc1 ;500-\03 1'
Nitrate -N tnglL
2.14 0.50 10N2,J6
1012105 10.0
&M 4500-NO3-E
Niffte-N mg/t.
0.09 0 CS 10:12105
10112100 1.0
To' of Nitrate/Nitrite rn^ll. 2.14 ^ °C +Cl.V05 10/12105 10.0
Legeno' MRL s Mat od Ropad Level
MCL • Max. Contamnare Law]
B - Prownt In Method Blank
E e Evirrated Valu
Ii - Abwa MCL
D • Lost to Dtlutton
s
RtporWd By Jon Paul Campbell
Lab Manager
ASBUILT SEWARD & ASSOCIATES LAND SURVEYING 69
1 HEREBY CERTIFY -THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY
F/i1/�li�fl/BLOTrO
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONSTRUCTION
OFFENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES.
SCALE'
���
SOF At
i :�' . T M
"" •' •••••• ••
! ':.'.
o.M. MeA ....d` ^j
1�'•, LS-6918 , �•
'co
Agiya
DATE-
�� �' as
GRID,
FB'
DRAWN:�1
Municipality of Anchorage
..,
�-- Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St. ' A `
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ek.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. DFO-7,I1-$7 HAA#
Expiration Date: Ll, -L,57- 02-
1.
2
1. GENERAL INFORMATION
Complete legal description Lot 2n Finch Snhdiviainn
Location (site address or directions) 10 71 1 xi Rh R 1 ,; f f n,.
Current Propertyowner(s) Larry Beauboeuf Dayphone 694-9434
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
10711 High Bluff Dr. Eagle River.AK 99577
Day phone
Day phone
Unless ollierwise requested, HAA will be held by DSD forpickup.
2. NUMBER OF BEDROOMS: 11'
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well
U
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Individual On-site
❑
Individual Holding tank
❑
Community On-site
❑
Public Sewer
El
The Municipality of Anchorage Development Services Department (DSD) 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 Slate 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 period of up to one year with
valid water samples.) Certifid'ates 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 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 Slate codes, ordinances,
and regulations in effect at the time of Installation.
S 8 S ENGINEERING
Name of Firm 17034 Faol. RrVPr. 10613
Road Nay 204 Phone C99'71—)L-9 7 0/
Address Eagle River, Alaska 99577
Engineer's Printed Name t 0/3,e,Rr C. Co W4,a Date / /a 3 /0 Z
S. DSD SIGNATURE +�+ �'• Ro Cj 88C. C1rAN
Approved for _ bedrooms.
Disapproved. =_ _
Conditional approval for bedrooms, with the following stipulations:
---------------------------
Additional Comments ziz' wATFR Amn m
WASTEWATER .
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X Maintenance Agreements
Supplemental Engineer's Report
Other
By: A�/ # V � a°-e�( Original Certificate Date: _/ — ;)_ -6,__ 0 �_)
+n" 11 j
Municipality of Anchorage
• Development Services Department
Building Safety Division
On-site Water S Wastewater Program
4700 South Bmgaw St.
P.O. Box 196650 Anchorage, AK 99519.6050
www.ci.androrage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: )-b r2-0 t r r "i C H f/ 2
A. WELL DATA
Well typeT1!t-i/ATI6 If A, B, or C provide PWSID #
Date completed 14 Sanitary seal (Y/N) -Y—
Total depth JI —611L' Cased to Bio +fl.
FROM WELL LOG
Date of test ( `l (°y
Static water level 1 ZZ ft.
Well production 9•P•m-
WATER SAMPLE RESULTS:
Parcel ID: 0.67-0 -a 1/' S 7
Well Log (Y/N) Y6--1_
Wires properly protected (YIN) y
Casing height (above ground) 1 f in.
AT INSPECTION
I to vv
I'Lt� ft.
Zr 3 g.p.m.
Coliform � colonies/100 mi.
Nitrate & 1 1 mg./i.
Other bacteria
U colonies/100 ml.
Date of sample: L44-
Collected by: s s
G tfJ�IL/1fG
B. SEPTICIHOLDING TANK DATA
Tank Type/Material
Tank size gal.
Foundation cleano.d (Y/N)
Date of pumping
q A -w vJ Ll
Date installed
Of Compartments _ Cleanouts (YIN)
Depression over tank (Y/N) _ High water alarm (Y/N)
Pumper
C. ABSORPTION FIELD DATA N IA; /I)+ -1-i W 0
Date installed Soil rating (g.p.dJfF or fFlbdrm) _ System type
Length ft. Width _ Gravel below pipe ft.
Total depth _ 0 - Ff ct=.—f lion fF Monitoring tube _ Depression over field
Date of adequacy test Results (PasslFeil) For _ bedrooms
Fluid depth in absorption field before st _ in. Water added_ gal. New depth_ in.
Elapsed Time: _ min. I fluid depth _ in. Absorption rate >= g.p.d.
Any rejuvenation treatment (p 12 mo.) (YIN 8 type) If yes, give date
D. LIFT STATION N /�
Date Installed S' n gallons Manhole/Access (YM)
"Pump on" level at In "Pump ofr level at _ in. High water alarm level at
Datum Cycles tested Meets alarm S circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N R
Absorption field on lot N
Public sewer main �S y r 4
r
Sewer /spffc service line l 1
r
On adjacent lots ) OD 1
On adjacent lots 100 r t
Public sewer menholaideanout 100 ° 1t
Holding tank ^/ /q
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: tJ /a
Building foundation
Water main
Weiss on adjacent lots
Property line _
service line Surface water
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: N 1A,
Property line Building foundation Water main ,
Water Service line
Curtain drain
F.
Surface water
adjacent lots
parking/vehicle storage
Nom.
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined through field inspections and vlan��
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines In effecton this date.
Engineer's Printed NameiFUiAPOWAN
En '
t
9 CE -8801>-,
Date //a 3/O X ;'• ��J�'
HAA Fee $
3-7s—. "
Date of Payment
I / �L 1/0 2
Receipt Number
01 4 S(N 1 64
(Rev. 12/00)
Waiver Fee $
Date of Payment
Receipt Number
In.
JAN -22-02 10:55AM FROM -CUE ENVIRONIENTAL SRV
LTL. ME Environmental Services Inc.
ME Ret.9
1020356001
Client Name
S & S Engineering
Project NameN
N/A
Client Sample 1D
Finch S/D. LID
Matrix
Drinking Water
Ordered By
MID
0
9075615301 T-752 P.01/04 F-012
Client POM
Printed Date/rime
Collected Date7Tlme
Received Date/time
Technical Director
Released ByS146
01/2212002 10:45
01/17/2002 9:30
01117/2002 16:10
Stephen C. Ede
Sample Remarks:
Paremmer Resole: Allowable Prep Andyis
PQL Units Method Limits Detc [hie Init
waters Department
Nitrnic-N 2.88 0.200 mg/L EPA 300.0 (<10) 01/17/02 IDI
Microbiology Laboratory
Total Coliform 0
col/1 OOml. SM 18 92220 (<l )
01/17/02 KAP
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 2D Finch Subdivision T14N R1W Sec -7
2.
Location (address or directions)
Eavle River
6/27/86
(b) Applicant Name Louis Finch Telephone: Home 694-256; Business na____,_
Applicant Address Box 170 Citation Road, Eagle River, Alaska 99577 _
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder Q ; Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution First National Bank Telephone 694-2013
Address POB 770548, Eagle River, Alaska 99577
(e) Real Estate Company and Agent n/a
Address
Telephone
(f) Mail the HAA to the following address:
pickup by applicant
TYPE OF RESIDENCE
Single -Family ® Multi -Family ❑
Number of Bedrooms 4 --_
Other
3. WATER SUPPLY
Individual Well 12 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 DISPOSAL
Onsite ❑ Public ® Community ❑ Holding Tank ❑ AWWU
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 12-o25 (n 1A)
5. ENGINEERING FIRM PROVIDINI:.-ASPECTIONS, TESTS, FILE SEARCH, DA'. AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this He;wltlf
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional am 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 — — Telephone
Address EAGLE RIVER ENGINEERING SERVICES
Date <Z2 7, L P 0 BOX UaM-- -- ----- ---_ _
694-5195
ineer's Seal
ae .........
o A
ROFFSS1�fN
.. `;tis...: ".:• 4 7' ..
6. DHEP APPROVAL �
> i
Approved for /Q�bedrooms by Date
Approved DisapprovedConditional — / —
Terms of Conditional Approval --- _ —
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations 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 requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA) JUN .` O
CHECKLIST - FEBRUARY 1984
284-4720 R E CSE 1 V E g
Legal Description: t i nia� K boliy�ai a
T////✓ del 6-0 s.r� .
A. WELL DATA
Well Classification pde I V147 -L- If A, B, C, D.E.C. Approved (Y/N) IV
Well Log Present (Y/N) y Date Completed / jFe_z Yield
Total Depth 136 Cased to /33-1 Depth of Grouting A11
Static Water Level // 7 ' Be/ow AW L,Pump Set At /3y
Casing Height Above Ground i Sanitary Seal on Casing (Y/N) Y
Electrical Wiring in Conduit (Y/N)
Depression Around Wellhead (Y/N) ✓V
Separation Distances from Well:
To Septic/Holding Tank on Lot ; On Adjoining Lots 'L
To Nearest Edge of Absorption Field on Lot �- ; On Adjoining Lots r�oo
To Nearest Public Sewer Line t 7S To Nearest Public Sewer
Cleanout/Manhole ���'� To Nearest Sewer Service Line on Lot
Water Sample Collected by ck �r E S'""""- ;Date 6l;)-`>/��
Water Sample Test Results Sq 7
Comments
B. SEPTIC/HOLDING TANK DATA IV/4
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Size
Air -tight Caps (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High -Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well
To Property Line
To Water Main/Service Line
No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Course /
Comments 4IAL-AM A " " .02W" tr/l &.ze
n L' /' "moi` 7/%Al. Z/" 4,.S—.A
Page 1 of 2
72-026(11i84)
C. ABSORPTION FIELD DATA ��,4 Pf _41,, Sez,�
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course _
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test .
To Property Line
To Existing or Abandoned System on
On Adjoining Lots
To Cutbank (if present)
— Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed �i? Date
Comoanv /tinr(,r) _ M()A No
Receipt No. 35? C)"7 3 8
Date of Payment (P" so -8
Amount: $ Co S q9L
Page 2 of 2
72-026 (11/84)
Eagle River Engineering Services
P. 0. Box 773294
Eagle River, AK 99577
694-5195
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