HomeMy WebLinkAboutGLENN VIEW ESTATES LT 11Glenn View
states
Lot 11
051-521
-48
Municipality of Anchorage Page. /_of ,:~--_
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: .~/¢~D0~¢ PlDNumber: O.~'/-' ~'Z/-//
N~: ~ ~~ Wastewater System: ~ New ~ Upgrade
· d~,~,~:~O~ ~¢¢ ~~/~/~ ABSORPTION FIELD
Phone: No. of Bedrooms~ ~Deep ~rench D Shallow Trench D Bed ~ Mound D Other
LEGAL DESCRIPTION so,.~,.~: /' ~ GPD/Sq. Ft. Totai Depth from original grad~
Lot: // Block:~Subdiybion: __/,V~~/ Deplhtocpebo,tomfromodgin,lgr~de:~, ~¢ Fl. GrBveldepth beneath pipe
Township: Range: Section: Fill~¢~ ¢~"dded 8bove,~origin~grade:¢ Fl. Gravel le,gth:
WELL: ~ New ~ Upgrade Gravel width: ~ Ft./ "~ Ft.
Number ~ lines: Distance be~een lines:
Classification (Priva~, ~,B,C):/ Total Depth: Cased To: Total absorption area: Pipe mBterial:
Yield: /~ GPMII Pump¢~Set at: Ft.~ Casing Helght~Above Ground:lc ~ TANK
SEPARATION DISTANCES ~septic u Holding U S.T,E.P.
To Septic Absoetion Lift Holding 'ubllc/Prlvate Manufacturer; Capacltyln gallons:
From Tank ~ield 81afion Tank Sewer Lines ~ / ~
Weir /¢~ ' ' /0~ ,, -- -- ¢ Malerial: ~ ~/ Number of Compadments:
Water /D)+ /0b'* _ _ _ TATION
Lot / Size in gallon~cturer:
Li.e /O * /~ ~ -- ~ --
I , "~vel at: I "Pump off" levol~igh water alarm at:
Foundation /~ ~ /¢ 4 -- ~
Cudain ~ /~ ~ /00% PumpMske&Model lElectricalf~pedormedby:
Drain ~ ~ ~
Remarks: ~¢ ~¢~n ¢~¢~/~ ~¢;~. BENCH MARK
Location and Descripfiom
/
Assumed
Elevation:
ENGINEER'S SEAL
Inspections performed by: ~g~/~¢e¢~¢' ' Dates: 1si ~/~7/ ,.
O ~ 2nd ~5/¢ 7 ~
Department
of
Health
and
Human
Se[vices
Reviewed and approved by: ~'*'¢¢ ~ ~ Date: ~'/~ '~
12-013 (Rev 9/91) MOA 25
AS-BUILT SYSTEM DETAILS/SITE PLAN
LET 1t, GLENN VIEW ESTATES S/D
Pemmi± SW970049 I
PIDi~051 5~1 48 I
A-D-lO.2'
B-D-28.0'
A-E=19.8'
B-E=33.4'
F-32.5'
]3-F=38,3'
62,8'
C-G=33,9'
A-H=57,5'
C-H=34,8'
KNI
1500 GAL,
PRBPBSED RESERVE AREA
KN
C~
MT H
SPLI
4 ~DRM
SFD
3M
OTH II
J MT
TH ~96-1
~96 2
SCALE: 1' = 50'
~ d d dd d
FINISHED GRADE
SEWER ROCK
SCALE~ NIS
PREPARED FOR:
REX T[JRNER
ARCTIC DEVCB, INC,
P,D, BDX 3489
Pal NEB, ALASI<6 99645
I<ND ENGINEERING
20441 P'IARMIGAN BLVD
EAO[.E RIVER, AK, 99577
(907)696 6lll/Fcix (907)696 811i
rE: 8/31/97 ] DRAWING
SdL-E2_ AS ~TED/ worn
PERFORMED FOR:
LEGAl
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Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
WAS GROUND WATER ./.
ENCOUNTERED?.
S
IF YES, AT WHAT O
DEPTH? p
E
SLOPE SITE PLAN
Deplh Io Water Aller
Monilorin§7 Date:
J~ r-
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE __
/minutes/tach) PERC HOLE DIAMETER
lEST RUN BETWEEN
FT AND __.__ FT
CERTIFY ]HA; TH/~ ~EST WAS PERFORMED iN
DA E.
ADDRESS
DATE-Started £nded _. q/{:~' ~
PERJVIIT NUMB~.R
· DOC co,
SULLIVAN WATER' WI LLS
P.O, BOX 07027~, CHUGIAK,.ALASKA gg~$? * TELI~PHONB
')RI'TH OF WELL
ST.<'IC LEVEL 0" W.&TER FL
KIND OF CASING
Fromm. F't to .... Fl ......
From~Ft, to __Ft.~
From--- FI, to Fl..
From . .-
From~
From ,.
F~om.
,._FI. to Ft.__
Fl. to~Ft, .
Ft. to~Ft ......
_~FI,
.. Fl__
Ft.
Fl.
From~Ft. tu__~Ft ....
From FI, Io___ Ft. ~
From .. Ft. to~ FI,
From Ft. Io-- . Fl- ~
From FI, Io__ };I, ~
From ~Ft. to~Ft
From FI, to.__Ft...
From~ Fl1 {o~.. Ft. ,,
From~ FI,
From FI, to~ FI~
MISCL, INFORMATION:
RECEIVED
SEP 13 199'/'
Municipality o! Anchorage
Dept. Health & Human Services
.DRILLER'$NAME /'~-~ ~'
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PEP~MIT NUMBER:SW970049
DESIGN ENGINEER:KND ENGINEERING
OWNER NAME:TURNER CONSTRUCTION
OWNER ADDRESS:P.O. BOX 3489
PALMER, AK. 99645
i .
PARC~E-L--~D~06~ZI2-6
LEGAL DESCRIPTION:
~NEW PID# 05152148
LOT SIZE: 55417 (SO. FT.)
NUMBER OF BEDROOMS: 5 THIS PEP~MIT:
DATE ISSUED: 4/04/97
EXPIRATION DATE: 4/04/98
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN A~NCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 ~LND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AACS0) .
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
AT THE TIME OF CONSTRUCTION EXCAVATE AN ADDITIONAL
TEST HOLE TO A DEPTH OF 15 FT. (6'DEEPER THAN TRENCH).
SUBMIT SOIL LOG WITH AS~BUILT/INSPECTION REPORT.
ISSUED BY: :~ ~'~. 1 L/~ r~'~'l~
DATE:
DATE:
~D ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-6111/FAX (907)696-8111
March 27, 1997
Municipality of Anchorage
Dept. of Health & Human Services
On-Site Services Section
P. O. Box 196650
Anchorage, Alaska 9951%6650
RECEIVED
Municipality of p~chorage
Dept. Health & 'rtuman Services
Subject: New sewer/well permit - Glenn View S/D, Lot 11
Gentlemen:
On March 21, 1997, we excavated two new testholes for the subject property. There is
one previous testhole which was dug during the preliminary plat process, however
it was not suitably located for the five bedroom house which is proposed for this lot.
The results of these tests and water monitoring are attached.
We propose to install a deep 2' wide trench. Although the original testhole
indicated water it was located in a lower portion of the lot and not representative of
the site. Additional fill will be placed over the system to provide a minimum of 3'
of cover when complete.
There are no public or private wells within 200' of our proposed system location
except as noted. There is neither surface water within 100' nor any curtain drain
within 50'. We do not expect that there will be any adverse effect on adjacent lots by
the development of this system.
If you have any questions, please contact me at 696-6111/FAX 696~8111.
Respectfully submitted,
Engineering
attachments:
On-Site Well and Sewer Application
Wastewater Absorption System Details/Site Plan
Soils Log/Percolation Test
WASTEWATER SYSTEH ]DETAILS/SiTE PLAN
LBT 11, GLENN VIEW ESTATES S/D
VACANT
VACANT
VACANT
~DSED RESERVE AREA
i?-
' ~WELL
]500
VACANT
10' ~I]U~$~IAN/W~KV/AY ESNT,
DESIGN DETAILS
5 BDRM X 150 GPD = 750 GPD
750 GPD/1,a GPD PER SQ, Fl', = 625 SO, ET
G25/(6'X2-') (6,0' GRAVEL) = 52,1 f [, I'RENCH
To~:(l[ dep-th oF syst. em is 9,0' From oniDin(l[ 9p(ide,
Toi. ct depth oF gp(ive[ is 0,0' ,
MOLES',
1, USE 1500 GALLON SEPTIC TANK, INSULAIE TANK IF <4' CDVER,
2_. INSULATE TRENCHES WITH 2~ HD BURIAL FBAM.,
~, CE]NTRACTOR WILL ENSURE MAXIMUM 2-Y. SLDPE INTO SEPTIC TANK,
4, ADDITIDNAL FILL WILL BE ADDED OVER SYSTEM TD ACHIEVE
NIN, 3' C~VER IF REQUIRED,
PREPAREI) FOR:
REX TURNER
ARC'[lC BEVCO, INC.
P,O, BOX 3489
PALMER, ALASKA 99645
I<ND ENGINEERING
20441 PTARMIGAN BLVD
EAGLE RIVER, Al<, 99577
(907)696-6111/Fax (907)696 8111
DATE, 3/26/97 DRA~ING It
SCALE: l~ = ]00' 970 7 S1
PERFORMED FOR:
Municipality o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
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2
3
4
5
6
7
8
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19
2O
DEPTH
WAS GROUND WATER
ENCOUNTERED?
s
L
IF YES, AT WHAT /1/~
DEPTH? ,-r~ pO
E
Oeplh 1o Waler ^lte/~ ~,,
Moniloring? __~:~. Dale:
DATE PERFORMED:~
SLOPE SITE PLAN
Gross Net Depth to Net
Reading Date
Time Time Water Drop
I ~; ~. I,¢/,,¢. ~ ~ ,,
~ ~: ~ ,, y~ ', ~"
~ - ~ : o¢ " ? ' ~/~ "
~ ~:~? ,. ?~/~.. ~/~,.
PERCOLATION RATE (mmules/mch) PERC HOLE DIAMETER
TEST RUN.ETWEEN ~ FTAND ~' ,T
PERFORMED BY: ,"~'/t,/'/- ~ ~ ,~/¢'~'/'/~-2 ¢'.--~-~ / '~/4¢~ I ..... CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE ANDMUNI L GUIDELINES IN EFFECT ON THIS DATE. DATE:
Municipality ol Anchorage
DEPARTMENT OF HEALTFI & HUMAN SERVICES
82,5 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
.EOAL DESCRIPTIO.: Lb b//I
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10
11
12
13
14
15
16
17
18
19
2O
SLOPE SITE PLAN
WAS GROUND WATER ,/
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Deplh to Waler After. u,_,
,...y
Gross Net Depth to Net
Reading Date Time Time Water Drop
~1~,/::~.':~ _. ~ ~/~' _
/ z ,'/¢ /,,,,~ ,~'//~"
~ ~:~/ .~ ',','~ '+~;/,/ V~';,
~. ~,'Z3 ,.
/ ,z,,;z~-,' _ ~' ~/<~"'/z"
~- ;z ..~ 7" 'Y ~" Y'~ "
Z ~'~/ " ¥ ~/v" '/z,'
PERCOLATION RATE /~' (mmules/mch) PERC HOLE DIAMETER
TEST RUN BETWEEN /"~' FTAND ~Z,~- F7
i ~[' ~.j
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE:
Municipality o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: 4/~.~ /~) ~'~ ~-¢~///
5
bKo v..)r'l ,.~
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8
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20-
Township, Range, Section:
SLOPE SITE PLAN
WAS GROUND WATER ,/
ENCOUNTERED?
S
IF YES, AT WHAT /A ~)
DEPTH? , p
E
I
Gross Net Depth to Net
Reading Date Time Time Water Drop
/ 7.'~7 z ~,'~ ~" ~h"
Z ~: ~ " 7" ~/~"
~, _~: ~/ " 7 "Zd' ~"
~ ~ .' ~ " 7 ~" ~//~ "~
~ : ~3 .' 7/z" 'Y6"
Depth 10 Wal~r Aller~
PERCOLATION RATE /~ Immules/Jnch) PERC HOLE DIAMETER
TEST RUN BETWEEN *:~ FT AND 7 FT
PERFORMED FOR:
Munlclpalll¥ ol Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL OESGRIPTION:_~__/~//~ ~//~" ~"~'~'.~'~..~
9
I0
11
12
13
14
15
16
17
18
19
2O
Township, Range, Section:
SLOPE
WAS GROUNO WATER
ENCOUNTERED?
SITE PLAN
S
IF YES, AT WHAT
OEPTH? c),, ? P
E
rlepal to WaJ~' Al~er :
Reading Oate Gross Net Oa~th ~o Net
Time Time Water Orop
PERCOLATION RATE ~--- / (m,nulesy,ncnl PFRCHOLEOIAMETER --
rEST.U~ ~ErW~r-~ a'5 FT ANO_ ~'5' ~
COMMENTS
PERFORMED BY: L~/~--..~ I ~~ CERTIFY THAT THIS TEST WAS CERFORMEO
MUNICIPALITY NCH
�y 6'''u'
Development Services Department r Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051 521 48
1. GENERAL INFORMATION
Expiration Date
Complete legal description GLENN VIEW ESTATES LOT 11
Location (site address) 23434 GLENN HILL CIRCLE
I 1- 1.3-2 0Z (D
Current property owners) NICKRAVESH Day phone
Mailing address
Real estate agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 5
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well El
Private Septic
F-1
Water Storage ❑
Holding Tank
❑
Community Well ❑
Community
❑
Public Water System ❑
Public Sewer
❑
Waiver request for: NONE
Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $-912.-'50 C -OV O
Waiver Fee $
Date of Payment %/;7-91W
Date of Payment
Receipt Number C78.G6V
Receipt Number
COSA # OSG� I ��
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 C&M ENGINEERING Phone 8545558
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI Date 7/28/2020
11�k
kl
OF A1,4s1iAw1-1l
j*�qg TH
6. DSD SIGNATURE ...5� .. �
System #1 Approved for bedrooms �� ' ' ' ' ' ' ' �
CHARLES G BALZARItyI
System #2 Approved for bedrooms �rt�F��s CE -13854
Disapproved �,l)k �, FESSIONP��r
Conditional approval for bedrooms, with the following stipulations:
�`l�lllllTY OF((��/�i
1 11Z7 ITE
Wi4TFR n IN t
Lj
rr�Wgsr`
TER R z
r� RAM
SFRVI
y: Original Certificate Date: S-
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
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
Nitrate Advisory
Arsenic Advisory
Othe 2
Legal Description: GLENN VIEW ESTATES LOT 11
If more than 1 septic system on lot: COSA Checklist # 1 of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 1997
Total depth 202 ft
Cased to 202 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) +12 in.
Date of flow test for COSA 7/15/20
Static water level at beginning of test 172 ft.
Comments
B. TANK DATA
Age of tank(s) 23 years
Tank type/material STEEL
Measured operating fluid level in septic tank 50
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 8/11/20
D. ABSORPTION FIELD DATA TRENCH
Which system tested (date installed) 1997
❑ ALL standpipes present per record drawing
Total measured depth from grade 10 ft (max)
Measured depth to pipe invert from grade 4 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 NA gallons
Comments/Deficiencies: STANDPIPES REPAIRED.
COSA Checklist yellow sheet
Parcel ID: 051 521 48
Structure served by this system 1
Well production at time of test +3.2 gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ❑ N
❑ Coliform bacteria is Negative
Nitrate 5.12 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by C.Balzarini
Date of Sample 7/15/20
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 7/15/20
Results El Pass For 5 bedrooms
Fluid depth prior to test 7 in
Water added 750 gal
New depth 9 in
Elapsed time 10 min
Final fluid depth 7 in
Absorption rate 750 gpd
Any rejuvenation treatment (past 12 months) NO
If yes, enter date NA
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'
Q
Yes
Community Sewer Manhole/Cleanout > 100'
Q Yes
if No
ft
M Yes
if No ft
Neighboring Tank > 100' M Yes
if No
ft
Private Sewer/Septic Line > 25' F-1 Yes
if No ft
Absorption Field on Lot > 100' 0 Yes
if No
ft
Holding Tank > 100' El Yes
if No ft
Neighboring Absorption Fields > 100'
Q Yes if No ft
Water Main > 10'
Animal Containment > 50' 0 Yes
if No ft
M Yes
if No
ft
0 Yes if No ft
Water Service Line > 10'
0
Yes
if No
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway comment below
Community Sewer Main > 75' M Yes
if No
ft
M Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
Q
Yes
if No
ft
Surface Water > 100'
Q Yes if No ft
Property Line > 5'
0
Yes
if No
ft
Wells on Adjacent Lots:
Q
Absorption Field > 5'
if No
Yes
if No
ft
Private Wells > 100'
Q Yes if No ft
Water Main > 10'
Q
Yes
if No
ft
Community Wells > 200'
0 Yes if No ft
Water Service Line > 10'
0
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)
Building Foundation > 10'
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
Q
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
Q
Yes
if No
ft
Private Wells > 100' E] Yes if No ft
Water Service Line > 10'
Q
Yes
if No
ft
Community Wells > 200' 0 Yes if No ft
Surface Water > 100'
Q
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that 1 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. 7/28/20
COSA Checklist yellow sheet
c� OF A/,gs�l
49 TM '•
..� jam'.. ..
CHARLES G BALZARINI
CE -13854
`��pROfESSiONP-
Septic 'Tank Advisory
Certificate of On -Site Systems Approval #OSC 201384
Subdivision: Glenn View Estates lot 11
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this property is 23 years old. Typical replacement costs range from $8,000 to $11,000
This advisory must be attached to all copies of the subject Certificate of On -Site Systems
Approval.
This is an example of what the metal of a 20 year old steel tank MAY look like.
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT �� `� 907-343-7904
On -Site water and wastewater Section ' Fax: 343-7997
www.muni.org/onsite
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC 201384
Subdivision: Glenn View Estates Lot 11
A water sample revealed a nitrate concentration of 5.12 milligrams per liter (mg/Q.
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.
-`sa ,. s -=i �.*`` ,,.: r ,• „, ` '.
Mailing Address P O Box 196650 * Anchors e, Alask"995'19!,,-6650,-,,,1a *www mum org >
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.
�` �� Ma�hng Address ROS Box 196650 *Anchorage, Alaska 99519 6650 *www murn org ���
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`_ / On-Site Water and Wastewater Prcgr.:rta :. �w'i .
*/ (907) 343-7904 0. A�� G �} �'?;l '1➢ 5 A E T Y
i
C.
Certificate of On-Site Systems A. • al �.,
051 -521 -48 << a/ 6 8 L� 1�.
Parcel I.D. Expiration Date: V" d �i doll
1. GENERAL INFORMATION
Complete legal description Glenn View Estates, Lot 11
Location (site address) 23434 Glenn Hill Circle
Current Property owner(s) Jill Butikofer Day phone
Mailing address 23434 Glenn Hill Circle, Chugiak, AK 99567
Real Estate Agent Day phone
2. TYPE OF DWELLING:
El Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 5
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well CI Individual 0
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: ....--, ' ------
1/1 Date: 9 1 X3117
COSA to be released to the engir,unless otherwise requested by the engineer.
COSA Fee $ Sze Waiver Fee $
Date of Payment q`25—/l3 Date of Payment
Receipt Number Qq-11 a I Gj Receipt Number
COSA# Cita?""1J47 Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixe—dikereto 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 Anderson Engineering Phone 522-7773
Address PO Box 240773, Anchorage, AK 99524
Engineer's Printed Name Benjamin Schiller Date 4124/17
fb�re�
^ �: .. ->
6. DSD SIGNATUREorb` a
X System #1 Approved for ��l � • '�
y pp 5 bedrooms �
iile
System #2 Approved for bedrooms l� �: ` j cCE•12592 FPcif
itr
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Disapproved O •Y1?`t�.t.-•' 4'
Conditional approval for bedrooms, with the following stipula�ibns:
OFAAie
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WATER AND m'
WASTEW
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SFp\i\C
By: 2,6
QA u- -Q Original Certificate Date: 2. 2S 1 -7
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory X
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet_c - c
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: Glenn View Estates, Lot 11 Parcel ID: 051 -521 -48
A. WELL DATA
Well type Private If A, B. or C provide PWSID# Well Log (Y/N) Y
Date completed 4/1997 Sanitary seal (Y/N) Y Wires properly protected (YIN) Y
Total depth 202 ft. Cased to 202 ft. Casing height (above ground) 24 in.
FROM WELL LOG AT INSPECTION
Date of test 4/1997 4/19/17
Static water level 175 ft. 180 ft.
Well production 12 g.p.m. 4.7 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mL Nitrate 6.24 rng/L
Arsenic 0 ug/L Date of sample 4/17/17 Collected by: Anderson Eng
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 4/1 5/97
Tank size 1 500 gal. Number of Compartments 2 Cleanouts (Y/N)
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 4/26/17 Pumper JR's Pumping
C. ABSORPTION FIELD DATA
Date installed 4/14/97 Soil rating (g.p.d /ft2 or ft2/bdrm) 1 .2 gpd System type Trench
Lengt i- - .�_•2;5 -`ft_ . Width 2'0 ft. Gravel below pipe 0'2 ft.
Total depth 10. ft.ft. .2f-f, absorption area 672 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 4j1 91 7 Results (Pass/Fail) Pass For 5 bedrooms
*
Fluid depth sin absorption figlia.before test 3 in. Water added 750 gal. New depth 5-5 in.
Elapsed Time: 1440; Final fluid depth 0 in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
*Home was vacant for 6mo, so trench was pre-soaked before test was performed
'
tx Morkfootr“, Tuff PePtaR.S To ItfWE ^., 1•0 01 p is AY TOE, 130-now,
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YIN)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested _ Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot >100' On adjacent lots >100'
Absorption field on lot 100' On adjacent lots 100'
Public sewer main >75' Public sewer manhole/cleanout 100'
Sewer/septic service line >25' Holding tank >75'
Animal containment areas >50' Manure/animal excrete storage areas >100'
SEPTIC/HOLDING TANK ON LOT TO:
>5' >5' >5'
Building foundation Property line Absorption field
' >10' >100'
Water main >10Water service line Surface water
Wells on adjacent lots >100'
ABSORPTION FIELD ON LOT TO:
>10'
Property line 10 Building foundation 10 Water main
Water Service line >10Surface water >100 Driveway, parking/vehicle storage
Curtain drain None Noted Wells on adjacent lots X100'
F. COMMENTS
G. ENGINEER'S CERTIFICATION •r�e or AtillB.•
I certify that I have determined through field inspections and p.o-.•
review of Municipal records that the above systems are in •vj� `""s a'1-T,4
conformance with MOA COSA guidelines in effect on this date. 41. .;
Engineer's Printed Name Benjamin Schiller, PE ��.....�.m
Date 4/24/17 a,� ,: : ! Sd'«'yes,•'
CE-1292 4;
COSA brown sheet 10-10-12.doc
. Municipality of Anchorage T'
/•, t�� Development Services Department
Building Safety Division '"e l ri
_____.j
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 # OSC 171147
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Lot 11 of Glenn
View Estates subdivision. This inspection revealed a nitrate concentration of
6.24 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.
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PLOT PLAN AS BUILT x SCALE '_.12::so GRID �
N-1�t13fa. Pr ec1 No. Ma:AA_
G. ��
�em�®; ;a �s1731 George Bell Circle
>• `�R-�.S. Anchorage,Alaska 99515 (907) 345-6476
I Hereby certify that I have surveyed the foltowina described property:
Lot-11__.Block OtTeT6R ( ..u+s,inti
AN1L Recording District,Alaska, end that the improvements situated ci .......` i
thereon ate within the property lines and do not encroach onto the property {h`-•'`• • .y,$•.�s
adjacent thereto, that no improvements on the properly lying edjsccnt thereto v=+,,. `"., '• i
cocroacb on the slsrvs ed premises and that there are no roadways. transmission 4
tines or other visible easements on said property except as indicated hereon. >w i
Dated ibis the_�_Day of timed tS,ets �• .. "•
19'x]_.at Aochoreae.Masks s.•• • ua• O.:
tis the rcapogslbillty of tba owner to dstertnlec Ike existegce of any easements, 1t t.• •
i• LS-S202 . Ii
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ovenants,or restrictions which do not appear an the recorded subdivision t u".•�•s•••• �
plat. '���'�_!r.rnllt�`�,�v
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
Parcel I.D. 051-521-45
1. GENERAL INFORMATION
Complete legal description
COSA # O<'~C [/i (~ o~--~
~Piration Date: ~'-"-,~.-~ / /
GLENN VIEW ESTATES, LOT 11
Location (site address) 23434 GLENN HILL CIRCLE, CHUGIAK, AK 99567
Current Property owner(s) JENNIFER & MICHAEL DENNIS
Mailing address
Lending agency
Mailing address
Day phone
23434 GLENN HILL CIRCLE, CHUGIAK, AK 99567
Day phone
Real Estate Agent
Mailing Address
LARRY DYKES - W/PRUDENTIAL Day phone 273-7329
Un/ess otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
,~ - Individual Well,~ []
Individual Water.Storage []
,CommunitY Clas'S Well '[]
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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 vedfy 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.
DSD SIGNATURE
~" Approved for ~
Disapproved.
Conditional approval for
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3792
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date. 01/12/2011
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 dudng 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 vadous 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 Iong a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen ~'. ~. ~~i~;::..
encroachments, deficiencies or discrepancies exist.
...~.~!.: ..... ... :: ..... ~;~:
bedrooms. -~~c~,...
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
[ mSTEWAT
Arsenic Adviso~ ~ ~ ~ '
Maintenance Agreements
Supplemental Engineer's Repo~
Other
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: GLENN VIEW ESTATES, LOT 11
A. WELL DATA
Well type PRIVATE. If A, B, or C provide PWSID # Well Log (Y/N) _y.Y
Date completed ~1997 Sanitary seal (Y/N) Y__
Total depth 201 ff. Cased to 201 f.
FROM WELL LOG
Date of test 4/1997
Static water level 175
Well production
WATER SAMPLE RESULTS:
Coliform
Parcel ID: 051-521-48
Wires properlY protected (Y/N) Y
Casing height (above ground) 24+ in.
12 g.p.m. 6.5
AT INSPECTION
1/3/2011
179
4.24 mg/L
Collected by: A~cTerra
NEG colonies/100mL Nitrate
g.p,m.
Tank Type/Material Septic/Steel Date installed 4/1997 Tank size' 1500 gal.
Number of Compartments _2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) __N
High water alarm (Y/N) N Date of pumping ].2/30/].0 Pumper )Rs
C. ABSORPTION FIELD DATA
Date installed ,t/].997 Soil rating (g.p.dJf~ or ff2/bdrm) ]..2
Length 5`1.2 ft. Width --2 ft. Gravel below pipe 6.2 .ff.
Eft. absorption area 672 fi2 Monitoring tube Y
Date of adequacy test ]./3/20/].
Fluid depth in absorption field before test 0
Elapsed Time: 90 min. Final fluid depth 0
Any rejuvenatiOn treatment (past 12 mo.) (Y/N & type) N__lf yes, give date -_~-
Arsenic: ND .mg/I Date of sample: 1/3/2011
B. SEPTIClHOLD[NG TANK DATA
System type Deep Trench
Total depth 9.66.ft. (Measured 1/3/11)
Depression over field N__
Results (Pass/Fail) Pass For 5 bedrooms
__ in. Water added 780 gal. New depth ].0 in.
__ in. Absorption rate >= ?50+ g.p.d.
Dm
LIFT STATION
Date installed
"Pump on' level at~
Datum
in.
E. SEPARATION DISTANCES
Size in gallons
"Pump off' level at ~
Cycles tested
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+
Absorption field on lot 1-00'+
Publicsewer main.
Animal containment areas 50'+
Manhole/Access (Y/N)
High water alarm level at in.
Meets alarm & circuit requirements?
On adjacent lots 100'+
On adjacer~t lots 100'+
Public
Manure/animal eXcrete storage areas 100+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line
Water main 10'+ Water service line 1-0'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 1_0'+ Building foundation 1-0'+
Water Service line 1-0'+ Surface water 100'+
Curtain drain 50'+ (None Known)
COMMENTS
Absorption field
Surface water
Water main 10'+
Driveway, parking/vehicle storage, 10'+
Wells on adjacent lots 100'+
G. ENGINEER'S CERTIFICATION
l 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 KENNETH M. DUFF-dS
COSA Fee $490.00
Date of Payment i'- 3 l- ) I
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
L. oT
LOT lo
LoT
Hereby Ccrtitry tits! I have surveyed the rollowin deserib
Ibarcon .are within Ibc properly lines and do riel encroach ohio lbo property
adjaccnl thereto, lbal aa lmprovemcnts on tho property lying adjacent thereto
cncroa~b on thc surveyed-pramiaca and that tbcrc are no roadways, ]ranamleaiou
linen or o~hcr viaiblc easements on aa~d properly cxcepl as indicated hereon.
Deled Ibis Ibc _~ Day of _ ~~. igC.. al Anchorage, Alaska
Ja ~hc rcsponllbillfy of lbo OWner ye dat~mluc thc cxtatcucc of any ca'scmcnta,
~ovcuants, or rcalrictions which do not appear on U~c recorded subdJvl.sioa plat.
PLOT PLAN ~ AS BUILT ~ SCALE .j?._ s~ GRID ~ Pro~ecl No. ~
Anchorage, Alaska 99:~i:~ (907) 34.~-6476
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D, # ~)~ I- I~Z-/ ~ L//~'
1. GENERAL INFORMATION
Complete legal description ~o/ //
~ONMENTAL ~_ F ANCi. ioP~Ge
b'ERVIcES DIVI310N
RECEIVED
Location (site address or directions) /17/~/4 ~/~ p//~///5//~/'/~,
Property owner
Mailing address _
Lending agency
Mailing address
Day phone
Agent ~¢,_~
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91} Front MOA #21
STATEMENT OF INSPECTION BY ENGINEER.
As certified by my seal affixed hereto and as of the valiCa~ion date shown below, I verify that my
· .investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm 'KND Engineering
2044~ ,%-,,~,~ 8~vd. Phone ~ ~'~ -~///
Address Eagle River, ~K 99577.8736
Engineer's signature. ~. ~.,¢~_~
DHHS SIGNATURE
~'/ Approved for ~lk~_
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
ra
e
Municipality ofAncho g -
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division 8~p
825 L Street, Room 502 · Anchorage, Alaska 99501
Health Authority Approval Checklist ~ECEI
A. WELL DATA
Well type /F/Ct/
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter, ADEC water system number
~ Date completed
,?_.D/ / Cased to ~O/ / _ Casing height (above ground)
Wires properly protected (Y/N) V
Date of test
Static water level
Well production
FROM WELL LOG
175 /
g.p.m.
AT INSPECTION
,,,.-
./
g.p.m.
WATER SAMPLE RESULTS:
Coliform ¢
Date of sample: ~" / - ~ 7
iii. SEPTIC/HOLDING TANK DATA
Nitrate
$. 37
Collected by:
Other bacteria
Date installed ~/~ ~ '~ _Tank size /~ (-~ Number of Compartments Z Cleanouts (Y/N)__
Foundation cleanout (Y/N) _ "// Depression (Y/N) /4,/ High water alarm (Y/N) ~
Date of Pumping ~- . Pumper ~-
C. ABSORPTION FIELD DATA
Date installed z./~ ~, -~
Length ,_~'¢. 2. Width
Effective absorption area __~'
Soil rating (g.p.d./ft~ or fF/bdrm) /.~, System type'~£~;)
,2. Gravel thickness below pipe ~, ~ Total depth ~,,~ '~ /,~ '
Monitoring Tube present (Y/N) ~ Depression overfield (Y/N) /I,/'
Date of adequacy test
Results (Pass/Fail) ~ For
bedrooms
Fluid depth in abs/~on field before test (in.); / Immediately after, gal,~r added (in.):
Fluid depth / (ins) Minutes later: Absorption rate/~ g.p.d.
Peroxide e~atment (past 12 months)(Y/N/ I' yeS,./g[~ date
72-026 (Rev. 3/96)*
LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
Size in gallons
J "Pump on" level at* ,~,~"P um p off" level at*
*Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main ~ ~ 4
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation /~) ~ Property line /~ -/- Absorption field
Water main/service line ~,~ ..L Surface water/drainage ~/~D 4-
!
/bD
'¢
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ,/('.~ "~
Surface water /~)
Curtain drain //~;) ~''~'
Building foundation /~ /¥ Water main/service line
Driveway, parking/vehicle storage area
/
Wells on adjacent lots / ~ ¢
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal records
in conformance with MOA HAA guidelines in effect on this date.
Signature ~.
Engineer's Name
HAA Fee $.
Date of Payment
Receipt Number
72-026 (Rev, 3/96)*
Waiver Fee $
Date of Payment
Receipt Number