HomeMy WebLinkAboutSKYHILLS PH 1 BLK 1 LT 4kyhI*IIs #1
Block i
Lot 4
#011-122-15
Municipality of Anchorage Page . 1 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 B Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
r
Permit Number: SweRnd,jti PID Number: oil -i"--�
Name:
Wastewater System: XkNew ❑ Upgrade
The Petersen Group
Address:
ABSORPTION FIELD
3820 Lake Otis, Suite 204
Phone:
No. of Bedrooms:
G Deep Trench 3;1 Shallow Trench G Bed G Mound ❑Other
562-1170
Four
Soil Rating:
Total Depth from original grade:
LEGAL DESCRIPTION
1.2 GPD/Sq. Fl.
121
Lot. Block: Subdivlsio ap-
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
4 1 Sk Hills
A. Ft.
4 Ft.
Township:
Range:
Section:
Fill added above original grade:
Gravel length:
Ft.
Ft.
Gravel width:
Number of lines:
Distance between lines:
WELL: ❑ New ❑ Upgrade
5 Ft.
1
- Ft.
Classification (Private. A.B.C):
Total Depth:
Cased To:
Total absorption area:
Pipe material:
Municipal Water
Ft.
Ft.
507 So. Ft.
ASTM D3034 PVC
Driller:
Date Drilled:
Static Water Level:
Installer:
Date installed:
3/1Z99
Ft.
Kincaid & Son
Yield:
Pump Set at:
Casing Heignt Above Ground:
TANK
GPM
Ft.
Ft.
SEPARATION DISTANCES
AXSeptic G Holding G S.T.E.P.
To
Septic
Absorption
Lilt
Holding
Public/Private
Manufacturer.
Capacity in gallons:
From
Tank
Field
Station
Tank
Sewer Lines
Material:
Number of Compartments:
Well
>200
>200'
N/A
N/A
N/A
Steel
Two
Surfac
>100'
>100'
N/A
N/A
N/A
LIFT STATION- N/A
>5 I'
6Lot
N/A
N/A
N/A
Size in gallons:
Manufacturer:
Line
"Pump on" level at:
"Pump off' level at:
High water alarm at:
Foundation
> 5 1
>10'
N/A
N/A
N/A
Pump Make & Model
Electrical Inspections performed by:
Curtain
Drain
None
on Lo
BENCH MARK
Remarks: See Waiver for Separation
Location and Description: Door Sill Bottom Floor
Between Lot Line and Absorption
West Side
Trench.
Assumed Elevation:
10 0 FL
ENGINEER'S SEAL
V(%
l Dates: 1st 3/1 /99v
Inspections performed by: n Hara a
2nd /1 /99 sw
6'
0i9i t .
Department of Health and Human Services approval
oNltt
' ��f Date:
Vie,
Reviewed and approved by:
r2-0U;Pe 9BS1 MCA 25
Municipality of Anchorage Page 2 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 - Anchorage, AK 99519-6650 - 343-4744
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number SW980436
N 00012'59"W 183.37'
10' UTIL. ESMT.
PID No. 011-121-06
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24.5
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Municipality of Anchorage Page 3 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 - Anchorage, AK 99519-6650 - 343-4744
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number SW980436 PID No. 011-121-06
U U) U) U U
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50.7'
iI t _h `aA
PROFILE
AB -BUILT
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HORIZONTAL
SCALE 1" 10'
=
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SCALE
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,MINE,
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oe
®� Municipality of Anelhorage
Department of Health and Human Services
825 " L" Street
Rick Mystrom. P.O. Box 196650 Anchorage. Alaska 99519-6650
Mayor
http: :;^r: w.ci.anchorage.ak.us
Anderson Engineering
ATTN: Michael E. Anderson, PE
PO Box 240773
Anchorage, AK 99524-0000
May 26, 1999
Subject: Waiver Request for SKYHILLS PH 1 BLK 1 LT 4
Waiver # WR990029 Lot Line Request for Parcel ID 0 11- 122-15
Dear Engineer:
Your request for a waiver of the required 10 feet horizontal separation of the on-site wastewater
disposal system to the lot line has been approved. The approved separation distance is 6 feet.
This waiver approval applies to the current on-site wastewater disposal system and lot line
separation only. Any future upgrade to the on-site wastewater disposal system and lot line will
require all separation distances to be met or another waiver approval from this department.
If there are any further concerns or questions regarding this waiver, please call our office at
343-4744.
Sincerely,
Jeff Poet
Engineering Technician III
On -Site Water Quality Program
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR# WR990029 PID# 011-122-15 HA# HA990229 Permit # SW980436
Date Received: May 25, 1999
Legal Description: Lot 4 Block 1 SKyHills Phase 1
Engineer: Michael E Anderson, PE., Anderson Engineering
PO Box 240773, Anchorage, Alaska 99524
Applicant: The Peterson Group
Waiver Requested: Trench to south property line of 6 feet.
Criteria: 1. Geology:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
2. Special Conditions:
3. Other:
Points:
Waiver is Granted: Waiver is NOT Granted:
List Conditions or Reasons for. above:
Date: ( - / 0 1 q By:
Reviewer
Rec #: 04871/4486 Amount: $_115.00 Date Paid: May 25, 1999
PABOX 240773
ANCHORAGE,AK'99524,
5221 7773 $22-6779 (FAX)
May 24, 1999
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject: Lot 4, Block 1, Sky Hills
Separation Distance Waiver
Absorption Trench to Lot Line
Dear On Site Services Engineer:
oOpMy;���gj' 2S, i9 �.�
ea��h/i yet 9,9
®3`
The absorption trench on Lot 4, Block 1, Sky Hills Subdivision was constructed within 6'
of the south lot line. The work was completed in early March of this year with heavy
snow cover on the ground. It was difficult to clearly define the location of the lot line
and the contractor apparently encroached within the 10' separation distance
requirement between an absorption trench and the line. We are therefore requesting a
waiver be issued allowing the placement of the trench in its present location 6' from the
lot line.
All lots in the subdivision are served by the Municipal water system so conflicts with
wells on adjacent properties is not an issue. Further, the soils on this and the adjacent
lot are coarse sands which percolate at a rate under 5 minutes per inch. Placement of
the trench at this location will not adversely affect the placement of a septic system on
the adjacent lot. We therefore recommend that a waiver be issued allowing the trench
to be located 6' from the south property line.
Sincerely,
Michael E. Anderson, P.E.
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
MEMORANDUM
DATE: June 9, 1999 RECEIVED ECEIVED
TO: Jeff Poet
JUN 10 1999
��,,^^ municipality of Anchorage
FROM: Mike Anderson, P.E. �r l oept. Health & Human Services
SUBJECT: Lot 4, Block 1, Sky Hills Subdivision
Additional Percolation Test
Certificate of Health Authority Approval
Attached is the additional percolation test requested for Lot 4, Block 1, Sky Hills
Subdivision. Hopefully this will satisfy your requirements and the Certificate of Health
Authority can now be issued.
Thank you for your assistance with this matter.
Municipality of Anchorage
D PARTMENT OF HEALTH d HUMAN SERVIC=S
825 "L' Street, Anchorage, Alaska 995020
SOILS LOG — PERCOLATION TEST
PERFORMED FOR- GTL-�S[/J G x0Up
DAT:
CR
LEGAL DESIPT ION: '7 Township, Range, Section:
1
2
3
4
0
7
8
9
10
i1
i2
13
14
15
16
n.
18-
19.
20 -
ENC D WATER
ENpUNTE r t
tJNTERED?
S
IF YES. AT WHA; L
DSP7H? 0
Dann w Wur /lnrr
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271.45'
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45,523
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�---- TES RUN HCiW—N �, AND COMMENTS lESTN9L£ �%LCs/S6 [.t'd i� _ -r- FT
PERFORMED BY:/
— RTIFYTHAT TF1I
AC^;,RDANO� Yr; -r A`, 5 TEST WA$ PERFORMED IN
S-A AN; MUNIC:PAS �'Jlri-_-IN=S IN="-- 4
-�� ON THIS DAT. DAT_;
, 2-,.,E (rev, 419=,
14Cf\ W
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PO BOX 196650 ANCHORAGE, ALASKA 99519 343-4744
HAND WRITTEN PERMIT
Permit Number: Sw986H3(a Permit Type: 1ht4t�� �c-v,er �nt�
Date Issued: NoQev,nber e2,19R8 Expiration Date: Qov. Q, t999
Design Engineer: ytee_r%'A
Owner Name: %N� Day Phone:
Owner Address : 3�ZGO��S-�a���
A14—
Ine rag2 . /S)L 9970 03 N-�A.hl1
Parcel ID: N�sekl P-�2i'UUc� ---- !s\\-° \,), %.
Lot Legal: Subdivision: TC $ Lot: +{ Block: t
Section: Township: Range:
Lot Size: Li5523 (sq.ft. or acres)
Max Bedrooms: This Permit:, Total Capacity:
t25o
SEPTIC TANK: Minimum septic tank capacity:i40-6-v gallons. Each
septic tank must have at least 2 compartments, insulation is
required if depth to top of septic tank(s) is less than 4.0'.
Lift stations require an appropriate electrical inspection.
WELL LOG: A copy of the well log must be sent to DHHS within 30
days of the well's completion.
CERTIFY THAT:
1. I will install the on-site sewer system and/or well in
accordance with all codes and regulations of the
Municipality of Anchorage (MOA) and State of Alaska , and
in compliance with the design criteria of this permit.
2. I will adhere to all MOA and State of Alaska requirements
for separation distances from any existing well, septic
system, or surface water on this or any adjacent or
nearby lot.
3. I understand that this permit is valid for a single
family dwelling with a maximum of bedrooms. I also
understand that any enlargement will require an
additional permit.
4. 1 understand this permit is issued for 365 days and
expires one year from the date of issue.
5. I will notify DHHS prior to all inspections by the
engineer or well driller.
SIGNED:
(owner/designee)
ISSUED BY: ��/ver
db/115
DATE:
DATE: �I /Z
November 3, 1998
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject: Lot 4, Block 1, Sky Hills Subdivision
Septic System Design
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of Lot 4, Block 1, Sky Hills Subdivision intends to construct a
four bedroom home on the lot. We are therefore requesting a permit to
construct a septic system on the lot to serve the house. The subdivision
is served by the Municipal water system so a well permit is unnecessary.
The attached site plan and backup documentation describe the proposed
system and show the location of the new system.
The testholes placed on the property revealed gravels and sands ranging
from well to poorly graded. Some silt pockets were found in the sand.
Percolation rates were uniformly under 5 minutes per inch. Groundwater
was not encountered during the excavation nor was any noted during the
monitoring period. We have therefore designed a 5' wide absorption trench
with 4' of gravel beneath the distribution piping. The trench will be 50'
long with a total depth from original grade of 9'.
The ground surface of the lot slopes to the northwest at rates between 50/o
and 10%. The absorption trench will be placed across the slope near the
northwest corner of the lot to provide sufficient fall from the house for
gravity flow. No other lots surrounding this lot are currently being
developed. No conflicts currently exist with other systems in the area.
Lot 4, Block 1, Sky Hills
November 3, 1998
Page Two
If the system is constructed as designed the following statements apply:
1. The system, if constructed as designed, will have no adverse impact
on the wells in the area or those to be constructed in the future. The
subdivision is served by the Municipal water system.
2. The system, if constructed as designed, will have no adverse impact
on existing septic systems in the area or those to be constructed in
the future.
3. The system, if constructed as designed, will have no adverse
impact on reserved space, either surface or subsurface, on any lots
located in the area.
4. The system, if constructed as designed, will have no adverse impact
on drainage patterns in the area. The current drainage pattern will
be maintained.
Sincerely,
Michael E. Anderson, P.E.
°
pp
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Attachments 910
MIC
SkyMills Subdivision
TRACT A
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N 0001:2'59"W 18-3.,37-
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LOT 43 BLOCK 11 SKYHILLS
DESIGN FACTORS:
Four Bedroom Home
Perc. Rate: 2.5 Min./Inch
Application Rate: 1.2 GPD/SF
SYSTEM REQUIREMENTS:
5" Wide Trench System
1,250 Gallon Septic Tank
4' Drainfield Rock
4 Bedrooms X 150 GPD / 1.2 GPD/SF = 500 SF of Absorption Area
500 SF/5 LF X .5 (Red. Factor) = 50 LF Trench Length
Therefore: Construct a 5' Wide Absorption Trench System With One
Lateral 50' in Length with 4' of Drainfield Rock Beneath the Lateral.
Distribution Pipe in Trench Placed at 5' Below the Original Ground
Surface.
5`
TYPICAL 5' WIDE TRENCH SECTION
(NO SCALE)
NOTE: Grade Area Over Trench to Drain Away.
Minimum 3' of Cover over Septic System.
Maintain 10' Separation From Lot Line.
1)
o00o Y.
49 TH*
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g8,p,ope _ �o,efeoe
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MCNAEL E, ANDERSON
_ 4999E o
-k"'h EA.LI
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ulrj
Municipality of Anchorage
DEPARTMENT OF HEAL T H & HUMAN S=RVICES
825 "L" Street Anchorage, Alaska 9°SC2-0650
SOILS LOG — PERCOLATION TEST ...
° `
AE. ANDE
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PERFORMED FOR: p701V7 5Ehj Gj2DrJla 4d °°° 4M -E �✓
DATC PERFOT�AA
LEGAL DESCRip'nON:L V �
Township. Range, Section:
DEPTH SLOP
(FEET) Sl i PLAN
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El
2 I I I I IMI I�
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45,523 sq.fl.
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- :.N,', M::NIC1rA� w'JIG�;N° I; �' — ON L I�—_!
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Municipality of Anchorage
•tom____ J� DEPARTMENT OF H=EALTH $ HUMAN SERVICaS
825 "L" Street. Anchorage. Alaska 99502-0650
SOILS LOG "— PERCOLATION TEST
PERFORMED FOR: PC7lrL •E'hJ 6&V,)P
DATE PER
LEGAL DES RIPTION: � j I �' �{ rry �„L) �Ib Township Range. Section:
4
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10
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201,
COMMENTS
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�qqqqE.. ANDERSON "e t,
o '1dF7�•� +.p�
SLOP@ SITE PLAN
C> C9INI
271-45'
45,523 sq.It. ^W
C/
WAS GROUND WATER
ENCDUNTERE02
S
IF YE_'• AT WHAT L
D=ri•i? / 0
Dean m war AW
Melutnnnglum
PERCOLATION RATE Im+nuWW[nC,'li PERC HOLE DIAMETER
TEST RUN SCiWEaNP , AND FT
`RTIFY TNA; THIS TE$T WAS PE FORMED IN
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 4, BLOCK 1, SKY HILLS SUBDIVISION
GENERAL:
1. The scope of this project includes the procurement and
placement of a 1,250 gallon septic tank. It also includes
the construction of a new 50' long X 5' wide X 4' effective
depth absorption trench at the location shown on the site
plan.
2. Construction shall be in accordance with the approved site
plan, design drawings, Municipal Permit with any special
provisions or conditions, and all applicable State and
Municipal Wastewater Disposal Regulations.
3. The Contractor shall be
responsible
for
obtaining all
underground utility locates
and for the
layout
of the septic
system and verification of
the location
of all
lot lines.
4. Unless specifically agreed otherwise, the contractor shall
be responsible for final grading areas subsequently
depressed from soil settling. Property owner shall be
responsible for revegetation of affected areas unless
specifically agreed otherwise.
5. Contractors installing wastewater disposal systems must
be certified by the Municipal Department of Health and
Human Services for system installations. Owners installing
their own systems must receive prior approval from D.H.H.S.
before beginning system installation.
SEPTIC TANK INSTALLATION
1. A new 1,250 gallon septic tank must be procured from an
approved source and installed at the location shown on the
Site Plan.
Lot 4, Block 1, Sky Hills
November 3, 1998
Page Two
2. A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts
for pumping access.
3. The septic tank shall be sufficiently bedded to prevent
settling or shifting of the tank.
4. All standpipes on the septic tank shall extend a minimum of
12 inches above final grade.
5. Tanks installed without 4' of cover shall have a minimum of
2" of direct burial insulation.
6. A foundation cleanout shall be installed one to four feet
from the building foundation. Two cleanouts are required
between the tank and the drainfield.
7. Final grading over the tank shall be such that a positive
slope exists away from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown
on the design. The bottom of the trench shall be within 2"
of level.
2. Distribution piping
must
be placed
level with perforations
down atop a level
bed of
drainfield
rock. Rock should then
be placed over the
pipe
to provide a
minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between
the drainfield rock and the natural soil backfill.
4. Monitor tubes must be 4" in diameter and installed at the
locations shown on the design. The portion below ground
must be perforated.
Lot 4, Block 1, Sky Hills
November 3, 1998
Page Three
5. Contractor shall verify the septic tank and drainfield are a
minimum 100' away from any private water wells in the
area, 150' from a Class "C" Well or 200' from any community
well.
6. Direct bury insulation must be placed over the distribution
system if less than 3' of backfill depth is available. Finish
grade over the trench must be mounded to prevent
settlement or depressions.
7. Grade area surrounding the absorption trenches to drain
away.
8. A minimum 2' of accepting soil is required below the
drainfield rock for a 5' wide trench. Contractor shall verify
this condition prior to placement of the rock. All pockets of
unacceptable materials must be removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a Municipally approved
septic tank manufacturer.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C.
(perforated and solid), ASTM F810 or H.D.P.E. (perforated,
but not solid) and ASTM D2662 or A.B.S. (perforated and
solid).
3. Insulation shall be at least 2" thick extruded direct burial
polystyrene (Dow Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
Lot 4, Block 1, Sky Hills
November 3, 1998
Page Four
5. A permeable geotextile
be installed between
native soil layer.
fabric (Typar, Mirafi or equal) must
the final drain rock layer and the
6. All drain rock shall be .5" to 2.5" in diameter with less than
3% passing the #200 sieve.
INSPECTIONS:
A minimum of two inspections are required by Municipal
Ordinance. These inspections must be conducted under the
supervision of a professional engineer registered in the State
of Alaska. The first inspection must be conducted after the
excavation of trenches, beds or pits and before the installation
of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement
of the geotextile fabric, gravel, distribution piping,
standpipes, cleanouts and insulation. No backfill should be in
place at the time of inspection.
Contractor shall provide a copy of all field survey layout and
construction notes for use in preparing the certified as -built
of the completed system.
Municipality ollAnchoragc
Development Services Department
Building Safety Division
Onsite 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
ParcelLD. 011122-15 y�S�nSq
COSA #_
1. GENERAL INFORMATION Expiration Date:, 0_q
Complete legal description Lw 4, ak)ck 1, SkYhMsSubdJvWon No. 1
Location (site address) 8312 skyhms Drtve
Current Property crvner(s) Roderick and Paakia Shipley
Day phone 243-8595
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
8312 SkyhMs Dove An&oraye, AK 99502
Unless otherwise requested, COSH wrp be held by DSD forpickup.
—^. NUr1eE^ 017 BEDROOMS: Four (e�
3. TYPE OF WATER SUPPLY:
Individual Well
0
Individual Water Storage
0
Community Class Well _
Public Water System
-�
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
_ Community On-site
Public Sewer 0
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of Onsite 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-SRe 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 Onsite 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 On-Sfte 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.
Anderson Engineering 3
Name of Firm Anderson Phone 522-777
Address P.O. Box 240773 Anchorage, AK 99524
Michael E. Anderson, P.E. Date 311 12008
Engineer's Printed Name
it
m : AuatAEL R ANDERSON; : ; iu
S. DSD SIGNATURE �0�`�•• tE-4381y'�'��,�
Approved for 4 bedrooms. ♦���Fa FBOFESSO .A :oo
Disapproved. d tittm�a�0.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By �/1/, / /(� / —17-el� Original Certificate Date: 3—;2.5 08
Municipality of Anchorage ,
\• 6,
Development Services Department \
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onske
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Lot 4, Block 1, Skyhltls Subdivision Phase 1
Parcel ID: 011-122-15
A. WELL DATA
Well type AWWU If A, B, or C provide PWSID # Well Log (YIN)
Date completed _ Sanitary seal (Y/N)— Wires properly protected (YM)
Total depth ft Cased to R Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft R ,
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
COlifor colonies/100 mL Nitrate mg/L Other bacteria colonies/100 mL
Arsenic: _ ug/I Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel -
Date installed 3/1199
Tank size 1.250 gat. Number of Compartments Two Cleanouts (Y/N) Y
Foundation cleanout (YM) Y Depression over tank (Y/N) N High water alar (Y/N) N
Date of pumping 1101612006 Pumper Northland Pumping
C. -ABSORPTION FIELD DATA --- -- - - -
Date installed 3/1199 Soil rating (g.p.d./ft2 or ftz/bdrm) 1.2 GPD/SF
System type S Wide Trench
Length 60•7 R Width 5 - ft. Gravel below pipe 4 g
Total depth 12 R Eff. absorption area 507 ft Monitoring tube Y Depression
N
Date of adequacy test 3n0108 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 0 in. Water added 7S6 gal. New depth .01n.
Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 600 9-P.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFTSTATION
Date installed Size in gallons Manhole/Access (Y/N)
'Pump on' level at_ in. 'Pump ofr level at _ in.
Datum Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
Animal containment areas Nona
High water alarm level at in.
Meets alar li circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas None
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >6 Property line >5' Absorption field >s
water main N/A Water service line >10' Surface water >100'
Wells on adjacent lots 1100'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 6" , Building foundation 110' Water main
110•
Water Service line
110' Surface water >100' Driveway, parking/vehicle storage >2S
Curtain drain None Noted Wells on adjacent lots >100'
F. COMMENTS' Property Is Served by Awwll Water System. —Lot Line Waiver Issued 5/26199.
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined through field inspections and 49•n ^
review -of Municipal -records that the above systems are -in — — -- :
conformance with MOA COSA guidelines in effect on this date. r t a; H.0' E. MDERsov
No CE -4381 1
Engineers Printed Name Michael E. Anderson. P.E.
�.'Pi;, •4444.-__✓"
Date 31112008 '�ar.�����•��
COSA Fee S 3 D Waiver Fee $
Date of Payment 3 —12, — 40 R Date of Payment
Receipt Number Jr q g Receipt Number
(Rev. 11105)
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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. # n 1 1-424�Pi; '1 -.Q - HAA # 0 Q I) aQ'Q
1. GENERAL INFORMATION la.�Q_P' c La` \
Complete legal description Lot 4, Block 1 , sky Hills r
Location (site address or directions)
Property owner The Petersen crour Day phone 562-1 1 70
Tailing address 3820 Lake Dtiq Parkway., Suite 204 AnchQrage, AK 9950V
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
Four (^
XXX
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XXX
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
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 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 furtherverify 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 Anderson Engineering Phone 522-7773
Address
Engineer's signature
6. DHHS SIGNATURE Y^ ,�
Approved for r_0 U 2 bedrooms.
Disapproved.
Conditional approval for
Additional Comments
0
a11TIC
Date 5/24/99
bedrooms, with the following stipulations:
Date 6-1c)
(
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 x21
Municipality of Anchorage RECEIVED
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division MAY 25 1999
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Municipality of Anchorage
Dept. Health & Human Services
Health Authority Approval Checklist
Legal Description: r nt 4 , R1 nr•k 1 , Sky u; 1 1 s Parcel I.D.: 011-121-06
A. WELL DATA - Municipal Water System
Well type If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Date completed
Total depth Cased to Casing height (above ground)
Sanitary seal (Y/N) Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
Date of test
Static water level
Well production g.p.m. 9•p•m-
WATER SAMPLE RESULTS:
Coliform Nitrate Other bacteria
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed 3 1 9 9 Tank size 1, 2 5 0 Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) y Depression (Y/N) N High water alarm (Y/N) N
Date of Pumping New Pumper Construction
C. ABSORPTION FIELD DATA
Date installed 3/1/99 Soil rating (g.p.d./ft2 orft2/bdrm) 1 .2 System type 5' Wide Trench
Length r, n_ 7 1 Width S I Gravel thickness below pipe 41 Total depth 1 2 ,
Effective absorption area 5 0 7 s Monitoring Tube present (Y/N) Y Depression over field (YM) �N—
Date of adequacy test New const- _ Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test (in.); Immediately after_ gal. water added (in.):
Fluid depth (ins) Minutes later: Absorption rate = g.p.d.
Peroxide treatment (past 12 months) (Y/N) If yes, give date
72-026 (Rev. 3/96)'
D. LIFT STATION - None on Property
Date installed
Manhole/Access (Y/N)
High water alarm level at* _
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
"Pump off" level at*
Municipal Water System
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation >51 Property line > 1 0! Absorption field > 5' _
Water main/service line > 25' Surface water/drainage > 1 nn' Wells on adjacent lots > 200'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 61** Building foundation
> 1 n' Water main/service line >25'
Surface water >1001 Driveway, parking/vehicle storage area >25'
Curtain drain None on Lot
Wells on adjacent lots >200'
*** See
Lot Line Waiver
F. ENGINEER'S CERTIFICATION
inspections and review of Municipal records. �11ar.#$ � js stems are
1 certify that I have determined thru field
in conformance with MOA HAA guidelines in effect on this date. /z 3 pct
_
Si nature
g
Engineer's Name Memel E And rGon,P.E_'np
O l y{
X44' , IV�Iljr tom. I Ll�{.:��UON v9'
b`
Date 5/24/99
t� AMR
°
f ,
Waiver Fee $ r
HAA Fee $
Date of Payment-C1l
Date of Payment
�� �-
Receipt Number
Receipt Number
72-026 (Rev. 3/96)*