HomeMy WebLinkAboutSKYLINE VIEW LT 2Onsite File
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Municipality of Anchorage
On-Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP221216 PID Number: 051-192-05
Dwelling: OR Single Family (SF) El with ADU rj Duplex (D) R Two Single Family Project: R New FO-1 Upgrade
Name
Vern and Doris Stevenson
ABSO.RPTION FIELD
❑ De Trench Fj Wide Trench n Bed F] Mound
Site Address
19405 Wildwood Dr Chugiak
Other
Phone
Number of Bedrooms
Soil Rating1
depth from original grade
3
/SF ITotal
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original de
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Skyline View 2
Fill added above original grade
Ft.
Gr el length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Dist ce between lines
Ft.
SEPARATION DISTANCES
To! Septic I Absorption
Lift Station
Holding Sewer
S
Total absorption area
Number of trenches
Dist. between lm�'Ches
From Tank I Field
T i
Tank Line
F t2
t.
Well >100.1
TANK [9 Septic [I S.T.E.P. El Holding [I Other
Manufacturer
Greer
Capacity
1000 Gal,
Surface Water>1 00,
Material
plastic
Number of compartments
2
Lot Line >1 0,
. ...... ....
NA
Foundation i 9'
LIFT STATION
a rer
Capacity
Gal.
i
Remarks 2" insulation provided over
inlet pipe
Alarm location
al installed by
PIPE MATERIAL House to tank 3034 drainfield Tankto 3034
Installer
JRs Septic
Drainfield CO/MT 3034
Inspector Curtis Townsend
BENCH MARK (Assumed elevation) 100 ft
Inspection is' 7/27/2022 8/3/2022
dates:
Location and description
2m
3rd 4h___-_-_-
concrete stair landing
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval: Date
OF Ak-
...4
. 7
-'W'* "49 1H
.... . ................
Ar .......
...
t "Mift-
�j'% No CE IIIW4
Septic 1��tsjtgD2___
Approved 1 Date
Note: this approval does not include well permit requirements.
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�P� OF A �,9��p4
x..49 TH*'*
SHANE A. HOLT .'
P� LS -6914 o` e
�4aA .-- . cJ_o
jessIonaY
THESURVEYDATA AND MEASUREMENTS HEREON ARE PREPARED FOR THE
OWNER OF RECORD AS OF THE DATE OF THIS SURVEY.
ANYUSE OF THIS DRAWING BY THIRD PARTIES IS PROHIBITED UNLESS
WRITTEN PERMISSION IS PROVIDED.
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOGI ANY
CONFLICTS BETNEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS
NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELIN£S-
£ASEMENTS OF RECORD, OTHER THAN THOSE APPEARING ON THE RECORD PLAT , ARE NOT SHOW
HEREON ( UNLESS INDICATED)
NOTE= FENCELINES THAT MAY APPEAR ON THIS DRANING ARE NOT TO BE USED TO DETERMNE
PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS.
ANY PAVING SHOW HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNO/V AND/OR ICE.
AS-BU/LT SURVEY f"=30'
NO CORNERS SET THIS DATE
l HEREBY CERTIFY THAT / HAVE PERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY
ACRE LOT2SKYLINE VIEWEST.4TES (PLAT P- 08)
ANCHORAGERECORDING DISTRICT, ALASKA, AND THAT THE
VISIBLEIMPROVEMENTSS/TUATED THEREON AREWITHIN
THEPROPERTYLINESAND NO VISIBLEENCROACHMENTS
EXIST OTHER THAN NOTED.
DATED ATANCHORAGE,ALASKA THIS 1 -'Ty DAYOF
AUCLIST -2022
1552 i25-26
HOLT LAND SURVEYING
9309 GROVER DRIVE
ANCHORAGE,AK 99507
223-8615
MUNICIPALITY OF ANCHORAGE
On-Site Water & Wastewater Program
PO Box ',|96650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone; (907)343-7904 Fax: (907) 343-7997
httpr//wwu muni. org/on site
Effective Date:
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
Date:
Date:
l)af trn en r
On-Site Wastewater Disposal System Permit
Permit Number: O5P221216
Work Type: SepticTank Upgrade
Tax Code Number: 05119205000"
Site Legal Address: SKYLINE VIEW LT 2 G:1159
Site Mailing Address: 19405 WILDWOOD DR, Chugiak
Owner: STEVENSON VERNON R & DORRIS A
Design Engineer: EKLUTNA ENGINEERING, LLC*
This permit is forthe construction of:
fl Disposal Field EI Septic Tank E Hotding Tank [J privy ! PrivateWell E Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and '15.65 and the State of Alaska
Wastewater Disposal Regulations (18A C72) and Drinking Water Regulations (18AACSO)
3. The wastewater code requires inspections during the installation. The engineer shall notifi7 the Development
Services Depaftment per AMC 15.65. Provide notification by calling (907) 343-7904 (2417).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
',|,
Special Provisions:
' Deck supports within 5' of the proposed tank are to be removed and replaced with supportS that are
deeper than the bottom of the tank.
' The engineer is to indicate on the Record Drawing the location and depth of the supports replaced.
6129t2022
612912023
43560
3
Received By:
MUNICIPALITY OF ANCHORAGE
Development Services Department epartment ._.. � phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 051-192-05
Property owner(s) STEVENSON VERNON & DORRIS
Mailing address PO BOX 671935 CHUGIAK, AK 99567 1935
Site address 19405 WILDWOOD DR
Legal description (Sub'd., Block & Lot) SKYLINE VIEW
Legal description (Township, Range & Section)
Lot Size 43,560 Sq. Ft. Number of Bedrooms 3
LT 2
Day phone
APPLICATION IS FOR:
APPLICATION IS AN: TYPE OF DWELLING:
(M all that apply)
Receipt Number:
Absorption Field ❑
Initial ❑ Single Family (SF) Q
Septic Tank Q
Upgrade [Q (wlGvoA`D ' )
Holding Tank ElRenewal
❑ Duplex (D) ❑
Privy ❑
Multiple Dwellings ❑
(SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES
A WAIVER REQUEST FOR:
Distance:
I certify that the above information
is correct. I further certify that this is in accordance with
applicable Munigjjal Codes.
(Signature of prdpeffy owner or authorized agent)
Permit/Rush Fees:
Date of Payment: ( ab,)_�
Waiver Fees:
Date of Payment:
Receipt Number: 00 3 2 3b
Receipt Number:
Permit No.
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Eklutna Engineering, LLC
curtistownse nd @gma il.com
June 21,2022
Subject: Skyline View Lot 2
Upgrade Septic System Permit Request Narrative
osP 22t2L6
This is a design narrative for a permit to upgrade the septic system at this property. The proposed
system will serve a three bedroom house. The existing tank and field are 39 years old. The existing septic
tank will be removed and disposed of. The existing trench was tested in May 2022 and found to be
adequate. lt will not be replaced at this time.
L. Soils. A test hole was previously dug to a depth of L4' and no groundwater was encountered.
Soils are gravels and silts.
Wells. This lot is served by a private well. This well was tested for nitrates in May 2O22.The
concentration of nitrates is 9.1-2 mg/1. The well has a sanitary cap and the electrical wires are
protected. The well is greater than L00' from the septic field and tank. The tank will be greater
than l-0' away from the water line. Neighboring wells are all greater than 100' from the
proposed system.
Neighboring Wastewater systems. lmmediate neighboring septic systems are all +30' distant.
Surface Water: There is no surface water within 100 feet of the proposed septic tank and drain
field. The proposed drain field upgrade will maintain at least 100 feet from all surface water and
drainage ditches.
5. Topography: The area where this tank will be installed has a slope of less than L%.
The proposed installation will not affect the future development of this or the surrounding lots.
Sincerely,
Curtis L. Townsend, P.E.
2.
3.
4.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221216, Deb Wockenfuss, 06/29/22
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On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221216, Deb Wockenfuss, 06/29/22
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On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221216, Deb Wockenfuss, 06/29/22
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING
*
DIVISION
825 L Street - Anchorage, Alaska 99501
L
Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR
WELL INSPECTION REPORT
NAME
PHONE
SEW
�> —..<.VF;_s 1(�
6%4—Z`3%5
❑UPGRADE
MAILING ADDRESS
P. ®' max_ to) IqK(<
' S -C(" -
LEGAL DESCRIPTION
LOCATION
NO.
OF BEDROOMS
13
Well
Absorption area
/
Dwelling / PERMIT
NO.
DISTANCE TO:
/G d�
U
_Y
I-_ Q
Manufacturer
�a 12-.�i
MatgfLayl��� No.
of compartments
LU ti
c�
1 Cs
Z.
rn
Liq. c acityingallons
(( p
IF HOMEMADE:
Inside length
Width Liq
uid depth
X
DISTANCE T0:
Well
Dwelling
PERMIT
NO.
0Z
O Z Q
Manufacturer _
Material Liquid
capacity in gallons
DISTANCE TO:
Well /
Foundt3-� atio !.-
Nearest lot line,, / PERMIT
NO. �,
S
r
Z
No. of lines /
Length of ea�b,line(
q
Total length lines,,
Trench widt Distance
between lines h!
F. u
0
inches
7a
cut`
tinches
Top of tile to finish grade
Material beneath tile
Total
effective absorption area
Length
Width
Depth
PERMIT
NO.
w
(7
F-
Type of crib
Crib diameter
Crib depth
Total effective absorption area
OQ.
LU
LU
Well
Building foundation
Nearest lot line
DISTANCE TO:
ClasspegtIt
Driller
Distance to lot line PERMIT
NO.
LU
i�
I DISTANCE TO:
Building foundation
Sewer line
Septic tank Absorption
area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
c
REMARKS
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''obert A. Sh❑for t4e
Y " No. f457.E r R ,
c t,c
APPROVED:` r DATWECE
PI 69i-,
72-013 (Rev. 3/78) % /
MUNICIPALITY OF ANCHORAGE
Department 'f Health and Environmenta Protection
825 Street, Anchorage, AK. >9501
264-4720
# HANDWRITTEN PERMIT
Permit # ELL AND/OR ON-SITE SEWER PERMIT
Applicant:<. '(%P/�i/�U Mailing Address:1 Aoy A-577
Location: Phone Number: l
Legal Description: LG ��/I �P ���� `f� Lot Size:
Type of Soil Absorption Sys em Is:
Trench: Drainfield: _ Seepage Bed: Holding Tank:
Maximum Number of Bedrooms:_ Soil Rating(sq.ft/br)�� �r
The Required Size of the Soil Absorption System Is:
DEPTH LENGTH G� GRAVEL DEPTH WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
# REQUIRED SEPTIC(HOLDING) TANK SIZE _ GALLONS # #
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve. '
.# TWO(Z) INSPECTIONS ARE REQUIRED
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feel
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 u 3 es
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enla em t if
the residence is remod led to include more th t 3 drooms
Signed: Issued by:
Applicant
Date:
SWP/024(1/81)
XSOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
t( s �1� TEST
i 825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
/12
opo cn QnnGn tinct l (�/��� j/i /'/ DATE PERFORMED: / y �J
LEGAL DESCRIPTION: //0- /`'SLOPE ho
1 SITE PLAN
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
y
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
S// Z'/, r% DEPTH?
�U P
F,R•� �1�3 _r;
L� S
L
O
P
E
M
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
fel ,
PERCOLATION RATE /M (minutes/inch)
TEST RUN BETWEEN -- FT AND - FT
72-008 (6/79)
DEPHRTMEHT HEHLTH HN� ENVIRONMENTRL �OTECTION
STR2E[/ HHCHORHGE/ HK995G1
264'4720
PERMIT NO ( 82025� )
HPPLICHNT KHTIE PHILLIPS
LOCRTION
LEGRL L2 �KYLINE VIEW S/D
BOX 164 EHGLE RIYER HK
LOT SIZ�
]0008 SQUHRE F��T
MIHIMUM DISTHNCE
BETNEEN
H WELL
HND HNY OH~SITE SEWH�E DISPOSHL
SYSTEM IS
100 F�ET
FOR H PRIVHT�
HELL OR
15G TU
20G FEET FROM H PUBLIC NELL
DEPENDING
UPOM THE
TYPE OF PUBLIC
NELL
MINIMUM DISTHNCE
FR0M
H PRIVHTE
WELL
TO H PRIVHTE SEWER LIHE lS
25 FEET HMD
TO H COMMUMITY
SENER LI�E
IS 73
FEET
HELL LOGS
HRE REQUIRED
HN� MUST
BE RETURNED
TO THE DEPSRTMENT WITHIN
]0 DHYS
OF THE WELL
COMPLET{ON
OTHER REQUIREMENTS
MHY
RPPLY
SPECIFIC8TIONS
HND CONSTRUCTION
DIHGRHMS HRE
HVHILHBLE
TO INSURE PROPER
INSTHLLHTION
��- .111. �l���
I CERTIFY THHT
i� I HM FHMILIRR WITH THE REQUIREM�Nl�S FOR ON�SITE SEWERS HND WELLS HS SET
FORTH BY THE 11NICIPHLITY OF HNCHORHG�
2� I WILL I��THLL THE����EM IN HCCORDHNCE H�TH THE CODES
ISSUED BY
S
__-
~_.~DHTE.~~~^
' v
Trrjtfirb l5rillingj'arvaig
by
DOC Co. dba
SULLMN WATER WELLS
P.O. BOX 272, CHUG IAK, ALASKA 99567 • TELEPHONE 688-2759
OWNER OF LAND
ADDRESS
LEGAL DESCRIPTION -
DATF. -Started _ Ended
PERMIT NUMBER
KIND OF FORMATION:
From
Ft. to`
Ft.
From
From
Ft. to 'f -
Ft. _' `
Ft. to
From
Ft: to
Ft.
Ft.
From '
Ft. to
Ft.
From
From
Ft, to
Ft.
Ft. to
From
Ft. to -LL-'
Ft..
From
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DRILLER'S NAME
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/WELL SUBMITTAL COMMENT SHEET
To: Tobben Spurklond
Legal description: Skyline View Lot 2
The attached paperwork has been reviewed and is being returned for the following reasons:
❑ Original signature or stamp missing on _
❑ Calculation error in design. _
❑ Additional soils information needed. _
❑ Water monitoring results inadequate. _
❑ Discrepancy in information submitted. _
❑ Topographic information missing or inadequate. _
❑ Incomplete; missing
❑ Incomplete; missing _
❑ Additional adequacy test information needed.
® Water sample unacceptable. Allowable Nitrate is 10.
❑ Measured/proposed distances/dimensions missing. _
❑ Locations of all soils, percolation and water monitoring tests not shown. _
❑ Proposed system too deep for soils information submitted.
❑ Well log required. _
❑ Omission in narrative. _
❑ Insufficient fill over tank or field._
❑ Other.
Name of reviewer: Jeff Poet
Date: 10-28-02
Please supply the necessary information and re -submit your request.
LEAVE THIS FORM ATTACHED TO THE PAPERWORK
Certificate of On -Site Systems Approval
Parcel I.D. 051-192-05
Legal description Skyline View lot 2
Site address 19405 Wildwood Dr Chugiak
Current property owner(s) Vernon Stevenson
Expiration Date:
11-26-22
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
By: 1.-.._- Original Certificate Date:
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
Absorption Field Advisory
Tank Age Advisory
Other
X Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
COSA Approval_June 2022
��1�UMCPAUTY OF AHCHORQGE
Development Services DepartmentPhone: 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. 051-192-05
Complete legal description SKYLINE VIEW LT 2
Location (site address) 19405 WILDWOOD DR Chugiak
Current property owner(s) STEVENSON VERNON & DORRIS Day phone
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
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: 0 Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel Jfl Plastic ❑ Concrete ❑ Fiberglass
Age <1 - 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
11-6 ZZ Date of Payment
COSA # 05G 22I y 09 Waiver #
COSA Application_ June 2022
Legal Description: SKYLINE VIEW LT 2
Parcel ID: 051-192-05
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)
Well production at time of test 7.8 gPm
Date drilled 1982 Total depth 81 ft
Water storage tank volume 0 gallons
Cased to $1 ft
Well disinfected for coliform test? ❑ Yes ❑ N
❑ Sanitary seal is functioning correctly
❑ Coliform bacteria is Negative
❑ Wires are properly protected
Nitrate 9.12 mg/L ❑ Nitrate less than MRL (ND)
Casing height (above ground) '24 in.
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Date of flow test for COSA 5/25/2022
Collected by Curtis Townsend
Static water level at beginning of test 63 ft.
Date 5/25/2022
Comments verified that well has a sanitary seal and electrical wires are protected
B. TANK DATA
Measured operating fluid level in septic tank _
Date of pumping tank installed July 2022
❑ Required maintenance completed, if AWWTS
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 1983
❑ ALL standpipes present per record drawing
Total measured depth from grade 9.8 ft (max)
Measured depth to pipe invert from grade 4.83 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) no
If yes, enter date
Comments/Deficiencies:
COSA Checklist June 2022
STATION
❑ Require aintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 5/25/2022
Results ❑ Pass
Fluid depth prior to test 49 in
Water added 467 gal
New fluid depth 58 in
Elapsed time 1417 min
Final fluid depth 45 in
Absorption rate ' 450 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 60 in
Effective depth used 45 in
Effective depth remaining 15 in
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 9
Community Sewer Manhole/Cleanout > 100'
Q Yes
if No
ft
Fal Yes
if No ft
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ❑ Yes
if No ft
Absorption Field on Lot > 100' [-1 Yes
if No
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 tank or field is under driveway
comment below
F. ENGINEER'S COMMENTS
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' 0 Yes
if No
ft
❑ 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 9
ft
Surface Water > 100'
Q Yes if No ft
Tank to Property Line > 5'
® Yes
if No
ft
Wells on Adjacent Lots:
Field to Property Line > 10'
Ful Yes
if No
ft
Private Wells > 100'
0 Yes if No ft
Water Main > 10'
no Yes
if No
ft
Community Wells > 200'
0 Yes if No ft
Water Service Line > 10'
Pn� 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 Finn Ek, & 0_/VA C /�'J 6 (Ak fzz,(Z'l Phone 907.406.1058
Engineer's Printed Name 1./ U .-'f1, Date 15�Z
COSA Checklist June 2022
�F • " . ce 11 'x^ •' • ,,'
hc�sTn. _ • , ... • •_aa�.�.v
ENGINEER'S
R
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC 221409
Subdivision: Skyline View Lot 2
A water sample revealed a nitrate concentration of 9.12 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.
Mailing Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni 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.
Mailing Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org
/ Municipality of Anchorage
! • �1 Development Services Department :•
\ Building Safety Division
On -Site Water and Wastewater Program
4700 South Bracaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchcrage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. _� CJ �— jQ)_-0t5-
HAA#, Q,12
Expiration Date:
1. GENERAL INFORMATION
Complete legal description
Lccation (site address or directions) 101 4 v0 5 W; kd , , o �_
Current Property owner(s) Steve Lt j K a� Day phone _ � S3 P — g7.0-5
Mailing address
Lending agency
Mailing address
Real Estate Agent S v n ri et i eo_I L, T—
Mailing Address ve gi e izedl e a
Unless otherwise requested, HAA will be held by DSD for pickup.
C
Day phone
7
Day phone�-
��L gg6,c; J
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:'
TYPE OF WASTEWATER DISPOSAL:
Individual Well
�/
Uv
Individual On-site
(7�
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 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 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(we) safe, functional and adequste 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 Stale codes, ordinances,
and regulations in effect at the time of installation.
Name of
Address
Engineer's Printed Name _ n irb rH SRO, I lgl LaC _
Phone _9-7q- 3-01/J6
Date
Y.-
1 _ 1
5. DSD SIGNATURE c` ".Ly
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: Original Certificate Date:
JR. 01.02)
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.ci.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L42 2 S k/ A I i&u V t tut' Parcel ID: 051-- Lg2,06
A. WELL DATA
Well type
Date completed !l -U2-
If A, B, or C provide PWSID # NA
Sanitary seal (Y/N)
Total depth _al_ft. Cased to _81_ft.
FROM WELL LOG
Date of test
Static water level
Well production
ft.
WATER SAMPLE RESULTS:
Coliform _o—oolonies/100 ml.
Arsenic: ✓ mg.A.
B. SEPTICIHOLDING TANK DATA
Nitrate
Date of sample: to]I40 7 -
Tank
Tank TypelMaterial�4, S k e c
Tank size lovig gal. Number of Compartments
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground) 99 n.
AT INSPECTION
10/11CL
b 6 fL
% g.p.m.
Other bacteria N -D colonies/100 ml.
Collected by: Lars S.p,1 rik la w °�
Date installed !-7-83
Cleanouts (Y/N)
Foundation cleanout (Y///N) _)L_ Depression over tank (Y/N) --N Hih water alarm (Y/N) U
Date of pumping /O(3%ot Pumper SC! &C; K L4 -w le -4 rS
C. ABSORPTION FIELD DATA
Date installed 7 -7-�i 3 Soil rating (g.p.d./ft= or ft�/bdrm) (L System type I.uw.ic
Length '�y ft. Width 215 ft. Gravel below pipe ft.
Total depth ft. ER. absorption area .2ugg_f1:2 Monitoring tube -y— Depression over field N
Date of adequacy test r ° Results (Pass/Fail) tom' For 3 bedrooms
Fluid depth in absorption field before test 3 7 in. Water added Loo gal. New depth in.
Elapsed Time: _ min. Final fluid depth 17 in. Absorption rate >= 6 6O �.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) 11-1/ If yes, give date r/
�, r.,+ ! .r..
D. UFT STATION
Data installed SIZA n gallons
'Pump on" level at _ in. 'Pump otr level at _ in. High r alarm level at in.
Datum Cycles tested eft alarm 8 circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 1 t0 0 1 On adjacent lots roc
Absorption field on lot
11004
Public sewer main t-4/Al-
On adjacent lots /e0 r
Public sewer manhole/cleanout N/h
Sewer /septic service fine I ;C) t Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO
Building foundation 10 Property line qi) Absorption field .6
Water main t-41,,, Water service line % h Surface water 100 t
Wells on adjacent lots 100+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ti0 Building foundation 13 Water main NA
Water Service line > ;- .5— Surface water, 100+ Driveway. parking/vehide storage 101
Curtain drain Meg eg Wells on adjacent lots 100
f
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and W—tom,
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.Oft
06
Engineer's Printed Name ( Q %ktN �ny Y V. l aK t \ ,,�� s�ti•.
Date QL� 3� ��,; F•OrE55�0��
HAA Fee $ 3 7 Waiver Fee $
Date of Payment IOIy *102Date of Payment
Receipt Number a7 9-119--1.+- Receipt Number
(Rev. 12/01)
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