HomeMy WebLinkAboutTENGBERG LT A1Onsite File
#01 5am 231 am43
Municipality of Anchorage ,
On -Site Water and Wastewater Program • (907) 343-7904 C14 Pat � ,:.:sof 3
ON-SITE WASTEWATER INSPECTION REPORT 2 ,: h
Permit Number: OSP181272 PID Number: 015-231-43
z'
Dwelling: ❑■ Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ❑ Upgrade
Name:
Carol Schatz & Jeremy Lansman
ABSORPTION FIELD
❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
7200 Alatna Avenue Anchorage, AK 99516
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
250-5048
4
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Tengberg Al
Fill added above original grade
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ft
Ft.
Well
>100'
>100'
N/A
N/A
>25'
TANK 9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Anchorage Tank
Capacity
11250 Gal.
Surface Water
>100'
>100'
N/A
N/A
Material
Number of compartments
Lot Line
>10'
>10'
N/A
N/A
Steel
2
NA
Foundation
>l0'
>10,
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Curtain Drain
None
Noted
Gal.
Remarks Tank replacement only
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
Pump make and model
Electrical Inspections performed by
PIPE MATERIAL House to tank Exist. Tank to
drainfield D3034
Installer
PCN
Drainfield EXIstinci CO/MT
Inspector J. Millette
BENCHMARK (Assumed elevation) 100 ft
Inspdat 15 8/28/18 8/29/18
Location and description
es: 2nd
3`d 4th
Bottom of siding
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
ri
law • • .Atgs l
Conditional Approval: Date
��g�Q:•' • •
•!i�,�1�
*: 49 TH •.
.... .. .......
enJami • •chiller
Approved &IZ12�e& Date
�F•• C 12 92 ••`�/
�'srF�• 9 aH •���AW
l�iF�'°ROfESS10NP
Inspection Report_9-1-12.doc
TENGBERG LOT Al
PERMIT # OSP181272 PID # 015-231-43
ALATNA\AVENUE
® 1�
(iEXISTING WELL
1,250 GALLON 3-BDRM HOME
SEPTIC TANK /
\,co LOT Al ,
- — —" sv1 SHED
SHED � sv2 - co
iQ EXISTING
ABSORPTION
j, TRENCH
i
Lu r
w
2E
w i �
wi
E—i O.H.POWER LINE
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.T_
•.' Benjamin chiller '.
CE 12592
.e.z...°.a..-F�G�
PROFES510��P
PLAN AS -BUILT
A
B
SV1 15.7
36.6
SV2 23.6
1
37.9
1
2C0 26.3
38.8
0 50 100
FEET
1.1=50'
LEGEND
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEAP
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
TENGBERG LOT Al
PERMIT # OSP181272
G
��EENGINEERING
P I D # 015-231-43
PROFILE AS -BUILT
(NO SCALE)
JV.J
OF A
. ' Renja .Schiller .....
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I,�I��FRO
CE 12592
��� PROFESSIONP�`
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`'°""Tpofr MUNICIPALITY OF ANCHORAGE
On-Site Water&Wastewater Program _. S
PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 .-
http://www.muni.org/onsite 111
l)eparttticnt
S' NON pVE
On-Site Wastewater Disposal System Permit
Permit Number: OSP181272 Effective Date: 8/16/2018
Work Type: SepticTank Upgrade Expiration Date: 8/16/2019
Tax Code Number: 01523143000
Site Legal Address: TENGBERG LT Al G:2739
Site Mailing Address: 7200 ALATNA AVE, Anchorage
Owner: SCHATZ CAROL E & Lot Size in Sq Ft: 91536
Design Engineer: FORGE ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
❑ Disposal Field El Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 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 (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
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
Received By: 1AL-11//9(11,0Date:
Issued By: -RtAX,CJ C9L,"( 'X Date: 6 /l•7 1'
56189701,
MUNICIPALITY OF ANCHOR A
AUG 15 2018
Community Development Department P• •: -: 907-343-790,
Development Services Division ' - •07-343- ••jl
On-Site Water & Wastewater Program 01 6 8 1, 9
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 015-231-43
Property owner(s) Carol Schatz & Jeremy Lansman Day phone 250-5048
Mailing address 7200 Alatna Avenue Anchorage, AK 99516
Site address Same
Legal description (Sub'd., Block & Lot) Tengberg, Lot Al
Legal description (Township, Range & Section)
Lot Size 91,536 Sq. Ft. Number of Bedrooms Fa c,�.r (LI)
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field Initial Single Family (SF) IXi
(w/wo ADU)
Septic Tank ❑X Upgrade n
Duplex (D) ❑
Holding Tank Renewal Multiple Dwellings
Privy I I (SF and/or D)
Private Well n
Water Storage Li
THIS APPLICATION INCLUDES A VARIANCE /WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: c (3 Waiver Fees:
Date of Payment: 1)/(.0112 Date of Payment:
Receipt Number: O(04(09-f Receipt Number:
Permit No. ( 5 Pl it a'D. Waiver No.
Permit App_:- ':.,c;
idf '
GE
ENGINEERING
PO BOX 240773
ANCHORAGE,AK 99524
522-7773 677-7766(FAX)
August 15, 2018
Municipality of Anchorage
Development Services Dept-On-Site Water& Wastewater Program
4700 Elmore Rd
Anchorage,AK 99507
Subject: Tengberg,Lot Al —7200 Alatna Avenue
Septic System Design and Permit Application
Dear On-Site Services Engineer:
The septic tank on the subject lot is leaking and must be replaced prior to the issuance of a
COSA for the property. The attached site plan identifies the location of the home and the existing
well and septic system. No conflicts exist between this proposed system and any other well or
septic system,whether on this lot or adjacent lots.
The septic tank will be placed outside the 100' protective radius for the well near the two
existing septic tanks on the lot. The existing tanks will be decommissioned in accordance with
MOA Code.
The existing well on the lot is shown. The placement of the new septic tank will not encroach
into surrounding protective well radii. Please refer to the attached plan sheet for the septic
design. If this design is followed,there will be no adverse impacts to adjacent properties.
Sincerely, .410" NN
Michael E. Anderson,PE "I*: 49 TH
'. Michael E.Anderson . die
4381-E . /
•, 8/15/18 ';\c; ,,�
�10:°PROFESS���P
TENGBERG LOT Al
PERMIT # OSP181XXX PID # 015-231-43
// , � ALATNA& VENUE
4-- ) - __ \ — — —
Il
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I I i1
LL
^5
1 IEXISTINW
C� E
\ /
1,250 GALLO
fMHOP / > ' O
SEPTIC T K A,
N *co/ / rOT Al
r — T7 —
'N,/ '
s �
15 ROADWAY .10, ...,,s
2CO
EASEMENT J , DECOMMISSI _ ISTING /
TANKS PER OA CODE
Ir
- /
1 I /.. (Ni)
1
, '°1
/2 I - ISTING /\ \
ABSO"PTION J
10'U ITY
EASEMENT l RENCH
/ ` WOO' FENCE
,:i
/
} ---..._ _/
: S
\ ‘IL_ V , O.H.POWER LINE
moo_ _
I�
1
\ I
I �
I
illikGE
FXGINEE■1X6
I NOTE:
���0k� 1a4i, NO SLOPES>25%WITHIN 50'OR SURFACE WATER WITHIN 100'OF THE LEGEND
.. �.r.lJr -, �,+� PROPOSED SEPTIC SYSTEM
� �,.r t �� CO-CLEANOUT
• 2C0-DOUBLE CLEANOUT
IS 4 ' j� a- - ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
49th . ..,j FCO-FOUNDATION CLEANOUT
r / PROPERTY ARE SHOWN.NO CONFLICTS WITH WELLS OR SEPTIC
r. ».....«.p.�. �� SYSTEMS. MT-MONITORING TUBE
�MICHAEL E. ANDERSON ._ al SV-SEPTIC VENT
.c,-,%
�% No. cE-438i l r 0 50 100 TH-TEST HOLE
• • ,► : = = FEET
•+,4?OFESS\ +4• 1"=50'
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Nar.~ DISTANCES
Ad~ress ' WELL
Phone(s) Permit No. ,o o~ B~oms WELL
AS-BUILT DIAGRAM (Show location Gl well, septic system, properly 1mas, foundation,
~ SEPTIC ~ HOLDING
TYPE OF SYSTEM
Deplh to pipe botJom ,rom Total depth Irom original grade
originalgrade ~ FT~ /O [T -- --
Fitl added above original grade Gr.vel depth beneelh p, pe
Total ~bsorption acea Distance between lines
Date Instaaed
WELLS -
~PRIVATE ~ OTHERfldentifv)
~ssdication (A,B,C) Total Depth ET Cased to
__ Inspections Pedormed by:
[ __~, ~ __ cedily that tills Inspection was pedormed according to all .
72-013 (3/85)
PERFORMED FOR:
Municipality of Anchorage
820 "L" Street, Anchorage, Alaska 99502-06~~,'~;
__
LEGAL DESCRIPTION:'7'---~4'~7~ /¢'
5
6
8
9
10
11
12
13
14
15
16
17
18
19
2O
~,~JNr~e'! ~//~. Township, Range, Section:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
iF YES, AT WHAT
DEPTH?
Dopth l0 Waler After ~Z /
Monitoring? Bate:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
tm~nutes/mch) PERC HOLE DIAMETER __
TEST RUN BETWEEN FT AND FT
COMMENTS .CO/Z.
PERFORMED BY: /¢¢z~'~,~ /¢~. ~./,~-/,/t I ~&'~"~ ~--~'¢'"'~- CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATF: ~'~"~ ~'/'' dc ~
72-008 (Rev, 4/85)
2
I is the responsibility of the owner to determine Karl DewlJng
the existence of any easements, covenants, or re-
strictions which do not appear on'the'recoffded sub~: . .... ..:
division plat. Under no circumstances should any ; . NOTE
da~a hereon be used for construction or for estab- ~vs
lishing boundaEy or fence lines. The surveyor take~ S~OWNON NO~
SSOWN ~on.
respons?~lity fo,.the initial transaction only. ..
~C~GE RECORDING DISTRICT u nO. · r~. .....
ANCHORAGE, ALASKA , 99~01 ffEVlSlON OATS ·
ALASKA [ZI1UIROIlmI FITAL COFITROL SEMUIC $, IFIC.
UNIFIED SYSTEM ASTM D-2487
09/24/87
TENGBERG SUBDIVISION TRACT A
SAMPLE IDENTITY I
PASSING #200 SIEVE: 2,86% RETAINED: 21.65%
PASSING # 40 SIEVE: 24.50% RETAINED: 32.74%
PASSING # 10 SIEVE: 57.24% RETAINED: 11.60%
PASSING # 4 SIEVE: 68,84% RETAINED:
PASSING 1/2 IN SIEVE: 84.64% RETAINED: 5,82%
PASSING 3/4 IN SIEVE: 90,46% RETAINED: 7.69%
PASSING I INCN SIEVE: 98.15% RETAINED: 1.85%
PASSING 2 INCH SIEVE: 100.00% RETAINED: 0.00%
PASSING 3 INCH SIEVE: 100.00% RETAINED: 0.00%
D10 IS 0.27 MM.
D30 IS 0.50 MM.
D60 IS 2.50 MM.
THE LIQUID LIMIT IS UNKNOWN
TIlE PLASTIC LIMIT IS UNKNOWN
THE PLASTICITY INDEX IS UNKNOWN
CU = 9.26
CC = 0.370
TIlE SOILS ARE COARSE GRAINED
SANDY SOILS
TIlE SOILS ARE POORLY GRADED SAND.(SP)
1200 L[J~sl 33r~ Aucnu¢, Suil¢ B .Anchord§¢. ^l ka 99503'(907) 561-5040
TEST HOLE NO. /
/
Legal Deecription.-~?-~
Sample Depth_. , /~
D
Con~nent s_
Reported
Plotted _~,
,~hecked by_
_~proved by
t SIEVE
SIZE OF OP~NING IN INCHES J NUMBER Of: MESH PER INCH U,S. STANDARD
t m
J JJ J~
BRAIN SIZE IN MILL.
CO~B~S
GR~VEL
PERFORMED FOR:
LEGAL DESCRIPTION: '7~i~''' ~
.~, ~', /'l ~.E~:~ [~E ER'S SEAL)
Municipality of Anchorage
DEPArTmENT OF HEALTH a HUMAN SERVICESg';;:'~
~ Township, Range, Section:
'1
2
3
4
5
6-
7-
8-
9-
10
11
12
13
14
15
16
17
18
19
20-
COMMENTS
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth to Wafer After
M6nitoring? Date:
Gross Net Depth to Net
Reading Date Time Time Water Drop
"---... _
_
PERCOI.ATION RATF-
(minutes/tach) PERC HOLE DIAMETER
TEST RUN BETWEEN __ FTAND __FT
PERFORMED BY: ,/~t~--~ ~"' '~"/~) I
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE,
72-008 (R~v. 4/85)
F:IIEPLY
472
SIGNED
SEND PARTS I AND 3 WITH CARBON INTACT -
PART 3 WILt BE RETURNED WiTH REPLY.
DETACH AND FID: FOR FOLLOW-UP
DATE
//
GRE!
'R ANCHORAGE AREA BOI~'"GH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
,INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION
SI-- PTIC TANK:
DISTANCE~
FROM WE~~NUFACTURER ~¢~2¢
INSIDE LENGTH INSIDE WIDTH__
MATER,AL __ /
NUMBER OF
COMPARTMENTS
__LIQUID DEPTH
.LIQUID CAPACITY /~g)(~ __GALLONS.
SEEPAGE PIT:
NUMBER OF: PITS / DIAMETER _-
LINING MATERIAL ~',~'10't~ / CRIB SIZE:
OR W,DTH 151
DIAMETER
BUILDING FOUNDATION__
NEAREST LOT LINE
ADDITIONAL ABSORPTION
LENGTH~., DEPTH
DEPTH g~tI. DISTANCE FROM: WELL~~
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA) SQ. FT.
TYPE F~'; ~'~t'~-" CONSTRUCTION
BUILDING NEAREST
FOUNDATION -- LOT LINE
CESSPOOL
OTHER SOURCES
APPROVED
DISAPPROVED
_ DEPTH _
NEAREST SEPTIC
SEWER LINE TANK
REMARKS
/ DISTANCE FROM:
SEEPAGE
SYSTEM
DISTANCES:
LOT SLOPE:
Form No. EQ-031
DIAGRAM OF SYSTEM
GREATER ANCHORAGE AREA BOROUGH
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
INSTALLATION LOCATION
PERMIT NO.
[NSTALLATION OF: SEPTIC TANK
TYPE AND SIZE OF FACILITY TO BE SERVE[)
FINANCED THROUGH
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REQUIRE[:}, BACKFILLING OF' ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMFNT OF ENVIRONMENTAL QUALITY AUTHORITY Will BE SUBJECT TO PROSECUTION.
SEPTIC TANK SIZE TYPE
FOUNDATION TO SEPTIC TANK '~ 1
FOUNDATION TO SEEPAGE PIT ~ / DRAIN FIELD
SEPTIC TANK TO SEEPAGE PIT WALL / ,¢ {~
SEPTIC TANK SEEPAGE PIT ~
WELL TO SEPTIC TANK r/'~ '/~ , SEEPAGE PIT
WATER MAIN TO SEPTIC TANK
DRAIN FIELD
SEPTIC TAN K. X~/~ ~'~,~ E EPA'2 E
TO RIVER, LAKE, STREAM,
· SEEPAGE PIT ~
P,T 100_.
CAST IRON INTO AND OUT OF SEPTIC TANK AND ~NTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOil.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVE/ BACKFILL
CONFORM TO BOROUGH F~EGULATIONS REGARDING INSTALLATION.
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-6b AND THAT THE ABOVE
GREATER ANCHORAGE AREA BOROUGH
Depar 'ent of Environmental Quality
3330 "C" Street
Anchorage, Alaska 99503
Performed ~or ~ Date performed
JhI$ focal reports: Soils qog~_ Percolation test
Depth
F£et
1-7. .......
3-
5-
7-
10-
12-
13-
14 -
Was ground water encountered?
If yes, at what depth?
Reading
'Date
GroSs l'ime ~ Net Time
Depth to H20
mi nu te.
Proposed installation: Seepage Pit ..... Drain Field '
Depth of.][nl~et ~._.~. Depth to bottom of ~i ~ or trench
................
Performed By: .... er~ified By: Date:
, ,~ONSULTA, NTS, INC.
January 21, 1975
Mr. Gene Sleeper
Star Route A, Box 395T
Anchorage, Alaska 99507
No. 562001
Re: Test Hole and Soil LOg Report for Sanitary System
Tengberg Subdivision, Track A --
Dear Mr, Sleeper: ~ ~ ~'~ ~ ~ ~ 7'~ ~-~
We are submitting herewith the test boring results and our comments
regarding soil conditions encountered at the subject site. This
investigation was performed in accordance with your request of
January 16, 1975, and those procedures outlined in a letter dated
Decen~er 19, 1975 by Mr. Rolf Striekland. of the Greate~ Anchorage
Area Borough Depar~uent of Environmental Quality.
A single test hole was put down within the Lot area for the purpose
of defining general subsurface soil conditions for the proposed
sanitary system. Excavation was accomplished with an auger type
drilling rig and the test hole was extended to a total depth of
20.0 feet below ground surface. One sample was recovered from a
depth of 8.0 to 12.0 feet in the test hole and retained for grain
size analysis. The results of this test are enclosed. The final
log prepared for the test hole has been incl~lded ~n Drawing
Ground water was not encountered in the test hole.
We appreciate being given this opportunity to be of service to you.
Should you have any questions with regard to the above, please do
not hesitate to contact us.
Very truly yours,
R & M CONSULTANTS, INC.
eames W. Rooney
Vice President
LABORATORY TEST REPORT
TEST ON Insitu Material
PROJECT NO, PROJECT NAME. ~.ene Sleeper
SAMPLE[) FROM. Test Hole No. 1 .SUBMITTED 8Y Jones
SOURCE Track A, Tengber~ Subdivision__
LOCATION Anchorage __DEPTH
SIZE DISTRIBUTION
#4
fl~M PROJECT NO.-~,~.O~.-___ ,
8 - 12' DATE SAMPLED--1-20-75
CLASSIFICATION
%+10
GRAVEL
SAND
°/o CLAY
FSV
LL
PL
UNIFIED
AASHO
FAA
LAB NO. 75A-141
1
FIELD NO,
DATE REPORTED 1-21-75
DATE RECEIVED 1-20-75
COMPACTION
SM
NATURAL I~ERSITY
NATURAL MOISTURE
WEIGNT LOOSE
WEIGHT RODDED
REMARKS
STATIC IMMERSION
i% ___ i i/a% ___ 2%
DELETERIOUS MATERIAL.
MINUS ~'~ 200 MESN
SOFT FRAGMENTS
COAL ~ LIG. OR LT. WT. PART.
CLAY LUMPS
STICKS B ROOTS
L.A, ABRASION LOSS GRADE
DEGRAOATION VALUE
THIN - ELONGATED
ORGANIC COLOR
MOISTURE - PERCENT
F~v~. ~Englneering ~ Geological Con~ulton?~
Gene Sleeper Property
MUNICIPALITY OF ANCHORAGE
c;
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 015-231-43
1. GENERAL INFORMATION
Complete legal description Tengberg, Lot Al
Location (site address)
Expiration Date: /-)
—I
7200 Alatna Ave, Anchorage, AK 99516
Current property owner(s) Carol Schatz & Jeremy Lansman Day phone 250-5048
Mailing address 7200 Alatna Ave, Anchorage, AK 99516
Real estate agent Day phone
2. TYPE OF DWELLING:
Q Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
El
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for:
Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $_V0_0'0
Date
V0 -
Date of Payment (D 1I
Receipt Number Oct1 4 r4
COSA# VS Gl Ila01�
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
1e hush, � eplan
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Engineering Phone 907-522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage AK 99503
Engineer's Printed Name Michael E. Anderson, P.E. Date 7/9/19
6. DSD SIGNATURE
System #1 Approved for 4 bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for
-MUMM
bedrooms, with the following stipulations:
_V4 of Ali
ON-SITE
WASTEWATER Z
PROGRAM
By: .�._ (� N Original Certificate Date:
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
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
X Nitrate Advisory
Arsenic Advisory
Other
Legal Description: Tengberg, Lot Al
Parcel ID: 015-231-43
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
❑ Well log is filed with Onsite (or attached) Well production at time of test 4.9 gpm
Date drilled Unknown Water storage tank volume 0 gallons
Total depth 67 ft Well disinfected for coliform test? ❑ Yes ❑ No
Cased to 67 ft ❑ Coliform bacteria is Negative
❑ Sanitary seal is functioning correctly Nitrate 7.45 mg/L ❑ Nitrate less than MRL (ND)
❑ Wires are properly protected Arsenic ug/L ❑ Arsenic less than MRL (ND)
Casing height (above ground) 14 in. Collected by FORGE ENGINEERING
Date of flow test for COSA 7/24/18 Date of Sample 7/8/19
Static water level at beginning of test 45 ft.
Comments Well and casing depths from MOA files. No well log is available. *Bacteria sample retaken 7/16/19
B. TANK DATA
Age of tank(s) 82018 years
Tank type/material Septic/Steel
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping Septic Tank installed 8/2018
D. ABSORPTION FIELD DATA Shallow Trench
Which system tested (date installed) 11/5/87
❑ ALL standpipes present per record drawing
Total measured depth from grade 10 ft (max)
Measured depth to pipe invert from grade 6 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 7/24/18
Results ❑✓ Pass For 4 bedrooms
Fluid depth prior to test 0 in
Water added 783 gal
New depth 0 in
Elapsed time 0 min
Final fluid depth 0 in
Absorption rate 600+ gpd
Any rejuvenation treatment (past 12 months) None
If yes, enter date
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
F✓
Yes
Community Sewer Manhole/Cleanout > 100'
Q Yes
if No
ft
Q Yes
if No ft
Neighboring Tank > 100' F/� Yes
if No
ft
Private Sewer/Septic Line > 25' F-/� Yes
if No ft
Absorption Field on Lot > 100' F,/� Yes
if No
ft
Holding Tank > 100' F/� Yes
if No ft
Neighboring Absorption Fields > 100'
Yes if No ft
Water Main > 10'✓0
Animal Containment > 50' 0 Yes
if No ft
FV -1 Yes
if No
ft
Q Yes if No ft
Water Service Line > 10'✓71
Yes
if No
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway
Community Sewer Main > 75' F/� Yes
if No
ft
Fv� Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
F✓
Yes
if No
ft
Surface Water > 100'
R✓ Yes if No ft
Property Line > 5'
0
Yes
if No
ft
Wells on Adjacent Lots:
✓-1
Absorption Field > 5'0
if No
Yes
if No
ft
Private Wells > 100'
Yes if No ft
Water Main > 10'✓0
ft
Yes
if No
ft
Community Wells > 200'
Q Yes if No ft
Water Service Line > 10'✓71
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 Lane > 10'
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
✓-1
Yes
if No
ft
Private Wells > 100' ®✓ Yes if No ft
Water Service Line > 10'
FV -1
Yes
if No
ft
Community Wells > 200' F/ Yes if No ft
Surface Water > 100'
✓�
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that l have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
COSA Checklist yellow sheet
s,
` 49th a
rpnai�(snea.rt, ssaa Ksaan4�tcvart uis:�
1RlWt�w2MLl:ilPt11R/l�[lfli iilptt�itait��ft�
b tkICHAEL E. ANDERSON
No. CE -4381
7/17/19
R ,`SS
ALATNA AVENUE
- ------------ _ ---- -- . ....... ............ ___ -------- . ... ..... ... ... .......
10:
49
SRANEA. HOLT
CaCCF
11 FE M.
I T�
AS -BUILT SURVEY I" =30'
I A v ()!z M.
1) F ii i
TRACT A-1, TENG9ER6 SU9. ( PLAT 76-191)
A %, GtiIR A G E K l.: R I: I NG dISTPI^T
A I, s < A A N
V E E M N, si .11 E n A R - N
V!,'IeLE F F, ^ Tet
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- -------- -
ffl, 191 WA
DEVELOPMENT SERVICES DEPARTMENT
On -Site water and wastewater Section
www.muni.org/onsite
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC191294
Subdivision: Tengberg, Lot: Al
A water sample revealed a nitrate concentration of 7.45 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.
�,4ne .fir g K_ as JS�J 50 w1n o g,
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.
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
Parcel I.D.
CERTIFICATE OF HEALTH AUTHORITY
APPROVAk FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address "~¢0¢ /3, L~ L.~
Day phone
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well ~
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4, TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
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 further verifythat 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.
NameofFirm ~"'~ o/~b~ ~r~¢V.~l~z.L¢ ~.'¢~--- Phone
Address ~
Engineer's signature
bedrooms.
DHHS SIGNATURE
X' Approved for
Date
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Note: The well for this property meets existing State and Municipal Codes.
performed to insure the wells continued suitability. Current nitrate
...... +--~4~-- 4-- 5 13 ~/1 EPA ~ximum ...... ~+4~ 4~ ~n n /
....................... ~ ......................... mg !.
~o=e in[o=mation on nit=ares is available [rom the On-site Services Prog=am,
DHIIS, ' ' ' ' '
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.
72~25 (Rev. 1/91) Back MOA ~21
Municipality of Anchor;~geSERViCES$[
DEPARTMENT OF HEALTH &. FIUMAN
Environmental Services Division ~UNIC;IPALII'~
825 L Street, Room 502 · Anchorage, Alaska 99501 ·
Health Authority Approval Checklist
A. WELL DATA
Well type ~- ~-.,
Log present (Y/N) ~J'%~
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
If A, B, or C, attach ADEC letter, ADEC water system number
Date corr pleted
"7 Cased to
FROM WELL LOG
Casing height (above ground)
Wires properly protected [Y/N).
AT INSPECTION
g,p,m.
WATER SAMPLE RESULTS:
Coliform ~ ~) '-
Date of sample;
Nitrate
Collected by:
Other bacteria
,5.
B. SEPTIC/HOL;DING TANK DATA 16~...~-~) ~J-- ~o-¢i)
Date installed ~',~e x~ ~ 5 .-~_lTank size _ ,5~o Number of Compartments
~ Cleanouts(Y/N)
Foundation cleanout (Y/N)_ "/ DeDression (Y/NI h{
C. ADSORPTION FIELD DATA
Date installed I/- :~,~? Soil rating (g.p.d./ft~ orfF/bdrm) I~'D
Length ~/',~ Width __ ~,,~ _ Gravel thickness below p~pe
Effective absorption area __ ~ Monitoring Tube present (Y/N) ~
Date of adequacy test q/~ '{,/'/¢' Results (Pass/Fail) ~
High water alarm (Y/N) N
System type
// Total depth J
. Depression over field (Y/N) JX, I
For ¢"/ bedrooms
Fluid depth in absor3tion field before test (in,);
Fluid depth - ~ -- (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N). ~"/
Immed ately after (¢¢o gal. water added (in.):
Absoretion rate = 7 (~4'~ _g.p.d
f yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
"Pump on" level at*
"Pump off" level at*
High water alarm level at*
*Datum
Cycles tested
E, SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
I cra ~ ..~¢,0 'i' ,'..'(
Septic/holding tank on lot '1 ~, ~ ,0,~¢ ~
Absorption field on lot I I~
Public sewer main
Sewer/septic service line ~ dP
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation /O Property line '~ ,~ Absorption field
Water main/service line ~'~ Surface water/drainage I lo Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Surface water
Curtain drain
--/5o Building foundation
~ ~ Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots ?) ¢'o~
F, ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal
in conformance with MOA HAA guidelines in effect on thie date.
Signature '-~ J ~,,..~ ~.~ ~
Engineer's Name T~o I ~ g/Po ¢ ~[~
Date Q~ C/~
HAAFee $. ,~OO,.~::) O
Date of Payment <~/[ 7/~,,r~
Receipt Number (~ ? ('.0~; '2__ (-~'7// )
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
SEP-17-±998 07:%'q CT.~,E ESI ANCHORAGE
CT&E Environmental $o~ices IrlC.
'B1375E,~5301 P, 0~, 0_
Collects8 Date~ime 09/l~/P~ I2:D
Proj~t Nam¢/~ n/a ' '
Client S~ple ~ Tract lA Tengberg Received Date~T~ 09/14/98 14:50
Matrix DriVing Water Tactical D rector. Stephen C. Erie
Orderea By 0 Role B
Tote[ cotiform 0 cot/500mL $1,118 922~ 09/16/9/3
ttitrate-N 5.13 0,100 ~;~/L EPA 300.0 10 max 09/14/98 09/14/98
Parcel I.D. it
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
HAAit
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
(b)
Location (address or directions)
Propertyowner "~ ; ll Flo¥c/
Mailing Address _ "~-~,
(c) Lending Institution ~',,~.,,y. ~[,~,~,~l,C,; ~ Hu[~-o~/ 'telephone
Mailing Address
Telephone: (home) ~ MS-- 3~O~Susiness
(d)
Real Estate Company and Agent
Address
(e)
Telephone ,,~. ,
Mail the HAA to the following address: (or check here [-1. if hold for pick up.) : ,,~' ~ ':
List contact person and day phone number below: "" .
2. TYPE OF RESIDENCE
Single-Family ¢ Number of bedrooms
3. WATER SUPPLY
Individual Well'~ Community [] Public E'1
Note: If community well system, must.have written conf 'mat on from.the Stateq3epart~ent of Environmental
~>0on~ervatl0n' a~'t~sting to th legality and Siatus. ' " · ·
SEWAGE DISPOSAL '
4.
On-site~[( Public [] Community rq Holding Tank []
Note: If community well system, m~i'have written confirmation from the State Depa~nent of Environmental
Conservation attesting to the legality J~fid status. :'x,;;.,,:: :, ~ : .... -
: ': 7~-o~s (,0~. ?/~) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional .and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
NameofFirm '~-~J~,J')~/ ..~pu-,--~'~.[,~.,~.~ Telephone ~LZ/c~- ~
Address ~ 7~/ ~- ~ I~N ~
Date
Engineer's Seal
6. DHHS APPROVAL
,Approved for ~¢ b~drooms by
Approved "~ ' '''~
Disapproved
Terms of Conditional Approval
Oonditional
'llPlli'li
The Municipality of Anchorage Department of H~alth and Human Services (DH'HS) issues Health Authority Approval
cerificated 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
inst!tutions 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.
A. WELL DAT~
Well Classification
Well Log Present (Y/N) _~'~ Date Completed
Total Depth ~/ Cased to_ ~ L/
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
84:3-4744
Legal Description: ~/~-¢ ~r
If A, B, C, D.E.C. Approved (Y/N)
~'l ~*,-~4.~ _ Yield ~ Cp ~
Depth of Grouting '~-
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N) '~/
; On Adjoining Lots
; On Adjoining Lots
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N) _ '"//
/
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot /~ ~ :''~
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ,-'-'
To Nearest Public Sewer Cleanout/Manhole _
;Date
'1'o Nearest Sewer Service Line on Lot
Water Sample Collected by t , ~.~
Water Sample Test Results
Comments
To Water-Supply Well
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments
B, SI=PTIC/~ TANK DATA
Date Installed ~7 Size ~ No. of Compartments
Standpipes (Y/N) ___y _Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
/
/
'"// Foundation Cleanout (Y/N)
Date Last Pumped __ I ~ , I '7 ' ¢/~2 ~'r~'
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation /,~./
To Disposal Field
72°026 (Rev 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed //' ¢/~'
Width of Field ;~f,2
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTIQN FIELD:
To Water-Supply Well I I O '/'
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
IO
To Building Foundation
Lot .~
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
; On Adjoining Lots
To Existing or Abandoned System on
To Cutback (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and H~A g~i~eiih~s J.n effect on the date of this
inspection.
Signed
Company
MOA No.
Receipt No.
Date of Payment
Amount:
72-026 (Rev. 7/88) Back
Engineer's Seal
Waiver Fee: $
Date of Payment
Page 2 of 2
675! ~l. DIHDNB BLVD.
AN£HORAGE, ALASKA
(~07) 24~-50~5
LEOAL:
El[ICA T I LIN:
OWNER:
TYPE OF WELL: F:'r":i. vat:~:~,,
NELL LO[~ AVAILABLE:
,: :i. g.I. ~ F:auli ]. y
INSTALLATION REDUIREIqENTS MET:
NELL YIELD FROM NELl_
F:'OMP ¥IEI-D FR[]PI TEST.'
DATE OF INSPEI]I'ION.' Nc~vci!mbl:?r'
TEST PROCEDURE." Well. v~af.~ I:~ulnp~:~d at a cc)ns~LalrL r alt:~:z v~h:i, lo i.:hl~
TESI' FOR E.ICOL. I AMI:) TOI'AL NI'FROI~EN." Watl:~r' w,:ls hc!~4i'ked .,~:l::)r" ti:.CI]]J
E,, [:l:~i i O. Total Ni 'Lr(::)i;j[,'H'~ 4. 4mg/] ,,
Pl~ix. alll:~wabll.t, Fol:a] N:i. tr-c~cjc!r~ 10 rog/l,,
TE~T RESULTS: "lh:i. !,s
I~k.u'~ ± <:: :t I:h~Zl i 'L y (::rF AnC:I m~'c~g(:.~ .
THIS UELL WILL PRODUCE HORE 'I'__HA__U. ~J_ GALLON!3 PEER I','!!l~]_Ul'_~. FO__R_
THAN FOUR H_0U]~_
6751H. DIIDND EVB.
~NCIIOR~GE, ~L~K~ 99502-3~0a
L. EOAL:
LOCAT ]~ I]r,I:
OWNER:
RES I DENCE
~'IELI_.:
SEPTIC
SEPTIC SY~'I'EM ADEQUACY
F'ROM PIIJN I C I F:'AI.. F;;ECCIRDS; 4 Bl~:Jr'oom Sys
llANK: (Sr(~(:.~r' St.:eel I,':ud::!~. UO(), l()t)O Ga/,,
ABSORF'T i ON SYS*'I EM ~ 'l'~ c.:,~ ~c:l ~
ABSORF'T ]:ON ARISA2 600 SCl,, I::'t'.,,
S[)II_ RAT~ NG~
INS]AL.LAI]:CIN OA'I'IZ: UpClr'ade :I. EIg?
DATE OF LAST I:'UMPIN~i: ~nch. Ih!s!s F'oc)l Nc, v. ]/, 1990
DATE OF TEBT:
TE~T PROCEDURE." ,System wa:; :i,r~sl::)ectc~!d and measured. :LOC)() qal.
· t:ank ~q~*s .Fcaund w:iLh :S,,',':; 'Fec.~t o.F cc:~ver' and wit:Il
[]r~gJ, rial c:r'ib ~,¢as 13 ~:{?m~b <:h.~:~p with a ~al.'.er' d~.q~'L:h o.f 41 :inches.
[: I ~ e c: r' i b
TEST REgUI..T:
t) ~.:~f,:~ a r' ~: m (.:~l~ 't o ,F
b I'u,,¢ I.leal I:h al ~<:1 Sc:~c :i. al ,cite r' v i c: ~:.?~
Mu~lic::Lpality o'~ ArJc:hc)ral.7~-~.
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
ANALYSIS REPORT BY SAMPLE for Wo~k Order # 30131
Date Report Trlnbod: NOV 15 90 ~ 08:46
Client Sample ID;TRACT A1 TENGEERG
PWNID :UA
Collected NOV 13 90 @ 12:00 hrs.
ReceiYed NOV 13 90 8 12;30 hrs.
Preserved with ;AR REQUIRED
Client Name : TOBEEN SPURNLAND, P.E,
Client Root :TOBBENS
P.O.~ NONE RECEIVED
Req ~
Ordered By : TOEBEN SPURKLAND
Analysis Completed :NOV 14 90
Send Reports to:
i)TOBBER SPURKLAND, P.E.
2)
Special
Chemlab Roi ~: 904807 Lab Smpl ID: 1 Matrix: WATER
Allowable
Parameter Tested Result Units Method Limits
NITRATE-N 4.4 mR/1 EPA 353.2 10
Sample ROUTINE SAMPLE.
Remarks: SAMPLE COLLECED BY T. SPURKLAND.
I Tests Pezformed See Special Instructions Above UA-Dnavailable
NI)- None Detected *' See Sample Remarks Above
NA= Not Analyzed LT~Less Than, OT=Greater Than
MUNICIPALITY OF ANCHORAGE
OEPARTMENT OF HEALTH & HUMAN SERVICES
o,v,s,ON OF E.V,.ONME.TAL SERV,OE
CERTIFICATE OF INSPECTION FOR HEAl_TH AUTHORITY APPROVAL
OF ON-SiTE SEWER AND WATER FACILITY
264-4744
Application Date //,/~/8 "~
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Descripti,o.n (include lot, block, subdivision, section, township, range)
;~oc.a. tion' (address or- dtreCt!pns)
(b):;~ Property Owner /~ ,~7'~/~ ~'/hd~' Telephone: Home ,..~ Mailing A~ress /~ ',. ~, ~
(c) 'Lending Institution * ~/
Malli6g Address ""' '"
(d) Real Estate'C~m~any and Agent '
Address 7~ ~
Telephone
(e) Mail the HAA to the followine address: or; Check here'~i'f hold for pick up.
List contact 9erson and day ph9ne ~umber belo~.
Business
TYPE OF RESIDENCE
Single-Family'~
Number of Bedrooms
WATER SUPPLY
Individual Well~, Community [] Public [] ;
Note: If community well system, must have written confirmation fi'om the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite~J~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 fRev 8/861Fronl
NOIJ. n¥3
.g
MUNICIPALrrY OF ANCHORAGE (MOA)
MUNICIPALllY Of ANCt. IO,t~IE~ALTI"I AUTHORITY APPROVAL. (HAA)
ENviRONMENTAL SEI,;VICES DiV[SIO6HECKI. IST - FEBRUARY 1984
264-4744
Nov 2 0 1987
WELL DATA
RECEIVE[)
Legal Description:
Well Classification ~)'~'/~'/'~'9~c~ If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (YO Date Comp?eted ~,~A,b~d/J Yield
Total PepthL~_ ~'~ ~ Cased, to~'? ~'7 Depth of Grouting xd/~
Static Water Level ~_/',~ '
Casing Height Above Ground
Electrical Wiring in Conduit N)
Separation Distances from Well:
PumpSetAt __(~,) ~¢''
Sanitary Seal on Casing
Depression Around Wellhead~N)
To Septic/Holding Tank on Lot o?~/~
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line __
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results ,'~/~--
· /t)/-~J 1/.;3 / ; On Adjoining Lots
/.~O / ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ~"~ ¢-
//¢. ¢J/t~J ; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed //" "~'-~¢
Standpipes ~'4) __
Depression over Tank (Y/~)
/0~1~ /
__ Size 5~*r~ No. of Compartments f
Air-tight Caps ~IN) __ Foundation Cleanout (YLt~
Pumping/Maintenance Contract on File (Y/N) __
Holding Tank High-Water Alarm (Y/N)
Date Last Pumped
;for_
Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Property Line o~ /
To Water Main/Service I~lne
113
To E~uJlding Foundation
To Disposal Field
Course
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2 _
72 026 fRev 8/861
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed //~
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line ?o
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness ~7/
Standpipes Present'N)
Date o~ Last AOequacy Test
_ To Property Line 45*0
To Existing or Abandoned System on
; On Adjoining Lots ,2'~;5"
To Cutbank (if present)
Comments
D. LIFT STATION
"~talled Dimensions
Size in ~ ~,/~./,~ Manhole/Access (Y/N)
"Pump On" Level at ~ _ "Pump Off" Level at
~;gsthe dWf8~ ~r Alarm Level at '~*"~ '~,.....~,..~ ~e~ (gY/o~)cles d u ring Adequacy Test. Meets M OA
Electrical Codes (Y/N) ~~
Comments ~
Signed Date
Company //~ MOA No.
Receipt No. ~. -
Date of Payment
Amount: $
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I hav.%e,,~he~ked,~verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspectibn.
Page 2 of 2
72-026 fRev 8/86/ Back
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL, SERVICES
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL]
(a) Legal Description (include lot, block, subdivision, section, township, range)
[o~a{i~n': (a~dr~s~ or'dir~tions)
i ............. ~ ~"~' ~ Telephone Home
(b):~ Property Owner
"'" ' '" '"'""
Mmhng Ad?egs. ,
(d) Real Estate'Gbmpany and Agent
,Address "7~ ~
Telephone ~']
(e) Mail the HAA to the followinq address: or: Check here~, if hold for pick up.
List conta~/~¢
' -- - /-
TYPE OF RESIDENCE
Single-Family'~
Number of Bedrooms
.¥
Business ~. ~"~',,-'
WATER SUPPLY ,
Individual Well'~, CommunityI-
· ,, (I/t I\/, '
Note: If community well system, must have written confirmation from the State Department of EnvirOhnlental Oonservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite'~ Public [-i Community [] Holding Tank []
Note: If corn rnunity well system, must have written confirmation from the State Department of Envirom'nental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 fRev 8/861 Fro~i
ENGINEERING FIRM PROVIDIN,.., INSPEC't'IONS, TESTS, FILE SEARCH, £)A'I ~,, AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm ' ,/~-'~ Telephone
Date
DHHS APPROVAL
Approved for _
Approve~d \~ i
Terms of Conditio, nal ',~p, ~)r~c~,¢~!
', , ,~ ,~ ;~
Disapproved
Conditional
CAUTION
The Municipality of Anchorage Depadment of Health and Humae 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 DFIHS 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.
Page 2 of 2
& GEOLOGICAL LABORATORILS OF ALA,gKA, 1NC.
FEDERAL TAX ID # 92-0040440