HomeMy WebLinkAboutEASTERLY PORTION LOT 87 LT 2M-W DRILLING, INC.
DRILLING LOG
James Sandburg UseofWe]l
Well Owner
.,,
Location (address of: Township, Range, Section, if known; or distanee main rosd
S 1/2 L 87 U.S. Survey 3042
Dom.
if
Size of casing_ Depth of Hole
Static water level 65 ft. [4¢6X~)
Screen ( ); Perforated (
81 feet Cased to 80.7 feet
(below) land surface. Finish of well (check one) open end
Describe screen or perforation N/A
~Well pumping test at l~ gallons per ~r)
of drawdown from static level.
x );
(minute) for 1 hours with 100%
Date of completion 7 / 9 / 77
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
0 _TO 2 Casing stickup
2 TO 4
4 TO.
29 TO.
65 TO.
TO
___TO
TO
___TO
TO_
TO.
TO_
_____TO
TO.
TO.
Organics
29 Gravelly hardpan
65 Loose gravel
85 SandyA gravel
/
1 -- CUSTOMER
• � Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 075-132-75
1. GENERAL INFORMATION:
Expiration Date: T I 3 - ZD ZZ
Complete legal description EASTERLY PORTION; LOT 87 LOT 2
Location (site address) 132 Jewel Mine Road *Girdwood 99587
Current Property owner(s) Thomas Geils
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone 330-9293
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual
❑
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
WaiverNariance request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 2 Waiver Fee $
Date of Payment �►, �, r2 B 2 Z Date of Payment
Receipt Number Z D 4 Receipt Number
COSA # (iS G22 [ "p Waiver #
gin
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm: Gamess Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date:
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system
in accordance with the guidelines and regulations established by the Municipality of Anchorage and
industry practices. The reported results describe the condition of the systems on the date/s of the
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or
encroachments may exist that were not identified during the evaluation. The operational life of all wells
and septic systems depend upon a variety of variables, including but not limited to, soil conditions,
groundwater levels (that may fluctuate during the year), quality of construction (materials and
workmanship), and the water usage of the family utilizing the systems. These conditions can vary, and
- - - - are -outside -ft control of GEG. Satisfactory test results do not guarantee future performanceof the
systems; therefore, GEG makes no warranty (express or implied) regarding the future performance of
the well or septic system. GEG makes no representation whether an alternative well or septic system
can be installed on the property in the event either of the current systems fail to perform adequately in
the future. The content of this report is for the sole benefit of the person/party that retained GEG to
perform the evaluation. Reliance upon the information provided in this report by any other person or
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
OF g�po
-� ...................
( ffr A. Gornpss!
ss. CE/-. 3
c O
d
a Fo
�1O� o ressic� Q
#AECC884
6. DSD SIGNATURE
System #1 Approved for —3 bedrooms l��llllll(((ffrrr
System #2 Approved for 4—M.LITY p iii
Disapproved
Conditional approval for
bedrooms ``�C,\P
_ bedrooms, with the followir4g pLAV {'"d`ii >��R IV
q/u0
,�rj
y
c�
r,T,_
:rrl ;V,
m^
J�J
9))
Original Certificate Date:
J� Z 2
,1
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of Onsite Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage Is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
Legal Description: EASTERLY PORTION; LOT 87 LOT 2
tZ s—o aD
57[tZ I I
Parcel ID: 075-132-75
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)
Date drilled 1973(?)
Total depth '71.5+ ft
Cased to UNKNOWN ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 4/24/22
Static water level at beginning of test 70.1 ft
Comments *PER GEG TEST DATA
SEWER
B. TANK DATA 1EW:W:1
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA
Which system tested (date installed)
❑ ALL standpipes present per record drawing._ __ _
Total measured depth from grade ft (ma
Measured depth to pipe invert from grade ft (min)
❑ N/A —pressurized field
❑ Monitor tubes go to bottom of ective. If not, state
depth into effective
❑ Code -required soil er over field
❑ System pres ed
(Required if cant for greater than 30 days prior to
date of t
introduced gallons
COSA Checklist yellow sheet
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
1\dequacy test date
Results ❑ Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
raw
Well production at time of test 7.5+ gpm
Water storage tank volume NSA gallons
Well disinfected for coliform test? ❑ Yes 0 No
a' Coliform bacteria is Negative
Nitrate mg/L-El—Nitrate less than MRL ND
Arsenic ug/L Arsenic less than MRL (ND
Collected by y"
iVu
Date of Sample 4/24/22
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA
Which system tested (date installed)
❑ ALL standpipes present per record drawing._ __ _
Total measured depth from grade ft (ma
Measured depth to pipe invert from grade ft (min)
❑ N/A —pressurized field
❑ Monitor tubes go to bottom of ective. If not, state
depth into effective
❑ Code -required soil er over field
❑ System pres ed
(Required if cant for greater than 30 days prior to
date of t
introduced gallons
COSA Checklist yellow sheet
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
1\dequacy test date
Results ❑ Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
raw
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'
N/A
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No ft
Q Yes
if No ft
Neighboring Tank > 100' Yes
if No ft
Private Sewer/Septic Line > 25' 0✓ Yes
if No ft
Absorption Field on -Lot > 100' ❑ Yes
if No N/A ft
Holding Tank > 100' Yes
if No ft
Neighboring Absorption Fields > 100'
Private Wells > 100'
Animal Containment > 50' Yes
if No ft
F] Yes
if No ft
ft
Communi ells > 200'
❑ Yes , if No ft
Water Service Line > 10'
Manure/Animal Excreta Storage > 100'
if No
Community Sewer Main > 75' RYes
if Na ft
R Yes
if No ft
From Septic/holding Tank on Lot to: (Please enter distances if less than required) , MYv vvv, �cvvert
Building Foundations > 10'
❑ Yes
if No
ft
Surface Water > 100'
❑ Ye�N-""— ft
Property Line > 5'
❑ Yes
if No
ft
Wells on Adjacent Lots.-
ots:Absorption
AbsorptionField > 5'
❑Yes
if No
ft
Private Wells > 100'
❑ Yes if No ft
Water Main > 10'
❑ Yes
if No
ft
Communi ells > 200'
❑ Yes , if No ft
Water Service Line > 10'
❑ Yes
if No
ft
If c tank is under driveway
comment below
From Absorption Field on Lot to: (Please enter dista s i
Building Foundation > 10'❑ Yes i ft
Property Line > 10' es if No ft
Water Main> 10' F1 Yes if No ft
Water Sery ine > 10' El Yes if No ft
ace Water > 100' ❑ Yes if No ft
F. ENGINEER'S COMMENTS
less than required)
If absorption field is under driveway comment below
.Wells on Adjacent Lots:
Private Wells > 100' ❑ Yes if No
Community Wells > 200' ❑ Yes if No
G. ENGINEER'S CERTIFICATION o
l certify that 1 have determined through field inspections and review
of Municipal records that the above systems are in conformance with 49 H { t£
MOA COSA guidelines in effect on this date. . , . t , . ,
0 J,
� frr, '�1G9Lness:
E 79 3
0 9s ' . CSG
COSA Checklist yellow sheet
M
ft
#AECC884
Vj�
Well Owner
DRILLING, INC.(- -, :'.
DRILLING LOG
Use of We]l
Location (address of: Township, Range, Section, if known; or distance main road
?.; t/2 L o7 U.:~, ~ ..... .~042
Size of casing_
Depth of Hole [; :[ feet Cased to ,~}0.7 feet
Stat{c water level 6 5 ft. '(~6~'~) (below) land surface. Finish of well (check one) open end ( );
Screen ( ); Perforated ( ).
i'"] lA
Describe screen or perforation
Well pumping test at i[ 5 gallons per
of drawdown from static level.
(minute) for i hours with 10',)','( ft.
Date of completion
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
4 .TO
2 ) _TO
65 _TO.
_TO
_TO.
.TO
JTO
_TO
_TO
_TO.
ZQ
1TO
Gravelly hard~a~
Loose gravel
Sandy~grave]
NWWA Cortii:icd Contraoto:
C~,Ulicate t~o's. ~L,i ,~_ 973
2--STATE
•
�•�) Municipality of Anchorage �„G` ,'
On-Site Water and Wastewater Program K • l'
�� (907) 343-7904 5
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 075-132-75 Expiration Date: t r 1 ZS
1. GENERAL INFORMATION
Complete legal description _EASTERLY PORTION LOT 87 LT 2
Location (site address) _132 JEWEL MINE RD, GIRDWOOD AK
Current Property owner(s) _DAVID KASSER Day phone
Mailing address _645 G STREET # 612 ANCH AK
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (wlwo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual
•Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: M% Date: /C.07-"V7-__
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 52c, Waiver Fee $
Date of Payment 10[3b 111- Date of Payment
Receipt Number t O 3q2. Receipt Number
COSA# (5L-('161-1-4- Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864
Address 4661 NATRONA AVE.
Engineer's Printed Name MIKE N ANDERSON. PE Date 10/30/17
r.. '1
•
0 0 .
.
- •-
Y J Jr F;) F ,'
•
6. DSD SIGNATURE �.,`rt N. ANDERSON .4
C'"-'�• Cc-9 54 "- ,J
System #1 Approved for bedrooms. • f��3r •� `•
System #2 Approved for bedrooms. �;�`, �.:� - •
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
ts,,
ON-SITE
WATER AND
, WAS►MATEGRAMR o=
PRO
I _
• 4/47..SERN���
By: Original Certificate Date: 1 3 J
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10.10.12 doc
- - If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system _
Certificate of On-Site Systems Approval Checklist
Legal Description: USS 3042 EASTERLY PORTION LOT 87 LT 2 Parcel ID: 075-132-75
A. WELL DATA
Well type Private If A. B. or C provide PWSID# Well Log (YIN) N
Date completed 1980 Sanitary seal (Y/N)Y Wires properly protected (Y/N) Y
Total depth 71'" ft. Cased to 71' ft. Casing height(above ground) 12"+
FROM WELL LOG AT INSPECTION
Date of test 10/1812017
Static water level ft. 71 ft.
Well production g p m 5.5 g p.m
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate _0.951mg/L
Arsenic ND ug/L Date of sample: 1 011 812 01 7 Collected by: 907 WATER WELL
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material _ Date installed
Tank size _ gal Number of Compartments Cleanouts (Y/N)
Foundation cleanout (Y/N) Depression over tank (YIN) High water alarm (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA— 1985 SYSTEM TESTED
Date installed Soil rating (sf/bedroom) System type
Length ft. Width ft. Gravel below pipe ft.
Total depth _ft. Eff. absorption area ft2 Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before test in Water added _ gal New depth in
Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
•
_
'd
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YIN)
"Pump on" level at in. "Pump off" level at in.High water alarm level at in.
Datum Cycles tested Meets alarm& circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot NA On adjacent lots 100'+
Absorption field on lot NA On adjacent lots 1004
Public sewer main 75'+ Public sewer manhole/cleanout 1001+
Sewer/septic service line 25'+ Holding tank 1001+
Animal containment areas 501+ Manure/animal excrete storage areas 1001+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
ABSORPTION FIELD ON LOT TO:
Property line Building foundation Water main
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
F. COMMENTS
* WELL CASING AND DEPTH VERIFIED BY 907 WATER WELLS.
G. ENGINEER'S CERTIFICATION . �� �'� s-1/,��
I certify that / have determined through field inspections and y.' * ••�
review of Municipal records that the above systems are in ;;*1497t1
conformance with MOA COSA guidelines in effect on this date. .. ..../
r L ,,
Engineer's Printed Name MIKE N. ANDERSON, PE d �: NJCHN.EE N. ANDERSON ter°
` •�. C 9469
Date 10/30/2017 I 01/4%sit. , I •,••
COSA canary sheet_2-6-15.doc
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.orglonsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 01.7§19-"q COSA# O$Darq-
1. GENERAL INFORMATION
Expiration Date: / 0 -/ ,t Q
Complete legal description U.S.S 3042 EASTERLY PTN L87, LOT 2
Location (site address) 132 JEWEL MINE ROAD •GIRDWOOD, AK 99587
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
KATHRYN STONE Day phone
132 JEWEL MINE ROAD •GIRDWOOD, AK 99587
786-0183
Day phone
Day phone
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
❑
•
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 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. 1 further verify that based on the
information obtained from the Municipality of Anchorage files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm
GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE. Al< 99507
Address
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
systom under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how bng the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
I a Approved for
Disapproved.
Conditional approval for
2
bedrooms.
Date
bedrooms, with the Mowing stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Reort
Other
Original Certificate Date* 1 -Aft 0 0
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATEOFON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Well type PRIVATE
Date completed
B.
Total depth j73±
Date of test
Static water level
Well production
U.S.S 3042 EASTERLY PTN L87, LOT 2 Parcel ID: 0 75"1"/ 32 -75
-
*PER PREVIOUS HAA
If A, B, or C provide PWSID# N/A Well Log (Y/N)
• 1980 Sanitary seal (Y/N) YES
ft. Cased to *40+ ft.
NO
Wires properly protected (Y/N)
YES
Casing height (above ground) 12+
FROM WELL LOG AT INSPECTION
OG 4/11/2008
g.p.m.
WATER SAMPLE RESULTS:
Coliform 0
colonies/100 ml. Nitrate 0.10 4 mg./L.
Arsenic- _0 ug./L.
SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal
Date of sample- 4/11/2008
72 ft.
7.1 g.p m
in.
Other bacteria 0 colonies/100 ml.
Collected by: GEG Ltd.
PUBLIC SEWER
Number of Compartments
Foundation cleanout (Y/N)
mping
C. ABSORPTION FIELD DATA
Date installed
Length ft.
Total depth
Date installed
s�Y7
ver tank (Y/N)_ High water alarm (Y/N)
Pumper
fBELOW EXISTING GRADE'
Soil rating (g.p.d./ft'o
Width
ft. Eff. absorption area
Date of adequacy test
Fluid depth In absorption field before
Elapsed Time:
ft.
ft3 Monitoring tube
Results
In.
Final fluid depth
uvenation treatment (past 12 mo.) (Y/N & type)
ail)
System type
Gravel below
Water added _ gal.
in.
ft.
Depression over field
For bedrooms
New depth _in
g.p.d.
Absorption rate >=
If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N
High water alarm level at in.
"Pump on" level at in. "Pump off' level - Hi 9
Datu Cycles tested Meets alarm & circuit requirements?
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
50'+ Manure/animal excrete storage areas 100'+
SEWER
N/A
N/A
75'+
25'+
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
100'+
100'+
100'+
N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC
Building foundation Property line Absorption field
Water main
We
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Water service line
Property line
Water service line
Curtain
F. COMMENTS
Building foundation
Surface water
Wells on adjacent lots
G. ENGINEER'S CERTIFICATION
1 certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date %/9(D/3
ace water
Water main
par ingtvehicle storage
A.64,c
Pio f es s1o�°oc�
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
14,2)o--
9
/tog
Waiver Fee $
Date of Payment
Receipt Number
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.cLanchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
HAA# HMOZc &ie
Parcel I.D. 075-132-75
1. GENERAL INFORMATION
Expiration Date: 3 /12/02 -
Complete legal description USS 3042 EAST PTN; LOT 87, L2
Location (site address or directions)
JEWEL MINE ROAD • GIRDWOOD, AK
Current Property owner(s) DAVID McCORMICK Day phone 783-3009
Mailing address
Lending agency Day phone
Mailing address
Real Estate Agent F.S.B.O.
Day phone
Mailing address
P.O. BOX 110907 * ANCHORAGE, AK 99511
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System0
i•
0
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 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 samples. (Certificates may be reissued for a period of up to one year with valid
water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water
system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's
work.
'Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $ at, or prior I
to closing for the engineering services provided.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my
investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the
information obtained from the Municipality of Anchorage files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with al! applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm
ALASKA WATER & WASTEWATER CONSULTANTS, INC.
Address 6901 DEBARR ROAD. SUITE 26 * ANCHORAGE, AK 99504
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments: •
In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSO Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered of the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year. and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. AKWWC, Inc. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
Phone 337-6179
Date
�i'7-1-)0)..
5. DSD SIGNATURE
✓ Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the filowing stipulations: ttffffr
OF AN64
ON'S1;E ••` tt
WATERAr g •
WAS1E`Nn`
PROGRAM •
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
By:
(Rer.17N1) (jJ
••.
'•.°PMENT
Manitenance Agreements J•0llllli))11
Supplemental Engineer's Reort
Other
Original Certificate Date: /2/12/07.
Legal Description'
A. WELL DATA
Well type PRP/ATE
Date completed
B.
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
•1980
USS 3042 EAST PTN; LOT 87, L2
'PER PREVIOUS HAA
If A, 8, or C provide PWSID# N/A
Sanitary seal (Y/N) YES
Cased to 40+
FROM WELL LOG
Total depth 72+ ft.
Date of test
Static water level ft,
Well production g.p•m_
WATER SAMPLE RESULTS:
Coliform C7 colonies/100 mL
Arsenic: N/A mg./L.
SEPTIC/HOLDING TANK DATA
Tank Type/Material
ft.
Parcel ID: 075-132-75
Well Log (Y/N)
NO
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
11/21/2002
70 ft•
5.1+ g.p.m.
YES
12+ in.
Nitrate 0.45 mg./L. Other bacteria C) colonies/100 ml.
Date of sample•11/21/2002 Collected by- AKWWC, INC.
PUBLIC SEWER
Date installed
Tank size gal.
Foundation cleanout (Y/N)
Number of Compartments
De
0
nk (YIN) _ High water alarm (Y/N)
9 Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ftor ft7bdnn
)— System type
Length • ft. Width ft. Gravel below .i. - ft.
Total depth ft. Eff. absorption area ft2 Monitoring tube Depression over field
Date of adequacy test . ail) For bedrooms
Fluid depth in absorption field before Water added _gal. New depth In.
Elapsed Time:
Results P
_ in
Final fluid depth _ in.
uvenation treatment (past 12 mo.) (Y/N & type)
Absorption rate >=
If yes, give date
g.p.d.
D. LIFT STATION
Date installed Size In gallons Manhole/A
'Pump on" level at in. "Pump oft" = - -
_m. High water alarm level at In.
Datu i Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots
Absorption field on lot
N/A On adjacent lots 100'+
a
100'+
Public sewer main 75'+
Sewer /septic service line 25'+
Public sewer manhole/cleanout 100'+
Holding tank
N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line
Water main Water service li
os
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation Water main
Surface water
Wells on adjacent Tots
Property line
Water service line
F. COMMENTS
Absorption field
u ace water
G. ENGINEER'S CERTIFICATION
I certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name
Date 1//1 -7 -/CA -
JEFFREY
JEFFREY A. GARNESS
ay, parking/vehicle storage
ess:
-79 V. F•`
tot ssto^oo,
000000,
HM Fee $ 75*
Date of Payment 12/10 /OZ.-
Receipt
OZReceipt Number 2g q s to
(Rev. 12/01)
Waiver Fee $
Date of Payment
Receipt Number
•
12/09/02 12:37 FAX 907 561 2415 NAIL DOES ETC 655
wr.71.rad..'..-.v1
e
(4 002
MICHAEL POLZIN
excursion NOR? 11 Y Kn ower? reepeee4141 le Ielrwwe
Me nein.; el ewe nernnll MMMIL I nenkl.ne
-b M *HAAs n Me herded 'medal 4N pet NOR:
Was, M eYrwelMen Meed Py Nle erns be end M
erlNnnls r Iv nleM_M, MM✓11 Me
SLANA SURVEYS, INC
LANKY RRMKAD0.. LlnTCCN en .—a.c, a
seen. why M 12.1e properly n Mew s nn 400 0C 1-
dro eO end INN Me Y-nn.wne Sk. &oo We. MRC?.
Ile ere Meet /he proprl, Nee eel M rand'- aLMyI-
laine eSol 01M Wan Millet MAnI-
LE ND: 5(7 !NO
Sae ./<r0 LA' n 0
123' gam e$ O44I
IM a not 0
[KL �0a —
Onlard.
LAND k CONSTRUCTION SURVEYORS -PLANNERS -ENGINEERS
440 WEST OENSON BLVD. / 03
ANCHORAGE. ALASKA 99503 (907) 562-6103
wow( 64:411 Watt rut,
I], 1992
.]0' (foo) 561-6676
9, ,.1I ^ DM. `"1. w50 , 9423/25
AS—BUILT OF: l[GM 00011,1101e
SVaC Il.. .a}
Walla nu- 63
LOT 2,EASTERLY PORTION
LOT 87 SUBDIVISION
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.# f11<- \ -h'
HAA # (71—In .244
1. GENERAL INFORMATION
F,
o�
Complete legal description Portico YALot 87, U.S. Survey No. 3042 Alaska
Location (site address or directions) NHN Jewel Mine Re, Girdwood, AK
Property owner Michael Polzin & Diana Woods 562-7653
Day phone
Mailing address PO Box 468 Girdwood, AK 99587
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
4
x
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
Holding tank
Community on-site
Public sewer
x
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72.025 (Rev. 1/11) Front MOA 121
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 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.
Environmental Manage. nt, Inc. Phone (907) 272-9336
Name of Firm
Address 206 E. Fireweede 01 Anchorage, AK 99503
A// Date ? e,15-- 7
Engineer's signature
6. DHHS SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
AtOFgC"
„sc.i....et.„t, .
vi
A John Eat ---;
r S.mp.on `�
�/t a•,, �y CE -8C61 I`e.
1ttttl�`rrur••• ' =~rye
Additional Comments
By:
Date 9/q2
CAUTION
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.
72425 (R«. 1/91) Sack MOA 1121
Municipality of Anchorage 11
DEPARTMENT OF HEALTH & HUMANHUMAN SERj:Cet
Environmental Services Division ivurtov w"'t-
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343 Afir�labrutErvrAL SE"RAGE
RVICES DNISIOA
Health Authority Approval Checklist AUG 05 1997
Portion of Lot 87, U.S. Survey No, 3042 : r
Parcel LD.:________•Q�
Legal Description:
A. WELL DATA
Well type Private If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) N Date completed 1980
Total depth 81.5* Cased to 60*
Sanitary seal (Y/N) Y
* Based on previous HAA checklists
FROM WELL LOG
Unknown
Date of test
Static water level
Well production
Unknown
Unknown
WATER SAMPLE RESULTS:
Coliform 0 Nitrate
g.p.m.
N/A
Casing height (above ground) 20"
Wires properly protected (Y/N) Y
0.41 mg/1
AT INSPECTION
7-17-97
70 ft
4.5
Date of sample: 7-17-97 - 7-24-97 ** Collected by:
** Water resamples after disinfection
B. SEPTIC/HOLDING TANK DATA
Date Installed N/A
g.p.m.
Other bacteria 32/0 **
Todd Helgeson
Tank size Number of Compartments Cleanouts (Y/N)
Depression (Y/N) High water alarm (Y/N)
Foundation cleanout (Y/N)
Date of Pumping
C. ABSORPTION FIELD DATA
Date Installed N/A
Length ; Width
Pumper
Soil rating (g.p.d./ft2 or ft2/bdrm) System type
Gravel thickness below pipe Total depth
Effective absorption area Monitoring Tube present (Y/N) Depression over field (Y/N)
Date of adequacy test Results (Pass/Fail) For
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
N/A
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:
Septic/holding tank on lot N/A On adjacent Tots N/A
Absorption field on lot N/A On adjacent Tots N/A
Public sewer main
100+ ft Public sewer manhole/cleanout 100+ ft
Sewer /septic service line 25+ft Lift station N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDINGTANK ON LOTTO:
Foundation N/A Property line Absorption field
Water main/service line Surface water/drainage Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line N/A Building foundation Water main/service line
Surface water
Curtain drain Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
Driveway, parkingNehicle storage area
I certify that I have
in conformance wi
Signature
Engin r -Name
Date 7 —07-1 /q
F
mined ru field inspections and review of Municipal 'vamp'
guideli • =s in effect on this date. i 5
P
John Earl Simp�fQ
L..........2
A *AsCE-8061 ,+` 0,
r`
HAA Fee $
Date of Payment r/ �9 7
Waiver Fee $
Date of Payment
Receipt Number '303 ' 071 Receipt Number
72-026 (Rev. 3/96)"