HomeMy WebLinkAboutDELUCIA LT 45Delucia
Lo1' 45
#051 - 141 -04
Municipality of Anchorage Page I of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~'~_~. ~)~ ?~_,LO _,~ .(.~ 4~) PID Number:
~~ ~ ~~ . Wastewater System: Q New ~Upgrade
Address: ~L
~ ~, ~~ ~ ~~, ABSORPTION, D
LEGAL DESCRIPTION Soil Rating: GPD/S~/ Total Depth from originalgrade:
Lot: ~ Block; . Subdivision: Depth to pipe bottom from origin~e: Gravel depth beneath pipe
Township: I Range: Section: Fill added above origi~ade: Gravel length:
Ft. Ft.
WELL; ~New ~ Upgrade Gravel width: / Number of Unes: I Dist,nc, between lines:
Ft. Ft.
sification(Private. A.B.C): Total Depth: Cased To: Total ab~n area: Pipe materiah
Driller: Date Drilled: Static Water LevehFt. ~¢lnstaller: ~~, Date ~Ttall~_ -~ ~
Y'e'd: I um"seta': I
SEPARATION DISTANCES ~Septic ~ Ho~dina ~ S.T.~.,.
TO Septic Absorption Lift Holding ~ublic/Private Manufacturer: Capac~t~ns:
From Tank Field Station Tank Sewer Lines ~~ ~~
~ Material: Numb~mpartments:
Surface t~ ~
Water ~ I~ -- LIFT STATION
I
LineL°t ~1 ~ / ~ ~ -- Size in gallons: Manufacturer:
Foundation ,~ / ,~, -- ~ ~ "Pump on" leve~f" level at:
CurtainDrain __~~ ~¢~ ~ Pum~odel Electrical Inspections performed by:
Remarks: BENCH MARK
Location and Description:
Assumed Elevation:
ENGI~EAL
-- OF A
S & S E~IGINEERING
Inspections performed by:1ZO34E"gle~ver LooP~='d."e'~S: 1st ~}-~~ ~9~ ~
Department of Hea~nd Human Services approval ~ ~' ~?~'~ I~,'... --N°' ~S ."
Reviewed and approved by: ~ Date:/~ - ~- ~2
72-013 (Rev. 9/91) MOA 25
Permit No.
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description:"~L-L, Iz~J~- ~,t~, ~
72-013 A (Rev. 9/91) MOA 25
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT ~ /~/~L
PERMIT NUMBER:SW920360
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:LACE ROBERT G &
OWNER ADDRESS:P.O. BOX 670748
CHUGIAK, AK 99567
DATE ISSUED: 10/21/92
EXPIRATION DATE: 10/21/93
PARCEL ID: 05114104
LEGAL DESCRIPTION: DELUCIA LT 45
LOT SIZE: 72301 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT:
4
THIS PERMIT IS FOR THE CONTRUCTION OF:
SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST 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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY
DATE:
ROBERT SHAFER, P.E
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
October 15, 1992 FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SiTE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: Lot 45; Delucia Subdivision
Request you issue a permit to replace the existing septic tank serving
the referenced property. The existing fiberglass tank has collapsed.
Please refer to the site plan attached. If you need any additional
information to complete your review, please contact us.
Sincerely,
ROGER J. SHAFER, P.E.
RJS/tv
Attachment
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
SCALE
GRE -' R ANCHORAGE AREA BOR - GH
Department of Environment Quality
3500 Tudor Road
Anchorage, Alaska 99507
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
LOC^T,ON
SEPTIC TANK:
FROM WELL _ MANUFACTURER
MATERIAL ///~COMPARTMENTsNUMBER OF
INSIDE LENGTH
INSIDE WIDTH
LIQUID DEPTH
LIQUID CAPAC I TY//2-~)GA LLON S.
TILE DRAIN FIELD: ,~' 5]'P~'
DISTANCE FROM WELL FOUNDATION
NUMBER OF LINES / DISTANCE BETWEEN LINES
ABSORPTION AREA
DEPTH: TOP OF TILE TO FINISH GRADE
NEAREST LOT LINE
TOTAL LENGTH
...OF LINES
TRENCH WIDTH IN. TOTAL EFFECTIVE
SQ. FT.
LENGTH OF EACH LINE
DEPTH OF FILTER
MATERIAL BENEATH TILE
IN. ABOVE TILE IN.
WELL:
TYPE
BUILDING
FOUNDATION
CESS POOL
APPROVED
CONSTRUCTION
NEAREST
LOT LINE__,
OTHER SOURCES
DISAPPROVED
NEAREST SEPTIC
SEWER LINE__, TANK__
REMARKS
DEPTH
SEEPAGE
SYSTEM
DISTANCE FROM:
DISTANCES:
INSTALLED BY:
SEWER LINE DePth:
PIPE MATERIAL'
LOT SLOPE:
REMARKS:
DIAGRAM Of SYSTEM
'~ DAT~ ./¢.~7~ APPROVED
G.A.A.B.
Form PW*027
GRE, --r ANChOraGE Area Bo[ Ugh
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-456!
SEWAGE DISPOSAL SYSTEM m APPLICATION AND PERMIT
PERMIT NO.
INSTALLATION LOCATION
LEGAL DESCRIPTION L ~ _/-'"-'
INSTALLATION OF: SEPTIC TANK
TYPE AND SIZE OF FACILITY TO BE SERVED
FINANCED THROUGH
~/ SEEPAGE PIT , DRAIN FIELD ~ OTHER
TO BE INSTALLED BY
SOIL TEST RESULTS .~'~-~'~T ~~ ~~ NOTE: THIS PERMIT IS NOT VALID WITHOUT ~lL TEST
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
FOUNDAT,ON TO SEPT,C TANK
-----"---
FOUNDATION TO SEEPAGE PIT DRAIN FIELD
DIAGRAM OF' SYSTEM
SEPTIC TANK TO SEEPAGE PIT WAll
SEPTIC TANK f , SEEPAGE Pit
TO NEAREST LOT LINE.
/
WEll TO SEPTIC TAnk / ~/
DRAIN FIELD
WATER MAIN TO SEPTIC TANK
DRAIN FIELD /K--~ I .
SEPTIC TANK, /~/~ , SEEPAGE PIt
TO RIVER, LAKE, STREAM.
,DRAIN FIELD_
SEEPAGE PIT
ALSO CONSIDER AREA WELLS.
SEEPAGE Pit
/ --
., DRAIN FIELD
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION S Feet iNTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
G ,A .A .B.
OR
LICENSED DESIGNER
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE.
O6' EGEOI_CHNICAL 6' DEVELL.~MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
6,94-2774 or 888-2280
Russell Oyster ~ Earl Ellis
694-2774 SOl~. LO~,, 6~8-2280
Soils ~t Foundations Land Development
Performed for: Name: ,-~/o
Iqatltng Address: ~;~: .~.~7r L~_/~z~ ~/~,~[~_+ /~, ~J~77
Lega~ Description: ,~7-
Depth (feet) Sotl Characteristics
2
15
16
~)r'L(~round
Proposed
Comments:
D~/~,
~ater Encountered: Yes ~
Installation: Seepage Pit
/-/E~K-
Performed by:
If yes, whet depth /~'F'~o.~ ~,<o,5ou~: ,4.r-
Dretn Fte~d *"~
No
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE
1 OF
ON-SITE WELL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920407
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:LACE ROBERT G &
OWNER ADDRESS:PO BOX 670748
CHUGIAK, AK 99567
DATE ISSUED:12/09/92
EXPIRATION DATE:12/09/93
PARCEL ID:05114104
LEGAL DESCRIPTION: DELUCIA LT 45
LOT SIZE: 72301 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT:
THIS PERMIT IS FOR THE CONTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST 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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
PROVIDE DHHS WITH WRITTEN CONFIRMATION THAT THE EXISTING
IS PROPER ,Y ABANDONED.
ISSUED BY:
DATE:
DATE:
D~c~mber 7, 1992
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX 694-!211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
M ECNANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
Muni~pality of Anchorag~
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Stre~
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: Lot 45; D~lucia Subdivision
R~qu~st you issue a permit to drill a n~w w~ on the referenced
property. The proposed w~ll location is shown on th~ attached copy of
th~ r~c~nt s~ptic tank inspection report ah~t 2 of 2.
An inspection of the ~xisting w~l for H~zlth A~thority Approval
purpos~ found th~ w~ll p~rforat~d at approximately 11 fe~t b~low th~
ground surface.
If you hav~ any questions or r~quir~ additional information for your
r~vi~w, please contact us.
Sincerely,
ROGER J. SHAFER, P.E.
RJS/tv
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
%,.
Permit'
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
SULLIVAN WATER WELLS
OWNER OF LAND
ADDRESS
LEGAL DESCRIPTION
DATE - Started
PERMIT NUMBER
P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688.2759
Ended
DEl'TH OF WELL ¢~'~' ~ /, ~ .
STATIC LEVEL OF WA/ER F'r. ,5"0
DRAW DOWN FT.
GALS. PER HR /,~) ~
KIND OF FORMATION:
From__~ Ft. to ~'~ Ft.
From ~ Ft. to ~ Ft.
From ~ Ft. to / ] Ft.
From /{' Ft. to ~ ~ Ft.
From ~"~' Ft. to / ~'~, Ft.
From.~Ft. to.__Ft.
From Ft. to Ft.
Fromm. Ft. to Ft,
From Ft. to Ft.
From Ft. to~ Ft.
From__ Ft. to Ft.
From Ft. to Ft,
From Ft. to__.Ft.
From Ft. to.~Ft.
From Ft. to Ft.
From Ft. to Ft
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to FL
Ft. to Ft.
Ft. to Ft.
From
From ~
From Ft. ~l~w_~ 1~03
From .~I~F~j ~p~.. gp.C.h.O r ~ 0~
From DeptF~[e~alth & HuFtm.an'Services
From Ft. to Ft.
From Ft. to Ft
From Ft. to Ft.
From ~.Ft. to__Ft.
From Ft. to Ft.
From Ft. to_ Ft
MISCL. INFORMATION:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-141-04
1. GENERAL INFORMATION
Complete legal description
Delucia, Lot 45
Expiration Date: ¢-~.-
Location (site address) 19844 Lace Rd, Chugiak, AK 99567
Current Property owner(s) Purifoy, Stacey
Day phone 854-1788
Mailing address same
Lending agency
Day phone
Mailing address
Real Estate Agent
Da
Day phone na
Mailing Address na
,? 1~, -~; ~,;', ?. ~-,
·;'UniesS bth'er~¢sec, cequested, COSA will be held by DSD for pickup.
,r2 ,' NUMBER,OF B~;~ROOMS:
3. TYPE O~ WATER SUPPLY:
individual Well
Individual Water Storage
Community Class __
Public Water System
4
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] Individual Holding Tank []
[] Community On-site []
[] Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I 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 NorthRim Engineering
Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng
Date 11/7/2011
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow
and absorption rates may change due to subsurface conditions that may not be observed from the surface,
changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. The operational life of all well and are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system.
DSD SIGNATURE
'~JApproved for L./-
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
_
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
A=
Legal Description: Delucia, Lot 45
WELL DATA - Public Water
Well type P If A, B, or C provide PWSID # ~
Sanitary seal (Y/N) Y_
Date completed 12/92
Total depth !00 ft.
Date of test
Statid'Water level
Well production
Cased to 40% ft.
FROM WELL LOG
12/92
50 ft.
25 g.p.m.
WATER SAMPLE RESULTS:
Coliform Pass colonies/100mL Nitrate 0.307
ArSenic: 4,49 mg/I Date of sample: 10/1_9/11
B. SEPTIC/HOLDING TANK
Well Log (Y/N) Y
Wires properly protected (Y/N) Y_.
Casing height (above ground) 20 in.
AT INSPECTION
10119111
76.2 ft.
8+ g.p.m.
Results (PasS/Fail) Pass For 4__ bedrooms
0 in. Water added 600 gal. New depth 0 in.
0 in. Absorption rate > 600 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) unknown If yes, give date --
Date of adequacy test 10/19/11
Fluid depth in absorption field before test
Elapsed Time: 6__0 min. Final fluid depth ~
Tank Type/Material Se~ Da~ installed 11/13/02 Tank size 1250 gal.
Number of Compartmenta 2_ Cleanou~ (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) _N
High water alarm (Y/N) :N ~~ 10/19/11 Pumper lR's
C, ABSORPTION FIELD DATA
Date installed 10/75 Soil rating (g.p.d./ft2 or ft2/bdrm) 85 System type Trench
Length 57 ft. Width 4 ft. Gravel below pipe 3__ff. Total depth 7..__~5 ft.
Eft. absorption area 342 ft2 Monitoring tube _Y. Depression over field _N
Parcel ID: 051-141-04
.mg/L
Collected by: NRim Eng.
D. LIFT STATION
Date installed na
"Pump on" level at na in.
Datum na
E. SEPARATION DISTANCES
Size in gallons na
"Pump off" level at na
Cycles tested na
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+
Absorption field on lot 100'+
Public sewer main NA
Sewer/septic service line 25'+
Animal containment areas 50'+
Manhole/Access (Y/N) n_.Qa
High water alarm level at na in.
Meets alarm & circuit requirements? n_Aa
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout NA
Holding tank zta
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Property line 10'+
Water service line 10'+
Building foundation
Water main na
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Absorption field 5'+
Surface water 100'+
Water main na
Driveway, parking/vehicle storage 10'+
Property line 10'+ Building foundation 10'+
Water Service line 10'+ Surface water 100'+
Curtain drain ~/a Wells on adjacent lots 100'+
COMMENTS
A new steel monitor tube driven into trench. Old monitor tube blocked- insufficient dePth.
G. ENGINEER'S CERTIFICATION
I 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 Steve
Date 11_~7/2011
COSA Fee $490.00
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
ANALYTICA
GROUP
NorthRim Eng
Attn: Steve Eng
17237 Bear Paw Circle
Eagle River, AK 99577
907-694-7028
Fax: 907-694-7026
Client Sample ID: ER 6
Sampling Location: [ ~ ~,/.//./r ~-~O.~..
Client Project: ER 6
Sample Matrix: Drinking Water
COC #:
PWS#:
Residual Chlorine:
Comments:
Analytica Anchorage
4307 Arctic Boulevard
Anchorage, AK 99503
Phone: 907-258-2155
Fax: 907-258-6634
Report Date: 11/3/2011
Receipt Date: 10/19/2011
Sample Date: 10/19/2011
Sample Time: 2:00:00PM
Collected By: HE
Flag Definitions:
MRL = Method Reporting Limit
MCL = Maximum Contaminant Limit
B = Present also in Method Blank
H = Exceeds Regulatory Limit
M = Matrix Interference
J = Estimated Value
D = Lost to Dilution
** = RL higher than MCL; target not detected
TNC = Too Numerous to Count - result rejected
CF = Confluent Growth - result rejected
TCNG = Turbid Culture No Growth - rejected
Lab#: Al 110339-01A
Analysis Method Prep Prep Analysis
Parameter Result Units Flags MRL MCL Method Date Date Analyst
4500-NO3E (Aqueous) - Nitrate+Nitrite pres Test was conducted by: Analytica - Anchorage
Nitrate-Nitrite as Nitrogen 0.307 mg/L 0.10 10 10/31/201110/31/201 IMC
Lab#: All10339-01B
Analysis Method Prep Prep Analysis
Parameter Result Units Flags MRL MCL Method Date Date Analyst
9223B-PA (Aqueous) - Coliforms in DW
E. Coli Pass PASS/FAIL 1.0
Total Coliform Pass PASS/FAIL 1.0
Lab#: A 1110339-01C
Test was conducted by: Analytica - Anchorage
1 10/19/201110/19/2011KM
1 10/19/201110/19/201 IKM
Analysis Method Prep Prep Analysis
Parameter Result Units Flags MRL MCL Method Date Date Analyst
200.8/200.8 (Aqueous) - Family Well Water I
Arsenic 4.49 ug/L
0.15
Test was conducted by: Analytica - Thornton
10 200.8 10/27/201110/27/201 IRM
Page 3 of 3
Municipality of Anchorage
Development Services Department/--,
Building Safety Division
On-Bite Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
1. GENERAL INFORMATION
Complete legal description Lot 45; Delucia Subdivision
Location (site address) 19844 Lace Rd. Chugiak, AK 99567
Expiration Date:,
Current Property owner(s) Ryan&DeannHargrave
Mailing address same
Day phone 351-0801
Lending agency
Mailing address
Day phone
Real Estate Agent Eva Loken
Mailing Address
Un/ess otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
Day phoner~9-6476
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 sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-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 S & S Engineering
Engineer's Printed Name/_'/~
5. DSD SIGNATURE
~ Approved for
Disapproved.
Conditional approval for __
Phone 694-2979
bedrooms.
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: /~) -'.~ - ~) .~
Bo
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www,muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:
WELL ~
Well type
Date completed
Total d;ith
Date of lest
IfA, B, or C provide PWSID #
Sanitary sea~l)'/~
I
Cased to t~)"l'ft.
FROM W~LL LOG
,~.z~ ,. O g.p.m.
Static water level
Well p[oduction
WATER SAMPLE RESULTS:
Coliform O colonies/100 mL Nitrate ~, ~5~ m.g/L
Arsenic: = ~ug/L date of sample: ._~,
SEPTIC/HOLDING TANK DATA X
Tank TyPe/Material ~i~'~"~ C/'~T~ C.
Tanksize ~2,P-~ gal. Number of Compartments o~
Parcel
Well LogaN)
Wires properly protected~N)
Casing height (above ground)
AT INSP/ECT~ONj.
~ c~.? g.p.m.
Other bacteria
Collected by:
~:) colonies/100 mL
Cleanout~"t~i
Foundation cleanou .t~Ni/.~ Depression over tank (Y(~) ~'~ ~.,~water alarm (Y/~D ~)
Date ofpUmping q/?/~'~ Pumper ~i/7~/~/l~4f'~ "~/t,'ppc3[~;
ABSORPTION FIELD DATA
C. Soil rating ( p d Irt2 o
Date in~;ialled ' {
~ Length 5~1 ft. Wid~ ~-'- ft.
System type !
Gravel below pipe
Total d?pth '7, ~ ~t. Eft. absprption area ~/~ft' Monitorin~ttube
Date of.adequacy test V~/D~ Results ~Fai,)~
Fluid depth in absorption field before test ~. water added ~gal.
Elapsed Time: ~min /
Final fluid depth ~ in.
Any rejuvenation treatment (past 12 mo.) ~ ~pe)
Dep!ession ov~ field ~O
' For ._.~_ bedrooms
New depth ~ in.
Absorption rate:>=. ~,l~O'f- g.p.d.
If yes, give date --
LIFT STATION
Date installed' ~ize in gallons
'Pump on level at n~ in- _High wa/eralarmlevelat--
Datum ~ Cycles tested Meets alarm & circuit requ rements?.
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main /f--)/~)'
Sewer/septic service line
Animal containment areas
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
/
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ,~ ~.~t.. Property line ~ Ii_ ,, Absorption field
Water main /~)/f}' Water service line
Wells on a. djacent lots /
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /E) t..~ Building foundation /~D "/ Water main
Water Service line /~) /'~' Surface water /~:~) /
Curtain drain /~c"t4)E /Oc~(X,O~.,) Wells on adjacent lots
Surface water / ~ ''/'
Driveway, parking/vehicle storage
/
in,
F. COMMENTS
ENGINEER'S CERTIFICATION
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
I certify that I have determined ~ugh field inspections and
review of Municipal records that tf~.abo, ves. yst~s, are
conformance with MOA COS~es~eff~l~ ~ thl; ?t~'./~
Engineer's Printed Name / ,.)/././)~/'/ /~(-)
Date
A/,~~''] ~ Waiver Fee $
~?0 ~ ~)~) Receipt Number
H.R.B, ~'Eh~TiFY THAT I HAV£ $~JRVEY[~ THE
FOLLOWING DESCRIBED PROPERTy~
AND ~T NO FN~:HM~TS [XIST ~C[~
~N~ ~ D~ERM NE TH~ E:~ISTENCE OF ANY
E~ME~TS, COVENANTS. OR
WH~ DO NOT ~PEAR ON THE RE~
VISION P~T. UND~ NO CIRCUMSTANCES
~Y DATA H~EON EE USED FOR CON~TRU~ION
OF FENCE LIN~, OR FOR EST~LISHtNG
A~y LINES.
SG~; Ref.# 1085019001
Client Name S & S Engineering Printed Date/l'ime 09/29/'2.008 8:26
Project Name/# 1~45, Dcivcia Collected DatelTime 09/[ 5/2008 ] ] :30
Client Sample II) L45, Delvc[a Received Date/'l'ime 09/15/2008 [3:i0
**,l~tri~ Drinking Wa{er Technical Director Slephen C. Ede
P%V.SII) 0
Sample Remarks:
AIIo*~able Prep Anal)sis
Arsenic
ND 5.00
ugtL EP200.8 C (<10) 09/23/0g 09/26/08 NRB
0.339 0,100 mg/L SM204500NO3-F B {<I0) 09/23/08 JDZ
Microbioi oc~, Laboratory
Colony Counl 0
Total Colifi)ml 0
Fecal Coliibnn 0
col/100mL SM20 9222B A (<200)
col/100mL SM20 9222B ^ (<1)
col/I 0OraL SM20 9222B A (<1)
09/15/08 DLC
09/15108 DI.C
09115/08 DLC
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P,O. Box 196650
Anchorage, AK 99507
www. muni.org/onsite
(907) 343-7904
Parcel I.D.
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
COSA# 0 I10
Expiration Date: ~- /f"' O_,,~
C~)mplete legal description Lot 45; Delucta Subdivision
Location (site address) 19844 Lace Rd. Chugiak, AK 99567
Current Property owner(s) Deanne Hargrave
Mailing address same
Lending agency
Day phone 351.0801
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class Well []
Public Water System []
TYPE OF WASTE1NATER 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 pdvate or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a pedod of up to one year with valid water
samples.) Certificates ara valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this epplication,
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 ail applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm s & s Engineering
Address 15861 s. Birchw°°d L°°P Ch/'~ )/K 99.
Eh gin e er's Printed Name
5. DSD SIGNATURE
I./'/ Approved for ~
Disapproved.
Conditional approval for
Phone 694-2979
bedrooms.
bedrooms, with the following stipulations;
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
~'~'" :-.~fi- - ...... :.-'~* On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description.
A. WEL L~.QA.T~
Well type _L~_ J W}'~_ -
Date completed
Total depth c~ ~/"ft.
IfA, B, or C provide PWSID # '~'
Sanitar7 seal t~Y-~l) ~/~>
Cased to /~J"ft.
' Parcel ID: Ob"l-lq'l'o~
Well Lo [~.bXl )
Wires properly protected(~)
Casing height (above grou"d) 78 '~'n
Date of test
Static water revel
Well produ~ion
FROM WELL LOG
m/q
ft.
g.p.m.
AT INSPECTION
75''
· ~,7 gp.m.
WATER SAMPLE RESULTS:
r "' Coliform (~) coloniesll00 mL
Arsenic: ~/I?~ mg/l
B. SEPTIC/HOLDINGTANK DATA
Tank Type/Material ~---~ ~':[r"F1
Tank size ~ gal. Number of Compartments
Other bacteria (~ colonies/100 mL
Cotlectedby: ~",~ ~(-~I~LZ'~-J'4~''
Date installed
Fo.undation ~leanout~l, ) ,.~t~.~ Depression over tank (Y~ ~ _...~h water alarm
Dar.e of pumping '~/~-,,~/~ Pum~r ;~~ ~t~1~
C. ,ABSORPTION FIELD DATA
Datelnstalle~ tOJ~S Soilrating (g.p.dJft'or~ ~S
Length ~?' ft. Width q' ft.
Total depth ~, 5;t. Eft absorpt on area ,~,' Monitoring tube'~
Date of adequacy test ~ Results~ail)~
Fluid depth i9 absorption field before test ~in. Water added~gal.
Elapsed Time: ~ min, Final fluid depth in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y~ ~e) ~
System lype
Gravel below pipe
ft.
Depression over field
For 4 bedrooms
New depth I in.
~E- g.p,d.
If yes, give date '"'-
D. LIFT STATION ~/~3~
Pump on leve at~ water alarm level at ~
Dat~..~...._ . Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic fan.irt station on lot
Absorption field on lot /~
Public sewer main ~/*~
Sewer/septic service line
Animal containment areas
On adjacent lots /~:~")
On adjacent lots ,/~,) ~"
i
Public sewer manhole/clean~,ut
Holding tank
I
Manure/animal excrete storage areas ¢~,,~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation
Water main /,,3/)~ Water service line.
Wells on adjacent lots
Absorption field ~"
Surface water /~"~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Properly line. ,/&) ~"/~ Building foundation /~) ~- Water main
Water Service line /~) /~'' Surface water /~:~9 -/~- Driveway, parkingNehicle storage
Curtain drain ~'-~-/~'~ Wells on adjacent lots /~ ~/'
F. COMMENTS
G. ENGINEER'S CERTIFICATION ;'~~..
I ced/fy that I have determined~gh field inspections and
review of Municipal records ~at th~/above systems are in
conformance with MOA COSA'~id~s in~c~ this ~e.
?~ -- Waiver Fee $
'/07~ Receipt Number
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
SGS Ref.# 1081545001
Client Name S .e. S Engineering
Froject Name/# L45 Delucia S/D
Client Sample ID L45 Delucia S/D
Matrix Drinking Water
All Dates/Times are Alaska Standard Time
Printed Oatefflme 04/28/2008 14:51
Collected Date/Time 04/16~00g 15:50
Received Date/Time 04/17/2008 12:00
Technical Director Stephen C.
PWSID
Sample Remarks:
Allowable Prep Analysis
Parameler Resubs PQL Units Method Container ID Limits Dale Dale Inil
~etals b~ ICP/MS
Arsenic
ND 5.00
ug/L EP200.8 C (<10) 04/21/08 04/22/05 NRB
Waters Depar~ment
Total Nitrat¢/Nitrite.N
1.82 0.100 mg/L SM204500NO3-F B (<10) 04/21/08 LCP
IVL'L crob'l oloc$~ Laboratoz-~'
Colony Count 0
Total Coliform 0
Fecal Coliform 0
col/100mL SM20 9222B A (<200)
col/100mL SM20 9222B A (<l)
co]/100mL SM20 9222B A (<1)
04/17/0g SDP
04/17/08 SDP
04/17/0g SDP
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
v,~w/.ci.anchorag e.ak. us
(907) 343-79O4
RUSH
CERTIFICATE OF HEALTH AUTHORITY APPROVAL.
FOR A SINGLE FAMILY DWELL!NG '
Parcel I.D. O~'1,
1. ,~,G.ENERAL INFORMATION
? .,:,3',,.".Complete. ·
., legal description ~_.~,7'--t-~',)
Expiration Date:
Location ({ite address or directions>
'.. Current Property owner(s)
Mailing address 3 ~ ~
Lending agency
Day phone
Day phone
Mailing address
Real Estate Agent
Mailing Address
Un/ess otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: ~
Day phone
3. TYPE OF WATER SUPPLY: '
Individual Well
Individual Water Storage
Community Class .~ Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holdir~g tank []
Community On-site []
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 propeCdes served by a single-family on-site wastewster 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 pedod 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 professicnal engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown belch, I verify that my ;nvestigatien,
based on procedures outlined in the Health Authority Approval Guidelines fcr this applicaticn, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, function, al and adequate for th~ number of
bedrooms and type o[ stmctur~ indicated herein. I further verify that based on the infomlat[en obtained from the
Municipal[fy"of Anchorage~-,-~ and from my investigation and inspection, the Ch-site water supply and/or
wastewater disposal syste~ i~lare) in compliance with all applicable Mumcipal and State codes, erdinances,
and regulations in effect at the time of installation.
NameofFirm ~'~S ~'~..I&,.J&C--,~.--~JC- Phone..._~"~-'~-~-~
Engineer's Pdnted Name ~,,~c,.-w_~ (~, ~--~c<J~-,J Date .~'/,3 '7/0 7_,.
5. DSD SIGNATURE
, ~ Approved for /'~
Disapproved.
Conditional approval for
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Wail Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Repcrt
Other
Original Certificate O~te: ~ -.~ '~' ~-~.,.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 ~oulh Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.a}~.us
(907) 343-?~04
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Descflptlon:
A, WELL DATA
we,
Date completed
Total depth
Date of test
Static water level
Well production
If A, B, or C provide PWSlD # ~
Sanitary seal (Y/N) y
Cased to 4~ 4'fl,
FROM WELL LOG
we, Lo~ (Y/N) "'7/
Wires p;opedy protected (Y/N) ~
Casing height (above ground) [_{~J-~"'in.
ATINSPECTION
0...m. 4:.4g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/lOOmL Nitrate ~.'~r~"mg.;l. Other bacteria ~:) co,onies/lOOml.
B. SEPTIC/NOLDINOTANK DATA
Tank Typ~1~l~' 'ri~l · ~"11 ~... / ~'r'~- · Date.tailed
Tank kize I '~'~4 gal. Number of Compartments ~/'' Cleanouts (Y/N)
Foundation cieanout (Y/N) '~/ Depression over tank (Y/N) .l~J High water alarm (Y/N)
Date of pumping ")'~J).? ' Pumper
C. ABSORPTION RELDDATA
To.I dep~.¢ .. Eft. abs~.on ~ ~ M~.oHn~ ~ Depression ~.r field 4
Date of ad.ua, test ~ I ~ / ~ ~ (P--'ail) ~ For&bedrooms
Fluiddep~tnabs~Uonfleldbe~re~t ~ ~. Wa~radd~/~g~. N~dep~in.
Elaps~ T~e:~ m~. F~al fl~d dep~ ~ ~. ~o~n mt. >= ~ g.p.d.
~y mjuvenafi~ ~nt (past 12 mo.) (Y~ & ~) ~ If y~, g~e date ~
D. LIFT STATION
Date installed
'Pump on" level at/ in.
Datum
E. SEPARATION STANCES
Size in gallons
'Pump off' level at -- in.
Cycles tested
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tenkAl~L,~,etiffh on lot
Absorption field on lot
Public sewer main
~/septic service line
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Suilding foundation
/~/~ Watersewicellne /0 ~'~
Water main
Wells on adjacent lots /0~ ~'~ /
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /~) ! ~ Building foundation / ~) ~ Water main
Water Sewice line ~f'~ ~4-- Surface water ' /OG ~'~'
Curtain drain ~ ~(rFJf~Weil, on adjacent lots
On adjacent lots
On adjacent lots /
Public sewer manhole/cteanout
Holding lank '~/
Absorption field ~'
Sudace water /~7 t"~'
Driveway. paddng/vehicie storage
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections end
revfew of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer'sPrintedName R a ,~.,~ ~' ~.
Date
Waiver Fee $
Date of Payment
Receipt Number
Ab'~-Z$-02 0]:39P1,l FROU-CT&£ ENVI~ON~NTAL SRV
,~?~__.. CTIE Envlmnmenlal Services Inc.
9075615301
T-IlO P.03/07 F-GS~
CT&lc Pef, P~ 1025454002
]'roJect Hlm~ ~A
Client Sample ID Deluci~ ~5
Matrix D~k~nE Water
Ordered By
~WSID 0
Sample Remad~$?
Ail Dote~TIme~ are Aln~kn Standard Time
l'dnted Dals/Time 08/26/2002 15:17
Coll~t~ Da~tme 08~3~2 13:20
Reee~ed DaYtime 06~3~002 17:10
'R~,~utts
Units
Aflow~btc Prep Anst~,.$ts
]Jmi~, Da~e Date Init
1~itrate-N
0.395
0.:~0o m~L £?^ 300.0 (<-,lO) 0&/2:~/o2
]DT
Microbiology' T,aboratory
Total Coliform
col/1O0mL SMI8 9222~,
(<-t) 08~3/02 KAP
'l.~t /~ ~...'
~,pe,~:~ ~,.~.. I- ................
An~'horafie Recor~;n~ ~c~n~t, 'Alaska, ~nd that ~e
meres sl[u~ted the~on are within ltw ~p~'~)' li:~es and
overlap or enc~h o~. L~e pro~y lying ~di~¢en~ Ihewio,
on tee p~ml, es in que~tiu~ ~t~ thai t~em are' no toadwa
~i~.E_ _~a~ or...~.~ ..........
MUNICIPALITY OF ANCHORAGE ~i~
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
APPROVAL FOR A SINGLE FAMILY DWELLING
IL~I-~L[ NAA# ~ ~ -~ ~)~ ~)--
GENERAL INFORMATION
Complete legal description
Lot 45/ Delucia Sabdivisi°~ii"
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Robert Lace
P.O. Box 670748
Day phone
Chu~iak~ AK 99567
688-3039
Day phone
Day phone
e
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Y, XX
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XXX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
=
=
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the 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 inves.ti__gation 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 .___._ . .. )
Address ',6 River, Alaska
Engineer's signature ~~
DHHS SIGNATURE
~" Approved for
~--~P-~ ~ (/"~_.~ bedrooms.
Phone
Date
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
Parcel I.D.
A. Well Data
Well type
Log present~)N)
Total depth
Sanitary seal
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed \?._ ~,3.-- Driller
Cased to ~-~ ~5 ~ ~ ~' Casing height
Wires properly protected(~N)
Date of test
Static water level
Well flow
FROM WELL LOG
,~sPUmp level1 ~ ¥~
EPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
g.p.m.
AT INSPECTION
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed ~.~,~
Cleanouts ~/N)
High water alarm (Y,~
Date of pumping
Nitrate
Other bacteria
Collected by:
Tank size
Foundation cleanout~.~/N)
& $ ENGINEERING
70.34 Eagle Rive~ Loop Road No. 204
~.~ ~!~ River, Alas~.a 99577
Compartments ~
,,~ Depression. (Y~) ~
Alarm tested (Y/N) ~ l~
Pumper ~.~-~% -t~-~ ~ ',~ t~.
Well(s) on lot
To property line
Surface water/drainage
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at "Pum~
High water alarm level Cy~d
Meets MOA electrical codes (Y/N)
SEPARATION DI~J~'~M LIFT STATION TO:
VV'~on lot On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed \ O ~
Length ~""~ ~ Width
Total absorption area '~/,..7
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y~)
Soil rating (GPD/FF) ~/1>~.~ Systemtype
~ J Gravel thickness ~ I
Total depth
Cleanout present (~N) ~ Depression over field (Y~i)
Result~ail) ~'p,~. for ~1L Bedrooms
After test ~ ~
~,~.¢.. ¢-~1~ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot \ ~
To building foundation
On adjacent lots "~
Surface water
Curtain drain
On adjacent lots \ ~ o ~ t-- Property line
~ To existing or abandoned system on lot
Cutbank t'~l ~ Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified,
Signature S & S ENGINEERING
17034 Eagle River
Engineer's Nal~l~
Date
all MOA and HAA guidelines in
HAA Fee $ ~-~) D - ~
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
COMMERCIAL TESTING & ENGINEERING CO.
ENVIRONMENTAL LABORATORY SERVICES
S~NCE 1908
Chemlab Ref. ~, : 93 ~ 479';-1
Client Sample ID :L45 D~,'~LUCIA S/D
Mat r ix : WATER
REPORT of' ANALYSIS
5633 B STREET
ANCHORAGE, AK 99518
TEL: (907) 562-2343
FAX: (907) 561-5301
Clien~ Name :S & S ENGINEERING
Ordered By :R. SHAFER
Project Name :
Project~ :
PWSID :UA
Sample Remarks: ROUTIN~.i SAMPLE COLLECT£D BY: RAY.
WORK Order :70927
Report Completed :09/16/93
Collected :09/13/93 @ 14:30 hrs,
Received :09/14/93 @ 17:00 hrs.
Technical Director:STEPiiF_~C. EDE/
Released By
QC Allowable Ext. Anal
Parameter Results Qual Un].ts Method.,~ Limits Date Date Init
Nitrate-N 0.42 mg/L EPA 353.2/300.0 I0 09/!5 DJS
See Special Instructions 'Above UA = Unavailable
>ee Sample Remarks Above NA = Not Analyzed
!3ndetected, Reported valise is the practical quantification li~it. L'£ = Less Than
Seconcia].y di!uti~>'~, G7~ :~ Greater Than
~.~.~SGS Member of the SGS Group {Soci~t~ G~n~rale de Surveillance)
ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA