HomeMy WebLinkAboutMATHIESON LT 3DMathieson
Lot 31:)
#051-102-66
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 AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW950228
DESIGN ENGINEER:CONSTRUCTING ENGINEERS,
OWNER NAME:MATHIESON MADELYN L
OWNER ADDRESS:P.O. BOX 770511
EAGLE RIVER, AK 99577
INC.
DATE ISSUED: 8/21/95
EXPIRATION DATE: 8/21/96
PARCEL ID:05110266
LEGAL DESCRIPTION:
MATHIESON LT 3D
LOT SIZE: 50941 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
RECEIVED BY: _
DATE
ISSUED BY:
1
x ~-"~ ' .1.,4-,,,/'-
~.~ ,,~,, o
? I
~ J -- .-~/
olll. / I / ~
I ~o~ ~o 'll.,///C/
O/ 0 s~w~
LOT AP. IA = 50,~41 SF /
L~ C~TE, AO~5, W~LI. D. ADII.
DP. IV~WA¥ AND HOUS~ F'OOTPI~.INT .... WATE,~
= 2Z,405 ,gF AVALL. AI~/-E. FOR .q~PTiG
gF..P'FIC, ,~ITF_. PLAN
OWNr_..12: P~.,T..,~TI~E. HOME, 5 TP.U~T PHONE.: 522-1664
~A'r~: ~/,s/~ ~^~.~: ,.:,oo'
ANDHCEA~5. ALAgI~.A 55516
PERFORMED FOR:.
LEGAL DESCRIPTION:. ~ 3~ ,~,~t~,,~/~",~O,~ TownshiD, Range. Section:
1
2
3-
4-
8
10
11.
12
13
14
15
16
18-
19
20
COMMENTS
SITE PLAN
WAS GROUND WATER~*/~'*--'
ENCOUNTERED? ..
S
IF YES, AT WHAT t..
~- 0
DEPTH? .. p
E
Reecllng Date Grosl Net
Time Time
[ i~-,'/ P~
.......... ~ .... ~ ~
,,,z~
~ ~
PERCOLATION RATE ,, ~- ('/ (m,nuteu,nc~) PERC HOLE DIAMETER
TEST RUN OETWEEN ~ t) FT AND ~ ''~ FT
PERFORMED nY: ~C'tJ~, ~c=~JE~ I ~t,,~ F~/.~/c.$~,~.)
ACCORDANCE WITH ALL ,~TATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. EAT E
G~ANOUT I' TO 4' AND TAN<
F~OM ~OUNDATION WA~L~
~PTIC TAN~ ~l ~ - ~
I 2~.5' . ..... _
I~A~
NT~ NT~
~COP~: N~W A~;O~TION SY~T~ rO~ A FOU~ 14) ~D~OOM HOM~. TH~ ~Y~T~M WIlL ~ A
D::P T~:NCH WITH 8.5' Or ~AV:L ~:LOW TH~ PIP:.
A~;O~PTION A~A CAlCUlATIONS:
MiNi~U~ ~:OUI~:D: 4 ~D~OOM~ X 150
=600 ~ CAPACITY
MINIMUM ~ZIN~ = ~00/0.~ = I000 ~F TRSNCH WA~ AESA
P~O~A~L~ IMPACT~ TO AD~AG~NT ~OT~: A~ ~HOWN ON TH~ ~IT~ P~AN. DSV~OPMSNT
TH~ WSL~ AND ~SPTIC ~Y~T~M~ FO~ THI~ ~OT WIlL HAV~ NO ~I~I~ICANT ADV~
ON TH5 ADJACENT P~OP~Tf~: A. W~L~
~. WA~T~WATE~ ~Y~T~M~
C. R~EV~D ~PAC~ / ~U~A~ AND
D. D~AINAO5
IN N5 I/4, ~, TISN, ~lW, ~% ALASKA-- ..~.~t~'~l
7721 SCHOON ST. SUIT~ ,4 ~.~ ..... ...,.~
~601 ~UDDY W~NS~ D~IV~ 2 OF
ANCHO~A~5. A~A~A
( erlifieh Drilling
by
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK0 ALASKA ~9567 * TELEPHONE 688.2759
OWNER OF LAND
ADDRESS 7 "7 .~ /
L[GAL DESCRI~ION
DATE - Sta~ed
PERMIT NUMBER
DEPTII OF' WELL /"~ '~" -
STATIC [EV£LOF WATER FF. / ~"-
I)RA~V DO',VN FT.
GA~S. PERtIR /30_~
IXDOFCAS XG 6
KIND OF _F,ORMATIONL.
From ~ ' Ft. to C~: Ft.
from .2 Et. to ~ ~ Ft.
From ~ Fi. to ~ ~
From ~rt. lo II 0 FL
Fmml I ~ FLIo t ~t Ft
From /~[ FLlO I[~ FL
F,om./~
From ~ Ft. to Ft.
From Ft. Io Et,
From ~ Ft. to Ft.
From Ft. to FI.
From Fi. to ' ' Ft..
From Ft. to Ft.
From Ft. to Ft
From ~Ft. to Ft.
From ~Ft. to
From Ft. to Ft.
' ~/~ .-- From
From
From ,'
From
From
From
From
From
Ft. to FI.
Ft. to Ft.
Ft. to~ Ft.
FI. lo FI,'
FI. ID--F!
Ft.
FI. to FI.
FI. to Ft.
· Ft. 1o ' F'I.'
FI. to
Ft. to Ft.
' ' Ft.'to ' , Ft.'
Ft. to FI
Ft. lo Ft
Ft. to Ft.
.Et to Ft.
Ft. 1o Ft
·7
MISCL. INFORMATION:
MUNIOpALITY OF ANCHORAGt:
ENVI~ONt'~- SERV:C~S
,J~:: ~ 1996
RkCEIVED
DRILLER'S NAME
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and 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
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-102-66
GENERAL INFORMATION
Complete legal description Lot 3D ~
Location (site address)
COSA #
Expiration Date: J- ~-~- / ~
Mathieson Subdivision
20710 Bill Stephens Drive Chugiak, Aia.ska 99567
· Current Property owner(s)
Mailing address
Lending agency
JosePh & Laura Tichenor Dayphone(907) 688-1180
20710 Bill Stephens Drive chugiak, Alaska 99567
Day phone
I Mailing' address
Real Estate Agent
· . Mailing Address
Brian Sherburne/Keiier Wiiii~phone (907) 727-4715
101 W. Benson Blvd.-#503 Anchorage, Alaska 995.03
Unless otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 4
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
[]
[]
L I
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. Cedificates 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 bel°w, 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 Pinard Engineering Phone (907) 357-3647
Address PO Box 871347 Wasiiia, Alaska 99687
Engineer's Printed Name Paul E. Pinard, P.E.
5. 'DSD SIGNATURE
\..~"/ApProved for
Disapproved...
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well .Flow Advisory
Nitrate Advisory
(Rev, 11/05)
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ,/0 '- .~- ~---//
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650 '
www.muni.org/onsite
(907) 343:7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:
Lot 3D, Mathieson Subdivision
A. WELL DATA
Well type Pvt If A, B, or c provide PWSID # ~
Date completed 9/95 Sanitary seal (Y/N) Y
Total depth 1 89 ft. Cased to J+0+... ff.
~ FROM WELL!LOG
Date of test ' c. 9./05
Static water level 150 ft.
Well production 20 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100mL Nitrate 3-/:R mg/L
Arsenic: ND ug/L date of sample: I o./11/11
B, SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel
Tank size 1 250 gal. Number of Compartments 2
Foundation cleanout (Y/N) ~ Depression over tank (Y/N) ~
Date of purdpLng 10/1.~/11 Pumper
C. ABS(~RPTION:
FIELD DATA
Parcel iD:.051-1 02-66
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground) 18+
AT INSPECTION
10/16/11
153.8 ft.
5.3 g.p.m.
Length 60
Total depth 13 ft.
Date of adequacy test
in.
Collected by: Pinard Engineering
Date installed
Cleanouts (Y/N) Y
N High water alarm (Y/N)
Sanitary Pumpers
Date installed 10/95, Soil rating (g.p.d./ft~x~~;X 0.6
fl. Width 3+ ft.
Eft, absorption areal 080ft2 Monitoring tube ~
1 0/1 6/1 1 Results (Pass/Fail) Pass
Fluid depth in absorption field before test 60.. in. Water added640 gal.
Elapsed Time:l/+2~Smin. Final fluid depth 60 in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type) None Faro'an
10/95
N
System typeDeep Trench
Gravel below pipe 8. ~ ft.
Y Depression over field N
For 4 bedrooms
New depth ?2 in:
600+ g.p.d.
If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at
Datum
in.
Size in gallons
"Pump off' level at~
Cycles tested
in.
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
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
25'+
1 O0 ' + On adjacent lots 1 O0 ' +
· '1'00 '+ On adjacent lots 1 O0 ' +
Public sewer manhole/cleanoUt
Holding tank
in.
Animal containment areas 50 ' +
Manure/animal excrete storage areas 1 O0 ' +
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5 ' + - ~ Property line 5 ' + Absorption field
Water main t{A Water service line 10 ' + Surface water
100'+
Wells on adjacent lots 100 ' +
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10 ' + Building foundation 10 ' + Water main
Water Service line 10'+ Surface water 100'+ Driveway, parkinglvehiclestorage 10'+
Curtain drain 1{one ][~touzt Wells on adjacent lots 100' +
~F; COMMENTS
,
review of Municipal m~s ~at the above systems are in ~~~=
~n~an~ with MOA COSA guidelines in effe~ on this date. ~7~~ ,
COSA Fee $ ~ ~ Waiver Fee $
Date of ~yment ~ O~ ~ [ ~ ~ ~ ~ Date of Payment
Re~ipt Number ~ ~ ~ ~ ~ Receipt Number
(Rev. 4/10)
SGS Ref.# 1114999001
Client Name Pinard Engineering Printed Date/Time 10/20/2011 13:29
Project Name/# 3d Mathieson Collected Date/Time 10/11/2011 13:35
Client Sample Il) 3d Mathieson Received Date/Time 10/11/2011 14:25
Matrix Drinking Water Technical l)irector Steohen C. Ede
PWSID 0
Sample Remarks:
Allowable Prop Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals b~ ICP/MS
Arsenic
5.00 U 5.00 ug/L EP200.8 C (<10) 10/11/11 10/12/11 NRB
Waters Department
Total Nitrate/Nitrite-N
3.48 0.100 mg/L SM204500NO3-F B (<10) 10/18/11 LCE
Microbiolo97~ Laboratory
E. Coli
Total Coliform
Negative I 100mL SM20 9223B A 10/11/11 DLC
Negative 1 100mL SM20 9223B A 10/11/11 DLC
PINARD ENGINEERING
P.O. Box 871347
Wasilla, AK 99687
(907) 357-ENGR (3647)
ADEOUACY TEST
LOCATION: Lot 3D, Mathieson Subdivision
APPLICANT: Joseph & Laura Tichenor
20710 Bill Stevens Drive
Chugiak, Alaska 99567
SEPTIC TANK TYPE/SIZE: Steel/1250 Gallons, per MOA Records
ABSORPTION SYSTEM: Deep Trench, per MOA Records
DAILY FLOW:
4 BEDROOMS x 150 GAL/BR = 600 Gallons
JOB NUMBER: 11-344
DATE OF TEST: 10116111
FIELD STAFF: PJ Pinard
NUMBER OF BEDROOMS: 3
SCUM: 0.0' SLUDGE: 0.0'
NEEDS TO BE PUMPED: Yes
CURRENTLY IN USE: Yes
No XX
No XX
TEST DATA
Time Flow Volume Cumulative Septic Tank Septic Soil Absorption System Comments
Rate Volume Tank
AM (GPM) (GALs) (GALs) Liquid Level /~ Level Monitor b SAS Monitor b SAS
* Tube 1' Level Tube 2* Level
8:05 5.3 4.1' 5.0' Start Flow- Meter 242070
8:20 5.3 80 80 4.1' 0.0' 5.1' 0.1' 242150
8:35 5.3 80 160 4.1' 0.0' 5.2' 0.1' 242230
8:50 5.3 80 240 4.1' 0.0' 5.3' 0.1' 242310
9:05 5.3 80 320 4.1' 0.0' 5.5' 0.2' 242390
9:20 5.3 80 400 4.1' 0.0' 5.6' 0.1' 242470
9:35 5.3 80 480 4.1' 0.0' 5.7' 0.1' 242550
9:50 5.3 80 560 4.1' 0.0' 5.8' 0.1' 242630
10:05 80 640 4.1' 0.0' 6.0' 0.2' Stop Test - 242710
RECOVERY
Date Time ST MT SAS MT
10/16 8:55 4.07-0.1' 5.6'/-0.4'
PM
10/17 9:50 5.07-0.6'
AM
*ALL MEASUREMENTS IN FT.
TEST: PASSED XXX FAILED
COMMENTS:
Testing on this WWDS found it to be operating satisfactorily. There was 5.0' of measurable liquid in
the SAS MT prior to beginning the test. With the addition of 640 gallons to the system (slightly more
than the design daily flow), the level rose 1.0' to a depth of 6.0', still leaving 2.5' of ED in the Trench.
Recovery measurements showed satisfactory absorption with a return to the starting level within 24
hours of stopping the test flow.
Reviewed by: Paul Pinard/~-~
Date: 10/19/11
PINARD ENGINEERING
P.O. Box 871347
Wasilla, AK 99687
(907) 357-ENGR (3647)
WELL FLOW TEST
LOCATION: Lot 3D, Mathieson Subdivision
DRILLER: Sullivan Water Wells
DATE WELL COMPLETED: Sept/95
WELL DEPTH: 189'
STATIC WATER LEVEL (top of casing): 153.8'
JOB NUMBER: 11-344
DATE OF TEST: 10/16/11
FIELD STAFF: PJ Pinard
Elapsed Static Flow Cumulative
Time Time Water Rate Gallons Remarks
(Minutes) Level (~lpm) Pumped
7:00 AM .... 153.8' 5.3 --- Start Test - Meter 241720
7:15 15 154.1' 5.3 80 241800
7:30 30 154.1' 5.3 160 241880
7:45 45 154.1' 5.3 240 241960
8:00 60 154.1' 5.3 320 242040
8:15 75 154.1' 5.3 400 242120
8:30 90 154.0' 5.3 480 242200
8:45 105 154.1' 5.3 560 242280
9:00 120 154.1' 5.3 640 242360
9:15 135 154.1' 5.3 720 242440
9:30 150 154.0' 5.3 800 242520
9:45 165 154.1' 5.3 880 242600
10:00 180 154.1' 5.3 960 242680
10:15 195 154.1' 5.3 1040 242760
10:30 210 154.1' 5.3 1120 242840
10:45 225 154.1' 5.3 1200 242920
11:00 240 154.1' 1280 Stop Test 243000
RECOVERY
11:05 5 153.8' All well'protection features are adequate.
Average Flow Rate: 5.3 gpm
Comments:
DURING THIS TEST, THIS WATER SUPPLY WELL WAS CAPABLE OF
PRODUCING 5.3 GPM. THIS TEST DOES NOT CONSTITUTE A
WARRANTY OR GUARANTEE THAT THE WATER SUPPLY SYSTEM
WILL CONTINUE TO FUNCTION AND PRODUCE AT THIS RATE.
Reviewed by:
Date:
Paul Pinard
10/19/11
Oct 19 11 05:55a Betty Van Boven 907 688-0993 p.1
SANITARY PUMPERS
20627 UPPER BOWERY LANE
CHUGIAK, AK 99567
907-688-4602
T
PHONE
TAX
TOTAL
/T5 ~
Is
bill.
Thank You!
Munlclpahty' ' ' of Anchorage "
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
USH 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. 051-102-66
'1. GENERAL INFORMATION
Complete legal description, tot 3D; Mathieson Subdivision
Location (site address) Do710 Bill Stevens D~'. C~ugiak, AK 99567
COSA# O ? O O
Expiration Date: - o 7
Current Propedy ortner(s) J~nn & Che~ Keogh
Mailing address same
Lending agency
Day phone
Day phone
Mailing address
Real Estate Agent Ka~e Ru~edgo
Mailing Address
Unless otherwise requested, COSA wi//be held by DSD for plckup.
2. NUMBER OF BEDROOMS: I~
Day phone 862.0416
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 Ce~ficates 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 ara 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. Ce~§cates 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 proposes 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 show~ below, I vedfy that my investigation,
based on procedures outlined In the Certificate of On-Sita 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 vedfy 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
Address 15861S. BirchwoodLoop~,.,~'~ak.A~995.67 ~..~J ~
Engineer's Printed Name /' .' /~'( /- A ,~'l'~-~,~'
5. DSD SIGNATURE
· ~ Approved for /~
Disapproved.
Conditional approval for
Phone 694-2979
bedrooms.
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
.... ~. Septic..$y~te. m Advisory'
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By': 0~/,,-.,-~ / /~. '~,~ Original Certificate Date:
G
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 CHECKLIST
Logal Description:
A. WELL DATA
Total depth ~'/ ft.
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
IfA, B, otC provide PWSID # ~
Sanitary seall~) ~'~
Cased to /'~)~ ft.
FROM WELL LOG
ft.
g.p.m.
Coliform"'"~55 colonies/lO0 mL Nitrate ~.~' mg/L
Arsenic: ~).~ ug/L dateofsemple:~/'¢/O"~
Parcel ID: Q~I-/~),~T-~'~o
Well Logi~N). \ [ ~--~'~
Wires properly protectec~) '~E,"~
Casing height (above ground) /8'~' in.
AT INSPECTION
ft.
Other bacteria ~) coloniesll00 mL
Collected by: ~-_-_~¢
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material ~ ~"T'E::~ (...
Tank size I~cc~ gal. Number of Compartments ~,.
Foundation cleanouti~N)
Date of pumping q/,~/O~)
C. ABSORPTION FIELD DATA *
Dateinstall~f!,~Cj Soilrating (g.p.d./ff'orft2/bdrm)__
Length ft. Width ~)1.~.
Total depth JJ'-13fff. Eft. absorption area IO,~O ft2 Monitoring tube
Oat, Of adequacy tast /o/~,/O~ ResuR~lFa,I, ~ ~'
Fluid depth in absorption field before test ~ in. Water ad[led ~ ~gal.
Elapsed Time:4/~ min. Final fluid depth
Any rejuvenation treatment (past 12 mo.) (Y~ type)
~)o b System type '"~"~
ft. Gravel below pipe ~,co ft.
Depression over field
For ~ 1' bedrooms
N.e _w~d~pth...~ ~n. ,
Absorption rate >= ~ g.P.d
If yes. give date
D. LIFT STATION
Date installed
'Pump on' level at
Datum__..---------
Size in gallons Manhole/Access (Y~[~,/
m level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
Absorption field on lot
Public sewer main
Sewer/septic service line
Animal containment areas
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tanldlift station on lot /'~) ~'~
On adjacent lois
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 5 ~"
Water main
Wells on adjacent lots
Absorption field
Surface water
Property line "~ ~
Water service line
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /~ f-C- Building foundation ~) ~
Water Service line /~0 ~_~L Surface water /g~) I..~.
Curtain drain ~O~"L~ I~.A.t,~D~L~ Wells on adjacent lots ./¢--"'~) ~--
Water main ~,J/~
Driveway, parking/vehicle storage
F. COMMENTS
Engineer's Printed Name '
COSAF~$ ~'~ ~
Date of Payment ~/~'~ ~ Date of Payment
Receipt Number O~) 5/.~i~ Receipt Number
(Rev. 11/05)
Analytica International, Inc.
4307 Arctic Blvd.
Anchorage, AK. 99503
Phone: 907-258-2 { 55
Fax: 907-258-6634
GROUP
S&S Engineering
Arm: Tami / Yoshl
17034 Eagle River Loop Rd.
Eagle River, AK. 99577
907-694-2979
Fax: 907-694-1211
Client Sample ID:
Sampling Location: Lot 3D Mathieson SD
Client Project: none
Sample Matrix: Aqueous
COC iV: 54919
PWS#:
Residual Chlorine:
Comments:
Report Date: 6/19/2007
Receipt Date: 6/12/2007
Sample Date: 6/I 1/2007
Sample Time: 6:00:00PM
Collected By: YN
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#: A0706112-0lA
Analysis Method
Parameter Result
9223B-PA (Aqueous) -Coliforms in DW
Units Flags MRL
Prep Prep Analysis
MCL Method Date Date Analyst
Test ~ras condocted by: dnalytica - dnchorage
E. Col i
Total Coliform
Lab#: A0706112-0lB
Pass PASS/FAI 1.0 1
L
Pass PASS/FAI 1.0 I
L
Analysis Method
Parameter Result
6/12/2007 6/12/2007 PL
6/12/2007 6/12/2007 PL
4500-NO3E (Aqueous) - Nitrate
Units Flags MRL
Prep Prep Analysis
MCL Method Date Date Analyst
Test was coudocted by: dnalytica - dnchorage
Nitrate as N 2.76 mg/L
Lab#: A0706112-01C
0.50
!0
6/13/2007 6/13/2007 AJ
Analysis Method
Parameter Result Units
200.8/200.8 (Aqueous) - Family Well Water I
Flags
MRL
Prep Prep Analysis
MCL Method Date Date Analyst
Test ~vas conducted by: dnalytica - Thornton
Arsenic 0.589 ug/L
0.15
10 200.8 6/14/2007 6/15/2007 KS
Reported by: Krissy Plett,
Laboratory project Manager
Page I of I
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Parcel I.D. #
1.
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
GENERALINFORMATION
Complete legal description L o ~Z
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Day phone
Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
'NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
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: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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.
Name of Firm ~"'~ ~,j-f4 ~,~. ~//,77 ~--,?~/,,/¢.< ~. Phone 3
Address., ~,0/ /~c/4;/c,~,./ ~.~4'/'~/.~/ '~/.' /~,'/c./-~
Engineer's signature. '~,~ '~u,~..~._ Date /~,-
DHHS SIGNATURE
!~"_ Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approv31 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 ahalyze data before a 'certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
MunicipalRy of Anchorage ~'~'C - ~'~ ~
DEPARTMENT OF H~& HU~N SERVICE~ ~ ~ 188~ ~
825%" S~et, Room 502 · ~omge, ~ 99501e (907)
A. W~.I.I. DATA
Well type
Lo~, prcsgnt (Y/N)
Tom d~ /g7
samuuy se~J (Y/N)
Health Authority Approval Checklist
~ a~/*/¢ $,*,'* Pa~l I.D.:
Date completed
WATER SAMPLE RESULTS:
Coliform ~
SEPTIC/HOLDING TANK DATA
Dal~ in,~lalled /D ' ~' Tank size
Fmm~on ck~lom (Y/N) ~'~
Date of tesl
StaUc w~ter ~
Wdl production
FROM WELL LOG
Nitram
/ /+
y,
lq*id ~ in ab~oq~on field before mst (in.);
Fluid depth ~ (ins.) Ivlinutcs lat~:
Pe~z~fide tr~*m-m (past 12 months) (Y/N)
imm*.di*tely. ~ ~ ~IL ~ ~_~1~,~'1 (in.):
Absorption tnt= = ~ gp.d.
AT INSJ~EC'TflON
If A. B. or C, attach ADEC le~r. ADEC wamr system nmaber
Casi~ heist (~ovc ground)
Wires property' p~ (Y~)
I~am i~aJled --
Manhole/Access (Y/N) ~ "Pump o~" level
High water aJann level al* ~ *Datum
"Pump off' level al* '~
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on Io! 'f/O O '
Ab~oq~tion fidd on lot ~' / ~ 0 '
Public sewer main ~ /00 ·
Sewer/septic sen'ice line -/- ~'C) '
: On adjacent lots ~'/
; On atliacem Iot~ '/'/o O '
Public sewer n~nhale~cleanout
Lift ~afion
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation /~ ' Property line '~' .~o Absorption ~ -4..~-
Wate~mam/sen,ieeline ~'30' Slllr~_ce_water/dr~inp~e -f/aa 'Wells on al~u:em lots ~./~,o
SF-.,PARATION DISTANCE FROM ABSORI:qlON FIELD ON LOT TO:
Surfa~ wate~ '~/
Driveu~., pa~ing/ve~e stora~ area '~ .~O
Curtain drain 4- .5-0 · Wells on adj~al lots ¥-/~O ~ Pmp~ty line
I ceftin, thai I ha~e determined thra field inspectmns
in conformance with MOA If.4A g~idelines in affect on t~is date.
HAAFee $ ~,), ~/
Rev. 8/95 aSS: haa.wk.doc
Waiv~ Fee $
Date of PrO'mom
Receipt Number
Municipality of Anchorage
Department of Health and Human Services
Division of Environmental Services
On-Site Services Section 825 %" Street Room 502
P.O, Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O ~'1 - lC ~. --(. (,
GENERAL INFORMATION
. Complete legal description Lot 3~,
Location (site address or directions)
HAA# - '~'ff) FT"-'~,;
Expiration Date:
Mathieson Subdivision
20727 Glennway Drive
Current Property owner ,_s~. _~a...m_.¥~o~U~or r. oaoe
Mailing address '/z/F-' ~, / /~' -7~',~ ~'
Lending agency
Day phone 907-745-1556
Day phone
Mailing address
Real Estate Agent p~niel/Frudential Vista
Mailing Address /,;'/.1 R 5~reor: Anchnr~o: AK 90503
Unless othenNise requested, HAA will be held by DHHS for pickup. HAA picked up by:
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
Day phone 727-4447
TYPE oF WASTEWATER DISPOSAL:
[] Individual On-site rx'i
[] Individual Holding Tank i'-I
[] Community On-site []
[] Public Sewer []
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of
Health Authority Approval (HAA) based only upon the representations given in paragraph 5 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) on properties served by a single family on-site
wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners.
Certificates of Health Authority Approval are valid for 90 days from the date cf issue for properties served by
a private or Class C weft and may be reissued with new water sample results less than 30 days cid. Ce.,lificates
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.
Se
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below. I verify that my investigation
based on procedures outlined in the Health Authority Approval Guidelines for the Health Authority Approval
application show 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 flies and from my investigation and inspection, the on-
site water supply and/or wastewater disposal system is in compliance with all applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
$ & $ ENGINEERING
Name of Firm 17034 Eagle River Loop Road No. 204
Address Eagle River, Alaska ~'o/~'
Engineer's Printed Name Robert Cowan
DHHS SIGNATURE
/.."" Approved for /.iL- bedrooms.
Disapproved.
Conditional approval for __
Phone (o cj ~
bedrooms, with the foflowing stipulations.
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Expiraticn Date: //' / ~ - 0 C)
Original Certificate Date:
Reissue Date:
cJ-I %-oo
75,025 ~Rev 01 001'
RECEIVED
Municipality of Anchorage AUG lo
DEPARTMEN. T OF HEALTH & HU_.M~.. SERVI~C~^u,, Enwronmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 ·
Legal Description:
A. WELL DATA
Heal~ Authority Approval Checklist
Well type '~J~ ~/A-f~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N)
Date completed
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
FROM WELL LOG
Casing height (above ground) ~- /~-
Wires pmpedy protected/N)~
AT INSPECTION
'
Nitrate 1, ~' Other bacteria O
SEFTIC/HOLDING TANK DATA'
I
Foundation cleanout~'N) (~//~"~
Date of P,~mplng
C. ABSORPTION FIELD DATA
Tanksize /~"'~ ,umber of Compartments
Pumper
Datd, tnstalled I ~)/q ~' Soil rating (g.p.dJft~ or fff/bdrm) ~?' ~ ~,S,,yetem type '7
:" Gravel micknese below pipe 4~ Total depth /.~
~ ~/N)~"q~ Depr~ion ovarfleld (Y~!)
Effective at~orl.3ti.'on area /.0~ Monitoring Tube present
Fluid del~l in abeorption field before test (in.); ~ ~ ' immediately atta~r/2~ gal. water added (in.):
Fluid depth '~' ~ ~' ' =
(ins) Minutes later:. I ~. e I Absorption mt° ~' ~ O -/-- g.p.d.
Pem3dde treatment (past 12 months) (Y/N) /V'o~¥,'/~//~/A/ If Yes, give date
72-026 (Rev. a/ge)*
D. UFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at'
Cycles tested
/
E, SEPARATION DISTANCES
/ Size in gallons
,,/~"Pump on" level at'
*Datum
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot //o0 .~
Absorption field o~ lot / O 0 -/
Public sewer main ~./ /~,
Sewer/septic sewice line Z~' ~-
On adjacent lots
On adjacent lots
Public sewer manhole/oleanout /%//~'
/oo
/~o
SEPARATION DISTANCE8 FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~ ~ Property line ~'/'/- Absorption field
Water main/sewice line / O ~ Surface water/drainage./~ /'~' Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /'~)/¥- Building foundation / 0 ~ Water main/service line /~/'~'
Driveway, parking/vehicle storage area
Wells on adjacent lots
Surface water
Curtain drain -/VO/,/~ ~/O
F. ENGINEER'S CERTIFICATION
HAA Fee S.
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*