HomeMy WebLinkAboutUS SURVEY 3043 LT 1 OF 65BOnsite File
US Survey 3043
Lot 1 of 65B
#075-061-57
MUNICIPALITY OF ANCHORAGE
ail
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Parcel I.D. 075-061-57
Certificate of On -Site Systems Approval
Expiration Date:
Legal description US SURVEY 3043 LT 1 OF 65B
Site address 120 BURSIEL CIR Girdwood
Current property owner(s) ROWLEY
X The On-site system(s) is/are approved for 2 bedrooms
Conditional approval for
Comments or advisories:
bedrooms, with the following stipulations:
By: Original Certificate Date: 8/15/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approva"une 2022
Development Services Department ^ li Phone 907-343-7904
On -Site Water & Wastetifater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application F
1. GENERAL INFORMATION
Parcel I.D. 075-061-57
Complete legal description US SURVEY 3043; LOT 1 OF 65B
Location (site address) 120 Bursiel Circle *Girdwood 99587
Current property owner(s) Michael Rowley
2. ON-SITE SYSTEMS SIZED FOR 2 BEDROOMS
Day phone 503-351-8224
3. TYPE OF WATER SUPPLY: ❑® Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank H Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested:
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ / D Waiver Fee $ _
Date of Payment /5 Z
COSA # C Z 117 � S
Date of Payment
Waiver #
COSA Applicatlon—June 2022
q�
COSA Checklist
Legal Description: US SURVEY 3043; LOT 1 OF 65B
Parcel ID: 075-061-57
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled PRE 10/80 Total depth *67.5 ft
Cased to *67.5 ft
X Sanitary seal is functioning correctly
❑■ Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 8/7/23
Well production at time of test 5.1+ gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes ❑■ Nc
Coliform bacteria is Negative
J
Nitrate 0.44 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L `El'Arsenic less than MRL (ND)
Collected by GEG, Ltd.
Static water level at beginning of test 42.1 ft. Date 8/7/23
Comments *PER HEFTY DRILLING PUMP INSTALLATION LOG DATED 4/8/08 IN MOA RECORDS
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping
❑ Required maintenance completed, if AWWTS
Comments: -
D. ABSORPTION FIELD DATA
Which system tested (date installed)
❑ ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
❑ Monitor tubes go to bottom of effective.
If not, state depth into eXr
❑ Presoaked required if
(Required if house vacanmore
than 30 days prior to datGallons introduced date
Any rejuvenation trea ent (past 12 months)
If yes, enter e
COSA Checklist June 2022
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test da
Results ass
Fluid de prior to test in
er added gal
fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100' **50'+
❑Yes if No NSA ft ❑ Yes if No ft
Neighboring Tank > 100' ❑■ Yes if No ft Private Sewer/Septic Line > 25' [:]Yes if No *17.5 ft
Absorption Field on Lot > 100' ❑ Yes if No NSA ft Holding Tank > 100' [E Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment > 50' [E Yes if No ft
g Yes if Noft
`*50'+ Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑Yes if No ft ❑■ Yes if No ft
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
❑ Yes if No ft Surface Water > 100' [:]Yes if No ft
Tank to Property Line > 5'
❑ Yes if No ft Wells on Adjacent Lots:
Field to Property Line > 10'
❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft
Water Main > 10'
❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft
Water Service Line > 10'
❑ Yes if No ft If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
*NO REQUIRED SEPARATION DISTANCE AT TIME OF CONSTRUCTION
**WELL AND AWWU SEWER BOTH PRE -1982
G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Gamess Engineering Group, LTD. (GEG) Phone 907-337-6179
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 system/s 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 system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not
guarantee future performance of the system/s; 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.
COSA Checklist June 2022
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LICENSE OQ ProfessW'
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Parcel I.D.
Municipality of Anchorage
On -Site Water & Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
5/-
075-061-75"
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
•
n
Expiration Date:
US SURVEY 3043; LOT 1 OF 656
120 BURSIEL CIRCLE *GIRDWOOD, AK
ANDY COLLINS
120 BURSIEL CIRCLE *GIRDWOOD, AK
Day phone
JACKIE MOSER
Single Family (w/wo ADU)
Duplex
Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
WaiverNariance request for:
N/A
2
Day phone 947-0494
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
❑ Individual Holding tank
❑ Community On-site
❑ Public Sewer
•
Distance' —
Received by✓' (f6'n
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date: 9/257(%
COSA Fee $
Date of Payment
Receipt Number Qi Dq c'`
OSL1 112-5
COSA #
Waiver Fee $ -
Date of Payment
Receipt Number
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. l 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
Address 3701 E. TUDOR ROAD, SUITE 101 *ANCHORAGE, AK, 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
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 descnbe the
condition of the system/son the date/sof 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 ale wrens and septic
systems depend on a vend), of variables including, but not limited to, soil condiions, groundwater levels (that may fluctuate during
the year), qualify of construction (materials and workmanship), and the water usage of the family utilizing the system's. These
conditions can vary, and are outside the control o/ GEG. Satisfactory fest results do not guarantee future performance of the
sysfeMs 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 fad. The content of this report is for the sole benefit of the person/party who retained GEG. Reliance upon the
information provided in this report by any other person or party, including but not limited to subsequent properly purchasers, is not
authorized. In short, GEG disavows any legal duly to anyone other than the person/pady who paid for this report.
6. DSD SIGNATURE
System #1 Approved for bedrooms.
System #2 Approved for bedrooms.
Disapproved.
Conditional approval for
Date qi0if,
bedrooms, with the following stipulations:: -?j "
6/0
ON-SITE
WAl EN ANL)
WASTEWATER oz
PROGRAM �_
Oo 5N)
4NrcpTh r
By:
Original Certificate Date: 4[2 5 ^ !
The Municipality or Anchorage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenatations 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. ATTCHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
(Rev. 1011912)
Nitrate Advisory
Arsenic Advisory
Other
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: US SURVEY 3043; LOT 1 OF 65B
A. WELL DATA
Parcel ID: 075-0617-7P
*PER HEFTY DRILLING PUMP INSTALLATION LOG DATED 4/8/2008 IN MOA RECORDS.
Well type PRIVATE
If A, B, or C provide PWSID# N/A
Date completed PRE 1980 Sanitary seal (Y/N) YES
Well Log (Y/N) NO
Wires properly protected (YIN) YES
Total depth *67.5 ft Cased to *57.5 ft. Casing height (above ground) 12+ in.
AT INSPECTION Vit tL-fl 01,1 wEu-
Date of test 3/30/2016 11"0 C.M. 0/.4
pG
Static water levelEt-� ft. * * UNK ft
=NA
Well production g.p.m. 3.5+ g p.m.
WATER SAMPLE RESULTS:
(444
Coliform O colonies/100 ml. Nitrate°' mg./L. Collected by: GEG. Ltd.
FROM WELL LOG
Arsenic: /U cD ug./L.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Date of sample: 3/30/7016
PUBLIC
Date installed
Tank size gal. Number of Compartments _ Cleanouts (Y/N)
Depression over tank (Y/N) — High water alarm
Foundation cleanout (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2or ft2lbdr System type
Length ft. Width ft. Gravel below pipe ft
Total depth ft. Eff. absorption -a ft' Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absor. • field before test in. Water added _gal. New depth in.
Elapsed T — min: Final fluid depth _ in. Absorption rate >= g p d.
rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date, installed Size in gallons Manhole/Access (Y/N
"Pump on" level at in. "Pump off" level . High water alarm level at in.
Datum 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 100'+
Absorption field on lot N/A On adjacent lots 100'+
Public sewer main 75 + Public sewer manhole/cleanout
Sewer /septic service line *17.5' Holding tank
Animal containment areas 50'+
100'+
75'+
Manure/animal excrete storage areas 100'+
SEPARATION,DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line Absorption field
Water main r. Water service line Surface water
Wells on adjacent lots
PUBLIC SEWER
SEPARATION DISTANCE FROM ABSORPTION FIE 1 e ' OT TO:
Property line Bui ."-. oundation Water main
Water service line Surface water Driveway, parking/vehicle storage
C • •' . rain Wells on adjacent lots
F. COMMENTS
*THE 25 'FOOT SEPARATION REQUIREMENT FROM WELL TO PRIVATE SEWER/SEPTIC SERVICE LINE WAS
ESTABLISHED IN 1983, HOWEVER, PROPERTY WAS CONNECTED TO SEWER IN 1979.
lift.— lid A Ar uT (n2• tr�ED•
G. ENGINEER'S CERTIFICATION
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
Date Lf I $)
(Rev. 11/05)
JEFFREY A. GAR NESS
Legal:
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JACK WHITE COMPANY
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E%OLDSON NOTES: It Is the owners' responsibility to determine
the existence of my easements, covenants,. or restrictions
Mich do not appear an lite recorded subdivision plat. NOTE:
Under no c minuteness ahould my dots hereon be used for
construction or for setcheish&ig property lines,
LAND & CONSTRUCTION SURVEYORS -PLANNERS -ENGINEERS
440 WEST BENSON. BLVD. # 03
ANCHORAGE. ALASKA 99503 (907) 562-5291
Kea ORDER NlpltlIlh.#.„yt.,,..
96-L-2t7A
998'
flox) 561-6626'
RE 8599
SURVEY CERTIFICATION; LarrecH has conducted a
phydtcd survey -of this properly os shown on this
drowing and that the Improvements situated there-
on are within the property lines and no encroach-
ments exist other than noted.
AS—BUILT OF: IECAL DESCRIPTION:
LOT
LOT 1,
U S SURVEY NO. 3043, A REPLAT
OF LOTS 65A & 658
ACCORDING TO PLAT 69-11
LEGEND: SET PND
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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
COSA# OtOIOa-
Parcel I.D. 075-061-57
1. GENERAL INFORMATION
Complete legal description US Survey 3043 Lot 1 of 65B
IC;
Expiration Date: 7 - 2. 3 -
Location (site address) 120 Bursiel Cir, Girdwood, AK
Current Property owner(s) Barbara Gimlin
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
PO Box 1527, North Bend, OR 97459
Day phone
Day phone
Sam DanieV Glacier City Realty
PO Box 550 Girdwood, Alaska 99587
Day phone 783-1910
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 2
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
o ❑
❑ ❑
❑ 0
❑ Q
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. 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 Watkins Engineering, Inc.
Address
PO Box 110443, Anchorage, AK 99511-0443
Engineer's Printed Name Cindy W. Ellis
5. DSD SIGNATURE
JZ Approved for a. bedrooms.
Disapproved.
Conditional approval for
Phone 907-349-1851
Date 4/21/08
bedrooms, with the following sti
t(tttlt(((((Wa ��i
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• WATER AND • R1"
�..•
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PROGRAM
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•
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•
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
By: `//
(Rev 11/05)
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
6/ la TPS
Original Certificate Date: — oZ 3- 0E3
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
Legal Description: US Survey 3043 Lot 1 of 65B
A. WELL. DATA
Welt type Private
Date completed 1976 +/-
Total depth 67.5' ft.
If A, B, or C provide PWSID #
Sanitary seal (Y/N) Yes
Cased to 67.5' ft.
FROM WELL LOG
Date of test NA
Static water level ft.
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mL Nitrate 0.413 mg/L
Arsenic: 0' mg/I Date of sample: 4/11/08
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material NA - public sewer
Tank size gal. Number of Compartments _
Foundation cleanout (Y/N) Depression over tank (YM)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed NA Soil rating (g p.d.lft2 or ft'lbdrm)
Parcel ID: 075-061-57
Well Log (Y/N) No
Wres properly protected (WN) Yes
Casing height (above ground) 22 In.
AT INSPECTION
11/28/07
42 ft.
8.8
g.p.m.
Other bacteria 0 colonies/100 mL
Collected by: Rocky Trainor r Watkins Engr
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eft. 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. LIFT STATION
Date installed NA
Size in gallons Manhole/Access (YM)
'Pump on level at _ in. 'Pump off level at _ in. High water alarm level at in.
Datum Cycles tested Meets alarm 8 circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot NA - public sewer
Absorption field on lot NA
Public sewer main 109'
On adjacent lots NA
On adjacent lots NA
Public sewer manhole/cleanout 100+
Sewer /septic service line 19.5 (Connected 10-79) Holding tank 100+
Animal containment areas 1001+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation NA Property line _ Absorption field
Water main Water service line Surface water
Wells on adjacent Tots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line NA
Water Service line
Curtain drain
Building foundation Water main
Surface water Driveway, parking/vehicle storage
Wells on adjacent lots
F. COMMENTS: 25 ft requirement for separation from well to sewer service line began in 1983. Sewer connection
was In 1979.' Hefty Drilling confirmed total depth and casing depth on 4/8/08. "Arsenic test date 11/28/07. Well brushed
and disinfected on 4/8/08.
G. ENGINEER'S CERTIFICATION
1 certify that 1 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 Cindy W. Ellis
Date 4/21/08
A
COSA Fee $ y-30
`ilai/o 8
Date of Payment
Receipt Number
(Rev. 11/05)
/0c1.QQ 3
Waiver Fee $
Date of Payment
Receipt Number
•. ,A,
49TH
Ciy W. Ellis %.
CE 10577 •;
ass✓
APR -8-2008 06:20P FROM:
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V' Te 107‘,11
T.
•
To
well was disinfected upon completion.
method: calcium hypochlorite.
TO.CL -Top 04 .CaS:hS
Water WeOEaicd Punp Service
%%nenorage, 9[ias(a
(907) 345-0593
..
$51
_00000Op
p
o.
v •enneth L Dreyer; ��
0 of •• LS -8202 ' aawp
4002 tion;__
SingaraMjarnaspifignina, en
JACK VANDENBERG
rent THE JACK WHITE COMPANY
66A
2
nu�oa� r7 r m• owners responsibility to determine
the existence of any easements, covenants, or restrictions
which do not appear on the recorded subdivision plot NOTE
Under no circumstances should any doto hereon be used for
construction or for establishing property lines.
LAND & CONSTRUCTION SURVEYORS—PLANNERS—ENGINEERS
440 WEST BENSON BLVD. I 03
ANCHORAGE. ALASKA 99503 (907) 562-5291
WORK ORDER NUitBFR
96 -L -217A
MAY 10, 1996 -30
Scum sr. locate er w loareCtt
BAB f KEN 4814
1
(fox) 561-6626
soaksoo
REF 80S199
SIRVEY CERTIFICATION: LANIECN hos Conducted o
physical survey of this property os shown on this
drawing and that the bestowments situated there-
on are within the property lines and no encroach-
ments exist other Mon noted.
AS—BUILT OF: LEGALDESCR.rnON:
LOT 1,
U.S. SURVEY NO. 3043,
OF LOTS 65A & 65B
ACCORDING TO PLAT 69-11
LEGEND: SET FND
e/e"RB witeRS s,'r Re 0
3.3E ALNCN. 0 NO1N&CIT
HOB it TACK LI
MCC- —x-- x —
OVERHAND -
WOOD CECKS-
CONCRETE-
ASPHALi- 1•.,+-••••:•: .�
GRAVEL-
SEPnc STANCPDES.
WATER rrttl-
deale®f
A REPLAT
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 ID # 07c— 04 — S7 HAA# \F\Qc\�:G:
1. GENERAL INFORMATION
Complete legal description
Lot 1 o{c 658 U.S. Swcvey 3043
Location (site address or directions) NHN Bwrh Le 2 Cihc ( e
G,indwood, AK
Property owner Man& 8 Debbie Modeicow Day phone 346-1206
Mailing address 6141 went Thee Di,ive Anchorage. AK 99516
Lending agency Day phone
Mailing address
Agent Jack Vandenbeto/ Jack white Co.
Address
Unless otherwise requested, HAA will be held for pickup.
3
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
XXX
Day phone 762-5851
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
XXX
NOTE: 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
S. 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
Address
Engineer's signature
S & S ENGINEERING
1/U94 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Phone 61`(
6. DHHS SIGNATURE
Approved for ) bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Date rh�y )`f, (11b
Additional Comments
2
Date U6 /06/76
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 /i21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVRIE' E 1 V E
Environmental Services Division
825"L" Street, Room 502 0 Anchorage, Alaska 995010 (907) g433Y7444
INV 91996
Municipality of Anchorage
Dept. Health & Human Services
Health Authority Approval Checklist
Legal Description: LOT- 1 o c 6 r6 v 5 Sv.ev f. y &oq3 Parcel LD.: 07 S`
A. WELL DATA
Well type PR Yin
Log present (Ye) )V o
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed PQIa,e 7e /o /8 0
Total depth
Sanitary seal (t/N) Y - 5
Date of test
Static water level (// K
Well production V/ K g P m
WATER SAMPLE RESULTS:
i
Cased to y d Casing height (above ground)
Wires properly protected (9/N)
FROM WELL LOG AT INSPECTION
0/K
Coliform
Date of sample:
0
Nitrate
B. SEPTIC/HOLDING TANK DATA
Date installed Tank size
Foundation cleanout (Y/N)
Date of Pumping Pumper
Citi -ABSORPTION FIELD DATA
/vlA —
0.4r>
Collected by:
Pv,3t, C
/e6
3 • 3 t g.p.m.
Other bacteria d
S & S ENGINEERING
1i034 Eagle River Loop Road No. 204
dale River Alaska 99577
SEwth
Number of Compartments CI uts (Y/N)
Depression (Y/N) High w. , alarm (Y/N)
„.Date installed
.,Length
Width
Effective absorption area
Date of adequacy test
Fluid depth in
Fluid
th
Soil rating (g
/ft2 or ft2/bdnn) System type
Gravel thickness below pipe Total depth
Monitoring Tube present(Y/N) Depression over field (Y/N)
Results (Pass/Fail) For
rption field before test (in.);
bedrooms
Immediately after gal. water added (in.):
(ins.) Minutes later: Absorption rate = g.p.d.
If yes, give date
eroxide treatment (past 12 months) (Y/N)
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N) "Pump on" leve "Pmnp off' level at*
High water alarm level at* *Datum
Cycles to
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot t' / 4 ; On adjacent lots T ht
Absorption field on lot N / 4 ; On adjacent lots !V /A
Public sewer main / p e -!- Public sewer manhole/cleanout /00 '`
Sewer /septic service line / o -/- Lift station N �A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: N74 — A uTy , c Si w f,e
Building foundation
Property line Absorption field
Water main/service line Surface water/drainage We a. jacent Lots
SEPARATION DISTANCE FROM ABSORPTION ' i ON LOT TO:
Building foundation
Surface water
Curt
ram
F. ENGINEER'S CERTIFICATION
Property Line Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots
I certify that! have determined thru field inspections and review ofMunicipal records th
in conformance with MOA HAA gui elines in effect on this date.
Signature {�Z�� 7)Z✓?��
Engineer's Name 2G`3L27 C. CpwAn/
Date 5 �� � 4 C.
HAA Fee $
Waiver Fee $
S
s are
nem *
ili
ROBERT C. COWAN 4
CE -8801 /4-',• ( i'.`.' r ,rte ✓v
Il..^..._ ..
\\^. iia i.�..?1 i.Y✓
Date of Payment ��q/ //— Date of Payment
lReceipt Number f//' C?Q �� Receipt Number
Rev. 8/95 OSS: haa.wk.doc
A. WELL DATA
Well Classification
Well Log Present (Y
Total Depth U tiez, a Cased to /mitten/ Depth /o/f Grouting Un��nO t
Sanitary Seal on Casing
n
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
NO11031021d lY1N3WNONIAN3
CHECKLIST - FEBRUARY 1984 8 H11H314 dO 1d30
3SV OHONy dop.pyvdpuryprlv
Legal Description: /of /) hibra-222&
05 6arliej 4.34=1-3
If A, B, or C, D.E.C. Approved(Y/N)
a3A!3D3N
P8b6 G AVVJ
dlv/Jua(
Date Completed Yield `/rya/
Static Water Level Z4'j -zsak Pump Set At
Casing Height Above Ground /- 4/
te
Electrical Wiring in Conduit IVN)
elhg)
Depression Around Wellhead (Y61)
Separation Distances frau Fell:
To Septic/Holding Tank on Lot /014 ; On Adjoining Lots t/DO ,
To Nearest Edge of Absorption Field on Lot 4J/4- ; On Adjoining Lots 7-1,00/
To Nearest Public Sewer Line into"
Cleancut/Manhole PO/ To Nearest
/� /j ; Date
itete /3
mevnA0/'C Ilu%<e baro /�v�ry Pi10/1t 1/ a Ld
Water Sample Collected By
Water Sample Test Results
Convents %IX Ant,otr
Juvns 4rrm
To Nearest Public Sewer
Sewer
Service Line on Lot 2A0'
B. SEPTIC/HOLDING TANK DATA m --P0,8144: SBW e57e
Date Installed
Mc 6e.wer /cre
e'er /t6/ .
Size No. of Canpartments
Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/N) Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ; for
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances frau Septic/Holding Tank:
To Water -Supply Well To Building Foundation
To Property Line To Disposal Field
To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course d n I I
Comments 5j y: haat- Lttt ekoomm k pa -141c ztvoer
6 olartict aMd ad)rr - '51.0 wn.ct
[Page 1 of 2]
2-15-84
C.
ABSORPTION FIELD DATA -- 770 L!C
5CGW &72
Soils Rating in Absorption Strata Type of System Design
Date Installed Length of Field
Width of Field Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area Standpipes Present (Y/N)
Depression over Field (Y/N) Date of Last Adequacy Test
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well To Property Line
To Building Foundation To Existing or Abandoned System cn
Lot ; On Adjoining Lots
To Water Main/Service Line To Cutbank(if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Cua¢rents
D. LIFT STATION r" AJDA)�
Date Installed Dimensions
Size in Gallons
"Pump On" Level at
Manhole/Access (Y/N)
"Pump Off" Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy
Electrical Codes(Y/N)
Cunrrents
Test. Meets MDA
** **
Check Permitted Bedroom Rating Against HAA Request
I certify that I have checked, verified, or conformed to all MOA
on the date of this inspection.
Signed
Company
KB1/d5/s
/19E'C) dine
[Page 2 of 2]
Date , D�$
MOA No. ..r -R3. -,o(21/
HAA Guidelines in effect
� ,. ate,- c, * � o
Leroy C. Reid, J
r.No. 2257E a ;/
�. INSPECTION APPOINTMENTS
DATE RECEIVED
TIME
TIME
TIME
flat' ISI. -4' V`- -
DATE
DATE
DATE ^
\ni-ILo- 9n CNA A Lns
INSPECTOR
INSPECTOR
INSPECTORn
DEPARTMENT
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF HEALTH &
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL PROTECTION
SANITATION DIVISION OCT C 1980
Telephone 264-4720
OF INDIVIDUAL WATER AND SEWEIRFA6€pi(
C
\
KII�.
\` (+ , ENVIRONMENTAL
REQUEST FOR APPROVAL
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days fo processing.
1. PROPERTYOWNER
Robert J. Griffin
PHONE
276-6678
MAILING ADDRESS
0/0 Jack White Go. 3201 C St, Anchorage 99503
PROPERTY RESIDENT (If different from above)
Vacant
PHONE
2. BUYER
J. Martin Woods
PHONE
274-9463
MAILING ADDRESS
P.O, Box 10-336, Anchorage, Ak. 99511
3. LENDING INSTITUTION
Home Federal Savings & Loan (Sandy)
PHONE
272-14.51
MAILING ADDRESS
535 D St,, Anchorage, i?,k, 99501
4. REALTOR/AGENT Q
Jack White Co - Jack Vanden Herr 4,4
PHONE
277-1553
MAILING ADDRESS•
3201 C St., Anchorage, Ak. 99503 // J-2
5. LEGAL DESCRIPTION
Lot 1 of resubdivision on Lot 65-B, U.S,Survey 3043, Girdwood.
1
STREET LOCATION ms r a.A. cJ /„ �c.,
Main Alyeska Highway (Across from hardware store) .w i,
.(e
6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS
O One 0 Four 111 Other
SINGLE FAMILY
•O
Two IN Five
• MULTIPLE FAMILY `.• Three • Six
7. WATER SUPPLY
P1 INDIVI DUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
■ COMMUNITY since June 1975. For wells drilled prior to that date, give well
0 PUBLIC UTILITY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
• INDIVIDUAL/ON-SITE** 1 979 YEAR ON-SITE SYSTEM WAS INSTALLED.
rA PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
• SINGLE FAMILY
O MULTIPLE FAMILY
NUMBER OF BEDROOMS
• ONE El THREE ■ FIVE • OTHER
O TWO • FOUR M SIX
2. WATER SUPPLY
O INDIVIDUAL
• COMMUNITY
• PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
• INDIVIDUAL/ON -SITE
■PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
■ Septic Tank or • Holding Tank
Size: If Tank is homemade
SOILS RATING
give dimensions:
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
1 -APPROVED FOR I.? -BEDROOMS
• CONDITIONAL APPROVAL (letter
LI— DISAPPROVED
must accompa ertificate)
/) ,
DATE / /%_ _c---.:17)
BY
72-010 (Rev. 6/79)
N 37" a4' E v . 'i `
e
SUnyr, CENTIrICATIDN
May CI IIfWy TNAT 1 HAVE RIDIVT TI II INT
IrEIE 41'11�TN row DISCl/MIN Alf IN 0100 AND
W1TNINTog
OVt TN TS SITUA11U TNEIIEUN
11DACIIMENT3 Ex ST ASIETY LINES ANO Nq
hid W GTIIALA Y. RANDALL. !11 N Lana Sw•,vp
2020 "C".i7nctr . SUITE 3
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i
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14 kx:72 •.WA aaa`
IT IS )NE MIN lilac Trot•$ 7114•nNS111tt.1 TY
CIIUrs tor OT Mt IND* rI11N IN N1 LA.
TII)
SI T SACKS IN N IU rIN1511 GIIAtj/ AND 1INID)N/i
IATIDN TO lOt LINES
AND EASEAT HIS
LEGAL DISCfip NDN "Ar •• buy /
Lo+ I. Re..pk f erF LOfGv6
053+¢ 30743
LEGCtnt
• 571:•111AN
• Sri IIESAN
1I ?%r111,14
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NA TUM AS.
SCALE /•1
JUN- 6-96 THU 8:02 AWWU
.. OCr,5.5:
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FAX Na 9075625427 P. 05
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., • r I r •v _ ... r, e•s-r ..4 bre,- G ! P.-twoof7 -raw r.f s rrt
f •
1, General Information
Att.
u PRO!' x t RL L:i
Application Date //
ecAV
(a) Legal Description (include lot, block, subdivision, section, township, range)
"Y- / ge,p /c f e ( 66 L3 j ed 301q
Location (address or directions)
/i/`/e / 3 41%y5/ca_ /hy/way, //--
(b) Applicants Name lam'/Ja'r// !)l�ItMit, ,.jc&:. ' �c�/tk Telephone 2„3---,57.5c90
Applicants Address 32c/ _j 5/2e.e.:7 945673
(c) Applicant is (check�� �ore) Lending Institution/; Owner/builder ;
r
Buyer L- ; Other J5i(explain); ,(»a./ tivJ/z-z7
(d) Lending Institution Telephone
Address
(e) Real Estate Co. & Agent
Address 52e1
Telephone yo:'.53 oO
�1/4/0 e ? Ali Al
e7- 33
2. Type of Residence
Single -Family t>4 Multi -Family f
Number of Bedrooms
3, Water S
Individual Well Community I I Public
Other (describe)
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
Is the well adequate for the number of bedrooms specified in this HAAY 1)
4. Sewage Disposal
Onsitefi Public
Community f I Holding Tank
Is the wastewater disposal system adequate for the amber of bedrooms (X/N)
4-
5. Engineering Firm Providing Inspections, Tests, Data and Information
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in
effect on the date of this inspection.
Signed it W ..2oteir%
Name of Fir 4Fc >7_r /
Address / L>U
ZZ) 5 41 `ie R 927523
Signed by
Date
s
5 1/4j /;;;;-/
(ENGINEER SEAL)
6.DHEP Approval
Approved for bedrooms
Approved Disapproved fi
Terms of Conditional Approval
Date
Telephone
il/go/gr
Conditional's
Date //Fy
The Municipality of Anchorage Department of Health and Environmental Protection does
not guarantee the continued satisfactory performance of the water supply and/or the
wastewater disposal system. This approval indicates that, as of the validation date
shown above, based on the data and information furnished by an engineer registered in
the State of Alaska, the water supply and wastewater disposal system is safe and funs
tional for the number of bedrocrs and type of structure indicated.
(DHEP SEAL)
7. Mail the HAA to the following address: