HomeMy WebLinkAboutPOTTER POINTE LT 6Potter Pointe
Lot 6
#020-091-90
Mayor
Municipality of Anchorage
Department of Health and Human Services
825 or Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
http:/Nrnw.U.anchorage.ak.us
Permit Number: #SW 010150 Date of Issue: 5-31-01 Parcel Identification Number. 020-091-90
Date Started: 6-10-01 Date Completed: 6-11-01 Is well located at approved permit location? g Yes ❑ No
Legal Description: 'Potter Pt Lt 6 '
Property Owner Name & Address: Hagen Investments
NHN Sage Ct.
Anchonige, Ak 99516
Borehole Data:
Soil Type, Thickness & Water Strata
Depth (ft)
From To
Method of Drilling g air rotary ❑ cable tool
Casing type: steel
stick-up
0
2
Wall Thickness: .025 inches
organic & silt
2
9
Diameter: 6 inches -- Depth: 20 feet
silt
9
13
Liner Type:
gravelly silt
Bedrock
13
15
15
227
Diareter: inches Depth: feet
Casiug stickup above ground: 2 feet
Static water level (from ground level): 13 feet
Pumping level: 227 feet after
2 hoots pumping 2_5 gpm
Recovery Rate: 2_5 gpm
Method of Testing: airlift
Well Intake Opening Type:
g Open End g Open Hole
❑ Screened Start feet Stopped feet
❑ Perforations Start feet Stopped feet
Grout Type: Bentonite # 8 Volume: Lbg
Depth: Start0 feet Stopped ± feet
IIPump: Intake Depth feet
Pumn size hr) Brand Name
Well Disinfected Upon Completion? 0 Yes ❑ No
Method of Disinfection: Clorine Tablets
Comments:
Well Driller: Alpine Drilling & Enterprises
P O Box 110496
Anchorage AK 99511
Attention: The well driller shall provide a well log to the property owner within 30 days of completion and the property
^% n nr th. %v 11 JAIIr 01,01 nmv:il. a ....II L. to th. nl t of "r Ith R, Unman C.rv:r.a woMn !.n J." of rmmnh.l:m.
L
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WATER SUPPLY PERMIT
Initial
Permit Number: SWO10150
Legal Description: POTTER POINTE LT 6
Date Issued: May 31, 2001
Expiration Date: May 31, 2002
Parcel ID: 020-091-90
Design Engineer: 0000 None Required Site Address:
Owner Name: HAGEN INVESTMENT Lot Size: 20000 SO. FT.
Owner Address: NHN SAGE COURT Total Bedrooms: 4 Permit Bedrooms: 4
ANCHORAGE . AK 99516 -
This permit is for the construction of:
❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy Q Private Well ❑ Water Storage
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 DSD at least 2 hours prior to each Inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By:
Date: D/ CZAC—
n
Date:
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
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWERMELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
90
Parcel I.D. OoZO—O9/-8?I?—DDD Permit Number SW016/3'0
Property owner(s) 11,45AP'AJ Day phone2! '' 'ee d"
Mailing address (1) f/y'�
5 ATE
#er6ngaddress(2) NHAI SRbi= COURT
Legal description (Lot, Block & Sub'd.)
Zip Code 995-/L
Legal description (Section, Township & Range)
Lot Size 20inv0 Acres q.Ft. Number of Bedrooms
THIS APPLICATION IS FOR:
Sewer Only
❑
Well Only
Sewer and Well
❑
Water Storage
❑
Sewer Upgrade
❑
THIS PROPERTY CONTAINS:
Hot Tub
❑
Jacuzzi
❑
Swimming Pool
❑
Water Softening Unit
❑
Therapy Pool
❑
I certify theme above i9(ormation is
correct.
I further certify that this application is
being made for a
Single pfimilyPV
ej% n a d is in accordance with applicable Municipal Codes.
(Signature of pro6erty owne(ol authorized agent)
Permit Fees: ,/ 2 O Waiver Fees:
Date of Payment: 5--A3-01 Date of Payment:
Receipt Number: % qZ Receipt Number:
(Rev. 12100)
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Parcel I.D. 020-091-90
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Complete legal description Potter Pointe, Lot 6
Location (site address) 4330 Sage Cir.
Current Property owner(s) Jason Stevens
Expiration Date: S - / 6 -
Day phone
Mailing address 4330 Sage Cir.
Real Estate Agent Day phone
2. TYPE OF DWELLING:
Q Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
El
Individual
❑
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
LJ
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5 aj&' cv
Date of Payment�J
Receipt Number ORSy�C,
COSA# OSGU(I�6
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. 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 Pannone Engineering Services LLC
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone
6. DSD SIGNATURE
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Phone (907) 272-8218
Date 4/30/2014
Conditional approval for bedrooms, with the following stipulations:
By: ( 6 • /J — �-(� Original Certificate Date: -/
Then, ali o nchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory_ Other
COSAbWesheet S ., c
If more than 1 septic system is on the lot:
COSA Checklist # + of
Structure served by this system 1
Certificate of On -Site Systems Approval Checklist
Legal Description: Potter Pointe, Lot 6
A. WELL DATA
Well type Private If A, B. or C provide PWSID #
Date completed 6111/2001 Sanitary seal (Y/N) Y
Total depth 227 ft. Cased to 20 ft.
FROM WELL LOG
Date of test 6/11/2001
Static water level 13 ft.
Well production 2.5 g.p.m.
WATER SAMPLE RESULTS:
Coliform fJe4 colonies/100mL Nitratey°-�1:71 mg/L
Arsenic IUD ug/L Date of sample: gh o t
B. SEPTICIHOLDING TANK DATA
Tank Type/Material
Tank size gal. Number of CompBftment
Parcel ID: 020-091-90
Well Log (YIN) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 18+ in.
AT INSPECTION
4/30/2014
64 ft
0.6 g.p.m.
Collected by: PIGS
Foundation cleanout Depression over tank (Y/N) _
C. ABSORPTION FIELD DATA
Date installed
Length ft.
Total depth ft.
Date of adequacy test _
Fluid depth in absorption.
Pumper
Soil rating (g.p.d./ftZ or ftZ/bdrm)
Width
Eff. absorption area
Date
Cleanouts(Y/N)
High water alarm (YIN)
System t
ft. ravel below pipe ft.
'ing tube Depression over field_
Results (Pass/Fail)
test in. Water added gal.
Elapsed Ti min. Final fluid depth in. Absorption rate >=
For bedrooms
New depth in.
treatment (past 12 mo.) (YIN & type) If yes, give date
T...
D. LIFT STATION
Date installed
"Pump on" level at
Datum
Size in gallons _
in. "Pump off' level at
Cycles tested
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot N/A
Absorption field on lot N/A
Public sewer main 75+
Sewer /septic service line 25+
Animal containment areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation
Water main
lots
Property line
service line
ABSORPTION FIELD ON LOT TO:
Property line Building foundation
Water Servi Surface water
Gurtain drain Wells on adjacent lots
F. COMMENTS
Manhole/Access (Y/N)
in. High water alarm level
Meets alarm & circuit requirements?
On adjacent lots 100+
On adjacent lots 100+
Public sewer manhole/cleanout 100+
Holding tank 100+
Manure/animal excrete storage areas 100+
G. ENGINEER'S CERTIFICATION
i certify that t 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 Steven R. Pannone
Date 4/30/2014
COSA brown sheet -1 0-10-1 2.doc
field
Surface water
Water main
Driveway, parking/vehicle storage
r1l
Municipality of Anchorage
Development Services Department °
Building Safety Division s E r V
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
Water Well Advisory
Certificate of On -Site Systems Approval (COSA) # 141180
During a recent COSA on-site inspection and test of the potable water
supply well on Block , Lot 6 of Potter Pointe subdivision, the well's
productivity was determined to be 0.6 gallons per minute. The minimum
well productivity required by this Department (AMC 15.55) for a 4 -bedroom
residence is 0.4 gallons per minute. Although the subject well currently
exceeds this minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction of non-critical
water uses such as washing cars and watering lawns and gardens may be
required.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
Municipality of Anchorage
• Development Services Department
Building Safety Division x 2
On -Site Water and Wastewater Program a µ
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
oao- 001 oto
Parcel I.D. oz - - COSA # b C 10 j 3 Sod
Expiration Date: �z
1. GENERAL INFORMATION
Complete legal description _Potter Pointe. Lot 6
Location (site address) 030 Sage Circle
Current Property owner(s) Kenneth & Laurie Huckeba Day phone
Mailing address
Lending agency
Mailing address
41Z_:5c SACT
Day phone
Real Estate Agent Jack White Prudential Day phone 3o3. -8o37
Mailing Address
Unless,.otherwise requested, COSA will be held by DSD for pickup.
2. -�,,NUMBER OF BEDROOMS:
3.` TYPE OF WATER,SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual On-site
❑
Individual Water Storage
❑
Individual Holding TankEl
Community Class Well
❑
Community On-site
Public Water System
❑
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, 1 verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. 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 Pannone Engineering Services, LLC Phone 272-823.8
Address P.O. Box 3.0023.7, Anchorage, AK gg53.o
Engineer's Printed Name Steven R. Pannone, P.E. Date 3.0/27/203.0
Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions
encountered at the time of the test, and separation distances measured to readily identifiable features.
The operational life of all wells and septic systems depend on the local soil condition, ground water OF, q� ����
levels that may fluctuate during the year, and the water usage of the family being served by the system. ��� P•,.•••""" "•••.: qS 11
These conditions are outside the control of the evaluator of this system. All systems eventually fail and �,••'� ���
satisfactory test results do not guarantee future performance of the system, nor do they guarantee that 49LH
there are no hidden defects or encroachments. PES can therefore not provide any warranty for future �••••• �• ••• ••. •• ••••••• �••••• j
performance nor give any estimate of how long the system will continue to meet the operational
requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed ��_jP\ :Steven R. Panno .ei
above. Any reliance upon or use of this report by any other person or party is not authorized nor will it �Is'•.,•• No. CE 8149 ZA
confer any legal right whatsoever. AV
•
5. DSD SIG ATURE �����;;��.•��
Approved for �l _ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
VV ASTEWATER
J PROGRAM
Attachments:
COSA Checklist X Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory Other
By: av Original Certificate Date:
(Rev. 11/05)
1
Mminicipahty of Anchorage
Devetopment Services Department
Building Safety Division
On -Site'- Water & Wastewater Program k T Y
4700 Bragaw Street
P.O. Bok 1966.50
Anchorage, AK 9951.9-6650
www.muni.org/onsite
(907) 343-7904'
CERTIFICATE OF, 0 SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Poster P2h9% Loth
Parcel ID: -021-291-90
A. WELL DATA
Weil typePrivateIf
A, B, or C provide PWSID #
Well Log (Y/N) Y
Date completed'
Sanitary seal (Y/N) Y
Wires properly. protected (Y/N) Y
Total: depth _an, ft.
Cased to zo ft.
Casing height (above ground) in.
FROM WELL LOG
AT INSPECTION
Date: of test
61m4woi
12/16/2030
Static water level
33 ft.
23 ft.
Well production-
2.5 g.p.m.
z.s+ 9-P.M.
WATER SAMPLE RESULTS:
Catiform colonies/100 pTl_ Nitrate / _ mg/L
Other bacteria colonies/1100 mL
Arsenic: /i%1Q ug/I
Date of sample: ' fbl*
Collected by: �� = r•��
1r� jza�t
B. SEPTICIMOLDNG TAM DATA,
Ilaerial
Date installed
Tank size gall:
E7ero€G mems `
Cleanouts.(Y/N)
Foundation cleanout (YM)
Depression over tank (Y/N)
i #er-alaLm jY/N)
Date of pmping;
Pumper
C. A8S01WTJ0,M ;FJELD D ATA
tailedSoikrating
(gp.d./ftp or ft2/bdrm)
System type
Length
Wd#t
ft.' Gravet below pipe ft.
Total,depth ft. Eff.
area —fl? Monitoring tube Depression over field
Date of adequacy test
Resuits ( ail)
For - bedrooms
Flu, id.depth in.absorptlen,§eld
before test in. Water
gat. New, depth in.
Elapsed Time: Hain:
Final fluid depth in.,
Absorption - g.p.d.
Any rejuvenation: treatment (past 12 mo) (Y/N & type) If yes, give date
D. LIFT STATION
Date -este Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. I at in. �Highwateralarm level at in.
Datum Cycles tested a nts?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot ioo+ On adjacent lots ioo+
Absorption field on lot ioo+ On adjacent lots ioo+
Public sewer main 75+ Public sewer manhole/cleanout zoo+
Sewer /septic service line 25+ Holding tank ioo+
Animal containment areas 5o+ Manurelanimal excrete storage areas ioo+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building o Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION- DISTANCE FROM ABSORPTION. FIELD ON LOT TO:
Property i _ Building foundation Water main
Water Service line rface water
Curtain drain Wells on adja(
F. COMMENTS
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 Narne Steven R. Pannone, P.E.
Date 12/27/2010
Driveway, parking/vehicle storage
r ••••• ��
�1•o•
..Jium�
j .............................. .�
.Steven R. Ponnon
!�'•.• No. CE
8149
COSA Fee $ LjgO Waiver Fee $ -
Date of Payment 1 r}-'-� I 1 Date of Payment
Receipt Number Receipt Number
(Rev. T t /05) C�
■
SGS Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Sample Remarks:
1106642001
Pannone Eng. Srv.
Potter Pointe Lot 6
Potter Pointe Lot 6
Drinking Water
Printed Date/Time
Collected Date/Time
Received Date/Time
Technical Director
12/27/2010 12:24
12/16/2010 18:00
12/17/2010 8:40
Stephen C. Ede
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic ND 5.00 ug/L EP200.8 C (<10) 12/20/10 12/21/10 KDC
Waters Department
Total Nitrate/Nitrite-N ND 0.100 mg/L SM20 450ONO3-F B (<10) 12/17/10 AYC
Microbiology Laboratory
E. Coli Negative 1 100mL SM20 9223B A 12/17/10 DLC
Total Coliform Positive 1 100mL SM20 9223B A 12/17/10 DLC
SG-11-S-11-
SGS
Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
1106667001
Pannone Eng. Srv.
Potter Pointe Lot 6
Potter Pointe Lot 6
Drinking Water
Printed Date/Time
Collected Date/Time
Received Date/Time
Technical Director
12/22/2010 11:21
12/20/2010 10:50
12/20/2010 13:00
Stephen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Microbiology Laboratory
E. Coli Negative I 100mL SM20 9223B A 12/20/10 DLC
Total Coliform Negative 1 100mL SM20 9223B A 12/20/10 DLC
/
:
�
�
I
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(�(
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -She Waterand 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. 020-091-90 COSA #_ V 5 L ouQ
Expiration Date:/ z,2,2,— D q
1. GENERAL INFORMATION
Complete legal description Lot 6, Potter Pointe Subdhdslon
Location (site address) 4330 Sage Grde Anchorage, AK 99516
Current Property owner(S) Nels and Lora Jorgensen Day phone 229-6796
Mailing address 4330 sage circle Anchorage, AK 99516
Lending agency 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: Four (4)
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
(]
Individual On-site
❑
Individual Water Storage
❑
Individual Holding Tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
El
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 engineers 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 Finn Anderson Engineer(ng Phone 522.7773
Address P.O. Boz 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
6. DSD SIGNATURE .
Approved for ___�— bedrooms.
Date W20i'2008
11
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
CE -4331
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory .
Maintenance Agreements
Supplemental Engineer's Report
Other
(Rw „As)
Original Certificate Date:/ .2 g
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite, Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsfte
(907) 343-7904 r;
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Lot 6. Potter Pointe Subdivision Parcel lb: 02D -091 -GO
A. WELL DATA
Well type Private If A. B. or C provide PWSID 0
Date completed 6111101 Sanitary seal (YM) Y
Total depth 227 ft. Cased to 20 ft.
FROM WELL LOG
Date of test 6/11101
Static water level 13 R
Well production 2.5 g.p.m.
WATER SAMPLE RESULTS:
Coliform --L-colonies/100 mL Nitrate •127 mg/L
Arsenic: . 6/D ug/l Date of sample: 1OM8
B. SEPTICIHOLDING TANK DATA
Tank Type/Material Municipal Sewer System
Tank size gal. Number of Compartments_
Well Log (Y/N) ' Y
Wires properly protected (Y/N) Y
Casing height (above ground) >18 in.
AT INSPECTION
10111108
2s"s ft.
2.3 g.p.m.
Other bacteria 0 colonies/100mL
Collected by: J. Anderson
Date installed
Cleanouts (Y/N)
Foundation cleanout (YM) _ Depression over tank (Y/N) _ High water alarm (Y/N)
Date of pumping
Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d.M2 or fe/bdrn) System type
Length fL Width ft. Gravel below pipe IL
Total depth fL Eff. absorption area _ft2 Monitoring tube _ Depression over field_
Date of adequacy test Results (Pass/Fail) For_bedrooms
Fluid depth in absorption field before test in. Water added ' "gal.' 'New depth ' __. - In.'
Elapsed rime -*min. Final fluid depth in.
Any rejuvenation treatment (past 12 mo.) (YM & type)
N
Absorption rate >= g.p.d.
If yes, give date
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (YIN)
'Pump on' level at _ in. 'Pump off level at_
in. High water alarm level at in.
Datum Cycles tested
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot N/A
On adjacent lots >100'
Absorption field on lot NIA
On adjacent lots >10a
Public sewer main >75'
Public sewer manhole/cleanout
Sewer/septic service line >2V
Holding tank NIA
Animal containment areas None
Manurelanimal excrete storage areas None
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line _
Absorption field
Water main Water service line
Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD
ON LOT TO:
Property line Building foundation
Water main
Water Service line Surface water
Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
F. COMMENTS: Lot Is Served by Municipal Sewer System.
A►7 /T
G. ENGINEER'S CERTIFICATION 4
I certify that I have determined through field inspections and or* • 49�
review of Municipal records that the above systems are in •
conformance with MOA COSHuidelines in effect on this date. r.•••."•"" •��' "•'
8 Cd r- :MiCHML'E"ANDru
Engineer's Printed Name Michael E. Anderson, P.E. ��`�ry�
dfA� sPP-0►ESSIOa��
Date 10120r2008
COSA Fee $ W/
Date of Payment �Onn,'I /I�LL
Receipt Number V "( --7 1)'1
(Rev. 1 1105)
Waiver Fee $ _
Date of Paymant
Receipt Number_
10/23/2003 10:57
6235513007
SGS RcLM
1085553001
Chest Name
Anderson Engineering
Project Name/a
Potter Pone L6,Site 4330 Sage
Client Sample ID
Potter Ponte L6.Site 4330 Sage
Matrix
Drinking Watts
Plt'SID
0
Samplc Remarks:
(<I0)
THE UPS STORE
Printed Dntdiime
Collected Date/fime
Reeelved Date/Time
Technical Director
PAGE 01/02
10123/2008 9:06
10/0812008 13:18
10/08/2018 13:40
Stephen C. Ede
ParameterResults POL Unit Allowable Prep Analysif
hicdwd Container ID Limdt Date Date [nit
Mntala LY IcP/Ms
Axenic
Watwra Dermrtmnnt
Total NitratcAitrite•N
Microbiology taboratory
Colony Count
Total Coliform
Fccat Coliform
ND
S.00
ug/L
EP200.8
C
(<10)
10/16'081020108
NRB
0.127
0.100
mgtL
SN1204500N*03-F
B
(<I0)
10114/08
JDZ
0 c011100ML SN12092229
A
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10/08/08
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A
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Municipality of Anchorage yvi£�
,a s
ot*)
Development Services Department �•' =
Building Safety Division =.
< a
Onsite Water and Wastewater Program s •' a
4700 South Bragaw, St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLIN''GII
Parcell.D. 020-091.90 HAA# ZJA-CQ DO%y
Expiration Date: G — %— o
1. GENERAL INFORMATION
Complete legal description • Lot 6, Potter PointiSubdivision
Location (site address or directions) Sage Circle
Current Property owner(s) Hagen Investments, LLCIHagen Homes Day phone 229-8400
Mailing address P.O. Box 240186 Anchorage AK 99524
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD forpickup.
2. NUMBER OF BEDROOMS:
Four 4
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual On-site
❑
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
121
The Municipality of Anchorage Development Services Department (DSD) 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) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued fora 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 Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and'State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm Anderson Engineering Phone 522.7773
Address P O Box 240773 Anchorage AK 99524
Engineers Printed Name Michael E. Anderson, P.E. Date 314002
5. DSD SIGNATURE
Approved for �_ bedrooms.
Disapproved.
Conditional approval for
oF*.A� AOJ
ENGJC1EElj'SS�'ra
<e �� • •'. i n
(tC TAMP, a •;�
J
:�. _
C_.4�2I ,.
s .•• <::
Zlaecae�'
bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
gY, al. Original Certificate Date: 3 %— a :2,
�F
(Rev. IWO)
Municipality of Anchorage
' Development Services Department
/ Building Safety Division
-
On -Site Water 8 Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 6. Potter PointSubdiyisiion Parcel ID: 024091.90
A. WELL DATA
Well type Private If A. B, or C provide PWSID # _ Well Log (YM) Y
Dale completed 6/1112001 Sanitary seal (YM) Y Wires properly protected (YIN) Y
Total depth 227 ft. Cased to 20 ft.
FROM WELL LOG
Dale of test 6!11@001
r
Sta tic water level 13 ft.
Well production 2.5 9 -
p.m -WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate .2 mgA.
Casing height (above ground) >24 in.
AT INSPECTION
ft.
g.p.m.
Other bacteria 0 colonies/100 ml.
Date of sample: 1I30f2002 Collected by: _ Arrow Pump and Well
B. SEPTIC/HOLDING TANK DATA
,
Tank Type/Material Municipal Sewer System
Tank size gal. Number of Compartments _
0
Foundation cleanout (YIN) _ Depression over tank (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
a
Date installed Soil rating (g.p.dlft2 or felbdrm)
Length ft. Width ft.
Date installed
Cloanouts (YM)
High water alarm (YM)
System type
Gravel below pipe ft.
Total depth _ ft. Eff. absorption area ftZ Monitoring tube Depression over field
,i �. —
Date of adequacy test Results (PassfFail) For bedrooms
Fluid depth in absorption field before lest in. Water added_ gal. New depth_ in.
Elapsed Time: _min. Final fluid depth =1n.
4
Any rejuvenation treatment (past 12 mo.) (YM & type)
I
Absorption rate >=' g.p.d.
If yes, give date
D. LIFT STATION
Date installed Size in gallons
'Pump on' Ievel at _in. "Pump off level at _in.
Datum Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankA; t station on lot
Absorption field on lot
Public sewer main >75'
Sewer /septic service line >25'
Manhole/Access (Y/N)
High water alar level at in.
Meets alar S circuit requirements?
On adjacent lots >100'
On adjacent lots >100'
Public sewer manhole/cleanout .100'
Holding tank
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
Cuilding foundation Property line
Absorption field
i
Water main Water service tine
Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundation
Water main
Water Service line Surface water
i
Driveway, parkinglvehicle storage
Curtain drain Wells on adjacent lots
I
F. COMMENTS
Lot is served by the Municipal Sewer System
G. ENGINEER'S CERTIFICATION
fz�,.
I certify that 1 have determined through field inspections and A 9 TH
r':
review of Municipal records that the above systems are in
, . • • ..
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Michael E. Anderson, P.E.
-.MSTAMpnn.ea:oN r �°
C� - <3S1 (" •�%
Il4
Date 311!2002
4'c FH .,<q�l ,'
HAA Fee $ O _
Waiver Fee $
Dale of Payment 5- % - C)
Date of Payment
Receipt Number �/Og
Receipt Number
/Rev. 12/00)
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