HomeMy WebLinkAboutRABBIT CREEK VIEW & HEIGHTS BLK 5H LT 24A
RABBIT CREEK VIEW
& HEIGHTS
Block 5H
Lot 24A
#020-561-31
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON
-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP231088
PID Number: 020-561-31
Dwelling: ❑■ Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: 9 New ❑ Upgrade
Name
Deas Bode
ABSORPTION FIELD
❑ Deep Trench ❑■ Wide Trench ❑ Bed El Mound
Site Address
8144 Marino Drive
❑ Other
Phone
(907) 250-4989
Number of Bedrooms
4
Soil Rating
Total depth from original grade
6.0 GPD/SF
+0.5 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
+1.0 Ft.
Gravel depth beneath pipe
0.5 Ft.
Subdivision
Block Lot
Rabbit Creek V&H
5H 24A
Fill added above original grade
4.6 Ft.
Gravel length
2 0. 0 Ft.
Township Range Section
Gravel width
5.0 Ft.
Beds: Number of Lines
N/A
Distance between lines
N/A Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
100 Ftz
1
N/A Ft.
Well
>50'
>50'
N/A
N/A
>25'
TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑■ Other
Manufacturer
Greer
Capacity
1530 Gal.
Surface Water
>50'
>50'
N/A
N/A
Material
Plastic
Number of compartments
2
Lot Line
>5'
> 10'
N/A
N/A
NA
Foundation
I > 1 0'
> 1 0'
1 N/A
N/A
LIFT STATION
Manufacturer
Greer
Capacity
540 Gal.
I
Remarks
Alarm location
NW Corner by garage I
Electrical installed by
Home Owner
Installer
PIPE MATERIAL House to tank D3034 Tank to
drainfield D3034
D&K Construction
Drainfield D3034 CO/MT D3034
Inspector M. Jakubisin
BENCH MARK (Assumed elevation) 100 ft
Inspdection ` 10/11/23
10/16/23
Location and description
2nd
N E corner of house
3rd
4m
ON -SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
s�G /
,
Conditional Approval:
Date
v' `i
��Q '9cp,���1�
f 4 iH
'chiller
Septic System�enc25
Approved
Date b �-�Z
��'�rF� . 12/6/24 •��`
tl1t� pROFESSiO4�
Note: this approval does not include well permit requirements.
(Kev ub/uz/ia)
1
0
'
1
0
'
U
T
I
L
I
T
Y
E
A
S
E
M
E
N
T
(
T
Y
P
)
Benjamin Schiller
CE 12592R
E
G
ISTEREDPROFE S S I O N A L E N GINEER
1"=40'
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
BBP - BIOBARRIER POD
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
PERMIT # OSP231088 PID # 020-561-31
RABBIT CREEK V&H, BLOCK 5H LOT 24A
A B
FCO 18.9
MH1 18.1
SV1 23.7
B
BBP 22.9
2CO 30.6
CO1 61.0
26.3
35.1
41.9
44.5
45.9
33.6
FEET
0 40 80
PLAN AS-BUILT
6/16/26
D
I
A
N
E
D
R
I
V
E
4-BDRM HOME
1220
1215
1210
1205
1225
50' SURFACE
WATER SETBACK
SURFACE WATER
MEASURED AT
TIME OF
INSPECTION
4-BEDROOM
BIOMICROBICS
AWWTS
20' LONG x 5' WIDE,
0.5' EFFECTIVE DEPTH
ABSORPTION TRENCH
TH#1
ALTERNATE SITE
EXISTING WELL
MAR
I
N
O
D
R
I
V
E
WELL LOCATION UNCLEAR, BUT AT
A MINIMUM SEPARATION IS >50'
FROM PROPOSED SEPTIC SYSTEM
EXISTING SEPTIC
SYSTEM > 100'
FROM WELL
SV2 20.745.0
MT1 62.4
CO2 60.6
34.5
49.5
MT2 60.748.2
MT1
CO1 MT2
CO2
2COSV1
MH1
BBPSV2
A
FCO
ALARM LOCATION
BENCH MARK
PROFILE AS-BUILT
(NO SCALE)
PERMIT # OSP231088 PID # 020-561-31
RABBIT CREEK V&H, BLOCK 5H LOT 24A
1530 GAL PLASTIC
SEPTIC TANK
Benjamin Schiller
CE 12592
R
E
GISTEREDPROFE S S I O N A L E N GINEER
6/16/26
95.1
90.8
95.4
98.5
MH
SV
2C
O
95.7
95.3
91.4
96.0
99.1
MH
95.2
FC
O
540 GAL PLASTIC
SEPTIC TANK
BIOBARRIER
POD
2" FOAM INSULATION
2" FOAM INSULATION
98.1 FINISH GRADE
20'
DRAINFIELD ROCK
MT
TH#1
GROUNDWATER @ 91.8 5/2/23
94.0
94.5
CO CO
86.5
94.0
94.5
93.5 ORIGINAL GRADE
MT
2" FOAM INSULATION
MOA APPROVED SAND
92.5
•
W,A
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Permit Number: #_231088 Date of Issue: 5/24/23 Parcel Identification Number:
Date Started: 5/30/23 Date Completed: 5/31/23 Is well located at approved permit location? Yes FE-1 No E]
Legal Description: Rabbit Creek View & Heights BLK 5H LT 24A
Property Owner Name & Address: Bode Deas
Borehole Data: Depth (ft)
Soil Type, Thickness & Water Strata From To
Caing Stick Up
0
2
Fill
2
4
Silt & Gravel (Boney)
4
10
Silt & Gravel
10
50
Wet Silt & Gravel
50
53
Coarse Gravel W/ H2O
53
54
water quality tested 5/2026
Water Sample Results:
Arsenic: ND
Nitrates: ND
Total Coliform Bacteria: Neg
ug/L
mg/L
colonies/100mL
Method of Drilling F-01 air rotary R cable tool
Casing type: Steel
Wall Thickness: .250 inches
Diameter: 6 inches Depth: 54 feet
Liner Type: none
Diameter: inches Depth: feet
Casing stickup above ground: 2 feet
Static water level (from ground level): 25 feet
Pumping level: feet after
hours pumping gpm
Recovery Rate: Z__gpm
Method of Testing: air lift
Well Intake Opening Type:
xQ Open End F-1 Open Hole
❑ Screened Start feet Stopped feet
F-1 Perforations Start feet Stopped feet
Grout Type: Rentonite Volume: 2 Bags
Depth: 20 Feet Start 0 feet Stopped 20 feet
Well Disinfected Upon Completion? No
Method of Disinfection: tabs Comments:
Well Driller: Johnny Kay
FX1 M
Company: Hefty Drilling Inc.
Mailing Address: PO BOX 112130 Anch AK 9�
Attention: The well driller shall provide a well log to the
On -site Water and Wastewater Section within 30 days of
completion.
MUNICIPALITY OF ANCHORAGE
Development Services Department _ __� Phone: 907-343-7904
On -Site Water & Wastewater Section ` Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: 231088 _ Date of Issue: 5 24 23- -
Parcel Identification Number: 020 -561 -31
Legal Description Block Lot Property Owner Name & Address:
Rabbit Creek View & Heights 5H 24A Deas Bode
I Pump Installation Date: 12 -27 -23
Pump Intake Depth Below Top of Well Casing:
Pump Manufacturer's Name: Grundfos
I Pump Model: 1 OSQE07-200
I Pump Size: '75 hp
IPitless Adapter Burial Depth: 10 feet
Uzi PE (t i+ G f t `t Uk.
5' feet
IPitless Adapter Manufacturer's Name: Campbell B10 Type
I Pitless Adapter Installer: Hefty Drilling
Well Disinfected Upon Completion? X Yes ❑ No
Method of Disinfection: Tabs
I Comments:
IPump Installer Name: Johnny Kay
I Company: Hefty Drilling, Inc.
Mailing Address: P.O. Box 112130
City:
Anchorage State: AK Zip: 99511
Attention: The pump installer shall provide a pump installation log to On -site within 30 days of pump installation.
∆
∆
Taylor L. Dosch
No. 189892
R
E
GISTEREDPROFESSIO N A L L A N D S U RVEYOR
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Water & Wastewater System Permit
Permit Number: OSP231088
Work Type: WellSeptic Initial
Effective Date:
Expiration Date
Tax Code Number: 02056131000
Site Legal Address: RABBIT CREEK VIEW & HEIGHTS BLK 5H LT 24A G:
Site Mailing Address:
Owner: BODE DEAS M & KARLENA
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
ilzcnt S
1°
Department
5/24/2023
5/23/2024
Lot Size in Sq Ft: 17458
Total Bedrooms: 4
Q Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: r—O(L-C7
-I
Issued By:
Date:
Date:
S `� �Z3
GLV UHC CC PDAL.0TV OF „HCH0
---------------
-,
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 020-561-31
Property owner(s) Deas Bode Day phone 907-250-4989
Mailing address 7800 Marino Dr, Anchorage, AK 99516
Site address NHN Marino Dr
Legal description (Sub's., Block & Lot) Rabbit Creek V&H B5H L24A
Legal description (Township, Range & Section)
Lot Size 17458 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑x
Initial R
Single Family (SF) x❑
Septic Tank
x❑
Upgrade El(w/wo
AD U)
Holding Tank
ElRenewal
ElDuplex
(D) El
Privy
❑
Multiple Dwellings ❑
(SF and/or D)
Private Well
❑x
Water Storage
❑
THIS APPLICATION
INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
k
(Signature of property owner or authorized agent)
Permit/Rush Fees: c6 2- D Waiver Fees:
Date of Payment: s� V Z,-, Date of Payment:
Receipt Number: 0 Receipt Number:
Permit No. 03P2 )osS Waiver No.
Permit App_::- : :'-.,:c
May 3, 2023
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Rabbit Creek V&H B5H L24A-NHN Marino
Septic system design
Dear On-Site Services Engineer:
The owner of the above lot intends to build a 4-bedroom home on the property, so we are
submitting this permit application for the construction of a new well and septic system. The
attached site plan identifies the location of the home as well as the propo sed well, septic location
and alternate site. No conflicts exist between this proposed system and any other well or septic
system, whether on this lot or adjacent lots.
Contours are shown on the site plan showing the grade and direction of flow. Stormwater drainage
will not impact this septic system. The new trench will be constructed parallel to the slope as much
as possible. Wells on this and adjacent lots are shown. The new system will be a minimum of 50’
from all wells and surface water, and more than 5’ away from the septic tank. The alternate site is
located more than 6’ away.
This new septic system will be a BioBarrier system, which is an Advanced Category III treatment
system. The application rate for this system with a perk rate just over 30 min/in is 6 GPD/SF, and
there are reduced horizontal and vertical separation requirements to groundwater. The layout and
components will be per manufacturer’s instructions as approved by the Municipality.
Please refer to the attached test hole log, plan and profile pages for the septic design. If this design
is followed, there will be no adverse impacts to adjacent properties.
Sincerely,
Benjamin Schiller, PE
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231088, Curtis Townsend, 05/24/23
1
0
'
1
0
'
U
T
I
L
I
T
Y
E
A
S
E
M
E
N
T
(
T
Y
P
)
Benjamin Schiller
CE 12592REGISTEREDPROFESSION A L E N GINEER
1"=50'
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
PID # 020-561-31
RABBIT CREEK V&H, BLOCK 5H LOT 24A
FEET
0 50 100
SEPTIC PLAN
5/3/23
D
I
A
N
E
D
R
I
V
E
4-BDRM HOME
1220
1215
1210
1205
1225
50' SURFACE
WATER SETBACK
SURFACE WATER
4-BEDROOM
BIOMICROBICS
AWWTS
20' LONG x 5' WIDE,
0.5' EFFECTIVE DEPTH
ABSORPTION TRENCH
EXTENT OF
MOUND
TH#1
ALTERNATE SITE
PROPOSED WELL
MAR
I
N
O
D
R
I
V
E
WELL LOCATION UNCLEAR, BUT AT
A MINIMUM SEPARATION IS >50'
FROM PROPOSED SEPTIC SYSTEM
EXISTING SEPTIC
SYSTEM > 100'
FROM WELL
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231088, Curtis Townsend, 05/24/23
RABBIT CREEK V&H BLOCK 5H LOT 24A
TYPICAL TRENCH SECTION
(NO SCALE)
NOTES:
1. GRADE AREA OVER TRENCH TO DRAIN AWAY
2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2'
WITH 2" OF INSULATION
3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER
THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY
Benjamin Schiller
CE 12592REGISTEREDPROFESSION A L E N GINEER
4" PERFORATED PVC
(HOLES DOWN)
DRAINFIELD ROCK
5'
6"
1'
DESIGN FACTORS:SYSTEM REQUIREMENTS:
600 GPD PEAK FLOW
PERK RATE: 34 MIN/IN
APPLICATION RATE: 6.0 GPD/SF
5' WIDE TRENCH SYSTEM
2070-GAL ADVANCED TREATMENT TANK
BIOBARRIER SYSTEM
BOTTOM OF TRENCH: 0.5' ABOVE GRADE
FLOW LINE ELEVATION: 1.0' ABOVE GRADE
TOP OF TRENCH: 3.5' ABOVE GRADE
600 GPD / 6.0 GPD/SF / 5' WIDE * 1.0 RED FACTOR = 20 LF TRENCH REQUIRED
GEOTEXTILE FABRIC
6"
5/2/23
2'
MOA APPROVED SAND
6"
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231088, Curtis Townsend, 05/24/23
LEGAL DESCRIPTION:
PERFORMED FOR:
DATE: PARCEL ID#:
SOILS LOG AND PERCOLATION TEST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
DEPTH
(feet)
TEST HOLE 1
DATE READING START TIME NET TIME
(minutes)
DEPTH to
WATER NET DROP
PERCOLATION RATE: (MIN/INCH)
(inches)(inches)
DATE OF MONITORING
WAS WATER ENCOUNTERED?
DEPTH TO WATER AFTER MONITORING
IF YES @ WHAT DEPTH?
34
7/16/20 1
2
3
GC (CLAYEY GRAVEL)
Professional Engineers Stamp:
NO
RABBIT CREEK V&H B5H L24H
7/16/2020 020-561-31
D.BODE
2:50 0
3:20
3:50
1' OB
30
Benjamin Schiller
CE 12592REGISTEREDPROFESSION A L E N GINEER
PERC TEST LOCATION
TECHNICIAN: L.TIDWELL
15 16
-
1.7
5/2/23
COMMENTS:
SITE PLAN
15 16
USCS SOIL CLASSIFICATION WAS VISUALLY DETERMINED
5/2/23
30
30
0 1416
0 1416
1416
1416
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231088, Curtis Townsend, 05/24/23
Maintenance Check List
Date �ea S r) 06
Client 6;- -22- - Z
Items to be checked and documented:
N
• Was this cheduled inspectio or an Alarm response
• Check control panel for history and note /F? V^� L e�4
• Check Blower performance in Manuel modeyc9091
• Check discharge pump flow in Manuel mode, note if CIP needed
• Is a deep clean required, pull membrane & perform 24hr deep cleaning i1G
• Check Ftoat Tree for slime or build up L--(96L ado
• Test alarm function, ok? 0---No
• Effluent Temperature
• Check solids In first tank or compartment INA i n t
• Any additives needed?
• Check field for effluent in standpipes, how many inches v
• Perform site walk around, power and Manhole lids fastened
• Was any work billable or was it all warrantee 1\0
Q t)vt j1 '6-t" (
Technician l wt C—�Mv Ld
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: (907)343-7904
On -Site Water & Wastewater Section Fax: (907)343-7997
Certificate of On -Site Systems Approval
OSC261198
Parcel ID 020-561-31
Legal description RABBIT CREEK VIEW
Site address 8144 MARINO DR
Expiration Date:
HEIGHTS BLK 5H LT 24A
Current property owner(s) BODE DEAS M & KARLENA
X The On -site system(s) is/are approved for 4 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or conditions:
By: Curtis Townsend
Original Certificate Date: 6/26/2026
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 Service 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 submittal.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
MUNICIPALITY OF ANCHORAGE
• A
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 020-561-31
Complete legal description RABBIT CREEK V&H, BLOCK 5H LOT 24A
Location (site address) 8144 Marino Dr, Anchorage, AK, 99516
Current property owner(s) DeaS & Karlena Bode Day phone (907) 250-4989
2. ON -SITE SYSTEMS SIZED FOR 4 BEDROOMS
3. TYPE OF WATER SUPPLY: ❑■ Private Well serving # 1 dwelling units
❑ Other Non-public well as regulated by MOA ❑ Water Storage
❑ Community Well or Public
4. TYPE OF WASTEWATER DISPOSAL: W Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel I Plastic ❑ Concrete ❑ Fiberglass
Age 2.6 - See advisory if steel or fiberglass 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 $ II
Date of Payment
COSA#
Waiver Fee $
Date of Payment
Waiver #
COSA Application_Apr2025.doc
COSA Checklist_May2025.docx
COSA Checklist
Legal Description: Parcel ID:
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 Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. DISPOSAL 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 effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Adequacy test date
Results Pass
Fluid depth prior to test in
Water added gal
New 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
Comments/Deficiencies:
COSA Checklist_May2025.docx
E. SEPARATION DISTANCES
From Well on Lot to:(Please enter distances if less than required)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’Yes if No ft
Disposal Field on Lot > 100’Yes if No ft
Neighboring Disposal Fields > 100’
Yes if No ft
Sewer Line/Main > 100’ Yes if No ft
Sewer Manhole/Cleanout > 100’
Yes if No ft
Sewer Service/Septic Line > 25’Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Disposal Field(s) on Lot to:(Please enter distances if less than required)
Tank to Foundation > 10’Yes if No ft
Field to Foundation > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main/Service Line > 10’Yes if No ft
Surface Water > 100’Yes if No ft
Wells on Adjacent Lots:
Wells > 100’Yes if No ft
Community Wells > 200’Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
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 Phone
Engineer’s Printed Name Date
611Y civil a ctttart arisilig from this Agreement shall be
the, Third Judicial District of the Stets of Alaska t
of shall govern theriglits and obligations ot` the
this Agreement decreed in arliz by a countof coil i e-teit
Ic rcollrlululg Provisions of the Agreement,
aI o1
M\ NER:
By — _(signature)
Y►^'�'(print nante)
STATE: OF ALASKA )
ss.
TI IIRD JUDICIAL DISTRICT )
The foregoin Instrument was acknowledged before me this Z6-day of ���
20&(, by �,t�uiGCLL r
KOT.�ABLIC FOR ALASKA
My fission expires: _�= 7 Z - Z o3 v
MUNICIP ,ITI':
By (signature)
1 \D L,/-v 515,0
(print name)
"Oft -al sear
Notary Putwfc
Alyssa Porcelll
State of Alaska
Canmss on r1E09TY0op Exam 0YtJR470
Date: 2 Z 6
Title: Gt vit_
(rev. 05/18/2018)
Page 3 of 3