HomeMy WebLinkAboutSAND LAKE #2 BLK 4 LT 7and Lake #2
Block 4
Lot 7
#011-135-46
kI I M
ENGINEERING
Bate: 4/18/18
To: MOA On -Site Services
Steve Eng, PE, P
PO Box 770724, Eagle River AK 99577
907-694-7028
SteveEngPE@gmail.com
Subject: Sand Lake #2 Block 4 Lot 7
Number Of Bedrooms
Debby Wockenfuss Telecon (4/18/18)
Number of Pages: 1
The subject property has been served by a septic system for a number of years. The MOA file
information lists the approved septic system size as 2 -bedrooms. In the subject telephone
conversation it was discovered that a change could be made to 3 -bedrooms, detailed in this memo:
o A recent COSA inspection revealed the septic system is functioning for 3 -bedrooms.
• A 1250 gallon septic tank was installed in 2007- adequate for 3 -bedrooms.
® The deep trench constructed in 1983 was sized at 312 FT'. The soil was rated at 100
FT2/Bedroom. This is sized large enough for 3 -bedrooms.
• The soil test log from 1983 exhibits suitable soil for the 100 FT2/Bedroom rating.
• The owners state that to their knowledge this has been a 3 -bedroom home.
Because of this information, we request the COSA be approved for 3 -bedrooms.
Thanks -Steve
Municipality of Anchorage
Development Services Department
Building Safety Division '
On -Site Water and Wastewater Program, 4700 Bragaw St.
P.O. Box 196650 Anchorage, AK 99519.6650 Page I of 2
www ci anchorage ak.us (907)143.7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: S C(/07y0 7p PID Number:
Nal* Davt TollierF El « 04'
Wastewater System: [INew Upgrade
A".,&
8oS-3- Suro< tc ke Rd. A -CA 99SOZ
ABSORPTION FIELD —XI -CT -
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LEGAL DESCRIPTION
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Inspections performed by: F /� tea
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Development Services Department Approval 010' '•..1' ��
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Conditional Approval Date: ............
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:11fEODORE F. 160ORE
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Reviewed and approved by: Date: ,.�iS'
.Rn w4dr dAr�,2t. �^i»•�•
PERMIT NO: SW070070
PID NO: 011-135-46
SWING TIES:
FROM:
COR. "A"
COR. "B"
TO:
FDN. C.O. "E"
22'
18'
S.T. C.O. "F"
34.5'
21.5'
S.T. C.O. "G"
38.5'
28.5'
DBL. C.O. "H"
39.5'
31'
TR. M.T. "1"
51'
38.8'
PAGE 2OF2
EXISTING SOIL ABSORPTION TRENCH A'
� NEW 1250 -GALLON SEPTIC TANK
PLAN VIEW
SCALE: 1" = 30'
LOT 7, BLOCK 4
SAND LAKE #2
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MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water 8 Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519.6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: May 22, 2007
Expiration Date: May 21, 2008
Permit Number: SW070070 Parcel ID: 011-135-46
Legal Description: SAND LAKE #2 BILK 4 LT 7
Design Engineer: 0019 FLATTOP TECHNICAL SERVICES Site Address: 008055 SAND LAKE RD
Owner Name: ELYCE HAGE Lot Size: 6600 SQ. FT.
Owner Address: 8055 SAND LAKE ROAD Total Bedrooms: 2 Permit Bedrooms: 2
ANCHORAGE. AK 99502-4011
This permit is for the construction of:
❑ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ 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:
Date: / /47
Issued By. �1 1a1 Date: Z J
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
ON-SITE SEPTICIWELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O It 133- N/
Propertyowner(s)
Da -e- Trf5erF
It Eflr
o /gyp
_Dayphone ?36-36.6-5'
Mailing address
P d fiat
23 Z;-`//
Rretiorg{-e-
Zip Code99SZ S
Site address dy s S- Zip Code
Legal description (Sub'd, Block & Lot) 1-0t7, flee 4 y • -Ci* /)d yoke -V /-0 # Z
Legal description (Township, Section & Range)
Lot Size C n pt)C) Sq. Ft.
THIS APPLICATION IS FOR (®all that apply):
Absorption Field
❑
Septic Tank
19
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
Number of Bedrooms ?
THIS APPLICATION IS AN:
Initial
❑
Upgrade
Renewal
❑
certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
'rX4 :t
(Signature of property owner or authorized agent)
Permit/Rush Fees: Waiver Fees:
Date of Payment: J ��07 Date of Payment:
Receipt Number: cl q 743_0114J Receipt Number:
(Rev. 11/05)
YFUW EC INICA_L SERVICE
CML S ENVIRONMENTAL ENGINEERING • ENERGY CONSERVATION 6 ANALYSIS
TED MOORE, P.E.
PHJFAX:(907)345-1355
E -Mail: tgmoore@gci.net
M.O.A. DSD
P.O. Box 19-6650
Anchorage, AK 99519
Dear Sirs:
May 16, 2007
14530 ECHO CANYON ROAD
ANCHORAGE, AK 99516
The purpose of this letter is to provide the required design narrative in support of our application
for a permit to install a new septic tank on Lot 7, Block 4, Sand Lake S/D #2, located at 8055 Sand Lak:
Road. The purpose of this installation is to allow construction of a garage that will partially overlie the
existing tank location. A site plan and specifications are enclosed for your review.
The property owner, Dave Tolbert, wishes to do the installation work himself. I have request
him to provide your office with the necessary documentation of his relevant experience.
Please give me a call at 345-1355 if you have any questions on this submittal.
Sincerely,
Tom-.{ 7310-.,._
Ted Moore, P.E.
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•LOT 7. BLOCK■ LAKE SID #2
SEPTIC TANK REPLACEMENT
1. SITE PLA14
FLATTOP 1
1 ECHO CANYON ROAD DRAWN BY Tch
ANCI IORAGEALASKA 99516 MY,/1
NOTE: THIS IS NOT A SURVEYED PLAT.
ALL LOCATIONS SHOWN•
Tfattop 7echnicaCServices
14S30 Echo Canyon &aef, Anchorage, Ax 99516
Thone (907) 34S -135S
Lot 7, Block 4 Sand Lake S/D #2
8055 Sand Lake Road
Septic Tank Replacement
Specifications
1.0 General:
1.1 The scope of the project consists of abandoning a 1000 -gallon steel septic talk and rep]aci:ig
it with a new 1000 -gallon septic tank located as shown on the site plan.
1.2 Construction shall be as depicted on the approved site plan. Minor deviations from these
drawings may be allowed or required by the engineer conducting the inspections. All ccristruction
procedures and material specifications shall conform to Municipal and State requirements. All
separation distances shall be in conformance with Municipal requirements, unless specifically waived.
1.3 The installer shall be responsible to obtain any necessary utility locates, and to work around
any buried utilities.
1.4 The installer shall provide adequate cover material and rough grading over th-a tank to ensure
that proper drainage is achieved after settlement and that there are no residual depressions.
1.5 The homeowner shall be responsible for finish grading after the soil is compacted, as well as
placement of topsoil and reseeding all areas disturbed by the construction.
2.0 Septic Tank:
2.1 The existing septic tank must be properly abandoned by thoroughly pumping, removing the
top and backfilling with soil. The backfill material must be fully compacted NFS material 14.11 ere the
present tank shell will be overlain by the proposed garage foundation.
2.2 The new 1000 -gallon, 2 compartment septic tank shall be Municipally approved and shall be
set level on undisturbed soil. Each compartment shall be equipped with a watertight manhole cover and
a 4" cleanout.
2.3 A double cleanout shall be installed in the discharge line between the new tank and the point
of connection to the existing soil absorption trench. A newfoundation cleanout shall be insealled
within I to 4 feet outside of the proposed new garage foundation.
3.0 Inspections:
3.1 A total of 3 engineering inspections will be required during the course of the project: (1)
initial discussion with the contractor to finalize the location of the tank and construction procedures, (2)
after the tank is set level and piping connected but prior to backfill, and (3) after rough backfill and
grading is complete. The installer shall coordinate the timing of the inspections with the engineer
sufficiently far in advance to ensure the availability of the engineer.
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAMET ��������
PHONE IRNEW
_�% ❑ UPGRADE
cam✓
MAILING ADDRESS
�5C R
-<i -A ® 99
LEGAL DESCRIPTION
S
7
La�
LOCATION
NO. OF BFDROOMS
t
r
2x
DISTANCE TO:
Well /�
1. 00
Absorption area _
Dvyellin ^
N !i ,Ge11
!
PER T NO.
Jy
iQ
Manufacturer2Lf
Material
1
No. of compartments Z_J
wF
y
Liq. ca achy in allons
g
IF HOMEMADE:
Inside length
Width
Liquid depth
z
DISTANCE TO:
Well
Dwelling
PERMIT NO.
02<
Manufacturer
a
Material
Liquid capacity in gallons
w=
DISTANCE �O:
Well �D 4•
Found "on
Nearest lot line (
PE T 0
J LL z
F Z w
No. of lines
Length of each lin /Total
length of lines /
Trench widthJ'I
7,'�nches
Distance between lines
- 6-
F
Top of t(le to finish grades
y
L
Material beneath tile .�
_ z
Total effective alcor tion area
—"
incHe�
z -f f.�- ✓
w
Length
Width
Depth
PERMIT NO.
C7
CL F
wa
Type of crib
Crib diameter
Crib depth
Total effective absorption area
Lu
y
DISTANCE TO:
Well
Building foundation
Nearest lot line
w
Class
/ViAn
DO . _n n
T
Driller
Distance to lot line
PERMIT NO.
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
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PIPE MATERIALS
pc_ 4_rT
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SOILTT,EST TING
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APPROVED
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Permit #
Applicant
Location:
—MUNICIPALITY OF ANCHORAGE,—,
Department' 'E Health and Environmenta Protection
825 1, Street, Anchorage, AK. 99501
264-4720
# # HANDWRITTEN PERMIT
AND/OR ON-SITE SEWER PERMIT
% C2r7 - Mailing Address: <5e�9,6nY v 351+1 `l' S62-
Phone
6ZPhone Number: k3?Y 5c-) G 70
Legal Description: L 7,6 y , k_A_o, -fq 7 Lot Size:
Type of Soil Absorption System Is:
Trench: Drair_field: _ Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is:
DEPTH %/ LENGTH �� GRAVEL DEPTH WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(MOtDTNG) TANK SIZE _ /da GALLONS #
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
# # # TWO(2) INSPECTIONS ARE REQUIRED # # #
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum, distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
# # # PERMIT EXPIRES DECEMBER 31, 1 9 3 3
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that a bedrooms.
Signed: '//�%! ' 4y4 ,/ Issued by
A .c�vcQ C
Applicant
Date:
SWP/024(1/81)
�\ SOILS LOG
r '
MUNICIPALITY OF ANCHORAGE
e +.e DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
' TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: aoo aEl,. Vt �t� DAjT�E PERFORMED: 117-7
—— U3
LEGAL DESCRIPTION: satid Lae Ll
Lake ,n 1 �Q� 7
P SLOPE SITE PLAN
' F �SMi S, �fy �a d
2Sr It
3
!CGP1SQndy Grave
4
401 •
Q'D (6 W)
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9- ,a
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to �If 0
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ENCOUNTERED? P
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• IF YES, AT WHAT E
13 ♦ . DEPTH?
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15
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19Ler4 C. Reid, Jr.
Aft. 2251-E
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20 �i9 �P ........•Pv
COMM
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE
PERFORMED BY: V/YVl Grey -,o- ti CERTIFIED BY:
MONSTe3S-0& /
72-008 (6/79)
(minutes/inch)
CONSTRUCTION AND OPERATION CERTIFICATE
ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION .
PUBLIC WATER SYSTEM
APPROVAL TO CONSTRUCT
Plans for the construction of Lt, 7,
-- T J e iA l public water system located
in IZ -a ' , Alaska, submitted in accordance with 18 AAC 80.100
by Te r have been reviewed and are
W approved.
❑ conditionally approved (see attached conditions).
by TITLE DATE
If construction has not started within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED CHANGE ORDERS
Change (contract order no.
or descriptive reference)
/oo�
Approved by
Date
The "APPROVAL TO OPERATE" section must be completed before any water is made available to
the public.
APPROVAL TO OPERATE
The construction of the
public
water system was completed on (date). The system is hereby
granted interim approval to operate for 90 days following the completion date.
TITLE DATE
As -built plans submitted during the interim approval period, or an inspection by the Department has
confirmed the system was constructed according to the approved plans. The system is hereby granted
final approval to operate.
TITLE DATE
MUNICIPALITY OF ANCHORAGE
Development Services Department -r Phone: 907-343-7904
On -Site Water & Wastewater Section — Fax: 907-343-7997
Parcel 1. D. 011-135-46
1
Certificate of On -Site Systems Approval
Expiration Date: / - 23 - 2 0 Z 1
GENERAL INFORMATION
Complete legal description SAND LAKE #2 BLK 4 LT 7
Location (site address) 8055 Sand Lake Rd
Current property owner(s) EVANOFF LISA
Mailing address
Real estate agent
Diana Garney
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone 223-2076
Day phone 223-2076
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
0
Water Storage
❑
Holding Tank
❑
Community Well
0
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date of Payment
Waiver Fee $
Date of Payment
Receipt Number 0 (� a 5 � I6Receipt Number
COSA # OS C a, 0 1 5 H I I Waiver #
5. STATEMENT CSP INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, base(
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that th(
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number o
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from th(
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wvastewate
disposal system is (are) in compliance with all applicable Municipal and State costes, ordinances, and regulations it
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm North Rim Eng. Phone 694-7028
Address PCS Box 770724, Eagle River
Engineer's Printed Name Steve Eng Date 10/3/20
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•
6. DSD SIGNATURE s * .49
System t1 Approved for bedrooms
.j
Steve
System #t2 Approved for bedrooms ♦♦� % CE -6
Eng
Disapproved T#1�® 10/ 3 % 2Y
Conditional approval for bedrooms, with the following stipulations:
Original Certificate Date:
The Municipality of Anchorage Development Semices Division (DSD) issues Certificates of on -Site Systems Approval (COSA) based only upon th
repre, entations given in paragraph 5 by an independent pmle,;si-anal ci-Al engineer re&,4ere•t in the State of Maska. The Municipality 0i Anchorage i
not responsible for errors or omissions in the professional engineer's viork.
7. ATTACHMENTS:
COSH Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory X—
COSA Checklist
Legal Description: SAND LAKE #2 BLK 4 LT 7 Parcel ID: 011-135-46
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
❑ Well log is filed with Onsite (or attached) Well production at time of test 6+ gpm
Date drilled Link Water storage tank volume 0 gallons
Total depth unk ft Well disinfected for coliform test? ❑ Yes ❑ No
Cased to unk ft ❑ Coliform bacteria is Negative
❑ Sanitary seal is functioning correctly Nitrate mg/L ❑ Nitrate less than MRL (ND)
❑ Wires are properly protected Arsenic ug/L ❑ Arsenic less than MRL (ND)
Casing height (above ground) 12+ in. Collected by NRimEng
Date of flow test for COSA 92120 Date of Sample 9/21/20
Static water level at beginning of test 94.8 ft.
Comments * Sample taken 10/15/2020 for Arsenic prior to treatment: 31.3 ug/L
B. TANK DATA
Age of tank(s) 13 years
Tank type/material septicSN
Measured operating fluid level in septic tank 50"
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 9/25/20
D. ABSORPTION FIELD DATA 12/83
Which system tested (date installed) same
❑ ALL standpipes present per record drawing
Total measured depth from grade 10 ft (max)
Measured depth to pipe invert from grade 4 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date si2v20
Results R Pass For 3 bedrooms
Fluid depth prior to test 6 in
Water added 450 gal
New depth 15 in
Elapsed time 30 min
Final fluid depth 8 in
Absorption rate 450 gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
no
E. SEPARATION DISTANCES
From Private Well on Lot to' {Plcac5c ontcr dic3tDnccs if lc35 than required or if community wall)
Septic Tank,'Lift Station on Lot > 100'
Yes
if No 8
Community Sewer Manhole/Cleanout > 100'
Surface Water > 100'
E]
Yes
if No
ft
7 Yes
if No ft
Neighboring Tank > 100`
Q
Yes
if No
ft
Private SeweriSeptic Line > 2T F71 Yes
if No ft
Absorption Field on Lot > 100'
�
Yes
if No
ft
Holding Tank > 100' M Yes
if No ft
Neighboring Absorption Fields
> 100'
ft
If septic tank is under driveway
Animal Containment 2: 50' Rv Yes
if No ft
F�
Yes
if No
ft
h4anure/Animal Excreta Storage > 100'
Community Sewer Main > 75'
P-1
Yes
if No
ft
n Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
Yes
if No 8
ft
Surface Water > 100'
Yes if No ft
Property Line > 5'
Q Yes
if No
ft
Wells on Adjacent Lots,
Wells on Adjacent Lots:
Absorption Field > 5'
� Yes
if No
ft
Private Wells > 100'
FvJ Yes if No ft
Water Main > 10'
Yes
if No
ft
Community Wells > 200'
E] Yes if No ft
Water Service Line -- 10'
Yes
if No
ft
If septic tank is under driveway
comment below
From Absorption Field on Lot to: (Please enter distances if less than required
Building Foundation > 10'
U
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
F71
Yes
if No 5
ft
Wells on Adjacent Lots:
Water Main > 10'
Yes
if No
ft
Private Wells> 100' Yes if No ft
Water Service Line > 10'
Yes
if No
ft
Community Wells > 200' Yes if No ft
Surface Water > 100!
Yes
if No
ft
F. ENGINEER'S COMMENTS
Absorption Field Partially In Driveway
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and review
of P11unicipal records that the above systems are in conformance with
/VOA COSA guidelines in effect on this date.
Steve Eng ivy
CE 6256
/'',3/ 2
Arsenic Advisory
Certificate of On -Site Systems Approval # OSC201544
Subdivision: Sand Lake #2, Block: 4, Lot: 7
A water sample revealed an arsenic concentration of 31.3 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. information on arsenic is available from the On -Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Madmg Address `P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org
Municipality of Anchoragec. •
•i On-Site Water and Wastewater Program o^'
t _ (907) 343-7904
5 J,( civ
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 011-135-46 Expiration Date:
-2d--f y
1. GENERAL INFORMATION
Complete legal description Sand Lake #2 Block 4 Lot 7
Location (site address) 8055 Sand Lake Rd
Current Property owner(s) Hage Day phone 830-3228
Mailing address Same
Real Estate Agent Carmi Day phone 830-3228
��5
67897,
v 77
2. TYPE OF DWELLING:
Z Single Family (w/wo ADU)
❑ Duplex a. E:, t _ u c.,J..; t,
111Multiple Dwellings (Single Family and/or Duplex) i
�
c.
3. NUMBER OF BEDROOMS: 3 6 8 L c3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well N. Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class C Well --> 25 Community ❑
Public Water System ❑ Public Sewer ❑
Received by: � Date: t
COSA to be released to the engineer,unless of /29/i rwise requested by the engineer.
COSA Fee $ rj , Date:
Date of Payment q-(I-ig Date of Payment
Receipt Numbers 13 . Receipt Number
COSA# 05C-(Xill 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 NorthRim Engineering Phone 694-7028
Address PO Box 770724,Eagle River
Engineer's Printed Name Steve Eng Date 4/18/2018
6. DSD SIGNATURE
Iv System #1 Approved for 3 bedrooms.
System #2 Approved for bedrooms.
Disapproved. l40
Conditional approval for bedrooms, with the following stipulations:.
•
"C/51
04
- ON-SITE m
WATER AND
WASTEWATER a
PROGRAM =
Original Certificate Date:
The Municipality of Anchorage Devlopment 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
COSA blue sheet_9-1-12.doc
• .
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
L.Legal Description:,S� ane. � t5 L7 Parcel ID: o/` /-5.5-VC
A. WELL DATA
el a
Well type C.. If A, B, or C provide PWSID# Z/(O 7,5 Well Log (Y/N) -
Date completed "' Sanitary seal (Y/N) Y Wires properly protected (Y/N) 7'
Total depth "" ft. Cased to " ft. Casing height(above ground) /2+ in.
FROM WELL LOG AT INSPECTION
Date of test -
Static water level - ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mL Nitrate /A/ 6 mg/L
r�nic ug/L Date of sample: V/6// ? Collected by: Al,?' ".^
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material •J.5 EP77C_ ,S7—EL Date installed CA 9/6 7
Tank size/Z SO gal. Number of Compartments Z Cleanouts (Y/N) >/ , /
Foundation cleanout (Y/N) Depression over tank(Y/N) ./k/ High water alarm (Y/N) / /..
r
� ve/
Date of pumping 3/2a/ / �' Pumper Z(< Oj -05(..7717 C..
J
C. ABSORPTION FIELD DATA Otte
Date installed /2/83 Soil rating (g.p.d./ft2 or ft2/bdrm) /0 O System type Tre t c.-11
Length 24- ft. Width L ft. Gravel below pipe 6" ft.
Total depth /C ft. Eff. absorption area 3/2 ft2 Monitoring tube ' Depression over field N
Date of adequacy test 3/2 7//i Results (Pass/Fail) P ( For 3 bedrooms
Fluid depth in absorption field before test 3C in. Water added 'YS.O gal. New depth ST in.
Elapsed Time: 30 min. Final fluid depth 3C in. Absorption rate >= `7' 50 g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) VN/iC If yes, give date
D. LIFT STATION Abrt
Date installed Size in gallons Manhole/Access (Y/N)
"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
WELL ON LOT TO:
Septic tank/lift station on lot /CC/ On adjacent lots /e/O '-
Absorption field on lot /00/4- On adjacent lots /60(
Public sewer main /04 '•f- Public sewer manhole/cleanout /OO'f
Sewer/septic service line e S �, Holding tank /06 /.„_
Animal containment areas S Orf Manure/animal excrete storage areas /O 0 "
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation o Property line /0 Absorption field s
Water main r/° /4- Water service line /Q"f " Surface water /DO 'S
Wells on adjacent lots /O4 f1-
ABSORPTION FIELD ON LOT TO:
t /0 ,/--
Property line 6 Building foundation l� ',' Water main
Water Service line A4 /-f- Surface water /QO 7 Driveway, parking/vehicle storage
Curtain drain /i1('< Wells on adjacent lots /UO r'
F. COMMENTS
G. ENGINEER'S CERTIFICATION . ,,,,,� OF "toti3O�
. L 1
'"IdS 191
/ certify that / have determined through field inspections and �,..''•��•a�°•`•O. •
review of Municipal records that the above systems are in of co c` •'".-��O.
•.�91
conformance with MOA COSA guidelines in effect on this date. iff' t49-'i'. :' '4�x , ti. '1*
� ;
Engineer's Printed Name P .•:z
c Steven W. Eng •: rte,
Date 4pa•° �P .•si
m .PROFESSi0w;...",
COSA yellow sheet_2-6-15.doc
MUNICIPALITY OF F ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT I • r907-343-7904
On-Site Water and Wastewater Section \. ; Fax: 343-7997
www.muni.org/onsite
Arsenic Advisory
Certificate of On-Site Systems Approval # OSC181151
Subdivision: Sand Lake#2, Block: 4, Lot: 7
A water sample revealed an arsenic concentration of 36.4 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. information on arsenic is available from the On-Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-Site
Systems Approval.
Mailing Address: P.0. Box 196650*Anchorage,Alaska 99519-6650 *www.muni.org
NICRTHI M
ENGINEERING SteveEng.com
Steve Eng, PE, PH
PO Box 770724, Eagle River AK 99577
907-694-7028
SteveEngPE@gmail.com
Date: 4/18/18 Number of Pages: 1
To: MOA On-Site Services
Subject: Sand Lake#2 Block 4 Lot 7
Number Of Bedrooms
Debby Wockenfuss Telecon (4/18/18)
The subject property has been served by a septic system for a number of years. The MOA file
information lists the approved septic system size as 2-bedrooms. In the subject telephone
conversation it was discovered that a change could be made to 3-bedrooms,detailed in this memo:
• A recent COSA inspection revealed the septic system is functioning for 3-bedrooms.
• A 1250 gallon septic tank was installed in 2007- adequate for 3-bedrooms.
• The deep trench constructed in 1983 was sized at 312 FT2. The soil was rated at 100
FT2/Bedroom. This is sized large enough for 3-bedrooms.
• The soil test log from 1983 exhibits suitable soil for the 100 FT2/Bedroom rating.
• The owners state that to their knowledge this has been a 3-bedroom home.
Because of this information, we request the COSA be approved for 3-bedrooms.
Thanks-Steve
.��, Of- 44
row It( A
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8471G
Lot 6
0
p 30 EAST 135.00 Lot 47
cc
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1
1 o II
_
X
W 1 1 i °
Y 111 i Covered'
iii
i, 24.0 i \ storage shed Lot 46
p �',�', Septic o ents
0 to g. deck
1,1 ,1 ttttU °° Greenhouse O
I+7,_, - Cr) — / Q
ICOcia j ;";'` 23.8 — in
•
I—CS :--.- �"" •
2 StoryFrame House Lot 7 =
;.Asphalt N H
-: .:
Municipality of Anchorage
Development Services Department •' (�
/ Building Safety Division
On -Site Water and Wastewater Program (f in / s • r
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
wvvw.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 011-135-41° COSA # bt a DA84
Expiration Date:
1. GENERAL INFORMATION
Complete legal description SGcnc/
Letk-4.
_ :tt=- et XY4 7-
(dock N
Location (site address) 8055"
Soy. +d
LRk
Current Property owner(s) 1,t l i 11
t n m 410nt
. Day phone
a 3 - otos o
Mailing address 11311
$1
crt C o-1 ff, ,c
SIG c1`ISp�
Lending agency AQti tz
ojt-r
Day phone
Mailing address
'
Real Estate Agent FSR
n
Day phone
Mailing Address
Unless otherwise requested, COSA will be
held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3-
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
(
Individual On-site
[-f
Individual Water Storage
❑
Individual Holding tank
❑
Community Class C 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 Onsite Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined In the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my Investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations In effect at the time of installation.
Name of Firm Eagle River Engineering Services Phone &f) 4 - s f 9 S
10421 u e
Address Eagle Riyer, AK 295=
Engineer's Printed Name i F1riS�Y"ood 'Date co�2`f�CH
5. DSD SIGNATURE
✓ Approved for ,2 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By.-„.- �� Original Certificate Date: —7—/3-0(o
(Rev. 11105)
Municipality of Anchorage
• j 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.orglonsite
(907) 343-7904
Arsenic Advisory
Certificate of On -Site Systems Approval # 060284
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 4, Lot 7 of
Sand Lake #2 Subdivision. This inspection revealed an arsenic concentration
of 40.8 micrograms per liter (ug/L) for the property's well water sample.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems.
While private wells are not subject to this regulation, EPA standards are
based on existing health information and can therefore be used to gauge the
relative quality of water from private wells. information on arsenic is
available from the On -Site Water and Wastewater Program website
(www.muni.or /og nsite) or at 343-7904.
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
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7W4
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: So rid Laks- J" Z Q 99 Parcel ID: 01 1 — 13 5--4 6
A. WELL DATA
Well type C if A, B, or C provide PWSID # 1216015 Well Log (Y/N)
Date completed Sanitary seal (Y/N)= Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (above ground) — in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level -' ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate _1)�._ mg/L Other bacteria '(9— colonies/100 mL
Arsenic:V Date of sample: Wibb Collected by. ChQY llo Ba 12IAYin I
-tin ffw
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material qP bl1 c' ! S -ell Date installed 12 13
Tank size JQQ Q gal. Number of Compartments Cieanouts& lA f/� d (i1S-11
Foundation cleanout ON) IMb Depression over tank (Y®N-0 High water alarm (YA N 0
Date of pumping q-13- 0005 Pumper _NQ O %I Ard 9nm1pinq rVI rg
C. ABSORPTION FIELD DATA
Date installed I'L 113 Soil rating (g,pA W or ft2/bdrm) 100 System type ire h t^ h
Length 2 (-v ft. Width I-{ ft. Gravel below pipe�l _ ft.
Total depth 10— ft. Eff. absorption area 3l2fe Monitoring tube k" Depression over fieldiJ 0
Date of adequacy test (0 - q 04. Resultsas ail) P-Q.W For bedrooms
Fluid depth in absorption field before test in. Water added gal. New depthy:S, in.
Elapsed Time: 10 min. Final fluid depth '2-3 in. Absorption rate >= a. OHO g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y& type) QQ11Q k-rio W" If yes, give date 1`4 1 P�
D. LIFT STATION
Dale installed
'Pump vel a� t in.
Datum
E. SEPARATION DISTANCES
Size in gallons r. Manhole/Access (YM) f
'Pump o lev II in. High water alar Fates
Cycles tested eels alarm 8& circuit requirements? _
SEPARATION DISTANCES FROM WELL ON LOT TO:
1
Septic tank/lift station on lot
Absorption field on lot + I OO t * ffl
Public sewer main •+" 100,
1
Sewer /septic service line + 25
Animal containment areas + 1W
On adjacent lots +0`11
In.
On adjacent lots A- (CO 1
Public sewer manhole/cleanout t ( OU
Holding tank 4- 1013 `
Manurelanimal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
i
t
Building foundation i S Property line f S Absorption field t S
i 1 1
Water main t I O Water service line { Surface water 1 OU
Wells on adjacent lots i- +00\
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
I®1
Property line •krJ Building foundation Ol Water main
Water Service line i 1(7 Surface water % 100 Driveway, parking/vehicle storage 0_
Curtain drain A O , Wells on adjacent lots -F Ib 0
t
F. COMMENTS
G. ENDtNEER'SCERTIFICATION S �p oved on per or V veU JO r�UO�ky
I certify that 1 have determined through field inspections and ��;..-Q•F••.A, 7 p1'rUyo.cA.
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name GtFt2i5TaPlt} R- t fraalj
Date b//Z11 /D � � : 10lrFIER&WOW
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Dale of Payment �W-
Receipt Number
0
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NORTH 5000
NORTH 5000
SAND LAKE ROAD
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MUNICIPALITY OF ANCHORAGE
• Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
1
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # HAA # Aa.8 -D,h 7y
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
7: Block 4: Sand Lake Subdivision
Location (address or directions)
8055 Sand Lake Road
(b) Property owner
HUD
Mailing Address #111-025800-203
(c) Lending Institution
Mailing Address
Alaska
Telephone : (home) Business
Telephone
(d) Real Estate Company and Agent MARSTON PROPERTIES/Ed Tolley
Address 4105 Turnagain Boulevard, Anchorage, Alaska 99517
Telephone
(e) Mail the HAA to the following address: (or check here 13, if hold for pick up.)
List contact person and day phone number below:
EVGINEERIN(-�/,50,4-2979
2. TYPE OF RESIDENCE
Single-FamilyXX Number of bedrooms z
3. WATER SUPPLY
Individual Well ❑ Community El Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On -situ Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
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 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
S & S ENGINEERING
Addre
Date
Telephone 6 �fY-20Z9
(I A.ro cJ$pp
�T-^%Ys .•sec• � �'9 'J'
` 06 t9V. ILA4 7
6. DHHS APPROVAL
n d -
Approved for bedrooms by Date
Approved Disapproved Conditional
Terms of Conditional Approval
r ..-.;.; CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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 orderto 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. 7/88) Back Page 2 of 2
A. WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA) M i
CHECKLIST - FEBRUARY 1984 —
343-4744
Well Classification
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Date Completed
Electrical Wiring in Conduit (Y/N)
Legal/Description:
Depth of Grouting
SEPARATION DISTANCES FROM WELL:
If A, B, C, D.E.C. Approvedd'N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
To Septic/Holding Tank on Lot . off' ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot CX2 k ; On Adjoining Lots
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
To Nearest Public Sewer Cleanout/Manhole
; Date
Water Sample Test Results
Comments
ti4C: tie!2 /—,1/-8l .G?c5 -oo Z-,-
B. SEPTIC/HOLDING TANK DATA
Date Installed Size � (220 No. of Compartments
Z
StandpipesaWN) i Air -tight Caps/N) �_4( Foundation Cleanout2WN)
Depression over Tank (Y& *—S to Last Pumped
Pumping/Maintenance Contact on File (Y/N) � ; for
Holding Tank High -Water Alarm (Y/N) N Temporary Holding Tank Permit (Y/N) 21A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well \��o( To Building Foundation tot
To Property Line t To Disposal Field
(
To Water Main/Service Line o
To Stream, Pond, Lake or Major Drainage Course 1
CommentsV' CM6'
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata )Oc2 /1 (LI Type of System Design
Date Installed �2- - S - g"� Length of Field 2
I
Width of Field Depth of Field
Gravel Bed Thickness l� )
Square Feet of Absortion Area 1 2 Statndpipes PresenkMN)
Depression over Field (Y/&1Y Date of Last Adequacy Test
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD: I
To Water -Supply Well o� I k To Property Line S
To Building Foundation To Existing or Abandoned System on
Lot '�
On Adjoining Lots 3 t�7> '�'
To Water Main/Service Line To Cutback (if present) /.?
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area I o
Comments
D. LIFT STATION /n
tDate Installed F�
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
— Dimensions
Manhole/Access (Y/N)
—"Pump Off" Level at
Y/N)
Pump(n cies during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request"
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed 5 & S ENGINEERING
17034 Fagleo. o.
Company --ga le River, Alaska 99577
Date 42, /ZK ZrK
MOA No r /?, gy-aD
Receipt No. c o 2
Date of Payment /a�
Amount: $ / 7iJ
Receipt No.
Waiver Fee: $ —
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
DEPT. OF ENVIRONMENTAL CONS Eii"TI®N
ANCHORAGE/WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 1334
ANCHORAGE, ALASKA 99503
TO: S & S ENGINEERING
DATE: December 27, 1988
PWSID: CLASS C, 216075
To Whom It May Concern:
STEVE COWPER, GOVERNOR
563-6775
According to the records on file in this office, the SAND LAKE
#2, LOT 7, BLOCK 4 Water System is in compliance with the State
of Alaska Drinking Water Regulations.
Sin�ceereel y,
Vera E. Craig
VEC:pkk Environmental Fie Officer
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date
(a) Legal Description (include lot block, subdi ision, section, township, range)
Location (a[dress or directions)
(b) Applicants Name 7 % Telephone - Home Business 3Y5 ZO
Applicants Address
t
(c) Applicant is (check one) Lending Institution ; Owner/builder ;
Buyer ; Other E::l (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Co. & Agent
Address
Telephone
(f) Mail the HAA to the following address:
2. ape of Residence
Single -Family 5E� Multi -Family
Number of Bedrooms
3. Water Supply
Individual Well M Community M
Other (describe)
Public M
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Onsite r,_'�_T Public M Community M Holding Tank Q
VSNote: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 21
f
5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information
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 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 regula-
tions in effect on the date of this inspection.
Name of Firm Q/asci �i[yr}JovGi%e/�, �Cn L-C)IurGPS Telephone 50`fC�
Address 1;2n/?
Date /"�-I �— Sy
oaria Mas oa�a�o.e e • d
(ENGINEER SEAL) e
i we ••..eee a.°.e
• Q�
c ; roy C. Reid, J4Q'
6. DHEP Approval p 8� J'� .a No. 2251•E
Approved for bedrooms B 2 c�
Y�" v! � Date
Approved Disapproved Conditional '
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP 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.
(DHEP SEAL)
RR4/ej/D18
,[Page 2 of 2] 7-19-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
A. WELL DATA Legal Description: Zoa T !�—
S
Well Classification 6t, If A, B. or 0 D.E.C. Approve /N)
Well LoPresent (Y/N) JuzDate Completed L•Vi4 Yield
Total Depth Cased to A) « Depth ' of Grouting
Static Water Level l* Pump Set At ~I
Casing Height Above Ground�Sanitary Seal on Casing(Y )
Electrical Wiring in Conduit /N) Depression Around Tbllhead (Y62
Separation Distances from Well:
To Septic/Holding %fX? On Adjoining Lots p f
Tank on Lot
To Nearest Edge of Absorption Field on Lot `F ; On Adjoining Lots ICo'4
To Nearest Public Sewer Lire AM To Nearest Public Sewer
Cleanout/Manhole /(/A To Nearest Sewer Service Line on Lot
Water Sa
Water Sa
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed Q '2 Size /000 No. of Compartments
Standpipes Y ) Air -tight Caps ( /N) Foundation Cleanout /N)
Depression over Tank Date Last Pumped bA
Pumping/Maintenance Contract on File (Y/N)A*f for 1/
Holding Tank High -Water Alarm (YM) Temporary Holding Tank Permit (YM)
Separation Distances from Septic/HoWing Tank:
To Water -Supply Tn�llM To Building Foundation_�'?O
To Property Line /rj 0 To Disposal Field �; � 0
To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course R)A
Comments
a
Receipt #
Date Paid:
Amount:
[Page 1 of 2]
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata Q Type of System Design
Date Installed 1,2-5-q''� Length of Field
Width of Field g ` Depth of Field /Q
Gravel Bed Thickness
Square Feet of Absorption Area `j/� PP Standpipes Present &aN)
Depression over Field (Y ) Date of Last Adequacy Test14
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Will l00 r�` To Property Line
To Building Foundation O ` f To Existing or Abandoned System on
(-K-
Lot On ddAdjoining Lots9 I
To Water Main/Service Line /VA To Cutbank(if present) /y
To Stream/Pond/Lake/or Major Drainage Course
r
To Driveway, Parking Area/, or Vehicle Storage Area
Commants pec!
D. LIFT STATION
Date Installed
Size in Gallons _
"Pump Or." Level at
/i
High Water Alarm Level at
Tested for
Electrical Codes(Y/N) 0
Comments
Dimensions A4 X
Manhole/Access (Y/N) A
„ 11
Pump Off Level at WIA
Vent (Y/N) 04A
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request*
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection. _ .®
Date /3- S y m�QO.Q���
Signed /�' •••.. oa°®° Vr
o O'
Company ���.<�u�C4v- �a�4ir�l �'�r�rce�� MOA No. 9Y -C acj � �t.`� o� Or
'-a /0.o
KBl /d5/s v - °....a., ,.....
7"t,40�N-.0
oy C. Reid, Jr
6As. 2251E r-
[Page 2 of 21cts1
W 2-15-84
Mj
DEPT. OF ENVIRONMENTAL CONSERVATION
1
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
I L�
PWS I.D.#
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
To Whom it May Concern:
According to records on file in this office the
Water System is in compliance -with the State Drinking
Water Regulations
Sincerely,
)5�1Sri r00%.'4' �q�noer-
t