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SAMPSON ESTATES BLK 1 LT 3
Sampson Estates Block 1 Lot 3 #051-822-21 tKev uo/uzri 6) Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201383 PID Number: 051-822-21 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade Name MILDRED MILLER REV. TRUST ABSORPTION FIELD - EXISTING ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 23652 GOLIATH DRIVE, CHUGIAK ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot Fill added above original grade Ft. Gravel length Ft. SAMPSON ESTATES 1 3 Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line FtZ Ft. Well 100'+ -- 25'-x. TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1000 Gal. Surface Water 100'+ -- Material HDPE Number of compartments 2 Lot Line 10'+ -- NA Foundation 10'+ __ LIFT STATION Manufacturer Capacity Gal. Remarks Alarm location Electrical installed by Tankto PIPE MATERIAL House to tank 3034 3034 Installer NORTHERN EXCAVATION dra nfield Drainfield CO/MT 3034 Inspector FWC BENCH MARK (Assumed elevation) 100 ft Inspdecction 1 s' 10/19/20 10/20/20 Location and description es:2nd 3`d 4'n BOTTOM OF SIDING ON-SITE WATER AND WASTEWATER SECTION APPROVAL a • Conditional Approval: Date .�VIN• ' •.� iH ... . .....•... • Septic System Approved jj.. Curtis Huffman -:% •. f�j Date[c��'lF�•.•10/23/20�4•4P�i� c�` CE 128991 ���F� �'ROFESS10Ht.�o.-a Note: this approval does not include well permit requirements. tKev uo/uzri 6) PID: 051-822-21 PERMIT: OSP201383 I I1\ LOT 3 �.2 3 S A EXISTINGUSE 38R HO 303 A -C=39,1' B -C=15.3' A -D=41,1' B -D=18,9' A -E=43,5' B -E=21.3' SEPTIC SECTION SAMPSON ESTATES BLOCK 1, LOT 3 PREPARED FOR: MILDRED MILLER REV. TRUST 23652 GOLIATH DRIVE CHUGIAK, AK 99567 FIRST WATER CONSULTING 13030 SUES WAY ANCHORAGE, AK 99516 907-350-9566 firstwaterAK@gmail.com SCALE, NTS SUPPORT SERVICES: ' ip, OF .AL�' F 5 9 TH DATE: 10/23/2020 rtis Huffman 4 SURVEY: LCG 2020 CE 128991 DRAWN: FWCS 10/23/202V SCALE: 1 " = 30J�?O SSIO'0y CO MH FCO DECK ® o DCO C EXISTING - E D FIELD O 0 i SHED DECOMMISSIONED EXISTING S.T. & INSTALL NEW 1000 -GAL (� C!) HDPE SEPTIC TANK WITH NEW DCO PER PERMITTED DESIGN. � N LOT 4 O LOT 2 6, SCALE] 1' = 30 A -C=39,1' B -C=15.3' A -D=41,1' B -D=18,9' A -E=43,5' B -E=21.3' SEPTIC SECTION SAMPSON ESTATES BLOCK 1, LOT 3 PREPARED FOR: MILDRED MILLER REV. TRUST 23652 GOLIATH DRIVE CHUGIAK, AK 99567 FIRST WATER CONSULTING 13030 SUES WAY ANCHORAGE, AK 99516 907-350-9566 firstwaterAK@gmail.com SCALE, NTS SUPPORT SERVICES: ' ip, OF .AL�' F 5 9 TH DATE: 10/23/2020 rtis Huffman 4 SURVEY: LCG 2020 CE 128991 DRAWN: FWCS 10/23/202V SCALE: 1 " = 30J�?O SSIO'0y MUNICIPAL1 Y OF ANCHORAGE 0n -Sits Water &Wastewater Pregrarn PC Bax 1986 4700 Elmore -Road Anehmge. Alaska "519.6550 Phone; (907) 349.79174 Fax; (907) 3f3-7597 � �: f�UY4YYJJYi151 rl L 01� i a r16 r6a On -Site Wastewater Disposal System Permit Permit Number: C P2013V Work Type: SepticTa nk upgrade Tax Duda Number 0S7 $221000 Site Legal Address: SAMPSON ESTATES BLK 1 LT 3 G:1560 Site Ma tiing Add res s- 2 � 2 GC UATH DR, C hug Isk Owner. MILLER MILDRED P REVOCAIKE Design EngInee r: FIRST WATER CONSULTING Th is pe rmit is for the c Dn5tru ction of; Effef.tiue Date: Expiration [date Lot Size in Sq Ft: Total Bedrooms - ftrKLqMqr L)jl).'kVTrt ono 9r24=20 94F2021 47056 0 Disposal Field fZ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Vvell ❑ Water Storage All construction shall be in accordaneewith; 1. The attached approved desiq rr. Z All requirements 5peoiFed in Anel orage Mun loipal oede Chapters 15.55 and 16-65 and the State of Alaska astawater Disposal Regu lotions (1SAAC72) and Drinking Water Reg ulatioris (18RAD84) 3_ The wamtewaEer rude req ui res i nepaclim 6 during the imtulllotlo n. The crl gi ncer :A oll riotify the Dcvc lap meat Services Department per AMC; 15.55. Pr❑vAe n13 ifieation by calling (907) 343-7904 (2417). 4. Frorin October 15 to April 15, a subsurface soil absorption systarn under construction during freezing weather ,hall 100 eit.11eF. a. Opened and Qluse4 on Lbe same day, or b. vered, sealed, and heated to prevent "wing Re�eived By: 'Issued By: W2412020 Date: Date: 2Y 20aO 3 ON-SITE SEPTICM/ELL PERMIT APPLICATION Parcel I.D. 051-822-21 Property owner(s) MILDRED MILLER REV. TRUST Day phone Mailing address PO BOX 672183, CHUGIAK, AK 99567 Site address 23652 GOLIATH DRIVE, CHUGIAK, AK 99567 Legal description (Sub'd., Block & Lot) SAMPSON ESTATES B1, L3 Legal description (Township, Range & Section) Lot Size 47055 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) Fx_1 (w/wo ADU) Septic Tank FX_1 Upgrade Q (D) El Holding Tank ❑ RenewalDuplex ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: � 1a9cs l obi it) 'I� Date of Payment: Vlv/'?0910 Receipt Number: 0 61YI3.3 Permit No. 02 20 M 3 Waiver Fees: Date of Payment: Receipt Number: Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\FormsOient Forms\Permit Appiication.doc 13030 Sues Way, Anchorage, AK 99516 907-350 -9566 / firstwaterAK@gmail.com September 14, 2020 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: SAMPSON ESTATES BLOCK 1, LOT 3 PHYSICAL: 23652 GOLIATH DRIVE, CHUGIAK, AK 99567 The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic tank on the above referenced lot. We propose to install a 1000-gallon HDPE tank outside any deck supports or supports to be installed to bottom of tank to serve the existing 3-bedroom residence. Please see attached design. The lot and adjacent lots are served by private water as noted. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201383, Rebecca Carroll, 09/24/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201383, Rebecca Carroll, 09/24/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201383, Rebecca Carroll, 09/24/20 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION a ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME Fenton. Timmerman p licant 4X � x1rx*'Ac'-1'r X X %X X PHONE /p ':�;%7 NEW 1 ❑UPGRADE MAILING ADDRESS jl,ft�xx 7�xxxJ),�q 2085 Campbell Place Anchorage, 99507 LEGAL DESCRIPTIO LOCATIO NO. OF BEDROOMS / ' e Uy DISTANCE TO: Well / / Absorptionarea / -S Dwelling S PERMIT NO. &yo&Z wzQ Manufacturer _ Material / / No. of compartments F In Liq. cap�tyin gallons IF HOMEMADE: 1 Inside lengt 14Width / /(/ Liquid depth 14- ® DISTANCE TO: Well Dwelling PERMIT NO. 02 It ❑ z Q - 2F Manufacturer Material Liquid capacity in gallons ❑ w = DISTANCE TO: Well I r �L( Foundation 1 y I Z - l� SPB OrgU�� Nearest lot Ifne �3 PERMIT NO. -yon 2 J wZ Z w No. of line Length of each line r JC' / Total IGeng of lines U� Trench width Z inches Distance be een lines // 3A)W7 aTop of tile to finish grpde Material beneath tile / Total effective absorption area ❑ 3% - // %ro inches 1 yy -5QF7' Length Width Depth PERMIT NO. w C7 Q F Type of crib Crib diameterrib epth Total effective absorption area as LU W W Well Buiiding(foLfirdatIon Nearest lot line DISTANCE TO: Class -/ /i/� s;dp .a Depth ZZ 1 Driller Jo C ' lu�aws�s' Distance to lot line PERMIT NO. W DISTANCE Building f uny,;ion Sewer IIrW, Septic pk, Absorptar (s) TO: o`- lk /V-- `% OTHER w A^49 49 PIPE MATERIALS See SOIL TEST RATING yy5 SQ Fi/�' '. .Aldrµskd INSTALLER - / uri6- REMARKS T z � gS N / Sr \ >D C use fri /i %a seri 76r- et// o CPQ i 7,31l N - e a /�+ ��? /1 % ( , z: - ✓ �'r - i>i'9�p j/ - /071 _Z, I �; 1� - 1 I nil! Ile I I'► yt ®OOOe9 ooeaei oeo ee eoeta Ja 1 yi I __-- — _ _ _ k — - 1 = — _ N r -rJeoO 00000 o e e o o o o. oeo aueaco,•' e Ja,,,s IL Kinney e G - J APPROVED DATEyj LEGAL 11 .., O l I _.. O hal, IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODEG, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE QBTAINED; (2) AS--BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN" ` SIGNEDDATE: ���c APPLICANT FENT RM ��,� v' ISSUED BY DATE: �__ u^ ` M U P,11 '.1 C, 3: 111-=` .�T -T. -,,r 0� F:�' ��J C�,ll-Al Cj�' �CM-I U7. DEPARTMENT OF HEALTH AND ENVIRONMENTAL lzR8TECTION ` 825 L STREET, ANCHORAGE, Al-:"' 99501 264-4720 ` 01. ~^�'F� l -T- ET_ c=� EEWWE lFZ Q^11 E-A_ 9_ �t._, r 1p"�� » .. PERMIT NO: 840802 D#TE ISSUED: 09/19/84 ' APPLICANT: FENTON TIMMERMAN APBELL PL ADDRESS: 2085 CM ANCHDRAGE, AK 99507 CONTACT PHONE: 563-8236 LEGAL DESCRIP: SUBDIVISION: SAMPSON ESTATES LOT: 3 BLOCK: 1 SECTION: 3 TOWNSHIP: 15N RANGE: 1W LOT SIZE: 47055 (SQ.FT" OR ACRES) MAX BEDROOMS: 3 Listed'below are the options available to youin designing your septic system. Choose the option that best fits your site. 7~�R.��P,j Cz� 11-A U'm EE, 1cp W~ DEPTH TO PIPE BOTTOM (FT.) 4.0 4.0 4.0 GRAVEL DEPTH (FT.) � 6.0 0.5 3,5 TOTAL DEPTH (FT. ) 1b .0 4.5 7.5 GRAVEL WIDTH (FT.) 2.5 28.0 GRAVEL LENGTH (FT.) 112"O ** 54.0 � 144^0 ** GRAVEL VOLUME (CL). YDS. 67.5 56.0 106.7 TANK SIZE (GALS) 1,000^0 ** 1,000.0 I 1 1,000.0 ** -SOIL RATING (SQ.FT. /BR) 445 330 445 ** GRAVEL LENGTH >75 FT. REQUIRES MULTIPLE 6WuS (NOT EXCEEDING 75 FT. EACH) ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS I certilf'y that: I. I am familiar with the requirement� f'or on --- site sewers and wells as set forth by the Municipality or Anchorage (MOA) and the State of' Alaska. 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria o[ this permit. 3" I will adhere to all MOA and State of' Alaska requirements for the set back distances from any existing well, wastewater, disposal system or public sewerage system on this or any adjacent -or nearby lot" 4. I ul�derstand that this permit is valid for a maximum of 3 bedrooms and anenlargement will require an additional permit" IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODEG, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE QBTAINED; (2) AS--BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN" ` SIGNEDDATE: ���c APPLICANT FENT RM ��,� v' ISSUED BY DATE: �__ i MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST xSOILS LOG ❑ PERCOLATION TEST PERFORMED FOR: / CrI%�fI -r✓�S ®UL OSI DATE PERFORMED: / / 9�OU LEGAL DESCRIPTION: SLOPE SITE PLAN DEPTH (FEET) A41, 40311cS K 3 4- 5 6- 7 8— -A 9 10 11 -rte 12 13 14 15 16 n 18 19 20 'o�caao�L`< c ii1/ J �S w36 WAS GROUND WATER S ENCOUNTERED? L O P IF YES, AT WHAT E DEPTH? r. Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT :OMMENTS 7C CSO L'C�t �09 �l r� /"��.5'!^l'I Coi)/-iu Ttlr� @rCGliln YP :�t7,fT'itf X)l to & le; PERFORMED BY: 7�n�� CERTIFIED BY: .J, P 5 1�p '^t/�/?e DATE: /Z Mo,g- Sr*P -Grid 72-008 (6/79) `l [P SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 34 PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: �00 < DATE PERFORMED: LEGAL DESCRIPTION: Zo 3 e Rloe 1 S!/771a5©P% [, CSTGIL S DEPTH -�I ' SLOPE SITE PLAN p. (FEET) 1 MG 2 . •��� OF q�q �i � ,,,`fie. .•s @P+ 3 h: •..� _ *:'49T' 4- % .. ... ... ....e.a� 5 i l JAMES R. KINNEY r CE -603 6 = �� �1A' • ' Ci�'e dZ1 P?OFESSt4NIr ��+ 8- -31 �. 9 C - j' WAS GROUND WATER 11 ` ENCOUNTERED? 12 IF YES, AT WHAT DEPTH? 13 16 17 18 19 20 NNNEEMEMEN Date Gross Time Net Time Depth to,� Water Net Drop MENNOMMENE 10' 16aC, ! C, � ! ■NINENNNNNE 30 ;, y NEENNOMENE f/- yoaM 30 ■■,11225®E1'1■. M■MEMEN„'.E, ■WEE'NEM■■' /Z -/06N �0 ENINER(1( ■EEE■ERIMEENIENEENUM ENNE ', ENEEZENNNE /vo � -29 Reading Date Gross Time Net Time Depth to,� Water Net Drop 9 �5 10' 16aC, ! C, � ! /o: off, , 30 ;, y f/- yoaM 30 /Z -/06N �0 PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN �� FT AND T - r. f- 'OMMENTS ✓c� t . d , ��::•, l/?�l� r /7 �. 4 ' r, r/' %� h�� �r� � -T57 fOnl -���l"� SLrlln:S%lr' J/D:SS .�t- / Y PERFORMED BY: CERTIFIED BY: �1Ciy7�5 %���-> r4�DATE: �Y r~ PERFORMED FOR LEGAL Efff PT 7-W012 m, --q F 2 34 7 812131415161719 MUNICIPALITY OF ANCHORAGE PERCOLATION DEPARTMF ' OF HEALTH AND ENVIRONMENTAL PRr:CTJON TEST >�• : Sa•!L Anehor•pe, Atrska 99501 2644720 SOILS LOG - PERCOLATION TEST QQ 460b C�71-01- DATE PERFORMED: Twn, iso Rhe iy�les�' I SeG• 3, L3�M L.4� L3 1.T Iyl 61c SAw3oc4 6/• s�� Coes 1 �/ i�'IbfeiYs:Ofi� OF A r p OS�90d1 ?3�V�'�u'JOnUJa•:J 91 WAS GROUND WATERQ ENCOUNTERED? 1F YES, AT WHAT DEPTH? a� PERCOLATION RATEz TEST RUN BETWEEtII js.r ��• AND PERFORMED BY: CERTIFIED BY. '°• t WIN t .% . 72.008 16/79) ' •x � t, � . ar i a� PERCOLATION RATEz TEST RUN BETWEEtII js.r ��• AND PERFORMED BY: CERTIFIED BY. '°• t WIN t .% . 72.008 16/79) ' •x � t, � . ar fel �� c gLG-LT.T 1 .r 2. Q 5� rs � ��FFSSIONAIIP�O a SUP dEY CERTIFICATION: I hereby certify that I have surveyed the property shown and scribed hereon and that the improvements situated thereon are within the property lines and encroachments exist other than noted. ® PLEASE NOTE: is the contract LEGEND: SET FOUND % - ENGINEERS • PLANNERS • SURVEYORS -or's responsibility to check top y 5/8" REBAR 0 0 of foundation in relation to HUB & TACK p ® DRR. ev: n 440 WEST BENSON BLVD. 272-9231 finish grade and building set- MONUMENT 0 ® /7 ANCHORAGE, ALASKA 99503 562-5291 backs In relation to lot lines AL -CAP Q e CNKD' and easem ants. PK NAIL X LEGAL DESCRIPTION: IRON PIPE O° ELEVS. - DATUM GRID: S4U=L�(LT_ PLAN ASSUMED F.a.. 2_T 4 } y SCALE:G/JA7� �noo oe ooyoo�000cooce;eo� �aoo 000 oo eooa oe oao oeooeoo � - t James R. Kinney (' Cr -6036 76, u 667 �iWn ; �' .�Gn+'1 �,a" • �o �'�iiJ� j OR's+ j ��%�, � .� %�� "� /J Ju .fid �� -s �� r.� ��i � � �� �� Sys 54 _ �✓ %�� w as 0/&q rlie6 77 � l/ I � ? �. d��f�i � � /� �'�� f) / •, w���ti r�o �v�J®tee c/ s/m/'/� NMI m �f In -n ^n •n In m -n on �l "n Inv m rHn r m > 77 77 m w x x m = = O 1 1 1 m 77 O O O O O o O O O O O O Z a _� vi O m 3 3 3 3 3 3 3 3 3 3 3 3 O v H w - m 0 a �G C) .\ y v o v w :o :o :O : p o En ND z \ \ m --non � � � � -TI -fl -n on �n � V m ;r.H .-3 . . . 3 .H . .-1 . . H . � : � � : � � D H H H H H H � H H H H H O o O o O o O o O O o Oi ion (,X1TI TI :.. c Hld: r y 5dd� hy� ZD o o 0 5»: (D x m � �>�m mz�r C+ AwZa CD M Z O 77 T� .9 77 7J x7 7d 7J rZ7 TJ v v� H H n D O O O O O O O O O O O O p 9 n x N > ■ x z m tTj y n O :lD H H H H H H H H H H H H •n :C+ O O o O O O O O :�d :H `+ :O :0 CD (D :N c+ U M U T F AmCHORAGE Development Services Department �` Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I. D. 051-822-21 1. GENERAL INFORMATION Expiration Date: 1 -'�' C, l Z oz! Complete legal description SAMPSON ESTATES BLOCK 1, LOT 3 Location (site address) 23652 GOLIATH DRIVE, CHUGIAK, AK 99567 Current property owner(s) MILDRED MILLER REV, TRUST Mailing address Real estate agent PO BOX 672183, CHUGIAK, AK 99567 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone Day phone 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ � 1 a.'so ((_t)y ID'1`1 Date of Payment 1191211 2 Receipt Number Z2 Z �bf COSA # 0 JC- -k D 15 S o� Date: 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY ANCHORAGE AK 99516 Engineer's Printed Name CURTIS HUFFMAN PE Date 10/19/2020 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the-4®�.®��� system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the s •� "•v� well and septic system. Therefore, any estimate of how long a system will function satisfactory ®/`�•' • . for current or future occupants or guarantee that no unseen encroachments, deficiencies or �•' '� I discrepancies exist can be given by First Water Consulting & FW®� •• ...... .......... DSD SIGNATURE '• • Curtis Huffman ' System #1 Approved for bedrooms �����`m�s�.. •CE 128991 ��F�FD pR"� System #2 Approved for bedrooms �d®___.,t OFESSIO�P Disapproved llllttt((((((fr Conditional approval for bedrooms, with the following stip `F ANCy�rr��rr r� O O y: Original Certificate Date: ! CJ ^ Zy The Municipality of Anchorage 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 Legal Description: SAMPSON ESTATES BLOCK 1 LOT 3 Parcel ID: 051-822-21 If more than 1 septic system on lot: COSA Checklist # _of A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled 9/22/1984 Total depth 221 ft Cased to 221 ft ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 24+ in. Date of flow test for COSA 9/9/2020 Static water level at beginning of test 171 ft. Comments B. TANK DATA Age of tank(s) NEW 0 years Tank type/material SEPTIC / HDPE Measured operating fluid level in septic tank NEW ® Standpipes/foundation cleanout per record drawing Date of pumping NA - NEW D. ABSORPTION FIELD DATA Which system tested (date installed) 9/20/1984 ® ALL standpipes present per record drawing Total measured depth from grade 12.2 ft (max) Measured depth to pipe invert from grade 4.1 ft (min) ❑ N/A — pressurized field ® Monitor tubes go to bottom of effective. If not, state depth into effective Structure served by this system _ Well production at time of test 6.6 gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ® No ® Coliform bacteria is Negative Nitrate 5.31 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ® Arsenic less than MRL (ND) Collected by_ NE's Date of Sample 9/9/2020 C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: Adequacy test date 9/9/2020 Results E Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 1180 gal New depth 0 in Elapsed time <1 min ® Code -required soil cover over field Final fluid depth 0 in ❑ System presoaked Absorption rate 450 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies:. F E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ® Yes if No Community Sewer Manhole/Cleanout > 100' ® Yes if No ft ® Yes if No Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ® Yes if No ® Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft ® Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No _ Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: ® Yes Absorption Field > 5' ® Yes if No ft Private Wells > 100' ® Yes if No _ Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No _ 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' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No _ 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 Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION l certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Al Aw TM Ito, ....... • Curtis Huffman ��� FFG,/•� CE 128991 .•7��� �k-F' ROFESSIO �`�'�4� ft ft ft ft ft ft ft ft Nitrate Advisory Certificate of On -Site Systems Approval #OSC201582 Subdivision: Sampson Estate, Block: 1 , Lot: 3 A water sample revealed a nitrate concentration of 5.31 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/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. Since nitrates are known to slowly increase, we recommend you monitor the water quality. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby' disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Mailing Address P O Box 196650'* Anchorage, Alaska 99519 * w ung org 6650 ww m � E +s. LL 0 0 r 0 x F Q a n zZ zZ oQ= Ov/i urZF- X�Ow 0 LL W >wZ wUv=iz p J C X v o x F- U� - v. w S a ¢ z t7 a w :a p V LL Q w U ° c O S W v �� 2i 2 a -0 N W Z Q I -F =uZ w¢2a F— z Fx-w w>v0 w m Q ¢F-0 Q¢�z Q 0 o=z 03:ucc Qu.o N Ocr � J CNz �0z O a Z = a �F' �¢ Y w z o Ow mEZw o g °w= Z�=� a LL J =gz Qo� 0o, - V a W =Zw n,.,az o U F- z u< wza0 -o z z Zc70 0z2 > o O Za �UOO 0 5' a U = - _ U >i w z K _ � (�(�„ME 69 , L,v w o vQi Uj Q o z o� m z o 91i6�8 .moo ~=vai> �_it =F�o N o O w>� uF-_ F zQ� Ln �z 3 N¢ 0 N N Z 0� F- w w wO .. O® p ( N II O OZ¢6 >Oww Q O• GOOF- OUB 0 0 x til Q U x w 0 Z U �G viwma C3 a U �¢FQ zzz�a J i QQ m Q v Q x 0 w O a w z Z w (r1 O r W F- EF �^Q�2a p 0 r O= x v r aF¢p w Q F u Q Q w Q w £8 N �•- DX F- X a a 0 ¢ z ofS U i� W O ¢¢ Q LL '> W Q Q U to CIA -Z tJLf) J O o l w Lu o Q Lu Q Ln Ln CY) O w coN N ¢ m c = O ”'I L' 6Z Q CO O � vi i- O 06 w Lo W C7 3 rn co Q rl 00 F- = S p Of N Q N Lfl CO E Ln d e- W p� io�ouj U ,LO'L8£ 3FF09 X96 oZos N Q to a a J U E' o� 000000Op� �Ow u N © .• �� ��� z m m Zw Ln H J �• fl S O O < �—CL Q J o•. 0�0 o< y i J O c Q 0 V- _ �`~� N W z N a o 0 0 �I : z � o � o w Ql-,x Im { 0Q Ld4wQ q O 0 w 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/onsile (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 061_19 �-" 1. GENERAL INFORMATION Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address COSA# 6604'�D Expiration Date: 11– 30-0& 23652 GOLIATH DRIVE • CHUGIAK, AK 99567 JAMES ROTHERMEL Day phone 688 16505 P.O. BOX 670769 • CHUGIAK, AK 99567 Day phone BROOKE STILTNER w/ REMAX Day phone 6961 4200 16600 CENTERFIELD DRIVE • EAGLE RIVER, AK 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 ii, Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class—Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSDIssues Certificates of On -Si e ys ems 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 Onsite 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 samples. (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 riles and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with alt applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system In accordance with ADEC and MOA DSD Guidelines 8 Regulations. The reported results described the performance oftho system under the conditions encountered at the time of the lost, and separation distances measured to readily Identifiable features. The operational life of all wells and septic systems dop end on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden detects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will It confer any legal right whatsoever. 5. DSD SIGNATURE Approved for 3_ bedrooms. Disapproved. 337-6179 Date 8h8�ra�! Conditional approval for bedrooms, with the flowing stipulations: Attachments: Septic System Advisory Well Flow Advisory Nitrate Advisory Maintenance Agreements Supplemental Engineers Reort Other `—ON-$fTE— WATER AND •; -WAST MT€R PROGRAM '•••....••_moo. By: �—s/ /�(/ J��y� Original Certificate Date: 9-31-0 e (, Municipality of Anchorage Development Services Department ewding Safety Division o"its Water & Wastewater Program 4700 Bregaw, Street P.O. Boor 198850 Anchorage, AK 995196650 www.muni.org/onsite (907) 3437904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: SAMPSON ESTATES SUBDIVISION; LOT 3, BLOCK 1 parcel lD A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 9/22/1984 Sanitary seal (YM) YES Total depth 221 ft. Date of test Static water level Well production Cased to 221 ft. FROM WELL LOG 9/22/1984 121 ft. Well Log (YM) YES Wires property protected (YM) YES i Casing height (above ground) 12+ in. AT INSPECTION 9/28/2004 171 R, 10 g.p.m. 6.5 —g-P.T. WATER SAMPLE RESULTS: i Coliform 0 colonies/100 mi. Nitrate LO—mg./L. Other bacteria colonies/100 ml. Arsenic. _hj1_ugA. Date of sample: 8/2/2006 Collected by: GEG Ltd. a. SEPTIGNOLDINO TANK DATA Tank Type/Material SEPTIC/STEEL Date installed 9/20/1984 Tank size 1000 gat. Number of Compartments 2 Cleanouts (Y/N) I YES Foundation cleanout (YM) YES Depression over tank (Y/N) NO High water alarm (YM) N/A Date of pumping 8 2006 Pumper JRa PUMPING C. ABSORPTION FIELD DATA ! Date Installed 9/20/1954 $0fl rating (g,p.ddit'or� 445 System type DEEP TRENCH i Length 84 ft. Width 2 ft. Gravel below pipe 8 ft. Total depth 12.2 ft. Eff. absorption area 1344 fe Monitoring tube YES Depression over field NO Date of adequacy test 9/28/2004 Results (Pass/Fall) PASS For 3 bedrooms Fluid depth in absorption field before test 36.5 in. Water added 1020981. New depth 49 in. I Elapsed Time: 144 min. Final fluid depth 48 in. Absorption rete >= 450+ g.p.d. 1 Arty rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date — *MT HAD 31 INCHES OF LIQUID ON 8/2/2006. D. LIFT STATION Date installed Size in gallons 'Pump on" level at _in. "Pump off leve E. SEPARATION DISTANCES Manhole/Access (Y/N) water alarm level at Cycles tested Meets alarm 8 circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAtR station on lot 100'+ On adjacent kns 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Sewer /septic service line 25'+ Public sewer menhole/clesnout N/A Holding tank N/A Animal containment areas 50'+ Manurelanimal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parldng/vehicie storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I car* that I have determined through ABM inspections and review of Municipal records that the above systems are in conformance with MOA COSA guldeUnes in eNed on this date. Engineer's Printed Name JEFFREY A. GARNESS Date 8�1 lOL COSA Fee Date of Payment 9 g ©to Receipt Number (wv. 1 1106) Waiver Fee $ Date of Payment Receipt Number SCS Reta 1064301001 Client Name Garness Engineering Group, Ltd. Project Name/N Sampson Est. Lot 3 Dlk 1 Client Sample ID Sampson Est. Lot 3 Dlk 1 Matrix Drinking Water Sample Remarks: All Dates/flmes are Alaska Standard Time Printed Date/rime 08/112006 8:30 Collected Dale/Time 08/022006 10:00 Received Date/time 08/022006 11:20 Technical Director Stephen C.IEde Allowable Prep 1 Analysis Parameter Results POL Units Method Container ID Limits Date', Date Init Metals by ICP/MS Arsenic ND Waters Department Nitmic•N 1.69 Microbiology Laboratory Total Coliform 0 5.00 ug/L EP200.8 C (<10) 08/03/06 08/07/06 M11 0.100 mg/L EPA 353.2 D (<I0) col/100mL SN1209222B A (<1) 08/02/06 ALR 08/02/06 TLF Municipality of Anchorage Development Services Department' Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 VV ERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING y� Parcel I.D. _ 1�i —9X1-� HAA# flu D559 1. GENERAL INFORMATION Expiration Date: d Complete legal description SAMPSON ESTATES SUBDIVISION: LOT 3 BLOCK 1 Location (site address or directions) 23652 GOLIATH DRIVE s CHUGIAK AK. 99567 Current Property owner(s) JAMES ROTHERMEL bay phone 688-6505 Mailing address P.O. BOX 670769 • CHUGIAK AK. `99567 Lending agency Day phone Mailing address Real Estate Agent LANETTE W/ REMAX PROPERTIES Day phone 694-4988 Mailing address 16600 CENTERf1ELD DRIVE • EAGLE RIVER AK 99507 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System 3 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 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. TYPE OF WASTEWATER DISPOSAL: Individual On-site ❑ Individual Holding tank ❑ ❑ Community On-site ❑ ❑ Public Sewer ❑ 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 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 certiripdKby my seal affixed hereto and as of the validation date shown below, I verify that my investigation, ba6ed on procedures outlined in the Health Authority Approval Guidelines for this application, s1iows that1the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 1 further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described 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 soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit,of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nof will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. Phone 337-6179 Date /r,' O Conditional approval for bedrooms, with the flowing stipulations: Attachments: C� HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other • ON-SITE InTY'fS Al.iri � 1.", WASTEWATER . °c • oma,,: l�J�`opilAce• �CnG�S �-� By: Original Certificate Date: /0 '2 (Rev. 12/M) =MN!"Ot=M e P � A ry Well Log (Y/N)_'3;,���n�w3.�a"n»cx �'�"*kks�sr,�rn .mss^;-�.�c„'s�.IfJI`VES gni,. ` -r:.__ ..,... 1"71 ft. WINV RAMPOWS ft, DY: — irll4w +�a�n mscauao � cu iao4 �. Cleanouts,(Y/N) YES L- High water alarm (Y/N)�N/A � } , Ltnauiis �rassiralp rnaa ., For 3 bedrooms id before test 3 � ,n Water added 1020ga1 New depth 49 in Final flui'1 Hnnfh 4A .. n.__"_..__ __. •en . un�cipa ity o nc orage development services CSepar�menf' " � 3° Building SaTetyl3ivisioi � y r ; , • On Site Water`�'Wasfewa�e� I�`r"ogram s " "" _ 1' KymY.T'di.J+fiEY ,w.aw dvak.+wo. ca .e �_ ��n�a � a..anohorage a)C.us ..., =MN!"Ot=M e P � A ry Well Log (Y/N)_'3;,���n�w3.�a"n»cx �'�"*kks�sr,�rn .mss^;-�.�c„'s�.IfJI`VES gni,. ` -r:.__ ..,... 1"71 ft. WINV RAMPOWS ft, DY: — irll4w +�a�n mscauao � cu iao4 �. Cleanouts,(Y/N) YES L- High water alarm (Y/N)�N/A � } , Ltnauiis �rassiralp rnaa ., For 3 bedrooms id before test 3 � ,n Water added 1020ga1 New depth 49 in Final flui'1 Hnnfh 4A .. n.__"_..__ __. •en . Size in gallonsrel6nhbie/Ac In. High water alarm level at Cycles testedMeets alarm & circuit requirements? A�- �,711M �--IMATM Holding tan PTIC/HOLDING k'bN LOTTO:' Iropwty ji66 5 + Absorption geld Vaier service line 10+ "S'u'rface water 100' records that the above systems are in 10A HAA ouidefines in effect on this date. f / 75)Z1t6W, Waiver Fee $ Date of Paym Receipt Numl A. G ess.: 53 771, OCT -22-2004 FRI 09:21 AM LANTECH FAX NO, 5616626 p, 02 LOT ........ Michael L Jokela.• o QO LS -7839 $' QQhr eScipnd �:�--'! GDLI ATH DRIB w C r ,d MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel l.D. # f 1� 1 _ \ HAA # 1. GENERAL INFORMATION Complete legal description 1-o� 3 Location (site address or directions) a 3 5z o i 0.t �'� Property owner Wa,,j�rJU Day phone 15 Mailing address Lending agency Day phone Mailing address / >� Agent Cryo / `ie� P� Day phone kuy ��D O s � • - �O�/_;�/moi Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: if community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: if community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev.1/91) Front MOAe21 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 of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage -files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm KND Englneef6ig Phone 6, 9ZO 20441 Ptarmigan Blvd. Address — Engineer's signature 6. DHHS SIGNATURE ✓� Approved for T / J Q �Cbedrooms. Disapproved. Conditional approval for Additional Comments UJITlr Date 'E �p,��• of 'A Laqja�g8 co� •• 7 r • cr S Kenneth M. DuffuQ\� fC �• CE 7115 ' 0-s(c '•° -a � �i`i .•'' `acs 4je���,S���� bedrooms, with the following stipulations: Date �' 2 The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in 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. 1/91) Beck MOA 021 Municipality of Anchorage & K E N C LA DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division MAY 03 1999 825 L Street, Room 502 • Anchorage, Alaska 99501 • (90' '-i CI A47Y4o`� ANCHORAGE ENVIRONMENTAL SERVICES DIVISION 4Health AuthorityApprovalChecklist Legal Description: L 3 S I k I S� pson C-5� Parcel I.D.: A. WELL DATA //�� / Well type /Yt I`f/A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) . 9 Date completed Ze Total depth �� / Cased to �aCasing height (above ground) Sanitary seal (Y/N) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION O Date of test 9,8 `/ �V2 / / Static water level NO � 16 9. 5 Well production /U g.p.m. 9•p•m• WATER SAMPLE RESULTS: Coliform Nitrate m Other bacteria Date of. sample:� 1ff Collected by: AD Z/1 /1' ffLz�!2 B. SEPTIC/HOLDING TANK DATA Date installed _- I� Tank size /DOb Number of Compartments_ Cleanouts (YIN)--Y— Foundation cleanout (Y/N) �_ Depression (YIN) /V High water alarm (Y/N) /✓A Date of Pumping % Pumper J C. ABSORPTION FIELD DATA Date installed 87 Soil rating (g p.tl4W or 2/bdrm `��i`7 C� System type a eh Length 3aI Width a Gravel thickness below pipe 6 Total depth 2 ' 1,;2-/ Effective absorption area 3`l Monitoring Tube present (YM) -i— Depression over field (YM) Date of adequacy test 2I jq9 Results (Pass/Fail) R5 S For bedrooms Fluid depth in absorption field before test (in.);�Y��� , Immediately aftergal. water added (in.): �_ Fluid depth (ins) Minutes later:��7 Absorption rate = + a.p.d. Peroxide treatment (past 12 months) (Y/N) A If yes, give date 72-026 (Rev. 3/96)` D. LIFT STATION Date installed Manhole/Access (Y/N) _ High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: "Pump off" level at* Septic/holding tank on lot / LOD On adjacent lots /OD Absorption field on lot /Do + On adjacent lots /D D 1 4 Public sewer main /00 -i" Public sewer manhole/cleanout /00 4 Sewer /septic service line 215 t 4 Lift station AIA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: I Foundation 5 Property line lb Absorption field ID 4 Water main/service line `�5 Surface water/drainage 1 DO' 4- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ID / 4' Building foundation / D , + Water main/service line 2_5 14 Surface water / DO -1 Driveway, parking/vehicle storage area / o + Curtain drain Hone KnotA)h Wells on adjacent lots / /p (7 -4- F. ENGINEER'S CERTIFICATION I certify that / have determined thru field inspections and review of Municipal recordkt io�ve systems are in conformance with MOA HAA guidelines in effect on this date. �� ®F PQ � %� �V- ovvBgaev°e aapve k 1� X- ae Signatu q, e� o ooa esa aoe „ neosr°pf!®von Engineer's Name _. or o0o tot, o° I �Q o, Kenneth M. Du'i Date g-/ °e° ee 6v HAA Fee $ od " Waiver Fee $ Date of Payment " 0 3/ /V 1 Date of Payment Receipt Number © `( 3 T 7J / Receipt Number 72-026 (Rev. 3/96)* t `7OFESWAO ;a ` CTtik. Ref.# Client Name Prgject Name/# Client Sample ID Matrix Ordered By FWSIA CT&E Environmental Services Inc. �.r�u.Rarr�iursriirrrrrs�ssi 991694001 KNP Enginecrtng Sampson Fst Blk 1 Lot 3 Sampson Est Blk 1 Lot 3 1?rinicing Waier Parameter Results 0 Client PO# Printed DateMme 04/29/99 16:32 Collected Aare/'Time 04121/99'21:00 Rmeis ed Date/Time 04/23/99 13:47 Technical Director: Stephen C. Ede Released By PRL Units McV1W Allowable Prep Analysis Limps pate late Inst total Coliform 0 cat1100mL SM18 92226 04/23199 RMV Nitrate -N 2.00 0.500 m9/L RPA 300.0 10 max 04/23/99 04/26/99 SCI. DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE I. General Information (a) Lega ascription (include 6>7 Loca ion address or direc Application Date j subdivision, section, township, range) J It= r 1:11— (b) Applicants Name ���/� c/DAF-1 IPJX/4/ Telephone :E63 —8-';G-i--� Applicants Address �0 � e� P� �c� �L �i�✓e,�, . At<. (c) Applicant is (check one) Lending Institution Owner/builder ; Buyer r—_1 ; Other f -:j (explain); (d) Landing InstitutionALA5U Mu -roll L A4/1/� Telephone ,336- 79Gr'D Address (e) Real Estate Co. & Agent �L,�W � �ld�� ccnAllst, Address E.467Le, i2 1 u6r,- o)=ec.i2!5 Telephone 2. Type of Pesidence Single -Family Multi -Family Other (describe) Number of Bedrooms 3 3. Water Supply - Individual Well Community r:::f Public Note: If cc munity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status.. Is the yell adequate for the number of bedrooms specified in this HAA (YIN) 4 See c,*Lgclred we// %, 4. Sewage Disposal (znd enAmailsf FV4646 Onsite �RJ Public Community Holding Tank � Qcsr-z GpDS jyl Is the wastewater disposal system adequate for the number of bedrooms-(Y/N) [Page 1 of 21 2-15-84 .. �. - � �• CJS T,', /'7 ��� . Signed by _ li..s2 ��---' �LG,,, �°e:°° ���j 4� Date IV ®ooee000°eoeo o��/eyoyeo oe oo`eeee� �^oae c o. ES p° . ... oo `+ e Jamo R. e ( ENGINEER SEP.%,) V hy CE _ 6036 6.DHEP Approval Approved for bedrooms Approved Disapproved Terms of Conditional Approval ----t Date ` ll Conditional The Municipality of Anchorage Department of Health and Environmental Protection does not guarantee the continued satisfactory performance of the water supply and/or the wastewater disposal system. This approval indicates that, as of the validation date shown above, Used on the data and information furnished by an engineer registered in the State of Alaska, the water supply and wastewater disposal system is safe and func- tional for the number of bedroom and type of structure indicated. (DHEP SEAL) 7e Mail the HAA to the following address: KB2/d5/s- [page 2 of 21 i N—` 0PALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION' MUNICIPALITY OF ANCHORAGE (MC HEALTH AUTHORITY APPROVAL (HAA) DEC 1 0iaa�+ CHECKLIST - FEBRUARY 1984 RECEIVED A. WELL DATALegal Description: p G°n iv& CBs� Well Classification If A, B, cr C, D.E.C. Approved(Y/N) � Well Log PresentLN) ejate Coupleted c/ -03-6Y Yield µ Total Depth Z2 1 Cased to Z2 I Depth of Grouting Static Water Level loo Pump Set At Z ! Casing Height Above Ground Z ` Sanitary Seal on Casing &I) Y Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y A/ Separation Distances from Well: To Septic/Holding Tank on Lot //Y ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /Zy ; On Adjoining Lots % /00 To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot N M Water Sample Collected By Mark T /nmery� ; . Date Nod Gil E, Water Sample Test Results SaT sA-6 /yrj a Rn u IfS A -A' aLa Com Tents B. SEPTIC/HOLDING TANK DATA Date Installed Size 1000 No. of Compartments Standpipes (Y/N) _Air -tight Caps (Y/N) I Foundation Cleanout (Y/N) Depression over Tank (Y/N) A/ Date Last Pumped &41 Iye<,j Pumping/Maintenance Contract on File (Y/N) i ; for Holding Tank High -Water Alarm (Y/N) N Temporary Holding Tank Permit (Y/N) A Separation Distances fron Septic/Holding Tank: To Water -Supply Wall To Building Foundation S To Property Lire `✓P To Disposal Field 5 To Water Main/Service Line /L/ To Stream, Pond, Lake, cr Major Drainage Course Cor ants Receipt # Date Paid: Amount: [Page 1 of 2 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Type of System Design Date Installed 19g:Z Length of Field Width of Field Z��` Depth of Field 1/,L12 ' Gravel Bed Thickness Square Feet of.Absorption Area 13y4KStandpipes Present (Y/N) Depression over Field (Y/N) /1/6 Date of Last Adequacy Test NZ4 Results of Last Adequacy lbst Separation Distance from Absorption Field: To Water -Supply T\b11 /Z G%� To Property Lire To Building Foundation /2/' /P To Existing or Abandoned System cn Lot >J�' f-- ,- ; On Adjoining Lots IV14 To Water Main/Service Line To Cutbank(if present) / VA _ To Stream/Pond/Lake/or Major Drainage Course A 14 To Driveway, Parking Area, cr Vehicle Storage Area 50 Comments D. LIFT STATION Date Installed Dimensions Size in Gallons "Pump On" Level at f , High Water Alarm Level Tested for Electrical Codes(YM) Comments e/Access (Y/N) Off" Tavel at Vert (Y/N) 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. r Signed DateA. E` Co an E MOA No.S% S�O`' r . o <, ZNGTNEERS KB1/d5/s� (Page 2 of 21 _. '�'" 2-15-84 Ala 6� MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE (MOA) DEPT. OF HEALTH Q, HEALTH AUTHORITY APPROVAL ( HAA) ENVIRONMENTAL NC TEC T ION CHECKLIST - FEBRUARY 1984 D E C 0 « 9984 WELL DATA RECEIVED Well Classification..T411,11d41 If A, B. or Cr D.E.C. Approved(Y/N) Well Log Present if TM) S� Date CompletedYield. Total `Depth 4Cased to Z01 Depth of Grouting Static Water Level / 10 Pump Set At Casing ,Height Above Ground 010A Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Y Depression_ Around Wellhead (Y/N) /y Separation Distances from rtbll: To Septic/Holding Tank on Lot le i CXR Adjoining Lots To Nearest Edge of Absorption Field on Lot 125 on Adjoining Lots To Nearest Public Sewer Line /✓�f To Nearest Public Sewer �4 Cleanout/Manhole To Nearest Sewer S_er'vice Line on Lot Water Sample Collected By /V%Qr,C� / ire jrc-� // Date /Vo✓PmF/ - /Mf Water Sample Test Results .S ee 4 bAnI7al APSE LST Cements B. SEPTIC/HOLDING TANK DATA Date Installed sevl 93e Size 'GL'sqal No. of Capartments Standpipes (YIN) _A-ir-tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (YIN)/_ Date Last Pumped �lVllq 1LAL12) Pumping/Maintenance Contract cn File (YM) AIIA ; for Holding Tank High Water Alarm (Y/N) Al Temporary Holding Tank Permit (Y/N) Al Separation Distanfrom Septic/Holding Tank: ^� To Water -Supply Wr11 To Building Foundation -� To Property Lire 5` /Zrs To Disposal Field To Water Main/Service Lim _ To Stream, Pond, Lake, or Major Drainage Course Comments - C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata `$ SGS / " e Type of System Design Date Installed Length of Field �J `� / lulls z 5�' ` Width of Field Depth of Field Gravel Fed Thickness f'Z Square Feet of Absorption Area. /3 SO Standpipes Present (Y/N) Depression over Field (YM) 1V Date of Last Adequacy Test 4L& 42L6 Results of Last Adequacy, Mast Separation Distance from Absorption Fie1Q: 13�� To Water -Supply Well / Z �/ To P` cper. ty Lire To Building Foundation/, ' /m- RTo Existing or Abandoned System on Lot : On . Ad j oinirg Lots Nei To Water Main/Service Line /l/. _ To Cutbank(if present) To Stream/Pond/Lake/or Major. Drainage Course N14 To Driveway, Parking Area, or Vehicle Storage Area %40 /Z + Comments D. LIFT STATION Date installed A/O? e Dimensions Size in Gallons Manhole/Access (YIN) "Pump On" Level at "Pump Off" Level at High Water Alarm Level at Tested for Electrical Codes(YM) CCiMTerts Vent (YM) Pumping Cycles during Adequacy Test. gets 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. Signed ; �. %� -`� Date :Company - MOA NorIA,GZNr.�RS. 'KBl/d5/s , [Page "2 of 21 01,- - 2-15-84:`