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SAMPSON ESTATES BLK 1 LT 5
Sampson Estates Block 1 Lot 5 #051 - 822 - 23 Well Drilling Permit Number: SW Date of Issue Parcel Identification Number: 051- 9Z2— Z 3 Legal Description Sampson Estates Block 1 Lot 5 Pump Installation Date: 12-6-18 Pump Intake Depth Below Top of Well Casing: 190 Pump manufacturer's Name: F&W Pump Model: 4F07P07305S Pump Size: 3/4 Pitless Adapter Burial Depth: 10 Pitless Adapter Installer: Unknown Disinfected Upon Completion? ® yes ❑ no Method of Disinfection: Chlorine 50 PPM Comments: Pitless Manufacturer: Martinson 11 Pump Installers Name: Sullivan Water Wells Property Owner Name & Address McCade Olsen. 23730 Goliath Dr. Chugiak, AK 99567 feet Is feet Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. NO SURFACE WATER NO KNOWN CURTAIN DRAINS, - TEST HOLE • - MONITOR TUBE SEWER CLEANOUT - WELL EASEMENT . PROPOSED LEACHFIELD EXISTING LEACHFIELD WELL/SEPTIC SITE PLAIN LEGAL: Lot 6 BK. -1 SAMPSON ESTATES OWNER:. LANCE CONTRACTOR: N/A ' SCALE 1" = 60' JOB# 97-036A I DATE: 07/31/97 AEAGLE RIVER ENGINEERING SERVICES P.O. Box 773294 EAGLE RIVER, AK 99577 (907) 694-5195 FAX: (907) 694-3297 OF 447! ki j ., LOUIS A. BUTERA • �,`��� � ••••CE'6736••.: 1'Q i AV MUNICIPALITY OF ANCHORAGE tt ® DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION `.f 4 ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264.4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME Fenton Construction Incorporated PHONE 563-8236 E] NEIN ❑ UPGRADE MAILING ADDRESS 2085 Campbell Place, Anchorage, AK 99501 LEGAL DESCRIPTION Lot 5, Block 1, Sampson Estates, located within Sec. 3, T15N, R1W, S.M., AK LOCATION Goliath Drive, Peter's Creek NO. OF BEDROOMS three (3) Uy 1=2 NF DISTANCE TO: Well 1 06 Absorption area 10' Dwelling 5' PERMIT NO. 840961 Manufacturer Mat-Su Material Steel No. of compartments two (2) Lig. capacity in gallons 1000 IF HOMEMADE: Inside length N/A Width N/A Liquid depth N/A -J 2 z DISTANCE o < TO: Well Dwelling PERMIT NO. Manufacturer Material Liquid capacity. in gallons TILE DRAINFIELD TRENCH DISTANCE TO: Well 1 1 1 Fou 5ation U Nearest lot line 15 PERMIT NO. 840961 No. of lines 1 Length of each line 72.5 Total length of lines 72.5 Trench width - 18 inches Distance between lines N/A Top of tile to finish grade 3.2 Material beneath 104.4 j4e e /7 inches Total effective absorption area 1261.5 sf SEEPAGE PIT Length Width Depth \ PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area DISTANCE TO: Well Building foundation Nearest lot line J J Class Depth Driller Distance to lot line PERMIT NO. DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER - .- •' I - PIPE MATERIALS ABS sched. 40 and ASTM 2729 _ `/a , SOIL TEST RATING 419 sf/bedroom , f ' INSTALLER Pieratt Excavating In _ / D REMARKS Design change from 8.0' effective depth to 8.7' was in order to shorten trench i due to limited replacement area. 1 h .,, aBoll Oay� Ilililil111111111 T ¢t �c 0 Z' Z. r i E. 0 g�"SI c. ae _, cb hill1o1 � 1111111 1 �, goB ®0 " 7�,0 °oeeu®s e® ��.. ,„,,..„...,..„„.......„4, ,,� p 0o OOP r:rPr i'o u..10 or aurins ust�'•� ®1 APPROVED DTE LEGAL ,t n�✓ /2: 7/O 72-013 ( Rev. 3/78) � PERMIT NO: • DATE ISSUED: 17.3 F=7 paq Fncti EFE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264~4720 840961 11/27/84 APPLICANT: FENTON CONSTRUCTION ADDRESS: 2085 CAMPBELL PLACE ANCHORAGE, AK 99507 CONTACT PHONE: 563-8236 LEGAL DESCRIP: SUBDIVISION: SAMPSON ESTATES LOT: 5 SECTION: 3 TOWNSHIP: 15N � RANGE: 1W LOT SIZE: 11167. /SO"FT" OR ACRES) MAA BEDROOMS: 3 ` Listed bclow are the options available -to you in designing`your septic system. Choosc the option that best fits your site... BLOCK: 1. DEPTH TO PIPE BOTTOM (FT.) 'GRAVEL DEPTH (FT.) TOTAL DEPTH (FT.) GRAVEL WIDTH (FT.) GRAVEL LENGTH (FT.) GRAVEL VOLUME (CU"YDS") TANK SIZE (GALS) SOIL RATING (SQ.FT"/BR) �L.K-4��� 4.0 8,0 12'0 2^5 79.0 62"2 1,000"0 ** 419 EMF]D • 4.0 0.5 4^5 27"0 53.0 53.0 1,000^0 318 4"O 3.5 7.5 5,0 136^0 ** 100.8 1,O00"0 ** 19 ** GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 EACH) ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS - - - - - - - - I certify that: 1^ I am familiar with the requirements for 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 of 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. J. understand that this permit is valid for a maximum of 3bedrooms and any enlargement will require an additional permit" IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT' AND INSPECTION MUST BE OBTAINED; (2) AS~BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND THE ELECTRICAL WORK MUST BE DONE BY A LICENSEDELECTRICIAN^ SIGNED APPLICANT: FENTON CONSTRUCTION / ' ISSUED BY ~ ' -~-,-,-~~'/ DATE: ... ..................... DATE: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST SOILS LOG L PERCOLATION TEST PERFORMED FOR: Fes'-Fv \ I f1 C� , DATE PERFORMED: 1 I20 -r?, I I P`i' LEGAL DESCRIPTION: Lb/+ 6 P.) I) 1 ' la .z of ) P: 1 ' T E Re. AlA I e.S. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 ro FR+Irfi 0.0 - o,y — e.9 - 2 0 - SILT L-tr1-k organics (� ) redallar brow-) ©' 6,E - 0'6N/ell SAk1 Some- s'!lsc�+d tiere CS M) Cobbles and boulcters 0V-av)Veru de-neldrui COMMENTS CGo-h .G1 ° ; F:O. CE- 84 0° <9/ < 6, °'0990080'° SLOPE ID 4 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? 11 14 (3 14(� s L 0 P E SITE PLAN I "c SO. .-l. ,. ,..i Reading ti4tn/ nt)�, 1...0 ,— Date �- Gross Time Net Time Depth to Water Net Drop I-5 1\\2.1\81 1102 : 55 ti .'5 3oK,;n. /y 0 j -- �,V✓l,t op `<l'i e. d Wtlil `7-,CD114'Vjc :5C) \133 e/fl_n 1 H I'/ c: j f1 IG �/ Iia 7 `< 1 I I� 24 !Si -, Ctle. r reCICI.i-tvel,..( IeL,el N. I T4...,. le- -gI 11. � �/"/oOSb C�- SYS. H _ Q I�SCp-k., .-l. ,. ,..i Reading ti4tn/ nt)�, 1...0 ,— Date �- Gross Time Net Time Depth to Water Net Drop I-5 1\\2.1\81 1102 : 55 ti .'5 3oK,;n. 1 13 84 111 %1(a CV 11 IG IE 11121161 31 X35 u!zoi: v5 `7-,CD114'Vjc :5C) \133 e/fl_n 1 H I'/ c: j f1 IG �/ Iia 7 `< 1 I I� 24 !Si 12:3(4.: O, r reCICI.i-tvel,..( IeL,el .-l. ,. ,..i Reading ti4tn/ nt)�, 1...0 ,— Date �- Gross Time Net Time Depth to Water Net Drop I-5 1\\2.1\81 1102 : 55 ti .'5 3oK,;n. 1 13 84 111 %1(a CV 11 IG IE 11121161 31 X35 u!zoi: v5 `7-,CD114'Vjc :5C) \133 e/fl_n 1 H I'/ c: j f1 IG �/ Iia 7 `< 1 I I� 24 !Si 12:3(4.: O, PERCOLATION RATE - 3 , 3 (minutes/inch) TEST RUN BjTWEEN �'� FT AND 1.2-/ FT elm PERFORMED BY: 01111 Ia.ce4 72-008 (6/79) CERTIFIED BY: DATE: /1 Z7 0 C c -17 0 t- o- 0 ‘Pt a 0 to 4-- f0 0 N PERMIT NO: DATE ISSUED: ���������__I -F '41( CD gf4 IEN-11C-3 !FR��� DEPARTMENT OF H[!‘/ T|| AND' ENVIRONMENTAL PROTECTION `825 L REE1, ANCHORAGE,AK 99501 264 4720 850098 04/12/8� APPLICANT : CONST INC FENTON ADDRESS: 2085 CAMPBELL PL, ANCH, AK 9950/ CONTACT. PHONF: 563^8236 • ! EGA! DESCRIP: SUBDIVISION: SAMPSON ESTATES LOi: 5 SECTION: 3 • TOWNSHIP: 15N RANGE: 1W LOT SIZE: 41467 (SQ'FT. OR ACRES) LOT LOCATION: XX . BLOCK: 1 I ccrtify that: 1. I am familiar with the requirements for on-site sewers and wells as.sct forth by the Municipality of.Anchorage (MCA) and the State .o{ Alaska. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria o{ this permit. 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. ��cucn APPLIC'NT: COL3T-1kC • ISSUED BY DATE: (1) 3 6 0 gC z NJ 3 3 g 0 LIFETIME ALASKAN SERVING ALASKA P.O. BOX 772847, EAGLE RIVER, ALASKA 99577 DEPTH OF WELL AVNER OF LAND Fenton STATIC LEVEL OF WATER FT DRAW DOWN FT. 95% est ci) tx4 Ct I F (4.1 LLI LT. Li. r 0 0 0 0 0 0 0 0 0 0 .., (-4 F LT.1 LL4 ‘41 Lr. {J. LT. LT. GALS. PER HR KIND OF CASING 2 2 2 2 2 2 2 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 c4 1:4 g LLo LT. CO 00 ffl cy, ‘—t CA NELL — SITE )ATE — STARTED )ATE — ENDED KIND OF FORMATION: 0 0 0 0 0 0 0 0 0 0 0 E— L.f.r.. LT. fa. LL. Lr. LL• fs. 0 A cr) 2 2 00 cd LT. LT. CO Cs1 •—t ‘CI 1—t 2 2 2 n 0000 1:4 LS. LT. Lim Li. 2 2 n 0000 c4 c4 MISCL. INFORMATION 1• 8 DRILLER'S NAME Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 051-822-23 1. GENERAL INFORMATION Complete legal description SAMPSON ESTATES BLOCK 1, LOT 5 Location (site address) 23730 GOLIATH DRIVE, CHUGIAK, AK 99567 Current Property owners) TERRY & PATSY HENDRICKSON Day phone Mailing address 8708 TIMBERLYN WAY, FORT SMITH, AZ 72903 Real Estate Agent Day phone Expiration Date: / 0 —/ T%'/ 9 2. TYPE OF DWELUNG: ►1 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage r_nrnmiinity Class Well Public Water System n TYPE OF WASTEWATER DISPOSAL: Individual Holding Tank Community Public Sewer 9 n WaiverNariance request for: Distance: Received by: ,,Si 'f /l `J • Date: %-/ 7' // COSA to be released to the engineer, unless,' - a requested by the engineer. COSA Fee $ Date of Payment Receipt Number COSA# Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 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 ARC 1 LRRA CONSULTING, INC. Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Phone 868-3791 Date 3/24/14 Engineefs Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 10 subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year end the water usage of the family being served by the system. 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 well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen �. encroachments, deficiencies or discrepancies exist. Aar 4tt O l 6. DSD SIGNATURE I� System #1 Approved for 3 bedrooms. By: System #2 Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: OL; OF A4fr Q� y© r-4,1SrTF ��'�, WATER AHD o WASTEWATER o p ROcARAM 14Nr )SER 9<,co,\: Original Certificate Date: 2 ' / 7-1 V The lCfunlrage Development Services Division (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given M 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 SGS Rcf.# Client Name Project Name/# Client Sample ID Matrix 1142987001 ArcTerra Engineering and Surveying Sampson Est. LotS, BKI Sampson Est., Lot 5, BKl Drinking Water Printed Date/Time Collected Date/Time Received Date/Time Technical Director 07/15/2014 9:15 07/09/2014 8:38 07/09/2014 10:58 Stephen C. Ede Sample Remarks: 4500NO3-F - Nitrate/Nitrite - MS recovery is outside of QC criteria. Refer to LCS for accuracy requirements. Parameter Results LOQ Units Method Allowable Prep Analysis Container ID Limits Date Date Nit Waters Department Total Nitrate/Nitrite-N Microbiology Laboratory E. Coli Total Coliform 3.31 0.100 mg/L SM2I4500NO3-F B (<10) Negative Negative 100mL SM21 9223B A 07/11/14 CDE 07/09/14 MEV 100mL SM21 9223B A 07/09/14 MEV Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I . 051-822-23 Expiration Date: / 1-71 l 1. GENERAL INFORMATION Complete legal description SAMPSON ESTATES BLOCK 1 LOT 5 Location (site address) 23730 GOLIATH DRIVE CHUGIAK AK 99567 Current Property owner(s) TERRY & PATSY HENDRICKSON Day phone Mailing address 8708 TIMBERLYN WAY, FORT SMITH, AZ 72903 Real Estate Agent Day phone 2. TYPE OF DWELLING: Single Family (w/wo ADU) LJ Duplex [ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage [ Holding Tank Community (lass wall ( Community Public Water System 1 I Public Sewer 3_ TYPE OF WASTEWATER DISPOSAL: Individual WaiverNariance request for: Distance: Received by: fC(`th' ' % 711. -< =/z;«d COSA to be released to the engineer, unless other iaa requested by the engineer. Date: II- L/ `%C/ COSA Fee $ 5.9Co Waiver Fee $ Date of Payment 41aw Date of Payment Receipt Number at/56V Receipt Number COSA # 03C/til l 13 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 ARCI ERRA CONSULTING, INC. Phone 868-3791 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK99577 Engineer's Printed Name KENNEL H M. DUEFUS Date 3/24/14 Engineer's Comments: This Investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the wet 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 inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. 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 well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. 6. DSD SIGNATURE t/IGSystem #1 Approved for ,3 bedrooms. By: System #2 Approved for bedrooms. Ar Disapproved. Conditional approval for bedrooms, with the following stipulations: v/ » 0 "w��V OF n, V Cyi ON SITE n, WATERPROCPAM AND tT o WASTEWATER o^ 1 -11 Original Certificate Date: The Mufiicx¢'aPC'af t chorage Development Services Division (050) 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 If more than 1 septic system is on the lot: COSA Checklist # of _ Structure served by this system _ Certificate of On -Site Systems Approval Checklist Legal Description: SAMPSON ESTATES BLOCK 1, LOT 5 A. WELL DATA Well type PRVT If A, B, or C provide PWSID # Date completed 11129/1904 Sanitary seal (WN) y Total depth 201 ft. Cased to 201 ft. FROM WELL LOG Date of test 1112911984 Static water level 161 ft. Well production 10 g.p.m. WATER SAMPLE RESULTS: Coliform /(fib colonies/100 mL Nitrate R. %8 mg/L Arsenic: NO ug/L Date of sample: 3/2012014 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC 1 STEEL Tank size 1000 gal. Number of Compartments 2 Foundation cleanout (WN) Y Depression over tank (YIN Date of pumping p " 7- /3 Pumper Parcel ID: 051-822-23 Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) 24+ in. AT INSPECTION 312012014 166 ft. 3.46 g.p.m. Collected by: ARCTERRA Date installed 411512004 Cleanouts (Y/N) Y High water alarm (Y/N) N (ttiu i0M/6 ( C. ABSORPTION FIELD DATA Date installed 121711984 Soil rating (g.p.d./ft2 or ft /bdrm) 419 System type DEEP TRENCH Length 72.5 ft. Width 1.5 ft. Gravel below pipe 8.7 ft. Total depth 11.8' ft. (Measured 3/20/14) Eff. absorption area 1261.5 ft2 Monitoring tube Y Depression over field N Date of adequacy test 3/20/2014 Results (Pass/Fail) PASS Fluid depth in absorption field before test ¢¢ in. Water added 640 gal. Elapsed Time: 1220 min. Final fluid depth in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N For $ bedrooms New depthjj in. Absorption rate >= 450+ g.p.d. If yes, give date D. LIFT STATION 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 1004 Absorption field on lot 100'+ Public sewer main 75'+ Sewer /septic service line 25'+ Animal containment areas 501+ On adjacent lots 1001+ On adjacent lots 1001+ Public sewer manhole/cleanout 100'+ Holding tank 1001+ Manure/animal excrete storage areas 100'+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line S+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 1001+ ABSORPTION FIELD ON LOT TO: Property line 104 Building foundation 104 Water main 10'+ Water Service line 10'+ Surface water 1004 Driveway, parking/vehicle storage 10'+ Curtain drain 504 (NONE KNOWN) Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name KENNETH M. DUFFUS Date 3/24/14 COSA brown sheet10-10-12.doc ��� OF Aze0 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-822-23 1. COSA # DSC I I (:,)-( Expiration Date: j _ if GENERAL INFORMATION Complete legal description SAMPSON ESTATES S/D; LOT 5, BLOCK 1 Location (site address) 23730 GOLIATH DRIVE, CHUGIAK, AK 99567 Current Property owner(s) TERRY & PATSY HENDRICKSON Mailing address PO BOX 672313, CHUGIAK, AK 99567 Lending agency Mailing address Day phone Day phone Real Estate Agent CARLA STEPHAN w/ PRUDENTIAL Day phone 907-242-5340 Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OFBEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System 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 On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 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 ARCTERRA CONSULTING, INC. Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Phone 868-3792 Date 11/17/2010 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. 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 well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: t1tr(o lit*••••�•••A'/ ••• • r • • rr ON-SITE: Gs : WATER AND 110, wAsTEWATER . PROGRAM Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X •••••.•••••S ii))))J 11lr) \4‘ Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: -=_� Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: SAMPSON ESTATESS/D; LOT 5, BLOCK Y A. WELL DATA Well type PRIVATE If A, B, or C. provide•;PWSID # Well Log (Y/N) , r Date completed 11/29/1984 Sanitary seat (Y/N) Y Wires property protected. (Y/N) Y Total depth 201 ft. Cased to 201 ft. Casing height (above ground) 24 in. AT INSPECTION 11/04/2010 o¢ e a u z 4 0 SA . s VII Parcel ID: 051-822-23 FROM WELL LOG Date of test 11/29/1984 Static water level 161 ft. Well production 174 ft. 10 g.p.m. 3.42 g.p.m. WATER SAMPLE RESULTS: Coliform NEG colonies/100mL Nitrate 3.15 mg/L Arsenic: ND mg/I Date of sample: 11/04/2010 Collected by: ArcTerra B. SEPTIC!HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed .12/7/1984 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) ¥ Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 11/04/10 Pumper JR's C. ABSORPTION FIELD DATA Date installed 12/7/1984 Soil rating (g.p.d./ft2 or ft2/bdrm) 419 System type DEEP TRENCH Length 72.5 ft. Width 1_5 ft. Gravel below pipe 8.7 ft. Total depth 11.8 ft. (Measured 11/04/10) Eff. absorption area 1261.5 ft2 Monitoring tube Y Depression over field N Date of adequacy test 11/04/2010 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 56 in. Water added 650 gal. New depth 80 in. Elapsed Time: 1150 min. Final fluid depth 55 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION 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 SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ On adjacent Tots 100'+ Public sewer main 75'+ Public sewer manhole%leanout 100'+ Sewer /septic service fine 25'+ Holding tank 1004 Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 51+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent Tots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10'+ Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain 50'+ (None Known) F. COMMENTS Wells on adjacent Tots 100'+ G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name KENNETH M. DUFFUS Date 11/17/10 COSA Fee $490.00 Date of Payment Receipt Number 0553 Jam- C. di9_ (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number 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 Ica CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-822-23 1. GENERAL INFORMATION HAA# 05032-9 Expiration Date: / 0 ' a-7 " O S Complete legal description SAMPSON ESTATES SUBDIVISION; LOT 5, BLOCK 1, Location (site address or directions) 23730 GOLIATH • CHUGIAK, AK. 99567 Current Property owner(s) DAN AND CARRIE DICKEY Day phone (907) 688-8897 eo 'Box '} 70248 O; c -+t -E• asa .Ar- `risR R Mailing address Lending agency Mailing address Real Estate Agent Mailing address Day phone LYNN SWANSON w/ PRUDENTIAL REAL ESTATE Day phone 242-2212 16635 CENTERFIELD DRIVE * EAGLE RIVER, AK. 99577 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 TYPE OF WASTEWATER DISPOSAL: IS 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 4 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 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 Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functionl and adequate for the number of bedrooms and typo of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage tiles and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone _ 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, 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 of the system undor 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 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, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. Date "7/i /or Conditional approval for bedrooms, with the following stipulations: l`P�`�YfOf er 1.14104. e S. ON-SITE • 0-..i.m= zr_L:M WATER AND WASTEWATFR PROGRAM ; Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements 1�mmfl)fl'1) Supplemental Engineer's Report Other (Rev. 1201) Original Certificate Date 7- a7 -0.s. Municipality of Anchorage Development Services Department Building Safety Division OnSte Water & Wastewater Program 4700 South Bregaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.d.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description' SAMPSON ESTATES SUBDMStON: LOT 5 BI OCK 1. Parcel ID: D51-822-23 A. WELL DMA Well type PRNAIE If A, B, or C provide PWSID# N A Well Log (YM) YES Date completed 11/29/1984 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 201 ft. Cased to 201 ft Casing height (above ground) 12+ in FROM WELL LOG AT INSPECTION Date of test 11/29/1984 6/27/2005 Static water level 181 ft 174 ft. Welt production 10 g p m 2.82 g.p.m. WATER SAMPLE RESULTS: 1 Coliform 0 colonies/100 ml. Nitrate 2 19 mg /L Other bacteria n colonies/100 M. Arsenic: SeLmg.IL. Date of sample: 6/29/2005 Collected by: GEG. LtD. B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Date Installed 12/7/1984 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (Y/N)Y S Depression over tank (YM) NO High water alarm (YM) N/A JR's PUMPING Date of pumping 6/28/2005 Pumper C. ABSORPTION FIELD DATA Date installed 12/7/1984 Soil rating (g.p.d./ tb4Ibdrrr�) 419 System type TRENCH Length 72.5 ft. Width 1.5 ft. Gravel below pipe 8.7 ft Total depth site ft. Eff. absorption area1261.5ft° Monitoring tube'YES Depression over field NO Date of adequacy test 6/27/2005 Results (Pass/Fall) PASS For 3 bedrooms Fluid depth in absorption field before test 75 in Water added 705 tis New depth 92_25 in. Elapsed Time: 200 min. Final fluid depth 843 in Absorption rate >: 450+ g p4. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date 'MT ONLY EXTENDS 96' BELOW INVERT t. MEASUREMENTS ARE IN THE WEST SUMP. D. UFT STATION Date installed Size in gallons Manhole/ "Pump on' level at in 'Pump High water alarm level at in Datu Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankflf station on lot 100'+ Absorption field on lot 100'+ On adjacent Tots 100'+ Public sewer main N/A Public sewer manhole/deanout N/A Sewer /septic service line 25'+ Holding tank N/A On adjacent lots 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field - 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 10i1+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Curtain drain NONE KNOWN F. COMMENTS G. ENGINEER'S CERTIFICATION Surface water 100'+ Driveway, parking/vehicle storage 10'+ Wells on adjacent lots 100'+ 1 certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in efled on this date. HAA Fee $ 1130 Waiver Fee $ Date of Payment 7 -‘S -0S Date of Payment Receipt Number OX $1(T1 \4Y\ Receipt Number (Rev. 12!01) FAX N0. 6616626 0. 72���v pfd EPSP ,p E55-3: u.-- LOT 4 2" 0 s LOT 6 PLAY HOUSE O� COVERED HOT TUB Q s DECK � `��.• pF.AC,9Soa 0k* 49711 *DO Q•OO+MiCh •r0 • a; • LS-• 4 7839 Ca� ZP ge 400�%i P. 02 TRACT A r9 • ,111.11:17,11=1:M20.511S.T.S;IreratterarnIr rwprwl:o Ur •11%.11•I SWANS?ON Wilt. I'IKUULNIIAL JACK WI111E tt`fi'n"1,,'i;rT` x:7.T?Y,1. nk'G'S!r1'%li"'p!'r:TeeTs`F`;T,?"N" '' TRACT A NOTE: THIS DRAWING IS NOT TO DE MODIFIED FOR EXCLUSION NOTES: It is the owners responsibiily to_ determine the existence of any easements. covenants, or restrictions which do not appear on the recorded subtvision plat. NOTE: Under no cirCUm$tances should any dale hereon be used for construction or for establishing property lines. T21 USE AS A PLOT PLAN. t EGENO: SET FND 5/0'RS W/CeP* SAC RO 0 3 2a' AL.MUM. qty VONVuEN f 4 HUD & TACK 0 rNCE- —x— K Lantana' —TAN° & CONSTRUCTION SURVEYORS—PLANNERS—ENGINEERS 440 WEST BENSON BLVD. B 200 (fax) 561-6626 ANCHORAGE, ALASKA 99503 (907) 562-5291 Wa:K UNJtI NUMt'TER. Dent: au.0 rtn sweat JULY 25, 2005 1-a40' 84-10 r 2005—L -218A NFB a` ices Qat MI C& 1560 SURVEY CERTifICATION: LANTECH has conducted a physical survey of this property os shown on this drawing and that the Improvements elluoted there— on are within the property lines and no encroach— ments exist other than noted. AS—DUILT Or: LEGAL DESCRIPTION: OvENNANG. WOOD OCCK$— CONCRLTt- A:PHALT- scpnc SiNNOPlvts- WATER WATER Wilts LOT 5, BLOCK 1, SAMPSON ESTATES 06/29/2005 11:39 9073449821 JRs Pumping PO Box 773415 Eagle River, AK 99577 (907) 694-6454, �Bll—llnp informs on Gamess Erglneerirg Group 3701 E Tudor Rood Suite 101 Anchorage, AK 99507 (907) 337-6179 Meagan & Chris JRS SEPTIC Job Description: 1250g P.O. Number: Tema: Net30 Salssrep: Kania Map Book: IJob Site Information Cross Streets: Sampson Drive Ride ewJob Comments; N- last serviceunknown un 23730 Goliath Drive ICk & Pump Tank !Thick Crust - Heavy solids Chuatak. AK 99567 (907) 337.8179 317-9433 Robb cell Service Type Septic SeMm 15K Addlbonel Location Continents: Cedar Home wlceder garage door Septic 0 back of home PAGE 02 Service Agreement Number: 017121 Order Date: 27 -Jun -2005 Service Date: 28 -Jun -2005 12:00 am Technldan: Tony Job Type New Map Grid: 15 1 Tax Percent: 0 Price Each x 2 Men Tax Extension Actual 3125.00 No No 3125.00 Diagram: *rank • Gallons Planned: 1250 Gallons Actual: Hose Length: Double Tank: Pump System: RI Baffles Inlet: 0 Baffles Outlets 0 Estimated Charges: Actual Charges: Nontaxable Total Taxable Total Tax Total 3125.00 50.00 50.00 Grand Total 5125.00 Customer agrees to the terms and conditions printed on the back. THIS ISA BINDING AGREEMENT. Signature and nue or Customer Representative Date Accepted by JRs Pumping Date Accepted For your added convenience we accept; American Express. Dieover, Visa and Master Card payments over the phone. After 30 Days accounts will be turned Over to collections. 525.00 For NSF Checks Returned. MUNICIPALITY OF ANCHORAGE •- r� 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 I.D.# 12 \ = HAA# /•\agilnli 1. GENERAL INFORMATION :,. Complete legal description. Lot 5; B.Caciz,1;, Sampi.:on Estate.s Location (site address or directions) 23730 Gotiath Vnive Eagle R.iveA, ' AK Property owner Jack and Shaky Ashur. Day phone 688-6052 Mailing address P.O. Box 67022 Chug.iaiz, AK 99567 Lending agency Day phone Mailing address Agent Bkooke Stip na/ CENTURY 21 COLONIAL Day phone 696-8600 Address 11901 13w.s nus Blvd. Eagle Riven, AK 99577 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well XXX Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site, Public sewer XXX NOTE: If community wastewater system; provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, l 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 incompliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this ins•ection. Name of Firm S & S ENGINEERING / Address 17034 Eagle River Loop Re: cI . ` 204 Eagle River, Alaska 9957 Engineer's signature Phone 6gt-79 r Approved for Disapproved. bedrooms, with the following stipulations: CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska, The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineers work. 72-025 (Rev. 1/91) Bock MOA N21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lor' C 6144 1 :Cfrr'/PJ4.f Parcel I.D. A. Well Data Well type Pga kA-rt- If A, B, or C, attach ADEC letter. ADEC water system number Log present &N) Y Date completed 11- 29 —s `� Driller Glib /�crt�1 dlGi I2',J Total depth 2< 1 ' Cased to 2� 1 / Casing height I Sanitary seal )N) V Wires properly protected /N) a FROM WELL LOG AT INSPECTION uJ 2 Date of test 1(-299 f 3-a9-. /4 a 5 � � W W 0CI Static water level a 70 > > Well flow /D.t) -5' < g.p.m. 3, S g4 Lt.J Pump levell /o ' oFF ea 2-7-7,4 . LJ lL m L.LI. tx c SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot !Oo' Absorption field on lot Public sewer main A- Public sewer manhole/cleanout /d- Sewer service line 2 Petroleum tank 2S /001 ; On adjacent lots ; On adjacent lots /oo 'DD ( f WATER SAMPLE RESULTS: Coliform Nitrate /, G e Other bacteria Date of sample: 3- 2 B-”- Collected by: S ¢ S y,e, B. SEPTIC/HOLDING TANK DATA Date installed t1 / t Tank size %00 o Compartments Z Cleanouts ®/N) / Foundation cleanoutO/N) Depression/OW High water alarm (Y ri Alarm tested (Y/N) 'I.4 Date of pumping 1-2k-9¢ Pumper 7 /4 Cess ea a 1, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot '1 a d / On adjacent lots /40 To property line Absorption field Surface water/drainage /Oa 72-026 (3193)' Front 0 Foundation Water main/service line d CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump Levet-a� High water alarm level Cycle -tes et d Meets MOA electrical codes (Y/N) SEPARATION DISTANCE- 'OM LIFT STATION TO: W on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed /2 ' / Soil rating (GPD/Ft2) / 7 //.0 • System type T724--,—(e-is/ Length 72 - S) Width /' Gravel thickness Total absorption area /a6,/, Date of adequacy test 3--2 Cleanout present ON) Y Resultsc. ail --) f s Water level in absorption field before test -`f S N / After test 8-7 Total depth Z' Depression over field (1 !f ) 4' for Peroxide treatment (past 12 months) (Y& ,) J _ /LAID !JAI SEPARATION DISTANCE FROM ABSORPTION FIELD TO: 3 - Bedrooms If yes, give date / ` /3 Well on lot /v o On adjacent lots /o o Property line To building foundation / % / To existing or abandoned system on lot ,--V � / y On adjacent lots 2- / Cutbank ' 6 /� Water main/service line 2 S t Surface water Curtain drain tots Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, Signature Engineer's Name17034 confo med to all MOA and HAA guidelines in efffof on,t're t Date Eagle River Iaska 99577 this inspection. t, HAA Fee $ 30° Waiver Fee $ Date of Payment 4 l 1 / \ Date of Payment Receipt Number 2 5 1(5 L` ��- ,) Receipt Number 72-026 (3/93)' Back MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # i X — HAA # W W51f-.C1A.9(.1 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) La.# 5; BPacfz 1; SampAon Estate - Location (address or directions) 23730 Got ath Vn i_ve (b) Property owner Wet4to 2k% S %6YLlJ Telephone : (home) Business Mailing Address (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone JACK WHITE COMPANY ATTN: Lon -L C'wwden 694-5500 (e) Mail the HAA to the following address: (or check here i.if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17(34 Eagle River Loop Road No, 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single -Family GXX Number of bedrooms 3 V 3. WATER SUPPLY Individual Well 0k. Community ❑ 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 -sited 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 Address Date S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Telephone 69 V -Z 979 6. DHHS APPROVAL Approved for bedrooms by O �f t" �T rt Date 7 7Z/`7G Approved x Disapproved Conditional Terms of Conditional Approval Vi$41 s '.1 , 6 t= $+.�c��:,--zcg4a : f, .rug �a c+.✓; CnuTrQRiNv�1°,iu 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 order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7.88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) PALM OF Hatiti RAi3Fthority Approval (HAA) MENSpE SERO OLSegt — FEBRUARY 1984 343-4744 Legal Description bf J, J Aft.1 81990 RECEIVED A. WELL DATA Well Classification Z1/77k Qom4 If A, B, C, D.E.C. Approved (Y/N) Nil Well Log Present 0/N) y Date Completed 29" 51 Yield 4 ' p fi Total Depth 20/ ' Cased to 2n/ Depth of Grouting /IUIi /(1— 13 ' ela } a Static Water Level /6, / Pump Set At // // Casing Height Above Ground gr/2 Sanitary Seal on Casing 0/N) Y Electrical Wiring in Conduit /N) Y Depression Around Wellhead (Y/I43 // SEPARATION DISTANCES FROM WELL: To Septic/kolding Tank on Lot /Z3Z? „ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line / /t% '' ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole 717/ To Nearest Sewer Service Lin, on Lot /0(9i14 q Water Sample Collected by Z 11 '//2--(7. . ; Date 1-H-90 / 0 Water Sample Test Results JG 5744L/cs fy — /v/ Comments B. SEPTIC/HOLDING/TANK DATA Date Installed /1` S¢ Size /00°4 No. of Compartments`/2 1/ Standpipes (6N) y Air -tight Caps (ON) f Foundation Cleanout (ON) J' Depression over Tank (Y/6? /Y//Date Last Pumped 7--/Z-7Q Pumping/Maintenance Contact on File (Y/l� 4/14; for /I/A Holding Tank High -Water Alarm (Y/N) /V4 Temporary Holding Tank Permit (Y/N) /f/%9 SEPARATION DISTANCES FROM SEPTIC/G TANK: To Water -Supply Well To Property Line To WaterMain/Service Line To Building Foundation To Disposal Field 60-4 /o/ To Stream, Pond, Lake or Major Drainage Course I it Comments 71415 CESS PMOL POOPiP-16• 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 41/7`1e e Date Installed /2 -/- e34 Width of Field Type of System Design 9=2e>61 Length of Field Depth of Field 72 5' /z,2' Gravel Bed Thickness 0.7 Square Feet of Absortion Area /Z/5 , Statndpipes Present/N) Y Depression over Field (Y/IN /v Date of Last Adequacy Test 7-/3 -7 0 Results of Last Adequacy Test r/) S TY e ry — 3 gam. SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well /00/ f To Property Line /3 To Building Foundation / 7 To Existing or Abandoned System on Lot /Y/9 ; On Adjoining Lots e../74 To Water Main/Service Line 5i " To Cutback (if present) Ali To Stream, Pond, Lake, or Major Drainage Course /DO/ -14 To Driveway, Parking Area, or Vehicle Storage Area 55 Comments D. LIFT STATION Date Ins Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at "Pump Off" Level at High Water Alarm Level at 4', Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments **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 & 5 ENGINEERING Company 17034 Eagle River Loop Road No. 204 Eagle River, a7 99577 Date 7 MOA No e- O c5zo_3 Receipt No. V3 /2q02/ _ Receipt No Date of Payment 2-/e- 7U Waiver Fee* $ Amount' $ /�����% Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 .;� —. } `Nreferit Seal glop _ it.�Ye. q eLJM uu nu CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET • ANCHORAGE, ALASKA 99518 • TELEPHONE (907) 562-2343 FEDERAL TAX I.D. #92-0040440 ANALYSIS REPORT BY SAMPLE fox Work Order # 25307 Date Report Printed: JUL 16 90 0 20:25 Client Sample ID:L5 BI SAMPSON EST PWSID :UA Collected JUL 11 90 @ 14:30 hrs. Received JUL 12 90 @ 14:00 his. Preserved with :AS REQUIRED Analysis Completed :JUL 13 90 Laboratory Supervisor : TEPHEN C. EDE Released By : Special Instruct: Chemlab Ref #: 902406 Lab Smpl ID: 1 Parameter Tested Matrix: WATER Result Units Client Name : S & S ENGINEERING Client Acct : SNSENGP P.O.* NONE RECEIVED Req # Ordered By : R. SHAFER Send Reports to: 1)S & S ENGINEERING 2) Method Allowable Limits NITRATE -N Sample ROUTINE SAMPLE. Remarks: SAMPLE COLLECTED BY RR. 1.1 mg/1 EPA 353.2 10 ===6=enn====6_=666=======6==aa==6===66==6e_=_ne======a_=a_=.z6ea=a_a6..a=a.====a===e=e.n_n=_a=6=._.e.a=._=_.=6 1 Tests Performed ND= None Detected NA= Not Analyzed See Special Instructions Above " See Sample Remarks Above LT -Less Than, GT -Greater Than UA -Unavailable KO 71 CHE CAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 rinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER ❑ PUBLIC WATER SYSTEM I.D.# (!PRIVATE WATE STEM 17777 Name / Phone o / 76 3,-- / 79j if/Yer Zo 0 Mailing Address/ 67 City SAMPLE DATE: SAI)PLE TYPE: Routine O Check Sample (for routine sample with lab ref. no. ❑ Special Purpose Mo. A/ Day State SAMPLE NO.KATION 4 S 1 2 3 4 5 Year Zip Code 0 Treated Water 0 Untreated Water Time Collected „ _ I Collected iB �l/1er�,n� gig d�i READ INSTRUCTIONS BEFORE COLLECTING SAMPLE ITO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: Satisfactory ❑ Unsatisfactory 0 Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received Time Received Analytical Method: q --129b 1400 Membrane Filter * No. of colonies/100 mi. Lab Ref. No. 902406 2 Result* Analyst a BACTERIOLOGICAL WiATER ANALYSIS RECORD Membrane Filter. Direct Count O Coliform/100m1 Verification: LTB Final Membrane Filter Results i Collform/100m1 Reported By BGB TNTC = Too Ntlimberous To Count OB = Other Bacteria 713 -Sa Time: !wk) a T. p.m. PART ONE OF TWO, REMAINDER TO FOLLOW; MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY. APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date April 9, 1985 1. GENERAL INFORMATION Legal Description (include lot, block, subdivision, section, township, range) Lot 5, Block 1 Sampson Estates (a) Location (address or directions) North Peters Creek (b) , Applicant Name Jim Fenton Telephone: Home 563-8236 Business same Applicant Address 2085 Campbell Place, Anchorage, Alaska 99507 (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ®; Buyer 0 ; Other 0 (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: Fenton Construction 2085 Campbell Place, Anchorage, Alaska 99507 2. TYPE OF RESIDENCE Single -Family [J Multi -Family 0 Other Number of Bedrooms 3 3. WATER SUPPLY Individual Well ® Community 0 Public 0 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 ® Public 0 Community 0 Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of.2 72-025 (11)84) 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 Gilfilian Engineering, Inc. Telephone Address P.0. Box 871868, Wasilla, Alaska 99687 Date April 9. 1985 6. DHEP APPROV ���f►' �� Approved for �s bedrooms - - - Date Approved r/ (907) 376-3005 o tll} R.i E . '1111 a • ©o IEo. MOP a P -ed oho oo� C9 A DPROFESSI©t,t1�t. kOP Terms of Conditional Approval Conditional gineer's Seal CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations 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 requirements. 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. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAG DEPT. OF HEALTH & MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) APR 1 O 1985 CHECKLIST - FEBRUARY 1984 264-4720 �/ (� Legal Description' Lot 5, Block 1RECpEoLVED A. WELL DATA Well Classification Private If A, B, C, D.E.C. Approved (Y/N) NA Well Log Present (Y/N) Y Date Completed 11-29-84 Yield to gal. /min. 1 Total Depth 201 404 201 to 201 Depth of Grouting None Static Water Level 40 Pump Set At 190 I Casing Height Above Ground 29" Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot conduit not ver_tLcal Depression Around Wellhead (Y/N) Sanitary Seal on Casing (Y/N) Well Cap Ysr over 100 ; On Adjoining Lots R N over 1001 To Nearest Edge of Absorption Field on Lot over 100 ; On Adjoining Lots over 1001 To Nearest Public Sewer Line over 100 To Nearest Public Sewer over 100 Cleanout/Manhole over 100 To Nearest Sewer Service Line on Lot 100'- - Water Sample Collected by Fenton Construction ; Date 4-2-85 +�-� Water Sample Test Results Satisfactory Comments B. SEPTIC/HOLDING TANK DATA Date Installed 11-30-84 Size 1.000 No. of Compartments two (2 ) Standpipes (Y/N) Y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) Y Depression over Tank (Y/N) N Date Last Pumped NA `— Pumping/Maintenance Contract on File (Y/N) N ; for Holding Tank High -Water Alarm (Y/N) N Separation Distances from Septic/Holding Tank: To Water -Supply Well over 100 To Building Foundation 5 To Property Line 40' To Disposal Field 10' e To Water Main/Service Line over 25 To Stream, Pond, Lake, or Major Drainage over 1001 Temporary Holding Tank Permit (Y/N) N Course Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 12-1-84 419 sq.ft./bedroom Width of Field 1 •5' Type of System Design Deep Seepage Trench Length of Field 72.5' Depth of Field 12.2' Gravel Bed Thickness 8.7 Square Feet of Absorption Area 1261.5 sq. ft. Standpipes Present (Y/N) Depression over Field (Y/N) N Date of Last Adequacy Test NA Results of Last Adequacy Test NA Separation Distance from Absorption Field: 1 To Water -Supply Well over 100 To Property Line 13' To Building Foundation 17 To Existing or Abandoned System on Lot NA • On Adjoining Lots over 25' To Water Main/Service Line over 25' To Cutbank (if present) NA To Stream/Pond/Lake/or Major Drainage Course over 1001 To Driveway, Parking Area, or Vehicle Storage Area over 55' Comments D. LIFT STATION - NOT REQUIRED Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at "Pump Off" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I %have checked, veri •ed, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed 41-//7"1/:' - Date 4-- 0 ��4 Company `�fr /ito l /l1P(�r,;t Receipt No Date of Payment Amount $ Page 2 of 2 72-026 (11/84) y-ID-$7ez 45 MOA No PROFE$SIOtt .i0