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SAMPSON ESTATES BLK 1 LT 12
s I amozyN uud6 � coo Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP 191493 PID Number: 05105360 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New X Upgrade Name DAVE URBANOVSKY ABSORPTION FIELD ❑ Deep Trench ■❑ Wide Trench ❑ Bed ❑ Mound Site Address 22043 CLOVERLEAF ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 0.8 GPD/SF 8 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 4 Ft.4 Gravel depth beneath pipe Ft. Subdivision Block Lot SAMPSON ESTATES BLOCK 1 LOT 12 Fill added above original grade 2.2 Ft. Gravel length (2) 38 Ft. Township Range Section Gravel width 5 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 760 Ft z 2 6 Ft. Well +100 +100 - _ +25 TANK ❑9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1250 Gal. Surface Water +100 +100 _ _ Material Number of compartments Lot Line +10 2 - - NA HDPE 2 Foundation +10 +1 0_ _ LIFT STATION Manufacturer Capacity Remarks OLD SEPTIC TANK HAULED OFF - _ Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield Installer GUARANTEED SERVICES Drainfield 3034 CO/MT3034 Inspector CHARLES BALZARINI BENCH MARK (Assumed elevation) 100 ft Inspdeactiiosn 1st 12/18/20 12/19/20 Location and description 2�d 3`d 12/21/26 4"' BTM OF SIDING AT HOUSE CORNER ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date 0F A/-:qS��, �TM •'*fir HARLES G BALZARINI� j Septic S Ste p Y (� Approv �•. Date Z ' Zo r Fc•, CE -13854 .•��/ �j'�rFq•.12/2s/2o2o ���� lll\ PROFESSIONP�.r Note: this approval does not include well permit requirements. kR U: IVLI 10) LEGEND c I CLEANOUT OF At MONITOR TUBE co i �:' 49 T-".. NCHARLESG BALZARINI r�� ���/• CE -13854 .•��`�®.�� JTZ • ' • szizsizp .��� PROFESSIO�P��.� 5'Wx38'Lx4' EFFECTIVE � .�•�. I I \ SHALLOW TRENCH I � I K I I 6' 'k L I \\ A \ CAPORT F� \\ 5 4 BR HOME \ \\\ NEW 1250 GAL HDPE TANK DOUBLE CLEANOUTS FLOW SPLITTER ' H \\ DRIVEWAY B I \\ 7TH -1 \\ 6' SWINGTIES A 1 B l f 23.3 30.3 5'Wx38'LI4' EFFECTIVE 2 D D 26.9 31.3 / / I E zs.s 32.1 SHA4LOW TRENCH G 33 F 30.4 33.2 34.4 H 31.41 21.5 I 51.21 34.6 J 66.81 49.7 1 18.2 60.1 / L 21.4 52.3 / MI 31.21 48.2 / SCALE: 1" = 30' +100.0' BTM SIDING FLOW SPLITTER ONITOR TUBE 98.67 50150 EACH FIELD FILTER FABRIC 99'1 FINISHED FILTER FABRIC 97'0 TESTHOLE 1 GRADE 97 4.5' COVER 5.7' 96,g. 5.2' 95.2' COVER ORIG. GRADE COVER ORIG. GRADE 93.5 SEPTICTANK 92.9 INVERT 91.3 INVERT 93.2 88.9 87.2 4"O DISTRIBUTION PIPE 88.9 4"0 DISTRIB"SE.R 87.2 4' EFFECTIVE SEWER ROCK 4.1' EFFECTGROUNDWATE NO GWT (12!1826) SCHEMATIC PROFILE VIEW SHOWS ELEVATIONS OF INSPECTED 83 ELEMENTS BUT DOES NOT DEPICT SYSTEM IN ITS ENTIRETY. FILTER SAND NOT INSTALLED FILTER SAND NOT INSTALLED INSPECTION FOR GENERAL CONFORMANCE TO DESIGN AND MOA DUE TO FAVORABLE SOILS DUE TO FAVORABLE SOILS REQUIREMENTS ONLY. SCHEMATIC SETCION, NTS C&M ENGINEERING SERVICES 907-854-5558 LEGAL DESCRIPTION:SAMPSON ESTATES BLOCK 1 LOT 12 OWNER:URBANOVSKY DATE: 12/29/20 I REV: 0 1 DRAWN: CB I REF: SITE PLAN Municipality of Anchorage Development Services Department On -Site Water and Wastewater Section .a.,� 4700 Elmore St. P.O. Box 196650 Anchorage, AK 99519-6650 WWW.muni.org/onsite (907)343-7904 Soils Log - Percolation Test Performed For: URBANOVSKY Legal Description: SAMPSON ESTATES BLOCK 1 LOT 12 _Z0 A� ®�NGINEER' EA � — 49TH. CHARLES G BALZARINI i I��'Fc�•. CE -13854 .•���� ®;�pROFESSIO Date Performed: 12/12/20 Township, Range, Section: Site Plan WAS GROUND WATER Date TOPSOIL 1- Depth to Water S 2- L Depth to Water After P P Monitoring? None SW/SM 3- SAND WITH SILT 30 2-9/16 SOME COBBLES 4 - 3:09 5- 0 0 6- 3:39 7- 2-8/16 2-8/16 8- 4:09 9- 0 0 10- 4:39 11- 2-9/16 2-9/16 12- 13- 14- BOH 15- 16- 17- 18- 19- 20- _Z0 A� ®�NGINEER' EA � — 49TH. CHARLES G BALZARINI i I��'Fc�•. CE -13854 .•���� ®;�pROFESSIO Date Performed: 12/12/20 Township, Range, Section: Site Plan WAS GROUND WATER Date ENCOUNTERED? NO Net Time Depth to Water S IF YES, AT WHAT DEPTH? NA L Depth to Water After P P Monitoring? None E Date: 12/20/20 Reading Date Gross Time Net Time Depth to Water Net Drop 1 12/13/20 2:38 0 0 0 2 3:08 30 2-9/16 2-9/16 3 3:09 0 0 0 4 3:39 30 2-8/16 2-8/16 5 4:09 0 0 0 6 4:39 30 2-9/16 2-9/16 PERCOLATION RATE 1z (minutestinch) PERC HOLE DIAMETER 6" TEST RUN BETWEEN 5 FT AND 6 FT COMMENTS PRESOAKED AND PERFORMED IN ACCORDANCE WITH MOA REQUIREMENTS PERFORMED BY: CHARLES BALZARINI 1 CHARLES BALZARINI CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 12/13/20 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP191493 Work Type: Septic Upgrade Tax Code Number: 05105360000 Site Legal Address: SAMPSON ESTATES BLK 1 LT 12 G:1561 Site Mailing Address: 22043 CLOVERLEAF RD, Chugiak Owner: URBANOVSKY DAVID C & JANE A Design Engineer: C & M Engineering This permit is for the construction of: Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Effective Date: Expiration Date \t»cnr. s, !J U � 1 llepa1,tInent Lot Size in Sq Ft Total Bedrooms: 11/17/2020 11/17/2021 51316 ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: 1. If the existing field is exposed when installing the tank, the field is to be decommissioned. 2. The Engineer is to do additional test holes prior to the construction of the septic field. Construction may proceed at your own risk before the 7 day water monitoring is complete. Please submit stamped and signed results with the As -built Inspection Report. If the results require a design change, construction of the system will stop pending On -Site review and approval. Received By: /, q Issued By: Date: Date: /r 4 Municipality of Anchorage Uep:ntment P.O. Box 196650 ® 4700 Elmore Road Anchorage, Alaska 99519-6650 ® (907) 343-7904 ® Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Division On -Site Water and Wastewater Proqram * * * * VARIANCE/WAIVER REVIEW * * * * Waiver#: OSV201075 COSA#: Permit#:OSP191493 PID#: 051-053-60 Legal Description: SAMPSON ESTATES BLK 1 LT 12 Engineer: CM Engineering Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the property line has been approved. The approved separation distance is 0.0 feet. This waiver approval applies to the proposed absorption field only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. .......................................... 0 0 M M Z ...... 0 0 M M 0 Z ..... t ..... t 2 M 0 Z K 1 Waiver is Granted: X Waiver is not Granted: Date: ( /7 Approved by: Name of Review ............................................... 0 M N 0 x x ...... ■ 0 0 0 0 0 0 0 Z M x 0 M .... ■ 1 **** VARIAN C EMAIVE R REVIEW **** 91askil - Jell UMUPAUTY OF ANCHORAGE Development Services Department 4 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051 053 60 Property owner(s) DAVE URBANOVSKY Mailing address Site address 22043 CLOVERLEAF Day phone 980-9533 Legal description (Sub'd., Block & Lot) SAMPSON ESTATES BLOCK 1 LOT 12 Legal description (Township, Range & Section) Lot Size 51316 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field 0 Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank El Upgrade 0 Duplex (D) ElHolding Tank ❑ Renewal ElMultiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: DRAINFIELD TO LOT LINE Distance: 0 1 certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. C&M ENGINEERING (Signature of property owner or authorized agent) Permit/Rush Fees: gJ52. Waiver Fees: _#160,7_5 Ce)viD Date of Payment: to [at ! Iq Date of Payment: 1 /09 a 0 a O Receipt Number: (0 (®t lV 1) Receipt Number: Q b l 2 $ fl < �S P I A 1 `-ia) Waiver No. C5 V ZOI 07,E S Arn E Permit No. (ZEcE� P7 /l 1. re l 111,ho GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: Proposed Septic System replacement for Sampson Estates Block 1 Lot 12 Dear Reviewer, The above referenced property is currently served by an older, failed septic system. The owner would like to replace it with a new septic 4 bedroom system. We are proposing to install a new septic tank and a new drain field. The old tank will be demolished per moa requirements. Our review of available documentation and field investigation show that this project will not adversely impact any nearby wells, wastewater disposal systems, replacement disposal sites, or drainage flowing onto and off of the subject property. New testholes will be excavated on the subject property to a minimum depth of 15-feet and percolation tests will be conducted. The soils in the area are characterized as silty sands. The existing soils log shows a 1’ layer of ML material near the expected bottom of field elevation. If this layer is encountered as shown on the historic soil log, it will be excavated and replaced with moa approved filter sand. The new field is sized based on a 4’ effective depth. The existing drainfield will remain as a backup site. Although optional, connection to the old field with a diverter valve is recommended. The adjacent lots are large and impacts are not expected. The new tank will encroach on the old drainfield. The distance should be waived to 2.7’. The waiver is justified due to the constrained lot and the fact that it occurs over a limited portion of the field and the old field is to be used as a backup system. The encroachment is less than the encroachment between the old tank and field. The old field encroaches on the house foundation to approximately 2’. We are requesting the separation distance be waived. The waiver is justified as it has been in place for almost 40 years with no adverse effects. A drainfield to lot line is requested we are requesting a separation distance of 1- feet to the South property line and 2-feet to the East property line. The existing drainfield to lot line separation is requested to be waived to 3.5-feet. The waivers are justified due to the constricted area suitable for septic installation. Included with this letter is a permit application and design package, including plans, and calculations. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE 11/11/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191493, Deb Wockenfuss, 11/17/20 Residence: number of bedrooms 4 br Water usage/bedroom 150 gpd/br Water Usage 600 gpd type: shallow Application Rate 0.8 gpd/sqft required absorption area 750 sqft width (W) 5 ft minimum effective depth 4 ft below distribution pipe see narrative Trench Factor 0.5 Min Required Length: 75 ft Effluent Pipe: Calc By: CGB Date: 10/25/2020 C&M ENGINEERING SERVICES 907-854-5558 Septic Design Calculations RESIDENCE/LOT INFO DRAINFIELD 4" ASTM 3034 CALCULATIONS ARE FOR REFERENCE PURPOSES ONLY USE DIMENSIONS SHOWN ON PLANS CALCULATIONS ARE FOR REFERENCE PURPOSES ONLY USE DIMENSIONS SHOWN ON PLANS SAMPSON ESTATES BLOCK 1 LOT 12 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191493, Deb Wockenfuss, 11/17/20 4 BR HOME 10 0 ' W E L L R A D I U S 5'Wx38'Lx4' EFFECTIVE SHALLOW TRENCH 8' MAX EX DEPTH TO BOTTOM OF SEWER ROCK. EXCAVATE TO BOTTOM OF OF ML MATERIAL (APPROX. 9') AND REPLACE WITH MOA FILTER SAND REPLACE OLD TANK WITH NEW 1250 GALLON MOA APPROVED POLY TANK DUAL CLEANOUTS FLOW SPLITTER 1983 TESTHOLE DIG NEW TESTHOLE HERE SAMPSON ESTATES BLOCK 1 LOT 12 SAMPSON ESTATES BLOCK 1 LOT 13 SAMPSON ESTATES BLOCK 1 LOT 18 SAMPSON ESTATES BLOCK 1 LOT 16 NO DOCUMENTED WELL/SEPTIC FLAG 100' WELL RADIUS SEPTIC FLAG 100' WELL RADIUS DIG NEW TESTHOLE HERE 8' 7' 8' 5' 5' 2.7'OPTIONAL:BULL RUN DIVERTER TO OLD FIELD 3.5' 1' 2' 2' D OWN- SLOP E 1' CONTOURS 5'Wx38'Lx4' EFFECTIVE SHALLOW TRENCH 8' MAX EX DEPTH TO BOTTOM OF SEWER ROCK. EXCAVATE TO BOTTOM OF OF ML MATERIAL (APPROX. 9') AND REPLACE WITH MOA FILTER SAND C&M ENGINEERING SERVICES 907-854-5558 SITE PLAN LEGAL DESCRIPTION:SAMPSON ESTATES BLOCK 1 LOT 12 OWNER:URBANOVSKY DATE: 10/30/20 REV: 0 DRAWN: CB REF: SCALE: 1" = 20' CHARLES G BALZARINI CE-13854R EGISTEREDPROFES S IO N ALENGINEER LEGEND CLEANOUT MONITOR TUBE NOTE: THE PROPOSED SEPTIC SYSTEM MUST BE INSTALLED GREATER THAN: 100' FROM ANY PRIVATE WELLS 200' FROM ANY PUBLIC WELLS 100' FROM ANY SURFACE WATER 5' TO ANY TEST HOLES 10/20/20 THE TOP OF THE SEPTIC TANK WILL BE INSTALLED 7-FEET FROM THE FOUNDATION AND NO LOWER THAN THE BOTTOM OF THE FOOTING TO STAY OUTSIDE THE FOUNDATION BEARING PRISM. THE EXISTING TANK AND FIELD WERE LOCATED BY FIELD MEASUREMENTS WHICH VARY SLIGHTLY FROM THE ASBUILT SURVEY, BUT ARE BELEIVED TO BE CORRECT. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191493, Deb Wockenfuss, 11/17/20 Ilep °s6 30111�02'p r ASBUILT-NO CORNERS SET THIS DATE, HEREBY CERTIFY -THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY, AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED. IT I$ THE RESPONSIBILITY. OF THE OWNER TO DETERMINE THE MSTENCE OF ANY EASEMENT$, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI" %frernr.► of n'r iimn" mn CIRntJMSTANCES SHOLU Y IJILJi7 !-i✓�. vvr.•• - ...,.. r..•r• "r-Mrr►tr nr 11CMCnA e%o"Q-rpjirTInm RJ4 T UHIN nu-nrWi`I our vvy.v I v,. ..�,. OF FENCE LINES, OR FOR ESTABLISHING BOUND- ARY LINES. SEWARD & ASSOCIATES LAND SURVEYING 688-45CA SCALE= OF A4 Wk viii �.` �� j i `[' ' •. u 4 r * 4�J�" FB i yS�r LS -6918 pV 4r d DRAWN; ��4�L�� .o•�.r' at,ti►.►..� ) t - MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 0* 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME., PHONE IVNEW - IV 1 �F _ ❑ UPGRADE MAILING ADDRESS LEGAL DESCRIPTION T ,3 Lot 12 Block 1 Sampson Estates SID 15, KIWI 6N-1LOCATION/n� nn LL-AF NO. OF BEDROOMS 4 1..�' Lo I Well.t{ DISTANCE TO: No Absorption area p Dwelling f PERJM/�IT`tNO . N Uy 1- I l.AN I h Z Manufacturer Material No. of compartments y HGa;'eLL Liq. appaci gallons IF HOMEMADE: Inside length Width Liquid depth DISTANCE TO: Well Dwelling PERMIT NO. J t�Z O z H Manufacturer Material Liquid capacity in gallons O DISTANCE TO:�- Well - Z Vpp�}�,�� © P M �..�IT � w= Aten/IqFoundation.arestlotline LL z No. of linesLength of each line Total length of lines Trench width Distance between lines h z w . ' 7 3Dinches Q F Top of tile to finish grade- I) Material beneath the Total effective bso ti rea O /' 8 inches t� Length Width Depth PERMIT NO. w C9 CL F wa Type of crib Crib diameter Crib depth Total effective absorption area LU DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERMIT NO. J W DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS A TM C..T' SOIL TEST RATING h 150 INSTALLER GeOLA9,�x REMARKS pc-&ed bv /. © JA 7N o J lM islLs%i �o�CcU� APPROVED DATE LEGAL L-i /2 -UI -5 uiev. 3115) UNICIPALITY OF ANCHORAGE Department ' Health and Environment a]"protection t� 825 L Street, Anchorage, AK. v9501 264-4720 Permit # # # # HANDWRITTEN PERMIT # # # WELL ANDS ON-SITE SEWER PERMIT Applicant: _TaQ_, J- S eA4 Mailing Address: `fS ' O 3 Z Location: `' Lta_F Phone Number: 3 `f S - aO Z. Legal Description: �J5' �l w soc 3 $L01 3 ' Lot Size: S d Type of Soil Absorption System Is: 1 a. 6 ( jao s Trench: ✓ Drainfield: _ Se page Bed: Holding Tank: Maximum Number of Bedrooms: _ Soil Rating(sq.ft/br) f C` The Required Size of the Soil Absorption System Is:' DEPTH U LENGTH GRAVEL DEPTH , WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE _ ( � V GALLONS # # Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * # * TWO(Z) INSPECTIONS ARE REQUIRED # # Backfilling of any system without final inspection.and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 3 3 I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the resid,9 s remodeled to include more that 3 bedrooms. Signe-d A Issued by: �S is an Date: SWP/024 (1/8 % O L o `^ 5 i -J-M.c'k w r La k -µ• (Q 5 rya � SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: aE&T n51AY (())M�fT�,ky,-`''F— ,y� DATE PERFORMED: Nov. I ms LEGAL DESCRIPTION: ��� I\ V1f P'fIr}I� �i"� �� _�%admr'�) ,4. �� SLOPE11 SITE PLAN I 1 2 3 4 5 6 7 9 10 11 12 13 14 15 17 18 19 20 COMMENTS Or -Orzi y , 6a('YJ GM�)��I��a►�,I�� Mitxe l;bio1 10I-Owr\ 5/'I' I QI"rj-y,-sk-1006 0 R wig Iy4errmAev> + Iayc-C6 4 5 wJ 5 P, 6M AL'-Lk�� A w k larc� Are-x)c.09—wes. WAS GROUND WATER S ENCOUNTERED? NO L 0 �N D P E IF YES, AT WHAT DEPTH? `` i /k 0 -� , i. 'T A- U 7 PERCOLATION RATE TEST RUN BETWEEN PERFORMED BY: CERTIFIED B 72-008 (6/79) / 0 �T 3 _� zq F{ `KEA0104T[''T lav'/D0(n (minutes/inch) FT AND -5 FT i DA j Reading Date Gross Time Net Time Depth to Water Net Drop RDD ilz.0 a� I©/ 3:i57 zml ADD 4zo a:�8 ,too 14:00 2 M • r'I5 P 2 �DD qzo 41.'01 ,�� > y.`07 a m I rd v /D Rob !I> -C) PERCOLATION RATE TEST RUN BETWEEN PERFORMED BY: CERTIFIED B 72-008 (6/79) / 0 �T 3 _� zq F{ `KEA0104T[''T lav'/D0(n (minutes/inch) FT AND -5 FT i DA j LOCATION OF WELL (Please complete either to, Ib or Is.) WATER WELL RECORD STATE OF ALASKA DEPARTMENTOF NATURAL RESOURES Division of Geological a Geophysical Surveys Drilling Permit No. A.D.L. No. Ia. Borough Subdivision Lot Block I/a gtrB Section No. Township N❑ Range E® Meridian Fib. am _ i, s® Wo Ic. DISTANCE AqFD DIRECTION FROM RO�1 INTEf R$ CTIONS 3. OWNER OF WELL Mrs Trent Slaymaker Well '#2 Address: Street Address and Area of Wall Location 2. WELL LOG Feet 6arf°°° Below 4. WELL DEPTH: (final) 5. DATE OF C1PLETIO O 12 214 ft. - -1093 Top Bottom Material Typo -12-- �-- Gravel and sand 6. ®Cablo toot {r 5LOt°ry ®Drivon ®Dug It51h Auger ®Jetted C] Bored ® Other: Gravel, , Gravel and sand- y ��pYss77 7, USITY��f301noatic Q Public Supply 0 Industry a Irrigation D Recharge Q Comrnerlcal [3 Test Yloll ❑Other. 0 1 s t gra (' Gravel and sand- Gravel, silt moist 180 E185 0. CASING: ❑ Threaded alkeldad diam. 6 In. P14— 4P. Depth Weight 17 tbs./ft. dlam. In. to ft. Depth Stickup ft. Gravel, silt dry 185 Clay and sand 191 ---2T2 Sand gravel, water 9. FINISH OF WELL: iameter:0 Typo: Diameter:- Slot/Mosh Size: Length: i 0j.4 Set between ft. end ft. C Backfilling Gravel path 10. STATIC WATER LEVEL: ft. Above or C] Below land surface Dote ORALE used; eF ppUNICIPEduipmont 11, PUMPING LEVEL below land surface and YIELD ft, after hrs. pumping g.p.m. VIRON�ENTAL P ft. after hro. pumping g.p.m. 12.GROUTING Wall Grouted: ❑ Yea ❑ No Material: [] Neat Cement C] Other: 13. PUMP: (if available) HP Length of Drop Pipe Pt. capacity G.P.M. Subm. Q Jet 0 Contrificol ® Other 14. REMARKS -Production of 5 GPM 16. WATER WELL CONTRACTORS CERTIFICATION: 15. Water Temperature —0 o F 0 C This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Magnuson Drilling AL -53-8- Rogistored Business Name Contract License Number Address: P.O. Box 770504 Eagle River, Ak. 99577 F , Data: Dec. 21, 1983' Authorized Reprosentotiy Form 02-WWR(II/81) — Copy Distribution: WHITE -State OGGS, PINK-Drill°r, CANARY -Customer HNIUHM PAUTY OF AHCHORQGE 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. 051 053 60 1. GENERAL INFORMATION Expiration Date: `l ''3 I -? Complete legal description Sampson Estates Block 1 Lot 12 OCatlOn (site address) 22043 Cloverleaf Current property owner(s) Dave Urbanovsky Mailing address Real estate agent 2. TYPE OF DWELLING: Day phone Day phone 0 Single Family (w/wo ADU) ❑ Duplex .z� ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 336 COVID Waiver Fee $ _ Date of Payment 0�/30/ _010 Date of Payment Receipt Number ON 5 %(ob Receipt Number COSA # OSC201700 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 C&M ENGINEERING Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI 6. DSD SIGNATURE ._ System #1 Approved for k1 bedrooms System #2 Approved for bedrooms Disapproved Phone 8545558 Date 12/29/2020 �11����� of Ak-k i i law TH ? . .. rI�• CHARLES G BALZARIM ,•. •CE-13854Adw .•����� l`F�F� PROFES S10NP�'���� Conditional approval for bedrooms, with the following stipulations: �kl(ll((((�rrrr ON 141A 1_' 7F7 AAlO m Joy OGAA�YI o=` Original Certificate Date: 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 COSA Checklist blue sheet Legal Description: SAMPSON ESTATES BLOCK 1 LOT 12 Parcel ID: 05105360 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 1983 Total depth 214 ft Cased to 214 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) +18 in. Date of flow test for COSA 18/23/19 Static water level at beginning of test 175 ft. Comments B. TANK DATA Age of tank(s) 0 years Tank type/material SEPTIC Measured operating fluid level in septic tank NA ❑ Standpipes/foundation cleanout per record drawing Date of pumping NEW POLY TANK D. ABSORPTION FIELD DATA SHALLOW TRENCH Which system tested (date installed) 2020 ❑ ALL standpipes present per record drawing Total measured depth from grade 10.2 ft (max) Measured depth to pipe invert from grade 6.2 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced NA gallons Comments/Deficiencies: NEW SYSTEM, NO TEST REQUIRED COSA Checklist yellow sheet Well production at time of test +4.6 gpm Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ❑ Nc ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by C.Balzarini Date of Sample 12114/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date - Results ❑ Pass For - bedrooms Fluid depth prior to test - in Water added - gal New depth - in Elapsed time - min Final fluid depth - in Absorption rate - gpd Any rejuvenation treatment (past 12 months) NA If yes, enter date NA 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 Community Sewer Manhole/Cleanout > 100' ❑✓ Yes if No ft ❑✓ Yes if No ft Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' M Yes if No ft Absorption Field on Lot > 100' 0 Yes if No ft Holding Tank > 100' [Z] Yes if No ft Neighboring Absorption Fields > 100' F,71 Yes if No ft Water Main > 10' Animal Containment > 50' El Yes if No ft ❑✓ Yes if No ft 0✓ Yes if No ft Water Service Line > 10' ❑✓ Yes if No Manure/Animal Excreta Storage > 100' If septic tank is under driveway comment below Community Sewer Main > 75' ✓� Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑✓ Yes if No ft Surface Water > 100' Q Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: ft Absorption Field > 5' 0 Yes if No ft Private Wells > 100' F,71 Yes if No ft Water Main > 10' ✓ I Yes if No ft Community Wells > 200' 0✓ Yes if No ft Water Service Line > 10' ❑✓ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' I2✓ Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No 2 ft Wells on Adjacent Lots: Water Main > 10' Yes if No ft Private Wells > 100' E1 Yes if No ft Water Service Line > 10' ❑✓ Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Surface Water > 100'✓0 Yes if No ft F. ENGINEER'S COMMENTS NEW SEPTIC SYSTEM. SOME SETTLING OF FILL MAY OCCUR IN THE SPRING. 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. 12/30/20 COSA Checklist yellow sheet °F A1,4 T. 49 .. .... • • CHARLES G BALZARIt.f �Fc •.• CE -13854 .• �`�� Flf�p•....•PL�� ROFESSI4NAIN L!1 co I? 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Ln N O L O ; •• _ O LL E (vE°�° OQ ! 6'. 07 _CL ' till m $ E a �" REG\��`� W a Q ���.�..•��`' U N M 4 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 Parcell.D.# HAA# 1. GENERAL INFORMATION Complete legal description Lot 12; Block 1; Sampson Estates 22043 Cloverleaf Drive Chugiak, AK 99567 Location (site address or directions) 22043 Cloverleaf Drive Property owner Peter A. Goeders Day phone688-0591 (h) 552-4390 (w) Mailing address P-0- Box 671261 Chugiak, AK 99567 Lending agency Day phone Mailing address Agent Linda BAnner, REMAX/EAGLE RIVER Day phone 694-4200 Address 16600 Centerfield Drive Eagle River, AK 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 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. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XXX 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 MOA N21 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 furtherverify 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. S p 5 "',INEERING Name of Firm t >..... ( p' � � Ro6.-,..Phone L� River, Address Engineer's signature 6. DHHS SIGNATURE X Approved for bedrooms. By: Disapproved. Conditional approval for Additional Comments �t-c Date bedrooms, with the following stipulations: Date 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 engineer's work. 72-025(Ray.1/91) Back MOAR21 Municipality of Anchorage Department of Health and Human Services 44 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ��r12 C�,�� t � ,,5 �r. Parcel I.D. A. Well Data 0 51- 0:!5-75-60 Sewer service line -2-� ( -�- Petroleum tank WATER SAMPLE RESULTS: zst� Coliform D Nitrate C;). S� Other bacteria Date of sample: - i -93 I '� - 2 -OI3 Collected by: S & 5 ENGINEERING ag e River Loup Rand-NOV204— B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99577 Date installed 1\ -1\ k - g -t) Tank size \2S� Compartments Z CleanoutsaN) Foundation cleanout (9/N) Depression (I a High water alarm (Y No. Alarm tested (Y/N) I Date of pumping C)3 Pumper �� C�"SPam L SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot \ o,� On adjacent lots 1 oc> Foundation 13 To property line \ o \ k Absorption field \k Water main/service line \c) Surface water/drainage \ o 'D \-\- 72-026 (3/93)* Front k 72-026(3/s3)•Front CONTINUED ON BACK PAGE ',IA Well type If A, B, or C, attach ADEC letter. ADEC water system number Log presento/N) _Date completed (2 - �-, - `53 Driller Maecat.oco� Total depth ti1lY� Cased to X14' Casing height 121+ Sanitary seal ON) � Wires properly protected (WN) � FROM WELL LOG AT INSPECTION M 3 Date of test �2� - �3 'I - -7 -`1 3 ii'I oo z v Static water level L) LJ Loi _ m D Well flow 79-P.M. `� o g•p•m• 9•p•m. r o = D Pump levell J u J>L ® w z o SEPARATION DISTANCES FROM WELL TO: E m Septic/holding tank on lot 100 ; On adjacent lots Z Absorption field on lot \ o ; On adjacent lots I 11�D V,' Public sewer main rJ >k Public sewer manhole/cleanout "�" Sewer service line -2-� ( -�- Petroleum tank WATER SAMPLE RESULTS: zst� Coliform D Nitrate C;). S� Other bacteria Date of sample: - i -93 I '� - 2 -OI3 Collected by: S & 5 ENGINEERING ag e River Loup Rand-NOV204— B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99577 Date installed 1\ -1\ k - g -t) Tank size \2S� Compartments Z CleanoutsaN) Foundation cleanout (9/N) Depression (I a High water alarm (Y No. Alarm tested (Y/N) I Date of pumping C)3 Pumper �� C�"SPam L SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot \ o,� On adjacent lots 1 oc> Foundation 13 To property line \ o \ k Absorption field \k Water main/service line \c) Surface water/drainage \ o 'D \-\- 72-026 (3/93)* Front k 72-026(3/s3)•Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes "Pump on" level at Manufacturer Manhole/Access (Y/N) les tested I at 4RATIO ANCE FROM LIFT STATION TO: on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed \\ - C6 -17 Soil rating (GPD/Ft') �`�I �P— System type fiC rE Length -11 ' Width Gravel thickness Total depth 43 Total absorption area Lo 110 Cleanout presenta)N) _Depression over field (Y/u w( Date of adequacy test I - -7 - i 3 Resultsail) IPA -s -S for 4- Bedrooms Water level in absorption field before test .33 N After test 31 1a. u G Peroxide treatment (past 12 months) (Y(i l 4on(e_ IZA4d If yes, give date " a SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ) (� 0 r L On adjacent lots /ob, Property line ///b r To building foundation L. r To a fisting or abandoned system on lot ^(_14- On adjacent lots 3 Cutbank ' �� Water main/service line 1v' Surface water I on r Driveway, parking/vehicle storage area �a Curtain drain X16, E. ENGINEER'S CERTIFICATION I certify that ! have checked, verified, or conformed to all MOA and NAA guidelines in effect on.the date. of this inspection. S & S ENGINEERING Signature 17034 Eagle River Loo Roa age River, Alaska 99577 Engineer's Name ,, A,, Date HAA Fee $ 170, 4�, _ 1r Date of Payment 6/ Receipt Number G 9 l 79.n9ri !7/4.91' Rank Waiver Fee $ Date of Payment Receipt Number COMMERCIAL TESTING & ENGINEERING CO. ENVIRONMENTAL LABORATORY SERVICES 51NCE 1908 REPORT of ANALYSIS 5633 B STREET Chemlab Ref.# :93.3202-55 ANCHORAGE, AK 99518 Client Sample ID :L12 Bl SAMPSON EST TEL: (907) 562-2343 Matrix :WATER FAX: (907) 561-5301 Client Name :S & S ENGINEERING WORK Order :67860 Ordered By :RAY SHAFER Report completed :07/08/93 Project Name Collected :07/02/93 @ 09:30 hrs. Project# Received :07/02/93 @ 17:00 hrs. PWSID :UA Technical EDE ReleasedcByr:TSG Sample Remarks: ROUTINE SAMPLE COLLECTED BY: RAY. QC Allowable Ext. Anal Parameter Results Qual Units Method Limits Date Date Init ------------------------------------------------------------------------------------------------ Nitrate-N 0.53 mg/L EPA 353.2/300.0 10 07/07 GLH ----------------------------------------------------------- * See Special Instructions Above UA = Unavailable *� See Sample Remarks Above NA = Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT = Less Than D = Secondary dilution. GT = Greater Than 40*04SGS Member of the SGS Group (Societe Gdndrale de Surveillance) ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA MUNICIPALITY OF ANCHORAGE • T DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services M1 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. # HAA # 1. GENERAL INFORMATION Complete legal description Sampson Estates, Lot 12, Block 1 T15N R1W Sec.3 Location (site address or directions) 22043 Cloverleaf Drive Property owner FDTC Day phone 269-3573 Mailing address P. 0. Box 196639, Anchorage, AK 99519 Lending agency N/A Day phone Mailing address Agent N/A Day phone. Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 I 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 X 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 MOA#21 tnVOYI a0e8 (16/l'AgH)WZ U -� joM s, oaui6ua leuolssalo,(d aql ul suolsslwo ao saoaaa aol alglsuodsw IOU si a6eaogouy to AllledlolunW aql •panssi si aleollp iao a aaolaq elep ozAleue ao suoiloodsui lonpuoo IOU op SHHo to saaAoldw3 •sluewaainbaa alels pue leaapal uiel eo Ajsiles oliapio ui suoilnlllsui 6ulpua! alagl pue sawoq to sjasegoand olAsalinoo a se slgl scop SHHG aql •ei{sely to 91e1S aql ul paaalsl6aa aaauibuo leuolssaloid luapuadapui ue Aq anoge S gde.)6e.ied ul uan16 suoileluasaadaa agl uodn Aluo paseq salsoi1poo lenoaddy Al!aoglnd glleaH sonss! (SHHa) saoitueS uewnH pue glleaH to luawlaedad a6eaog0uy to AIIIedloiunyq agl NULLFIVU ale(] :suollelndlls 6uimollol oql ql!M 'swooapaq F3 ?: D via -M, SM ol �� +'lam O OU •9GSCBV(' I, /., .. �p nr •Upti •p D a n i ky s yZ— alea w sluawwo0 leuolllppy aol lenoidde leuoll!puoo panoaddesla -swooapaq aol panoaddy X 3unIVNJIS SHHO '9 LLS66 XV 'aanzg einleu6ls s, aaul6u3 'b6Z£LL X08 'O'd ssaappy •uolloodsui slgl to alep eql uo loalla ui suo!leln6aa pue 'saoueulpao 'sopoo alelS pue ledlolunw lie ql!M aoueildwoo ui si welsAs lesodslp aalemalsum ao/pue Alddns aalem ol!s-uo aql 'uolloadsu! pue uolle61lsanul Aw woal pue sal!l abeaogouy to AllledlolunW aql woal paulelgo uolle(uaolui aql uo paseq legl Al!aanaaglanl I •ulaaaq paleolpui eAnlonals to adAl pue swooapaq to aagwnu aql aol alenbape pue leuollounl'ales sl walsAs lesodslp aalemalsm ao/pue Alddns aalum al!s-uo oql legl smogs uolleolldde lenoaddy Allaogln`d glleaH s!ql to u011e61lsanul Aw legl Al!aan I 'nnolaq umogs alep uollep!!en aql to se pue olaaaq pax!lle leas Aw /\q pa!lpoo sy H33NION3 AS NOLLOUSNl d0 LN3W31t11S °S Municipality of Anchorage Department of Health & Human Services M HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: �n��2 ���� �� ter" '52 Parcel I.D. A. WELL DATA Well typeIf A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) }� Date completed Driller Total depth �21y Cased to a i y Casing height 37 61021� Sanitary seal (Y/N) y Wires properly protected (Y/N) y FROM WELL LOG AT INSPECTIOJ*NICIPALiTY OF ANCHORAGE SERVICES DIVISION Date of test ENVIRONMENTAL 7A --�/yi J 1991 Static water level '3'"` - ' G�� /er i Well flow S g.p.m. 5R SGIE I V C D Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot On adjacent lots/oa Absorption field on lot / 3v ; On adjacent lots t/ay Public sewer main ^� Public sewer manhole/cleanout A -V4 P-�r*e sewer service line /7a ' Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate �, ""S�� Other bacteria Date of sample:?/� ?/ si Collected by: B. SEPTIC/HOLDING TANK DATA Date installed 114e3 Tank size /,_�r�? Compartments -2— Cleanouts (Y/N) Y° Foundation cleanout (Y/N) y Depression (Y/N) /xi High water alarm (Y/N) ''�14- Date of pumping 7/ai /yi Tiff Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: w /-I Well(s) on lot / av/ On adjacent lots t%� Foundation J3 To property line t/o' Surface water/drainage "_�I_ Absorption field —Water main/service line 72-026 (Rev. 3/91)Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION A)/,q Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Surface water . Date installed __199-3 Soil rating ysel System type 7��� ^ Length 721 Width 3o Gravel thickness 4e Total depth Total absorption area 6 J b Cleanouts present (Y/N) Y Depression over field (Y/N) Date of adequacy test 7/a 9 i Results (pass/fail) le:2A rs for bedrooms Peroxide treatment (past 12 months) ( /N Z✓ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot —On adjacent lots tie o Property line %O To building foundation 6 To existing or abandoned system on lot On adjacent lots t ?,> Cutbank ^V/,J Water main/service line Surface water "��d Driveway, parking/vehicle storage area 7-10 Curtain drain ^'"' fl�oarc ✓f E. ENGINEER'S CERTIFICATION I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name lt>e/lj �y�----- Date HAA Fee $ Waiver Fee: $ Date of Payment �— �� ' Y I / Date of Payment Receipt Number �a-� �� Receipt Number 72-026 (Rev. 3/91) Back MOA 21 NORTHERN TESTING LABORATORIES, INC. 3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 • FAX 456.3125 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 277-8378 • FAX 274-9645 Eagle River Engineering P.O. Box 773294 Eagle River AK 99577 Attn: Louis Butera Our Lab #: A112381 Location/Project: Your Sample ID: Sampson 12/1 Sample Matrix: Water Comments: Method Parameter ---------------------- SM 418 C Nitrate -N Q_&A�' F, - U I Reported By: William E. Bu n Anchorage Operations Manager Report Date: 07/29/91 Date Arrived: 07/24/91 Date Sampled: 07/23/91 Time Sampled: 1510 Collected By: GJN Flag Definitions U = Below Detection Limit DL Stated in Result B = Below Regulatory Min. H = Above Regulatory Max. E = Below Detection Limit Estimated Value Date Units Result Flag Analyzed ---------------------------------------- mg/l 0.6 07/26/91 Eagle River Engineering Services A11940 Business Blvd, Suite #205 P.O. Box 773294 694-5195 Eagle River, Ak. 99577 Fax 694-3297 Legal: LvC 12 , �tc�cK t , �Dr1PSQt� 1=sTd► Owner: Date: Z•2-23.1a�91 Type of test: ❑ Well Flow Test d Septic Test Only WWell & Septic Test ❑ Other: 1 o F2• Time Meter Reading Monitor �Level2 Well Level Tank Level GPM PSI Remarks 22»�_ r4:sg Fri 116%,z D d I GZ ��Z An 12SCo2 261 1�03 10:10:07 195'63 162, �� 72 1 - 6T�eT Tc�s( "loft 10:1b:6S> Z595r, — — 7216rr - -. Iv7144c_ lo; Z I I ZG -- 170 - Cv Jv;ZG'31 I2Gb3 291 _ �2Y " _- - 1121 46(- !1: 29 19710 — — /-71 — —' 10:3¢'5 12 -7 59 2A_ -- %" - - 1171 <AL o;3ia 1275-4 — — 6;e — 1o;43;Ib 2 -7 �.3 29/1�ev , _ - 72'' — — I aL� l 2 z> 3 3 2.1 -' - 704 -" -' 1 2 7 dL / Z c�p 5'21 — 17Z ,-- 12 6 2" � � - --- 7 09' - 1 rzZ L II:a8:32 1 33 !/6 -- -- 1371 dc. 11'12 12553 - - /7Z - 11 .'(6 1 Lqr 3 29 — — [-7 rorr tt:iq JZ - - 172- J:Zs'`2 '%Z n _ . — 1-4-71 GSL 11 27 13044:, -72 -7-- 11 A?"1 7 /.3135 3J�' — — 7Z %' -- — 15" 71 d� 1r45' 1314-7 - - 17 - 11; 1316,3 3O v ll - -- 7Z% rr - - 10 21 ��. a �'r4o ` Time .x Monitor Level2 { Eagle River Services.-' Tank Level GPM .Engineering 11940 Business Blvd, Suite #205 Remarks `- P.O. Box 773294 694-5195 J Eagle diver, Ak. 99577 Fax 694-3297' Ys 1 ;do;o 77 Legal: 19 K I Litt 'S liasrI.-Ms n} Owner. Fqke, Date:ZZ-23 Jud E¢f ! -i Y" 5'q — Type of test: 1390o 42;b — ❑ Well Flow Test ❑ Septic Test Only XIWell & Septic Test ` ❑ Other: 79ka T,9 a a F �. o Time Meter Reading Monitor Level2 Well Level Tank Level GPM PSI Remarks `- 1 ;do;o 77 %V -i Y" 5'q — 2 So bl. 1390o 42;b — 172 79ka T,9 o 14aor�) 2%" -- 173 7 21'" Z;ZS' 017 433/ - 73 72/" 23`I•3 1-4/AS 4 3 4j" -- 17 %� _ 242Q! 4d Gt�i' 2VU —79 173 -- -• — c yr w e �� 2:<ev: 4q 2; sr,7; 39 -- _ - T 0 -- — — Sb I G W — — ._ —. 3 e H 10 4,6CTIc. eEc„ 172 171 -- — — :11 — — 170 — — —v 3: l!224-- - - I — — -' 3: Gro— — G 7 -- — — 3.19: g -- 1— '41 116" --- -- –" — 4�- �4o "io 5Et cfG -6e-, (oo m icej serT t etc, 70 n,N-5mFccc. mac, EDO 0 0 se -MC rbc, S ��ccv�ry i S" 54/, rrco �✓y J 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 October 27, 1986 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, townships range) Lot 12; Sampson Estate (`8 &0 C W Location (address or directions) (b) Applicant Name Trent Slaymaker Telephone: Home 345-2032 Business same Applicant Address Box 110787, Anchorage, Alaska 99511 (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder 11 ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution United Bank of Alaska Telephone 276-1911 Address Anchorage, Alaska/ATTENTION: Paula (e) Real Estate Company and Agent Re/Max of Eagle River Address Eagle River, Alaska Telephone (f) 9%��pp�� D the HAA to the following address: S & S ENGINEERING SRB 196X Eagle River Road Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single -Family EX Multi -F Other Number of Bedrooms 4 3. WATER SUPPLY Individual Well Q Community ❑ Public ❑ 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 5l Public ❑ Community ❑ 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/e4) 5. ENGINEERING FIRM PROVIDhvG INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S & S ENGINEERING Telephone 6 �� �2,,?79 Address SR B 196X Date EAGLE RIVER, AK 99577 ® -`i LY F - OfOf 4 OBtBGIx 48) . r al sz �"-I A. Zhetw 1 6. DHEP APPROVAL L� Approved for — f bedrooms by to Approved ct Disapproved Conditional Terms of Conditional Approval 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 ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION n MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) Novi 10 CHECKLIST - FEBRUARY 1984 RECEIVED 264-4720 Legal Description: LJz ✓ Sc�nnG��cA A. WELL DATA Well Classification -S If A, B, C, D.E.C. Approved (Y/N)Well Log Present (9/N) Date Completed Yield �XCFOS 4�SC�r� Total Depth Zl t Cased to Z1Y Depth of Grouting ~^ Static Water Level sit Pump Set At Casing Height Above Ground Lc`3r r Sanitary Seal on Casing (1�(/N) Electrical Wiring in Conduit O/N) Depression Around Wellhead (YAP Separation Distances from Well: To Septic/Holding Tank on Lot On Adjoining Lots t 00 t f To Nearest Edge of Absorption Field on Lot l00 14- ; On Adjoining Lots; /00 4 - To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole �'J� To Nearest Sewer Service Line on Lot ✓D t4- Water Sample Collected by d 5 `� I'U` t'6��' ; Date /O •30-6?& Water Sample Test Results ._> I r �+ r) --f ' nn Comments XGE��Q Oa, tti 1, .eG� 4.1A /Y 7<2 `9—V, 4hIrr O l0 () �' i l,•. // Z s dv� t-0C"A 1%�-� sli�w� . /e rf AXA Z re �`� B. SEPTIC/HOLDING TANK DATA /'ZS -ti Date Installed J f� Size /W� J �*L�, No. of Compartments Z - Standpipes (IQ/N) Air -tight Caps (9N) Foundation Cleanout/N) Depression over Tank (Y/(9 Date Last Pumped Pumping/Maintenance Contract on File (Y/N) QA ; for �— Holding Tank High -Water Alarm (Y/N) P��� Temporary Holding Tank Permit (Y/N) N16 Separation Distances from Septic/Holding Tank: To Water -Supply Well too /-1- To Building Foundation t To Property Line tat fi To Disposal Field /t r To Water Main/Service Line �� -F To Stream, Pond, Lake, or Major Drainage Course - nr j a I t 1�5 .! - L Comments" I N 5ZAPLJi{cor:Z a"iy 7'd U v`dAlc:�P—r r %ltc3N 5f -Ay &.4') Page 1 of 2 72-026(11/84) 1 m / C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /Sb��C�C- -'Type of System Design �jzutilc-N Date Installed Length of Field Width of Field ,r Depth of Field A +'Gravel Bed Thickness Square Feet of Absorption Area (o/[��. Standpipes Present (&N) Depression over Field (Y/0 Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well lDU/,/- To f To Building Foundation Date of Last Adequacy Test To Property Line /iS/ Lot Y8 ; On Adjoining Lots To Existing or Abandoned System on 3b i4 To Water Main/Service Line (U /-f' To Cutbank (if present) _I�J To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area X &7( I 5vf>ma Comments e)LA H liS 3cc3r.1 1, (tc.A-,uT 5 1 tjCu w W 05 1 l`Q LLL ,i A u srcP,lu L- / ?. -),3 i StA Y M ALL -P- D. LIFT STATION Date Installed - Dimensions Size in Gallons — Al Manhole/Access (Y/N) "Pump On" Level at A "Pump Off' Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certify that I have checked, verified, or conformed to all M A and HAA guidelines in effect on the date of this inspection. S & S hiaiG9��;�P1INf -6 SR B I 96x Signed Date _Z1 16 Company MOA No. 0' 6- o -D3 EAGLE RIVER, AK �. Receipt No. 2_4ol e Date of P�Ymn�A. ✓�a i. 5S*4 I Jc � Amount: rs •e a�+�e.�a.,aen •.ate a. ;U i raAt'✓al'i f.. �b07%[ �'t/n, Page 2 of 2 AV 72-026 (11/84)