HomeMy WebLinkAboutSAMPSON ESTATES BLK 2 LT 1Sampson
Estates
Block 2
Lot 1
#051-811-43
Municipality of Anchorage ,
Development Services Department
Building Safety Division
Onsite Water and Wastewater Program, 4700 S. Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page of
www.ci.enchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SW060065 PID Number: 051-811-43
NE4e[ Hensley
Wastewater System: ❑ New ® Upgrade
Adb•ss
23939 Delfilah Cir. Chuaiak. AK, 99567
ABSORPTION FIELD
PMro N, Wr of Beds s
O Deep Teem ® Sw" Trwx11 Cl Bed O Mauro 0 otn°r
LEGAL DESCRIPTION
sa Rat.q
T"Dpm llpm wgnM wail,
0.45 GPDW?
8 Ft.
BwA La S"d *M
Dean w pw oattom from a,pnal precis
G," dean Iwlsah Pe»
2 1 Sampson Estates
3.94/4.0 Ft.
4.06/4.0 FI
Tovmsnp Rave Secow+
FA added croon orvvell grade,
or" Lwptn
-1.13 to 0.26 Ft.
102 Ft.
Well:❑
[:]New Upgrade rade
cra1,M WIN
Nu Jts r of Ines
DdMnc• b•tw•en N
5.0 Ft.
2
10 FL
Cisuff atvxl (Plmle, A B, c)
TotalDeptn
Coad to
TMI aosaggn was
Poe Mat"
Class
F.
Ft
1020 Fr
I D3034 & F810
Dnaw r,410
Dme Dnn
SWK waw 1.61,01
Maiw
DM•1,ste,w
FI
RPC
6/2/06
YOM
pwv sM M
c»vv Hog"ADov6 Gn•ea1
TANK
GPM
FL
FI
SEPARATION DISTANCES
® Septic ❑ Holding O S.T.E.P. O Other.
To
Septic
Absorption
Ldt
Holding
PubIIUPmaI
---
II
From
Tank
Field
Station
Tank
Sewer Lina
Anchorage Tank
1000 GM
wen
200'+
200'+
NA
NA
25'+
Malwwl
Nu WdGaPpwMamsSteel 2
SaAacawaa
100'+
100'+
NA
NA
LIFT STATION
ld Lna
5'+
10'+
NA
NA
sa
Gal
ac urw
FowrMlnn
5'+
10'+
NA
NA
•^ 011,01M
ump se M se
1-19" walw wam at
in
M
h
C,~ Dam
NA
*50'+
1 NA
NA
PI ,, Maea Mo
Eiecpaal lnapec.$;; rm•d by
Remark.
*none known
BENCH MARK
Lmelon as DesI
Tank & trench 2 Insulated. Septic
Top of deck
service line partial Insulated as
Atsusad EN W,cm
100 FL
shown on drawing. Old system
abandoned In place per code.
Engineers stamp
OF igC��111
�9+II
of *: 49Ll►
t
.Dates: 1 6/2/C06
Inspections performed by: KND Engineering. IrIC:
• •• +•�••«•»: ......... j
.2nd 6/2/of;
•.J1 • •«»•.. •• • ..Se¢«�
Development Services Department Approval
enneth is W
�� s :, ct 116 :'���`i
Reviewed by: Date:
j 9Fp'�`•».��`�a�-'�
and approved .
12=)1
(Rev
\
AS -BUILT SYSTEM DETAILS/SITE PLAN Permit t SW060065
SAMPSON ESTATES SUBDIVISI❑N Block 2 Lot 1 PID#: 051-811-43
A.I.P. - Abandoned In Place Lor 1
T 06-01
co TRENCH 2 � co
LOT 1
INS c TION F BLK 2
E MT
MT
SPLITTER
EXISTING SEPTIC
1SULATIONFIELD A.I.P.
1000 GAL
STEEL ST
A -C=21.3'
COYPUTM
B -C=62.4'
8.4 8.
A -D=24.0'
f m/��m
B -D=63.2'
CHECKED:
A -E=72.7'
"seusr, JLS KNDE
B -E=47.8'
et.9'
A -F=100.2'
d _0
`•
B -F=47.8'
1 N
A -G=88.2'
.I 1000 GAL
B -G=88.0'
SEPTIC
A -H=110.0'
TANK
B -H=63.9'
GRAPHICS SCALE
//*:49 *
M. DU US
` C -7
\' fEsslONpV
vk `_
51'
T
0
0
0
A
ET
N
t
r7
LOT I
BLK
VARIES
0.5'
4.0'
1 BOH
or �o
os 96.1 FINAL GRADE 96.4 acs
FILTER FABRIC L INSULATION �� V
TR
51'
DAVID 6 ELIZABETH EDGECOMBE
P.O.BOX 671274
CHUGIAK, AK 99567
688-0441
FIELD BOOKS
COYPUTM
89.9'
D
DRAWL:
f m/��m
STAXINQ
CHECKED:
BMW/KN
"seusr, JLS KNDE
�\ d
'YisN
et.9'
yCs o
d _0
`•
NW1560
1 N
`t1�OQ\1$� G •
40
:AA
�-
GRAPHICS SCALE
•...;.D/w
•
SCALE: 1:40
2.0'r4.7'
C31-
n 97.3 FINAL GRADE
t C3
<Zin e
51'
T
0
0
0
A
ET
N
t
r7
LOT I
BLK
VARIES
0.5'
4.0'
1 BOH
or �o
os 96.1 FINAL GRADE 96.4 acs
FILTER FABRIC L INSULATION �� V
TR
51'
DAVID 6 ELIZABETH EDGECOMBE
P.O.BOX 671274
CHUGIAK, AK 99567
688-0441
FIELD BOOKS
COYPUTM
e"DNNr.
DRAWL:
f m/��m
STAXINQ
CHECKED:
BMW/KN
"seusr, JLS KNDE
DATE
06/21
DRc. ME:
CNO:
NW1560
"c"D "-; 06008.DWG
'pe R`
06-008
S:\.1u • SWW - nW by 1.oa\S� Eriot.N swa\8b z\ta t\D.l\N00d.d.E
0.5'
,J..'.:itr•�i"00'
69.3 1
I -BOH 80.4
SCALE- NTS
ABBREVIATIONS
BOH BOTTOM OF TESTHOLE
CO CLEANOUT
MT=��yyI
M��O\\NN�IITOORING TUBE
IMID ENGINEERING. INC.
20441 PTARMIGAN BLVD.
EAGLE RIVER. AK 99577-8736
(907)696-611E/9u1 (907)896-8111
m.KND8nsln•erin(.ee=/I=deng*Jk.nal
061.0-898(L06) XVd/TUC-999(406)
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£ 118 \
S L 101
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I
MUNICIPALITY OF ANCHORAGE
Development Services Department
Onsite Water 6 Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: Apr 20, 2006
Expiration Date: Apr 20, 2007
Permit Number: SWO60065 Parcel ID: 051-811-43
Legal Description: SAMPSON ESTATES BLK 2 LT 1
Design Engineer: 0070 KND ENGINEERING Site Address: 023939 DELILIAH CIR
Owner Name: SHEL HENSLEY Lot Size: 51906 SO. FT.
Owner Address: PO BOX 671274 Total Bedrooms: 3 Permit Bedrooms: 3
CHUGIAK . AK 99567 -
This permit is for the construction of.
Q Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72 ) and Drinking Water Regulations (18AAC80 ).
3, The engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling
(907) 343-7904 ( 24 hours). ( Not required for a Water Supply Permit only).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Date: e24
Issued Bl� Date: 2Oo b
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
www.muni.org/onsite
(907)343-7904
ON-SITE SEWERIWELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-811-43
Property owner(s) Shel Hensley Day phone 569-7435
Mailing address 200 W. 34th, Ste. 1249, Anchorage, AK Zip Code 99503
Site address 23939 Delilah Cir., Chugiak, AK Zip Code 99567
Legal description (Sub'd., Block & Lot) Sampson Estates Block 2, Lot 1
Legal description (Township, Range & Section)
Lot Size 5 / 9'0 64 Sq. Ft.
THIS APPLICATION IS FOR (® all that apply):
Absorption Field
Septic Tank
Holding Tank ❑
Privy ❑
Private Well ❑
Water Storage ❑
Number of Bedrooms 3
THIS APPLICATION IS AN:
Initial
❑
Upgrade
0
Renewal
❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwellingand is in accordance with applicable Municipal Codes.
of property owner or authorized agent)
Permit/Rush Fees: $460.00
Date of Payment: 6040 b
Receipt Number. tl
(Rev. 11/05)
Waiver Fees:
Date of Payment
Receipt Number.
MND ENGINEERING, INC.
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-8111
April 18, 2006
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Sewer Upgrade — Sampson Estates, Block 2, Lot 1
Gentlemen:
The owner has requested we proceed fonvard to obtain a septic permit to upgrade and
replace the existing septic system and tank for the subject lot. The existing septic tank
will be abandoned in place and in accordance with municipal standards. On March 28,
2006 a testhole was performed for the proposed system. The results of this test are
attached. The general slope of this lot is from south to north at a grade of
approximately 2 —5%.
We have designed our system utilizing the testhole we excavated for the existing 3 -
bedroom house. The lot is served by a community well. We propose to install two 5'
wide shallow trenches. Water was not encountered during the excavation, but was
recently monitored at 14'. The system has been designed to be 6' above the
groundwater monitored level.
There are no public or private wells within 200' of our proposed system location except
as noted. There is no surface water within 100' of the proposed system and there are no
known curtain drains within 50'. We do not expect there to be any adverse effect on
adjacent lots by the development of this system.
If you have any questions, please contact me at 696-6111/FAX 696-8111.
Respectfully submitted,
KHD Engineering, Inc.
Kenneth uffus, P!E.
Attachments: On -Site Well and Sewer Application
Wastewater Absorption System Details/Site Plan
Soils Log/Percolation Test
Owner/ Contractor Specs
WELL & WASTEWATER DISPOSAL SYSTEM SITE PLAN
SAMPSON ESTATES SUBDIVISI❑N Block 2 Lot 1
\\ \ \\\ � 35 J i i � I 14
K�D \\ \ \ \ 1 6 I ' —
\\\A—
_ -- I7:F 11E11 APPROIOYAIE
`✓ i � � t0' EMe ! TNsomm E,mL l0CAS011 1 by�l
X21 ��\ �\ - 1
\\�1 ( �2, / 1 17
ON
SEPnc— J
r22
— — — •_., \ .:rte: i� \ \ -
- - `
NOTE: WATER SERVICE rEHOU�� SOUTHSIDE OFOFF DELILAH CI
iMAX \� 4 7 �
DESIGN DETAILS
3 BDRM X 150 GPD - 450 GPD
450 GPD/0.45 GPD PER SO. FT. (34 MIN/IN.)= 1000 SO. FT
(1000 / 5' (V)) x 0.5 (RF) (4' GRAVEL) = 100 FT. TRENCH
USE 2 TRENCHES - 50' (L) X 5' (W) X 4' (D)
Total max. depth of system Is 8' from original grade.
NO PUBLIC WELLS
PROPOSED SYSTEM.
NO PRIVATE WELLS
PROPOSED SYSTEM
NOTED.
WITHIN 200' OF
WITHIN 200' OF
EXCEPT AS
NO SEPTIC SYSTEMS WITHIN 200' OF
PROPOSED WELL EXCEPT AS NOTED.
AS OF ACIA
AW
I/
' KENNETH Y. D US
CE- } Ora
�FE.S-S-I
NOTES,
1. INSTALL 1000 GALLON SEPTIC TANK L INSULATE IF < 4' COVER
2. INSULATE TRENCHES WITH 2' HD BURIAL FOAM IF (3' COVER
W/MIN. OF 2' FILL
3. CONTRACTOR WILL ENSURE MINIMUM 2% SLOPE INTO SEPTIC TANK.
4. CONTRACTOR WILL ENSURE ALL SEPARATIONS TO ADJACENT
WELLS, SEPTICS, LOT LINES, FOUNDATIONS AND ALL OTHER SETBACKS.
PREPARED F❑Rt
DAVID L ELIZABETH EDGECOMBE
P.O.BOX 671274
CHUGIAK, AK 99567
688-0441
nELO BOOKS cwmt .
BoLwom C IDRAIN: rsm
STARNa
CHE01 : BMW
ASBULT:
o.c. /SF
DATE 04/18/
aaa NW1560
ACRD `06008.DWG
'108 Y' 06-008
S\YaL L SWW - nW by 1pN\Sa EM S bd\8b 74M 1\D"\06M4K
Scaler 1'= 100'
PAGE 1 OF 2
La1bNi LW ENGINEERING, INC.
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)868-3701/FAX (907)888-3793
WASTEWATER DISPOSAL SYSTEM DETAILS
SAMPSON ESTATES SUBDIVISION Block 2 Lot 1 — — — —
KND
-----------------------------
10'
--- --------------------10 Elec & Telecomm Esmt.
`.swrGLTIE CHART
A -C=26.44
B -C=58.53
A -D=62.05
B -D=73.65
A -E=87.04
B -E=39.34
I
TH06-01
\S
s
d MT TRENC
o MT TRENCH
\ C00ji LUCr -Teewd s
MT C� v"Iw. S' AIJAY fp--� •�A ilv"
J (2)50'Lx5'Wx4'D �It'I•�
urI MAX DEPTH O.G. 8'
--- v MAINTAIN 16'
\ E SEPARATION FROM
\ SPLITTER _ ' /N EXISTING FIELD
\\ LA
\ 4" SOLID PIPE AT
\ 2% MAX GRADE EXISTING SEPTIC
\ \\ 1000 GAL C C .,. i • 'FIELD A.I.P.
\ STEEL ST F
\ 4" SOLID PIPE AT
\2% MAX GRADE A co •`.' f
Ab oned in Place
GENERAL NOTES:
1. MAINTAINED 10 FOOT SEPARATION DISTANCE FROM WATER LINES.
2. MAINTAINED MINIMUM OF 10 FOOT SEPARATION FROM ANY PROPERTY LINES.
3. FOUNDATION CLEANOUT PLACED WITHIN 4 FEET OF FOUNDATION.
4. CONTRACTOR VERIFIED ALL SEPARATIONS TO ADJACENT/SUBJECT WELLS, SEPTICS, LOT LINES, FOUNDATIONS AND
ALL OTHER REQUIRED SETBACKS.
5. PLACE A MINIMUM OF 3 FEET OF EARTH COVER (OR EQUIV) OVER ABSORPTION FIELD. ONE INCH OF WESTERN
"Insulfoom II" (OR EQUIV) MAY BE SUBSTITUTED FOR ONE FOOT OF EARTH COVER UP TO A MAXIMUM OF TWO
INCHES OF INSULATION.
6. MAXIMUM OF 2% GRADE TO TANK.
KENNETH Y. D FF S; %
`1�c►Ewe t
(�.•AW
�FEsstoN�� �.
PREPARED FOR:
DAVID 5 ELIZABETH EDGECOMBE
P.D.BOX 671274 Scale, I'= 30'
CHUGIAK, AK 99567
688-0441 PAGE 2 OF 2
FIELD BOOKS wmwI .
Boukom,, DRAW rsm ENGINEERING, INC.
STA m aE«w BMW 20441 PTARMIGAN BLVD.
ASBMr.. DATE: 04/18/0EAGLE RIVER, AK 99577-8736
M ML anm NW1560
"0"D "L° 06008.DWG "" 06-008 (907)888-3791/FAX (907)888-3793
s\WELL • SO= - n W M LA•d\Sa E. m rA 1\DA•\0600&•-o
oF At
KhM ENGINEERING, INC. C -3
L '•;.9fJ
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
•f "if :• C 7116
SOILS PERCOLATION TEST f��Fq''• f�o�• *,
k"S0,FES510NA\'
Performed for: Shel Hensley Date Performed: 3/28/x''"
Project: Sampson Estates B2, Ll TEST HOLE A 06-1
Depth
(Feet) SEE ATTACHED SITE PLAN
1-
2-
3-
4-
5-
6-
7-
8-
9-
10-
11-
12-
13-
14-
15-
16-
17-
18-
19-
20-
Org/OL
GM—w/cobbles to 1'
B.O.H.
HOLE PRESOAKED
PRIOR TO TEST
FOR HOLE LOCATION
Was Ground water encountered? NO What depth? NA
Depth to water after monitoring? 14' Date? 4/17/06
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
1
3/29/06
1:00
-
6"
-
2
1:30
30 min
5"
1"
3
1:30
-
5"
-
4
2:00
30 min
612/16"
14/16"
5
2:00
-
52/16"
-
6
2:30
30 min
34/16"
14/16"
'
Water
Added
Percolation Rate 34 (min/ in) Perc Hole Diameter 6"
Test Run Between 6 feet and 7 feet
I, Kenneth hi. Duffus, certify that this test was performed in accordance with all State and Municipal guidelines in
effect on this date.
KNDD ENGINEERING, INC.
24141 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
696.6111/FAX (907) 696.8111
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES AND MATERIAL SPECIFICATIONS
LEGAL DESCRIPTION: Sampson Estates, Block 2, Lot 1
GENERAL:
1. The scope of this project includes the installation of a septic tank and/or drainfield to serve a
single famil residence on the referenced property as delineated on the attached Municipality of
Anchorage MOA) permit and site plan.
2 Construction shall be in accordance with the approved site plan and design drawings; MOA
permit with any special provisions or conditions, and all applicable State and Municipal
Wastewater Disposal Regulations.
3. KND Engineering Inc (KND) assumes no responsibility of the accuracy of the as -built survey
provided by the owner or owner's representative.
4. The owner or contractor is responsible to notify the engineer of any discrepancies noted on the
design plans or drawings prior to commencing work. These discrepancies could be, but not
limited to, possible encroachments, surface water, varying soils, unplatted easements, types or
use of dwellings on or adjacent to property, nearby public wells, etc.
5. The contractor shall be responsible for locating any necessary underground utilities, easements,
property lines and surface water. The owner and/or contractor shall ensure, if deemed
appropriate, that a registered land surveyor prior to construction flags all setbacks.
6. The contractor shall be responsible for verifying all pertinent separation distances and
component layout.
7. Unless specifically agreed otherwise, the property owner shall be responsible for final grading
areas subsequently depressed from soil settling. On all leachfield mound systems, the property
owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded
area.
8. The MOA Development Services Department On -Site Water & Wastewater Program must
certify contractors installing wastewater disposal systems. Owners installing their own systems
must also receive prior approval from said MOA Department.
SEPTIC TANK / HOLDING TANK / LIFT STATION INSTALLATION:
1. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall
include two 4" cleanouts for pumping access.
2. The septic tank shall be sufficiently bedded with proper material and compacting to prevent
damaging, settling or shifting of the tank
3. All standpipes on the septic tank shall extend a minimum of 12 inches above the final grade.
4. Septic tanks installed with less than 4 foot of cover shall be insulated. The contractor will
ensure that the fill over the tank does not exceed the burial depth rating.
5. A foundation cleanout shall be installed one to four feet from the building foundation. In the
line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent
pumping system exists within the septic tank). These cleanouts shall be located on undisturbed
soil not more than 10 feet from the tank. The second cleanout, in line, shall be to clean toward
the septic tank.
6. Final grading over the septic tank shall be such that a positive slope exists away from the septic
Page 1 of 3
Reference: Sampson B2, Ll
Date: 01/18/06
Page: 2 of 3
7. All H.D.P.E. tanks shall have a vertical length of 4 -inch perforated drainpipe besides the tank
extending to the bottom of the tank to above grade to monitor ground water.
8. All tanks shall be anchored when there is not enough adequate soil cover to resist buoyancy
forces in high -groundwater areas.
9. All holding tanks and lift stations shall have an audible and visual alarm inside the residence.
10. All lift stations shall be wired in compliance with the Uniform Electrical Code and all MOA
guidelines.
11. The contractor shall remove the old tank, or abandon it in compliance with the Uniform
Plumbing Code. The contractor is solely responsible for the abandonment procedure.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
1. Excavate the proposed trench to the dimensions shown on the design. The bottom of the
excavation shall be within 2 inches of level. If the sidewalls of the excavaction become smeared,
they must be raked or scratched (roughed -up) before gravel (sewer rock) placement.
2. Once the sewer rock is installed, the distribution pipe is installed level with the perforations
facing downward. Gravel is then to be placed over the distribution pipe to provide a minimum
of 2 inches of cover over the pipe.
3. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure
the silt barrier covers the entire gravel surface before placing backfill.
4. Monitoring tubes shall be four- (4) inch diameter, installed approximately in the locations
shown on the design, and extend a minimum of 12 inches above final grade. The portion of the
monitoring tube extending through the gravel shall be perforated from the bottom of the trench
to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as
noted on the design.
5. Backfill over the final gravel layer must not be less than twenty-four inches. Insulation must be
installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the
trench must be mounded to prevent the formation of a depression after settling.
6. All advanced technology waste water disposal systems (Advantex, Biocycle, Intermittent
Dosing Sand Filter, etc...) shall be constructed, installed, maintained and monitored per
manufacturer's specifications and MOA requirements.
MINIMUM MATERIAL SPECIFICATIONS:
1. A MOA approved septic tank manufacturer must construct any septic tank proposed for
installation.
2. The following pipe materials are MOA approved for use in septic system installations:
Type of Pipe Perforate 5QU
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F810 (HDPE) Yes No
ASTM D2662 (ABS) Yes Yes
3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company
Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or
equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between
the final leachfield gravel layer and the native soil backfill.
6. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing
the #200 sieve. If deemed necessary, a sieve analysis should be performed.
7. When sand is being used as a filter material, its gradation specification must conform to current
MOA or DEC requirements.
Reference: Sampson B2, Ll
Date: 04/18/06
Page: 3 of 3
INSPECTIONS:
Typically there will be three (3) inspections required during the installation of the wastewater
disposal system. These inspections will occur as follows:
1. The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds
and before the installation of any gravel. A septic tank may be set in place, but may not be
backfilled before this inspection.
2. The second inspection must be Conducted after the placement of the sewer rock distribution
lines, standpipes, and cleanouts, but before the placement of the silt barrier, insulation, or any
other backfill.
3. The final inspection is to occur upon final grading of the property.
Often there will be more than these 3 inspections required, especially with the installation of multiple
trenches, sand filters, pressurized distribution systems, etc. The inspecting engineer is to be contacted
at least 24 hours prior to the start of construction. If necessary, a pre -construction meeting will take
place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractor's
activities.
The owner shall contract with the contractor to perform the work outlined in these specifications and
attached plans and in accordance with the attached MOA permit. All materials, components, and
construction practices shall comply with the MOA's and the State of Alaska's latest ordinances,
regulations, or policies regarding wells and septic systems. The failure of the inspecting engineer to
notice a material or construction non-compliance does not relieve the contractor of his/her
responsibility to correct such deficiency. There will be no contractual arrangement existing between
the contractor and KND Engineerin&, Inc. KND shall be the owner's representative and will inspect the
work as stated above to document the contractor's activities. Final acceptance of the contractor's work
rests with the owner and the MOA.
KND shall have no liability to the owner or to others for acts or omissions of the contractor or any other
persons performing work on this project or the failure of the contractor to carry out the work in
accordance with these construction documents. KND's inspecting engineer will not be responsible for
the construction means, methods, and techniques, sequence, procedures or the safety precautions
incident to this project.
BY PROCEEDING FORWARD WITH THE INSTALLATION OF THE WATER AND/OR
WASTEWATER SYSTEM (S), THE PROPERTY OWNER, CONTRACTOR, AND WELL DRILLER
ACKNOWLEDGES HAVING READ AND ACCEPTED THESE SPECIFICATIONS.
i
MUNICIPALITY OF ANCHORAGE
/ 0 DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
EW
� ee q - `-Z I/'
UPGRADE
MAILING ADDREe/ i ,/ 'y
LEGAL DESCRIPTION
LOCATION
NO. OF BEDROOMS
Well
Absorption area.
Dwelling J
PER IT 0.
v Y
DISTANCE TO:
N
I.- z
w
Manufacturer
Material_ ,r.
No. of compartments •�
F
y
Liq. c pacity in g.Wlons
IF HOMEMADE:
Inside len tc�h�^
-
Width-
Liquid depth
DISTANCE TO:
Well
Dw ling
PERMIT NO.
02 G
2 - F
Manufacturer _-._._. _._.....
Material
Liquid capacity in gallons
=
DISTANCE T0:7
Well
Cev; /"%aN/•ice
Fbundati4 /
) !-�
Nearest lot ne L
a 7
PE Iy �0.
`�" r
Lu
Z
No. of lines
Length
Total leng h ofd
Trench wid
Distance b ween lines /t%
F w
Lj inches
FTop
of tile to finish grade--- - -
Material beneath tile
0 -
Total eff cove absorptijarea
Ov f
nches
Length
Width
D pt h
PERMIT NO.
w
4 F
Type of crib
Crib diameter
ib depth
Total effective absorption area
as
Lu
En
Well
Building foundation
Nearest lot line
DISTANCE TO:
-
Cl a
Depth
Driller
Distance to lot line
PERMIT NO.
J
Lu
DISTANCE TO:
fodat on
Buidingun
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
M.
••�
—
�iC_
INSTALLE
7R�� p
/nr C<-4`if �.
'--
REMARKS
�s~V.••••~• a�
• ♦ . •..... .....
r • R.bM �. $Aalsf 11 iR
w4
I'
�. ••
APP VED
C7
72-013 (Rev. 3/78) C/ /
rl AJ r-4 I C I F� I I -r I -e 03 F=- F-1 P-4 C -; H Fl C -i E:
'
DEPARTMENT 0. HEALTH AND ENVIRONMENTAL F..,ITECTION- 45
82 7 �_
5 L STREET, ANCHORAGE, 99501
264-4720
ID" -4-:3 I -FF=
'H.F=WaF;?
Wal L F"IEFRI-1 I -F
PERMIT NO: 840471
DATE ISSUED: '021-5/18/84
APPLICANT: SCHMIDT BROS.
EXC.
ADDRESS: % S8.S ENGINEERING
SRB 176X
,EAGLE RIVER,
AK 99577
CONTACT PHONErr -1594-2979
LEGAL DESCRIP : SUBDIVISION:
SAMPSM L10- LOT: I
BLOCK: 2
SECTION: 3
TOWNSHI P:
15N RANGE: IW
LOT SIZE: 51906 (SQ. FT.
OR ACRES)
MAX BEDROOMS: 3
LISTED BELOW ARE THE OPTIONS
AVAILABLE TO
YOU IN DESIGNING
YOUR SEPTIC
SYSTEM. CHOOSE THE OPTION THAT BEST FITS
YOUR SITE.
- - - -
- - - - - - - - - - - - - -
- - - - - - -
-IF FRO E-= P-4
- - - - - - - - -
ED Ez- E--
- - - - - -
t4 - E--- Fe F:l I r-4
DEPTH TO PIPE BOTTOM (FT.)
4.0
4.0
4.0
GRAVEL DEPTH (FT.)
7. 0
0. 5
3. 5
TOTAL DEPTH (FT.)
11. 0
4. 5
7. 5
GRAVEL WIDTH (FT.
2.5
26.0
5.0
GRAVEL LENGTH (FT.
75. 0
50.0
11.3.0
GRAVEL VOLUME (CU. YDS.)
52.0
48.1
83.7
TANK SIZE (GALS)
1: 000. 0
1,000. 0
:L, 000. o
SOIL RATING (SQ.FT. /BR)
349
284
349
GRAVEL LENGTH >_75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH)
TANK MUST HAVE AT LEAST TWO COMPARTMENTS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --- - - - - -
I CERTIFY THAT:
1. 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS As SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE (MOA) AND THE STATE OF ALASKA.
2. 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL NOA CODES AND REGULATIONS,
AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT.
3. 1 WILL ADHERE TO ALL MOR 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. 1 UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 3 BEDROOMS AND
ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT.
IF A LIFT STATION.IS INSTALLED IN AN AREA COVERED BY NOR 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 (3) THE
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED
APPLICANT
ISSUED BY
GATE :94
-61-111- Al -f -
GATE 4�4eeAL
I II
❑ SOILS LOG
MUNICIPALITY OF ANCHORAGE
ra DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 5K- PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST ff�
PERFORMED FOR: S I- PAI 17 V J? Zez>S DATE PERFORMED:
LEGAL DESCRIPTION: Cep S4�
H SLOPE SITE PLAN
1 (IIET) I I n
2
3-
4
5
6
7
8 �`
9
t7�
G
10
11 Q
12
13 of
14'
6'r
15
,:2-
617 16-
17
18
19
20
�q
COMMENTS
G h1
zoc/ X182
(349 1132 AbT)
Qc:TTbl`K Or-
r -
'* �:s�ifi1E
PERFORMED BY:
_-------.--
72-008 (6/79)
WAS GROUND WATER S
ENCOUNTERED? t4 L? L
O
P
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
r1
�n er
-
S
lL%r P
ro
�3
i�
rZ Ls"P
to
PERCOLATION RATE `Y0 (minutes/inch)
TEST RUN BETWEEN FT AND -- [�— FT
Municipality of Anchorage
On -Site Water and Wastewater Program . p 46`
(907)343-7904
5A E T Y
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 051-811-43
1. GENERAL INFORMATION
Expiration Date: - / '57'' % 3
Complete legal description Sampson Estates Block 2 Lot 1
Location (site address) 23939 SamDSOn Drive, Chueiak, AK 99567
Current Property owner(s) HENSLEY-RHEINOR SHEL Day phone 688-7450
Mailing address same
Real Estate Agent Hensley, Shel Day phone 688-7450
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
3
4. TYPE -OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual
Individual Water Storage
❑
Holding Tank
❑
Community Class C Well
®
Community
❑
Public Water System
❑
Public Sewer
❑
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $
Date of Payment
Receipt Number
COSA # `cZ l 3 S L
Date of Payment
Receipt
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm NorthRim Engineering eering_ Phone 694-7028
Address PO Box 770724 Eagle River
Engineer's Printed Name Steve Eng Date 1/1442013
6. DSD SI NATURE
System #1 Approved for bedrooms.
Staven W. ENS rid
System #2 Approved for bedrooms. F 625
Disapproved.
Conditional approval for bedrooms, with the following atipulatlorti
By;or
Original Certificate Date:
f
The Municipality of nchorage Devlopment Services Division (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 9-1-12AM
NorthRim Engineering
Atm: Steve Eng
17237 Bear Paw Circle
Eagle River, AK 99577
907-694-7028
Fax: 907-694-7026
Client Sample ID:
ER7
Sampling Location:
X3939 54W.Osdn
Client Project:
Eagle River
Sample Matrix:
Drinking Water
COC #:
PWS#:
Residual Chlorine:
Comments:
Lab#: A1212300 -01A
Analytica Anchorage
4307 Arctic Boulevard
Anchorage, AK 99503
Phone: 907-258-2155
Fax: 907-258-6634
Report Date: 1/10/2013
Receipt Date: 12/27/2012
Sample Date: 12/27/2012
Sample Time: 9:00:OOAM
Collected By: SE
Flag Definitions:
MRL = Method Reporting Limit
MCL = Maximum Contaminant Limit
B = Present also in Method Blank
H = Exceeds Regulatory Limit
M = Matrix Interference
J= Estimated Value
D = Lost to Dilution
** = RL higher than MCL; target not detected
TNC = Too Numerous to Count - result rejected
CF = Confluent Growth - result rejected
TCNG = Turbid Culture No Growth - rejected
Analysis Method Prep prep Analysis
Parameter Result Units Flags MRL MCL Method Date Date Analyst
4500-NO3E (Aqueous) - Nitrate+Nitrite pies Test was conducted by: Analytica - Anchorage
Nitrate -Nitrite as Nitrogen 3.55 mg/L 2.5 10 1/9/2013 1/9/2013 MC
Lab#: A1212300 -01B
Analysis Method Prep prep Analysis
Parameter Result Units Flags MRL MCL Method Date Date Analyst
922313 -PA (Aqueous) - Coliforms in DW Test was conducted by: Analytica - Anchorage
E. Coli Absent Present/Absent NA 12/27/2012 12/27/2012 KM
Total Coliform Absent Pwsent/Absent NA
Page 3 of 5
12/27/2012 12/27/2012 KM
Municipality of Anchorage
• Development Services Department z
Building Safety Division a '
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
Parcell.D. 051-811-43 COSA# O -DC tP1 D
Expiration Date:i%2 0 — / _�?,
1. GENERAL INFORMATION
Complete legal description Sampson Estates Block 2 Lot 1
De\',1tah llsir.
Location (site address) 23939mcjaesex Br�i�e, Chugiak, AK 99567
Current Property owner(s) HENSLEY-RHEINOR SHEL Day phone 688-7450
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
same
Day phone
Hensley, Shel Day phone 688-7450
Shel Hensley
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
❑
Individual Water Storage
❑
Community Class C 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 NorthRim Engineering Phone 694-7028
Address PO Box 770724 Eagle River
Engineer's Printed Name Steve Eng Date 8/22/2012
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 sepkcnN§,J s are
subject to these various and dynamic characteristics and are outside the control of the`a `O 4. 1
evaluator of the well and septic system. ®4.,n•«• -0•n.« �°`
5. DSD SIGNATURE
_L Approved for bedrooms.
Disapproved.
Conditional approval for
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
bedrooms, with the following
ON-SITE
PROGRAM
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date:
(Rev. it/05)
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water & Wastewater Program a
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 Estates, Block 2 Lot 1 Parcel ID: 051-81143
A. WELL DATA- Public Water
Well type C If A, B, or C provide PWSID # Well Log (Y/N) Y
Date completed 1 5 92 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 178 ft. Cased to 178 ft.
FROM WELL LOG
Date of test 10/15/92
Static water level 153 ft.
Well production 20 g.p.m.
WATER -SAMPLE RESULTS:
Coliform Pass colonies/100mL Nitrate 1.65 mg/L
Casing height (above ground) 30 in.
AT INSPECTION
8/15/12
150 ft.
8+ 9.p -m.
Arsenic: 1.14 ug/I Date of sample: 8/15/12 Collected by: nr
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 06 Tank size 1000 gal.
Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
High water alarm (Y/N) N Date of pumping %4'// -?A Pumper Z6ZI
C. ABSORPTION FIELD DATA
Date installed 6/2/06 Soil rating (g.p.d./ftZ or ft2/bdrm) 0.45 System type Trench
Length 102 (2 lines) ft. Width 5 ft. Gravel below pipe 4 ft. Total depth 8 ft.
Eff. absorption area 1020 f 2 Monitoring tube Y Depression over field N
Date of adequacy test 8/15/12 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 450+ gal. New depth 2 in.
Elapsed Time: 30 min. Final fluid depth 0 in. Absorption rate > 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) Unk If yes, give date -_
D. LIFT STATION
Date installed na Size in gallons na Manhole/Access (Y/N) na
"Pump on" level at na in. "Pump off' level at na in. High water alarm level at na in.
Datum na Cycles tested na Meets alarm & circuit requirements? na
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot na
Absorption field on lot na
Public sewer main NA
Sewer /septic service line na
On adjacent lots na
On adjacent lots na
Public sewer manhole/cleanout NA
Holding tank na
Animal containment areas na Manure/animal excrete storage areas na
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10'+ Property line 10'+ Absorption field 10'+
Water main na Water service line 10'+ Surface water 100'+
Wells on adjacent lots AW I/ SU 1- 1�
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main na
Water Service line 101+ Surface water. 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain Wit Wells on adjacent lots -(
COMMENT§
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 Steve Eng
Date 8/22/2012
COSA Fee $490.00 Waiver Fee $ _
Date of Payment 5�23� 1 a. C Date of Payment
Receipt Number 63 3 C Receipt Number
(Rev. 11105)
Steven W. Eng
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE
• Department of Health & Human Services}i
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
051-811-43
HAA #
1. GENERAL INFORMATION (Must be completed prior to submittal)
HA900418
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 1 Block 2 Sam son Estates Subdivision
Location (address or directions)
NHN Delilah Circle
% Janet Des Granges
(b) Property owner Security Pacific Bank Telephone: (home) Business
Mailing Address PO Box 107007, Anchorage, Alaska 99510-7007
(c) Lending Institution
Telephone
Mailing Address
(d) Real Estate Company and Agent Cheryl Ponder Centruy 21/Pacific North
Address 1120 Huffman Road, Anchorage, Alaska 99508
Telephone 345-1444
(e) Mail the HAA to the following address: (or check here ❑, if hold for pick up.)
List contact person and day phone number below:
S & S Engineer
17034 Eagle River Loop Road #204
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family FIX Number of bedrooms three (3 )
3. WATER SUPPLY
Individual Well ❑ Community Mxx 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-sitedRxx 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((iev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm S & S Engineeri
Telephone 694-2979
Address 17034 Eagle River Loop Road #204, Eagle River, Alaska 99577
Date October 3, 1990
Engineer's Seal
6. DHHS APPROVAL
Approved for three brooms by G GZI Date October 8, 1990
Approved xxxxxx Disapproved Conditional
Terms of Conditional Approval
This is a replacement Certificate since the original Certificate
has been lost. This is taken from DHHS files. Any questions, please
call our office at 343-4744.
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do notconduct 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��
• -� Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES M—1
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # �' i -)) ' �i 17.? HAA #
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal -Description (include lot, block, subdivision, section, township, range)
Lot 1• Black 2• Sam aon Estatu
Location (address or directions)
NHN DeUtah C 1tcZe
(b) Property owner Seeuh cty PaciAic Bank Telephone: (home) Business
Attn: Janet De,0 .angel
Mailing Address P U Bax 107007 Anehonage A.2aska 99510-7007
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent CENTURY 21 IPACIFIC NORTH ATTN • ChexyP Pondea.
Address 1120 Hu46man Road Anchunge, Ataska 99508
Telephone
zA9-1AAA
(e) Mail the HAA to the following address: (or check here M if hold for pick up.)
List contact person and day phone number below:
5 & 5 t�;vl�le�• ,�
17034 Earle River Loop Road No. A204 _
Eagle River, P"a"- -
2. TYPE OF RESIDENCE
Single -Family Cox Number of bedrooms 3
3. WATER SUPPLY
Individual Well ❑ Community Ix 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-siteXK 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 5 & 5 ENGINEERING Telephone
17034 Eagle River LoopRoad Ado. 204
Address '115r.ka99577
Date
Z)
r .
r -i;
a..:r..h/f� • n
n eY'434aI'wil
r
6. DHHS APPROVAL
Approved for _2 bedrooms by , Z�/% Date
Approved__..—Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Municipalityof Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
;registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in orderto satisfy certain federal and -state requirements. Employees of DHHS do not conduct inspections
nor 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
os��y��� •
OGS
Q �G V
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Grou
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984 i
343-4744
Date Completed
Electrical Wiring in Conduit (Y/N)
Legal Description: Le -r ) Bwc_G Z
5A.-MYso�l �rrP.-r'�5
Depth of Grouting
SEPARATION DISTANCES FROM WELL:
If A, B, C, D.E.C. Approved ON) Y
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
To Septic/Holding Tank on Lot'o; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot 7ac�' `t ; On Adjoining Lots
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
To Nearest Public Sewer Cleanout/Manhole
; Date
Comments 'JT:-�G Lr-r-s`f:-:* y?_ 0 F O}Q12 Zc�r--T�. 4 -T _r kV c- 1-4 If Q
B. SEPTIC/HOLDING TANK DATA
Date Installed (--ZZ-9f Size /000 No. of Compartments
Standpipes &/N) N/'- - Air -tight Caps (9/N) Foundation Cleanout/N)—
Depression over Tank (Y, to - Date Last Pumped Q- 7 6119CD `—
Pumping/Maintenance Contact on File (Y/N) �/A ; for
Holding Tank High -Water Alarm (Y/N) r"IIt- Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well
2oa t }
To Property Line / G ! }
To Water Main/Service Line /0 �+
To Stream, Pond, Lake or Major Drainage Course
To Building Foundation
To Disposal Field
Off -
Comments PUr-A?IA`,a Zu
72-026 (Rev. 7/88) Front Page 1 of 2
5"7�-
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 3� �jg� Type of System Design �Y1 Er.1CF1
Date Installed x-12-84 Length of Field 75 1
i
Width of Field 3a,1 De th of Field )
V
I
Gravel Bed Thickness
Square Feet of Absortion Area ��� `' Statndpipes Present*YN)
Depression over Field (YO ✓ Date of Last Adequacy Test C1 -Z. a -9 b
Results of Last Adequacy Test F_0e_ 31312 -
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well ZDoI +_
To Property Line t b I4 -
To Building Foundation t o To Existing or Abandoned System on
Lot N/A ; On Adjoining Lots 30 1 f
To Water Main/Service Line !o r� To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course `(pnI+-
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
Size in Gallo
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
II—
Dimensions
Manhole/Access (Y/N)
**Check Permitted Bedroom Rating Against HAA Request**
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test.
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed 5 & S ENGINEERING
17034 Eagle River hoop Road No. 204
Company
EagleRiver,Date
MOA No. Cg
Receipt No. a S " 1� a -;� S-0
Date of Payment 10-11-90
Amount: $ 170. 0
Receipt No. _
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
r
' t
STEVE COWPER, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE WESTERN DISTRICT OFFICE 563-6775
3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
FOR: S & S Engineering
Attn: Ray
October 2, 1990
PWSID: #214374
According to the records on file in this office, the Sampson
Estates, Lot 1. Block 42 Water System is in compliance with the
State of Alaska Drinking Water Regulations.
Sincerely,
VERA E. CRAIG
Environmental Specialist
VEC:pf
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
(a) Legal Description (include lot, b
4. / A '�7)_ .<
Location (address or directions)
(b) Applicants
Application Date
subdivision) section township, range)
W-) �r� IV �� --7-
W1(6(4_' Telephone - Home Busines
Applicants Address ��C),/ Z %U �6�n s 7F �� 2'c�—
(c) Applicant is (check one) Lending Institution; Owner!"_7'1 ;
Buyer � ; Other � (explain);
(d) Lending Institution /(-.) 0 X_-) F Telephone
Address
(e) Real Estate Co. & Agent
190 Ls -P
le/'/ -I L
Address �I
�: %U
9� 511 ✓� />
�7.1G /7 %lJ� 2
(f)
Tele hone
-- the HAA to the following address:
SE
i ER ii.t.AS KZ.
' Ile ->.. •I �-�li.
2. Type of Residence
Single -Family Multi -Family
Number of Bedrooms
3. Water Supply
Other (describe)
Individual Well E] CommunityPublic
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 Community E:1 Holding Tank El
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]
5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein. I further verify that,
based on the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm e r
Address _Si D 1,0"
Telephone
A $
Date
6. DHEP Approval
Approved for 3 bedrooms
Approvpd
Terms of Cond tional
(ENGINEER SEAL) y ,
Disapproved
Approval
she r
pC •, Reo+ 1b57•E o �a
J
Date G J�
Conditional
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2] 7-19-84
rte,
A. WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Well Classificatiorh If
Well Log Present (Y ) Date
Total Depth Cased to
Static Water Level
Casing Height Above Ground
A, B. or C. D.E.C.
Completed
Depth of
i.4UNIGPHL�� C',
DEP(, OF Hcf
L; Ji1r;S;1jr+LP:�
N0V 2 '084
tz � L
V
Approve (Y /0 /2_ 8
Yield
Grouting
Pump Set At
Sanitary Seal on Casing (YM)
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (YIN)
Separation Distances from Will:
To Septic/Holding Tank on Lot 2-M on Adjoining Lots
To Nearest Edge of Absorption Field onLot Z� 4 , On Adjoining Lots
To Nearest Public Sewer Lind AfG /� To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line on Lot
Water Sample Collected By, ( ��� �i�� +l/�'ZDate
Water Sample Test Results �i� �� S F,4 C 4rO
Comments J r
'0 /2� V /S Y- c C t1 S _r 4,:-
B.
B. SEPTIC/HOLDING TANK DATA //��
Date Install d , 2 Z Size LO ao No. of Compartments
Standpipes Al Air -tight Caps Foundation Cleanout (Y }
Depression over Tank07�?tract
1g)Date Last -Pumped !(f �✓
Pumping/MaintenanorFile (Y)Wm ; for
Holding Tank High -Water Alarm (Y/t�sx /� Temporary Holding Tank Permit (M A
r
Separation Distances from Septic/fTank:
To Water -Supply Well 2-00 C To Building Foundation
To Property Line /0 To Disposal Field
To Water Mai-rr/Service Line 30 C� To Stream, Pond, Laker or Major Drainage
Course
Comments r- `
o, C,
[Page 1 of 21 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ��Type of System Design
Date Installed ngth of Field
Width of Field f� Depth of Field
ave1 Bed Thickness
Square Feet of AbsorptionAreaea C? .`� �� Standpipes Present Y
Depression over Field (if` N) Date of Last Adequacy Test
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply vb11 C� To Property Line A? 7�
To Building Foundation 7 To Existing or Abandoned System on
� �-
Lot /V 5 On Adjoining Lots �;5,0C �__
To Water Main/Service Line L'�_O (-/— To Cutbank(if present)
To Stream/Pond/Lake/or Major Drainage Course /J 0 ^y
To Driveway, Parking Area, or,Vehicle Storage Area
Comments
D. LIFT STATION
^-1
^-1 0 /,J
Date Installed Di nsions
Sitz in Gallons M4X,:.7ee
s (Y/N)
"Pump On" Level at P"vel at
High Water Alarm Level at ent (Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (YM)
Comments
** Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection.1.
tea i
Signed IOIlU - tv' x w"° . •» e 9.0
:. � Dt`!�t r Date
Company P'lt ;ot f:�;.': MOA No
KB1/d5/s';;
.... Y.
kvbari A. Sf,efar
1457-r-
nN.
�
�llp�/i�j n'aa nn.a��Ay r:.9'
[Page 2 of 21
2-15-84
A. APPROV
Plans for
in
r
STATE OF ALASKA
DEPARTMENT OF ENVIRONMENTAL CONSERVATION
CONSTRUCTION AND OPERATION CERTIFICATE
for
PUBLIC WATER SYSTEMS
TO CONSTRUCT V
construction or modificatioeof:S; A H V,� C �O FS t r TT -- IL) c d Ts
7 l �� j i� - d t� C S I I
��`, � Gyle � _public water system located
n .
g + f -r7IAr
Alaska, submitted in accordance with 18 AAC 80.100
been reviewed and are
X approved.
❑ conditionally approved (see att h conditions).
0 — TITLE DATE
If constructi I n has not started within two years of the approval date, this certificate is void and new plans and
soecificatio�ljjs must be submitted for review and approval before construction.
B. APPROVED, CHANGE ORDERS
Change (contrPct order no. or descriptive reference)
MUNICIPALITY OF ANCHORAGE
Approved by DEPT. OF Fb&i &
ENVIRONMENTAL PROTECTION
RECEIVED
C. APPROVAL TO OPERATE Ere
�'�TO OPERATE" section must be com leted and si ned b the De artment befany water
The APPR VAL p 9 Y P
is made available to the public. ? iz,;-Z1 r-4 0
The constru tion of the li /S�( public
water system was completed on (date). The system Is hereby
granted into im approval to operate for 80 days followin6 the completion date.
BY - - TITLE - DATE
As -built plan3 submitted during the Interim approval period, or an inspection. by the Department, has confirmed
the system was constructed according to the approved plans. The system is hereby granted final approval to
ope ate.
BY TITLE DAT
DISTRIBUTION: 1. WHITE - ENGINEER (complete Section C)
2. YELLOW - WATER SYSTEM FILE (Complete Section C)
3. PINK - ENGINEER/MUNI-BOROUGH (complete Section C)
18.0407 (Rev. 11183) 4. GOLDENROD - MUNI -BOROUGH (Complete Section A)