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HomeMy WebLinkAboutSAMPSON ESTATES BLK 3 LT 4ampson Estates Block 3 Lot 4 #051-811-30 Municipality of Anchorage Community Development Department Page I of 3 On -Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http:/Iwww.muni.org/onsite • (907) 343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: O S P[2 2Zo PID Number: 05f-0011-30 ❑ New ,® Upgrade Name: 7—FV'F O ABSORPTION FIELD ❑Deep Trench E] Shallow Trench ed El Mound Address --7 EO / 71 S ❑ Other Phone Q z,?/ —S37i� Number of Bedrooms Soil Rating O•� Total depth from original rade _5 GPD/SF 4�S Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath cpipe 0� 5 FL Subdivision Block Lot �'�7- Q 45E7 3 Fill added above original grade Gravel length Township Range Section /f Ft. 75 Ft. Gravel width �S Ft. Beds: Number of Lines 3 Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between frenches I From Tank Field Tank Line 11.2.5 Ft' Ft. Well/ lQO lGo t,,_ lOG — r Sf TANK ❑ Septic ElS.T.E.P. [I Holding El Other Manufacturer Capacity r Surface Water [o�'�" r [aQ t !'� . '�' .- / 7—/�C Gal. Material Number of compartments Lot Line Foundation LIFT STATION Manufacturer Capacity Curtain Drain .- — -- '- Gal. Remarks Sr so/� DuR/,ys eo/�lrr��'na�U Pump on level at in. Pump off level at in. Hip V water alarm at n. % o 8E /_. 2 Q*A/ �/�rll /9T/ori /J.t'FS6 d/lJ Pump m e and modelE� rical Inspections performed by / t`fi9-LL-4'w PIPEMATERIAL Housetotank Tankto N Installer D6,44A( C'� 4-1s i�'�gV -Se-�. Ljo Drainfield Pte-GO/MT CO/MTC, Inspector �ar % BENCH MARK (Assumed elevation) /QO ft Inspection Inspection 1815 2 2ntl X612 dates: Location and description rO,i v A �T .J 3'v z /Z 4m �^ ( 572/lis COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer' t +q.,7tamp E OF.g4�ef! Conditional Approval: Date �y�iQ•''•' ••,�'g t! '• A �*'4�'�H ':* 9 S •................ ..e .. to Steven W. Eng v o n . NJ, e p56 ®���Q•p80FE�T"_ W� Approved /_ Date8 �-�-/z Inspection Report_1-1-12,doc MT1 MT2 vi 60 67 130 135 New Line MT1 v \(u MT2 Exist g S,T.E,P. Tank a Existing Bed a revious Te t Holes \ON ew Bed -GroundwatMonitor (12. v a r" CU Q) 0- 0 N ��*���� ?P��.°F° NOR THRIM y: ENGINEERING * 4 SAMPSON ESTATES BLOCK 3 LOT 4 1" = 40' PLAN Po Bax 770724 "• `LAYOUT Fogle River, Alaska 99577 ¢ FAILED LEACHFIELD 907.694.7028 � ��' RECORD DRAWING OW.— °° 6/27/12 i'o'f 2 0 m tDd m t=) ;;;- -u m 7u F-1 ed m F- tj m w 0 F- F- m 4�1 m 0 m 0% CA A Cl) M t-- (-) cn Eml and - A < 0 t:J 0 ro Z Cl) < Lq 3 ro p p C) C+ -3 :3 ro < P 70 & n -5 fD u— Sc :7 — c 1 ro 0 -1, --1 :3 (D Ln LA 7 hC�) -.-j Z 003 c hp 3 3 < -U p— n p ro n :5 0 ro o Q--3 (D n rD c rD Q_ D7 -4 M n . a-0 . 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On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP121220 Tax Code Number: 05181130000 Work Type: Septic Upgrade Permit Effective Dates: August 08, 2012 to August 08, 2013 Design Engineer: NORTH RIM ENGINEERING Subdivision: SAMPSON ESTATES Site Legal Address: SAMPSON ESTATES BLK 3 LT 4 G:1560 Owner/Address: BENSON STEVEN J & PATRICIAA PO BOX 771945 EAGLE RIVER AK 995771945 Site Mailing Address: 22705 SAMPSON DR, Chugiak This permit is for the construction of: Y Disposal Field N Septic Tank N Holding Tank /2 sof l6/ra Lot Size in Sq Ft: 40117 Total Bedrooms: 3 N Privy N Private Well N Water Storage `? () o 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Special Provisions: I The Engineer needs to do groundwater confirmation 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. /7/ea Received By: _'151� Date: Issued By: Date: g 8 Municipality of Anchorage P.O. Box 196650 • 4700 Elmore Road Anchorage, Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997 http:llwww.muni.org/Onsite Development Services Division On -Site Water and Wastewater Program E,r S, e. n ep" tinent **** VARIANCE/WAIVER REVIEW **** Waiver#: OSP121221 COSA#: Permit#:OSP121220 PID#: 051-811-30 Legal Description: Sampson Estates Block 3 Lot 4 Engineer: North Rim Engineering Applicant: Steven Benson 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 1.0 foot. 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. ® The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. ❑ Notarized letter(s) of nonobjection have been received from the owner(s) of the affected adjacent property. ❑ Adjacent properties are not affected by this waiver. ............................................................................... Waiver is Granted: X Waiver is not Granted: Date: g �Z- Approved by: Name of Reviewer .............................................................. ............... Rec#: 03562C Amount: $200.00 Date Paid: 7127112 **** VARIANCEMAIVER REVIEW **** MUNICIPALITY OF ANCHORAGE Community Development Department ` Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program Mayor Dan Sullivan ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. �S! — ��l^ O Property owner(s) J en$�rt, S �Z✓e ✓� Day phone Mailing address Z 2 %05 5a'+Ws c). D r �Loq t Site address Legal description (Sub'd. Block & Lot) _ n r_��p $ on Ec ttft r & .3 L Legal description (Township, Range & Section) Lot Size O % Sq. Ft. Number of Bedrooms _— THIS APPLICATION IS FOR: THIS APPLICATION IS AN: (® all that apply) Initial E]Absorption Field �z Septic Tank ❑ Upgrade Holding Tank ❑ Renewal ❑ Privy ❑ Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property owner or Permit/Rush Fees: d 530 -40 Waiver Fees: a n, w Date of Payment: TkZ /a Date of Payment: Receipt Number: Receipt Number: ® 35� Permit No. O�S p l3 /aaD Waiver No. O's P/ a 12 OQ / G:\Building\On SIte%Forms\Client Forms\Permit App_010411.doc (Rev. 1/11) TN IM - ENGINEERING MEMO Steve Eng, PE, PH (907) 694-7028 tel NorthRimEng@aol.com Date: 8/8/12 Number of Pages: 3 To: Deb Wockenfuss MOA On -Site Services Subject: Sampson Estates, Block 3, Lot 4, 8/3/12 Comments Deb, 1. Monitor Tubes added in each corner per sheet 1. 2. Easement label changed. 3. Agree to monitor for groundwater. 4. As one of your comments states, a longer run creates a greater drop on a slope- the reason for a wider drain field will minimize the drop. A slope over a greater length is difficult to keep level. It has less width than the 50' wide field it is replacing. 5. Additional slopes added. At the vicinity of the proposed leachfield, the site is more level than other areas of lot. 6. Previous soil tests demonstrate it to be impossible to encounter groundwater at this depth, with this slope. Comment #3 should provide for this concern. 7. We request 1' lot line waiver. It is difficult to find edge of the system until construction. This will not impact the neighbor. We will attempt to provide the greatest distance possible. 8. There is limited area on the lot. The lot line waiver is required if we are to use existing test holes. 9. The as -built drawing is not correct. The dimensions don't match the drawing. We have attempted to match the written dimensions in the updated drawing. If there is need for additional information or clarification please give me a call. Thanks -Steve ENGINEERING MEMO Steve Eng, PE, PH (907) 694-7028 tel North Rim Eng@aol.com Date: 7/26/12 Number of Pages: 4 To: Jay Crewdson, PE MOA On -Site Services Subject: North Woods S/D, Block 4, Lot 26 Jay, I followed your direction for septic system replacement design. This system is designed to previous soils information and test holes. The test holes are located in the appropriate location to be used for the replacement field. Soils will be scrutinized during construction. The owner is under hardship due to failure. Please review as soon as possible. We are requesting a lot line waiver to 1 foot due to the tight location. If there is need for additional information or clarification please give me a call. Thanks -Steve C�o 1 DESIGN NOTES : 1. Total Depth of nch is 4.5'. 2. Connect New Field o S.T.E.P. Tank. 3. Previous Test Holes sed For Design. 4. Lots Served by Private Water Wells. 5. No Conflicts Within 200 6. Install Valve In Order To Use Both Fields. DO NOT DRIVE ON BED B TTOM DURING CONSTRUCTION. o5e R1®0, oil- v 0 a. Q.L 0 u� a, 3 ed oomN CL o e 0 N New Line MT 1' Lot Line o Waiver \CU MT a Exist g S,T.E.P. Tank Q o C'. Existing Bed o N \a'New BedGroundwat r ') Previous Test Hobs Monitor (12, a N NORTHRIM J�P�F.°F.AC SAMPSON ESTATES 1 ao ENGINEERING * as BLOCK 3 LOT 4 PLAN Po Box 770724 LAYOUT Eagle River, Alaska 99577 .., FAILED L E A C H F I E L D I 907.694.7028 DESIGN—CHANGE❑RDER 5R6/15i1z 1�of 2 / ) 0\ { 0 _ A / » i 0 _/ E 0/ � j k k 0 j w e 3 O & b 2 2 : S , 9 / w G ± S § % !> O x § �d ± m V) = f. �u �\ f �� CL / \ ( q K f/ ¢ i ) u » : E 2 22g uj q -/V) \ m � > / ( j / � b % $ - g \_ �j �9\/ u fa § b m 32 &,j // S m ) Lo§ §L! sLA ,C °SZ) <0Ln � -- / z e r, '. \\ e e x � xK -°°� oJP:i Q{§!,%�K-®{# ] w® \=e±: aj °»® ! ie yz * 0 !2 L L0- w » . : � \{%_Cl.,( c (�3~d/d,fo \o [ ® 2;$ 0 a//\/{)/\c\ (�[m>\7U _ ±E),; $Q�!\ \�/3j�:/:L I\ \ƒ0 ) )� ���° > O©oƒ) 2 eA3®3>4J�a� : bw< w¥aa K / EN�2TH GINEERINGING Sampson Estates, Block 3, Lot 4 SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing: This is an existing 3 -bedroom, single family home. The absorption bed has failed. A new design is submitted for a new bed & the existing septic tank & lift station (S.T.E.P.) will continue to be used. The neighboring lots are developed with no conflict. Previous soil tests were used for design and are located on drawing. A 4.5' deep bed will be constructed. This construction will not impact any water wells. No adverse impacts are expected from development. The easements are located on the drawing and are not encroached upon. Previous soil tests revealed a silty soil rated at 0.4 GPD/FT2. A conventional pressure system will be used, application rate of 0.4 GPD/FT'. Bed Length = 50'. Bed Width = (150/0.4 x 3) /50 = 22.5' Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations. • Connect New Bed To Existing Lift Station. Install Valve To Previous Bed For Possible Later Use. • 5' minimum between the tank and bed. 10' to property lines. A 1' property line waiver is requested. • 3.5' of cover is required for bed. 2 inch insulation board may be used for 1' soil. • Solid pipe must be set on well compacted, stable soil • All cleanouts must extend to at least ground level • Trench to be placed level, minimum of 4' to groundwater, 6' to bedrock from drain - rock • Drain rock to be Yz inch to 2 'h inch screened. Drain rock to be distributed uniformly throughout the trench. • Distribution pipe shall be 1.25" Schedule 40 PVC w/ 1/8" orifices @ 27" on center. • Force main shall be 1.25" Schedule 40 PVC, Force main burial to be 4' minimum. • Silt barrier (filter fabric) to be installed above the drain rock • Smeared trench sides must be raked or scarified before drain rock placement • Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661, PVC Schedule 40. • Sewer Service Line is minimum 2% slope • Septic Tank to be pumped every two years or when required • Insulation board shall be extruded direct burial polystyrene (Dow Styrofoam HI or equal) • Maintain minimum 10' separation between water line & wastewater system. Municipality of Anchorage Page of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 O Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: C -;w C%Z06)4, 1 PID Number: 0,5-/- F// - 3c Name: L 7%CV�II � I�cN���V Wastewater System: ❑ New ,KUpgrade Address: 2'L7o5 �H,xP`ao-J 7.72 ABSORPTION FIELD Phone: 6,� _ .35� No. of Bedrooms: 3 ❑Deep Trench El Shallow Trench Bed ❑Mound ❑Other LEGAL DESCRIPTION Soil Rating®+�7 Total Depth from original grade: 7"' GPD/S. Ft. J � Lot: Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe 3 1yc�j us 1— 5.7 Ft. C7), 5 Ft. Township: c' Range: Section: Fill added above original grade: Ga Ft. Gravel length: 4--4 Ft. WELL: =x1� New G 11 Upgrade Gravel width: 3n FL Number of lines: 4' Distance between lines: � Ft. Classification (Private, A,B,C): U" rL Total Depth, 7 C Ft. Cased To: I g14D Ft. Total absorption area: SQ. Ft. Pipe material: Pvc. 30-34.- 034^DP/L Driller: riller: iVte GIJ ","3,S0 -^J Date Drilled: � 8 ¢ Static Water Level: Ft. Installer:/-�rr� bJ+9X_ �-OA3-67 - Date installed: / `I � 7 J gL Yield:Pump Set at: Casing Height Above Ground: TANK GPM Ft. Ft. SEPARATION DISTANCES El Septic ❑Holding XS.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: &V,1I- Capacity in gallons: le From Tank Field Station Tank Sewer lines r�jt/ (yLL�L'GJ -50 Well j o. i2Co 1/0 Material: Number of Compartments: Z rAA71W,0 94101Y Surface LIFT STATION Water— I(=rot- IOc,`} -- Lot Line �� �� �� — Size in gallons: ILv Manufacturer: kvc-f- OltCv/gzO "Pump on" level at: "Pump off' level at: High water alarm at: Foundation�.Z f I _� �$I 2 Curtain Pump Make 8 Model Electrical Inspections performed by: Drain ca2Lc%G� BENCH MARK Remarks: Location and Description: ->b' r-t� L� R.- 4J L-A-@> Assumed Elevation: Ft ENGINEER'S SEAL � ��;••°peY9�P�q';"�R���ye•o Q"A YY lr�sx Inspections performed by: Dates: 1st i" �i t ••� 2nd 7 /z .9 610aMMMpolo" 0oe David R. DayJoa Department of Health and Human Services approval ��6i NO. 2295-E •; �� CS=�i�— Date: ,944 g�4`�110'.fEsgi�N PRO F%ow Reviewed and approved by: 72-013 (Rev. 9/91) MOA 25 .ev m c-��;=/_S�//-3cl -GV41P�J& TILS A -i '57- to' A-2 4z.7' A-3 65,0' ,4-4- 98,1 5-1 33.7' 13-z _40.0' UN D&0 tl`L5 D ��vrJ ISG � v �jt: W G2 V P G -i r�.Ar DavidfR. Dayton P.E. HC 78 Box 1026 Chugiak, Alaska 99567 3/3 Permit No. 15 W —Z gpoc�j Page t- of 3 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report LOT 4- �K �- �;��� �`mM PID No.: 00- !F// -;3P I anal f�asr.rintinn� � Ii�ou �hF. r✓/p"/ TogFs ELcG� a 16J - I - I _ q7b Tc1'riTt+a.` cyz P 1VGI �� �TL-P -'hNtL 1S BUILI 72-013 A (Rev. 9/91) MOA 25 1NZv�"cw^1 3 Z' OV°��tcrtE.t Fl.�rt. '—'IsAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE / 5, DEPARTMENT OF HEALTH AND HUMAN SERVICES %- P.O. BOX 196650, 825 "L" STREET, ROOM 502 ---�" ��------- ANCHORAGE, ALASKA 99519-6650 3U Q�h ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT 1-15 - y a PERMIT NUMBER:SW920061 DESIGN ENGINEER:DAVID R. DAYTON, P.E. OWNER NAME:BENSON STEVEN J & OWNER ADDRESS:22705 SAMPSON DR CHUGIAK, AK 99567 PARCEL ID:05181130 LEGAL DESCRIPTION: SAMPSON ESTATES BLK LOT SIZE: 40117 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 3 LT 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED: 4/17/92 EXPIRATION DATE: 4/17/93 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 FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ISSUED BY: ��. `� �+•�a, . �sti 232 , j , ��-�.-�-�,Qv . DATE: DATE: 0 3oA� cv rJ 12 ri G o�'v Ua LoT 4rte-. 3 SA-w.�SorJ � r�T Ciris�. David R. Dayton P.E. FIG 78 Box 1026 Ghuglak, Alaska 99567 -rye Mo -O David R. Dayton P.E. HG78 Box 1026 Chugiak, Alaska 99567 n�nl A e David R. Dayton P.E. HG78 Box 1026 Chugiak, Alaska 99567 i�1,ry r bo r4-,, 7-;5 V- 4?_' T. �- az, Ccs int �Tz 12- ' i2 F -s t � 4-r- t4gi-p S, OiGt� z 61,41 5 David R. Dayton P.E. HC 78 Box 1026 C"ugiak, Alaska 919567 4 �--A- o C ---C12- 'at L Z5:- 2"" SU 10 i o�`i � �v w �rt-w- �2z�p DS 4� •�c� �kc��a i CD iL z- cls L Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR:,,?F�y��c;ao.J DATE PERF LEGAL DESCRIPTION: Lzr 4 6 3 5:A Aps4,j 0;;� Township, Range, Section: �; .T ! j /j 2 Z -w SLOPE SITE PLAN DEPTHF„Arw�> I I I I I (FEET) _ 1 2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18 19 20 COMMENTS Vz -" �Ti "iJ`o irr 'S -'w y n WAS GROUND WATER A' / ENCOUNTERED? /`�'=� S L O —P— E . 7 % — IF YES, AT WHAT DEPTH? Depth to Water After Monitoring? 01149 Date: 11 Reading Date Gross Net Depth to Time Time Water Net Drop PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT PERFORMED BY: '�' ` -�'Y� I TIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) Municipality of Anchorage A' DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST ( PERFORMED FOR: -�5—rVVC=' )--D07 �tVA -' DATE PERFORMED: LEGAL DESCRIPTION: (4-6-3 -lv su�-) [Sr Township, Range, Section: 5ee. :3 ,`F I5 /-J, %?) w S- wxl DEPTH SLOPE (FEET) 0C,-GN'"��11 w -S 4 - 1 —::571 cry 2 l�T�l✓' k�� 3-r ury ���!D 5 6 L Ggwrvv�L 7 8 9 10 WAS GROUND WATER ENCOUNTERED? O 11 IF YES, AT WHAT DEPTH? 12 Depth to Water After , / Monitoring? /t/a Dale: 7 14 15 16 17 18 19 SITE 2 Tl'!tr Gross Reading •®ate' Time Net Time Depth to Net Water Drop / 0 3 iZ pit, Z3� 20 20 t—j PERCOLATION RATE --I-qL— (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT COMMENTS CRL fvLx r�z j� �C�i tit !L3� PERFORMED BY: �`� I / CERTIFY THAT TH !p TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Az' 72-008 (Rev. 4/85) 72-013 (Rev. 3/78) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION / - ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE EW r G -/-/r/Yt oZ % y 0 /.1 6 ❑ UPGRADE y, 7� MAILING ADDRESS p`T J LEGAL DESCRIPTION Lf ellt- 5'1 A ><e r Ti S- ti 3 -3 .Fe C LOCATION NO. OF BEDROOMS 0®� 2LO�-'r c e__ rc 3 Uy DISTANCE TO: Well /OD Absorption area / Dwelling PERMIT !!TT P z W < Manufacturer Gree ,- Material S7�e No. of compartments v! Liq. capacity in gallons ODD IF HOMEMADE: Inside length Width Liquid depth C7 DISTANCE TO: Well Dwelling PERMIT NO. _ FQ- Manufacturer Material Liquid capacity in gallons p w= DISTANCE TO: Well / Dov Foundation / 3 3 Nearest lot line 7 PERMIT N0. �y D �f9 3 J E z No. of lines Length of each line / Total length of lines / Trench width —30 Distance between lines P z w I d ,S Q inches cc CC Top of tile to finish grade / Material beneath tile Totaleffective abs ion area /f inches Length Width Depth PERMIT NO. w G Q F Type of crib Crib diameter Crib depth Total effective absorption area w °- w N Well Building foundation Nearest lot line DISTANCE TO: J Class Depth Driller Distance to lot line PERMIT NO. J LU DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS A routr.Q LfS*n t �; [/ SOI L TEST RATI NG INSTALLER /�. t REMARKS K o cl o • ,® OF A/q lk ®� . �S c ' • ,• �': LdbI�� / P' I#A oar • 3' l� B1 /1rC /�'9• .• y;_,_, 013 •• LI T.DEF ONT o. 2225-E • p';d {' `. JUNE 25, 19/1 EWI O L I R TE TION P ag �c ia_Z� APPROVED DATE LEGAL / �Gi 72-013 (Rev. 3/78) MUNICIPALITY OF ANCHt,..AGE DEPARTMENT OF HEALTH AND EIRONMENTAL PROTECTION I NV� 825 L STREET., AN AK 99501 264-4720 PERMIT NO: DATE ISSUED APPLICANT ADDRESS: 0 - I-=. I TIS fIr F= w F= p4l F= I I 84049-S 06/20/84 CONTACT PHONE LEGAL GSE SCR IP LOT SIZE: MAX BEDROOMS Fnlr_=Fpljr-1 T _r SHASTA CONSTRUCTION BOX 773294 EAGLE RIVER, AK 99577 694-5195 SUeDiVISION: SAMPSON ESTATES LOT: 4 SECTION: 3 TOWNSHIP: 15N RANGE: 3W 1A fSQ. FT. OR ACRES) 3 LISTED BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR SITE. BLOCK: 3 YOUR SEPTIC - - - - - - - - - - L -J- E.-xF;?F=i 11 4.0 3 .3. 5 7.5 5. 0 79.0 58. 5 1, 000, 0 243 2 % GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (LICIT EXCEEDING 75 FT. EACH) TANK MUST HAVE AT LEAST T140 COMPARTMENTS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - CERTIFY THAT: 1. 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS As SET FORTH BY THE MUNICIPALITY OF ANCHORAGE 0-10A) AND THE STATE OF ALASKA. 2. 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS. - AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK DISTANCES OOM 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 _7 BEDROOMS AND ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOR 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. 516NEDDATE: -------- APPLICANT: SHASTA CONSTRUCTION ISSUED BYDATE: .. .... ------------------- __ . -r FRO E= 8 -4 0 Ev FEE E:--* DEPTH TO PIPE BOTTOM +FT.) 4.0 4.0 GRAVEL DEPTH (FT.) 7.5 0.5 TOTAL DEPTH (FT. 1:1. 5 4.5 r iRAVEL WIDTH (FT. 2.5 - 23. 0 GRAVEL LENGTH (FT. 49.0 44.0 GRAVEL VOLUME (CU. YDS. -'E•. 2 37.4 TANK SIZE (GALS) :1, 000. 0 :1, 000. 0 SOIL RATING (SQ.FT. /BR) 243 224 BLOCK: 3 YOUR SEPTIC - - - - - - - - - - L -J- E.-xF;?F=i 11 4.0 3 .3. 5 7.5 5. 0 79.0 58. 5 1, 000, 0 243 2 % GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (LICIT EXCEEDING 75 FT. EACH) TANK MUST HAVE AT LEAST T140 COMPARTMENTS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - CERTIFY THAT: 1. 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS As SET FORTH BY THE MUNICIPALITY OF ANCHORAGE 0-10A) AND THE STATE OF ALASKA. 2. 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS. - AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK DISTANCES OOM 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 _7 BEDROOMS AND ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOR 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. 516NEDDATE: -------- APPLICANT: SHASTA CONSTRUCTION ISSUED BYDATE: .. .... ------------------- __ ❑ SOILS LOG MUNICIPALITY OF ANCHORAGE I +� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOGS— PERCOLATION TEST $h/5s,'�'4 C'dtigtr•xc'f'ia7v PERFORMED FOR`tJ�"' 7 4j� 3 Si"� soy ,x 1� !(�'r DATE PERFORMED: LEGAL DESCRIPTION: t`— t u SP_c 3 DEPTH ;' < T SLOPE SITE PLAN (FEET) �� C�rG ��/ I I mmmmmmmmFAIEI i 2 3 4 5 6 7 ve 8 9 10 11 12 13 14 15 16 � _, � _0o ie- /S r CF A R •�i• •esoo•�,, 18 f• L}(ATii+ (u 0 0 e j? ,• ............ 19. E'.,. �• 2225-E `n;P y(Y" I NE 25 1971 WAS GROUND WATER n S ENCOUNTERED? 1V L O P E - `IF YES, AT WHAT DEPTH? Reading Date Gross Time Net Time Depth to Water Net Drop / /, ■■■■■■E,■I■ ■0Nzaf-,l1r0"WHI■ ■100MMUNNNE 11■!r INNER ■I■fi'111 eZ ANN==00 fii NARNMEME W-01011MR-1 lNMEME■ ■I■E■■■■■■■ _? 11MMEE■■■■■ 7/ e d' 9 A0 . S 1 Reading Date Gross Time Net Time Depth to Water Net Drop / /, SocaK pe rI<Q eZ 7/ _? 7/ e d' 9 A0 . S 1 4v37'� 20 d�Y�,F..••.....•' ,'9�a PERCOLATIONRATE�i3 Sbaolj Ksire( �3 (minutes/inch) TEST RUN BETWEEN 7 FT AND 4L._ FT COMMENTS p'f'7'C, L!a jt' U /G17Q kh 9/4 .("f Gio G� 6 tcm-1 ha le - PERFORMED BY: fZ-••'S-moi CERTIFIED BY: 72-008 (6/79) S DATE i MUNICIPAL DEPT. 2FHE/' 16. WATER WELL CONTRACTORS CERTIFICATtnu- —' Typo• Dlamehr: _ .SIOI/Meeh _ Size Length: - Sol between _ ft, and ft. Backfilling Gravel pack _ r C.'OAn 10. STATIC WATER :.EVEL: ff. „f _ Ej Above ol- El Below land surface - Date Equ i pmenl used: 1 7— II, PUMPING LEVEL. -below land surface and YIELD It. oiler hro. pumping -- ft. _oiler - hre. pumping a•p•m. 12 -GROUTING - Well Grouted: - ❑ Yes ❑ N.a Material: ❑ Neat Cement C] Other: 13. PUMP: (if available) - HP Length. of Orap Pipe - ft. capacity - g.p,m �j Subm, Jet ❑ Centre elect ❑ Other 19,- REMARKS: Production 'of 15 GP'M - C I a WATER WELL RECORD STATE OF ALASKA DEPAR i MENT OF NATURAL RESOURES Divlsiol. of Geological a Geophysieol Surveys .:.LOCATION OF WELL (Piens• Complelo either lay Ibor le.) - ' 0r111inp Pars 11 NO. - - Borough ;71c. -Subdivlelon Sa(npson Lat �._/a_gtrs. Block-� -A.O Ib, IAnch Saelion No. TownfhlPN❑ Le:flo., rr Rt lgf E❑ N.r101gn—of..._of._of_.SQ AND DIRECTION FROM�ROAD INTERSECTIO14S WO1DISTANCE 3. OWNER OF WEI L: MrRay Pelletier_>` Aadr�ee: Shasta Construction - Strsoi Adcress-.,cnd Arco `!of Well•Locotion-�-' - - _ - 'Axe ch C?irr�g e,•; AR 2. WELL`LOG Foot Below - - -I !.l cleric t-. Type Surface '..Top 4, WELL LAA -DEPTH: ( Ina" 1`F� fl. �. S. DATE OF rC�OMPLETION Grave!, soil, .`--Bottom 6 20 _ - —0 3 Gdallu. ❑ Cable tool--- RalorY - ❑ Driven -_ CO] Dug --fir--- - f G2—? ve f -�'!a er - --{'��• -❑-.Auger - Dialled..-CBerod-�OOIMr: _ f cTr va e U.I. sand `t7 7, USE DamestoPublle Supply O DD Y ❑ industry —gave , gray an ❑Jrrlga: on' 0 Rrdharg• 0 Commerical - ! f san s' -z6 --�� Teat% -11 - - O pother: Gravel, san Itwa et r �1 i 0. CAS NG ❑ 1404 }� Waded - •1 diem. lie. to _ __Weight Depth Weight 17 1be./h: - - - diem, In. to __ if. 006111 • Sllckup - 1 -- -. '-- 9, FINISH OF WEL-'• - i MUNICIPAL DEPT. 2FHE/' 16. WATER WELL CONTRACTORS CERTIFICATtnu- —' Typo• Dlamehr: _ .SIOI/Meeh _ Size Length: - Sol between _ ft, and ft. Backfilling Gravel pack _ r C.'OAn 10. STATIC WATER :.EVEL: ff. „f _ Ej Above ol- El Below land surface - Date Equ i pmenl used: 1 7— II, PUMPING LEVEL. -below land surface and YIELD It. oiler hro. pumping -- ft. _oiler - hre. pumping a•p•m. 12 -GROUTING - Well Grouted: - ❑ Yes ❑ N.a Material: ❑ Neat Cement C] Other: 13. PUMP: (if available) - HP Length. of Orap Pipe - ft. capacity - g.p,m �j Subm, Jet ❑ Centre elect ❑ Other 19,- REMARKS: Production 'of 15 GP'M - C I a Municipality of Anchorage • Development Services Department p a Building Safety Division On -Site Water and Wastewater Program s s E 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I. D. 051-811-30 COSA # 05Z i21'b'1'I Expiration Date: //" �2 q _" /2 1. GENERAL INFORMATION Complete legal description Sampson Estates Block 3 Lot 4 Location (site address) 22705 Sampson Drive, Chugiak, AK 99567 Current Property owner(S) Benson Steve Day phone 229-5370 Mailing address same Lending agency Mailing address Real Estate Agent Mailing Address Day phone Partners Real Estate- Brandon Day phone 694-4994 Partners Real Estate of Eagle River Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of 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 septics stems are subject to these various and dynamic characteristics and are outside the control of the �m evaluator of the well and septic system. � a'E, 4 6. DSD SIGNATURE AZ Approved for Disapproved. . Conditional approval for Attachments COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory bedrooms. bedrooms, with the following Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other �............ Steven W. "Eng WATER By: Original Certificate Date: (Rev. 11105 A Municipality of Anchorage e • Development Services Department Building Safety Division On -Site Water & Wastewater Program 2 "" 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 3 t. f Legal Description: Sampson Estates, Block *Lot A Parcel ID: 051-811-30 A. WELL DATA- Public Water Well type P If A, B, or C provide PWSID # _ Well Log (Y/N) Y Date completed 6/20/84 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth 144 ft. Cased to 140 ft. FROM WELL LOG Date of test 9/24/84 Static water level Unk ft. Well production 15 g.p.m. WATER SAMPLE RESULTS: Coliform Pass colonies/100mL Nitrate 4.61 mg/L Casing height (above ground) 24 in. AT INSPECTION Arsenic: 1.14 ug/I Date of sample: 7/23/12 Collected by: nr B. SEPTIC/HOLDING TANK DATA 7/23/12 Tank Type/Material STEP/Steel Date installed 7/15/92 Tank size 1250 gal. ft. g.p.m. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) Y Date of pumping 8/15/12 Pumper iR's C. ABSORPTION FIELD DATA Date installed 8/16/12 Soil rating (g.p.d./ft2 or ftz/bdrm) 0.4 System type Bed Length 75 ft. Width 15 ft. Gravel below pipe 0_5 ft. Total depth 4.5 ft. Eff. absorption area 1125 ftZ Monitoring tube Y Depression over field N Date of adequacy test NEW Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test na in. Water added na gal. New depth na in. Elapsed Time: na min. Final fluid depth na in. Absorption rate > na g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NO If yes, give date = D. LIFT STATION Date installed 7115192 Size in gallons 1250 Manhole/Access (Y/N) Y "Pump on" level at 43 in. "Pump off' level at 40 in. High water alarm level at 44 in. Datum tank bottom Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 1001+ Absorption field on lot 100' + Public sewer main NA Sewer /septic service line 25'+ Animal containment areas 50'+ Meets alarm & circuit requirements? Y On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout NA Holding tank na Manure/animal excrete storage areas 100'+ 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 1001+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /Q t Building foundation 10'+ Water main na Water Service line 10'+ Surface water. 100'+ Driveway, parkinglvehicle storage 10'+ Curtain drain n/a Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that l 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 $ ar�D •Ott l Date of PaymentI r? 11 a C Receipt Number 0 3frl 1 C. (Rev. 11105) Waiver Fee $ Date of Payment Receipt Number . .............. Stevan W. Eng �`,�� A: 3�� S L' " I r R' 1 ry FeJq�'hG. 4 -7 AS -BUILT F hereby certify that I have surveyed the following described property cel v) yr } to c P 3 I .F A.� 14 t'" Anchorage Recording Precinct, Alaska, and that the improve- ments situated thereon are within the property lines and do not overlap or encroach on- the property lying adjacent thereto, that no improvements on property lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated at Eagle River, Alaska the :1: � __ day of ROBERT C.tJOHNSON -A SCALE. Registered Land Surveyor No. 8SAS r y �` Box 77-0456, Eagle River, Alaska 49577 Phone (907) 6942543 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 Ju— lY 17 , 1986 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 4 Block 3 Sampson T15N R1W Sec. 3 Location (address or directions) (b) Applicant Name Julie Lapierre Telephone: Home N/A Business N/A Applicant Address 1736 Toklat St Anchorage Alaska 99508 (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ® ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution 1st Nat' 1 Bank of Anch. Telephone 694-2013 Address P.O. Box 770548 Eagle River, Alaska 99577 (e) Real Estate Company and Agent Re/Max Lee Walker Address P.O. Box 772849 Eagle River Al aska 99577 Telephone 694-4200 (f) Mail the HAA to the following address: P; ckuTYy engineer 2. TYPE OF RESIDENCE Single -Family ® Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well ® 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 ® 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. 72-025(11/84) Page 1 of 2 5. ENGINEERING FIRM PROVID, , INSPECTIONS, TESTS, FILE SEARCH, L �A 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 Telephone Address EAGLE RIVER ENGINEERING SERVICES 5 �5b EAGLE RIVER, AK 99577 Date 0. BOX 773294 694-5195 AZ oct 9 •Ee° � o RrS� ` O ,A y� r�c bp°op op ooe oo°°o v°oe'O °C� <f?' ` ° Loin Ab�Ju�tera °o ''l gineer's Seal �. 1� 0°°ooaooeoD9°C <:e7 6. DHEP APPROVAL d� Approved for %IJP bedrooms by Date lL Approved 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 (17/84) MUNICIPALITY OF ANCHORAGE (MOA1 HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: 45s ft -`FES 'r /5'N /e tvi S4 c 3 A. WELL DATA Well Classification t)14 TF_ If A, B, C, D.E.C. Approved (Y/N)WIA Well Log Present (Y/N) y Date Completed 6 - -f;)- z:)'-. zt Yield }7 6%/'"` 7-e-5 A:! -,w v Total Depth /moi-/ I Cased to /'" r ✓ Depth of Grouting /v 1-4 Static Water Level F.;Zo ' rg ;7 , C, Pump Set At f3� rr.~ Casing Height Above Ground a r Sanitary Seal on Casing (Y/N) Y Electrical Wiring in Conduit (Y/N) i Depression Around Wellhead (Y/N) !U Separation Distances from Well: To Septic/Holding Tank on Lot (dor ✓ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ¢'°� ; On Adjoining Lots To Nearest Public Sewer Line /''1h To Nearest Public Sewer Cleanout/Manhole NIA To Nearest Sewer Service Line on Lot s Water Sample Collected by �` ` c S'^ ��r" ;Date %-/ Water Sample Test Results r y Comments B. SEPTIC/HOLDING TANK DATA Date Installed / % `/ Size / 000 4 a 1, No. of Compartments a Standpipes (Y/N) x Air -tight Caps (Y/N) i Foundation Cleanout (Y/N) J Depression over Tank (Y/N) /t/ Date Last Pumped sr e Pumping/Maintenance Contract on File (Y/N) A-� ; for N/A Holding Tank High -Water Alarm (Y/N) TemporaryHolding Tank Permit Y/N) I fIA 9 Separation Distances from Septic/Holding Tank: To Water -Supply Well /O0 To Building Foundation r � To Property Line -t/O To Disposal Field G To Water Main/Service Line }'L' To Stream, Pond, Lake, or Major Drainage Course I-) C, Comments _fzs�ZAe,*e .%a `T �,: sr a� �Qi �av� �Z4s/a6 Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed y 9, w " Width of Field 3 3 4Z�/ Z Square Feet of Absorption Area 75_0 Depression over Field (Y/N) /V Results of Last Adequacy Test S 4t's �` �v�r7 Abs- < 4 J­iaY, rwde /Ii, Separation Distance from Absorption Field: To Water -Supply Well �y 0a To Building Foundation 33 Lot N/A To Water Main/Service Line ' �O To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field Depth of Field Gravel Bed Thickness 1• S Standpipes Present(Y/N) i Date of Last Adequacy Test 7- /g D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments To Property Line L2J To Existing or Abandoned System on On Adjoining Lots / -3'D To Cutbank (if present) /U Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed cJ�� Date Company F_4a 4_ /eMOA No. Receipt No. Date of Payment '� �L•a Engineers Seal Amount: $ EAGLE RIVER ENGINEERING SCRVICES- EAGLE RIVER, AK 99577 Page 2 of 2 P. 0. BOX 773294 1. 1_;:; 694-5195 C. !'. S i3 , 72-06 (11/84) d CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street its - n Anchorage, Alaska 99518 ` Mft'v Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY ❑ PUBLIC WATER SYSTEM I.D.# Analysis shows this Water SAMPLE to be: M PRIVATE WATER SYSTEM Satisfactory Name 'AGLE RIVER ENGINEERNG SEPPVtI%EeSNo- EAGLE RIVER AK 99577: Mailing Address P. 0. WX 773494 694-5195 , City , State Zip Code SAMPLE DATE: Mo. Day Year SAMPLE TYPE: Routine ❑ Check Sample (for routine sample with lab ref. no. } ❑ Treated Water ❑ Special Purpose ❑ Untreated Water SAMPLE Time LOCATION Collected Collected By Lot y ak 3 11:00 -_ iI { 4 5 READ INSTRUCTIONS BEFORE COLLECTING SAMPLE ❑ Unsatisfactory ❑ Sample too long in transit; sample not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received :z' /vliQ-96 Time Received " z &00 Analytical Method: Membrane Filter " No. of colonies/100 ml. Lam R BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter. Direct Count Verification: LTB Final Membrane Reported By TNTC = Too Numberous To Count OB = Other Bacteria i Analyst Coliform/10omi GB d Coilforml100m1 DA7,6 Time: p.m. 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 h r 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Zo7' � �1* �rrm �r., Es �'%S 7-19 it/ w Scc 3 Location (address or directions) iii/ i.2 /N �. r,r r�rp e k /I�t•r%G SGi dri�sdra741 o/5 -G (b) Applicant Name S��s7`� �' ��' Telephone: Home -D�� �-i 5" Business �d R—d -2--1 S— Applicant Address es �� �� �� 6lood�o= ` SS`o -7 (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution ���� Telephone Arlrirocc a (e) (f) Real Estate Company and Agent Ar' Address Le %e` A � Telephone C2'/ S S S Sm Mail the HAA to the following address: TYPE OF RESIDENCE Single -Family Multi -Family El Number of Bedrooms Other zf j., l�lwe l/ C - /--e, lis`?7 3. WATER SUPPLY Individual Well 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'Fw 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 (11,84) s 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. 1 further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this insp U'RIVER ENGINEERING SERVICES Name of Firm EAGLE RIVER AK 99577 Telephone Address P. 0. BOX 773294 Date ss vim Engineer's Seal 6. DHEP APPROVAL Approved for bedrooms h -" Date r P• " a Approved ,�� 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 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) ®3A I J38 CHECKLIST - FEBRUARY 1984 264-4720 tif?j AM, Legal Description: LD f .? S� ,F1 7,4 7- 3 j4Z ,��jATaIANg �OHJNb dO 3� unvd0INriw Well Classification 1 r/A %F If A, B, C,, D.E.C. Approved (Y/N) yl� Well Log Present (Y/N) Date Completed 46 m00% y Yield Total Depth /41y Cased to /4/o el Depth of Grouting Iv/4 Static Water Level y0T /ne4rk.ed �" z� Pump Set At Q� Casing Height Above Ground r N Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot 1019 4 - Depression Around Wellhead (Y/N) ; On Adjoining Lots — To To Nearest Edge of Absorption Field on Lot /ao ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole ti"'ie To Nearest Sewer Service Line on Lot a� Water Sample Collected by G h5�tiee ; Date Water Sample Test Results T4 O fOY b Comments B. SEPTIC/HOLDING TANK DATA V Date Installed "%f% Size ���U G�� No. of Compartments Standpipes (Y/N) y Air -tight Caps (Y/N) _/- Foundation Cleanout (Y/N) v Depression over Tank (Y/N) /U Date Last Pumped Pumping/Maintenance Contract on File (Y/N)//� ; for Holding Tank High -Water Alarm (Y/N) N/� Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: ToWater-Supply Well �Do f To Property Line �d To Water Main/Service Line Course tio„ e Comments Page 1 of 2 72-026(11/84) 72-026(11/84) To Building Foundation i To Disposal Field 6 To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 17,541 Juh Width of Field 30 ' ::� N3 0/d' J"' Type of System Design Tr P`' `-� _Q 46 Length of Field Depth of Field Gravel Bed Thickness 7' / Square Feet of Absorption Area / S Standpipes Present (Y/N) Depression over Field (Y/N) n) Date of Last Adequacy Test 7r Results of Last Adequacy Test AA- 6cJ J tr4, t'-`. Separation Distance from Absorption Field: To Water -Supply Well To Building Foundation I nt 1VJ)1t_ To Water Main/Service Line 16 To Stream/Pond/Lake/or Major Drainage Course _ To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION y/ Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments To Property Line '1�o To Existing or Abandoned System on On Adjoining Lots 30 ,t - To Cutbank (if present) yQY,e Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I ha v checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Date Company MOA No. S 7— Receipt Receipt No. 7� S--,% 553 Date of Payment 5 16 Amount: $ apo "v!� Engineer's Seal Page 2 of 2 72-026 (11/84( voo°nca acon�v ��c�o o°000 av c^o co VI �. 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