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SAMPSON ESTATES BLK 4 LT 2
Sampson Estates Block 4 Lot 2 #051-811-07 �BIUL m COLE SP.O.Box 670269, Chugiak, ULLIVANWATER WELLS www.sullivanwaterwells.com Pump Installation Log Well Drilling Permit Number: SW Parcel Identification Number: Date of Issue Legal Description Sampson Estates Block 4 Lot 2 Property Owner Name & Address Julie Marcey 22706 Sampson Drive, Chugiak, AK 99567 Pump Installation Date: 7-23-15 Pump Intake Depth Below Top of Well Casing: 133 feet Pump manufacturer's Name: Goulds Pump Model: 10HS07412CL Pump Size: 3/4 hp Pitless Adapter Burial Depth: 11 feet Pitless Adapter Installer: Unknown Disinfected Upon Completion? ® yes ❑ no Method of Disinfection: Chlorine 50 PPM Comments: Pump Installers Name: Sullivan Water Wells Attention: The pump installer shall prnvide a pump installation log to the DSD within 30 days of pump installation. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES r, _ F �1 ._--Q 7 Environmental Health Division V / 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name / 'tt 1, 0 DISTANCES Address oZ r/✓ & A4 qr�/u�.� 954 3 Phone(s) I Permit No. No. of Bedrooms a27/—Lt3ua, jzvd�/� 3 FROM TO WELL SEPTIC TANK ABSORPTION FIELD WELL fo? LEGAL DESCRIPTION Lot r� I Bloc)k� 'Subdivision 4✓Yvl/QS'✓.14 LOT LINE �/o r Township, Range, Section 7-76-1"/ ,e -3 r Sz< FOUNDATION 2or S E / 17.5-- TANKS s TANKS ® SEPTIC A, 4, 'Ft. ❑ HOLDING Manufacturer Capacity in gallons /.Z. S>' Material 5' e, No. of Compartm coup fr A 15't sKe-/ TYPE OF SYSTEM ❑ TRENCH 6d BED ❑ W. DRAIN ❑ OTHER Depth to pipe bottom from original grade FT Total depth from original grade FT Fill added above original grade FT Gravel depth beneath pipe 6 `I -FT Gravel length 3 FT Gravel width A- FT Total absorption area Number of lines ,,bed3 ere" SQ FT Soil rating /$ ' SQ FT Distance between lines 6 / FT Pipe material %ls3.)3'j FE/d" Installer C v L)c Date Installed 7h,-74,,4. WELLS I PRIVATE r• ❑ OTHER (Identify) Classification (A,B,C) Total Depth FT Cased to FT Installer Date Installed: AS -BUILT DIAGRAM (Show location of well, septic system, property lines, foundation, driveway. water bodies etc.) N t TA rH r¢f REMARKS: 0 L /6'c1 /Se,/ / /4c, ece -- -- /e v --el .> � S- tri {v a n-,, • tar in 7"- Scale: /✓.'f.s , Inspections Performed by: Eagle River Engineering Services Cr F f P. 0. Box 773294 Date: Eagle River, AK 99577 /'r.,-` '- 1^r,.i S� /r<e..�se�{ /=lec-�- CX-/ /-�-� ; ?Az" 694-5195 -I Y') certify that this inspection was performed according to all Municipal and Stale guidelines in effect his data Health Department Approval: y 174.7P' ' Date. Lcuiz ,`,. I;uferci o rte' 72-013 (3/85) MUNlC1RALl |Y ANGHUkAGE Department of Health & Human Services 825 L Street, Anchorage, Alaska 99501 343-4720 ON~S1TE SEWER & SFpTIC TANK PERMIT •Permit Number: 900216 Upgrade ~'CYlca\lAD Date Issued: 07/25/90 Engineer Designed Owner Name: HUD Owner Address: 222 W. 81H AVE. MCH, AK 99813 Parcel Id: 051~811-07 Lot Lgal: Subdivision: SAMPSON ESTATES Lot: 2 Block: 4 Section: 3 Township:• 15N Range: �W Lrt Size �C���(��"�t. or acres) Max Bedrooms: This Permit: 3 Total Capacity: 3 Day Phone: 271-4342 SEPTIC TANK: Minimum total septic tank capacity: 1,000 gallons' Each septic tank must have at least 2 compartments, Depth to top of septic tank(s) < 4.0 feet requires insulation over tank(s), THIS UPGRADE BED CAN EITHER BE INSTAL/ED AT A TOTAL DEPTH OF TWO FEET WITH A TWO FT, SAND FILTERING LAYER UNDER THE GRAVEL BED, OR GROUNDWATER MONITORING CAN BE CONTINUED UNTIL 10/15/90, A LIFT STATION REQUIRES AN ELECTRICAL INSPECTlON, DHHS MUST BE NOTIFIED PRIOR TO EACH INSPECTION. THIS PERMIT IS FOR A THREE OR SINGLL FAMILY RESIDENCE ONLY, AND EXPIRES ON 12/31/90" I CERTIFY THAT: 1. l am familiar with the requirements for on-site sewers and wells as set [orth by the Municipality of Anchorage (MOA) and the State of Alaska" 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. 3^ I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot" 4. I understand that this permit is valid for a maximum of J bedrooms, l a1so understand that the capacity of the total system is 3 bedrooms and any enlargement will require an additional permit" Signd: ~,M ~ � � ���' ���^��� ��� �� ,- ����7` �'' '^ 7~ 2 &/-- /,13O/2,/1^ No Wells +100' No Wells a; +100' NO KNOWN STREAMS +100' NO KNOWN CURTAIN DRAINS 10' Utility Easement {B — TEST HOLE • — MONITOR TUBE o — SEWER CLEANOUT ▪ — WELL +F144141lF - PROPOSED LEACHFlELD --- — EASEMENT SEPTIC SITE PLAN LEGAL: Sampson Estates Sub. Lot 2, Blk 4 OWNER: H.U.D. Properties CONTRACTOR: N A JOB # 89-137 DATE: 07/16/90 SCALE 1" = 50' AEAGLE RIVER ENGINEERING SERVICES P.D. Box 773294 EAGLE RIVER, AK. 99577 (907) 694-5195 FAX: (907) 694-3297 0 c�o-CB99oll ttn �. ,y p oa LID 6,3ee3 •! L.0�s.G.. 2utd735 rU ry a �Jf/ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: //ifd igt PERCOLATION TEST DATE PERFORMED: 7" 3 %v LEGAL DESCRIPTION: L/',- '2 /K v Sy.r,/o,ra, 6r1 'e / /S'r✓ 3 SLOPE SITE PLAN r • / 1' L✓/�/G�Be/ sr4 ✓E / yrEY rna•St 0CI0C-00 Geo CE -672 `> `0.. 20 – COMMENTS r WAS GROUND WATER YES L 0 P ENCOUNTERED? IF YES, AT WHAT DEPTH? /.,. •• , tr.tq 7 .[d2 E 40' L n( s 0 Reading Date Gross Time Net Time Depth to Water Net Drop -. Sissr / 7//a //OA, ?_.rte,, /4,-..„:,3 y _7 'fib /'% a / tf;a 9 /o,,,,,,, / ,, V 7 /a // s / /6 3 / y : 17 : 3 a /D y., , .;, 3 •'--7 % � y�/c n W. /// Z_a /a "'ie.,3 ' 7 '/C / /. S/Is „ PERCOLATION RATE AI // 2 •Y, ,,•• ?' 7 'J,6 / 6//s 7, 6 (minutes/inch) _ /3'o 4444. TEST RUN BETWEEN 3 FT AND FT PERFORMED BY: 72.008 (6/79) Eagle River Engineering Services P. 0. Box 773204 Eagle River, AK 99577 694-5195 CERTIFIED BY: DATE: 7/ 7/49'6 SPECIFICATIONS FOR ON—SITE SEPTIC SYSTEM LEGAL: Lot 2, Block 4, Sampson Estates GENERAL The well and septic plan are for a single family The drawing and or site plan shall be a specification. All materials and workmanship Department of Health and State Conservation requirements. All soil tests are advisory to the design or modified in the field by the engineer. advisory and are to'be verified, contractor to meet Municipality Conservation. residence only< part of this shall meet the Anchorage'•: Department of Environmental All excavations and depths are or modified in the field by the of Anchorage, Department of Environmental requirements. 6. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. and are to be BED 8. The bed is to follow the natural .land contour to mainta'n` uniform total depth of the bed bottom. The bottom of the bed shall be level, plus or minus 1.5". The total depth of the bed excavation is not to exceed 2' at any point. Final bed grade is to be at ground surface after imported material placement. The sewer line is to replace the existing sewer line that leads. to the existing bed. The bed gravel is to be covered with typar fabric material Soil or combination of soil and extruded board insulation to -a depth of 4' or equivalent is to be placed over the leachfield. The area over the bed is to be finish graded to prevent ponding;;` of surface water runoff. The septic tank and leachfield must not be closer than 100'•''.to"__ any existing private well, 150' to any Class "C" well, or 200 feet to any community well. RECOMMENDED LEACHFIELD DIMENSIONS TOTAL DEPTH = 2' GRAVEL DEPTH = 1' BED LENGTH = 38' BED WIDTH = 18' Soil Rating = 150 Bedroom Capacity = 3 Septic Tank Size = 1,250 gal. including lift station **NOTE: **NOTE: LIFT STATION REQUIRED. ANCHORAGE TANK ORENCO PACKAGE. REMOVE. AND DISPOSE OF EXISTING TANK. BURY TANK A MINIMUM OF 5' DEPTH,'.- BELOW EPTH BELOW EXISTING GRADE. INSTALL PVC PRESSURE LINE TO NEW FIELD WITH POSITIVE DRAINBACK` TO LIFT STATION. INSULATE 2' WIDE OVER PIPE RUN. INSULATE LEACHFIELD (2") ADD ONE FOOT MOUNDED COVER. EAGLE RIVER ENGINEERING SERVICES k4401*Lou Butera, P.E. P.O. Box 773294 Eagle River, Alaska 99577 Telephone (907) 694-5195 IJ July 25, 1990 Mr. Robbie Robinson Dept. of Health & Human Services 825 'L' Street Anchorage, Ak. 99501 RE: Lot 2, Block 4, Sampson Est. Dear Mr. Robinson, DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION t, 7 0 199 0 RECEIVED I am requesting clarification of the highlighted note on permit #900216 issued 7/25/90. Are you requesting a total depth at the leach gravel level of 0' (or the ground surface) with 2' sand replacing the topsoil layer? Or are you asking for over excavation of the material rated GP to 4' with 2' of sand filtering layer and bottom of leach gravel level at 2' depth. It should be noted that the soil was perced in the GP layer at 3' depth at 150 S.F./br.. So I would question the need for a filtering sand layer if 4' separation to ground water is the issue. Please provide written clarification. If you have any questions or any further concerns please call me at 694-5195. Sincerely, Louis Butera, P.E. er () I f 1 . �\ �� 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 Jgir)es_S � ne").0td, //? T/1/' 5. / 5 r v /( i PHONE '76-2617 eEW ❑ UPGRADE MAILING ADDRESS / 2 Z// ///!/l/0/C / / 41--i-y-A q7/;J 5— LEGAL DESCRIPTION V LOCATION / ! i -' , m OA iri,%rL NO. OF BEDROOMS 3 SEPTIC TANK DISTANCE TO: Well ' /03 Absorption area Z5-' Dwellin ���� PERMIT NO. 6l'6 966 Manufacturer �Hi7 -C/A /"l p( Materia / No. of compartments Liq. capacity in gallons 06 IF HOMEMADE: Insength __—_.-- Width Liquid depth o 2 Z F DISTANCE TO: Well Dwelling PERMIT NO. Manufacturer ! Material Liquid capacity in gallons -94 �' DO ISTANCE TO: No. of lines? p J l0. fre.i Well /35' A� Length of each line Gam? f Foundation L�.3 r Total le gt of lines ��� Nearest lot line .- 7e01± Sser�eh-a/id#1 D /4004W PERMIT NO. Distance betweenlines /4 / s. -4 >0 - ' �= i'n, X t —n=n%^e3 ... _ Top of tile to finish grade,Material .3,5 beneath tile 4i inches Total effective absorption area 563 S7 SEEPAGE PIT Length Width Depth PERMIT NO. — Type of crib Crib diameter Cri de t Total effective absorption area DISTANCE TO: Well Build] ouvation Nearest lot line Class S/t7/ eesd,rR Depth//7,/i Driller Joe 6,ekr000E,% Distance to lot line Z 3 PERMIT NO. DISTANCE T0: Building foundation Sewer line Septic t�� 3 / Absorption Iql- OTHER i c,9 —C.0 /ti / PIPE MATERIALS AJ1OTpr ,�' D z72 - / ' • ! 44s DWVSC115tJ i \ _ SOIL TEST ATING / ./Z5 -,"rage `-- \ '� C.r) /�, �7.-Y,,N INSTALLER7 /4 RAO (max. z) J/ REMARKS *77412r6I *as 0.0v s yo ii �zs6h�� ,4 Ite no/ sip a, sols i . I 4-/"1�.7"-5H ��AA �b/� A-7 /Cs Ore td f/� / / �� /Xs'/‘7174,41>1/i'QP// 76 ®'3I\1 7..i J3d /�„.i i6-za - yfF; S 6 Cdr _ _ S[i ,-e-Z e fiti . )-1_ `101103-O21d 1 H.L1VAH Td1V3WiJO211M13 AO '.1.PCI It t _ . ° `. 9� L.�6 = IOhQNV 40 JUnY clIOINI1W �. oe•oa° Jam^' �nFy Si ja - /, 0 7 (, •� ,,F 6036 7 N rs c Oat AP D `' ., � 6ATE LEGAL -1 ZQ NA" c:§t10-4 -1:44i/ ----- 79- Mot, 2/781 EAGLE RIVER, ALASKA 338-5312 JOE GIELAROV4 AI DRILLING CO. LIFETIME ALASKAN SERVING ALASKA P.O. BOX 772847, EAGLE RIVER. ALASKA 99577 VNER OF LAND Fenton Construction/ Timmerman Ventures DEPTH OF WELL 141Feet )DRESS 29$5..Gam.➢beil..kaaG.e..Mach..Ak.....99507 3LL - SITE Lot 2 Blk j Sampson Estates STATIC LEVEL OF WATER FT. klEt.....inhol.e..e. DRAW DOWN FT. 95% est. kTE - STARTED ....9/.24/84 GALS. PER HR....660..Ga1.s. per -hots: eat.. bTE - ENDED 924084 KIND OF CASING 141 Ft. of 6inch SCH ;ND OF FORMATION: FROM 0 FT. TO 4 FT..auerburden FROM FT. TO FT. FROM 4 FT. TO 28 FT gaol &gravel FROM FT. TO FT. FROM ....2$ FT. TO ...8,5 FT..gray.el FROM FT. TO FT. FROM ....85 FT. TO ...100 FT..hardpan FROM FT. TO FT. FROM 100 FT TO 120 FT silt FROM FT. TO FT. FROM ....120 FT. TO...1k:1 FT. .sand.,€ravel..&..water FROM FT. TO FT. FROM FT. TO . FT. FROM FT. TO FT. FROM FT. TO FT. FROM FT. TO FT. FROM FT. TO FT. FROM FT. TO FT. FROM FT. TO FT. FROM FT. TO FT. FROM FT. TO FT. FROM FT. TO FT. FROM FT. TO FT. FROM FT. TO FT. ISCL.INFORMATION: Hang pump 5 Feet off bottom. No warranties or warranties implied. DRILLER'S NAME Norman Wilson Milli NO C3:][F?..lek ~1- IF- C311-11IES: DEPARTMENT • C HEALTH AND_ENVIRONMENTAL ' OTECTION • 825 L STREET/ ANCHORAGE, AK :99501 264~4720 • E; -IF fEE E3 EE:Fif IVY IF" �TR:11-1 "T' PERMIT NO: 840888 DATE ISSUED: 10/18/84 APPLICANT: CURT PIERATT ADDRESS: BOX 15000#29 WASILLA: AK 99687 CONTACT -PHONE: 376-6786 LEGAL DESCRIP: SUBDIVISION: SAMPSON ESTATES LOT: 2 SECTION: 3 TOWNSHIP: 15N RANGE: 1W LOT SIZE: 1A (SQ,FT" OR ACRES) MAX BEDROOMS: 3 BLOCK: 4 Listed below are the options available to you•in•designing your septic system" Choose the' option that. best [its your site. • P4 (7: Vi DEPTH TO PIPE BOTTOM (FT.) 4^0 GRAVEL DEPTH (FT.) 8"0 TOTAL DEPTH (FT") `12.0 GRAVEL WIDTH (FT") 2"5 GRAVEL LENGTH (FT.) • ''73.O GRAVEL VOLUME (CU"YDS") 57.5 TANK SIZE (GALS) 1,000"0 ** SOIL RATING (SQ`FT"/BR) 365 ,.� :BEG') :ot���� 4"0 4"0 0"5 3"5 4"5 7"5 .17.0 5^0 34"0 144.0 ** 21"5 106.7 1,000"0 ** 1,000"0 ** :125 ' 445 ** GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH) ** TANK MUST HAVE AT LEASTTWO COMPARTMENTS I certify that: 1. I am familiar with the requirements foron-site sewersand wells as set forth by the Municipality of Anchorage (MOA) and the -State of Alaska. I will install the system in accordance with all MOA codes and regulations` and in compliance with the design criteria :of this permit. 3" I will adhere to• all MOA and State of Alaska requirements for the set back distances from any existingwell, wastewater disposal system or public sewerage system on this or any adjaCent or nearby lot. 4" I•understa:d•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 MOA BUILDING CODES` THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL NOT BE APPROVED WITHOUT ANELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN, SIGNED APPLICANT: ISSUED BY CURT PIERATT / DATE: ^/ DATE: s PERFORMED FOR: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST 1wo Cis eitec el LEGAL DESCRIPTION: 2- 3- 4- 5- 6- 7 - 8- 9- 10 DEPTH (FEET) 11 - 12- 13- 14- 15- 16- 17- 18- 19- 20 - Lot Z 8/k 274 -�eso'7 SLOPE wemmeoa ®F ' A�- • �/c ..4••°•o. a t t.•,r ®te�e ° �:h.:`4 ro H 49Yij c ,-- 4 e 8ae94. 0.0001)00000000004.4",“1 Dee : e 6eb e990 Yso 000eoe,.,_7, cc-=' 4 a James R. Kinney - OA"- ''e° CE - 6036 4 /L® so°osoeoeoso°� Vii, �kggPrW4170X\ > Srf —(5"0 DATE PERFORMED: SOILS LOG (PERCOLATION TEST //7-6. f Scc ge t Juti //U S WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? /4 s Se- /r it/ewf L E see geode-) SITE PLAN See re✓/tius Se Reading Date Gross Time Net Time Depth to Water Net Drop InUJ \-_____, PERCOLATION RATE //, TEST RUN BETWEEN 3FT AND FTJ ,.L/ 'OMMENTS /)�Gi/J L /�7t�, L'6, �--4 %�� � /ya//02fp ��CO/l/r} .(1/%c5,4 //74„.. 1� ' 7 L-�' , 310 _:�eCOwci J ,�//� /6-1 rest ro /iC'C�6/n;iM� Zed 1/e5��1 c/f4 6 -s-AA( PERFORMED BY: / 242&7 CERTIFIED BY: ' /` 4 7 DATE: (minutes/inch) 72-008 (6/79) = /z54'.44A < /.- MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: 111 -**--SOILS LOG IIVP'ERCOLATION TEST 6- -617 DATE PERFORMED: LEGAL DESCRIPTION: L0L Z 1 2 3 4 5 6 7 8 10 12 13 14 15 16 17 18 19 20 DEPTH (FEET) 0 tier' —Z- -2, 0MMENTS PERFORMED BY: 72-008 (6/79) 40.7ec Sam/os,o/2 tet134,./4 T tt.:0A r w t***** • 0 ** •••, -90 t•• ***** • James R. Kinney iv , • CE - 6036 *. .• .4r • • ........Op, PrOfeSSirila...\.• ."14,11keks: SLOPE c3N‘ CI) I`s WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? /q:3'L 0 P SITE PLAN IJ 6s Jo SI/ et Reading Date Gross Time Net Time Depth to Water Net Drop / /•-/;' 17,2Z/9/41 10 5 " z /a '4'," '7.5z /0,,,, 3o 3 /0'1'7 3 ,,,,,, 30 i'O-/s? _6 ,5 2 ,,, 30 /6, ,1" 4 , ---,.._ ----- , PERCOLATION RATE ‘e, TEST RUN BETWE N War:. • /Roc,- 6 Z/sz,,,-) coas CERTIFIED BY: /4, DATE: /Z) (minutes/inch) FT AND FT (I (J.! (Z) 6:) re, ••• a ••• ; Gerald V. Rendall Jr. •d s� •. NO. 4053-8 • • `, AAOfESSIONAt'-' Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-811-07 1. COSA# 05C fLaN Expiration Date: 9 a o-/.2., GENERAL INFORMATION Complete legal description Sampson Estates Block 4 Lot 2 Location (site address) 22706 Sampson Drive, Chugiak, AK 99567 Current Property owner(s) Stann Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Robin & Anita Day phone 240-4258 same Day phone Jan Deering RE/MAX of Eagle River Day phone 240-4258 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE QF WATER_S_UPPLY• Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL. Individual On-site ❑ Individual Holding Tank ❑ ❑ Community On-site ❑ ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm NorthRim Engineering Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date 6/12/2012 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 andeplt'h gms are subject to these various and dynamic characteristics and are outside the control of thee, Or 4CAti evaluator of the well and septic system. `. ,•++.wn tr'®+m�1� et co e *'ifff49TH '.• • 5. DSD SIGNATURE 1.7V Approved for 3 bedrooms. Disapproved. Conditional approval for 0 c Steven W. Eng••,•, W to": • P 62•+�, °a bedrooms, with the following stipulations: \``;'�`ii\tY `OF.44 �/i� w'▪ r CcO Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory aret J� ON-SITE WATER AND WASTEWATER gf PROGRAM %�lJ I S )l G10 t% Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: 6 P .2 0— /-2 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Sampson Estates, Block 4 Lot 2 Parcel ID: 051-811-07 A. WELL DATA — Public Water Well type P If A, B, or C provide PWSID # _ Well Log (Y/N) Y Date completed 9/24/84 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth 141 ft. Cased to 141 ft. Casing height (above ground) 18 in. FROM WELL LOG AT INSPECTION Date of test 9/24/84 5/31112 Static water level 41 ft. 114.5 ft. Well production 11 g.p.m. • WATER SAMPLE RESULTS: Coliform Pass colonies/100mL Nitrate 5.08 mg/L Arsenic: 1.24 ug/I Date of sample: 5/31/12 Collected by: nr • 6+ g.p.m. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 9/24/90 Tank size 1250 gal. Number of Compartments 2 Cleanoi D. LIFT STATION Date installed 9124190 "Pump on" level at 43 in. Datum tank bottom Size in gallons 1250 Manhole/Access (Y/N) Y "Pump off level at 40 in. Cycles tested 3 E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100' + Public sewer main NA Sewer /septic service line 25'+ Animal containment areas 50'+ High water alarm level at 44 in. Meets alarm & circuit requirements? Y On adjacent lots 1001+ On adjacent lots 100'+ Public sewer manhole/cleanout NA Holding tank na Manure/animal excrete storage areas 1001+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main na 5'+ Property line 10'+ Absorption field 5'+ Water service line 101+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 101+ Water Service line 10'+ Surface water 100'+ Curtain drain n/a Wells on adjacent lots 100'+ F. COMMENTS Surface water 100'+ Water main na Driveway, parking/vehicle storage 10'+ G. ENGINEER'S CERTIFICATION I certify that t 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 6!12!2012 s �E'OF '4C Ah 0*'49Th •17. ie !•..:a.. .� ICI c • • Steven W. Eng • •' Si 61`� ,INT :> 62 <Val % ROFE:i)c''`JC. ��l1�oro. COSA Fee $490.00 Date of Payment 6O`(a/0o0 Receipt Number G 35952 (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Community Development Department Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 121218 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 4, Lot 2 of Sampson Estates subdivision. This inspection revealed a nitrate concentration of 5.08 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. .4 'z's ',war svazx". tq "p$4.*, -*;0".0c *, • AseLJILT—NO CORNERS 4E7' INIS 00E. ilmwAtOmpnwinno I CeRTITY THAT 1 HAVE. St.RIVETEP SHE FOLLOWikG DESCRIBED: PR.OPEATY, 6:45:171iNion Eatateo Subd.,Lot 2,Bik. 4 AND MAI" NO ENORCAPNENTS EXIST DZEPer AS INDICATEU IT 13 THE RESPoKsisiurr OF OWNER TO OcTERAINC ThE EXISTOCE OF ANY: tuna:xis, COVIXANT'3, OR RESTRICTIONS lifH1C:14 DO MOT AP!U ON THE K=0 $UM. ¥1SICei Fi.AT. LAMER P4 CIRCUMITTANUS 1143141 ANY OM HEREON PC USED FD OONCTRUCTION I ILJ IMP "Ilb 1E1.4 V. ...PA II*4 I i***W et v144 43 AsfoWcrizLAD.517V7111; ii,..01,0614,N, .c",... ,Avet OF A i ... 0 ' *i• 0 *46' 044 iti.441, , o ****** 7. 441 / 49 :W 0 . "V4 0/110t., * 1r 4 ** *rertle *I NOM *Mt lioriglardi l,. Parcel I.D. Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL 051-811-07 FOR A SINGLE FAMILY DWELLING 051-811-07 1. GENERAL INFORMATION Complete legal description Location (site address) 22706 Sampson Drive Sampson COSA # 05 C 101202 Expiration Date: / 'Z- / i4- Estates, Block -4, Lot 2 0 Greg Haggard 688-1426 Current Property owner(s) Day phone Mailing address Lending agency Day phone Mailing address Les Bailey 696-6514 Real Estate Agent Day phone Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 22706 Sampson Drive 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System Keller -Williams 3 El El TYPE OF WASTEWATER DISPOSAL: Individual On-site f 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. 1 further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. _ NorthRiri Engineering 694-7028 Name of Firm Phone P.D. Box 770724 Address Steve Eng 9/8/10 Engineer's Printed Name Date •. # 0.::: •` x •� 0. se 5. DSD SIGNATURE ��_: Steven w. Eng �.ey' \, "� Approved for �A ��•� PE 6? .�' ,.� bedrooms. d�� g''•s, f� . ,�•�` t:� .� 8� FRCFEs v,,,� Disapproved: Conditional approval for bedrooms, with the following stipulations: ON-SITE • WATER AND • rrm WASTEWATER e 4 _ ,,... , - _,,_ o SEv\t 5��' )l)))))))1 Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: t ��� .���'s�' �' eT 8-` Original Certificate Date: - it / (Rev. 11105) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, LAK 99519-6650 www.muni:org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Sampson Estates Block 4. Lot 2 Parcel ID: A. WELL DATA Well type P If A, B, or C provide PWSID # - Well Log (Y/N) Y 051-811-07 Date completed 9/24/ 8 4 Sanitary seal (Y/N) Y Wires properly protected (YIN) Y Total depth 141 ft, 141 18" p Cased to ft Casing height (above ground)in FROM WELL LOG AT INSPECTION Date of test 9/24/84 8/19/10 Static water level 41 ft,, 116.2 ft. , Well production 11 g.p.rn. 6 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate 4.03mg/L Other bacteria 0 colonies/100 mL Arsenic: 1.26 ug/L date of sample:. 8/19/10 Collected by: N R i m E n g B. SEPTIC/HOLDING TANK DATA Tank Type/Material. Anch Tank (steel) Date installed 9/24/90 Tank size 125001' Number of: Compartments 2 Cleanouts (Y/N) Y Foundation o1Lranot t,(Y/N) Y ' Depression over tank (Y/N) N High water alarm (Y/N) Y Date &vamping 9/9'/10Pumper Sanitary Pumpers C. ABSORPTION FIELD DATA t` Date installed 9/24/9goii,ng (g.p.d./ft2 or ft2/bdrm) 150 System type B e d Length 38 ft. Width 18 ft. Gravel below pipe 0.5 ft. Total depth 3.5ft. Eff: absorption area 684ft2 Monitoring tube Y Depression over field N Date of adequacy test 8/19/10 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 450ga1. New depth 0 in. Elapsed Time: 60min. Final fluid depth 0 in. Absorption rate >= 450+ g.p.d. na Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed 9/24./90 Size in gallons 1250 "Pump on" level at _4_3_1n. "Pump off" level at in. Datum Tanl< Bottom Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100' + 100' + Absorption field on lot Public sewer main NA Sewer /septic service line 25' + Animal containment areas 100' + Manhole/Access (Y/N) Y High water alarm level at 44 in. Meets alarm & circuit requirements? 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 5' + Water main NA Water service line 25' + Surface water 100' + •Welts on adjacent lots 100' + SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 1 + Water main NA Water Service line 10 + Surface water 100 + Curtain drain NA Wells on adjacent Tots 100'+ F. COMMENTS Driveway, parking/vehicle storage10' + G. ENGINEER'S CERTIFICATION. I certify that l have determined through geld 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 9/8/10 mkt.0 A « 1 44. •. •. ay CO s* f49114 • .1 * ♦0 I% ;YUAN*, W. Eng * 6256 eh\ 9/ttei-* dir .% °kROFESS'J���."a COSA Fee $ 1-7110 Date of Payment Receipt Number (Rev. 11/05) O3Cgcic. Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I D # 051-811-07 1. GENERAL INFORMATION HAA# AIY1F. Complete legal description Lot 2, Block 4, Sampson Estates Location (site address or directions) 22706 Sampson Drive Property owner Dwayne & Sandy Kelch Day phone 688-3939 Mailing address PO Box 671615, Chugiak, AK 99567 Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. - 2. NUMBER OF BEDROOMS: 3 ' 3. TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer xxx NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA /21 Lot ) 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm 5 & $ ENGINEERING 17034 Edyle River Loop Road No. 204 Address Eagle River, Alaska 99577 Engineer's signature Date Phone 6 6/11-9 7/, 6. DHHS SIGNATURE By' \/ Approved for �PREG- bedrooms. N^�� ``.,••.......... YSl 144 Epi ,1.0' / P: f! C2,. :y H 101 ROBERT C. COWAN i ,Q 1ff44 CE 8801 fV��� •'E� e. ` b\:>1—t i:.:S3\V' Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 1 ,onyx/ Date 2 J ` CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA N21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division RECEIV 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 DEC 0 7 1998 Legal Description: A. WELL DATAp / Well type PRI UATE Log present (�jY N) /65 Total depth /17// / Cased to /77' Casing height (above ground) Health Authority Approval Checklist inr z /44 s '50,1 fs T MUNICIPALITY OF ANCHORAGE Parcel I.D.: 0 S- pNVnNN�1AL SERVICES DIVISION If A, B, or C, attach ADEC letter. ADEC water system number Date completed 9-21/MW Sanitary seal Date of test Static water level Well production N) 6 5 /6.5 FROM WELL LOG AT INSPECTION 9g' Wires properly protected (/N) t 51/12147Z.6 WATER SAMPLE RESULTS: Coliform 0 Nitrate //—E048 Date of sample: g.p.m. /to/ Tis s;D • 1 Li Other bacteria 0 B. SEPTIC/HOLDING TANK DATA Date installed Tank size SQ g.p.m. Collected by: c0a- t /J (id1 LC-, /41,tit.5 5 & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Number of Compartments o2 Cleanouts &N) / 5 Foundation cleanout(ON) Gyc�7 S Depression (Ye 46 High water alarm (9/N) yks Date of Pumping Pumper 54A1/7;4,7 Pu>ti(/���5 C. ABSORPTION FIELD DATA Date installed /`- Yz) Soil rating (g.p.d./ft2 or ft2/bdrm) /52 System type , Lb Length 28" Width /g / Gravel thickness below pipe to r/ Total depth + Effective absorption area [P Monitoring Tube present 6'N), S Depression over field (Y/(g) /UD Date of adequacy test // 26 9f by Results (Pass/Fail) /94.5-5 For 3 it bedrooms t/ Fluid depth in absorption field before test (in.); . Immediately after ,Zgal. water added (in.): 4‘1 Fluid depth -2,. (ins) Minutes later: /6.0i/1 Absorption rate = -/-1/SZ) g.p.d. r✓t KNfiw nl Peroxide treatment (past 12 months) (Y/N) fJ/il If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed ` Size in gallons /22 f C.1144t5 St/67C Tek- Manhole/Access ON) €6 High water alarm level at* SS -1i *Datum 77,044 Of /lf%5-7-/i77au "Pump on" level at* 3�r "Pump off" level at* 36 Cycles tested •� E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: i Septic/holding tank on lot 7 On adjacent lots +/M( Absorption field on lot io'O On adjacent lots +n(50 Public sewer main A01 Public sewer manhole/cleanout Ai* Sewer /septic service line Lift station f SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation 2611 Property line `O Absorption field 7L� Water main/service line 1 -ii) Surface water/drainage -/1,00 Wells on adjacent lots f/LV% SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: / Property line Building foundation 66' Surface water /l//1 Curtain drain i Water main/service line 7'/O / ( Driveway, parking/vehicle storage area L F. ENGINEER'S CERTIFICATION Wells on adjacent lots (4,5 f certify that I have determined thru field inspections and review of Municipal recon tl" in conformance with MOA HAA guiidd ines in effect on this date. Signature Engineer's Name (0 tug Date r C` eov ystems are �t3 -n ROS RT c. CQwAN y 4? CE -'880i - O 08' 4a��aa�. ."- HAA Fee $ ' Waiver Fee $ Date of Payment /6/7?/ Receipt Numbers 72-026 (Rev. 3/96)* v Date of Payment Receipt Number AIL CT&E Environmental Services Inc. CT&E ttef.# Client Name Project Name/ti Client Sample 11) Matrix Ordered By pwsm Sample Remarks: 986916001 S & S Engineering Lot 213k 4 Sampson Est Lot 213k 4 Sampson Est Drinking water 0 Client PON Printed bate/Time 12/03/98 22:39 Collected Date/Time 11/30/98 11:20 Received Date/Time 11/30/98 15:00 Technical Director: Stephen C. Ede Parameter Total Coliform Nitrite -N Results POL L1 is Method Atlowable Prep Analysis Omits Date Date init co1/100mL SM18 92228 11/30/98 KAP 2.74 0.100 mg/L EPA 300.0 10 mex 11/30/98 11/30/98 SCL E170 -d E0/80"d 808-1 10E5190 1V1N3VHN0dIAN3 313-flOd 81:01 80-70-330 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I D # 051-811-07 HAA # (•,- ci r')SS 1 L4 1. GENERAL INFORMATION Complete legal description Sampson Estates Lot 2, Block 4 T15N R1W Section 3 Location (site address or directions) 22706 Sampson Drive Property owner Ed & Carol Alumbauqh Day phone Mailing address 277nti Sampgnn Drive. rhugiak, AK 99567 N/A Lending agency Northland Mortgage/Carol Day phone 694-7872 Mailing address 11421 Old Glenn Hwy., Eagle River, AK 99577 Agent Cathy Geraci/Great Land Realty Day phone 694-9125 Address 11411 Old Glenn Hwy., Eagle River, AK 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3 V x NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer X NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA 921 Ra VOW HDe9 (l6/l'' B) WO -U. •>1.1oM s,aaaul6ue leuo!ssa;oad ew u! suo!ss!wo JO saoaaa .to; a!glsuodseJ lou s! a6eaogouy ;o A}!led!o!uny'l au •panss! s! a}e0WPaa a eio;eq e}ep azAleue JO suo!}oadsu! Tonpuoo }ou op SHHa ;o se oldw3 •s}uaweilnbw ems pue !papa; u!e}Jao A;s!}es o}Japan u! suo!}n}!}su! 6u!puel.Ilay} pue sewoy;o saasegwnd o} Asa}inoo a se sly} saop SHHa eq.!. •e>!selb';o W19841 1.1! paJels!bal ieaul6ue leuo!ssa;oad }uapuadapu! LIE Aq eAoge g ydea6eJed u! uan!6 suo!}e}uasaadai ay} uodn Apo paseq seleol;!}JeO !enoaddy A}poy}ny y}IeaH songs! (SHHa) sao!naas uewnH pue y}leaH;o }uawpedaa a6eaoyouy;o A}!led!olunynj ayl Z - // - Z/ a}ea s}uewwoa levo!}lppy :suo!}eIndI}s 6u!Mollo; ay} y}!M `swooapaq .ivA�J p1SS3dOy 4o• •• r03�N) o• ?7,i 9ELl"3J 0 J hi i D,(84flu � .if10 1 Ps 6 v icy 1 P 0P9 P e 90 fiii eeeeieeee °°u, eeeeseeees eeeA0 et yg P a '1731pp�y e 9C 21 4a P CVt0Ge4PD° t ‘i,)'7 1 i C �-6'v :A8 ao; lenoadde Ieuo!}lpuoa •peAwddesla swooapaq ao; panoaddy 3Hf iVNoIS SHHa '9 // 91%3 aan}eubpspawbu3 LL566 NV '.zantg, aTbea `16Z£LL XOS 'o'd ssalppv auoydWald ;o eweN 96-C9-V69sao?nzaS bu?zaau?bug .zanig aTbeg •uo!}oadsu! sly};o a}ep ay} uo }oa;;a u! suo!}eln6aa pue `seoueu!pao `sapoo awls pue ledlo!unW Ile y}!M aouelldwoo u! s! wa}sAs lesodslp Ja}eMa}seM Jo/pue Alddns Ja}eM a}!s-uo ay}'uo!}oadsu! pue uo!}e69seAu! Aw woo; pue salt; a6eJoyouy;o A}!Ied!olunW ay} woa; peulelgo uo!}ewJom ay} uo paseq }ey} A;uan aay}an; l •ulaaay pa}eolpw aan}ono}s;o adA} pue swooapaq;o aagwnu ay} Jo; a}enbepe pue leuol}oun; 'ales sl wa}sAs Iesodslp as }eu}m Jo Alddns as}eM e1!s-uo ay} 121-11 smogs uo!}eolldde !enoaddy A}uoy}ny y}Ie8H s! };o o! } }sanu Aw }ey; A;!aan 1 `Moleq uMoys a;ep uo!}epllen ail 40 se pue o}away pax!};e leas Aw Aq pe!;!vao sy 1:133NIDN3 AS NOI103dSNI d0 1N31N31V1S '9 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: S4M>'SON 6,57: £O1 Z 8LK 4 Parcel I D 0 0 '7 %aN /2/lc) Sc'rL 3 A. WELL DATA Well type Pell/47-6 If A, B, or C, attach ADEC letter. ADEC water system number iki/4 Log present (Y/N) Date completed 0-4/./F N Driller 6L/iEakt,S',../ Total depth 14t1 Cased to / Casing height Sanitary seal (Y/N) YE 5 Wires properly protected (Y/N) FROM WELL LOG Date of test a9/2y/ J/ � Static water level 4/ j Well flow //•Uv gpm Pump level UNNOhN SEPARATION DISTANCES FROM WELL TO: Septicg tank on lot /02/ Absorption field on lot /60/ Public sewer main Sewer service line 1151 Yes m AT INSPECTION //AS/ OEE n // n <> z 1"T'[ e_., m 0 r ii g is n Z a / I i,.y y 37. <n O rn G ; On adjacent lots ; On adjacent lots 7110D Public sewer manhole/cleanout Petroleum tank N bet WATER SAMPLE RESULTS. Coliform Nitrate /-y �''3� Other bacteria Date of sample: >/ a 39 Collected by. FNC7/A/G8 N/A B. SEPTIC/HOLDING TANK DATA Date installed P9/ 90 Tank size 7' Compartments Cleanouts (Y/N) Yes Foundation cleanout (Y/N) yea Depression (Y/N) NO Z High water alarm (Y/N) /0/ Alarm tested (Y/N) /Y iA Date of pumping �� O /11 9 Pumper \Tie iS SEPARATION DISTANCES FROM SEPTIC/I 4el=BfNG TANK TO: Well(s) on lot 1071 t On adjacent lots /00/ i Foundation �sC� To property line 40' Absorption field 17 1 Water rFaifriservice line "1- - /0 / Surface water/drainage f/d / 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed /920 Manufacturer XA/CHJ 'T+Q'NK Size in gallons it -0 Gil sr- 7 !- 4/`/4Aanhole/Access (Y/N) �/GS rr r'r Vent (Y/N) Y66 "Pump on" level at //.7 "Pump off" level at 4'd High water alarm level G/4/ Cycles tested jf Meets MOA electrical codes (Y/N) yds SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot /i / D. ABSORPTION FIELD DATA On adjacent lots tr'w / Surface water f/00 Date installed /220 Soil rating /S-42 System type /3e_i) fig' /7/ b'' Total depth n s Length Width Gravel thickness p Total absorption area &VI" 0 Cleanouts present (Y/N) yep Depression over field (Y/N) /`/D Date of adequacy test / / /Z3/yZ. Results (pass/fail) PA -5 S for NS bedrooms Peroxide treatment (past 12 months) (Y/N) %J//4 If yes, give date A//4 - SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /lam 0 ' On adjacent lots .100 5CD' To building foundation On adjacent lots ' 30 Surface water /DD' Property line /D To existing or abandoned system on lot Cutbank /`JJ A Curtain drain N /A 71 -SO/ Water mai./service line /1-//) Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effecf.on the date of this inspection. Signature Engineer's Name �a�J Date o �I nG; EF.c \C)‘ ,' HAA Fee$ 70'.7") Date of Payment / —D/` q?--- Z4' Receipt Number �7C.5-2,1,57) ? ',AOC 10... iron CIRRI" AAne 91 Waiver Fee' $ Date of Payment Receipt Number ,NOV 27 '92 10:03 NORTHERN TESTING, ANCHORAGE P.1/5 NORTHERN TESTING LABORATORIES, INC. 3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701, (907) 4564110 • P. X' 4563125 2:05 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 277-8378 + FAX 274.9845 Report nates 11/2692 Eagle River Engineering P.O. Box 773294 Eagle .River AK 99577 Attn: Louis Butera Our Lab #: A121554 Location/Project: Your Sample ID: 3ampeon 2/4 Sample Matrix: Water comments: Lab Number Method Parameter Units Date Arrived: 11/2)/92 Date Sampled: 11/2/92 Time sampled: 1102.: Collected By: LB * Definitions * 8 = Below Regulatory H n M = Above Regulatory E = Estimated Value M = Matrix Interferenc0 D = Lost to Dilution HDL = Method DetectionLimit Dae Date Result * MDL Prep Analyzed A121554 EPA 353.3 Nitrate -N Reported By: Susan C. T fental Microbiology Supervisor mg/1 1.9 0.2 11/25/92 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # fl m \ X51 \ -C-c) HAA# V4\�r�r�.t1�°1 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 2. Block 4. Sampson Estates T15N R1W Sec. 3 Location (address or directions) 22706 Sampson Driva (b) Property owner HUD properties Telephone : (home) Business 27.1-4342 Mailing Address 727 W. 8th Avenue, Anchorage. Ak 99513 (c) Lending Institution "'i- Telephone Mailing Address (d) Real Estate Company and Agent '"� Address Telephone (e) Mail the HAA to the following address: (or check here ❑, if hold for pick up.) List contact person and day phone number below: FrirTi naar 2. TYPE OF RESIDENCE Single -Family] Number of bedrooms 3" 3. WATER SUPPLY Individual Well ® Community 0 Public 0 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ® Public 0 Community 0 Holding Tank 0 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 Eagle River Engineering Services Telephone 694-5195 11940 Business Blvd, Suite 205, P.O. Box 773294, Eagle River, Ak 99577 Address Date 7/(:'1 ss��o 6. DHHS APPROVAL Approved for -S bedrooms by ---0 141`1 SiM ‘TZf ngifieer's Seal tJ� Approved X Disapproved Conditional Terms of Conditional Approval Date (o//c qe 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 order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description• /2- y Tis`+✓ tti S e� . 3 A. WELL DATA Well Classification / r' "" - - Well Log Present (Y/N) Y Date Completed Total Depth /V/1 Cased to /`q/ / Depth of Grouting Static Water Level 7/`/ / Casing Height Above Ground a" N/4 - If A, B, C, D.E.C. Approved (Y/N) ry/4 Yield - ` 3 ,., /e'ic`"( ///7/5u Pump Set At '//s- / Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) T`i SEPARATION DISTANCES FROM WELL: s To Septic/Holding Tank on Lot /' 7 ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /60 / ; On Adjoining Lots 7`luo/ To Nearest Public Sewer Line Nva To Nearest Public Sewer Cleanout/Manhole ",./ //} To Nearest Sewer Service Line on Lot /-•)•-',__ / Water Sample Collected by 7.-7-c5 le''"'z`"' F"5'''``e-'-'-fs ; Date ,9A--/-4/./0 1 Water Sample Test Results ,-k_—_ ate /- s' ''^5/� Comments B. SEPTIC/HOLDING TANK DATA Date Installed ,A5'/"‘) Size /40?.(v No. of Compartments Standpipes (Y/N) l Air -tight Caps (Y/N) Y Depression over Tank (Y/N) w oZ Pumping/Maintenance Contact on File (Y/N) Foundation Cleanout (Y/N) % Date Last Pumped ;for / Holding Tank High -Water Alarm (Y/N) /' / Temporary Holding Tank Permit (Y/N) .","�A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well O" 7' To Property Line To Building Foundation To Disposal Field To Water Main/Service Line ' 70 7 7‘). To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page 1 .of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /5—)) Date Installed Width of Field its Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design 38' Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test eve cc, --rte-. /'-'/4 SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well To Building Foundation Lot /8" Ste'. To Property Line /e' To Existing or Abandoned System on ; On Adjoining Lots`' To Water Main/Service Line ' /�' To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments i✓ /4 D. LIFT STATION Date Installed r�" Dimensions "/^e z6 /,-s—vs<,i Size in Gallons 1-1-5") ' " ' "' 'Manhole/Access (Y/N) "Pump On" Level at "Pump Off" Level at High Water Alarm Level at Vent (Y/N) r Tested for '✓. Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) / Comments **Check Permitted Bedroom Rating Against HAA Request** I certify that I have inspection. Signed Company checked, verified, or conformed to all MOA and HAA guidelines ect ttg• dateilof this • ,V p CRI, P• O 10 a ez aa0 moe aec oxoaduo a F' � rng:: ee s Seal . Louis A. Butern : 44/ Eagle Haver Engineering Services P. 0. Box 773294 Date ��-S-Ao MOA No. Eagle River, AK 99577 694-5195 o - 1( Receipt No. � l 3 k (33 ,c3 a Date of Payment / e Amount. $ 72-026 (Rev. 7/88) Back Receipt No Waiver Fee' $ J'">, CE -5735 e �• ® QN ,�QFEss°\ .."tl Date of Payment Page 2 of 2 NORTHERN TESTING LABORATORIES, INC. 2505 FAIRBANKS STREET 3330 INDUSTRIAL WAY Eagle River Engineering PO. Box 773294 Eagle River AK 99577 Attn: Louis Butera Our Lab #: Location/Project: Your Sample ID: sample Matrix: Comments: A105483 Sampson Est. Lot 2, Block 4 Water Method Parameter ANCHORAGE, ALASKA 0503 FAIRBANKS, ALASKA 99701 Units Report Date: 907.277-8378 • FAX 2740645 907456.3116 • FAX 4563125 Date Arrived: Date Sampled: Time Sampled: Collected By: 10/01/90 09/25/90 09/24/90 1735 LB Flag Definitions U 1K Below Detection Limit DL Stated in Result $ = Below Regulatory Min. H = Above Regulatory Max. E = Below Detection Limit Estimated Value Date Result Flag Analyzed EPA 300.0 Nitrate -N MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION CCT 31 990 RECEIVED Reported By: Francoie Rodigari Anchorage Operations Manager mg/1 1.3 09/28/90 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I D # (-42)\-R11- n-1 HAA# (qn, 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Sampson Est., Lot 2, Block 4 T15N, R1W, Sec.3 Location (address or directions) 22706 Sampson Drive Chugiak, AK (b) Property owner H . U . D . Telephone : (home) Business 271-4342 Mailing Address 222 W. 8th Ave. (Box N-64) Anchorage, AK 99813 (c) Lending Institution N/A Telephone Mailing Address (d) Real Estate Company and Agent Associ aced Brokers Address 640 W. 36th Ave.. Suite #1, Anchorage, AK 99503 Telephone 563-3333 (e) Mail the HAA to the following address: (or check here 0, if hold for pick up.) List contact person and day phone number below: Pick-up by Engineer 2. TYPE OF RESIDENCE Single -Family Q Number of bedrooms 3 3. WATER SUPPLY Individual Well f1 Community ❑ Public 0 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-site4KI Public 0 Community 0 Holding Tank 0 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 Eagle River Engineering Telephone 694-5195 Address P.O.B. 773294 Eagle River, AK 99577 Date SY150 6. DHHSAPPROVAL Approved for - bedrooms by Approved -- roved elarrcti#ionnl G1,., Lc CE -671:6 ,es'11 Terms of Conditional Approval ��C D �� �occsaam Date ,/4.47 z' /yo 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 order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) AtitlifiitR/tp"Proval (HAA) ENViRONOWEdlifiltErs FEBRUARY 1984 343-4744 JAN 2 2 1990 /.��dry Legal Description* A. WELL DATA Well Classification /'& ftrizAl' RECEIVED'I If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Y Date Completed /#y Yield cp# i/yo Total Depth /`//' Cased to /`f1' Depth of Grouting N/d J Static. Water Level //'/ Pump Set At Casing Height Above Ground -q " Sanitary Seal on Casing (Y/N) ' Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N) N SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot /o.-' ; On Adjoining Lots y /ov t /30' i>r<< /(% To Nearest Edge of Absorption Field on Lot , On Adjoining Lots To Nearest Public Sewer Line y/" To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot 85'' Water Sample Collected by Water Sample Test Results Comments a f /pr"g (/l o1.4.er &GLG P- ; Date i/y/yo /1"/ 1. 7 /2r0 /0/'13 e- b4nv�/Nf B. SEPTIC/HOLDING TANK DATA 00/0-4/ Date Installed / g1.`e Size /4°'11`2.5. No. of Compartments Standpipes (Y/N) X Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) y Depression over Tank (Y/N) ^ Date Last Pumped //g" ye s Pumping/Maintenance Contact on File (Y/N) N/`k ; for N/4 Holding Tank High -Water Alarm (Y/N) /.04- Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well /6.- / y�'r pp y To Building Foundation , To Property Line M' To Disposal Field To Water Main/Service Line 60' To Stream, Pond, Lake or Major Drainage Course 4/44 Comments 72-026 (Rev. 7188) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /-1 Date Installed /9.<-/ /-/CrB`/ Width of Field /2/ Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field 39/ Depth of Field Gravel Bed Thickness 6 4- .5-21 45 Statndpipes Present (Y/N) Glyn•• Date of Last Adequacy Test / 77 0 /k/'Ad �4 /r fes,- 3 lie N JGa SEPARATION DISTANCE FROM ABSORPTION FIELD: i To Water -Supply Well 1"�97-/ /4!S To Building Foundation Lot ^1/A - To Water Main/Service Line /Z)/ To Property Line // To Existing or Abandoned System on t 3v ; On Adjoining Lots To Cutback (if present) _-/ �1 To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Le4c.4'`.. �rZ JU 7 -ea pr. pr iv Rr./2fuAu�. D. LIFT STATION 4%/4 Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at "Pump Off" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA p guidelines�zin;�effe%t on the date of this '' 39 inspection. AT 4' ��- Signed -- Company Eagle Rivor Engineering Services P. 0. Box 773294 Date ///e7,0 Eaglo River, AK 99577 _ 6 694-5195 MOA No. Receipt No. 2/eet/e, / XCD Date of Payment Amount' $ 72-026 (Rev. 7/88) Back 6a E9 0 ©oveo. Louis A. Butera •�_ fdf %se CL -6736 °_Engineer's Seal Receipt No Waiver Fee' $ Date of Payment Page 2 of 2 % %a»RUFESSo CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. LABORATORIES 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order # 19249 Date Report Printed: JAN 15 90 @ 11:18 Client Sample ID:SAMPSON EST L 2/4 PWSID :UA Collected JAN 9 90 @ 15:20 hrs. Received JAN 10 90 @ 15:45 hrs. Preserved with :AS REQUIRED Analysis Completed :JAN 12 90 Laboratory Supervi#or :STEPHEN C. EDE Released By : Special Instruct: Chemlab Ref #: 9164 Lab Smpl ID: 1 Parameter Tested Matrix: WATER Result Units Client Name : EAGLE RIVER ENGR Client Acct : EAGLERP P.O.* NONE RECEIVED Req # Ordered By : LOU BUTERA Send Reports to: 1)EAGLE RIVER ENGR 2) Method Allowable Limits NITRATE -N Sample ROUTINE SAMPLE Remarks: SAMPLE COLLECTED BY L.A.B. 1.7 mg/1 EPA 353.2 10 1 Tests Performed ' See Special Instructions Above UA=Unavailable ND= None Detected " See Sample Remarks Above NA= Not Analyzed LT -Less Than, GT -Greater Than Eagle River Engineering Services i 11940 Business Blvd, Suite #205 P.O. Box 773294 694-5195 Eagle River, Ak. 99577 Fax 694-3297 Legal: !)c,,,,,05�„-, s� 1--0t 2 131 !k q Owner: \-\uo Prop, };,- Date: 1 - to - y 0 Type of test: o Well Flow Test 0 Septic Test Only Well & Septic Test 0 Other Time Meter Reading Monitor Level Well Level Tank Level GPM PSI • Remarks 1-I0- 90 11'-1 6w L 10.1".". 2o07l,-o o' 11S 72. S" I�o 1 � ,v/f .ON (i.14,+-rQ7 Z:.roy., '%00` 10 0'. i 1 „ 1/(a0 I 10; is i,.,.. 201 1-I 5-b O 11 S 74c," t- /-e7o 61; 0 2.0 1, 5 rr) t„ i, OF' (wA Q) 10 O pr, /-/Z- c/ 0 12:520„ 2031,54 nVp Iii -C Wotl ?4 �.0 SI" I. Z' 203BG6 Ii6' 5.3 N/A 1')CT 1;41 11LI ' G (Y = 3,/, 5 o 5 �o .F.rc- •,-., mT vl4srr d ,/ii✓t /'Se j' * r" -e4 .4r / MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH 11 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL VAap-- t k 1`'- OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date d0//g 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) L. Z g I IC 4 Eam►esorJ Location (address or directions) erJ i // .111dL �e. Z LeJ-e O u 664. (b) Applicant Namee- e i 5 Telephone: Home 607-052,0 /We 776'602'0 2, Applicant Address /) 0 Box 6, 7f)� 7 r' �jju f/6.�l�[ /We (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ; Buyer 0 ; Other 0 (explain); (d) Lending Institution 10)14 &f Ne Jh hc.Io LJ Address (e) Real Estate Company and Agent Address Telephone l .le elephonee. (f) t1 HAA to the following address: S & S ENGINEERING SR B 196X EAGLE RIVER, AK 99577 2. TYPE OF RESIDENCE Single -Family Multi -Family 0 Other Number of Bedrooms 3 3. WATER SUPPLY Individual Well Community 0 Public 0 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL OnsitePublic 0 Community 0 ' Holding Tank 0 Note: if community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DM M AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Date S & S ENGINEERING Telephone EAGLE RIVER, AK 99577 /7/0 6 �40 gni cP O°0 V .aK•C .g. •• 4 .. . � of )bort A. shag.%(tell:': s ,, No. 1447- cid tia S‘1 t421 6. DHEP APPROVAL l� Approved for Vtiz-9 2J bedrooms by G / Date 10r' ,V6 Approved /' Disapprove Conditional Terms of Conditional Approval CAUTION%'' The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) • A. WELL DATA Well Classification MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 / Legal Description. Lbi Z s. Well Log Present/N) Total Depth / '/ 1 r Static Water Level Cased to '-/1' MUNICIPALITY OF ANCHORAGE HEALTHDEPT. OF ENVIRONMENTAL ROTECTION NOV 7 1986 -�ECEI /11 ED J(�P 1 Svc L -Si• If A, B, C, D.E.C. Approved (Y/N) -Z-t( 8`f Date Completed Yield L`> 5 to ?/‘f f /y/` Depth of Grouting Pump Set At /AY.' Casing Height Above Ground Electrical Wiring in Conduit/N) Separation Distances from Well: To Septic/Holding Tank on Lot Sanitary Seal on Casing ( /N) Depression Around Wellhead (YQl 3 To Nearest Edge of Absorption Field on Lot 13 To Nearest Public Sewer Line 6e74 Cleanout/Manhole ; On Adjoining Lots /c ( ; On Adjoining Lots /�` To Nearest Public Sewer To Nearest Sewer Service Line on Lot /bb0,02 's Water Sample Collected by S,t-S ; Date Water Sample Test Results ;5,7 7S' elC so.e-7 Comments Vd LL- Lo(, &zo/o �/wtel (K- A.Sl: // e '-L 7 V, XC.e Je- O rJs��!/v� - B. SEPTIC/HOLDING TANK DATA Date Installed 46/5/63- Size /000641. No. of Compartments Standpipes 67V) Air -tight Caps (a1) Depression over Tank (Y/� Pumping/Maintenance Contract on File (YIN) Holding Tank High -Water Alarm (YIN) /� Separation Distances from Septic/Holding Tank: To Water -Supply Well /0 3 To Property Line To Water Main/Service Line /s -t7/1 Course <tO' /1 Foundation Cleanout (PN) Date Last Pumped ;for Temporary Holding Tank Permit (Y/N) ?9A To Building Foundation / log To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ///s/Bs Date Installed Width of Field /7. Square Feet of Absorption Area Depression over Field (Y0 Date of Last Adequacy Test Le ..5 ?N 21( 2,4 Results of Last Adequacy Test Separation Distance from Absorption Field: /55- To Property Line 4/0 / Type of System Design 3y, Length of Field Depth of Field Gravel Bed Thickness 54;3Pf (../ S' D.sf Standpipes Present ON) // To Water -Supply Well To Building Foundation Lot h1 Y3 1 To Water Main/Service Line /Orfi ; On Adjoining Lots To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Existing or Abandoned System on 3cV To Cutbank (if present) D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at "Pump Off" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MO and HAA guidelines in effect on the date of this inspection. //�6/'6 Signed S & S ENGINEERING Date MOA No 7‘-"" dc33 CompanySR B 196X EAGLE RIVER AK 99577 Receipt No./d Date of Payment /r/l7�. Amount" $ Page 2 of 2 72-026 (11)84) .° er bee. A. Siasiee °• AJJ i °° No. 1451.14 .° '''...se MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date /® A.. . /M5 (a) Legal Description (include lot, block, subdivis 4. Z C Location (address or directions) �. rs C'/< ___ on, section, township, range) (b) Applicants Name yr,�, f f1 Telephone - Home Business,57,74Z3Z Applicants Address 2.0 5 6. 1 6/IL sQ (c) Applicant is (check one) Lending Institution ; Owner/builder ; Buyer ; Other j (explain); (d) Lending Institution Adss 14114/10c51 (e) Real Estate Co. & Agent Address - Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single -Family L7Multi-Familyri Other (describe) Number of Bedrooms 3 3. 112.5.2E -§2.12222 Individual Weli f '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) 7/4Public 7i Community Holding Tank ni 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 Telephone Z V 651? Address 2 Z/ Date /25--A. 5 - 6. DEEP Approval Approved for 3 bedrooms By/` Approved Disapproved Terms of Conditional Approval (ENGINEER SEAL) v'11 "*".0 James R. Kinney • CE -6036 Rate.'. onal 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 A. WELL DTA Well Classification $$,4 / ri If A, B, or C, D.E.C. Approved(Y/N) �// Well Log Present (Y/N) Y / Date Completed 7 -?9-{y Yield detOr' Total Depth pi/ ft Cased to / r/ /9' Depth of Grouting Static Water Level y/ ,i< Pump Set At /.3g 4 I MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUrfICIPALI T ( OF ANCHORAC DEPT. OF HLALTi I & ENVEZONMENTAL P RCJCCTIO; I Legal Description: J� 4I / JAM 101985 Casing Height Above Ground 2 / Electrical Wiring in Conduit (Y/N) f Sanitary Seal on Casing (Y/N)7 Depression Around Wellhead (Y/N) /(/ Separation Distances frau Wall: To Septic/Holding Tank on Lot /b3 / ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /35 ; On Adjoining Lots i1J/ To Nearest Public Sewer Line /1//4 To Nearest Public Sewer Cleancut/Manhole AJ 7. To Nearest Sewer Service Line on Lot /v/ Water Sample Collected By ell, 61 n ; Date /-3-E5 Water Sample Test Results .5e /iSJRc ��y Comments GtJP // boy 54 ,4 ari Adel B. SEPlIC/HOLDING TANK DATA Date Installed it) --57-55P" Size 400417...e . No. of Canpartnents Z. - Standpipes Standpipes (Y/N) Y Air -tight Caps (Y/N) / Foundation Cleanout (Y/N) Y A/ Depression over Tank (Y/N) Date Last Pumped /V&A) Pumping/Maintenance Contract on File (Y/N) /F% ; for /V0 Holding Tank High -Water Alarm (Y, NA. Temporary Holding Tank Permit (Y/�j /v Separation Distances from Septic/Holding Tank: To Water -Supply Well 43_3 / ' To Building Foundation `6 / yO To Disposal Field ES l To Property Lire To Water Main/Service Line /✓"- To Stream, Pond, Lake, or Major Drainage Course Comments [Page 1 of 21 Receipt # 30 Date Paid: (U f Amount: c4 s-,-6 2=178-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /25 Type of System Design / Date Installed '/C) --.5"---17f" Length of Field 34' Width of Field /7 C1 Depth of Field y. f' Gravel Bed Thickness6 ~/ow �r Square Feet of Absorption Area 5, 3 Standpipes Present (Y/N) yd /4 Depression over Field (Y/N) /V Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well 135' To Building Foundation Lot To Property Line 4sr /e3 'y3 To Existing or Abandoned System cn N� To Water Main/Service-Line On Adjoining Lots /VA To Cutbank(if present) /VML __ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area /G Continents D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Dimensions Manhole/Access (Y/N) Electrical Codes(Y/N) Comments Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA **** HAA Re Check Permitted Bedroom Rating Againstquest I certify that I have checked, verified, or conformed to all MOA HAA Gtidel� in effect on the date of this inspection. Signed Company KB1/d5/s [Page 2 of 2] • Date M - / 1' 5 Re MOA No. �D U 2-15-84