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SAMPSON ESTATES BLK 4 LT 3
Sam Oum 'ioJa56 A I,,,& Lt c -v v ,nav, 01.o/ MUNICIPALITY OF ANCHORAGE p 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 .N EW v cr; C�CP C r'1 �Ip� `�� u ❑ UPGRADE MAI LING ADDRESS LEGAL DESCRIPTION V LOCATION NO. OF BEDROOMS DISTANCE TO: Well Abtorption area f Dwelling a ..� �- PERMIT NO. O Y 1 C ,- , ,•� y a Z Manufacturer ` Material No. of compartments LL a Liq'. capacity in gallons f� �E-�L IF HOMEMADE: Inside length Width Liquid depth 0 � DISTANCE TO: Well A , Dwelling PERMIT NO. J z = z F Manufacturer Material Liquid capacity in gallons " = DISTANCE TO: Well 3 ►�;�-1' I ti.J�=� Fou n tion f Nearest lot lin ef L� ,�- PER NO. 9 e-- _/�l I I .wa Z No. of line Length f each line �� Total len th of lines Trench w' Distance between lines .;J F -LU p�'j �J inches F- Top of the o finish grade I Material beneath tile /�}} I%4- inches Total effective absor on area Length Width De th PERMIT NO. Lu O a F- Lu Type of crib Crib diameter rib depth Total effective absorption area LU W DISTANCE TO: Well ding foundation Nearest lot line J Class s Depth Driller Distance to lot line PERMIT NO. J Lu DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER �L PIPE MATERIALS Ali- s I q og %i'b� s 231 C3 SOIL TEST RATING INSTALLER > REMA KS � °��T• y .: v� ° as a a• .. °.. ....aa.,.n aao�.3 ... � 3Y+ ° Rabari A. ShOtar -� ,�' ':'i ;. by C��� a�.' .f •s+ ' #tae APPROVED _.`I x [�jbil`.� n ;'c" +'- ' -`:.` DATE LEGAL " Z6 c -v v ,nav, 01.o/ LEGAL DESCRIP: SUBDIVISION: SAMPSON ESTATES LOT: BACK: 3 4 SECTIQN: 3 TOWNSHIP W LOT SIZE: 40315 (SQ.FT, OR ACRES) MAX BEDROOMS: 3 Listed belare Cow thca options available to you in designing yco r septic sysose the option that best Fits your site. .... ..... ... _..... ~..... ... ..... ... _�~_�__~~~___ DEPTH TO PIPE BOTTOM (FT,) 4.O 4,0 4,0 (.311RAyEL DEPTH (FT.) 7,0 0. 3.5 TOTAL DEPTH (FT,) 11,0 4.5 7"5 GFlePi. VEL WIDTH (FT.) 2`5 25.O 5,0 GRAVEL LENGTH (FT,) 65.0 47.0 97,0 ** GRAVEL VOLUME (CU.YDS.> 45;2 43"6 71`9 TANK SIZE ASALS) 1�000.0 ** 1�000,0 X to SOIL RATING (SQ,PIT. MR) 299 257 �00O,0 29� ** GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH) ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS ' ..... ..... ������������������������������������'^� ' I certi�y that: 1. I am familiar with therequirements fur on~site sewers and wells as set Porth by the Municipality Anc�orage of (MOA) and the State o{ Alaska` 2, I will install the system in with all MOA codes and regulations� and in compliance with the desigri criteria o� this permit. 3I will adhere to all MOA and State o{ Alaska For the back requirements set distance�� 12 al any existing well�� wastewater 111 sposal syst�m or public sewerage system on this or any adjacent or nearby lot, und�rstand that thispermit isvalid for a maximum o{ ,3'bedrooms and any enlargement will require ah addiLional pe� 1mit. MUNICIPALITY OF ANCHORAGE P�+.e DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST ❑ SOILS LOG �s-z)>/7 PERCOLATION TEST PERFORMED FOR::EM r-7& J --Foo DATE PERFORMED: 15� -•21 - S LEGAL DESCRIPTION: 1—•c�,T L1� . �R(✓1{��7L]ti lsS) �ET}i SLOPE SITE PLAN (F E l U v 2 3 4 (% 6 8 k� 9 c 10- 11 0 11 �( c` c 12 13 ®/ 14, p ,e 15 16 17 del - 25'7 O)r�/L- C2a 9 Plea- Af�Q • 18 e VI -3 `, p a a Gross Time JiGflif P 19 =g„a �tq {Z4}SSf1 A.. 9htiiFY o 20 �a No. 1A57 -E P° 1 o COMMENTS tA (9 TWA” PF,oG I-1,' WAS GROUND WATER S ENCOUNTERED? III���lllj� L P IF YES, AT WHAT E DEPTH? Irf Reading Date Gross Time Net -rime Depth to Water Net Drop 1 r� 3 l cyc) t o w �I 10 iL I D �> 45� N WAS GROUND WATER S ENCOUNTERED? III���lllj� L P IF YES, AT WHAT E DEPTH? Irf Reading Date Gross Time Net -rime Depth to Water Net Drop 3 l cyc) t o w �I 10 iL I D �> 45� N PERCOLATION RATE �1z- TEST RUN BETWEEN FT PERFORMED BY: a3GIiv;=E'Ri�' z CERTIFIE d 142141yVZR9�1LAIS�Kpp�A Oluat� 7J 72-008 (6/79) PH, 604-2J —(minutes/inch) 2 FT I A 02 9p do 2 Y Lo rn `t n a- 0) 0) 0 N � w J 2 o -3 F F F F F F F F F FF F Y C,4` O O a 3: 0: F F F F F F F F F F F F W N; U1: F+ F F+ F+ E+ F F•F F F F FF F -H F F 3 A x0 a COG a0' x0 x0 a a x0 Ox x0 Ik D - co b € b lo/l B B. �; w w w w w w w w w w w w w M' ry • C •. �: Ln �' rl J ir) 00' O F O F O F O F O F O F+ O F+ O F O F O F O F O F ° w< W W 43 �°€ Lr o :• : z • CR e W W O y, `n h W wO O O O O O O O O O O z x a x a x x a a O a W x a z w w g w w w w w w w w w w w w a ca a F F z v •, Municipality of Anchorage °rr On-Site Water and Wastewater Program (907)343-7904 5 • < < Certificate of On-Site Systems Approval Parcel I.D. 051-811-08-000 Expiration Dater ^1 a -17 1. GENERAL INFORMATION Complete legal description Sampson Estates B4 L3 Location (site address) 22676 Sampson Dr. Current Property owner(s) Theodore & Ava Manolas Day phone 830-1045 Mailing address 22676 Sampson Dr., Chugiak, AK 99567 Real Estate Agent Matthew Bex Day phone 854-6689 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: ( ail&M/rA_.,,,i Date: G//01-//, COSA to be released to the enginOrs otherwise requested by the engineer. COSA Fee $ 6-20 Waiver Fee $ Date of Payment (gt11,9- Date of Payment Receipt Number ei1�v> 33030 Receipt Number COSA# d,�j('��'1 a` t Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Alaska Rim Engineering, Inc. Phone 907-745-0222 Address 9131 E. Frontage Rd. Palmer, AK 99645 Ii Engineer's Printed Name ik.1 }r L 'J l�f��' �`� Date kl' 1 SsOF AL lr����y�lttt' 5 co /4. 6. DSD SIGNATURE �r gTH ,.'* NiC System #1 Approved for 3 bedrooms /7414 • r � I System #2 Approved for bedrooms s9fi Mary Shreves ,= Disapproved ::11.1.q � ' . iffES:FgE3SS5L,,,:: •• Conditional approval for bedrooms, with the following Y 0c- AYin niu W�is, TERA AND G) trtl PRGGP4M Original Certificate Date: 9 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: . COSA Checklist X Nitrate Advisory ; — Septic System Advisory Arsenic'Advfsory • Well Flow Advisory Other • ' . • COSA Clue sheet C c If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Certificate of On-Site Systems Approval Checklist Legal Description: Sampson Est. B4 L3 Parcel ID:051-811-08-000 A. WELL DATA Well type Private If A, B, or C provide PWSID # Well Log (Y/N) Y Date completed 6131$5 Sanitary seal (YIN) Y Wires properly protected (Y/N) Y Total depth 141 ft. Cased to 141 ft. Casing height(above ground) 22 in. FROM WELL LOG AT INSPECTION Date of test 6/3/85 5/11/17 Static water level 22 ft. 119.4 ft. Well production 8.7 g.p.m. 5.1 g.p.m. WATER SAMPLE RESULTS: Coliform ND colonies/100 mL Nitrate 7.67 mg/L Arsenic ND ug/L Date of sample: 5/10/17 Collected by: Brandon Jones B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 5/25/85 Tank size 1 000 gal. Number of Compartments 2 Cleanouts (YIN) Y Foundation cleanout(Y/N) Y Depression over tank(YIN) N High water alarm (Y/N) N/A Date of pumping 5/18/17 Pumper JR's Pumping C. ABSORPTION FIELD DATA Date installed 5/25/85 Soil rating (g.p.d./ft2 or ft2/bdrm) 299 FTiBDRM System type Trench Length 65' ft. Width 2.5 ft. Gravel below pipe 7 ft. Total depth 10.8 ft. Eff. absorption area 910 ft' Monitoring tube Y Depression over field N Date of adequacy test 5/11/17 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 52" in, Water added 990.2 66 p pgal. New depth in. Elapsed Time: 1282 min. Final fluid depth 52 in. Absorption rate >= 4774 g p d None Known Any rejuvenation treatment(past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed N/A Size in gallons N/A Manhole/Access (Y/N) N/A "Pump on" level at N/A in. "Pump off level at N/A in. High water alarm level at N/A in. Datum NIA Cycles tested NIA Meets alarm&circuit requirements? N/A E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100'1- On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 1001+ Public sewer main WA 7 5r-k- Public sewer manhole/cleanout 0 WO-1- Sewer Sewer/septic service line 25'+ Holding tank 1 1' 7 5--t-- Animal Animal containment areas Mt* 5-0+ Manure/animal excrete storage areas None SEPTIC/HOLDING TANK ON LOT TO: Building foundation 151+ Property line 10'+ Absorption field 10'+ Water main 101+ Water service line 14'+ Surface water 1001+ Wells on adjacent lots 100'+ ABSORPTION FIELD ON LOT TO: Property line 101+ Building foundation 30'+ Water main 10'+ Water Service line 1r01+ Surface water 100 + Driveway, parking/vehicle storage 50�+j' Curtain drain N��f Wells on adjacent lots 1001+ F. COMMENTS G. ENGINEER'S CERTIFICATION ``0..VMliIiii, I certify that I have determined through field inspections and �".'(��F A�,giir�/�' review of Municipal records that the above systems are in ,<S,-.. ..,::,/,- I,, conformance with MOA COSA guidelines in effect on this date. CO/ Engineer's Printed Name / � �i 1.4 , -iit-------f--- Date / ff — ��',,.'• Mary ' Shreves � r lS' '.,� CE 9351 ;•��` I/i, 2 ROFESS\,.0. � COSA canary sheet_2-6-15.doc I • • Municipality of Anchorage e U I•_ Development Services Department-46 --'' Building Safety Division is;1 ti SA E T Y 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 # OSC 171226 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 3 of Sampson subdivision. This inspection revealed a nitrate concentration of 7.67 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. Nitrate Fact Sheet From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. RECOVERED 5/8" REBAR (NOT USED FOR THIS SURVEY UNSUBDIVIDED N9000'00"w 116.30'(R&C) 0 / ELECTRIC 33' SECTION UNE / EASEMENT EASEMENT I / / / ,/ LOT 1 / / LOT 3 , 40,315 S.F. SHED NO FND-\ z 0 ao Col LOT 4 0 9°. C°. SHED ¢ BLOCKLA a�NO FND hi 0r 99 ;a LT tp 4" PLASTIC LOT 2 r (1W) RISER ( CONCRETE ,s-------PAD o U.G. T&E CANT ;, C/O 2st. }a, w 42'1. DWELLING 6.0 O0 4.S'0_ NAT. �a �. GAS Q a Loc 0 0) 10' T&E UTILITY EASEMENT PEDS LEGEND: RECOVERED .;;. WELL I r r (C)=CALCULATED DATA 5/6" REBAR (M)=MEASURED DATA (TW ) ". r — 4 00 (R)=RECORD DATA PER PLAT 11A 00'(R) 115.01'0) U.G.=UNDERGROUND T&E= ELECTRIC MUNICATION & ° N81 LA BA 518 110E ' RiNG NAT.=NATURAL 0 r ---------- FND=FOUNDATION pS DR• (TYP.)=TYPICAL ,SA1Y1 1" - 50' NOTES: 1. EXCEPTING FOR GROSS NEGUGENCE, THE LIABILITY FOR THIS SURVEY SHALL NOT EXCEED THE COST OF PREPARING THIS SURVEY. 2. THIS SURVEY REPRESENTS VISIBLE IMPROVEMENTS & CONDMONS ON THE DATE OF SURVEY. 3. THIS DOCUMENT DOES NOT CONSTITUTE A BOUNDARY SURVEY & IS SUBJECT TO ANY INACCURACIES THAT A SUBSEQUENT BOUNDARY SURVEY MAY DISCLOSE. 4. THIS SURVEY SUBSTANTIALLY COMPLIES WITH ASPLS MORTGAGE STANDARDS. 5. TIES TO PARTIALLY MONUMENTED OR UNMONUMENTED PROPERTY LINES ARE ±1 FT. 6. THIS SURVEY PERFORMED FOR MANOLAS FAMILY TRUST, IT SHOULD ONLY BE USED FOR A SINGLE PROPERTY TRANSACTION_ REUSE OF THIS DRAWING FOR ANY PURPOSE NOT STATED ABOVE WITHOUT THE EXPRESS WRITTEN CONSENT OF ALASKA RIM ENGINEERING, INC. IS A VIOLATION OF FEDERAL COPYRIGHT LAW. EXCLUSION NOTE: IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES. `������N1111�I1,� JG ALASKA RIM ENGINEERING, INC. AS—BUILT 9131 E. FRONTAGE RD. +� ' C:...........'9 liI PALMER, ALASKA 99645 • ••P4- � _ PH: (907)745-0222 : FAX: (907)746-0222 5." TH /\ •9 ,� 7sf%,..., EMAIL: akrimOalaskarim,com : WEB: www.alaskarim.com IN •1 4 •:�` i WO: 1700261 FB: 17-04 o �. ARE PAGE: 1 of 1 GM: NW1560 e t ; Engineers: Planners: Surveyors SCALE: 1" = 50' FILE: 1700261 AS • Robert J. Farmer •. o .. T._•• I HEREBY CERTIFY THAT A MORTGAGE INSPECTION WAS PERFORMED IM � st 10615-S ' 14. ED A ',.11 .. I0NA4 L!'a±�.��� SAMPSON. UNDERYESTATES, BLOCKDIRECTION ONT4E LOT 3,W PING LATDNo.ESC84-10PROPERTY: III��11��t1���`,� ANCHORAGE RECORDING DISTRICT. ANCHORAGE ALASKA. SURVEYED ON THE 5th OF JUNE, 2017. 2017 MUNICIPALITY OF ANCHORAGE ' DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services 44 On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING` p Parcel I.D.# �% '1= \l-- CA HAA# AAD 1 nn��(1 1. GENERAL INFORMATION Complete legal description Lao 3; «_oc1<. 4; Sarnpsosi Fs':icea Location (site address or directions) 22676 Samirsoy, V&jve. _ (, 'c(.LC Harz. AK Property owner David 9 Debbie ,'Icc _, e I, Day phone 6-"8'- l i 46 Mailing address P.O. Uox 672432 C'tu.Ciaf AK 99567 I Lending agency /���� ��';��'-' ; i`.'� Day phone C,Q4i 77;? Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 5 3. TYPE OF WATER SUPPLY: Individual well Community well Public water MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION JUN 14 1996 RECEIVED NOTE: If community well system, provide written confirmation from State AGIF-C attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA x21 S. 6. 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. S & S ENGINEERING Name of Firm d Nei 904 Phone Address Eagle River, Alaska 99577 Engineer's signature DHHS SIGNATURE — Approved for -----— bedrooms. Disapproved. Conditional approval for Eco-)_`/ 7 ei Date 6. /j y bedrooms, with the following stipulations: Additional Comments BY: e- ., L Date G CAUTION icioality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority A""ro''aj Certificates based only upon the representations given in paragraph 5 above by an independent 9ineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes ng institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not tions or analyze data before a certificate is issued. The Municipality of Anchorage is not `Tors or omissions in the professional engineer's work. u- . J Municipality of Anchorage C DEPARTMENT OF HEALTH & HUMAN SERVICE E C E I V E D Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) QjWj,�4 1996 Health Authority Approval Checklist Municipality of Anchorage Dept. Health & Human Services Legal Description: Lo -r 3 Ai-cci� 14 1 SAMP-5,r) F -%-r. S/o Parcel I.D.:-05 I e tt -- Oe A. WELL DATA Well type fe-Wkm Log present 1&N) `I Total depth Iii i , Sanitary seal &N) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 Date of sample: If A, B, or C, attach ADEC letter. ADEC water system number Date completed _ Cased to V FROM WELL LOG 6-3-85 ZZ.I 9--7 g.p.m. d' -G=9(- -6-3-ss Casing height (above ground) Wires properly protected(O/N) AT INSPECTION Nitrate Z • I I 1 1 Collected by: Other bacteria 0 b" !S� EAC. wE6r-,dC. B. SEPTIC/HOLDING TANK DATA Date installed 5 - 26 --85 Tank size 1000 Number of Compartments Z Cleanouts (CON) Foundation cleanout (9q) Y Depression (Ya 1J High water alarm (Y/N) 0 ✓'1 DateofPumping b-io-tiX C. ABSORPTION FIELD DATA i Pumper 3-9, ?Unnfl4 f Date installed 25 78T:3 Soil rating (g.p.d./1112 or ft2/bdrm) Z`1'7 System type �`lE tJ c H 3 Length Width :.3o" Gravel thickness below pipe 8911 To Cal depth t I Effective absorption area Monitoring Tube presentYDI) Y Depression over field (Y/ND 1s Date of adequacy test ` I �' HL / Result ass Fail) 'ASS i For 3 bedrooms Fluid depth in absorption field before test (in.); 4g rS " Immediately after'i6° gal. water added (in.): Fluid depth • (ins) Minutes later: foo Absorption rate = `tomd. 9•P• Peroxide treatment (past 12 months) (Y/N) /4OA J 1410,`i If yes, give date 72-026 (Rev. 3/96)* 06/12/96 16:24 CT&E ESI ANCHORAGE � 9076941211 NG._=' ME Environmental Services Inc. Laboratory Division - Laboratory Analysis Report C'1'&l; Ref.# 962247.962247002 S l m LOT 31zr 4 Sam son Est Collected Gate 06/06/96 Cltent aMP e p Matrix Drinking Water Technical Director: Stephen C. I= PWSED 0 Released By —kq&L. - Sample Remarks Parameter Results oc PQL Units Method ALLoHabte Prep Qual Limits Date uitrate•N _ 2.19 0.200 mg/L EPA35 3.2 Nitrite -N 0.100 U 0.100 mg/L EPA 353.2 TotaL Coliform 0 0 col/100mL SM18 92220 Undet L.' U - LT - Le6�: ,':.. GT - Gree';. J - 66101'r Y:-_ :M1 200 W- Potter Drive. Anchorage, AK 98518-1605 — Tei: (907) 562-2343 Fax (907) 561-530' 3180 Pager Road Fairbanks, AK 98709-5471 — Tel: (907) 474.8656 Fax: (907) 474-9685 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA. ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY. 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.# b�� -8�/� Off' ti HAA# 1. GENERAL INFORMATION Complete legal description Zz,7-.3 13c -e - 2. 3c e-- 2. Location (site address or directions) 76, 5/}�A50Af i Rk Property owner Nc-� 51-144,0-4 Day phone c'8r1 - /893 Mailing address PD. 6o,e- 667 31 It'4472t- 9Z�,cy- S57aS 1731 Lending agency Day phone Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup NUMBER OF BEDROOMS: -3 3. TYPE OF WATER SUPPLY: Individual well K Community well Public water Day phone 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 �C Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev.1/91) Front MOA#21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: `ora -gw- ¢ n o J AP> Parcel I.D. ��— 01'//—,Dr A. Well Data Well type Qui J 4-� If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) y Date completed 613 & i Driller T a-- Total depth 141 1 Cased to / `f / Casing height Z ' Sanitary seal (Y/N) V Wires properly protected (Y/N) y FROM WELL LOG AT INSPECTION r Date of test ` £' 6—y ;V 3 o z Static water level ZZ' /�7' Z Well flowtT —' g.p.m. f Gs g.p.m. T` m o Pump levell �//� u/� y Z tT 11=1<0 SEPARATION DISTANCES FROM WELL TO: < O O rn Septic/holding tank on lot /®9 ; On adjacent lots /a Z Absorption field on lot 3 ; On adjacent lots /0e) Public sewer main L11-41— Public sewer manhole/cleanout Sewer service line Z5 t Petroleum tank �✓�✓� WATER SAMPLE RESULTS: c• Coliform 5 Nitrate Other bacteria Date of sample: a �z/dam Collected by: 040 B. SEPTIC/HOLDING TANK DATA Date installed 6�u/�� Tank size /000 Compartments 2 Cleanouts (Y/N) y Foundation cleanout (Y/N) y Depression (Y/N) High water alarm (Y/N) A14 Alarm tested (Y/N) �✓,e2 Date of pumping Pumper 5 /7WIrA�y SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /09 On adjacent lots 14�'-024- Foundation To property line ��.Absorption field G ' Water main/service line LS't Surface water/drainage 10 o -r- 72-026(3!93)• Front CONTINUED ON BACK PAGE D. R. DAYTON, P.E., R.L.S. 20210 Donalar Chuglak, Alaska 99567 May 111 1994 WELL FLAW TEST Legal Description: Lot 3, Block 4; Sampson Estates Date of Test: May 4, 1994 Well Depth: 141 ft. Static Water Level: 117 ft; Requirements: 3 BR - 450 gallons per day (907) 696-2417 Test: The well was tested with the existing pump through an outside hose bib. Drawdown and volume measurements were taken at regular intervals. Recovery measurements were taken after the pumping was stopped. Results: The well produced 465 gallons in 100 minutes with a maximum drawdown of 2 ft. The drawdown was fully recovered within 20 minutes after the pumping was stopped. The well is currently producing adequately for a 3 BR home. t f 41 o g + �� + +naasE sea eo+aoeo es a+ ac• , nOR. Dayfan ''4Y.r�y r D. R. DAYTON, P.E., R.L.S. 20210 Donalar Chugiak, Alaska 99567 (907) 696-2417 May 11, 1994 ADEQUACY TEST Legal Description: LOt 31 Blk 4, Sampson Estates Date of Test: May 10, 1994 Septic Tank: 1,000 gallon, 2 compartment, steel tank (DHHS Records) Absorption System: 65' long x 212-' wide x V effective depth trench (DHHS Records) Soils Rating: 299 sq. ft. per bedroom (DHHS Records) Requirements: 3 BR - 450 gallons per day Test: Water was pumped into the trench while measuring volume and water level rise at regular intervals. After pumping was stopped, the water leveldrop was measured at timed intervals. The results were plotted on a graph of time and gallons absorbed and extrapolated to 24 hrs. Results: The system is currently functioning adequately for a 3 BR home. kSO-LDBYT-CASH - C.O.D. j CHAR( 1 - DATE SINCE 1908 CT&ERef.# Client Sample ID Matrix ClientName Ordered By Project Name Project# PWSID Commercial Testing & Engineering Co. Environmental Laboratory Services o�� ZZ7&I LABORATORY ANALYSIS REPORT 94.1994-1 L3 B4 SAMPSON EST. WATER DAVID DAYTON, P.E. DAVID DAYTON UA Sample Remarks: ROUTINE SAMPLECOLLECTED BY: D.R.D. Parameter Nitrate -N QC Results Qua1 Units WORK Order 78007 Printed Date 05/05/94 @16:08 hrs. Collected Date 05/02/94 @16:30 hrs. Received Date 05/03/94 @ 11:15 hrs. Technical Director STEPPBE,N C. EDE Released By: �s�%%%'�/��✓ es Allowable Ext. Anal Method Limits Date Date Init 1.59 mg/L EPA 353.2/300.0 10 * See Special Instructions Above UA=Unavailable ** See Sample Remarks Above NA=Not Analyzed U =Undetected, Reported value is the practical quantification limit. LT= Less Than D = Secondary dilution. Gr= Greater Than li. NR33 R RtrPPt Anehnrnno AK CIGIR1 -19ZAA T-1. 10071 r.R9 OQA4 1E--. /nnT CGS GOn1 05/04/94 CMR ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA n Commercial Testing & Engineering Co. n vi ronmenta I Laboratory Services"e��s�®v�►�9os:ry��r�+��ors�eis»ii�� 5033 3 S,ree? Anchorage, AK 99518-1600 Dri-i-ikinor Water nalysis Report for Total Coliform Bacteria 31: f907) 562-2313 =ax: (907) 56 i -5301 READ I VSTR L-CTIO ti'S ON RE,'ERSE SIDE B_ FORE COLLFCTLYG S Ll'fPLE S1 UUNL^_Fz. -D 3` `.`,?.! K5 '_'L T03=C0: �i T - - PtiBLIC WATER SYSTEMS LD. = I I I = - s:> 't"o;, __ .00 PRIVATE )XATER SYSTEM J_:s_acro _ Sm_a !moxt 30 ^ou s Old, -^. :CO 1022 tri tans''.; Samp[- shoo!" tonna. uao :v- ur_vr V I n"F 0B O 0[ '�3 'ours ole 2E --x —H i`2 1On - i0 iIlC!CfliO r�li2blc -, sll.u. Please se=!u sa`n018 `iia spOC'ai I � DateReceired J i Time Received - StndR:s:�� � endlnvoirt 5 i rJ 'Z' -/;,j Analtisis Bean +—� — - 2,0 Zi o ur4rc � >5707 Month Dae Year 3 Routine ❑ Treated Water Repeat Sample (for routine sample 'Untreated Water with lab ref. no. ) Special Purpose Time Collected SAMPLE LOCATIOcY Collected By �nah Ileal Mlethod; Vfembrar,=lute' VLVIO MUG O: Oi c01On-,zsi0 ' Lab Ref. -No. Result- Analvst Sen to A.D.E.C.cn Fbls Jun LJ r Da;�: 5 I Tint-- imeClient Faxed Client:notified of unsatisfactory results: J nn J Phoned Spoke with Fazed Date: Tiny: B-4i.CTERtIOLOGIC--A,i;'kV-ATERt -j -LYSIS RECORD MM10-NTUG Result: Total Coliform E Coli Membrane Filter:_ Direct Count Coloniesl1130 ml Verification: LTB Fecal Coliform Confirmation BGB COLIr" IRAI n-rC - ran ,V.m,.� F. C..,, Final Membrane Filter Results Coliform/100 ml Reported $} Date 5_� Time /�� V" hrs PART ONE OF TWO: REMAINDER TO FOLLOW ENVIRONt�1=NSA! FAMLITIF31NAL- ince) OHIO. UTAH, WEST VIfi61NIA 2. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL H(Qpj•- O S6 OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include ot, block, subdivision, section, township, range) 4oT 3 /& s.YPsr/ �0?7- . Location (address or directions) y267 6 S Psn✓._. ZD . (b) Property Owner %7TTi,%!f Telephone: Home % Business Mailing Address POSAV 6,44/.'W 11 /7C 99s 7 (c) Lending Institution - Telephone Mailing Address y •t_ 1 " (d) Real Est=ate Corhpany;and.Agent Address Telephone (e) Mail the HAA to the following address: or: Check here Li'l if hnid fnr nick Pin TYPE OF RESIDENCE Single -Family Number of Bedrooms_ Fj 3. WATER SUPPLY Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL _ Onsite Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 IRev 8/861 Front A. WELL DATA CIPALITY OF ANCHORAGE (MOA) NdNt�tPENTA�ER�CEsITH AUTHORITY APPROVAL (HAA) t14,moNM CHECKLIST - FEBRUARY 1984 9a$ 264-4720 RkJG2gl RECE�\10 65'r 8 11-06 Legal Description: /10Y/' 84#L' S` S �` � F�ii Well Classification ��'�✓fFT�r If A, B, C, D.E.C. Approved (Y/N) A11,4 Well Log Present) Date Completed PvP3-b'S Yield •T �/�� Total Depth Cased to l`�/ Depth of Grouting Static Water Level (a/ Pump Set At .✓/4 Casing Height Above Ground Sanitary Seal on Casing) Electrical Wiring in Conduit((Y N) Separation Distances from Well: To Septic/Holding Tank on Lot Depression Around Wellhead (16 On Adjoining Lots /OV -14-- To tTo Nearest Edge of Absorption Field on Lot /07 t ;On Adjoining Lots /" i-10- To Nearest Public Sewer Line 5 To Nearest Public Sewer CleanouUManhole /� To Nearest Sewer Service Line on Lot . Water Sample Collected by C% /4. d�E/J ; Date `—/6 Water Sample Test Results 01/ e `T -.& All � �• Comments _& e,4-41- Ftp -re-57- 8--/o--,Fr, B. SEPTIC/HOLDING TANK DATA yS / _71 - Date Installed 1 �� Size /0" No. of Compartments 2, Standpipes(9N) Air -tight Caps Y/ V) Foundation Cleanout (Y N) 1 /J Depression over Tank (Y19 Date Last Pumped Pumping/Maintenance Contract on File (Y/N) � ; for Holding Tank High -Water Alarm (Y/N) / Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: i To Water -Supply Well /07 To Building Foundation. To Property Ligp Tb',1/1�a)er,Marn/Sgrvice Line Y } Commentsr Page 1 of 2 72-026(11/84) dw % r To Disposal Field to e To Stream, Pond, Lake, or Major Drainage CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order # 8458 Date Report Printed: AUG 15 88 @ 14:40 Client Sample ID:L3, B4 SAMPSON EST. Client Name AECS PWSID :UA Client Acct AKECSRP Collected AUG 10 88 @ 14:50 his. P.O.# NONE REC D Received AUG 10 88 @ 16:00 his. Req # Preserved with :4 DEG. C Ordered By : A. WEIN Analysis Completed :AUG 12 88 Laboratory Superv'soi :STEPHEN C. EDE Released By Special / Instruct: Chemlab Ref #: 2161 Lab Smpl ID: 1 Parameter Tested ------------------- NITRATE-N Sample ROUTINE SAMPLE Remarks: SAMPLE COLLECTED BY A. WEIN. Send Reports to: 1)AECS 2) Matrix: WATER Result/Units --------------------------------------- 1.2 mg/l 1 Tests Performed See Special Instructions Above ND= None Detected See Sample Remarks Above NA= Not Analyzed LT=Less Than, GT=Greater Than Allowable Method Limits -------------------------------- EPA 353.2 10 UA=Unavailable CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. g TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 "'° •�^'°° Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY ❑ PUBLIC WATER SYSTEM I.D.# FTI Analy 's shows this Water SAMPLE to be: �l PRIVATE WATER SYSTEM AEG S Z7 i—SSSS Satisfactory ❑ Unsatisfactory Name i n Phone No. _ j3 ❑ Sample too long in transit; sample should not be over 30 hours old at examination Mailing Address to indicate reliable results. Please send 79so3 new sample via special delivery mail. City - State Zip Code j Date Received SAMPLE DATE: o b / U S 5 Mo. Day Year Time Received U SAMPLE TYPE: Analytical Method: Membrane Filter Routine ❑ Check Sample (for routine sample with lab ref. no. ) ❑ Treated Water No. of colonies/100 ml. ❑ Special Purpose i `0 Untreated Water SAMPLE Time Collected Lab Ref. No. Result' Analyst NO, LOCATION Collected By / 1 L-3 1S/ EST FTO e s T. 2: 3 IBJ m j 4 I IBJ m 5 I I I m BACTERIOLOGICAL WATER ANALYSIS RECORD V READ INSTRUCTIONS Membrane Filter. Direct Count Coilforml1100ml BEFORE Yerificatiom, LTB BGB COLLECTING SAMPLE Final Membrane Filt s It Coilform/100mi Reported By D)to Time: ��� a.m. p.m. TNTC = Too Numberous To Count PART 1 OF 2 OB = Other Bacteria REMAINDER TO FOLLOW MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION 2. (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name –119 —Telephone: Homey Business, -S 6-`'6 Applicant Address ? '� €3 �s t -Li>i P/ , - Ar'_"f_t-L (c) Applicant is (check one): Lending Institution ❑ ; GKvffter/buildey Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Ma4 the HAA to the following address: A <�fj' y ijl_`F✓ -aR ftie,r iia Ia E-594-2WP TYPE OF RESIDENCE Single -Family Multi -Family ❑ Number of Bedrooms 3 _ 3. WATER SUPPLY Other Individual WellCommunity ❑ 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�R(_ 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) 5_ ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND 1N Ot pjA' Tl0t.; � a As certified by myseal affixed hereto and as of the validation date shown below, I verify that my investigatiol I of 111'rip I te"aslth FuithorilyApprovai stows 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 ir7pect"tcn. Name of Finn -_ Telephone Address __=u Date i °gapaopp r ds 6. DHEP APPRG&I'U c Approved fur r�_. bedrooms by -d -4' - Date Approved Disapproved —_ Conditiona Terms of Concrt;cnal Approval — CAUTION The Muncipat'oy of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval cer;i`!cates eased solely upon the representations given in paragraph 5 above by an independent professional engineer reg,s"ered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending inStitutions in order tc 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 emmneers v:ork. Page 2 of 2 �l MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTIOfI HEALTH AUTHORITY APPROVAL (HAA) r. P �986noC, CHECKLIST - FEBRUARY 1984 S 264-4720 Legal Descri tion: L,,r-7 � � A. WELL DATA Well Classification �` If A, B, C, D.E.C. Approved (Y/N) of,, Well Log PresentCWN) Date Completed (*0'- Yield Ste© G,PH Total Depth � Cased to 1 �-1 t Depth of Grouting Static Water Level 2� r Pump Set At 1), {� . Casing Height Above Ground Sanitary Seal on Casing<2�N) Electrical Wiring in ConduitO/N) Depression Around Wellhead (Y4V Separation Distances from Well: To Se tic/ p t-lekai;+g� Tank on Lot 1 ; On Adjoining Lots 1 Fri k 1 To Nearest Edge of Absorption Fiell n � Lot 1 �� ; On Adjoining Lots 1 >� To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot'"r Water Sample Collected by t �ti�j(�Z(.xe ;Date Water Sample Test Results Comments B. SEPTIC/Net&NIMTANK DATA Date Installed S'Zi -0' Size No. of Compartments Standpipe>�V/N) Air -tight CapsON) Z Foundation Cleanout®N) Depression over Tank (Y/Q Date Last Pumped Pumping/Maintenance Contract on File (Y/N) i rJ A - ; for Holding Tank High -Water Alarm (Y/N) w 1* Temporary Holding Tank Permit (Y/N) �/A Separation Distances from Septic+totding Tank: r 1 To Water -Supply Well , C� To Building Foundation 4L To Property Line \cam c� To Disposal Field_ l To Water Main/Service Line Course Comments Page 1 of 2 72-026(11/84) 03 la t �- To Stream, Pond, Lake, or Major Drainage CHEMICAL & GEO_ 3GICAL LABORATORIES G- 'ALASKA, INC. TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER wow�rowr.. 5633 B Street --- Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: I (•) See It on back I.D. NO. water System Name Phone No. SlS4 X Mailing Address City State Zip Code SAMPLE DATE: SAMPLE TYPE: yin --© =© 4 " Routine ❑ Check Sample (for routine sample with lab ref. no. ► ❑ Treated Water ❑ Special Purpose Untreated Water SAMPLE Time Collected NO. LOCATION Collected By 1 1 3 f-3 —K. zl Is lS w -A - 3 I I 4 II 5 t READ INSTRUCTIONS BEFORE TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: Satisfactory ❑ Unsatisfactory ❑ Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received . �✓ S/ Time Received 2 . 5 J !L4y Analytical Method: ❑ Fermentation Tube ,AE!�^Wembrane Filter Lab Ref. No. Result' Analyst � I � I m I m j FTI .No. of colonies/ 100 ml. or No. of Posmve ponions. 06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1983 Membrane Filter. Direct Count Verification: LTB Final Membrane Filter Results Reported By COLLECTING SAMPLE TNTC = Too Numerous To Count Cate Time: Coilform/100ml Collform/100ml a.m. P.M. C. LIFT STATION Date installed A/ Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) High water alarm level "Pump on" level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA "Pump off" Level at Cycles tested Surface water Date installed Soil rating (GPD/Ft2) 7-79 5rII2 System type Length Width Gravel thickness 7 Total depth Total absorption area V/0 -34 Cleanout present (Y/N) Y Depression over field (Y/N) AZ Date of adequacy test S5`� Results (pass/fail) A 5 for Bedrooms Water level in absorption field before test % UQ After test Z• 8 a 1t Zi a Peroxide treatment (past 12 months) (Y/N) Aio If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot `00�On adjacent lots /®fit G To building foundation 30 line 1t' To existing or abandoned system on lot A/ai -Ir- On adjacent lots 40-�Cutbank Water main/service line Surface water 10-V t Driveway, parking/vehicle storage area Curtain drain / ."ViE E. ENGINEER'S CERTIFICATION I t certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. David R. Dayton P.E. 20210DonalarSt. � f , Signature Chugiak `Alaska 92567 Engineer's Name �� iOClLP G5dSn9f r uooa000 Joao , Date��o. a HAA Fee $ J[)a 'ein Date of Payment Receipt Number Q's l 72-026 (3/93)' Back Waiver Fee $ Date of Payment Receipt Number 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 David R. Dayton Nd Phone --'x117 20210 Donalar St. Address c ueriaLAlarka99r:lam Engineer's signature a 6. DHHS SIGNATURE X Approved for _ bedrooms. Disapproved. Conditional approval for Additional Comments 0 ,(1TIr Date 'ml nee,PC ft ca.s n.e eoaen se vena. tieona bedrooms, with the following stipulations: Date -3--,/ 7 - `14 The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-M (Rev. 1/91) Beck MOA #21 D. LIFT STATION Date installed Size in Manhole/Access (Y/N) High water alarm lei tested E. SEPARATION DISTANCES *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot I o©' 4 Absorption field on lot i00) i - at* On adjacent lots On adjacent lots "Pump off" level at* Public sewer main iJ�LA Public sewer manhole/cleanout Sewer /septic service line ZS Lift station 1 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation is t'} Property line J0 Absorption J001 -f- IC)O J + t, JA Ido�-f Water main/service line ) b 14 Surface water/drainage fy0 i4 Wells on adjacent lots 100` SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line 10 1+ Building foundation 3G` 4 Water main/service line )b 14 Surface water i 0014- Driveway, parking/vehicle storage area 50' '= Curtain drain � /A Wells on adjacent lots I oo 14 F. ENGINEER'S CERTIFICATION certify that I have determined thru field inspections and review of Municipal records thstems are in conformance with M A NAA guid lines in effect on this date. ywPOF q��s Signature Engineer's Name �i) �R Co • sA "" Date c //4Y / 6 A� ROBERT C. COWAN l �Q CE-8Sol HAA Fee $ � ` , CIO Date of Payment o Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed LS�B Width of Field y s 7-79 Type of System Design Length of Field �S r Depth of Field Gravel Bed Thickness / P Square Feet of Absorption Area 7/0 Standpipes PresentON) Depression over Field (Yo Date of Last Adequacy Testy'/O Results of Last Adequacy Test Abcau it Separation Distance from Absorption Field: To Water -Supply Well % To Property Line i To Building Foundation 74- To Existing or Abandoned System on A)1,4 Lot ; On Adjoining Lots TA -/- r To Water Main/Service Line /o `,# To Cutbank (if present) A/0 r To Stream/Pond/Lake/or Major Drainage Course /O fi To Driveway, Parking Area, or Vehicle Storage Area /o r Comments D. LIFT STATION to Installed Size in Gallon "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments — Dimensions Manhole/Access (Y/N) — "Pump Off' Level at Vent(Y/N) umping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I hav�c ickk vdr11A.:-- ed, or conformed to all MOA gand HAA guidelines in effect on the date of this inspection. Signed G^ � " Date a'f Company ���� MOA No. •'f •,�'fG'OF AtCl? y� r/ O ' / os Receipt No. r� _ `S �b / i� V. `• LL Date of Payment �� T •'r �, Amount: $ 1 ,/ } gineer's ea CE . 2251 Page 2 of 2 72-026 (11/84) 4c-7 R r _�/rnrxs✓ 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�/ Telephone Z79-53SS3 Address 33^� /�ic�G:• $�' y'9soj Date r 6. DHHS APPROVAL Approved for ��Jy bedrooms by Date �i��4 Approved Disapproved Conditional Terms of Conditional Approval CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (Rev 8/861 Back C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata �(�' Type of System Design Date Installed Z – Length of Field _(-Q!;— � Width of Field " Depth of Field 1 hr Gravel Bed Thickness i�N Square Feet of Absorption Area �i/o Y, Standpipes PresenteN) Depression over Field (Ap Date of Last Adequacy Test _/L42S'� Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well 1 l 2, To Property Linefi- tk To Building FoundationTo Existing or Abandoned System on Lot 'a la ; On Adjoining Lots I+ To Water Main/Service Line f D t To Cutbank (if present) t� 4 To Stream/Pond/Lake/or Major Drainage Course ,A To Driveway, Parking Area, or Vehicle Storage Area Comments 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 MOA and HAA guidelines in effect on the date of this inspection Signed fi a P E"ICM"=t�1P(C Date SSD i2V; Company,-, LL. RIVER, USKI? ,",30= MOA No. 2:,5-60P Receipt No. H. 6P 2 7J 7 ._ �5 4 C-) Date of Payment q -q -�5 � �. ; • •�'��� Amount: $ 45 `�6 v ra _ Safi Page 2 of 2 72-029 (11/94) 4 R®bart A. Shafer v' i" No. 1457-E, NZ ��.