HomeMy WebLinkAboutSAMPSON ESTATES BLK 4 LT 11Municipality of Anchorage Page I of z
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: 5w-T4.ol96 PID Number: 051 - 1811 - re
Name: ALAa P;-asofs
Wastewater System: El New 0Upgrade
Address: LA . -0RA�tL IN
322 Luf+AQ, aJE N.oSaI
SB
ABSORPTION FIELD
Phone:
(70 1) ZSS 4 184
No. of Bedrooms:
3
@'Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other
LEGAL DESCRIPTION
Soil Rating:
Total Depth from original grade:
t
0 • 6 GPD/Sq. Ft.
9
Lot: Block: Subdivision:
11 IjAMPSot
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
4 L -ST,
3 Ft.
6 Ft.
Township: _—
Range:
Section:
Fill added above original grade:
Gravel length: t
__
O. 5 - 1 • S Ft.
50 Ft.
WELL: ❑New ❑Upgrade
Et't
Gravel width:
Z. 5
Number of lines:
Distance between lines:
_�
t ST fs
, Ft.
I
Ft.
Classification (Private, A,B,C): Total Depth, ased To:
p�tvATc
Total absorption area:
Pipe material: A i9 m 03o3y
Ft. Ft.
LOQ SO. Ft.
/ Fe7o
Driller: Date Drilled: Static Water Level:
Installer:
Ti.I
Date installed:
Ft.
EEp �XGJU A7aA6
SA/44
Yield:
Pump Set at:
Casing Height Above Ground:
TANK
GPM
Ft.
Ft.
SEPARATION
DISTANCES
X Septic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer:
Capacity in gallons:
From
Tank
Field
Station
Tank
Sewer Lines
f%V4 a t4 o itgG t T tJ IL
10 o 0
Well"
i
loo +
too
�,
-
1
�5 F
Material:
ST -a E-L_Surface
Number of Compartments:
2
Water
)004
too'+
—
—
_
LIFT STATION
Lot
Line
IR•
1
Size in gallons:
Manufacturer:
Foundation40
3t
I
—
_
"Pump on" level at:
"Pum vel at:
High water alarm at:
Curtain.
1
o
t ,C
1
Pump Make a
Electrical Inspections performed by:
Drain
aLr
j
Remarks: /J,Rry NAF _ CAo OF rKF,4..A
BENCH MARK
Location and Description:
W
— BOTTDM aF
Y �.
45 1014 AT (90jA7- Ar
Assumed Elevation:
Jc�o, o
Ft
E AL
a
pt
Inspections performed b . S a s RNGINEIRIN4 e - 6- ..
p p Y' D�t s: 1st
,
$ - b - 9 6 .,
1703 Eagte River 4 Road, N®• 2 ` 2nd C. COWAN a
�' ROBERT
Eagle Iver, Alask 9 577 �"� �� . BF301 •" jY�
Department of Healt and H a vices approval f�9 w�,
�
Reviewed and approved by: mate:
72-013 (Rev. 9/91) MOA 25 �'
SW960196 2 2
Permit No. Page of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
LOT 11, BLOCK 4, SAMPSON ESTATES S/D 051-811-16
Legal Description: PID No.:
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SEPTIC
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PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE 1L,L�lJ
DEPARTMENT OF HEALTH AND HUMAN SERVICES 1
P.O. BOX 196650, 825 "L" STREET, ROOM 502M_� c��
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW960196
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:PERSON LEONARD A & MARY LOU
OWNER ADDRESS:P.O. BOX 670716
CHUGIAK, AK 99567
PARCEL ID:05181116
LEGAL DESCRIPTION:
SAMPSON ESTATES ELK 4 LT 11
LOT SIZE: 40531 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
DATE ISSUED: 7/15/96
EXPIRATION DATE: 7/15/97
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED B
ISSUED BY:
DATE: 46
DATE: e
HEALTHAUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER&WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
S&
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
June 28, 1996 CIVILENGINEERS
(907) 694-2979
FAX (907) 694-1211
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: Lot 11, Block 4, Sampson Estates Subdivision
Request you issue a permit to upgrade the septic system
serving the existing three bedroom house on the referenced
property.
A test hole was excavated and percolation test performed in
the area of the proposed upgrade. The approximate location
of the test hole is located on the attached site plan.
At the time of excavation no water was encountered and
atfer seven day ground water monitoring, the monitoring
tube was found to be dry.
Attached is the proposed upgrade design.
We do not anticipate any adverse effects on neighboring
wells, septic systems or drainage patterns by the
installation of the proposed septic system.
The proposed 1000 gallon septic tank is to be placed
outside the well protective radius. Attached is a site
plan which depicts the location of the proposed tank.
If you require additional information, please contact us.
Sincerely,
Obert C. Cowan, P.E.
RCC/gk
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
JUL 01 1996
Enclosure RECEIVED
17034 NORTH EAGLE RIVER LOOP • SUITE 204 0 EAGLE RIVER, ALASKA99577
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ROBERT C. COWAN, P.E.
ROBERT A. SHAFER, P.E.
CIVILENGINEERS
(907) 694-2979
FAX(907)694-1211
ii..+. : I r....
ROBERT C. COWAN
CE .8801 r;
w
N
PERFORMED FOR:DcA P�io�j
DATE PERFORMED: '• �• � � � ( '+
LEGAL DESCRIPTION:—L---r I k &-lg4 `I SA -MPS o j Township, Range, Section:
(DEPTHi 6ST. SLOPE SITE PLAN
r
2
O C
3-
4
6-
7 7
a
8
9-
10-
11 If
10 11
12
0
13-
14-/
J"
15
16-
17
18
19
20
COMMENTS
S tA/,
WAS GROUND WATER _ ��
ENCOUNTERED?
IF YES, AT WHAT1� L
DEPTH? N /ar 0
P
E
Depth to Water After 1P-2--5-9(,Monitoring?_ pate:
Reading Date Gross Net Depth to
Time Time Water
Net
Drop
uJ
b -9 (P ,
,s
Z— 1 O
3
N »
� w
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER to
TEST RUN BETWEEN FT AND L15- FT
PERFORMED BY -17034 Eagle River Loop Road No. 204 1 CERTIFY THAT THIS TEST WAS PERFORMED IN
Eagle River, Alaska 99577
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (^r.:•. 2185)
S&
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
HEALTHAUTHORITY and
APPROVALS MATERIAL SPECIFICATIONS
ROBERTC. COWAN, P.E.
ROBERTA. SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
PREFERENCE: Lot 11, Block 4, Sampson Estates Subdivision
SEWER&WATER I June 28, 1996
MAIN EXTENSIONS
1. The scope of this project includes the installation of
SEWER&WATER
a leachfeild trench to serve the three bedroom
INSPECTION
residence located on the referenced property. The
existing septic tank is to be excavated to verify its
integrity. If of good integrity, the tank is to be.
moved 1-2 feet south outside of well radius. If the
ENGINEERINGSTUDIES
AND REPORTS
integrity of the existingseptic tank is poor
existing septic tank is to be excavated pumped,
p p
crushed, and abandoned in place and a new 1000 gallon
septic tank installed, outside of well radius.
WELL INSPECTION
&FLOW
OWTESTEST
2. Construction shall be in accordance with the approved
site plan and design drawings, Municipal permit with
any special provisions or conditions, and all
applicable State and Municipal Wastewater Disposal
SITE PLANS
Regulations.
3. The contractor shall be responsible for obtaining any
necessary underground utility locates.
ROAD DESIGN
4. Unless specifically agreed otherwise, the property
owner shall be responsible for final grading areas
subsequently depressed from soil settling.
SOIL TEST
5. Contractors installing wastewater disposal systems
must be certified by the Municipal Health Department
for system installations. Owners installing their own
PERCOLATION
systems must also receive prior approval from the
TEST
Municipal Health Department.
SEPTIC TANK INSTALLATION:
STRUCTURAL&
MECHANICAL
INSPECTIONS
1. A septic tank is to be constructed b a certified
y
septic tank manufacturer. Construction shall include
two 4" cleanouts for pumping access.
ONSITE
2• The septic tank shall be sufficiently bedded to
WASTEWATER
prevent settling or shifting of the tank.
DISPOSALSYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
Page Two
Lot 11, Block 4, Sampson Estates Subdivision
June 28, 1996
3. All standpipes on the septic tank shall extend a minimum of
12 inches above final grade.
4. Septic tanks installed with less than 4 ft. of cover shall
be insulated.
5. A foundation cleanout shall be installed one to four feet
from the building foundation. In the line between the tank
and the leachfield there shall be two adjacent cleanouts
(unless an effluent pumping system exists within the septic
tank). These cleanouts shall be located on undisturbed
soil not more than 10 ft. from the tank. The first
cleanout, in line, shall be to clean toward the leachfield.
The second cleanout shall be to clean toward the septic
tank.
6. Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
1. Excavate the proposed trench to the dimensions shown on the
design. The bottom of the excavation shall be within 2
inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (ruffed -up) before
gravel (sewer rock) placement.
2. Once the gravel is installed, the distribution pipe is to
be installed level with the perforations faced downward.
Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
3. A silt barrier must be installed between the final gravel
layer and the native soil backfill. Ensure the silt
barrier covers the entire gravel surface before placing
backfill.
4. Monitor tubes shall be of four (4) inch diameter,
installed approximately in the locations shown on the
design, and extend a minimum of 12 inches above final
grade. The portion of the monitoring tube extending
through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is
equivalent to the effective depth of the gravel as noted on
the design.
Page Three
Lot 11, Block 4,
June 28, 1996
Sampson Estates Subdivision
5. Backfill over the final gravel layer must not be less than
twenty-four (24) inches. Insulation must be installed when
the backfill depth is less than thirty-six (36) inches.
The finish grade over the trench must be mounded to prevent
the formation of a depression after settling.
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Type of Pipe Perforated Solid
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F810 (HDPE) Yes No
ASTM D2662 (ABS) Yes Yes
Use of a type of pipe other than listed above must be
approved by the inspecting engineer.
3. Insulation shall be at least 2" thick extruded direct
burial polystyrene (Dow Chemical Company Styrofoam HI or
equal).
4. Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N,
or equal) must be installed between the final leachfield
gravel layer and the native soil backfill.
6. All leachfield gravel (sewer rock) shall be 0.5"-2.5"
screened gravel with less than 3% passing the #200 sieve.
7. When sand is being used as a filter material, its gradation
specifications must conform to current M.O.A. or D.E.C.
requirements.
Page Four
Lot 11, Block
June 28, 1996
INSPECTIONS:
4, Sampson Estates Subdivision
Typically there will be a minimum of three (3) inspections
required during the installation of the wastewater disposal
system. These inspections will occur as follows:
1. The first inspection must be conducted after the
excavation of ditches, pits, trenches, or beds and
before the installation of any gravel. A septic tank
may be set in place, but may not be backfilled before
this inspection.
2. The second inspection must be conducted after the
placement of the silt barrier, gravel, distribution
lines, standpipes, cleanouts, and insulation, but
before the placement of any other backfill.
3. The final inspection is to occur upon final grading of
the property.
Often there will be more than these 3 inspections required.
Especially with the installation of multiple trenches, sand
filters, pressurized distribution systems, etc. Thus, the
inspecting engineer is to be contacted at least 24 hours prior
to the start of construction. If necessary, a pre -construction
meeting will take place on-site. The inspecting engineer will
not coordinate, direct or control in any way the contractors
activities.
The owner shall contract with the contractor to perform the work
outlined in these specifications and plans and in accordance
with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S
Engineering. S & S Engineering shall be the owner's
representative and will inspect the work as stated above to
document the contractors activities. Final acceptance of the
contractors work rests with the owner and the M.O.A.
Page Five
Lot 11, Block
June 28, 1996
41 Sampson Estates Subdivision
S & S Engineering shall have no liability to the owner or to
others for acts or omissions of the contractor or any other
persons performing work on this project or the failure of the
contractor to carry out the work in accordance with these
construction documents. S & S Engineering's inspecting engineer
will not be responsible for the construction means, methods,
techniques, sequence, procedures or the safety precautions
incident to this project.
CONTRACTOR/INSTALLER
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
M NEW
❑ UPGRADE
MAILING ADDRESS ; y
-.
LEGAL DESCRIPTION
C
Lo C VC
LOCATION �`
, ^
Na. OF BEDROOMS
1 ��
�7
2Y
Well Absorption area
DISTANCE T0:
Dwelling
PERMIT NO.
CC77
F 2
y F
Manufacturer _ v
Material -
���
No. of compartments
Liq, capacity in gallons Inside length
tj � IF HOMEMADE: ..�—
C
Width
Liquid depth
q P .._�.
®� 2
DISTANCE TO:
Well
Dwelling
PERMIT NO.
z FQ-
Manufacturer
Material
Liquid capacity in gallons
=
Well
DISTANCE TO:
Foundation 1 Nearest lot line
c� U ��
PERMIT NO.
2
~
No. of lines Length of each line
Total length of Ines Trench width
Jd
Distance between lines 7
b
Top of tile to finish grade
�
Material beneath til// i nches
Total effective absorption a ea
inches
,�•'C/Z�
w
Length Width
Depth
PERMIT NO.
U
a h
wa
Lu
Type of crib
Crib diameter
Crib dep
Total effective absorption area
N
DISTANCE TO:
Well
Building founlifation
Nearest lot line
JClass
J
w
Depth
i X� (S .�
Dril er
1,i `
v
Distance to lot line
PERMIT NO.
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
`
SOI LTESTRATING
(�
INSTALLER
a
1A -r
, 0
REMARKS
C
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Jev,
•�
A .q aae♦�ooa �i ®
A CL
t s No. 1457-E
til /' ae sa aea �
APPROVED ` c?�A:. "-:;afa` DATE
1., -
LEGAL
Ste. ra10
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95
7?_niz to... �/�Ql
DEPARTMENTOF HEALTH AND ENVIRONMENTAL pROTECTION
_ 825,��,STREET� ANCHORAGE� AK �n=�1 `
r ' 264-4720
����
��� �
PERMIT NO: ^ 850�49
DATE ISSUED: 03/04/85
`
APPLICANT: FENTON CONST INC,
ADDRESS: BOX 1500 #29
WASILLA; AK 99687
CONTACT PHONE: 376 6786
LEGAL DESCRIP: SU�DIVISION:
SECTION: 3 TOWNSHIP: 15N RANGE: 1W
LOT SIZE: 10531 (SQ,FT^ QR ACRES)
MAX BEDROOMS: �
Listed below are C availabl� to you in designing your se�tic
system. Choose theoption that best �its your site^ r
... ..... ..... _~~..... .... _.... ..... .....
__~
r A,^if �- 0� H Ulv PA
DEPTH TO PIPE BOTTOM <FT
D 8
) 4 0 4 0 ~
GRAVEL EPTH (FT > B 0 ^ "
. " 0,5 3 5
TOTAL DEPTH
GRAVEL WIDTH
GRAVEL LENGTH (FT) ^
^ 40.0 60 D
GRAVEL VOLUME (CU.YQS,)31,2 44^�
TANK SIZE (GALS) ~ `~
SOIL RATING
~ 183
** TANK MUST HAVE AT~-
[8MPARTMENTS
I certi|y that:
1, I am �amiliar with the requirements �or on�site .... and wells as �et
forth by the Municipality o� An�horage (MOA) L. State o[ Alaska
2 I will install the t i ' ^
^ s;s em n accordance with all MOA ons
codes and regulati
a�d.in compliance w/ith the design criteria o� this permit ;
3. I will adhere to all MOA and Stat � Al k i `
e o as a requ rements �or the set back
distances �rom any existing well� wastewater disp�sal system or public
sewerage system on this or any adjacent or nearbylot.
4" I undeCstand that this permit is valid for a maximum o{ 3 bedro�ms and
any enlargement will require anadditional permit.
^
IF A LIF�STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING COD�
THEN (1) AN ELECTRICAL PERMIT AND INSPECTzON MUST BE OBTAINED; ` (2) ASILTS
WILL NOT BE APPROVED WITHOUAN ELECTRICAL INSPECTION REPORT;AND (3) E
ELECTRICAL W
ELECTRICIAN"
SIGNFD
DATE:
—� v . �----_~~--���-~�~ ~___._.`__._~~_
APPLICANT: LX_1[O�qT 7wr
ISSUED BY
DATE:
❑ SOILS LOG
MUNICIPALITY OF ANCHORAGE
• +ac • DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTIONPERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
S' 7
PERFORMED FOR: -��� �� �� i ��/\./ � DATE PERFORMED: 3-Z -e5--
LEGAL
5—LEGAL DESCRIPTION: ` ( 7' � �0 p'j "7-
1
2.
3
K,
4-
5 5
C
6
f
7
L
8 ,
9 i.
10 et
11
12
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13 Ii
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14 -
15
16
17
18-
19-
20
81920 -[_
COMMENTS
S-'i�z� Shy
6:
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1457_E
`q t<�4.>S r•a
h9l
-WND WATER/L/,( /,fj S
ERED? y L
O
P
AT WHAT E
i
P
�•a'n
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
3112,
-
c�
51'74C
b " /Z' ,& r 1z11 -11-14PERCOLATION RATE (minutes/i h)
TEST RUN BETWEEN FT AND -t=-- FT
DATE 5'e— /y ,5
72-008 (6/79)
P,
MUNICIPALITY OF ANC•unopn-
i
Qi
m
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p OU�.t• CJI.
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3
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o: o r I a
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n F 0F 0F 0F 0F 0F� OF E- 0E- 0 0 0 ouroQ"
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FC M N a Q O O
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p � 3
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 M21
Development Services Department
On -Site Water & Wastewater Section
Parcel I.D. 051-811-16
,�; °�� .•sem
Phone: 907-343-797
Fax: 907-343-7997
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Expiration Date: _10-2-1-20
Sampson Estates 134 L11
22612 Gabriel Circle
Current property owner(s) Wacker
Mailing address
Real estate agent Cindy Wilson
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone 244-1930
Day phone 244-1930
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
FX_1
Private Septic
Z
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for:
Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the. engineer.
D
COSA Fee $ y 12. GO V i n Waiver Fee $
Date of Payment �. r 7-2L,)'Z� Date of Payment
Receipt Number COI I r -I 5:? Receipt Number
COSA # _ 0sG 201333 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 (arc) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm NorthRim Eng. Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng Date 7/17/20
.�P�-'�y
s *�' •49 �i� •'•.''may*fit
6. DSD SIGNATURE t : ••••
:•ts
System f,1 Approved for - bedrooms tfyyy
System 'f12 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
11)))))111
Original Certificate Date: �7
The btuNcipality of Anchorage Developroont Servicos Division (DSD) issues Certificates of On-Sito Systoms Approval (COSA) based only upon the
representations given in paragraph S by an independent profess!orL31 civil er?gineer registered in the State of Alaska. The %lunicipality of Anchorage is
not responsible for errors or omissicris in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
rose, C=)t.:P1.11 blue ate*!
09
Nitrate Advisory
Arsenic Advisory
Other t Gc.vu
yo
Sir
m
A`s
m
VA
'[UG'' R
off,
11)))))111
Original Certificate Date: �7
The btuNcipality of Anchorage Developroont Servicos Division (DSD) issues Certificates of On-Sito Systoms Approval (COSA) based only upon the
representations given in paragraph S by an independent profess!orL31 civil er?gineer registered in the State of Alaska. The %lunicipality of Anchorage is
not responsible for errors or omissicris in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
rose, C=)t.:P1.11 blue ate*!
09
Nitrate Advisory
Arsenic Advisory
Other t Gc.vu
COSA Checklist
Legal Description: Sampson Estates B4 L11
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 3/7/85
Total depth 141 ft
Cased to 141 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 24+ in
Date of flow test for COSA 7/10/20
Static water level at beginning of test 39 ft.
Comments
B. TANK DATA
Age of tank(s) 24 years
Tank type/material "Pt' 51-1
Measured operating fluid level in septic tank 50
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 8/26/19
D. ABSORPTION FIELD DATA 8/6/96
Which system tested (date installed) same
❑ ALL standpipes present per record drawing
Total measured depth from grade 10 ft (max)
Measured depth to pipe invert from grade 4 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test) 2000
Gallons introduced gallons
Comments/Deficiencies: west Trench- Lower Fluid Level
COSA Checklist yellow sheet
Parcel ID: 051-811-16
Structure served by this system
Well production at time of test 5+ gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate 1.81 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by NRimEng
Date of Sample 7/10
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 710/20
Results Q Pass For 4 bedrooms
Fluid depth prior to test 5 in
Water added 600 gal
New depth 10 in
Elapsed time 60 min
Final fluid depth 5 in
Absorption rate 600 gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
1091
E. SEPARATION DISTANCES
From Private Well on Lot to.- (Please enter distances if less than required or it community well)
Septic Tainkil-Ift Station on Lot > 100'
M-/
Yes
Community Sewer Manhole/Cleanout > 100'
ft
Yes
it No
_ ft
0
Yes
if No ft
Neighboring Tank > 100'
Yes
if No
ft
Private Sewer/Septic Line > 25 -*-7,
Yes
if No ft
Absorption Field on Lot > 100' 7
Yes
if No
ft
Holding Tank > 100' ED
Yes
if No ft
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' FRI
Yes
if No ft
LD
Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' M-1
Yes
if No
ft
21
Yes
if No ft
From Septicti-lolding Tank on of to: (Please enter distances if less than required)
Building Foundations > 10' 21 Yes if No ft Surface Water > 100' -ID Yes if No ft
Property Line > 5'
M-/
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
Yes
if No
ft
Private Wells > 100' nv Yes if No ft
Water Main > 10'
Yes
if No
ft
Community Wells > 200' 2] Yes if No ft
Water Service Line > 10'
S
Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances it less than required)
Building Foundation � 10'
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
Yes
if No
ft
Private Wells > 100' JD Yes if No ft
Water Service Line > 10"
S
Yes
if No
ft
Community Wells > 200' El Yes if No ft
Surface Water > 100'
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through Field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date,
Steve Eng
CE -6256
2 -4-
Septic Wank Advisory
Certificate of On -Site Systems Approval #OSC 201338
Subdivision: Sampson Estates B4 L11
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this property is 24 years old. Typical replacement costs range from $8,000 to $11,000
This advisory must be attached to all copies of the subject Certificate of On -Site Systems
Approval.
This is an example of what the metal of a 20 year old steel tank MAY look like.
FOUND N41' 04' 42"W 318.37' [318.36' (M)]
ALCAP
FOUND
%" REBAR < j N41' 04' 42"W 144.37'
0 C t i
Utility � � i W ELL
Boxes t 1
1 l 54.4
� l
! 1
i ASPHALT
DRIVE Concrete
S�oroge 1 Walk
Shed 1
Foundotion, /100 ti �<
'C;rnbe
GABRIEL CIRCLE
N
L=31.42'
ip' T&E EASEMENT
R=20'
FOUND
" REBAR
f
47.3 e �}
cs o
\ 6 �
i
S 0
2nd Level Deck w
12x26 Co
Ground Level Deck 11x18 1n
r� 56.0
d " 0 3rd Level Deck 4x10 { b3
w {
N o
0 0
co SEPTIC ``%�,ti�t��> ttttt
Q CLEANOUTS �`` 0.F. qL ttt,
u .� X\�_ QST X 11
bo
"' = g TH '.
r
LOT r� .. ........ .... ,
......
I
BLOCK 4 ,. VERNON L. ROELF
L.S. 7617v�
0.93 Acres fir `�Ir�N
it
�rr``a Pesti
t
MESS I OO- .
s�� I HEREBY CERTIFY THAT I HAVE SURVEYED THE I
DESCRIBED PROPERTY AND NO ENCROACHMENT
E EXISTS EXCEPT AS INDICATED, IT IS THE INE
PSO� TRESPONSIBILITY DD
THE EXISTENCE OF ANY EASEMENTS, TS,COVENANTS,
OR RESTRICTIONS WHICH DO NOT APPEAR ON THE --
RECORDED SUBDIVISION PLAT.
17203.
--~"EASf V01 r 2A
to pRA1NA0E
FOUND
ALCAP
30' t
t
00
O p
CV N
R
MY
Ln u-)
LO 0
�CO
Z Z
WI
0
Q
FOUND
ALCAP 1
L=43.38'
R=205' ti
i
AS -BUILT
SLKMY oALM.
1/30/2020
-ate 15 30 VEIConsultants Sampson Estates DRAWWgwEVR
rLot 11; Block 4
1345 RUDAKOF CIRCLE SUITE 2!}t C°°NW156C
`f SCALE: 1- = 30' ANCHORAGE. ALASKA 99508 NW 1/4, SEC. 3, T15N, R1W, S, M. was ....
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 S & S ENGINEERINM Phone Cqq
Address 17034 Eagle River loop Road No. 204
—Earle Rive.4 Alaska 9957tJ
Engineer's signature
6. DHHS SIGNATURE
Approved for
Disapproved.
bedrooms.
Date / z l C/'&
;' r
ROBERT C. COWAN - fi
CE -8801
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
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 courtesyto 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 engineers work.
72-025 (Rev.1191) Back MOA #21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICER E C E! V E D
Environmental Services Division a
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) AAA4 1996.
Municipality of Anchorage
Health Authority Approval Checklist Dept. Health & Human Services
Legal Description: L e•r it i 8t-ve K 14 , SAMvso,j _ Esr. Parcel
A. WELL DATA
0s, - oil -I$
Well type PR, -J a-ra' If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y"7, N) YEs Date completed 3--7 -65
Total depth 141, Cased to t 4 i � Casing height (above ground)
Sanitary seal (N) YE s Wires properly protected (9N) _
Date of test
Static water level
Well production
FROM WELL LOG
3 -7 -Ss'
40)
70.6
AT INSPECTION
12 if 4
Ye
g.p.m.
'� ReS7k,GT�i9 Sy' 0vmA 4 PLuMdiVC,
WATER SAMPLE RESULTS:
Coliform -r j— Nitrate ! . y8 rnq/L Other bacteria _7(!�r-
Date of sample: --7- 11L Collected by: E AJs i reEKi04
B. SEPTIC/HOLDING TANK DATA
Date installed 8 - (_- 9 6 Tank size )Oo0 Number of Compartments Cleanouts (DN) Yes-
Foundation
esFoundation cleanout (ON) YE -s Depression (Y/Q 1J a High water alarm
Date of Pumping t4 a tI Pumper
C. ABSORPTION FIELD DATA
Date installed i 8 - 6 - qc. Soil ratingz
(g p d /ft2 or ft /bdrm) AS Grs t T2E4JGN
Length So i
ys em type
Width Z . 5 Gravel thickness below pipe Total depth r o i
Effective absorption area ('00 Monitoring Tube present ON) Yts Depression over field (Y/M No
Date of adequacy test a a ,.s Results (Pass/Fail) ff a LJ For S bedrooms
Fluid depth in absorption field before test (in.); Immediately after_ gal. water added (in.): _
Fluid depth (ins) Minutes later: Absorption rate = _ 9 P d,
Peroxide treatment (past 12 months) (Y/N) If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
"Pump on"
*Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Se ti holding tank on lot /oo'+
Absorption field on lot
Public sewer main
Size in gallons
On adjacent lots
On adjacent lots
"Pump off" level at*
Public sewer manhole/cleanout ^j/A
Sewer /septic service line ZS t Lift station
SEPARATION DISTANCES FROMSEPTIC HOLDING TANK ON LOT TO:
i
Foundation )s %
3, Property line (05' ± Absorption field 'I
Water main/service line 10 1 + Surface water/drainage 100'-F Wells on adjacent lots 100 t
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line z2 t Building foundation 'to I Water.main/service line )b f
Y 9 g o'±
Surface water 100 -t Driveway, /vehicle storage area y
Curtain drain 0 �A Wells on adjacent lots too'+
F. ENGINEER'S,CERTIFICATION
1 certify that I have determined thru field inspections and review of Municipal records fttw
in conformance wit hy�A guid nes in effect on this date.
Signature 7
-
Engineer's Name / t 0130-1Q r C • Ca w9^i
Date
C Q
HAA Fee $ Soo. - Waiver Fee $
Date of Payment C f y I q( 1 Date of Payment
Receipt Number j cl0 q ( j/ Receipt Number
72-026 (Rev. 3/96)*
tido. AY5 are
r" r1
M1 f{
,�0lNAN
SSOI ° 4
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) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicants Name �. s Tcm !�/J S s Telephone - Home Business
Applicants Address 2G'E� /�jt-1P�i�%( G f'�_ Z�JC-N, , A q ei5V r%
(c) Applicant is (check one) Lending Institution ; Own-er/builder ;
Buyer ; Other E�:l (explain);
(d) Lending Institution 'Out-) Telephone
Address
(e) Real Estate Co. & Agent ® N F
Address
Telephone
(f) Ma&l� the HAA to the following address:
ii.
RIVER. ALASKA 'O.S571
2. Type of Residence
Single -Family Multi -Family Other (describe)
Number of Bedrooms
3. Water Supply'
Individual Well Community Public
Note:,If comTun'ity well system, must have written confirmation from the State
Department'of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Onsite � Public F_:�j 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]
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
r - !a
Address
.r0W_i/
--- w
LYb G Oe AJ
Date 6 1/1 IeP5
m alas �'ae a-assosae o.
(ENGINEER SEAL) s.. .a ..e..e.,
6. DHEP Approval
Approved for ��edrooms
Approved /x Disapproved
Terms of Conditional Approval
Robert A. S. a rNo. 1457-
J ♦ a. (. Y
�4' vc"aa a.aa
By t
Conditional
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO,PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR' ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2] 7-19-84
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL ( HAA) U U N 17 1QAF
CHECKLIST - FEBRUARY 1984 RECEIVE
Legal Description: LoT // 134-K
A. WELL DATA
Well Classification 5,If A. B, or C, D.E.C. Approved(Y/N) /1
Well Log Present MIN) Date Ccnpleted -- Yield 2,oCC&M
Total Depth_ Z- I� Cased to ,q-�I Depth of Grouting
Static Water Level 4-0 Pump Set At
Casing Height Above Grcund ,Lo Sanitary Seal on Casing Tt)
Electrical Wiring iii Conduit (tVN) Depression Around Wellhead (Y4D
Separation Distances from Well:
i
To Septic/lLolding Tank on Lot /C? On Adjoining Lots jtam I_t
To Nearest Edge of Absorption Field on Lot On Adjoining Lots It x:,1+
To Nearest Public Sewer Line Ila To Nearest Public Sewer
aI
Cleanout/Manhole !(n To Nearest Seer Service Line on Lot
Water Sample Collected By i2-. Date -12�-
Water Sample Test Results 5
Comments
B. SEPTIC/H6 TANK DATA
Date Installed .a (� gS,� Size /C>00 No. of Ccnpartments -*--
Standpipes ai/N) Air -tight Caps N) Foundation Cleanout <OW
Depression over Tank (YeV Date Last P d A,/c
Pumping/Maintenance Contract on File (Y/N) ^ ; for
Holding Tank High -Water Alarm (Y/N) '" Temporary Holding Tank Permit (YIN) aA
Separation Distances from Septics Tank:
To Water -Supply Well I b 4-' To Building Foundation 10 "t
To Property Line )4- To Disposal Field )Q 1
To Water Main/Service Line To Stream, Pond, Lake, cr Major Drainage
Course 'J/A
Comments
Receipt # * c( SIS
Date Paid: (,7-7
Amount:
[Page 1 of 2]
2-15-84
C. ABSORPTION FIELD DATA(,,,,)
Soils Rating in Absorption Strata / g Q rP e Type of System Design
Date Installed v �C> < �� Length of Field
Width of Field Depth of Field !�
Gravel Bed Thickness _ Ito E,
Square Feet of Absorption Area 54�+ Standpipes Present (rY/N)
Depression over Field (Y
N
Date of Last Adequacy Test 4c�
Results of Last Adequacy 'lest 1A
Separation Distance fran Absorption Field:
To Water -Supply (AJe11 / / To Property Line / o
To Building(( Foundation `'� To Existing Or Abandoned System cn
Lot �1ti ; On Adjoining Lots
N
To Water Main/Service Line F3 C--:) I -t To Cutbank{if resent)
-
To Stream/Pond/Lake/ar Major Drainage Course
To Driveway, parking Areae or Vehicle Storage Area 117 e4'
Camnents
D. LIFT STATION
Date Installed Dimensions
Size in Gallons nhole/Access
"pump On" Level at
ump
�, , 'pOff" Level at
High Water Alarm Level at Vent (YM)
Tested for Rm pi g Cycles during Adequacy Test. Meets MOA
Electrical Codes(Y/N)
Ccmmnts
**
** Check permitted Bedroan Rating Against RM Request
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection. a?, N-6
v",
�Date �s 8
Signed
. n��.
+�.'re:.� s:,�.,C ,; f � MOA No.
Company
a�
KB1/d5/s
(page 2 of 21
.
.vim.
�, o Aabert
•, No.
�� ••etl e.•e ��efX
//,�PP 6 V e 5• r-
2-15-84