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SAMPSON ESTATES BLK 4 LT 17
Sampson Estates Block 4 Lot 17 #051-811-22 Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OS PI 81210 PID Number: 051-811-22 Dwelling: A Single Family (SF) F"I with ADU � Duplex (D) E Two Single Family Project: Ci New [FBI Upgrade Name KERN RICHARD ABSORPTION FIELD F7 Deep Trench F! Wide Trench F-1 Bed F, Mound Site Address 22411 Pharaoh Cir Ef Other Phone Number of Bedrooms Soil Ratingal depth from original grade 306-5119 13 GPD/SFrt Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot SAMPSON ESTATES BLK 4 LT 17 Fill added above original grade Ft. Gravel length Ft. Tm#mship Range Section Gravel width ft Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES TO Septic Absorption Lift Station Holding Sev., Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft` Ft. Well 100'+ 100'+ na na TANK Septic Eff:,, S,T,E.P, 0 Holding Other El Septic Manufacturer Anchorage Tank Capacity 1250 Gal. Surface Water 100'+ 100'+ na Material Steel Number of compartments 2 I Lot Line 10'+ 10'+ na NA Foundation 10'+ 10'+ na LIFT STATION Manufacturer Anchorage Tank Capacity 1250 Gal. Remarks Alarm location F-lectrical installed bv Side of House Rising Son Installer PIPE MATERIAL House to tank D3034 drainfieldTankto D3034 Dean Drainfield CO/MTD3034 InspectorNorthRim Eng. BENCH MARK (Assumed elevation) 100 ft Inspection 7/30118 7/31/18 Location and description dates: r1% Deck V 411 ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date OF 4/ %44 rQ�� Septic System Approved tL% -k Date ........... ... ....... Steve Eng CE -671% Air 14\44 Note: this approval does not include well permit requirements. 1 :' / kKeV VWV41 I t5j 10' T&E EASEMENT OCL\ 3 Bdrm ST2 316 191 Lot 24 Approximate Bed Location N OR THRI M 1" = 50' ENGINEERING SAMPSON ESTATES steveEny.com '*• ••• ••••• ••••*• BLOCK 4 LOT 17 RECORD PO Bo -v770724 LAYOUT Engle River, Alaska 99577 a -am,•' r WASTEWATER UPGRADE 907.694. 7028 �' 37722 -Date: STEP TANK �°°t3i7izz z of 3 70 () fTl � n r� i;u tj D iC7 O �1 F— FTI bd V) F D n 7� 0 � z F- rl o � D rpl XOD Z Q � C:) r0 O r+ 70 () fTl � n r� i;u tj D iC7 O �1 F— FTI bd V) F D n 7� 0 � z F- rl o � D �R) F-9 X Q � C:) r0 O r+ D � O Q n Q � Q D � Q T 0 + : s � C � 0 0 N � Q Ln 3 0 0 �o Q D Q F-9 X Q � r0 � r+ D � O Q Q � Q D � Q T 0 + : s � C � 0 co-- D P N � Q Lot I hereby certify that I have surveyed the following described property: f I LOT 17, BLOCK 4, SAMPSON ESTATES (PLAT No. 84-10) 0 49TH v* Anchorage Recording District, Alaska, and that the Improvements situated thereon are �....' • • • • . within the property lines and do not encroach onto the property adjacent thereto, that Q no Improvements on the property lying adjacent thereto encroach on the surveyed Q premises and that there are no roadways, transmission lines or other visible '. KEN ETy G. LAN easements on said property except as indicated hereon. 000�'•,.�(,� G Dated this the So11 4� �F� LS -5202.. -' gJO Day of i_1`-�`,_i_______, ,� at Anchorage, Alaska Q aR NO�o 440 �FfSSIONA� �o It is the responsibility of the owner to determine the existence of any easements, �400000� covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 Lot 26 NOTE: DUE TO SNOW & ICE COVER, SOME SURFACE LEVEL FEATURES ARE APPROXIMATE. I PLOT PLAN ___ AS BUILT _x_ SCALE —11 __ 50__ GRID _ NW 1560Project No. ____ 22=06 fAt____ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone (907) 522-4625 Fax 0000�p4� oo O F ^ / 0444 Professional Land Surveyors kenOlangsurvey.com o ,•, q ' jonothanOlongsurvey.com A .,S�Qk I hereby certify that I have surveyed the following described property: f I LOT 17, BLOCK 4, SAMPSON ESTATES (PLAT No. 84-10) 0 49TH v* Anchorage Recording District, Alaska, and that the Improvements situated thereon are �....' • • • • . within the property lines and do not encroach onto the property adjacent thereto, that Q no Improvements on the property lying adjacent thereto encroach on the surveyed Q premises and that there are no roadways, transmission lines or other visible '. KEN ETy G. LAN easements on said property except as indicated hereon. 000�'•,.�(,� G Dated this the So11 4� �F� LS -5202.. -' gJO Day of i_1`-�`,_i_______, ,� at Anchorage, Alaska Q aR NO�o 440 �FfSSIONA� �o It is the responsibility of the owner to determine the existence of any easements, �400000� covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 C10 N,C1MUNICIPALITY OF ANCHORAGE mens F On-Site Water&Wastewater Program \oPO Box 196650 4700 Elmore Road Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997r. http://www.muni.org/onsite 1)1 mi-uncut 4"010;i0- On-Site Wastewater Disposal System Permit Permit Number: OSP181210 Effective Date: 7/20/2018 Work Type: SepticTank Upgrade Expiration Date: 7/20/2019 Tax Code Number: 05181122000 Site Legal Address: SAMPSON ESTATES BLK 4 LT 17 G:1560 Site Mailing Address: 22411 PHARAOH CIR, Chugiak Owner: KERN RICHARD C Lot Size in Sq Ft:, 41947 Design Engineer: NORTH RIM ENGINEERING Total Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field El Septic Tank ❑ Holding Tank ❑ Privy 0 Private Well 0 Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing (2 a a Received By: / to- 6 Date: 7 Aummo- 1 Issued By: 47 ' , ! o Date: /0 MUNICIPALITY OF ANCHORAGE i.,,,„a! f1.,-,:- , 1 '�Y�� l ; Development Services Department -� Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 ri ., U H' ..t . ON-SITE SEPTIC/WELL PERMIT APPLICATION x JUL 1 8 [018 Parcel I.D. OSI- I//- 22- �c Property owner(s) �' p Y l �� Day phone !4 o� g g Mailing address 221.111 "'ha rz..04) a,,. Site address r5G#)- Q.. Legal description (Sub'd., Block & Lot) —SA//if'fO/tf ' cT 7 St/ LI 7 Legal description (Township, Range & Section) Lot Size 41/i 7s/7Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) (w/wo ADU) Septic Tank Upgrade Holding Tank ❑ Renewal Duplex (D) 111❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. 'C: Z.,:ca-, ODE- (Signature of property owner or aut Ized agent) Permit/Rush Fees: `i2A5•l00 Waiver Fees: Date of Payment: -70118 Date of Payment: Receipt Number: a6c41 Is Receipt Number: Permit No. arlefl Ll C Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc \CRT1—�I M ENGINEERING SteveEng.com Steve Eng,PE, PH 907-694-7028 SteveEngPE@gmail.com Date: 7/18/18 Number of Pages: To: MOA On-Site Services Subject: Sampson Estates Block 4 Lot 17 STEP Tank Failure The subject STEP tank has failed-a new tank will replace the old one.The existing bed appears to be working OK . Please issue a permit so the tank can be replaced. The existing bed will remain. Please review as soon as possible. If there is need for additional information or clarification please give me a call. Thanks-Steve \ERTH M EIVGINEERING SteveEng.com Sampson Estates Block 4 Lot 17 SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing: This is an existing 3-bedroom home. Most of the neighboring lots are developed. The current STEP tank requires replacement-the bed still functions. These lots are large and are served by the water wells.No adverse impacts are expected from STEP tank replacement.The easements are depicted on the lot.The slope is indicated in the area of the septic system. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications(AMC)& State of Alaska Drinking Water Regulations and Wastewater Regulations. • New 2-compartment,1250 Gallon STEP tank. Anchorage Tank or Equal. • Watertight couplings on inlet&outlet. • 5' minimum between the tank and trench. 10' to property lines. • 4' of cover or insulation is required for tank; an equivalent of 1" insulation for 1' foot soil cover. Minimum of 2' soil with insulation. Tank&solid pipe must be set on well compacted, stable soil. • Force main to be 1.25" Schedule 40 PVC or equal. • 4" diameter cleanouts with airtight caps are required 1' to 4' from foundation wall, prior to any 90 degree bend in 4 inch line,in each tank compartment,and two adjacent opposing cleanouts between the tank and the absorption field, not more than 10' from the tank positioned to provide cleanout access towards the tank and towards the absorption field. • All cleanouts must extend to at least ground level. • In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron. • Insulation must be placed over any pipe installed under driveways or parking areas. • Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661, • Sewer Service Line is minimum 2% slope. • Septic Tank to be pumped every two years or when required. • Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal) o "'MP Stenon W. Eng • 4.1 PE 6256 aF0IDROFESS\0th .'s' DESIGN NOTES: • . Existing Bed Remains In Place. raoh Circte 2. ewer Servic- Line minimum 2% slope. lip, . � 3. R lace STE• Tank/Decommission Old Tank Per UPC. 4\11"3 1x` ` Co ect Ne Tank To Existing Bed. 4. Lots Serve. by Private Wells. 5. No C nflic s Within 200'. 6. Check C• dition Of Sewer Service Line— Replace If Necessary. 5% Sta. 7. Add D -•Ie Cleanouts Before Tank If No FCO. \ 8. Insula - Tank If Required. 0 Well 0 Well - 0s d -100 co 9 .L ' 3 Bdrth 5% Stol fr S I EP1 Q0 Gallon nk Decommission Old STEP Tank PER UPC \5% Slop. Approximate • Bed Location / No Conflicts \ NORTHRIM o 1• = 50' ��..7: ' . SAMPSON ESTATES ENGINEERING Q1-... SteveEng.com •* .4 m *• BLOCK 4 LOT 17 DESIGN PO Box 770724 % ;M.; LAYOUT fog,* River. 0 99577 a-•r• .•1 WASTEWATER UPGRADE 907.694. 7028 ( ' "r'e REPLACE STEP TANK Dote:ilsils 12oF 3 , FC❑ Tank Cleanouts w Final Grade INSULATED MU - - 1250 Gallon I STEP Tank 4 Foot Coveror Equal• UIFiIrr= E --.--To Absorption Bed :s*IN Id I'll,� / I 1;/ u ,, II15' 1.25' Schedule 40 PVC Force Main .r _1 11 DESIGN NOTES: 1. Connect New STEP Tank To Existing Bed. 2. Septic Tank & Solid Pipe to be Placed on Compacted, Stable Soil, Free from Boulders. 3. Sewer Service Line is Minimum 2% Slope & 3' Cover. 4. Water-Tight Couplings. 5. See Specification Sheet. 6. All Work To Conform to Municipality of Anchorage (AMC) Requirements & Specifications. 7. Decommission Old STEP Tank Per UPC. 8. If No FCO, Install DC❑'s. 9. Check Condition Of Sewer Service Line- Replace If Necessary. NOR THRIM _.ti of Ac' ENGINEERING Jr*/ •••• 1,..,: SSTEP TANK PREFILE SAMPSON ESTATES SteveEng. com --, PO Box 770724 '2,,..cm ' 4 BLOCK 4 LET 17 Eaglet River. Alaska 99577t. ej 907.694.7028 I I �'� = TANK REPLACEMENT Doti:7/18/18 rr. By: SE ro..: i, = 5 :8 of 3 I SE • • • • PHARAOH CIRCLE Al v A 00000ppp U Or A o.Shaw .o O/ 6HAHE A.HOLT: ;O �'•-•'• La-69 IA OQ IU,tni . o fg 000 ok Lo. am 11111\1111111111111111',.'';: O•00 S ESP N � d1 300• p0 • ' SOOA N 72 AS-BURT SURVEY SCALE:V.40 14/1/ST CIRTYYTMAT IMAM!0,rORYEDA ItOR'GAGE EYMKCTOM Or TK IatO*W10 SCLIIWWICAVATY LOT 11./LOCR A.YWSON I{TATEI • 114 10014ATOMK11E011S IW 114 UMEO/LE*TP10 14TI1VE1041 IPOCIIC411 TO WOW AM'00.141C11 11 TAW Di I)1C110O�OE RECA CR'10 OIfTMICT.ALASKA MAT 141”.05 RyCT0RER MO',ATM LOT LACS 00 ASESENIS APO OCT TO Sl MD POR TGOT1p4.04001 CPA1 TI0 0 RECOMEMI MS SITUATED CAME STROCTV11Ef OR I[MCIIMf NR101 TME MOIL TV UILT AM MAT EIO NASA ESE WW1 O/MECCAS,OT111R TIM.TAME I*OAE1OM T1(RECO110[O RAT.MC MOT SHOW.NERCO. EMC110AORL MT S LUST 01KR TATA Pot[0 WPC Mn MC/TAU WS..AAS LOCATE D,,P0DSSIATILYAM0 ME NOT 1011*10 TO CCTV 814.9 PROPERTY LIKE DATIDA1 A11U10RAOF..uwSIn TAR_ETA_ OR"CCAlSTRUCTVER DAY OF 100111/1* ESO! nn PANMO 110A11 MAY K AIPROuwTT 0M TO SHOW C0IOTOMf. HOLT LQ 1auRV!Yu1Z E11Y,11»Er Municipality of Anchorage Page of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 ® Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report 'S of x-17 0 3 D61' 0//—ZZ Permit Number: PID Number: Name: -- IPa-LAL ge,_3 i Wastewater System: ❑ New ❑ Upgrade Address:- Ct-�-yGl -7,2-4,t( ABSORPTION FIELD, Phone: 8 2 QJ 3 �j/+ No. of edrooms: j ❑ Deep Tr h O Shallow Trench ❑ Bed ❑ Mou ❑ Other /"± R LEGAL DESCRIPTION Soil Rating: Total Depth fro riginal grade: /S . Ft. Lot: - Block: pSubdivision: _ C1 L- S O'er �S Depth to pipe bottom from original gra ravel p Gth beneath pipe ?C` 1 { I Ft. Ft. Townshi Range: Section: y Fill added above original grade: rave gth: 'Se t. Ft. L' ❑ New ❑ Upgrade r-� Gravel width: Number of lines: 'stancebelweenlines: Ft. Ft. Classification �(Pil�� Classif)catlon.(Pn C): Total Depth: ased To: Total absorption a Pipe material: Ft. Ft. SQ. Ft. Driller. Drilled: Static Water Level: Install Date installed: Ft. Yield: Pump Set at: Casing Height v Ground: TAN K GPM Ft. SEPARATION DISTANCES ❑ Septic ❑ Holding )4-T.E.P. To Septic Absorption Lift Holding Public/Private Man =ft 1 C i—t Cap'city'm ga(l s: From Tank Field Station Tank Sewer Lines iQr�) ��U Welh' (�I /+ (A IG I r,j A ✓I h� Material C,- Number Compartments: Surface- ( I mo+ ,( I o c '+' IDU a Water Lot 1,Line 25 ,t. G 2`� t� 22 4 Size lZ fb s: ManufagtZ CA_A I ��",,Puump Foundation g f V — "Pump` oon(" level at: off" level at: 41 High water a rm at: Curtain Drain N P , 1 N A Pump Make & Model Gs �1CX� Elect ical Inspections performed by: �01G Io Lf--- -F Remarks: BENCH MARK Location and Description: F OF- Lt P7- S -i4"-+ oma./ of � r�G e��Vj C0CZ),j 2- Lt�� Assumed Elevation: 100. 00 Ft O efl e1�±, 2� �� �S`' �S f_. Inspections performed by: Dates: 1s �1L79" �� z 7 C�f'�:Dr'.--> '�':+- 2nd BOpflmf >Pf ^aL^� :. `J f y A. Gomm, CE -7953 Department of Heal and HVInan S rvices approval R Reviewed and approved by: ate:/e) -31 '�•v OpL oo NO@D t +i b:Y ;v H��r'ivr_'i SS10 erre 72-013 (Rev. 9/91) MOA 25 WELL ATOSl=26 \ B TO Sl = 9.6 ATOMH=31 BTOMH=17.6 BENCHMARK IS TOP OF THE STEP TANK CONTROL PANEL AT THE SW CORNER OF THE HOUSE, ASSUMED ELEV. = 100.00 INVERT ELEV. AT TANK INLET = 90.67 TOP TANK = 91.12 TO 91,2 GROUND OVER TANK = 95,6+ MIN. COVER = 4.4 FEET. 'A NEW 1250 G STEP 1 EXISTING HDPE PRESSURE SW970383 PID#j 051-811-22 WELL 3 BEDROOM HOUSE NOTE, THE OLD STEP TANK WAS COMPLETELY REMVOVED AND HAUL- ED OFF SITE. BED AS -BUILT DWG OF STEP TANK UPGRADE: LUT 17, BK 4, SAMPSON ESjff PREPARED FOR: MARTIN RAYNOR PREPARED BY: ALASKA WATER & WASTEWATER DATE: 10/28/97 DRAWN: GARNESS SCALE: 1' = 30' WAR A. Garriess;' IC—7953 pofessio�0\ �40000a� OCT -27-97 r9oN 20:58 CIE - CHI_IGIAK OFFICE 9076881540 F. 01 Dvk Inlet ]E4flelctrie, Inc. P.O, Box 670375 Cbugiak, AK 99567 907-688-3202 fax 688-1540 1,6T'WU To: Alaska Water and Wastewater Attention: Jeff Fax Number: 338-3246 From: Marty Date: 10/27/97 Number of Pages( including this one) 1 In regard to: Paul Bentley, L17 B 4 Samson Estates This is to certify= that the on site sewer lift station at the above address has been wired in accordance with the 1996 NEC and manufacturers specs. Tyhee system was checked and performed as specified in the system manual. Martin Lovej� Electrician Journeyman License #108634 Rick Mystrom; Mayor � 1 � -" ' YCD Department of Health and Human Services 825 U' Street P.O. Box 196650 Anchorage, Alaska 99519-6650 November 3, 1997 Jeffrey A. Garness, P.E. Alaska Water & Wastewater 8471 Brookridge Drive Anchorage, Alaska 99504 Subject: Waiver Request for Lot 17 Block 4 Sampson Estates Subdivision Waiver Request #WR970073, PID #051-811-22 Dear Mr. Garness: Your request for a waiver of the required 10 foot separation between an on-site wastewater disposal system and a lot line has been approved. The waived distance is 4 feet from the absorption bed to the south property line. This approval applies to the existing on-site wastewater disposal system lot line separation only. Any future upgrade to the on-site wastewater disposal system will require all separations be met or another approval from this department. If there any further questions or concerns regarding this waiver, please call our office at 343-4744. Sicerely, Daniel J. Roth Civil Engineer On-site Services ljw #7 Bentley MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR# WR970073 PID # 051-811-22 HA# NA970346 Permit # Date Received: October 30, 1997 Legal Description: Lot 17 Block 4 Sampson Estates Subdivision Engineer: Jeffrey A. Garness, P.E., Alaska Water & Wastewater 8471 Brookridge Drive, Anchorage, Alaska 99504 Applicant: Paul Bentley Waiver Requested: Lot line waiver of 4 fleet from the absorption bed to the south lot line. Criteria: 1. Geology: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Points: Waiver is Granted: Waiver is NOT Granted: List Conditions or Reasons for above: :5Fe �,�/,//v/✓l�RS i97I/9 CM 519 Date: j(j-31-`17 By: V/7 Name of Reviewer Rec #: 03358/4405 Amount: $ 115.00 Date Paid: Oct 30, 1997 Alaska Waiter & Wastewater 8471 Brookridge Drive — Anchorage — Alaska 99504 Phone (907) 337-6179 Fax (907) 338-3246 Consulting Engineers October 28, 1997 Municipality of Anchorage Department of Health & Human Services Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 RECEIVED OCT 30 1997 MunioipRIlly of Anchorage Copt. hia$Ith & .Human Services Subject: Waiver of Separation Distance from Septic Absorption Field to Lot Line. Lot 17, Bk 4, Sampson Estates S/D. To whom it may concern: According to the 1985 inspection report, the separation distance from the bed to the property line is 65 feet. Per the 1991 HAA (S & S Engineering), the bed was noted as being 65 feet from the lot line. During the installation of the septic tank upgrade, I noted the location of the bed relative to the flagged lot corners. Based upon my evaluation, it appears that the bed is as close as 4 feet from the south lot line. This condition has existed for approximately 12 years with no adverse impact. There are no wells, or septic systems, in the vicinity which would be affected by this encroachment. Given these facts, it is my recommendation that the separation distance from the absorption field to the lot line be waived to 4 feet. The $115.00 waiver fee was submitted with this package. If you have any questions, please contact me at 337-6179, or 244-9612. Thank you for your assistimce. Sincerely, P.E., M.S. AOR con; PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW970383 DATE ISSUED:10/24/97 DESIGN ENGINEER:ALASKA WATER & WASTEWATER SERVICES EXPIRATION DATE:10/24/98 OWNER NAME:BENTLY PAUL OWNER ADDRESS:22411 PHARAOH CIR CHUGIAK, ALASKA 99567-5504 PARCEL ID:05181122 LEGAL DESCRIPTION: SAMPSON ESTATES BLK 4 LT 17 LOT SIZE: 41947 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY 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 BY: , . DATE: ISSUED BY: G DATE: MG - 2,1 - Alaska Water & Wastewater 8471 Brookridge Drive — Anchorage — Alaska 99504 (907) 337-6179 — Fax (907) 338-3246 Consulting Engineers October 23, 1997 Municipality of Anchorage Department of Health & Human Services Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 ,� s �.% " t: ,F A F � o % 4 na Luso nce L ), i i ey A. Gurnes J t,F-7953 Ref STEP Tank Replacement for Lot 17, Bk 4, Sampson Estates. Peters Creek To whom it may concern: The existing 3 bedroom house is served by private well and septic system. The existing 1250 gallon STEP tank (fiberglass) is leaking and must be replaced immediately. Attached is a 1" = 30' site plan. There are no wells within 100 feet of the new tank. There are no surface waters within 100 feet of the proposed upgrade. I am unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact me at 337-6179, or 244-612. Thank you for your assistance. Sincerely, P.E., M.S. H : iNn4` dl 3t_�V1 6xS OkIkS1ON OCT 2 4 1997 RECEIVED o® NOTE: THIS IS NOT A SURVEY, THE CONTRACTOR SHALL VERIFY THE LOCATIONS OF ALL WELLS PRIOR TO INSTALLATION OF THE NEW STEP TANK, LOT 16, BK 4 SAMPSON ESTATES S/D, PVT WELL AND SEPTIC SYSTEM LOCATION OF EXISTING NEW 1250 GALLON STEP LOT 27, BK 4, SAMPSON ESTATES S/D, PVT. WELL AND SEPTIC SYSTEM. a LOT 26, BK 4 SAMPSON ESTATES S/D, PVT. WELL AND SEPTIC SYSTEM. THE WELL IS AT THE SOUTH END OF THE LOT, LIFT STATI❑N UPGRADE: L❑T 17, BK 4, SAMPS❑N ESTATES PREPARED F❑R: MARTIN RAYN❑R LOT 18, BK 4, SAMPSON ESTATES. PVT. WELL AND SEPTIC SYSTEM BED 24' x 58' LOT 25, BK 4, SAMPSON ESTATES. PVT. WELL AND SEPTIC SYSTEM. THE WELL IS AT THE SOUTH END OF THE LOT. PREPARED BY: ALASKA WATER & WASTEWATER DATE; 10/23/97 DRAWN: GARNESS SCALE: V = 100' LOT 24, BK 4, SAMPSON ESTATES. PVT. WELL AND SEPTIC SYSTEM, THE WELL IS AT THE SOUTH END OF THE LOT. 0 e r A. Garness;' 4�0gS •. —7953 CoQ 44Qt�ipr� f e sslon�aa 1WELL WELL e NOTE: THE CONTRACTOR 3 BEDROOM SHALL BE RESPONSIBLE HOUSE FOR LOCATING THE PROPERTY LINES ABANDON OLD STEP TANK BY FILLING WITH SOIL, AND INSTALL A NEW 1250 GALLON STEP TANK EXISTING PVC PRESSURE LINE� I [-EXISTING BED LIFT STATI❑N UPGRADE; LOT 17, BK 4, SAMPSON ESTATES PREPARED FOR; MARTIN RAYN❑R PREPARED BY: ALASKA WATER & WASTEWATER DATE; 10/23/97 DRAWN; GARNESS SCALE; 1° = 30' 'A.' eyrness•. 0 �� •, CE -7953 ' �mk 4 Fc��rJ 72-013 (Rev. 3/78) MUNICIPALITY OF ANCHORAGE ® DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME y' 6e? kL-!!5�rr'u C� r PHONE /,�� j� IEW ❑ UPGRADE MAILING ADDRESS P,0 e�jJ4,K 7,5-& 7 LEGAL DESCRIPTION L� t,;r i "1 ��� + LOCATION ' `A im �J� �� �Well NO. OF BEDROOMS O Y / Absorption rea [ TO: & Dwelling 1 f PER 0; � F Z ra F LDISTANCE ufacturer [ a � t � /1 ` i �d / t � - �: ,iu ( { t� PMA Material o°,r � , !s No, of compartments pacity'.n gallons .j ® IF IF HOMEMADE: E: Inside length g Width Liquid depth 6 le JOZ • I A E Well Dwelling P RMT N _O?Q ManVaft0reV t ial j, y clc a iS. w = DISTANCE TO: Well r Foundation - ( / Ne st Iot.JZq�I [ PERMIT NO. J LL Z Z_W No. of lines Length of each line d Total len h f I' 4s Trench w'dd Distance between lines f Q a a O Top of tile to finish grade � [2 Materia beneath tile inches ptign arQa Total effectiv a s inches w ngth Wi Dep ERMN 0 i F- wa T pe of r' C ib i to Cr b h of I ff tiv a son o a ea Lu rn D TAN E T ell uil n un do Ne r st I t ne V IJU V VA 4� J W Clas 2 VA TE Depth j Driller jA-V Distance to lot lire PERMIT O. DISTANCE TO: Building foundat'on Sewer line Q i Septic tank [ Absorption areas) �� % OTHER AlPIPE MATERIALS SOIL TEST RATING P _ �r �• L � INSTALLER REMARKS -STA-vaL Mor ail c T. G[Z C / ItPod l ® ! � - � 47 AM � � a B 'Y se c orwm 10. CE -5283 APPRO O 'Oaoceec,.os' �`��a3' DATE LEGAL F 'moi 72-013 (Rev. 3/78) ^ � , 1-1 LT CA I I li ...... -1 ���� ��9 --- I C-3 0 §!2,!h CD VEE: DE�ARTMENT OF HEALTHAND ENVIR8NMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264~472O ���FR �F-_ 9_ L_ ��F';,' M 1. -IF PERMIT NO: 850700 DATE ISSUED: 10/29/85 APPLICANT: SKAGGS CONSTRUCTION ADDRESS: F" Cl BOX 6,00690 CHUGIAK, AK 99567 ` CONTACT PHONE: 688-2831 LEGAL DESCRIP: SUBDIVISION- SAMPSON ESTATES LOT:17 SECTION: 3 TOWNSHIP: 151\1 RANGE: 1W LOT SIZE: 41947 (SQ"FT" OR A(:.,RES) LOT LOCATION.- PHARAOH CIRCLE MAX BEDROOMS: is Listed below are the options available to you system. Choose the option that b^st H'ts yOur PIPE BOTTOM < ... ... ..... ~~_... ... -_������. JEE 13 DEPTH TO PIPE BOTTOM (FT") 3.O ** GRAVEL DEPTH (FT^) 0^5 TOTAL DEPTH (FT. > 3�5 GRAVEL WIDTH (FT"> 27.0 GRAVEL LENGTH (FT") 51^0 GRAVEL VOLUME (CU"YDS.) 51"0 TANK SIZE (GALS) 1,000"0 ** ' SOIL RATING (SQ"FT"/BR) 305 BLOCK: 4 in designing your septic site. ** DEPTH TO PIPE�BOTTOM < 3,5 FT" REQUIRES INSULATION ** DEPTH TO PIPE BOTTOM < 4"0 FT" MAY REQUIRE A LIFT STATION **-TANK MUST HAVE AT LEAST TWO COMPARTMENTS I certi1*y that: 1" I am familiar, with the rtequirements for on-site sewers and wells as set forth 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 den�ign criteria of this permit" is. I will adhere to all MOA and State of Alaska requirements for, the set back distancens 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, 3 bedrooms and any enlargement will require an additional permit" IFA LIFT STATION IS INSTALLED I 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 AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST' BE DONE IA LICENSED ELECTRICIAN" SIGNED DATE: ~~~����----�--~~�-- APPLICANT: SKAGGS CON��RUCTION l}n ISSUED BY DATE: / `...... .... ... -..... ���... ......... ~~... ..........����~� Lw SOILS LOG MUNICIPALITY OF ANCHORAGE nw// e ye DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: Li C1 --r (fes t4 DATE PERFORMED: `r -�✓ LEGAL DESCRIPTION: t,.u-r i'7 rLf'� 4 f ✓olJ ie-uuo (e/i7) 6 W Q Q x b X 0 m Q a Y a0) Y0) a Cl) C7 ao => 00 _CD U In m ra DEP1 OF HEqL-YH i ENVIRONMENTAL pRpi NODI 1gmn . CEj F.; w w w w w w w w w w w o00000000000. F H [-+ H H [• F F H H H H O' O w O w O w O w O O O O w w w w w Lu w w a a c3L F o ,a w w H z 3 Q x x a z v� v A A co A C7 d4 In m ra DEP1 OF HEqL-YH i ENVIRONMENTAL pRpi NODI 1gmn . CEj F.; w w w w w w w w w w w o00000000000. F H [-+ H H [• F F H H H H O' O w O w O w O w O O O O w w w w w Lu w w In m ra 14 04 ^.a: tc si nE v.. c. . LD O O O .O O O O OF F � w w w w w w w o Oi c E NE • COi N F U' r e 0 0 0 0 0 0 0 w 0 a w w w w w w w w A 52 In m &6Wr IJ&aV,J 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 f Parcel I.D. 051-811-22 COSA # 0 o 0D 3 -�1 Expiration Date: -t-2, —.;2- 02 1. GENERAL INFORMATION Complete legal description SAMPSON ESTATES LOT 17 BLOCK 4 Location (site address) 22411 PHAROAH CIRCLE CHUGIAK AK 99567 Current Property owner(s) TACK ALLEY Day phone Mailing address Lending agency Mailing address Real Estate Agent Mailing Address PO BOX 671785 CHUGIAK AK 99567 Day phone TERRI BARRUS Day phone 562-3638 664313RAYTON DRIVE ANCHORAGE AK 99507 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class 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 ArcTerra En ineerin & trry ying Inc Phone 868-3792 Address 20441 PTARMIGAN BLVD EAGLE RIVER AK 99577 Engineer's Printed Name KENNETII Df. DUFFUS Date 09/22/2008 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, A�cTerra can not give any estimate of how long a i.ZE OF A4 %%I,, system will function satisfactoryfor current or future � •��,....•..���� occupants or can ArcTerra guarantee that no unseen or C2 / encroachments, deficiencies or discrepancies exist. or fA„�., 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Hnacnments: COSA Checidist X Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory Other 6y: Original Certificate Date: f r 2 5�_ 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 LOT 17, BLOCK 4 Parcel ID: 051-811-22 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID # _ Well Log (YIN) X Date completed 10/01/1985 Sanitary seal (Y/N)y . Wires properly protected (Y/N) y Total depth 760 ft. Cased to j6o ft. Casing height (above ground)_24±in. FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: 135 ft. 9— p.m- AT INSPECTION 09/04/2008 141 ft. 3.06 g.p.m. Coliform _Q_colonies/100mL Nitrate 1,36 mg/L Other bacteria 0 colonies/100 mL Arsenic: rIn mgli Date of sample: 9/8/08 Collected by: Arclerra' B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 10/27/1997 Tank size 12Sn fs P) gal. Number of Compartments 2 Cleanouts (Y/N) XFoundation cleanout (Y/N) Y Depression over tank (YIN) ZL High water alarm (YIN)']_Date of pumping 49/09/08 Pumper Sanita C.''ABSORPTION FIELD DATA -Date installed 11/09/1985 Soil rating (g.p.d.lff or ff/bdrm) 3M System type _REIZ Length _aft. Width 14 ft. Gravel below pipe JUft. Total depth 3,6 ft. Eff. absorption area 1392 ftp Monitoring tube Y Depression over field rL Date of adequacy test 9/9108 Results (Pass/Fail) PASS For jbedrooms Fluid depth in absorption field before test J_ in. Water addedM gal. New depth _2&_4_in. Elapsed Time:1Qo—min. Final fluid depth & in. Absorption rate >= 450+g.p.d• Any rejuvenation treatment (past 12 mo.) (Y/N & type) N -If yes, give date D. LIFT STATION Date installed 10/27/199? Size in gallons 12So "Pump on" level at •91In Datum JQUQ of Tank E. SEPARATION DISTANCES 'Pump off" level at .!J$in. Manhole/Access (Y/N) Y High water alarm level at 1*4$1n. Cycles tested -Z_ Meets alarm & circuit requirements? Y SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 300'+ Absorption field on lot 100'+ Public sewer main 75'+ Sewer /septic service line _ 25'+ On adjacent lots log,+ On adjacent lots _100'+ Public sewer manhole/cleanout 100'+ Holding tank 100'+ Animal containment areas _50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 1+ Absorption field 5'+ Water main lo'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ••a' Building foundation 101± _Water main _So'+ Water Service line 10'+ Surface water loo'+ Driveway, parkingNehicle storage l0_ _ +__ Curtain drain _5r+ jNQne Known) Wells on adjacent lots 100'+ F. COMMENTS )'STEP float field measurements (+/- w/ bottom of tank d a ) r 1 ection rc COSA showed heti, .,��. .., •.,,r-".& .., R-�D�LaIIiL P�YlOSL4 G. ENGINEER'S CERTIFICATION JCP;.••.. *--13#405 certify that I have determined through field inspections andar g,•review of Municipal records that the above systems are in %conformance with MOA COSA guidelines in effect on this�.. date. Engineer's Printed Name -KENNETH M DIIFFUS ,� f �• CE 1 Date 09/22/2008 �.` •'••� V.i COSA Fee $430.00 �v Date of Paymen aG�4 0 Receipt Number j5 f �ii (Rev. IM) Waiver Fee $ Date of Payment Receipt Number SCS RAN 1084785001 Client Name ArcTerra Engineering and Surveying Project Name/N Sampson Est. B4,L17 Client Sample ID Sampson Est. B4,L17 Matrix Drinking Water PN'SID 0 Sample Remarks: Printed Date/time Collected Date/rime Received Daterrime Technical Director 09/23/2008 14:14 09/0812008 13:45 09/08/2008 14:45 Stephen C. Fde Allowable Prep Analysis Parameter Results PQL Units Method Container ID Limits Date Date Init Metals by ICP/M3 Arsenic ND 5.00 ug/L EP200.8 C (<10) 09/15/08 09122/08 NRB Waters Department Total Nitmtc/Nitritc-N 2.36 0.100 mg/L SP12045DONO3-F B (<10) 09/15/08 JDZ Microbiology Laboratory Colony Count 0 col/100ml. SM209222B A (<200) 09/08/08 DLC Total Coliform 0 col/100mL SM209222B A (<I) 09/08/08 DLC Fecal Coliform 0 col/100mL Sh1209222B A (<I) 09/08/08 DLC Municipality of Anchorage ' Development Services Departme Building Safety Division Onsite Water 8 Wastewater Program 4700 South Bragaw St. I P.O. Box 196650 Anchorage, AK 99519-6650 1 Il) `/ pS www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. nSI-RII-a„'t HAA# drjOtjCls 1. GENERAL INFORMATION Expiration Date: _ (o ' 0 6/ Complete legal description SAMPSON ESTATES SUBDIVISION; LOT 17, BLOCK 4 Location (site address or directions) 22411 PHAROAH CIRCLE • CHUGL4K. AK 99567 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address Day phone 688-2838 A� Day phone phone BUTLER TEAM f 1�� Qn oQ_- iq y phone 110 W. 38TH, SURE 100 * ANCHORAGE, AK 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 257-0161 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Welt ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health Authority 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 samples. (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 Health Authority 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 applicablo Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Finn GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD. SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system In accordance with ADEC and MOA c DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells andseptic co4 systems depend on the local sails condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. are outside the control of the evaluator of the system. Satisfactory test These conditions results do not guarantee future performance of the system, nor do they guarantee that defects GEG, Ltd. can therefore not provide QQ 9 QO� there are no hidden or encroachments. any warranty or future estimate of how long the system will continue to meet the QQ operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the ownerlisted above. Any reliance upon or use of this report by any other person orparty is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for — bedrooms. Disapproved. Conditional approval for Attachments: HAA Checklist Septic System Advisory Well Flow Advisory bedrooms, with the following Maintenance Agreements Supplemental Engineer's Report Other -7[ Gamess:'.) 953 ;' df OF1A,#it& PROGRAM By: (N Original Certificate Date: (Rev 11101) Municipality of Anchorage Development Services Department ° Building Safety Division OnSBe water & wastewater Program ° 4700 South Bragaw SL P.O. Box 196M Anchorage, AK 99519.85W www.ei.anchorage.akA s (907)343.7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: SAMPSON ESTATES S/D: LOT 17 BLOCK 4 Parcel ID: A. WELL DATA Well type PRNA7E If A, B, or C provide PWSID# N/A Well Log (YM) YES Date completed 10/1 /1985 Sanitary seal (Y/N) YES Wires property protected (Y/N) YES Total depth 160 ft. Cased to 160 ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 10/1/1985 11/2/2005 Static water level 135 ft. 141 ft. Well production 5 g.p.m. 3.29 g,p,m, WATER SAMPLE RESULTS: Coliform �Q oolonies/100 ml. Nitrate )^ mgA. Other bacteria-y'_colonies/100 ml. Arsenic: N A mg./L. Date of sample: 11 /2/2005 Collectedby: GEG. LtD. _ B. SEPTICIHOLDING TANK DATA Tank TypefMaterial STEEL Date installed 10/27/1997 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (YM) YES Depression over tank (Y/N) NO High water alarm (Y/N) YES Date of pumping 11/8/2005 Pumper JR'S PUMPING C. ABSORPTION FIELD DATA Date installed 111171985 Soil rating CEi> ft%drm) 305 System type BED Length 58 ft. Width 24 fl. Gravel below pipe 0.5 ft. Total depth 3.5 ft. Eft. absorption area 1392 ft' Monitoring tube YES Depression over field NO Date of adequacy test 11/2/2005 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 568 gal. New depth 3_5 in. Elapsed Time: 1142 min. Final fluid depth 0.13 in. Absorption rate >= 450+ g.p,d, Any rejuvenation treatment (past 12 mo.) (Y/N 3 type) NONE KNOWN If yes, give date — D. UFT STATION Date installed 12ZZZLI997 "Pump on" level at 41 in. Datum BOTTOM OF TANK E. SEPARATION DISTANCES Size in gallons 1250 "Pump otr level at 41 in. Manhole/Access (Y/N) YES High water alarm level at 45 in. Cycles tested 3 Meets alarm 8 circuit requirements? YES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankilift station on lot 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/deanout N/A Holding tank N/A SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building foundation 5+ Property line 5'+ Absorption field 5'+ Water main N/A Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line •4' Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION 1 cer* that I have determined through field inspections and t': '* • • review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. ......esa..... A. ms Engineers Printed Name JEFFREY A GARNESS �i ' • M Date jf 9/off sd Drof*us b�d HAA Fee $ `\114\ Date of Payment \\ Receipt Number 7(Aqq YAM (Pw. 12101) Waiver Fee $ Date of Payment Receipt Number 11-09-05;16:45 ; —S&%— SCS RcL# 1057414001 picot Namc Garnets Engineering Group, Ltd. ProjectNamc/# Sampson Est L17B4 Client Sample ID Sampson Est L17 B4 Ma M: Drinking Water PWSM 0 Sample Remarks: 907 561 5301 # 2/ 4 All Datcs/Cimes are Alaska Standard Time Printed Datcaime 11/09/2005 15:06 Collected Datclfime 11/02/2005 14:30 Received Date/time 11/032005 8:58 Technical Director Stephen C. Ede Parameter Rwltr Allowable Pap Anatysis POL Units Method ConteincrM Limiu Date Date laic Nitrate -N 1.85 0.100 mr/L. EPA 353.2 B (<-10) 11/03/05 AZS 111erobiology Laboratory Total Coliform 3 0B. No Coli col/100ml. S%120 9222E A (<-I) 11/03/05 TL.F MUNICIPALITY OF ANCHORAGE DEPARTMENT on of Environmental ServicesVICES Ds o�`/~ti On -Site Services Section FNT,glro,,�^ P.O. Box 196650 Anchorage, Alaska 99519-6650 SFR yin 343-4744 OC�3 VCFS�� G�c CERTIFICATE OF HEALTH AUTHORITY c f I99j APPROVAL FOR A SINGLE FAMILY DWELLING �� Parcel l.D.# \; HAA#'��1-iln��`�n 1. GENERAL INFORMATION L"`-'2_, CC1 Complete legal description Loo- 17 1 9A, -'q - Location (site address or directions) -,;'Zgl ( Eli -A'2 CA—i4 Property owner P' L �' �' �/ Day phone 75 3 _ 2s4Z Mailing address So< -'k Lending agency Mailing address Agent EUS, i ^;yc Address C ' Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 'y V Day phone . Day phone V9. -4-+1q- Or -1470 3. TYPE OF WATER SUPPLY: Individual well Community well QO2 P)G-gip 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 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 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 furtherverify 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 Engineer's signature ,4 CC,_tY)t.T70VA-t.- 114,4 W49 PF1r--u('eUSL,`/ r, -►L-- u Vic-Li�L' P_/A�lo 6. DHHS SIGNATURE Approved for Disapproved. By: 3 bedrooms. Conditional approval for Additional Comments WTla Phone 337- 179 Date / d 2- e) bedrooms, with the following stipulations: Date%%�,- 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 pu rchasers 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 (Re .1/91) Back MOA#21 F/yy�O/y/ciH�( • Municipality of Anchorage 'SMF cryo DEPARTMENT OF HEALTH & HUMAN SERVICES��SFp Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 3¢ 744 ® 1,90;off Health Authority Approval Checklist I � Legal Description: L o -r / 7 �� Sr -1 PSU-�/ , Parcel 1. D.: 05-/— 6 // '— z' A. WELL DATA Well type If A, B, or C, attach ADEC letter. ADEC water system number AJ Log present (Y/N) Date completed %�// 8� Total depth /bO Cased to fb Casing height (above ground) f Sanitary seal (Y/N) Y%�s Wires properly protected (Y/N) yG� _s FROM WELL LOG AT INSPECTIO Date of test cj Static water level l 3� ' 14-3 / Well production g,P,m. 3.6/ + 9 -P.M. WATER SAMPLE RESULTS: Coliform Nitrate ie / q' M Other bacteria Date of sample- - 24'r�7 Collected by: J /p') (,y) LL -(A** Yy B. SEPTf64NAbBFNG%`7`TAN DATA Date installed (01_VTank size /25I) Number of Compartments Z Cleanouts (Y/N) Foundation cleanout (Y/N) yS Depression (Y/N) NO High water alarm (Y/N) Yje�% Date of Pumping 1-i t4_ Pumper - N 1A C. ABSORPTION FIELD DATA Date installed 0 Soil rating (g.p.d./ft2 or ft2/bdrm) 30F System type -3i=-p Length tat , Width ;]L+ t Gravel thickness below pipe 65- ! Total depth 3, 5 - Effective Effective absorption area 13 9 a Monitoring Tube present (Y/N)--Y— Depression over field (Y/N) _/V6 Date of adequacy test Results (Pass/Fail) PSS For bedrooms Fluid depth in absorption field before test (in.), Immediately after 60 gal. water added (in.):^ Fluid depth 4 (ins) Minutes later: 950 Absorption rate = 450+ g.p.d. -r-EJ2AnuPeroxide treatment (past 12 months) (Y/N) r' If yes, give date ?1/ /L9jL_ 72-026 (Rev. 3/96)* SyS�t�� Wag P9 -4y 6^/ D. 61FT r9 -A-1 Ie N Date installed i0 �'t /C� Size in gallons er r� Manhole/Access (Y/N) "Pump on" level at* 44'1 "Pump off" level at* 4'i rr High water alarm level at* !4� *Datum 9.0-1-T-w"f Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 10 1 r + On adjacent lots 100 r/,f Absorption field on lot 145 +- On adjacent lots /0O AJ ` Public sewer main rJ 1,4 Public sewer manhole/cleanout r Sewer /septic service line d S /� Lift station /o/ '+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: 14- / Foundation / Property line 25Absorption field `—S 4• Water main/service line 10 tom' Surface water/drainage lO® Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: i I Property line 4 Building foundation 5� � Water main/service line Surface water /dO /'f• Curtain drain Driveway, parking/vehicle storage area A 5 ( Ayr pry 19cl I "aA Wells on adjacent lots I 00r4- F. ENGINEER'S CERTIFICATION ( tn/•4 i vF/L fQU6 S I certify that I h4VIR dqtmrnru reld inspections and review of Municipal rec in conforman e w tA gui lines in effect on this date. / Signature Engineer's Nam Date /D2 e X47' HAA Fee Date of Payment Receipt Number 72-026 (Rev. 3/96)* are Waiver Fee $/� w 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. # — _ Z Z HAA # �04on C),�4CIp 1. GENERAL INFORMATION Complete legal description Loi 1-7) QV- 4-, Sam-1i9Sc3..l Location (site address or directions) -,-> 24-1 Property owner Day phone 2,"- Mailing address `ZOO n1011T-4 PIGI�—i —k A''7- /CDS ��X�^'0a'a' � , Lending agency D h Mailing address Agenti�r=, Address ay p one 94-e=siayphone 336-4414- Unless 36"4l4- Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well 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 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 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 Alaska Water& 1F 1..,.a� Cin pgor Address Engineer's signature 6. DHHS SIGNATURE BY: Approved for bedrooms. Phone 737 / 29 Date OF 4 tv e A. Garn -7953 Disapproved. 22 Conditional approval for J bedrooms, with the following stipulations: The on-site wastewater disposal system serving this property has recently undergone a Terralift procedure This is a new procedure in Anchorage which attempts to rejuvinate septic system leachfields. The success or failure of this- provedure is determined by an adequacy test conducted 30 days following the procedure Money ! 1 put !:a eserew for 69mP1gt u .i rae of the w"tAwAter System in the event the drainfield does not pass another adequacy test after 30 days from the Terralift until this office has given final approval. MITir 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 DH HS 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-M(Rev. 1/91) Back MOA #21 MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION Municipality of Anchorage JUL 3 1 1997A-rGs DEPARTMENT OF HEALTH & HUMAN SERVICES e*Environmental Services Division RECEIVE 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: LAT 1'1 N-4- Sr"- ?S0^J Parcel I.D.: A. WELL DATA Well type PVT- If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N)Date completed Total depth i 6 Sanitary seal (Y/N) NO Cased to //6 o Casing height (above ground) FROM WELL LOG Date of test 10/$5 - Static water level Well production Wires properly protected (Y/N)� AT INSPECTION ('12Ig�- /43 r g.p.m. 9.(0/+- g.p.m. WATER SAMPLE RESULTS: Coliform % Nitrate t4 -ft VLli Other bacteria Date of sample:7 4�1� Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Tank size 0190 Number of Compartments Cleanouts (Y/N)-Y—"— Foundation cleanout (Y/N) _ Depression (Y/N) N6 High water alarm (Y/N) !l F --J Date of Pumping NI/S Pumper c!6v6e- C. ABSORPTION FIEL DTA Date installed if Soil rating (9.prd-hYeor ftz/bdrm) 'go s;- System type M191 Length � / r 9 Width �9- Gravel thickness below pipe a 5� Total depth 3� Effective absorption area Monitoring Tube present (Y/N)-Y— Depression over field (Y/N) N 0 Date of adequacy test z3 IL Results (Pass/Fail) ZA-35' For 3 bedrooms Fluid depth in absorption field before test In. ; r g ( ) Immediately after water added (in.): Fluid depth (ins) Minutes later: / 3ao Absorption rate = 46-D a' g.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) /// 0 5,� i{, fE�JS Size in gallons "Pump on" level at* High water alarm level at* / *Datum Cycles tested a(A- �� Cov&'Z Lr --T- ' E. SEPARATION DISTANCES "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: I Septic/holding tank on lot 100� + On adjacent lots too {" Absorption field on lot //l(9Or f On adjacent lots Public sewer main Of+4 Public sewer manhole/cleanout t.1 Sewer /septic service line Lift station (©D 41 - SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ! (+ Property line 5 �4- Absorption field I Water main/service line 10f' Surface water/drainage j00 1 4- Wells on adjacent lots (off t SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: i Property line (fJ f4- Building foundation 10 4- Water main/service line f 4- � Surface water 100 -I- Driveway, parking/vehicle storage area -3CO 4- A 1 f Curtain drain "75 4- Wells on adjacent lots ! W 4- F. ENGINEER'S CERTIFICATION t certify that I have in conformance Signature Engineer's Name Date -7130 HAA Fee $ OD Date of Payment -) /?21 b Receipt Numbers C(� 72-026 (Rev. 3/96)* inspections and review of Municipal w in effect on this date. Waiver Fee $ Date of Payment Receipt Number m .lhge tStY agis are o G9' _� www9 O fe ,69t: -Z zz q! r. p ea .00 e' PROFESS%' N.w Alaska Water & Wastcewaltelry CN *'®ic1PAL1rynrAA/CN. NMervrq! ®vsroN 8471 Brookridge Drive — Anchorage — Alaska 99504 s vrc�s Phone (907) 337-6179 — Fax (907) 338-3246 JUL 3 Consulting Engineers pr V %%%Ii - - KED ED July 30, 1997 Municipality of Anchorage Department of Health & Human Services Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 Subject: Conditional HAA for Private Well & Septic System. Lot 17, Bk 4, Sampson Estates S/D. To whom it may concern: The subject lot has a 3 bedroom house on it which is served by a private well and septic system. The specifics are summarized as follows: SEPTIC SYSTEM ADEQUACY TESTS: The septic system was originally tested on 6/3/97 and the results were inconclusive. Repairs were made to the monitoring tubes, and the septic retested on 6/30/97. It was determined that the absorption capacity was only about 350 gallons per day. The system was Terralifted on 7/11/97 (Jerry Leach, Alaska Drainfield Restoration) and retested on 7/23/97. The results of the post Terralift adequacy test are summarized as follows: Prior to starting the adequacy test the drainfield was dry. Two -thousand & twenty-six (2026) gallons was introduced into the north monitoring tube over a period of approximately 336 minutes (5.6 hours). The first 959 gallons rose the level in the bed 3 inches. The next 1067 gallons only produced a rise of 1.5 inches. In short, the total rise was 4.5 inches. Twenty-two (22) hours later the level had dropped 1.5 inches, indicating an absorption of approximately 1067 gallons. This corresponds to an absorption rate of approximately 1164 gallons per day. Based upon this data it was determined that the drainfield will absorb greater than 450 gallons per day, as required for a 3 bedroom home. We are aware of the fact that drainfields which are Terralifted must be retested, after 30 days of use, before a non -conditional HAA can be issued. The house is currently vacant, and should be occupied at least 30 days prior to retesting. If the system fails to pass an adequacy test at that time, an upgrade will need to be performed. Based upon conversations with Dan Roth (DHHS engineer), it is my understanding that it is no longer DHHS policy to require soils testing and a design (for the possible upgrade) prior to issuance of a conditional HAA. If an upgrade is required, there appears to be enough area in the southeast portion of the lot to install a similar size drainfield as the existing one. If soils proved unsuitable in that area, it may be necessary to utilize the existing drainfield site, which would require excavating out the contaminated material, and importing new sand and drainrock. In addition, if the upgrade is required, the lift station will need to be inspected for structural integrity. The escrow account should be large enough to cover the costs for soils testing, design, permits, construction, and inspection of a complete system , including the lift station and drainfield. Twenty -thousand dollars ($20,000) should be adequate to cover all contingencies, including the possibility of installing an innovative system such as a Biocycle, Intermittent Sand Filter (ISF), or a Recirculating Upflow Filter. B. SEPTIC TANK HAS YET TO BE PUMPED: The septic tank has yet to be pumped. It seemed prudent to wait until the final adequacy test was performed (30 days after occupancy) before incurring the expense of pumping the tank, since, if it is determined that the drainfield is inadequate, it way be necessary to replace the tank at that time (if it has holes in it). The tank pumping receipt will be submitted with the request for a non -conditional HAA, should the drainfield pass an adequacy test 30 days after occupancy. C. LIFT STATION NEEDS REPAIRS: The lift station manhole is badly corroded, does not extend adequately above grade (sits in depression which allows surface water intrusion), and the manhole lid cannot be securely fastened. It is my recommendation that the manhole be replaced. In addition, the float switch that controls the pump does not appear to be operating properly. The switch activates and deactivates the pump in response to any introduction of water into the lift station. This float should be repaired when the manhole is replaced. As with the septic tank pumping, these repairs will be done after the adequacy of the drainfield is verified (again, 30 days after occupancy). D. SANITARY SEAL AND WIRES ON WELL: The well does not have a sanitary seal on it, as required by M.O.A. code. This will need to be corrected prior to issuance of the non -conditional HAA. In addition, it appeared that some of the wiring was bare (no insulation) where it enters the top of the well casing. This should be corrected by the well driller, when the sanitary seal is installed. E. CLOSING: If you have any questions, please contact me at 337-6179, or on my digital pager at 1-800-481-1162. Th4nk you for your assistance. , M.S. MUNICIPALITY OF ANCHORAGE �� • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services 19 �� 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 l.D. # HAA # 1 IAS 1 a 21 1. GENERAL INFORMATION Complete legal description Lot 17; Block 4; Sampson Estates Location (site address or directions) 22411 Pharaoh Circle Property owner Bi 1 1 Stevens /EXEC'[ITTVE MANAGEMENT st phone 6R8 -54'i5 Mailing address 2020 Abbott Road, Suite 5, Anchorage, Alaska 99507 Lending agency Day phone Mailing address Agent Carol Bennett/FORTUNE PROPERTIES Day phone Address 3000 A Street, Anchoraae, Alaska 99503 Unless otherwise requested, HAA will be held for pickup 2. NUMBER OF BEDROOMS: 3 V 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 XXX 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 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 furtherverify 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. �y q Name of Firm 7"m4 F,agic- River Loco Road tiro. p04 phone 6f %"' 'Eagle River, Alaska 99577 Address Engineer's signature 6. DHHS SIGNATURE Approved for An4) bedrooms. Disapproved. Conditional approval for Additional Comments Date bedrooms, with the following stipulations: By: V_,a, z j X5- Date Uffir 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. 72-025(Rev.1/91) Back MOA#21 Z Municipality of Anchorage r Department of Health & Human Services a-NFALsLKfoioN HEALTH AUTHORITY APPROVAL CHECKLIST Lar 11 a ,L- 4 Sn�,,.� s�, Legal Description: P rParcel I.D. t, A. WELL DATA RECEIVED Well type 122iQber15If A, B, or C, attach ADEC letter. ADEC water system number lik t -i 14 - Log present O/N) Date completed tom- ► - B5 Driller :" W LAA A MS Total depth ) LP 0, Cased to I Lon Casing height 17- 't Ar Z'r} Sanitary seal (y/N) Date of test Static water level Well flow Pump level FROM WELL LOG lD— an SEPARATION DISTANCES FROM WELL TO: Wires properly protected �jl /N) AT INSPECTION (o-13- `)1 1 23� g.p.m. 0,5 + g.p.m. UK Septic/holding tank on lot 11-05 ; On adjacent lots /oo r Absorption field on lot /[po, ; On adjacent lots — Public sewer main IJ1d- Public sewer manhole/cleanout Public s� ewer service line - /4_ Petroleum tank 14- WATER SAMPLE RESULTS: Coliform D c o��ouM� Nitrate Mfh • Other bacteria N/vNE Date of sample: 4 -.5- 9/ Collected by: S t 5 E✓G.ir✓� 2i,f�, B. SEPTIC/HOLDING TANK DATA Date installed Tank size /7-s0 Compartments �- Cleanouts&N) — — Foundation cleanoutnN) —Depression (Yo High water alarm (Y49 A/ Alarm tested (Y/N) ' A' Date of pumping 5-30-%/ jQ_ Ssrooc PcJi1P�.JL, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /2-5 J On adjacent lots / I& I Foundation To property line /b Absorption field Water main/service line �r7 Surface water/drainage /d0 t 72-026 (Rev. 3/91)Front MOA 21 - CONTINL)ED ON BACK PAGE C. LIFT STATION Date installed BSManufacturer � o2 �;j lX Size in gallons /ZSb Manhole/Access/N) V /' 14 Vent/N) _"Pump on" level at 9/ "Pump off' level at /3 N High water alarm level Cycles tested -3 Meets MOA electrical codes(Ig/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On ZS ad ' tf adjacent lots /4� Surface water /�0 D. ABSORPTION FIELD DATA Date installed //-1- 85' Soil rating - 305- Y/2. System type Be -D Length 8 Width 24 Gravel thickness Z S Total depth 3,S Total absorption area /39Z S. F. Cleanouts present Y N) Depression over field (Y& Date of adequacy test G - /3 —9 / Results as /fail) FA-S.S for -7-dere- 63) bedrooms Peroxide treatment (Past 12 months) (YO IJ/L If yes, give date 1`J1s4 SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / Lr D; On adjacent lots / DD ' Property line &S, To building foundation Le I ' To existing or abandoned system on lot On adjacent lots 3v ' Cutbank IJIA Water main/service line /o Surface water /D a '+ Driveway, parking/vehicle storage area 30 ' Curtain drain qs-� E. ENGINEER'S CERTIFICATION i certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect onf�i ate of this insQection. ut35+a•av2E �� '�r t4r 6'�F 0 0 15�0.5�r r=aji c� "� {a1Vf Loop 6s+^aa�x l�Q. g1� � i l�F� "n`•r�� 7 Signature Eagle River, Akaska !057.7 Engineer's Name " Date / � / ,"t.. r+�r �•¢ " � , lc,, Ii'J7.r y , a� HAA Fee $ Waiver Fee: $ Date of Payment Date of Payment Receipt Number �? 0 Receipt Number 72-026 (Rev. 3/91) Back MOA 21 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 ANALYSIS REPORT BY SAMPLE for WORKorder# 35009 Date Report Printed: JUN 10 91 @ 10:38 Client Sample ID:L17 B4 SAMPSON EST. PWSID :UA Collected JUN 5 91 @ 15:30 hrs. Received JUN 6 91 @ 17:30 hrs. Preserved with :AS REQUIRED Analysis Completed :JUN 7 91 Laboratory Supe sor :STEPHEN C. EIDE/ Released By L!�/ Chemlab Ref #: 912533 Lab Smpl ID: 5 Parameter Tested ------------------------------------------------- NITRATE-N Sample ROUTINE SAMPLE COLLECTED BY: RAY Remarks: Client Name :S & S ENGINEERING Client Acct :SNSENGP BPO # PO # NONE RECEIVED Req # Ordered By :R. SHAFER Send Reports to: 1)S & S ENGINEERING 2) Matrix: WATER Allowable Result Units Method Limits ------------------------------------------------------------- 1.4 mg/l 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 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 (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) f� fjj- C(Z6G6- (b) Applicant Name �f� ���J` CdN�7� Telephone: Home� �o=�� Business N Applicant Address (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder 0?" Buyer ❑ ; Other ❑ (explain); — (d) Lending Institution l?7n/Ai �Telephone/i �7[a "�r��i� Address 550 lt) %t!2 A -0e /-trinIn9(�— & (e) Real Estate Company and Agent _ areu Address t 52 12 r U LL °1Ll- - ` Telephone �g� qJ��5�� (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single -Family L/Multi-Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well [E 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 l�/ Public ❑ Community ❑ Holding Tank ❑ e Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (11/84) Page 1 of 2 •5. ENGINEERING FIRM PROVIDING, 41PECTIONS, TESTS, FILE SEARCH, DATE. .i D 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. f _ i Name of Firm Address Date /✓ " pJ a o ��� e: Zocooeon u rine s sees ee ansa ae c J. Corwin a +4+C1 C[-5253 Engineer's Seal 000 so ooaz' 6. DHEP APPROVAL _ ,7 Approved forte bedrooms by (�� ate Approved Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval cer4ificates 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) .9 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) 1•40v j 1 CHECKLIST - FEBRUARY 1984 284-4720 R13LU IV E z D Legal Description: L07 / 5nMPS0/J S0 3UIVf,5J6AJ A. WELL DATA Well Classification PRIVATE If A, B, C, D.E.C. Approved (Y/N) AJA Well Log Present (Y/N) YFS Date Completed /0_/_8S Yield 300 C� PH Total Depth %� �� / Cased to d Depth of Grouting /t -IM Static Water Level /35 / Pump Set At /5-157 Casing Height Above Ground 4 Frf E T Sanitary Seal on Casing (Y/N) YDS Electrical Wiring in Conduit (Y/N) Y'ES Depression Around Wellhead (Y/N) N Separation Distances from Well: To Septic/Holding Tank on Lot 15 ; On Adjoining Lots fid® 4 - To Nearest Edge of Absorption Field on Lot «'® ; On Adjoining Lots To Nearest Public Sewer Line A�� To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ti/A Water Sample Collected by Date Water Sample Test Results 5 9 7/5 FAC 7d2 y Comments B. SEPTIC/HOLDING TANK DATA Date Installed /% `j E'er Size 105-C3 No. of Compartments Standpipes (Y/N) ( Air -tight Caps (Y/N) Y Foundation Cleanout (Y//N) Y Depression over Tank (Y/N) !J Ci 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 Tangy: � To Water -Supply Well To Building Foundation 2 f To Property Line 8 � To Disposal Field .361 To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026(11/84) n C. ABSORPTION FIELD DATA '� Soils Rating in Absorption Strata 305 sr, Z-80/Z1Mr Type of System Design 42F_-7 D Date Installed /1 �T�%S Length of Field Width of Field Depth of Field 3, S Gravel Bed Thickness /� untb�2 elPG Square Feet of Absorption Area ) 3 `f' Z 5,F Standpipes Present (Y/N) Y' 5 Depression over Field (Y/N) Date of Last Adequacy Test /LJ,49 Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well & D To Property Line To Building Foundation 6-57 / Lot ; On Adjoining Lots G5- / To Existing or Abandoned System on /OC> /`f. i To Water Main/Service Line AJ /,ft To Cutbank (if present) AJ IM To Stream/Pond/Lake/or Major Drainage Course I\J II/'7 To Driveway, Parking Area, or Vehicle Storage Area 70 " TO DRIVE GUd4-1 Comments D. LIFT STATION Date Installed /I �i� s Dimensions Size in Gallons /2 d Manhole/Access (Y/N) YES "Pump On" Level at '1-t- "Pump Off' Level at High Water Alarm Level at / Vent (Y/N) yO Tested for /y Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) m S Comments 5E� �119��HDOZG4LG� %W Il T,ElM ®N Pl�E *` Check Peflmyted Bating Against HAA Request'" I certify th*,hecAk,fied, or conformed to allllMOAyand HAA guidelines in effect on the date of this inspection. Signed Date [ G Company MOA No. S7 -8T 2V4 Receipt No. �(L u 11 Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) igineer's Seal Cern ft7rc5,-D S'7 - ,No -c; . '7 tk 15 5.1-pf �A—T 1cPI0�,j j --"'' WALITY OF AN CHORAOg ENV/ RONMEOF HE""' a NTAL PROTECTION NOV 1 g , _RECEI VEp