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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
Permit Number: 5W950511 A wR55-D05/l2 PID Number: 6j/-8//S
Name.
1
Wastewater System: ❑ New )d Upgrade
e M
Address; 5. Sa p `195
ABSORPTION FIELD
Phone:No.
&8 - /0 70 B
of Bedrooms:
3
❑ Deep Trench ❑ Shallow Trench YBed ❑ Mound ❑ Other
LEGAL DESCRIPTION
Soil Rating: _
Total Depth from original grade:
O.5 GPD/Sq. Ft.
Z f
Lot: Block:Subdivision:
20 41
Depth to pipe bottom from original grade:
Gravel depth beneath pipe _
Q5AmP W 6-rA t�S
115 FL
. 5 Ft.
Township:
Range:
Section:
Fill added above original grade:
Gravel length: 5
VARIE l - 0.5 Ft.
30` eO-C,h Ft.
WELL:New El Upgrade
wids. ��I>
Number of lines:
Distance been lines:
a�Gravel
n Ft.
gee Ie
Classification (Privat , A,B,C):
Total Depth:sed
To:
Total absorption area:
_,3
Pipe material,
Ft.
q00 SQ. Ft.
F 9 10 IID 303
Driller:
Date Drilled:
Static Water Level:
Installer:
Date installed:
FL
WAc e_CvNS
I(7 — rf B
Yield:
Pu p Set at:
asing Height Above Ground:
TANK
GPM
Ft.
SEPARATION DISTANCES
❑ Septic ❑ Holding P,S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer:
Capacity in gallons:
From
Tank
Field
Station
Tank
Sewer Lines
AMC.*0fZA4 E 7
c-
izsci
Well-/00'-J-r
loo�
/Qo +
/�
�
STS - Material:
�
Number of Compartments:
Z
Surfac
Water
200'.+
Zoo'+
zool+
/
/
LIFT STATION
Lot
Line
/Q / +
i. 7
/Q f +
/
/
Size in gallons:
/25 0
Manufacturer:
�ENLI�o2 4G I to N lC
Foundation
Is is
/a / ¢
/� 1�
/
/
"Pump on" level at:
"/Pump off" Level at:
High water alarm at:
//
Curtain
Drain
/VQ
(
/UO a
M�
��
Pump Make & Model
ORE/JCo 20oSLo5
Electrical Inspections performed by:
Na- 1-45Av5MoY L/6,qTs
Remarks: I Fnc.l r b c.o e �
BENCH MARK
A
s r/h Vi c✓ round aw5 Z %e 6� s�o a✓
Location and Description: r I - I
5 Corner fi iW s $e 45-� vt
fi, ro er //'r)6 grealeI'M 61.4
aba,v.. neJ in o (d
Assumed Elevation:
100 Ft
�. �� �iu,�-ioh u,+•1 e� c,,ru � � I�o�c.(�.�'�(,le� n �,ac>�.
ENGINEER'S SEAL
�®�®®®®��
OF
41.
®� r °• 0
Inspections performed by: _ KKQ Dates: 1st Pf 7a'°•m
..Ift
.....,..,•,
2nd /1/7
•,••• .;,,•
d os• s•i •w o••
z�
u
��N
Department of Ht1th andServices a proval
pp
o°KennCE 1
*Oo.
and approved byDate: —L�
*.*@*aReviewed
�1 p9�o;FE/SS10N®�
72-013 (Rev. 9/91) MOA 25 �`/
A -C
= 16'
+/-
B -C
= 64'+/-
A -D
= 22'
+/-
B -D
= 67'
+/-
A-E
= 154'
+/-
B-E
= 174'
+/-
A -F
= 181'
+/-
B -F
= 207'
+/-
F -G
= 13'
+/-
A -H
= 179'
+/-
B-H
= 199'
+/-
A -I =
207'
+/-
B -I =
232'
+/-
AS -BUILT P.I.D. if 051-811-25
WASTEWATER DISP❑SAL SYSTEM
LOT 20, Block 4, Sampson Estat, �bdlvision
CD
CD
M
--------------------- T_
-
LOT 19
LOT 18
OF � �
_ ,4' 1
�* 49TH* *�
/ KENNETH M.°DU S: /
` CE -7116
1 \ `D?OBESSI013A�
SEPTIC IVENT
9
G
a
CD
S88°04'42 -E
R220. 00, CS
100,00' (')
L51
r..'. o WELL
Jaz 47.29'
I 68'6 �A'W
j,71 S�2°5$
ARED FOR:
DEAN & RAE MAXWELL
22506 SAMPSON DRIVE
CHUGIAK,
688-67 08 AK 99567
a
42,29, N
LOT 20 0
o a
o N
Z
Q
T.H. #
Q T.H. #1
LOT 21
—
70.00'
KND ENGINEERING
20441 PTARMIGAN BLVD
EAGLE RIVER, AK, 99577
(907)696-6111/Fax (907)696-8111
DATE-11-28-95/rev 6/7/96 DRAWING #
SCALEr 1' = 50' 95031-S1
89.83
98.40
AS -BUILT DESIGN DETAILS
WASTEWATER ABS❑RPTI❑N SYSTEM
LOT 20, Block 4, Sampson Estates Subdivision PTLD. # 051-811-25
98.70
w
WE
SHED GRADE
F 116.07
0
SEWER R❑CK
Gngnnl Grd.
I 117.39 Z
D
FINAL SLOPE
3d
\
FILTER FABRIC AND INSUL
25 LF 1 1/4' PVC W/3/16' HOLES
e 5' SPACING (TYP)
SEWER R❑CK
O
MIN. '0,5' SAND ,F:ILL . .:. -.
�_� L M� 112.06 E
S.T. UHL�
S,T.E,P, 116 Fi
Lift Stntlon
89.82
Sand was added to level beds .
System was installed in GM material. 2.5'(typ)—
T
1 1/4' PVC FROM TANK TO[-
FIELD
1 1/4' PVC FOR MANIFOLD M.T.
Field Dimensions
Ol Approx. 15' x 30' Trapizold
Inside angles approx. 63 deg./117 deg.
O2 Approx. 15' x 30' Trapizoid
Inside angles approx. 81 deg./99 deg.
9
M,T.
F112.07
I 114.22
9711WIDWO
WATER MONITORED @
L00.75' 7
2.51(typ)—\, CAP FNT1S nF PTPF
0
25 LF 1 1/4' PVC W/3/16' HOLES
e 5' SPACING (TYP)
D
O
30'
0
2.51(typ)-1 CAP FNT5S flF PTPF_
0
25 LF 1 1/4' PVC W/3/16" HOLES
5' SPACING (TYP)
D
O
M.T.
T
M.T.
T
30'
OF AL\ Lj 0 u s
1 ti Lo
M D� � 4
0Note:
0 01. Drawing above is a schematic.
49TH * L' 2, Fields were constructed as trapezoids
N in order to maximize separation distances.
/KENNETH M. D S : / m 3. Piping and absorption are the same.
`-. CE-7116,Wa PREPARED FOR:
KND ENGINEERING
20441 PTARMIGAN BLVD
\ D / �y' / DEAN & RAE MAXWELL EAGLE RIVER, AK, 99577
ARo
FESSID' / 22506 SAMPSON DRIVE
CHUGIAK, AK 99567 (907)696-6111/Fnx (907)696-8111
688-6708 DATE: 11-28-95 DRAWING #
NTS 95031-S2
-4
Rick Mystrom,
Mayor
11�Iunicipali-(y ofAnchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
October 13, 1995
Ken N. Duffus, P.E.
KND Engineering
20441 Ptarmigan Boulevard
Eagle River, Alaska 99577
Subject: Waiver Request for Lot 20 Block 4 Sampson Estates
Waiver Request #WR950046, PID #051-811-25, SW950311
Revised
Dear Mr. Duffus:
Your request for a waiver of the required 10 foot separation
between a septic system and a lot line has been approved. The
waived distance is 1 foot to the west property line.
Please be advised that the above referenced waiver is for a
minimum setback distance of 1 foot between the septic system
and the west lot line. The septic system includes all portions
of the drainfield which includes the mounded area over the
drainfield. For clarification purposes the toe of the slope
of the mound must be no closer than 1 foot to the referenced
property line.
A
Any future upgrade to the septic system will require all separations
be met or another approval from this department.
n
'Sincerelyi,
r 1 ''v} JLnvl—
James P. Williams
•'Civil Engineer
On-site Services
JPW/ljm
Con ur:
f
ames Cross, P.E.
rogram Manager
On-site Services
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
i PID# 051-811-25 HA# Permit # w"l� 03
WR#r.;�Q�ibm lla
Date Received: Sept 12, 1995
Legal Description: Lot 20 Block 4 Sampson Estates
Engineer: Ken N Duffus, P.E., KND Engineering
20441 Ptarmigan Boulevard, Eagle River, Alaska 99577 8736
Applicant: K. Dean Maxwell
Waiver Requested: Lot line waiver requested of feet to the
west property line
Criteria: 1. Geology: Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
2. Special Conditions:
3. Other:
Waiver is Granted: Waiver is NOTAD115—e,�f—
Rec
rantted:
A4 d-4 r� a nr Reasons for above: 0o
#: #01291/2944 Amount: $ 115.00 Date Paid: 9-12--95
KND ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
1 /FAX (907)696-8111
December 28,1995
Jim Cross, P.E.
On -Site Services Manager
Dept. of Health & Human Services
Municipality of Anchorage
P. O. Box 196650
Anchorage, Alaska 99519-6650
Subject: Lot 20, Block 4, Sampson Estates Subd., - Lot Line Wavier
Modification
Dear Jim:
As a follow-up to our conversation on December 26th, I am requesting a
modification of our lot line wavier to include both the south and the west lot
lines of the subject property.
Thank you for your consideration of this request. If there are any questions,
please contact me at 696-6111.
Sincerely,
Kenneth M. Duffus, P.E.
KND Engineering
NOV-13-95 MON 10:00 PM,walkar contractinv 907 694 4858 P.01
MOV -13-95 MON 21:45 HEAVENLY LIGHTS ELECT 00 6a6 6061 P.01
22609 McManus • Chugiak, Alaska 99567
phone# (907) 688-6060 • FAX# 688-6061
dem a -I -�,-7u k0fi
aaub�
y -)
R;
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:SW950311
DESIGN ENGINEER:KND ENGINEERING
OWNER NAME:MAXWELL KERRY D & RAE J
OWNER ADDRESS:22506 SAMPSON DR
CHUGIAK, AK. 99567
PARCEL ID:05181125
LEGAL DESCRIPTION:
SAMPSON ESTATES BLK 4 LT 20
LOT SIZE: 44276 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
lC)
DATE ISSUED:10/05/95
EXPIRATION DATE:10/05/96
r
Se7F !/,Si7
! N ht/9 ci — lied 1lL CCe'7
wros 7 ilk Fc';t'g-dq
Qpm
11-R-15�_
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /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:
ABANDON EXISTING SEPTIC TANK AND LIFT STATION.
MAINTAIN A MINIMUM 1 FT. SETBACK FROM WEST
PROPERTY LINE PER ATTACHED WAIVER.
RECEIVED BY:
/44&>
DATE • /a -- &
ISSUED BY:W(Lt ca�DATE: 6
KND ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
1/FAX (907)696-8111
September 11, 1995
Municipality of Anchorage
Dept. of Health & Human Services
On -Site Services Section
P. O. Box 196650
Anchorage, Alaska 99519-6650
Subject: Lot 20, Block 4, Sampson Estates Subd., - Sewer System Upgrade
Gentlemen:
Attached is our request for an on-site sewer permit for an upgrade on the above
lot. The subdivision is served by on-site wells.
As shown on the site plan, there are no conflicts with proposed wells, sewer
systems or with potential reserve areas. In addition, there are no class "A" public
wells within 200' of the property.
This lot is gently sloping from south to north at a slope that varies from 1% to
approximately 7%. There is adequate area directly north and south of the test
hole location on the lot to install the replacement system. Minor encroachment
into the property line setback is necessary and we are therefore requesting a
wavier from property line in addition to the above request. The natural slope will
provide positive drainage away from the proposed installation site. There is no
surface water within 200 feet of any portion of the proposed installation.
Several testholes were excavated on this property in an attempt to locate a
suitable site for the installation. Testholes #1 & #2 were excavated just northeast
of the proposed site; percolation and water monitoring results indicate that
testhole #2 is inadequate. Testhole #1 has adequate soils but is lower and poses
increased susceptibility to ground water. Testhole #3 has suitable soils and will
not be impacted by ground water. Use of these site however will require your
approval of a lot line wavier for the site. The design we are submitting is based
on the existing three bedroom house and a worst case percolation rate of
approximately (11 min./inch). Based on adjacent soils tests it is anticipated that
the percolation rates for the area soils should be better than 11 min/in. Although
Subject: Lot 20, Block 4, Sampson Estates Subd., - Sewer System Upgrade
September 11, 1995
Page 2 of 2
water was monitored at only 12.5' we have chosen a shallow installation due to
high water encountered in the area.
Thank you for your consideration of this request. If there are any questions,
please contact me at 696-6111.
Sincerely,
Kenneth M. Duffus,
KND Engineering
attachments: On -Site Well and Sewer Application
Wastewater Absorption System Details
Site Plan
Soils Log/Percolation Test
SITE PLAN
WASTEWATER DISPOSAL SYSTEM
LOT 20, Block 4, Sampson Estates Subdivision
P.I.D. # 051-811-25
WELL
�-ft ``
OF AZ\ 1�
49 T -H*
KENNETH M. DU /
CE DU
_
IN
Al
Ph30FESSI0I3P�,
WELL - 100'+
PARED FOR:
DEAN & RAE MAXWELL
22506 SAMPSON DRIVE
CHUGIAK, AK 99567
688-6708
.4 , j4-�-b
LOT SIZE 44,283+
LESS HOUSE FOOTPRINT: 2,263
LESS EXISTING SYSTEM 1,280
TOTAL AREA LEFT: 40,740
KND ENGINEERING
20441 PTARMIGAN BLVD
EAGLE RIVER, AK, 99577
(907)696-6111/Fax (907)696-8111
DATE, 9/tl/95 DRAWING #
1'
Scute: = Oi; AM ! I 9531—SI
WELL - 1001+
SAMP N DR.
0 225a�-
- _
M SWOr•12•E
IOUOV
VELE
LOT 19
"'MMMVVV 3129' ��
�
r229•
WELL - 100'+
sunt
v rts
ccr TO Ex:snxs syslrR,
LOT 20 LOT 21
x�
0 rH x2
WELL
LOT 18�
nc vsxr
0
H. tl
WELL
�-ft ``
OF AZ\ 1�
49 T -H*
KENNETH M. DU /
CE DU
_
IN
Al
Ph30FESSI0I3P�,
WELL - 100'+
PARED FOR:
DEAN & RAE MAXWELL
22506 SAMPSON DRIVE
CHUGIAK, AK 99567
688-6708
.4 , j4-�-b
LOT SIZE 44,283+
LESS HOUSE FOOTPRINT: 2,263
LESS EXISTING SYSTEM 1,280
TOTAL AREA LEFT: 40,740
KND ENGINEERING
20441 PTARMIGAN BLVD
EAGLE RIVER, AK, 99577
(907)696-6111/Fax (907)696-8111
DATE, 9/tl/95 DRAWING #
1'
Scute: = Oi; AM ! I 9531—SI
:Q
P.I.D. # 051-811-25
DESIGN DETAILS
WASTEWATER ABS❑RPTI❑N SYSTEM PERMIT #
LOT 20, Block 4, Sampson Estates Subdivision
1,250 GALFMIM
S.T.E.P.
TANK
FILTER FABRIC AND INSUL
SEWER ROCK
2 - 30' x 15' BEDS
PRESSURIZED DISTRIBUTION SYSTEM HOLE SPACING
1. RESIDUAL HEAD = 5'
2. HOLE SIZE = 3/16' = 1.00 GAL. PER HOLE @ 30 PSI
3. 30 GALS (PUMP DELIVERY)/1.00 GALS./HOLE = 30 HOLES
4. 150 LF LATERAL/30 HOLES = 5' SPACING PER HOLE
5. ALL HOLES SHALL HAVE CAPS INSTALLED PER MANUFACTURES SPECS.
TO 2ND FIELD(SAME SIZE)
1 1/4' PVC FROM TANK TO FIELD
1 1/4' PVC FOR MANIFOLD
0
u
4' SOLID FROM HOUSE
G,
M
r
0
r
z
O
E
ORG. GROUND
I w
0
WATER MONITORED
12.5' BELOW GRADE
DESIGN BON 14.0,
11 2.5 (typ)—\ rAP P-wwC nF PTPF(TYP)
2.5'(typ)--\
OF AZ4 'k
*49TH *�
I S /
. KENNETH M. D S: /
CE -711 : k7�
411
Awir
\ d %PESS100 dw
M.T.
JNr`P
G,
E'1@75 LF 1 1/4" PVC W/3/16' H❑LES
5' SPACING (TYP) (PER EACH BED)
r
O
K
0
r
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z z
0 o
z z
Q
z o £
w w
w
J J
U V
z
w w Z
J Q
U £
1,250 GALFMIM
S.T.E.P.
TANK
FILTER FABRIC AND INSUL
SEWER ROCK
2 - 30' x 15' BEDS
PRESSURIZED DISTRIBUTION SYSTEM HOLE SPACING
1. RESIDUAL HEAD = 5'
2. HOLE SIZE = 3/16' = 1.00 GAL. PER HOLE @ 30 PSI
3. 30 GALS (PUMP DELIVERY)/1.00 GALS./HOLE = 30 HOLES
4. 150 LF LATERAL/30 HOLES = 5' SPACING PER HOLE
5. ALL HOLES SHALL HAVE CAPS INSTALLED PER MANUFACTURES SPECS.
TO 2ND FIELD(SAME SIZE)
1 1/4' PVC FROM TANK TO FIELD
1 1/4' PVC FOR MANIFOLD
0
u
4' SOLID FROM HOUSE
G,
M
r
0
r
z
O
E
ORG. GROUND
I w
0
WATER MONITORED
12.5' BELOW GRADE
DESIGN BON 14.0,
11 2.5 (typ)—\ rAP P-wwC nF PTPF(TYP)
2.5'(typ)--\
OF AZ4 'k
*49TH *�
I S /
. KENNETH M. D S: /
CE -711 : k7�
411
Awir
\ d %PESS100 dw
M.T.
JNr`P
71
DESIGN CRITERIA
M.T.
in
L
1. 3 BEDROOMS X 150 GAL✓DAY/BEDROOM = 450 GPD
2. SOILS RATING 9 MIN./INCH = 0.5 GPD/SF(BED)
3. 450 GPD/0.5 GPD PER SF = 900 SF
4. 900 SF /15' W = 60' L
5. MINIMUM DESIGN SIZE = 2- 15' W x 30' L BED (900 s•f.)
6. 2' HD INSULATION REQUIRED OVER FIELD <3' OF COVER
7, 2' HD INSULATION REQUIRED OVER TANK <4' OF COVER
8. CONTRACTOR TO PUMP TANK, REMOVE INTACT AND ABANDON IN PLACE.
9. ANY ASPHALT, CONCRETE OR APPERTANENCES DAMAGED OR
DESTROYED BY THE CONTRACTOR DURING CONSTRUCTION SHALL BE
REPLACED BY THE CONTRACTOR AT NO ADDITIONAL COST TO THE OWNER.
10. CONTRACTOR TO VERIFY AND INSURE 2Z GRADE FROM HOUSE.
REPARED FOR: KND ENGINEERING
DEAN & RAE MAXWELL 20441 PTARMIGAN BLVD
22506 SAMPSON DRIVE EAGLE RIVER, AK, 99577
CHUGIAK, AK 99567 (907)696-6111/Fax (907)696-8111
688-6708
Dater 9-11-95 DRAWING #
SCQIe: NTS 9531-S2
O
E'1@75 LF 1 1/4" PVC W/3/16' H❑LES
5' SPACING (TYP) (PER EACH BED)
in
O
71
DESIGN CRITERIA
M.T.
in
L
1. 3 BEDROOMS X 150 GAL✓DAY/BEDROOM = 450 GPD
2. SOILS RATING 9 MIN./INCH = 0.5 GPD/SF(BED)
3. 450 GPD/0.5 GPD PER SF = 900 SF
4. 900 SF /15' W = 60' L
5. MINIMUM DESIGN SIZE = 2- 15' W x 30' L BED (900 s•f.)
6. 2' HD INSULATION REQUIRED OVER FIELD <3' OF COVER
7, 2' HD INSULATION REQUIRED OVER TANK <4' OF COVER
8. CONTRACTOR TO PUMP TANK, REMOVE INTACT AND ABANDON IN PLACE.
9. ANY ASPHALT, CONCRETE OR APPERTANENCES DAMAGED OR
DESTROYED BY THE CONTRACTOR DURING CONSTRUCTION SHALL BE
REPLACED BY THE CONTRACTOR AT NO ADDITIONAL COST TO THE OWNER.
10. CONTRACTOR TO VERIFY AND INSURE 2Z GRADE FROM HOUSE.
REPARED FOR: KND ENGINEERING
DEAN & RAE MAXWELL 20441 PTARMIGAN BLVD
22506 SAMPSON DRIVE EAGLE RIVER, AK, 99577
CHUGIAK, AK 99567 (907)696-6111/Fax (907)696-8111
688-6708
Dater 9-11-95 DRAWING #
SCQIe: NTS 9531-S2
."AV
V" ,00 oe.oaooe
J�. ; a ago
Municipality of Anchorage tipa
Y DEPARTMENT OF HEALTH & HUMAN SERVICES 0: 49TH*a
g
8006 saeee3po..®a .e
825 "L" Street, Anchorage, Alaska 99502-0650 ,� �✓
SOILS LOG — PERCOLATION TEST �ge •vKenneth M•Duffus
CE 711
�-�, / f�,/ooao _ aoo,C,
PERFORMED FOR: �`^'(^� "r�YG{%EL.0-�/ IJ FQ •eoeoa•��
DATE PERFORMED:®111190Ea
LEGAL DESCRIPTION: 4^' zo Township, Range, Section.
DEPTH �� Sr. SLOPE SITE PLAN
(FEET)
1 oz_
2
N
3P .J fJIN�j ►� t_y.L./f'l��L
4 S U//I; 012 �- Ulj L I h I -H
m
1w(I
5 E.D. �1%,/5,,�
J) I d6
.r
7
1
8
1
10- WAS GROUND WATER , /O
ENCOUNTERED? /IJ
��a ink s
11 L
11 IF YES, AT WHAT
12 01l9• DEPTH? P
E
13 Depth to Water After r
Monitoring? /o Date: `1 /�
tt
14
15
16
17
18
19
Reading
Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
;2
t�67
2�fl�
S 3
S
/.02z
5
z
54'
20 u !I % `VI&
m 9 irP
PERCOLATION RATE (mufevinch) PERC HOLE DIAMETER ���
/1� ,7 TEST RUN BETWEEN Zj FT AND 3' F'r
COMMENTS Lel
PLHI UIrtdLD t3Y._.�F-0�- (,I nlllY III/I IIt,%II 'J w/1" II IU(d'l611�Ifa
/ c
ACr: (1110/.NGL WITH ALL STALL AND 6AUIJI(,IPA! (V III NI.I IN( -,114 1.11 ((, 1� !f! 1111', lih r DA I I /�`��
• 4 MUnicipalilY of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOLS LOG — PERCOLATION TEST
®tI
4l i�
OF 4 6�j
C�t�66!
o °► 0.17s®
ep��TN
°pe ►e°u
Kenneth M.
v ;k. '►11"1110 • 40�
PERFORMED FOR:_,( -,( 7P At 2.- DATE PEREORI S� •'p�, ' ^ <<'v
0 eeewe _♦
/ .� OFE� SSW ®�
LEGAL DESCRIPTION: w 70 49(r—,"f s Township. Range, Section:
DEPTH CST. SLOPE SITE PLAN
COMMENTS
;M
> jq 64.fvew,
vau
n44er-
'3m,11
SEEM■II■■�
■EE■RAQ
owl
EElI1E■
No MEMO
■■9—aIr� '1d
WAS GROUND WATER
ENCOUNTERED? &5
IF YES, AT WHAT
SIs $
L
P
DEPTH?
E
Ikplh to Waler After
ManiwrinII7 /D 1
Ove:
Reading Date GrossMIet
Timerop
S' /o: Si3yS
23 15-
5 -
PERCOLATION
sPERCOLATION RATE e5o Im.nutevmchl FERC HOLE DIAMETER 41=�_
'(TEST RUN BETWEEN (//'' FT ANO a'S F'(
'4 /1 4A.
+
Ll�� e tinC_ vGu C Ck' r,,, la — A u � ve6 -n ( 4 A .
PE/n OI /1✓r0 RY IfY it I/- I I l fr, l f ' , I WA', hl ltl r rl •rl,f f� n:
"-r,UI!I)AN(,(_ WI 111 AI I. S1A 1t ANO I.AUNI(,IW I (i(llfj( 1 II-!( IN I I I f (, I ! I l u', IJ If O/. 11 ��
/% 001;
N®�E'°�C
• Municipality of Anchorage m'
DEPARTMENT OF HEALTH & HUMAN SERVICES °
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST p s'°°°° "" °"
CKenneth M. Duff,
®so. % CE 7116
PERFORMED FOR: e!/�%.T/..% - T �/y: �j 4 °°°°/ /y 3va
• � ( / � o? DATE PERFORME��:O,�pR °. •°
LEGAL DESCRIPTION
?Er
1
1
1
1�
1E
1E
17
18
19
20
COMMENTS
C"() 7- 6z Z
..6W
Gig- t -'j
6m /ems
Dtudl✓/
T, i n�
�)A
�®17-7�3
Township, Range, Section:
a1-urt
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
PERCOLATION RATE /D• / (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN 191-?- FT AND JY2 FT
PERFORMED BY: cS()Illj
CERTIFY THAT THIS
TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: %zlL�5"
72-008(Rev.4/85)
MUNICIPALITY OF ANCHORAGE
DE �3TMENT OF HEALTH AND HUMAN SER ES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name
DISTANCES
Address TO SEPTIC ABSORPTION
DO X30?( G 7 /2Z� FROM TANK FIELD WELL
Phones r(r/ l0 `�z23 Permit No. No. of Bedroom WELL I I O t I
e!5 h ISD
Lot Block' / Subdivision
z� `_ SA J 0, QST.
Township, Range, Section
-Fis R I
TANKS I
A
❑ HOLDING
Manufacturer
Capacity in gallons
G/Z
I o0
Material
No. of Compartments
ST Eft—
Z
TYPE OF SYSTEM
❑ TRENCH X BED
❑ W. DRAIN ❑ OTHER
Depth to pipe botto from
original grad '7
Total depth from original grade
FT
y 5�.
FT
Fill added above original grade
Gravel depth beneath pipe f
_ FT
FT
Gravel length L� �
�'_�
Gravel width
FT
o�Li�
FT
Total absorption area
Distance between lines
l�8RSOFT
yl 8d
FT
Number of lines S
LA j&i"0
Pipe material
FT
PVG
Installer
Date Installed
WELLS
PRIVATE ❑ OTHER (Identify)
alion (A,B,C) Total Depth Cased to
Vlbuc(I t7jESIPt 1Jc
1620
FT
II Date Installed:
�.IIL!a MS .jU(LA Iq94z�
REMARKS:
h ,I. t
FT
LOT LINE - + 15I 3c�I
FOUNDATION Z I I Opt+ �I
AS -BUILT DIAGRAM (Show location of well, septic system, property lines, founds
driveway, water bodies, etc.)
scale: 1 "=1 D0
Inspections Perp
W
by:
Date: �, i
9 as -8s i
r 1
certify that this inspection was performed accordinqiq all
Municipal and State guidelines in effect on this date:
Health Department Approval:
72-013 (3/85) Date:
S
Iss
°°°°° °.
9TH * 0
000000000000 o m00000 e$eee�
aoo 000000 000eeoaeeo o.oegj
°
Sm" L HmPen6urp ° A?
i
ze
CE. 6739
'TJ PTJ '21 '71 'Tj 'Ti 'TJ 'TJ
PV m
Mutv7c.
D) OP
MTJ W4 oil lz XCh
jWq 171
0 0 0 0 0;
6
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-4 .4 43,
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Ji����
DEPARTMENT OF HEALTH AND ENV�RONMENTAL �R��ECTION �
825 L STREET� ANCHORAGE� AK 99-0� �
�64-4720 �
PERMIT
NO:
DATE
ISSUED:
APPL�CA�T:
ADDRESS:
eONTACT
PH�NE:
LEGAL
DESCRIP:
LOT
SIZE:
MAX
BEDR�OMS:
�� � � ������
850264 '
06/�6/85
LEIF ERICKSON�
3031 LO�S DRIVE #310
ANCHORAGE� AK 99503
753~2737
SUBDIVISION: SAMPSON ESTATES
LOT: 20
44278 (SQ FTOTOWNSHIP: 15N RANGE: 1W
3
I certi{y that:
1, I am {amiliar with
the requirements
{�
' on~site.sewe's
{orth by the Municipality
and wells
o�
Anch o'age
as set
(MOA>
2^ I will install
and the State o{ �laska
the
system i n
acco'dance
with all MOA
and i li
comp ance�with
the design
codes d
an 'egulations;
3 I
criteria or this
^ wiln
all MOA and
State
permit
dista�caoneremto
�{
Alaska re�uirements^��� the
existing
well� wastewater
set b k
ac
disposal
sewer,g�=s/,oemany
�t �=^ u''
��'zs or any
adjacent
system or p�blic
,
4 I und_
or nearby lot `
any e�rsran�ethatithis
..^c y�".additional
permit
is valid
~
�or, a maximum ^[ 3 bedrooms and
permit.
FEA LIFTASTATIONRIS^INSTALLED
`
IN
AN AREA COVERED
B`� MOA BUILDINGCODES
��iy1��LIPERMIT
AND
INSPECTION
J. L. �u w
!�U;T AN
MUST B� OBTAINED; <�) AS~B�ILTS
ELECTRICAL
INSPECTInm
REPORT;
LELW�rr:u
DONE BY A
LICENSED
AND (�) T�E
n
ELECTRIC���N
DATE:
�!|~��
' ^
~~^`�``-
[
` __�
\~` " " ��-------===�-�-----------
DATE:
X SOILS LOG
MUNICIPALITY OF ANCHORAGE
+\l DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION A PERCOLAT{o,
IN
� j 625 L. Street, Anchorage, Alaska 99501 264.4720 TEST
SOILS LOG — PERCOLATION TEST 7�D�j
PERFORMED FOR:X/,( 61j/7 z "4, 4j1,44 C� n/LpgTE PERFORMED: 1L2 cT,1t 9a�
LEGAL DESCRIPTION: LOT ZQ BLOGK4 f�/`/�•J'Q/1/E,-S/�r��' �-"� /V /e?(tl /n1
r7L 0! SLOPE SITE PLAN
1
0ArCy /so"
ML ¢a"t 15a?fJ -s.•%7
2 d a;wP
3
0
7
sGrit ylu�-f/*//Y —sanc?y
rav2l
9
10
111
WAS GROUND WATER S
ENCOUNTERED? /70 L
O
12 P
IF YES, AT WHAT _- E
13 DEE/PTH?
/O T & Xoi� L,- /19
14 J.,110ra. 0 'r' fee' f
15 /t 0 /e
_ �%Vawa�
16
• e
17 e• �Y61 %
e o
•ooeoa o0
oeoo� �eele000000e
18 � • ee`,Illatfq
e e • uo BO�
19 � ar`� CE a 6739
Reading
Date
Gross
Time
Net
Time
Depth to
- Water
Net
Drop
rHzO
�JUA0a�
s3
z0 ,Yt,�
9. 7"
G.S!
I
a / !
0F:33
/
- /0 G(l T/!/mac
y. /9
tf/L 0
0 r: 31
q. iz 0
z
:0
kc.
2.9z
o.-79
ff/z0
V' -o
X3 0 Mr
3.90
° .80
fyLO
ti
0�:�6
G 9: 0
3 0 /vLr`vL
q. /Q
-5 3
0.
�y 0
S
UY 0 3
a9•'�
30
4. -70
3. 9L
7SP
4 rol�sstu ®®
i a�
2/ y l
J. l0 9
PERCOLATION RATE_
(minutes/inch)
TEST RUN BETWEEN
FT AND
17'-5 FT
COMMENTS Ov1�i/7/ /Z f
a / !
Te
/
- /0 G(l T/!/mac
1
PERFORMED BY: CERTIFIED DATE:��
72-008 (6/79)
ZR s`/.BU.2 4-31/.3 Si /lJ Q,C. CGdt vs �ari�J
r<e/
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 1. D. # L; \ - R � i - HAA #
1. GENERAL INFORMATION
Complete legal description �o� � SSOC IL 4A
Location (site address or directions) _ RR -6_10b -5�0,-M, 60,-7 Jar.
Property owner
Mailing address
Lending agency
Mailing address.
'asz co 'Se:,
ay p one
�7 OB:
Day phone
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well
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 #21
Y
S. 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.
KND Engineering,/�/
Name of Firm 20441 Ptarmigan Blvd. Phone
Eagle River, AK 99577-8735
Address
Engineer's signature
6. DHHS SIGNATURE
Approved for
Disapproved.
By:
Conditional approval for
Additional Comments
bedrooms.
Date , /96,
OF
CD
a
�-
n
� & CAt
boa •ora M�aEaa a°e.a
•aaa �.i u.• w
cc
Kenn,.; h1.
sy CE 711 ,• a�
t@ ��q0F oio'
Qs
bedrooms, with the following stipulations:
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-G25 (Rev. 1/91) Back MOA #21
M
Municipality of Anchorage
• DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-KEC E I V E D
14
Health Authority Approval Checklist MAY 28 1996
/l Municipality of Anchorage
Legal Description: 4/zo ��,Y j yy �=-9ePty}iy"lth & ilman Services
/�Sb�l Parcel I.D.: /)� r �/ Z
A. WELL DATA
Well type /zz If A, B, or C, attach ADEC letter. A�D�EC water system number
Log present (Y/N) Date completed
Total depth «Q Cased to
�1G0 Casing height (above ground)
Sanitary seal (Y/N) Wires properly protected (Y/N)_
FROM WELL LOG AT INSPECTION
Date of test
Static water level �,?� / 135,71
Well production C e_n_m
WATER SAMPLE RESULTS
Coliform Nitrate /, T Other bacteria
Date of sample: /9� Collected by:. /U
B. SEPTIC/HOLDING TANK DATA /
Date installed I/ Tank size 1250 Number of Compartments Z Cleanouts (Y/N) }I
Foundation cleanout (Y/N) y — Depression (Y/N) N High water alarm (Y/N)
Date of Pumping IVPQ
C. ABSORPTION FIELD DATA
Pumper IVA
Date installed// Soil ratin (g.p.d./ft2 or-ft�z drm•) �,� System type Med
Len h�heds � P_GL albeclS Lao,- 3"as /
to Width J- QCT, Gravel thickness below pipe Total depth OLI �2. gas
Effective absorption area 900 Srr Monitoring Tube present(Y/N)—L Depression over field (Y/N)
/7eA��
Date of adequacy test /1 Results (Pass/Fail) — For bedrooms
Fluid depth in absorption fiel fore test (in.); Immediately aft _ gal. water added (in.):
Fluid depth (ins.) Minutes later: Ab tion rate = g.p.d,
Peroxide atment (past 12 months) (Y/N) If yes, give date
D. LIFT STATION
Date installed ///%�j Size in gallons �ZS�
Manhole/Access (YIN) "Pump ori' level at* "Pump off' level at*
High water alarm level at* 7 7 *Datum
Cycles tested
.v
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
i
Septic/holding tank on lot /fid + : On adjacent lots
�
Absorption field on lot //}Q , -f ; On adjacent lots /,96) -f
Public sewer main /2q Public sewer manhole/cleanout /%Q
Sewer /septic service line IM Lift station /DiQ / -k
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO
Building foundation Property line /D 4 Absorption field /� f
Water main/service line %O / Surface water/drainage Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation /0 '- Water main/service line / &0 -./--
Surface
Surface water 200' '/ Driveway, parking/vehicle storage area 10D J
' -
Curtain drain /� I / Wells on adjacent lots /4V ,'/ Property line 17, / -5ee ,
Gva/u>!✓W2 95'U0116&evesej)
F. ENGINEER'S CERTIFICATION
certify that have determined thru field inspections and review of Municipalrec ffegCJ{x+q(; � is are
in conformance with ,LIOA HAA guidelines in effect on this date. . ; ' °•$o
6 `o®
:49M •:
Signature a as es *@..ease... $egos
Engineer's Name Qy/�9 �/ /%l ��c > Ac :Eh&jpjya 00 m
®�.• CE 711
Date �'�o?5/�jL' ®� �<° °'•• � � °'s
®%O-ESSIO®®�
HAA Fee $ .� . CADg
Date of Payment tp �P dD q/
/
Receipt Number Z (Z2 J
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number
3
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL 02�_E'Q8q
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application DateP"fT 7. /9 87
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
In ot 2G_ (3(ac(: �/, SgcmOSen Ccke1--J
Location (address or directions)
Susan b ri �z Fe- Aer-r C'rcc /T
(b) Applicant Name ["ard- Re (cca/ton Cove Telephone: Home IV, A. Business
Applicant Address 2w S. Branae /kue Su'fc (o/.� Gt-fnyt kny SIT 07039
Ti
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder 1Z ; Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution Fire Sn her.slal° San k Telephone 2 6K -S63S
Address 3000 C" St. ¢n chdr
ge /�� 99663
(e) Real Estate Company and Agent Dvnami c RecA M, 279 -?61/ Cc/ /e en
Address bD1 W. KarAern 6,K4/> R/L' Apnc'herc,ye* /y -ft 99So3
Telephone 279 -7111
(f) Mail the HAA to the following address: /
2. TYPE OF RESIDENCE
Single -Family ® Multi -Family ❑ Other
Number of Bedrooms 3
3. WATER SUPPLY
Individual Well ® Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite 91 Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11/84)
A
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm F(a f oo TecAn ccuf S vsf Telephone 3 5 S- r 3 C:5,-
Address
,,Address ('1530 Cctia S>` �Yn�hoicrgt, ,1} k 995
Date 5_1 Z 7 4 B 7
e ^?
��e.ee,a..,,..,..., •. e,,,,,,Al
THEODORE F. MOORS .: Engineer's Seal
t��4. ,•.. CE - 3589 •F,� t
��_ Araiess��= 3� �•m
6. DHEP APPROVAL r
Approved for OL>&_]�,)bedrooms by Date 61/111-410— 6�,
Approved Disapproved Conditional
Terms of Conditional Approval
�Jhep
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4744
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
MAY 2 9 1987
Legal Description: -Ina-L V, E
�L m d so n Es irr. �E!
A. WELL DATA
Well Classification Priva.4t If A, B, C, D.E.C. Approved (Y/N) &A•.
Well Log Present (Y/N) Y Date Completed 7 /15' /8,5- Yield >Y,8W." view 6'/Z01/8-7
Total Depth 16'0' Cased to 160
Depth of Grouting Ni A.
Static Water Level 1'(o' Pump Set At 15'SI
Casing Height Above Ground 110 Sanitary Seal on Casing (Y/N) Y
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) N
Separation Distances from Well:
To Septic/Holding Tank on Lot toe" ; On Adjoining Lots > too'
To Nearest Edge of Absorption Field on Lot ^^ 200' ;On Adjoining Lots > too,
To Nearest Public Sewer Line N, A. To Nearest Public Sewer
Cleanout/Manhole N. . To Nearest Sewer Service Line on Lot N, A.
Water Sample Collected by T. F. Nuore- ; Date 6l ZO / a 7 v
Water Sample Test Results Sarlts�acfoj A O eu(rforn, / 100#19/J 0.60 V/,e
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed 9/Zs/&S Size - f00� No. of Compartments 2
Standpipes (Y/N) I Air -tight Caps (Y/N) i Foundation Cleanout (Y/N) i -
Depression over Tank (Y/N) N Date Last Pumped 9/Z7/87 Spy J'j3's P��,�, y ✓
Pumping/Maintenance Contract on File (Y/N)
;for
Al.
Holding Tank High -Water Alarm (Y/N) N• A. Temporary Holding Tank Permit (Y/N) M. A.
Separation Distances from Septic/Holding Tank:
To Water -Supply Well (06I
To Property Line > (0'
To Water Main/Service Line N,A.
Course > too,
Comments SoMe "rrace cX ret rn
ViC"nt,LV of rD)'!2c ktn(c. ance
Page 1 of 2
72-026 (Rev. 8/86) Front
To Building Foundation 19 1
To Disposal Field 136'
(
To Stream, Pond, Lake, or Major Drainage
M,
ro(
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 26! 0' /Sotrm Type of System Design
Date Installed 9/ as /as- Length of Field 6`/ ( . _
Width of Field -2o'--- Depth of Field
Gravel Bed Thickness 0- S
Square Feet of Absorption Area 1260— Standpipes Present (Y/N)
Depression over Field (Y/N) N Date of Last Adequacy Test S/ zo /g 7 ,,..
Results of Last Adequacy Test Ado uaAe ccyror op how ree Ae .ror 3 bealruormr v
Separation Distance from Absorption Field:
To Water -Supply Well 200To Property Line 10,
To Building Foundation 1 SD To Existing or Abandoned System on
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
On Adjoining Lots
To Cutbank (if present) N..4.
To Driveway, Parking Area, or Vehicle Storage Area > too,
Comments All jy/Qoe&r en beoC ,were oQry cr/ 741eS/Er✓f o/ l -
Me Aerr
D. LIFT STATION
Date Installed
Dimensions 114Irn6wo
Size in Gallons 7.50 Manhole/Access (Y/N)
"Pump On" Level at 3 30 cyu!!ooy "Pump Off' Level at ro a!(av ✓
High Water Alarm Level at 2 Ce 011f uV on /e0e/ Vent (Y/N) Y
Tested for SGO h yallear on 5-1 ?0 /87 Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N) N.A. Oufsrole code enler/emenf area goer 2/7/86 AE
*gj
Comments Znfor/'^gJioo on evct<r anaC extgrm �Srorn 217186 N/F,4
&PwAV " 20,0/s SAW 6 o • —C� 4/
" Check P rmitted Bedroom Rating Against HAA Request
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed 1� - 9 %1--~ Date 5-/ 27 /87
Company F� Tecti.o r c a( Si*u MOA No. 6r7 o,S2
Receipt No. �1 oni co Sc ®OF9®�
Date of Payment F)-Q'c'`�1 ����`ee °et��®®
e
s °
Amount: $ I u(,°� 0 * .. 9TH* Engineer's Seal
®•e •oeeeeaeeeseoeeeeee •°seee�d -
Aseeeeee •°o°eoe�ieee ��e•
9 ea THEODORE F. MOORE j
AF
Page 2 of 2 �� CE - 3589'
�j
®'VIAJ •l •cavo°°e �`
72-026 (Rev. 8/86) Back ��TQI£SSiO`' ®�
®�W®.1AIN®
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)
Lot 20 Block 4 Sampson Estates Subdivision
(b)
(c)
Location (address or directions)
Applicant Name Leif Erikson Telephone: Home 688-9223 Business 753-2737
Applicant Address PO Box 671224 Chugiak, Alaska
Applicant is (check one): Lending institution ❑ ; Owner/builder ®� Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution Alaska USA Federal Credit UniorFelephone 563-4567
Address 4000 Credit Union Drive Anchorage
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
2. TYPE OF RESIDENCE
Single -Family E?c Multi -Family ❑ Other
Number of Bedrooms three(3)
3. WATER SUPPLY
Individual Well Mxx 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 ®xx Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11184)
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm LCMF Telephone
Address
Date
Engineer's Seal
This department has received written confirmation from the engineer
regarding the Conditional Approval of February 14, 1986.
The corrections have been accomplished and an inspection has been
completed by the engineer. The subject property meets with Municipal
standards and is now approved.
6. DHEP APPROVAL
Approved for three (3) bedrooms by
Approved
Terms of Conditional Approval
Conditional
dhep
CAUTION
June 17 1986
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 111/84)
E
Location (address or,directions)
'sampson�Drive Peter's
(b) Applicant Name Leif Erickson Telephone: Home 688-9223 Business 753-2737
Applicant Address 'P0 Box 671224 Chugiak, AK 99567
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ; Buyer ❑ Other ❑ (explain);
(d) Lending Institution` Alaska USA Fed.' Credit `U .Telephone 563-4567
Address 4000 Credit Union Drive
(e) Real Estate Company and Agent —
Address
Telephone
(f) Mail the HAA to the following address:
Creek
o GEOLAB
None
l
1131 E. 76th AVe.. #101
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. l 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
GEOLAB Telephone 344-8042
Address 1131 E. 76th Ave. #101 Anchorage, Alaska 99518
7 /7 /ftfi
rate
Recommend conditional approval pending final grac
station and trench for 211 pressure line to
bed; and pending final installation of
electrical lines into conduit and underground;
and pending installation of vent pipe in
manhole cover of lift station.
ft
6. DHEPAPPROVAL
Approved for bedrooms by to ro
Approved Disapproved Conditional
Terms of Conditional Approval
�?� C -d ✓ (2-)
43
77
dhep
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.,
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE (MOA) ENVI ONMENTALEALTH PROTECTION
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984i19
1149
264-4720
Legal Description: Sampson Estgwf
Sec 3 T15N R1
A. WELL DATA
Well Classification Individual If A, B, C, D.E.C. Approved (Y/N) NA
Well Log Present (Y/N) Y Date Completed 7/15/85 Yield 5 qpm
Total Depth 160Cased to 160' Depth of Grouting NA
Static Water Level 135' Pump Set At 155'
Casing Height Above Ground 12" Sanitary Seal on Casing (Y/N) y
Electrical Wiring in Conduit (Y/N) N* Depression Around Wellhead (Y/N) N
Separation Distances from Well:
To Septic/Holding Tank on Lot 110' * * ; On Adjoining Lots 1001+
To Nearest Edge of Absorption Field on Lot 216 1 ; On Adjoining Lots 1001+
To Nearest Public Sewer Line NA To Nearest Public Sewer
Cleanout/Manhole NA To Nearest Sewer Service Line on Lot NA
Water Sample Collected by DAStanleyGFGEOLAB ; Date 2/6/86
Water Sample Test Results J / �'
Comments *Electrical wiring shorted out after freeze-up. New
wiring to be buried and placed in conduit after spring
thaw. **101' from well to lift station.
B. SEPTIC/HOLDING TANK DATA
Date Installed July 1985 Size 1000 No. of Compartments 2
Standpipes (Y/N) Y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) y
Depression over Tank (Y/N) N * Date Last Pumped NA new system
Pumping/Maintenance Contract on File (Y/N) NA ; for NA
Holding Tank High -Water Alarm (Y/N) NA Temporary Holding Tank Permit (Y/N) NA
Separation Distances from Septic/Holding Tank:
To Water -Supply Well 110' To Building Foundation 171
' To Disposal To Property Line 40 Field 133'
To Water Main/Service Line NA To Stream, Pond, Lake, or Major Drainage
Course NA
Comments * No depression over septic tank, depression over lift
station to be filled when final grading is done after
spring thaw.
Page 1 of 2
72-028(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 281sgft/BR Type of System Design Bed
Date Installed July 1985 Length of Field 64'
Width of Field 20' Depth of Field 4.01 to 6.0'
Gravel Bed Thickness 0.51
Square Feet of Absorption Area 1280 sqft Standpipes Present (Y/N) Y
Depression over Field (Y/N) N Date of Last Adequacy Test NA new system
Results of Last Adequacy Test NA
Separation Distance from Absorption Field:
To Water -Supply Well 216' To Property Line 15'
To Building Foundation 159' To Existing or Abandoned System on
Lot NA ; On Adjoining Lots 1001+
To Water Main/Service Line NA To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course NA
To Driveway, Parking Area, or Vehicle Storage Area 1001+
Comments
D. LIFT STATION
Date Installed July 1985 Dimensions unknown
NA
Size in Gallons 750 gallons Manhole/Access (Y/N) Y
"Pump On" Level at 330 gallons "Pump Off' Level at 150 gallons
High Water Alarm Level at 211 above Pump on level Vent (Y/N) N *
Tested for NA new system Pumping Cycles during Adequacy Test. Meets MOA
Flortrinni rnrloc w/nh N - outside MOA code enforcement area
Comments * Vent pipe missing from manhole cover. To be installed.
** Check Permitted Bedroom Rating Against HAA Request **
I certify that ave checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date 2/7/86
Company GEOLAB MOA No. NA
Receipt No. I- S/ Lo L
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
Engineer's Seal