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SAMPSON ESTATES BLK 4 LT 21
Sampson Estates Block 4 Lot 21 #051-811-26 Municipality of Anchorage On -Site Water and Wastewater Program • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP 151296 PID Number: 051 811 26 Dwelling: ❑ Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ❑ Upgrade Name: FLANAGAN ABSORPTION FIELD 171 Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound Address 22424 SAMPSON ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 0.6 GPD/SF 6 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 2 Ft.4 Gravel depth beneath pipe Ft. Subdivision Block Lot SAMPSON ESTATES BLOCK 4 LOT 21 Fill added above original grade 2.1 Ft. Gravel length 75 Ft. Township Range Section Gravel width 5 Ft. Beds: Number of Lines -- Distance between lines -- Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 750 Ftz 1 -- Ft. Well +100 +100 -- -- +25 TANK ❑® Septic ❑ S.T.E.P. ❑ Holding ❑Other Manufacturer Anchorage Capacity 11000 Gal. Surface Water +100 +100 -- __ Material Number of compartments Lot Line +5' +10 -- -- Steel 2 NA Foundation +5 +10 -- __ LIFT STATION Manufacturer Capacity Curtain Drain __ +50 1 __ Gal. Remarks Pump on level at -- in. Pump off level at -- High water alarm at -- OLD TANK DISPOSED OF PER CODE in. in. Pump make and model Electrical Inspections performed by Installer PIPE MATERIAL House to tank 3034 Tank drainfie ld 3034 Guaranteed Services Drainfield 3034 CO/MT 3034 Inspector Charles Balzarini BENCH MARK (Assumed elevation) 96 ft InspectionX51 10/24!15 10/25/15 Location and description 2nd aro 4th CORNER OF SIDING COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp Akq���� Conditional Approval: Date d SOF AwQ'�.•• / . 49 TH • •� 77) •% CHARLES G BALZARINI ��� Approved Date �� a0� �F��•. CE -13854 .•��`��� ��,�TF'�Fo ' • .... • •����.� �� /'ROFESSIONP -�. mspecuon meport_a- t - i z.aoc SAMPSON ESTATESBLOCK 4 LOT 21SAMPSON ESTATESBLOCK 4 LOT 22SAMPSON ESTATESBLOCK 4 LOT 23EXISTING WELL100' WELL RADIUSDRIVEWAY3 BRHOMEFOUNDATIONCLEANOUTORIGINALLEACHFILEDNEW 1000 GALSEPTIC TANKNEW 5'x75'DRAINFIELDSEPTICAREAWELL +200'SEPTIC +50'WELL +200'SEPTIC +50'SAMPSON DRIVE10' UTILITY EASEMENTABCD SWING TIES A BC 27.5 71.5D 37.8 57.7BM+96' BOTTOM OF SIDING AT CORNER90.3'84.2578.384.2588.2588.2590.4FINISHEDGRADE1000 GAL TANK2" INSULATION4' EFFECTIVE SEWER ROCKFILTER FABRIC4"Ø DISTRIBUTION PIPEORIG. GRADEB.O.HCLEANOUTMONITOR TUBECLEANOUTMONITOR TUBE2" INSULATION+94.8TH-192.4NOGROUNDWATER 10/23/153.6'COVER90.6LEGEND CLEANOUT MONITOR TUBE TEST HOLEC&M ENGINEERING SERVICES 907-854-5558 SEPTIC INSPECTION DRAWING LEGAL DESCRIPTION:SAMPSON ESTATES B4 L21 OWNER: FLANIGAN DATE: 12/16/18 REV: 0 CHARLES G BALZARINICE-13854REGISTEREDPROFESSIONAL E N G INEERINSPECTION REPORT PLAN - SCALE: 1" = 30'SCHEMATIC SECTION - NOT TO SCALE12/15/18 Performed For: Legal Description : Depth Municipality of Anchorage Development Services Department On-Site Waler and Was tewater Se ction 4 700 Elmore St. P.O. Box 196650 Anchorage . AK 99519-6650 www .mun i.org/ons1te (907 ) 343-7904 ----oF AL\\\' ;~~·······~~ 't ;t;-.··· ~·~·, 1* ... 491H ~ ··.*';, ~"w.·· ·~"·r) ·:..:;_:" ~ ~ ' l ~ ••• • • •• ··(!._!..!J-L••· ~ ~j CHARLES G BALZARINI I ''•~· •• CE·13854 .• ·°$~ Soils Log -Percolation Test t (1'1; • • ~--~Fis'sio~~'-~ Jot r LA µJ 0A ✓ Date Performea : L Or_,n_'r-5 SJ4.M J>5&AI 'c7if l'f i& S ~l/ l,J,/ Township. Range. Section : ________ _ Slope Site Plan /" I/ I/ / / 4-?cJH es/ V / 5- 6- 7- 8- 9- 10- 11- 12- 13- 14- 15- 16- 17- 18- 19- 20- WAS GROUND WATER ENCOUNTERED? IF YES . AT WHAT DEPTH? &A Depth to Water After Monitoring? ;V~ Date: )/~ s L / 1/ / / 0 t---+---+-+--+-+--+--1---+----f--l p E t----t-----t--+--+-+---+--1----+----t-----l Read ing Date Gross Ti me Net Time Depth l~r Net Drop S-o lb 1-1/t 6 i PERGOLA TI ON RA TE ':?---... (rnnutesi ,nch) PERC HOLE DIAMETER ..JEST RUN BETWEEN . FT ANO s FT COMMENTs_t?-e-'---=",....:;.5 .;:_M __,_k.l..:/3:'-'-'Dc:::.__S-1..~~.;..,;T/JrL=a..:-==---'1'2~~7la=-SL,L;L-C --+-n'-"'~....l,..:c_;__,&..:..:w,-=-.t.,t:;;i._y ______ _ PERFORMED BY: C « 8Al2~I I l, ~IJ-L-2/112g:-1V12--CE RTIFYTHATTHIS TEST WA S PERFORMED IN AC CORDANCE WITH ALL STATE AND MUNI CIPAL GUI DE LIN ES IN EF FECT ON THIS DAT E. DATE: j0&-1/5 On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP151296 Tax Code Number: 05181126000 Work Type: Septic Upgrade Permit Effective Dates: September 02, 2015 to September 01, 2016 /j Design Engineer: �/I CL✓%�s( (ZF(Wj h I Subdivision: SAMPSON ESTATES Site Legal Address: SAMPSON ESTATES BILK 4 LT 21 G:1560 Owner/Address: FLANAGAN JOSEPH M & KAREN M PO BOX 670278 CHUGIAK AK 995670278 Site Mailing Address: 22424 SAMPSON DR, Chugiak This permit is for the construction of: Y Disposal Field Y Septic Tank N Holding Tank N Privy All construction must be in accordance with: Lot Size in Sq Ft: 42306 Total Bedrooms: 3 N Private Well N Water Storage 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 must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Special Provisions: PRIOR TO CONSTRUCTION: Additional soils testing shall be completed prior to construction to verify 6 feet minimum vertical separation between the drainfield and impermeable soils or bedrock, and percolation tests such that all portions of the drainfield are within 30 feet of a percolation test. If design revisions are required, an approved change order shall be acquired prior to construction. Test results shall be submitted with the final inspection report. RAA' '0-" Received B1 Issued By: Community Development Department`\� f AUG 2 7 2015 PhLe: 907-343-7904 Development Services Division W Fax: 907-343-7997 On -Site Water & Wastewater Program Gretchen StUller ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D.,)5/-J�//-Z6' Property owner(s) ol:�1_4,U4 0,,f !tI, -16,E g' k4f cA/ Day phone C&Z- 77s Mailing address Z Z 41Zzi S44110i &V diZ Site address JAIW6 Legal description (Sub'd., Block & Lot) _S_,4M?X a t/ Legal description (Township, Range & Section) Lot Size 4/2, 306/ Sq. Ft. Number of Bedrooms APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (0 all that apply) Absorption Field Initial ❑ Single Family (SF) Septic Tank Upgrade (w/wo ADU) Holding Tank ❑ Renewal ❑ Duplex (D) ❑ Privy ❑ Multiple Dwellings ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. � OF (Signature of property o er or authorized agent) Permit/Rush Fees: 4 5k.9 � Waiver Fees: _ Date of Payment: V2241 Date of Payment: Receipt Number: Receipt Number: Permit No. 5P/5/2_ Waiver No. Permit App_-1-12.doc C&M ENGINEERING SERVICES Ph: 907.854.5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: Proposed Septic System Replacement for Sampson Estates Bk 4 Lot4G' j�vc Dear Reviewer, We are requesting approval to change the design of a new 3 bedroom septic system at the above referenced property. The property is currently served by an older 3 bedroom septic system, which is operating in a state of failure, and the owner wishes to replace it. A permit has been approved for a deep trench type system, contingent on soils exploration. We excavated a test hole and found the soils to be extremely dense during excavation at a depth of about 10- 12'. It was determined that a shallow trench type system would better suit the site conditions. The proposed design features a new leachfield, and a new steel septic tank. The design uses new and existing soils logs. Installation of the proposed system will not negatively impact adjacent lots. Drainage is not a major consideration in this design. Included with this letter is a changed order request, plans, specifications, and calculations. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email co balzarini(a)gmail. com with any questions or concerns. Sincerely, Charles Balzarini, PE i" Ca- C&M ENGINEERING SERVICES SPECIFICATIONS FOR ONSI EPTIC' SYSTEM - LEGAL: Sampson Estates BI ck 4 Lo?8- �p June, 2015 �l I vynC A. GENERAL 1. The septic design is for a 3 bedroom, residence only. 2. The site plan and drawings shall be a part of this specification. INSTALLER 3. The Wastewater system shall be installed by a certified installer in accordance with moa requirements. All materials and workmanship shall meet the Anchorage Department of Health and State Department of Environmental Conservation requirements. 4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer. 5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage, Department of Environment of Conservation requirements. 6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any adjacent multi -family wells. A licensed surveyor should locate all nearby lot lines, easements, exact 100' radius from the existing and neighboring on- site wells, and any nearby surface water. 7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. B. Any remaining open test hole excavations shall be filled and monitor tube removed, after construction of the Drainfield. 9. The contractor shall provide the engineer with adequate notice to perform inspections. 10. Insulate the sewer line if it passes under the driveway or parking area, with a minimum of 2" extruded board insulation, rated for burial, and on the moa approved list. B. SEPTIC TANK 1. Septic tank shall be a fiberglass or steel, 1000 -gallon tank capacity of MOA approved construction. Installed to meet MOA requirements. 2. Install a foundation cleanout within 5' of the foundation. 3. Install 2 after tank cleanouts between the tank and drain field. 4. A combination of soil and 2" minimum of insulation shall be placed over the tank, to prevent ponding and promote drainage. The insulation shall be rated for burial and meet moa requirements. C. DRAINFIELD The Drainfield is to be located as shown on the site plan. Notify Engineer of any changed site conditions. 2. The total depth of the initial drainfield excavation is to be at maximum 6' deep Bottom of excavation shall be level +1- 1.5" max. If bedrock, groundwater, or inconsistent soils are encountered, notify the engineer immediately. 3. In the event of over -excavation, a moa filter sand shall be used to maintain the 6' separation distance from the bottom of each trench to the bottom of the test hole(s).The top of the sand layer shall be level, plus or minus 1.5", and raked, prior to placing sewer rock. Care shall be taken to not compact the sand. 4. A 48 inch effective layer of sewer rock is to be placed in the each trench. The effluent piping is to be set on top of this layer, buried with sewer rock, with 2" of sewer rock cover over the piping. 5. The Distribution pipe shall be 4" perforated pvc pipe conforming to ASTM D3034. 6. The complete Drainfield gravel and piping is to be covered with a geotextile filter fabric. 7. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed over the drainfield. Mounded side slopes shall not to exceed 3:1. The minimum insulation thickness shall be 2". Insulation shall be moa approved and rated for burial. 8. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any Class "C" well, or 200' to any community well. Design Summary: Excavation Depth: 6' Drainfield Length: 75' Soil Rating: 0.6 gpd/sgft Gravel Depth: 4' under distribution pipe, 2" over pipe. System Capacity: 3 Bedrooms cnarles G. Raltarinf •'• � •rg I C&M ENGINEERING SERVICES 907-854-5558 Septic Design Calculations Residence: SAMPSON ESTATES B4 LOT 21 Cover: 3 ft type: number of bedrooms 3 br Water usage/bedroom 150 gpd/br Water Usage 450 gpd Groundwater Depth 10 Test Hole Depth 12 ft bgs Perc Rate 6 min/in system type: conventional Cover: 3 ft type: shallow trench Use Length: Application Rate 0.6 gpd/sqft Based on historic testhole data required absorption area 750 sqft trench width (W) 5 ft gravel depth (D) 4 ft below distribution pipe Shallow trench factor 0.50 (W+2)/(W+1+2D) (Shallow trench factor * Required Min Required Length: 75 ft absorption area /W) Total Depth: 6 ft Cover: 3 ft Insulation: none Use Length: 75 ft ok Effluent Pipe: 4" ASTM 3034 System type: Conventional Tank: 1000 gal Drainfield: 5'x75'x4' shallow trench Calc By: CGB Date: 9/25/2015 M A� 10 •+?ilnt �fa�i4`ln.• •�1�+��.��a� SAMPSON ESTATES BLOCK 4 LOT 20 4 l TH \ N CHARLES G BA Nr CE -11 854 ,t+II,F'�Fp? 0 ES o ,���� WELL+200' SEPTIC +50' WELL .20(Y SEPTIC +50' o \ \ a SAMPSONSTATES r BLOCK LOCK4 LOT 21 m NEW 1000 GAL SEPTIC TANK p v` 'G EXCAVATE PERC�j 0' 1 BENCH THIS LOCATION 1 FOUNDATION . CLEANOUT � m NEW Sk75' DRAINFIELD TOE OF LEGAL DESCRIPTION: SAMPSON ESTATES B4 L21 3 BR HOME \ 2'-3' TALL EXIS NG WELL SLOPE PROPERLY SEPTIC EXISTING ABANDON AREA LEACHFILED EXISTING TANK WELL -200' WELL 200" SEPTIC 501 SEPTIC +50 SAMPSON ESTATES BLOCK LOT 22 LEGEND SAMPSON ESTATES NOTES: BLOCK 4 LOT 23 D CLEANOUT 1. THE PROPOSED SEPTIC SYSTEM IS GREATER THAN: • MONITOR TUBE 100' FROM ANY PRIVATE WELLS 200' FROM ANY PUBLIC WELLS ® TEST HOLE 100' FROM ANY SURFACE WATER 50' FROM ANY STEEP SLOPES 0.5% SLOPE INDICATOR 10' TO ANY PROPERTY LINE OR FOUNDATION 5' TO ANY TEST HOLES HCAI F- 1" =An' C&M ENGINEERING SERVICES 907-854-5558 LEGAL DESCRIPTION: SAMPSON ESTATES B4 L21 OWNER: JOE FLANAGAN DATE: 09/27/15 1 REV: 0 1 DRAWN: CB I REF: SITE PLAN C 01 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www, ci.a nchorac e. a k. us (907) 343-7904 Soils Log 61L/oQg - Percolation Test -Fv Performed For: ©� liVA Date Perft Legal Description: mN2,j U 7- RT� 7 `{ 01 Township, Range, Section: p 6 0AIJ6. ©F,G4N1c5 S J� 701 5_TLT�r 12 M PENS I T Nu215mc_ t"/V HARD 'DP GGD�76. E019H WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT DEPTH? L Depth to Water After o P Monitoring? p / P Date: Site Plan Reading Date Gross Time Net Time Depth ter Net Drop ® 1 11 S -©/lb b I to 3' zi 3 `Vlb I `%!6 D 5--69/14 3: z 3-0111, a -o/r` If 3:3 5-n�tl, a 10 3- �frr [ - 14116 PERCOLATION RATE 12 (minutesfinch) PERC HOLE DIAMETER "f TEST RUN BETWEEN _5 FT AND 16 FT COMMENTS �/�L-�A(5,�V 12jZra-7-0 X57— PERFORMED BY: C r t 6 t_{� 6(�-PPyY I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNIC GUIDELINES IN EFFECT ON THIS DATE. DATE: ✓L MUNICIPALITY OF ANCHORAGE �RTMENT DE OF HEALTH AND HUMAN SER ES F7 Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES i TO FROM SEPTIC ABSORPTION WELL Address ,� r� �-t TANK FIELD WELL � J t r loo t + V ���J{� J� Phones O Permit No. No. of Bedrooms 3'7,-(�71 810b14L/ 9 1 -3 LOT LINE ' O I `- LEGAL DESCRIPTION Lot Block �' Subdivision —Slf FOUNDATION zOI+- ;1 3D t� Township, Range, Section / S 3 AS-BUILT DIAGRAM (Show location of well, driveway, water bodies, etc.) septic system, property lines, foundation, TANKS SEPTIC ❑ HOLDING Manufacturer Capacity in gallons S I vIno Material No. of Compartments TYPE OF SYSTEM OTRENCH ❑ BED ❑ W. DRAIN ❑ OTHER Depth to pipe bottom from original grade Total depth from original grade 411 FT FT Fill atltletl above original grade Gravel depth beneath pipe FT FT Gravel lenyth — Gravel width G S`P FT FT Total absorption area Distance between lines IZ SQ FTFT Number cf lines Soil rating Pipe material 1' ~ Z SQ FT P✓6 fT� %� 3� `O Installer Date Installed 1 eA JAL 5- 3 J-04 r.• ' WELLS PRIVATE ❑ OTHER (Identify) Classification Total Depth Cased to 2 0 / FT 2Ci / T Installer Date Installed. A40It7117 RE ARKS: O/ L S T—p Scale: ) C P 7f) • if' C, 2 6 B f3� Inspections Performed ormed by: N '$ s6pi1; .r • v# Q / cJt/C GI f Date. S 3 /'� �D $ ?! y n ® 'k : r"!'+ t SIR g certify that III inst(action was performed according to all C: �nbatt A. str.fe r �": �Ad,'4'a' ��nn ( Municipal anAACI i� MERV AKs"577 +,?u1 ii ( tle Health Department Approval: Date: 72-013 f3/851 II A T L) f AI_ V 0 Li R E 1, G,.,of) h y! ico I cS OCAI ION 01' WW'_l. 1110005 tumplele Iyhor 10, fh or IC.) A J,L. No. I P. o ph u Jlvin Ian i I of I IIIaC% IoJI 1/4 qlft r atl v No.0, p It o a , 0 cc! Mor I d I or, r c' am r, L -iu L,!Sl ANCE AND D;Rr.-,:I'iO'4 I;F..'jh ROAD 114TERSECTIONS D. 0 N F. P. OP W C Li- A.TOT—C—r we]-] Shasta Com--trucilion i, Acj '0 '12-11 .1i2]];-:. , - , , isLoot A I C,f-1 e 1: Ade.,ess Of,d A,eo of Wall L.ocatj6r, n c 'I I C) r 2. LUG I ! 1) . I if, I.Q w Sur 0-0 Mut mol Typo. 4. VIE, -L DEPTH; (final) I DATE OF COtAf'LTl(,.z 201 It 1.2 It 6. El CCUO. fociRCJCrY Driven U Dt g Auger L-1 Jolted Bore, 7. USE: Dcr.4011c 'P'UL'IIC Supply ❑ lnd,sl:, Irrigation plitchoroo LJ com.76!;zOl Test Well Other: 8. CASING: O Threaded .,Idod _in. fo__2jCLI _ f1. Da W u i y h I I— to__ ft. L,apl,, Stickup it. 9. FINISH OF WELL: Typo: slol/mOon. Zile: Length: Sol 1,01ween ft. and BOcI;f1I!InV L------------------,— Grovai pool; 10. STATIC A'ATE'l LEVE:L: -- --- --?j. Fjabove of Below lend sjrfo:O Data Equipment used: PUI,',,"[.NG LEVEL bGlow ------------- -- — -- ------- land 6ur?aca and .':EL.0 --.--ft. c f lar Ara, p do, � in " q. P. e. ft. allot Ilm purrp;ng g.p M. I'LGROUTING Wall Gfoolod! U , , o, 5 ENo ] Materiel: 0 Hoot Cement fj Other: 15. PUIAP: Of cvoiiob;ol lip Lcngth of Drop Pipe ft. COVCC.ly 5 11 subm.. U dot Conlrift'al -Omer 14, REMARKS: I roduction of 20 CYF 16. WATER WELL CO&TfitCTOR'S CERTIFICATICN: 15. Tnis %10: was drtllcd t,nU,,lr my jurlsa;,lion and this report true to lt.c i—sl of n,y hnowl,j,'e and bollLf; A AalS � J I- Rogisloroo nu6r,OLs Name Conlrucl L 1 lju,nh:r A,fares s -P k ....... .. <vv Go I j 41 -5 Fc, 011131) Copy DisIr4buI:o;i: Stott, VGCS, 11':K-Orillef, -Customer Fl: c ** GRAVEL LENGTH > 75 FT" REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT" EACH) ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS I certiIy that: 1. I an, familiar, with the requirements 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 design criteria of' this permit" 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater, disposal system or public sewerage system on this or any adjacent or nearby lot" 4. I understand that this permit is valid for a maximum of 3 bedrooms and any enlargement will require an additional permit, IF A LIFT�STATION ���-, 0 10, R=. !r�������� "825 DEPAlf,," TMEN OF HEALTH AND ENVIRONMENT�� PROTECTION INSPECTION MUST BE DBTAINEDp (2) AS~BILTS L STREETr ANCHORAGE� AK 99501 INSPECTION REPORT; AND (3) T~~ ''° ELECTRICAL 264-4720 BE DONE BY A 1[*3 P4_.l_,3 I -Y, EE: ph,.,p �� C::�P*L�> I -rt C�v�� PERMIT NO: 860149 ��.`� f1nm. W° XWOOM !o,�� DATE ISSUED: 05/3O/86 ~~����»����� APPLICANT: CURT PIERATT ADDRESS: BOX 15000 #29 WAS ILLAr AK 99687 ~- CONTACT PHONE: 376-6786 LEGAL DESCRIP: SUBDIVISION: SAMPSON ESTATES LOT: 21 BLOCK: 4 SECTION: 3 TOWNSHIP: 15N RANGE: 1W LOT SIZE: 42306 (SQ.FT. OR ACRES) MAX BEDROOMS: 3 Listed below are the options available to you in designing your septic system" Choose the option that best fits your, site. � ^F_ FR FW%J Cl 1-1 1_3 13 S: to :1 0141 DEPTH TO PIPE BOTTOM (FT" ) 4.1..) 4 0 " " 4"0 GRAVEL DEPTH (FT`) 7"0 0"5 TOTAL DEPTH (FT") 3.5 11.0 4"5 7"5 GRAVEL WIDTH (FT. 2"5 24"0 5"0 GRAVEL LENGTH (FT. ) 58.0 45.0 87,0 ** GRAVEL VOLUME (CU.YDS,) 4O"3 40"0 64.5 TANK SIZE ((.3ALS) 1,000.0 ** 1 0O0"0 ** 1,000^0 ** SOIL RATING (SQ.FT"/BR) 268 239 268 ** GRAVEL LENGTH > 75 FT" REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT" EACH) ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS I certiIy that: 1. I an, familiar, with the requirements 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 design criteria of' this permit" 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater, disposal system or public sewerage system on this or any adjacent or nearby lot" 4. I understand that this permit is valid for a maximum of 3 bedrooms and any enlargement will require an additional permit, IF A LIFT�STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING (30M"..61, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE DBTAINEDp (2) AS~BILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) T~~ ''° ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN° SIGNED DATE: �41 `I _^�°��~������� x APPLICANT: CURT PIERATT ISf�31J�D DY ��, DATE: i9tRNaa.n•erro.s-n .., i..:. rr.. s `f �\ A A :-T �Ob/ ISZ� x 20 f Lo �$-o a ?UZ r—v N N k 0 �S SEAL) CID • Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES _s•' •'"'°° " °' .°.e. ` 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST +"' A. shy ' PERFORMED FOR: LD I--$ pROFESSI�+ 0,Q DATE PERFtlft%E;,A �' G1—S(o LEGAL DESCRIPTION: LZ.I Township Range Section: b I,-� I Q \/,I I S t1 SLOPE SITE PLAN 2 O j 3 { O d 4 (� G 6 a 7 O 8 9 r/G 10 /C 11 /` G 12 U . s 13 14 15 16 17 18 19 20 COMMENTS GM zt')gd 0)2 A -a7 WAS GROUND WATER w ( ENCOUNTERED? f�F' O S IF YES, AT WHAT / DEPTH? OL P E Depth to Water After Monitoring? V/ Date: 2-9-06 7 PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN^� FT AND FT PERFORMED BY: CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEL IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) 1 % % C}-ro, January 10, 1986 TO: Permit Applicant r. P.O. BOX 5650 ANCHORAGE, ALASKA 99502-0650 {907) 264-4711 TO i, k %'01,1/LES. DEPARTMENT OF HEALTH & HUMAN SERVICES Subject: Permit 4850301 Lot 21 Block 4 Sampson Estates Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1985. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system the original as -built inspection report(three part form) must be sent to this office for review and approval,and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Susan E. Oswalt Program Manager On-site Services SEO/ljw enc: Copy of Permit � c; ir �j r p4�� � ^. DEPARTMENT 00, �ALTH AND ENVIRONMENTAL PF' �BCTION ` 825 L STREET� ANCHORAGE, AK 99501 264-4720 ` C3 V'J E3 31 1F 1-:E S! I=- VJ EF_ F -C F:0 F.- FR 1-1 1 "'F- ~ 'PERMIT N8: 050301 ` DATE ISSUED: 06/14/85 APPLIC4NT: RAY PEI. SHASTA CONST, INC, : ADDRESS 200 WEST34, SUITE ANCHORAGE, AK 99503 CONTACT PHONE: 274~0156 LEGAL DESCRIP: SUBDIVISION: SA/ S0 |�EST��TES . _ �,, ', w L��: ��1 BLOCK: 4 / SECTION: 3 TOWNSHIP: 15N RANGE: 1W ` LOT SIZE: 43560 (1-30.FT. OR ACRES) MAX BEDROOMS: 3 Listed below are tMe options available to you in designing your septic system. Choose' the option that best fits your site. 'T~F-C EF, MK:� F-1 IEC KpJ~ 13K -e u�N][jr%j DEPTH TO PIPE BOTTOM (FT") 4"0 ' 4,0 4.0 GRAVEL DEPTH (FT. ) 7.0 0"5 3.5 ^ TOTAL DEPTH (FT.) 11.0 4.5 7"5 GRAVEL WIDTH (FF.) 2.5 26.0 5.0 GRAVEL LENGTH (FT. > 78,0 51"0 117°0 ** GRAVEL. VOLUME (CU.YDS. ) 54.� � 49.2 86"7 TANK SIZE (GALS) .1,000.0 ** 1,0O8.0 ** 1r000.0 ** SOIL RATING (SQ.FT./BR) 362 290 362 ** GRAVEL LENGTH > 75 FT. REQUIRE MULl[IPLE RUNS (NOT EXCEEDING 75 FT. EACH) ** TANK MUST HAVE Al[ LEAST TWO COMPARTMENTS certify that: ' 1 I am familiar with th " am ar w e requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of' A�aska. 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of' this permit, 3° I will adhere to all MOA and State of' Alaska requirements f'or the set back - distances from any existing wellv 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 ma;imum of 3 bedrooms and any enlargement will require an additional permit. IFA LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, [HEN (1) AN ELECTRICAL PERMIT AND INSPECTION M|ST BE OBTAINED; (2) AS-0UILTS 4ILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE -LECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. 3IGNED IFIF"LICA)VT RAY IER SHASTA CONSTv INC. DATE. �SSUE ° "^ DATE: �� � ' . �F=- ��P4 C--,.- F-9 C3 IF`7,�z n--. V=- [E= DEPARTMENT OF HEALTH AND -~ENVIRONMENTAL PROTECTION 825 L STREET; ANCHORAGE, AK 99501 264-472O �IN R 11 'T'E- ��111.41 E irFR - ID E.:7�� ��IF;,. Ph :1 T PERMIT NO: DATE ISSUED: APPLICANT: ADDRESS: CONTACT PHONE: LEGAL DE -:SCRIP: LOT SIZE: MAX BEDROOMS: 84O852 10/05/84 SHASTA CONSTRUCTION 200 W 34TH #556 ANCHORAGE, AK 99503 268-8725 SUBDIVI19I(.DN: SAMPSON ESTATES LOT: 21 SECTION: 3 TOWNSHIP: `15N RANGE: 1W 42306 (SQ"FT" OR ACRES) 3 Listed below areth ti e op ons available to you in designing system" Chocjse the option that best fits s your site. _..... �~��!F-' ^ �..... 1-D,UZ-7.13 DEPTA TO PIPE BOTTOM <Fr ) 4 ` /^ GRAVEL DEPTH (FT ) . o] " � O 4 0 " TOTAL DEPTH (FT") 11.0 0 5 4"5 GRAVEL WIDTH (FT ) � -�r���' " " GRAVEL LENGTH (FT") �^ 78,3 ** 26 � 51"O GRAVEL VOLUME (CU.YDS.) 54.2 49`2 TANK SIZE (GALS" 1;000^0 ** 1 000"0 ** ^ SOIL RATING (SQ FT /BR) . . 362 � ' 290 ` �* GRAVELENGTH > 75 FT" REQUIRES MULTIPLE RUNS L ** TANK MUST HAVE ATLEAST TWO COMPARTMENTS m BLOCK: 4 your septic 4.0 3"5 /.5 5"0 117"0 ** 86"7 1,000"0 ** 362 (NOT EXCEEDING 75 FT" EACH) o I cery that: 1" I am familiar with the requirements for on-site sewers and wells as �et forth by the Municipality of Anchorage (MOA} and the State o� Alaska� 2. I will instail the system in accordance wi'Lh all MOA d d l" and in`compliance with the design criteria o, this pecoies an 'egu ations� 3. I will adhere to all MOA and State of Alaska req' irem'"t~"for the set back distances �rom any existino �ell wa�tewater di ~ l^~t '' , sposa sys em or public sewerage system on this or any adjacent or nearby lot, 4. I understand that this permit is v�lid �or a maximum o{ 3 bedrooms and any enlargement will require an additional permit" � IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES;, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2> 'AS -Bb.] S WILL NOT BE APPROVED WITHOUT AN ELECTR L �CAISPECTION REPORT� /^' AND (3) E ELECTRICAL WORK MUST BE DONE BY A LICENSED E1 ECTRICIAN^ SIGNED ` DATE: _� APPLTC�N T: SHA�TA CO�c�R.CTT0\ ISSUED BYy0 . DATE:^ ~..... .... ~~--~_~�_.~�.~.L_��� SOILS LOG MUNICIPALITY OF ANCHORAGE • ar DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: S,l�-5-;;'� DATE PERFORMED: la /-4' LEGAL DESCRIPTION:G-f ( ��7 fil J�is-i�.S�+ L—,)^"�'K7/4J' 7- I vt PAH I SLOPE SITE PLAN 1 Date Gross Time 000 Depth to Water Net Drop 2 0�0 -2 116 �,,, Sia — n oo. 3 s Q 0 4 0. o d � 5 .0 6 7 v P 8 II / 0 10- 12 12 13 d ' 14 G° c� U C- Gol s� y� �, /,,.c4 /-4-jz- 15 fJork 16 4':`1-1 ') 18, r' �. 2225 -Ex 19 1 iJE '5, 1371 s WAS GROUND WATERS S ENCOUNTERED? /!/ L O P IF YES, AT WHAT E DEPTH? Reading Date Gross Time Net Time Depth to Water Net Drop -2 116 �,,, Sia — n 6-��Z16 / 111/G }I Ill ��•';. °, �,_._'��;A�,",��'N PERCOLATION RATE 46L��/�grnL/j�!� �((minutes/inch) •r.. /� TEST RUN BETWEEN FT AND FT COMMENTS '�j G(r4 - t� � ,. �YocJkYl 6 C� Slo,r}� 4 74- Yc_.f7�' /o ��P` L'-2 "w - PERFORMED BY: Aylc� i CERTIFIED BY: '. � DA 72-008 (6/79) U MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services MU OF ANCHORAGE On -Site Services Section ENVI AL SERVICES DfYISION P.O. Box 196650 Anchorage, Alaska 99519-6650 JUN 7 �996 343-4744 CERTIFICATE OF HEALTH AUTHORITY RECEIVED APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# �-411 -Al" HAA# �-AQ'�1 :f�2.a, 1. GENERAL INFORMATION Complete legal description Lot 21; Plock 4, Sampson Estates Location (site address or directions) 224" Snmpoon Drive Chuaiak, A" Property owner Dr. Anton Ji.rka Day phone 663-5300 Mailing address P.O. Box 671966 Chuc,ia;;, AK 99567 Lending agency Day phone Mailing add Agent Kathy Olmstead/ Remax of ^,r 1 e Diver Day phone 691-42.00 Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well 7 f 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. 1191) Front MOA 121 5. 6. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms .and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S& S ENGINEERING Phone y 4 7 17034 Eagle Rrver oop oa o. Address By: Engineer's signature DHHS SIGNATURE 3 X Approved for Disapproved. Conditional approval for Additional Comments bedrooms. Date -7 l l 6 pF At n '� •ROBERT C. COW AN C[ .. j:t y�Y' r1• .�� 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 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) Bacx MOA 921 A i Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICF.iE C E I V ED o0*a Environmental Services Division 1C 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) JUt 47 f4996 Health Authority Approval Checklist Municipality of Anchorage Dept. Health &Human Services Legal Description: LQ -c 2t i 6Lor-K 4 SAW1Fso�J Parcel I.D.: A. WELL DATA Well type kiv A- a If A, B, or C, attach ADEC letter. ADEC water system number Log present &N) Date completed i2_841 Total depth -20, Sanitary seal N) Date of test Cased to Y FROM WELL LOG 12-8q Static water level iifi K Well production WATER SAMPLE RESULTS: Z© Casing height (above ground) IZ Wires properly protected ON) Y AT INSPECTION 17c) g.p.m. 9.p -m. Coliform Nitrate 19- - / - 2.8 Other bacteria _-6- Date of sample: 5 Z S 16 �- 6/3/16 Collected by: � + _,!� i✓ At G, N &p_ v- t ni c B. SEPTIC/HOLDING TANK DATA Date installed 5 31 - 8(- Tank size to Number of Compartments Z Cleanouts (DI) `1 Foundation cleanout% 1) Y Depression (Y4&) N High water alarm (Y/6 hl Date of Pumping 5x`28-- It G Pumper C. ABSORPTION FIELD DATA Date installed - 5 - 711 - $ (, Soil rating (g.p.d./W or ft2/bdrm) .System type TkeA c N Length S8 i Width . -2 - 6 Gravel thickness below pipe f Total depth t I + Effective absorption area 1612- Monitoring Tube present ON) `� Depression over field (Ya N Date of adequacy test e `16 - Results as Fail) PAsS For 3 bedrooms Fluid depth in absorption field before test (in.); q5 i{ Immediately after&!® gal. water added (in.): 70 Fluid depth ' (ins) Minutes later: 45-D Absorption rate = 4IS D/f g.p,d, Peroxide treatment(past 12 months %a tic.)aj If yes, give date (r t 72-026 (Rev. 3/96)" D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level E. SEPARATION DISTANCES Size in gallons "Pum a at" *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Se tic holding tank on lot 1 O°I Absorption field on lot f O© 1 + On adjacent lots On adjacent lots "Pump off" level at" Ioo14- /dot f Public sewer main N JA Public sewer manhole/cleanout Sewer /septic service line Lift station C - SEPARATION DISTANCES FROM SE�HOLDING TANK ON LOT TO: I I Foundation 5 P Property line 10 -4' Absorption field Water main/service line to 14- Surface water/drainage 1001 "f Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: I I Property line 16 Building foundation f d "I Water main/service line 10 1 Surface water ) DO 1 4 Driveway, parking/vehicle storage area )00' t Curtain drain 0 11A, Wells on adjacent lots / a 01 f F ENGINEER'S CERTIFICATION I certify that l have determined thru field inspections and review of Municipal records th 4 in conformance with MPA "f I4A gv" elfin n effect on this date. ,y�............... r J Signature, V fi Engineer's Name v d,3¢x C. Date /7 1 ROBERT C. C01 t fm �{ s ' HAA Fee $ �U qq Waiver Fee $ _ Date of Payment /.6 Date of Payment Receipt Number �/03��7 ��� Receipt Number 72-026 (Rev. 3/96)* ns are MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES a 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. # CAS - C'� \ \ - Ql -� 1. GENERAL INFORMATION Complete legal description HAA# Q13�q_Qnlo6°) Lot 21; Block 4; Sampson Estates Subdivision Location (site address or directions) 99424 Sampson Drive Property owner Pet'pr ThurSt-on Day phone 688-6306 hm P.O. Box 1252, Chu iak, Alaska 99567 562-7378 wk Mailing address g Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 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 further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm 5 & 5 ENGINEERING Phone Address 17234 Eagle River Loop Road No. 204 casts 1 J1fes ; .., iaska 99577 Engineer's signature 6. D�SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for 0 Additional Comments Date 1 62— 3 —`tZ OF 4L����� m4,40 a.„we,eeeo a :g .p d' r=, R�GER 3HAF'cR a �f J,'.a No. 215 4W bedrooms, with the following stipulations: 111TIC 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 X21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: fj/47MIt �(Parcel I.D. C�5�1 A. WELL DATA Well type 'a�%-_ If A, B, or C, attach ADEC letter Log present4WN) _ 4 Total depth Sanitary seal¢N'N) Date of test _ Static water level _ Well flow _ Pump level _ Date completed ADEC water system number V2_ - Driller t/!A�_-n(USoL-/ ?,o x t u Cased to Casing height 12 "- FROM WELL LOG 20 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 1 k Absorption field on lot I �__>C_>`_�` Public sewer main t_1 ( th, Sewer service line 2l -Ir- WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDING TANK DATA gNitrate Wires properly protectedQV�N) AT INSPECTION`S 1 LOtO i1-rE C7 m y 74. r_ g.p.m. g•I O V 1--(L. , C cry m < z r1 N M O O v d' m On adjacent lots ; On adjacent lots Public sewer manhole/cleanout N Petroleum tank j-1 P> 6 Z Other bacteria®^ Collected by: Date installed I- 6(a, Tank size I Compartments CleanoutsepVN) High water alarm (Y/N) Foundation cleanoutl-VN) Date of pumping 2 Z Depression (Y/ftp ^1 Alarm tested (Y/N) Pumper a12 S I `J"'P,"6 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Wells on lot 1 k ` On adjacent lots (� } Foundation To r t 1' F oyer y Ine Absorption field S -Water main/service I Surface water/drainage l t �d ,�_ � )k 10` -I- 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off' level at Cycles tested Surface water _ Date installed Soil rating � � �?— System type l -g`._," Length 4�1?1_ Width ZGravel thickness Total depth Total absorption- area 812 Cleanouts presentMN) — Depression over field (YLUP ' —= Date of adequacy test — Results,lfasa/fall) �� for Peroxide treatment (past 12 months) (Yj�W d�l� �LaJeW P -J If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 1 t57,-� -�- On adjacent lots 1 ter`- Property line_ To building foundation l ��k To existing or abandoned system on lot ) On adjacent lots k Cutbank � Water main/service line_ Surface water ��� "r Driveway, parking/vehicle storage area Curtain drain 10 �- rJ A l ,=� r—A-- bedrooms E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. 4 4i ®F 4E� S & S ENGINEERING �Opp,°°0000"Go, ®Q��®�� Signature 17034 Eagle River Loop Road No. 204 �� �'® o�'dvp A VA Eagle River, Alaska 99577 _9 % 2 Engineer's Name Date 1©- `5 -1 -1 - HAA Fee $ Date of Payment 6 Receipt Number 2 41,9-� 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number ROGER J. PK No. 8215 ;°ROFESSIO0� 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 Parcell.D.# HAA# 1 i��lnlc��i 1. GENERAL INFORMATION Complete legal description Lot 21; Btock 4; Sampson E3tates Subdivision; 2. Location (site address or directions) 22424 Sampson D i.ve Property owner cam Q Annette Mg N�cijzl Day phone Mailing address Lending agency Day phone Mailing address Agent Pete (ztdiof TARGET, Day phone. 694-2388 Address17�fe R,('veA I aan Road Eagep Rivohi AL 99577 Unless otherwise requested, HAA. will be held for pickup. NUMBER OF BEDROOMS: 3 \' 3. TYPE OF WATER SUPPLY: Individual well XX 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 Xx 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. 6. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm -G Phone ��7y 5; a y ` Address 17034 Eagle River Loop Road No. 204 Eagle W1 Engineer's signature DHHS SIGNATURE Approved for _ bedrooms. Disapproved. Conditional approval for Additional Comments Date bedrooms, with the following stipulations: By: 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 purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA a21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: C6t_'4-4 as Parcel LD A. WELL DATA Well type�+-1oN tOJybKt if A, B, or C, attach ADEC letter. ADEC water system number Log present &N) V Date completed IZ-84 DrillerL�DrL�,J.asa�4 7P�t�t to,v, Total depth ZO t I Cased to Z,-� x t Casing height 1Z'% A. - Sanitary seal ( rS�N)y Wires properly protected &N)y FROM WELL LOG AT INSPECTION Date of test 12 —134 4— I v -�11 Static water level VrJ K1,1o\A1A 1 L'PUPt Ar - Well flow 4C2. O g.p.m. S:'E g.p.m. Pump level yk,4'Ao) SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot toot ; On adjacent lots xnc>� - Absorption field on lot Ivo" ; On adjacent lots Ioc>' { Public sewer main Public sewer manhole/cleanout Public sewer service line 'yln Petroleum tank X14 WATER SAMPLE RESULTS: Coliform (D Goi.•llooatl Nitrate 1 . 2 M /.i Other bacteria 7,L 0t.iG Date of sample: Collected by: S & S ENGIN99RING 17034 Eagle River Loop Road No. 204 B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99,577 Date installed 5-31- pule Tank size - 1 L'Y�b Compartments 2- Cleanouts (SY N) y Foundation cleanout &N) T— Depression (ytfly �s High water alarm (Y& to Alarm tested (Y/N) t"'A Date of pumping 4-10-`11 i;>0r'kqt,..Ilq SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I0C> t .a— On adjacent lots I C::� "- Foundation Z5 1 *11 To property line iot F Absorption field 1h Water main/service line 1(-,>, r Surface water/drainage \ Op II 72-026(Rev.3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed �S. . allons Vent(Y/N) High water alarm level " level at Meets MOA electrical codes (Y/ SEPARATIOIjI,9i5' ANCE FROM LIFT STATION TO: lot D. ABSORPTION FIELD DATA On adjacent lots Manufacturer Manhole/Access (Y/N) level at tested Surface water Date installed S .b to —Soilrating `� 9 Zto9 /6V- System type 'riz_r .-1 G els Length S8 � Width 2.5, Gravel thickness. " 7t Total depth 1 1 Total absorption area 7-4 Cleanouts presentCVN) _J Depression over field (Y/6, - ►� Date of adequacytest t0 -c1 1 Results as ail) 0F for 'rAggr 1' 3� bedrooms Peroxide treatment (past 12 months) (Y© C 1Alob y ► !\ If yes, give date rA /A SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot Iod iJr- On adjacent lots l oc> 1, Property line 10 k To building foundation I } To existing or abandoned system on lot On adjacent lots 330 } Cutbank �4/6r Water main/service line 1D'"`' Surface water leo "r Driveway, parking/vehicle storage area 3 0 Curtain drain -LPv E. ENGINEER'S CERTIFICATION 1 certify that l have checked, verified, or conformed to all MOA and HAA guidelines in effect o, 170'34 Cads: River Loop Road No. aQ4 I Signature Eagle River Alaska 9957.7 � g n Engineer's Name c' ;�` , , C f 0-te of this inspection. ejr 2= N Date �^/ 7/!2 z /7D a. HAA Fee $ Wai F $ Date of Payment Receipt Number 6,5,z2-7_(o/j2 6114, 72-026 (Rev. 3/91) Back MOA 21 ver ee. Date of Payment Receipt Number 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 1uty 16, 1986 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 21; Mock 4; Sarnpson E6tate-5 2. Location (address or directions) (b) Applicant Name Tim Fenton Telephone: Home Business 563-8236 Applicant Address 2085 CatnpbeU P2aee, Aneh.onage, Ata-ska 99547 (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution L4S'1C4 6VI, 4. IJ&Aj � Telephone / — Address (e) Real Estate Company and Agent Address Telephone ((,,D (f) o the HAA to the following address: S 9 S EnqineVtiykq Ea .2e. Rauelt Ata6ka 99577 TYPE OF RESIDENCE Single -Family In Multi -Family ❑ Number of Bedrooms 3 Other 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 10 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. 72-025 (11184) Page 1 of 2 5. ENGINEERING FIRM PROVIDIK NSPECTIONS, TESTS, FILE SEARCH, D& AND INFORMATION, As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Telephone - Z� % % Address JUL 1 81986 Date , �.w 6. DHEP APPROVAL -s¢� Approved for bedrooms by (/ Date Approved —--- Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 „ n,g .. . lyltlNICIPAEIiY Or AtJ%" PALITY OF ANCHORAGE (MOA) MPT, OF HE-ALTtHIKALTH AUTHORITY APPROVAL (HAA) UNIRONI TAL PRBE '9,'IIECKLIST - FEBRUARY 1984 264-4720 PAUL 2 1 '186 RECEIVED A. WELL DATA Well Classification _ 5 Well Log PresentcY *- Total Depth ZoCased Static Water Level Legal Description: L -Z- > `-t 5A, -r -x-0" Fr-rlc If A, B, C, D.E.C. Approved (Y/N) Date Completed I Z '- g Yield v Za t t Depth of Grouting Pump Set At A Casing Height Above Ground IZN Electrical Wiring in Conduit/P47— Sanitary Seal on Casingow Depression Around Wellhead -(?fes Separation Distances from Well: r To Septic/Holding Tank on Lot (� + ; On Adjoining Lots 1 b � a - To Nearest Edge of Absorption Field on Lot (� t ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer tF- CleanouUManhole r To Nearest Sewer Service Line on Lot �`S Water Sample Collected by Water Sample Test Results Comments �� st�t�r�2trvs ;Date B. SEPTIC/HOLDING TANK DATA 6 Date Installed -3!-86 Size 104 No. of Compartments Standpipes6q< Air -tight CapsLf iW)' Foundation CleanouE9/W Depression over Tank OV Pumping/Maintenance Contract on File (Y/N) Holding Tank High -Water Alarm (Y/N) Qate Last Pumped A/ /,-f,4- ; for Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well �b d To Building Foundation Z� �. i To Property Line �. t To Disposal Field To Water-Maio/Service Line Course Comments Page 1 of 2 72-026(11/84) 3a r.J To Stream, Pond, Lake, or Major Drainage i C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Z (. 91b�` Type of System Designf`(� Date Installed ' 3 — a� Length of Field �g , ✓ Width of Field Z��t Depth of Field Gravel Bed Thickness Square Feet of Absorption Area Z Standpipes Presenlay� Depression over Field --(• t Date of Last Adequacy Test Results of Last Adequacy Test Separation. Distance from Absorption Field: t O � i• �` To Water -Supply Well To Building Foundation Lot To Water Pd}aiir/Service Line 3a z To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION f To Property Line Z) To Existing or Abandoned System on On Adjoining Lots To Cutbank (if present) Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at "Pump Off' Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify thatSeL�Ei`�r conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed —SSR n 196X Date i ! 8 Company FAGI E RIVER, A -K 99577MOA No.A Receipt No. � Ob1 .. dp0� �"' • : ,.•• •:.e, °��`i' Date of Payment i'a1- '• CC • '» Amount: $ , ail." .......... buw A. 111*%? 191. iK.t 4 Page 2 of 2 72-026 (ivaa)