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Home My WebLink AboutSCIMITAR #3 BLK 1 LT 5 Onsite File Scimitar # 3 Block 1 Lot 5 #051 - 132 - 72 Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 1 ON -SITE WASTEWATER INSPECTION REPORT Permit Number: OSP 181370 PID Number: 051 132 72 Dwelling: 9 Single Family (SF) El with ADU El Duplex (D) n Two Single Family Project: n New nN Upgrade Name COBB ABSORPTION FIELD n Deep Trench E] Wide Trench n Bed n Mound Site Address 19766 BELDLIQUE El Other Phone [Number of Bedrooms Soil Rating depth from original grade 13 GPD/SF ITotal Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot SCIMITAR#3 BLOCK 1 LOT 5 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width 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 Ft2 Ft. Well 100 — — +50 TANK N Septic [:1 S.T.E.P. El Holding El Other Manufacturer GREER Capacity 1000 Gal. Surface Water +100 — — Material Number of compartments Lot Line +10 - - NA POLY 2 Foundation +10 - LIFT STATION Manufacturer Capacity Remarks TANK REPLACEMENT ONLY. Gal. PRE -MANHOLE POLY TANK Alarm location Electrical installed by Installer PIPE MATERIAL House to tank EXIST d,ainfieldTank to 3034 GUARANTEED SVCS Drainfield EXIST CO/MT 3034 Inspector C&M ENGINEERING BENCH MARK (Assumed elevation) 100 ft Inspedatection Zia 1st 10/25/18 10/26/18 s: Location and description 3rd 4th SIDEWALK BY TANK ON -SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp F Akq Conditional Approval: Date S� co 49 TH ... .. ..... •I;HARLES Septic System G BALZARIUI Approved Date CE-13854 .. Oiw 0111E1116W Note: this approval does not include well permit requirements. 3/1012K- CHARLES G BALZARINI CE-13854R E G I S TEREDPROFE S S I O N A L E N GINEER 8/1/24 LOT 33 \ \ BLOCK 2 \ LOT 32 BLOCK 2 h 00 LOT 6 BLOCK 1 iN \ 24 30" OF e W 239 28RlNGS. 24* 6,51 0.8' / / LL 45.3< � � LOT BLOC] HI 100' WELL RADIUS P LOT 4 BLOCK 1 30, l I ASPLS MORTGAGE LOCATION SURVEY NOTES: NO TITLE REPORT WAS PERFORMED FOR THIS SURVEY, EASEMENTS SHOWN PER THE RECORD PLAT. THERE MAY BE ADDITIONAL EASEMENTS NOT SHOWN HEREON. THIS MORTGAGE LOCATION SURVEY HAS BEEN PREPARED IN ACCORDANCE WITH ASPLS MORTGAGE LOCATION SURVEY STANDARDS. IT IS A REPRESENTATION OF THE CONDITIONS THAT WERE FOUND AT THE TIME OF THE SURVEY. THIS SURVEY DOES NOT CONSTITUTE A BOUNDARY SURVEY AND IS SUBJECT TO ANY INACCURACIES THAT A SUBSEQUENT BOUNDARY SURVEY MAY DISCLOSE. THE INFORMATION CONTAINED IN THIS DRAWING SHALL NOT BE USED TO ESTABLISH ANY FENCE, STRUCTURE, OR OTHER IMPROVEMENTS. UNLESS GROSS NEGLIGENCE IS DISCOVERED, THE LIABILITY EXTENT OF THE PREPARER SHALL BE LIMITED TO THE AMOUNT OF FEES COLLECTED FOR SERVICES IN PREPARATION OF THIS PRODUCT. LEGEND () RECORD DATA PER PLAT #80-51 O FOUND 5/8" REBAR, NO CAP GRAVEL DRIVEWAY -� EDGE OF ASPHALT FENCE — E E — OVERHEAD UTILITIES _ P POWER POLE 0 UTILITY PEDESTAL SEPTIC PIPE WELL DECK BRICK PAVERS 0' 30' 60' SCALE: 1" = 30 FEET (11"X17") �. OF A�gsl j *'••49TTH ... *1 ••Ryan G. Johnson; No 192159 711312024•'c,�AW AS -BUILT OF: �,,JN��PAIITY OF, MUNICIPALITY OF ANCHORAGE rnent On-Site Water&Wastewater Program \o` S� ® aRr PO Box 196650 4700 Elmore Road ^ Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 ,. 1 S `r http://www.muni.org/onsite �+ \ \.__ I cp'ittm+•nt 9NCHp RNC' On-Site Wastewater Disposal System Permit Permit Number: OSP181370 Effective Date: 10/17/2018 Work Type: SepticTank Upgrade Expiration Date: 10/17/2019 Tax Code Number: 05113272000 Site Legal Address: SCIMITAR#3 BLK 1 LT 5 G:1261 Site Mailing Address: 19766 BELDUQUE CT, Chugiak Owner: COBB GARDNER L & KATHY L Lot Size in Sq Ft: 40027 Design Engineer: C & M Engineering Total Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field Ei Septic Tank 0 Holding Tank 0 Privy 0 Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72)and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: - Date: 6 (L 4 Issued By: ,II I A �-1, Date: 011,020 /67 Municipality of Anchorage °';.' t `.� Depart nivnt P.O. Box 196650 • 4700 Elmore Road Anchorage, Alaska 99519-6650 ® (907) 343-7904 ® Fax (907) 343-7997 http://www.muni.orq/Onsite • Development Services Department On-Site Water and Wastewater Section **** VARIANCE/WAIVER REVIEW **** Waiver#: OSV181079 COSA#: Permit#: OSP181370 PID#: 051-132-72 Legal Description: Scimitar#3 Block 1 Lot 5 Engineer: Charles Balzarini Applicant: Gardner Cobb Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the property line has been approved. The approved separation distance is 1.8 feet. This waiver approval applies to the existing absorption field only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. Waiver is Granted: X Waiver is not Granted: l0 17 )017 Approved by: fate.a Date: � Name of Reviewer **** VARIANCE/WAIVER REVIEW **** PLd*ftJS MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section — Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051 132 72 Property owner(s) Gardner Cobb Day phone Mailing address 19766 Belduque Site address 9766 Belduque Legal description (Sub'd., Block & Lot) Scimitar#3 Block 1 Lot 5 Legal description (Township, Range & Section) Lot Size 40,027 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (Z all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑ (w/wo ADU) Septic Tank Upgrade n Duplex (D) [ Holding Tank ❑ Renewal Li Multiple Dwellings ❑ Privy U (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: drainfield to lot line Distance: 1.8' I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. Charles Balzarini, C&M Engineering (Signature of property owner or authorized agent) Permit/Rush Fees: 2. 15 Waiver Fees: 021� Date of Payment: /n l[5118 Date of Payment: io/l51I2? Receipt Number: l a,'S9 aZI3 Receipt Number: Oa59�0 Permit No. QS PJ7I39O Waiver No. O5V I ? 10? G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 10/10/2018 RE: Proposed Septic System Modification for Scimitar#3 B1 L5 Dear Reviewer, The above referenced property is currently served by a 3 bedroom septic system installed in 1980s. The 1000 gallon tank has failed and is in need of immediate replacement. We are proposing that the existing tank be replaced with a new 1000 gallon tank constructed and installed in accordance with MOA requirements. A polyethylene tank is recommended. As shown on the plan, the tank will be greater than 10’ from the house foundation. The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover. The repair shall be performed by a moa certified installer in accordance with MOA requirements. The engineer will inspect the tank before backfilling. Repair of the proposed system will not negatively impact adjacent lots. We are requesting that a waiver be granted for the existing leachfield to the property line. The system has been in place for 35 years with no apparent impacts on the adjacent lots. Upon completion of the installation, a record drawing will be submitted showing the location of the new tank, leachfield, well, and other applicable features. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181370, Rebecca Carroll, 10/17/18 CHARLES G BALZARINI CE-13854R EGISTEREDPROFE S S I O N ALENGINEER10/10/18 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181370, Rebecca Carroll, 10/17/18 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 0* ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME--., -ca �.� PHONE W y i!.( �j ❑ UPGRADE MAI LING ADDRF / l6 LEGAL DESCRIPTION t-ur i" 1 7W le- JF, I LOCATION NO. OF BEDROOMS DISTANCE Well Absorption a, Dwelling /� PERMIT NO. /a U TO: Oe _Y H Za Manufacturer fie' AMR �J9/�/L Ma ial 7- No. of compartments t Z LU I.- i -' � N Lio. a acity in gallons IF HOMEMADE:Inside length Width Liquid th dep Y DISTANCE TO: Well _ Dwelling PERMIT NO. , S= FQ- Manufacturer Material Liquid capacity in gallons DISTANCE TO:Lu Well Foundation Nearest lot li e / f PERMIT NO. 1 n, = zNo. of lines Length of each line j Total leng off/ lines/' Trench wid D'•stance betweennj e " F LU /'Finches � ¢ Top of tile to finish grade / Material beneath tile J- ,;,, .-Total ((,z['J effectiybsprptionnAa inches Length Width Depth PERMIT NO. Lu Q F- Type of crib Crib diameter rib depth Total effective absorption area as LU Lu DISTANCE TO: Well Building foundation Nearest lot line J Class /q� Depth J]'�ill Distance to lot line PERMIT NO. 7 / w � DISTANCE TO: Building foundation Sewer line Septic tank Absorption areas) OTHER PIPE MATERIALS 1 vc SOI L TEST RATI INSTALLER REMARKS r rA 3 e' n-, vt)lpsr; A Alo, i9.�t. " YS' -v6" Z APP- OVED ATE LEGAL !1101I WENRI Ilia SRB 193X 72- 7 (Rev. 3/78) r Permit Department fvHealth -and Environments ?rotection 825 Street, Anchorage, AK. � 9501 264-4720%ter # # HANDWRITTEN PERMIT #L WELL ANDIOR ON-SITE SEWER PERMIT`' Applicant: helue 0 Mailing Address Location: Phone Number: Legal Description:/Z/ Sc.cs99c �G c. Lot Size: Type of Soil Absorption System Is: Trench: X_ Drainfield: _ Seepage Bed: Holdin Maximum Number of Bedrooms: Soil Rating(sq.ft/br) g Tank: The Required Size of the Soil Absorption System Is: DEPTH LENGTH 2 4� _ GRAVEL DEPTH S WIDTH ItII The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = 1Z)dQ GALLONS # Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. # # # TWO(Z) INSPECTIONS ARE REQUIRED # # # Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feel for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 3 3 I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of .Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the esidence is remodeled to i Elude more that 3 bedro m . Signed: GIG Issued by: Applicant Date: SWP/024(1/81) MUNICIPALITY OF ANCHORAGE +.e DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED LEGAL DESCRIPTION: CI�EPTH Gi 1 � 2 b 3 ( b 4 5 6- 7 7 8 N U , 9- 10- '( 10 C /tel / X SOILS LOG ❑ PERCOLATION TEST DATE PERFORMED:�j SLOPE SITE PLAN C WAS GROUND WATERS 11 �% ENCOUNTERED? /U 0 L d O \ P 12 d IF YES, AT WHAT E L DEPTH? 13 . 14- Gross Net Depth to Net 5 15- Date Time Time Water Drop 16- 17 17dz a, < x itctberP J'�. Sih�f4td n 4 18 a ;"il Nc. t-Sw7-G 9� fl �Jai i 20 COMMENTS PERFORMED BY: 72-008 (6/79) PERCOLATION RATE TEST RUN BETWEEN FT AND CERTIFIED (minutes/inch) DATE: Gross Net Depth to Net Reading Date Time Time Water Drop T f• A fl i PERCOLATION RATE TEST RUN BETWEEN FT AND CERTIFIED (minutes/inch) DATE: LOCATION OF WELL (Please complete either la, Ib or Ic.) WATER—WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological & Geophysical Surveys Drilling Permit No. A.D.L. No. la. Borough Subdivision - Lot Block Ib. 1/4 gtrs. Section No. Township N Range E[3 Meridian AnCh Scum �'a2 5 _of—of_of— SE] WE ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELL: Zk. Id -u Ml?fie" P.O. Box 1" Address: ChucgiA A. 99567 Street AddressandArea of Well Location o 2. WELL LOG Feet Belw - Surface 4. WEL Li,_[PTH: (final) J 5. DAT/E OF COM / V M ateriol Ty,Dy TAP Bot= }L i c 6, Q Cabla fool aRatary C] Driven El Dug ❑ Auger O Jetted O Bored ❑ Other: Rdg�7 9Aeen and /Led jAeen and C/PAC >U � � 7.USE: laDomestic C] Public Supply � Industry C] irrigation E] Recharge O Commerical p Test Well ❑ Other: /Leen and 9Aa /UJC (U[ cfz 30 mateA S. CAS G+ D Threaded Welded diam. In. to 75 ft. Depth Weight 17 lbs./ fI. diam, in. to ft. Depth Stickup_ ft. jet 18"E p/UNI & 9. FINISH OF WELL: Type: Diameter: uEr'.T`P ENTAL PROTECTIO Slot/Mesh Size: Length: Set between ft. and ft. Backfilling Gravel pack L O 1,a 10. STATIC WATER LEVEL: ft. Above or C] Below land surface Date . Equipment used: I1. PUMPING LEVEL below land surface and YIELD ft. after hrs. pumping - g.p.m. ft. - after hrs. pumping g.p.m. 12.GROUTING Well Grouted: O Yes F] No Material: ❑ Neat Cement E] Other: 13. PUMP: (if available) HP Length of Drop Pipe ft. capacity g.p.m. Subm. Jet O Centrifical Other 14.REMARKS: %/jyj(uc;t-[An Ol ? j(PM 16. WATER WELL CONTRACTORS CERTIFICATION: 15. Wafer Temperature 0 F E] C _° This we [led 1�R Ur,,Mp �ri_sdictlon and this report is true tog p b�asjja my knowledge and belief; 1�V�1 jU—.Contract l�LlI�l�1,Jgi�G.Ore¢{OBxuUsi [•o¢;;,C'I.ANp License Number g(,7e era /�iVe�, . [ ��(J (i`I` ' Address: _ f �/ 1 Signed:✓%'1(t'Zr .,ry..1�✓ �1 /r -;t l�?�lT.._----.,__. Date: ) J Authorized Repress ofive Form 02-WWR (11/81) - Copy Distribution: WHITE - State OGGS, PINK - Driller, CANARY- Customer Certificate of On -Site Systems Approval Parcel I.D. 051-132-72 Legal description SCIMITAR #3 BILK 1 LT 5 Site address 19766 BELDUQUE CT Chugiak AK Current property owner(s) COBB Expiration Date: X The On -site system(s) is/are approved for 3 bedrooms Conditional approval for Comments or advisories: 8/7/2025 bedrooms, with the following stipulations: Original Certificate Date: 8/23/2024 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory X Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 MUNICIPALITY -OF ANCHORAGE lzu.5VA v v v Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax- 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 05113272000 Complete legal description SCIMITAR #3 BLOCK 1 LOT 5 Location (site address) 19766 BELIDUQUE CT Current property owner(s) COBB 2. ON -SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 3. TYPE OF WATER SUPPLY: RN Private Well [] Private Well serving 2 dwelling units 1771 Private Well serving 3+ dwelling units R Community Well or Public r_1 Water Storage 4. TYPE OF WASTEWATER DISPOSAL: X Private Septic E] Private Septic serving 2 dwelling units F71 Holding Tank El Community Septic or Public Sewer 5. SEPTIC TANK: OR Steel 1771 Plastic R Concrete R Fiberglass Age 6 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: 0 AWWTS R Bed RN Deep Trench 0 Wide Trench R Seepage Pit Waiver request for: Expedited review requested: r_1 Distance: By applying for this entitlement, this property is subject to inspection by municipal On -site staff to verify the accuracy of the information provided. COSA Fee $ Waiver Fee $ Date of Payment COSA# Q�C 'Zq 1-30-Z— Date of Payment Waiver # COSA Application —June 2022 MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT On -Site Water and Wastewater Section www.muni.org/onsite Well Water Advisory Certificate of On -Site Systems Approval # OSC241302 Subdivision: Scimitar #3, Block: 1, Lot: 5 907-343-7904 Fax: 343-7997 This well's productivity was determined to be.5 gallons per minute. The minimum well productivity required under (AMC 15.55) for a 3-bedroom residence is .31 gallons per minute or 150 gallons per day per bedroom. Although the subject well currently exceeds this minimum requirement, the production capacity can fluctuate and may be insufficient to meet your needs. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. 'A ai in M Addriess: 0.' Box 19,6650- ,,�pch��' Iaska,99519-6650 �www.mun rg:� 9 I 'I, � '. I I - - _1 1, 1 1_11 , �� COSA Checklist_June 2022 COSA Checklist Legal Description: Parcel ID: If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes go to bottom of effective. If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: COSA Checklist_June 2022 E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F.ENGINEER’S COMMENTS G.CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Phone Engineer’s Printed Name Date C&M ENGINEERING CHARLES BALZARINI, PE 8/11/24 `.v MUNICIPALITY OF ANCHORAGE AIICff�l6gj17y OFANCHO r DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTI07� IWN ENf.ALSER?4GE V DIVISION OF ENVIRONMENTAL HEALTH S DIVISION CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL 4" OF ON-SITE SEWER AND WATER FACILITYh �i9g� 264-4720 9t Application Date Mane 3 �1 8FD 1. GENERAL INFORMATION" (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 5; Stock 1; Sc,i.m.ita.)t 03 Location (address or directions) Tots oA h.iU on S.ieka D i.ve (b) Applicant Name Z.imbowen Telephone: Home Business Applicant Address (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder Lel ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Commonwea2.th We,6tenn Telephone Address Anchorage Ataska (e) Real Estate Company and Agent Anea Commonweal#h/Lost i. Long Address Eaqte R.fv ,k, A.lazka Telephone 194-9555 Nt (f) the HAA to the following address: 4 9 4 ENGINFFRING 17034 Fac Qo R,ivur LooP LooRoad, 4n.iy 04 Fa�gF_o Rjuea APaAba 99577 8uyen3 - Gandnen and Kathy Cobb Onder.ed by Lori Long 2. TYPE OF RESIDENCE Single -Family CN Multi-Family ❑ Other Number of Bedrooms 3 3. WATER SUPPLY Individual Well,Q] 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 Q 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 (1 1184) 5. ENGINEERING FIRM PROVIDL-A INSPECTIONS, TESTS, FILE SEARCH, D>,�a 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. S & S ENGINEERING Name of Firm Telephone RiverLoop eua Address Eagle River Alaska 94577 Date C_�5 - I/— 6. DHEP APPROVAL Approved for Approved ° . .4 i'CCD OOI Je9 a' ti•t'_ � 9Ss �w 0FESSI�' fln�et(3 bedrooms by e�� '�o * " �'"''`� Date Disapproved Conditional Terms of Conditional Approval cJhep 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) MUNIQIPALITY OF ANCHORAGE (M(>Fq f)F prtClF WLTH AUTHORITY APPROVAL (HAA) M�Nt�cvojt�F�* ISSN�"C)iECKLIST - FEBRUARY 1984 LJ A. WELL DATA Well Classification !a -S. P Legal Description. o � 5C_(AA1-7 k *'S If A, B, C, D.E.C. Approved (Y/N) Well Log Present &9N) Date Completed X:> r / — g 3 Yield er,- Total Depth 308 Cased to Depth of Grouting Static Water Level /I/ 9 Pump Set At f� Casing Height Above Ground — Electrical Wiring in Conduit &N) Separation Distances from Well: r, Sanitary Seal on Casing (O/N) Depression Around Wellhead (YA To Septic/Holding Tank on Lot /Lv7'L ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot 10014 ; On Adjoining Lots _ T N arest Public Sewer Line To Nearest Public Sewer o e / Cleanout/Manhole &�� To Nearest Sewer Service Line on Lot ZS { Water Sample Collected by S `f S N ln�NcZ �( � ; Date ?"-sem Water Sample Test Results Comments a_LL Y/' L.� C��c9�ML� D'`! 3�5�8� 1CP2 �4��r B. SEPTIC/HOLDING TANK DATA Date Installed Size /ooD No. of Compartments Standpipes ('/ ) Air -tight Caps (�DN) Foundation Cleanout (&N) Depression over Tank (Y/ODate Last Pumped Pumping/Maintenance Contract on File (Y/N) IJIA ; for Holding Tank High -Water Alarm (Y No tel/ Temporary Holding Tank Permit (Y/' Separation Distances from Septic/Holding Tank To Water -Supply Well /oo To Property Line ys To Water Main/Service Line /O 14 Course NIA Comments Page 1 of 2 72-026(11/84) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Str to �S� Type of System Design 1 Date Installed '57 Length of Field Z � Width of Field 3 �r Depth of Field q Gravel Bed Thickness Square Feet of Absorption Area Z1fly [h Standpipes PresentoM Depression over Field (Y1 Results of Last Adequacy Test J1 Date of Last Adequacy Test S� s, PAC y F-4w� 3 32 Separation Distance from Absorption Field: To Water -Supply Well /co r`{ To Property Line 26 / r To Building Foundation Z2 To Existing or Abandoned System on Lot AJIA On Adjoining Lots yU To Water Main/Service Line /017` Tgnutbank (if present) _NJ14 To Stream/Pond/Lake/or Major Drainage Course (/� 1 To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed 4 / Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at "Pump Off' Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certify that I have checked verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspecfio—n_� S & S ENCINEERINd; Signed17034_15"le River Leo Ro d4j"(Ppte c/ Comppgla River, Alaska 99577 MOA No. a 6 —�� 1 Receipt No.�t_�/ �G Date of Payment ! 0"4O Amount: $ 406 Page 2 of 2 72-026 (11/84) MUNICIPALITY OF ANCHORAGE D:CVISION OF ENVIRONMENTAL HEALTH DEPARDMEN'T OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CEI -M FICATE 1, General Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicants Name Applicants Addr (c) Applicant is (check one) Lending Institution Owrer/builder�; Buyer ; Other (explain);_ -- (d) Lending Institution Address (e) Real Estate Co. & Agent Address /G)D /'ui Telephore 2. Type of Residence Single -Family. Multi -Family Other (describe) Number of Bedreoms L 3. water Supply Individual wellft� Cowunity Public X Note: If con=nity X11 system, must have written confirmation from the State Department of Environmertal Conservation attesting to the legality and s atus. Is the well adequate for the number of bedcocans specified in this HAA ( /N) 4. Sewage Disposal Onsite Public F,::j Community Holding Tank i Is the wastewater disposal system adequate for the ri mber of bedrocros (Page 1 of 21 2-15-34 I 5. Enrr- n_eering Firm Providing Inspections, Teets, Lata and Information I certify thwqave checked, verified, or conformed to all MOA HAA Guidelirrns in effect on _ Q da_ fi inspection. Si re �� l g � "' � �Date Natr2 _1' irm Tel.ephore Address _ as i!`! [v 'a t n�s �"`. Signed by ego e Date _ a r • 7-8 (ENGINEER SEAL) `PBq"$ 6.DHEP Approval Approved for = bedrooms By cl2._-yc_ Dclte J Approw)` __-) Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Environmental Protection does not guarantee the continued satisfactory performance of the water supply and/or the wastewater disposal system. This approval indicates that, as of the validation date shown above, based on the data and information furnished by an engineer registered in the State of Alaska, the water supply and wastewater disposal system is safe and func- tional for the number of bedreoms and type of structure indicated. (DHEP SEAL) O 7. Mail the HAA to the following address: KB2/d5/s [Page 2 of 21 2-•1584 A. MUNICIPALITY OF ANC.`iOP.AGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION APR 710 'lou' WELL DATA RECEIVED Well Classifica.tio� If A, B. or C. D.E.C. Approved(Y/N/_ a� Well Log Presen ( j Dateleted /��`T / /j Yielder ' 77- Total Depth Cased to % � Depth of Grouting �— Static Water Level Pump Set At LL Casing Height Above Ground % / Sanitary Seal on Casin(/�) Electrical Wiring in Conduit (xz Depression Around Wellhead 6( ) Separation Distances from Well: To Septic/Hcldi;ng Tank on Lot /00 ; On Adjoining Lots /t 7 - To Nearest Edge of Absorption Field on Lot - ; On Adjoining Lots To Nearest Public Sew rLire }� %� To Nearest Public Sewer Cleanout/Manhole /I VTo Nearest Sewer Service Line on Loth , L Water Sample Collected By ��1��G1E'� /. ; Arte /ZZ�' Water Sample Test Results B. SEPTIC/I �TANK DATA Date Instal �Z Size Standpipes (Y/ �-iit-tight Depression over Tank W Date Pumping/'Maintenance Contract on File <7' No. of Ccmpartments Z Foundation Cleanout (YIN) /Lfe for Holding Tank High -Water Alarm (WW./ -1r4 -Temporary Holding Tank Permit.( Separation Distances from Septic/Holding Tank: To Water -Supply 4b 11 % (� � To Building Foundation To Property Lines - To Disposal Field�� To Water Main/Service Lines To St ream, Pond, Lake, or Major Drainage Course Comments N (Page 1 of 21 2-15m84 C. ABSORPTION FIELD DATA Soils Rating in Ab sor tion Strata � `S Type of System Design CJGI� Date Installed Z % 0 5 Length of Field �i Width of Fields Depth of Field c! Gravel Bed Thickness j CJ Square Feet of Absorption Area Standpipes Present (Y)L Depression over Field ( /N Date of Last Adequacy Test�� Results of Last Adequacy Test 61f /P T Separation Distance from Absorption Field: / To Water -Supply Wb11 f/U To Property Line <?d To Building Foundation c Z 0 To Existing or Abandoned System cn LotOn Adjoining Lots 46 To WaterIa3fService Line To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Sj Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level Tested for Electrical Codes(Y/N) Comne nts Dimensions Manhole/Access (YM) pq7 Off" Level at Vent (YM) Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroan Rating Against HAA Request ** I certify th I ave checked, verified, or conformed to all MOA HAA Guidelines in effect on the da of ion. Signe Date �✓ i / f � .�_ Ccmpa MOA No. KB1/d5/s [Page 2 of 21 lid �j �R�90r11 a f. �, ist � � 2_i nVhf��•i' J' Mb. 147-1 kms' 'iP q9 1�0 2-15-84