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SCIMITAR #3 BLK 1 LT 12
cimitar #3 Block 1 Lot 12 #051-132-79 Municipality of Anchorage Community Development Department Page 1 of 3 On -Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http:Ilwww.muni.org/onsite • (907) 343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP131062 PID Number: 051-132-79 ❑ New ❑✓ Upgrade Name: Steven and Cynthia Mate ABSORPTION FIELD ❑ Deep Trench ❑ Shallow Trench [—]Bed ❑ Mound Address P.O. Box 672231 Chugiak, AK 99567 ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 GPDISF Ft. LEGAL DESCRIPTION Depth to pipe invert from original -grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot Scimitar #3 1 12 Fill added above original grade t. F Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines I Ft. SEPARATION DISTANCES To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist, between trenches From Tank Field Lift Station Tank Line Ff - Ft. well >100' >100' NIA N/A >25' TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Anchorage Tank Capacity I 1,000Gal, Surface Water >100' >100' NIA N/A Material Steel Number of compartments Two Lot Line >5' >10' NIA N/A NA Foundation >5' >10' NIA N/A LIFT STATION Manufacturer Capacity Gal. Curtain Drain None I Noted Pump on level at Pump off level at High water alarm at RemarksTank Only Rep laced Under This Permit. in. in. in. Existing Tank Decommissioned in Accordance With Municipal Code. Pump make and model - Electrical Inspections performed by PIPE MATERIAL Housetotank D3034 Tankto D3034 drainfield Installer Royce Martin Dralnfeld CO/MT D3034 Inspector MEA BENCH MARK (Assumed elevation) 100.Oft Inspectioni 1' 10/2/13 1012/13 Location and description " 2^a dates: Bottom Concrete Step Back Porch. a" 4'" COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL *44 OF,A4 Conditional Approval: Date =�C, • (! i yid 49 TH A . MICHAEL E. /2a �444 Approve Date OFE�4® Inspection Repo _1-1-12.doc M 0) R O N M N N N O a d Z M co I W I o w I IIII I W N I NSI o I I m w I I o I c6 V� Gravel Driveway 1 I � I N — W I V) � Q i� 8Zz W o d^ \\�\i/ J Q ZM /O I w �o I WM m J / \ T poj� I - 0 OfU �m \\ I ) U I? ooh // opt m- \ I I p Wx £ � cwo, mW I d I a.:p_v ¢v mo o>Y yy \ I I mem Of wW rn m O I c m E'o m o z / l�� otu'c .� Z S� 1 s! ~~oma I a-= Z M, p ��.QZ 0 ov g -s U p a O �_ I z 055 > o V)O J w w pd >mN W co M r W CL n �r OV) O Z e w m "i 7. Municipality of Anchorage Page 3 of 3 DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 On -Site Wastewater Disposal System or Well Inspection Report Permit Number: OSP131062 NOTF PID No. 051-132-79 X100.8 Er &sl 8 Finishetl ratle 1,000 Gallon r to Existing Septic Tank on Trench 5.4 9 .25 Septic Tank and Two Post Tank Cleanouts Placed Under this Permit. Existing Absorption System Connected for Continued Use. PROFILE AS -BUILT No Scale On -Site Wastewater Disposal System Permit Permit Number: OSP131062 Tax Code Number: 05113279000 Work Type: Septic Permit Effective Dates: April 25, 2013 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 to April 25, 2014 Design Engineer: ANDERSON ENGINEERING Subdivision: SCIMITAR #3 Site Legal Address: SCIMITAR #3 BLK 1 LT 12 G1261 Owner/Address: MATE STEVEN J & CYNTHIA L PO BOX 672231 CHUGIAK AK 995672231 Site Mailing Address: 19613 BELDUQUE CT, Chugiak Lot Size in Sq Ft: 40038 Total Bedrooms: 3 This permit is for the construction of: N Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage 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 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. Received Issued By MUNICIPALITY OF ANCHORAGE Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/VVELL PERMIT APPLICATION Parcel I.D. 051-132-79 Property owner(s) Steven and Cynthia Mate Day phone 688-5549 Mailing address P.O. Box 672231 Chugiak, AK 99567 Site address 19613 Belduque Court Chugiak, AK 99567 Legal description (Sub'd., Block & Lot) Scimitar #3, Block 1, Lot 12 Legal description (Township, Range & Section) Lot Size 40,038 Sq. Ft. Number of Bedrooms Three APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) El (w/wo ADU) Septic Tank ElUpgrade 0 Duplex (D) El Tank El Renewal El Multiple Dwellings ❑ Privy ❑ (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. li� (Signature of property owner or authorized agent) Permit/Rush Fees: a00 —112tl 6A#k0*aiver Fees: Date of Payment: Lllad4la 4 _ Date of Payment: Receipt Number: bL415C�4 1 c) Receipt Number: Permit No. 05 p) 3) 0G;L Waiver No. Permit App_9-1-12.doc ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 522-6775 :,FAX April 21, 2013 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: Lot 12, Block 1, Scimitar Subdivision No. 3 Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer The septic tank on Lot 12, Block 1, Scimitar Subdivision No. 3 is near failure and must be replaced. We are proposing to replace the tank with a new 1,000 -gallon steel septic tank to serve the three-bedroom home on the lot. We are therefore requesting a permit be issued for the construction of a new septic tank to serve the home. The attached Site Plan and backup documentation identify the location and configuration of the existing septic system and the location of the new tank. Also identified on the plans are the existing wells on the adjacent lots. The new septic tank must be placed a minimum of 100' from all private wells in the area. The existing tank on the lot will be decommissioned in accordance with Municipal Code. The drainage patterns on the property will be maintained after construction. The ground surface on the lot slopes to the southeast at a 5% grade in the area of the new tank. The new septic tank will be constructed near the location of the existing septic tank and tied in to the existing service line. The tank will be constructed parallel with the contours of the land as much as possible in conformance with Municipal requirements. If the tank is constructed in accordance with our design the following statements apply The tank, if constructed as, designed, will have no adverse impact on the wells in the area or those to be constructed in the future. 2. The tank, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. Lot 12, Block 1, Scimitar No. 2 April 21, 2013 Page 2 of 2 3. The tank, if constructed as designed, will have no adverse impact on reserve space, either surface or subsurface, on any lots located in the area. 4. The tank, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, Michael E. Anderson, P.E. Attachments 49th MICHAEL E. ANDERSON ._ No. CE -4381 . � U O y� x � O W S O p C c c 3 UO O N O p r vNi c � V O c y N I-GOOF-C Cy+J E O O O -�= J °U¢V c30.m I pCO2 ®w3 ov�a�z�n a° .20in I I w 002F, -j I �o� F N = I m I z I � rd Dr°vel Dnvem°y I � � � Ln I Q W V0 w° a — di I IW O I r I o I O O j > m N C) M C 0 x 75 E5 OL� W � O Q ••.•••ter ,� 'y3��+�, • E ., T �� V) 6`fie • MUNICIPALITY OF ANCHORAGE / ® DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264.4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE NEW �! 6 4�11 411/ 1:1 UPGRADE MAILING ADDRESS - x LEGAL DESCRIPTION - L Mr 7_1� ae LOCATION NO. OF BEDROOMS Pa s r6k Well Absorption arya Dwelling / PERMIT NO.n U y DISTANCE TO: dor .-r/y r t / 3:t 6d :33 a z Manufacturer Materiarl __ 5�9. No. of compartments w F , y Liq. capacity in gallons ��� IF HOMEMADE: Inside length Width Liquid depth DISTANCE TO: Well Dwelling PERMIT NO. J0z 0z H Manufacturer Material Liquid capacity in gallons O DISTANCE T0: Well N /9 Foundation Nearest lot line PERMIT NO. Z 33 w= (� •f J w z No. of lines Length of each I Total lengthp{ Ike;: Trench width Distance between lines a z w G C(} inches F Top tile to finish Material beneath tile Total 0 of grade , / `f /� effective absorp on area O 0 inches ye Length Width Depth PERMIT NO. LU 0 4 h Type of crib - Crib diameter Crib depth Total effective absorption area LU FL N Well Building foundation Nearest lot line DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. W � DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS 2 SOI L TEST RATI NGP2.5" i INSTALLER n� / " IRIS _ r REMARKS I / AL1 7 07" j8/V I� L_Lr yS IF 0 V's C P • 6 x! Poo ® ® Robert A. Sh e 2 o e QJ ��9FO °j.oe..e emsoo PCO � I ®Arip® AOV D DATE LEGAL i, r• GPc` i 72-073 (Rev. 3/78) �WAVA lrc 1 1 -1-1w" A 510 ' DEPHRTMENT/� , _� �E� /L/ STREET, ANCHORAGE/ HK, 99501 �~~ 264~4720 A 0 FEE L. L. Fol Pol [Do ��--- ST :1 W K 12 EE A8Ell A! �EEEE ?l -4, J~� PE�MIT NO. ( 820]]2 ) RPPLICHNT MYERS CONSTRUCTION ' PO BOX ]51 CHUGIHK 6944144 LOCATION LEGAL L12 Bl SCIMITAR LOT SIZE 42000 SQUHRE FEET TYPE OF SOIL HBSO�PTION SYSTEH IS� TRENCH MHKIMUM NUMBER DF BEDROOMS B]IL RHTI�U FT/BR)� 85 THE REQUIRED SIZE OF THE SOIL 8BSORPTION SYSTEM IS: Bon FO, W 1-1 "A 1— Q 114 10 7 q -q, Z 1=1 IV, W L, ESS W F"M Wl = � THE LEl;.jGTH D1MENSICIN" IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD THE DEPTH OF A TRENCH OR PIT IS THE DISTHNCE BETWEEN THE SURFACE OF THE GROU?-.!D HND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES THE GRHVEL DEPTH IS THE MINIMUM DEPTH OF GRHVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE (IN FEET). �", (71 U I Fit W Eon W EE.- 1`::2, 7, 1 R70 �n=bi P401:"� !"E:': 1 21 W == fl_��1"E'n ������� PERMIT HPPLICHNT HAS; THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURII'lG THE INSTALLATION INSPECTIONS OF ANY WELLS 8DJHCEN1' TO THIS PROPEEFq� HND THE NUMBER OF FRESIDENCES THAT THE WELL NILL SERVE �WA (.0 �� 3: ROURF"Mc-1-1- X 1,10110 �Fit FEE--, L-9 3.'. 9 ". E_:, r BHC[. -,'FILLING OF HNY SYSTEM WITHOUT FINAL INSPECTIO� HND HPPROVHL BY THIS DEPHFTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DI5THNCE BETWEEN H WELL AND ANY OW~SITE SEWHGE DISPOSHL SYSTEM IS 100 FEET FOR H PRIVATE WELL OR 1!�50 TO 200 FEET FROM H PUBLIC WELL DrE.EPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DI�THNCE FROM Q PRIVATE WELL TO H PRIVATE SENEF! LINE IS 25 FEET HND TO H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS HRE REQUIRED HND MUST BE RETURNED TO THE DEPHrRTMENT WITHIN ]Q DHYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTIQN DIHGRHMS HRE .AVAILABLE TO INSURE PROPER INSTAIL LHTION. �ffi"�. 11 - 0 1 T *,..-.< F",- 1. F-', Q Q E02 (Z: EEE P -P E3 EE Fi_� ��� . f L. A�� I CERTIFY THAT 1: I HM FHMILIHR WITH THE REQUIREMENTS FOR TE SEWERS Hr-lD WELLS HS SET FORTH BY THE MUNICIPHLITY OF HNCHORHGE. 2� I WILL INSTHLL THE SYSTEM IN HCCOR�HNCE WITH THE CODES. ]� I UNDERS SEWER sYSTEH MH� �EQUIRE EHLHRGEMENT IF THE RESIDE':MORE THHN ] BEDRQ8MS� SIGNED:_. HF. PLICHNT MYE�� CQNST���TION Oe 11 � ; X SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION M PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR:�DATE PERFORMED:- LEGAL ERFORMED: LEGAL DESCRIPTI 2 3 �. :4 6 � aC zi 7 �. 9 10- 11 Y7 12 13 14 15 16 .. . 'fir a°A L"A,,-.. z S`9S9 17 18 1 •40 Robert A. v ` r e` c 19 v °o No. 145 > &i� ��qFO°1000° va�e�0°PCO �� COMMENTS 1 7U,- r SLOPE f` c WAS GROUNDWATER S ENCOUNTERED? L 0 P IF YES, AT WHAT E DEPTH? SITE Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE /`�/� (minutes/inch) TEST RUN BETWEEN FT AND FT PERFORMED BY: CERTIFIED B 72-008 (6/79) DATE: q .00ATION OF WELL (Places complete either to, Ib or Ic.) Borough Subdivislon Lot Block Ib. 1/q gtrs. Anch Scimitar /' �-. ,I—ar_al�ar — ]a DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS Street Address and Arse of Wall Location 2. WELL LOG Material Type Gravel Greenstone Fracture Greenstone Gray rock n, -re An re+one — Greenstone Coal seam Black rock Black rockii basalt, increase water .,.,. _. pcpT C' Top WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological a Geophysical Surveys Drilling Permit No. A.D. L. No Section No Township N ❑ Ro rigs E ❑ Marldion S f_I.[__.--" .__--.__.__._ 3. OWNER OF WELL Mr. Paul Myers Address. Myers Const. Chugiak, Ake Foot Below g_ WELL DEPTH: (111 01) 5. DATE OF COMPLETION Sa;face 68cft 6-1-82 _ Bottom _. _..._..__ _.—_.. ,1770 JOV 185 3,05 301 580 662 662. 6 ❑ Cable tool Rolory ❑ Driven ❑ Dug 180 ❑ Auger E) E] Bored .❑ Other_- - - _ ----- ----- 1 5 7 USE: Domestic ❑ Public Supply ❑ Industry 305 Irrigation ❑ Recharge ❑ commerical 310 [] Test Well ❑ other. 80 8. CING—:[-] Thr-aded U Welded �7 662" dlam._..__In to ,' O_ft. Depth Weight 1/ Iba./ft. 6620 to ft. Depth Stickup--- ft. 663 9. FINISH OF WELL: T 0 en__Hol tt yDe -�__ �-_-- Diameter;- 6__.__ SIol/Mosh Sl:e:_ Length: Set belweon ft. and ft. - ---- Sockfillinq _.__-_. Gravel pack 10. STATIC WATER LEVEL: ___,__ft• --1— -- ❑ Above or ❑ Below land surface Data Equipment used: II. PUMPING LEVEL. below land surface and YIELD fl. after hrs. pumping 9 -P.M. It. after _ his, pumping g.P. in 12. GROUTING Well Groulod: Yes ❑ No -- Muterial� �-I Neat Cement Other: .. 13. PUMP I if uvailobit) HF ---"-"--- Length of Drop Pips ft. capacity 9 P.M, ❑ Subm. ❑ Jai ❑ Centrilical ❑ Other 19 REMARKS: Bail tested at one G.P.M. IS. WATER WELL CONTRACTORS CERTIFICATION: 15, Wales Tomparature --_a ❑ F ❑ This well was drilled under my jarisdlatlea a it this roporl is true to the b(re . l t niy knuwlcdge and bollof, MartnLgon Drilling_—�"' 3 1,41q AA 5385 -- Registered Business Nome - Conlr(ict i. icon,u Number Address:Signed---- ( June 1. 1982 - Authorized Representotive Form 02•WWR (11/8I) f )is tribulmri: WHITE- Sluts D6(; PINK - Or Ilei, i; APIA III' Cu.torner Municipality of Anchorage On-Site Water and Wastewater Program (907)343-7904 ` NA CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Y iF q Parcel I.D. 051-132-79 Expiration Dater✓� r 1. GENERAL INFORMATION Complete legal description Scimitar #3 Block 1 Lot 12 Location (site address) 19613 Belduaue Court, Chugiak, AK Current Property owner(s) Boyd Day phone 244-2693 Mailing address same Real Estate Agent Lam Ross, Buyers Real Estate Day phone 244-2693 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class C Well Public Water System Received by: COSA to be released to the engineer, 3 TYPE OF WASTEWATER DISPOSAL: z Individual ❑ Holding Tank ❑ ❑ Community ❑ ❑ Public Sewer ❑ Date: S S otherwise requested by the engineer. COSA Fee $ 6�21i•440 Date of Payment Receipt Number COSA # 11 511 as Date of Receipt Number Waiver 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm NorthRim Engineering Phone 694-7028 Address PO Box 770724 Eagle River Engineer's Printed Name Steve Eng Date 6. DSD SIGNATURE System #1 Approved for System #2 Approved for Disapproved. Conditional approval for bedrooms. bedrooms. bedrooms, with the following sloven W. EDO a° c Original Certificate Date: ` �u Tre Municipality of Anchorage Devlopment Services Division (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory COSA blue sheet 9-1-12.doo X Nitrate Advisory Arsenic Advisory Other 3i sloven W. EDO a° c Original Certificate Date: ` �u Tre Municipality of Anchorage Devlopment Services Division (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory COSA blue sheet 9-1-12.doo X Nitrate Advisory Arsenic Advisory Other If more than 1 septic system is on the tot`. COSA Checklist # Of Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description SC/ / 77,4:g3 B / L /Z Parcel ID:0.5/-/32 A. WELL DATA Well type _I If A, B, or C provide PWS ID # Well Log (YIN) y Date completed C//&z Sanitary seal (Y/N) Wires properly protected (Y/N) �L Total depth 6 �o ft. Cased to -L76 ft. Casing height (above ground) n. FROM WELL LOG AT INSPECTION Date of test t' �2 3 3 I / 5 - Static Static water level ft. 117 ft. Well production g.p.m. g.p.m. WATER SAMPLE RESULTS. Coliform colonies/100 mL Nitrate 0i 03g/L Arsenic Q ug/L Date of sample 2 / 5 Collected by: �l B. SEPTIC/HOLDING TANK DATA Tank Type/Material Srt7-(q Is7-A661-Date installed Tank size 16,00 ,gal. Number of Compartments --g2, Cleanouts (Y/N) Foundation cleanout (YIN) - Depression over tank (Y/N) -AZ High water alarm (Y/N) Date of pumping Pumper S AA)( 7-62 e C. ABSORPTION FIELD DATA Date installed p Soil rating (g.p.d./f:2 or ftz/bdrm) AQ5 System type Length Z oft. Width 3 ft. Gravel below pipe ft. Total depth J ft. Eff. absorption area28d ft, Monitoring tube Depression over field Date of adequacy test / 3 Results (Pass/Fail) MSr For -3 --bedrooms Fluid depth in absorption field before test in. Water added 50 gal. New depth 0 in. Elapsed Time: 30 min. Final fluid depth Q in. Absorption rate >= f g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date D. -LIFT STATION 11114 Date installed "Pump on" level at in. Size in gallons Manhole/Access (YIN) "Pump off" level at in. High water alarm level at Datum Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot AM 174- Absorption 7`Absorption field on lot l04 Public sewer main AMW /On r+– Sewer /septic service line 0 S If- Animal rAnimal containment areas 50 rf SEPTIC/HOLDING TANK ON LOT TO Meets alarm & circuit requirements? in. On adjacent lots /0 O "e - On adjacent lots f0 Ile - Public fPublic sewer manhole/cleanout 40W Z00 r-;�- Holding tank . AIWl©r9rd Manure/animal excrete storage areas �00+ Building foundation S f Property line 10 �t Absorption field S �t Water main 141OW14 4 -Water service line p '� Surface water Wells on adjacent lots / 0 d ABSORPTION FIELD ON LOT TO: Property line �/ 0 rt Building foundation — Water main 1111101 /04 Water Service line 0 �� Surface water ZOO " Driveway, parking/vehicle storage Z 5 'f Curtain drain A& Wells on adjacent lots / d '0` F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name f AJ t Date b//-S� COSA yellow sheet 2-6-15.doc AiS L� • Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 ;++ Certificate of On -Site Systems Approval Parcel I.D. 051-132-79 Expiration Date: ! f 1. GENERAL INFORMATION Complete legal description Scimitar #3, Block 1, Lot 12 Location (site address) 19613 Belduque Court Chugiak, AK 99567 Current Property owner(s) Steven & Cynthia Mate Day phone 688-5549 Mailing address 19613 Belduque Court Chugiak, AK 99567 Real Estate Agent 2. TYPE OF DWELLING: [] Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3, NUMBER OF BEDROOMS: Three Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well FX1 Individual ] Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Received by QL Date: e COSA to be rele ,ed toa engineer, unless otherwise requested by the engineer. COSA Fee $� p a Date of Payment t 0 J Receipt Number ��aiy G COSA # ®5c-9?) b Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Engineering Address P.O. Box 240773 Anchorage, AK 99524 Engineers Printed Name 6. DSD SIGNATURE Michael E. Anderson, P.E. Phone 522-7773 Date 11/17/2013 Oyu wuaaaaodac°°oal a'p °c°m5o e m 6""doh o r 14- System #1 Approved for bedrooms 1 o ' V Aorll CE . !.3a3 t System #2 Approved for _bedrooms 17b�r;,°. ,, _ % y� Disapproved v q.Q P "' "0' PP � Ro�ESStm Conditional approval for bedrooms, with the followi ng stipulations By. 4��� Original Certificate Date: 6Th L=apality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the Stale of Alaska. The Municipality of Anchorage is not responsible forerrors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory % Arsenic Advisory Well Flow Advisory V� Other COSA blue sheet—f C, 0 If more than 1 septic system is on the lot: COSA Checklist # of _ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: Scimitar #3, Block 1, Lot 12 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 6/1/82 Sanitary seal (Y/N) Y Total depth 680 ft. Cased to 170 ft. FROM WELL LOG Date of test 611/82 Static water level Well production Undetermined ft 1.0 Parcel ID: 051-132-79 Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) >12 in. AT INSPECTION 10/10/13 199.1 ft. .45 Coliform 0 colonies/100 mL Nitrate '813 mg/L Arsenic N/D ug/L Date of sample: 10/11/13 Collected by: Anderson Engrg. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Tank size 1,000 gal. Number of Compartments 2 Foundation cleanout k/N) Y N Date of pumping New Const. Depression over tank(Y/N) Pumper Date installed 10/12/13 Cleanouts(Y/N) Y High water alarm (YIN) N C. ABSORPTION FIELD DATA Date installed 5/82 Soil rating (g.p.d./ftz or ftz/bdrm) 85 SF/BDRM System type Deep Trench Length 28 ft. Width 2.5 ft. Gravel below pipe 5 ft. Total depth 9 ft. Eff. absorption area 280 ftz Monitoring tube Y Depression over Feld N Date of adequacy test 10/10/13 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 550 gal. New depth 0 in. Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 450 g p d Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed "Pump on" level at Datum in. Size in gallons Manhole/Access (YIN) 'Pump off' level at in. High water alarm level at Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot > 100' Absorption field on lot >100' Public sewer main N/A Sewer /septic service line >25' >50' On adjacent lots >100' On adjacent lots >100' Public sewer manhole/cleanout N/A Holding tank N/A Animal containment areas Manure/animal excrete storage areas > 1 fl(1' SEPTIC/HOLDING TANK ON LOT TO Building foundation >51 Property line >5' Absorption field >51 Water main >10' Water service line >10 Surface water >100' Wells on adjacent lots >100' ABSORPTION FIELD ON LOT TO: Property line >10' Building foundation >10' Water Service line >10' Surfacewater >100' Curtain drain None Noted Wells on adjacent lots >100' F. COMMENTS Water Storage in House Totaling 240 Gallons. G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Michael E. Anderson, P.E. Date 11/18/2013 COSA brown sheet-10.10-12.doc Water main N/A Driveway, parking/vehicle storage >10, 0 rte° NUCHArl. E ANDERSON = y� CE -4381 erg 0® ESSO' 4" Municipality of Anchorage s , Development Services Department a Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Advisory Certificate of On -Site Systems Approval (COSA) # OSC131603 During a recent COSA on-site inspection and test of the potable water supply well on Block 1, Lot 12 of Scimitar #3 subdivision, the well's productivity was determined to be 0.45 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a three- bedroom residence is 0.31 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. tts - j �-j•"r / 7 � s c � + / t 4) 3 3 _r v= F +r Z�/i�1 7f AS -BUILT I hereby certify that I have surveyed the following described property: IX Anchorage Recording Precinct, Alaska, and that the improve- ments situated thereon are within the property lines .and do ��h.••`�a�= , y,� not overlap or encroach on the property lying adjacent there - MV �g�+ ,� to, that no improvements on property lying adjacent thereto .4 49th P 3 q, ,f encroach on the. premises in question and that there are no �e gae ••a c+• vn n. �o a .o•g) roadways, transmission lines or other visible easements on said property except as indicated hereon. •• G6� '•" ' ' Dated at Ea0e, River, Alaska Ts' t- L iC.R i1 ���''�'• c a J th;a ��- day of ROBERT. C. JOHNSON SCALE; Registered Land Surveyor No. 886 -IS 1" Box 456, Eagle River, Alaska - $`H"' 't"° Phone (907) 694-2543 I( 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 l.D.# 051 132 79 HAA# 1. GENERAL INFORMATION Complete legal description Lot 12, Block 1, scimitar Subdivision, unit No. 3 Location (site address or directions) 19613 Belduque Court Property owner Paul and Arlene Myers Day phone 688-1236 Mailing address P.O. Box 670495 Chugiak, AK 99567 Lending agency Mailing address. Day phone Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: Three (3 ) 3. TYPE OF WATER SUPPLY: Individual well xxxxxx 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 xxxxxx 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 Anderson Engineering Phone 563 7155 Address P,O. Box 24077/3 Anchorage, AK 99524 Engineer's signature %����LK�tc��� Date 10/15/96 ..j Or 'w�� n .,y poi . I}- S ( 6. DHHS SIGNATURE K Approved fcr j Ledrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: By: Additional Comments 411TI C, 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 (Rw. 1/91) Back MOA #21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICRT C Environmental Services Division WED 825"L" Street, Room 502 • Anchorage, Alaska 99501 * (907) 343-4744 OCT ? 1 1996 Municipality of Anchor°;ire Health Authority Approval Checklist Oepts Health & Human man Servilcaa Legal Description: to --f- %L1 f3 to GIt_ l �C_i M (7-44L- Parcel I.D.: ® � 1 5t1g))i\/IS)Onlz 0fNice' rlD, A. WELL DATA Well type FiZi\/A:T 4 - If A, B, or C. attach ADEC letter. ADEC water system number ' Log present (YIN) ( Date completed & // I t9 Z_ 1 Total depth k 8®t Cased to /70 ' Casing height (above ground) 4- Sanitary seal (YIN) I Wires properly protected (YIN) FROM WELL LOG AT INSPECTION Date of test 1'/% I?' L 1) ./.Z,% l g t' Static water level .i h a--T'mm I ni tib O pi )t, -r t t-J'y Well production %: g.p.m. 9 -P.m. WATER SAMPLE RESULTS: Coliform 0 Nitrate @ / t_ (°, 9 I Other bacteria JI OL Dateof sample: %Qhy In Collected by: B. SEPTIC/HOLDING TANK DATA �JLL�iiJ Date installed 5 s- 4 Tank size4 13 LO 0— Number of Compartments Z- Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) 4 High water alarm (Y/N) Oj Date of Pumping 05Z� Pumper 5At4 /iA1L� l�S C. ABSORPTION FIELD DATA Date installed e, G Soil rating (g.p.d./W or ft2/bdrm) �L� —Fr. system type b 4'�LP—"7 U4 i Length Fs Width • tz�- Gravel thickness below pipe Total depth 9. Effective absorption area Monitoring Tube present(Y/N)__V_ Depression over field (Y/N) Date of adequacy test D �- q cY Results (Pass/Fail) ltd 5 For I Md� bedrooms Fluid depth in absorption field before test (in.); (9 Immediately after g54al. water added (in.): Fluid depth (ins.) Minutes later: !70 Absorption rate= /�� g.p.d. Peroxide treatment (past 12 months) (YN /J If yes, give date � Jit STATION Date installed Manhole/Access (YN High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: r Septic/holding tank on lot i / ob ; On adjacent lots "Pump off' level at* Absorption field on tot 7/t30 ; On adjacent lots } Public sewer main N1 t u_^,S Public sewer manhole/cleanout Nj i l.<t,, s ,i � Sewer /septic service line > Z-,5 Lift station ''IdO /Joo.lL pnl 1 o-" SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 7 ID, Property line >/O Absorption field 1> G r Water main/service line >Zb ; Surface water/drainage '>1490 t Wells on adjacent lots 7/ ego � SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation i/o / Water main/service line Surface water 7106 � Driveway, parking/vehicle storage area > Curtain drain j / b 6 1 Wells on adjacent lots > / 0 17 � Property line ii a ' 1JVNc 0 t LV- F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review ofMunicipal recordsfhri the�db¢ue sy f, qts are in conformance with MOA HAA guidelines in effect on this date. Signature �l t✓t�L�Ca 1 Engineer's Name M t C44,4 tit, A d 1--- J Date HAA Fee $ �cn,L U Waiver Fee $ c� Date of Payment Receipt Number ' OQ—il',3 b� Rev. 8/95 OSS: haa.wk.doe Date of Payment Receipt Number October 2, 1996 MM & M Contracting P.O. Box 670495 Chugiak, AK 99567 Attention: Paul or Arlene Meyers Subject: Lot 12, Block 1, Scimitar Subdivision Well Flow Test Dear Paul and Arlene: A flow test was performed on the well serving the house on the subject lot on September 29, 1996. The test began at 12:58 P.M. with a measured flow of 4 gallons per minute. This flow continued until 1:50 when a measurement of 3.5 gallons per minute was observed. The flow then began to slowly drop until at 3:58 it was measured at 1.375 gallons per minute. After 4 hours the flow was measured at 1 gallon per minute and the well had produced over 500 total gallons. The test continued with measurements taken on a regular basis until 10:31 P.M. when the test was discontinued. At that time the well had produced in excess of 740 gallons and the flow had stabilized between .5 and .6 gallons per minute. The pump in the well ran continuously for a period of nearly 10 hours. I t would appear from the results obtained during the test the well is now producing in excess of .5 gallons per minute which exceeds the minimum requirements for a three bedroom single family home of .324 gallons per minute. Sincerely, Michael E. Anderson, P.E. CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix Ordered By PWSIb awnpic Icemarxs: Collected By: M.]?.A. Parameter Nitrate -N Total Coliform ME Environmental Services Inc. Laboratory Division Laboratory Analysis Report 965571001 Andersett Engineering L12 B1 Scitnitat L12, Bl, Scimitar Drinking Water Client PO# Printed Date/Time 10/21/96 12:30 Collected Date/Time 10/14/96 15:45 Received Date/Time 10/14/96 16:55 Technical DiFutor: Stephen C. Ede Released By C Allowable Prep Analysfs Results POI, Units Method Limits Date Data Init 0.160 0.100 mg/L 5X18 4500-NO3F 10 max 10/17/96 EMS 0 0 col/100mL SM18 92226 10/14/96 TMv 2 OR W/O COLI 0 200 W. Patter Drive, Anchorage, AK 99518.1605 — Tel: x907) 562-2343 Fax: (907) 561.5301 3180 Pager Road, Fairbanks, AK 99709-5471 — Tel: (907) 474-8656 Fax: (907) 474-9685 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA 7C/.Ej>' i"2S6;�4z- _,.536AW MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # n S )— 13'z--7 9 1. GENERAL INFORMATION Complete legal description Li -z- I Vn1F43 Location (site address or directions) Property owner t�z,I IA" le `G M�,'evs Day phone 68Z'157- Mailing 88tz3} Mailing address Lending agency Mailing address. Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3--, 3. TYPE OF WATER SUPPLY: Individual well x Community well Public water Day phone Day phone 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 X 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)fiev. 1/91) Front MOA n21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify thart my investigation of this Health Authority Approval application shows that the on-site water >upply 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 obtainE)d 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 Phone 3+6-14ma 4.9' - �g8 Address Engineer's signature —DY 6. DHHS SIGNATURE Approved for A4D bedrooms. Disapproved. Conditional approval for 2. ,fix 9351( - Date / - f 5 7 q� w NO. 1332.8 �; �c I q eA bedrooms, with the following stipulations: Additional Comments %fu e , 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 domes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS Ifo 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 tRev. 1/91) Back MOA N21 Municipality OT Ancnorage Department of Health & Human Services r_ HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L- Iz- 3k- I Scxw Svb)U,, -3 Parcel I.D. 6S 1- 13Z , -9 A. WELL DATA Well type _P'31VA-11 If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) 02Y"11 Date completed S""� ` )19bz Driller zarvsor11)n- Total depth ego Cased to 1-7o Casing height I Sanitary seal (Y/N) Y Wires properly protected (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG I• o SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 100' Absorption field on lot Public sewer main Public sewer service line WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate - 1 -i -9Z AT INSPECTIRNICIPALITY OF ANC}iORAGE i- 4- .9MVIRONMENTAL SERVICES DIVISION > r JAN l44 �l1& ,N 33 Nou5a ZAo 9-a1s tea' g.p.m. 1 4! E D > ; On adjacent lots ru�o On adjacent lots r)on Public sewer manhole/cleanout Petroleum tank 00, 0. Other bacteria Collected by: (ZVI-54yuc±�4, GK`S vers B. SEPTIC/HOLDING TANK DATA l�l�// Date installed � Tank size Compartments Z- Cleanouts (Y/N) y Foundation cleanout (Y/N) Y �- Higfl water alarm (Y/N) Alarm tested (Y/N) Date of pumping 11-1-91 Depression (Y/N) NA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well (s) on lot loo On adjacent lots 'J-'(oo Foundation i' 10 To property line �Z5 Absorption field 7$ 1 Water main/service line 4SD Surface water/drainage -+IeX 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE Date installed Size in gallons Vent(Y/N) "Pump on" level at _ Manufacturer Manhole/Access (Y/N) _.. IIP off' level at _. High water alarm level "Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA --/"d6 / Date installed Ma,, 15,$z Soil rating Length Zg ' Width Gravel thickness Total absorption area Depression over field (Y/N) Z-80 s -F tJ Surface water System type—�T9 En c, N_..:_ Cleanouts present (Y/N) Date of adequacy test Results (pass/fail) FAs5 for Peroxide treatment (past 12 months) (Y/N) ^J SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 4- 1 cx> To building foundation 5 On adjacent lots On adjacent lots 4-t 00 Cutbank Surface water + l0C; Curtain drain r1 o0 E. ENGINEER'S CERTIFICATION +- 100' 3 Total depth. Z. ... Y ., If yes, give date Property line "i- ZS , To existing or abandoned system on lot Water main/service line Driveway, parking/vehicle storage area N A -r- z.5 bedrooms 1 certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in sff t nr h rl�tecfTi *: e d jr�rye �.i#7,(•.�.��K9i+OY�tbr'd"�SyY t- Signature � ��'�'M:w`ebcaa ra..v4aMrrIs;pspw Engineer's Name � -� rte. 1s0. tM.�f ',tura 22. 1 r' 4Sj Date?' ��III � p O HAA Fee $ �G Waiver Fee: $ _.. Date of Payment l f /� Date of Payment Receipt Number c`� �,r y� Receipt Number—_....� 72-026 (Rev. 3/91) Back MOA 21 Time ^ APPLI( AT FILLS OUT UPPER HA;. ONLY Time P;opertyOwner Myers Construction, Inc. _ Phone - Mailing Address Box 1596, Eagle River, AK Zip Code 99577 694-9633 Buyer Rocky L, & Donna S. WME Nail 1n °izl-ii�ll�f Address 1725 Rosemary, Anchorage, AK Zip Code 99504 Inspector r) - Lending Institution Home Savings and Loan (Sandra Moore) Phone Address 536 D Street, Anchorage, AK 99501 272-1451 Field Notes: �l MUNICIPALITY OF ANCHORAGE Zip Code DFPT 019 Realty Co. BAgent Commonwealth Totem Realty, Inc. (Jim Montague) Phone PO Box 911, Eagle River, AK 2 (( - Address Zip Code 99577 694-9494 Legal Description Lot 12, Block 1, Scimitar #3 cc s kv Street Location NHN BeldB ue Court, Peters Creek, AK A ( ) CONDITIONAL APPROVAL' Type of Residence - 7 Single Family - - BY: y �j Multiple Family No. of Bedrooms 3 Date Sewer Installed ❑ Other Well Log Received Water Supply �r� •2.- Well to Tank XI Individual L) ATTACH WELL LOG. A well lag is required for all wells drilled since- June 1975. ❑ Community,) 1 / / Na For wells drilled prior to that date, give well depth (attach log if available). - ❑ Public Utility if"t if C Sewer Disposal :0 Individual x �;''�'1a C LLS Year Individual Installed: 1982 - ❑ Public Utility When Connected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time ^ Time Time Time Date Date Date Date - Inspector- 4-j Inspector (� Inspector r) - Inspector Field Notes: �l MUNICIPALITY OF ANCHORAGE DFPT 019 ENVIRJ-;; ,:_f..P.-.:--�, CTION 2 (( =�—�i L— -- E 1 c� — %� 6� r k2•c�Y!/ cc s kv ( 3) APPROVED BEDROOMS j� _ _ C� {'p .- ( ) DISAPPROVED +�'�' '7"�"'" `�I�fl C *CONDITIONS OF APPROVAL l -�✓�¢J1/I�Qn.� Vs'�z., �. Ilea A ( ) CONDITIONAL APPROVAL' - DATE BY: y Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received �r� •2.- Well to Tank Septic Tank Size 16cj-d