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SCIMITAR #3 BLK 1 LT 13
Scimitar #3 Block 1 Lot 13 #051-132-80 Municipality of Anchorage On -Site Water and Wastewater Program • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP191099 PID Number: 051-132-80 Dwelling: F* Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ❑® Upgrade Name: Jon Lowe & Michael Nickles ABSORPTION FIELD ❑ Deep Trench W Shallow Trench El Bed E] Mound Address 19643 Belduque Ct. Chugiak, AK 99567 ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade (907) 244-4014 3 1.0 GPD/SF 4.3 / 4.3 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 3.8 Ft. Gravel depth beneath pipe 0.5/0.5 Ft. Subdivision Block Lot Scimitar #3 1 13 Fill added above original grade 0.5/0.2 Ft. Gravel length 2 @ 45 Ft. Township Range Section Gravel width 5.0 Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic i; Absorption ' Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field � Tank Line 450 Ft z 2 >6 Ft. Well I >100' I >100' N/A ��A >25' TANK E Septic ElS.T.E.P. El Holding El Other Manufacturer Anchorage Tank Capacity 1000 Gal. surface water >100' i > 100'. N/A N/A Material Number of compartments Lot Line >5' >10' N/A N/A Steel 2 NA Foundation >10' >10' N/A N/A LIFT STATION Manufacturer Capacity Gal. Curtain Drain None I Noted Remarks 2„ Insulation over Septic Tank. Pump on level at in. Pump off level at in, High water alarm at in. Pump make and model Electrical Inspections performed by PIPE MATERIAL House to tank D3034 Tank to drainfield D3034 Installer JRs (Tank) / Northern Ex. (Trench) Drainfield D3034 CO/MTD 3034 Inspector J. Williams / J. Millette BENCH MARK (Assumed elevation) 100 ft Inspeection 15 6/10/19 7/5/19 Location and description Znd 3`d 4111 Bottom of back door jam. COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp q �® OF""'.qS�4� Conditional Approval: Date 49th .4 .... . .... 1 ............ase.................... MICHAEL E. ANDERSON g �; 0 r� << No. cE-4381 � T 7/7/19 s*'•t�'C�,� Approved Date �+AFD ,`o ......��P� t1°R ��S* inspection Keport_u-i-il.doc SCIMITAR #3, BLOCK 1 LOT 13 PERMIT # OSP 191099 PID # 051-132-80 EXIST IN WELL 7 \ 0q / \ \ 5'x15' A i j \ EXITING WELL -BD HOM \\ 1 ® \ \ \ A TH#1 by \ � S. Pannone CO3 \ \ C01 Svi SV2 NE 1,000 GALLON EXISTING WELL SEPTIC TANK A B C01 22.9 26.7 SV1 26.3 29.3 SV2 32.0 33.9 2CO 34.5 35.5 CO2 44.0 36.8 CO3 1 46.1 32.4 C04 87.5 79.1 MT1 86.6 77.7 C05 88.2 77.0 MT2 88.1 76.6 ------------------ ENGINEERGE ING C05 FLOW SPLITTER MT2 • TH 198 C8 Tj 33' SECTI LINE EASEMENT 10' UTILITY EASEMENT I I i JCHOR EASEMENT / 1 i/ 2-45' LONG x 5' WIDE x.5' EFFECTIVE DEPTH ABSORPTION TRENCHES. J / 1 PLAN AS -BUILT 0 50 100 FEET 1"=50' INKVy\ls'l CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE SCIMITAR #3 B1 L13 PERMIT # OSP191099 93.0 92.5 82.1 93.3 92.8 PID # 051-132-80 NORTH EAST TRENCH o�- 02 97.3 FINISH GRADE ' INSULATION O 96.8 ORIGINAL GRADE U MOA APPROVED FILTER SAND 90.5 90.5 45' NO GROUNDWATER @ INSPECTION 7/5/19 TH#1 SOUTH WEST TRENCH O�- O U2 97.3 FINISH GRADE 97.1 ORIGINAL GRADE U TH#1 MOA APPROVED FILTER SAND 90.8 90.8 45' -,- 82.1 PROFILE AS -BUILT (NO SCALE) 93.0 92.5 93.3 92.8 TEST HOLE 1 SOILS LOG -'PERCOLATION TEST SLOPE SITE PLAN OR ORGANICS SE TI 1 1 3BR I 2 SFD I \ 3 SP/SM GRAVELLY 4 SAND WITH SILT / 6 )( _TH PES / TH 7 O TH 1982 i \ SHAFER 8 13 9 \ { 10 11 \ STs 12 --- --- -- -------------- 13 I WAS GROUND WATER SLOPE 14 ENCOUNTERED? N 15 IF YES, AT WHAT TH 16 DEPTH? -DRY' x 17 DEPTH TO WATER AFTER MONITORING? -DRY 18 DATE: 5/20/2019 DATE PERFORMED: 5/13119 PERCOLATION RATE <1 (min/inch) SIEVE ANALYSIS PERFORMED BETWEEN 4 FT AND 5 FT COMMENTS: Test hole excavated by JR'S SEPTIC. PERFORMED BY: Dan Moran. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. NOTES: PAiVNONE ENG SVC, LLC Date SOILS LOG P.O. BOX 102954 ANCHORAGE, AK 99510 7/9/2019 PHONE (907) 272-8218 FAX (907) 272-8211 a• Scale •••,` NTS •• .• P.I.D. NO SCIMITAR #3, BLOCK 1, LOT 13 051-132-80 JONALEXANDRA LOWE & MICHAEL NICKLES �• }�' f . ..: PERMIT N0. 19643 BELDUQUE CT., `• 8i 9 OSP191099 She SOILS LOG CHUGIAK, AK 99567 et 1 OF 1 CLOCK WATER READING DATE NET TIME LEVEL NET DROP TIME READING � 5/13/19 2 s WATER WAS ABSORBED TOO FAST TO ACCURATELY READ 4 s s 6 010.002 Client: Pannone Engineering Services Project: Scimitar #3 Block 1 Lot 1 Date: May 15, 2019 Croirlher .Associades Particle Size Distribution Table (percent passing sieve size) Sample Source Block 1 Lot 13 Sieve Size Percent Finer Percent Finer Percent Finer Percent Finer 3 inch 100 1-1/2 inch 96 '/i inch 91 #4 51 #10 28 #40 12 #100 7 #200 6 0.02 mm Classification Gravelly Sand with Silt (SP -SM) 1632 Bellevue Circle /Anchorage, Alaska 99515 Telephone (907) 399-2198 / E mail: crowlher@alaska. net MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP191099 Work Type: Septic Upgrade Tax Code Number: 05113280000 Site Legal Address: SCIMITAR #3 BLK 1 LT 13 GA 261 Site Mailing Address: 19643 BELDUQUE CT, Chugiak Owner: LOWE JONALEXANDRA NIKOLE & Design Engineer: PANNONE ENGINEERING SERVICES This permit is for the construction of: Effective Date Expiration Date: n v f DepartIII ell I Lot Size in Sq Ft Total Bedrooms: 4/22/2019 4/21/2020 42510 Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ 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 ��k� { Special Provisions: A test hole is required prior to construction of the drainfield to provide 7 -da groundwater p q p� p Y monitoring and to confirm the percolation rate of the accepting soil. If results require a design change, construction shall stop pending On-site review and approval of a change order. Please submit test hole results with the change order (if required) or inspection report. 3 0 1 N2y'1`I�: Se -i'r�.nc�h tied► � baoec� or PerV_o(&-1oh -(-t64 res�t-fs. Received By: Date: Issued By: Date f� 2 Q ON-SITE SEWER/WELL PERMIT APPLICATION 2 Parcell.D. 051- -80 Property owner(s) JONALEXANDRA LOWE & MICHAEL LOWE Day phone Mailing address 19643 BELDUQUE CT, CHUGIAK AK 99567 Site address 19643 BELDUQUE CT Legal description (Sub'd., Block & Lot) SCIMITAR #3 131 L13 Legal description (Township, Range & Section) Lot Size 42,510 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑X Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank MUpgrade I -XI Duplex (D) ElHolding Tank ❑ Renewal ElMultiple 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. of property owner or authorized agent) Permit/Rush Fees: /�/� Waiver Fees: Date of Payment: ��1�/�7 Date of Payment: Receipt Number: ��� �- 7 Receipt Number: Permit No. 08 Waiver No. Permit App_.- : - ::...:c .. " GE E N G I N E E R I N G PO BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) June 24, 2019 MOA Development Services Dept. On -Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Scimitar #3, Block 1, Lot 13 —19643 Belduque Court Septic System Design Dear On -Site Services Engineer: The existing septic system on the subject lot has failed and must be replaced. We are submitting this permit application for the construction of a new septic system to serve the three bedroom home on the lot. The existing septic tank will be decommissioned in accordance with Municipal Code. The attached site plan identifies the location of the home and the existing well and septic system along with the proposed septic system. No conflicts exist between this proposed system and any other well or septic system on this lot or adjacent lots. The ground surface on the lot in the area of the proposed trenches is virtually flat. No slopes greater than 25% are within 50' of the proposed trench. Surface contours are shown on the site plan indicating the grade and direction of flow. Storm water drainage will not impact this septic system. The new trenches will be constructed parallel to the slope as much as possible. Wells on this and adjacent lots are shown. The new system will be a minimum of 100' from all wells and surface water, and more than 5' away from the septic tank. Please refer to the attached test hole log, laboratory analysis and plan and profile sheets for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, �} OF Michael E. Anderson, PE 2 2 _ 49th. _ A : MICHAEL E. ANDERSON : No. CE -4381 1111 6!24/19 .•••�t �� �isre®ROFESS\C �®® SCIMITAR #3, BLOCK 1 LOT 13 EXISTIN WELL 5'x15' ANCHOR EASEMENT / r f EX STING WELL -^` 1,000 GALLON SEPTIC TANK / -BDM HOM -45' LONG x 5' WIDE x.5' i FECTIVE DEPTH ABSORPTION TR NICHES. 6' APART. SSV co Il Dzc EC�MM SION).EXISTING /� FS EXISTING WELL SEPTIC TANK. R-MOA CODE. TH \ T ! REMOVE AB VE GROUND PIPE CO' f AND AB NDON IN PLACE. VG1T CO /f 33' SECT14 LINE EASEMENT 10' UTILITY EASEMENT T` — — — — — — — — — — — — — — — — — i / — � r { I � ENGINEERING NOTE. ® � OF qC �� NO SLOPES >25% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE LEGEND E ............:9,5�®®�®® PROPOSED SEPTIC SYSTEM CO - CLEANOUT ��P„.,••.• ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS 2C0 -DOUBLE CLEANOUT 49th ....® ® n •••••• ••• .� • •••• •�• v =� = PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC FCO - FOUNDATION CLEANOUT �•' MICHAEL •E••ANDERSON•�� SYSTEMS. FS - FLOW SPLITTER VALVE = No. CE -4381 ? ® ��®�Ff;••.,, 0 50 100 MH -MANHOLE . ®® ”=50' SV - SEPTIC VENT ®AIItt ®S�s�� ®� 1 TH - TEST HOLE SCIMI���K��U����� �V/����� Yv�T�� TAR ����^ t���� L��_������ 1 , LOT {�� �l��}/�yJ��������' ��^��''~�'" FACTORS: 45OGPD PEAK FLOW PERK RATE: <1M|N/|N APPLICATION RATE: 1.0GPD/SF c���T�yN ���/�U|��[N�yJTx�' SYSTEM ^^ . `_. " . . ``_ �� `^ . . ^^_.". �_. " . ~� . 5/VNDETRENCH SYSTEM 1.000 -GALLON SEPTIC TANK 45OGPD /1.OGPD/SF /5'VNOE^1.ORED. FACTOR =QOLFTRENCH REQUIRED (QOLFSPECIFIED) BOTTOM OFTRENCH: 4.O'BELDVVGRADE FLOW LINE ELEVATION: 3.5'BELOVVGRADE TOP OFTRENCH: .5'ABDVEGRADE 51 RATED PVC (HOLES DOWN) zrx/cnn^mn TYPICAL TRENCH SECTION (NO SCALE) NOTES: 1. GRADE AREA OVER TRENCH TODRAIN AWAY 2. PROVIDE 3'DFCOVER OVER TRENCHES AND zyOVERSEPTIC TANK, OR2' WITH 2'OFINSULATION 3. CHECK GROUNDWATER ATTIME OFCONSTRUCTION. |FLEVEL |8HIGHER 1 A% MICHAEL E. ANDERSON No. CE -4381 o 6124/19 0;0.002 Client: Pamzone Engineering Services Project: Scimitar #3 Block 1 Lot 13 Date: May 15, 2019 CPO1t-thM-11- 1ISSOC%C11eS Particle Size Distribution Table (percent passing sieve size) Sample Source Block 1 Lot 13 Sieve Size Percent Finer Percent Finer Percent Finer Percent Finer 3 inch 100 1-1 /2 inch 96 3/4 inch 91 #4 51 #10 28 #40 12 #100 7 #200 6 0.02 mm Classification Gravelly Sand with Silt (SP -SM) 1632 Bellevue Circle /Anchorage, Alaska 99515 Telephone (907) 349-21981E mail: crou.,1her0aalaska. net MUNICIPALITY OF ANCHORAGE �1 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 C - q1 4/ ❑ UPGRADE MAILING ADDRESS ! V LEGAL DESCRIPTION 3 d3Lk I t', -TMT 7- LOCATION C = NO. OF BEDROOMS 3 LL c K Well Absorption area Dwelling i PERMIT NO. Uy DISTANCETO: 7• / 23 aI__. G Manufacturer Material m No. of compartment ell Liq. capacity in gallons 17 IF HOMEMADE: Inside length Width Liquid depth _ 0 �' DISTANCE TO: Well Dwelling PERMIT NO. Jaz Yz FManufacturer Material Liquid capacity in gallons O w= w DISTANCE TO: Well /V Foundation , / && `f Nearest lot line / ,� PERMIT NO. 6A •� J LL z No. of lines / Length of Each line j Total length of lines � Trench width Distance between lines Fzc f 2� 20 e y!linches /u' t- Top of tile to finish grafle i Material beneath tile Total effective abso pt n area 0inches () + Length Width Depth PERMIT NO. LU a F- Type of crib Crib diameter Crib depth Total effective absorption area LU w DISTANCE TO: Well Building foundation Nearest lot line Class Depth Driller Distance to lot line PERMIT NO. _j Alor N Mr Lu 3 DISTANCE TO: Building foundation . Sewer line Septic tank Absorption areas) OTHER PIPE MATERIALS I� SOIL TEST RATING rfj INSTALLER S /' J G• REMARKS 4JE G. fis il6r , OF A4, (ort, f, f4r Robmrt A457 -E CS i o APP OV D DATE LEGAL r /zyw thev.3//t5) /y ncris./n nnv Emit rixum/wm/on, TuiLOU !1U@ 825 \,/STREET/ HNCHO�HGE/ AK9�.�1 1/ � Us EEC a.. U, ��RIIZ,:,� ��l -T- EEC Al EF h 1EFit F=* K to: 1-1 1 N PERMIT NO ( 820]]4 ) HPPLICHNT MYERS CONSTRUCTION PO BOX ]51 CHUSIHK 6944144 LOCATION LEGHL Li] B1 SCIMITHR LOT SIZE 42000 SQUHRE FEET TYPE OF SOIL H8SORPTION SYSTfjM IS� TRENCH MAXIMUM NUMBER OF RHTING (13Q FT/BQ- 85 THE REQUIRED SIZE OF THE SOIL HB5ORPTION 5YSTEM IS: ����R.- -R�: E.E'19 110 -Y'10 W ;E� CIA got ".0 NEW L.. ���11", R-11� � THE LEMQTH DIMENSION [S THE LENGTH (IN FEET) OF THE TRENCH OR D��F�INFIELD THE �EPTH OF H TRENCH QR PIT IS THE DISTHNCE BETWEEN THE THE GRO11-1ND AND THE BOTTOM OF THE FEET), THERE IS kO SET t4IDTH FOR TREN�HES THE GRHYEL DEPTH IS THE MINIMUM DEP-1,4, OF GRHVEL BETWEEN THE OUTFHLL PIPE HND THE BOTTOM OF THE EXCHVHTION (IN FEET). F72 EH Hot U I fit E=7 R? F:=" .1 C-,: �F:l N K- W 1 W W it, Q 10 owl All got J— j,, (:I�� PERMIT HPPLICHNT HHS THE RESPONSIBILITY TQ INFORM THIS DEPHRTP! ENT DURING THE INST�LLHTION OF HNY WELLS HDJHCENT TO THIS PROP�RTY HND THE NUMBER OF RESIDENCES THHT THE WELL WILL SERVE —�— �I MR 3. got F--' E.0 Fc,�C il.,-v P,j -K t-,�� BHCKFILLINQ OF HNY SYSTEM WITHOUT FINHL INSPE�TION �HD HPPROYHLBY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTIO�� MINIMUM DISTHNCE BETWEEN H WELL HND HNY ON~SITE SENHGE DISPOSHL SYSTEM IS 100 FEET FOR H PRI -,.--'HTE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEFENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTHNCE FROM H PRIVHTE WELL TO H PRIVHTE SEWER LINE I� 25 FEET HND TO H COMMUNITY SEWER LINE IS 75 FEET, WELL LOGS HRE' REQUIRED HND MUST BE RETURNED TO THE WITHIN ]0 DHYS OF THE WELL COMPLETIOKi OTHER REQUIREMENTS MHY HPPL\! SPECIFICATIONS. RND CONSTRUCTION DIHGR8MS HRE HVHILHBLE TO INSURE PROPER INSTHLLHTION EZ":������ �������� � , �W 10 0211. 1 CFUTTIFY THAT 1: I HM FHMILIHR WITH THE REQUIREMENTS FOR ON-SITE SEWERS HND WELLS SET FORTH BY THE P1 U P-1ICIPHLITY OF HNCHOR8GE. 2� I WILL INST8LL THE SYSTEM IN HCCORDHNCE NITH THE CODES` IT: I UNDER'SEWER SYS-TFEM MHY REX!UIRE ENLHR(3EMENT IF THE RESIDEMWE LUDE MORE THHJNI ] BEDROOMS- 5IGNED�_ - .�v � nPPLICHNT M\��S CON�TRUCTI0N � �/ ISSUED B SOI LS LOG MUNICIPALITY OF ANCHORAGE a.e DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: S %BOIN,'s DATE PERFORMED: LEGAL DESCRIPTION: /3 60 L �� iY>7�' �'- 9. (A ? SLOPE SITE PLAN 2 -wwlprc IP, I e c-�GL Time Water 10 16, 3 �a 4. a'; Q N^ 11 "� W ' WAS GROUND WATER //�//� �4 U I . 181 ENCOUNTERED? — No. 145%-E 0. 19OFESSJOW- 5 7 �b'v -CJ d 20 P 12 •' E IF YES, AT WHAT DEPTH? 8- 13 •b 9 14 0-,0 Reading Date Gross Net Depth to Net 1 w c t All f u` Oil- 8 a r�� Time Water 10 16, ® Y a'; Q N^ 11 "� W ' WAS GROUND WATER //�//� S L 181 ENCOUNTERED? — No. 145%-E 0. 19OFESSJOW- 0 V d 20 P 12 •' E IF YES, AT WHAT DEPTH? 13 •b 14 0-,0 Reading Date Gross Net Depth to Net COMMENTS Oil- 8 a r�� Time Water � g�.i.JOP9Ra5 ¢ 'tkjF 16, ® Y ✓� N^ 17 181 e , Robert A. Shafer e o No. 145%-E 0. 19OFESSJOW- 20 COMMENTS PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT PERFORMED BY: CERTIFIED/ / / DA 72-008 (6/79) Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT PERFORMED BY: CERTIFIED/ / / DA 72-008 (6/79) LOCATION OF WELL (Please complete either la, Ib or Is.) lo. Borough Subdivision _ Lot Block Ib. I/4 girt. Section No. Tow Anch Scimitar /�—J �°`-°'_I__ _ ___. Ic DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. 0 A Street Address and Area of Well Location — — —_ _W Feet Below 2. WELL L00 Surface Material Type Top Bottom --- 4. - Dry gravel 0 114 6 Wet sand very fine with water -114 _ 125 Clay 125 127 T.0 Dry grave 127 1 3 Greenstone _143 18 Fracture 185 195 0.6 Grustone 1 �t C diom. Greenstone 215 255 diam.- Fracture water included 255 265 -9 F Greenstone 26-5---295-- T S S B MUNICIPALITY OF AWPOW13F--- 1qFP;. QF--- ----- I o S ENVIRONMENTAL FROTECTI N — . EEB 12.6 13.p L 14. R 16. WATER WELL CONTRACTORS CERTIFICATION: I5. • YYNI Lr\ YYLLL I\LV VI\V STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological 8 Geophysical Surveys Dulling Pnrmif No. A D.L. No. ship 14 Range Er—I Merld,on Sr]� WLJ VNLR OF WF'L. lMr. Paul Paul Myers dfess: Myers Const. _._.......Chugak+ Ak&_._....._.-____ [LP L DETH: (sinal) 5. D ATE OF COMPLETION Q` [J Cable tool Xo Rotary ❑ Driven E] Dug Auger [j Jetted ❑ Bored ❑ Other: EXU Domestic Ej Public Supply 0 Industry Irrigation Recharge LJ commerical Teat Well Other: _--_--___-- (SING:I Threaded Welded 1 �7 Sri in. to 1-43 ft. Depth WeigtM I _Ibs./N. —._ _in. to ft. Depth Stickup_ ft. ---------------------- - NISH OF WELL: P,:_QnEn.__Hola.--- Dlamet.r.c\.!.-------- of/Meth Size: _ Length:_ it between ft, and ft. Ickfilling _ _..__.—___ Gravel pack "ATIC WATER LEVEL:ft. Abavo or C, Below load surface Date Equipment used IMPING Lf.VEL below land surface and YIELD _.. _._fl. of for ,._._hrs. pumping Q.P. m. If offer fire. pumping g.p.m. TOUTING Wall Grouted: �.� Yea ❑ No oferiul ( Neat Cement Other: imp (it available) HP 1%2 rngth of Drop Pipe 252 ft. capacity q. p.m :OX( (ibm. u Jet Centrifical E] Other MARKS: Bail tested at 15-20 GPM Water luaiperulnro F �, C This well was drilled under my jurisdiction and ]his report is flue to Il,e Le>I of my knowludip una heliel; _MagnuSx _Drilling------ AA 5355 - Regislored Buelness Name Cnld tact I. Il.,t ln.o Nnmlnr Address: P0. Box 504 Eagle River, Ake June 4, 1982 Signed: Authorlied Represen )dive Form 02-WWR (11/81) Copy Distribution: WHITE - Stutu DGGS, PINK Dnllul, CANARY Customer MUNICIPALITY OF /ANCHORAGE Development Services Department -:= Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 051-132-80 1. GENERAL INFORMATION Expiration Date: 16 — 9 I Complete legal description Scimitar #3, Block 1, Lot13 Location (site address) 19643 Belduque Court Chugiak, AK Current property owner(s) Michael Nickels & Jon Lowe Day phone (907) 244-4014 Mailing address 19643 Belduque Court Chugiak AK 99567 Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ "bD Waiver Fee $ Date of Payment 0161 Date of Payment Receipt Number O- I� l5 D Receipt Number COSA # S �' �I o`t 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm Forge Engineering Phone 907-522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage AK 99503 Engineer's Printed Name Michael E. Anderson, P.E. Date OF D' 49th 6. DSD SIGNATURE ' ®.•...... t... u ................ •.... •. System #1 Approved for bedrooms MICHAEL E. ANDERSON �. System #2 Approved for bedrooms ®�® vo. cE-4381 B l • 7/8/19 , ••'�aC' Disapproved Conditional approval for bedrooms, with the following stipulations: By: 0� OF AA&( i S�Tt SITE \NATER AND � o VVASTEV�Altm o5 J 1 1 �Nr S0:N\ Original Certificate Date: 7 Z -G ?I - The (( The Municipality 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 State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Legal Description: Scimitar #3, Block 1, Lot 13 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 6/4/82 Total depth 285 ft Cased to 143 ft ❑ Sanitary seal is functioning correctly Al Wires are properly protected Casing height (above ground) 24 in. Date of flow test for COSA 3/29/19 Static water level at beginning of test 150 ft. Comments Flow test completed by Sullivan Water Wells B. TANK DATA Age of tank(s) 6/10"9 years Tank type/material Septic/Steel Measured operating fluid level in septic tank n/a Al Standpipes/foundation cleanout per record drawing Date of pumping Septic Tank recently installed. D. ABSORPTION FIELD DATA Shallow Trench Which system tested (date installed) 7/5/19 ❑ ALL standpipes present per record drawing Total measured depth from grade 4.8 ft (max) Measured depth to pipe invert from grade 4.3 ft (min) ❑ N/A — pressurized field FOR Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: installed 7/5/19 by Northern Excavating COSA Checklist yellow sheet Parcel ID: 051-132-80 Structure served by this system Well production at time of test 4 gpm Water storage tank volume 1,000 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 Forge Engineering Date of Sample 6/26/19 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date New Construction Results 13 Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' F/ Yes Community Sewer Manhole/Cleanout > 100' 7v Yes if No ft [✓ Yes if No ft Neighboring Tank > 100' Fv Yes if No ft Private Sewer/Septic Line > 25' M Yes if No ft Absorption Field on Lot > 100' ❑✓ Yes if No ft Holding Tank > 100' F✓ Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' Yes if No ft Fv Yes if No ft if No ft F. ENGINEER'S COMMENTS Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' �✓ Yes if No ft ✓v Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water > 100' Yes if No ft Property Line > 5' F/ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' F771 Yes if No ft Private Wells > 100' 0 Yes if No. Water Main > 10'✓❑ Yes if No ft Community Wells > 200' Yes if No Water Service Line > 10' Q Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ED Yes if No ft If absorption field is under driveway comment below Property Line > 10' Yes if No ft Wells on Adjacent Lots: Water Main > 10' Yes if No ft Private Wells > 100' ®✓ Yes if No Water Service Line > 10' Q Yes if No ft Community Wells > 200' P/1 Yes if No Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS Septic Tank and Absorption Trench were recently installed. G. ENGINEER'S CERTIFICATION ho/ certify that I have determined through field inspections and review `; °"®� `'°•,t _ of Municipal records that the above systems are in conformance with °<y 4° 9 MOA COSA guidelines in effect on this date. MICHAEL E. ANDERSON b i c ¢ ° No. CE -4381 e° � 7/8/19 COSA Checklist yellow sheet F� � }�. ft ft ft ft ASBUILT-NO CORNERS SET THIS 9.- I I HEREBY CERTIFY THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY: Scimitar Subd.,Unit No. 3,Lot 13,B1k. 1 AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI- VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OF FENCE LINES, OR FOR ESTABLISHING BOUND- ARY LINES. 0 xj S94ARD & ASSOCIATES LAND SURVEYING 688-4566 SCALE: "V6 % V, , 1"=40' F A� DATE. xl% 2-12-91H 4, GRID., NW 1261 � Duarte Mprk Seward FB! LS 8 18-62 DRAWN: w DMS P.O. Box 670269 Chugiak, AK 99567 P: (907) 688-2759 F: (907) 688-2259 TO: Michael Nickles 19643 Belduque Ct. Chugiak, AK 99567 Scimitar #3 Block 1 Lot 13 Flow Test Report: Resting Static: 150' Max Drawdown: 262' Well Depth: 285' Total Yield of Well: 4 GPM Date: 3-29-19 Municipality of Anchorage 1 Development Services Department Building Safety Division On -Site Water 3 Wastewater Program 4700 BStreet P.O. Boxox 19 19 650 Anchorage, AK 99519-6650 www.muni.org/onsit/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL ++�� FOR A SINGLE FAMILY DWELLING Parcell.D._I151— l3sZ'$U COSA# NVDQ9Q 1. GENERAL INFORMATION Expiration Date: 6-13—OCC Complete legal description SCIMITAR N3: LOT 13, BLOCK 1. Location (site address) 19643 BELDUOUE • CHUGIAK. AK 99567 Current Property owner(s) PEGGY BAILEY Day phone C/O AGENT Mailing address Lending agency Mailing address Real Estate Agent Mailing address C/O AGENT Day phone BROOKE STILTNER w/REMAX Day phone 244-6742 16600 CENTERFIELD DRIVE • EAGLE RIVER, AK 99577 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: • 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site E Individual Water Storage ❑ Individual Holding tank ❑ Community Class Weil ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite Systems Approval (COSA) based only upon the representations given In paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also Issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage Is not responsible for errors or omissions In the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the 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 riles 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 GARNESS ENGINEERING GROUP, Ltd. I Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date 3 Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily Identifiable features. The operational Uto of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the solo benefil of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. Conditional approval for bedrooms, with the fllowing stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory V Arsenic Advisory —� Maintenance Agreements Supplemental Engineer's Reort Nitrate Advisory Other By: W U car /Rw 11M1 0Ft WVgAASTfifAN�ER PROGRAM Original Certificate Date: 3 ` % P-3 - C)4 Municipality of Anchorage ' Development Services Department Building Safety Division " On -Site Water 8 Wastewater Program 47W Bragaw Street P.O. Box 195650 Anchorage, AK 99519-6850 www.muni.org/onsft (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: SCIMITAR /3: LOT 13, BLOCK 1, Parcel ID: D .SI - 13 X - $ D A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 6/4/1982 Sanitary seal (YIN) YES Total depth 285 ft. Cased to 143 ft. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi. Nitrate <1 mg./L. Well Log (Y/N) YES Wires property protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 2/15/2006 ft. 0.55 g.p.m. Other bacteria _2 colonies/100 ml. Arsenic: <5.0 ug./L. Date of sample: 2/16/2006 Collected by: GEG Ltd. 13. SEPTICIHOLDINO TANK DATA "FOUNDATION CLEANOUT IS IN CRAWLSPACE. Tank Type/Material GREER / STEEL Date installed 5/30/1982 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation deanout (YM) `YES Depression over tank (YM) NO High water alarm (Y/N) N/A Date of pumping 11/1/2005 Pumper SANITARY PUMPERS C. ABSORPTION FIELD DATA Date installed 5/30/1982 Soil rating (g•p•d./It'or6%; 85 System type TRENCH Length 28 ft. Width 3.33 ft. Gravel below pipe 5 ft Total depth •7.4 ft. Eff. absorption area 280 W Monitoring tube "YES Depression over field NO Date of adequacy test 2/14-16/2006 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test DRY in. Water added 697 gal. New depth 17 in. Elapsed Time: 1426 min. Final fluid depth DRY in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YM & type) NONE KNOWN If yes, give date - "MONITORING TUBE ONLY EXTENDS 3.5' INTO DRAINROCK. FROM WELL LOG Date of test 6/4/1982 Static water level 285 ft, Well production 15-20 g,p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi. Nitrate <1 mg./L. Well Log (Y/N) YES Wires property protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 2/15/2006 ft. 0.55 g.p.m. Other bacteria _2 colonies/100 ml. Arsenic: <5.0 ug./L. Date of sample: 2/16/2006 Collected by: GEG Ltd. 13. SEPTICIHOLDINO TANK DATA "FOUNDATION CLEANOUT IS IN CRAWLSPACE. Tank Type/Material GREER / STEEL Date installed 5/30/1982 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation deanout (YM) `YES Depression over tank (YM) NO High water alarm (Y/N) N/A Date of pumping 11/1/2005 Pumper SANITARY PUMPERS C. ABSORPTION FIELD DATA Date installed 5/30/1982 Soil rating (g•p•d./It'or6%; 85 System type TRENCH Length 28 ft. Width 3.33 ft. Gravel below pipe 5 ft Total depth •7.4 ft. Eff. absorption area 280 W Monitoring tube "YES Depression over field NO Date of adequacy test 2/14-16/2006 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test DRY in. Water added 697 gal. New depth 17 in. Elapsed Time: 1426 min. Final fluid depth DRY in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YM & type) NONE KNOWN If yes, give date - "MONITORING TUBE ONLY EXTENDS 3.5' INTO DRAINROCK. D. LIFT STATION Date installed "Pump on" level at _in. E. SEPARATION DISTANCES Size in gallons High water alar level at Cycles tested Meets alar & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAift station on lot 100'+ Absorption field on lot 100'+ Public sewer main 100'+ Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer menhole/deanout 100'+ Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 1001+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 100+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehide storage 10'+ Curtain drain 25'+ Wells on adjacent IM 100'+ 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. Engineers Printed Name JEFFREY A. GARNESS J Date3�lr D6 �+ COSA Fee I 3 ' G Waiver Fee E Date of Payment Gt✓ Date of Payment Receipt Number —1 ti �) Receipt Number (Rev. 11/05) Y A. Rrrneas:' • • CE-7�s3 ` •3�t/aL, �•'',�� Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Advisory Health Authority Approval # 060074 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Block 1, Lot 13 of Scimitar #3 subdivision, the well's productivity was determined to be 0.55 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 3 -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 Health Authority Approval. i ASBUILT-NO CORNERS SET THIS DATE. I HEREBY CERTIFY THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTYl Scimitar Subd.,Unit No. 3.Lot 13,131k. 1 AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI- VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OF FENCE LINES, OR FOR ESTABLISHING BOUND- ARY LINES. 0 SEWARD b ASSOCIATES LAND SURVEYING 688-4561 SCALE: 0 1•'=40' _ r QEF OF Al .•• DATES 2-12-91 lowT:� .. , s- r .... ...... GRIDS hW 1261 ,, � yc o•«. Merk S.- 'd � I� yam•, LS -6918 t • FS • 18-62 ` DRAWNe DMS 2/1'd 9b2£8££L06:oi ;wojd 15:01 9002 -80 -Mi MUNICIPALITY OF ANCHORAGE • t 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 1 APPROVAL FOR A SINGLE FAMILY DWELLING �/j Parcel I.D. # ��� >32-9Cd HAA # �/7 1. GENERAL INFORMATION Complete legal description scimitar #3, Lot 13 block 1 TI 5N R1W Sec. 10 Location (site address or directions) 19643 Belduque Court Property owner Him Homes of Alaska Day phone 271-4342 Mailing address 222 W. 8th Avenue (Box N-64), Anchorage, AK 99513 Lending agency N Day phone Mailing address Agent Sandy Hjelmsted/Associated Brokers Day phone 563-3333 Address 640 W 36th Ave. Suite 1 Anchorage, AK 99503-5807 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 1 3. TYPE OF WATER SUPPLY: Individual well X— 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 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 (Rev. 1/91) Front MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Eagle River Engineering Services Phone 694-5195 Address P.O. Box 773294, Eagle River, AK 99577 Engineer's signature Date 6. DHHS SIGNATURE _ Approved for bedrooms. Disapproved. Conditional approval for a�N'� P10 y 0) a �0 0o o+10e°a.' �n C5 ..6l.fU A�9 �a f.ofa as �A^ a Louis A. "UOMVS y Cc -5736 >s V.� 'to�lf �.fe form', `Ci!19 LA`V Fid el�'^`•` '� bedrooms, with the following stipulations: Additional Comments 1%9y '76 7-Y, uJell�z2 e&_ -e5 Z% l 11ITIC Date a�A 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 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 N21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: lop>"13 elwl Scin ;tt -0�? Parcel I.D. D 5 -_ A. WELL DATA Well type i�r�va If A, B, or C, attach ADEC letter. ADEC water system number Log present(Y/N) Date completed D,riller /"42214 mY4 132 11;J' Total depth -26r Casedto /N Casing height Sanitary seal (Y/N) Date of test Static water level Well flow Pump level Wires properly protected (Y/N) FROM WELL LOG a�✓1r.,�s✓r✓ /s- -zo a,-- 6--4 g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /6T Absorption field on lot Public sewer main Prwv� Pt+13Fio sewer service line WATER SAMPLE RESULTS: x AT INSPECTION Z �Q a.v�' � uas ItiA4t 0.13 g.p.m': �5 U r� " � --�' Z6JI ; On adjacent lots 7+ leo' On adjacent lots I Public sewer manhole/cleanout ^ 1--+ Petroleum tank Coliform Nitrate Other bacteria Date of sample: �23'/5i Collected by: B. SEPTIC/HOLDING TANK DATA Date installed S �����-z Tank size a Compartments Cleanouts WN) ,y Foundation cleanout (Y/N) y Depression (Y/N) �✓ High water alarm (Y/N) 'V 1A Alarm tested (Yl�1 Date of pumping ;K/91 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot —On adjacent lots fi"o' Foundation a To property line 7s Absorption field s / Water main/service line 5 S Surface water/drainage N 72-026(Rev_391) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION ^Ile4 Date installed ��' Manufacturer Size in gallons Vent(Y/N) Nigh water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA "Pump off' level at Cycles tested Surface water _ Date installed Soil rating FI– System type Length -29 � Width 4' Gravel thickness •s Total depth Total absorption area Depression over field (Y/N) Results (pass/fail) Cleanouts present (Y/N) Date of adequacy test for Peroxide treatment (past 12 months) (Y/N) If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot //!– On adjacent lots 7`14 Property IineZ_ To building foundation T-- To existing or abandoned system on lot ^ �� On adjacent lots t -Fo ,� Cutbank "'l-+ Water main/service line t le ' Surface water ^'/a Driveway, parking/vehicle storage area 7`/-O' Curtain drain -y E. ENGINEER'S CERTIFICATION J bedrooms 1 certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the d to of this inspection. Signature , Engineer's Name Date 9/ �• NAA Fee $ t1� Waiver Fee: $ / Date of Payment — Date of Payment < r. 7 3 � (0 t1 Receipt Number Receipt Number 72-026 (Rev. 3/91)Back MOA 21 Eagle River Engineering Services 11940 Business Blvd, Suite #205 P.O. Box 773294 Eagle River, Ak. 99577 Legal: Owner: Time Meter Reading Well Level GPM s /�J 1. 3s' J�`S av7 St t /; y5 rGov Asa �• s sI/s me On rAw—( Q,!3 S �3 �sss o,s S Ib --279 274 o. 1i F:/sq 6&mak 2t9' 0.6 r r/ /;ay /oatsa �bo o,ai -77/a 1;2 dy D.S' S i8 y;sa �36o a6& o,5- 9 ig 80 4H s�z ! r5a.D 286 0.37 i 71 694-5195 Fax 694-3297 Date: TimeMeter Reading Well Level GPM �757.2- S /y me On rAw—( Q,!3 S �3 /:se --279 274 o. 1i /apv r /;ay /oatsa �bo o,ai ! 3o v F�= REMARKS: /r-. ie . e / O o, is GPS , r �d f ZUAqZ;,,,t'� 0 Eagle River Engineering Services 11940 Business Blvd, Suite #205 P.O. Box 773294 Eagle River, Ak. 99577 694-5195 Fax 694-3297 Legal: Gd I- /.� Ste" ' r Date: Owner: ,tea Type of test: [I Well Flow Test Septic Test Only 13 Well & Septic Test [3 Other: 0 MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services b i DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel 1. D. # (`�)� ' 1 -' `� HAA # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 13• Block 1• Scimitar Subdivision #3 Location (address or directions) NHN Beldu ue Court off Sieka Drive (b) Property owner Sue Karl Telephone: (home) Business Mailing Address 1-y (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent RF/MAY DE FACT F RTVFR non McKenzie__ Address 16600 Centerfield Drive, Suite 201, Eagle River, Alaska 99577 Telephone 694-4200 (e) Mail the HAA to the following address: (or check hereja if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING/694-2979 17034 Eagle River Loop Road, Suite 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single -Family 0( 3. WATER SUPPLY Number of bedrooms 3 Individual Well Rk Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On -situ Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025(Rev _7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval .shows that the on-site water supply and/or wastewater disposal system is safe, functional .and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of FirmTelephone S & Road No. 204 Address 17034 Eagle River Loop sag e KWOFY Date �^Uh t:i7`�,q�" 6. DHHS APPROVAL Approved for 3 bedrooms byDate Approved x Disapproved Conditional Terms of Conditional Approval CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 notconduct 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. 1/88) Back Page 2 of 2 z r` j,'o A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) A Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: _kQt_ 13, Well Classification ..J di J i dy A I If A. B, C, D.E.C. Approved (Y/N) �l- Well Log Present (Y/N) Date Completed (p 3 ` �� Yield -� I X(- rm1xwt Total Depth_a._E3!5�Cased toLrAl Depth of Grouting Static Water Level 4 � � Pump Set At L)lf5� Casing Height Above Ground j Sanitary Seal on Casing O/N) Electrical Wiring in Conduit (Y/N) r Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot —I nn 7t" ; On Adjoining Lots �� t To Nearest Edge of Absorption Field on Lot f oo ' J' ; On Adjoining Lots ( (DO '1 To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ( t, 1 Water Sample Collected by 'S F�aitoeeP;nta Date h �JuN(S�, Water Sample Test Results ;'> A n S 7�A G LOf Comments B. SEPTIC/HOLDING TANK DATA Date Installed ize 10100 No. of Compartments Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N) y Depression over Tank (Y/N) A) Date Last Pumped o2 ( c uNe. 97 Pumping/Maintenance Contact on File (Y/N) fy! A ; for Holding Tank High -Water Alarm (Y/N) _ � Temporary Holding Tank Permit (Y/N)1JT SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well / oo rh To Building Foundation To Property Line :57 'i' To Disposal Fie d S To Water Main/Service Line I�\-� To Stream, Pond, Lake or Major Drainage Course sn N 1 P# Comments .� P 5 r�� 72-026 (Rev. 7i8e( Front Page 1 of 2 C. ABSORPTION FIELD DATA _ rr Soils Rating in Absorption Strata Type of System Design �Q2NGN Date Installed 30 1" 66, Length of Field 12 , n � WidtDepth of Field / Gravel Bed Thickness I/ Square Feet of Absortion Area 42 P,0 Statndpipes Present (Y/N) r Depression over Field (Y/N) t Date of Last Adequacy Test oZ a NC r Results of Last Adequacy Test �u4fi S fW Gfol4 3 Q�d ✓ 6ovH SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well !�� I + To Property Line S f/�"►/ To Building Foundation _3110 -r To Existing or Abandoned System on Lot t Dy i" ; On Adjoining Lots D i" To Water Main/Service Line ! (0 �"� To Cutback (if present) �68 To Stream, Pond, Lake, or Major Drainage Course NA To Driveway, Parking Area, or Vehicle Storage Area :5n t Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Check Permitted Bedroom Rating Against HAA Request" "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on,"e date of this inspection. �S %3F �b LLA _ s^��� _4® Signedm 14G d t OV Company 17034 Eagle River Loop Road No. 204 Of Eagle River, Alaska 99577� Date // a• MOA No. Receipt No. a�� Date of Payment Amount: $ /,219 D Receipt No. Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 v".•+s........ � r 4. sh** =gp No. aasr.6 e° E5Sl0�o. CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order # 14410 Date Report Printed: JUN 29 89 @ 20:26 Client Sample ID:LT 13, BLK 1 SIMITAR PWSID : Collected @ hrs. Received JUN 27 89 @ 17:00 hrs. Preserved with :AS REQUIRED Client Name S & S ENGR Client Acct SNSENGP P.O.# VERBAL Rea # Ordered By UA Analysis Completed :JUN 28 89 Send Reports to: Laboratory Supe visor STEPHEN C. EDE 1)S & S ENGR Released By ���� �( / 2) Special Instruct: Chemlab Ref #: 5987 Lab Smpl ID: 3 Matrix: WATER Parameter Tested Result/Units --------------------------------------------------------------------- NITRATE-N ND(0.10) mg/i Sample ROUTINE SAMPLE. COLLECTED BY RJS. Remarks: Allowable Method Limits -------------------------------- EPA 353.2 10 1 Tests Performed See Special Instructions Above UA=Unavailable ND= None Detected °° See Sample Remarks Above NA= Not Analyzed LT=Less Than, GT=Greater Than CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. & TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 j�f = ; L 4,--�„m.,.. Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY ❑ PUBLIC WATER SYSTEM LD.# Anal sis shows this Water SAMPLE to be: PRIVATE WATER SYSTEM Satisfactory Unsatisfactory Name Phone No. S&1iEWAMPRING ❑ Sample too long in transit; sample should not be over 30 hours old at examination Mailing Address Ows"S - to indicate reliable results. Please send new sample via special delivery mail..,, City State Zip Code ' ® © ® Date Received SAMPLE DATE: Mo. Day Year Time Received SAMPLE TYPE: 1I Routine ❑ Check Sample (for routine sample with lab ref. no. ) ❑ Treated Water ❑ Special Purpose ❑ Untreated Water SAMPLE Time Collected NO. LOCATION Collected B 1XT rmffafr 6A. 21 1 3 4 Gil Analytical Method: Membrane Filter I No. of colonies/100 ml. I Lab Ref. No. Result' Analyst ® - IUJ m U m IUJ m i I m f BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS Membrane Filter. Direct Count b Collform/100ml BEFORE COLLECTING SAMPLE Verification: BG Final Membrane Filter Results O Collform/100ml Reported By— Aj Time: r a.m. ;f p.m. TNTC = Too Numberous To Count OB = Other Bacteria APPLIG` VT FILLS UU I Urrr-M nN►L ,VIIL- I Time - Phone Property Owear Myers Construction, inc. 99577 694-9633 Mailing Address Eagle River AK zip code Buy,`e;, Susan M. Karl - - Address Gould Hall, APU r c/o USGS zip code Phone Lending Institution National Bank of Alaska Address 301 W. Northern Lights- zip Code Phone Realty Co. B Agent Totem Realtyr Inc. (Jim Montague) Eagle River AK Zip Code 99577 694--9494 Address 1 Legal Description Lot 13, Block 1, Scimitar #3 Bedduque Court Street Location Field Notes: Type of Residence l[X Single Family 3 ❑ Multiple Family No. of Bedrooms El Other `CONDITIONS Water Supply ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. �l Individual - - For wells drilled prior to that date, give well depth (attach log if available). El Community ( ) CONDITIONAL APPROVAL* ❑ Public Utility Sewer Disposal Year Individual Installed: � Individual - - When Connected to Public Utility: ❑ Public Utility ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time - Time Time - Gk-At� -Ac' Date Date Date Date 10- S - S a Inspector Inspector Inspector_ Inspector W Y . 0-Cl Field Notes: L ( APPROVED BEDROOMS `CONDITIONS OF APPROVAL ( ) DISAPPROVED - ( ) CONDITIONAL APPROVAL* j- 11;96 DATE ✓ DATE. BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received /(/O Well to Tank Septic Tank Size (Q�(j p 72.023 (3182(