HomeMy WebLinkAboutSCIMITAR #3 BLK 3 LT 1Scimitar #3
Block 3
Lot 1
#051-132-84
Municipality of Anchorage
On-Site Water and Wastewater Section • (907.) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP211259 PID Number: 051-132-84
Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade
Name
A ORPTION FIELD
Elmer Harmon
E01D Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
20008 Solleret Drive, Chugiak, AK 99567
Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
1S
F Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original a Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Scimitar #3 3 1
Fill added above original grade Gr I length
Ft. Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Dista a between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Holding
Sewer
Total absorption area
Number of trenches
Dist. between t ches
From
Tank
Field
Lift Station
I Tank
Line
Ftz
Well
100+
TANK 0 Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
GREER
Capacity
1000 Gal.
Surface Water
100+
Material
Number of compartments
Lot Line
5+
NA
PLASTIC
2
Foundation
10+Y
I
I
TATION
Manufacture
Capacity
Remarks x , �,
Field verified 5 6 separation from deck
Gal.
foundation post.
Alarm location
Elec r ailed by
*x Field verified 5'+ separation of tank to trench
Installer
PIPE MATERIAL House to tank Tank to
D3034 drainfield D3034
Highland Excovation
Drainfield CO/MT D3034
Inspector Arcterra Consulting
BENCH MARK (Assumed elevation) 100.0 ft
Inspection r
dates: 8/6/21 2nd 8/6/21
Location and description
,
31" 8/10/21 4'"
Downstairs door frame
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
mA��and���
OF 444
Conditional Approval: Date
,4$�d�,y.•��4
Septic System
%�,� KENNET Si
Arov
pP Date
CE 711 .r° ��
Note: this approval does not include well permit requirements.
tQ�Ra♦e
�w v.'ruu Tui
AS—BUILT SYSTEM DETAILS/SITE PLAN
Permit O3P211259
SCIMITAR #3 BLOCk(3 LOT 1 PID# 051-132-84
/
' \
/ \
/
/
EXISTING
TRENCH
/
cx /
/
= /
A—C=Z3.4'
B—C=23.5'
DRAW: KSD
A—D=16^O'
CHECKED: KMD
B—D=28.I'
�
A—E=18O~
.
�
B—E3'
_ .
�
�
A—F=22.5'
B—F=20.5'
�
A—G=23.3'o
U�
SCALEs NTS
PREPARED FOR'
[LMER HARMON
20088 SOLLERET DRIVE
CHUGIoK, AK 99567
SCALE: NTS
BOUNDARY' N /A
DRAW: KSD
STMNQ_ N/A
CHECKED: KMD
AS8UILT'.
DATE 8/16 /21
DWG. RLE-
NW1261
ACAD FILF- FILE
JOB No' 2104
SCALE: NTS
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: OSP211259
Work Type: SepticTank Upgrade
Tax Code Number: 05113284000
Site Legal Address: SCIMITAR #3 BLK 3 LT 1 G:1261
Site Mailing Address: 20008 SOLLERET DR, Chugiak
Owner: HARMON ELMER H JR & HELEN M
Design Engineer: ARC TERRA CONSULTING INC
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date
Expiration Date:
Lot Size in Sq Ft
Total Bedrooms:
N,
Ikx�
D partment
7/21 /2021
7/21/2022
40157
❑ 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
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By:
(N
Issued By:
Date:
Date: 2( 2
3
Development Services Department
On -Site Water & Wastewater Section
Parcel I.D.
Property owner(s)
051-132-84
f AT
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Elmer Harmon
Mailing address 20008 Solleret Drive, Chugiak, AK 99567
Site address 20008 Solleret Drive, Chugialc, AK 99567
Legal description (Sub'd., Block & Lot) Scimitar #3 Block 3 Lot 1
Legal description (Township, Range & Section)
Day phone
Lot Size 40,157 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
(® all that apply)
Absorption Field
❑
Initial ❑
Septic Tank
E
Upgrade ■
Holding Tank
❑
Renewal ❑
Privy
❑
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
TYPE OF DWELLING:
Single Family (SF)
(w/wo ADU)
Duplex (D) ❑
Multiple -Dwellings -Q
(SF and/or D)
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
Dea Duffus
(Signature of property owner or authorized agent)
Permit/Rush Fees: &Z5 Waiver Fees:
Date of Payment: Date of Payment:
Receipt Number: Receipt Receipt Number:
Permit No. �� 2 I/2.5611 Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211259, Deb Wockenfuss, 07/21/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211259, Deb Wockenfuss, 07/21/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211259, Deb Wockenfuss, 07/21/21
MUNICIPALITY OF ANCHORAGE
q, DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
j ENVIRONMENTAL ENGINEERING
DIVISION
825 L Street - Anchorage, Alaska 99501
Telephone 264.4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION
REPORT
NAME
PHONE
I fi4NEW
/
!&L�i
& .Q*
❑ UPGRADE
MAILING ADDRESS
P. c:>)
-1 Qt
LEGAL DESCRIPTION
Lam,
LOCATION
NO. OF BEDROOMS
Well
Absorption area
Dwelling
PERMIT NO.
Uy
DISTANCE TO:
, ds
S 1
rJc'f I'_'S
�s�2tB0
H z
W
Manufacturer
G-► P, �G -
Material
sem_
No. of compartments
Z -
y
Liq. capacity in gallons
IF HOMEMADE:
Inside length
�---
Width
Ligiad daoth
p z
DISTANCE TO:
Well
Dwelling
PERMIT NO.
.j 0=
z
Manufacturer
Material
Liquid capacity in gallons
=
DISTANCE TO:
Well t
Foundation
Nearest lot line
PERMIT NO.
w O
w
No. of lines
Length o e� line
g �h
Total len ,th of,lines
Trench width
L4'0
Distanco ween lines
I
/'I'S
inches
/�
hTop
of the to finish grade I
Material beneath the
LOO
Total effective abso rption area
-j
inches
ZJ-�Y
Length Width
Depth
PERMIT NO.
Lu
C7
Q F
Type of crib Crib diameter
Crib depth
Total effective absorption
area
L
d
w
Well
Building foundation
Nearest lot line
'
DISTANCE TO:
Class De th
Driller
Distance to lot line
PERMIT NO.
J
I
Lu
Bu (ding foundation
DISTANCE TO:
Sewer line
Septic tank
Absorption area(s)
OTHER
`^'
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
Fi�i �ti eT
REMARWS
J
t tieue n
x ae ee J�S GT �r
u R
�' a (tiabert /..uShr4er i;`;�;f
APPROVED 8 V ESNCINURINO DATE LEGAL
SLS
�Lt �S
,� �IvER��, AfJ�s� �s3� JP14, 69&2972
-/,)_nlq ipo,, znRl
`
** TANK MUST HAVE AT LEA�T TWO COMPARTMENTS
) ISSU..... . .
-�.... ..... ... ... ==�_~~~�
- SOIL .LOG
,— MUNICIPALITY OF ANCHORAGE
�.,. ❑ PERCOLATION
• DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST
�.J 825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR:• DATE PERFORMED:
LEGAL DESCRIPTION:--=�'r�u'
SLOPE n$ITE PLAN
1 o
2 r
3 -�
4
5
6
'• n
7
9 ;
/D
10-
11
0 11 �� r
12 c o'
e
13
Sw
L—\ L -i Nj SSl %Y
� S C5
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
( v'VrDY--A f)5 t4L r
14
15
yyy
Yff' fY
.'000 M'.
16 07 �� ('s `a,0
Oltt
17 m 59 ,90
18 �. ,`= ylobvrt•A oShafer
�A, No. 1457-e r a°
19—
pp 4 \-
20
COMMENTS
PERFORMED BY:
72-008 (6/79)
--1-� s
L
O
P
E
■MA■■�I■■■M
■■■■■.I■■■I■
Gross
Net
Depth to
Net
Reading
Date
Time
■■E■■ERI■■M
Water
Drop
1101110=1-191901M
'.■NI■■.■■■IM
NEENE■■■.IE
MENNE■■■.IEI
WEENN■■.RIN
I (`
R'■■■■■.,■
.
W„■■■E.■■
W■'NEW■■■■
-
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
CERTIFIED BY:
DATE:
Gross
Net
Depth to
Net
Reading
Date
Time
Time
Water
Drop
I (`
.
-
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
CERTIFIED BY:
DATE:
• .Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. _051-132-84 Expiration Date:Z3
—�---- -
1. GENERAL INFORMATION
Complete legal description Scimitar #3 Block 3 Lot 1
Location (site address) 20008 Solleret Drive,_Chugiak, AK 9956.7
Current Property owner(s) Elmer Harmon Day phone
Mailing address
Real Estate Agent
20008 Solleret Drive, Chugiak, AK 99567 _
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 _ Well
❑
Public Water System
❑
WaiverNariance request for:
3
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual
Holding Tank
❑
Community
❑
Public Sewer
❑
Received by:
_---------- Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 550
Date of Payment 5 /7 y
Receipt Number 356:
Waiver Fee $
Date of Payment
Receipt Number
COSA # 6 5GZ 1 1995 Waiver #
istance:
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 ARCTERRA CONSULTING, INC. Phone 696-6111
Address 20441 PTARMIGAN BLVD.,_EAGLE RIVER,,AK 99577
Engineer's Printed Name KENNETH M. DUFFUS
_ Date oG/
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessme�tof the condition
of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface
conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system-
The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of
the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
OF .41
�r
�`��
6. DSD SIGNATURE
System #1 Approved for bedrooms.
I KENNETH Its 1,
System #2 Approved for bedrooms.
Axe
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
B
Y(p(�r(rr(�i�i
WAT_FR Af�p m
WASTEvVATER Z
PROGR
aM
Original Certificate DatJ?,
-z-/
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 blue sheet -10-10-12 doc
Legal Description: Scimitar 43 Block 3 Lot 1
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled 4/30/84
Total depth 126 ft
Cased to 60 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 25 in.
Date of flow test for COSA 6/18/21
Static water level at beginning of test 42 ft.
Comments
B. TANK DATA
Age of tank(s) New years
Tank type/material Septic/Plastic
Measured operating fluid level in septic tank New
IN Standpipes/foundation cleanout per record drawing
Date of pumping New tank 8/6/21
D. ABSORPTION FIELD DATA
Which system tested (date installed) 2/15/85
ALL standpipes present per record drawing
Total measured depth from grade 11 ft (max)
Measured depth to pipe invert from grade 6 ft (min)
❑ N/A - pressurized field
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:
COSA Checklist yellow sheet
Parcel ID: 051-132-84
Structure served by this system
Well production at time of test 1.8 gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes No
Coliform bacteria is Negative
Nitrate 2.01 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L U Arsenic less than MRL (ND)
Collected by Arcterra Consulting
Date of Sample 6/18/21
FT STATION
❑ Req-311N4.mmaintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 6/18/21
Results Q Pass For 3 bedrooms
Fluid depth prior to test 25 in
Water added 450 gal
New depth 31 in
Elapsed time 200 min
Final fluid depth 25 in
Absorption rate 450+ gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
t
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'
® Yes
if No *
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25'FO Yes
if No
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' ® Yes
if No
® Yes
if No
ft
ft
If septic tank is under driveway comment below
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ®Yes
if No
ft
® Yes
if No
From SepticlHoiding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
® Yes
if No *
ft
Surface Water > 100'
Yes if No
Property Line > 5'
® Yes
if No
ft
Wells on Adjacent Lots:
® Yes
Absorption Field > 5'
® Yes
if No **
ft
Private Wells > 100'
® Yes if No
Water Main > 10'
® Yes
if No
ft
Community Wells > 200'
® Yes if No
Water Service Line > 10'
® 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)
ft
ft
ft
ft
ft
ft
ft
ft
Building Foundation > 10'
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 ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No ft
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
* Field verified 5'6" separation of tank to deck foundation post oq 8/6/21
x* Field verified 5'+ separation on 8/6/21
G. ENGINEER'S CERTIFICATION
l 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.
COSA Checklist yellow sheet
s m
.....ti.,.w. ...pie::.
°�: KENNETH M. U FUS
G�U'y'4 GE } ` e
PLOT PLAN ___ AS BUILT _X_ SCALE _ 1___ 30__
GRID _ NW 1261 Project
No.
21-54 /R1
Lang & A s s o c i a t e s inc.
11500 Daryl Avenue, Anchorage, Alaska
(907) 522-6476 Phone
99515-3049
'
Professional Land Surveyors
(907) 522-4625 Fax
ken0longsurvey.com
F A
o 0
jonathanQlongsurvey.com�544�
I hereby certify that I have surveyed the following described property:
LOT 1, BLOCK 3, SCIMITAR SUBDIVISION — UNIT No. 3 (PLAT No. 80-51)
Anchorage Recording District, Alaska, and that the improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
no improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission lines or other visible
easements on said property except as indicated hereon.
Dated this the �2 fCti
_______ Day of � _ C _ at Anchorage, Alaska
It is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat.
P 4 91H y*�
KENNETH . 'LANGo
Its
S— 202. gJ4�
40�R�FeSS10NA�-
AECC963
• '° Municipality of Anchorage
On -Site Water and Wastewater Program
(907)343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 051-132-84
1. GENERAL INFORMATION
T.
SU
3a 6
MAY 1 2 2014
Expiration Date: 2 t
Complete legal description Scimitar #3, Block 3, Lot 1
Location (site address) 20008 Solleret Drive, Chugiak, AK 99567
Current Property owner(s) Jodie A. Jolley Day phone
Mailing address P.O. Box 672287 Chugiak, AK 99567
Real Estate Agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: Three
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
El
Individual
0
Individual Water Storage
❑
1Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
WaiverNariance request for:
Distance:
/ ` �"
� '��
Received by:
Dater
"' 4!vt Y
COSA to be released to the engineer, unless otherwise
requested by the engineer.
COSA Fee $ 500L
Date of Payment 511o(iq
Receipt Number
COSA# 0sr 411
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
Phone 522-7773
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
Date 5/11/14
c
E
6. DSD SIGNATURE
System #1 Approved for bedrooms
16,a� � > 1
Txb
System #2 Approved for bedrooms
Disapproved
S
�K ! = .,Sr-
Conditional
Conditional approval for bedrooms, with the following stipulat on'sL-, Y
By: �%O , /—� Original Certificate Date:
Th nay If el orage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the repre entations 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
COSAbluesheet f '.t c
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 3, Lot 1
A. WELL DATA
Well type Private
Date completed 4/30/84
Total depth 126 ft.
Date of test
Static water level
Well production
If A, B, or C provide PWSID #
Sanitary seal (YIN) Y
Cased to 60 ft.
FROM WELL LOG
4/30/84
Undetermined ft
2.0 g.p.m.
WATER SAMPLE RESULTS
Coliform 0 colonies/100 mL Nitrate 1.13 mg/L
Arsenic N/D ug/L Date of sample: 4/30/14
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel
Tank size 1,000 gal. Number of Compartments 2
Parcel ID: 051-132-84
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) >12 in.
AT INSPECTION
4/28/14
36.8 ft.
2.3
g.p.m.
Collected by: Anderson Engrg.
Date installed 9/15/85
Cleanouts(Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 4/23/14 Pumper Sanitary Pumpers
C. ABSORPTION FIELD DATA
Date installed 9/15/85 Soil rating (g.p.d./ft? or ft2/bdrm) 150 SFIBDRM System type Deep Trench
Length 45 ft. Width 3.3 ft. Gravel below pipe 5 ft.
Total depth 11 ft. Eff. absorption area 450 flz Monitoring tube Y Depression over field N
Date of adequacy test 4/28/14 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 565 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 in.
Datum
E. SEPARATION DISTANCES
WELL ON LOT TO:
Size in gallons
"Pump oft"level at in.
Cycles tested
Septic tank/lift station on lot > 100'
Absorption field on lot >100'
Public sewer main
Sewer /septic service line
N/A
>25'
Animal containment areas >50'
SEPTIC/HOLDING TANK ON LOT TO
Manhole/Access(Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots >1 00'
On adjacent lots >100'
Public sewer manhole/cleanout _
Holding tank N/A
Manure/animal excrete storage areas >100,
N/A
rel
Building foundation >5' Property line ">5' Absorption field >51
Water main >10, Water service fine >10' Surface water >100,
Wells on adjacent lots >100'
ABSORPTION FIELD ON LOT TO:
Propertyline >10 Building foundation >10 Water main
N/A
Water Service line >10 Surface water.. >100 -Driveway,parking/vehicle storage >10
Curtain drain None Noted Wells on adjacent lots >100'
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that t 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 5/11/14
COSA brown sheet_10-10-12.doc
^^an -N P
r E"i""EE
C6` j C=-43:,1
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.muni.org/onsite
(907)343-7904
r210 7
4 -
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. i�J`—/-13�-�4 COSA # (0140go.,
Expiration Date: 0— 2 9- Oz
1. GENERAL INFORMATION
Complete legal description Lot 1. Block 3, Sanitar #3 DIC
Location (site address) 20008 Shcoret Drive, Chugiak, Alaska 99567
Current Property owner(s) Richard Stephen Williams Day phone (907) 668-2026
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
P.O. Box 671812, Chugiak, Alaska 99567
Day phone
Audrey Mason Day phone (907) 622-3344
1660 Cenlerfield Drive. Suite 201, Eagle River, Alaska 99577
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well❑
❑�
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
❑�
Individual Holding Tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site 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 sample results. (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 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 Douglas T. Kenley
Phone te07l27s-1073
Address 9606 E. North Star Circle, Palmer, Alaska 99645
Engineer's Printed Name Date �* a S • v '�
CA
*J:4 .. ...
5. DSD SIGNATURE '//' 1 ' CE 8176
00
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Ely:C% %%%`e��.�• �Original Certificate Date: (G ' 02 8— 0 7
(n« 11,05)
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water 8 Wastewater Program
4700 Btagew Street
P.O. Box 198850
Anchorage, AK 995198850
www.muni.orglonaite
(907) 3437904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Lot 1, Blodr 3. Sadler #3 SM Parcel ID:
A. WELL. DATA
Wen type Pmro If A, B, or C provide PWSID 0 _
Date completed 4Me4 Sanitary seal (Y/N) Y
Total depth 125 It. Cased to 50 R.
FROM WELL LOG
Data of test 484
Static water level unknown ft.
Well production 2 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 co►onias1100 mL Nitrate 0.50 mg/L
Arseerec: 10 mgA Date of sample: 5n iw
B. SEPTICIHOLDING TANK DATA
Tank Type/Material Swkft st
Well Log (YIN) Y
Wires property protected (YIN) Y
Casing height (above ground) 12+ in.
AT INSPECTION
04x"7
114 R.
2.5 9.p.m.
Other bacteria 0 colonkW100 ml-
Collected
L
Collected by: Fred Kenley
Date Installed 9115/95
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (YIN) Y Depression over tank (YIN) N High water alarm (YIN) NIA
Data of pumping 5nero7 Plumper J. R. Aerrolno
C. ABSORPTION FIELD DATA
Date installed ar15155 Soil rating (g.p.d./fe or fe/bdrm) 150 System type asrch
Length 45 ft. WId1h 3.3 ft. Gravel below pipe 5 ft.
Total depth ' 71 ft. Eftabsorption area u0 fe Monitoing tube Y Depression over held N
Date of adequacy teat 4/3oW Results (Pass/Fail) Pm For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 813 gal. New depth 2-1/4 in.
Elapsed Time: 39 min. Final fluid depth o In. Absorption rate >= 450 g.p.d.
Arty rejuvenation treatrrleht (past 12 mo.) (Y/N 8 type) No If yes, give date —
D. LIFT STATION
Date installed
'Pump on' level at _ in.
Size in gallons Manhole/Access (Y/N)
'Pump off" level r alarm level at
Cycles tested Meem alarm & circuit requirements?
in.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAHt station on lot 103f
On adjacent kits 100+1
Absorption held on lot 119+1
On adjacent kits 100+1
Public sewer main NIA
Public sewer manhole/deanout wA
Sewer /septic service kne 25+'
Holding tank WA
Animal containment areas 75+'
Manure/animal excrete storage areas 100+'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation s+• Property line 10+'
Absorption field 5'
Water main NIA Water service line
25+' Surface water 100+'
Wells on adjacent lots 100+'
SEPARATION DISTANCE FROM ABSORPTION FIELD
ON LOT TO:
Property line le+' Budding foundation
lo+• Water main NIA
Water Sarvice fine 25+' Surface water 100+' Driveway, parkinoshide storage 30+'
Curtain drain rrm.ra� lo =W Weds an adjacent lob
100+'
F. COMMENTS:
G. ENGINEER'S CERTIFICATION
/ certo that I have determined through Held inspections and
review of Muntapal records that the above systems are in
conibmu nce with MOA COSA gukfelines in effect on this date.
Engineer's Printed Name DswIn T• Kenley
Date _ (4. 2 T - tD 7r-
COSA Fee S 0
Date of Payment
Receipt Number.
(Rev. eros)
Waiver Fee $ _
Date of Payment
Receipt Number,
Municipality of Anchorage
Development Services iDepartment o ti;,re
:1
_ Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchoeage.ak.us
(907) 343-7904 .
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING 11''
ParcelI.D. 051-132-84 HAA #_ E�
Expiration Date: 1 ' G ' p
1. GENERAL INFORMATION
Complete legal description SCIMITAR 41, RLOCK 3- LOT 1
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone
Day phone
• . RRA"•i.
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual On-site
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional
civil engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health
Authority 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 sample results. (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-ublic 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 Health Authority 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• • ui .►FP ► ► ► 07M C*Tf
Engineer's Printed Name Kenneth M. Duffus Date 9/18/2003
Engineer's Comments:
This investigation was completed in compliance with
ADEC and MOA regulations. The assessment of the
condition of the well and septic applies only to the
conditions as of the day tested. The flow and absorption
rates may change due to subsurface conditions that
may not be observed from the surface, changes in
land use, local soil characteristics, groundwater levels
that may fluctuate during the year and the water usage
of the family being served by the system. The operational
life of all well and septic systems are subject to these
various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system.
Therefore, KND can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can KND guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
5. DSD SIGNATURE
Approved for 3 bedrooms.
Disapproved.
Wy�Qur
'(E.........
.... . .......
Kenneth M. ff
CE 71
Conditional approval for bedrooms, with the following stipulations:
(f
ON-SITE • G1
€R -AND m
WASTEWATER
Attachments: �� •'•.
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report �JJII�►1 X11)111
Well Flow Advisory
Other
By: Original Certificate Date:
..............
Municipality of Anchorage •,
* Development Services Department
4 �
Building Safety Division °
Onsite Water & Wastewater Program "
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: SCIMffAR #3, 833, 11 Parcel ID: 051-132-84
A. WELL DATA
Well type or� It A, B. or C provide PWSID # Well Log (Y/N) Y
Date completed 4/30/1984 Sanitary seal (Y/N) y_ Wires properly protected (Y/N) Y,
Total depth 126 ft. Cased to 60 t.
FROM WELL LOG
Date of test 4/,30/1984
Static water level SIX ft.
Well production 2.0 g.p.m
WATER SAMPLE RESULTS:
Casing height (above ground) 2
AT INSPECTION
8/28/200,3_
38 ft.
1.66 g.p.m.
Coliform __Q__wionles/100 mi.Nitmte D.4ft2 mg./I.Other bacteria _ 0 colonies/100 ml.
Arsenic: M mgA. Date of sample: 8/29/2003 Collected by: KND Enginegd=
B. SEPTICIHOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL Date installed 9/1S/8S Tank size 1o00 gal.
Number of Compartments 2 Cleanouts (Y/N).Y
Foundation cleanout (Y/N) Y_Aepression over tank (Y/N).H_High water alarm (Y/N) JR
Date of pumping ,8J28/Z,Q,0,3— Pumper SANITARY
C. ABSORPTION FIELD DATA
Date Installed 9/15/85 Soil rating (g.p.d./f? or fP/bdrm) 150 System type TRENCH
Length 45 ft. Width 3.3 ft. Gravel below pipe 3 ft.
Total depth " ft. Eff. absorption area 4Wfe Monitoring tube Y Depression over field H
Date of adequacy test 8128/03 Results (Pass/Fall) PASS For 3-_ bedrooms
Fluid depth in absorption field before test DRY 0 in. Water added 450 gal. New depth -23-1n.
Elapsed Time: _U min. Final fluid depth.- in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off" level at in.High water alarm level at in.
Datum Cycles tested Meets alarm 8 circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+
Absorption field on lot 100'+
Public sewer main 75'+
Sewer /septic service line 25'+
On adjacent lots 10 0 1 +
On adjacent lots 100'+
Public sewer manhole/cleanout 100'+
Holding tank 10 0'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5 ' + Absorption field 5 ' +
Water main ' 10'+ Water service line 10'+ Surfacewater 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line, 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water 10 0'+ Driveway, park)ng/vehicle storage 10'+
Curtain drain 50'+ Wells on adjacent lots 10 0'+
F. COMMENTS .
Vacant residence -2K gal, surcharge prior to testing. Recommend pumping tank shortbs after new
nnrnn�n+c Mnun in 1 curl tnc+ael n+ d 7Z nnh _ eo+icf0rtnn1 roculte _ 0IIA"Inhln lirnitc (i—I S)
G. ENGINEER'S CERTIFICATION
/ certify that l have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Kenneth M. Duffus
Date 9/18/2003
HAA Fee $375.00 Waiver Fee $ _
Date of Payment Q I I ` Date of Payment
Receipt Number l Receipt Number.
(Rev. 12101)
Aq
+1._
CE 7116
�0
Q
�3 DECK
/2.0' CAN
N //
/ y Pdow CANT
\ L■121__-
15' UTILIW EASEMENT
1-41
PLOT PLAN _ ASBUILT X SCALE 16 ' 40t GRID NW 1261 Project No. _
Lang & Associates, inc. 11500 Daryl Avenue, Anchorage, Alaska 99515
907 522-6476 Phone
Registered Land Surveyors 907 522-4625 Fax ! OF
i h rttt tis t 1 h d the toll i desarlbed ro '�` • •'"'
03-260
WW1641Y a are surveys own p .V • s�
L0T 1. BLOCK 3, SCIMITAR SUBDIVISION. UNIT3 (PLAT tM-51 �Q:•' • '•.�
Anchorage Recording District, Alaska. and ,that t e improvements situated • 9
thereon are within the property lines and do not encroach onto the property • ..... 4
adjacent thereto, that no improvements on the property lying adjacent thereto •' ' • ....... '
encroach on the surveyed promises and that there are no roadways. transmission .•
lines or other visible easements on said properti except as indicated hereon. ;t
+� • KENNETH 0. •L NO
Dated this the �� Day of p�a�i'- � 3 . at Anchorage, Alaska LS 5202 ; •' `
•
It is the responsibility of the owner to determine the exlstenos of any easements, p�
covenants, or restrictions which do not appear on the recorded subdivision plat. "'ssloNM.
eroby
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. #
1. GENERAL INFORMATION
4
3.
4.
HAA #
Complete legal description Lot 1 • B2ock 3• Scimitar. Subdiyi6ion. #3
Location (site address or directions) 20008 enet, Pet Caee
Property owner J•R. EDWARDS
Day phone 688-5241
Mailing address P U BOX 670885 Chugiak, A2azka 99567
Lending agency
Mailing add
Day phone
Agent LES BAILEY / CENTURY 21 Co2owi.a2 Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well XXX
Community well
Public water
696-8600
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site XXX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm S & S ENIGINEERING Phone
34 :aagle River Loop Road No. 204_
Address Eagle River, Alaska 99577
Engineer's signature
6. DHHS SIGNATURE
Approved for� 1 , bedrooms.
Disapproved.
Conditional approval for
Additional Comments
11ITlr
Date
�.:.. r.rlac.i i�.3e a.:ira4�e1•�^. r2'.a
'. eeS LG chin a Me'r— u 1l'/.Y
y. �aq r[ia aJuuO.. �\•�,sd�
bedrooms, with the following stipulations:
Date
'�—
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineers work.
72-025 (Rev. 1/91) Back MOA N21
Municipality of Anchorage
Department of Health & Human Services _
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:���� Sa�M �TPn�s1�� 3 Parcel I.D. C 4:;Z(1 �jC/
A. WELL DATA
Well type ?C-Np,e If A, B, or C, attach ADEC letter. ADEC water system number
Log presentON) 1 Date completed 4-30 - $!' Driller
PE.e i-.
Total depth �Z�t Casedto loop 'q9 -"FSS Casingheight J -2 -
Sanitary sealYON) Wires properly protected4&YN) 4
FROM WELL LOG
AT INSPECTION
rn
Date of test - 3 0 -12-
o z
Static water level014-
Well flow 2. a
9.p.m..4 g,{ .
z
Pump levelyIL
1 L2t ryl `P",
o
SEPARATION DISTANCES FROM WELL TO:
p "
Septic/holding tank on lot dos t
; On adjacent lots
Z
Absorption field on lot 1S
; On adjacent lots
a��'�
�,
Public sewer main
Public sewer manhole/cleanout A
Sewer service line Zs t
Petroleum tank ZS I a-
WATER SAMPLE RESULTS:
Coliform O C OL'% Nitrate
t Other bacteria �°
Date of sample: A-
Collected by:
17034 Eagle River Loop Road No. 204
B. SEPTIC/HOLDING TANK DATA
Eagle River, Alaska 99577
Date installed `A - \,5-, SS;- Tank size
noo Compartments �
Cleanouts CVN) T— Foundation cleanout&N)
— Depression (YAQ fJ
High water alarm (YO Ili
Alarm tested (Y/N) bra
Date of pumping 44- lZ -,-1 Z
Pumper 5l2 _ LESSPatir✓
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot On adjacent lots t o n Foundation
To property line o Absorption field
Water main/service line
Surface water/drainage I o a I
72-026 (Rev. 7/91)Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent(Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access
Meets MOA electrical (Y/N)
SEP TION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
On adjacent lots
"Pump off" level at
Cycles tested
Surface water _
Date installed C -\S - Soil rating 15D 4155 System type
� u(
Length Width �D Gravel thickness ra Total depth t
Total absorption area Cleanouts present &N) �I
Depression over field (Y69 Vl� Date of adequacy test
Results iYfail) PD -SS for SCA (3) bedrooms
Peroxide treatment (Past 12 months) (YCN) v-�oe,� �o \J KS If yes, give date �-i 1 A
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot—\__\42- ` On adjacent lots i'C>p Property line 41 -
To
To building foundation _Od To existing or abandoned system on lot '� A
On adjacent lots \ Cutbank 1.0 0 Water main/service line—
Surface
ine
Surface water \ o X Driveway, parking/vehicle storage area
Curtain drain
'o t 4-
E. ENGINEER'S CERTIFICATION_
I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
S 8, J ENGINE-15RINC
Signature - IY034-4i4igle Fiver I nop toad. No 204
Eagle Idiver, Alaska 99577
Engineer's Name
Date
1) -92 -
HAA Fee $ Waiver Fee: $ —
Date of Payment _. Date of Payment
Receipt Number - Receipt Number
72-026 (Rev. 3/91) Back MOA 21
MUNICIPALITY OF ANCHORAGE I�ji
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
GSA G.v�; " ,� /f��,fi--P�J � �-�� ��ti✓��,i �t�
Location (address or directions)
(b) Applicant Nam Telephone:: Home �✓JBusiness
Applicant Address'
(c) Applicant is (check one): Lending Institution ; Owner/builder; Buyer ®; Other C7 (explain);
(d) Lending Institution _ — Telephone
Address _
(e) Real Estate Company and Agent
Address _
Telephone —_
(f) Mail the HAA to the following address:
rias;i4 °t' d- A n.Al l 5"V7
2. TYPE OF RESIDENCE
Single-FamilyM Multi -Family El Other
Number of Bedrooms s_5P
3. WATER SUPPLY
Individual Well [ Community ❑ Public CJ
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite K Public E] Community ® Holding Tank C�
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025(11/84)
5. ENGINEERING FIRM PROVIDIN�`rdSPECTIONS, TESTS, FILE SEARCH, DAiw-AND INFORMATION .r;
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm Telephone 6 /– 7.7
Addre
Date
����o�op esoBn ogaoa� ��ppA�
�A
k
30 - c9aoa co,c lfi
1h bart A. SRmh,r
�.0 fit �0oeo 3 ,r_ "POFE;Sv)l
6. DHEP APPROVAL
Approved for �` edrooms by Date
Approved —_ Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
MUNICIPAIIn--`-' ANC �I�F�
DEPT. OF TgfAITPPALITY OF ANCHORAGE (M6)q-
ENVIRONMENTAL PRg7=k" AUTHORITY APPROVAL (HAA)
DEC2 C ��J CHECKLIST - FEBRUARY 1984
UU264-4720
RECEIVED Legal Description:
k _;;Nen -,
A. WELL DATA
15, If A, B, C, D.E.C. A N /p
Well ClassificationApproved (Y/N)
Well Log Present (pi/N) Date Completed e'+ Yield 2 G�PwJI
Total Depth 1 Z Cased to �A , Depth of Grouting
Static Water Level t o Pump Set At04—
Casing
`—
Casing Height Above Ground —
Electrical Wiring in Conduit (PN)
Separation Distances from Well:
µ Sanitary Seal on Casing C7%)
Depression Around Wellhead (Y/&
To Septic/Ide+dirrg'Tank on Lot I a--5 ; On Adjoining Lots 1 Ct-�
To Nearest Edge of Absorption Field on Lot i S ; On Adjoining Lots
To Nearest Public Sewer Line rS JA To Nearest Public Sewer
1
Cleanout/Manhole To Nearest Sewer Service Line on Lot ZS
Water Sample Collected by SS i� -�^ ; Date
Water Sample Test Results S t S
Comments
B. SEPTICA40t MM TANK DATA
Date Installed 9 "tS -85 Size 1 doa No. of Compartments
-2—
Standpipes
Standpipes (Y/N) Air -tight Caps (3%) Foundation Cleanout (VN)
Depression over Tank (Y/P pate Last Pumped ) �'�
Pumping/Maintenance Contract on File (Y/N) lA ; for
Holding Tank High -Water Alarm (Y/N) A Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holdi�ffg Tank:
To Water -Supply Well C> To Building Foundation
20 r�
To Property Line l
To Water Main/Service Line rJ ��
Course "—
Comments
Page 1 of 2
72-026(11184)
1 t- To Disposal Field
r}
To Stream, Pond, Lake, or Major Drainage
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 1 SS I - Type of System Design Tfx-T-ti to
Date Installed - t5 -S6 Length of Field SFS
Width of Field
Depth of Field
N
Gravel Bed Thickness lab
Square Feet of Absorption Area jb� Standpipes Present (PN)
Depression over Field (Y/0)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well S
To Building Foundation
3S 1 F
Lot - 13)_4_ A
To Water Main/Service Line I D �-A-
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
,,,Date of Last Adequacy Test fl�6.�
P.
To Property Line
To Existing or Abandoned System on
On Adjoining Lots 3 Z> I
To �utbank (if present) la o 1 k
� p
M
Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at "Pump Off' Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA uidelines in effect on the date of this inspection.
S �, S Engineering
SignedSe�B Date
CompanyEatile v?ivcr, Alaska 99577 MOA No. S U�� '��'
� j fig
Receipt No. IG • ���� 13�6;
J �•� rte' , oe oa a*eo oee�o �€Seu
Date of Payment I ;A ` ate_ e ;
Amount: $ CC, V lC)b
Page 2 of 2
72-028 (11/84)
O
a o Ufwl A. Shefor
{i J. % No. 1457-E
A o
+ `t
t};rji)F 5c1U'e€n
LOCATION OF WLLL %rr}a.• r• -r.
Mid. ear049h 3d1vlelen,, Let,stock
Anch ,':u4Scimit r r
? i; :WATER WELL RECORD •, .:z
STATE OF ALASKA
OEPAR,TMENT OF NATURAL RESOUREQ(,..
9M14 n at GeolGpicol d Geophysical Surveys:.
Drilling Pgrlalt_ No.
Ib t'I'll .
3ectlon NO.
ToweehlpN0
Range 11
Merldlon
�ee of_.if—
sp
AU
'
'
3. OWNEN OF WELL.. Mr.. Paut'.•.rlyer.:3 .•: .
Aadr: �.: P; .Box 35,1; .:
Chugiak, Ak. 99567.
e '
WELL -DEPTH: (final) " s. OAT; OF OMPLETIO
,:.126• 4 ...-:>:�50_-_;
` v r
¢•+'. 0 Cali lobi '" ler�r,-� ❑ Or(Jid . -[� Duq
0 Auger _ ���Q Jai.b � ❑eared "�-� Q OtMr I , I,
.
::use D.moolie`- Pukud.sunir. Inao.(�y:::.
Q
" '" ❑�Cernn�•r11a1 .
O Irrigation .0 Roehdrga60
Q Toot W•II" Q Other: "
-
'
. e. CA31NG+ Q Throadod" 0 Wald•p::.,.
x'6011. Depth" `Wo19hC_Ib•.��II,
dlora. 6 In, la�
dlom. In. - le -- ft. Depth �311o)ju ft'
9. FINISH OF WELL! " - ' i'"1
.. Type: Olamolat, - ...
flat/Mash. _ %ISO: :. .`,Lln9tk:-
aN b•1.•M'.. ^"f I. and r.?t.: ..
3aoYfllling " Gravel Dacli '
-
10. STATIC WATER LEVEL: - _ fl. -�
Data
Above et C]eolar land Surface
. •.....
Equipment used:
I1. PUMPING LEVEL 49160 land egrf000 and YIELD.
fl• after hr$• pumplag" 9•p•n!••
__11. oiler hro..pumpin1 0.p•m•
12. GROUTING Well Grouted: C1 Yes0, No.-
MaUr1al: , Q Neal Cement Q Other:
'IS. PUMP, - (if .e"rc.11pblel..".N►-
Lengih of Drop Pipe - it. capoolly_ 2 -p -m
C] Subm. Jet, O Contrlfleal.• ❑ Other
14.REM.Aarks: Production .Of ,2' GPM• .
Perforations from 40-45
" IS.'WATER WELL CONTRACTOR'S CERTIFICATION: 15Wafer ,Tomperolur• —0 ❑ F _ -_ ❑ C
This •ell` was drilla0 under my luiledlellon'and 1111% report Is true to the ball Of my knowledge and belief, :.
nuson Uri.11ing' . AA 5385 ____--- i.
MdIo1vH sudnoaa —_—Cool nu umber ..
P 0.. _ Box 7'7M64 .Eagle River, Al:. g`%
Address'. 984
'April 3,0, '
signed.
Representative
Authorized Repre
't
'( ..
_ _. - - - .�-_u�a_r�...r�u.LLee_i�..-. na•na�a. - - 1_�y sav�t..�i��.e_—_-_—� _