HomeMy WebLinkAboutSTORCK #2 LT 4torck #2
Lot 4
#017-091-48
MUNICIPALITY OF ANCHORAGE Flattop Technical Service
DEPARTMENT OF HEALTH AND HUMAN SERVICES 14530 Echo Street
Environmental Health Division
' 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 Anchorage, Alaska 9951
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name
Geos a Matt DISTANCES09<-
ADd,essTO SEPTIC ABSORPTION
box 967,9., Harland- Rd ,finch 99577 FROM Tauv n WELL
phonepl Perms No. No OI bw,00ms WELL
561 — 78 77 1 89 -01Z& 3
LEGAL DESCRIPTION LOT LINE
Lot IIOCI, SuDOmYOn
`l I lvr4. StoreIr FOUNDATION
Township, Range. Section
5*ec 3S, 7-1ZN R3Cv, S. r1. AS-BUILTDh
d", ay. water
TANKS
FK SEPTIC ❑ HOLDING
Manuracture, Gapauty In ganons
'44nehoma TanAi loop
Mateual No, of compartments
V -eel Q
TYPE OF SYSTEM
❑ TRENCH X BED ❑ W. DRAIN ❑ OTHER
WELLS
LSi PRIVATE ❑ OTHER (Identifv)
Gassd�te:Iun tA.Ia L1 total Depot eases to
PV f. FT FT
mstaw" Date Insta ied.
5ulllvan Wbirfer (%l(l /9t39
REMARKS:
1`0491 ms -if
50, f0' '�' 5-0�
Not XA Illicit sA Not rA
N (bliss location of well. septic system. property Imes, lounoa,(
etc)
aeafe: y n p e�Zj r
I If
l�uq ortfh O� o,/ qbI 6 Inspections Performed by
%A QHiEa,Lµy�/ V s' D�ft.V. Q'A4/lai Date EE.89-Uoid
Ran�e� 1.�L J fsa(dN mgeAwa! vrr ,fie. k 9//( /g%
I %- ��LaL Willy that this inspection was performed according to all
Municipal and Stale guidelines in eflect /,
on this date:
'
Health Department Approval: —"—"-^-' Oale. 42113 Y
72-013 (3,85)
T
ENGINEER'S SEAL
OF
........... �p
qty=VIS, Its
4•••'.7*1
.
THEOD02E F. MOORE
re �•. Cc' • 3599 vAr
et
FT
0's-
•SEIIO
Pitauclea above Ueg,nal
graou
Glavel Depth beneath pipe
3.S
FT
O•S-
Gravw lengo'
Gravel wlofh
K2
FT
f6
total absorption area
(Distance between tines
7SW
SO FT
S
Number of laws
Solt rating
Pipe mate..
D -?o3'/
Sol,z
3
13f �$FT
n
r -,6/v
Pcrf
mstatie'
I loj
v
Date mstatied
Z"sa6el(e
Ex c.
9//T
WELLS
LSi PRIVATE ❑ OTHER (Identifv)
Gassd�te:Iun tA.Ia L1 total Depot eases to
PV f. FT FT
mstaw" Date Insta ied.
5ulllvan Wbirfer (%l(l /9t39
REMARKS:
1`0491 ms -if
50, f0' '�' 5-0�
Not XA Illicit sA Not rA
N (bliss location of well. septic system. property Imes, lounoa,(
etc)
aeafe: y n p e�Zj r
I If
l�uq ortfh O� o,/ qbI 6 Inspections Performed by
%A QHiEa,Lµy�/ V s' D�ft.V. Q'A4/lai Date EE.89-Uoid
Ran�e� 1.�L J fsa(dN mgeAwa! vrr ,fie. k 9//( /g%
I %- ��LaL Willy that this inspection was performed according to all
Municipal and Stale guidelines in eflect /,
on this date:
'
Health Department Approval: —"—"-^-' Oale. 42113 Y
72-013 (3,85)
T
ENGINEER'S SEAL
OF
........... �p
qty=VIS, Its
4•••'.7*1
.
THEOD02E F. MOORE
re �•. Cc' • 3599 vAr
et
J qq/t�3�q
( M U N I C I P A L I T Y O F A N C H O R A G E
Department of Health & Human Services p�(�
825 L Street, Anchorage, Alaska 99501 343-4720
O N- S I T E S E W E R & W E L L P E R M I T
Permit Number: 890128
Date Issued: 07/19/89 Engineer Designed
Owner Name: GEORGE MATZ
Owner Address: BOX 9878 HILAND ROAD
ANCHORAGE, AK 99577
Parcel Id: 017-091-48
Lot Legal: Subdivision:�STORCf:. Lott 4 Blocks -
Section: 35 'township: 12N Range: 3W
Lot Size 54450 (sq.ft. or acres)
Max Bedrooms: This Permit: 3 Total Capacity: 3
SEPTIC TANK: Minimum total septic tank
tank must have at least 2 compartments.
feet requires insulation over tank(s).
Day Phone:
561-7077
capacity: 1,000 gallons. Each septic
Depth to top of septic tank(s) < 4.0
WELL: Log must be submitted to Municipality of Anchorage Department of Health
and Human Services within 30 days of well completion.
INFORM D.H.H.S. PRIOR TO 1ST & 2ND INSPECTIONS BY ENGINEER, IF
AFTER OFFICE HOURS, CALL 343-4601 AND LEAVE A MESSAGE.
CONSTRUCT PER ENGINEERS ATTACHED APPROVED DESIGN.
THIS PERMIT EXPIRES 12/31/89 AND VALID FOR A SINGLE FAMILY HOME.
I CERTIFY THAT:
1. I am familiar with the requirements for on-site sewers and wells as set
forth by the Municipality of Anchorage (MOA) and the State of Alaska.
2. I will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit.
3. I will adhere to all MOA and State of Alaska requirements for the set back:
distances from any existing well, wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot.
4. I understand that this permit is valid for a maximum of 3 bedrooms. I
also understand that the capacity of the total system is 3 bedrooms and
any enlargement will require an additional permit.
Signed:
------ --------------------
(Owner) GEORGE 9ATZ �
Issued By: �j�(
_�L__6� ----
DATE:-� IC i
- ----
DATE: -0 a
Municipality of Anchorage
Department of Health and Human Services
Tom Fink, 825 "L" Street
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
January 9, 1989
George Matz
2423 East 50th Avenue
Anchorage, Alaska 99507-1402
Subject: Lot 4 Storck Subdivision
Permit #880089, PID #017-091-48
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1988.
Permits are issued on a calendar year basis by authority of
Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system
not installed by the expiration date.
If you have drilled the well, a well log needs to be sent to
this Department for documentation of the installation and to
close the permit.
If a private engineer inspected the installation of the
on-site sewer`system,.the original as -built inspection report
(three-part form) must be sent'to this office for review and
approval, and for documentation.
When applying for a new permit, the fees are: $90.00 for
an on-site sewer permit; $50.00 for a well permit; $140.00
for a combined sewer and well permit.
If there are any further questions, please call this office
at 343-4744.
Sincerely,
Daniel J. Roth
Acting Program Manager
On-site Services Section
DJR/ljw
enc: Copy of Permit
M U N I C I P A L I T Y O F A N C H O R A G E
Department of Health S( Human Services
825 L Street, Anchorage, Alaska 99501 343-4720
O N- S I T E S E W E R & W E L L P E R M I T
Permit Number: 880089
Date Issued: 06/21/80 Engineer Designed
Owner Names GEORGE MATZ
Owner Address: 2423 EAST 50TH AVENUE
ANCHORAGE, AK 99507-1402
Day Phone:
561-7877
Parcel Ids 017-091-48
Lot Legal: Subdivisions STORCK SUBDIVISION Lot: 4 Block: -
Section: 35 Townships 12N Range: 3W
Lot Size 1.25A (sq.ft. or acres)
Max Bedroomss This Permit: 3 Total Capacity: 3
SEPTIC TANK: Minimum total septic tank capacity: 1,000 gallons. Each septic
tank must have at least 2 compartments. Depth to top of septic tank(s) < 4.0
feet requires insulation over tank(s).
WELL: Log must be submitted to Municipality of Anchorage Department of Health
and Human Services within 30 days of well completion.
INFORM D.H.H.S. PRIOR TO IST & 2ND INSPECTIONS BY ENGINEER, IF
AFTER OFFICE HOURS CALL 343-4681 AND LEAVE A MESSAGE
CONSTRUCT PER ENGINEERS ATTACHED APPROVED DESIGN
THIS PERMIT'EXPIRES 12/31/88
THIS PERMIT VALID FOR A SINGLE FAMILY RESIDENCE ONLY
I CERTIFY THAT:
1. I am familiar with the requirements for on-site sewers and wells as set
forth by the Municipality of Anchorage (MOA) and the State of Alaska.
2. I will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit.
3. I will adhere to all MOA and State of Alaska requirements for the set back
distances from any existing well, wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot.
4. I understand that this permit is valid for a maximum of 3 bedrooms. I
also understand that the capacity of the total system is 3 bedrooms and
any enlargement will require an additional permit.
Signed:
DATE: 2/. -moi
-------------------------------------
---------------
(Owner) GE MATZ
y� �I
Issued Sys --a'=m ---- - , DATE:
TRACT
A
LOT 6
(VACANr)
HSE
LOT S
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frevo HoaS E �
LOT 2 �PAoP 1060 i
(IeAGAA/T) EXrrTiNG fuF
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wa
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W Tfrg?q n ps I
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I
o 1; 1O107-3
O RESE/; f/E AREA
U OGj16:NATBQ SY DASHFp
So1/, R �Exn ?S�� .iQCV 01
,3S 4'/QDRy
SLOPE AMA4. kS4:.
�T SLOPES DOtv/r
r SOUTN wF Cr
- • •nY WEt
$CgY1/J6 40T 3
H
LOT y�SToRC t S/O
/IodN # 2
S tTE PLAN
.SCALE: 1"r So
,DATE: 6/5/BB
DWN a y,-. TF/y
NOTE, TN1S IS No7
A Sui?vEYFO PLA
ALL LOCAT1omf Ai
A PPRox/ MATE
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
Lot 4. Storck Subdivision
Wastewater Disposal System
Construction Specifications
Addendum al. June 20. 1988
Per the request of Dan Roth at the Municipal Health Department, an additional two
feet of medium sand is to be placed on top of the sand leveling course, prior to
palcement of the sewer rock and distribution piping. The purpose of this is to
achieve a minimum of 4 feet vertical separation between the bottom of the sewer
rock and the sand -silt interface which is periodically saturated during breakup.
The top configuration of the sand shall be as shown on the plans, with side slopes
as steep as practical. The two feet of cover material over the mound and
wastewater feed 1iT �shall be imported from off site, and the side slopes shall not
exceed 3:1/ \
hPP/{pvF,0
�'(. OF AP rw
49TH 9*�
..........................
................
THEODORE F. MOORE
CE -3589
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
JUN 201988
RECEIVED
2s'
0 MIT• 5'
isl _ _ _ =
C.O• SI
?S'
0
1000 6Ai., 2C0HPArt7Mf=NT
SEPTIC .TA/JIT. SNSULAre 1p
BUAlro LPSC THAN y'
CLEAN OUT PIPE
H°N PPMMRATED P/Pf
SLOPG• �ASTH D -.?Of M/MIM un
Y"DIA
1 DU Pf Rr'ORArFO ►IPD
LAID Lev Pj
•� _ = =— 20.5' ! = c c ca
/ /TN 00,PAV?LA N�lE w
PPRO ,,f0
CLPANOur
3 ZO'
covc-n i/P/PO
C°vER MATERIAL
/ " 2AIFID
..
i•
SAND L90PL/N6 (Olins e
Sy
nc THfs tpA10
CAYfR w/t[ RESECTION IA-A�
141=51
M1afum 0% Z' Arope
up$,Iffe Nd or PF
DFO. �E OF•A4
P S�
*�49TH�
•9i
:
.......... ...........:
CL@AN o,T PIPP
NONITbe T"of WIT,
PIRP PIPE 'INRu 6RA6'SL
AOh7RPno+'I BED
,It TU QA! P90✓I06 INS"&Armm I
elcoVBR eVaR S«PPI
LINE /INT/L M' DPPrN
'DIA PORP AGNIE veD
OUT. ►-IPE SWPLY L/Nn
.'71- -- - - ---- -
Y:"-zh" c�aEi,ttp SM
SEWED 6.TAv64
ML
LOT 1 STORCk S/I)
ADDIN# 2
WASTCUTATER DISP, BED
THEODORE F MOORS fS •L j
STALE: AI NOTFp
CE - 3569 a} A'
o
AV
•'•... •' ac�DATE: 6/9/Bg
���?Ifessl—,M:o r
� OWN er: Ts•H
Lot 4. Storck Subdivision
Wastewater Disposal System
Construction Specifications
All materials and construction practices shall conform with M.O.A. requirements.
The configuration of the wastewater disposal system shall be as shown on the site
plan and design drawing, except that minor deviations may occur to accomodate
field conditions.
The septic tank shall have two compartments and a capacity of 1000 gallon§. The
septic tank as well as lines leading into and out of it shall be buried to a depth of at
least 2 feet, and shall be covered with 2 inches of rigid, burial type, foam if the
depth is less than 4 feet.
The soil rating of 135 square feet per bedroom is based on a measured perc rate of
5 minutes per inch. The total absorption area required for a three bedroom system
is 608 square feet, which is best accomplished by a bed 15 feet wide by 41 feet
long.
The soil absorption bed shall be constructed by stripping the peat layer
(approximately 6" thick) from the site, and then leveling the site through the
addition of a sand leveling course as needed. The perforated distribution pipes
shall be laid level on top of a 6" thick layer of approved sewer rock, with another
6" layer surrounding and covering the pipes. Two inches of rigid, burial type
insulation shall be placed over the entire bed prior to placement of a minimum of 2
feet of soil cover. Cover side slopes shall not exceed 3:1.
Three inspections will be required: The first after the site is stripped; the second
after placement of the sand leveling course, and the third after the perforated
distribution pipes are laid, but prior to backfill.
a I y Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
/`�
TEST /104.F 0 1
PERFORMED FOR: ErLi3nip /lax l'L Z DATE
LEGAL DESCRIPTION:- I—of �, S-lorC k S/Ii Township, Range, Section:
DEPTH ♦ SLOPE
IFF FTI
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
T./i#1
COMMENTS _7-1
SM ReAlur4 Sawdr /oen
H%O Sew
Hl. Denz 6rPud►y V;//-
rteny C0116/..
Sca.4,'alm
WAS GROUND WATER
ENCOUNTERED? Y
8 N.
IF YES, AT WHAT
DEPTH? Ste Cones
Depth to Water Alter Sy a S/2/
Monitoring? 167 Dalt 4/8
J2NGINEE S SEi *
���•49T"•9*�
..........................0
I
�..THEODORE F. MOORE;
1, •.��•CE - 3589.Vc��
/2
SITE
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
PERFORMEDBY:-r/ci/ior 7ecl.gren/ Svcr I ��„ � %--V—
CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: —; 4 A e
72-008 (Rev. 4/85)
M.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
TEST NORE #2
.OF AP
pj': rr .
* . 49TH :y*
.........................
10,77 t
• THEODORE F. MOORE
( :•••CE -3589 •: ii�.
PERFORMED FOR: 1'EOr'IIQe Maltz. DATE PERFORMED:
LEGAL DESCRIPTION: /-OT f $fo/c it ,S/O Township, Range, Section: See 3t 7-/2.N j2V to S_/
otrrH pt
1
S/y
2
3
4
5
6
7
8
9
Aedcfab 5,0y Lo -o^
Hao ree/V
M1. G.pr Grwuelr, Self
Ca/t4ralroC)
0 6P 51"Ir Fr"itu .0 6tw(mek
S. I). (eecfrvr )
10WAS
ATER
ENCOUNTERED?Y
11
IF YES. AT WHAT See 031~eAA
12
DEPTH? 7-,q. At/
13
Depth to Water Atter M9 S/2 /
Monitoring? F07 Date 9'/6
14-
15-
16-
17-
18-
191
41516171819
20
T. N
COMMENTS
SIT
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
PERFORMED BY: n iC[/iil rtn� Suer 1 J K T ilfe.,uCERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/&S)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
rc-;r HoAF it?
OF
:Cl):-
..........................
. THEODORE F. MOORE �•
1 ••.� CE - 3589 � A
f ;P'-��AF
PERFORMED FOR: tymrQe tta 17 DATE PERFORMED: SI Z/IBg
LEGAL DESCRIPTION: VbrCk S /b Township, Range. Section: Sec M 7-I2 AtR 3 w, S"
DEPTH Pt SLOPE SITE PLAN
' SP Redd4h Gn"ueoy soar 6w.,
z
87 517 sslFy SOr+cri loon
3
Nf G,,r ff,p„crry SIMw �jlv
a
8H
5
6
7
8
9
10 WAS GROUND WATER
ENCOUNTERED?
11
IF YES, AT WHAT
12 DEPTH?
, 44terce
Depth to Water Alter Con fro" e.t 6/6 /48
13 Monitoring? Date:
14
PFI?C T -FLT #1
15 '
Set Site flan
16 -4Zoe 27raCf
17 joiCct{tan
18
19
20
T. h
COMMENTS
Reading
Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
Pwon fe
S/G/ 5'.115—
t7 yt
6"
r:22
23'3.7?—
4tf
X132
to
21 y=
r B
+K o
S•3L:Jo
23r
ZFvy
2 6
it3
SSS : rS
FO
2/ vi
p.s
4 Hyo
s:s6 •YI1
ZS'
oy6*'06
a
zF 6
E 6
tNaa
6
PERCOLATION RATE (mmutes/mch) PERC HOLE DIAMETER
TESTRUNBETWEEN 2.O FTAND 2.s FT
PERFORMED BY: t %fG/Iq t[[t I Sb r I 'f�Jit b'—tCERTIFY`THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-M (Rev. 4/85)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
�^+ PERC TFsr 02
PERFORMED FOR: 6 �eqe MA17-DATE
LEGAL DESCRIPTION)-o� "/. 54 re Ir S/!) Township, Range, Section:
0•�i DEPTH Pf SLOPE
4FEET
1
S P (jroatlry saidy /oon
2 l+tany Cob 6/r
3-- 13. H.
4 S
5 h r•
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
WAS GROUND WATER
ENCOUNTERED? U
11
IF YES, AT WHAT
DEPTH?
Depth to Water Alter
Monitoring) Date:
OF AL''„%111
nom':
49TH
i.o....................
0..i .�
I. THEODORE F. MOORE
CE - 3589
••.z
Reading Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
rr ah 5't es,
rl:o
27 s/6
t U
II tZf:oo
2J v=
#f
:16:w
10
2/10,a
Za
+ NaU
it : 3r: via
2i t
U
I I : r17:Ob
23 //c
1*3
to :.f7: 00
0
2 114
- 7—f-
=It:o7:b
1? :07: its
Ia
2r•rL
�z�
PERCOLATION RATE -..5 (minutes/inch) PERC HOLE DIAMETER 7
TEST RUN BETWEEN - 1• r FT AND ILO FT
COMMENTS -LJon?Y1"MIn// /1tr'c *Crf 47 CO rt �Cl �-7r<fCA1- O .. T>'a2a� a� fOtK Mr& r
Sty srly �1un J•%r- exaC?4 /orape". r
PERFORMED BY: �t'Lt ��o/. 7- elf S V ex I �,,L...�.,, J;f %/is.K_ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Tur?G 1, /9B9
72-008 (Rev. 4/85)
COC Co. Goa
SULLI"N. WATER WELLS
P.O. BOX 67027$ CHUGIAK, ALASKA 99587 • TELEPHONE 61182759
OWNER OF LAND �aE�KEE /44-rZ s ,
ADDRESS 9IL.+✓4 /(r0 e
LEGAL DESCRIPTION L07 STDRst'yiQ_
,x p
DATE -Started �� 1 Ended
PERMIT NUMBER
51,J f) 0 /2 P
O 1 7 -0,7i -4r
DFI'TII OF %%LLL a '� '? F
STATIC LEVEL OF WATER FF. _Z
DRAWDOWN FT.
GALS. PER HR A"
KIND OF CASIVG � d Q
�r
KIND OF FORMATION:
COC Co. Goa
SULLI"N. WATER WELLS
P.O. BOX 67027$ CHUGIAK, ALASKA 99587 • TELEPHONE 61182759
OWNER OF LAND �aE�KEE /44-rZ s ,
ADDRESS 9IL.+✓4 /(r0 e
LEGAL DESCRIPTION L07 STDRst'yiQ_
,x p
DATE -Started �� 1 Ended
PERMIT NUMBER
51,J f) 0 /2 P
O 1 7 -0,7i -4r
DFI'TII OF %%LLL a '� '? F
STATIC LEVEL OF WATER FF. _Z
DRAWDOWN FT.
GALS. PER HR A"
KIND OF CASIVG � d Q
DRILLER'SNAME IT, /JJc
KIND OF FORMATION:
AM1MdPALITY OF ANCHORAGE
O C/'gSi.JG S i ICK JP
From Ft. to Fl. _
From
Ft. to
DEPT. OF HEALTH 3
From c� Fl. to Q Ft. 009 C ad,(A_,!FrJ
From
Fl. to
Ft.
G
From 3 Ft.lo�_Ft. Wg4,d)',4,J
From
Ft. to
Ft.
From10 Ft. to FP l3t7e,OnCoL l2! j��
From
Ft. to
FRE C E I V E D
From ��� Ft.tO-LJ-r—Ft. (l9aR3t_& c�(dr41 y
From Ft. to
Ft
From Ft. to—Ft. OJ4,-7-2
From
Ft. to
Ft.
From, 1.31�_Ft. to -22 LFt.Gi5Dtouc c!?z�c.[J _
Froin—Ft.
to
Ft.
From �_Ft. to R31 Ft.
From
Ft. to
FI.
From Ft. to—Ft * of qA -, Z $ 64 s
From
Ft. to
Ft.
From Ft. to Ft.y G/i✓t
From
Ft. to
Ft.
- From -13 3 Ft. toN_Ft. 13tnA1)e t Q_J,4_17Z
'From
Fl. to
Ft.
From Fl. to ' Ft.' 464mr sV b
From
Ft. to
Ft.
From Ft. to Ft.
From
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From Fl. to Ft.
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MISCL. INFORMATION:
6 " Cars •.� 8
1 /, ; a � lam
�
DRILLER'SNAME IT, /JJc
Municipality of Anchorage •.
�77 Development Services Department i
�f Building Safety Division
_�- On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650 _
Anchorage, AK 99519-6650 c /
www.muni.org/onsite-C�✓ '
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. (917- tQg 1 2 COSA# 0 Gi 0
1. GENERAL INFORMATION Expiration Date:
Complete legal description
STORCK
#2 S/D;
LOT 4
Individual On-site
Location (site address)
14345 CODY
CIRCLE
• ANCHORAGE. AK * 99516
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
RYAN HOKANSON Day phone
14345 CODY CIRCLE • ANCHORAGE. AK • 99516
Day phone
317-1754
CLAIR RAMSEY W/ DYNAMIC PROPERTIES Day phone 317-1754
3111 C ST. • ANCHORAGE. AK ► 99503
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
0
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 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 (;OSAS upon request to homeowners. Certificates of On -Sita 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. 1 further verify that based on the
information obtained from the Municipality of Anchorage tiles 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.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG. VD. 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 Identiriable features. The operational life orall 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 t
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 sole benefit 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
_Z Approved for bedrooms.
Disapproved.
Phone 337-6179
Date 6/7`
Conditional approval for bedrooms, with the tllowing stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Nitrate Advisory 9ther
By -
.e 71 i
=Vs o
........ ........
ey A. ess:..
CE-79cI7S
OFgty'
C ,
i
ONSITE ••'�c=
WATER AND
WASTEWATER
PROGRAM
Original Certificate Date: 9—,2,r-09
Municipality of Anchorage
Development Services Department
�, • y� Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage. AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: STORCK #2 S/D; LOT 4 Parcel ID: Q 1 —oql- Ll
A. WELL DATA
Well type PRNATE If A. B, or C provide PWSID# N/A Well Log (Y/N) YES
Date completed 7/1989 Sanitary seal (YIN) YES
Total depth 242 ft. Cased t0'20 (BEDROCK) ft.
FROM WELL LOG
Date of test 7/1989
Static water level 15 ft.
Well production 5 g.p.m.
WATER SAMPLE RESULTS:
Coliform __0_ colonies/100 ml.
Arsenic: NK) ug./L.
B. SEPTIC/HOLDING TANK DATA
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ in.
AT INSPECTION
3/18/2009
35
3.37 g.p.m.
Nitrate q'5mg./L. Other bacteria--&—colonies/100mi.
Date of sample: 8/6/2009 Collected by: GEG Ltd.
*LOCATED IN CRAWLSPACE
Tank Type/Material SEPTIC/STEEL Date installed 9/11/1989
Tank size 1000 gat. Number of Compartments 3 Cieanouts (Y/N) YES
Foundation cleanout (YIN) *YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A
Date of pumping 11/14/2008 pumper ISAAC'S PUMPING
C. ABSORPTION FIELD DATA tBELOW EXISTING GRADE
Date installed 9/11/1989 Soil rating (g.p.ddf o /bd 135 System type BED
Length 42 ft. Width 18 ft. Gravel below pipe
Total depth +4_4•1 ft. Eff. absorption area 756 ft' Monitoring tube YES ,Depression over field NO
Date of adequacy test 3/18/2009 Results (Pass/Fail) PASS ` For 3 bedrooms
Fluid depth in absorption field before test DRY in. Water added 694 gat. ' New depth DRY in.
Elapsed Time: 0 min. Final fluid depth DRY in. Absorption rate >= 450+ g,p.d•
Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN jlf yes, give date —
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N1
"Pump on" level at in. "Pump off' leve High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+
Public sewer main N/A
On adjacent lots 100'+
Public sewer manhole/cleanout N/A
Sewer /septic service line 25'+ 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 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main N/A
P
Water service tine 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
z*t-OF
G. ENGINEER'S CERTIFICATION o`C.....•••••..
O� •.5,�000,
i certify that 1 have determined through field inspections and p IH �e
review of Municipal records that the above systems are in (Al . . . . . . . . ......
conformance with MOA COSA guidelines in effect on this ,, „ •, •, • • ..
date. '•.J r y ssr
Engineer's Printed Name JEFFREY A. CARNESSQO v CE -1795 `FOt>
I 4�'e,110 cr%,J
Date '�lZ��o�t 04�e °Prof."srofldlm��
COSA Fee �� SIO Waiver Fee $
Date of Payment OI O 9 Date of Payment
Receipt Number Uy SCJ O V Receipt Number
(Rev. 11/05)
\ Municipality of Anchorage ..
1 0, .
•
Development Services Department }°
Building Safety Division
On -Site water and wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Nitrate A(Ivisory
Certificate of On -Site Systems Approval # 090282
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
4 of Stork 112 subdivision. This inspection revealed a nitrate concentration of
9.5 milligrams per liter (mg/L) was reported for the property's well water
sample. The Environmental Protection Agency (EPA) has established a
maximum contaminant level (MCL) of 10.0 mg/L for public drinking water
systems. While private wells are not subject to this regulation, EPA
standards are based on existing health information and can therefore be used
to gauge the relative quality of water from private wells. Please see the
attached "Nitrate Fact Sheet" for important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
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ell
SG9
SGS ReLN
1094027001
Client Name
Gayness Engineering Group. Ltd
Project Name/#
Storch #2 U
Client Sample ID
Storch #2 U
Matrix
Drinking Water
Sample Remarks:
Parwncter
Metals by ICP/MS
Arsenic
Waters Department
Total Nitrete/Nilritc-N
Microbiology Laboratory
Colony Count
Total Coliform
Fecal Coliform
Printed Datcll'ime
08.1192009 15:35
Collected Date/Time
081062009 13:00
Reeeired Datefrime
08.'062009 16:50
Technical Director
Stephen C. Ede
Allowable Prep Anal)sis
Results PQL Units bledttal Container ID Limits Date Date Ing
ND
5.00
ug/L
EP200.8
C
(<I0)
08/11/09 08/H/09
NRB
9.50
0.100
m./L
SM2045WNO3-E
11
(<10)
08.'07/09
LCE
0 cot/100ml.
SM20922213
A
(<200)
08.'06/09
DLC
0 col/100mL
SV209222D
A
(<I)
08.'00/09
DLC
0 col/IOOmL
S\120922213
A
(<1)
08.'06/09
DLC
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 01-7 -091 - '/a HAA # n t4 d ( (0
Expiration Date: 9-11-0
1. GENERAL INFORMATION
Complete legal description L o f `y, SI -or c Lc S/0 Al: -2
Location (site address or directions) f y 3 `/.S % dv G rc /e
Current Property owner(s) George t-7 u f -L Day phone 3 YS- - 3139
Mailing address 113 YS adv Grcye . Aec4e,22 Acc 99s'r6
Lending agency
— Maiiig-Tddress
Real Estate Agent
Mailing Address
Day phone
11un c i s 130 Day phone
Unless otherwise requested, HAA will be held by DSD forpickup. Pleure- ca/1 Gecr' e MGf^z e
2. NUMBER OF BEDROOMS: 3
3`ls -3h39 w�tn lith/� rauo% Tom �.cc,
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual On-site
10
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 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 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.
Name of Firm F fa I -be
Teti A;ca
/
Phone
Address IVY30 Eco,
5�..
A/+<<+a�oyt ,44c
91S Jol
Engineer's Printed Name
-1-_A eo A r -e f–. rrc ce-e-
Date Ko�LX 200 y
M, ---I--
,sem .
THEODORE F. UoORE
5. DSD SIGNATURE ?��.•••CE-3569 r
s:. •
I� Approved for 3 bedrooms. " "b •••..�� �
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date:
71-7-01
(R•v. 01R2)
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site 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: L -s f H, 51z;r C 4 LIZ) *2 Parcel ID:
A. WELL DATA
Well type _ 'v t If A, B, or C provide PWSID #
Date completed 189 Sanitary seal (Y/N) i
Total depth 2 Y 2 ft. Cased to eft.
FROM WELL LOG
Date of test
Static water level
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 2 6 in.
AT INSPECTION
y/zo/oy
27
ft.
Well production S 9.p -m. 7S g.p.m.
WATER SAMPLE RESULTS:
Coliform O colonies/100 ml. Nitrate 40.1 mg./I. Other bacteria G colonies/100 ml.
Arsenic: — mgA. Date of sample: y/z3 /GY Collected by: Floh4v TecA Sur
B. SEPTICIHOLDING TANK DATA
Tank Type/Material S fe &C l S/ -re I Date installed 9 /r r / 69
Tank size 1000 gal. Number of Compartments 2 Cleanouts (YIN) %
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N•
Date of pumping 7/ i6103 Pumper A -r
C. ABSORPTION FIELD DATA
Date installed /1//Soil rating (g.p.d./ft=orft�/bdrm) 13Srrae
, System type Oe�C
Length H 2 ft. Width ft. Gravel below pipe G. S- ft.
Total depth 3. S ft. Eff. absorption area 2LLfe Monitoring tube Y Depression over field N
Date of adequacy test y / 20 / v y Results (Pass/Fail) Pa-rJ For 2 bedrooms
Fluid depth in absorption field before test D in. Water addeds8d" gat. New depth_ in.
Elapsed Time: j. min. Final fluid depth Q in. Absorption rate >= y SQ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date ".4
D. LIFT STATION N. R
Date installed
'Pump on' level at _ in.
Datum
E. SEPARATION DISTANCES
Size in gallons
Manhole/Access (Y/N)
"Pump off" level at_ in. High water alarm level at
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO: x
Septic tank/lift station on lot 1 O6 On adjacent lots > r D a '
Absorption field on lot I y 5, On adjacent lots > 100 '
Public sewer main N• A. Public sewer manhole/cleanout N• .�.
Sewer /septic service line > ZS' Holding tank N• A.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 1-7 r Property line •f0 ' Absorption field 1940 '
Water main N• A.
Wells on adjacent lots _ > 100'
Water service line > lo' Surface water > 161G '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line IS' Building foundation '70' Water main N• A.
Water Service line > /O' Surface water > IUCJ' Driveway, parking/vehicle storage SS
Curtain drain None Sten Wells on adjacent lots >I610 '
F. COMMENTS* Per a iertn!` d'jfuJJron ye ten the p. 12er A.- ocaner c�a( Dgn/'iortf
/3,Pt 1A,01-exftncZ 2y' b.yJ. nea. tAe seoHc fancy ;t not
a reel/ C14 0( 7'*erF kee Blow i7vf Act 4' rb bo aSernc(ana nc'a�.ad
G. ENGINEEI{S CERTIFICATION
4 .. ' OF AC`�a'8
1 certify that I have determined through field inspections and ,r,A p �(I
review of Municipal records that the above systems are in r gTt! 4
conformance with MOA HAA guidelines in effect on this dale. >7 n' • h
En...Engineer's Printed Name Th to4-4ee 1=. r -ray,.- i
9 C d. e�^e!l�:T.
..:...
!
CEOdc F. MOORE ; k
Date
HAA Fee $ L130 e /� Waiver Fee $
Date of Payment S r v Date of Payment
Receipt Number
<103Z4= -Receipt Number
(Rev. 12101) S
SGS
SCS Rcu#
1042037002
Client Name
Flattop Technical Srv.
Project Name/tl
N/A
Client Sample ID
LA, Storck S/D #2
Matrix
Drinking Water
PWSID
0
Sample Remarks:
All Dates/Times are Alaska Standard Time
Printed Date/rime 04/29/2004 14:29
Collected Date/rime 04/23%1004 10:00
Received Date/time 04/23/2004 12:45
Technical Director Ste� C. Ede
Released Ba.wr�
Paramda Results PQL Units Method Container ID Allowable Prcp Analysis
Limits Date Date Init
Waters Department
Nitrate -N 0.100 U 0.100
Microbiology Laboratory
Total Coliform 0
mg/L EPA 300.0 B (<=10)
coUl00mL SM189222B A (<=1)
0423/04 JJB
0423/04 DKC
W
V �+
1�
VI 30-
L
-7i9
° 5Z 30
i E
�vrIL�-
N !
56 -�
r p�
o �
F
J 1�
qq
PARTIAL
GRAVEL DRIVE uw ERAnED
• '� NDUSC.
`• • SAO .,
Q N
Q, N �/ c
V
.N
STAND PIPES
pal �
N
i M / p O
I �
o p .
In O
30°
Al n.• -..l -_
O WELL
L-4
.L1
MUNICIPALITY OF ANCHORAGE
Department of Health &Human Services yt
• _ 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 I.D. # IC11-1- 91- �l C HAA # Ei fl�i(' Cf -S
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
/_ f !4. CAcrckr 9 40 -"ia
Location (address or directions)
IN3AYE 600(v Circ (4 Anchoc5ye �k 99S1�
(b) Property owner aeorq¢
Ma f:
Telephone: (home)
Business 561-76>7
Mailing Address 9/Zl
ameelm fPC
Ane Aore % A
-k 99502
IF
(c) Lending Institution E rf
Nat'l 6,mtr of
+fch Telephone
26S -3Y76
Mailing Address P. 0.C3ox
/00720.f)�r
/fes 99S/D
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here 19, if hold for pick up.)
List contact person and day phone number below:
6p4e_ Kafz - 515-( -78.77.
%CO< P7Uore 9 Y -r3SS�
2. TYPE OF RESIDENCE
Single -Family E Number of bedrooms 3
3. WATER SUPPLY
Individual Well E 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-site 19 / 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(A". 7/BBI 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.
NameofFirm Ffaflo� T, -c44;0( Scrv7Cq Telephone----3WS-13St
Address 115 30 ectio SY. �4�cti� g.
Date 2 / 7 / 94
s� r A 7
q-�Ea:...l �
v........ ..�
0,��^?.... . �. Engineer's Seal
�. TAEOD02E F. ;.tOO,Zc - 9
•i�
Jam: �.
aooa��o
6. DHHS APPROVALS
Approved for —� bedrooms b�` Date
i
Approved 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 not conduct inspections
oranalyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rw. 7/88) Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
• arnuiY MedNh'Authority Approval (HAA)
nuErtrnLSCHIENtVWL'FEBRUARY 1984 '
343.4744
FEB . / 1930 Legal Description: - L,of Y, Sfo r-c(r S /0
RECEIVED
A. WELL DATA
Well Classification r r ✓A k If A, B. C, D.E.C. Approved (Y/N) — /
Well Log Present (Y/N) Date C pleted 716Y Yield �lf^ '&'r lay?
r � �' 3n
Total Depth 2 y2 Cased to go(Itrk Depth of Grouting N. A.
Static Water Level Is' Pump Set At – utile
Casing Height Above Ground fell Sanitary Seal on Casing (Y/N) i
Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N) N
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot foe' ; On Adjoining Lots > 100'
To Nearest Edge of Absorption Field on Lot f 60 ; On Adjoining Lots > WE
To Nearest Public Sewer Line N'4, To Nearest Public Sewer Cleanout/Manhote N.A.
To Nearest Sewer Service Line on Lot !> 2S'
Water Sample Collected by FTS ;,Date / �!
Water Sample Test Resulht cjoev – O cc'tfk'• /r0o 0%.[i 29Vy/e
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed 9 /If / B9 Size Lfi g No. of Compartments 2
Standpipes (Y/N) Y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) Y
Depression over Tank (Y/N) N Date Last Pumped Nr A. Cncwl
Pumping/Maintenance Contact on File (Y/N) NIA. ; for N• A.
Holding Tank High -Water Alarm (Y/N) 1'124• Temporary Holding Tank Permit (Y/N) IV. R•
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well 106 To Building Foundation 2 2' c• 0•
To Property Line so To Disposal Field YO
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course > 1O0'
Comments
72 -VA (Aw.7/68) Fr nl Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 13 S o' //a 0(�, Type of System Design 13
Date Installed 9 /r' / E9 Length of Field � V Z r
Width of Field 18 ' Depth of Field O• S
Gravel Bed Thickness
Square Feet of Absortion Area 7 6-K Statndpipes Present (Y/N) f'
Depression over Field (Y/N) N Date of Last Adequacy Test N /�• C n cc.j
Results of Last Adequacy Test N. A. (new co r/rwc>ir'o...)
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well 1 HS' To Property Line o'
To Building Foundation ' ' 6S To Existing or Abandoned System on
Lot N. A• ; On Adjoining Lots 30'
To Water Main/Service Line To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course 1!> too '
To Driveway, Parking Area, or Vehicle Storage Area 15,0 8
Comments
D. LIFT STATION N. A.
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)
"Pump Off" Level at
Vent(Y/N)
"Check Permitted Bedroom Rating Against HAA Request'
I certify that I have checked, verified, or conformed to all MOA and HAA
inspection.
Signed �- 5r 71rp-�+<-
Company F/aNv, T cA,1i Rr / Se—u�te
Date 2/7/%0
MOA No. 90 _426=� Gb79
Receipt No. 5,91e0 24! / 0267
Date of Payment
Amount: $
72-028 (Rev. 7/88) Back
Receipt No.
Pumping Cycles during Adequacy Test.
in effect on the date of this
E
CE -3509 •. o}
��ae �'� �SSio7�1E.°gym
Waiver Fee: $ _
Date of Payment
Page 2 of 2
Engineer's Seal
/,r r CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC
5633 8 STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562.2043
FEDERAL TAX ID N 920040440
ANALISIS REPORT BY SAMPLE for Work Order B 19610
Data Report Printed: [EE 6 90 4 12:47
Client Sample ID:L4. STORE S/0 PRESSURE TIME ROSE RIR Client Nana : PLITTOP TECHNICAL SAV
PWSID :UA Client Beet : ILkTTOT
Collected JIM 31 90 4 14:30 his. P.O.B NONE RECEIVED
Received JAN 31 90 4 16:4S hrs. Req t
Preserved with :IS REQUIRED Ordered Ey : TLD MOORE
Analysis Completed :LRB 2 90 Send Reports to:
Laboratory Supervise TIPHRN C. RDE 1)ILATTOP TECHNICAL SRV
Released By : e. Z?A --- . 2)
....................................................................................................................................
Special
Instruct:
Chemlab Ref 4: 9398 Lab Smpl ID: 3 Natriz: WATER
Allowable
Parameter Tested Result Unita method Limits
__________________________________________________________________________________________
NITRITE -N 2.9 mg/1 LPA 353.2 10
Sample ROUTINE SIMPLE
Remarks: SAMPLE COLLECTED BI T.I.N.
1 Tests Performed See Special Instructions Above Uh-Unavatlable
ND- None Detected " See Sample Remarks Above
NA- Not Analyzed LT -Less Than. CT•Cxeatex Than