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Home My WebLink AboutT13N R3W SEC 26 LT 10 LESS N178'T13N R3W SEC 26 Lot 10 Less N178 I #007-022-22 MUNICIPALITY OF ANCHORAGE r• DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME c PHONE - EW 243Ctinal❑ UPGRADE t7`fi MAILING ADDRESS ?1_1 i.1N o LEGAL DESCRIPTION !&PA z LOCATION cir�4 Claim F, — NO.OF BEDROOMS LC_ hon e ar DISTANCE TO: Well Absor O � p � Dwelling/ PERMIT NO. u Y E!gQr 84 b 3 ilQ Manufacturer Mat al � No. of ompartments a F Liq. capacity in gallons Inside len th 17 05401 IFHOMEMADE: g W'dth�� Liquitl de tph 6 Y J V $ DISTANCE TO: Well Dwelling PERMIT NO. S F Manu-lecturer Material Liquid capacity pacitY in gallons D Well Foundation r Near lath a PEHMI�NO DISTANCE TO: x W!2 U Fi ZW O '�s No. of lines Length of each lin ♦ Totat lengt of lies Trench width �� Distance between lines ~ ¢ H Top of the to finish gra dq / Materi Iheneath tiln In hes Toth absorption area L{ O Q Jrr U ` Length Inches W� Len g Width Depth W PERMIT NO. O f au S ILI Type of crib Crib diameter Crib depth Total effective absorption area a DISTANCE TO: Well Building foundation Nearest lot line J J Class Depth Q,- r C/lJ ille Distance to lot fine PERMIT NO. W 3 Septic tank Absorption area(s) DISTANCE TO: Building foundation fse;�Frriine OTHER PIPE MATERIALS N �-3C SO ST HATI G -I I IN 7„E- Tic P STALLE fai REMARKS �acQ� eP�E .......... far s e - * :� 49TH— ZV ; — — ,...;. — — CE -6793 .� 3 i T �� i a � �'/Cle;riosCs� wee APPHOVED DATE LEGAL / 72-013 (Rev. 31781 MUM I C I FP- L- I TY OF At�7C1--)IDI-,:->(DT--- DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION e25 L STREET, ANCHORAGE, AK 99501 264-4720 ON—S I TE E3EWF=Ft Q< t JU-LL - F'CF~iM I T PERMIT NO: DATE ISSUED: ,APPLICANT: ADDRESS: CONTACT PHONE: LEGAL DESCRIP: LOT SIZE: MAX BEDROOMS: 850 114 04723/05 LARRY ,< JACKIE SMITH 3123 LINDEN DR. ANCHORAGE, Al- 99502 243-0047 SUBDIVISION: NA SECTION: 26 TOWNSHIP: 13N 36328 (SO.FT. OR ACRES) J LOT: S1/2-10 RANGE: 3W BLOCI': N.4 � Listed below are the options available to you in designing your septic system. Choose the option that best fits your site. ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I certify that: 1. I am familiar with the requirements for on-site sewers and wcllz 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 regulation,, and in compliance with the design criteria of this permit. I will adhere to all MOA and State of Alaska requirements for the set bacl: distances from any e;:isting'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 and any enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORT; MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED ��-_<� DATE: APPLICANT: LARRY_,: JACKIE SMITH ISSUED BYDATE:' - 1- -------------------------- TF:CNCH LIED 1�2 _ Df-i�ll I l^J! DEPTH TO PIPE BOTTOM (FT.) 6..0 6.5 6.0 GRAVEL DEPTH (FT.) 5.0 0.5 2.0 TOTAL DEPTH (FT.) 11.0 7.0 0.0 GRAVEL WIDTH (FT.) 2.5 19.0 5.0 GRAVEL LENGTH (FT.) 45.0 36.0 63.0 GRAVEL VOLUME (CU.YDS.) 23.0 25.4 29.2 TANK SIZE (GALS) 1,000.0* 1,000.0 * 1,000.0 ** SOIL RATING (S0..FT./BR) 150 150 150 ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I certify that: 1. I am familiar with the requirements for on-site sewers and wcllz 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 regulation,, and in compliance with the design criteria of this permit. I will adhere to all MOA and State of Alaska requirements for the set bacl: distances from any e;:isting'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 and any enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORT; MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED ��-_<� DATE: APPLICANT: LARRY_,: JACKIE SMITH ISSUED BYDATE:' - 1- -------------------------- 71' ^ WATER WELL RECORD 6l STATE OF ALASKA DEPARTMENT OF NATURAL RESCURES Division of Geological a Geophysical Surveys Drilling Permit No. LOCATION OF WELL (Please Complete either la, to or IC.) A.D.L. No. 1a. Borough Subdivision Lor BIocY Ib. 1/4 al rt. Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS Street Address one Area of well Location Section No. Township NO Range E❑ Mvl°lan 3. OWNER OF WELL Address Feet Bolo. 2. WELL LOG $YI I°Ce Material Type Too Bolton 1. WELL O_IPTH: (final) (J �f1. S. QATE OF COMPLETION 3 _ — , Z!6 - --Ly / Ty/)Seat 6. ❑ Cable tool C•Rory ❑ Driven ❑ Dug ❑Auger ❑Jetted ❑Bored ❑Others /•f A 11-6A^VQ a2 n p V Cemew d 6'R/9✓Q •( 8 3 7.u3E:MDom.aNc ❑ Public Supply ❑ Industry ❑ Irrigation ❑ Recharge ❑ commerical ❑ Test Well ❑ Other: 10 3 / G4C- 6qq SAA >r- G /gve OV 5- 0 B. CAS NG: ❑ Threaded W.Idod 4100 Mln. to—Z ft. Depth Wight 07 lbs./ft. Glom. In. to it. Depth Stick.9 9. FINISH OF Ell: �a .i Type: U"* UO/ /J/16 i°m°t.r: Slot/Mesh Slse: Length: Set beieuen ft. and ft. Bockfllling gravel Pack . 10. STATIC WATER LEVEL: 60 ft. ❑ Above or ❑ B•lo. land our loge Date Eauipme"t used: � .4 a �i II. PUMPING LEVEL Belo. land surface and YIELD 77 ft. after _lz_hr•, pumping r g.p.m. H. after hr•• Pumping_g.p.m. 12.GROUTING Well Grouted: ❑ Yes ❑ No Material: ❑ Neal Content ❑ Other: 13.puMP: (If oeallable) NP Length of Drop Pipe fl. capacity 9 P.M. ❑ Salem. ❑ Jet r❑ Contriflcal ❑ Other 1/.REMARKS: 16. WATER WELL CONTRACTOR'S CERTIFICATION: IS. Water Temperatuse ❑ F ❑ C This SII .as drl,Id under my )uric91tllan and this report Is true to the best of my knosd•dg• and o.u•f; Registered Business Nam. 9 CC,on tract Liters• Number Address: .(�. U i 713 "r) . sigr•a: / ./ate �r('i., 2 Data: Adthorlt.d Re7elsental.its corm 02•WWP (11/0I) Copy Distribution: WHITE -State OGGS, PINK -Driller, CANARY -Customer r. ` Itrlunicip�&tity of Anchorage r, POI,. -.I i G-650 ANCHORAGE. ALASKA 99502-0650 (907) 264-4111 TONY ANOW1I S MA YOU DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit #: 840356 January 31, 1985 TO: Permit Applicant SUBJECT: T13N R3W Section 26 Lot Sh of 10 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984. 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 and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, ""�_ Keith E. Bandt�or Environmental Engineering Program KEB/ljw enc: Copy of Permit SNP/057 v� r'1� 1tJ I C I PSL I TY 01 F= F'1 (DFZt=1GE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 OM—'� I _r 1-= SF=WEFT & wELL- F=>ERM I T 'PERMIT NO: 'DATE ISSUED: APPLICANT: ADDRESS: ;CONTACT PHONE LEGAL DESCRIP LOT SIZE: LOT LOCATION: MAX BEDROOMS: 840356 05/18/84 LARRY & JACKIE SMITH C/O 33123 LINDEN DRIVE ANCHORAGE, AK 99502 243-8047 SUBDIVISION: NA SECTION: 26 TOWNSHIP: 36328 (SQ. FT. OR ACRES) � OFF CAMPBELL AIRSTRIP ROAD 4 V- v LOT: S1/2-10 BLOCK: NA ANG : 3W LISTED BELOW ARE THE OPTIONS AVRI BLE TO YOL)\IN DESIGNING OUR SEPTIC SYSTEM. CHOOSE THE OPTION THAT BE FITS YOUR ITE. TFRF=F^J H - - - - F=L? W E>F?Ft I - DEPTH TO PIPE BOTTOM (FT.) 6. 0 6.0 6.0 GRAVEL DEPTH (FT.) 5. 0 0. 2.0 t TOTAL DEPTH (FT.) 11. 0 .5 8.0 GRAVEL WIDTH (FT.) 2.5 .0 5.0 GRAVEL LENGTH (FT.) \60. 0 41.0 84.0 ** GRAVEL VOLUME (CU. YDS. ) 0.5 33.4 38.8 TANK SIZE (GALS) 1, 250. 0 ** , 250.0 ** 1, 250. 0 ** SOIL RA ING CSO. FT. /BR) 150 150 150 ** GRAL LENGTH > 5 FT. 'EQUIRES\MULTI LE RUNS <NOT EXCEEDING 75 FT. EACH) ** TRNK\MUST HAVE AT EAST TWO COMPARTP NTS I CERTIFY T RT: 1. I AM FA ILIRP. WITH THEEQ E NTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH B THE MUNICIPALI Y OF t HORAGE (MOA) AND THE STATE OF ALASKA. 2. I WILL I STALL THE SYST IN ACCORDANCE WITH ALL'MOA CODES AND REGULATIONS, AND IN COMPLIANCE WITH TYMIT IGN CRITERIA OF THIS PERMIT. -3. I WILL ADHERE TO ALL MOATATE OF ALASKA REQUIREMENTS FOR THE SET BACK DISTANCES OM RNY EXISTLL, WASTEWATER DISPOSAL SYSTEM OR PUBLIG SEWERAGE SY EM ON THIS ADJACENT OR NEARBY LOT. 4. I UNDERSTAND HAT THIS PIS VALID FOR A MAXIMUM OF 4 BEDROOMS AND ANY ENLARGEMEN � WILL REQN ADDITIONAL PERMIT. IF A LIFT STATION I5 IN5T9LLL`D IN AN AREA COVERED BY MOR BUILDING CODES, ,THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS ,WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ,ELECTRICAL WO L( MUST BE DONE BY ArL ICENSED ELECTRICIAN. SIGNEDIle APPLICANT: LARRY & JACKIE SMITH �% ISSUED BY 4+� � — DATE: /lf/k/ ' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L Street, Anchorage, Alaska 99501 2644720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: / I L' n7 LEGAL DESCRIPTION: T 3 _ i 3 V✓. 5, ( l 1, It(OL.) Or�inic S�6raM� w� 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 ti 4GC S/71 BroY✓h 6 P) :5;7 arowh s WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Grnl SOILS LOG �1L0 3� ❑ PERCOLATION TEST DATE PERFORMED: 3--:,;,o— V Lf Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE TEST RUN BETWEEN PERFORMED BY: (tel P 0 aI� / CERTIFIED 72-008 (6/79) (minutes/inch) FT DATE: ekksh 102460 6 8 9 ru • Municipality of Anchor On -Site Water and Wastewater Progr fm (907) 343-7904 0v t 0 20 Parcel I.D. 007-022-22 1 Certificate of On -Site Systems Expiration Date: Z-// 6 /6 GENERAL INFORMATION La95 Complete legal description T1 3N, RM, Sec 26, Lot10, N178 Location (site address) 3434 Campbell Airstrip Rd. Current Property owner(s) US Bank National Association TTE Day phone Mailing address 60 Livingston Ave. St. Paul, MN 55107 Real Estate Agent 2. TYPE OF DWELLING: " i] Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual lx Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Received by:, -,-7-1 COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee Date of Payment Receipt Number COSA# O T I Waiver Fee $ _ Date of Payment Receipt Number MnM=.'j Il�l(laoIS- er ,� i 5. STATEMEN� INSPE'y:GSTION by ENGINE�q,1t 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 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water 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 this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone 6. DSD SIGNATURE Vf System #1 Approved for Ll bedrooms System #2 Approved for bedrooms Disapproved Date 11/9/2015 Conditional approval for bedrooms, with the following stipulations: By; Original Certificate Date: 1 16 /S The Municipality of Anchors 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 r - ., 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 1'eft, Legal Description: T13N, R3W, Sec 26, Lot10, N178 Parcel ID: 10,07-022-22 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 5/26/1984 Sanitary seal (Y/N) Y Total depth 80 ft. Cased to 80 ft. FROM WELL LOG Date of test 5/26/1984 Well Log (Y/N) Y Wires properly protected (YIN) Y Casing height (above ground) 12+ in. AT INSPECTION 11/4/2015 Static water level 60 ft. 59.6 ft, Well production 5 g.p.m. 3.6 g -p -m, WATER SAMPLE RESULTS: ,'I Coliform colonies/100 mL Nitrate 15, 1'4 mg/L Arsenic $•S% ug/L Date of sample: 11/4/2015 Collected by:_Sullivan Water Wells B. SEPTICIHOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 5/27/1985 Tank size 1,250 gal. Number of Compartments 2 Cieanouts (YIN) Y Foundation cleanout (Y/N) Y Depression over tank (YIN) N High water alarm (Y/N) N Date of pumping 11/4/2015 Pumper A+ Home Services C. ABSORPTION FIELO DATA Date installed 5/27/1985 Soil rating 1�0 SP/BR` Deep Trench '(g.p.d./ftz orftz/bdrm) System type Length 63 ft. _ Width 3 ft. Gravel, below pipe 7 ft. Total depth 11 ft.. -Fff. absorption area 882 ftz Monitoring tube Y�_ Depression over field N Date of adequacy test 1 1,/4/2015 Results (Pass/Fail) pass' For 4 bedrooms Fluid depth in absorption field before test 23 in. Water added 600 gal. New depth 53 in. Elapsed Time: 15 min. Final fluid depth 23 in. Absorption rate > 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) No If yes, give date D. LIFT STATION Date installed Size in gallons "Pump on" level at in. "Pump off" level at Datum Manhole/Access (YM) in. High water alarm level Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100+ Absorption field on lot 100+ Public sewer main 75+ On adjacent lots 100+ On adjacent lots 100+ Public sewer manhole/cleanout 100+ Sewer /septic service line - 25+ Holding tank 100+ Animal containment areas 50+ Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Absorption field 5+ Water main 10+ Water service line 10+ Surface water 100+ Wells on adjacent lots 100+ ' ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water retain 10+ Water Service line 10+ Surface water 100+ Driveway,parking/vehicle storage �10+ Curtain drain ' 50+ Wells on adjacent.lots 100+ F. COMMENTS House Vacant. Presoaked in accordAnce with engineers bulletin 89-2. ITi1 Survey Of]file. Fac...�aco jLj Aj ,dq g.lw n o S c� u .. . r /I �l (0 [20 G. ENGINEER'S CERTIFICATION V I certify that I have determined through field inspections, and review of Municipal records that the above systems are in conformance with MOA COSA guidelines ire effect on this date. Engineer's Printed Name. Steven R. Pannone bate 11/9/2015 COSA canary sheet 2-e-15.doc Municpalify of AHchorage Development Services Department Building Sefety Division Onsite Water 8 Wastewater Program 4700 South pragaw SL P.O. Box 19$650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING RG%SSV Parcel I.D. 007-022-22 HAA# n tLn 1. GENERAL INFORMATION Expiration Date: �-- 1'7 --_CO _ Z 7 Complete legal description TOWNSHIP 13N RANGE 3W SEC 26• LOT 10 LESS N178 - Location (site address or directions) 3434 CAMPBELL AIRSTRIP ROAD * ANCHORAGE AK • 99504 Current Property owner(s) Mailing address Lending agency Mailing address LARRY dr JACKIE SMiTH Day phone 244-6026 3434 CAMPBELL AIRSTRIP ROAD + ANCHORAGE AK • 99504 Day phone Real Estate Agent BRIAN BRODERICK w/PRUDENTIAL VISTA Day phone 273-7261 Mailing address 3801 CENTERPOINT DRIVE #200 • ANCHORAGE, AK. 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well K Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Weil ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of 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 samples. (Certificates may be reissued fora 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 engineers 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 onsite 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 1s(am) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of Installation. Name of Finn GARNESS ENGINEERING GROUP, Ltd. Address 3701'E. TUDOR ROAD, SURE 101 • ANCHORAGE, AK 99507 Engineers Printed Name JEFFREY A. GARNESS. P.E. Engineers Comments: in conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system In accordance with ADEC and MOA DSD Guidelines 6 Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ltdcan 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 orparty is not authorized, nor will N confer any legal right whatsoever. 5. DSD SIGNATURE 1/ Approved for --4-- bedrooms. Disapproved. Conditional approval for Attachments: HAA Checklisty Septic System Advisory Well Flow Advisory Phone Date 337-6179 bedrooms, with the following stipulations: Maintenance Agreements Supplemental Engineers Report Other qTER AND EVVAI tK ' m •• WPROGRAM . a'. /'JJJJi: ANTS •. By Original Certificate Date: — 7 - 0 trsr. 1vorl Municipality of Anchorage e , Development Services Department Building Safety Division On -Sits Water& Wastewater Program 4700 South Sragaw SL P.O. Box 196650 Anchorage, AK 99519.6650 www.d.anchorege.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: T13N, R3W, SECTION 28: LOT 10 LESS N1780 Parcel ID: 007-022-22 A. WELL DATA Well type EMAX If A, B, or C provide PWSIDX N/A Well Log (YM) YES "- Date completed 5/26/1984 Sanitary seal (y/N) YES Wires properly Protected (YM) YES Total depth 80 ft, Cased to 80 ft. Casing height (above ground) 24+ -in. FROM WELL LOG AT INSPECTION Date of test _ 5/26/1984 8/1/2004 Static water level 60 64 ft Well production 5 g.p m. 0.74 g.p.m. WATER SAMPLE RESULTS: Coliform _A c0l0nteS/100 rd. Nitrate0.1 mg Other bacteria _l�_coloniesH00 mi. 1129 2004 Arsenio: N/A mg./L• Date of sample: 6/11/2004 Collected by: CEO, Ltd. B. SEPTICIHOLDING TANK DATA Tank Type/Material STEEL Date installed 5/27/1985 Tank size 1250 gal, Number of Compartments 5; = Cleanouts (YM) YES Foundation cleanout (YM) YES Depression over tank (YIN) NO High water alarm (YIN) N/A Date of pumping 6/1/2004 Pumper MCDONALD'S PUMPING C. ABSORPTION FIELD DATA HER EiMMKINI Date installed _8/5/1985 SoI1rating (g.p dJIJ% rrtd 150 Systemmm TRENCH Length 83 a Width 3 R Gravel below pipe 7 ft, Total depth 06 2 ft. Eff. absorption area 882 ft' Monitoring tube YES Depression over field NO Date of adequacy test 6/1 /2004 Results (Pass/Fen) PASS For 4 bedrooms Fluid depth In absorption field before test DRY in, Water added 747 gal. New depth12 1n. Elapsed Tine: 10 min. Final fluid depth IDRY in. Absorption rate )o= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date — *SUMP ONLY EXTENDS 6.2 FEET BELOW GRADE AND 23' BELOW DRAINPIPE INVERT D. LIFT STATION Date installed "Pump on' level at _in. E. SEPARATION DISTANCES Size in gallons High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAtft station on lot 100'+ On adjacent lots 100'+ Absorption field an lot 100'+ On adjacent lots 1001+ Public sewer main N/A Public sewer manhde/deanout N/A Sewer /septic service line 25'+ Holding tank N/A 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 1006+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water t 00'+ Driveway, parkingivehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent kits 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that I have determined through field inspedlons and review of Munidpal records that the above systems ere in conformance with MOA HAA guidelines to effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date zZ�vcc HAA Fee $ �-i() Date of Payment a Alco �C%] Recelpt Number 06 3 1ifi !�Z m (Rev. 1201) Waiver Fee $ Date of Payment Receipt Number 06-07-04 02:37PM FROM -CUE ESI, SGS ENV SERVICES SGS' SGS ReEll 1043024001 Client Name Garness Engineering Group, Ltd. Project Name/# T13 R3W Sec 26 Lot 10 N178 Client Sample ID T13 R3W Sec 26 Lot 10 N178 Matrix Drinking Water Sample Remarks: 9075615301 T-650 P.02/03 F-459 All Datnffimes are Alaska Standard Time PrintedDateffime 06/072004 8:53 Collected Dste/fime 06/012004 17:50 Received Date fime 06/022094 12:00 Technical Director SteribesT. Ede Parameter Results PQL Unity Method Container ID AOo*r Prep Analysis Linin Date Date Init Waters Department Nitratc-N 0.1000 0.100 mg1L EPA300.0 D (<-10) 06/03/04 JIB Microbiology Laboratory _. .. .. Total Coliform 0 eol/100mL SM189222D A (<-I) 06/0211/4 DKC N 89058'00" E 252.85' to C ` . T 9 O O ep O e O Vert8 CDC) C) Z FW. FEW S 89058'00" W 239.84' FOR: LARRY SMITH Little Bear Services 525 W. 54th Ave. Anchorage. Alaska 99518 — --(905-877-1040 — C� �e o +.p <O i' j} retto-lesz to P to �� 0 FND.?ALUM CAP Q4A W SCALE I k ch . b Fist 20 10 6 10 20 w a0 1' = 40106/15/04 AS–BUILTSOUTH HALF 1638rawn DyField Book BLM LOT 10 RJB-- - - - - I hereby certify that the property described hereon has been surveyed by me, or at my direction, and that the improvements situated thereon are within the property lines and do not overlap or encroach on the property = adjacent thereto unless otherwise shown. 7bat no Improvement on the property lying adjacent thereto encroach on the ppremises In question and that there are no roadways, transmission Hnesor other easements on said property except as shown. It Is the responsibility of the owner or builder, prior to construction. to verity proposed building grade relative to finish grade and utility connections and to determine the existence of 6" easements, covenants, or restrictions which do not appear on the recorded subdivision plat. Listed distances prevail over scaling. Reproduction may cause distortion. OF A 7 D0B%t1oEaT rIllli . n 1-atexl7 1 / �3910N1Y Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519.6650 www.d.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. 007-022-22 HAA# 1. GENERAL INFORMATION Expiration Date: Complete legal description Location (site address or directions) 3434 CAMPBELL AIRSTRIP ROAD • ANCHORAGE. AK • 99504 ]♦ Individual On-site Current Property owner(s) LARRY do JACKIE SMITH Day phone 244-6026 Mailing address Lending agency Mailing address Real Estate Agent Mailing address 3434 CAMPBELL AIRSTRIP ROAD • ANCHORAGE. AK • 99504 Day phone MARY COX W/ REMAX PROPERTIES Day phone 2600 CORDOVA STREET • ANCHORAGE, AK • 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 276-2761 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 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 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 Tilos 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 codas, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SURE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily Identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the 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. V� Approved for 14 bedrooms. Disapproved. Conditional approval for Attachments: - / HAA Checklist __lam Septic System Advisory Well Flow Advisory bedrooms, with the fllowing Phone 337-6179 Date 6 f 5'10 4 j J CATER AN[ 1NASTEWATE • D-.--PRflt=RAN 0' Manitenance Agreements Supplemental Engineers Reort Other By:� / 1 . , - r �. Q,nQ,._ Original Certificate Date: (Rw.11,01) Municipality of Anchorage ° Development Services Department BuIltling Safety OlvBiwn r On -Site Water & Wastewater Program 4700 South Bragaw SL P.O. Box 195650 Anchorage, AK 995196650 www.cI.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: T13N, RMC SECTION 26: LOT 10, LESS N178' Parcel ID: 007-022-22 A. WELL DATA Well type MATE If A, B, or C provide PWSID# N/A Date completed 540/1984 Sanitary seal (Y/N) YES Total depth 80 ft. Cased to 80 ft. FROM WELL LOG Date of test 5/1984 Static water level 60 ft. Well production 5 g.p,m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate .10 mgA. Wee Log (YM) YES Wires properly protected (Y/N) YES Casing height (above ground) 24+ in. AT INSPECTION 6/1/2004 64 ft. 0.74 — 9 -p.m - Other bacteria 0 colonte3/1DO ml. Arsenic: N/A mgJL. Date of sample: 6/1 2004 Collected by: GEG, Ltd. B. SEPTICfHOLDING TANK DATA Tank Type/Material STEEL Date installed 5/27/1985 Tank size 1250 gal. Number of Compartments 5 Cleanouts (YIN) YES Foundation cleanout (YIN) YES Depression over tank (YIN) NO High water alarm (YM) N/A Date of pumping 6/1/2004 Pumper MCDONALD'S PUMPING C. ABSORPTION FIELD DATA Date instatied 8/5/1985 Soo rating (g.p.d.fRibrill§dR0 150 System type TRENCH Length 63 ft. Width 3 ft. Gravel below pipe 7 ft. Total depth —*62 ft. Effabsorption area852 fe Monitoring tube YES Depression over field NO Date of adequacy test 6/1/2004 Results (Pass/Fall) PASS For 4 bedrooms Fluid depth in absorption field before test DRY in. Water added 747 gal. New depth 110 in. Elapsed Time: 110 min. Final fluid depth DRY In. Absorption rate >= 600+ g,p,d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date – `SUMP ONLY EXTENDS 6.2 FEET BELOW GRADE AND 23' BELOW DRAINPIPE INVERT D. LIFT STATION Date installed Size in gallons "Pump on" level at _in. E. SEPARATION DISTANCES High water alarm level at Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAtft station on lot 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Holding tank N/A SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main Water main N/A Water service line 10'+ Surface water 100'+ 106+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 106+ Surface water 100'+ Driveway, parkinglvehide storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION l certify that I have determined through field inspections and ;!` -''+ review of Municipal records that the above systems are M ...... conformance with MOA HAA guidelines in effect on this date. ..... _ ... • ... y A. sea.: Engineer's Printed N e JEFFREY A GARNESS 4 7953 Date Off% o°Drofnsw^a HAA Fee E Waiver Fee E Date of Payment fai Date of Payment Receipt Number nG]1 zz(a Receipt Number (Rev. 17101) 06-07-04 01:37PM FROM -CUE ESI, SGS ENV SERVICES SGS Ref.N 1043024001 Client Name Gamess Engineering Group, Ltd. Project Name/# T13 RM Sec 26 Lot 10 N178 Client Sample 1D T13 RM Sec 26 Lot 10 N178 Matrix Drinking Water Sample Remarks: 9075615301 T-650 P.02/03 F-459 All Dates/Times; are Alaska Standard Time Printed Date/fime 06/072004 8:53 Collected Date/time 06/012004 17:50 Received Date/time 06/0220 4 12.00 Tecdnical Director StepbepCC. Ede Parameter Results PQL Unita hfe0wd Container ID ALim is Prep Dates Limits D�rte Date Ini[ Waters Department Nitrate -N 0.10013 0.100 Microbiology Laboratory Total Coliform 0 mg/l. EPA 300.0 D (<-10) 06/03104 JIB coV100mL SM199222D A (<=1) 06/02/04 DKC I 8 N V) T VA FND. AEOM N 89058'00" E S 89058'00" W FOR: LARRY SMITH Little Bear Services 525 W. 54th Ave. Anchora`e, Alaska 99515 (907) 677-1040 sg vqo s 252.85' 239.84' 06/15/04 M M. I�Mm spa LO WEM o-te.sz � iNn B g0 t g � o aro eo C 0 SV01 e r FND.2ALUM CAP OI 0= :: Cn 0= ) J LU I (Co -51 UI I GRAMC SCALL 1 s,M - 40 F"t * 1b 6 t0 20 AO 00 r=4a I hereby certify that the property described hereon has been surveyed by me, or at my direction, and that the improvements situated thereon are within the property lines and do not overlap or encroach on the property tying adjacent thereto unless otherwise shown. That no Improvements on the property lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission Imes or other easements on said property except as shown, It is the responsibility of the owner or builder, prior to construction, to verity proposed building grade relative to finish grade and utility connections and to determine the existence of any easementa, covenants, or restrictions which do not appear on the recorded subdivision plat. listed distances prevail over scaling. Reproduction may cause distortion. SOUTH HALF BLM LOT10 OF.41��1 I �BO9aU6' is MM 1 ��'assionw� \ Municipality of Anchorage 1 • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Advisory Health Authority Approval # HA040424 During a recent Health Authority Approval on-site inspection and test of the potable water supply well at T13N, R3W, Section 26, Lot 10 less N178 feet, the well's productivity was determined to be 0.74 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 4 -bedroom residence is 0.42 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. �.1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 2644720 �1 / Application Date �••�"( �( ?==^�-�yC� 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) 6 Z �..�'clt �/,- i3�-Vh C.ar I O 1.7cz ZF —t— (Z M =,a , c A Location (address or directions) (b) Applicant Name�� 1�� Telephone: Home z 4Business 30 ]`Mk Applicant Address 3 % Z 3 L I (c) Applicant is (check one): Lending Institution ❑ ; caner/build ❑ ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single -Family D Multi -Fa dy ❑ Other Number of Bedrooms 3. WATER SUPPLY Telephone Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL , Onsite Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11;84) n 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of thevalidation date shown below. I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/pr wastewater disposal system is sale, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. �7 l J cel C1-'wfiZLt— �i�% C 1� ele hone Name of Firm p Address �6G0 Clgd ` ,-t= At— c_ c9 ,j% 6_ Date 1 e ?0Z:6%*'A hF 11A , c 03C -C-" 16r) Q tr[ti� 4�/zc l8S a PDAT+ T 6I,3/as- OF Az %t4 _.•••'..A--- s #*. Engineer's Seal �.............� 7)401A A. FISCHER ` p CE -6793 q.,W z ,• ccAr 44�aCeSSk��,e: 6. DHEP APPROVAL G� Approved for bedrooms by? j nk' ate a Approved X Disapproved Conditions _ Terms of Conditional Approval t % CAUTION' 1 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 Municipalitylof Anchorage is not responsible for errors or omissions In Itis' professional engineer's work. - Page 2 of 2 - - r2-025 111.641 .. _ _ .... B. SEPTIC/HOLDING TANK DATA Date Installed 5/Z7&- Size M60 No. of Compartments Z Standpipes (Y/N) `r4 Air -tight Caps Y/N) Y� Foundation Cleanout (Y/N) h10 Depression over Tank (Y/N) :l5!!!!:Y� S, %Z" Date Last Pumped 0.& Pumping/Maintenance Contract on File (Y/N) N /6 ; for -N ALsi; Hold ng Tank High -Water Alarm (Y/N) N/A= Temporary Holding Tank Permit (YIN) N f1} Separation Distances from `Septic/Holding Tank: To Water -Supply Well 1/02 To Building Foundation X43 T 01 To Property Line 45 4•- To Disposal Field `I i To Water Main/Service Line Z1s To Stream, Pond, Lake, or Major Drainage Course Comments ..3ahZrr Ic_ ",JT- R =b;j ?'IME 'LN '-f1-ie- 5?/ ¢}vase- is of s p,i,I;-r- a Is f1�� Page o8�' 'T?hS r LY Cc�5�P1t•1 Cti" iS, stow o>v -iliE M..rCCe St-ii3Ttit+41ir n q� SKsT' S 1I✓17UD "1714- F-1 1n+Z' fNslp(r a94V-+L Sly v�.rs;� ��z1r a,Tst,� St,Ye1i►.�, eAPri.J pspc- 8Y 614TLir J kc s'UcTjM -To plrc lresitD� - - = MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL(HAA) t ?. CHECKLIST/-�F�E•IBgRUARY 1984. l r •i Ir„ ¢~ ' P ' . w;.Hr y fir,¢ �: r•' :' ..:rp - .' r ry'. i .1 .,. a _ a''fi..;: -Legal Description.SOuTtit , q.pF A. WELL DATA ; Well Classification, I�vAr� If A B. C, D.EC `Approved (Y/N) f .? .. Well Log Present(Y/N) Date Completed �, ��3t� `.Yield k . Total Depth :Cased I' Depth of Grouting ,• 'Static Water level. '' �O F` ' PumpFSetAt '' ' 6 Casing Height Above Ground " sanitary Seal on Casing (Y/N) "Y6" �� Electrical Wiring in Conduit (Y/Nj Yb' Depression ArdGnd Wellhead (Y/N) ' • :�'.: Separation Distances from Well: To Septic/Holding Tank on Lot ` OZ ; On Adjoining Lots. To Nearest Edge of Absorption Field on Lot :6n Adjoining Lots4- To Nearest Public Sewer Line gra 'To Nearest Public Sewer Cleanout/Manhole W/A To Nearest Sewer. Service Line on 1.6t.. Water Sample Collected by ��f fovv� � "� ; Date 4=Ag!-St0-=--. ""• Water Sample Test Results ti> S � '�"r _, _ - ., pis wo of •Comment PyC. �ws�§T �,F- "CLL ENDS % i}Ec+ GRa.nm .. B. SEPTIC/HOLDING TANK DATA Date Installed 5/Z7&- Size M60 No. of Compartments Z Standpipes (Y/N) `r4 Air -tight Caps Y/N) Y� Foundation Cleanout (Y/N) h10 Depression over Tank (Y/N) :l5!!!!:Y� S, %Z" Date Last Pumped 0.& Pumping/Maintenance Contract on File (Y/N) N /6 ; for -N ALsi; Hold ng Tank High -Water Alarm (Y/N) N/A= Temporary Holding Tank Permit (YIN) N f1} Separation Distances from `Septic/Holding Tank: To Water -Supply Well 1/02 To Building Foundation X43 T 01 To Property Line 45 4•- To Disposal Field `I i To Water Main/Service Line Z1s To Stream, Pond, Lake, or Major Drainage Course Comments ..3ahZrr Ic_ ",JT- R =b;j ?'IME 'LN '-f1-ie- 5?/ ¢}vase- is of s p,i,I;-r- a Is f1�� Page o8�' 'T?hS r LY Cc�5�P1t•1 Cti" iS, stow o>v -iliE M..rCCe St-ii3Ttit+41ir n q� SKsT' S 1I✓17UD "1714- F-1 1n+Z' fNslp(r a94V-+L Sly v�.rs;� ��z1r a,Tst,� St,Ye1i►.�, eAPri.J pspc- 8Y 614TLir J kc s'UcTjM -To plrc lresitD� C. ABSORPTION FIELD DATA Soils Rating in AbsorptionStrata5D Type of System Design Date Installed $�Z7/ Length of Field" -6 r -- Width of Field __- Depth of Field Gravel Bed Thickness Square Feet of Absorption Area Standpipes Present(Y/N)' Depression over Field (Y/N) -N`Q Date of Last Adgquacy Test f`x� Results of Last Adequacy Test M Separation Distance from Absorption Field: ' To Water -Supply Well 1 (Z / To Property Line To Building Foundation er'?� To Existing or Abandoned System on Lot P I A ; On Adjoining Lots / To Water Main/Service Line 9 5: r To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course _- N rte• To Driveway, Parking Area, or Vehicle Storage Area 5O t Comments D. LIFT STATION Date Installed Size in Gallons 'Pump On- Level at _ High Water Alarm Level Tested for Electrical Codes (Y/ Comments Dimensions Manhole/Access (Y/N) _ "Pump Off' Level at Vent (Y/N) . Pumping Cycli Adequacy Test. Metts MOA •• Check Permitted Bedroom Rating Against HAA Request .. I certify that I have checked. enfieorconformed toally OA and HAA guidelines in effe ct on the date of this inspection. Signed S1 Date Company C- vy%TU� 0 --Cor-- MOA No. Receipt No. Date of Payment Amount: S Page 2 of 2 72.026 111,841 i�P`' '•..... ys�' L }:..:......:...:..�•s..e .... 1441 7% CE -6 793 eR o� U s rte' ....••'ear Ia✓o�A�e�ioc��w� t MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 2644720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) 143� ¢ Ckmesda A-ttzsrrr.,P (oma (b) Applicant NameTelephone: Home 3 _ tlti4%Business C��rMt✓ Applicant Address -' r=Atc— I (c) Applicant is (check one): Lending Institution [3; Own r/build 6Buyer 13; Other 13 (explain); (d) Lending Institution V/+s%[i4 0—'cL,-Uc Telephone •�'7�` Address (e) Real Estate Company and Agent Address Telephone (1) Mail the HAA to the following w; // 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms 4 3. 'WATER SUPPLY Individual Well Community ❑ Public ❑ a Note: If community well system, must have written confirmation from the State Department of EnvironmentalConsenatien attesting to the legality and status. 4 SEWAGE DISPOSAL OnsityCVd�' Public 13Community ❑ Holding Tank ❑ Not : le f 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{:5 0n a+l 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 verity 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 W ' Telephone S�—%fJ0£; Addre Date �P�E OF q4 �+` oW , ........,,•,9 ++ *�.• TH �J •.�♦ Ttt0.101 a riscNSR •'a 0 11,.%. CE -6793 o ngineer's Seal 6. DHEP APPROVAL Approved for r+ p bedrooms by t Date Approved // Disapproved Conditional _X TermsofCcnditional App rdvral f� ric�N_+� (YUt7Gl/f �e�/C rU �� f'rLG-/�: �GPreSSro.J Gve�� -rn� //aa,�� Ups/9cc• CLOG-�'.�c��''. Wor'Y / 5 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 MUNICIPALITY OF ANCHORAGE 1 DEPT. OF HEALTH 8 MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) APR 2 2 19% CHECKLIST - FEBRUARY 1984 R F rr 284.4720 ►/ ' L:T a D Legal Description* S�utT�► /[ A. WELL DATA Well Classification FA4,er = If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) e"1 Date Completed 5� 463[ Yield - 5 CrE/n Total Depth 50 Cased to 8O ! Depth of Grouting N �� Static Water Level ('Vo Pump Set At Casing Height Above Ground 6 Sanitary Seal on Casing (Y/N) - Y6 Electrical Wiring in Conduit (Y/N) 'tJ:n Depression Around Wellhead (Y/N) NO Separation Distances from Well: / To Septic/Holding Tank on Lot On Adjoining Lots To Nearest Edge of Absorption Field on Lot 12 On Adjoining Lots �� } To Nearest Public Sewer Line — To Nearest Public Sewer r Cleanout/Manhole WZA To Nearest Sewer Service Line on Lot Water Sample Collected by �� u+n' ; Date 4 -- Water Sample Test ReResultsof S Pat& Comments 2- ► ' c"'A rT F "gL' Eav,S 40 4 —Cil'_ Fo z Tcm P. C • a B. SEPTIC/HOLDING TANK DATA Date Installed Z 9 Size (ZSo No. of Compartments 2 - Standpipes Standpipes (Y/N) YgM Air -tight Capsr(Y/N) Foundation Cleanout (Y/N) NO Depression over Tank (Y/N) -tom' Z Date Last Pumped ,/A Pumping/Maintenance Contract on File (Y/N) N.16 ; for N/A Holding Tank High -Water Alarm (Y/N) —Jif- Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well 107-" To Building Foundation 4 3 To Property Line�tJ� ' — To Disposal Field 7 / To Water Main/Service Line Z'S 'f' To Stream, Pond, Lake, or Major Drainage Course Ar Comments C-0. Ar 3Es TIME' �N ?Nc 'tit -L Page roll?Tm -By —f i -;s 72-026111;64) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ISO Type of System Design T ►� Datelnstalled 5_1Z7A Length o1 Field 6 Width of Field 3� �• Depth of Field �Z Gravel Bed Thickness -7 sa Square Feet of Absorption Areag8 Z Standpipes Present(Y/N) S Depression over Field (Y/N) !�M Date of Last Adequacy Test N _ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well __ - 117- To Property Line To Building Foundation To Existing or Abandoned System on Lot P I A ; On Adjoining Lots 9�+ To Water Main/Service Line Z J'T "r- To Cutbank (if present) ty ti To Stream/Pond/Lake/or Major Drainage Course - N ( f} To Driveway, Parking Area, or Vehicle Storage Area 15C7 -t- Comments Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at — High Water Alarm Level Tested for Electrical Codes (Y/ Comments — Dimensions _ Manhole/Access (Y/N) — 'Pump Off' Level at Vent(Y/N) Pumping Cycl •• Check Permitted Bedroom Rating Against HAA Request .. Adequacy Test. Meets MOA Icertify that Ihave checked, nfieCprconformedtoall OAandHAAguidelinesineffectonthedateofthisinspection. Signed s Dateor --4/ Company 13.C41itMOA No. Receipt No. Date of Payment Amount: $ LN Page 2 of 2 72026 111, 841 •— OF i�P�(`G......, TH ...... .... .� ..... .... �..j • THOM A. FISCHER CE -6793 •SAV 4 4F Seal