HomeMy WebLinkAboutHERITAGE PARK BLK 2 LT 24e ritage Park
Block 2
Lot 24
#050-211-56
Municipality of Anchorage
On-Site Water and Wastewater Program • (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP 181118 PID Number: 05021156
Dwelling: ❑■ Single Family (SF) ❑ Duplex(D) ❑ Multiple(SF and/or D) Project: ❑ New ❑■ Upgrade
Name:
MATT AND ELISABETH DEFOOR ABSORPTION FIELD
Address ❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
19523 CITATION ❑ Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
-- GPD/SF -- Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot -- Ft.-- Ft.
Fill added above original grade Gravel length
Township Range Section -- Ft. -- Ft.
Gravel width Beds:Number of Lines Distance between lines
SEPARATION DISTANCES -- Ft. -- -- Ft.
To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist.between trenches
From Tank Field Tank Line __ Ft2 -- -- Ft.
Well +100 -- -- __ -- TANK ■❑Septic ❑S.T.E.P. ❑ Holding 0 Other
Manufacturer Capacity
premier plastic 1000 Gal.
Surface Water +100 -- -- -- Material Number of compartments
Lot Line +5 -- -- -- hdpe 2
NA
Foundation +5 __ -- _- LIFT STATION
Manufacturer Capacity
Curtain Drain __ -- __ -- -- -- Gal.
Remarks Pump on level at Pump off level at High water alarm at
Tank was raised and pipe grades
were corrected -- in. -- in. -- in.
Pump make and model Electrical Inspections performed by
PIPE MATERIAL House to tank 3034 Tank to 3034
Installer drainfield
guaranteed services Drainfield exist CO/MT3034
Inspector charles balzarini BENCH MARK (Assumed elevation) 100 ft
Inspection 1s' 6/7/18 2nd 6/10/18 Location and description
dates:
3rd 4th bottom of siding near fco
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL .ISVII* ritiir�;
p. ..***•q•_ QS..1
Conditional Approval: Date • •,�f- I�
s� 49 , *�I
- r• 0
[o 1%4. its ®O/ l 4 raised .... i
,. Q. .r.. ;fa
-}-p pua tic°„p ) oS ,�-t•A" I e-ry �v Dt 1„a ,,, 60.,-/d - �•,, CE-13854
• • •Isar
Approved �. 's Date �j`� �"-� I Qi��• E S Wil!
Inspection Report_9-1-12.doc
MUNICIPALITY OF ANCHORAGE
On-Site Water&Wastewater Program `)0
PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
http://www.muni.org/onsite Vital
l)i•partIntl)t
h,yCH Up AVS
On-Site Wastewater Disposal System Permit
Permit Number: OSP181118 Effective Date: 6/4/2018
Work Type: SepticTank Upgrade Expiration Date: 6/4/2019
Tax Code Number: 05021156000
Site Legal Address: HERITAGE PARK BLK 2 LT 24 G:0055
Site Mailing Address: 19523 CITATION RD, Eagle River
Owner: DEFOOR MATTHEW HALL & Lot Size in Sq Ft: 20125
Design Engineer: C & M Engineering Total Bedrooms: 3
This permit is for the construction of:
❑ Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received : : Date: 1(//.
Issued By: kube Caru Date: (o%{ 6
MUNICIPALITY OF ANCHORAGE
•
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 050-211-56
Property owner(s) Matt and Elisabeth Defoor Day phone
Mailing address
Site address 19523 Citation
Legal description (Sub'd., Block & Lot) Heritage Park Block 2 Lot 24
Legal description (Township, Range & Section)
Lot Size 20125 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(El all that apply)
Absorption Field H Initial Single Family (SF) [x
(w/wo ADU)
Septic Tank Upgrade N I Duplex (D) ❑
Holding Tank H rip*/ 7 ❑
u5 �� Multiple Dwellings
Privy ti f A (SF and/or D)
Private Well [ I
Water Storage I
[ a MAY . ` 2018
yQ ti
THIS APPLICATION INCLUDES ° P. VER R ' • - T FOR:
0[ 89
none Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Munici.,a.Codes.
/tel
(Signe of property owner or authorized agent)
Permit/Rush Fees: ‘016 Waiver Fees:
Date of Payment: (11/112 Date of Payment:
Receipt Number: Oq -14b Receipt Number:
Permit No. O5pI1I`l' Waiver No.
G\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
C&M ENGINEERING SERVICES
Ph:907-854-5558
Municipality of Anchorage
Onsite Water&Wastewater Program
4700 Elmore Rd Anchorage, Ak 99507
RE: Proposed Septic System Modification for Heritage Park Block 2 Lot 24
Dear Reviewer,
The above referenced property is currently served by a 3 bedroom septic system.
A Recent adequacy test revealed that the leach field pipe invert elevation was approximately 4" above the
tank outlet elevation. Though the system still functions, the moa requires that there is drop from the tank
to the leach field.
We are proposing that the existing tank be raised to correct the pipe slope to meet MOA requirements.
The drop from the house to the tank shall not be less than 2%, which may require plumbing work inside
the crawispace.
The existing tank is constructed of HDPE and it may be possible to raise it without damage.
In the event that the tank can not be raised without damage, a new 1250 gallon tank will be installed and
the old tank will be decommissioned per UPC and MOA requirements.
The home is constructed with a deep crawl space, and as such the existing tank location and proposed
tank location is outside of the soil bearing prism. The bearing prism is based on a 72" footing depth and 5'
minimum horizontal separation between the tank and foundation.
The tank shall be covered with a minimum of 2" moa approved insulation and 3' of cover.
The existing after tank cleanouts will be replaced if determined necessary by the engineer.
The repair shall be performed by a moa certified installer in accordance with MOA requirements.
The engineer will inspect the tank before backfilling.
Repair of the proposed system will not negatively impact adjacent lots.
Note that we are not including a site plan with this drawing, but will submit a record drawing upon
completion of the repair.
Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854-
5558 or by email cqbalzarinigmail.com with any questions or concerns.
Sincerely,
Charles Balzarini, PE
Municipality of Anchorage :
Development Services Department
Building Safety Division ,
On-Site Water and Wastewater Program, 4700 S. Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page of
www.cl.anchorage.ak.us (907) 347.7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: 5wooiss PID Number: 0So -a M e
R«M
11
Wastewater System: New 59 Upgrade
Aa... 43;w PpaFQ��QI� 4957
1;Y ABSORPTION FIELD
r y S 3
Dep 71ar11 O Srunw h«M O ab O MomW O OIMr
LEGAL DESCRIPTION
s iRarq
Tar Dm1hk "wVWWVr
9
• P iFlr
fl
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Fi idtee aa.a e•ipnM prk: 0FI.
Gr.+a Loy", >r'✓1+
F1.
Well: New ❑Upgradec,.
M
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SEPARATION DISTANCES
NSeptic ❑Holding ❑S.T.E.P. ❑Other.
To
From
Septic
Tank
Absorption
Field
Lift
Station
Holding
Tank
PubnNPdval
Sewer LtineMm«b1
Mr"IxN.
*C
p/A
`/ 5 S
11000
WN
1604-Mie•
N D P4
caGla
va.
Sp .@ WOW
16014
F4.
LIFT STATION
La LM
Ot
10'
Zel��
h
c« a.
ornd
no
-
Fury ln+p.al"n+ P.•Ia W
R«n.rY+
BENCH MARK
Lpcam" w o.+a�pbm � � J
C
Asw.m.0 EMrma"
100 FI
En T ate'kamp
C� fr~ �?•�--'.,%L+d
5 d S ENGINEERING
Inspections performed b 17034 Eagle Rivar Leop Road, No s: to _ 11-a5-0
Eagle Rive., Alask. 99M
Develri me ServiC Department Approval
p p pp
ROBERT C. COWAN ; �C
CE-8801
ria �''
"'i g
Pft�f,�
Reviewed and approvedt. Date: 2 3
Y�
••
J ••., _ „, •,`C�r
PERMIT NO. SWO10465
PACE 2 OF 3
Municipalityof Anchorage
DEPARTMENT OF HEATH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Bax 196650 *Anchorage, Alaska 99519-6650 • Telephone 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL LOT 24, BLOCK 2, HERITAGE PARK S/D P.I.D. NO. 050-211-56
LOT
25
LOT 21
DECK
EXISTING
3 BEDROOM
HOUSE
LOT 22
DV (DIVERTER VALVE)
)BL1 & DBL2
20
I
NEW 1000 GALLON
HDPE SEPTIC TANK
___ _ KEYBOXI
10' UTILITY EASEMENT
LOT 23
CITATION ROAD
-----------------------
SCALE. I` - 40'
rf jti ROBERT C. COWAN i `C
CE -8801 j u
PERMIT N0. SWO1 0465 PAGE 3 OF 3
Municipalit of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone+ 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL LOT 24, BLOCK 2, HERITAGE PARK S/D P.I.D. No. 050-211-56
ST1 ST2 99.0'
FINAL GRADE
2" INSULATION
NEW
94 9'
1000 GALLON
POLYETHYLENE 94.7'
SEPTIC TANK
A B
FCO 42.0 3.0
ST1 39.5 12.0
COI =97.2
ST2 38.5 16.0
CO2=97.3'
oBLI 38.0 20.0
-6-B _L2
38.0 21.0
DV 38.0 25.0
COI 64.5 43.0
MTI 65.0 44.0
CO2 48.0 74.0
FINAL GRADE
MT2 1 49.0 74.5
C01=93.9'
SR CO2=93.9'
N. T. S.
-M1
MT1=88.5'_/
sjtsll!i,
MT2=88.5'
Nei
U�`�.
WATER FOUND
..: .:
NO
Gi?v-.-,..,,>
82.0' B.O.H.
i' - ROEnT C. COWAN
�f
°�'• CE -8301 r•,i
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water& Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ONSITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Nov 13, 2001
Expiration Date: Nov 13, 2002
Permit Number: SWO10465 Parcel ID: 050-211-56
Legal Description: HERITAGE PARK BILK 2 LT 24
Design Engineer: 0003 S & S Engineering Site Address: 019523 CITATION RD
Owner Name: Bill Klemovitch Lot Size: 20125 SQ. FT.
Owner Address: 19523 CITATION ROAD Total Bedrooms: 3 Permit Bedrooms: 3
EAGLE RIVER. AK 99577-8418
This permit is for the construction of:
❑✓ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3_ The engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling
(907) 343-7904 (24 hours). ( Not required for a Water Supply Permit only).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By:
2
Date:
//-(3-0/
Date: 11-15-01
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.ek.us
(907) 343-7904
ON-SITE SEWERMELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. Permit Number SW O/0465
Properly owner(s) R"// kl emov i 9-C l7 Day phone D q q- qq 5 q
Mailing address (1) 1q 523 e;4-af;oln Pond
Mailing address (2) Fal10- 1 - Zip Code q q 5
77
Legal description (Lot, Block & Sub'd.) Loi a�f IOGk �, I eir �aAR Par k
Legal description (Section, Township & Range)
Lot Size a o las Acre q.Ft. Number of Bedrooms 3
THIS APPLICATION IS FOR:
Sewer Only ❑ Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
certify that the above information Is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
1 b 5 ENGINEERING /VI Z Z
17034 Eagle River Loop Road No. 204 --1 ^ ��
(Signature of property owner or authorized agent)
Permit Fees: 3 X 0. Waiver Fees:
Date of Payment: 11 I el /O Date of Payment:
Receipt Number: O a y 6 7 Receipt Number:
(Rev. 12100)
EI1Gl11t?ERIIiG ROBERT C. COWAN, P.E.
CMLENGINEERS
(907)694-2979
' FAX(907)694.1211
November 8, 2001
Tv
APPFIMALS
MUNICIPALITY OF ANCHORAGE
Development Services Department
P.O. Box 196650
SEWEns WATEn
Anchorage, aa AK 99519
►NRI IXTENSgFG
REFERENCE: Lot 24, Block 2, Heritage Park Subdivision
sEWEnawATEn
MPECTM
It is requested that you issue a permit to upgrade a septic system to serve the existing
three bedroom dwelling on the referenced property.
S1DE9
A test hole was excavated and a percolation test performed on 10/31/01. The approximate
ANDAEFonn
location of the test hole is located on the attached site plan. At the time of excavation, no
water was found. Ground water was monitored and after seven days water was not found
as shown on the attached soils logs.
WELL WSPECTM
i FLOW TEST
We do not anticipate any adverse effects on neighboring wells, septic systems, reserve
areas or drainage patterns by the installation of the proposed septic system. The
construction of this system will not prevent any future development on any of the adjacent
&IE PVNS
properties.
If you require additional information, please contact us.
AW DESIGN
Sincerely,
SOa TEST
IZKIC2
Robert C. Cowan, P.E.
RCC/bj j
PEACOLATICN
TEST
Enclosure
sTAL CTUM A
MECNANCAL
HSPECUM
ONSITE
WASTEWATEn
&SPOMSnTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SURE 204 • EAGLE RIVER ALASKA 99577
1" = 40' DESIGN SITE -PLAN
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--
----------------___ :;
Performed For:
Legal Description:
J'
Depth
i
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o
2-
3-
4-
5-
6.
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6. -- —
8-
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Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
www .cl anchorane.ak.us
(907) 343-7904
Soils Log - Percolation Test
✓1 fLN
02G�N1�5
Aft'C. COYrAW
GE - 8801
Performed: / ll /0
Township, Range, Section:
WAS GROUND WATER
ENCWNTERED7
Date
Gross Time
Net Time
Depth to Water
5
IF YES, AT WHAT DEPTH?
01
DepthtoWaterAnor
Monitoring?47,
n
1^ V _
P
E
Date:
n-
18-
19-
20 -
Reading
Date
Gross Time
Net Time
Depth to Water
Net Drop
10,4
01
--
�0
30
15 "
42'
30
30
14 t
,t
3a
3,•
PERCOLATION RATE (m eskxh) PERC HOLE DIAMETER (� ••
TEST RUN BETWEEN FT AND FT
COMMENTS 5)n slhy�s 'gPVC SLov4& rn4/Lc- /Lar•£ 'r//A, C- r,
PERFORMED BY: h t K. 4.- G j,�%✓L I2�[div' —j! pp ✓ CERTIFY THAT THIS TES WAS
PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUID LI ES IN EFFECT ON THIS DATE. DATE: II/T101
S&
ROBERT C. COWAN. P.E.
CrALENGINEE IS
(907)6944979
FAX (907) 694.1211
ON-SITE WASTEWATER DISPOSAL SYSTEM
AL NORIry
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
SEWERS WATER
LWNEXTENSIONS
REFERENCE: Lot 24, Block 2, Heritage Park Subdivision
November 8, 2001
SEWERS WATER
INSPECTION
GENERAL:
1. The scope of this project includes the verification of the existing 1000 gallon
septic tank, replacement with a 1000 gallon minimum septic tank if required,
ENWWETVMST"s
ANOREPMYS
and installation of a new trench to serve the existing three bedroom residence
located on the referenced property.
2. Construction shall be in accordance with the approved site plan and design
WEuINSKCTaN
9 ROW TEST
drawings, Municipal permit with any special provisions or conditions, and all
applicable State and Municipal Wastewater Disposal Regulations.
3. The contractor shall be responsible for obtaining any necessary underground
SITE PIANS
utility locates.
4. Unless specifically agreed otherwise, the property owner shall be responsible
ROADDESTON
for final grading areas subsequently depressed from soil settling.
5. Contractors installing wastewater disposal systems must be certified by the
8011TEST
Municipal Health Department for system installations. Owners installing their
own systems must also receive prior approval from the Municipal Health
Department.
PERCOLATION
TEST
SEPTIC TANK INSTALLATION:
1. A septic tank is to be constructed by a certified septic tank manufacturer.
STRUCTU IL
W00WAL
Construction shall include two 4" cleanouts for pumping access.
INSPECTIONS
2., The septic tank shall be sufficiently bedded to prevent settling or shifting of
'the tank.
ONSRE
WASTEWATER
OMPOSAL94TEM
DESIGN
17034 NORTH EAGLE RNER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
Page 2
Lot 41, Block 1, Wynter Park Subdivision Al
August 1, 2001
3. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade.
Septic tanks installed with less than 4 ft. of cover shall be insulated.
A foundation cleanout shall be installed one to four feet from the building foundation. In
the line between the tank and the leachfield there shall be two adjacent cleanouts (unless
an effluent pumping system exists within the septic tank). These cleanouts shall be
located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line,
shall be to clean toward the leachfield. The second cleanout shall be to clean toward the
septic tank.
6. Final grading over the septic tank shall be such that a positive slope exists away from the
septic tank.
ABSORPTION TRENCIUDRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the design. The bottom of the
excavation shall be within 2 inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (ruffed -up) before gravel (sewer rock)
placement.
2. Once the gravel is installed, the distribution pipe is to be installed level with the
perforations faced downward. Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
A silt barrier must be installed between the final gravel layer and the native soil backfill.
Ensure the silt barrier covers the entire gravel surface before placing backfill.
4. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations
shown on the design, and extend a minimum of 12 inches above final grade. The portion
of the monitoring tube extending through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is equivalent to the effective depth of
the gravel as noted on the design.
5. Backfill over the final gravel layer must not be less than twenty-four (24) inches.
Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The
finish grade over the trench must be mounded to prevent the formation of a depression
after settling.
Page 3
Lot 41, Block 1, Wynter Park Subdivision #1
August 1, 2001
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be constructed by a Municipal approved
septic tank manufacturer.
2. The following pipe materials are approved for use in septic system installations in the
Municipality of Anchorage:
Type of Pine Perforated Solid
Cast Iron
Yes
Yes
ASTM D3034 (PVC)
Yes
Yes
ASTM F810 (HDPE)
Yes
No
ASTM D2662 (ABS)
Yes
Yes
Use of a type of pipe other than listed above must be approved by the inspecting engineer.
3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Styrofoam I-II or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or
equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mimfi 140N, or equal) must be installed
between the final leachfield gravel layer and the native soil backfill.
6. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3%
passing the #200 sieve.
7. When sand is being used as a filter material, its gradation specifications must conform to
current M.O.A. or D.E.C. requirements, which ever requirement applies.
INSPECTIONS:
Typically there will be a minimum of three (3) inspections required during the installation of the
wastewater disposal system. These inspections will occur as follows:
Page 4
Lot 419 Block 1, Wynter Park Subdivision #1
August 1, 2001
The first inspection must be conducted after the excavation of ditches, pits,
trenches, or beds and before the installation of any gravel. A septic tank may be
set in place, but may not be backfilled before this inspection.
2. The second inspection must be conducted after the placement of the silt barrier,
gravel, distribution lines, standpipes, cleanouts, and insulation, but before the
placement of any other backfill.
3. The final inspection is to occur upon final grading of the property.
Often there will be more than these 3 inspections required. Especially with the installation of
multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer
is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre -
construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or
control in any way the contractors activities.
The owner shall contract with the contractor to perform the work outlined in these specifications
and plans and in accordance with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be
the owner's representative and will inspect the work as stated above to document the contractors
activities. Final acceptance of the contractors work rests with the owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or omissions of the
contractor or any other persons performing work on this project or the failure of the contractor to
carry out the work in accordance with these construction documents. S & S Engineering's
inspecting engineer will not be responsible for the construction means, methods, techniques,
sequence, procedures or the safety precautions incident to this project.
CONTRACTOR/INSTALLER
MUNICIPALITY OF ANCHORAGE
\ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
I�
I`\ ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 2644720
ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
- EW
L% Ur 6 f I
I
❑ UPGRADE
MAILf OD?S4� ��
0 Iheci n sK / G X
LEGAL DESCRIPTION
Z S 2 !2e 7 FE i/A-lew E O
LOCATION '571—) T / z1 N time/ to
NO. OF BEOROOMS_3
f
Absorption aret
Dwelling
PE I
9
DISTANCE TO:
a lleZou4
Ag%
Manufxturer `
M
No. of co Pants
F6aweWell
Liq. c p�ityjn gallons
IF HOMEMADE:
1^side length
Witlth
Liquitl depth
DISTANCE TO:
Well
Dwelling
PERMIT NO.
Manufacturer
Material
Liquid capacity in gallons
=
DISTANCE TO:
W IIFoundati
•f uBu (.
•f-
Nearest Ilne
PERM
%
Z
No. of lines
/
Lengthj p ch pne
Total n th Pf lines
Trench w 9
Distance between lines
W
inches
F-
Top of tile to finish r de/
Material beneath the
7Z yfinches
Total fy� ,tive a pt_ign area
37d (/
Length I
Width
Depth
PERMIT NO.
W
<H
Type of crib
Crib diameter
i dept
Total effective absorption area
o.
W
rn
Well
Buildino foundation
Nearest lot line
DISTANCETO:
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
�+
Building foundation
Sewer line
Septic tank
Absorption area(s)
DISTANCE TO:
OTHER
Ca
PIPE MATERIALS
C, Z, — vC
SOIL TEST RATING
ZS
INSTALLER
CAO
REMARKS
L c C[/Cvn
ra 10-fr"
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_
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i;aw
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y-4 Robert A. Shah, iZ y.
�•
No. 1�37•Q
SOF ION �.
ot1
APPHOVED s E:lalNccr�lRC DATE LEGAL
SRD '193Y
AU,0K% =77
x,;CLE RIVER,
72-013 (Rev. 3/78) -.
/vI
MUNICIPALITY OF= ANCH�! _
• DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, At: 99501
264-4720
ON—SITE ' SEWEF2 P'EF ZM I T
PERMIT NO: 840748
DATE ISSUED: 09/05/84
APPLICANT: DEVCON-BOB HAINES
ADDRESS: S&S ENGINEERING
EAGLE RIVER, AK 99577
CONTACT PHONE: 694-2979
LEGAL DESCRIP: SUBDIVISION: HERITAGE PARE: LOT: 24 BLOCK: 2
SECTION: 7 TOWNSHIP: 14N RANGE: 1W
LOT SIZE: 20125 (SO.FT. OR ACRES)
MAX BEDROOMS: 3 -
Listed below are the options available to you in designing your septic
system. Choose the option that best fits your site.
** TAN); MUST HAVE AT LEAST TWO COMPARTMENTS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
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 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 WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED
APPLICA
ISSUED
DATE:
DATE:
5_� �%� /-
TRENCH
13F=D
W _ DF:A I N
DEPTH TO PIPE BOTTOM (FT.)
4.0
4.0
4.0
GRAVEL DEPTH (FT.)
6.0
0.5
3.5
TOTAL DEPTH (FT.)
10.0
4.5
7.5
GRAVEL WIDTH (FT.)
2.5
17.0
5.0
GRAVEL LENGTH (FT.)
32.0
34.0
41.0
GRAVEL VOLUME (CU.YDS.)
19.3
21.5
30.4
TAN): SIZE (GALS)
1,000.0 **
1,000.0 **
1,000.0 **
SOIL RATING (SO.FT./BR).
125
125
125
** TAN); MUST HAVE AT LEAST TWO COMPARTMENTS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
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 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 WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED
APPLICA
ISSUED
DATE:
DATE:
5_� �%� /-
PERFORMED
(MN, ,^ SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 0 PERCOLATION
TEST
925 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
LEGAL DESCRIPTION: L 2— T R _ Z_ _..
IFFFTI q`°z"4" 0/22 6—,q /V/ C
2
3 �
v�
a
�� r7
5_"6' `' G19— 12S
6
`'v
Gross
Time
Net
Time
Depth to
Water
Net
Drop
7
�Los
e
vj
G
10
`
11
<r
S
7
12
a _
SW
13-
_
14
15
16
17
Mbert A. Shafer
18 c Ho. 1117 E
19
COMMENTS
'kf
/NE�J DATE PERFORMED: _L= if
SLOPE
SITE PLAN
WAS GROUND WATERS
S
ENCOUNTERED? A L
0
P
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
S
PERCOLATION RATE on (minutes/inch)
TEST RUN BETWEEN FT AND FT
PERFORMED BY: Es CERTIFIED
T;,,,R
jr..ALE BIER, ALA„ 2L
A LETT
PN.
72-00e (6/79)
rb�667897p
O
Municipality of Anchor eJ'JN = 1
On-Site Water and Wastewater Progra
(907) 343-7904 ,F F ,Y
0! 6 8 L 9 -�ti
Certificate of On-Site Systems Approval
Parcel I.D. 05021156 —
Expiration Date: ! ^�� `
1. GENERAL INFORMATION
Complete legal description HERITAGE PARK B2 L24
Location (site address) 19523 CITATION
Current Property owner(s) MATT & ELISABETH DEFOOR Day phone 440-0762
Mailing address
Real Estate Agent Day phone
2. TYPE OF DWELLING:
O Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual 0
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System 0 Public Sewer ❑
WaiverNariance request for: NONE Distance:
Received b . Date: .476/6
6
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 594, Waiver Fee $
Date of Payment ,((L1 I(� Date of Payment
Receipt Number Oto/(31) Receipt Number
COSA# 6 56 l?1,207 Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm C&M ENGINEERING Phone 8545558
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI Date 6/11/2018
OF AL At
0
Ale* 4 9TH'• I�
°..
6. DSD SIGNATURE
System #1 Approved for bedrooms
System #2 Approved for bedrooms 7;HARLES G BALZARINI f
Disapproved t�)��'`ccdl 409/1'
CE-13854 ••���ESS
Conditional approval for bedrooms, with the following s: ?� i-1 -,,��
P�;� AiVf�f0
ON..s p <0
W PIER AN o
�0'o4�c-h 1 Cr-Opt\c.
By: - k ��^- Original Certificate Date: G -1 g _1
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory •
Well Flow Advisory Other
COSA blue sheet r • ..
If more than 1 septic system is on the lot:
COSA Checklist# 1 of 1
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: HERITAGE PARK B2 L24 Parcel ID:05021156
A. WELL DATA
Well type PUBLIC If A, B, or C provide PWSID# -- Well Log (Y/N) --
Date completed -- Sanitary seal (Y/N) - Wires properly protected (Y/N)--
Total depth -- ft. Cased to -- ft. Casing height (above ground) -- in.
FROM WELL LOG AT INSPECTION
Date of test -- --
Static water level -- ft. -- ft.
Well production -- g.p.m. -- g.p.m.
WATER SAMPLE RESULTS:
Coliform -- colonies/100 mL Nitrate -- mg/L
Arsenic -- ug/L Date of sample: -- Collected by: --
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SETPIC/HDPE Date installed 11/25/2001*
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 4/10/18 PumperALASKA QUALITY SEPTIC
C. ABSORPTION FIELD DATA
Date installed 11/25/ Soil rating (g.p.d./ft2 or-WA:Nam) 0.8 System type TRENCH
Length 58 ft. Width 2.5 ft. Gravel below pipe 5.5 ft.
Total depth 10 ft. Eff. absorption area 638 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 5/19/18 Results (Pass/Fail)PASS For 3 bedrooms
Fluid depth in absorption field before test 41 in. Water added 470 gal. New depth 47 in.
Elapsed Time: <144 min. Final fluid depth 40 in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N &type) NONE KNOWN If yes, give date N/A
D. LIFT STATION
Date installed -- Size in gallons -- Manhole/Access (Y/N) --
"Pump on" level at-- in. "Pump off' level at -- in. High water alarm level at -- in.
Datum -- Cycles tested -- Meets alarm& circuit requirements?--
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot -- On adjacent lots --
Absorption field on lot -- On adjacent lots --
Public sewer main-- Public sewer manhole/cleanout --
Sewer/septic service line -- Holding tank --
Animal containment areas -- Manure/animal excrete storage areas --
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 main +10
Water Service line+10 Surface water +100 Driveway, parking/vehicle storage +5
Curtain drain +50 Wells on adjacent lots +100
F. COMMENTS
TANK RAISED ON 6/7/2018 TO CREATE SUFFICIENT DROP TO LEACHFIELD
G. ENGINEER'S CERTIFICATION „'!%��������
'
I certify that I have determined through field inspections and * ° [
review of Municipal records that the above systems are in Are ��
conformance with MOA COSA guidelines in effect on this date. : 49TH .y0SAI
Engineer's Printed Name CHARLES BALZARINI ' ' ' ' . ° ' » l
Date 6/10/18 °
H ' •LES G BALZARINI /11
CE-13854p M � "or
EImp . '���
iv PROFESSIOW
ANIVICOSA canary sheet_2-6-15.doc1+►`►.
QUBMITTA
• Municipality of Anchorage
On -Site Water and Wastewater Program
(907)343-7904
ris Approval /
Expiration Date: ! �7 — I
Certificate of On -Site Syste
Parcel I.D. 050-211_56
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Heritage Park, Block 2, Lot 24
19523 Citation Rd
Current Property owner(s) Robert & Kristine Eubank Day phone _
Mailing address
Real Estate Agent
19523 Citation Rd Eagle River, AK 99577
2. TYPE OF DWELLING:
i] Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
WaiverNariance
Received by:
Day phone
TYPE OF WASTEWATER DISPOSAL:
❑
Individual
0
❑
Holding Tank
❑
❑
Community
❑
El
Public Sewer
❑
COSA to be released to the 19injer, unless otherwise requested by the engineer.
COSA Fee $ 50, ,
Date of Payment *0 8
Receipt Number 0497624
COSA# 6SCIS'1L
Date:
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
►S
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined
in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater
disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verifythat
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 alt 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 ran 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 Date 04/15/2015
6. DSD SIGNATURE
System #1 Approved for bedrooms Leven dnr t rie.
CE -8149
System #2 Approved for _bedrooms �#� �'
r
Disapproved }1I,-} POFE �+C
Conditional approval for bedrooms, with the following stipulations:
,a"j l Uiti..
=J2 ON-SITE
; PJ A QT€NAIATE
PROGRAM
By: Original Certificate Date: `4
Thuniapality of ®rage Development Services Division (DSD) issues Certificates of Onsite 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 engineers work. -
7. ATTACHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
COSA blue sheet E'- %, c
X Nitrate Advisory
Arsenic Advisory
Other
If more than 1 septic system is on the lot:
COSA Checklist # 1 of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: Heritage Park, Block 2, Lot 24 parcel 113:1050-211-56
A. WELL DATA
Well type Public If A, B, or C provide PWSID # MMU Well Log (YIN)
Date completed Sanitary seal (YM)— Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level
Well.production 9.p -m. g.p.m.
WATER SAMPLE RESULTS: _
Coliform colonies/100 mL Nitrate mg/L
Arsenic . ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/ HDPE Date installed 11/25/2001
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (YM) N High water alarm (YIN) N
Dateofpumping yll"14-01S Pumper *TaS Pt w
C. ABSORPTION FIELD DATA
Date installed 11/25/2001 Soil rating (g.p.d.e or ftz/bdrm) 0.8 g.p.d./sgft System type Deep Trench
Length 58 - ft. Width 2.5 ft. Gravel below pipe 5.5 ft.
Total depth 1.0 ft. Eff. absorption area 638 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 04/14/20 15 Results (Pass/Fail) Pass For 3 bedrooms
fluid depth in absorption field before test 24 in. Water added 495 gal. New depth 35 in.
Elapsed Time: 190 min. Final fluid depth 24 in. Absorption rate >= 450+ g,p,d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) No If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. `Pump off".level at in. High water alarm level at in.
Datum Cycles tested Meets alarm & Circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TG:
Septic tank/lift station on lot
On adjacent lots
Absorption field on lot
On adjacent lots
Public sewer main
Public sewer manhole/cleanout
Sewer /septic service line
Holding tank
Animal containment areas
_ Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO.
Building foundation 5+ Property line 5+
Water main 10+ Water service line 10+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+
Water Service line 10+ Surface water 100+
Curtain drain 50+ Wells on adjacent lots 100.+1
F. COMMENTS
As Built on File
G. ENGINEER'S CERTIFICATION
I certify that. I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven R. Pannone
Date 04/15/2015
COSA canary sheet_2-6-16.doc
Absorption field 5+
Surface water 100+
Water main 10+
Driveway, parking/vehicle storage 1+.
\ 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. HAA #
Expiration Date: .J %' 0 G
1. GENERAL INFORMATION
Complete legal description <'�>.�i! �5'/0���. // -/ ��ge Pfl�.E S« 6Mir%si�n
Location (site address or directions) /9 ?3 elle f1'i a'Gr A'/'
Current Property owner(s) Day phone
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address'.
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
❑
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of 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 _Qou �, /Aa f' hen AZ
Address 9"d d �' A /Y/n
Engineer's Printed Name /,?o e,:: 4-5 7'
S. DSD SIGNATURE
_V Approved for _3 bedrooms.
Disapproved.
Phone.(ao7) 7y!• -/o 73
Date
....A(, P
,49 ; it
• DO' T. KEM.EY
8176
.1. ..•
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: ^ �• Original Certificate Date: S' /7- OS-
(Rw, 0707)
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: 10 fa Al /OC K ` f/eri 147e- Ark Parcel ID:
A. WELL DATA
Well type p¢//? W ole, If A, B, or C provide PWSID # !'/0904 Well Log (Y/N)
Date completed _ Sanitary seal (Y/N) _ Wires properly protected (YIN)
Total depth ft. Cased to ft. Casing height (abo ound) in.
FROM WELL LOG AT IN ION
Date of test
Static water level ft
ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESU
Cofrform colonies/100 ml. Nitrate mg./I. Other bacteria colonies/100 ml.
nic: _ mg.A. Date of sample: _ Collected by:
B. SEPTICIHOLDING TANK DATA
Tank Type/Material o /: c Date installed
Tank size /000 gal. Number of Compartments ? Cleanouts (Y/N) V
Foundation cleanout (YIN) VDepression over tank (Y/N) iY High water alarm (Y/N) AIA
Dateofpumping Pumper 2 Pisoir�g
C. ABSORPTION FIELD DATA
Date installed 111gCh Soil rating (g.p.d.lft2 or ftZ/bdrm) e9,,F System type f"renn A
Length 14 P ft. Width ,,•.T ft. Gravel below pipe .S.t ft.
Total depth `7 ft. Eff. absorption area 438 ftZ Monitoring tube (L Depression over field Al
Date of adequacy test <i/r s' Results (Pass/Fail) For 3 bedrooms
Fluid depth in absorption field before test 6 � in. Water added -r/9gal. New depth /5' in.
Elapsed Time: _jL/Z min. Final fluid depth /Z:t in. Absorption rate >= f/1-4 g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) /I/ If yes, give date --
D. LIFT STATION
Dale installed
'Pump on" level at _ in.
E. SEPARATION DISTANCES
Size in gallons
"Pump off level
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
service line
Manhole/Access (Y/N)
level at in.
Meets alarm & circuit requirements?
On adjacent lots
On adjacent
Public sewer manholelcleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation G !f Property line •Yo S It Absorption field .Tr,
Water main a f Fr Water service line f t /:'A Surface water / oo f It
Wells on adjacent lots -q 96 + f'f.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line lee /f Building foundation `/a * ft Water main ;✓f 11 it
Water Service line St f y Surface water /o o + fJ Driveway, parking/vehicle storage
N+ne /(Hawn
Curtain drain To r l i s I Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections andi"' kDOU .. V
review of Municipal records that the above systems are in • ;
conformance with MOA HAA guidelines in effect on this date.
+I��6' CE 8176 •:
Engineer's Printed Name Dotrq/ris f /een/rt�
!-
Dater ... • •:-N
HAA Fee $ 3 0 Waiver Fee $
—r
Date of Payment� 13 - Date of Payment
Receipt Number 6-22.10 Receipt Number
(Rev. 12V)
May 13 OS 08:12a Rudrey Masan 6960214 p.2
4%
0
)o if
G/Tis>TIO�v �.4
W
i
^�""�• SCWARD h AbbOUTATGS LAND SURVLYiNG 694-082°
I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE -
FOLLOWING DESCRIBED PROPERTY z/, ��' At
F O
t 0
.�Er/rxE �u•�e'sae torzyae r
DATE: r`�P� A('�`.s,,!'
AND THAT NO ENCROACHVENTS EXIST EXCEPT AS 4
INDICATED. IT IS THE RESPONSIDILITY OF THE/ Q� LH S 7
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID
.01
EASEMENTS, COVENANTS, OR RESTRICTIONS ' Nw ss i�
WHICH DO NOT APPEAR ON THE RECORDED SUBDI- 0 V
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB: �IS-591 •. `�-X
ANY DATA HEREON BE USED FOR CONSTRUCTION Ile of°
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES. DRAWN:
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Brag3w 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. OSO-a f f- S(v
1. GENERAL INFORMATION
HAA #_Li 6t7jb 6 l O
Expiration Date: _33102
Complete legal description Lot24: bionk 2. NPritnpp Park
Location (site (site address or directions) 1 o s v i r i r a t; o n n d
Current Propertyowner(s) Bill Klemovitch Day phone 694-4959
Mailing address
Lending agency
Mailing address
Real Estate Agent
19523 Citation Rd, Eaple River, AK 99577
Day phone
Becky/Re?lax Anchornpe Day phone 244-5881
Mailing Address 2600 Cordova St. Suite 1001 Ar toravg, AK 99501
Unless otherwise requested, HAA will to held by DSD for pickup.
2. NUMBER OF BEDROOMS: -3
3. TYPE OF WATER SUPPLY:
Individual Well
❑
Individual Water Storage
❑
Community Class Well
❑
Public Water System
U
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 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 betveen spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upcn 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 less than 30 days old. (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 S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Address F,rImR!yPr Alnsk.,99577
Engineer's Printed Name C- Co��A.✓
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Phone G q y—_-2-`t'S
Date ►t 13.9 /0 /
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X Maintenance Agreements
Supplemental Engineer's Report
Other
By:� Original Certificate Date:/213/01
(Rev. 131C0(
Municipality of Anchorage V '.•
Development Services Department
Budding Safety Division
On -Site Water & Wastewater Program
4700 South Bragew St.
P.O. Box 196850 Anchorage, AK 99519.6650
www.ci.anchorage.ak.us
(907) 343.7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: "T 2y 8"f- c 2 IiE�tr rAc rt /�.lRK Nil Parcel ID: OS -0 -2!/ -S('
A. WELL DATA �r Isar #-A—
Weil type _d!i R A, B, or C provide PWSID #
Date completed
Total depth R.
Date of test
Static water level
Well production
WATER SAMPLE
Coliform
sample:
Sanitary seal (YM) _
Cased to R.
FROM WELL LOG
n
g.p.m.
TS:
les/100 ml. Nitrate _
Collected by:
Well Log (YIN)
Wires Propedprooeetro
In.Casing he' v
INSPECTION
ft.
g.p.m.
_ mgA. Other bacteria colonies/100 ml.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material s: -P r' r' / 4 Do E
Tank size 1000 gal. Number of Compartments
Foundation deanout&N) Y#J Depression over tank (Y(9 ^'o
Date of pumping4 A Pumper _
Date installed _
Cleanouts 6)N)
h/ar/oi
y 4 J
High water alar, (YQ rJ V
C. ABSORPTION FIELD DATA
Date installed 1! �lf�o/ Soil rating g.p.dJftZ R'/bdrm) S System type TAs.� c-14
Length S- g ft. Width S ft. Gravel below pipe X• 'r ft.
Total depth C1 ft. ER. absorption area 6 3 gtt= Monitoring tube %'E S Depression over field w O
Date of adequacy test NIA - M 6w/ Results (Pass/Fail) —_ For 3 bedrooms
Fluid depth in absorption field before test _ inadded_ gal. New depth_ in.
Elapsed Time: _ min.Fina epth _ In. Absorption rate >= g.p.d.
Any rejuvenation tree est 12 moJ (YIN & type) If yes, give date
D. LIFT STATION
Date installed
`Pump on" level at _ in.
Datum
Size in gallons _
`Pump air level at
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
Celt
Public sewer manhole/deanout
Sewer /s a Iine Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation fs Property line 810 Absorption ftel
Water main JO - Water service line /0 f Surface water
Weiss on adjacent lots 100 r t
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line / 0 Building foundation N 1 Water main
Water Service line o t Surface water 10 0 ' 4- Driveway, parking/vehicie storage 3 0
d
S-
JO f
In.
Curtain drain H Om4 Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspedbrls and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this data
Engineer's Printed Name !l o'qEA /T C COwA,J
Date It la -N l d /
HAA Fee $
3 O O • v o Waiver Fee $ _
Date of Payment
1,00/01 Date of Payment
Receipt Number
O 13 0 G CI l�+i�rk� Receipt Number
-
(Rev. 12/00)
V
n TT. COWAN 1 W
Thmasol
ttl2
MUNICIPALITY OF ANCHORAGE
I DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date neremher 17. 1986
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 24; Block 2; Heritage Park Subdivision
Location (address or directions)
19523 Citation
(b) Applicant Name _
Applicant Address
Mark Hulse Telephone: Home 694-8330 Business
19523 Citation, Eagle River, Alaska 99577
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder 6: Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent Jack White Realty/Connie Bates
Address Eagle River, Alaska 99577
Telephone 694-5500
(f) Wthe HAA to the following address:
4 S ENGINEERING
SRR 196X
Pag1e River, Al ska 99577
2. TYPE OF RESIDENCE
Single -Family tR Multi -Family ❑ Other
Number of Bedrooms _y
3. WATER SUPPLY
Individual Well ❑ Community ❑ Public ER
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 ll 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.
72-025 n1,84l
Page 1 of 2
S. ENGINEERING FIRM PROVIDIn INSPECTIONS, TESTS, FILE SEARCH, DA 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 InWti4[L .GINEERING
Name of Firm --S RB I 96X
Telephone
Address
Date
6
6. DHEPAPPROVAL
Approved for "14A bedrooms by �`�"�` �' Date
Approved Disapproved Conditional
Terms of Conditional Approval
CAUTION
/2—L 3 ^gti
The Muncipality o1 Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 6 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
Institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate Is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-M (111/84)
• n MUNICIPALITY OF ANCHORAGE (MO
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
2844720
Legal Description: I
A. WELL DATA
Well Classification �Lfti S> A If A. B. C. D.E.C. Approved &N)
Well Log Present (Y/N) Date Completed
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Depth of Grouting —
Pump Set At
Yield
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot ;> po i� ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot L V O 14- ;On Adjoining Lots —
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
—To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
: Date
Date Installed L�- Size / Ro0 No. of Compartments L
Standpipes (DN) Air -tight Caps (! 77N) Foundation cleanoutON)
N)
Depression over Tank (Y&? Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) _14 ; for
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well Pr7v f To Building Foundation �� r
To Property Line !o r -f To Disposal Field
S�
To Water Main/Service Line r f To Stream, Pond, Lake, or Major Drainage
Course
Comments
MUNICIPALITY OF ANCHORAGZ
CEPT. OF HEALTH b
ENVIRONMENTAL PROTECTION
Page 1 of 2
2 21986
RECEIVED
72-026(11184)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata /7.s A�716p_-
Type of System Design
Date Installed `7 _/l�1 - 8cF Length of Field ZZ/
Width of Field y Depth of Field
Gravel Bed Thickness _&
Square Feet of Absorption Area 3 A 4 0 Standpipes Present 6?N)
Depression over Field (Ytl)L
Date of Last Adequacy Test —17- -Z & -EJ [o
Results of Last Adequacy Test S +o rib 1=A c.-r5P_Y j'->? S'' R tr
Separation Distance from Absorption Field:
To Water -Supply Well __ Z.c t:, /-f- To Property Line /n r`
To Building Foundation
�j__ Z r� r E To Existing or Abandoned System on
Lot i :� ; On Adjoining Lots 3y r1�_
To Water Main/Service Line /Or -F To Cutbank (if present) ^YA
To Stream/Pond/Lake/or Major Drainage Course �,�A
To Driveway, Parking Area, or Vehicle Storage Area I/O i f
Comments
D. LIFT STATION
Date Installed Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at 114 'Pump Off' Level at
High Water Alarm Level at Vent (Y/N)
Tested for
Electrical Codes (Y/N)
Comments
Check Permitted Bedroom Rating Against HAA Request "
Pumping Cycles during Adequacy Test. Meets MOA
I certifS t$atl&afg1k181 eyfied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
SignegR$4M- ��^�'�iV�(�a Date /'2--2-0,8 C
Com*4004 PJE, K -99-C77- MOA No. �6 - ab ? �����►�\
Receipt No. z2 / , DQ ,g?
Date of Payment 4./
1�
Amount: $ � �
...... .` ..... ...r ..
Ibias A. Skdw
:4r
Ib. 14674 : A3-"
Page 2 of 2
72.026 ti1,84)
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
DATE:December 17, 1966
PWS I.O.! 212291
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Add ess:
274-2533
To Whom it May Concern:
According to records on file in this office the EAGLEC REST/IIERITAGE
HEIGHTS Water System is in compliance with the State Drinking
Water Regulations
Sincerely,
Steven Eng, PE
District Engineer
n
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date
(a) Legal Description (include ,ipt, b}9ck, subdiyAsion, section,, township, range)
Location (address or directions)
(b) Applicants
Applicants
z -r
- Home
Business
(c) Applicant is (check onh) Lending Institution ; Or"*/builder D�;
Buyer ; Other [=I (explain);
(d) Lending Institution 0 .L-> >= Telephone
Address
(e) Real Estate Co. 6 Agent /U 0 Afi!F
Address
Telephone
(f) H*" the HAA to the following address:
S Fi f'RC��'1�3IfFIEER!P:C,
�f11! •J VI\
2. Type of Residence
Single -Family Multi -Family
Number of Bedrooms
3. Water Supply
Individual Well 1= Community M
Other (describe)
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 Q 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 21
W
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 regula-
tions in effect on the date of this inspection.
Name of Firm Telephone
S & r �a,
Address SR4 19GK '
Date
6. DHEP Approval / 1
Approved fort'//13/ bedrooms
VI
(ENGINEER SEAL)
Approved i Disapproved
Terms of Conditional Approval
By
CAUTION
Conditional
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS 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 REQUIRE-
MENTS. 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.
(DHEP SEAL)
RR4/ej/DlB
[Page 2 of 2] 7-19-64
MUNICIPALITY OF ANCHORAGE (MCA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
MUNICPAUIN OF ANCHOPAC2
CEPT. OF HEALTpi &
C�':;::);Ud:NTAL P'ZTECTICN
NOV 2'1994
"ECEIVED
A. WELL DATA
Well Classification If A, B, or C, D.E.C.d(" Y/N)
Well Log Present (Y/N) Date Completed ApY3eid
Total Depth Cased to Depth of Grouting
Static Water Level Pump Set At'
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot 2-00 On Adjoining Lots
To Nearest Edge of Absorption Field on Lct ZGb Ik ; on Adjoining lotsTo Nearest Public Sewer Line To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line on Lot
Water Sample Collected By s
Water Sample Test Results
C* nts v
Date
B. SEPTIC/HOLDING TANK DATA
Date Installs146 6P Size, �Z!� No. of Compartments
,ldStandpipes Y ) Air -tight Cap ( Foundation Cleanou (Y
Depression over Tank W Date Pumped
Pumping/Maintenance Contract on File /( ; for f
Holding Tank High -Water Alarm (Y T- /J— Temporary Holding Tank Permit (Y /a -
Separation Distances from Septics -Tank:
To Water -Supply Well 7� 0 0 /7L To Building Foundation
To Property Line /0 '7L To Disposal Field
To Water-Main/Service Line f To Stream, Pond, Lake, or Major Drainage
Course lx/F
Comients *J C /J r`
1- o T' Z 4
ll�af8� A4DCirA6E
[Page 1 of 21
A 4 J�n—
YG 2-15-84
Soils Rating in Absorption Strata fZL5' Type of System Design
Date Installed /6- �/-' Length of Field 3 z
Width of Field 0 ` Depth of Field / Ci
_�i Gravel Bed Thickness Z `
Square Feet of Absorption ea %d Standpipes PresentdYlLn
Depression over Field (f Da of Last Adequacy Test t
Results of Last Adequacy Test /`��
Separation Distance from Absorption Field:
To Water -Supply Well 2 , io f,/- To Property Line
To Building Foundation Z O Gf� To Existing or Abandoned System on
Lot ;AJ /l'A- = On Adjoining Lots /--( //ti -
To Water ,'Galf{Service Line To Gutbank (if present) 0 O "�
To Stream/Pond/Lake% Major Drainage Course
To Driveway, Parking Area, cc_ Vehicle Storage Area SZ= /r
Cements k_ ,-J-
D. LIFT STATION
Date Installed
Dimensions
Size in Gallons ole/Access (Y
"Pump On" Level at I f" Level at
High Fater Alarm Level at Vent _(_Y/N)
Tested for Pumping s during Adequacy Test. Meets MDA
Electrical Codes(Y/N)
Ccaments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MDA HAA Guidelines in effect
on the date of this inspection.
+.-
OF A4. 1
Signed S & : E"1G�IF1LEnl�:C
sn��wcx Date / � ��P�� ..... '�S1tf
Caipany t ;OLE ;i R. ALwA 'L.�7. MCA
�� ".'�q�j
%*i
KBl/d5/s
(Page 2 of 21
rdw JL. ShAw
Ma, tAaLa
2-15-84