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Home My WebLink AboutKNIK VIEW BLK 1 LT 4KnI*k View Block 1 Lot 4 #051-031-27 • Municipality of Anchorage Page of 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 Permit Number: Stetg10 37--1 PID Number: 0 jr; t -• oat - Z7 Name: Wastewater System: SC New ❑ Upgrade A°°few P.O.oa6 ?oo4s A ABSORPTION FIELD Phone: 229 - $0 59 No. of Bedrooms: ❑Deep Trench 6CShallow Trench Deed ❑Mound ❑Other LEGAL DESCRIPTION Soil Rating: I 2 Total Depth from original grade: 5.51 GPDIS Ft Lot: Block: Subdivision: Depth to pipe bottom trim original grade: Gravel depth beneath pipe If 1 IFLJ 3 Ft Z•S Ft Township: Range: _ Section: Fill added above original grade: 1 Gravel length: 1 —' _ O -S — 11 Ft � Ft WELL: ❑New ❑Upgrade Gravel width: 51 Number of lines: lMtance betrrten lines: Ft Fi Clansticatiun (Pnvate. .C): Total Deptn: Cased Total absorption area:„z, Pipe material: M 'e I. S16 M+ s0 Ft Asim 03ozq F' :O Driller. eDrilled: Stabs water Laves Installer. Date Installed: Ft. JS►t CorlsT• Q -2q —97 Yield: Pump set ab Casing Height Above Ground: TANK GPM Ft, Ft. SEPARATION DISTANCES Pr Septic ❑Holding 0S.T.EP. To Septic Absorption Lin Holding bIMJ rwste Manufacturer. Capacity in gallons: From Tank Fold Station Tank Sewe, Units Aa P.GE h..l Izso Welt 200 { t 200 — ^ Z tt� Material: STEeI_ Number of Com rtments: T SurfaceLIFT Water too f IOot-} STATION Lot1 �iS % 161 Size in gallons: Manufacturer. Line FoundationI I E -zf� 1'�' �� 'Pump on' level at: 'Pump ofP' bve High water &term at: Curtainf �t O J� Pump WkeB lectncal Inspections performed by. Drain Remarks: Aaa,r,&r711L T4ST NdL-F 1:kC.4vd74D BENCHMARK , buiQ'. C CO n.1TRucTles/ i o 1)EPTN. Location and Description: + r-14 11 BET Is ND 4NANG E IN JO I L f C.L4Sf, "T O adv AIN as P No ABR 4— Noll, THRa�LNaer i...T,RE DEPTH. GLr/Sev Assumed Elevation: 100.0 F, =N�C �;L To Sr otPrN. OF i s' _??o Da:1s qz 1T Inspections performed by: s s slNtilN[tRINGt S” 17034 Eagle River Loop Road, No. 2nd qZ *I Eagle River, Alaska 99377 f w4a d/�4' iii - — -• .•• • •-- 7° ROBERT C. COWAN a ' CE=6801 •� r� Department of Health and Human §ervices approval 3'12'QB 4t%% \,F`'s�`=—'.t Reviewed and approved by: Date: 72-013 (Rev. 2411) MOA 25 PERMIT N0. SW970327 PACE 2 OF 2 Municipalityof Anchora e DEPARTMENT OF HEATH AND HUI`�AN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 a Te�l�ephone: 343-4744 YM ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 4, BLOCK 1, KNIK VIEW SUBDIVISION P.I.D. No. 051-031-27 MMM X. LO( AMN K INTER L E NEW 1250 GAL. ro, UT19I SEPTIC TANK i I 1 •� COW7TWSZ rALT.SITE-� Yfzl I B GRAVEL DRIVE COR Y — Z 1 Y NEW DRAINFIELD A__ B FCO 1 23.0 ' STI 28.0' 4 ST2 33.0' 41.0' DBL1 34.5 42.5 L2 4 5 C01 34.5 71.0 MT1 36.5 71.0 COI - 98.9' CO2 65.0 40.5 CO2 - 9e.7' MT1 Col MT2 65.0 40.5 STI ST2 88.9' MT2 CO2 FINAL GRADE --,,,,Seta I' - 40' INSULATION E Ak >e ..'.."'`y s NEW 85.3' 1250 CAL S.T. 85.1' C01 - 95.0' sR C2 *% *} CO2 - 95.1' 1 ', MT2 - 92.8' /� RODERT C. COWAN MT2 - 92.13' l� c 'CE -8801 r L\rr NO WATER FOUND 82.1 B.O.H. Date: ID',27-47 TtOOEFTT C. COWAN. PE. RO8EnTA. St1AFER.P.E. CIVILENGINEERS (907)694-2979 FAX(907)694.1211 IEKNIANINCnTV Pf•PIgVIls RECEIVED Municipality of Anchorage OCT 29 1997 sEWEnaWATEn DEPARTMENT OF HEALTH AND HUMAN SERVICES L"EXTENSENs 625 L Street Municipality ici al tyAnchorage P.O. Box 196650 Dept. ti Human Services Anchorage, Alaska 99519-6650 .SEWER S WATEn *&PECIION L �) /�/%/,C. LOT ! REFERENCE: QIOC.�� ENGIMEmmsiums Pw IIEPORTS The septic inspections for the referenced property were performed on 9 a and4 Prior to submitting the On-site Wa tewater Disposa System and/or Well Inspectio Report we are waiting for the-fiu.lda7l,, to be &FLOWIEST completed. +- oe6w'2t✓sa.v�� If we may be of further service please contact us. SITE PIANS Sincerely, ?V V' nwo CESIGII Robert C. Cowan, P.E. SMIESI PERCOIATICN TEST SYMMUPN. t • I• MECIVNICAI . SSPEMAIS ONSITE WASTEWAIETI CISPOSAL11"TEM OESM 1 11034 NOM11 EAGLE nIVEn LOOP 6 SUITE 204 • EAGLE RIVER ALASKA 99577 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 ^L^ STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW970327 DESIGN ENGINEER:S 6 S ENGINEERING OWNER NAME:LEROY ALDERMAN OWNER ADDRESS:P.O. BOX 670045 CHUGIAK, ALASKA 99567 PARCEL ID:05103127 LEGAL DESCRIPTION: KNIK VIEW BLK 1 LT 4 LOT SIZE: 20901 (SQ. FT.) NUMBER OF BEDROOMS: 0 THIS PERMIT: 0 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: PAGE 1 OF 1 DATE ISSUED: 9/19/97 EXPIRATION DATE: 9/19/98 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 DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: a✓/ z • 2nm•_ DATE: q /2 j" 14 % ISSUED 647 DATE: 11 Y / COPY MALTHAU1710RITY APPROVALS SEWER& WATER MAIN E%TENSIOHS SEWER & WATER INSPECTION ENGINEERINGSTUDIES ANDREPORTS WELL P4PECnoN & FLOW TEST SITE PLANS T::n,T: a� SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ONSITE WASTEWATER DISPOSALSYSTEM DESIGN nG September 11, 1997 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 4, Block 1, Knik Yew Estates Subdivision ROBERT C. COWAN, P.E. CML ENGINEERS (907) 6942979 FAX(907)694-1211 Request you issue a permit to install a septic system to serve the proposed four bedroom house on the referenced property. A test hole was excavated and a percolation test performed. The approximate location of the test hole is located on the attached site plan The monitoring tube within the test hole has been checked and found to be dry. This property is served by a Community Water System. This property has enough area for a future septic upgrade which can be seen on the attached site plan We do not anticipate any adverse effects on neighboring wells, septic systems or drainage patterns by the installation of the proposed septic system. If you require additional information, please contact us. Sincerely, I wan P.E. RCC(mg Enclosure ,�ryoF � V�o ON RtC�/v 99� FD 17034 NORTH EAGLE RIVER LOOP • SURE 204 • EAGLE RIVER, ALASKA 99577 1:' ='40' OHO c Zs<m yFc A��= "ZOQ .n..i�'�m�CZrAi Z - . Or ~ 2 N1� Vm�r�Ny 'umZDA�nm AZ~��m=M; vvm <mZ AA��OOv� rz � mmM MAT V10m�f) "Mo �o 0 M>- 2= 0 OZ� =z m Z N 50' PATENT R.O.N. EASEMENT — E I SITE–PLAN I 2 Z r .ro ro O ROOM MOH cn L r O L m tHOUSE �u----- V �..y i , `tel O 4 _ za)ET NCP hl'P fT N �o > � jy z cn r A. C i0 ^O -i ft n O m C �--� �- fil C FH X 0 M m 6 N u N 11 m 0 i 'Z9n D is 7CL------------ J PROPOS 4 BDRM HOUSE A O DECK 0 MY ro Eif N � ro DESIGN PROPOSED 4 BDRM HOUSE EC DK s s N 2 Z r .ro ro O 0-i MOH cn L r O L O "3 —J V �..y i , `tel O L v r 2 Z r .ro ro O 0-i MOH cn L r O +o O "3 zxy� M O V �..y Z ro t4 0 O 4 �6E/j C N za)ET NCP hl'P fT N �o > � jy z cn r A. C i0 ^O -i ft 10' UTILITY - - KNIK VISTA DRIVE (7 r Jpxpx z 0 2 O ss oYyy 0-i LAty ETA Y V V �..y i O > m * b `4 za)ET NCP hl'P fT N �o > OW& O O_E+ cn A. C i0 M -i ft n O m C �--� �- fil C FH X = m 6 Mu��.{ u N 11 i 'Z9n O.(v. O 10' UTILITY - - KNIK VISTA DRIVE (7 r Jpxpx z O F O ss oYyy 0-i Vi ETA p A m O ti Zj 7c�ZA 0 a _ OCy ti Z y A Xoom r0 a m A Z W 0 H 0 i> "a�F n o �•° H c o ti ~ a r7l X p A m O ti Zj 7c�ZA 0 a _ OCy ti Z y A Xoom r0 a m A Z W 0 H 0 PERFORMED Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST LEGAL DESCRIPTION: Ir -W ESTA1 9 12- 13 D. a 41516 14- 15- 16 -1- 17- 18- 19- 20- COMMENTS 7181920 COMMENTS DATE PERFORMED: Township, Range, Section: SEEN NNON EMINE NOWN WAS GROUND WATER ENCOUNTERED? GM/SM S IF YES, AT WHAT L DEPTH? p •f' E Depth to Iter g:Lu Monitoring? rinp7 R Dslc Reading Date Gross Net Time Time oR.c aalcs 1 Se tc 0org, .0 2 ,1O 3 21 12: 14 I04.01 49 1/2 ` 1 4 IZL17 # 6W C7 G 5H67 6/• 9 12- 13 D. a 41516 14- 15- 16 -1- 17- 18- 19- 20- COMMENTS 7181920 COMMENTS DATE PERFORMED: Township, Range, Section: SEEN NNON EMINE NOWN WAS GROUND WATER ENCOUNTERED? GM/SM S IF YES, AT WHAT L DEPTH? p •f' E Depth to Iter g:Lu Monitoring? rinp7 R Dslc Reading Date Gross Net Time Time Depth to Net Water Drop Se tc 0org, .0 21 12: 14 I04.01 49 1/2 ` 1 3 IZL17 # 6W I.Z:teis 6/• .1 PERCOLATION RATE �,4 (minutesnnch) PERC HOLE DIAMETER TESTRUNBETWEEN J FTAND 5•5; FT S & S ENGINEERING PERFORMED BY:' IM4 EM16 Kiver toop X00 No. W04 CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE V&Afft*tRlMT*IAI1JI0& 1VPAL GUIDELINES IN EFFECT ON THIS DATE. DATE ^ / f �' / q 7 72-008 (Rev. 4/115) S& ROBERT C. COWAN, P.E. CMLENGINEERS (907) 6942979 ON-SITE WASTEWATER DISPOSAL SYSTEM FAX(907) 6941211 CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS NEALTNAurNaaTY APPRMAtS REFERENCE: Lot 4, Block 1, Knik View Estates Subdivision SEWER& WATER MANDVIENSKM September 11, 1997 GENERAL: 1. The scope of this project includes the installation of a 1250 gallon septic tank and a SEWER& WATER INSPECTION five foot wide drainfield to serve the proposed four bedroom residence for the referenced property. 2. Construction shall be in accordance with the approved site plan and design ANDREPMS&T` $ drawings, Municipal perrnit 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 utility WELL INSPECTION &FLOWTEST locates. 4. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield SITES mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. ROADDESIGN 5. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SOIL TEST SEPTIC TANK INSTALLATION: ffACOLA"0N 1. A septic tank is to be constructed b a certified septic tank manufacturer. Y TEST Construction shall include two 4" cleanouts for pumping access. 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the STRUCTURAL & tank. MECI'MICAL lbPECRONS 3. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. ONSITE WASTEWATER DISPOSAL SYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP • SURE 204 • EAGLE RIVER. ALASKA 99577 Page Two Lot 4, Block 1, Knik View Estates Subdivision September 11, 1997 4. Septic tanks installed with less than 4 ft. of cover shall be insulated. 5. 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 TRENCH/DRAEMELD INSTALLATION: 1. 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 sidewalis of the excavation become smeared, they must be raked or scratched (naffed -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. S. 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. MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. Page Three Lot 4, Block 1, Knik View Estates Subdivision September 11, 1997 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Ping Perforat olid 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, Mirafi 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 MO.A. or D.E.C. requirements, which ever 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: I. 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. Page Four Lot 4, Block 1, Knik View Estates Subdivision September 11, 1997 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. CONTRACTORIOWNER Municipality of Anchorage ••` Y Development Services Department �•_ Building Safety Division ' On -Site Water and Wastewater Program : • S .. 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051— oat ` Z? COSA Expiration Date: ' 3 C) " 1. GENERAL INFORMATION Complete legal description Lot a Block i Knik View Subdivision Location (site address) 225o8 Knik Vista Street Chuoiak AK gq;67 Current Property owner(s) William L Kagle Day phone 688-1-% Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 225o8 Knik Vista St Chugiak AK g9s67 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class A 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 On -Site Systems Approval (COSA) based only upon the representations given In paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of ---- - ti Lie (except between spouses) for -properties served by a single-family on-site wastewater disposal and/or water supply system. DSDaiso-Issues-COSAs-upon -request to homeowners—Certificates of On -Site S stemy bs Approval ---- -.- are valid for 90 days from the date of Issue for properties served by a private or Class C well and may a reissued — with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of Onsite 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 Pannone Engineering Services, LLC Phone 272-8218 Address P.O. Box 202gS4. Anchorage, AK 49sio Engineer's Printed Name Steven R. Pannone, P.E. Date 4h6/o8 Engineers Comments: In conducting an adequacy test, l attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions encountered at the rime 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 arc 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. PPS can therefore not provide any warranty for future performance nor give any estimate of how long the system will continue to meet the operational requirements of the 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. S. DSD SIGNATURE "�L Approved for I bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory ----Other------ o By Original Certificate Date: 1' -3 0'Op (Rev. 11N5) Municipality of Anchorage `! Development Services Department j - Building Safety Division On -Site Water & Wastewater Program • • _. 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lot a Block z Knik view Parcel ID: O c -"t_ Oil- z A. WELL DATA _ Well type ASG Arian- If A, B. or C provide PWSID # Z!`IQC7�{ ell Log (Y/N) Date completed _ Sanitary seal (Y/N)_ ires property P P Y protected (YM) Total depth ft. Cased to ft. sing height (above ground) in. FROM WELL LOG AT INSPECTION Date of test l n Static water level ft ft. Well production g P m g.p.m. WATER SAMPLE RESOLTS. Coliform colonies/100 mL Nitrate mg/L Other bacteria colonies/100 mL Arse mg/l Date of sample: _ Collected by: B. SEPTIC/HOLDING TANK DATA Tank Typetmaterial Jlnchorage Tank steel Date installed 9/2ghgg7 Tank size 115o gal. Number of Compartments 2 Cteanouts (Y/N) Y Foundation cleanout (Y/N) y Depression over tank (Y/N) N High water alarm (YIN) 9A Date of pumping „/zzhooa Pumper _11111 Pumping C. ABSORPTION FIELD DATA Date Installed 9L9L'3g_ Soil rating (9.p.d,/ft2 or ft 1bdrm) jL.z System type -5-hallow Trench Length 66 ft. Widths ft. Gravel below pipe z.c ft. Total depth 5 8 ft. Eff. absorption area rig ft2 Monitoring tube Y Depression over field Ll Date of adequacy test 4/2-412oos Results (Pass/Fail) pa,, For.4 bedrooms Fluid depth in absorption field before test ji in. Water added600at. 9 New depths in. Elapsed Time: Ao min. Final fluid depth ii in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) _No If yes, give date D. LIFT STATION Date installed Size in gallons 'Pump on" level at _In. "Pump off' level at _in. Datum 'Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL Septic tank/lift station on lot T-.� Absorption field on lot Public sewer main Sewer /septic ice line TO: Manho Access (Y/N) �— gh water alarm level at in. Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manholelcleanout Holding tank Anlmvxbntainmeint areas Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ao'+ Property line %o+ Absorption field s'+ Water main "o+ Water service line ao+ Surface water aoo+ Wells on adjacent lots aoo+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line so+ Building foundation -i9+ Water main %o+ Water Service line io+ Surface water too+ Driveway, parking/vehicle storage }o. Curtain drain None Observed Wells on adjacent lots aoo+ F. COMMENTS 'r G. ENGINEER'S CERTIFICATION �P;"'?S��p ' I have determined through held Inspections and # ; x 0 I certify that �,.. ,.....� review of Municipal records that the above systems are In00 with MOA COSA guidelines in effect on this date. —i conformance Engineer's Printed Name Steven R Pannone P.E.e, s^, No C 81411 S 4 Date Nrkl 7�y ••;%JD ............... A��aFESSa::• LOO Waiver Fee $ COSA Fee $ Date of Payment L/ Uo Date of Payment Receipt Number �b Receipt Number (Rev.11105) AC. 4( 41, Municipality of Anchorage •, -/��/1 Development Services Department �•+'- Building Safety Division On -Site Water and Wastewater Program ' 4700 South Bragaw St. g P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-031-27 HAA # 1. GENERAL INFORMATION Expiration Date: Complete legal description Lot 4; Block 1; Knik View Subdivision Location (site address or directions) 22508 Knik Vista St., Chugiak Current Property owner(s)__Deanna Gott Dayphone 688-8485 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Day phone _-F.ra rnti••n RPAItp/ Jim Ct fef)qphone Unless otherwise requested, NAA will be held by DSO 6orpickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System 4 TYPE OF WASTEWATER DISPOSAL: ❑ Individual On-site ER ❑ Individual Holding tank ❑ ❑ Community On-site ❑ 0 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 S 6 S Engineering, Phone 694-2979 Address 17()14 K FnolP River i no, ate 204 Fny1P River, AK 99577 Engineer's Printed Name Robert C Cowan Date S llc lbs 5. DSD SIGNATURE i ROBERT C. COY/AN V-11 Approved for —A—bedrooms. i#1;1>:Rc:-ssol Disapproved. ' o'er ~ Conditional approval for bedrooms, with the following stipulations. Attachments: HAA Checklist x Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: �i � / �f 14�� Original Certificate Date: (R.. 01102) 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 11 t- `t IHEALTH AUTHORITY APPROVAL CHECKLIST L Legal Description: . F QL0c4- � I IG- V1t:w glA Parcel ID: 05 1 A. WELL DATA {�tJE3�l L Well type — If A. B, or C provide PWSID # — Well Log (YIN) Date completed — Sanitary seal (Y/N) _ Wires properly protected (Y/ Total depth ft. Cased to ft. Casing height ( ground) in. FROM WELL LOG AT CTION Date of test Static water level ft. Well production g.p.m. g.p.m. WATER SAMPLE �RES: Coliform colonies/100 ml. Nitrate mg.A. Other bacteria colonies/100 ml. Ar ic: _ mg./I. Date of sample: _ Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material '515 -Mc- / STE6IL Date installed Li L5'7 Tank size (ZSO gal. Number of Compartments 2 Cleanouts (J% J) Y6 S Foundation cleanout (T/N) Depression over tank (Y/IP 0 High water alarm (Y& A-30 r Date of pumping S lD 0$ Pumper SlZ 5 pc�wrPrrW C. ABSORPTION FIELD ATA Date installed % 2 Y Soil rating (g.p.d./ft2 or ft2/bdrm) _Z System type S144R 060 l>C0064 Length �— ft. Width Sr ft. Gravel below pipe Z S ft. r Total depth SoS ft. Eff, a sorption area 57/6 ft2 Monitorin tube � Depression over field �o Date of adequacy test OS Resultsd1g)Fail)For -�- bedrooms n rr Fluid depth in absorption field before test in. Water added6�3 gal. New depth 8 in. �,/� rr — Elapsed Time: ?L min. Final fluid depth 8 in. Absorption rate >= 6100+ g.p.d. Any rejuvenation treatment (past 12 mo.) (N�59 type) IV Q, If yes, give date D. LIFT STATION Date installed Size in gallons `Pump on' level at _ in. "Pump ofr stat Datum Cycles tested E. SEPARATION DISTANCES High water alarm level at Meets alarm ti circuk requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: 013Lle— Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer /septic On adjacent lots On Public sewer manhole/cleanout Holding lank DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation_ Property line S/� Absorption field S /� Water main Water service line 10+- Surface water Wells on adjacent lots 7-00 t+ in. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: f I/ Property line !D Building foundation (O 4- Water main i 4� Water Service line 10 Surface water 10014- Driveway. parkinglvehicle storage 1014— Curtain drain Ake Wells on adjacent lots 700r+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that i have determined through field inspections and review of Municipat records that the above systems are in conformance with MOA HAA uidefines in effect on this date. Engineer's Printed Named 8 L/L7 C. Date /� c -/O s HAA Fee $ Oro Date of Payment Srlk, lu Receipt Number 4Z 62Z (Rev. 12/01) Waiver Fee $ T; ROBERT C. COWAN CE • 8801 c'e, * ' IIIZt.�'. Date of Payment Receipt Number LOA BASIS 116..8 f I1;P yA 1 V T N N IW m O CO ®� 0:)o rl A O --IR /F DECK 130' ' A 21 A' •� • J �± L » P so' i • C 0.8 wl' x.l W � _ PORCH 11.1• � Z b �f e9� N A 10 FT. TELECO 8 ELEC. EASEMENT - ° 0 W 11291 (REC) 0 ;am mm Wo I �O u / v CO Il z W 27.5 iS• � KNIK VISTA DRIVE m o 0 v o v v 2 cQ1i r —'i �? �a0 o9 a3o3S.So ^� mo' m^o ne' o ao opo ° m O -4 m U ti N y CY, B or Rig •� � !!I�qN F AQ AAQw��oo �� ;masa-;� .teapot! :a'�•°�°. S�9��♦ o CD . c � ' Q N N O e IO • •W • N O C A O N 9 � N -� N / • r • I� • , � • Vl � FC •Q n 41 O n n iTt N tY �i% � �m Qn a«�w��'Q°R s � .a %sem to- •�, 001. • / i Z T _a �w�: ,: �• 'V a�'��••° m N o �/ ♦�; �. n 6 y m .`lam•• �a•,�"77� 1 tl E a O ��• = �C•V. W ?Cg O O Q .O A p O S ~ D o � •' A � O 1 Municipality of Anchorage Development Sep/ices Department Building Safeb! Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196850 Anchorage, AK 99519-6650 www.ci.anchcr~ge.~-k.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parce I.D. Z 1. GENE!~L INPORMATION · ' Complete legal des¢,dption Lot 4: Block 1; Knik View Subdivision · ,' Location (site address or directions) 22508 Knik Vista Current Property owner(s) Minica& barry Robert Mailing address. Lendin~'~gency Mailing address Real Estate Agent Mailing Address Street Chu~iak Day phone Day phone Kathy Geraci Greatland Realty 11411 UnM$sc~en~emqueste~ HAAwitlbehe~byDSD ~rp~kup. NUMBER OFEEDROOMS: A Dayphone 694-9125 Old Glenn Hwy. EaRle River, AK TYPE OF WATER SUFFLY: Individual Well Individual Wamr Storage Community Class ~ public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site ["i Individual Holding tank Community On-site Public Sewer The Municipality of Anchcrage Development Services Department (DSD) Issues Certificates of Health Authefit'/ Approval (HA,A) based only uccn the rebresentsticns given in p=:ragraph 4 by an independent professlcnal civil encineer recistered in the S~ate ' ~' - . . or A.I,=_~¢. Ce.';,ific---tes cf Health Au[hcrity Approval are required for the transfer cf t~t~e (exc~st be~veen spouses~ for prcpe~ies se.wed by a single-family on-site wastewater disp, csal and/or wa~er subPiy sys:am. DSD also issues HA`As u."cn recuest tc homeowners. CeAificates of Health Authodt'/Approval are valid for 90 da,is from the date "~* ¢ · or ~.~u_ fcr prcpe~ies served by = private or Class C weft and may be rc.s~u~, with new water samcie results. (Ce,'~ificates may be reissued fcra period cf up to cna year with valid water samples.) Ca~ificates are valid fcr cna ,./ear for prcce.qies se.wed by C',ass Acr E we!Is cra public ,,rarer sys;am. The Municipality cf A.~chcrage is nm resccnsib!e fcr errors or cmissicns in the profe.sicnal .heine.. 's 4. STATE,lENT OF INSPECTION EY ENGINEER As certified by my seal affixed hereto and ss of the validation date shown be!ow, I verify that my investi~caticn, based on procedures outlined in the Health Authority Approval Guide!inca for this application, shows that the Ch- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number cf bedrooms and type of structure indicated herein. I further verify that based cn the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the Ch-site water supply and/ct wastewater disposal system is(are) in compli.--.nce with all applicable Municlpal and State codes, ordinances. and regulations in effect at the time cf inst.'~llation. NameofFirm S & S EnRineering Address 17034 N. Eagle River Loop Ste. 204 Eagle Engineer's Ffinted Name Robert C. Cowan bedrooms. DSD SIGNATURE Approved for /~ Disapproved. Conditional approval for Phone 694-2979 River, AK 99577 Date 3 bedrooms, with the following stipulations:. Additional Comments ,,,: ;.%.. · 02.- ~: WATE,=,AND . ARachments: HAA Checklist Septic System Advisory Well Ficw Advisory (;.! ,/ Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: AD Mnnicipality of An orage DeveloPment Services Department Building Safety Division On-Site Water & Wastewater Program.. 4700 South Bragaw BL P.O. Box 196650 Anchorage, AK 99519.6650 www. ci.enchorage.ak, us (907) 343.7904 HEALTH AUTHORITY APPROVAL CHECKLIST WELL DATA Well type , IfA, B, or C provide PWSID # ~ Well Log (Y/N) Wires properlyi Casing height sn. bacteria by: Date co~pJetad Sa~ (Y/N) Total depth ~., .ft. //O~sed to ~ft. , ' ' FR,~,t'WELL LOG Date of test., i: . / Static water'level /.__.___~' ~ fL Well production/ ~ ~ g,p.m. WATER SAM~E RESULTS: Coliform .__~colonies/100 mi. Nitrate mg./t. Arsenic: a/----- mg./l. Date of sample: B. SEPTIC/HOLDING TANK DATA g.p.m, colonies/100 mi. Tank Type/Material ~~ Tank size ~ gal. Number of Compartments Foundation cleanout (Y/N) Depression over tank (Y/N) C. ABSORPTION FIELD DATA Date installed ~ Cleanouts (Y/N),, ~f High water alarm (Y/N) /~J Date installed ~t/ Length ~ ff. Total depth .~.~ ff. Eft. absorption area ~'/~ fi2 Monitoring tube Date of adequacy test ~ Results (Pass/Fail) Fluid depth in absorptiont ,field before test / · in. Water added~gal. Elapsed Time: .~ min. Final fluid depth / in. Any rejuvenation treatment (past 12 mo.) (YIN & type) Soil rating (g.p.d./~ or ~/bdrm) ,/" ~" System type ~ Width ~" fL Gravel below pipe ~., ~' fL Depression over field /~ For ~ bedrooms New deptha~l~.~in. Absorption rate >= ~' g.p.d. If yes, give date '"" So MFT STATION . 'Pump on level ay . in. ! Datum Size in gallons "Pump off level at in. Cycles tested Manhole/Access (Y/N) High water aiarm level at Meets alarm & circuit requirements? SEPARATION DISTANCES / Septic tank/lift station on lot /// On adjacent lots Absorption field on lot // On adjacent lots Public sewer main ~ Public sewer manh~cleanout Sewer/septic service line / Holding tank SEPARATION DISTANCES FROM SEPTIC/HO..bI~fNG TANK ON LOT TO: Building foundation ~' ~-' Property line ~ ~' Absorption field Water main /~7 ~ Surface water ~ Water service line / I~ ~/c Wells on adjacent lots ~ ~' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: /1~ /~' Building foundation /'O If._ Watermain in. Property line Water Service line / ~) I / {~) /'~' -~' Surface water Driveway, parking/vehicle storage Curtain drain/~/~'/~'A/~/'~rN/ Wells on adjacent lots COMMENTS ~view of Municipal .~s confo~ance wi, MOA H~ guMelines Engineers Pdnted Name Date HAA Fee $ Date of Payment Receipt Number Waiver'Fee $ Date of Payment Receipt Number (Rev. 12/01) I I I E~_M LOT 88 , xNt~ Vl~ ~OlVrSJ Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program a 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.enchorage.ek.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-031-27 HAA# HA O /10 P—hf S Expiration Date: S' 3 O - O 2 1.` GENERAL INFORMATION Complete legal description Lot 4, Block 1, Knik View Subdivision Location (siteaddressordirections) 22508 Knik Vista Drive Current Propertyowner(s) Tim Borgstrom Mailing address Lending agency Mailing address Real Estate Agent Kathy G./Greatland Realt _ Dayphone 688-5482 _ Day phone Dayphone 694-9225 Mailing Address 11411 Old Glenn Highway, Eagle River, AK 99577 Unless otherwise requested, HAA will be held by DSD for pickup. __�Wz 4111— rhI d e / 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class A Well ❑ Public Water System ❑X 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 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 or 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 affuced hereto and as of the validation date shown below, 1 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. S & S ENGINEERING Name of Firm 17034 Eagle River I cap 9m,9 No SO4 Phone 69,Y -)J) % i Address Eagle River, Alaska 99577 Engineer's Printed Name 'Robert C. Cowan, P.E. Date S -/-JL 3/o f IN 5. DSD SIGNATURE 10 :f, ROSERT C. COWAN f� c� CE • 8801 Disapproved. L Approved for'. bedrooms. ........... ` Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other_ By: Original Certificate Date: ' 3 " O/ (Rev. 12E0) Municipality of Anchorage ,,.� •�, ' Development Services Department v Building Safety Division ' On -Site Water & Wastewater Program ' r 4700 South Bragaw St. P.O. Box 196850 Anchorage, AK 99519.66W www.d.erxhorage.ek.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Descriptlon: 4arll; BU7GK 4 11-+V/_ C k1lizi S /0 Parcel ID: 19!;-1 — 03t — Z:7 - A. WELL DATA G Well type _ If A, B, or C provide PWSID # _ Date completed _ Total depth ft. Date of test Static water level Well production WATER E7 Coitform sample: Sanitary seal (Y/N) Cased to FROM WELL L ft. g.p.m. 1LTS: Well Log (Y/N) Wires property protected (Y/N) Casing height (above ground) in. AT INSPECTION 00 mi. Nitrate mg.A. Other bacteria Collected by: ft. g.p.m. coionies/100 ml. B. SEPTIGIHOLDING TANK DATA Tank Type/Material '' tr/ Date Installed 2 Tank size aj5+ get. Number of Compartments 2 Cleanouts&")' Foundation cleanout YN) Depression over tank (Y/N) M7 High water alarm (Y/N) N Date of pumping 4� I /A 0 / Pumper C. ABSORPTION FIELD DATA Date krstatl Sol p.d ft Abdrm) �Z System type S 11� T2L�/GH Length ft. Width S ft. Gravel below pipe Z Total depth 5.5 ft. Eff. absorption area _$�14 it= Monitoring tube &- Depression over field ' V Date of adequacy test Results (Pass/Fail) _fA15 For 4— bedrooms r Fluid depth in absorpri field before test r in. Water addedo0gal. New depthV in. Elapsed Timer min. Final fluid depth __L in. Absorption rate >= 4_ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N 6 type) NeNi' F•A(lY(,t/A( If yes, give date — D. LIFT STATION Date installed 'Pump on" level at in. Datum E. SEPARATION DISTANCES Size in gallons "Pump of level at _. in. Cycles tested SEPARATION DISTANCES FROM WELL Septic tankA)ft station on lot Absorption field on lot Public sewer Sewer IsaKe service line Manhols/Access (Y/N) High water alarm level at in. Meets alarm 8 circuit requirements? TO: 61,1 L On adjacent lots On adjacent lots Public sewer manhole/deanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HSG TANK ON LOT TO: s Building foundation a6 r� Property line r� Absorption field 5 Water main d r f Water service line / O m� Surface water /00 r r Wells on adjacent lots no t SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: r � r Property line j fBuilding foundation r Water main / C> / � r r Water Service line 'f Surface water / 00 + Driveway. parkingNshide storage r Curtain drain / hAAF--&//W At Wells on adjacent lots Z+� -A F. COMMENTS G. ENGINEER'S CERTIFICATION I cerdly that I have determined through field Inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines In effect on this date. Engineer's Printed Name /` oos* r C, CO w9r+ Date SIX 3 / 40 l HAA Fee $ 300. v J Waiver Fee $ _ Date of Payment r /} Date of Payment Receipt Number 0 0 4 f(I 0 Receipt Number (Rev. 12/00) .Q VAM^• lit Parcel I.D. # MUNICIPALITY OF ANCHORAGE O DEPARTMENT OF HEALTH &HUMAN SERVICES of Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 051-031-27 1. GENERAL INFORMATION Complete legal description Lot 4; Block 1; Knik View Location (site address or directions) NHN Knik Vista Drive f.. Chugiak, AK 'Property Owner. M2C1 Construction/Leroy Alderman Day phone 229-8059 Mailing address P-6. Box 670045 Chuaink, AK 99567 Lending agency Mailing address- Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual well Community well Public water Day phone Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: ,Individual on-site XXX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-MM".1191) Fro l MOAR21 S. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below. I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. S & S ENGINEERING Name of Firm - yy' Address Eagle River, Alaska 99577 Phone 6 a9 -7 Engineer's signature 6. DHHS,. SIGNATURE Approved for Disapproved. 0 Date 3 9 S' i ../ -0 ROBERT G 60' AM • `t `cv CE 8301 'f0V bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date 3 .12 ' 9a The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given In paragraph 5 above by an independent Professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions In order to satisfy certain federal and state requirements. Employees of DHHS do not conduct Inspections or analyze data before a certificate Is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 77-M (P-. 1N1) B�MOA 021 ._. IdUNMENIAL SERVICES e Municipality of Anchorage W p31993 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division D C r + v F 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 34%149411 Health Authority Approval Checklist Legal Description: Lor 4 &OC -K i . KNltc 4&al 5%D Parcel I.D.: 05 I – 031 – 21 A. WELL DATA Well type Ct Asc "A" 4 B, or C, attach ADEC letter. ADEC water system number Log present (YM) Total depth Sanitary seal (Y/N) Date completed _ Cased to FROM WELL LOCI Casing height (above ground) Wires property Protected (YM) AT INSPECTION Date of test Static water level Well production 9•P•m• g.p.m. WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDINGTANK DATA Nitrate Collected by: Other bacteria Date installed °I -21=41 Tank size 1250 Number of Compartments 2 Cleanouts i1) YF'S Foundation cleanout &N) '41& Depression (Ye L Si— High water alarm (Y" IJo Date of Pumping NBA Pumper C. ABSORPTION FIELD DATA Data installed 9 4,041 • Soil rating (§�r tN/bdrm) ) • 2 System" PKI406fi�0 t t � 1 Len bd '_Width 5 Gravel thicimess below pipe Z . S Total depth Effective absorption area 54bo Monitoring Tube present O/N) '4" Depression over field (Y)& tl Date of adequacy test �F�I ' Results (Pas ffiail) For bedrooms Fluid depth in absorption field before test (in.); — Immediately after= gal. water added (in.): Fluid depth � (ins) Minutes later: �— Absorption rate = a.p d. Perodde treatment (past 12 months) (YM) If yes, give date 72-026 (Rev. 3/96)' D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level E. SEPARATION DISTANCES 'Datum Size in gallons at* SEPARATION DISTANCES FROM WELL ON LOT TO: 60MAV►II-rY Septic/holding tank on lot 'Z0044 On adjacent lots Absorption field on lot Public sewer main Zoo'+ On adjacent lots "Pump off" level at' sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC(HOLDING TANK ON LOT TO: 1 Foundation 9 1 Property line Ills f- Absorption field 5 Water main/service line 10'h Surface water/drainage I oo'+ Wells on adjacent lots oo'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 15 Building foundation 2 51 t Water main/service line 10' t, Surface water 100 1 + Driveway, parkingNehicle storage area Curtain drain r leatn Y,4*0r) Wells on adjacent lots F. ENGINEER'S So' + I certify that 1 have determined thru Held inspections and review of MLwiWpal rtthat e 0 ms are in conformance with MC14 HAA �guid�sm—effect on this date. Signature _ Engineers Name Rdl3 fRr C. Ca ...f.. koeFrr C. COWAN l Q r CE MCI Date 3 13 19 $ HAA Fee $ 3 D D. U G Waiver Fee S Date of Payment 3 — Date of Payment Receipt Number y� d 3Ga Receipt Number 72-026 (Rev. 3196)'