HomeMy WebLinkAboutCAMPBELL HEIGHTS BLK 3 LT 16ACampbell Heights Block 3 Lot 16A #014-072-46 WATER WELL RECORD MUNICIPALITY OF ANCHORi.,,E STATE OF ALASKA CFPT 0= HEALTH ENW )I 4t,•2, -A. PROTEC:T!- •! DEPARTMENT OF NATURAL RESOURES Division of Geological & Geophysical Surveys j u : 2 8 1982 R KUly ® Drilling Permit No. LOCATION OF WELL I e slither la, Ib or Ic.) A.D.L. No. la. Borough Subdivision Lot Block Ib. 1/4 qtr$. Section No. Township N ED Range E [:1 Meridian —of_of_of — SEl W[ Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELL: •--- ,, Address: /? Street Address and Area of Well Location 2. WELL LOG Feet Belowurface Material Type Top Bottom 4. WELL DEPTH: (final)5. ft. DATE OF COMPLETION — — 6. E] Cable tool F] Rotary a Driven 0 Dug ElAuger Jetted [] Bored Other: ��,•�. 7. USE: 0 Domestic E] Public Supply E] Industry Irrigation Recharge Commerical Test Well Other: G,`, .z 8. CASING: ❑ Threaded Welded diam. in. To_ It, Depth Weight Ibs./ft. diam, in. to ft. Depth Stickup ft. t 9. FINISH OF WELL: Type: Diameter Slot/Mesh Size: _ Length: Set between ft. and ft. Backfilling Gravel pack _ 10. STATIC WATER LEVEL: ft. Above or Q Below land surface Date Equipment used: I I . PUMPING LEVEL below land surface and YIELD ft. after hrs. pumping g.p.m. ft. after hrs. pumping g.p.m. 12. GROUTING Well Grouted: Yes ❑ No Material: [-] Neat Cement Other: 13. PUMP: ( if available) HP Length of Drop Pipe ft. capacity g.p.m. n Subm. ® Jet ❑ Centrifical Other 14. REMARKS: 16. WATER WELL CONTRACTORS CERTIFICATION: This well was drilled under my jurisdiction and this report is true to the best Registered Business Name Contract Address: 15. Water Temperature ° E] F ❑ C of my knowledge and belief; License Number Signed : Date: Authorized Representative Form 02-WWR (11/81) Copy Distribution: WHITE -State DGGS, PINK -Driller, CANARY -Customer C: Cn G) Cn r 0 2 0 r•l a r4 I c I i rA L_ I -r �e Q F= F-1 r -J t=r t , F: 1=1 r E DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 'L' STREET, ANCHORAGE, AK. 99501 264-4720 L4 E= L_ L_ F} E F= t'1 I T PERMIT N0. C 820135 ) APPLICANT CIE ENT. INC PO BOX 10-991 99501 344-3494 LOCATION LEGAL L16A 63 CAMPBELL HTS LOT SIZE 8593 SQUARE FEET MINIMUM DISTANCE BETWEEN A WELL AND ANY ON—SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MIRIIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER. LINE IS 25 FEET AND TO A COMMUNITY SEWER. LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATION- AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F}EFRM I T EXF} I FtiES~ CmE=CEr-1E E: F;-: = 1s 1�48:;� I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. SIGNED APP'LIC�AJNT� CIE ENT. INC ISSUED EY t_'C-------- --DATE------ — V4. 0 1.11 Ir -i I C• I F='t-IL . J -1 47, C:IF • F1r-7r'I f F.:r t, ;u DE t•HR] Fu=.n r��F;E FIL 1 N tutu f I^?? E:E'!d!•tF Ft 1 nt. fi�'Z E t'1 J i+tr . ' ' '': L •1 F'f c 1. R!!C•1IGF:fa•E , f;t! g?' � .. -r t-ar:?u _ "F:ti)1 'MCI. C ocYsJ �. 3 52 v 7+.►Jl7 t:d:E FN1. JNt: P,J Ea+X JL+ -W--,4 Y•,¢Td "l -_M 94 it I CII: 11. L 1 f.FI E: ' CRI1F•E:E L L M!. I III 5.1 is ti`• a3 ;.r+1 fr.F:F FEF 1 00 m I IMLIM D I °•1 f{NrF E;E i b+L F tJ N VE t L FiFJU nuts' Cjrt-!�. , I E 5E ttr;C<E [, J �k'C1 .ftL = Y _.T E ti ) 5• . : rLfl FC'f: P. 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"�, • ,,. ' DATE OF APPLICATIONS WATER a SEWER UTILITIES SCHEDULED COMPLETION DATE l - 3000 ARCTIC BOULEVARD ZINGLE FAMILY PHONE -277-7622 . 13 MULTI -DWELLING No. APTS_ OCOMMERCIAL LOT/TRA1CT_/e/ BLOCK 3 D INDUSTRIAL SUBDIVISION f 117 TAXCODE - - GRID!��E-71" ' DRAWING No. 41 BUILDING ADDDRR�ESS �- -7,t.' OWNER l_!/<—_� - 1 -1 IC40 Y!«S- PHONE3L9y MAIL ADDRESS Z� fJ i/� X 110-941 CONTRACTOR: ASSESSMENTS (License abond requre ❑ Poid previously XON PROPERTY ONLY ❑ Main extension agreement ❑MAINTAP-TOPROPERTY LINEONIY ❑ Subdivision agreement ❑ Extended connect agreement 0MAINTAP80N PROPERTY CONNECT ❑ Pending -AMOUNTS L "/7:) PIPT ISSUED BY, CONNECTION SIZE 4 ,r CHARGE 1 INSPECTION FEE Cl ❑PAID [3 CASH PERMIT FEE # S /»Qf CK* REIMBURSIBLE NUMBER DEPOSIT `�• TOTAL # 2 /TE• Z V- L PHONE: Disr� ?9.IHAVE READ THE CONDI IONS AND REGULTIONS ON THE REVERSE SIDE OF THIS PERMITAND AGREE TO COMPLY WITH PERMITTEE SIGNATURE POST IN A I . 11.1 SPICUOUS PLACE ATTHE JOBSITE 11 ^� C, Y F Q O � m W O Z ♦ O O 1� Q O NO O (r "1 (n U W O O Z W L 2 W N y < ❑ C O C O Z � `o m Q c o d Z U O O Q O C Z ❑ O a❑ Q W n T'� d y O (n Lj CO o z Q 1'^ O a r v E C a z Qa C c 4 d U O40 Z O Z d d ❑ Z O O = ~o' z y E E d o ❑ t o rn 0 o c ? 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W cm L2 Z Z Z • W W W Z D N O O N N U U Z 1MMI N0113USNlIAMS MUNICIPALITY OF ANCHORAGE Development Services Department=� Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 014-072-46 Legal description Campbell Heights Block 3 Lot 16A Site address 4001 East 67th Ave Anchorage Current property owner(s) Nelson Expiration Date: 2.,/ 2 3 z oZ X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Engineer reports that well pit manhole gasket was verified to be working. 0 Original Certificate Date: 11/23/2022 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 MUNICIPALITY OF ANCHORAGE A. Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 014-072-46 Complete legal description CAMPBELL HEIGHTS BLK 3, LOT 16A Location (site address) 4001 EAST 67TH AVE. ANCH AK 99507 Current property owner(s) NELSON 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS Day phone 3. TYPE OF WATER SUPPLY: ❑E Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ■❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $. Date of Payment ;1 !I% 15 %202 Z Waiver Fee $ Date of Payment COSA # S C Z Z S `(Y Waiver # COSA Application—June 2022 COSA Checklist Legal Description: CAMPBELL HEIGHTS BLK 3, LOT 16A Parcel ID: 014-072-46 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA M Well log is filed with Onsite (or attached) Date drilled 5/22/82 Total depth 55 ft Cased to 55 ft ❑� Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) `PIT in. Date of Flow test for COSA 10/17/22 Static water level at beginning of test 10 ft. Comments 'WELL PIT SEE LETTER IN MOA FILE B. TANK DATA Measured operating fluid level in septic tank _ Date of pumping ❑ Required maintenance completed, if AWWTS Comments: AWWU SEWER SERVICE D. ABSORPTION FIELD DATA Which system tested (date installed) ❑ ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) _ If yes, enter date Comments/Deficiencies: AWWU SERVICE COSA Checklist—June 2022 Well production at time of test 5+ gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes No X Coliform bacteria is Negative Nitrate 1.23 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ElArsenic less than MRL (ND) Collected by MNA Dara 10/17/22 C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: Adequacy test date Results ❑Pass Fluid depth prior to test _ in Water added _ gal New fluid depth _ in Elapsed time _ min Final fluid depth _ in Absorption rate _ gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) _ in Effective depth used _ in Effective depth remaining _ in E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft ❑ Yes if No 50+ It Neighboring Tank > 100' Mn Yes if No _ ft Private Sewer/Septic Line > 25' ❑ Yes if No **25+ ft Absorption Field on Lot > 100' ❑ Yes if No _ ft Holding Tank > 100'❑ Yes if No _ ft Neighboring Absorption Fields > 100' Animal Containment > 50' Q Yes if No ft ❑i Yes if No ft _ _ Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑Yes f No _ ft Q Yes if No _ ft X N/A — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No _ ft Surface Water > 100' ❑ Yes if No _ ft Tank to Property Line > 5' Field to Property Line > 10' Water Main > 10' ❑ Yes if No _ ft ❑ Yes if No ft ❑Yes ifNo_ft Wells on Adjacent Lots: Private Wells > 100' Community Wells > 200' ❑Yes ifNo_ft ❑ Yes if No _ ft Water Service Line > 10' ❑ Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS " MET CODES AT TIME OF INSTALL, "" NOtREQUIRED AT TIME OF INSTALL G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm M�.rna�( rV Phone 727-8864 Engineer's Printed Name NIIIIn� A �nd.,9"&tdlDate t}1z i h E ' •' �� � •• MICHAEL N. ANDERSON•; CE - 9469 S l/ COSA Checklist June 2022 • •t ICpc,E aui _7 Municipality of Anchorage e On-Site Water and Wastewater Program a . 1, l1 i' (907) 343-7904 SAFETY Certificate of On-Site Systems Approval Parcel I.D O>sga-c1 C L t-(R-2-'4Expiration Date: c ?- - 2f -! ci 1. GENERAL INFORMATION: Complete legal description CAMPBELL HEIGHTS; BLOCK 3, LOT 16A Location (site address) 4001 East 67th Avenue*Anchorage,AK 99507 Current Property owner(s) Ryan Thompson Day phone 214-212-0658 Mailing address Real Estate Agent Day phone 2. TYPE OF DWELLING: ® 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 ❑ Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community Public Water System ❑ Public Sewer ❑ WaiverNariance reque •r: Distance: ilReceived by: . , i .` Date: 12,12 A ea COSA to be released to e igin f r,un- - - erwise requested by the engineer. COSA Fee $ .5.2(o Waiver Fee $ _. Date of Payment rI i 1210111 Date of Payment Receipt Number 0-75 2C? Receipt Number _.. COSA# 05C 1 Siled 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: Garness Engineering Group, Ltd (GEG) • .: Phone:(; 907-337-6179 Address: 3701 East Tudor Road, Suite 101-Anchorage,Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness _.• Date: 11/2.6,1t8 00000,04 In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system o Q r xl C ��� in accordance with the guidelines and regulations established by the Municipality of Anchorage and 'K_.. ........... . - r 1r industry practices. The reported results describe the condition of the system/s on the date/s of the QOk• -.•• • evaluation. Separation distances were measured to readily identifiable features. Hidden defects or • / '":� t7 encroachments may exist that were not identified during the evaluation. The operational life of all wells � , ; 4 Ti * Q . and septic systems depend upon a variety of variables, including but not limited to, soil conditions, ..... ••. Q groundwater levels (that may fluctuate during the year), quality of construction (materials and VA workmanship),and the water usage of the family utilizing the system/s. These conditions can vary,and a If are outside the control of GEG. Satisfactory test results do not guarantee future performance of the Q .e lie A. Torness: t' system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of (/0„:23(:,c) CE 795 QQ the well or septic system. GEG makes no representation whether an alternative well or septic system f ,� /�(.� •�ceQ can be installed on the property in the event either of the current systems fail to perform adequately in � °�e Z cc'; the future. The content of this report is for the sole benefit of the person/party that retained GEG to ("'Professl°n°oQ perform the evaluation. Reliance upon the information provided in this report by any other person or party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. #AECC884 6. DSD SIGNATURE ?C System #1 Approved for J bedrooms System #2 Approved for bedrooms Disapproved ..)\\ •,�% �` ON-SITE Conditional approval for bedrooms, with the folloAng Oii t cAN:D m WASTEWATER 2 PROURAM VrSER` I O Original Certificate Date: 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.s Nitrate Adviso Septic System AdvisoryArsenic Advisory Well Flow Advisory Other COSA blue sheer 10-10-12.doc If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Certificate of On-Site Systems Approval Checklist Legal Description: CAMPBELL HEIGHTS; BLOCK 3, LOT 16A Parcel ID: 014-072-46 A. WELL DATA *PIT WITH DRAIN-SEE ATTACHED EMAIL FROM AAROW WELL&PUMP SERVICE DATED 11/26/18 Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 5/22/82 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 55 ft. Cased to 55 ft. Casing height(above ground) *PIT in. FROM WELL LOG AT INSPECTION Date of test 5/22/82 11/8/18 Static water level 12 ft. 10.4 ft. Well production 7 g.p.m. 5.5+ g.p.m. WATER SAMPLE RESULTS: Coliform NEG colonies/100 ml. Nitrate 1.49 mg./L. Collected by: GEG, Ltd. Arsenic: <5.0 ug./L. Date of sample: 11/2/18 B. SEPTIC/HOLDING TANK DATA AWV/U Tank Type/Material Date installed Tank size gal. Number of Compartments Cleanouts(Y/N) Foundation cleanout (Y/N) Depression over tank(Y/N) High water alarm Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft2or ft2/bdr r System type Length ft. Width ft. Gravel below pipe ft. Total depth ft. Eff. absorptio - ea ft2 Monitoring tube Depression over field Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in absor. in field before test in. Water added gal. New depth in. Elapsed T.- e: min. Final fluid depth in. Absorption rate >= g.p.d. y rejuvenation treatment(past 12 mo.) (Y/N & type) 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 wa er alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A On adjacent lots 100'+ Absorption field on lot N/A On adjacent lots 100'+ Public sewer main •50+ Public sewer manhole/cleanout '50'+ Sewer/septic service line x•25'+ Holding tank 100'+ Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: AWWU Building foundation Property line Absorption field Water main Water service line Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIE 0 : 1 LOT TO: Property line B ' :• • oundation Water main Water service lin- Surface water Driveway, parking/vehicle storage -in drain Wells on adjacent lots F. COMMENTS * MET CODE AT TIME OF INSTALLATION "NO REQUIRED SEPERATION AT TIME OF INSTALL G. ENGINEER'S CERTIFICATION :�P,..•'' '''••.4v4: I certify that I have determined through field inspections and ' - ,49; review of Municipal records that the above systems are in • ' i • conformance with MOA COSA guidelines in effect on this , •• . ••,I date. •o G, -f • Garne s::i CE-7. • Engineer's Printed Name JEFFREY A.GARNESS �• /* ..• 12 �� *�C�:" Date ` � /I 414 PROFESS\ 144 LICENSE �1Ili"`♦♦♦ #AECC884 (Rev.10112112) Jeff Garness From: David Harper <dlharper2@gmail.com> Sent: Monday, November 26, 2018 8:29 AM To: Jeff Garness Subject: 4001 E 67th Avenue Jeff, as we discussed the interior of the manhole and the well seal and conduit looks rusty and in disrepair. However, it does all that is needed to meet MOA requirements. The cap is sealed, conduit is seal tite and in working order. The manhole is sealed with a rubber gasket. We were not able to find where the drain tube daylights but were able to run a snake 50 feet plus which suggests it is also in working order. If there are problems in the future the well can be extended if need be. David Harper Aarow Pump &Well Service, LLC 1 Municipality of Anchorage • Development Services Department Building Safety Division — On -Site Water &Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK rg/ons e J www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. D I Li- MA -LI to COSA# 08 OAI?A 1. GENERAL INFORMATION Expiration Date: vZ 0 ` O Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address CAMPBELL HEIGHTS: BLOCK 3. LOT 16A 4001 EAST 67TH AVENUE 'ANCHORAGE. AK CARL & ALICIA SADEN Day phone C/O AGENT 4001 EAST 67TH AVENUE 'ANCHORAGE. AK Day phone LAVERN PETTIGEN W/DYNAMIC Day phone 261-751 3111 C STREET *ANCHORAGE, AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well 0 Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site ❑ Individual Holding tank ❑ Community On-site ❑ Public Sewer 0 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seat 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 GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date g /13 /a S Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines d Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily Identifiable features. The operational #to of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system wig continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party Is not authorized, nor wilt it confer any legal right whatsoever. S. DSD SIGNATURE V Approved for _bedrooms. Disapproved. Conditional approval for bedrooms, with the filowing stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Reort Nitrate Advisory Other By: PROGRAM Original Certificate Date: ' oC ' Q Municipality of Anchorage Development Services Department • �i Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.orglonsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST __4 Legal Description: CAMPBELL HEIGHTS; BLOCK 3, LOT 16A Parcel ID: o A. WELL DATA "WELL ENCLOSED IN WATERTIGHT MANHOLE W/ A DRAIN. Well type PRNATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 5/22/1982 Sanitary seal (Y/N) YES Total depth 55 ft. Cased to 55 ft. FROM WELL LOG Date of test 5/22/1982 Static water levet 12 ft. Well production 7 g.p.m. WATER SAMPLE RESULTS: Wires properly protected (Y/N) YES Casing height (above ground) •0 in. AT INSPECTION 8/6/08 24 ft. 6.97 g.p.m. Coliform 0 colonies/100 ml. Nitrate 0.682 mg./L. Other bacteria _0 colonies/100 ml. Arsenic: NO ug./L. Date of sample: 8/l/08 Collected by: GEG Ltd. B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER Type/Material Tank'sti�gal. Foundation Clea-ft4(Y/N) Date of pumping C. ABSORPTION FIELD DATA Date installed Length ft. Total depth ft. Eff. Date of adequacy test Date installed Number of Compartments _ Cleanouts (YM) _ Depression over tank (YIN) _ High water alarm Pumper Soil rating (g.p.il:Ft =or ft'/bd _ Width bsorptio ea_ft' Monitor Results (Pass/Fail) System type Gravel below pipe ft. Depression over field For bedrooms Fluid depth in abso ' n field before test— in.. Water added _gal. Elased ' pe: —min. Final fluid depth _ In. y rejuvenation treatment (past 12 mo.) (Y/N & type) _ Absorption rate If yes, give depth _in. D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N "Pump on" level at in. "Pump off' leve High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A On adjacent lots 100'+ Absorption field on lot N/A On adjacent lots 100'+ Public sewer main '50'+ Public sewer manhole/cleanout "50'+ Sewer /septic service line 25'+ Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER Building foundation Water main Wells on adjacent lots Property line Absorption Water service line Surface SEPARATION DISTANCE FROM ABSORPTION FI Property line TO: Water main Water service ling/ Surface water Driveway, parking/vehicle storage Wells on adjacent lots F. COMMENTS *WELL INSTALLED PRIOR TO 1983 G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and •' 9 ya.QO review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this 0 date. J fry A. Car ess.. Engineer's Printed Name JEFFREY A. GARNESS �Q CE— Date la 113 / 8 0'Proreesio�0\ ��400 W\ COSA Fee Date of Payment -5/1 o8 _ Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number /Or zim, zSMtA 7• , lei O fcMr. IVY • • :.. .. H • ... . t .. •, • ".:' f:..� : �f : ',;• r•... •: AS �R MyjMspppp • ��� • �•R ... f,."�.1: ;1 j % It is the responsibility of the owner,to �deternine-- +ate• Icon the existence'of,any easements* covenants;- or.re=':.: cf �,; ::u•... strictions'•which do hot'appear on'the:recoFded'sub=';:_ ��` ; �t?..r., • • , �.• division plat:;Under no ;circumstances; should'.ky,',;; NOTE-:� '-tl�i:o«rRR•'��;�v`A ,data hereon.be'used for consfruction*.or*-for.estab- .,%., EASEMENTS OFRECORD,OTHER•T}(AN7f105E ',lishing'boundaiy'or fence lines. -The surveyor.taPesl .SHOWN HEREON THE RECOROEDPLATj;ARE;HOT.:. responsibility•for'the initial transaction only; ., LO'f BLOCK .j • :9 MASS CAI NORUMCNT.. :1:.. 'IC S PLATNow '••r.•�-'IRON II►[ ANCHORAGE' ECORDING;DISTRICT., RreARrRoeeoe.n+c- -,_•• t' •Q NUR A TACK: •t• ''^, fir•_ PREPAMEO`BTaDOWLING a ASSOCIATES • 'v,. " .='804 EAST: 15th 'Ave. Suite 2 ANCHORAGE. ALASKA ' '99501' nrvtetnu Wert ar E:�:J_3C�J ' •. I*OR K.—e5 ' IFIE-4DB',7rl/ �cnro: 20✓! 1 cY CCD J . 1 • z O N P' c C3 O W Z 2 O ?' 4 v W N a C O ..1 a V 4 •• o,_ • � T ••• O I ' 4 . 1 • W O N P' c C3 O W Z 2 4 W .J V S N CJ w W O N Z wa z� Wi J Wy O V � S y W O N V 6 LL W O O N a v 0 0 x N S W O ry O ?' 4 v W N a C O ..1 a V .. y > Zz • � T ••• O I N V_ V)1U043H NCIMUSN111MUS ry _[�_ Et`T�' ... � - y •a��a��;aa�xz�j��a>2paFF�sas ~# N c g rt s O Ln i ` •- • 1. a s E4 `RN,. 11 THIN'. D \ si t I i \`-��>_1 J 1 �f N• e .- i s 1)I t • 4 i •• i 1 f E � a i t l • 1 rj 75 t + _ fes+ N 1 2009 fi ...4Y t. a i • + __ � c I 1• s '� q As 1t • RRR Iy ,�.,m• k, p. Z I 1 1 1 1 9 r �• j 7 _ •E e . LT', j� 1` 197 1,,s E • d �. �q.. �}�` G _p S $$ •aO W k�*}{ei11t11 &7� Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 198650 Anchorage, AK 99519.8650 www.munl.onyonsile (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. _014-072.46 1. GENERAL INFORMATION Complete legal description Lot 16A. Block 3. Campbell Heights Location (site address) 4001 East 67th Avenue COSA# 016QnR(,i Expiration Date: 6, — 2 2, Current Property owner(s) slave„ HoI nes Day phone .Mailing address 4 O e� INZ e 7)( g6504 _ 2.P5,�) Lending agency Day phone Mailing address Real Estate Agent Janis Torbert- Pn,dentW rack whiteNista Day phone 273-M Mailing Address 3601 Centerpointe Drive, Anchmge AK 995M Unless otherwise requested. COSH Wit be held by DSD for pickup. 2. NUMBER OF BEDROOMS: Four (4) 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site G Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer 0 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 Onsite Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also Issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below. I verify that my Investigation, based on procedures outlined In the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system Is (are) safe, functional and adequate for the number of bedrooms and type of structure Indicated herein. I further verify that based on the Information obtained from the Municipality of Anchorage files and from my Investigation and Inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Engineering Phone 522.7773 Address P.O. Box 240773 Anchorage. AK M24 Engineer's Printed Name Michael E. Anderson 6. DSD SIGNATURE ✓Approved for L bedrooms. Disapproved. Date Wor2m 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 By: �, �� " r Original Certificate Date: 3 (0 (Rr. 1rxa) Municipality of Anchorage • Development Services Department Building Safety Division On -She Water d Wastewater Program 4700 Bragew Street P.O. Box 198850 Andwrage. AK 99519 -WW www.munLorglonsne (907)343.7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: _ La[ 1eA, ewdc s. Corow magma &* Awan Parcel ID: 0144M48 A. WELL DATA Wen type !-ft M A, B, or C provide PVVSID 0 _ Date completed srnne62 San" seal (Y" v Total depth 66 R. Cased to X40 ft. FROM WELL LOG Date of test eran992 Static water level 12 R 7 WATER SAMPLE RESULTS: Cdiorm -2--colonies/loo mL Amenia No mgn B. SEPTICIHOLDING TANK DATA Tank Typouaterw Wen Log (YIN) _v Wires property protected (YIN) Y Casing height (above ground) 12 In. AT INSPECTION W/2005 29 It g.p.m. a 9 - p.m - Nitrate 0.495 mg/L Other badaria 42 colonlW 00 mL Date of sample: !2L=— Collected by: t_ HwrAndez Tank size gal. Number of Compartments._ Foundation cleanout (YIN) _ Depression over tank (YIN) _ Date of pumping C. ABSORPTION FIELD DATA Date Installed Length it, Pumper Date In4aned Cteanouts(VIN) High water alarm (YIN) Son rating (g.p.dA a or felbdrm) System type VNdlh 2 Gravel below pipe Total depth R Eff. absorption area _f? Monitoring tube _ Depression over Bed _ rt. Date of adequacy test Results. (Pass/Fal) For _ bedrooms Fluid depth In absorption 8eid before teat in. Water added gal. New depth in. Elapsed Time: min. Final f uid depth In. Any rejuvenation treatment (past 12 mo.) (YIN a type) Absorption rate # g.p.d. K yes, give date D. LIFT STATION Date inatafied Size In gallons Manhole/Access (YIN) 'Pump on' level at _ in. 'Pump air level at _ in. High water alarm level at in. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: SeptiC tanlfiiR stetlon on let WA Absorption field on lot WA Public sewer main "W" Sewer /septic service Brie >xr Meets alefn b circuk requirements? On adjacent Iota WA On adjacent Iota WA Public sewer manhole/dearw 91"" Holding tank WA Animal containment areas Pio Manure/animal excrete storage areas No SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building fou ximon Property One Water main Wells on adjacent Iota Water service One Absorption field Surface water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property One Building foundation Water main Water Service One Surface water Driveway, parkingtabide aftW Curtain drain Wells on adJecent kb F. COMMENTS: "WON CMPMW in 1992 sepwadon d swm a meNWk ad eewa rink, was W at go Ems. Wen endopd in watmapM RW*WW wflh a drain. Wed heed hes a sanitary seal and is properly wked. G. ENGINEER'S CERTIFICATION I OeRMy that I have determined through JIM lnspeaUMS and review Of Municipal records that the above systems ars in conformance with MOA COSA guidellnGs In effect on Mb date. Engineer's Printed Name Mklrael E. Andes Date aaarmoe COSA Fee $x.00 Date of Payment a -2"M Receipt Number -7-703-7 (Rev. 11106) Waiver Fee $ Data of Payment Receipt Number L =9 Municipality of Anchorage Development Services Department Building Safety Division ' On -Site Water and Wastewater Program . r 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. 014-072-46 HAA # n AY-) %CHIC Expiration Date: 3 — 19 " U,-. 1. GENERAL INFORMATION Complete legal description _Lot 16A, Block 3, Campbell Heights Location (site address or directions) 4001 East 6r Avenue Current Property owner(s) Ron Knight Day phone 360.8999 Mailing address 'Lending agency Mailing address Real Estate Agent Mailing Address 4001 East 67th Avenue Anchorage, AK 99507 Day phone Karen Rich • Sleeper Realty Day phone 360-8999 800 E. Dimond, Suite 3-300 Anchorage, AK 99515 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 101111110;9 *61:11171-1111 1114tt-MMAJ WIF Individual Well Individual Water Storage Community Class Well Public Water System Four 4 TYPE OF WASTEWATER DISPOSAL: 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 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. 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 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 Anderson Engineering Phone 522.7773 Address _P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. Date 511712005 i° 49th _ 5. DSD SIGNATURE ✓ Approved for _ 4 bedrooms. Disapproved. 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: a.4g,. / LZ r O— ` Original Certificate Date:_ -7 ` I 1 " S (Rw. ruo) Municipality of Anchorage ' Development Services Department Building Safety Division On -Sita Water 8 Wastewater Program 4700 South Bragaw St. P.O. Box 19WW Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lot 16A. Block 3. Campbell Heights Subdtvlsion Parcel ID: 01407246 A. WELL DATA Well type Private If A, B, or C provide PWSID # _ Well Log (Y/N) Y Date completed 5MU1982 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth JU ft. Cased to4�ft. Casing height (above ground) 12 in. FROM WELL LOG AT INSPECTION Date of test 501211992 51@005 Static water level 12 ft. 29 ft. Well production 7 - g.p.m. 6 9 - p.m -WATER SAMPLE RESULTS: Coliform _Q,_oolonies/100 ml. Nitrate 1.07 mg.A. Other bacteria _L colonies/100 ml. Date of sample: 4N2005 Collected by: Aarow Well b Puma B. SEPTICIHOLDING TANK DATA Tank Type/Material Tank size gal. Number of Compartments Foundation cieanout (Y/N) _ Depression over tank (Y/N) _ Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d.Atz or ft'Abdrm) _ System type Length ft. Width ft. Gravel below pipe Total depth _ ft. Eff. absorption area ft Monitoring tube _ Depression over field Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of adequacy test Results (Pass/Fail) For _ bedrooms Fluid depth in absorption field before test _ in. Water added_ gal. New depth_ in. Elapsed Time: _ min. Final fluid depth _ in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date S D. LIFT STATION Data installed `Pump on' level at _ in. Datum Size in gallons 'Pump off" level at _ in. Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Manhole/Access (Y/N) _ High water alarm level at Meets alarm & circuit requirements? in. Septic tankAdt station on lot WA On adjacent lots _ WA Absorption field on lot WA On adjacent lots WA Public sewer main >W Public sewer manhole/cleanout 91— Sewer /septic service line >2T Holding tank WA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line _ Absorption field Water main Water service line Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Water main Water Service line Surface water Driveway, parking/vehide storage Curtain drain Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION •�O/�P��.~•• '4j4, AV —!,.•' I certNy that I have determined through field inspections and 49th review of Municipal records that the above systems are in c_ conformance with MOA HAA guidelines in effect on this date. IdV.�_-u` 1I' �3t .IQCW L E A11DD= s Engineer's Printed Name Michael E. Anderson. P.E. �j r °; Nm CE -43r Date 5K7I2W5 ,4ti j HAA Fee $ 430 It-, . Date of Payment 5- 17- 4&5- Receipt SReceipt Number (ft:7 R (Rev. 12/00) Waiver Fee $ Date of Payment Receipt Number T *Dud Conducted tiy: ,L Owner �KCly_ Well Location: _ Well Information: :0I Wd2£:80 NOW bT02-T2-8cH WATERWELL -TEST PUMP REPORT Depth of Casing: iT Screen Fromz_lo- Casing Size: 611 Sc�rreen um: Screen Slot: Remarks: _>�1�/r 1 I ria 7� ICK K� Au K. / t7 _;F — Pump Information r��� Intake Depth: 1� PunSize I Air Line Depth: Static Water Leveh • v. D4cha er GPM; Max Drawdwm: �1�• Pump On ������ Time: Date: _r -0 Pump Off: Time: Date: c ,' '1 Time Water Levei now 1 Remarkx GPM - o,ov Qaio 3a,av 39, 1 . ,00 1 of 6/ GPM w 'A _/W _ _ 1 • -r T0'd iC= T T •f MMM -T W_%. .,W Municipality of Anchorage • -- Development Services Department Building Safety Division On -Site Water and Wastewater Program ' • ' 4700 South Bragaw Street 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 l.D. HAA# JJA Ol o.s 33 Expiration Date:D�- 1. GENERAL INFORMATION Complete legal description Lot 16A. Block 3 Campbell Heights Location (site address or directions) 4001 East 67th Ave Current Property owners) - Patrick Williams Day phone Mailing address Lending agency Mailing address 4001 East 67th Ave. Anchorage, AK 99516 Day phone Real Estate Agent Beta Bodner Day phone 244-4415 Mailing Address Unless otherwise requested, HAA will be held by DHHS for pickup. NAA picked up by: 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site ❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer The Municipality of Anchorage Department of Health and Human Services (DHHS) 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. 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 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. (R".I11M 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 Health Authority Approval Guidelines for this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on- site water supply and/or wastewater disposal system is in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Pannone Encl. Svc Phone 272-8218 Address P.O. Box 102954, Anch, AK 99510 Engineer's Printed Name Steven R. Pannone, P.E. Date 1012/2001 Engineers Comments: In conducting an adequacy tat, l attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DHHS Guidelines & Regulations. The Nt# reported results describe the performance of the system under the conditions encountered at the time of the 4 �P •••••••• . •• •" •••'J.1�9�� test, and separation distances mcasmcd to readily identifiable feanua. The operational life of all welts and All* TH septic systems depend on the local soil condition, ground water keels at may fluctuate during the year, 49— and the water usage of the family being served by the system These conditions are outside the control of - F•.:�• «...»,• the evaluator of this system. All systems eventually fail and satisfactory tat results do not guarantee 01». _ •.: » future performance of the system, nor do they guarantee that there arc do hidden defects or encroachments. »» ....•,»»•... � PES can therefore not pnnidc arty warranty for future performance nor give arty estimate of how long the - ;Steven R. Pannone; � r system will continue to meet the operational requirements of the ADEC or h10A DHHS. The content of°., No. -1 E 8149 =� this spat is for the sole benefit of the owner listed above. Airy reliance upon a use of this report by wry ��. %- i t�� other person or party is not authorized nor will it confer arty legal right whatsoever. 14 «• 6. DHHS SIGNATURE Approved for _ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: ' . Ilrrrlrl�-� ��,kkk �jj OF AN&I, ,� \_ • nITC _ Additional Comments WATER AND - w - - Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Expiration Date: (Rw.1 wast Original Certificate Date: % 0 — R - g2l Reissue Date: Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 5 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lot 16A. Block 3 Campbell Heights Parcel 1. D.: ' O 1Z A. WELL DATA Well type Private • If A, B, or C provide PWSID # _ Well Log " YB S Date completed lS/z1�$Z Sanitary seal Yes Wires properly protected Yes Total depth I ES i ft Cased to f5lft Casing height (above ground) in. IlBf+a toT ¢ e,H u FROM WELL LOG AT INSPECTION 01A v#e t&r , Date of test 5- /Z do Z_ 6/11/2001 Static water level/Z ft 27 It Well production T g. p.m 6 g. p.m WATER SAMPLE RESULTS: -29. S� L ' AP Coliform 0 colonies/100 ml Nitrate 6-74• mg/I Other bacteria colonies/100 ml - Date of sample:-8{2R16B1 Collected by: S.R. Pannone I FIR/6U lad f LL tg�" B. SEPTIC/HOLDING TANK DATA Tank Type/Material N/A Date installed Tan sik ze ' gal Number of Compartments _ Cleanouts __.Foundat�eanout Depression over tank _ High water alarm Date yt pumping Pumper C. ABSORPTION FIELD DATA Date installed _ Soil rating (g.p.d./ft2 or ft2/bdrm) System type Length ft Width it Gravel below pipe ft Total depth _ ft Effective absorpti rea _ft2 Monitoring tube _ Depression over field Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in abso 'on field before test in Water added_ gal. New depth_ in. Elapsed Tim . _ min Final fluid depth in Absorption rate >= g p.d. Anyfe,uvenation treatment (past 12 mo.) (Y/N & type) If yes, give date (Rev. 11/99) 0. LIFT STATION Date installed Size in gallons 'Pump on" level at in' 'level at _ in Datum Cycles tested E. SEPARATION DISTANCES Manhole/Access Hiah water alarm level at _ in Meets alar & circuit requirements? _ SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A On adjacent lots 100+ Absorption field on lot N/A On adjacent lots 100+ Public sewer main 9-0 Public sewer manhole/cleanoutR 1 Sewer /septic service line .So` sHoldiingg tank �c Q SEPARATION DISTANCES FROM SEPTIC) LDING TANt< ON LOT T�: V ej a3 Building foundation N/A Property line Water main _ Water service line _ Dr i _ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line WA Buildin ndation Water Service line Surface water Curt ' in Wells on adjacent lots Absorption field Surface water Water main Driveway, parking/vehicle storage F. COMMENTS w e u -z✓ OvAr�n iJt FiT r�tAN1�OCIS ON t -ns -C -s Ma 4*_- 'DQAin,rva:,Artrt� TiJMANNac�• 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 HAA guidelines in effect on this date. Engineer's Printed Name _Steven R. Pannone, P.E. Date 10-2-01 HAA Fee $3©o , d u Date of Payment 10 1310 1 ReceiptNumber (Rev. 11199) Waiver Fee $ Date of Payment Receipt Number 'J�'e rao CC Stn9y.'=�' ►� 'Allard{>� e�ab�`OES�ta :���• MUNICIPALITY OF ANCHORAGE _. . • DEPARTMENT OF HEALTH HUMAN SERVICEQ - Division of Environmental Services : .. , .On -Site Services Section .._« P.O. Box 196650 Anchorage; Alaska 99519-6650 X343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # _O\i-1- n-) A - Ll i n :HAA # - �! n • 1. GENERAL INFORMATION - Complete legal description -1 of -'16 fF 6� lock 3� Ccr��, tll Hft -C 1b ,:.. ) ... ti ..,...,. Location (site address or directions) yOo/ E 67 A L;e p rty owner �tey,n EJcen , Sfci f e^ Day phone' -3'19 -3767 Pro e - r'- - . Mailing address HOG / � d74 Aue.� : a�'r y o�d9?r Atc ' 9 9So7 - Lending agency:FrtE-IVa17. Bank of payphone 276-6360 Mailingaddress `100720 aAC"A GY4C `i4k:'99S1G Agent H,c.bel►Day phone'2276-200/ "'- --->z"'{'' -- ---z.- ,:_: ..�.,nn....a.r.; -C :"_ "• .mac Vit- .{." �'--° _" Address 26010-Oenal�- Su�h�Kyao.- i4�cSoic�p """�¢lT '99so3-•� •-- - v_ti Unless otherwise requested, HAA will lie -held for plckul -z. -.w ..:;. !"'li v.` `.e<.. r-Y•=.w.f t+w :�::i•✓t i.;...1 a +. }�' .i lt_1 > 1 .i' {'fe o. t ._ 2.'r NUMBER OF BEDROOMS. 3.' : TYPE OF WATER SUPPLY: _ Individual well �.. ..... ._ Community well _ .. 7777 Public water ,���\1 t 1 �• NOTE: If community well system, provide written confirmation from State ADEC bttesf- - • k- -_` fng to the legality and status of system 4 TYPE OF WASTEWATER DISPOSAL --- 7:7.777-7, Individual on-site r var • s.rcn , ...w..>.r.. �... r 411 i Holding tank YJ_ �. Tl Sa. �' .`•,w t r •^l M 4 rs.u+a.:..{ Vli•.•-• i�--'S'. it e. HtILJr•!t . r S 1 .�La.. i �- i� •e 1 i ♦. (j _+ n to Y - -.. ' Community on-site ' Nn' Public sewer'r. 3? r""_V r.._i ••a"c«c + r.�v, ".,(ti.{urwl S^j 11 ! NOTE::, If community wastewater system,.providewritten confirmation from State ADEC„ attesting to the legality and status of system: n-=(Ft".1N1) Fm MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER - As certified by my seal affixed hereto and as of the validation date shown below, I verity that my Investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my Investigation and Inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes,' ordinances, and regulations in effect on the date of this inspection. Name ofFrrn Flcr!%n Ticti»fcul Serv'}cri Phone 3NS-13 {Address=-fNS3d =Fctio "'Sf An cho�oge �k 99516 - Engineer's signature ��%R O"t'^{ AGO' ` Date Apr' l 11, 19 95 A••1.• �b - —..–.f..t t v..•.•....••u• •..•• 41, go ;4A w 6 D S SIGNATURE ' _Tr+coCoo ;Q� "~ R iE E f 4 S+ �1,: w�-t f lit). It �•.)*• 4T`.: •. 3 'Approved forbedrooms ••• E�`� x - X i .x_ ..may � v.. {-x a u as-. -.:o., '. .et- a:h...-..•:+ :e+.•-.. � y Conddional approval for bedrooms, 4ith tits Yollowing stipulations: r • �•.k "i> .+,. { . .–,. •.h r� I< ra it F ate..'• {� r at r. M .4O +. 4Yq �"WY ...•MSw: w.....Y•'l. Nru. lLMi A-... i',. .+.......��T°Y••-.�.. . .. .... .. ..': Y. -.iw L v.I A•°•. t?'Additional Comments �1. * :r�2-K.> _� ♦ f, � L a 3.rt` �+, .1 .....R x .^- L.1!7}: b x -T A'!.�A1 : "_t�'�riF � -. . ` �: �� - • � - - The Municipality of Anchorage Department bf Health and Hu man (DHHS) Issues Health Authority a APProvai Certificates based only upon the repfesentations iven in - -_--_ 9 Paragraph 5 above by an independent"" professional engineer registered in the State ofAlaska.TheDHHS does this asacourtesytopurchasersofhornes `", and their lending institutions In orderto satisfy oertain federal and state requirements. Employees of DHHS do not � conductlnspectionroranalyze data before a certificate is issued. The Municipality•of.Anchorage is not - :responsible for errorsor omissions in the professional engineer's work - . }x425 mom•• vwr B.ax ww m ® Municipality of Anchorage AfWL AiGm Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L f 6A/ Q 3, amp bell IM S/U Parcel I.D. A. Well Data Well type PA-, va FG If A, B, or C. attach ADEC letter. ADEC water system number Log present (Y/N) Y Datecompleted 5*/Z2/5,2 Driller Alpine Drill, -2 Total depth SS Cased to SSS Casing height "y 1, Sanitary seal (YIN) Y Wires properly protected (Y/N) Y Date of test Static water level Well flow Pump levell FROM WELL LOG s/2z/5,2 12' 7 g.p.m. SEPARATION DISTANCES FROM WELL TO: AT INSPECTION oZ ry rn O 7.71t gpmC <� 7 H Y y rn Zn G. gf V;c z� Septic(holding tank on lot N.A. ( Pub be Self-er) : On adjacent lots N• A. Absorption field on lot N. A. ( Pus Lc Sewer) : On adjacent lots N. A. Public sewer main Ba Public sewer manhole/cleanout' 90' Sewer service line > 2S' Petroleum tank None see* i0 DiIfanee uvea determulece L7t-SN,0 S4r9'e1 and Awwu Setverline WATER SAMPLE RESULT�at -badt dracvin�Js Per ctucurlitn w,M Dan Rol+, 04 separaho� a(crtaAce wo.( lei4- ai i�rnieiinf%o/�pi+on in 1962 So r,0ILaiver rep.a. Coliform D col /too ^n e NitrVate c. if 9 mq /.0 Other bacteria rvune rep oePee,/ Date of sample: H /6195, Collected by: r1e4AA p Tech Svc_ B. SEPTIC/HOLDING TANK DATA N.4. ( Pub li c S ewe-' Date installed Tank size Compartments Cleanouts (Y/N) Foundation cleanout (YM) Depression (Y/N) High water alarm (Y/N) Alarm tested (Y/N) Date of pumping Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot On adjacent lots Foundation To property line Absorption field Surface water/drainage Water main/service line 72-026089)•Fmt CONTINUED ON BACK PAGE C. LIFT STATION Date Installed Manufacturer Size In gallons Manhole/Access (Y/N) Vent (Y/N) 'Pump on' level at 'Pump oft' Level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Cycles tested Well on lot On adjacent lots Surface water_ D. ABSORPTION FIELD DATA N.A. (AWKJu Sewer Date installed Soil rating (GPD/Ft2) System type Length Width Gravel thickness Total depth Total absorption area Cleanout present (Y/N) Depression over field (YM) Date of adequacy test Results (passrtal) for Bedrooms Water level In absorption field before test After test Peroxide treatment (past 12 months) (Y/N) yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot On adjacent lots Property line To building foundation To existing or abandoned system on lot On adjacent lots Cutbank Water main/service line Surface water Driveway, parking/vehide storage area Curtain drain E. ENGINEER'S CERTIFICATION I cen7y Drat I have checked, verified, or conformed to all MOA and HAA guidelines in effgor-Oi�")hg df9 n(.Ihis inspection. >` :•°[fray',, ••;'�+ c� ° ......................:::.fid Signature Engineers Name TAiadore F Hoo -e 1 =_•"�� °r +� Date Ap ri l 11 , 1995 y� '' •• HAA Fee $ 3 UO -Eo" Date of Payment —ld- -�-J _ Receipt Number BOJ 72.026 (sW)• Back Waiver Fee $ Date of Payment Receipt Number I MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information (a) Location (address Q.r 4�regf ions) Application Date qubdivis / v (b) Applicants Name// .�rt r/I Telephone - ,S Applicants Addresq• yj/Olj/ (c) Applicant.is'(check one) Lending Institution ; Buyer [—_I ; Other F_::1 (explain); (d) Lending Institution Address /O/ (e) Real Estate Co. b Agent Address Telephone (f) Mail the HAA to W dress: 2. Type of Residence Single -Family It Number of Bedrooms 3. Water Supply Individual Well I 1 W 7 — Q /9r-R-dd . cw il.[.Cez�%2 Multi -Family Other (describe) 3 Community 1= Public M Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite Public Community Holding Tank Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. (Page 1 of 21 r .. 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 Address (ENGINEER SEAL) 6. DHEP Approval Approved for `�ak�,. bedrooms Approved Disapproved Terms of Conditional Approval By CAUTION Conditional Telephone `�_Tl� q C. Reid. Jr. "M =51-E 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 REQULRE- ZIENTS. 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/D18 (Page 2 of 21 7-19-84 /'1 MLWIPAUTY OF ANCHORAGE DEPT. OF HEALTH d MUNICIPALITY OF ANCHORAGE (MOA) ENYIMONMENTAL PROTEC71ON HEALTH AUTHORITY APPROVAL (HAA) MAR 17 : CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: IRV, aur, 5« _ v A. WELL DATA Well Classification Pe PeCIO w e If A, B. C, D.E.C.AC. Approved (Y/N) Well Log PresentRY/N) Date Completed S I?I?- L Yield 7 6 A f Total Depth to Cased to5 1r Depth of Grouting Static Water Level 16 r Pump Set At Casing Height Above Ground Sanitary Seat on Casingl§71N) Electrical Wiring in Conduit©N) Depression Around Wellhead (Y& Separation Distances from Well: To Septic/Holding Tank on Lot ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots To Nearest Public Sewer Line r 5S (j To Nearest Public Sewer Cleanout/Manhole �1�n , To Nearest Sewer Service Line on Lot 7 ¢ Water Sample Collected by �Ilq<<, ,� ( ; Date 54 Water Sampl Comments B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Depression over Tank (Y/N) Size No. of Compartments — Air -tight Caps (Y/N) A Foui Pumping/Maintenance Contract on File (Y/N) Holding Tank High -Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well To Property Line To Water Main/Service Line 'Course Comments Page 1 of 2 / &72.026(11,84) Cleanout(Y/N) ;for Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage /-I&A, C. ABSORPTION FIELD DATA 11311 Omy(el //ZS. ~ Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well To Building Foundation Lot To Water Main/Service Line _ To Stream/Pond/Lake/or Major To Driveway, Parking Area, or/� Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) _ Comments ige Course _ Storage Area Type o'System Design — LeKOfLast ield Field Gravelness pes Present(Y/N) DaAdequacy Test . To Property Line To Existing or Abandoned System on ;On Adjoining Lots To Cutbank (if present) Dimensions Manhole/Access (Y/N) _ 'Pump Off' Level at — Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA Check Permitted Bedroom Rating Against HAA Request " Icertify that Ihave checkk d,verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed (Df, l�Date — 3 3a Company _- Ae-CS .7-A c MOA No.it Qf t' Receipt No. 175`7 $ y � P 00'' 4% 1� Date of Payment " 1i'SaAV Rtr4 fA ' �. • Z0 Amount: $ �� 5 — � Page 2 of 2 72-026 (11,84) �e W mac^ n� e S 7,# D- e,�J FIELD PUMPING TEST DATA SHEET PROJECT: DATE OF TEST: LOCATION OF WELL (Legal Description): ZL l el.c j�-CQ,,,,��/ WELL DEPTH: 5'S FT. CASING: SS FT SCREE::: sv� DATE DRILLING COMPLETED: / 9£fZ DRILLER: c::7 c STATIC WATER LEVEL (Toa of Casing): FT Clock Tine apses line Since I Pupping Started/ Stopped, Min. Depth Water, to Drawdo:•in/ I ft. Recovery Pupping Renarks Rate, GPM 'GbA 0 (swul 0 1 0 I Start • 1 � I io 10 t �tQ o .sS ' o 4-7.- o I 25 / e� I72 i 017 45 7 0 L,p 5 h: io .eN hour) 00 IZIJ (Z hours 1 hours !0 c hours I RECOVERY I 0 I 1 1317 Zvi I 1 I 21) I 25 I I � Time D� APPLI'�NT FILLS OUT UPPER HA. 'ONLY Property Owner �YCr-t<r Py I's C-, Z r^ C-• Phone Time 49 AZip Code Mailing Address , G •— Date Buyer Address,,ppe, Zip Code Lending InstitutionA/ PA G 6 I FI e- h Inspector Phone Address Zip Code Field Notes: I1�Q Y Realty Co. d Agent � 14< sG < . Pa it y - Phone Address ZIP Code Legal Description G e.�... 6 !g /� 3 e w•'s, 5 11fr Street Location ^ 1 Type of Residence ( )CONDITIONAL APPROVAL ;5 Single Family ❑ Multiple Family No. of Bedroom 3f ❑ Other Water Supply OR: Individual BY: ATTACH WELL LOG. A well log Is required for all wells drilled since June 1975. ❑ Community For wells drilled prior to that date, give well depth (attach log If available). ❑ Public Utility Well To Absorption Area Sewer Disposal Septic Tank Size ❑ Individual Well to Tank Year Individual Installed: zFl Public Utility When Connected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time D� Time Time Time Date Dale Date Date oZ 0 Inspector Inspector Inspector Inspector Field Notes: I1�Q Y (�) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED - ^ 1 ( )CONDITIONAL APPROVAL DATE BY: Solis Rating Date Sewer Installed Well To Absorption Area Well Log Received Septic Tank Size Well to Tank 1]OIl 1Yan