HomeMy WebLinkAboutKNIK HEIGHTS BLK C LT 4K ni"k Heights Block C Lot 4 #017-034-04 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP221260 PID Number: 017-034-04 Dwelling: 9 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New X Upgrade Name JOHN SHOWALTER ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ound Site Address 12540 SHELBURNE ROAD ANCHORAGE, AK El Other Phone Number of Bedrooms Soil Rating Total depth original grade 907-346-7600 13 (4 BEDROOM TANK) GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot KNIK HEIGHTS; BLOCK C, LOT 4 Fill added above original gr a Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total orption area Number of trenches Dist. between trenches From Tank Field Tank Line Ftz Ft. Well 100'+ TANK ❑® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER TANK Capacity 1250 (OVERSIZED Gal. Surface Water 100'+ Material Number of compartments Lot Line 5'+ NA HDPE 12 Foundation 10,+ LIFT STATION Manufacturer Capacity Remarks OLD TANK DECOMMISSIONED PER UPC Gal. PER CONTRACTOR Alarm location Electrical installed by Installer PIPE MATERIAL House to tank D3034 Tankto D3034 ENVIRONMENTAL SEPTIC Drainfield 03034/EXIsTING CO/MTD3034 Inspector GEG AND MOA BENCH MARK (Assumed elevation) 100.00 ft Inspection ection 15' 7/19/2022 - Location and description 2�d 3m _ 4"' _ BOTTOM OF TRIM AT SW CORNER OF HOUSE ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp oo�S�O Conditional Approval: Date o �. 0�4 91T ��p0 *... .. l....� ... ........... � D � .. ... i f A. 5.: Q •. p Septic S tem �� Approved Date E 7953 v O Note: this approval does not include well permit requirements. 000� 1 #AEcc8�e4 �r�cv vol vu io) PERMIT NUMBER: PARCEL ID NUMBER: OSP221260 RECORD D RA W I N G 017-034-04 A B / DBL3 23.6 1 37.5 DBL4 23.14 38.2 SWING TIES DERIVED FROM AS -BUILT SURVEY BY SHANE HOLT, PLS (ATTACHED) 10' UTILITY EASEMENT • Vii. •• � ... � _ •Y• .�...�. NEW 1250 GALLON HDPE •'• r; ' ' !r GREER TANK OVERSIZED • '`:• 1 ' ..� } ST MH -------------------, 10' UTILITY EASEMENT tale-" / SCALE: 1"= 40' ®�,�aa® a� P�E...OF .... G.s., ��%;..� L•u.�s:;>; t.w:.���..c :v ..,.fizw.xars»G.s., x;,s� .+mrw s.�srx ....�..�.�_�; .-F..�...s�zatin:v,.�a �,:�u.«.�.4.�-,, :..m...::x-e. ..� � _._ ®®®®... puo..... .. .. ..mu®® uouu uu..u.0 ENGINEERING --,SALES} CONSULTING 3701 E. TUDOR ROAD. SUITE 101 ' ANCHORAGE. AK 99507 -PHONE (907) 337.6179 • FAX (907) 336-3246 • WEBSI7E.wwwgamexunpneeM2g , .....„. .............. PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JOHN SHOWALTER 907-346-7600 2 OF 3 '• • e •• A. G mesB LEGAL DESCRIPTION: DRAWN BY: ®®® a ,� ��z 117, •�• � KNIK HEIGHTS, BLOCK C, LOT 4 D.J.G. ®®® 0 �••/� ............. . TYPE OF WORK: DATE: 0 '1VFESS` ®® � SEPTIC TANK RECORD DRAWINGS 7/21/2022 #AECC884 PERMIT OSP221260 RECORD DRAWING TOP OF MANHOLE = 98.04 FINAL GRADE = 97.67 TOP OF TANK AT INTLET = 93.91 --a w ' I /— TOP OF TANK AT OUTLET = 93.91 INVERT OF BUNG AT INLET = 93.31 NEW 1250 GALLON H.D.P.E. SEPTIC TANK PARCEL ID NUMBER: 017-034-04 INVERT OF BUNG AT OUTLET = 93.07 ENGINEERING * SALES v CONSULTING 3701 E TUDOR ROAD, SUITE 101 'ANCHORAGE, AK 99507 • PHONE (907) 3376179' FAX (907)3383246 • WEOSITE: M+w+.gamesunpnacin0.com PREPARED FOR: •ss PHONE NUMBER: PAGE NUMBER: KEVIN SHOWALTER LICENSER 4 907-346-7600 3 OF 3 LEGAL DESCRIPTION: DRAWN BY: KNIK HEIGHTS; BLOCK C, LOT 4 D.J.G. TYPE OF WORK: DATE: �,_ SEPTIC TANK PROFILE 7/20/22 ®�POF.°® ; .-••••... ®®� ......... ....UM ......\............... •ss Y,a,�ftyA. Ga cfj79[3 LICENSER 4 6 #IAECC88a `% � aM®®S` Lo � � � o N 89 58'E 300.00 oplVgVVAy KIELL GRA VEL PARKING AREA SHED DECK LEAN TO -------------------- AS-BUILT SURVEY 1" =20' NO CORNERS SET THIS DATE N 39 58'E 300.00 THE INFORMATION HEREON 15 FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY I TO SHOW ANY CONFLICTS BETWEEN EXISTING 51-RUCTURES AND PLATTED LOT LINES AND/Op EASEMENTS; AND Is NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINE5. EASEMENTS OF RECORD, OTHER THAN THOSE APPEAPIN6 ON THE RECORD PLAT, ARE NOT SHOWN HEREON ( UNLESS INDICATED) NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE PROPERTY LINES OR P051TION ADDITIONAL IMPROVEMENTS. ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE mEXCE55IVE SNOW AND/OR ICE. Z HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY OF THE FOLLOWING DESCRIBED PROPERTY LOT 4 , BLOCK [' KNIK HEIGHTS ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST '<OTHER -THAN --NOTED. —�--- DATED AT AN[H0R4GE,AL4SKA THIS 20 THDAY OF ___]UL , 2022 12639, F8 167-51 226-16 140LrLAxmuxpmnxw; 9309sROVER DRIVE Ax«HoRAsEAxeum/ anzomas MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program poBox 1oa8so 470oElmore Road Anchorage, Alaska nyo1n'nsnn Phone: no* Fax: (ou7)»*3-7ny7 nup://mmw.mun|.urg/onsite Permit Number: OSP221280 Work Type: SepboTankUp0rade Tax Code Number: 01703404000 Site Legal Address: KNiKHEIGHTS BLK CLT4 G:2838 Site Mailing Address: 12S4USHELBURNERD, Anchorage Owner: SHOVVALTEF|JOHN &ALICiA Design Engineer: GARNESSENGINEERING GROUP LTD This permit isfor the construction of: [] Disposal Field WSeptic Tank [] Holding Tank [] Privy Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: 7/13/2022 7/13/2023 El Private Well [] Water Storage All construction shall boinaccordance with: 1. The attached approved design. Z All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) andDrinking Water 3. The wastewater code requires inspections during the installation. The engineer shall notifythe Development Services Department per AMC 15.85.Provide notification bycalling (QO7)343'7SO4(24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall beeither: a. Opened and Closed onthe same day, or b.Covered, sealed, and heated toprevent freezing Receive Issued By Date: 7113 A -z 3 MUNICIPA QTY OF ANCHORAGE �j Development Services Department Phone 907 3a 3-7904 On -Site Water & Wastewater Section - Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 017-034-04 Property owner(s) JOHN SHOWALTER Day phone 907-346-7600 Mailing address 12540 SHELBURNE ROAD *ANCHORAGE, AK Site address 12540 SHELBURNE ROAD *ANCHORAGE, AK Legal description (Sub'd., Block & Lot) KNIK HEIGHTS; LOT 4 12 (� �- Legal description (Township, Range & Section) Lot Size Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial 0 Single Family (SF) 0 Septic Tank El Upgrade ❑ (w/wo ADU) (D) ElRenewal Holding Tank El Renewal❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: A 5 Waiver Fees: Date of Payment: Receipt Number: Permit No. Q W a s "1 2(o O Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc July 711, 2022 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Ref: Proposed Septic Tank Upgrade for Knik Heights; Block C, Lot 4 To whom it may concern: Per MOA records, the existing septic tank is approximately 38 years old (installed in 1984). Per MOA memorandum, a septic tank of this age should be physically inspected and/or replaced prior to COSA approval. Based upon this fact, we are proposing to replace the existing septic tank. We are proposing to decommission the existing septic tank per UPC and install a new 1000 -gallon HDPE Greer tank rated for 10' burial. See attached design drawings for tank location and other MOA requirements. We are unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your assistance. I •s � P. E., M.S. • +ey A. G rness �� PROFESStONP�`�'` 3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259 Phone: (907) 337-6179 * Website: www.garnessengineering.com THE DEPICTION OF ALL STRUCTURES SHOWN ON ADJACENT PROPERTIES ARE APPROXIMATE IN REGARD TO CONFIGURATION/LOCATION AND MAY BE ' BASED SOLELY ON PUBLICLY AVAILABLE MOA GIS RECORDS. THE LOCATION OF ALL WELLS AND SEPTIC SYSTEMS SHOWN ARE APPROXIMATE AND MAY BE BASED SOLELY ON INFORMATION OBTAINED FROM PUBLICLY AVAILABLE MOA ONLINE RECORDS AND/OR AS -BUILT SURVEYS �°0. °° S I KNIK HEIGHTS; BLOCK C, LOT 14 / KNIK HEIGHTS; BLOCK C, LOT 3 r KNIK HEIGHTS; BLOCK B, LOT 14 ED I KNIK HEIGHTS; BLOCK C, LOT 13 i7 OGS 10 KNIK HEIGHTS; BLOCK B, LOT 13 \ <,p 0° -– tyF KNIK HEIGHTS; BLOCK B, LOT 12 KNIK HEIGHTS; BLOCK C, LOT 12 1 KNIK HEIGHTS; BLOCK C, LOT 5 � � N ' SCAIE: 1" = 100' OF 1111114 =777-77 9 / ...... r ••.••i•••• • l •. ; ENGINEERING- SALES * CONSULTING 3701 EAST TUDOR ROAD *SUITE 101 'ANCHORAGE, ALASKA' PHONE (907) 337-6179WEBSITE:�.gamessengineenng.wm ••• �,••••••••• r �y A. 8 SSS �• r ���%,'' PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JOHN SHOWALTER 907-346-7600 1 OF 2 _• C -7,953 ' �� II ���.•'�� �t,p�j•."''• PROJECT/LEGAL DESCRIPTION: DRAWN BY: KNIK HEIGHTS; BLOCK C, LOT 4 D.J.G. • •�•••••'' �, �• ♦���p ESS\ TYPE OF WORK: SEPTIC SYSTEM UPGRADE DATE: 7/11/2022 #Recces ���11111k � GEG, Ltd. HAS AN 8 PAGE SPECIFICATION LETTER r-rA'* I- I%17°"j \ THAT PERTAINS TO THIS DESIGN. BY PROCEEDING / t —114p— pn'.(6✓n FORWARD WITH THIS INSTALLATION, THE TO ENGINEER, WELL DRILLER, CONTRACTOR AND CONTRALTO HAVE ALL 100' WELL RADII FLAGGED BY A \ PROPERTY OWNER AGREE THAT THEY HAVE PLS PRIOR TO CONSTRUCTION READ THESE SPECIFICATIONS AND AGREE TO \ ACCEPT THE TERMS AND CONDITIONS OUTLINED. KNIK HEIGHTS; BLOCK C, LOT 14 KNIK HEIGHTS; BLOCK C, EDT3 / / 10 UTILITY EASEMENT/ GENERAL LOCATION OF I GRAVEL DRIVEWAY •: ;3 • ':� `4.' EXISTING TRENCH—,E .•' \% •' f DRIVEWAY ' r EXISTING SEPTIC TANK TO BE 4 s '�• •+ _-•' , i DECOMMISSIONED PER UPC '' %'' P ;' ..:•a •:- ' .a PROPOSED 1000 GALLON HDPE / r • • ~ ~ % r GREER TANK; INSTALL DOUBLE •' '�, { \' CLEANOUTS AFTER TANK ' i J • 3 BEDROOM ( ; •, 4v HOUSE ,o SHED 3 J 0��\ KNIK HEIGHTS; BLOCK C, LOT 13 ; GREENHOUSE J -- - ---- --- -- - -- -- --- --- -- -- - ---- ----; moo° / 10 UTILITY EASEMENT \ / KNIK HEIGHTS; BLOCK C, LOT 12 \ / N \ / / ALE:--- \ V=40' • , w 4, 4 1 INS Iii IT ..........•.........:.....; 4 3701 EAST TUDOR ROAD SUITE 101 'ANCHORAGE. ALASKA' PHONE CONSULTING *-...a es �'e / � % -� • . �_., ENGINEERING � SALES �., ww.. (907)3375179'UVEBSITE www.gameswngineefing.com /-�..+a..0 ... I. •..... �.. •...u....n• .•. PREPARED FOR. PHONE NUMBER: PAGE NUMBER: f J Y • arness Ar JOHN SHOWALTER 907-346-7600 2 OF 2 �# �' -7 53 , 'A PROJECT/LEGAL DESCRIPTION: DRAWN BY: �.♦�^ ''.,.•�•� �� �+� •, w�r KNIK HEIGHTS; BLOCK C, LOT 4 D.J.G. C0�FO t ••,� �P�, �� TYPE OF WORK: DATE: LICENSE DESIGN OF SEPTIC TANK UPGRADE 1 7/11/2022 #AECC884 Municipality of Anchorage Page of 3 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: SW 4403Z& PIDNumber._ 0170$'10'/ Name. Wastewater System: O New EUpgrade Address: Z1540, iRK ABSORPTION FIELD Phone: No. of Bedrooms: 1J D Deep Trench eshallow Trench Dead ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: . 6P GPO/Sq Fl. —a.ror Lot: Block: Sub iyvision: Depth to pipe bottom from original grade: Gravel depth beneath pipe Ft. . I FI Township: Range: Section: Fill added above original grade: Gravel length: +3 Ft. 75.5 Ft. WELL'Nl+ ❑New ❑Upgrade Gravel width: Number ollines: Distancebenrceniinef S Ft 1 1-_� Ft. Classification (Private. A.B.C): Total Depth: Cased To: Total absorption area: Pipe material: Ft. Ft. % 7S0 50 Ft. Driller Date Drilled: Static Water Level //,�, Installer Date ins ailed: (Yield: Pump Set at: Cuing Height Above Ground: TANK GPM Ft. Ft. SEPARATION DISTANCES ;iept4ic 'i 0Holding 0S.T.E.P. To septic Absorption Lift Hominy nuns Manufacturer. Capacity in gallons: From Tank Field Station Tank Sew, Linea Well ��QLi %��a g' / / �>..�s: Material: Number of Compartments: SurfacWater '/5os '/Soy LIFT STATION Lot 5%, N.,�� / /�� Iona: Manufacturer. Line Foundation e' / a} S 'Pump on" level at: " u "level aL' High water alarm at: Curtain y Pump Make d Model Electrical Inspections performed Dy. Drain Remarks: BENCH MARK Location and Description: ?nrmq� f�4 ii Assumed Elevation: INEERSSEAL F r\li -_' .'.. "':. ('d.l: l:.l; � t'i... •ri i. f. •�. �,E.�?lY �e w�a e•r'o •a� Inspections performed by: /¢ Dates: 1st1[��; n ..................... 2nd oa `t' FMichcpl E. Anderson 4981-E .• �✓ Department of Heal h and Hum n Services appr al �*'lF9s'°'•••»••••''•��:.+' tCa Reviewed and approved by: i Date: Z 7 72-0121Pw. 91911 MOA 2S Permit No. SW 9` O3Z S Page Z of 3 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: !& P'I/K e," KNIK dW411i5 5/D PID No.: 0170_34L)4- ra MlcACONE. And on r Wari ICQ ;rOF� �ICc.I i - 1 ' i Iti ! I40 Y�lIIK i Permit No. SLj gg03Z8 Page 3 of 3 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 - Anchorage, Alaska 99519-6650 - Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description:� #� X Ae, KNIK 145146,5LP PID No.: 017034 o t4- RECEIVED SEP SEP 131994 Municipality of Anchorage Dept. Health & Human Services • See' pccia InslmctionsAbore '• SccSamplcRerwu:ksAbnvc UA-thtuvailahle U - Tlndctected, R Toned value Is the practical gttutli fication limit. NA -Not Analyzed -'v D=Smunduydilutlon. IX-Less'llum GI'- Quatcr1han _ 66338 Street, Anchorage. AK 99618-1600— Tel: (907) 562-2343 Fax: (907) 661.6301 ENVIRONMENTAL FACILRIEs IN ALAaKA rnr nnnn• 09/13/94 08:31 ME ENVIRD4,tENTAL LAB SERVICES N0.430 002 R1w: . / L Commercial Testing & Engineering Co. ,(� Environmental Laboratory Services LABORATORY ANALYSIS REPORT L`l'&L•Ref.N 94,4411.1 Client Sample Ili L4 B 'C"KNIK Hams NUBD Matrix WA1ER Clien(Name ANDERSONENGLYF,L'RN(1 Ordm-d By A1.1,1LNANDEl(SON WORK Order 82073 PrrjNtNalne Proieco Printed onto 09/13/94 (0'108:33 CollcctedDute hrs. PW'31D 09/09/94 @11:25 UA Received mtc 09/09/94 @12:15 hrs. hrs. Technical Director S1EPPIIjEN C. EDI; SumpleRtsrtatks: Rcleaaed By: ROU1L*IE3AhII'[.IiCOf,LL•CTI;DB� y;pll�&WT'fNESSF.i)BYB.W.CRAI('). --- Parameter QC al AUuwablc Ext. Anal Re.+ults Qul Units Method NitrntaN � Limit/ Date Date � )fit 0.36 m;A, 1PA3532/3(>D.0 10 RECEIVED SEP SEP 131994 Municipality of Anchorage Dept. Health & Human Services • See' pccia InslmctionsAbore '• SccSamplcRerwu:ksAbnvc UA-thtuvailahle U - Tlndctected, R Toned value Is the practical gttutli fication limit. NA -Not Analyzed -'v D=Smunduydilutlon. IX-Less'llum GI'- Quatcr1han _ 66338 Street, Anchorage. AK 99618-1600— Tel: (907) 562-2343 Fax: (907) 661.6301 ENVIRONMENTAL FACILRIEs IN ALAaKA rnr nnnn• PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE ('rgfi Q /7406,d DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW940328 DESIGN ENGINEER:ANDERSON ENGINEERING OWNER NAME:CRAIG GREGORY W & POLLY S OWNER ADDRESS:12540 SHELBURNE RD ANCHORAGE, AK PARCEL ID:01703404 LEGAL DESCRIPTION: KNIK HEIGHTS BLK C IT 4 LOT SIZE: 43560 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED: 8/31/94 EXPIRATION DATE: 8/31/95 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) . 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 ISSUED BY BY' DATE • 4 I l9 y DATE • .3 ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, ALASKA 99524 August 19, 1994 Municipality of Anchorage Department of Heath & Human Services 825 "L" Street Anchorage, AK 99502-0650 C Subject: Lot 4, Block/, Knik Heights Subdivision Well and Septic System Design Impacts to Adjacent Properties Dear On Site Services Engineer: The existing drainfield on the subject lot is apparently in a, state of, failure, and must be replaced. We have identified a site which will serve as an I lternate site for the drainfield. This site is shown on the attached plan. The plan also shows the topography of the lot. If the system is constructed as follows the following statements can be made: 1. The system, if constructed as designed, will have no adverse impact on the wells currently in use or those to be constructed in the future. 2. The system, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. 3. The system, if constructed as designed, will have no adverse impact on reserved space, either surface or subsurface, on any lots located in the area. 4. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. NVI Sincerely,^F OF Q(����• Michael E. Anderson, P.E. `�'�`�` • �`�= = � 94•Michacl E. Anderson FeF4381 -E , FRo I - �_.anHLAPS voi� ,,� Lor 4LK � IC��Kc_}I�IGNjS AR1.r A MAP SHEETNO. OF it O / CALCULATED BV DATE CHECKED BY DATE / SCALE �!� _.-----.. �_� ---..... , 1 Ul —•-- "L--'-- I I � 4S-� ' __._ !--1`-i-'- '--j —I-- - T_ — 1_ J �__I`� r I K�� ' .I .��., ,••• T .. �..y:.. N:..•®� ........... . �i . S%Wjc v7E-Anderwn••J W; . ♦981 E• ?/ -lar: W- . . .. - ... _. 1 .-...._._+_._, -.-.. - - - I 1 I i i 1 , I ! C Lot 4, Block Knik Heights Subdivision DESIGN FACTORS: SYSTEM REQUIREMENTS: Three Bedroom Home Wide Trench System Perc. Rate: 16 Min./Inch 1,000 Gal. Septic Tank (Exist.) Application Rate: .6 GPD/SF Place Within SM/ML Layer 4' Drainfield Rock Reduction Factor = .5 3 Bdrms. X 150 GPD / .6 GPD/SF = 750 SF 750 SF / 5' Wide = 150' Long X .5 /Red. Factor = 75 LF of Trench Therefore: Construct a Wide Trench System with Two Laterals Each 38' in Length. Place 4' of Drainfield Rock Beneath the Lateral. __.._.__.........._..._....__...._.. _ _..+ _.---._.._.._ ........ ............. -...... I /�vTt/4L I i I i 1 ta_ ! _. 1 O I `. O —L I , 1 I I I 1 i I I _' SM I iA....YCL 1� ' I _ __ , , 1 I I D -- - OF ` �a i f :�4971-14 TYPICAL WIDE TRENCH SYSTEM Cd9F Y�Mi,hool E. Anderson C • 4381-E (No Scale) �d1'FS'•M...».«••'�� %k `PfYOFr5S13a` NOTE: Remove all Material to Underlying SM Layer. Provl,df 3' of Cover over all components of system or 2" of direct bury insulation. Grade Area Around Drainfield to Drain Away From Field. r Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street. Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR:ZT. A 64R.AIGl DATE n LEGAL 2 3 Gross Time C7L/6I I ��•O� SIV►' r 0."°„o 31 4 0.87 2104. 3 AML2. 6- 7 8 L :Tv 2 ,o` 9 � L � 0 L a. 4 l r,; 16 171 18 ;c 3 19 '11 20 COMMENTS e. Section: WAS GROUND WATER ENCOUNTERED? N S IF YES, AT WHAT L DEPTH? p E 11081 to Water Mer fAon itllring? Dalt Reading Data Gross Time Not Time Depth to Water Net Drop 31 0.87 2104. 3 AML2. 75r L :Tv 2 ,o` 11�iG � L � 0 L a. 4 l r,; rs It7:1116 ^a0 lA1H1 4.31 r. PERCOLATION RATE �i. (mmutevinncP ch)) PERC HOLE DIAMETER 7 TEST RUN BETWEEN FT AND 42. FT FT PERFORMED BY: 141/ I 4- ldot ERTI Y THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE 72-008 (Rev. 4/85) r) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMFNTAL PROTECTION I� ENVIRONMENTAL ENGINEERING DIVISION 025 L Street • Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE (}(NEW GE L 0 1-1" A] 41 K_S ❑UPGRADE MAILING ADDRESS 13 It 0cc) AArr (Aj q Y A /vc 14ol? A a:E A K Cy 9 51 LEGAL DESCRIPTION L'nit 4ON C N;WE)r.14'T5 n2A) R-350 S 2. LOCATION NO. OF BEDJOMS Well , area , Absorption. Dwelling PERMIT NO !'Q caY DISTANCE TO: L5 IIf H Do irt�A; i 2 Manufacturer Material No. of corry� rtments 'C Wa j�C O -rce� N~ Liq capacity ingallons IF HOMEMADE: Inside length Width Liquid depth tj Y DISTANCE TO: Well Dwelling PERMIT NO. J02 _ FQ• Manufacturer Material Liquid capacity in gallons O W DISTANCE TO: Well 1 I Foundation Q , 6 Nearest lot line ,' n) �t'U PERMIT N J LL No. of lines Length of each ne Total len h of lines t Trench w.d/ Distance betwe n lines Top of tile to finish grad /+ I '{' Material beneath tile I S r Total effJj••.��ti absgul ion eTe'd V • inches C a Z Length Width Depth PERMIT NO. W 0 Q 1- Type of crib Crib diameter Crib depth Total effective absorption area W IL in Well Building foundation Nearest lot line DISTANCE TO: J J Clas •� Depth Driller Distance to lot line PERMIT NO. W 3 DISTANCE T0: Building foundation Sewer line Septic tank Q r Absorption rea(s) / OTHER PIL PIPE MATERIALS 133034 SOIL TEST RATING �a� r INSTALLER ii c j4 F_so±1_Fx 8 4 — OSq , REMARKS I �(ZLgtiewJ ouG? TAtJPC. dUILn.;'V9 f 0 i 4 1 ApCK__0QCK T jrElv�t}- i 'u f r JAI-Spgctrn6l_Z!O GALES DENDJE�(Q{lyn.1NG—CURSIC€NGLs C' s � 7 M AUD /yd ,Zj O �a s Z >;d TJ1N7 1' On L 3Q 13 R H11V3H d0 30"01-014Y d0 jol nW rHOVED DATE LEGAL ' SwG- 9�2��f L.� IC3G KNiK �T T12.v W SCG•27 72-013 (Rev. 3/78) -- - - sv%C/ ! L/ t n M -W DRILLING, Int. ' P.O. Box 10.378 • 10300 Old Seward Highway 84-237 (907) 349-8535 ANCHORAGE, ALASKA 99511 DRILLING LOG Well Owner CTEVE z*n"kYX Use of Well D=estic , Location (address of: Township, Range, Section, if known; or distance main road l.ct k Kock C Y.n1Y. Y.eiRhts — Anchorare Size of casing 6" nepth of Hole 101 Leet Cased to—EL--L—feet Static water level 57 ft. NilU%) (below) land surface. Finish of well (check one) open end ( X ); Screen ( ); Perforated ( ). Describe screen or perforatio^ None Well pumping test at30 gallons per fid) (minute) for--I----hours with 100 xz of drawdown from static level. Date of completion Aurust a. 1984 WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness 0 TO 2 Casing eticItua --L--To 4 `Orcanice kc):!cr •!lam o'- aucNo"n CEFf. OF HEALTH 8. --k—TO 18 .Silty rand ENVIRONMENTAL PROTECTION 18 TO 33 Silty gravel NOV 15 1984 33 TO 45 silty, clay RECEIVED _A2—TO—A.2— Silty eravel 8o TO 101 HaterbearinF• gravel TO TO TO TO TO TO TO TO 3—CONTRACTOR M U N I C.I F- A L I T V O F A N C H O R A G E DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AY 99501 264-4720 O N —SIT E S EWE R Z< W ELL P E R M I T PERMIT NO: DATE ISSUED: APPLICANT: ADDRESS: CONTACT PHONE: 840906 HAND WRITTEN 10/25/84 GERALD HANSON 13400 BRANT WAY ANCHORAGE, AK 99515 345-5277 LEGAL DESCRIP: SUBDIVISION: KNIK HEIGHTS LOT: 4 BLOCK: C SECTION: 27 TOWNSHIP: 12N RANGE: 3W LOT SIZE: 43500 (SQ.FT. OR ACRES) I certify that: 1. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska: 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY,MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST•BE OBTAINED; (2) AS-BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED APPLICANT: GERALD HANSON DATE: ISSUED BY DATE: MUNICIPALITY OF ANCHORAGE Departmer,^of Health and Environment--Protection � 825- L Street, Anchorage, AK. 99501 264-4720 * * * HANDWRITTEN PERMIT * * * ��0 Permit WELL ANDA? ON-SITE SEWER PERMIT Applicant://9' az23 Mailing Address: /2y160 Location:Cyjw� �K i95/S _ Phone Number: 3`/S- 5�7% s_ � Legal Description: Z 13 � Lot Size:- Type of Soil Absorption System Is: 2c o�/a N A-5. 1 Trench: Drainfield: —.Seepage Bed: � Holding Tank: Maximum Number of Bedrooms: Soil Rating(sq.ft/br) 'Ps The Required Size of the Soil Absorption System Is:, DEPTH 0 LENGTH . GRAVEL DEPTH WIDTH y tx,�ea E, A, The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC) TANK SIZE /006 GALLONS Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE'-REQUIRED " Backfilling of any system without final inspection and approval by this departme will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fe for a•private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum 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 this department within 30 days of the well completion. Other-requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 S-AT* 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 codes. (3) 1 un erstand that the on-site sewer system may require enlargement if the resid is emodeled to include more that 3 bedrooms. Signed: Issued by: �^ Applicant Date: 7 SWP/024 (1/81) 4_A_� L�� 7-10 -sv, %z✓� :T��� .�d� �,���171 ox 10 %i rE'La / 077FZ- z� .7 • 0 �IDTi/ 72i ii/�6 &M'01 Ar 12X:1fU;tvj:I : !^, MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 2644720 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION:�� IRICLK 1 j 2- 3- 4 34 �. 5' e ffi 6 , 7 s s 10 11 12- 13- 14- 15- 16- 17- 18- '91 213141516171819 20 COMM OL o�•faA'� G1,J cicaal �,=,�c1 Some- So - IAL +,.,1 jvA160 SOILS LOG gq,61 CL PERCOLATION TEST DATEPERFORMED: JUnI_ L-6 ICI Yi� N H 0 WAS GROUND WATERn _ � + ENCOUNTERED? �V O P IF YES, AT WHAT E DEPTH? A n J � _ SITE PLAN 4 Reading Date Gross Time Net Time Depth to Water Net Drop — z2�1 .31 2'2-j 1 SC — 1 Z25t30 1 ,2-9 -3[ yz? ,36 29 PERCOLATION RATE 1 9-7- (minutes/inch) 1" r TEST RUN BETWEEN 3 FT AND 37- FT T7, % r 1 -� /t.e d .+ es WA I PERFORMED BY:DCt�S+C✓e- CERTIFIED BY: /1 f o A- sT-�y o2 y 72-008 (6/79) DA Parcel I.D. 017-034-04 Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION: Expiration Date: j 2 ^'Z2 Complete legal description KNIK HEIGHTS: BLOCK C, LOT 4 Location (site address) 12540 Shelburne Road *Anchorage Current Property owner(s) John Showalter Day phone 346-7600 Mailing address Real Estate Agent 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 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 request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Waiver Fee $ Date of Payment Receipt Number COSA # 0 S C 2-213 (o Date of Payment Receipt Number 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: — 2Z a2. In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend upon a variety of variables, including but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fail to perform adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG to 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. 6. IGNATURE System #1 Approved for 3 bedrooms System #2 Approved for Disapproved Conditional approval for bedrooms bedrooms, with the fol % 01 15571 :13: Ilf PF +r,^ Gone _ e c s%c -' �­WECC884 p\Sf yf OF.rQ����,i�i/�� ON-SITE zv6g sti Gq isA D m 2 WAST`.V`Wrcr, J�o `rnUG�AM oa JJ��1))1111'�1111��1 By: 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 - - - Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Other HE COSA Checklist Legal Description: KNIK HEIGHTS; BLOCK C, LOT 4 Parcel ID: 017-034-04 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system B. TANK DATA Age of tank(s) NEW years Tank type/material SEM MOPi Measured operating fluid level in septic tank NEW ❑ Standpipes/foundation cleanout per record drawing Date of pumping NEW D. ABSORPTION FIELD DATA TRENCH Which system tested (date installed) 9110194 ❑ ALL standpipes present per record drawing Total measured depth from grade 8.83 ft (max) Measured depth to pipe invert from grade 5.08 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not state Well production at time of test 7.1 + gpm Water storage tank volume NIA gallons Well disinfected for coliform test? ❑ Yes ❑ No o Coliform bacteria is Negative Nitrate 1.34 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L % Arsenic less than MRL (ND) Collected by GEG, LTD. Date of Sample 7/1/22 C. LIFT STATION ❑ Required maintenance co Age of lift station ye Lift station materi Commen Adequacy test date 7/1/22 Results [(✓ Pass For 3 bedrooms Fluid depth prior to test 33 in Water added 677 gal New depth 40 in depth into effective Elapsed time 4,111 min ❑ Code -required soil cover over field Final fluid depth 35 in ❑ System presoaked Absorption rate 450+ gI (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) NONE date of test) N/A _ Gallons introduced N/A gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 8/3/84 r Total depth 101 ft 100.8 Cased to ft �A 7 ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 7/1/22 Static water level at beginning of test 59.1 ft. Comments B. TANK DATA Age of tank(s) NEW years Tank type/material SEM MOPi Measured operating fluid level in septic tank NEW ❑ Standpipes/foundation cleanout per record drawing Date of pumping NEW D. ABSORPTION FIELD DATA TRENCH Which system tested (date installed) 9110194 ❑ ALL standpipes present per record drawing Total measured depth from grade 8.83 ft (max) Measured depth to pipe invert from grade 5.08 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not state Well production at time of test 7.1 + gpm Water storage tank volume NIA gallons Well disinfected for coliform test? ❑ Yes ❑ No o Coliform bacteria is Negative Nitrate 1.34 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L % Arsenic less than MRL (ND) Collected by GEG, LTD. Date of Sample 7/1/22 C. LIFT STATION ❑ Required maintenance co Age of lift station ye Lift station materi Commen Adequacy test date 7/1/22 Results [(✓ Pass For 3 bedrooms Fluid depth prior to test 33 in Water added 677 gal New depth 40 in depth into effective Elapsed time 4,111 min ❑ Code -required soil cover over field Final fluid depth 35 in ❑ System presoaked Absorption rate 450+ gI (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) NONE date of test) N/A _ Gallons introduced N/A gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' IR Yes if No ft Wells on Adjacent Lots: Community Sewer Manhole/Cleanout > 100' 0 Yes if No ft [7V Yes if No ft Neighboring Tank > 100' Z Yes if No ft Private Sewer/Septic Line > 25' Fv-1 Yes if No ft Absorption Field on Lot > 100' CI Yes if No ft Holding Tank > 100' 0 Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' 0 Yes if No ft Fv� Yes if No ft if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' 0 Yes if No ft ❑✓ Yes if No ft From Septic/Holding Tank on Lotto: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No *5'+ ft Surface Water > 100' ® Yes if No ft Property Line > 5' IR Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 2"Yes if No ft Private Wells > 100' ® Yes if No ft Water Main > 10' C3 Yes if No ft Community Wells > 200' ['Yes if No ft Water Service Line > 10' ®`Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Q Yes if No ft If absorption field is under driveway comment below Property Line > 10' M Yes if No ft Wells on Adjacent Lots: Water Main > 10' Yes if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' n Yes if No ft Community Wells > 200' F/I Yes if No ft Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS *MET CODE AT TIME OF INSTALL _..__.____ __S.HED_BUILT O_V_ER;_DRAINFI.ELD -_SHED IS_SJTTING ON TIMBERS, NOT_A_. .._.___ FOUNDATION G. ENGINEER'S CERTIFICATION 1 certify that J_ have determined_ through_ field inspections and review - of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet RF—'Ji Q; fqZ #AECC884 Parcel I.D. 017 Municipality of Anchorage On -Site Water & Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS 1. GENERAL INFORMATION Complete legal description Location (site address) KNIK HEIGHTS; BLOCK C, LOT 4 / ? is s_ APPROVAL` (,. Expiration Date: 12540 SHELBURNE ROAD *ANCHORAGE, AK -17 Current Property owner(s) LACEY SAMET Day phone 830-5598 Mailing address Real Estate Agent 12540 SHELBURNE ROAD *ANCHORAGE, AK Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System - - WaiverNadance request 3 Received by: ��/vy �� Date: 7 1 ;L COSA to be released to the engineer, unless othervnse requested by the engineer. COSA Fee $ 52(0 Waiver Fee $ Date of Payment I i a)1-7- Date of Payment Receipt Number DBagaG Receipt Number COSA# onC19-wi $ Waiver# TYPE OF WASTEWATER DISPOSAL: Individual On-site 0 ❑ Individual Holding tank ❑ ❑ Community On-site ❑ ❑ Public Sewer ❑ --- -- - - - Distance: - - - -- Received by: ��/vy �� Date: 7 1 ;L COSA to be released to the engineer, unless othervnse requested by the engineer. COSA Fee $ 52(0 Waiver Fee $ Date of Payment I i a)1-7- Date of Payment Receipt Number DBagaG Receipt Number COSA# onC19-wi $ Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified b ; r al affixed hereto and as of the validation date shown below, l verify that my investigatio aged on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that th 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 Engineer's Comments: In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipally of Anchorage and industry practices. The reported results describe the condibdn of the systems on the dates of the evaluation. Separation distances were measured to readily idendfiable features Hidden defects or encroachments may exist that were not identified during the evaluation. The operational fife of all wells and septic systems depend on a variety of variables including, but not limited to, sail conditions, groundwater levels (that may fluctuate during the yeap, quality of construction (materials and workmanship), and the water usage of the family utilizing the systeMs. These conditions on vary, and are outside the control of GEG Satisfactory test results do not guarantee future performance of the systeMs; therefore. GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fail, The content of this report is for the sole benefit of the persoNparty who retained GEG. Reliance upon the information provided in this report by any other person orparty, including but not limited to subsequent property purchasers, is not authorized. In short, GEG disavows any legal duty to anyone other than the persoNparty who paid for this report. 6. DSD SIGNATURE �L System #1 Approved for bedrooms. System #2 Approved for bedrooms. \\s%% OF A 0 F • A�Camiss i �#c�f� CE -79 3 , ��FQ ••,,i(FZ . •• ES\\ \ LICENSE��1 #AECC884 Disapproved. YOFq',. Conditional approval for bedrooms, with the following stip Ulal4 ON-SITE ,m WASTEWATFR PROGRAM Original Certificate Date: I - l � - � -7 The Municipality or Anchorage Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the represenatations 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. ATTCHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory rRna V"1111V Nitrate Advisory Arsenic Advisory Other 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: KNIK HEIGHTS; BLOCK C, LOT 4 Parcel ID: 017-034-04 A. WELL DATA *SEE ATTACHED PHOTO Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 8/3/1984 Sanitary seal (Y/N) YES Total depth 101 ft. Cased to 100.8 ft. FROM WELL LOG Date of test 8/3/1984 Static water level 57 Well production 10 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate ),Rq mg./L. Well Log (Y/N) YES Wires properly protected (Y/N) *YES Casing height (above ground) 12+ in. AT INSPECTION 12/28/2016 53.1 ft, 5.0+ g.p.m. Collected by: GEG. Ltd. Arsenic: N r ug./L. Date of sample: 1 /4/2017 B. SEPTIC/HOLDING TANK DATA 32 YEAR OLD SEPTIC TANK IS APPROACHING THE END OF ,ITS USEFUL LIFE Tank Type/Material SEPTIC/STEEL Date installed 9/1984 Tank size 1000 gal. Number of Compartments 2 Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO Date of pumping 11/21/2016 Pumper C. ABSORPTION FIELD DATA F8 Cleanouts (Y/N) High water alarm (Y/N) MCDONALDS PUMPING Date installed 9/9-10/1994 Soil rating p.d./ r ft'/bdrm) 0_6 System type TRENCH Length 75.5 ft. Width 5 ft. Gravel below. pipe 4.1 ft. Total depth *8.6+ ft. Eff. absorption area 750+ ft' Monitoring tube "YES' Depression over field NO Date of adequacy test 12/28/2016 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 37 in. Water added 830 gal. New depth 44 in. Elapsed Time: 245 min. Final fluid depth 39 in. Absorption rate >= 450+ g,p,d, Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date — **MONITORING TUBE EXTENDS APPROXIMATELY 52" BELOW THE INVERT D. LIFT STATION Date installed - Size in gal "Pump on" level at in. "Pump off" E. SEPARATION DISTANCES Manhole/Access water alarm level at Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100 On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main 75'+ Public sewer manhole/cleanout 100'+ Sewer /septic service line . 25'+ Holding tank 75'+ Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation *10'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage **1' Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS *SHED APPEARS TO BE RESTING ON TIMBERS, NOT A FOUNDATION **PHOTOS OF BARRICADE ON FILE WITH MOA G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date ///2 - (Rev. //2 - (Rev. 11105) #otic 8f3 �l- nµVC nxb �M�AY (ate �n P SHANE A. HOLT BGG pp? JO� ' LS -6 914.' �Y�O U' I�M�I✓ F.I F.VPF m x AS -BUILT SURVEY 1- _ NO CORNERS SET THIS DATE N _v9 58' £ 300.00 I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY - - OF THE FOLLOWING DESCRIBED PROPERTY LOT 4 BLOCK C, KNIK,HEIGHTS ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND -NO VISIBLE ENCROACHMENTS' Q nE xrtaRMAnoNNEREo+l xs Ew THE ug or ieNolNs xNSTxTirrspu vEnExauv ro SIIJWAN/ EXIST OTHER THAN NOTED. D CQAIRS ETW[iT1F%[ST➢K SIAVCIWEI NAMTIED IDTLIIFS ND/PI EAS.MFIJTS:MLIS Nm To Mu bFou rosrrz� AGAxTxa STRuc 5.xMvaovFMars. w Esse 5r DATED AT ANCHORAGE,ALASKA THIS _STH_ DAY OF EASEMB T9QPE ROOT@TNN pgA £ 0LW EPE pU MT. ARE NOTSHJNN I0I4. OG IEREAIN( 81E53 LD CA k9) _AUGUST NOiE:/iNLHPFS TENT,WAY MiF/p CH 1{650C1WP6 APf NOT TO IF VS£O TOOEIEPAYE N0.Tl.4p SliAEV[N6 YI.IIES QI IOST[CN.AppIT1ClNLSMATE MEMS. IW HIbFYhW pI¢14 AMIA u+r IAYQY,vawN N3Eav MAY YE.AMNouMATE 9VOAV UD. C0.l(£ - - mop.EroF%LE55[VE 34o 13.cEAC NSAII 11639. FB 161-51 x Municipality of Anchorage < On -Site Water & Wastewater Programr (907)343-7904 1me CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 017-034-04 1. GENERAL INFORMATION Complete legal description KNIK HEIGHTS S/D; BLOCK C, LOT 4 Expiration Date: A 7t Location (site address) 12540 SHELBURNE ROAD, ANCHORAGE, AK, 99516 Current Property owner(s) MICHAEL & LISA GRAY Day phone 360-7781 Mailing address Real Estate Agent 2. TYPE OF DWELLING: 12540 SHELBURNE ROAD, ANCHORAGE, AK, 99516 CASSANDRA RAUN W/ COLDWELL BANKER Day phone 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System 3 Nj4 � Y f3 4 r ?J14 223-1463 waivedvariance request for: DRAINFIELD TO DRIVEWAY/PARKING Distance: 0 FEET r' Received by :i COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ e2( — Date of Payment ?I m I ly C Receipt Number 653%;G COSA #IIA2-5 A �> Date: Waiver Fee $ _ Date of Paymen Receipt Number Waiver # TYPE OF WASTEWATER DISPOSAL: Individual On site'" ❑ Individual Holding tank ❑ ❑ Community On-site U ❑ Public Sewer ❑ waivedvariance request for: DRAINFIELD TO DRIVEWAY/PARKING Distance: 0 FEET r' Received by :i COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ e2( — Date of Payment ?I m I ly C Receipt Number 653%;G COSA #IIA2-5 A �> Date: Waiver Fee $ _ Date of Paymen Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, t 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. t 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 Engineer's Comments In conducting this evaluation, GEG, LPD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA.�'' �l `VA If DSD Guidelines & Regulations. The reported results described the performance of the `` �- q + system under the conditions encountered at the time of the test, and separation �� distances measured to readily identifiable features. The operational life of all wells and r_�r� •`• i }K—�♦.. septic systems depend on the local soils condition, groundwater levels that may "J I.Y� fluctuate during the year, and the water usage of the family being served by the system. I ? ,• * ` These conditions are outside the control of file evaluator of the system. satisfactory test / � results do not guarantee future performance of the system, nor do they guarantee that %, ,,,;,,,,•„ 9 ,,,,,,,;;,,,,, 0 there are no hidden defects or encroachments. GEG, LTD. can therefore not provide / / any warranty or future estimate of how long the system will continue to meet the 0 �� ;�• ,1 • / operational requirements of the ADEC or MOA DSD. The content of this report is for 0•A . /,t � ■ the sole benefit of the owner fisted above. Any reliance upon or use of this report by any C� - eit • A. ne a ''LO= other person or party is not authorized, nor will it confer any legal right whatsoever. •�C/;• C/(F1'p7953 e. ,......... 6. DSD SIGNATURE *4�f�1,"`S"��� System #1 Approved for 3 bedrooms. System #2 Approved for bedrooms. L` `P���Y OF AIVC0'rr p r Disapproved. Ot�_SiTE Conditional approval for bedrooms, with the following stipulations:— VVAYt AZ WASTE o= pROGRAM j ` BY & e Original Certificate Date: g —" a)-" 6 a The Municipqtrlitylfor Anchorage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the represenatations 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. ATTCHMENTS: COSA Checklist Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other (Rev. 10!12/12) 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 A. WELL DATA KNIK HEIGHTS S/D; BLOCK C, LOT 4 Parcel ID: 017-034-04 Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 8/3/1984 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 101 ft. Cased to 100.6 ft. Casing height (above ground) 12+ in. Date of test FROM WELL LOG 8/3/1984 Static water level 57 Well production 10 g.p.m. WATER SAMPLE RESULTS: Coliform ) D colonies/100 ml. Nitrate t r O mg./L. Arsenic: /V Qug./L. Date of sample: 8/8/2014 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1000 gal. Number of Compartments 2 AT INSPECTION 8/8/2014 50 ft, 4.0+ —9 P.M. Collected by: _ Date installed _ Cleanouts (Y/N) Ltd. 9/1994 YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 8/5/2014 Pumper MCDONALDS PUMPING C. ABSORPTION FIELD DATA Date installed 9/9-10/1994 BELOW EXISTING GRADE Soil rating .p.d./ r ft2/bdrm) 0_6 System type TRENCH Length 75.5 ft. Width 5 ft. Gravel below pipe 4.1 ft. Total depth '8.9 ft. Eff. absorption area 750+ ft2 Monitoring tube YES Depression over field NO Date of adequacy test 8/8/2014 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 188 in. Water added 725 gal. New depth 26 in. Elapsed Time: 120 min. Final fluid depth 23 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access "Pump on" level at in. "Pump off' level Cycles E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot 100'+ Public sewer main level at in. Meets alarm & circuit requirements? On adjacent On adjacent lots Public sewer manhole/cleanout Sewer /septic service line 25+ Holding tank 100'+ N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 51+ Absorption Water main N/A Water service Wells on adjacent lots 100'+ 5'+ 10'+ Surface water 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation `101+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage "1'+ Curtain drain F. COMMENTS NONE KNOWN Wells on adjacent lots 100'+ `SHED APPEARS TO BE RESTING ON TIMBERS, NOT A FOUNDATION. "SEE ATTACHED PICTURES OF BARRICADE G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Nal/me JEFFREY A. GARNESS Date til! 6J/* (Rev. 10/12112) \ *e wz,ae S E aU &£ ROAD §§a6■ 3 ( a§q{\2 / \ @�omG2'. MM j �7 .�>MM:3 § ° kƒm m . `. \)§ (k")k {§/§� ;7§ . .�Mz Ln / /a _ (A �\ \\\j(/ }M( �/ z00 (§z > §(§ M r M X �©/® M § § § j\( 9 m , § \ *e wz,ae S E aU &£ ROAD Municipality of Anchorage 0*� Development Services Department Building Safety Division On -Site Water and Wastewater Program . • r 4700 South Bragaw SL 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. 017-034-04 HAA#_1� Expiration Date: - - C) 1. GENERAL INFORMATION Complete legal description Lot 4, Block C, Knik heights Subdv. Location (site address dr directions) 12540 Shelburne Road Current Property owner(s) Mailing address Lending agency Trudie Bryant 12540 Shelburne Road Day phone 344-1407 Day phone Mailing address ( Dan Wolfe — REmAx 257-0114 Real Estate Agent Y Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY:, TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site [y� Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer [❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. l 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 Envirormental Managerrerit, Inc. Phone Address 206 E. Fireweed Iane, Suite 201, Anchorage, AK 99503 Engineer's Printed Name Larry A. Helgeson 5. DSD SIGNATURE ✓ Approved for 3 bedrooms. Disapproved. Dat 272-9336 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: / 610 • /"OLX Original Certificate Date:_ ,Rw 01107) Municipality of Anchorage -1, 4 Development Services Department Building Safety Division - OnSite-�VPa•ter & Wastewater Program 4700 SbWrBmgaw $G P.O. Box 196850 Anchorage, AK 98519.6650 www.ci.andxxage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: i.of;li -&Zk Lf kA;u NParcel ID: Oj7'O3y"BY A. WELL DATA v Well type P • . If A, B. or C provide PWSID # _ Well Log (Y/N) Date completed Sanitary seal (Y/N) x Wires properly protected (Y/N) Total depth Ll—ft. Cased to It -Y R Casing height (above ground) Z' S r in. FROM WELL LOG AT INSPECTION Date of test- e - 3 - i-cl ` ' < ' 3 �L 0 e S Static water level —.S7 ft - SS ft. Well production U g.p.m. 3 3 g.p.m. WATER SAMPLE RESULTS: Cottforrn L coionles/100 ml. Nitrate 0 ( Z mg.A. Other bacteria '&- colonies/100 ml. Arsenic: mg.A. Data of sample: 3 22 05 Collected by: B. SEPTIWHOLDING TANK DATA Tank Type/Materbal $? 04x- Date installed 4 - % 7- ,i" y Tank si%tro o gal.' Number of Compartments -2, Cleenouts (Y/N) i FounABtion cleanout (YIN) -.,,, Depression over tank (Y/N) Af High water alarm (Y/N) AZM Datedpumpiry t -,)q -Dy_ Pumper YSw44s Pu ,, j Svvsr-e- 1006 C. ABSQRFnoN FIELDbA-rA Date irijiallee 9 10 -4y : 'Goll rating 6;.)or fe/bdnn) q_G System type /l0 Q Length ~' ft Width S R Gravel below pipe 1t Tofai depth 4• S ft Eft. absorption area 7% fe Monitoring tube GS Depression over field Date of adequacy test 3.12 - ° Results (Pass/Fall) a 5 S For 9 bedrooms Fluid depth in absorption field before test 33 in. Water added .�!7 gal. New depth2l in. Elapsed Time: I yo0 min. Final fluid depth 33 In. Absorption rate >= 5 QO g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N 44, If yes, give date D. UFT STATION Date Installed 'Pump on' level at _ in. E. SEPARATION DISTANCES Size in gallons Cycles tested High water alarm level at in. Meets alarm 3 circu t requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankilift atation on lot i I O o { 'On adjacent lots Absorption Heid on lot 7 1 Nor Public sewer main 7 I r i e• r Sewer hieptic service line 7 Q On adjacent lots Public sewer manhole/cleariout Holding tank ��lt SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 1- , P li >50 7 S" I `' 7 Water main SO ' Web on adjacent lots � I sa t ropenty ne c Absorption Held Jam, Water service line Surface water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: t � 1 Property line 14 Building foundation Water main 7 7$ Water Service line ! S 1 Curtain drain N/ f} F. COMMENTS G. ENGINEER'S CERTIFICATION Surfacewater > j S ° /, Wells on adjacent lots 7 11 `i 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 aMcke!t this date. Engineer's Printed Name Z csrr z N. Date HAA Fee s 3 O Date of Payment 5—, 2%2 Receipt Number T O 7 (Rev. ta(ot) Driveway, parldng/vehicte storage Waiver Fee $ Date of Payment Receipt Number •0198 loo, gc >mg jl �4N N , N J N ZZZ ♦ b N ^ 8 x , m � � 7C r D ci Z A w C m ay 0 0 S n 0 s (no n M C t m 0 m N �) up (n > o i Z x"`Egg R9 w=Ci S�Q G Lx s S E� uS 0l pCa O. aS• pg Z � 3 it n� ti L _$rd $30c cDr.O S P 3 s n n I xZ o4o'e Fo��In ;es �9g m 0 H N 0 f t 101 -i ra ,00•917l M„OO,ZO.00N 1N3VOSV3 unun ,ol r--------------------------------- r- 0 OIO W O 2 M..00.ZO.00N W O ad02J 3NkM3HS s 6 x n i o N x z It I0N0. u x i o c _ m LIMCM x � m 1&0 p O O N 4 � .00•01l M_00,20.CoN 1N3MMY3 AMLLA .o& r----------------------------------------- . 1 ' 0 1 : ' n 6 : O : —L I M 1 f `� .00'VVL M,00.MOON OVON 3Nane13Hs i/z a6ed `•Wdt1:1 SO-9Z•AeW `•E9S1LL9•L06 !saTljadoJd xeway :AS luag SCS Refa 1051516001 Client Name Environmental Mgmt Inc (EMI) Project Name/M 12540 Shelburne 4-C Knik Hts Client Sample ID 6959-1 hlatrix Drinking Water Sample Remarks: All Datesrrimes are Alaska Standard Time Printed DateMme 03292005 15:58 Collected Datdflme 03222005 12:00 Received DateMme 0322/2005 13:44 Technical Director Stephen C. Ede Allowable Prep Analysis Parameter Results PQL Units Method Container ID Limits Date Date Inil Metals by ICP/MS Arsenic 5.00 U 5.00 ug/L EP200.8 C 0324/05 0328105 SCL Waters Department Nitrate -N 0.602 0.100 Microbiolow Laboratory Total Colirorm 0 mg/L EPA 300.0 B (<.10) 0322105 XM eol/100mL Shf209222B A (<-1) 0322/05 TLF Municipality of Anchorage • --� Development Services Department Building Safety Division On -Site Water and Wastewater Program 1 4700 South Bragaw St. SA ` T 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 Parcell. �6.-.01l=034-04 .1: GENEyRA.6NFORMATION HAA# NA._0/0A*a Expiration Date: S - .29 - D 1 Complete legal description Lot 4, Block C, Knik Heights Subd. Location (site address or directions) 12540 Shelburne Rd. Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Joel Fuller Day phone 563-3342 12540 Shelburne Rd., Anchorage, Alaska Day phone Kathy Johnson, Jack White Prudenb�y phone 563-5500 Mailing Address 3201 C St., Suite 200 Anchorage, Alaska 99503 Unless otherwise requested, HAA will be held by DSD for pickup. — It // Dph 97e2'1133 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered In the State of Alaska. Certificates of Health Authority Approval ere 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 K 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. l 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 Environmental Management, Inc. Phone (907) 272-9336 Address 206 Fast Fireweed Lane, Suite 201 Anchorage, Alaska 99503 Engineer's Printed Name 5. DSD SIGNATURE Approved for Disapproved. 3 bedrooms. Dai 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: /�� j��� Original Certificate Date: .�' �-9" 0% (Rev. MCC) Municipality of Anchorage ' Development Services Department Building Safety Division On -Site Water S Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 995196650 www.cl.anchorage.ek.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lot4 Block C. Knik trP;gbra qihyj Parcel ID: 01703404 A. WELL DATA Well type Private Date completed 8/3/84 Total depth 101 ft. Date of test Static water level If A, B, or C provide PWSID # _ Sanitary seal (Y/N) Y Cased to 100.8 ft. FROM WELL LOG A -/3 -/AA -57 -57 ft. Well production 10 WATER SAMPLE RESULTS: Coliform _#—(colonies/100 ml. Date of sample: 5/17/01 Nitrate ,048 mg./l. Well Log (YM) Wires properly protected (Y/N) Y Casing height (above ground) 2'8" in. AT INSPECTION 5/17/01 -56 ft. >4 g.p.m. Other bacteria � colonies/100 ml. Cofletted by, Donald Dougherty (EMI) B. SEPTICIHOLDING TANK DATA Tank Type/blaterial Septic Tank Date installed 9/27/84 1 Tank size ' 1 s 000 Number of Compartments 2 Cleanouts (Y/N) Y Foundation deenout (YIN) Y Depression over tank (Y/N) N High water alarm (Y/N) N/A Date of pumping 5/22/01 C. ABSORPTION FIELD DATA pumper McDonald's Pumping Service Date installed 9/10/9i Soil rating (g.p.d./fl? or fe/bdrm) .6 Length 75 ft. Width 5 ft. System type Shallow Trench Gravel below pipe 4 ft. Total depth 8_5 ft. Eft. absorption area 750 ft2 Monitoring tube Yes Depression over field NO Date of adequacy test 5/17/01 Results (Pass/Fail) Pass Fluid depth in absorption field before test 3 1.5 in. Water added 500 gal Elapsed Time: 60 min. Final fluid depth 33 in. Any rejuvenation treatment (past 12 mo.) (YIN & type) No Absorption rate >= For 3 bedrooms New depth35 in. 500 g.p.d. If yes, give date D. UFT STATION N/A Date installed 'Pump on" level at _ in. Datum E. SEPARATION DISTANCES Size in gallons 'Pump off level at _ in. Cycles tested Manhole/Access (Y/N) High water alarm level at in. Meets alarm 8 circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAtft station on lot 71001 On adjacent lots Absorption field on lot 7140/ On adjacent kits '100, i 100' Public sewer main -1,000' Public sewer manhole/deanout 71,000' Sewer /septic service line 7 85 1 Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 131 Property line 750' Absorption field 750' Water main 501 Water service line 7 501 Surface water 7100' Wells on adjacent lots 7100' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 14' Building foundation 57' Water main 775' Water Service line 7 751 Surface water 7150' Driveway, parkingivehide storage Curtain drain N/A Wells on adjacent lots 7114' F. COMMENTS 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 Date HAA Fee $ 3 0 0, p o Date of Payment ,S' O / Receipt Number (Rev. 12100) Waiver Fee $ Date of Payment Receipt Number •9699 100' MAY -22-2001 15144 CUE ESI HNCHORgZ CUE Environmental Services Inc. CTAE Ref:u 1012725001 Client PON C seat Name Envuomnenal Mgmrt Inc (EMI) Printed Date/Tlme 05/2712001 1516 Project Name/N 12540 Shelburne Ed (Ancbonw) Collected Date fime 04/17/2001 13:00 Client Samoa D) 12540 Sheburne Rd (Awborage) Received Date/Time 05/17/2001 1416 Matrix DrinldngWater TrrbeltalDl r�C ltde By Rae By I - Pwsro PWSID o (iKGt� Sample Remarks -- AOowable Prep Ames Puametcr Arum PQL Units Me" thein Date pate Init water# Department nitrate -N 0.69S 0S00 mmmy/L EPA 300.0 Microbiology Laboratory Total Coliform 0 0 coVI00mL SM1892228 LL (<10) 05/17/01 SCL 05/17/01 SKW R-98% 9075620119 05-22-01 03:40PM P002 #01 .; . _ gyp. E MUNICIPALITY OF ANCHORAGE ra y. 'rP,t DEPARTMENT OF HEALTH & HUMAN 8ERVICE� µ ^ Division of Environmental Servici 4.1 On -Site Services Section .' 'rns ..NJ'. *L` ♦.. .b 1.'. ,iL P.O. Box 196650 < Anchorage, Alaska 99519 6650 < t •, ; y .1 343-4744 " . CERTIFICATE OF HEALTH AUTHORITY'-) APPROVAL FOR A SINGLE FAMILY DWELLING 94 4- - Parcel I.D. # 017034/04L HAA q .NA O SS - Ir�<7 "'� c, ..,�`. :1 tt at 1 L:1 } ♦..; :V 'n-.,ta!i "`-' 1 ^.GENERAL INFORMATION r:: '1 -Complete legal description ter � �LoCrl �C h 1�NII� 6t6WS ' sUg ;:- Location (site address or directions) Property ownernou yICt Day phone Mailing address Lending agency Day phone Mailing address Agent .:Day phone Address Unless otherwise requested, HAA will be held for pickup i:rYa-: '...,,:.a..{ .Lr1-!,•;i ".^'11:'!'s P'�:^,YL' � :: .,:ry t�lr :••II �1 .1 9} ]-..- 2.2 wNUMBER OF BEDROOMS. Y 3 `?TYPE OF WATER SUPPLY Individual well °xx Community well Public water -. NOTE If community well system, provide written confirmation from State ADEC attest-,:, -- ring to the legality and status of system 4TYPE OF WASTEWATER DISPOSAL. Individual on-site Xn X ; i, 'Holding tank ;r it _ _r 't J 1 , d T �7:. �. r.�y, e 5TU f., i:T , , c r'��.. I •-.., 1G tqi t,. cit r �` Community on site v.V 'r 1. 4 t ..g..' - :•t t J k; 1 - +.a.v• .!' ryl -, ;}, r! -Pub 77. i,'IC_" <..T� "t^GCG,� ,.. ., t v'.?,q t -. i. 7 ..:.t. .r.,.':•�:i .ha.i. Y..t NOTE. r ilf community.wastewater system,, provide written confirmation from State ADEC attesting to the legality and status ofsystem t i' t'a t 7I=M" 1/91)Fant[ MOA Qua• a /' 1 „ i-r.•n-.r rr i i 't•{�jR fpel r to , 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 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 verity that based on the information obtained from the Municipality of Anchorage files and from my Investigation and Inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations In effect on the date of this Inspection. Name of Finn A� OCRS 0 nl EiJG�n1G�2in1 G Phone Address Ph . 8nx 7-goz7 3 A -r wu "&C- ;41c "9eSz%1 Engineer's signature �Y -�G�a LUCUA� Date... 9 / 4 y QF cr �j te.ich • .• • . . C� col E. Anderwn F :. 4381 E o84Cp R•OFESS;���++ S. DHHS SIGNATURE �o.a gid, _� Approved for 3 bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: 7 Additional Comments By Date Z 9 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 orderto satisfycertain 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 oinissions in the professional engineer's•work rnm(Pw.IM) e.k Mwm ® Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L L,)7•' 4 f. uoUc" (; u 14L - I IIC Parcel I.D. D/70 34o `f A. Well Data /�t,HTS SUB. Well type-RuVATc If A, B, or C, attach ADEC letter. ADEC water system number /0Z On adjacent lots Log present (Y/N) Y Date completed 9/3/15 Driller AL W b p-iL JNG Total depth /0/ r Cased to /00• Casing height Z • g SD Water main/service line � SD Y YZ Sanitary seal (YIN) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION FROM 0 !n - o o Q fj�3�8`i SIl2I9`� o Date of test aY Static water Ievel 3r 'S"7/ "71•in W Well flow P• W W9 Pump levetl J^1 tw'ow,'i 59 SEPARATION DISTANCES FROM WELL TO: Septictholding tank on lot /O Z: - On adjacent lots > /00 Absorption field on lot /`E& ; On adjacent lots >/00,�� Public sewer main A4 r &cs Public sewer manhole/cleanout /vr r !CS Sewer service line i gSi Petroleum tank tdo ri C WATER SAMPLE RESULTS: Date of 0 B. SEPTIC/HOLDING TANK DATA .31P mgIL-Other bacteria 0 by: A. Valu LA Date installed 9/z7/8q Tank size /,000 GAC S• Compartments '-I'w 0 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression (Y/N//) High water alar (YIN) At Alarm tested (YM) &t /A Date of pumping 85 94 R Pumper Ic:?JAL1 IM1106 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /0Z On adjacent lots //L I Foundation /3 To property line S7 / Absorption rption field SD Water main/service line � SD Surface water/drainage > l OD I 72-02 rM)•Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (YM) 'Pump on' level at 'Pump off" Levet 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 Date installed I& /Df 9� Soil rating(GPD/Ftz) •6 Systemtype S1+AU1tj-7zgGI Length "7S Width S r Gravel thickness _Total depth B .`/ r - 5.6 Total absorption area 75"0 rte- Z Cleanout present (Y/N) Depression over field (Y/N) N r`" 3 Bedrooms Date of adequacy test ^l6LJ ry4 ST Results (pass/fail) inn S S for Water level In absorption field before test D After test O Peroxide treatment (past 12 months) (YIN) /NJ III yes, give date 41A SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 149 9 r On adjacent lots // t� • S r Property Line To building foundation 57' To existing or abandoned system on lot /Z r On adjacent lots i S S Cutbank �10nI C Water main/service line *> 75 r Surface water 7 1!5* D Driveway, parkingrvehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in >/10 ?on'thedate of Mis inspecBon. CF •a.-. ti Signature 71 l�4E� A� (�^ Engineers Name �vtr1 04C -Z- Date 9//3 /2V A•,� 4361 . E _...._. �C PFOF o$1C�1`d' HAA Fee $ / Waiver Fee $ Date of Payment -'7- Date of Payment Receipt Number 00-1 (�0�73 Receipt Number 72-a26 (ate+)• Ba& MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # r�\1 —n2)L1-�iLi HAA # AR4 �(1Lo� 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lo> Bcout �C.J/� /�A/6 f�Ts Tib X3.1 SEG 2,7 Location (address or directions),,:. LS�a 3/lEcd�:t�! (b) Property owner A9 Alm -%106 Telephone: (home) Business . • LN_ J 2L -m Mailing Address T2T7tt6Q �4 1(pa Ise Fig ` CAQ !S44, _ (c) Lending Institution Telephone Mailing Address L'rtXG'f b P�ifiJ (d) Real Estate Company and AgentI Address Telephone SG 2. - 7GS3 (e) Mail the HAA to the following address: (or check here', if hold for pick up.) List contact person and day phone number below: Ara Ala u/ 2. TYPE OF RESIDENCE Single-Family`o Number of bedrooms 3 3. WATER SUPPLY Individual Welles Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On -situ: Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-02S (R". Lee) Page 1 of 2 L� EG xj/K /%/i. 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by myseal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system Is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations In effect on the date of this inspection. Name of Firm IgfGS Telephone Z71- —3 Address 15IZ IJ 33` / he I15 3 Date Z —z -&--r7 i� '••....,• •:fi` 1 0 1o• •. • oY C. REID, JR. ; $ Sod CE -2251o *4i 6. DHHS APPROVAL Approved for 3 bedrooms by ��G' .C/n�l'L Date `Z ApprovedDisapproved Conditional Terms of Conditional Approval CAUTION The Municipality of Anchorage Departmental Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do notconduct inspections oranalyze data beforea certificate is issued.The Municipality of Anchorage is not responsible forerrors oromissions in the professional engineer's work. 72-025 (Re, 7/U) Back Page 2 of 2 4 P 0VOC,Q ESERV\� EoaO`u+ �g�g A. WELL DATA � Well Classi►+Z a"tion MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: GdT `/ Ba e- dye #73• Ti z L) F'-3 sJ iXe_ L7 If A. B, C, D.E.C. Approved (Y/N) _41L Well Log Present 6N) Date Completed 8'3-00 Yield 6,3r 6P/1 /oD. Total Depth �l_Cased to Depth of Grouting � A i Static Water Level S S Pump Set At i Casing Height Above Ground / + Sanitary Seal on Casin(Y N) Electrical Wiring in Conduit ON) Depression Around Wellhead (Y�l SEPARATION DISTANCES FROM WELL: i To Septic/Holding Tank on Lot On Adjoining Lots /0-0 it - To To Nearest Edge of Absorption Field on Lot /en t ; On Adjoining Lots /" t To Nearest Public Sewer Line a R To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ZS'fi Water Sample Collected by SGS A ; Date Water Sample Test Results ahle- 40.17- Comments •/ZComments dou- AnJ 7es> 8'L7-Fi' B. SEPTIC/HOLDING TANK ATA Date Installed -Z7 4 Size /"VNo. of Compartments Z% Standpipes) Air -tight CapsON) Foundation CleanoutOl N) Depression over Tank (Y, J� Date Last Pumped L'zr"" /SAaGs Pumping/Maintenance Contact on File (Y/N) �JA ; for W -A Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well To Building Foundation r i To Property Line To Disposal Field To Water Main/Service Line To Stream; Pond, Lake or Major Drainage Course Comments 72-M (A".7/68) From Page 1 of 2 L j% p- KN/K A" - C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ' 815' Type of System Design D�i*r,JFi� Date Installed y -L7 -d Length of Field Width of Field -` S Depth of Field Gravel Bed Thickness /• S Square Feet of Absortion Area y8L Statndpipes Present Y 4) / ' Depression over Field (Y( l� Date of Last Adequacy Test 8 L7 f r7 — Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well /00 �'*' To Property Line To Building Foundation Lot To Water Main/Service Line To Existing or Abandoned System on i On Adjoining Lots To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area /e t Comments LIFT STATION Dat d Size In Gallon "Pump On" Level at High Water Alarm Level at Tested for. Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) . -""Pump Off" Level at "Check Permitted Bedroom Rating Against HAA Request" I certify that I have checked, verified, or conformed to all MOA and HAA guidelines inspection. Signed �`�—� • Company Date 2'L8=89 MOA No. Vent(Y/N) Pumping Cycles during Adequacy Test. Receipt No. C �!6 ld oT�oGo2 / Receipt No. Date of Payment e / Waiver Fee: $ _ Amount: $ % – d Date of Payment 72-M (R...7/88) Beck Page 2 of 2 •� OF A4 DY C. REID, CE -2251 .......... on the date of this I Seat MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 18 July, 1985 1. GENERAL INFORMATION (a) Legal Description (include lot,,4lock, subdivision, section, township, range) 1 Location (address or directions) 2540 Shelburne Road Anchorage 'AK;99516 rrp" .p "-%t (b).;APplidant Name,Pven Zrake Telephone: Home 345-6441 ---; - Business274-4512 I rv-ApplipanI Address; 4 dame (c)„t Applicant is'(checkone):,Lending Institution 0 ; Owner/builder ®; Buyer O ;Other O (explain); 6 f.nFas & Nettleton Tele (d) ,.Le'riding Institution hone563-3542 P dtlrEssi00'.9vSt,,„*.P 10t Anchorage. AK 99503 `•• •ice•.,••..•.. Q,. .. (e) Rdal,Estate bDmpany and Agent N / A Address Telephone (f) Mail the HAA to the following address: Steven 7rnke Call when ready for nick un - 345-6441, 2. TYPE OF RESIDENCE Single -Family M Multi-Family[3 Other Number of Bedrooms Three 3. WATER SUPPLY Individual Well ® Community O Public O Note: It community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite I$) Public13 Community O Holding Tank O a - Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. tx-0sst Page 1 of 2 n.wl i 1 — n n 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm CPW ENGINEERING GROUP Telephone 562-3252 Address 3900 Arctic Blvd, Suite 203, Anchorage. AK 99503 Date 18 July- 1985 it i� I 6. DHEP APPROVAL / �1 Approvedfor = bedrooms by ^""" "w� Date Approved T Disapproved Conditional Terms of Conditional Approval '' i•il�l\11 mi CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct Inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineers work. Page 2 of 2 72-025 (11164) �4 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) L 1 CHECKLIST - FEBRUARY 1984 264-4720 RECEIVEDLegal Description: Ise A, R1 n r k C, K i_�k Heights Subdivision A. WELL DATA Well Classification Private If A, B, C, D.E.C.App,�oM(�jpy�/A Well Log Present (YIN) Yes Date Completed 7/� 9 S A_' Yield 10 gpm Total Depth 1 01 ' -4 Cased to 100.81 Depth of Grouting N / A Static Water Level Pump Set At Unlrnovn h G 3411 S 't S I C Y/N Yes Casing Heig t Above round _ Electrical Wiring in Conduit (YX Separation Distances from Well: To Septic/Holding Tank on Lot Yes To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line N / A Cleanout/Manhole N / A an ary ea on as ng ( ) Depression Around Wellhead�kWN) ; On Adjoining Lots 1001+ 150' ; On Adjoining Lots 100'+ —To Nearest Public Sewer . To Nearest Sewer Service Line on Lot N / A No Water Sample Collected by R_ I.nn n P y ; Date - 7 11 -r / a5 Water Sample Test Results SatiRfactnry Comments MeacnrPmantR frnm RtnndpineR - other data from well log B. SEPTIC/HOLDING TANK DATA 4 a-7- 8q bu!) Datelnstalled 9/27/85 Size 1,000 --No. of Compartments 2 ti Standpipes (Yqq Yes Air -tight Caps (Y/X Yes Foundation Cleanout (Y/W. Depression over Tank (YIN) No Date Last Pumped New - See Pumping/Maintenance Contract on File (Y/N) No ; for N / A Holding Tank High -Water Alarm (YIN) N / A Temporary Holding Tank Permit (YIN) _ Yes Note N/A Separation Distances from Septic/Holding Tank: To Water -Supply Well 101 ' To Building Foundation 131 To Property Line 301+ To Disposal Field 32' L To Water Main/Service Line N / A To Stream, Pond, Lake, or Major Drainage Course 100'+ Comments -System is less than a year old - residence has been unoccupied Pagel of 2, , e 72-026{11,84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 85 S.F. /BRA Type of System Design Trench Date Installed 9/27/84 Length of Field 44 1 Width of Field 51 Depth of Field 5 r Gravel Bed Thickness 1 • 5' Square Feet of Absorption Area 282 14 Standpipes Present (Y/) vac Depression over Field (Y/N) No Date of Last Adequacy Test New - See Note Results of Last Adequacy Test New - See Note Separation Distance from Absorption Field: To Water -Supply Well 1501 To Property Line 48' To Building Foundation 1 To Existing or Abandoned System on Lot N/A ;OnAdjoining Lots 501+ To Water Main/Service Line N/A To Cutbank (if present) N/A To Stream/Pond/Lake/or Major Drainage Course 1001+ To Driveway, Parking Area, or Vehicle Storage Area 70' Comments System less than a year old - residence has been unoccupied D. LIFT STATION N / A Date Installed Size in Gallons "Pump On" Level at _ High Water Alarm Level at Tested for Electrical Codes (Y/N) — Comments — 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 •• I certify thatlh a dverified r conformed to all MOA and HAA guidelinesineffect onthe date ofthis inspection. Signed Date 18 .luly, 1985 Company 0U EN2TAI�1F RU MIR MOA No. ST -85-751 Receipt No. �� Date ofPaymentT1c 1-$5 /* 7� Amount:$ �l �•••� 491 # i wakm Von Named . No. CE 4503 _ Page 2 of 2 72-026 (11,841 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE Application Date / 1. General Information (a) Legal Description (include lot, bloc] I AI � Q/ /J//! i► A Location (address or -directions) (b) Applicants Name Applicants Addres ►tf subdivision, section, township, range) Business06 �-2 (c) Applico�' s (check one)•Lending Institution ; Owner/builderBuyer; Other � (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. b Agent Address Telephone (f) Mail the HAA to the following address: _1. 14. �•�-�. .115. e7'-)1- ls�. t 2. Type of Residence Single -Family �6 Multi -Family Number of Bedrooms 3. Water Supply Other (describe) Individual Well Community Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewa a Dis osal Onsite Public Community Holding Tank Note: community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 21 6. t_U [iC KYkK tits N K3wSFc.z7 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 Telephone d1-LT(0e10 Address Z�) ru r " Date fou.... '.....�., ..... (ENGINEER SEAL) t •.�;e' DHEP Approval Approved for AV/" r_(r) bedrooms By�.�. (`�. c r ca `' •' D"ate Approved X Disapproved Conditional Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA- THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 nLUMCia.•.utt C7 /.r:Ctic. ;Ce C.' +_,I LTH x MUNICIPALITY OF ANCHORAGE (Mak) e.rn F:Creercw HEALTH AUTHORITY APPROVAL (HAA) 140 l is CHECKLIST - FEBRUARY 1984 A.� DATA Description: aeC f �T Well Classification Q11iVGAr_ If A, B, br Co D.E.C. Approved(Y/N) "/A Well Log Present Y J) Date CcmpletedA*JjYield {D j*b, Total Depth 10l Cased to 100.` Depth of Grouting WA Static Water Level Pump Set At LIM Casing Height Above Ground,l�� Sanitary Seal on Casing Y) Electrical Wiring in Conduit) Depression Around Wellhead (YA) Separation Distances from Wall: To Septic/Holding Tank on Lot 17I ; On Adjoining Lots •H(a'0/* To Nearest Edge of Absorption Field on Lot� t ; On Adjoining Lots:IzlO0l1F- To Nearest Public Sewer Line u 1A- To Nearest Public Sewer Cleancut/Manhole To Nearest Sauer Servi Line on Lot T Water Sample Collected By Date q(- Water Sade Vest Results .4 n s FSfc 72�Q y , B. SEPTIC/HoLDING TANK Date Installed R lal-� ' Size 000 No. of Coapartments Z Standpipes Air -tight Caps Y ) Foundation Cleanout Y ) Depression over Tank (YX)) Date Last Pumped E0 Pumping/Maintenance Contract on File (Y/N) for A) Holding Tank High -Water Alarm OY ) Temporary Holding Tank Permit (Y ) Separation Distances from Septic/Holding Tank: To Water -Supply Wall Ill/ To Building Foundation 14� I To Property Line 4 ?d < To Disposal Field '3:22 To Water Main/Servies Line * W To Stream, Pond, Lake, cr Major Drainage Course t"('?k- Caments 4' PIC so%oaa VX W (Page 1 of 21 2-15-84 �R&dC C W-� C. ABSORPTION FIELD DATA n Soils Rating in Absorption Strata _OR<2� Type of System Designuc 1 �y Length of Field y�/ Date Installed 4/ Width of Field c�J/ Depth of Field Gravel Bed Thickness //�'� tf' Square Feet of Absorption Area jga- Standpipes Present Y1) Depression over Field (Y ) Date of Last Adequacy Test AlfO ~II: Results of Last Adequacy lest A.) EO N�1+ Separation Distance from Absorption Field: To Water -Supply Well I+K, ),- To Property Line 14Ti To Building Foundation (epS� SM f To Existing or Abandoned System on Lot N I On Adjoining Lots •t4$ / 4 ;}' To Water Main/Service Line tea *YA To Cutbank(if present) J✓ I,* To Stream/Pond/take/or Major Drainage Course -x-100 t To Driveway, Parking Area, or Vehicle Storage Area • A 1 n D. LIFT STATION Date Installed Size in Gallons "Pump On" Level, at _ High Water alarm Level Tested for Electrical Access (Y/N) Off" Level at Vent (YM) Pumping Cycles during Adequacy lest. Meets NDA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the date of this inspection. Signed Company "I/d5/s [page 2 of 21 3 // / No. 1 fi.. ,a• • k l T• C��' O /J _ It ." s.'.• ' - .��`� W .oy C. Reid, Jr. o• � d 2rr i No. 2251•E • �'•� 2-15-84