HomeMy WebLinkAboutTHE TABLELANDS #2 BLK 7 LT 10The Tablelands
#2
Block 7
Lot 10
#051 - 801 - 69
40--. Municipality of Anchorage ;'"
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program, 4700 S. Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page /
www ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number:SWOSO/Di/ PID Number cy3j. -IQ9
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Wastewater System: ,New ❑Upgrade
Address 225/2/ SA#'IBA,2 LCOP
ABSORPTION FIELD
Peale // NumbBadrdana
7 !7 aGNumber d [71
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Deep Trench Q Shalt,. Trench Bed ❑ MarM 0 «
LEGAL DESCRIPTION+a
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Dock Lot Subd'nMal
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Depth to pp* bottom from original eo:
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Gravel depth beneath pipe
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SEPARATION DISTANCES
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R
NCV -17-2205 16:08 FROM:TIFNER COSSTP.UCTION 19077452335
November 77, 2005
To Alaska Cbsiom•/ismes
Fax: (907) 741-8335•
From: Silva Saviors •
OQIce/Fax:(907)892.2498
Re Lill 3tativn •
1.40 B-7, Table land
Peters: Creek, Alaska
19076947026 P:2'2
This is provided as confirmation that Silva Services completed the wiring installation for
the above referenced Litt station.
I may be contacted at (907) 02-2498 if there are any gncstions or If additional
information is neat'
Robed .J. Silva .
Ownc
Silva Services
td wses:ve S.^CZ 11 WA'
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Situ Water 8 Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: Jun 20, 2005
Expiration Date: Jun 20, 2006
Permit Number: SW050184 Parcel ID: 051-801-69
Legal Description: THE TABLELANDS #2 SUBDIVISION BLOCK 7 LOT 10
Design Engineer: 0838 North Rim Engineering Site Address: 22421 SAMBAR LOOP
Owner Name: AK CUSTOM HOMES Lot Size: 53184 SQ. FT.
Owner Address: 22421 SAMBAR LOOP Total Bedrooms: 4 Permit Bedrooms: 4
PETERS CREEK . AK 99567 -
This permit is for the construction of:
❑✓ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3_ The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
5. The following special provisions.
a.) The upper six inches of the mound absorption field shall consist of topsoil and be sufficiently vegetated to prevent
erosion.
Received By: 10-e- `-`J Date:
Issued By: / 1t . , 9s_.. a- D Date: Lp/ap(49(t5
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. bS%'moi ' 1DC1
Permit Number SW
Property owner(s) 4 K Os—) Sera 4'` �-1 Oek 5_3 Day phone 7174.10 0 �'
Mailing address P. 6- g Gi 3,97 , Altin 1 Zip Code 7977(-5-
Site
977(-sSite address aaya % Saretne L erc Zip Code 99
Legal description (Lot, Block & Sub'd.) 71&6C /PM S2 g % L /6
Legal description (Section, Township & Range)
Lot Size 'e"—S-0, d'°" .M s/Sq.Ft. Number of Bedrooms
53, 1V-1
THIS APPLICATION IS FOR:
Sewer Onlyi Well Only 0
Sewer and Well 0 Water Storage 0
Sewer Upgrade 0
THIS PROPERTY CONTAINS:
Hot Tub 0 Jacuzzi 0
Swimming Pool 0 Water Softening Unit 0
Therapy Pool 0
certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or prized agent)
Permit/Rush Fees: Y40 f /75. #C. kiaiver Fees:
Date of Payment:
a -..o-05
Date of Payment:
Receipt Number: (, 9 (, O2—` Receipt Number:
(Rev. 09104) jU
1-RNM
E NEERING
NorthRim Engineering
17237 Bear Paw Circle
Eagle River, AK 99577
907.694.7028
June 20, 2005
Julie Makela, P.E.
MOA On -Site Water & Wastewater Program
4700 Bragaw St
Anchorage, AK 99519
RE: Tablelands #2, Block 7, Lot 10- RUSH
Dear Ms. ¥a4cET: 3t It e•-•
Wehave been monitoring this system for quite some time. The lot has low relief and run-
off from spring melting has slowly been leaving the lot. The test hole on 5/4/05 was dry to
10 feet depth but surface melt -water above an ice layer flowed into the hole.
A 4th test hole was augered at the east side of the lot. This is the highest ground on the lot
and is adjacent to a vegetative easement. After monitoring the groundwater in this
undisturbed area, the level stabilized at 3.5 feet below the surface.
After discussions with your office, we are proposing an AdvanTex AX -20 Mode b to
serve this lot. A Category III drain field has been sized for the highest ground on the east
side of the lot.
We are requesting a RUSH approval.
Sincerely,
Steve Eng, PE, I
Design Enclosures
6FM
E QINEERING
Tablelands # 2, Block 7, Lot 10
,SPECIFICATIONS & DESIGN GUIDELINES
Wastewater System Sizing:
This is a new single family home to have 4 bedrooms. High groundwater exists in the area.
The most recent soil test on the east side of the lot revealed groundwater @ 3.5 feet
below ground level. The Category III absorption system will be located at this site. The
Orenco Systems, AdvanTex Treatment System will be utilized. This system requires a
1500 gallon processing tank and 1-AX20 filter pods. A Category III System drain field
will be utilized, which will allow an application rate of
6 GPD/FT2; an application rate of 1.2 GPD/FT2 with reduction factor for utilizing a 5' wide
trench. This allows a 5' x 20' bed. The top 6 inch organic layer will be removed and a
elevated trench will be constructed. A 1 foot thick effective layer will be utilized.
Adequate separation to groundwater will be maintained by elevating the entire system. No
adverse impacts are expected from development, especially due to the fact that a public
water system serves the subdivision. Most of the neighboring lots are undeveloped or
under construction. No water wells are impacted by this construction. The large area to
the north is undeveloped. Soil tests found typical soil for this area; a silty sand, with
relatively high groundwater table. A 25' vegetative easement on the back property line will not
be encroached upon. This is the highest ground on the lot.
Specification Requirements: All components and work must comply with the
Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water
Regulations and Wastewater Regulations, Orenco Systems AdvanTex Treatment
System Design/Installation Manuals, Anchorage Tank & Welding requirements.
• Installation by an Authorized AdvanTex Installer only; approval issued by Orenco
Systems & Anchorage Tank & Welding, Inc.
• 1500 gallon, two compartment AdvanTex processing tank, 1-AX20 filter, VeriComm
Monitoring System & Mode lb package requiring a discharge basin to pump to the
elevated absorption field, per AdvanTex Treatment System Manual.
• Watertight couplings on inlet & outlet.
• 5 foot minimum between the tank and bed. 10 foot minimum to property lines.
• 3 feet of cover or insulation is required for trench; an equivalent of 1" insulation for
each foot soil cover.
• Tank & solid pipe must be set on well compacted, stable soil.
• 4 inch diameter cleanouts with airtight caps are required 1 to 4 feet from foundation
wall, prior to any 90 degree bend in 4 inch line, prior to the processing tank
compartment, and two opposing cleanouts at either end of the absorption bed.
• All cleanouts must extend to at least ground level
• In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron
• Trench to be placed level, minimum of 3 feet to groundwater, 6 feet to bedrock from
drain -rock
• Drain rock to be'''/ inch to 2' 'A inch screened. Drain rock to be distributed uniformly
FRIM
E QINEERING
Tablelands it 2, Block 7, Lot 10
throughout the trench.
• Perforated pipe to be installed level with perforations down
• Silt barrier (filter fabric) to be installed above the drain rock
• Smeared trench sides must be raked or scarified before drain rock placement
• Backfill over drain rock must not be less than 36" or insulation required
• The finish grade must be mounded to promote drainage over the bed
• Insulation must be placed over any pipe installed under driveways or parking areas.
AdvanTex Treatment System and absorption bed shall not be located under driving or
parking areas.
• Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789,
ABS ASTM D2661,
• Sewer Service Line is minimum 2% slope
• Maintenance agreement for the AdvanTex Treatment System is required for approval.
• Insulation board shall be extruded direct burial polystyrene (Dow Styrofoam HI or
equal)
• Distribution pipe shall be 1.25" Schedule 40 PVC w/ 1/8" orifices @ 2T' on center w/
Flushing Valve Box at end of pipe on both ends.
• Force main shall be 1.25" Schedule 40 PVC, conforming to Anchorage Tank &
Welding/Orenco Systems specifications. Force main burial to be 4' minimum.
• Silt barrier (filter fabric) to be installed above the drain rock
• The finish grade must be mounded to promote drainage over the bed
•
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LOT PLAN
PLAN VIEW
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DESIGN MOTES:
1. Total Depth of Trendy Is 0.5 O TM. Remove Organic toyer.
Terrain w RMetledy not.
2. Sown Se*. fire mWnrum 21C Mops
3. Trench 1 Minimum 10' from Lot LM.
4. Lots Served by Public niter System.
AdtonTes A%20— Mode Ib to Meet Mtalbtbn Rsoulr nsnts Per Oren, Syettrrw Z 'Mchaops Trnk'.
Indies of Mand To Const of Top—Sol ! De Vspetotsd
7
16
Septic Inter. Cewrt.,retten
bore Not Preclude Ad)ossrl
Lots .row SanM.tbn
brprar.w.wts.
NORTHRIM ',Tr' �j _
ENGINEERING
17237 Boor Peer cra .
ERtr, Abate 119377i '•., aassj
1' = 100'
TABLELANDS #2
NEIGHBORHOOD
LAYOUT
BLOCK 7, LOT 10
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THRIM
Ftt NEERING
S❑ILS LOG - PERC❑LATI❑N TEST
Date Performed: 6/12/05
Performed For AK Custom Homes
Legal Description: Tablelands #2, Lot 10, Block 7
1 -
2 -
3 -
4 -
5 -
6 -
7 -
8 -
9 -
10 -
11 -
12 -
13 -
14 -
15 -
16 -
17 -
18 -
19 -
20 -
21
DEPTH
(FEET)
Organic
SM
Fine Sand
w/ Silt
Slope < 5%
Groundwater? Dam
Depth 4
Water Depth
After Monitoring. 3.5' Date: 6/12/05
#
Date
Gross Time
Net Tine
Depth
Net Drop
1
6/12
0
--
3.5'
--
2
6/12
2
2 min.
4.25'
.75'
3
6/12
5
--
3'
--
4
6/12
7
2 min.
3.75'
.75'
5
6/12
10
--
3'
--
6
6/12
12
2 min.
3.75'
.75'
Percolation Rate 3 min./Inch
Test Run Between 1' and 2'
Comments: Pre-4nnkPd
Performed ByklorthRim Fng I CERTIFY THAT THIS TEST WAS
Performed in Accordance with All State/Municipal Guidelines in Effect
ON THIS DATE. DATE: 6/20/05
Perc
Hole
Diameter
NORTHRIM %,"` %.c.'
: * .49Ri v
' arn
TESTH'LE LOG
T. H. 4
ENGINEERING
17237 Boar Pow arch"'
tog,. Rise; Alaska 99577 49 '•.,
907-694-7028?
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a 6/20/05 triOf 2
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THRIM
W NEERING
S❑ILS LOG - PERCOLATION TEST
Date Performed: 5/4/05
Performed For: AK Custom Horses
Legal Description: Tablelands #2, Lot 10, Block 7
DEPTH
(FEET)
1 - Peat
2- f.
3 - : ''
:':�' SM
4 — • .:
r,::Q': '••• Fine Sand
5 - w/ Silt
7 - tiO
8 :i� •'..
9 - ; '•.
10
11 -
12 -
13 -
14 -
15 -
16
17 -
18 -
19 -
20 -
21
Slope < 5%
Groundwater? (Vo- Initially Dry to 10' Depth.
Depth Surface Seeps Over Ice/Organic
Water Depth
After Monitoring. 1.5 Date! 6/15/05
#
Date
Gross Tine
Net Tine
Depth
Net Drop
1
5/4
0
--
4.5'
--
2
5/4
2
2 min.
5.5'
1'
3
5/4
5
--
4'
--
4
5/4
7
2 min.
4.75'
.75'
5
5/4
10
--
4'
--
6
5/4
12
2 nin.
4.75'
.75'
Percolation Rate 3 Min./inch
Test Run Between 2' and 3'
Comments: Pre-' nnked. Hnk' Filled With Run-Ilff Wnter Ahnve S' Tre
Performed By NorthRim Fng I CERTIFY THAT THIS TEST WAS
Performed in Accordance with All State/Municipal Guidelines in Effect
ON THIS DATE. DATE: 6/18/05
Perc
Hole
Diameter
NORTHRIM
ENGINEERING
77237 Boor Pow Circle
Fap/s We. Alaska 99577
Tye.•.. ‘
: + a9m .�+
TESTHOLE LOG
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907-694-7028
•
GE.TECHNICAL
°o6/15/05 rot 2
Filed for Record at Request of:
Alyeska Title Guaranty Agency
AFTER RECORDING MAIL TO: ,i1.
KATHLEEN VOLLEY
CYNTIIIA L. YATES
?Al IXY 2121P$Z
tin riva(05... AIL crani-2-6at
Escrow Number: 00013725 MS
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2005-086375-0
Recording Dist: 301 - Anchorage
11/30/2005 10.45 AM Pages: 1 of 1
lil��YIIV�Bpi:�ill�ll�IIC;o1&19 ip9rYU9i� il�
C C_
SPACE ABOVE THIS UNE FOR RECORDER'S USE
STATUTORY WARRANTY DEED
'DIE GRANTOR, Alaska Custom Ilomes, LLC
whose sailing address is: P.O. Box 3897, Palmer, AK 99645
for and in consideration of TEN DOLLARS AND OTHER GOOD AND VALUABLE CONSIDERATION
in hand paid, conveys and warrants to Kathleen Holley, an unmarried person and Cynthia L.
Yates, an unmarried person, as joint tenants in common,
wialsaantemillas
the following described real estate, situated in the Recording District of Anchorage, State of Alaska:
Lot 10, Block 7. The Tablelands Subdivision Addition No. 2, according to the official plat thereof filed under
Plat No, 2005.13, in the Anchorage Recording District, Thud Judicial District, State of Alaska.
SUBJECT TO reservations, exceptions, easements, covenants, conditions and restrictions of record, if any.
Dated this It -1'i .-221=b5
SELLERS: yy SELLERS:
&r.M:ag:embcr
STATE OF ALASKA
Third Judicial District
} SS,
TIIIS IS TO CERTIFY that on this II -'T9 -)r , before me the undersigned Notary Public,
personally appeared Drian Tomer known to me and to me known to be the individual(s) described in and
who executed the foregoing instrument and bt._ acknowledged to me that .IIL_ signed the same freely and
voluntarily for the uses and purposes therein set fords.
WITNESS my hand and official seal.
nary Public in and for Alaska
My commission exp res- 0i.S • ;20
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101' 10. BLOCK 7
THE TABLELANDS SUBDIVISION.
ADDITION No. 2
^ SI. O:::£HC+: a_ .31311
rMe=.*SCA
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Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 051-801-69
Expiration Date: (p -
1. GENERAL INFORMATION
Complete legal description The Tablelands #2 Block 7 Lot 10
Location (site address) 22421 Sambar Loop, Peters Creek, AK
Current Property owner(s) Hays Day phone 301-0701
Mailing address
Real Estate Agent
same
Hope Russo Day phone 301-0701
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class C Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual
Holding Tank n
Community ❑
Public Sewer ❑
Received by; ' 7 4-4 Date:
Date:
COSA to be released to the engineer, unless,,6therwise requested by the engineer.
COSA Fee $ 52-4,
Date of Payment
Date:
1 Date of Payment
Receipt Number i3o�JO10/-- Receipt Number
COSA# OSS -1 2
��e1 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 NorthRim Engineering
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng
6. DSD SIGNATURE
System #1 Approved for LIA bedrooms.
System #2 Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulatohs:
By:
Phone 694-7028
Date
6/24/2014
rt j 7iq
itttliUt(((///'
OF /Wt(0,
AQP �6 /c_
ON-SITE
WATER AND t""
WASTEWATER g
\ PROGRAM ��
9"OP)���SERN }GC.S«
' /A,' 7 Original Certificate Date: / g
The Municipality of Ancbrage Deviopment 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
COSA blue sheet 9-1-12.doc
X
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: TILE.774BLELA1st 45 Z 87 Z/b Parcel ID: 0518a/of?
A. WELL DATA PtiBL IC. W AYE/
Well type If A, B, or C provide PWSID # Well Log (YIN)
Date completed Sanitary seal (Y/N) _ Wires properly protected (YIN)
Total depth ft. Cased to ft. Casing height (above ground) • in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material A PV4n/7-46/ .C -rat Date installed //79/10 r
Tank size / 50 0 gal. Number of Compartments 2 Cleanouts (YIN)
Foundation cleanout (YIN) 7' Depression over tank (YIN) /11 High water alarm (Y/N) y
Date of pumping 0 dti%rcic..l Pumper A A/C l f d2A Cr TAA/ic
C. ABSORPTION FIELD DATA
Date installed /1/2/05 Soil rating (g.p.d./ft2 or ft2/bdrm) I.2 System type F3 n
Length 21 ft. Width /2 ft. Gravel below pipe / ft.
Total depth 3 ft. Eff. absorption area Z 52 ft2 Monitoring tube y Depression over field N
Date of adequacy test C/"C/r `% Results (Pass/Fail) PASS For y bedrooms
Fluid depth in absorption field before test 8 in. Water added €0 0 gal. New depth /1 in.
Elapsed Time: Co min. Final fluid depth it in. Absorption rate >_ (00 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) Unlit
If yes, give date
D. LIFT STATION
Date installed ///2/03
Size in gallons / 5n n4 -
"Pump
t
"Pump on" level at Li/ in. "Pump off" level at 30
Datum 80770ns Cycles tested
in.
E. SEPARATION DISTANCES
WELL ON LOTTO: NA
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
Animal containment areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation $ 'F Property line
Manhole/Access (Y/N)
yS
High water alarm level at
Meets alarm & circuit requirements?
in.
On adjacent lots
On adjacent bts
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
/O cf
Water main 56 44. Water service line /ci'4..
Absorption field 5 61t
Surface water / 00'4.
Wells on adjacent lots 2004
ABSORPTION FIELD ON LOT TO:
Property line /0 f Building foundation /00'f Water main /0 '4-
Water
fWater Service line /0 cr Surface water /0 0 4 Driveway, parking/vehicle storage /X f
Curtain drain iV A Wells on adjacent lots 2004
F. COMMENTS
G. ENGINEER'S CERTIFICATION "-;z
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in ''.Q r
conformance with MOA COSA guidelines in effect on this date. ` 4CITMOTAS
•
); 8«
Stovers W. e^
Engineer's Printed Name .Tft/E N G
F
Date i/e7a(h f
COSA brown sheet_10-10-12.doc
625G
V(21(I LUJJ 1J.VJ VVVV( ru
205 329
■■ S ■■
in ■■ in ■WWS
MM.rel
I S% ling
ORS ■ S a 0u.. ■ S■■ ■■ —
tt ■S■ SI SSE OM ■■sm
A ivanText Field Maintenance Report
Annual Inspection
Prvpety OWnnlheckl tp
Zack &Brea Hayes
She MOM.
22421 Sarnber Loop, Chugiak AK 99567
wait. log
AX -105740
County to #
SW050184
Retrieve O&M Info
Daily flow
Reolro ratio
Timer settings:
Perform Field Sampling/Obsorvatlons
NNttU ft x NPUe)
i q
pH (6-9)
(1
(DC (P-'6)
& r✓j
Odor of sample
Typical Musty ❑ Earthy
Non -typical l,Sulfde ❑ Cabbage
Oily Alm In nil ['Yes
Foam In tank ❑Yet
Chock Control Panel
gNo
N•No
❑ Moldy
❑ Decay
Roan; Amps
fZr�
Diec�he�rge Amps
Audible and visual alarms
B ial tone {telemetry only]
Inspect/Clean Pump System
14N OK
kI Yes ❑No
Inspect
Riser/Lid
FDox
Float Coria
Floats
Pump
Slott:be Filter
e iotulte Pump Vault
Recirculating splitter Valve
Comments
Clean
Pod M
205654
1 MIIL VV
AnchorageTank
907-272-3543
Measure Sludge/Scum
Opereter
Mike B)akeslee
aN UUL
RTU106349
acclaim Phone
(907) 688-2143
Ogle of last Inspection
08/06/2012
Scum
1st Compartment
_Vt
Currant
Previous
Current
2nd Compartment
3d'
Current
Previous
Current
Previous
west/Clean AdvanTex Filter
Odor. ddon�Normal El Pungent
In.
Blpmat Nonnal ❑ Fxcesslve
Bridging/Pending: CS211ona/Minor ❑ Excessive
Inspect/Clean Discharge Pump System
Inspect
Rlsertid
Splice Box
Float cords
1
Inspect/ =rvlce Other System Components
Inspect Clean
Disinftetic •uiprnont El ❑
Observations
Additional Seryl
❑ Cleaned textile she
El Replaced/Used other I
Inspect Clean
Lntemis/Onficat
Pod Bottom
Malec Vent
Floatt
Pump
Inspect Clean
y
Inspect Clean
parser Lateralarorifices ❑ n
['Replaced UV Items?
Parts Used: W = Ws able* Ne appropriate selection)
w B i •eodY gen
Final/Safety Inspection
01.R9V reinstalled
IX -Manifold reconnected; flush valves closed
Su m ma ry/Recommendatione
1-#Systent performing; no further action needed
D Call for service
-yids bolted on
}Control panel reactivated
❑ Tank needs pumping
❑ Other?
Signature
Data4
Fax completed form to 1-866-384-7404
ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
BETWEEN MUNICIPALITY OF ANCHORAGE
AND :ifc L\rTI ;F)
THIS MAINTENANCE AND REPAIR AGREEMENT made and entered into as of this
7 Day of 00y1y of 20/9 , by and between3tcL + d' didA(r 0✓K ill "cy.)
herein the "OWNER," and the Municipality of Anchorage, herein the
"MUNICIPALITY." In consideration of the mutual covenants contained herein, the
parties to this Maintenance and Repair Agreement agree as follows:
1. Advanced Wastewater Treatment Systems. Municipality grants permission to
Owner to utilize and operate an Advanced Wastewater Treatment System
(AWWTS), described as
AdVarile
located at (legal description).
fioib ck9,1h�Q" ab(ett�.�dsg'ab. Adds ►rrn 2 pttf 2,9105-l3
�YG�I wit Kt a»ltinj shoe a f 4iuskla,
2. Definitions.
Alteration. Any change to the design or function of an AWWTS that
includes the installation or removal of any parts, components or pieces not
included in the original construction permit and design.
Certificate of On -Site Systems Approval (COSA). An approval by the
Municipality of existing water and wastewater disposal systems given at
the time of property sale and title transfer in accordance with Anchorage
Municipal Code (hereinafter, "AMC") 15,65. These approvals certify that
the systems are adequate for the homes that they support and meet the
codes that were in place at the time of system construction.
Damage. Any man-made or natural change in a system that would inhibit
the system from performing as designed.
Maintenance and Repair. The scheduled and as needed replacement of
existing parts, components and pieces of an AWWTS that were included
in the original design which would allow the AWWTS to continue to
perform as designed.
Permit. An On -Site Wastewater Disposal Permit as required by AMC
15.65 to construct and operate an AWWTS.
3. Term. The term of this Maintenance and Repair Agreement shall begin on the
date of approval by the Municipality to operate the installed system or issuance of a
COSA, and shall continue while the AWWTS is in use or is operational or until the
property is sold or title is transferred by the owner and a new COSA is issued to the
new owner or transferee of the property.
4. Alterations, Installation and Removal of Additional Equipment. Prior to
performing any alterations to an AWWTS, the owner agrees to obtain an On-site
Wastewater Disposal Permit from the Municipality in accordance with AMC 15.65.
5. Maintenance and Repairs.
A. Throughout the term of this Maintenance and Repair Agreement, the Owner shall
maintain their AWWTS in a satisfactory condition capable of producing treated
septic effluent in accordance with the equipment's approval for operation in the
Municipality. The owner shall enter into a service agreement with an AWWTS
service and maintenance provider approved by the municipality and the
manufacturer of the AWWTS for the entire term of the AWWTS. In addition, it
shall be the responsibility of the Owner during the term of this Maintenance and
Repair Agreement, and any renewals thereof, at the owner's sole expense, to pay
for any and all: (1) repair(s), (2) maintenance, (3) adjustment(s), (4) replacement
costs, and (5) inspection costs.
B. Owner agrees to comply with all applicable ordinance, laws, regulations, rules
and orders for the AWWTS.
C. Upon request by the Municipality, the owner agrees to provide the Municipality a
written schedule of routine maintenance and repairs which have been performed
on the system. When a record of maintenance is documented and maintained by
the system vendor, the owner agrees to allow the Municipality access to this
information.
D. Owner acknowledges that the fine for failing to maintain and repair an AWWTS
may be assessed in accordance with AMC 14.60 for improper discharge.
E. Owner agrees that only maintenance and repair personnel approved by the
Municipality will inspect and make any necessary maintenance, repairs or
permitted alterations to the system.
F. Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS upon 24 hours written notice.
G. Owner agrees that any sale or transfer of title of the property will not occur
without a new Certificate of On-Site Systems Approval.
H. Owner agrees that the AWWTS installation and maintenance requirements as
provided by the AWWTS vendor/installer and approved by the Municipality are
the governing guidelines for the construction, maintenance and repair of the
Owner's AWWTS.
6. Nonwaiver. The failure of either party at any time to enforce a provision of this
Maintenance and Repair Agreement shall in no way constitute a waiver of the
provisions, nor in any way affect the validity of the Maintenance and Repair
Agreement or any part hereof, or the right of such party thereafter to enforce each and
every provision hereof.
7. Amendment.
A. This Maintenance and Repair Agreement shall only be amended, modified or
changed by a writing, executed by authorized representatives of the parties, with
the same formality that this Maintenance and Repair Agreement was executed
with, and such writing shall be attached to this Maintenance and Repair
Agreement as an amendment.
B. For the purposes of any amendment modification or change to the terms and
conditions of this agreement, the only authorized representatives of the parties
are:
a. Owner:.::7—kc;VC\ik ti'i ozo,3,dyly-v F)
b. Municipality: Director, Community Development or designated authority
C. Any attempt to amend, modify, or change this contract by either an unauthorized
representative or unauthorized means shall be void.
8. Jurisdiction: Choice of Law. Any civil action arising from this Maintenance
and Repair Agreement shall be brought in the Superior Court for the Third Judicial
District of the State of Alaska at Anchorage. The laws of the State of Alaska shall
govern the rights and obligations of the parties under this Maintenance and Repair
Agreement.
9. Severability. Any provisions of this Maintenance and Repair Agreement decreed
invalid by a court of competent jurisdiction shall not invalidate the remaining
provisions of the Maintenance and Repair Agreement.
(signature) Date:
STATE OF ALASKA
) ss.
THIRD JUDICIAL DISTRICT
The fpregoi instrument was cknwledged befo e me this 'May of c, u{ (iA
� - I� GU'! Q i�OS G t2P I�Q ��
20 by P A h !% ��� liiiiffrfery,„
U ♦r
•• s®e
• %jl ., OR ASP'
NOTARY PUBLIC FOR ALA K
My Commission expires: it) 0 i
MUNICIPALITY:
By:
(signature)
(print name)
Date:
Title:
11 i! )1 * )1111��, se
Parcel I.D.
1.
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
051-801-69
COSA # 05C- I l l i 3
Expiration Date: 7 -
GENERAL
`
GENERAL INFORMATION
Complete legal description The Tablelands #2, BLOCK 7, LOT 10
Location (site address) 22421 Sanbar Loop, Peters Creek, AK 99567
Current Property owner(s) Cynthia Yates
Mailing address
Lending agency
Mailing address
same
Day phone 688-2833
Day phone
Real Estate Agent Keller -Williams Day phone 301-0701
Mailing Address
Unless otherwise requested, COSA
NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
will be held by DSD for pickup.
4
Well
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
❑ Individual Holding Tank
❑ Community On-site
Public Sewer
El
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm NorthRim Engineering
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng
Phone 694-7028
Date 6/10/2011
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow
and absorption rates may change due to subsurface conditions that may not be observed from the surface,
changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. The operational life of all well and septi systems are
subject to these various and dynamic characteristics and are outside the control of the
OF
evaluator of the well and septic system.
5. DSD SIGNATURE
\i, °� Approved for4/bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following
�D^J
stipulatioi�I -
"\,oY OFrilwcii
`1
S;ev�n W. Eng
Fr- �23x
`\e�.••.•..• 131 %;
•
ON-SITE Gi=
• WATER AND : 0:
WASTEWATER =
• PROGRAM
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
'J;
• •
))))))))
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: (.. / 7'" ! /
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: The Tablelands #2, BLOCK 7 LOT 10 Parcel ID: 051-801-69
A. WELL DATA (AWWU)
Well type NA If A, B, or C provide PWSID # Well Log (Y/N) NA
Date completed NA Sanitary seal (Y/N) NA Wires properly protected (Y/N) NA
Total depth NA ft. Cased to NA ft. Casing height (above ground) NA in.
FROM WELL LOG AT INSPECTION
Date of test NA NA
Static water level NA ft. NA ft.
Well production NA g.p.m. NA g.p.m.
WATER SAMPLE RESULTS:
Coliform NA colonies/100mL Nitrate NA mg/L
Arsenic: NA mg/I Date of sample: NA Collected by: NA
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Advantex/Steel Date installed 11/2/2005 Tank size 1500 gal.
Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
High water alarm (Y/N) Y Date of pumping contract Pumper Anchorage Tank
C. ABSORPTION FIELD DATA
Date installed 11/2/2005 Soil rating (g.p.d./ft2 or ft2/bdrm)1_2 System type Raised BED
Length 21 ft. Width 12 ft. Gravel below pipe 1.0 ft. Total depth 3 ft.
Eff. absorption area 252 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 5/14/10 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 6 in. Water added 600 gal. New depth 8 in.
Elapsed Time: 180 min. Final fluid depth 6 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date =
D. LIFT STATION
Date installed 11/2/05 Size in gallons 1500+
"Pump on" level at 41 in. "Pump off' level at 30 in.
Datum BOTTOM Cycles tested 3
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot NA
Absorption field on lot NA
Public sewer main NA
Sewer /septic service line NA
Animal containment areas NA
Manhole/Access (Y/N) Y
High water alarm level at 45 in.
Meets alarm & circuit requirements? Y
On adjacent Tots NA
On adjacent lots NA
Public sewer manhole/cleanout NA
Holding tank NA
Manure/animal excrete storage areas NA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 10'+ Absorption field 50'+
Water main 50'+ Water service line 10'+
Wells on adjacent lots 200'+
Surface water 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 150'+
Water Service line 50'+ Surface water 100'+
Curtain drain (None Known) Wells on adjacent lots 200'+
F. COMMENTS
System Rechecked On6/9/2011
Water main 10'+
Driveway, parking/vehicle storage 200'+
G. ENGINEER'S CERTIFICATION
1 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 Steve Eng
Date 6/10/2011
444,,v_ OF ilk All
407.4.:„,;...... .....,,'4.S.1
'÷'fri
• o
s
fa.. r2.! .rrs *se* oN.rr1 .r
NnvJO
Steven W. Eng : ''`' s.
>,
.
q . •"fppj�}y� r 5/1r
' r•• Y',ra�;�uA,
�..
COSA Fee $490.00
Date of Payment i — /0 -
Receipt Number
(Rev. 11/05)
obs. a c
Waiver Fee $
Date of Payment
Receipt Number
05/03/2011 08:14 8686770
APLUS
188 823
PM Woo ■ x111 ■ 1 sono 11 11I■ gm 5
mil 11 1 A1■ UP• 1 1 11 111 s■ 11■1 —
1s1 1s 1111 1 ■ss11i■ R 1 s1 MIN no n
PAGE 04
*ivarflrese Reid Maintenance Report AnchorageTank & Welding, Ins
Annual Inspection _ . 907-272-3543
Romig owrtaYRuldne e
Cindy Yates
Ste Address
22421 Somber Loop, Chugiak AK 99567
nx se. tD
AX -105740
Retrieve O&M Info
Daily fknv
Retire rano
'Timer settings:
Milt
SW050184
Perform Field SetnpIIng/Obahenfwtions
JI05 a BTUs) pH o.9 DO (24),I. 6.5 'f-
ader of 5m pIs �/
Tvpmal 0 Muegv Nanny ❑ Muldy
No -typical ❑ sulnde ❑ Cabbage ❑ Decay
O11yRan InPVU [km Wla
Foam in tank ❑ Yoe
Check COntrol Parte!
Oftdo
ROOD AMPS
-3
Dbchergs Amps
1e3
Audible and visual Mame [SOK
Diet tone (telemetry only) Mu 0 No
inspect/Cleat FUISP ffiyBtemn .
Inspect Men
Riser/LW
Splice Boa
Float Corea
Floats Itad
Pump Lal
EintubOe Mar RI RE
Blotube Pump caul
Reclroulp9ng Altar valve...
Peet
own*
Mike Blakeslee
Dented Move
(907) 440-4905
frT11 erUL
1205664J RTU106349
Measure Sludge/Deem
Sludge'
Date et Lett Inepeelien
07/1.3/2010
let Compartment
Current
LI fr
Previous
Current
Previous
2nd Compartment
C ne t
Previous
Current
Previous
Inspect/Olsen AdvanThz Filter
Odor �n El ��
Biomet: ❑ Sreoeelvo
a ddging/Pa+dlnp: 114NonentlIncr ❑Elmossive
Inspect/Clean Discharge Pump System
Inepect
Aber Lid tor
spas. Box
02.
Float cord.
irapect/Servlee Other System Coeeponents
• lnepemt Clean
Disinfection Equipment 0 Q
1
Observations
M9peet Clean
Letesero1Nlees 0 0
Pod Bottom 0 0
Intake vent Q 0
Inspect
Roots
Pump
Inspect •Clean
ole 0 D.
Additional $ervlcee Rendered
❑ Cleaned textlseheeta? 0 Replaced UV hams?
0 Replaoedruead other. llama?
Parte Used: w • Warranty B. Billable (I/ amveartate selectlori)
W IS Item Number Description
FIMSatety inspection
RSV renneleilce
Menl►old reconnected: Mush valves closed
Summary/Recommendations
VSystem performing, no further action needed
0 cel for service
Comments
?IP
.Ids bolted oh
drcontrol panel reactivated
D Tank needs pumping
D Other?
Fax completed form to 1-866-384-7404
Municipality of Anchorage "?
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-801-69
COSA# DSCM/Os9
Expiration Date: G - / O — % r
1. GENERAL INFORMATION
Complete legal description The Tnhtelandq Rlnrk 7 1 nt 1n
Location (site address) PP4P1 Sanhar 1 nnp
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Add.
Cynthia Yates Day phone 688-2833
22421 Sanbar LOOD
Day phone
Craig Bennett
Mailing Address Keller-Wllllans
Day phone 242-3251
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
❑ Individual On-site (]
❑ Individual Holding Tank 0
❑ Community On-site ❑
Public Sewer ❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm NorthRin Engineering Phone 694-7028
Address P.O. Box 770724
Engineer's Printed Name
Steve Eng
5. DSD SIGNATURE
Approved for 4 bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
BY: 0A -g
(Rev BIOS(
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: C — / — / 0
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: The Tablelands #2. Block 7 Lot 10 Parcel ID:051-801-69
A. WELL DATA
Well type _ If A, B, or C provide PWSID # _ Well Log (YIN)
Date completed _ Sanitary seal (YIN) _ Wires properly protected (YIN)
Total depth . ft. Cased to ft. c$_ Casing height (above ground) in.
FROM WELL LOG �P AT INSPECTION
Date of test �'�L
\4\
Static water level tl\%�ft. Pft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mgfL Other bacteria colonies/100 mL
Arsenic:
ug/L date of sample: _
Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Advantex/Steel Date installed 11/2 /115
Tank size 1500 gal. Number of Compartments ,2_ Cleanouts (Y/N) y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N)Y
Date of pumping contract Pumper Anchorage Tank
C. ABSORPTION FIELD DATA
Date installed 11/2/05 Soil rating (g.p.d./f2 orft2/bdrm) 1.2 System type Elevated Bed
Length 21 ft. Width 12 ft. Gravel below pipd� _ ft.
Total depth 3 ft. Eff. absorption area252 ft= Monitoring tube Y Depression over fief!_
Date of adequacy test 5/14/10 Results (Pass/Fail) Pass For4 bedrooms
Fluid depth in absorption field before test 6 in. Water added600 gal. New depS1 S in.
Elapsed Time:18Inin. Final fluid depth 6 in. Absorption rate >100+ g.p.d.
unk
Any rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date
D. LIFT STATION
Date installed
'Pump on' level at41 in.
Datum bottom
11/2/05
E. SEPARATION DISTANCES
Size in gallons 1500+ Manhole/Access (YIN) Y
'Pump off" level at 30 in. High water alarm level at 45 in.
Cycles tested 3 Meets alarm & circuit requirements? Y
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main na
na
na
Sewer /septic service line na
Animal containment areas
na
On adjacent lots
On adjacent Tots
Public sewer manhole/cleanout INA
na
V10
Holding tank NA
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5' +
Water main 50'+
Property line 10' + Absorption field
Water service line in' + Surface water
Wells on adjacent lots 200' +
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Water Service line
Curtain drain NA
F. COMMENTS
10'
50' +
no
50' +
100'
Building foundation 150'+ Water main 10'+
Surface water 100' + Driveway, parking/vehicle storage 200' +
Wells on adjacent lots 200' +
G. ENGINEER'S CERTIFICATION
1 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.
Steve Eng
Engineer's Printed Name
5/24/10
Date'
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
!-{% t7
19
o.s'S 7I/ G
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`w : • TH 17 1/
v°•. , .•e
VVic , rB
b" "Steven W. Eng : 4,a.✓
uJ, :, PE 6256 ' OSA
8t`OPROFFSS'g/Xtle4v
Waiver Fee $
Date of Payment
Receipt Number
: 1 1;
19
13 1
11
1 1
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�- • .\'- ♦ / �/ // SURVEYOR'S CERTIFICATION
=�J•'s.o .\ \‘''. / /
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• The R.TCRNAtCN y.O•A: O% TNI 413-9.r.t K r,;s 1,1 CSI Cr .MC AC
r•Sl!unCNS SrC:nG,.t TO SC* AM+ COv"I:TS JUKE% LNST.•t
SCRs:MRCS ANO ".ATtC ICI Lnt! OR taSCRS%ts 1•t •S -N t• It
NC' 'G CC USCG IOP •:SROare. A.••:IPd.A. ST',.:WPCs OR 1I535
1 wi*C97 Cann That 1 NAK SURvt*CW T.0
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DETC: MS 2. 7Ar Or 111C7, s CC i
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2005-:3
*vol.
23 let se N
AS -BUILT
LOT 10. BLOCK 7
THE TABLELANDS SUBDIVISION.
ADDITION No. 2
°cut WON 54. t1511. RI* 5U.
ANC.CIA:•,E ReCe/1514 015171::. •!.ITKA
• a:. IrN.. OCI-23A
:w. TAM -1057.0%C
suRKKU 5/22/O5
1• a .. b•
MLN
BC's. --e—
Enel� .rine
1523 Aram, Mont C.c'.
"eat Lasko 9963•
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(97)343-7904
CERTIFICA t1EAi.TTi AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING •
d
/(ja i(oJ--
Parcel I.D. net - go 647
1.
GENERAL INFORMATION
Complete legal description 71/E T,48Lf1 Ades it2RLock 7 Lor /0
Location (site address or directions) 221/21 SAtAlet4R / odP
Current Property'owner(s) miser -64f 4/OME: Day phone. 7'/K'( 4'00
Mailing address • Ea ROC l97 f Pot af' e, ,4 k.. 7vgar
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
HAA# t)SfldL{
Expiration Date:1p/t5/c9C0(.0
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site •
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
/Vnd
Name of Firm iRt n Ent
Address /'7• 37 Garr 'Pc,..) \-0 on (e.
Engineer's Printed Name S r. v.E
Phone 6 -?y -706P
Date //7/4105
;�''�c t'4ti4
$tf49Z►tpa %isJ
1
,
01
IPA Steven W. 1 44, Or
Pi of
5. DSD SIGNATURE t# PA es "IAO
% PE 6256 : P4 .
eistApproved for bedrooms. py�tiOFE '.••••
Disapproved.
By:
Conditional approval for 1 bedrooms, with the following stipulations:
a.) Prior to June 15, 2006, Alaska Custom Homes shall ptnre air inrhec nf
on the mound absorption and vegetate the mound absorption field suffiently
prevent erosion. b.) At rhe rime nf rtncing, the na*-* proporty owner shall
sign the attached maintenance agreement and return to this office.
tap soil
to
Additional Comments
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
(R» 01/02)
,_o U'reViNputo_24
`14\% OF AN�/5,,...
014-S1SE '. Til
ys: \MAIERAND
WASSEN CR ; _
pROG :
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: tf/r41/61,c/tl
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: rift niatieLdrAMS4e 5tnc is 7 tar ,4 Parcel ID: b5l '$U( -laq
A. WELL DATA PUS/ iC ue-it
Well type _
Date completed
Total depth ft.
Date of test
Static water level ft.
Well production g.p.m.
WATER SAMPLE - ESULTS:
Coliform colonies/100 ml. Nitrate mg./I.
Arsenic: mg./l. Date of sample:
B. SEPTIC/HOLDING TANK DATA
If A, B, or C • ovide PWSID #
Sani . ry seal (Y/N)
C- ed to ft.
FROM ELL LOG
Tank Type/Material
/t)364,vr6,c- crEF�_
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above grou
AT INSPECTION
g.p.m.
in.
0 er bacteria colonies/100 ml.
ollected by:
Date installed
/1/470S
Tank size /500 _ gal.+ Number of Compartments 2 Cleanouts (Y/N) Y
7/
Foundation cleanout (Y/N) Depression over tank (Y/N) 4( High water alarm (Y/N) j y
Date of pumping il(FrAr Pumper
C. ABSORPTION FIELD DATA
Date installed /1/2/05 Soil rating (g.p.d./ft2 or)/Z System types/rrj/`47Zd PEA
Length 2.1 ft. Width /2 ft. Gravel below pipe / ft.
Total depth 3 ft. Eff. absorption area nZ ft2 Monitoring tube / Depression over field 4
Date of adequacy test 'NEN-) Results (Pass/Fail) / S For c/ bedrooms
Fluid depth in absorption field before test _ in. Water added_ gal. New depth_ in.
Elapsed Time: _ min. Final fluid depth _ in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
g.p.d.
D. LIFT STATION
et scireer
Date installed ///a /a 3 Size in gallons /500 + 6cc•rt Manhole/Access (Y/N)
"Pump on level at 14 ( in. "Pump off' level at 22.... in. High water alarm level at
Datum T4Atk (3077'dn Cycles tested .3
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station • n lot
Absorption field • lot
Public sewe ain
Y
y_S in.
Meets alarm & circuit requirements? Y
!RBL t c. nTE.c
On adjacent lots
On adjacent lots
Public sewer
Sewer . eptic service line Holding t
nhole/cleanout
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation. r Property line /D Absorption field SO f -
Water main
stilt
Water service line /0 '"` Surface water `00 11"
Wells on adjacent lots 200.14
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /0 14 -
Building foundation /50 •'r Water main
Water Service line Jr O' f Surface water /0 6 1'
Curtain drain At /4 Wells on adjacent lots 20 d 411-
F.
'fF. COMMENTS
/0"
Driveway, parking/vehicle storage 200 if
G. ENGINEER'S CERTIFICATION
I certify that 1 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.
STCvr alo
Engineer's Printed Name
Date gate -r
►; •
✓ ,
• t. Steven W.
11.6•:P,'•. rE 6256
,.•.• ,..••••••,, •s Is
se L
HAA Fee $ 5-1.6° '; \-15P° Qt). '\
Date of Payment 11/tyaOr 05
Receipt Number
(Rev. 12/01)
St) 1eict1
CzaLenceol
Fee $
A6 Do
Date of Payment
Receipt Number
�t/Bt/aoa3
12
13
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FOUNDATION DETAIL
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DETAIL
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Septic Stacks
1 Updated 11/17/05
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11
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NOTES
1 IT SHA,L 9L THE RESvONSeIJTvTWE 9UJL:ER CR O'e'ER rC vtRiY
THAT 9J^LI11C LOCATION SHOWN U_ZTS ALL 5L9CM9CN CCILNAN'S
*1.0 ZO':INC CAD'INA1.,^,ES
2 IT 'S •wr Rr S-PCN$'B:LM, Of TME 9JILDER TO Kar` A•L. E rVPI^_N$
w•H RESr.._T ro ALL U'VTIES
3 THIS A.-9U:L' RE°RrvNTS THE RARCL Cr PRCPERT' CESCReE: BEAK
tAvr.i FROM THE Rc:CRCE: PLA' CEs?P'9'IG THA' PAPE_
tk$'RUMENT$ RCCCPOrD PRIOR TC Cl AFTA the non,: vF NE RECCROEC
PLAT ARE NC' SHOWN ON THIS AS-9ulpT
• 114 ,NFORUAI'CN SHOWN ON MSS A5 -13J1.1 15 FGR THE USE Or -ENONC
IN$'ItunnCNS SPECFICAL.Y TO SHOW ANY CONFLCIS HETAEEN CAIEt1NC
STRJCTURES ANO PLATTED LCT L'NES OR EASEMENTS THE AS -9J' LT N5
NC TO SE USED FOA PCSTIONINC ACCIT.ONAL STRLCTJPES DR FENCES
1 HEREBY CERfVY THAT 1 HAVE SURV&Y C Tr•E
PROPERTY OESCR0EC ON rm5 A$ -BUILT AND THE
:MPRCVEMFNTS SITUATED t-EPECN ARE LCCAT C.
AS SHOWTI of TH:S A5-9JILT
4.4
DA-. M4 LP 'DA,' OF !1/ 4-7 4 CO -a
;;ATE
5/22/C5
1'"ICO'
;:LC. FLAt.
2005-73
JI AHLA,
53 154 sc .t
AS -BUILT
LOT 10. BLOCK 7
THE TABLELANDS SUBDIVISION,
ADDITION No. 2
LOCATEC WIHIN 54. T15N. RIW
ANCHORAGE RECCRO:NO OIS'R:C. A:.ASKA
Cu, ITA- 201-254
;TT'. TABU057.Dw0
SURvErr-U 5/22/05
T'kAYP. bT
MLK
Bes4f' ter-
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1890 Jane Mane Cave
'Nasfla. AlasI.a 99554
