HomeMy WebLinkAboutTHE TABLELANDS #1 BLK 9 LT 6The Tablelands #1 Block 9 Lot 6 #051-741-62 Municipality of Anchorage r:''•"' •, i • �"� Development Services Department - `� Building Safety Division On-Site Water and Wastewater Program, 4700 S. Bragaw St. pa e / Of 3 9 P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchorage.ak.us (907) 3417904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: �4�(_D_o LQ PID Number. t' 77 Nam. )SZOM 45S Wastewater System: nNew El Upgrade Adaaea: ? Q q Pr�� J ABSORPTION FIELD O / N�rtDM of 80& a '. PhaM ^ D O 20 C3 D••p Trench SNllov TrrMl I] Bad Moura OIMr Sd Rneq TNN Depth am dpm*I arsds D. FI. LEGAL DESCRIPTION GPD F2 Blatlr�-Y LN. r Subdmvm' ' e �1 r. DeMn b pp• ponan kam orgvw Psd• Gn+al Eepin Deraatn pPe F,. FI TpnnNep Rrr�*. Saaun. FY added anov*arq•W V•d•: � W*vN LaryT..n I� Ft 6 F,. Wett: IC ❑ New❑ grade Grewal,mm� NunDN N In*•' Dlnanc* benHan Inea S F,. Z /O FI C4a•drcal�on (PnvN•. A e. CI' TNN Wplh' Caw W TOW tlwrpllonru 750 FP P" MelanN. V C (.� U FI. FI DrYle� Dale Dr+ sulawalr *xN "t~ 2 EA ppb' Dal*anleued 3 ay v os F, YWd Pump Sol N. Cas•gR V% >r.Grlx.ld TANK GPM FL fl SEPARATION DISTANCES ❑ Septic ❑ Holding .T.E.P. ❑ Other. To Septic Absorytion Lift Holding uDiiCPmate Line Ma wr .*` aa*.uY. �. /[t C From Tank Field Station Tank Sewer Nanb«acplronm•ma- Mala�rW•� GGC` wee LIFT STATION Sunace Walr /00't /oo� /U6'f -- LN Lw /6'tt /a'* /Q 'f' aaurarn: Q' L /Jca C V1 !:%IfG ''� a+ 'PMllp Ort MVN rt TP p'r NvN N: Hyl WNN NYT at 3� sin. Fond~ / Q — l D in M Pump Max* a MO Eranul mp*amro ped — — — — S6 OSI os 1&F (Ced cmanDl,ln BENCH MARK R.mrxa LOral�On rq D•Wlpapn oj= FU Uf�I oN jrWG A•wmlW uxeuon. Q F1 T/Cp) OF q4, S i ••,4 yid• 1L' •• •• Inspections by: Dates:2nde performed j��..„• • W K` : Sewn w. Developm nt Services Department Approval V s•,. u, h . � a Reviewed and approved by: Date: tdlfppk�f�9S9P yf rp.. vopl ,1aa11.v': Septic System Construction Does Not Preclude Adjoining Lots From Sanitation Improvements. T,H.1 C M.T.1 Water Key Box 500 Gallon STEP Tank T & E Easement Trenches [ation -, ­­ TankO. 1 .H• .O. 2 Tube 1 Tube 2 C.O. 10 Flat Terrain M.T.2 Re erve Site Top of Bluff NOR THRI M ENGINEERING 17237 Bear Paw Circle I Eagle R7.er, Alaska 99577 i A B 40.8 13 43.7 14 101.6 94.5 101.6 5 \ 16.4 DESIGN NOTES: 1. Total Depth of Trenh is 1.5'. Terrain relatively flat. 2. Sewer Service Line miimum 2% slope. 3. Trench is Minimum 1 4. Lots Served by Public ,TABLELANDS S/D #1 LOT 6, BLOCK 9 from Lot Line. System. 1' = 40' AS -BUILT LAYOUT 8/10/05 2I 3 K W r 3x oa L3PQ C3 0 Q Z Z � O O W ¢ QQ� vi a a. 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PA oeM 10:31CM Pi Juy 5. 2ow AWWO Custom HCmss Po Box 3483 Palmar, AK WUS To Wtnm RMayca=m Ra UR Station Lot 6 B;oau gTab AWS PstWra CswkAWSIO cur ccrc�d W6 tmk tip 6R sodws. to tbn'Cistod is Tt station a�mOlft b Cse Pmdint mandts�sffes % K you have any qu swns ormquim anytkV Astw. Oeffle conte me star Off oe Sint a * C 6tseey Ma9nei orrice M wager 2/2sd 9zt31b69 06Ss01 S££9ShLL©6S NOII--MIS`'M Lf34ffj1twodj £Ss90 Sc',a-SS-" 311 1136 MUNICIPALITY OF ANCHORAGE Development Services Department Onsite Water & 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: Jan 06, 2005 Expiration Date: Jan 06, 2006 Permit Number: SWO50005 Parcel ID: 051-741-62 Legal Descriptbn:-THE TABLELANDS #1 SUBDIVISION BLOCK 9 LOT 8 -- Design Engineer: 0838 North Rim Engineering Site Address: NHN WAPITI CIRCLE Owner Name: AK CUSTOM HOMES Lot Size: 53618 SO. FT. Owner Address: NHN WAPITI CIRCLE Total Bedrooms: 4 Permit Bedrooms: 4 CHUGIAK . AK 99567 - This permit is for the construction of: E 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 specked in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72 ) and Drinking Water Regulations (18AACBO ). 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.) Depth of absorption trenches shall not exceed 1.5 feet below original grade. b.) The upper six inches of the mound absorption field must consist of top soil and be vegetated sufficiently to prevent erosion. V I a�cf, A�r�o�d 'A0 PLA Received By. Issued By. Date: G o. . 2OW AZunicipality of Anchorage J� 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.a nch orag e. ak.us (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. /)57 Permit Number SW /44% 0'!170 ,, gg,'e x Day phone74G7Jy Property owner(s) %AD GST; 3Ef % Ac; —Zip Code / �`�✓� Mailing address ; _116' Code Site address Legal description (Lot, Block & Sub'd.) Legal description (Section, Township & Range) Lot Size 6-3'toAoesl&q-FT. --•-- Number of Bedrooms 14 THIS APPLICATION IS FOR: El Sewer Only Well Only El Sewer and Well ❑ Water Storage Sewer Upgrade ❑ THIS PROPERTY CONTAINS: ❑ Hot Tub ❑ Jacuzzi 11 Swimming Pool ❑ Water Softening Unit Therapy Pool ❑ I 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 aL66rized agent) Permit/Rush Fees: Date of Payment: 17// to lei Waiver Fees: Date of Payment: Receipt Number: �oq� KN Receipt Number: (Rev. 09104) r�1C�INEERIN� NG Tablelands S/D #1, Lot 6, Block 9 SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing: This is a new 4 -bedroom, single family home. This is a new subdivision and the neighboring lots are not yet developed. Groundwater was monitored at 8' below the surface at T.H.1; this will require a shallow septic system to maintain separation. T.H.2 had excellent sandy soil for a leach field. This lot is over 1/2 acre in size and no adverse impacts are expected from development. The neighboring lots are similar. The lots are served by a public water system. No conflicts to the other lots will take place by this septic system construction, since other lots are not yet developed. The easements are located on the drawing and are not encroached upon. An application rate of 0.8 GPD/FT' with 0.87 reduction factor for utilizing a 5' wide trench. Trench Length = 750 FT'/5'x .87 reduction factor = 130.5'; 2 lines @ 66' each. No bedrock was encountered. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations. • Two compartment, 1250 gallon Septic tank, conforming to Anchorage Tank & Welding Specifications, allowing gravity -flow from outlet. • Watertight couplings on inlet & outlet • 5' minimum between the tank and bed. 10' to property lines. • 2' of cover is required for trench + 1 inch insulation board. • Tank & solid pipe must be set on well compacted, stable soil, with 2 inches insulation. • 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. • All cleanouts must extend to at least ground level • Trench to be placed level, minimum of 4' to groundwater, 6' to bedrock from drain - rock • Drain rock to be 1/2 inch to 2'/2 inch screened. Drain rock to be distributed uniformly throughout the trench. • Distribution pipe shall be 4" perforated pipe. • Silt barrier (filter fabric) to be installed above the drain rock or insulation may serve as silt barrier. • Smeared trench sides must be raked or scarified before drain rock placement • Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661, PVC Schedule 40. • Sewer Service Line is minimum 2% slope • Septic Tank to be pumped every two years or when required • Insulation board shall be extruded direct burial polystyrene (Dow Styrofoam HI or equal) • Maintain minimum 10' separation between water line & wastewater system. Septic System Construction Does Not Preclude Adjoining Lots From Sanitation Improvements. T.H Water Key Box 5 T & E Easement 250 Gallon Septic Tang Absorption Trenches Site Flat Terrain DESIGN NOTES: 1. Total Depth of Tren Terrain relatively flc is 4'. 2. Sewer Service Line mum 2% slope. Top of Bluff \ 3. Trench is Minimum 10' from Lot Line. \\ 4. Lots Served by Public ater System. 1' = 40' Ptd �A(ti� NORTHRIM TABLELANDS S/D #1 LOT ENGINEERING -•� LAYOUT 77237 B.ar Pow Ciral. ,. �„ Rlw, Aaska "577 Dabw Will 12/15/04 11 of 4 Eopl. ......• LOT 6, BLOCK 9 R=50.00' L=5236' LQt<51 eF gq, Ely F/ubli �1 .AlEvE,rl 6 M J 225.4' II 1 N 1 ' To of u z � ' 2re_2 1 i W9 ter 0. �.o. PROPOSED WOOD FRAME mOUSE s. 14's, GPRACE E_Ea,,3C7.4 SSG. COR. -307.73' SSE D TAIL 1 1'-30' LNDE ELOPED I-EGEND 8 r C; 4LT:A► wo:,A.Ev • !/a' REOAR i DPECTICM Or DRMKACE ye;lly PO:L cyst P) mtr<LV cxvw- uln IN e f f, Line 49L ➢C :, '••Richard L. Besa•��. �'yfn 4094.5 •'.�•. 5'.+ m 589 �52 01'W 243.9r SURVEYOR'S CFRTMATION 1 UNDEVELOPED �� 3 I eu EE T 0(500 TI AT, HAV4S LDTtUAIEVE3PuAg ANC i PROPSvCN 0(5008MSITUA On M! PLOT P,AN ANO UIE IYPpOy(N:HrS yNAT:O TMER:On ARE LOCATE() AS SWOON ON TNS h01 PLV+. I z EA" T._ NisLo"r Or y 1.1/I�CC 1• c NORTHRIM TABLELANDS S/D #1 S/D a. 9 '.♦ ENGINEERING LAYOUT r 17237 Bear Pow Ch ele •,,, w rerj Eagle R,. Naga 9955 ,,�,•..aa...= L❑T 6, BLOCK 9 12/9/04 12 of 4 I 7 Septiid, I Siry5,t4e,ry EAscu .: , \ Under 1,COns ru(�tn I o I 1 � 16LOCK 9 �. D I I 1 ' 1 t 1 �...0. SE V) z I oz.s* R=50.00' L=5236' LQt<51 eF gq, Ely F/ubli �1 .AlEvE,rl 6 M J 225.4' II 1 N 1 ' To of u z � ' 2re_2 1 i W9 ter 0. �.o. PROPOSED WOOD FRAME mOUSE s. 14's, GPRACE E_Ea,,3C7.4 SSG. COR. -307.73' SSE D TAIL 1 1'-30' LNDE ELOPED I-EGEND 8 r C; 4LT:A► wo:,A.Ev • !/a' REOAR i DPECTICM Or DRMKACE ye;lly PO:L cyst P) mtr<LV cxvw- uln IN e f f, Line 49L ➢C :, '••Richard L. Besa•��. �'yfn 4094.5 •'.�•. 5'.+ m 589 �52 01'W 243.9r SURVEYOR'S CFRTMATION 1 UNDEVELOPED �� 3 I eu EE T 0(500 TI AT, HAV4S LDTtUAIEVE3PuAg ANC i PROPSvCN 0(5008MSITUA On M! PLOT P,AN ANO UIE IYPpOy(N:HrS yNAT:O TMER:On ARE LOCATE() AS SWOON ON TNS h01 PLV+. I z EA" T._ NisLo"r Or y 1.1/I�CC 1• c NORTHRIM TABLELANDS S/D #1 S/D a. 9 '.♦ ENGINEERING LAYOUT r 17237 Bear Pow Ch ele •,,, w rerj Eagle R,. Naga 9955 ,,�,•..aa...= L❑T 6, BLOCK 9 12/9/04 12 of 4 L 0 6 � 3 _U 0 4 U E � Q. 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Ln 6- v d N • °+" J0010:7 i . • P i i'i'i' S❑ILS LOG - PERC❑LATI❑N TEST Date Performed: 10/8/04 Performed For: Rex Turner/ Rick Besse Legal Description: Lot 6, Block 9 DEPTH (FEET> 1 - 2 - 3 - 4 - 5 - 6 - 7 - e- 9 - 10 - 11 - 12 - 13 - 14 - 15 - 16 - 17 - 18 - 19 - 20 - 21 - Organic d'1 Silty Sand • 1• ti V, ~ 4• SP Sand w/Gravel Slope < 5% Groundwater? Yes Depth ieeo Water Depth 13' n..+o, to/iS/nd 1"11 YCI # 1",V.. Date lGross Time Net Tine De th Net Drop 1 10/8 0 -- 4.75' -- 2 10/8 30 30 min. 5.5' 0.75' 3 10/8 35 -- 5- -- 4 10/8 65 30 min. 5.75' 0.75' 5 10/8 70 -- 5' -- 6 10/8 100 30 rein. 5.75' 0.75' Percolation Rate 40 ml /Inch Perc Hole Diameter 6_ Test Run Between 4' and 5' Comments, - Performed By NnrthRim F -ng, I :- Performed Performed in Accordance with All ON THIS DATE. DATE: 10/15/04 NORTHRIM ENGINEERING 17237 Boor Pow Circle Eapis Riw, Alaska 99377 1� a 1 907-694-7028 ' _ CERTIFY THAT THIS TEST WAS e/Municipal Guidelines in Effect TABLELANDS S/D GEOTECHNICAL LOT 6 BLOCK 9 04 S❑ILS LOG - PERCOLATION TEST Date Performed: 12/14/04 Performed For: AK Custom Homes Legal Description+ Lot 6, Block 9 DEPTH 1'1V1 a Date •v. u • • + Gross Time --- _— Net Tine De th (FEET) 1 12/14 0 Organic 1 2 12/14 2 2 min. 12.75' 0.25' 2SP 12/14 5 3 -Sand -- 4 4 -w/Gravel 7V1. 2 min. 12.25' 567 5 12/14 10 -- 13' -- 6 12/14 12 8 - 0.25' 9 - 10 - 11 - 12 - 13 - 14 - 15 - 16 - 17 - 18 - 19 - 20 - 21 - Slope < 5% Groundwater? No Depth Water Depth I .._Il -..1..... Of n„+01 1 /cwnc; MT bCT # 1'1V1 a Date •v. u • • + Gross Time --- _— Net Tine De th Net Dro 1 12/14 0 -- 12.5' -- 2 12/14 2 2 min. 12.75' 0.25' 3 12/14 5 -- 12' -- 4 12/14 7 2 min. 12.25' 0.25' 5 12/14 10 -- 13' -- 6 12/14 12 2 min. 13.25' 0.25' Percolation Rate 8 min/Inch Perc Hole Diameter b_ Test Run Between 3' and 4' Comments:—Pre—SnnkEd Performed By NnrthRim Eng. Performed in Accordance wl n41 TUTQ neTr nnTr1 1/6/05 NORTHRIM ENGINEERING 17237 B,or Paw Circle ;� EOVO Rlw, Alaska 99377 •,•a -sem. 07-694-7028 CERTIFY THAT THIS TEST WAS t/Municipal Guidelines in Effect TABLELANDS S/D GEOTECHNICAL T.H. 2 LOT 6 BLOCK 9 Municipality of Anchorage Development Services Department +.e Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.orglonsite (907) 343-7904 ON-SITE SEWER/WELL SUBMITTAL COMMENT SHEET To: NorthRim Engineering Legal description: The Tablelands Addition #1. Block 9_ Lot 6 The attached paperwork has been reviewed and Is being returned for the following reasons: ❑ Original signature or stamp missing on ❑ Calculation error in design. ❑ Additional soils information needed. ® Water monitoring results inadequate. 6rour ❑ Discrepancy in information submitted. ❑ Topographic information missing or Inadequate. ❑ Incomplete; missing _ ❑ Incomplete; missing _ ❑ Additional adequacy test information needed. ❑ Water sample unacceptable. _ ❑ Measured/proposed distances/dimensions missing. ❑ Locations of all soils, percolation and water monitoring tests not shown. ❑ Proposed system loo deep for soils information submitted. ❑ Well log required. _ ❑ Omission in narrative. ❑ Insufficient fill over tank or field._ ❑ Other. _ Name of reviewer. Julie Makelo. P.E. Date: 12/20/2004 Please supply the necessary information and re -submit your request. LEAVE THIS FORM ATTACHED TO THE PAPERWORK Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 051-741-62 1. GENERAL INFORMATION Expiration Date: ID -2.2 — /w Complete legal description The Tablelands #1 Block 9 Lot 6 Location (site address) 22300 Wapiti Circle, Chugiak, AK Current Property owner(s) Spring Day phone 301-0701 Mailing address Real Estate Agent Hope Russo Day phone 301-0701 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) UBMITTA S L 3. NUMBER OF BEDROOMS: 4 01T,2 42014 A. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ - Community Class C Well ❑ Public Water System TYPE OF WASTEWATER DISPOSAL: Individual Holding Tank ❑ Community ❑ Public Sewer ❑ Received by: Date: ll COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ -5" Date of Payment I 012-q I tt Receipt Number b4k- `2_5? COSA # 05c N 1562 Date of 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 NorthRim Engineering Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date 10/23/2014 6. DSD SIGNATURE System #1 Approved for _1 bedrooms. System #2 Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: By: or Original Certificate Date: The Municipality of Anchorage Devlopment Services Division (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet 9.1-02dac 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: 7fi 7.96LF4Ajds grey ,B% L,6, Parcel ID:05/-7�KI-6Z A. WELL DATA )99&re. W,47-" Well type If A, B, or C provide PWSID # Well Log (Y/N) Date completed Sanitary seal (Y/N) _ Wires properly protected (Y/N) Total depth ft. Cased to ft. Casing height (above ground) in. FROM WELL LOG AT INSPECTION Date of test Static water level ft. ft. Well production g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate mg/L Arsenic ug/L Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEp%/C ZS /SEL Date installed OS Tank size /510—o gal. Number of Compartments z Cleanouts (Y/N) Fnundati on cleannih(Y!N) t/ Depression nye yank l%vrniI � HI... vrnn _ Date of pumping // / Pumper S-A U x77,9�y C. ABSORPTION FIELD DATA Date installed i i%S Soil rating (g.p.d./ftz or ftz/bdrm) O. 8 System type 5'yc�4r-" Length -2 ft. Width 5 ft. Gravel belowpp r e ft. Total depth 2 S ft. Eff. absorption area 750 ftz Monitoring tube Depression over field // Date of adequacy test ZZ Results (Pass/Fail) P For/ - bedrooms Fluid depth in absorption field before test o in. Water added 2 Coo gal. New deptfh--C_ in. Elapsed Time: 30 d min. Final fluid depth Cj in. Absorption rate >= 600 f g.p,d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) _ (/i(/�(, if yes, give date * S O,R(;eWi (L D. LIFT STATION Date installed 3 S Size in gallons 1-506 STEP, Manhole/Access (YIN)_ Pump on" level at !1- - in. "Pump off level at 30 in. High water alarm level at 41S in. Datum Cycles tested 3 Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOTTO: NA. Septic tankllift station on lot Absorption field on lot Public sewer main Sewer /septic service line _ On adjacent lots On adjacent lots Public sewer manholelcleanout Holding tank Animal containment areas Manure/animal excrete storage areas SEPTICIHOLDING TANK ON LOT TO: i Building foundation S�� Property line fD Absorption field Sf Water main �� rf Water service line /O -t Surface water /Do f Wells on adjacent lots 200'7(' ABSORPTION FIELD ON LOT TO: r Property line /617- Building foundation %Q f Water main 6 t r//0"f-�1 �I r Water Service line 1l� Surface water l06 rt Driveway, parkinglvehicle storage 1� r Curtain drain [/AJK Wells on adjacent lots Zoo r� F. CORNMENIS G. ENGINEER'S CERTIFICATION I certify that t 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 S!�✓, ENG Date �Q/ /141 COSA brown sheet_10-10-12.doc Municipality of Anchorage Development Services Department .� Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. 0. Box 196650 Anchorage, AK 99519-6650 N N 7ge.ak.us (907) 343-7904 ICERTIFICATE OF HEALTH AUTHORITY APPROVAL Iry FOR A SINGLE FAMILY DWELLING Parcell.D.��. HAA# flAi�"L8�1 •. ' Expiration Date: �� Aoht�— r'r'' . In �. 1. GENERAG�NFORMATION Completele�bldescr60 13 TffE T,��LFLA�/DJ � aLOCk SOT .. d , I... , . ...• 1 ;Lion oeat......... address o� d'rections)(site ^�'� WiEPiT/ C/ActE Current f'roperty-owner(sj Ak CJSTan f/Q.tt��f Day phone *Wiling address .: D RaJC 04 Lending agency Day phone Mailing address Real Estate Agent Mailing Address Day phone Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual On-site ;R" ❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System es 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 seat affixed hereto and as of the validation date shown below, I verify that my investigation, site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on - 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 Address Fiir�m7 pPhone — 760? Engineer's Printed Name n%EJE E f� 5. DSD SIGNATURE Approved for L— bedrooms. Disapproved. Date Wiz' o a ?'(F.OF•At 4114 . •••. sem.1. 5(evon W. g PE 6256 ti 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: — n Original Certificate Date: (Rev. 01002) 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: LOre Parcel ID: h�1.741 -L�__ A. WELL DATA P0514 C, r,j4r6Z Well type — Date completed Total de/evel Date of Static OvWell pr If A. B. or C provide PWSID # _ Sanitary seal (YIN) _ Cased to ft. FROM WELL LOG Log (YIN) properly protected (YIN) height (above AT INSPECTION ft. ft' 9-p. m g.p.m. SAMPLE RESULTS: colonies/100 ml. Ztof mg.11. Other cteria colonies/100 ml. T_ mg.fl, mple:_ Co ted I B. SEPTIC/HOLDING TANK DATA Tank Type/Materialf%AICHG 5766E Date installed Z4 -6S Tank size Z50C) gal• Number of Compartments Z Cleanouts (YIN) Foundation cleanout (YIN) 4 Depression over tank (YIN) 4� High water alarm (Y!N) Date of pumping /U�f�I� Pumper C. ABSORPTION FIELD DATA Date installed �OS Soil rating (g.p.d./fe or t &—p System type 5/{�9LLaw Ti �tlC ff Length � J Width S ft. Gravel below pipe �_ ft. Total depth % ft. Elf. absorption area _SQ f 2 Monitoring tube Depression over field �_ Date of adequacy test �(/tJ Results (Pass/Faip _� (A% For � bedrooms Fluid depth in absorption field before test _ in. Water added_ gal. New depth_ in. Elapsed Time: _ min. Final fluid depth _ in. Absorption rate >= g P•d. Any rejuvenation treatment (past 12 mo.) (YIN &type) If yes, give date D. LIFT STATION Date installed Size in gallons 1500 Manhole/Access (Y/N) "Pump on" levet at (u in. `Pump off' level at %Q in. High water alarm level at L/S in. Datum 7-,9.V& SOTTD.,, Cycles tested Meets alarm & circuit requirements? —4— E. —E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: PJBUC- w•47�Z Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer /septic servi6e line /adj lots lots manholetcleanout SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation_� r Property line 10 rt Absorption field S Water main /D •� Water service line /d r� Surface water /Q 0 14 - Wells on adjacent lots 00 o '-/-- SEPARATION -/" SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / U 0t Building foundation _ / 41 '4- Water main Water Service line Surface '� Surface water 4 40 F Driveway, parking/vehicle storage ,0 � t Curtain drain &2 Wells on adjacent lots? o * F. COMMENTS G. HAA Fee $ > -'5-0 -� 1-15.°0 (� ►�� Date of Payment�tt ReceiptNumber ZZ r17 LI -1 - (Rev. 12101) Waiver Fee $ Date of Payment Receipt Number ENGINEER'S CERTIFICATION ^ •.•`,,4� tT� r 4� ••• ,�,%� I certify that I have determined through field inspections and P* review of Municipal records that the above systems are in00 conformance with MOA HAA in effect this date. OF `si guidelines on f Engineer's Printed Name 7E50t 4W i "� k• Vi.. .-7S !/� �'l••. PF 6255 Date 4Z!010 t0 �Fp�'••.,. •• , c; \ ~ a HAA Fee $ > -'5-0 -� 1-15.°0 (� ►�� Date of Payment�tt ReceiptNumber ZZ r17 LI -1 - (Rev. 12101) Waiver Fee $ Date of Payment Receipt Number I 1 1 1 1 R=50.00' L=52.36' :Ec 1 I' -r' 1 I I 1 I I I 1 6 2' C1. ILCA� WK-.0IEnT j 1 I N 1 1 • did' I-IUAk NOTES ;u Z.6 - 3: i i3 9 [• I G E _e C• k�y'n, CC `� N r r• F0,P%DAT ON CrFTAl.. 1" 243.97' 3 C S -..y • 1'� fI iV CHi'U .I -I J r. Ul l•L':+ I:r ,1'. n Ic Y_V •• T -,T 7.1A•: L'C^: 'C'I it -:.•T ViE15 !'_ :V. J''i'2v :J(rJNli Ar7 Zn\nC C•1 ♦,1 FZS • ^_r i!' .°C•.59� l7 ° Al Cf? 1' .ffi "'f A. r-.:. AS-i4J MC`R :1B a TC %A'.:.1 '• rYG'4'.•r C!3:• st-. �..:♦ •Lrev cc T> NE c:C:F: i7, "L<- CJ;:P )r. 'S.Y 9•R:Y_ N9'rlwlr 1. •C:O•?EC •M.:• r] C• �•-[• irC SVG Ur rl•t •[L:•C PC -------- f. RIPTrFTff`-S CER-IFICATION . •1 r''[r+'Er C_aT `Y r�<r 1 ..<It 5�a,clEc `t: rrscfrr :r: r' c J <--w1 A II.9:•;'.C•r _•.-j !I•:,TE= Tom. TW �c7a^CCATC J ." l •'_ S-Ilr7� CI -4S A7-CL.f !i. rJ n.'•f7 EAY LOT 6, BLOCK 9 > • 1 'E THE TABLELANDS SMDIYASION. PLAT err 4_..• ADOITION No. 1 "L. 6 2' C1. ILCA� WK-.0IEnT N y} r • did' I-IUAk C[?rCTC't flr :F. -Ai U% -l' N C Y-3JY A'40 C- 'd� _ _ �/C i'IL•J ACCT.,C 19ES rn 'ai 4.4 .. IS'4 r I{ t rC L. Hesse 4✓ 4tr)4-,Ct,= 243.97' 3 C S -..y • 1'� fI iV CHi'U .I -I J r. Ul l•L':+ I:r ,1'. n Ic Y_V •• T -,T 7.1A•: L'C^: 'C'I it -:.•T ViE15 !'_ :V. J''i'2v :J(rJNli Ar7 Zn\nC C•1 ♦,1 FZS • ^_r i!' .°C•.59� l7 ° Al Cf? 1' .ffi "'f A. r-.:. AS-i4J MC`R :1B a TC %A'.:.1 '• rYG'4'.•r C!3:• st-. �..:♦ •Lrev cc T> NE c:C:F: i7, "L<- CJ;:P )r. 'S.Y 9•R:Y_ N9'rlwlr 1. •C:O•?EC •M.:• r] C• �•-[• irC SVG Ur rl•t •[L:•C PC -------- f. RIPTrFTff`-S CER-IFICATION . •1 r''[r+'Er C_aT `Y r�<r 1 ..<It 5�a,clEc `t: rrscfrr :r: r' c J <--w1 A II.9:•;'.C•r _•.-j !I•:,TE= Tom. TW �c7a^CCATC J ." l •'_ S-Ilr7� CI -4S A7-CL.f !i. rJ n.'•f7 EAY LOT 6, BLOCK 9 > • 1 'E THE TABLELANDS SMDIYASION. PLAT err 4_..• ADOITION No. 1 "L.