HomeMy WebLinkAboutEARL RAY BLK 3 LT 37Earl Ray
Block 3
Lot 37
#051-113-17
MUNICIPALITY OF ANCHORAGEn pE HEALTH T If �:
�
DFTMENT OF HEALTH AND HUMAN SER ES L►wIRONMEMK PROTECTION
& roN
• - Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 Nov 10 �pC
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT �R7:
Name 't DISTAN
Add eaa /I r t TO SEPTIC ABSORPTION
WELL
P013 67/0.6 C,4,,q/4/r {}/r Qqr
pnone(sl Ipermlt No. INo of B
68B'-3760 3
LEGAL DESCRIPDON
Lot 737 1
blocs SUbmYI$,On
3 E4 r / R4Ty
Township, Range. Section
--- r/s /✓ /L /w Se. t, /0
TANKS
X SEPTIC ❑ HOLDING
Manotactorer Lapaoty In gallons
Grt�r /oov
total absorption area Distance between lines
675- SOFT 6",w, Qti( FT
N°mCer 01 ones Sal raging 1; a material
-3 /.%SO FT *rY.• .7e.7
mslale, Date lnstaneol
%/.4/e Gr JILL, /o/06
WELLS
❑ PRIVATE D� OTHER (Identily)
Gussd�uou0 (A.B.(:f Total Deptn Gsed to
I N
i1 FT FT
Ins'aeal I Date Installed
REMARKS:
S.,/ Jii; 7`�, 45-11 4VeoP. 73
%rH t
eG<Yiia
An a,i I *h-- A'ar
FROM
TYPE OF SYSTEM
FIELD
❑ TRENCH 6'c
BED
❑ W. DRAIN ❑ OTHER
Depth to vNe bottom from
Total depth from anginal grade
6,$- /
original grade7
/ '�1 FT
FOUNDATION
8 FT
Fill Wo tt •Love ougmal grade
^/lf
Gravel oepth beneath pipe
O FT
6 i,
Grave, leng:n
Gravel w.dth
Beal 1LwS>`A =
3 7= FT
geo(
FT
total absorption area Distance between lines
675- SOFT 6",w, Qti( FT
N°mCer 01 ones Sal raging 1; a material
-3 /.%SO FT *rY.• .7e.7
mslale, Date lnstaneol
%/.4/e Gr JILL, /o/06
WELLS
❑ PRIVATE D� OTHER (Identily)
Gussd�uou0 (A.B.(:f Total Deptn Gsed to
I N
i1 FT FT
Ins'aeal I Date Installed
REMARKS:
S.,/ Jii; 7`�, 45-11 4VeoP. 73
%rH t
eG<Yiia
An a,i I *h-- A'ar
FROM
TANK
FIELD
WELL bis, sr
t ;L00 /
0".20.0 /
LOT LINE
6,$- /
-31,11
Al4
FOUNDATION
1,
26 01
^/lf
AS -BUILT DIAGRAM (Snow location of well. septic system. property lines. lounoation.
drwewav water coolies- etc I A/Tt
/
e
L
Scale: x - '� „:.ENGINEERS SEAL
Inspections Pedormeo by,. -
Eagle RiverEnglneerin Services' ;s> ;a••`"• '
. Box 773294 !"�^ '�: i. •,J j „';., ,
D°1B Eagle River, AK 99577 _ `
894.5195 •/ �~' `*'C,--� �� e..:io--•••0:00:':1
I eeNly that this Inspection was perlormed according to all L4 ,"�; ': Louts A. ^_urora • a /y�; /
/ b6 �� •.ct ors ,
Municipal and State guidelines in ellen on this dale: •
� • J , P• •,•'
Health Department Approval: Date://—/3 _86 ���.::�,;;.:-''•
,,-um L.pop)
1`IIJN I C I .:AL I 7"Y OF= ANCI-iS�f2AGl=
DEPARTMENT HEALTH AND ENVIRONMENTALOTECTION
825 L STREET, ANCHORAGE, AK 99501
264-4720
ON—Eu I TE SEW1 --- FR F---EF-ZM I T
PERMIT NO: 860307 ENGINEERED DESIGN /Jji
DATE ISSUED: 08/25/86
APPLICANT: KURT K.OHLER / ERES
ADDRESS: PO BOX 671026
CHUGIAK, AK. 99567
CONTACT PHONE: 688-3760
LEGAL DESCRIP: SUBDIVISION: EARL RAY LOT: 37
SECTION: 10 TOWNSHIP: 15N RANGE: IW
LOT SIZE: 41310 (SQ.FT. OR ACRES)
BLOCK: 3
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 DATE:
APPLICANT: KURT KOHLER / ERES
ISSUED BY DATE:
Z'sa�� /7.,— ���l,:ro( ,lei/,vim y.-,rurl !�-•
MUPA I C I PAL_ I TY OF 9=&P4r_-" MF:ZAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK 99501
264-4720
C]N—S I TE SEWSF:
PERMIT NO: 850422
DATE ISSUED: 07/18/85•
APPLICANT: KOHLER CONSTRUCTION
ADDRESS: P O BOX 67-1026
CHUGIAK, AK 99567
CONYACT PHONE: 688-3760
F}EF1M I -7-
LEGAL
LEGAL DESCRIP: SUBDIVISION: EARL RAY LOT: 37
SECTION: 10 'TOWNSHIP: 15N RANGE: 1W
LOT SIZE: 1.25A (SO.FT.•OR ACRES)
LOT LOCATION: SKI ROAD
MAX BEDROOMS: 4
Listed below are the options available to. you in designing
system. Choose the option that best fits your site.
BLOCK: 141,
your septic
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
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 MDA 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.
4. I understand that this permit is valid -for a maximum of 4 bedrooms and
any enlargement will require an additional permit.
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.
SIGNED9Gh/�i��_JC_GC/v--------------- DATE:
APPLICANT: KOHLER CONSTRUCTION f� L
ISSUED PY DATE: �8 _ 8r
------ ----------------------------- a -,F--
1s
13EI7
W _ DFtiA I N
DEPTH TO PIPE BOTTOM (FT.)
4.0
4.0
GRAVEL DEPTH (FT.)
0.5
3.0
TOTAL DEPTH (FT.)
4.5
7.0
GRAVEL WIDTH (FT.)
18.0
5.0
GRAVEL LENGTH (FT.)
34.0
47.0 .
GRAVEL VOLUME (CU.YDS.)
22.7
30.5
TANK SIZE (GALS)
1,250.0 **
19250.0 **
SOIL RATING (SO.FT./BR)
100
100
BLOCK: 141,
your septic
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
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 MDA 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.
4. I understand that this permit is valid -for a maximum of 4 bedrooms and
any enlargement will require an additional permit.
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.
SIGNED9Gh/�i��_JC_GC/v--------------- DATE:
APPLICANT: KOHLER CONSTRUCTION f� L
ISSUED PY DATE: �8 _ 8r
------ ----------------------------- a -,F--
1s
W0
ZY
-^ yc•sa�
choradz
January 10, 1986
TO: Permit Applicant
r"\
P.O. BOX 6650
ANCHORAGE, ALASKA 99502-0650
(907) 264-4111
'ova r.vJ.:�6s.
DEPARTMENT OF HEALTH 6 HUMAN SERVICES
Subject: Permit l 850422
Lot 37 BLock 3 Earl Ray Subdivision
A permit issued by this Department for an individual well and/or on-site
sewer system has expired as of December 31, 1985.
Permits are issued on a calendar year basis by authority of Municipal
Ordinance. A new permit must be obtained from this Department for any
well and/or on-site sewer system not installed by the expiration date.
If you have drilled the well, a well log needs to be sent to this
Department for documentation of the installation and to close the permit.
If a private engineer inspected the installation of the on-site sewer system
the original as -built inspection report(three part form) must be sent to
this office for review and approval,and for documentation.
If there are any further questions, please call this office at 264-4720.
Sincerely,
a
Susan E. Oswalt
Program Manager
On-site Services
SEO/ljw
enc: Copy o Permit
M�N1Ccpto tom` r��tF�tON
.f
` .01
Ra
B9. B0 / � ab yI'• i
• L� E , ret �, .� I
�rt(R
M
`W \ RESER✓. /! ` •y
X AREAPA
)�
�� \ � ♦` /� Bad !8 XSa • I
0 SG Q
v+ >.S / fsrfr I Q
T \
fill
OF .41t
�11•sl. � "CV v �
a. o
Gf d , rr •• A'?
7 •, 4
64.0 ..... -am- O.F...4C
• ..q\se; to• . "
I
^'?•W"Iliam McClintock'��ir*?,�� f�`r ••�••�,�,
ad r `fi% No. LS s no / �: ,�. T:1 i44 �I ~• a..,�
•` c • v i/ /. ••. •.• •• • q
0Ff 310,00.
AiO•fb\•L� 4: : Q•✓p pre.., ..t
c Louis A. Bufara
./i' •.
CE-6736 1
O•,••..•.•••,••�F<=,� *septic plan only
I hereby certify that LOT 37 , BLOCK 3 MCCLINTOCK
F.9,04 -�019y 'Su3D/✓/sib ✓ LAND SURVEY COMPANY
anchorage Recording District, Alaska, has been surveyed by me and P.O. Box 671089
that no encroachments exist except as shown hereon. It is the Chuglak, Alaska 99567
esponsibility of the owner to determine the existence of any
casements, covenants, or restrictions which do not appear on the
ecorded subdivision plat. Listed distances prevail and scaling
should not be attempted to determine unshown dimensions. This Phone (907) 688.4499
survey is not adequate for, nor should It be used for
establishing boundary or lance lines.
CatE X$- SG DRAWN BY 13M JOB NO. 940--/4/ GRID A/l✓i3G0 FIELD BOOK d64:-43 SCALE 4>
MUNICIPALITY OF ANCHORAGE
*11W
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street. Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
X SOILS LOG
❑ PERCOLATION
TEST
PERFORMED FOR: %'� O ICr Loa.r rte°.. -moi ^. DATE PERFORMED: ZO�/�i16
LEGAL DESCRIPTION: L 0t 3-7 131,0(3 i�54 r/ Re. y 7 -/S -,,v %Q/6J ,SGc , 1O
ru SLOPE 7 SITE PLAN
2-
3-
4-
5-
6-
7-
8-
9-
10-
11-
3 4 6789 10 11 . 0
12-
13
2
13
Tates.; /
(G r)
Tref P...aj S..•L•.•(
WAS GROUND WATER
ENCOUNTERED?
NO �
O 1. JG
ij IF YES, AT WHAT E
60 tY.^ DEPTH? c/4 lF
14
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
15
i 'l
17s
18j M ; La -.:s A. :wrc
J n a_ CCK 136
19
20
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
0,;.+(
P6Aetmi UN RATE /S
- O ft/Zi4sP-hn'rnw.,Snch)
EST RUN BETWEEN FT AND FT
COMMENTS Sii/ Zof ::;,Z,f�i'..TL dG,,r Lr a cc4e 7Y.,a., 47" Bum
Eagte River Engineering Services
PERFORMED BY: CERTIFIED BY: DATE: /��•%���
Eagle River, All 99577
694.5195
72.008 (6/79)
r1
X SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
825 L Street, Anchorage, Alaska 99501 264720 TEST
SOILS LOG — PERCOLATION TEST
PERFORMED FOR:
/7e.? IG
Gross
Time
DATE PERFORMED: 71 /e/`Fx-
Dep In to
Water
13
14
LEGAL DESCRIPTION:
he7° 37
B3 Fo/`l .0ak .,
_5*— T/cn/ xP/ui Sri /O
1
2-
3-
4
3 4 -a .
5
`O
6
7 so
n;
6 0-
4a t
97Dr�
10 ,
11 o
Tpra;l - o.e"A.PIC
We& -% 4,1
/co ¢
12
Date
Gross
Time
Net
Time
Dep In to
Water
13
14
Oc A
�
Jr
IV
�( .........•
Y
15
16
Veto •
...
17
9t
(?� .
18
CE -6736
, %R0FES Of 55
V
19
WAS GROUND WATER
ENCOUNTERED?
8�Y'9rG IF YES, AT WHAT
DEPTH? n,i ;'
SITE
Reading
Date
Gross
Time
Net
Time
Dep In to
Water
Net
Drop
20 -{ I PERCOLATION RATE l''_.. _� •. (minutes/inch)
'UI TEST RUN BETWEEN FT AND FT
COMMENTS a44.
Eagle (liver Enllneerlin Services Ll
PERFORMED BY: P. 0. Box 773794 CERTIFIED BY: A*^ DATE: % /,11FJ'
- Eagle (liver, AK 99577 br'�ia/J6
694.5195
72-009 (6/79)
r-'
n
EAGLE RIVER ENGINEERING SERVICES
P.O. BOX 773294
EAGLE RIVER, ALASKA 99577
694-5195
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL: Lot 37, Block 3, Earl Ray Subdivision
A. GENERAL
1. The septic plan are for single family residence use only. 2.
2. The drawing and or site plan shall be a part of this specification.
3. All materials and workmanship shall meet the requirements of
the Anchorage Department of Health and State D.E.C..
4. All soil tests are advisory to the design and are to be
verified or modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified or
modified in the field by the contractor to meet MOA, D.E.0 require-
ments.
6. It is the responsibility of the owner to obtain all necessary
permits or easements and to locate any adjacent multi -family wells.
7. It is always recommended that a surveyor locate the nearest lot line
position and the location of any easements.
B. DRAINFIELD
1. The drainfield is to an absorption bed with 2' sand filter.
2. The bottom of the bed shall be level, plus or minus 1.5."
3. The total depth of the bed is to be no more than 8' below ground
surface at monitor tube location. The bed should be excavated 2'
below the gravel depth and backfilled with sand designated filter
sand.
4. Soil or combination of soil and extruded board insulation to a depth
of 4' or equivalent is to be placed over the trench.
5. The area over the trench is to be finished graded to prevent ponding
of surface water runoff.
6. The septic tank and leachfield must not be closer than 100 feet to
any existing private well, 150' to any Class "C" well, or 200 feet
to any community well.
BED DIMENSIONS
;BED TOTAL DEPTH= 5-8'
BED WIDTH= 18'
BED LENGTH= 32' 1r7GQ
BED TOTAL SURFACE AREA= 563 SB. FT.
GRAVEL DEPTH= 6" under pipe/2" over
SEPTIC TANK SIZE= 1000 gallons
2' Sand filter required under bed
•
1:1 °A c-� Municipality of Anchorage
JOn-Site Water and Wastewater Program
/ (907) 343-7904 'i
S n r r r
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
113
Parcel I.D. 051-x,22-17 Expiration Date: 7r2,7-tg
1. GENERAL INFORMATION
Complete legal description EARL RAY SUBD. BLK 3, LOT 37
Location (site address) 23936 SKI RD CHUGACH AK
Current Property owner(s) Day phone
Mailing address SAME
Real Estate Agent Day phone
<-7, 34S6
7/.
2. TYPE OF DWELLING:
rv,® Single Family (w/wo ADU) , o❑ Duplexr l
❑ Multiple Dwellings (Single Family and/or Duplex) o cf. ) 3a
3. NUMBER OF BEDROOMS: 3 ��9 s 7 E Z \z,a
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class A Well ® Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
• ,1001111111 •
Received by: A- 4 _,_ _ Date: I Q:
COSA to be released to the engine-less otherwise requested by the engineer.
COSA Fee $ �Jo — Waiver Fee $
Date of Payment f gill fl Ck (oag-2 Date of Payment
Receipt Number ‘Lt -1-1 Receipt Number
COSA# OSC("JI 33 L 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 MIKE N ANDERSON. P.E. Phone 727-8864
Address 4661 NATRONA AVE.
Engineer's Printed Name MIKE N ANDERSON, PE Date 8/3/17
armt'' p• '°
�•! ! •"• {^
(0/ .' ti�..�• °
-,'r•',•9-F t%//� ;et
•°J a•tiV ! .• • f.
6. DSD SIGNATURE y'." r;vCHAEL N. ANDERSON
t1-5;• CE 9469 ,••
System •
#1 Approved for bedrooms. I, � //
System #2 Approved for bedrooms. �',.eisi;rs�s�L'' y�
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
EneriC- C ---("°(-tvt S e61.5'..°0-V.,_C/C:(-,",
1 .kreA,6.9_to
� c
k 6-e ,Z)\ QCjeay‘c 3 ON-SITE SG;
VUAT E R A N U r"`
VVASTEWATER cI
`; PROGRAM
B � ._ Original Certificate Date: —2-ti
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheer 0-t0-t2 doc
r
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: EARL RAY SURD. BLK 3, LOT 37 Parcel ID: 051--132-17
A. WELL DATA
Well type CLASS A If A. B. or C provide PWSID# Well Log (Y/N)
Date completed Sanitary seal (Y/N)— Wires properly protected (YIN)
Total depth _ft. Cased to ft. Casing height(above ground)
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 SEPTIC/STEEL Date installed 10.86
Tank size 1000 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) NA
Date of pumping 7-27-17 Pumper Alaska Quality Pumping
C. ABSORPTION FIELD DATA– 1985 SYSTEM TESTED
Date installed 10-86 Soil rating (sf/bedroom) 150 SF System type BED
Length 37.5 ft. Width 18 ft. Gravel below pipe 0.5 ft.
Total depth 7.6 ft. Eff. absorption area 675 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 7/27/2017 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 2 in. Water added 500+ gal. New depth 6 in.
Elapsed Time: 1440 min. Final fluid depth 2 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) UNKNOWN If yes, give date
• M
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YIN)
"Pump on" level at in. "Pump off" level at in.High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer/septic service line Holding tank
Animal containment areas Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5' Property line 5' Absorption field 5'
Water main 100'+ Water service line 25'+ Surface water 100'+
Wells on adjacent lots 100'+AND 200'+ FROM CLASS A
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10 Water main 100'+
Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+ (None Known) Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION yt�,ttia�d
OF Ain.1
1 certify that have determined through field inspections and •. ...is-
review of Municipal records that the above systems are in r Lj•• •q
conformance with MOA COSA guidelines in effect on this date. ' ;•497 A •• *111
Engineer's Printed Name MIRE N. ANDERSON, PE
Date 8/3/2017 MICHAEL N. ANDERSON ;4�
i•, CE 9 69 ' .
+•
COSA canary sheet_2-6-15.doc
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
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 0S/- /f3 - 1-1 HAA# 1)5n5q.'
Expiration Date: . / / - Z - D G
1. GENERAL INFORMATION
Complete legal description ;
Location (site address or directions) .R 3 9 3(0 5L; '<d.
Current Property owner(s) _4nnq Taylor r, Marcys ltAtii Day phone 34:; - 81a,5
Mailing address
Lending agency
Mailing address
Day phone
Real Estate Agent tludn
arta aan-
Day phone
3344
4r-
Mailing Address get -
Mau of
F!aat,c. J;_';✓ ,L -
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
a
Individual Water Storage
❑
Individual Holding tank
❑
Community Class A_ Well
Q�
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. 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
Eagle River Engineering Services Phone V74 5195-
1 D421 VFW Suite 20 1
,
Address EaoleRiver, AKsa5n
Engineer's Printed Name (lariSboghfr- A?• 1)ood Date C) l;L'r l05
5. DSD SIGNATURE
_L� Approved for _ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
u(()
Additional Comments : • Ole�ff— m-_
WASTFWATFR c
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date:
(Rev 01102)
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: CoL ✓ RA v Z a / 37 , /310 e It 3 Parcell
A. WELL DATA
Well typelf lass fi N
LOmWvrni'fJ
Dale completed _
Total depth ft.
Date of test
Static water level
Well production
WATER SAMPLE
Coliform
mg./I.
If A. B, or C provide PWSID # _ Well Log (Y/N)
Sanitary seal (Y/N)
Cased to ft.
05'/- //-3-/-?
Wires properly protected (Y/N)
Casing height (aboveyre d) in.
FROM WELL LOG AT
S� li
ft. _
g.p.m. _
JL
es/100 mi. Nitrate mg./I.
B. SEPTIC/HOLDING TANK DATA
ft.
g.p.m.
Other bacteria - colonies/100 ml.
Date of sample: _ Collected by:
Tank Type/Material '.rem -e 15 -t -La Date installed /01('b
Tank size Jri= gal. Number of Compartments Cleanouts (9N) ulr-�
Foundation cleanout ON) °' Depression over tank (Y(q)t� High water alarm No
Date of pumping 9/ 19 f OS a Pumper J# 's -Pi,rn,Pi"5
C. ABSORPTION FIELD DATA
Date installed /0196 Soil rating (g.p.d./ftZ or ft /bdr 0 System type WA d
Length 37.5 ft. Width 19 ft. Gravel below pipe
Total depth -_ ft. Eff. absorption area (e"IS ftZ Monitoring lube 14j,,4. Depression over field Y1 0_
Date of adequacy test &1'91040t; Results Fail) For 8_ bedrooms
Fluid depth in absorption field before test 0 in. Water added gal. New depths in.
Elapsed Time: 30 min. Final fluid depth Zr in. Absorption rate >= 45'0 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y& type) `11 &U ICnOWvt If yes, give date n/a
D. LIFT STATION
Date installed
"Pump on' level at_ in.
Datum
Size in gallons
'Pump off" level at_ in.
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT
Septic tank/lift station on lot
Absorption field on lot
Public sewer mai
service line
Manhole/Access (Y/N)
High water alarm level at
Meets alarm i requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 415 Property line y S 1 Absorption field 4457,
Water main + f 0 ' Water service line -to' Surface water -too
'
Wells on adjacent lots +•t00 ' 1v PWJIt C aura +2L.0 '0 Cc) `. kA.M NCU-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line + in' Building foundation 4 t0 ' Water main + t 0'
Water Service line + t0' Surface water +100' Driveway, parking/vehicle storage '15 '
Curtain drain +5'0 t Wells on adjacent lots + 100 7v pRaJA�,"5 UtecLS
+ZGU 1V C0.UW-#":,q 01L`,—
F. COMMENTS _mldme__
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 cmer"ifek 2. tnbr�
Date 9 %Z74T
HAA Fee $ 7' P
Date of Payment
Receipt Number����/
(Rev. 12101)
Waiver Fee $
Date of Payment
Receipt Number
in.
A�
A
8
ASBUILT SEWARD & ASSOCIATES LAND SURVEYING 694-0829
1 HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE'
FOLLOWING DESCRIBED PROPERTY:~�
c an��9l�ta� �r.f!� a% OF At t►
AND THAT NO ENC�OACHMEWTS�7BEXIST EXCEPT AS DATE
INDICATED. IT IS THE RESPONS13ILITY OF THE � y;'4 , `�� •:"A •
OWNER TO DETERMINE THZ EXISTENCE OF ANY GRIDS ••••••• .s
EASEMENTS, COVENANTS, OR RESTRICTIONS if/ly/_�S�jo
� —
WHICH DO NOT APPEAR ON THE RECORDED SUBDI- "
'� • • : D.sn. Mer4 S.v srd /
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD F& 1 •, is -avis
ANY DATA HEREON BE USED FOR CONSTRUCTION If y��
OF FENCE LINES, OR FOR ESTABLISHING BOUND— DRAWN �A\ 's.xult��"r
ARY LINES. j e�*gwwr �•
09/20/2005 07:49 9073449821 JRS SEPTIC PAGE 03
JRs Pumping
PO Box 773415
Eagle River, AK 99577
(907) 694-6454,
riiiirp iniorinetio� , J
Eagle River Engineering
10421 VFW Rd Ste 201
Job Description: 0009
P.O. Number.
Service Agreement
Number:
017869
Order Date:
16 -Sep -2005
Service Dale-
1"ep-2005 12:00 em
Technician:
Tony
Ea& River, AK 99577
Terms,
Nat 30
(907) 094-5195
Saiesrep:
Kadla
Job Typo Repeat
Map Book:
Map Grid: 29
•— -- • --• - , -'
IJob Sha Intarmallon
— "'1 Cross Streets:
J
Old Glenn Mvy
_ — ...._.
Chris -- — •- -• •-~
. Job Comments:
ILeei 8ary 09/15/05
6009 (Solids)
2900 Ski Road
Chugiak. AK 99567
(907) 694-2979
Service Type
Soptic Service 15K
1 Hr 112 Extra Time
Additional Location Comments7
cedar aided house wheddish trim
Tank ® ground level
IPer Chd3! Repump 09119
Was able to remove remaining solids
Tax Percent:
0 _ _ _
Oty Price Each x 2 Men Tax _ - — -•__ "Extension
1 $160.00 No No $180.00
Actual
Diagram: Gallons Planned: 1000
DW - - l Gallons Actual;
Hose Length: 4
Doubie Tank: [ I
Yawed Yasd PUMP System:
H Doi 021les Inlet:
Care Amis Baffles Outlet: LI
Tart Deck
NonTaxebleTotel Taxable Total Tax Total Grand Total
Estimated Charges: 5160.00 50.00 $0.00 $180.00
Actual Charges:
Cuslomer &gross to the terms and conditions of this service agreement. THIS IS A BINDING AGREEMENT.
Signature and Title of Customer Representative Date
Accepted by JRs Pumping Date Accepted
For your added convenience we accept American Express, Dicever. Visa and Master Card payments over the phone.
After 30 Days accounts win be turned over to coll&Ctidna. $25.00 For NSF Checks Retumed.
MUNICIPALITY OF ANCHORAGE
• ^' DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # _OELLI —/;7
1. GENERAL INFORMATION
jjjh /f6cd/vtb1 i3y;
as
II�S�lvj
Completelegaldescription Lot 37, Block 3, Earl Ray Subdivision
Location (site address or directions) 23936 Ski Road
Propertyowner Kurt & Catherine Koehler Day phone 694-3760
MailingaddressP_ 0 Box 671026, ChuQiak, AK 99567
Lending agency Residential Mtg/Jim DiMaggio Day phone
222-8800
Mailing address_ 1400 West Benson. 2nd Floor. Anchora8e, AK 99503
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well
Community well XXX
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest -
Ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XXX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72.Mo5 ft.1/91) front MOAS21
5.
A
M
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 furtherverifythat 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.
5 8 5 ENGINEERING Phone G q y- a h 7`�
Name of Firm 17034 age Iver Loop Road No. 234
Address Eagle River, Alaska 99577
Engineer's signature
DHHS SIGNATURE
_IG Approved for THISE E bedrooms.
Disapproved.
Conditional approval for
Additional Comments
•
Date
E OF
ROBERT C COWAN 1 WQ
1 :� CE -8801/4_,
rttlliJF�,v�c
bedrooms, with the following stipulations:
Date 11— T-1!7
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 satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions In the professional engineer's work.
non fp«. Vail B. MOAm
htCE{Vt'
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES NOV 03 1999
Environmental Services Division
825 L Street, Room 502 •Anchorage, Alaska 99501 • (90
-N 1MX �:K'a KES DIVI510N
Health Authority Approval Checklist
Legal Description: ��LECK3��-�9CL A s�Parcel I.D.: Osr^//3 /
A. WELL DATA
/J 0&4ss f�
Well type C -OHI IIA11Ty 110 13, or C, attach ADEC letter. ADEC water system number --Z/07-L78
Log present (YM) Date completed
Total depth Cased to Casin ght (above ground)
Sanitary seal (Y/N) W s property protected (Y/N)
FROM WELL LOG AT INSPECTION
Data of test
Static water level
Well production g.p.m. g.p.m.
WATER SAMPLE RESULT .
Coliform Nitrate Other bacteria
Date of sam Collected by:
B. SEPTIC/HOLDING TANK DATA
Data Installed i0 Tank size /DDO% Number of Compartments —'? Clean0ut3dj1N)e---S
Foundation cleanout (ON) %5 Depression (YAjam! _ High water alarm (YM)
Date of Pumping 1L- Pumper Sa`nlifl9�i_Y
C. ABSORPTION FIELD DATA
Date installed 10 Soil rating (g.p.d./ft° � System type Fz--n
Length F� " L -'Width / R / Gravel thickness below pipe Total depth 9
Effective absorption area Monitoring Tube present 69Pq S Depression over field (Y/&
Date of adequacy test /O Result t -i Fail) �gss For %H -L& -E bedrooms
Fluid de In absorption field before test in. ; �/
depth rpti ( ) � Immediately after gal. water added (in.): �• +-
Fluid depth YZ & (ins) Minutes Tater. /0 Absorption rate =g.p.d.
Permdde treatment (past 12 months) (Y/N) Nao;jE- "OVAl If yes, give date
72.026 (Rev. 3198)'
D. UFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at'
`Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/hoiding tank on tot �141,U V / t'`t A16 -C.(/ 1'`t A1G2(, On adjacent lots
Absorption field on lot
Public sewer main
Sewer /septic service line
On adjacent lots
"Pump ofP level at"
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation �4- Property line �'- Absorption Held
Water mainlservice line /O = Surface water/drainage BOO �< Wells on adjacent lots �O
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
i
Property line/fib /f Building foundation /O /'f Water main/service line /0 r
Surface water le67 /f- Driveway, parking/vehicle storage area
Curtain drain Of\/e- Af�ICWA/ Wells on adjacent lots :z6y-3��
F. ENGINEER'S CERTIFICATION
1 certfty that 1 have determined thru field inspectlons and review of Municipal realr the abQpB gtpms are
In conformance���0elines in effect on this date.Alf
Signature
l�
Engineer's Name Qahticr C. Ce>m7., �'� •acorn C. Cew�a I Q
CE- 1-
Date I,l 1 g� ,tri ..,
t
HAA Fee E goo
Date of Payment I ( - 3
Receipt Number �����1�
72-026 (Rev. 3/98)"
Waiver Fee $
Date of Payment
Receipt Number