HomeMy WebLinkAboutTONJESS ESTATES BLK 3 LT 18Tonjess
Estates
Block 3
Lot 18
#051-832-07
www.sullivanwaterwells.com
Pump Installation Log
Well Drilling Permit Number: SW Date of Issue
Parcel Identification Number:
Legal Description Property Owner Name & Address
Tonjess Estates Block 3 Lot 18 Thom Miller
Pump Installation Date:
2-7-19
Pump Intake Depth Below Top of Well Casing:
110 feet
Pump manufacturer’s Name:
F&W
Pump Model:
4F11P05305S
Pump Size:
1/2 hp
Pitless Adapter Burial Depth:
10 feet
Pitless Adapter Installer:
Unknown
Disinfected Upon Completion?
yes no
Method of Disinfection:
Chlorine 50 PPM
Comments:
Pitless Manufacturer: Unknown
Pump Installers Name:
Sullivan Water Wells
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Municipality of Anchorage Page of
' DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: SW 9800'f0 .ACAS PID Number: 05/8320-7
Name:1114xkv&11f 1)4nifllc {Merr
11Wastewater System: gNew Upgrade
Address: q20 qejVik S 11r1i. k'qq,57Lr
ABSORPTION FIELD
Phone: un – ob�
70
No. of Bedrooms:
J<Deep Trench ❑Shallow Trench ❑Bed ❑Mound ❑Other
LEGAL DESCRIPTION
Soil Rating:
Total Depth from original grade:
C`i. S GPD/S Ft.
2 F
Lot: Block: Subdivision:
•
/8 3
Depth to pipe bottom from original grade:
Gravel depth eath pipe
pen
Tcn S As76 CS
Ft.
Ft.
Township:'
Range: / W
Sec:tion'
!
Fill added above original grade:
O
Gravel length:
,5.
Ft.
31 Ft
WELL: (New ❑Upgrade
Gravel width:
Number of lines:
Distance between fines:
Ft.
7 Ft.
NIA Ft.
Classification (Private. A,B,C):
Total Depth:
Cased To:
Total abso 'on a: 11,Pip?,
material: PSMSO'c
Pr•/V4Iff
12& Ft.
Ft.
7 6 So Ft
y' PVc p-3o3y
Driller.
Date Drilled:
Static Water Level:
1
Installer.
Date Installed:
L n/E Dk1LJ.1A
5-27-9/o
Z-7 Ft.
CCG CONST2✓LT/ON
y- 1&-99
Yield: 3•S S•Z7•Y6
Pump Set atCasing
Height Above Ground:
TANK
S'L-O6 GPM
I2Z Ft.
Ft.
SEPARATION
DISTANCES
KSeptic [3 Holding ❑S.T.E.P.
To
Septic
Absorption
Lift
Holding
Nbliemrivats
Manufacturer.
Capacity In gallons:
From
Tank
Field
Station
Tank
Se ,Linn
11A.16t1612 IE ThNK
G70
Welh138
H
� So,
N/A
k/A
l35
Material:
STEEL
Number of Compartments:
Z..
Water
NIA
—
—
—
—
LIFT STATION /V/4
Lotl
Line
55LJ
J
3� r
N
Size in gallons:
Manufacturer.
Foundation
/6
NIA
"Pump on- level at:
-Pump off" level 7—F
t:
High water alarm at:
curtain
A
A
�
Pump Make d Model
Electrical Inspections performed by:
Drain
Remarks:
BENCH MARK
Location and Description:
CSE Ftoort
Assumed Elevation:
Ftiic:,Q
TH�� ••��/
Inspections performed by: Dates: tst y /5-48
•>r 'KEVIN D. DAVIS
2nd
�� f••, CE -6803
1ti��F.7.27 9f3.•�����.:
Department of Health and Human Services approval
fti
Reviewed and approved by: �el"e, r/ w 4E-✓1~Date: o-a9.0B
72-013 (Rev. 941) MOA 25
Permit No. SW 98i)O4D
Page of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
,ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: • aW9-5.S E.sTA785,B/�k 3, Lot hS PID No.:0,57 3207
5W
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Kevin D. Davis, RE
9304 Ka * St
hxhaage,AK 99515
August 3, 1998
Municipality of Anchorage
On Site Systems
Ref: Tonjess Estates, Block 3, Lot 18
Wastewater System As -Sulks
Attn: Jeff Poet
Dear Poet:
In response to your initial review comments I am resubmitting the wastewater disposal system as -built
along with a reference sheet displaying the separation distances for all system monitoring tubes.
Distances shown are relative to the well, southwest property comer and the comers of the house.
If you have any questions or comments please call me at 522-9655 or leave a message at 248-5235.
Thank you for your prompt review and your attention to this matter.
Sincerely,
Kevin D. Davis
10-28-1998 8:45PM FROM GOODFELLOW BROS. INC 1+907+522+9656 P.2
/1E�//Slonl /VO, I 101a9198
Permit No. S W 943 040 ya
Page la of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
'ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Description: %n%csS &7s t esu BL93 41t19 PID No: 0S/83207
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Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
'ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Legal Description:
8 -23 -Ye)
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Permit No. S W 980040 Page of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Legal Description:_Totjasss ESTA7C•s, &oLK 3 1 Lo -r Is p,nNe- 05-/83207
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Municipality
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
'ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or. Well Inspection Report
Legal Description: 7-0N,IESS ESTATES, BLOCK 3, LOT /8 p)n IJn • 05183207
72-013 A (M.. GM) MOA 25
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72-013 A (M.. GM) MOA 25
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE W 9D WASTEWATER DISPOSAL SYSTEM PERMIT
a
PAGE 1 OF 1
PERMIT NUMBER:SW980040 DATE ISSUED: 3/25/98
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES EXPIRATION DATE: 3/25/99
OWNER NAME:DOWAH PARTNERSHIP
OWNER ADDRESS:ALASKA HOMES, INC. - EVAN ROWLAND
3705 ARCTIC #2559 ANCH, AK 99503
PARCEL ID:05183207
LEGAL DESCRIPTION:
TONJESS ESTATES BLK 3 IT 18
LOT SIZE: 39293 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / PTEM
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 DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
INSPECTIONS BY A P.E. ARE REQUIRED DURING INSTALLATION OF
THE WASTEWATER DISPOSAL SYSTEM.
^� p �y
RECEIVED BY: Em-'_1C`=C--� DATE: :?-`S" ( r
ISSUED BY: //a-ytn'
DATE: .3-25%,76
Municipality of Anchorage
Department of Health and Human Services
825 "L" Street
Rick Mystrom,
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
June 3, 1997
Dowah Partnership
8001 Upper O'Malley Road
Anchorage, Alaska 99516 1122
Subject: Lot 18 Block 3 Tonjess Estates Subdivision
Permit fSW960078, PID 6051-832-07
The subject permit, issued May 20, 1996 by this office for a
single family well and/or on-site wastewater system, has
expired as of May 20, 1997.
A new permit must be obtained from this office for a well
and/or on-site wastewater system NOT installed by the
expiration date.
If you have drilled the well, a well log must be sent to
this office for documentation of the installation and to
close the permit.
If a licensed Professional Engineer has inspected the
installation of the on-site wastewater system, the original
as -built inspection report must be sent to this office for
review, approval and documentation. All inspection reports
must be submitted within 30 days of construction completion.
When applying for a new permit, the fees are: $320.00 for an
on-site wastewater permit; $120.00 for a well permit and
$440.00 for a combined on-site wastewater and well permit.
If you have any questions, please call this office at 343-4744.
S c rely,
,�4al�-1
Ja es Cross, P.E.
Pr gram Manager
On-site Services
enc: Copy of Permit
cc: Eagle River Engineering Services
MUNICIPALITY 0'r ANCNGRA6E
VINOMrENTAI SERVICES DIVISION
MAR 18 1998
RECE111F®
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW960078 DATE ISSUED: 5/20/96
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES EXPIRATION DATE: 5/20/97
OWNER NAME:LEBARON KAYLEN D
OWNER ADDRESS:8001 UPPER O'MALLEY ROAD
ANCHORAGE, ALASKA 99516
PARCEL ID:05183207
LEGAL DESCRIPTION:
TONJESS ESTATES BLK 3 LT 18
LOT SIZE: 39293 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BS 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 DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY:
DATE • 405/2I/961
DATE: 6--2c7-,9x
MUNICIPALITY Or AhCH6HAoE
ENVIRONMENTAL SERTCES 0:03ION
MAR 18 1998
RECE11TO
Eagle River Engineering ,Services
Louis I3utera, P.E.
P.O. Box 773294 (907) 69.1-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
May 10, 1996
Jim Cross, P.E.
Manager, On -Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Tonjess Estates Lot 18, Block 3
Narrative & Permit Application
Dear Mr. Cross:
We are applying for a three bedroom well and septic system permit for the above referenced
lot.
The lot has a very difficult terrain situation with steep slopes and gullies.
We have explored all of the areas below 25% grade on the lot, and have found the soil
unsuitable for on-site septic due to either water table or bedrock and impermeable layers.
The soil conditions change dramatically when you are located on the hill by test hole 3 which
is composed of GM -GP soil material. The owner has leveled off a house pad from this knoll
and we have excavated a test hole in the side slope to the north. Slope varies from 35-40%
depending on where you measure it. The trench system I have designed would be the best
option for this lot, and requires placement on this slope. The area available would
accommodate a field and reserve site. We have also determined that a mound septic field
could possible be located built-up over bedrock in the area indicated. The location of the
trench system in the steep side slope would not result in effluent break out based on our
experience in these installations that are placed on a fully vegetated slope. We therefore are
requesting a permit for this design.
if you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
\1996\96-006A.NAR
MUNICIPALITY Or NNCNUMA
ENVIRCNIAENTAL SERVICES Wi;ION
MAR 18 1998
RECE11TO
NEIGHBOR
VILL RADIUS
9 91
2 b� V 64o3j • E
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IQs LOT `
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a HOUSE / E MAR 18 1998
PAD w•u T 2 m
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S�°� 0 THl F I
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N 6 196 DR��f �
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for
�fOp SYSTEMTIG
ID 10 IX
- TEST HOLE
• - MONITOR TUBE
0 - SEWER CLEANOUT
NO SURFACE WATER ¢ - WELL
PROPOSED LEACHFIELD
NO KNOWN CURTAIN DRAINS - EASEMENT
SEPTIC SITE PLAN
LEGAL: TONGESS ESTATES LOT 18 BLK 3 �Q��•OF• 4
4qs10
OWNER: FOUTS A*' TH
••
CONTRACTOR: N/A ON....:49 ...'
JOB 96-006 DATE: 5/9/96 SCALE 1" = 50' 00•...... �'......�
•• LOUIS A. BUTERA
EAGLE RIVER ENGINEERING SERVICES ��-,��'•,. CE -6736
P.O. Box 773294 1� Pfo G
EAGLE RIVER, AK. 99577
(907) 694-5195 FAX: (907) 694-3297
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL: Tonjess Estates Lot 18, Block 3
05/10/96
A. GENERAL
1. The well and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of Health
requirements.
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 in the field by the
contractor to meet Municipality of requirements.
6. It is the responsibility of the owner to obtain all necessary permits or easements
and to locate any adjacent multi -family wells.
7. The excavation is to be exactly in the area shown on the site plan, any deviation
requires engineer approval.
8. It is always recommended that a surveyor locate the nearest lot line position and
the location of any easements.
9. Any remaining open test hole excavations shall be filled.
B. TRENCH
1. The trench is to follow the natural land contour to maintain uniform total depth
of the trench bottom.
2. The bottom of the trench shall be level, plus or minus 1.5".
3. The total depth of the trench excavation is not to exceed 12' at any point.
4. The effluent line within the trench shall be laid level within 0.03'.
5. The trench gravel is to be covered with typar fabric material.
6. Soil or combination of soil and extruded board insulation to a depth of 3' or
equivalent is to be placed over the leachfield.
7. The area over the trench is to be finish graded to prevent ponding of surface
water runoff.
8. The septic tank and leachfield must not be closer than 100' to any existing
private well, 150' to any Class "C" well, or 200 feet to any community well.
RECOMMENDED LEACIIFIELD DIMENSIONS:
TOTAL DEPTH = 12' GRAVEL DEPTH = 9' under pipe, 2" over pipe
TRENCH LENGTH = 31' TRENCH WIDTH = 3'
SOIL RATING= 0.8 GPD/ft2 BEDROOM CAPACITY = 3
SEPTIC TANK = 1,000 gallons, MOA approved
Twenty-four (24) hours notice required for all inspections.
\1996\96-006a-spc
EAGLE RIVER
ENGINEERING SERVICES
P.O. Box 773294
Eagle River, Alaska 99577
(907) 694-5195
ERES Project No.: 96-006
Calculated By: LB
Date: 5/9/96
Legal: TONGESS ESTATES LOT 18, ELK 3
Single Family 3 Bedroom Dwelling
Deep Trench Subsurface Wastewater Disposal Field
TEST HOLE 3
Water use at 150 gallons per bedroom = 450 gallons
Percolation rate = 12 minutes per inch
Wastewater application rate = 0.8 gallons per day per square foot
Required absorption area = 563 square feet
Trench width (W) = 3 feet
Gravel depth (D) = 9 feet
Required length = Required absorption area / 2 / D
Required length = 563 / 2 / 9
Required length = 31 feet
Total Excavation Depth = 12.0 feet
e
SINGLE FAMILY ON-SITE WORKSHEET
ERES PROJECT NUMBER: 96-006 CALCULATED BY: LB
LEGAL DESCRIPTION: TONGESS ESTATES LOT 18, BLK 3
NUMBER OF BEDROOMS:
3
562.5 SQ.FT
WATER USE PER BEDROOM:
150
GALLONS
PERCOLATION RATE:
12
MINUTES PER INCH
DEPTH TO GROUNDWATER:
18
FEET
DEPTH TO IMPERMEABLE LAYER:
18
FEET USABLE SOIL STRATA
ANTICIPATED DEPTH OF COVER:
3
FEET TOTAL USABLE DEPTH:
MOUND OR BED SYSTEM
47
USABLE SOIL STRATA DEPTH:
WASTEWATER APPLICATION RATE:
0.5 GAUSO.FT
ABSORPTION AREA REQUIREMENT:
900 SQ.FT
MINIMUM BED LENGTH
12 FEET WIDE BED
15 FEET WIDE BED
TRENCH SYSTEM
WASTEWATER APPLICATION RATE:
ABSORPTION AREA REQUIREMENT:
SHALLOW TRENCH OPTIONS
5 FEET WIDE TRENCH
EFFECTIVE REQUIREDTRENCH
DEPTH (FT) ENGTH (FT)
1 98
2 79
2.5 72
3 66
3.5 61
4 56
DESIGN SPECIFICS
FIELD SYSTEM: D
GRAVEL DEPTH: 9
TRENCH OR BED WIDTH: 3
LENGTH:
TOTAL
EXCAVATIO
N DEPTH:
31
75 FEET
60 FEET
12
9
0.8 GAUSQ.FT
562.5 SQ.FT
DEEP TRENCH OPTIONS
3 FEET WIDE TRENCH
EFFECTIVE
REQUIREDTRENCH
DEPTH (FT)
ENGTH (FT)
4
70
4.5
63
5
56
5.5
51
6
47
7
40
8
35
(B=BED, S=SHALLOW TRENCH 8 D=DEEP TRENCH)
FEET
FEET
FEET
12.0 FEET
EAGLE RIVER
ENGINEERING SERVICES
P.O. Box 773294
Eagle River, Alaska 99577
(907) 694-5195
ERES Project No.: 96-006
Calculated By: LB
Date: 5/9/96
Legal: TONGESS ESTATES LOT 18, ELK 3
Single Family 3 Bedroom Dwelling
Bed Subsurface Wastewater Disposal Field
TEST HOLE 4
Water use at 150 gallons per bedroom = 450 gallons
Percolation rate = 3 minutes per inch
Wastewater application rate = 0.8 gallons per day per square foot
Required absorption area = 563 square feet
Bed width (W) = 15 feet
Gravel depth (D) = 0.5 feet
Required length = Required absorption area / Bed width
Required length = 563 / 15
Required length = 38 feet
Total Excavation Depth = 1.5 feet
49
�P
!1i TH
:.'.LOUIS A. BU7ERA:
J'j •, CE -6736
SINGLE FAMILY ON-SITE WORKSHEET
ERES PROJECT NUMBER: 96-006
CALCULATED BY: LB
LEGAL DESCRIPTION: TONGESS ESTATES LOT 18, BLK 3
NUMBER OF BEDROOMS:
3
WATER USE PER BEDROOM:
150
GALLONS
PERCOLATION RATE:
3
MINUTES PER INCH
DEPTH TO GROUNDWATER:
8
FEET
DEPTH TO IMPERMEABLE LAYER:
8
FEET USABLE SOIL STRATA
ANTICIPATED DEPTH OF COVER:
1
FEET TOTAL USABLE DEPTH:
MOUND OR BED SYSTEM
USABLE SOIL STRATA DEPTH:
WASTEWATER APPLICATION RATE:
0.8 GAUSQ.FT
ABSORPTION AREA REQUIREMENT:
563 SOFT
MINIMUM BED LENGTH
12 FEET WIDE BED
15 FEET WIDE BED
TRENCH SYSTEM
WASTEWATER APPLICATION RATE:
ABSORPTION AREA REQUIREMENT:
SHALLOW TRENCH OPTIONS
5 FEET WIDE TRENCH
EFFECTIVE REQUIREOTRENCH
DEPTH (FT) ENGTH (FT)
1 66
2 NA
2.5 NA
3 NA
3.5 NA
4 NA
DESIGN SPECIFICS
FIELD SYSTEM:
GRAVEL DEPTH:
TRENCH OR BED WIDTH:
LENGTH:
TOTAL
EXCAVATION
DEPTH:
47 FEET
38 FEET
1.2 GAUSO.FT
375 SO.FT
2
1
DEEP TRENCH OPTIONS
3 FEET WIDE TRENCH
EFFECTIVE REQUIRED TRENCH
DEPTH (FT) ENGTH (FT)
4 NA
4.5 NA
5 NA
5.5 NA
6 NA
7 NA
8 NA
9 NA
B (B -BED. S=SHALLOW TRENCH 8 D=DEEP TRENCH)
0.5 FEET
15 FEET
38 FEET
1.5 FEET
• ti Munldpallty of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825'L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: Gb &f "0A/ DATE PER
- Q:
touis A. Bufew
CE -6736
GoT /P 3
LEGAL DESCRIPTION: Tn%7Z5Ss' ES7/4TEC Township, Range, Section: 71-5/V /W SEC Z.
r P� SLOPE SITE PLAN Nrf
1
1 2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
04,fNiCS
eMYCY SAND w/6,CAIA5L.
04AVCL w/CLAY � SAND
■E■■
■E■■
MEMO
■`M■
■■I■■
■■Il■
■m'v.
mmilm
MEMO
■ONNI
Q I v
WAS GROUND WATER
ENCOUNTERED? yES
t�+Kr S
wy' IF YES, AT WHAT L
DEPTH? II. 7 p �•
ma
307pH OG HO[EMwm wtnng7 ? _L_ O' S
One
COMMENTS 7'W"P'K / E „vsauf
a
PERCOLATION RATE a23 Immule inch) PERC HOLE DIAMETER
TEST RUN BETWEEN 41.0 FT ANO 6'0 FT
PERFORMED BY: C W 1 F 4cS -� 'j CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE s'" �`p— 9F.
72-0081R". 4851
r Munklpality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
625 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED
OF
� � •iENGINEER'�4�y I.�
*=49tH P:.a
I. Louis A. Buferu
Paw
�pRnn ecmt:A��
i '••
DATE PERFORMED: OS/Z/{�575-
LOT /Q B[.00,e 3
LEGAL DESCRIPTION: T/llTJ-i S• ESTgLrff Township. Range. Section: TSN P�Ge/ SEC
F4>•Et 77-•1 ORGAN/� SLOPE SITE PLAN rvrr
11 111
�2 1
3 SOMI 1 Z14
4
5 .
6
= I CLRY YELL.0W-&e0A1,,
�
k'ASSUA1,5 t -/2o
8
9 4 I BePRocx
10
11
12
13
14
16
16
17
18
19
WAS GROUND WATER s//l
ENCOUNTERED? IG�I
S
IF AT WHAT � O
DEPTH , r'a
DEPTH? p
E
Dip to
Mmimag? Water Aner 5 V • Cate P 2S
®
®®m
}®�
20 i
PERCOLATION RATE ��3 (mmutes/sn/cLn)CPERC MOLE DIAMETER
TEST RUN BETWEEN FT AND FT
COMMENTS -- /-��/ ��/•'e roar L..t vriee i•v
PERFORMED BY: CW I FR—CS --:EH CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. OATS
72-008 (Rev. 41851
OF '4Z
PERFORMED FOR: rOuTS DATE PERFORMED:
LEGAL DESCRIPTION: 7&_
,1*,,r E'tyref [/i< B 3 TOwnShip, Range. Section: T/s'rd" .(/W Sk .Z y/,r /y,
TN 3
Toyaoll
3C7C7/q : S,),5Sc rrf,
4 0 _brown, d/ -, y.,
13-
14-
16
314
16
17
0.
18
19
20
IV' Tf/
WAS GROUND WATER
,t:.4 91.4
ENCOUNTERED? �V
••_e .may ...
• r Municipality of Anchorage
..,,,,,,a;,,••... ....
DEPARTMENT OF HEALTH & HUMAN SERVICES
�c logit A. Dal.ro F W
825 "L" Street. Anchorage, Alaska 99502-0650
If �rr•..� CE•6736
SOILS LOG — PERCOLATION TEST
t�r�F� ••.......•..�E� r
PERFORMED FOR: rOuTS DATE PERFORMED:
LEGAL DESCRIPTION: 7&_
,1*,,r E'tyref [/i< B 3 TOwnShip, Range. Section: T/s'rd" .(/W Sk .Z y/,r /y,
TN 3
Toyaoll
3C7C7/q : S,),5Sc rrf,
4 0 _brown, d/ -, y.,
13-
14-
16
314
16
17
0.
18
19
20
IV' Tf/
WAS GROUND WATER
Date Gran
Time
ENCOUNTERED? �V
Death to
Water
Not
Drop
�< ,4 re
6 -z:yC7
5
T. z7
G'1 `/.a "
IF YES. AT WHAT
L
O
DEPTH?
P
E
? ARKMWAWMofy Can, r -7 --Ys
Reeding
Date Gran
Time
Net
Timo
Death to
Water
Not
Drop
�< ,4 re
6 -z:yC7
T. z7
G'1 `/.a "
PERCOLATION RATE L2 (minutevmn�cn),,PERC HOLE DIAMETER
L^L„
TESTRUNBETWEEN .FTAND "L^�FT
COMMENTS
PERFORMED BY: 5. CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE. f— 10-74
147
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street. Anchorage. Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
OF
Lour A. Bwe,, t ,2
�iPj, CE -6736
t,� k kor
PERFORMED FOR: FOuTi DATE PERFORMED: V—/0—f6
LEGAL DESCRIPTION: Tg �t
jERl t+/ Sec iYw /Sr6�
Epl SLOPE SITE PLAN
/ I/ 7
t
2 . �. Q.
3
4A
5
6-
7-
8 7
8
ti]
7-5,, organics
r:•OARSe GRqulL� A^40"ZN,p
elt.o;' tr';"co Tf,,
_Dryr__6ro wn
Begi'otk
&77vf * TH
10 WAS GROUND WATER w�
ENCOUNTERED?
11 S
IF YES, AT WHAT L
O
12 DEPTH? P
E
Depth to Waur ARM
13 Manta? Dry oft t-7
14
15
16
17
18
19
20
COMMENTS
Reading
Dan Grom
Time
Net
Time
Death to
Water
Net
Drop
5 G at a:3
6 G G 1
38 /
3' ra
3c
1 x'37
1 Ct,;
/,
3'
3!L111
Cl
I 77 1
c
Y
PERCOLATION RATE 3 (minuteymcn) PERC HOLE DIAMETER
3.
TEST RUN BETWEEN �FT AND �FT
PERFORMED BY: 1 -2 2F7 CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE r —• �� — 96
sr
2./
f
oS1-s 3a -o1
LOCATION OF WELL
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
DIVISION OF MINING & WATER MGMT
WATER WELL RECORD
BOROVOH
SUIPWION
LOT
BLOCCCK,
SECTION OTRS
SECTION
TOWNSHIP
RANGE
MERIDIAN
_
LOCATION/SKETCH:
WELL OWNER:
DEPTHS MEASURED FROMOcasing top ❑ground surface
WELL DEPTH: DATE.OF COMPLETION
.Depth of hole:'rv2 it
BOREHOLE DATA: Depth
Depth of casing: /-17 tt �� / Z %
Material Type and Color From To
DEPTH TO STATIC WATER LEVEL:
�Z
*7 }t below,,Z top of casing ❑ ground surface
Date: /eZ/ 1
%/
iMETHOD OF DRILLING: /l air rotary ❑ cable tool
❑ other
;JSE OF WELL: ,1� domestic ❑ irrigation ❑ monitor
❑ public supply ❑ other
CASING STICK -UR,. J. it. Diam: 6 in. to />ft
Casing type:�l�.c77 _min, to �7 ft
WELL INTAKE OPENING TYPE: ❑ open end ❑ screened
❑ perforated .) open hole -
Depths of openings: to It
SCREEN TYPE: Diam: in.
Slot/Mesh Size: Length: It
GRAVEL PACK TYPE:
Volume used: Depth to top:
GROUT TYPE: Volume:
Depth: from ft to ft
DEVELOPMENT METHOD: e.(; 14
Munlcipality Ot AnCh
rage
Duration: .2
ept. ealINSmull an
epiloes,
PUMPING LEVEL AND YIELD:
[L it after 2hrs pumping _'S:_S gpm
PUMP INTAKE DEPTH: MUfkIR¢O°wF&N6wA—
WELL DISINFECTED UPON COA4RWdiF)1 A E1(fpFs L
CONTRACTOR INFORMAT!PN:
REMARKS:
MAR 18 1998
CX 4UMPT
`. "'9-- ?G P DNR/DIVIEASE S OIN OF MI TE INING & WATER MGMT
Date—3601 C St, Suite 800
Anchorage, Ak 99503-5935
i
Alpine r •(fling & Enterprises
uomestic — Commercial 1 .
Pump & Water Systems
P. O. Box 110496 o Nam /Loc Ion
Anchorage, Alaska 99511
(907) 345 - 0202 lnn 1Pd4 F
TO:
0PJ
nLi
IIy/'
f
`l�
O n/�
n�
1 l.( ari /
DATE C Z 7 9In
J
QUANTITY
DESCRIPTION
AMOUNT
3.5
0
NInto
LABOR
HOURS
RATE
AMOUNT
TOTALMATERIAL
TOTAL LABOR
YYD1Yton0 KODY
DVEC
rorty
UBCn
PAY THIS AMOUNT
Thank You
SIGMTunE
Q Hereby AcknovAodge the Satisfactory Completion of the Above Described Work.)
TERMS: ACCOUNTS PAYABLE AT 18TH OF MONTH FOLLOWING PURCHASE.
SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS.
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES OIVISION
MAR 18 1998
RECERTO
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051 832 07
1. GENERAL INFORMATION
Expiration Date:
Complete legal description TOnjess Estates Block 3 Lot 18
Location (site address) 25343 Homestead
Current property owner(s)
Mailing address
Real estate agent
Miller
2. TYPE OF DWELLING:
0 Single Family (w/ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
0
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: NONE q Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5.50/ Waiver Fee $
Date of Payment "I a b ,/� Cq, Date of Payment
Receipt Number a y 1 a q Receipt Number
COSA # 0 S C. a �Z 1 1 31 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 C&M ENGINEERING Phone 8545558
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI Date 4/1/22
Alw
OF Akgsl�
6. DSD SIGNATURE /
.. 1
System #1 Approved for � bedrooms rr .• • ./
CHARLES G BALZARIK(
System.##2 Approved for bedrooms ��F�s.•• CE-13854����
Disapproved 'ilii pROFE5S10N�?�
Conditional approval for bedrooms, with the following stipulations:
tOF f A,(4,(ii
WATER AND
J m WAST!—"-v''ATER oz
J
BY: Original Certificate Date: J�
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
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
Nitrate Advisory
Arsenic Advisory
Other
COSA Checklist
Legal Description: TONJESS LOT 18 BLOCK 3
If more than 1 septic system on lot: COSA Checklist # 1 of 1
A. WELL DATA
❑E Well log is filed with Onsite (or attached)
Date drilled 1996
Total depth 126 ft
Cased to 17 ft
❑N Sanitary seal is functioning correctly
FE -1 Wires are properly protected
Casing height (above ground) +24 in.
Date of flow test for COSA 3/17/22
Static water level at beginning of test 33 ft.
Comments
B. TANK DATA
Age of tank(s) 24 years
Tank type/material septic STEEL
Measured operating fluid level in septic tank 50
❑■ Standpipes/foundation cleanout per record drawing
Date of pumping 9/2/2021
D. ABSORPTION FIELD DATA DEEP
Parcel ID:
Structure served by this system 1
051 83207
Well production at time of test 5.1 gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ❑■ No
9 Coliform bacteria is Negative
Nitrate 3.92 mg/L ❑■ Nitrate less than MRL (ND)
Arsenic ND ug/LX Arsenic less than MRL (ND)
Collected by C.BALZARINI
Date of Sample 3/16/22
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Which system tested (date installed) 1998
Adequacy test date 3/17/22
❑■ ALL standpipes present per record drawing
Results ❑✓ Pass For 3 bedrooms
Total measured depth from grade 12 ft (max)
Fluid depth prior to test 95 in
Measured depth to pipe invert from grade 3 ft (min)
Water added 450 gal
❑ N/A — pressurized field
108
New depth in
❑■ Monitor tubes go to bottom of effective. If not, state
Elapsed time 1440 min
depth into effective
❑N Code -required soil cover over field
Final fluid depth 95 in
❑ System presoaked
Absorption rate 450 gpd
(Required if vacant for greater than 30 days prior to
Any rejuvenation treatment (past 12 months)
date of test)
Gallons introduced na gallons
If yes, enter date na
Comments/Deficiencies: SYSTEM IS AT 90% CAPACITY, SEE PREVIOUS COSAS.
COSA Checklist yellow sheet
na
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
Yes
Community Sewer Manhole/Cleanout > 100'
ft
❑✓ Yes
if No
ft
M Yes
if No ft
Neighboring Tank > 100'
Yes
if No
ft
Private Sewer/Septic Line > 25' 0 Yes
if No ft
Absorption Field on Lot > 100'
Yes
if No
ft
Holding Tank > 100' [✓ Yes
if No ft
Neighboring Absorption Fields
> 100'
Surface Water > 100'
0
Animal Containment > 50' E✓ Yes
if No ft
ft
[D Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75'
�✓ Yes
if No
ft
❑✓ Yes
if No ft
From Septic/Holding Tank on Lot to: (Please
enter
distances if less than required)
Building Foundations > 10'
❑✓ Yes
if No
ft
Surface Water > 100' U✓ Yes
if No ft
Property Line > 5'✓0
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
Yes
if No
ft
Private Wells > 100' r✓ Yes
if No ft
Water. Main ..>._ 10'_ _ _
f] Yes
if No
ft
Community Wells > 200' Ifl Yes
if No ft
Water Service Line > 10'
Yes
if No
ft
If septic tank is under driveway comment
below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
F/1
Yes
if No
ft
Wells on Adjacent Lots:
Water Main >.10'
Q
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
❑✓
Yes
if No
ft
Community Wells > 200' ❑✓ Yes if No ft
Surface Water > 100'
0
Yes
if No
ft
F. ENGINEER'S COMMENTS
THE SEPTIC LEACHFIELD IS AT APPROX 90% CAPACITY WITH A OLDER TANK.
RECOMMEND ADVISORIES BE ATTACHED TO THE COSA.
G. ENGINEER'S CERTIFICATION
1 certify that 1 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. 4/7/22
COSA Checklist yellow sheet
44_'nll\ �
°F A1,4 lel
49TH '•*fir
.. ....
r� HARLES G BALZARINI j
CE -13854 , • ��
•....••'���law
tl� PROFESSI��P -�-
��1�i�114
Ali UMMP LI T Y OF AHCHGuD'D1 t G
DEVELOPMENT SERVICES DEPARTMENT ncTfll�)4_ On -Site Water and Wastewater Section
www.muni.org/onsite
Septic Tank Advisory
Certificate of On -Site Systems Approval #OSC 221134
Subdivision: Tonjess Estates Block 3 lot 18
907-343-7904
Fax: 343-7997
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this COSA / property is 24 years old. A leaking septic tank may be a source of contamination to
the aquifer. Typical replacement costs range from $10,000 to $15,000
This advisory must be attached to all copies of the subject Certificate of On -Site Systems
Approval.
This is an example of a 16 -year-old septic tank.
i
u
�j
ILI
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org
M' UHCJPA1 U TV OF ���NC HOPIA E
DEVELOPMENT SERVICES DEPARTMENT 907-343-7904
;..
On -Site Water and Wastewater Section Fax: 343-7997
www.muni.org/onsite
Septic System Absorption Field Advisory
Certificate of On -Site Systems Approval # OSC221134
Subdivision: Tonjess, Block: 3, Lot: 18
During -the --absorption field adequacy test, 95" inches of standing water was
observed in the absorption field. This indicates approximately 90% of the
absorption area is inundated. Although this system passed the adequacy test, the
remaining life expectancy may be limited.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org
G6 8G
SPP CO
• '� Municipality of Anchorage _
On -Site Water and Wastewater Program
(907)343-7904 sn Err
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 051-832-07
1. GENERAL INFORMATION
Expiration Date: 2 - J /
Complete legal description TONJESS ESTATES BLOCK 3 LOT 18
Location (site address) 25343 HOMESTEAD ROAD CHUGIAK AK 99567
Current Property owner(s) JAMES & NANCY LYMAN Day phone
Mailing address
Real Estate Agent
25343 HOMESTEAD ROAD, CHUGIAK AK 99567
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual
Individual Water Storage
❑
Holding Tank
❑
Community Class _ Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
COSA to be released to the engineer, unless
COSA Fee $ -tClb
Date of Payment
Receipt Number bt S c6�
COSA # S b ?�
Date:
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 10123/2012
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 septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.: , ^' `�'.�JL
6. DSD SIGNATURE
System #1 Approved for. bedrooms.
System #2 Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Original Certificate
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 .
: OSA bl,, _chaet 91-12 d.c
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: TONJESS ESTATES BLOCK 3, LOT 18 Parcel ID: 051.832.07
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID #
Date completed 5/29/1996 Sanitary seal (Y/N) Y
Total depth 126 ft. Cased to 17 (INTO BEDROCK) ft.
FROM WELL LOG
Date of test 512911996
Static water level 27 ft.
Well production 3.5 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEB colonies/100 mL Nitrate JZ6 mg/L
Arsenic: ND ug/L Date of sample: 10110112
B. SEPTICIHOLDING TANK DATA
Tank Type/Material SEPTIC I STEEL
Tank size 1000 gal. Number of Compartments 2
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
Date of pumping 101412012 Pumper JR
C. ABSORPTION FIELD DATA
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 24+ in.
AT INSPECTION
101812012
ft.
Collected by: ARCTERRA
Date installed 411998
Cleanouts (Y/N) Y
High water alarm (Y/N) N
Date installed 411998 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.8 System type TRENCH
Length 31 ft. Width 4 ft. Gravel below pipe 9 ft.
Total depth 12 ft. (Measured 10112) Eff. absorption area 576 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 101812012 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 90 in. Water added 470 gal. New depth 108 in.
Elapsed Time: 1440 min. Final fluid depth 90 in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at _ in.
Datum
Size in gallons
"Pump off' level at —in.
Cycles tested
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100'+
Absorption field on lot 100'+
Public sewer main 75'+
Sewer /septic service line 25'+
Animal containment areas 50'+
SEPTIC/HOLDING TANK ON LOT TO:
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout 100'+
Holding tank 100'+
Manure/animal excrete storage areas 1004
Building foundation 5'+ Property line 5'+ Absorption fiel
Water main 10'+ Water service line 101+ Surface water
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water. 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 100'+
F. COMMENTS
in.
VACANT SYSTEM SURCHARGED PRIOR TO TESTING. SYSTEM IS OPERATING IN THE TOP PORTION OF THE EFFECTIVE
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 KENNETH M. DUFFUS
Date
COSA brown sheet 9-1-12.doc
*j'A . " , '
t MIMS VY73bp,` M
-X, vv/++Al
Municipality of Anchorage s
Community Development Department
Development Services Division � s
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
Nitrate Advisory
Certificate of On -Site Systems Approval # 121503
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 3, Lot 18 of
Tonjess Est. subdivision. This inspection revealed a nitrate concentration of
9.28 milligrams per liter (mg/L) was reported for the property's well water
sample. The Environmental Protection Agency (EPA) has established a
maximum contaminant level (MCL) of 10.0 mg/L for public drinking water
systems. While private wells are not subject to this regulation, EPA
standards are based on existing health information and can therefore be used
to gauge the relative quality of water from private wells. Please see the
attached "Nitrate Fact Sheet" for important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite 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
Iro_U-i 1 X'A �J
�l S�D6 IZ•,gSP"i
e �i
r �
V �
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S• CT♦
Parcell.D. 051-832-07 COSA# 01pRbQ
Expiration Date: 4A ` d C'n
1. GENERAL INFORMATION
Complete legal description Lot 18; Block 3; Tonjess Estates
Location (site address) 25343 Homestead Rd. Chup,iak, AK 9956
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Melanie Brown
Kevin Taylor
Prudential/J.W. 3801 Cente
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
Day phone 273-7350
Day phone
Day phone
273=7223
int Dr. #200 Anchorage, AK
TYPE OF WASTEWATER DISPOSAL:
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of Onsite 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 Onsite 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.
Individual On-site
❑
Individual Holding Tank
❑
❑
Community On-site
❑
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of Onsite 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 Onsite 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 seat affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined In the Certificate of Onsite 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.
NameofFirm S & S Engineering,
Phone 694-2979
Address17034 N. Eagle River Loon /1204 Eagle River, AK 995777
Engineer's Printed Name _V OU47 C . Com,. Date 3 / 3 0 10C
5. DSD SIGNATURE '1) 3 ROBERT C. COWAN
Approved for bedrooms. tCE-8301
— t
Disapproved. ••;i";: �;�.;,:
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: !(fir Original Certificate Date:
(Rev. 11*5)
Municipality of Anchorage
• Development Services Department
Building Safety Division '
On -Site Water 8 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: L— 8 i'BLcxX 3 ; EsS Cyst . Parcel ID: Ds/ -
A, WELL 13
Well type _t t 1 FT>L If A, B, or C provide PWSID # = Well Log(R)N) /
Date completed 5 29/qI� Sanitary sea&)_yr-5 Wires properly protecte0Y 1) 16s
u
Total depth 12b� ft. Cased to �Zft.16To r'3t beat Casing height (above ground) / "( in.
FROM WELL LOG AT INSPECTION
Date of test '5/X9 160
rf t
Static water level 2 ft. 3 7 ft.
r
Well production 505 g.p.m. 5o7 g.p.m.
WATER SAMPLE RESULTS:
ColHormcolonies/100 ml Nitrate 3.Li mg/L Other bacteria colonies/100 mL
Arsenic: �/D mgli Date of sample: Collected by: J¢S ic�tzllt7t (►vf,�
B. SEPTICIFIOLDING TANK DATA
Tank Type/Material Sly L 3 L Date installed
Tank size � gal, m of Com wrIments Cleanouts�) y1�
l
10 f �Yfi�E) NO
Foundation cleanou ) Depression over tank�(Yp}I�High water alarm
-t�j)
Date of pumping Z.ob Pumper \ K 3 U►vlpl uG
C. ABSORPTION FIELD DATA Q
Date installed 15 -9416/18 Soil ratin (g.p.d. r fe/bdrm) Qa System type
i 1 1
Length �J� ft. Width �{ ft. Gravel below pipe o ft.
Total depth /2 ft. EH. absorption area r7 fiz Moniton�tube t✓ Depression over field A1_6Date of adequacy test 3 / Resu as ail) i_ For 1 bedrooms
Fluid depth in absorption field before test 63 ^^ in. Water added gal. New depth In.
Elapsed Time: 1 min. Final fluid depth 15+ in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y4D type) If yes, give date
D. LIFT STATION M /A
Date installed
Sae in gallons n oIe/Acoess (YIN)
'Pump on' level at _ in. 'P p v I at — in. High water alarm level at in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAtft station on lot /D O On adjacent lots / e5o -�
r
Absorption field on lot / 4�O On adjacent lots / 00 '4 -
Public sewer main "r4
Sewer /septic service line zS -/-
Animal containment areas GO 14 -
Public sewer manhole/cleanout rU
Holding tank pol d
r
Manurelanimal excrete storage areas 1004
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
l ) /
Building foundation S Property line S / Absorption field 154
Water main /.3t4 Water service line JD 1� Surface water _ /00 1
Wells on adjacent lots 100
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line JD / Building foundation JO '/ Water main
� t r
Water Service line /D Surface water Driveway, parkinglvehicle storage
Curtain drain NDUE, 1WOWN Wells on adjacent lots 100 11
F. COMMENTS
OF
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined through held inspections and
review of Municipal records that the above systems are in f
,t .
conformance with MOA COSH guidelines in effect on this date. '� ,, �;„ "i>fw-c: coivnrr p,ti
Engineer's Printed Name ��3�/L T C • COWA,-J �tt �.'.iCc``Ss01 N
1. <':
Date
COSA Fee $ `l ;�o ' cU Waiver Fee $
Date of Payment ?1 ?,1 n� Date of Payment
Receipt Number Receipt Number
(Rsv. t Vet)
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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. OSI -R 3 a —0'7
1.. GENERAL INFORMATION
HAA#
Expiration Date:O�-
Complete legal desc ription Lot 18; Block 3; Toniess Estates
Location (site address or directions) 25343 Homestead Road
Current Propertyowner(s) Maxwell Mercer Day phone 688-2417
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
P.O.Box 672417 Chupiak, AK. -99567
Unless otherwise requested, HAA will he held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well 129
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
Day phone
Day phone
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 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system Is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the Information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm 5 a 5 ENGINEERING
170=9 e
Address vaple River Alaska 99577
Engineer's Printed Name
Phone 6q'1 -,X97
Date
—QC- OF Ar -l.
-A,,\ ROBERT C. COWAN
5. DSD SIGNATURE 4�c1\ CE -8801
✓ Approved for 3 bedrooms.11+�iEVP�_«........
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
ONSITE
Additional Comments
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: /,J �') Original Certificate Date:
(Rw. 12W)
Municipality of Anchorage •.
Development Services Department {
Building Safety Division `
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519.8650
www.ci.enrdwrage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L /Ir gt gi /A" 3 ' �ONT�g r!J O Parcel ID: -8 3 a - 0 7
A. WELL DATA ( (�
Well type f kWA L— If A, B, or C provide PWSID # Well Log (YIN) / �/
Data completed5 /L4 i (. Sanitary seat (YM) Wires properly protected (YIN) T _
Total depth Mi—& I Cased to R. Casing height (above ground) in.
FROM WELL LOP A650&?tXJ AT INSPECTIOIJ
Date of test q O
Static water level Z ft. 3 ( ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform _>Zcolonies1100 ml. NOste-z--Vmg.A. Othe• bacteria (0 colonies/100 mi.
Date of sample: Coneaed by: !r- 1 S SIG f n� C—E--rti nf B. SEPTICIHOLDING TANK DATA ,A/
Tank TypelMaterial Date instaiied 4 t % s
/q
Tank size ICW gal. Number of Compartments `Z Cieanouts (Y/N) 4
Foundation cleanout (Y/N)4 Depression over tank (YIN) High water alarm (Y/N) A( LA
Date of pumping f Pumper
C. ABSORPTION FI LD ATA oo
Date installed K Q� Soil rating (g.p.d.lff or R22thdrm)Qa System type ��IC
Length 3 I ft. Width 7 ft. Gravel below pipe R.
Total depth ft. ,E�ffj. pab,rptio n area Aaaft2 Monitoring tube Y - Depression over field N1
Date of adequacy test1 VI { 1 l/ 1 Results (Pass/Fail) fi2i For bedrooms
Fluid depth in absorption fiend before test in. Water added6e-gal. New depth In.
Elapsed Time: min. Final fluid depth �C in. Absorption rate >= 4s--� g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N 8 type) NO If yes, give date
D. LIFT STATION
Date Instetled ^� Size in gallons
'Pump on' level at in. 'Pump off level at __ in.
Datum Cycles tested _
E. SEPARATION DISTANCES
Manhole/Access (Y/N)
High water alarm level at
Meets alarm d dreu t requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAlft� on lot /00 14c-- On adjacent lots (0<3 if -
Absorption
f -Absorption field on lot DO / f On adjacent lots
Public sewer main Public sewer manhotetcleanout20 �/ A
er /septic service line 2 r'F' Holding tank — i4
SEPARATION DISTANCES FROM SEPTIC/H� L0KG'G TANK ON LOT TO:
! r1 1
Building foundation Property kne Absorption field
/ I
Water main N / A Water service line -!` Surface water /On ler-
Wells
r
Wells on adjacent lots t aD rr
in.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10 1 {— Building foundation ( Q � Water main N�
Water Service the 1 Surface water (00 14'- Driveway, parkinglvehide storage (40 i F
f
Curtain drain ",E I�M�$�INells on adjacent lots 100 4t
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have detemdned through Held inspections and .OIC
review of Municipal records that the above systems are in 6 .:.:....�
conformance with MOA HAA guidelines /n effed on this date. _
;e 'RDebwAN ; ,.�.'
Engineer's Printed Name /e0 d 2 C _ C ,- V w,/,./ ��; CE . 8801
Date /a /r r %a (
HAA Fee $ 3 00, Waiver Fee $
Date of Payment /0 /1 S /01 Date of Payment
Receipt Number 4011 y S 9 Receipt Number
(Rev. 12/00)
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. # _ 05783207 HAA # �� (I IS
1. GENERAL INFORMATION
Complete legal description 7Q_
n.4ACS5 Akr&=S BLK 3 LOT /8
Location (site address or directions)
f%MES77CAD ROAD iii! /L"E7;r52A5 rPkcC Jcsr
Property owner INV IIVF' L gYJ L4N/FLLE Mc�R Day phone
Mailing address
Lending agency
Mailing address.
Agent
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well V
Community well
Public water
Day phone
Day phone
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
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.
77-033(+".1/91) Front M0An1
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm ee✓l� A A?Vy5, P'6' Phone 907- 2LN-5235"
Addressy'�• f? -)X 2D Zz
Engineer's signature
6. DHH6 SIGNATURE
Approved for IIIIREF bedrooms.
Disapproved.
Conditional approval for
Additional Comments
im
Date -7- Z 7- fy
bedrooms, with the following stipulations:
Date S' 3- 9 8
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 order to 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.
rxaasm.AM) 8. wwm
RECEIVED
Municipality of Anchorage JUL 2 8 1998
DEPARTMENT OF HEALTH & H.UMAN SERVICES
Environmental Services Division " avnun Of A CHU
825 L Street, Room 502 • Anchorage, Alaska 99501 • WSi 143 3-4744 KZ3 o
Health Authority Approval Checklist
Legal Description: 7D JESS 65,74M B LIC 3 GOT /t3 Parcel I.D.: 05'/83 2b 7
A. WELL DATA
Well type hWP1X#i- If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) I\/ Date completed E& 7 9W
Total depth /Z(o FE'E'T Cased to LWkWWAJ Casing height (above ground) .3 FFE7-
Sanitary seal (Y/N) Y Wires property pied (Y/N) -Y
Data of test
Static water level
Well production
FROM WELL LOG
WATER SAMPLE RESULTS:
3.S
AT INSPECTION
Z Z FEE T
g.p.m. ��• S g.P.m.
Coliform Nitrate 'i. ZB WQ'L''// Other bacteria O
Date of sample: /!D f 98 Collected by: /7Ff/!N !�, AN WS
B HEPTI OLDINO TANK DATA
Date instilled y-16-98 Tank size 1,QXa3L Number oAf /Compartments Z Cleanouts (YM)_
Foundation deanout (Y/N) Depression (Y/N) _(� High water alarm (Y/N)_
Date of Pumping N JA Pumper N /A
C. ABSORPTION FIELD DATA (NEW .S YSTE M,) I_
Date installed 'q-&-725 Soil rating (g.p dJf l or ft2/bdrm) d. iJ System type '- h
I / 1 I
Length 3 Wktth Gravel thidmess below pipe 9 Total depth �—
Effective absorption area (e SI Moi itodng Tube present (YM) --Y- Depression over field (YM) �L
Date of adequacy test N lA Results (Pass/Faiq "M For bedra
Fluid depth In absorption field before test (In.). — Immediately after= gal. water added On.):
Fluid depth —' (Ins) Minutes later. Absorption rate : a.p.d.
Peroxide treatment (past 12 maths) (YM) N.LA It yes, give date
72-028 (Rev. 3198)•
D. UFT STATION N/A
Date installed
Manhole/Access (Y/N)
High water alarm level at' _
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
'Pump on' level at' 'Pump off" level at'
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
ci;�holding tank on lot 13g, On adjacent lots
ZOo f
Absorption field on lot SD On adjacent lots ZDO r -t-
Public
Public sewer main %V //4 Public sewer manhole✓deanout N ! A
Sewer /septic service fine �S / Lift station NIA
SEPARATION DISTANCES FRO SEPTI OLDING TANK ON LAT TO:
Foundation ZG Property line SS' Absorption field /7/
Water main4j�joine 3_-�'_Surface water/drainage N A Wells on adjacent kft ZGb r -f-
SEPARATION DISTANCE FROM ABSORPTION FIELD ONLOT TO:
ly5
Property line 30 Building foundation /3 Water meinlsenrice line
Surface water N 1 A Driveway, parking/vehicle storage area .50 r
Curtain drain N A Wells on adjacent lots /SD '" ` NL _
F. ENGINEER'S CERTIFICATION
I certlfy that / have determined Mm field Jnspectlons and review of Munidpaf rerwrt ank
in conform urce wfM MOA HAA p4deknes In effect on Itds date.
Signature Ir". KEVI;I G'DAVIS •• ;� %f
Engineer's Name ✓� �/ '?� � ^` . s � `'
%'Z / —7
gco
Date `r cd•:.,.
HAA Fee Waiver Fee S
Date of Payment —1 �Q Q// , Date of Payment
Receipt Number n `� �V D Receipt Number
72-026 (Rev. 9196)•