HomeMy WebLinkAboutHIDDEN HILLS BLK 1 LT 4Hidden Hills
Block 1
Lot 4
#011-121-29
Municipality of Anchorage
On-Site Water and Wastewater Program • (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP181318 PID Number: 011-121-29
Dwelling: ❑■ Single Family (SF) ❑ Duplex(D) ❑ Multiple (SF and/or D) Project: ❑ New El Upgrade
Name: ABSORPTION FIELD
Address El Deep Trench El Shallow Trench ❑ Bed El Mound
6350 LOST CIR ❑ Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
3 1.2 GPD/SF 9 Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot 4 Ft. 5 Ft.
HIDDEN HILLS BLK 1 LT 4 Fill added above original grade Gravel length
Township Range Section 1-2 Ft. 40 Ft.
Gravel width Beds:Number of Lines Distance between lines
SEPARATION DISTANCES 2 Ft. 0 Ft.
To Septic AbsorptionLift Station li Holding Sewer Total absorption area Number of trenches Dist. between trenches
From Tank Field Tank Line 400 Ft' 1 Ft.
Well 100'+ 100'+ 150'+ TANK El Septic ❑S.T.E.P. ❑ Holding ❑Other
Manufacturer Capacity
Surface Water 1001+ 1001+ ANCH TANK 1000 Gal.
Material Number of compartments
Lot Line 10'+ *2'+ NA STEEL 2
LIFT STATION
Foundation 101+ 101+
1 I Manufacturer Capacity
Curtain Drain UN UN Gal.
Remarks * MOA LOT LINE WAIVER OF 2' Pump on level at Pump off level at High water alarm at
in. in. in.
Pump make and model Electrical Inspections performed by
PIPE MATERIAL House to tank 3034 Tank to 3034
Installer drainfield
MIKE ANDERSON, P.E. Drainfield 3034 CO/MT 3034
Inspector MIKE ANDERSON, P.E. BENCH MARK (Assumed elevation) 116.5 ft
Inspection 1,110-6-18 2nd 10-6-18 Location and description
dates:
3"' 4th CORNER OF SIDING
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL 4�zaLn�-`'�-'x1A p
—� OF Ate"1.
Conditional Approval: Date c2.•••• •'`.,i n:49TH
41.
t '. •i's
01,
MICHAEL N. ANDERSON•.;i -�
lrri'. ?-449e1,6 q , .
✓f . ;;
�) i 940 •''••...m.:'
Appis - Date10-11 16 11�\\\Ee4-,`�_�.
Inspection Report_9-1-12.doc
Permit No. OSP181318 Page 2 of 2
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: HIDDEN HILLS BLK 1, LOT 4 PID No.: 011-121-29
MARK A B
CO1 11 25
CO224 '2 — - -
TCO2 31' 55
MT1 60 92 —CO3 41 57 1
Tc.OlAlliSilk Sb r
EN- —19( 10'3 I 1
/ OLD TANK DECOMMISSIOt D l
/ I N Ips K8G. \
// , SEPTIC
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i / BENCH , (�3 \
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- SEPTIC
/ DRIVEWAY - c� _ _ �
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1 I \ 1000 GAL ON STEW\TAN(
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/ 1,000 GALLCN \ 1 SN 0
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9�/ \9B 9 4 ,/ •• ";MICHAEL N. ANDERSONL_=:
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••\ •••• / / • .iii
SEPTIC
SEPTIC SECTION 83 ./� `a' ..,-�.�-,�-\4\, +.
N.T.S. T 61 41 ,1�1 J t�---
0/n to ,vLT 6 �.•�t
Municipality of Anchorage P GkUEfi.EAA� % ,
=- Development Services Department �., • 4_,, ,f"'_, a
On-Site Water and Wastewater Section ••+' '��
4700 Elmore St. :::*149TH %'r t4
2c....
P.O. Box 196650 Anchorage,AK 99519-6650 0 "�
www.muni.orglonsite �+ i '
—/ (907)343-7904 /I
Y �••��IiCHAEI N. ANDLRSCN ...re' f
d c=• CE-9469 •"'tee
Soils Log - Percolation Test ��•i•c •'*'`� �
‘CAZ STA`\"
Performed For: (Y1..9 M t'f Date Performed: �y
Legal Description: 1i Ld v w 44/4. ' ill U 6i ownship, Range, Section:
Slope Site P an
4 —1/111101118:11.
Depth
(Feet)
dJct •
1- -----
2- ,Ce- c, 1-cvlo.i,
3- M ,
4-
5-
6- 1/19641e.
7-
8-
WAS GROUND WATER
9- ENCOUNTERED? PID
S
10- IF YES,AT WHAT DEPTH? L
0
Depth to Water After P
1 1- Monitoring? t/ E
12- Date /–W
13- 0%1'4 1OPiltV
14- Reading Date / Gross Time Net Time Depth to Water Net Drop
15- ///&//g/ /Orli/11 (f /' S II
16- 2 v/� 5 )l
17— (J,O/4irMt (In Irl
18- �� S 11
19-
to cit
20-
PERCOLATION RATE 'Z/ (minutes!nch) PERC HOLE DIAMETER 10 tC
1 TEST RUN BETWEEN FT AND LOFT
COMMENTS f1( Cj 464 A+t•-•thrt It"vs*r M.4t
PERFORMED BY: f`41NiA, I CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE
"'""', MUNICIPALITY OF ANCHORAGE
On-Site Water& Wastewater Program
PO Box 196650 4700 Elmore Road _
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
http://www.muni.orglonsite
I)cpar tin( tit
4NCNUIX0'
On-Site Wastewater Disposal System Permit
Permit Number: OSP181318 Effective Date: 9/12/2018
Work Type: Septic Upgrade Expiration Date: 9/12/2019
Tax Code Number: 01112129000
Site Legal Address: -IrbbEN HI LLS BLk 1 LT V
Site Mailing Address: (0351;) LOST GII2CLE
Owner: SEXTON GLEN C Lot Size in Sq Ft:
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 3
This permit is for the construction of:
0 Disposal Field Q Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions: A percolation test shall be completed for the SM soil strata (from 1 to 7.5 ft on soil log) prior
to construction of the drainfield. If results require a design change, construction shall stop pending On-site
review and approval of a change order. Please submit results with the inspection report.
Received By: /, 1_ Date: 9 / / O
Issued By: A eilivt Date: • M 1E
Municipality of Anchorage nt ^
P.O. Box 196650 e 4700 Elmore Road
Anchorage, Alaska 99519-6650 e (907) 343-7904 a Fax (907) 343-7997
http://www.muni.orq/Onsite
Development Services Department
On-Site Water and Wastewater Section
**** VARIANCE/WAIVER REVIEW ****
Waiver#: OSV181071 COSA#: Permit#: OSP181318
PID#: 011-121-29
Legal Description: Hidden Hills Block 1 Lot 4
Engineer: Mike N. Anderson
Applicant: Glen & Kim Sexton
Your request for a waiver of the required 10 feet horizontal separation from the absorption field
to the property line has been approved. The approved separation distance is 2.0 feet.
This waiver approval applies to the proposed absorption field only. Any future upgrade to the
on-site wastewater disposal system will require all separation distances be met or another
approval from this department.
Waiver is Granted: X Waiver is not Granted:
Date: '0.2/18 Approved by: 12thCC4 Cov
Name of Reviewer
*'k** VARIANCE/WAIVER REVIEW ****
MUNICIPALITY OF ANCHORAGE
•
Development Services Department ;! Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 011-121-29
Property owner(s) SEXTON GLEN C & KIM Day phone
Mailing address 6350 LOST CIR
Site address same
Legal description (Sub'd., Block & Lot) HIDDEN HILLS BLK 1 LT 4
Legal description (Township, Range & Section)
Lot Size 19,876 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field Q Initial ❑
Single Family (SF)
(w/wo ADU)
Septic Tank Upgrade Dupl- . • ❑
Holding Tank ❑ Renewal ❑ 'I 8 9 to ❑
I • eDwelTn
Privy ❑ ",� or A�
Private Well ❑ °
Water Storage ❑ . SSP Q /.0\18b �
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
c5
/ u 6 8 6
!stance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
///iL
(Signature of property owner or authorized agent)
Permit/Rush Fees: �(0 Waiver Fees: # 2 5
Date of Payment: q_r11? Date of Payment: 9/111F
Receipt Number: �i10 � Receipt Number:
Permit No. D3 P I'1 /31?` Waiver No. 65\1181 OM
G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Sept. 12, 2018
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage,Alaska 99519-6650
Fax 249-7847
Re: New Septic Permit
Legal: HIDDEN HILLS BLK 1 LT 4 (Revised)
To Whom it may concern:
This is a request for a new septic permit and lot-line waiver on the above referenced lot. The old system has
failed and needs replacing. Due to the small size of the lot we are proposing to rebuild the existing system.
The old test hole data shows sand for the entire depth with a perc rate of 125 sf/bedroom, this equates to a
rate of 1.2 gpd/sf. The old system will be entirely removed and a new system installed above the old per the
design. All of the surrounding systems have sand and perc rates to match this lot,and the system has lasted
for over 30 plus years.
Checking the neighboring soil logs showed all test holes to be dry. Lot 2, 17 feet dry, lot 3, 18 feet dry, lot
5, 15 feet dry and lot 15, 18 feet dry. A test hole will be done prior to the installation to verify that the soils
are consistent with the design and a perc at the level of the new system. If the perc rate is slower the system
will be revised with a change order. The tank will also be replaced outside the numerous well radius'. The
lot slopes 15 percent near the location for the leach field, see the site plan, then flattens out to less than 5
percent.
We are also requesting a lot line waiver due to the existing driveway, see the site plan.
Please call me if you have any questions.
Sincerely
Michael N. Anderson, P.E.
4661 Natrona
Anch, Ak 99516
Ph 727-8864
' DESIGN CRITERIA: MOUND OVER
(TH#1) o �— GRADE
3 BDRM X 150 =450 GPD 1 0 .ORG
SOILS =450/1.2 = 375 GPDW FILTER FABRIC
375 GA/10 = 38' ,SM -3.0 �• m •"f7J PIPE
7.5
(1)TRENCH I sw SEWER ROCK
8.0' DEEP 12.0
5.0' EFFECTIVE -8.0
2.0'WIDE sM 12.0' I
40' LONG 17.0
SEPTIC FIELD SECTION
S)
--ar —
ig
i ♦ SAI \
i
-- -KINCAID ROAD- /�� _-`\ A
- - - - �' - - _ T - -\ - - -
1
EXISTING HOUSE \ r 1
I - - - -- - - - - - J- - 1
-
- -1 I 1 `\ I
PROPERTY LINE EXISTING SEPTIC i\ i I
Ilide
i V OST CIR'-
rol C 2.4
iffP P4- X \- ' i
EXISTING WELL
11\ \ `-r`' I
100'RADIUS I \,\ �� \ \I �/
I
WI
II I CI
II I 6- I
II _ _ -QUIET CIR- I
II I '
1 I , 7 1
If ` l I
I
Septic Design Prepared for .�00.11�11igiii1,
GLEN & KIM SEXTON .P OF 44`,44. i♦
HIDDEN HILLS BLOCK 1, LOT 4 •
' a AN ••• ♦/
Anchorage, Alaska , •
Michael N. Anderson, P.E. DATE: 9/7/2018 V....m..ICHAEL N. ANDERSON/pi
No. CE 94694601 NATRONA AVE DRAWN: DJR ♦♦j j;ANCHORAGE,ALASKA 99516 •* /.. 4. ��•
• SS\ i
(907) 727-8864/FAX: (907) 345-1391 SCALE: 1"=200' ��'•,'„"s��
/
/ KINCAIR ROAD-
T — - — - - - _7 - -• — — — -- — — —
•
/
•
•
•
•
\
\
\
I I
V"—
�
I NEW 1000
j GALLON TANK
HIDDEN HILLS / \O
BLOCK 1,LOT 3 `S'T
/
/ \\\ "•>),-,_
/ i SEPTIC 11 OQ
----- / 1 c-)/ LOT LINE \
/ _'--—
WAIVER
`� w ,.'" // ��. �- REQESTED \•
•
.� w L �. • / O `-�(�IT �\I •-
.
\
_ /ZI PROPERTY LINE-' O,44i \ C6. , •i / `,
`J /i'J ---- c" TCY\ 4 I--- ._`\ ► I) SEPTIC\i
o\
11 ��\- ��// EXISTING EXISTING `.. //
I I HIDDEN HILLS ` HOUE,' J TANK TO BE �\
1BLOCK 1,LOT / ` �, DECOMMISSIONED \
\� 1
I ® •RAG: PER UPC, k
/ / \ r \
•
I L_ WELL // I \ r \
— / I \ I \
F T J ' TfLITY EASEMENT /' / I HIDDEN HILLS \ I
L 1 — /_ �r— BLOCK 1,LOT 5
1 I / 1 \ PROPERTY LINE II
I
\�\ I � EXISTING WELL i \ I 1\\
\\ I 1 100'RADIUS // ® j \
1
`i\ 1, /�,4 �1
`���� \\ \-c.NEXISTING WELL \ / \
I _---_---\c-- 100'RADIUS ///�
IHIDDEN HILLS �� I I�DEN HILLS ,/ /„
BLOCK 1.LOT 16 \ BLOcK 1,LOT 15 /
•\ \. ./ — //
Septic Design Prepared for
GLEN & KIM SEXTON ••' ��--------------- '<1S♦♦♦
HIDDEN HILLS BLOCK 1, LOT4 :� 49TH %\ •• ••
Anchorage, Alaska ; • •
•
•
i
Micha• O •• MICHAEL N. ANDERSON i
el N. And, P.E. DATE: 9/7/2018 • G-%
O.
No E 46/9
4601 NATRONA AVE DRAWN: DJR ♦
ANCHORAGE,ALASKA 99516 ♦ •'�
(907) 727-8864/FAX: (907) 345-1391 SCALE: 1”=50' �441 �SS,, i4
• MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
II ENVIRONMENTAL ENGINEERING DIVISION
825 L Street • Anchorage, Alaska 99501 Telephone 264.4720
ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
Bea AM,.vA
PHONE
�f:NEW
1[3
2y3 gltyy
UPGRADE
MAILING DDRES
�54K 99569
LEGAL DESCRIPTION
d/ dddud
LOCATION1
NO. OF BEDROOMS
O Y
Wel
DISTANCE TO:
Absorpborea
Dwelling 7
PERMIT NO. r . .
aF
Manufacturer ^ Qc'p
Materi 1
No. o coOmpartments
Lin. capacity in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
Z
DISTANCE TO:
Well
Dwelling
PERMIT NO.
b O
_ FQ-
Manufacturer
Material
Liquid capacity in gallons
O
w=
DISTANCE TO:
Well Foundation
.tt.
Nearest lot fine
PERMI NO.
u. =
ZW
No. of I��
Length of ch line Total leng of lines
Trench�idth
Distance between lines
Inches
_
f
Top of tile to finish grade .� Material beneath tile `
Total effective absorption area
O
v inches
W
Length Width Depth PEHMIT NU.
i7
i t—
wa
Type of Crib Crib diameter ptlt Total effective absorption area
a
DISTAN Building foundau Nearest lot line
J
J
Class Depth Ilei Distance 19 lot line
PERMIT NO
Absorption area(s)
Buildin foundation t4LI �r ..j Septic to k
DISTANCE TO: ZR
.�
411, ...........
OTHER
-. )
'.s
•ft
j, •y
PIPE MATERIALS A
..:..APO..
SOIL TEST RATINGAw
i
: n
11
}
/� J, •� '' -
INSTALLERCe.ri3o
r
REMARKS 8
cc
p
II i�+�•i,:
[SY11tI5E �E6�1—
AAJ
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n10
l�At at=sr� kLiu VALL4
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�p ��LA&A&o:3oA
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urltiailot/.aG1+?
APPROVED ATE LEGAL
4\--#f6 k 31
z
72-013 1Hev. 317Bl
M U V4 I C I FP A L. I -r Y O F= A"( --"C] F,: n C3 E
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
e25 L STREET, ANCHORAGE, AK. 99501
264-4720
®t-,i—S I TE Si=Wt=R WALL f=•t=FzM I T
PERMIT NO:
DATE ISSUED:
APPLICANT:
ADDRESS:
CONTACT PHONE:
650005
01/07/65
DOD ALBINA
5331 TUDOR RD
ANCHORAGE, AK 99507
563-7164
LEGAL DESCRIP: SUBDIVISION: HIDDEN HILLS
. SECTION:.9 TOWNSHIP: 12N
LOT SIZE: 19676 (SO. FT. OR ACRES)
MAX BEDROOMS: 3
Listed below are the options available to
system. Choose the option that best fits
TFti CtgI-- VA
DEPTH TO PIPE BOTTOM (FT.')
7.5
GRAVEL DEPTH (FT.)
4.5
TOTAL DEPTH (FT-.)
120
GRAVEL WIDTH (FT.)
2..5
GRAVEL LENGTH (FT.)
4'0
GRAVEL VOLUME (CU.YDS.)
19..5
TANK SIZE (GALS)
1,000.0 **
SOIL RATING (SQ.FT./BR)
125
LOT: 4 BLOCK: 1
RANGE: 4W
you in designing your septic
your site.
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
,- - - - - - - - - - - - - - - - - - - -- ac�a� �sv
I certify that:
1. I am familiar with the requirements'for on-site sewer= 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 critieria of this permit.
�. 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.
4. I understand that this permit is valid for a maximum of 3 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 DE 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 r DATE:
�G%C�- _�.-------- ---------------
APPLICANT: BOE: AL ' 'A
ISSUED BY DATE:
-V -- %/mss
rt
/0' Li TIL /Ty
EASE M EMT
a�q
sit
o o. �C, KeAmaw
'� '►.� 2211.E
•Req AR
1 HEREBY CERTIFY THAT I AM A REGISTERED
LAND SURVEYOR AND THAT THIS PLAT
REPRESENTS A SURVEY MADE BY ME.
BELTAIN reel KpZLp `' 1 2241-S
h2PIA. �F'
'EMrti AP Fd �.
/4 y 12 or Q/oN
� AFD
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A
00
SEPTIC.
TAN K
R-501
BUILDING LOCATION
LOT 4 BLOCK I
HIDDEN HILLS SUBDIVISION
Beltaine C. Kozlowski
4620 Emerald Court
Anchorage, AK. 99502
DATED; 10-14-85 SCALE: I"= 30'
/„1'.aL•f�'fY.1�'R°f?'� �14M a.t!Mr""'r77RVM EtR"','R- �.
WATER WELL RECORD
• STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological 9 GOOPhysical Surveys
Drilling ►semlt No
t.r.Tlnu OF WELL (Please Complete either Is. to or Ie.) A.D.L. No
Let It to 1/.4fra. Settle" No. Ta.n.MPNp Mnp 1[3Molillan
eak
la. Borough1110QQ
then
n c h Hills 4 1 —of—of—eta ap WO
le. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS E. OWNER Of WELL: Bob Albino
Address:
Sand bake
Sli►.t Aden.. .*d Area of Well Location
.2. WELL LOG Fe+1 •els.
aurloco
•. WELL1 DEPTH:
�,
a. DATE OF CO P( ETIP7
— 67
Material Type Too Bottom
(Z Cable foal [3Raterq p Driven 0 Dug
na.
0 Apgar [3,19144 0 $*red [3 Other I
Gr�y clay F. aV 1 2 78
Layers gray clay, Pravel -
LOSE: Q Domestic 0 Public $appy 0 Industry
[3 irrigation p Machetes 0 Commerical
78 196
brnwn grind
0 Toot wait pother:
Heaving sand 196 310
.�310 313
a. CASMGI [3 Threaded 0 Welded
dism.'_in. 4 31311. Oopfh W.Ifnt- 7 itte./n.
dlom. In. /e_1 ft. Depth stickup it.
a. FINISH OF WELL:
Open 6 inch
Tppe: olaan.t..:
Slot/Meeh ala.: Lugfh:
Sat between ft. and ft.
Saek111ting Gravel Peak
•
10. STATIC WATER LEVEL:_175 ft. •8 R 4L8
[3 Above or Jjo Belo. land @Verde* Dat. ,
"�
Eellt►m*nt wood:
ll. PUMPING LEVEL below lend surface and YIELD
g.P•m•
184 ft. alter 4 bre. pumping 10DEEM
OF HFAITH 2
ft. alter M*• pumPing _Lp m•
- ENVIRONMENTAL PROTECTIO
12.411$ounNa Well Grouted: ❑ rs P Na
Material: Onset Cement [3 Other:
IS. PUMP: (I1 available) He
Length of Drop Pipe ft. eyacity 2 P.M.
p Saban. O JN p Cenfrlfieal O Other
14.REMARKS:
Bailed 0 10 gpm for 4 hrs.
16. WATER WELL CONTRACTOR'S CERTIFICAT ON:
- � IS. Welt' Temperature —+ 0 F [3 C
'This moll was drilled under my )urledlclla"•and this report Is #roe to the bell of my knowledge and boll.+;
Sommerville Well Drilling A13788
Registered Business Nome Contract License Number
A41r.ss: 11140 Polar Dro,p Anchorage, Alaska 99516
sigma: Date: 8-28-8
�Aulhorle*d Representative
Form 02•WWR (11/BI) Copy Distribution: WHITE -Stale DOGS, PINK -Driller. CANARY -Customer
STAVE OF A^ SHEME1D, GOVERNOR
DEPT. OF ENVIRONMF,NTAI. CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501 274-2533
July 18, 1985
Barter and Associates
Tony D. Barter, P.E.
10461 Hampton Drive
Anchorage, Alaska 99516
SUBJECT: Horizontal Separation Waiver Between Well and Septic Tank,
Lot 4, Block 1, hidden Hills Subdivision, Anchorage, Alaska
8521 -WA -017
Dear Mr. Barter:
The Department has reviewed the subject waiver request and hereby waives
the horizontal separation between the avll and septic systEms to 85 feet
on the subject property for a single family residence only.
This waiver is contingent upon using an approved watertight septic
tank with Calder couplings or the equivalent.
Sincerely,
Steve Eng7PI�
District Engineer
SE/dd A1UNIDf� t1Egip
Ity OF RAG,
AN
ELJYIRONWNT' 1 ALTHPROTECTION
JAN 2 21986
RECEIVED
MUNICIPALITY OF ANCHuxAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK 99501
264-4720
at4—S5ITE SEWEFZ &?
-PERMIT NO:
.DATE ISSUED:
'APPLICANT:
ADDRESS:
CONTACT PHONE
LEGAL DESCRIP
LOT SIZE:
MAX BEDROOMS:
840484
06/19/84
BOB ALBINA .
5331 TUDOR RD.
ANCHORAGE, AK 99507
563-7164
SUBDIVISION: HIDDEN HILLS
SECTION: 9 TOWNSHIP:
19876 (SQ.FT. OR ACRES)
3
LISTED BELOW ARE THE OPTIONS AVAILABLE TO
SYSTEM.' CHOOSE THE OPTION.THAT BEST FITS
{t.f
WELL_ F'EFZt1I-r
,I
t:
LOT: 4 BLOCK: 1
12N RANGE: 4W
YOU IN DESIGNING YOUR SEPTIC
YOUR, SITE.
6�rAVZL dente • _ 3 „5--
T 7qC, d err.,
6rAt,CL to i f a"v S
Gr-AueL Lcu,g
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS- -�L� L1Lis'tJ lzdAzo <s -y
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.
4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 3 BEDROOMS AND
ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT.
IF A LIFT STATION IS INSTALLED IPJ 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
APPLICA
ISSUED
DATE:--tft7Q_f/_ ----
DATE:- / i Q'CG
TFriEt4 C"
DEPTH TO PIPE BOTTOM (FT.)
7.5
GRAVEL DEPTH <FT. >
4.5 '
TOTAL DEPTH (FT.)
12.0
GRAVEL WIDTH (FT..)
2.5
GRAVEL LENGTH <FT.)
42.0
GRAVEL VOLUME <CU YDS. >
19.4
TANK SIZE <GALS)
11000. 0 **
SOIL RATING (SQ. FT. /BR)
125
{t.f
WELL_ F'EFZt1I-r
,I
t:
LOT: 4 BLOCK: 1
12N RANGE: 4W
YOU IN DESIGNING YOUR SEPTIC
YOUR, SITE.
6�rAVZL dente • _ 3 „5--
T 7qC, d err.,
6rAt,CL to i f a"v S
Gr-AueL Lcu,g
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS- -�L� L1Lis'tJ lzdAzo <s -y
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.
4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 3 BEDROOMS AND
ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT.
IF A LIFT STATION IS INSTALLED IPJ 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
APPLICA
ISSUED
DATE:--tft7Q_f/_ ----
DATE:- / i Q'CG
MUNICIPALITY OF ANCH,.,AGE
•� . DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK. 99501
264-4720
OM —E; I TE S:EWEFZ .S�t WELL_ PERM I -F-
PERMIT
PERMIT NO:
DATE ISSUED:
APPLICANT:
ADDRESS:.
COfJTACT PHONE
',LEGAL DESCRIP
LOT SIZE:
MAX BEDROOMS:
840484
06119184
BOB ALBINA
5331 TUDOR RD.
ANCHORAGE, AK 99507
563-7164
SUBDIVISION: HIDDEN HILLS
SECTION: 9 T014NSHIP: 12N
19876 (SQ. FT. OR ACRES)
3
LOT: 4 BLOCK: 1
RANGE: 41.4
LISTED BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR, SEPTIC
SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR SITE.
TFZEV4CH-----i-----
DEPTH TO PIPE BOTTOM (FT.)' 7.5 � P,jq ,S r
GRAVEL DEPTH .(FT. ) 4.5
TOTAL DEPTH (FT.) 1�. 0 G r
GRAVEL WIDTH (ET. > r2. 5 T07AC, = FoZ• D
GRAVEL LENGTH (FT.) - - 42,0 `
GRAVEL VOLUME (CU. YDS. ) 19.4 an9ti
TANK SIZE (GALS) 1,000.0 .**
SOIL RATING (SQ. FT. /BR) 125 OF q (.4�f7G�i Y/ 7
** TANK, MUST HAVE AT LEAST TWO COMPARTMENTS kt tfttQ i la'GNl/ _ ,S
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
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 MOR 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.
4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 3 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 WORE: MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED
APPLICANT:
ISSUED BY
_8,u� --------------------
---- DATE:
BOB R NA
-------- DATE:
/l!o 7E:
ZaT 51-, 234/ rnurT �4
S 6u)4Z7f_ A/E f-� l-v,Hj fi-n/7> LoT
41 N r= O 4J
—0 7- - ' G!%z-L U1! L L /3c
�"2�c2 � issu��r�c= ani
�� s 7:4-ntGG %jEiZllE�r! cc.�ELJ� C .✓
L O T L U/E (. C.0 La T .J
2
• ' 1 �, SOILS LOG
,�. MUNICIPALITY OF ANCHORAGE
r r DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION It
PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
PERFORMED
LEGAL DESCRI
1
2 '•!
3 t.
a Of A(
P(.,...«......�
,ice r
5-
L ®y) 1 Itt `
t . Q0
7 •r ` � 0 C Tony D. Boner
CE 5130
t ..
�pRCFESSO'�P
9
10 ,., SW— 1JSSF�6daa1..
/S \
SLOPE
DATE PERFORMED: (0 —10 -8{l
+e-•11 '.r •, WAS GROUND WATERS
• . t ENCOUNTERED? ��_ LO
2 P
IF YES, AT WHAT E
.--
13- DEPTH?
I. X I.
PERFORMED
72-008 (6/79)
Reading
Date
Gross
Time
14
Depth to
Water
Net
Drop
.i'
Sm
15
16
17
18
19
20
PERFORMED
72-008 (6/79)
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE VKpfiL J1J,Cf51APps (minutes/inch)
TEST RUN BE�j EEN FT AND FT
19, n w/11lA �oi.,1 ..vJb rLAAA-1l
CERTIFIED
DATE:&-�R-Ry
M
Miro' icipality of Anchoiage
MEMORANDUM
DATE: October 4, 1982
TO: Laura Crow
FROM: Sewer and Water Program
SUBJECT: Request for Refund - Account #2460
Please make arrangements for a refund for the following; information
has been received that this lot is undevelopable due to location
of neighboring wells/sewer systems.
Receipt #197389
Permit #820714 $30.00 Sewer and Well Permit
Lot 4 Block 1 Hidden Hills Subdivision
North View Corporation
3605 Arctic #1065
Anchorage, Alaska 99503
Laura J. Ward
Senior Office Assistant
LJW/ljw
91-010 151781
11Ur-4 I Cl�lC,RF=3GE
' DEPARTMENTS HEALTH AND ENVIRONMENTAL rOTECTION
£25 'L' STREET, ANCHORAGE, AK. 99501
26_.4-4720
[JELL Fit-jr> i=stJ—=. I TE `= EI-JEF: F•ERt•1 I T
PERMIT NO. ( £20714 )
APPLICANT DEAN CR.EANE 422.5 SPENARD #68 99503
LOCATION
LEGAL B1L4 HIDDEN HILLS LOT SIZE 999999 SOURRE FEET
TYPE OF SOIL RESORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (_cQ FT/BR)= 150
THE P.EOUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
GEF TH= ' 4 1 r3FP*n %- EL J>EF•TH=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET)
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRA
AND THE BOTTOM OF THE EXCAVATION (IN F!KET).
CH OR DP.AINFIELD.
SURFACE OF THE
BETWEENITHE OUTFALL PIPE
REG!i_i I F:EG+ SEPTIC TFit JF = I =E1 iIDCt C3nL_ _Clt IE
PERMIT APPLICANT HAS THE RESPONSIBILITY TO IIFOPM THI_ DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJAr, TO THIS PR'OPER'TY AND THE
NUMBER OF RESIDENCES THAT IfHE WELL !•JILL SERVE. i
It �IEr TIQt-ate F? E: R !i_iIF'EG� ---
EACKFILLI)JG OF A? -JY SYSTEM W THOUT F�tJAL INSPECTION AND AF'P .0VAL BY THIS
DEPARTMENT WILL BE SUBJECT T PROSEC (TION.
MINIPUJM DISTANCE BETWEEN A ldEL AND Al ON-SITE SEI* E DISPOSAL SYSTEM IS
10'a FEET F iF, R PRIVATE WELL OR _'C' TO 00 FEET FP.0 R FLBLIC WELL DEPENDING
UPON THE T4 'E OF PUBLIC WELL.
MINIMUM DIS ANCE FF -)t A PRIVATE I LL TO PRIVAT SEWER' LINE IS 25 FEET AND
TO A COMMUNI Y SEWER INE IS 75 F T.
WELL LOGS RF,' REG!UIR.ED RND MUST
BE ' TUPJED T THE DEPARTMENT WITHIN 20 DAYS
OF THE !JELL C MF'LETIOPJ.
OTHER REOUIREM NTS MAY R' LY. SPECIFICATIOFS AMD CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO IP=URE PROPE INSTALLATION.
F•ERI'IIT lE=:iPIR
I CERTIFY THAT
1: I AM FAMILIAR, 1.1I THE RE
FORTH BY THE NUNICIP ITY OF
2: I WILL INSTALL THE _YSTE I
?: I UFJDEF:STA DJ THAT TH_ -
RESIDENCE IS REMODELED
SIGNED
L'�Et--E0 E3 EF: 21:. -JL, 1•=+o-?
IREMENTS/FOP. ON-SITE SEWERS AND WELLS RS SET
NCHOP.AGE.
N ACCORDANCE WITH THE CODES.
TE SEWER. SYSTEM MAY REQUIRE ENLARGEMENT IF THE
UDE !'HOPE THAN 2 BEDROOMS. ' ,r J
,?5 - W -c a fo
APPLICANT /DEA,N, ,CPP.EANE / /�6t. ��
ISSUED E;Y_� -"'��/ ---DATE 7L_!2��z--L,eo.,rV i. 0
PERFORMED
SOILS LOG •J
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION O PERCOLATION
TEST
825 L Street, Anchorage, Alaska 89501 2644720
SOILS LOG —,^ %PERCOLATION TEST
y
t• 1/ L-! GI / I C 1 GLIA/ / p_ DATE PERFORMED: / rG. V v
LEGAL DESCRIPTION: R Ud!° h N Ms
Is E
2-1 1 (00 0 yanl4 Si �t
111 sor, s-abw
a
r
6 r
7 /
8 r
s
—�` 9 a i
10
CK
SLOPE
_Lo f'fi
SITE PLAN
i
. 11 WAS GROUND WATERS
ENCOUNTERED? o U
12 r P
IF YES, AT WHAT E
13 ^ DEPTH)
14-
15-
16-
17-
18-
19
41516171819
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
20
PERCOLATION RATE
TEST RUN BETWEEN
COMMENTSVI's C1,
TPP_tr
r
PERFORMED BY:
72-008 (6/79)
J
IED
(minutes/inch)
AND FT
DATE: t �-s
MUNICIPALITY
Development Services Department `` �
P P `_ ==' Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I. D. 011-121-29
1. GENERAL INFORMATION
Complete legal description HIDDEN HILLS BLOCK 1, LOT 4
Expiration Date:
Location (site address) 6350 LOST CIRCLE, ANCHORAGE AK 99502
Current property owner(s) ADAM JACKSON & IZUMI NASH Day phone
Mailing address
Real estate agent
6350 LOST CIRCLE, ANCHORAGE, AK 99502
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:
Private Well
®
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 550
Date of Payment 1�2�d�2"2.
T
Receipt Number g0 2 3 y
Date:
Waiver Fee $
Date of Payment
Receipt Number
COSA # OSG 2 2 102,3 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY, ANCHORAGE AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 1/27/2022
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. 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 in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. 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 •�i
well and septic system. Therefore, any estimate of how long a system will function satisfactory g�Q: • •.
for current or future occupants or guarantee that no unseen encroachments, deficiencies or * . .�
discrepancies exist can be given by First Water Consulting & 1`145Q — I
r� ......
t/�.-
6. DSD SIGNATURE Curtis Huffman
System #1 Approved for bedrooms �r��``", •CE 128991•...����
F,p .1/27/Z2
System #2 Approved for bedrooms illk�, PROFESSO�
Disapproved
Conditional approval for bedrooms, with the following stipulations:
C
�o
OF.,vV/(i�r�
WATER AND m
'n0 i " WATER z
PRor,F o
/ SERVI`1 �����
`,"' Original Certificate Date: 2 r �ZZ
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
Legal Description: HIDDEN HILLS BLOCK 1. LOT 4 Parcel ID: 011-121-29
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
® Well log is filed with Onsite (or attached)
Date drilled 8-28-1985
Total depth 313 ft
Cased to 313 ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 24+ in.
Date of flow test for COSA 1/21/2022
Static water level at beginning of test 174 ft.
Well production at time of test 6 gpm
Comments
B. TANK DATA
Age of tank(s) 3 years
Tanis type/material SEPTIC / STEEL
Measured operating fluid level in septic tank 50"
E Standpipes/foundation cleanout per record drawing
Date of pumping 1/25/2022
D. ABSORPTION FIELD DATA
Which system tested (date installed) 10/6/2018
® ALL standpipes present per record drawing
Total measured depth from grade 11.9 ft (max)
Measured depth to pipe invert from grade 6.8 ft (min)
❑ N/A — pressurized field
® Monitor tubes go to bottom of effective. If not, state
depth into effective
® Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
Structure served by this system
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ® No
® Coliform bacteria is Negative
Nitrate mg/L ® Nitrate less than MRL (ND)
Arsenic 18.6 ug/L . Arsenic less than MRL (ND)
Collected by FWD
Date of Sample 1/21/2022
C. LIFT STATION
❑ Required maintenance completed
Age of lift station _ years
Lift station material
Comments:
Adequacy test date 1/21/2022
Results 2 Pass For 3 bedrooms
Fluid depth prior to test 31 in
Water added 450 gal
New depth 43 in
Elapsed time 1400 min
Final fluid depth 30 in
Absorption rate 450 gpd
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Fwrs
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
if No
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No ft
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No ft
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No ft
Neighboring Absorption Fields > 100'
Water Service Line > 10'
® Yes
Animal Containment > 50' ® Yes
if No ft
® 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
_ ®Yes if No ft
Property Line > 5'
® Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
® Yes
if No
ft
Private Wells >' 100
_ ®Yes if No ft
Water Main > 10'
� Yes.
if No..
ft
Community Wells > 200' Yes if No ft
Water Service Line > 10'
® Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
® Yes '
- if No _
_ ft
If absorption field is under driveway comment below
Property Line - 10'
[l Yes
if No _*2
ft
Wells on Adjacent Lots:
Water Main >.10'
® 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
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
*PER MOA WAIVER ISSUED 2018.
G. ENGINEER'S CERTIFICATION
l certify that l 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.
ANW
® .. ........
P.. .... .......... j
�.. Curtis Huffman
CE 128991
$} �jFe4* 213 20;2 •l��v��.a�
��t pROFESSO •�
Arsenic Advisory
Certificate of On -Site Systems Approval # OSC221023
Subdivision: Hidden Hills B1 lot 1
1-1--11.-11- - A water sample revealed an arsenic concentration of 18.6 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/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 ga.uge the relative quality of water
from private wells. Information on arsenic is available from the On -Site Water and
Wastewater Program website (www.muni.org%onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval
MKggMailinRAddress P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org
•
• Municipality of Anchoragel„ OCT 19 418
On-Site Water and Wastewater Program
(907) 343-7904 ANDREW W �' �'
C T
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 011-121-29 Expiration Date: 1 — f qr I GI
1. GENERAL INFORMATION
Complete legal description _HIDDEN HILLS BLK 1 LT 4
Location (site address) _6350 LOST CIR, ANCH. AK
Current Property owner(s) _GLEN C & KIM SEXTON Day phone
Mailing address _SAME
Real Estate Agent Day phone
I\ 2346,„
2. TYPE OF DWELLING:
® Single Family (w/wo ADU) Q �� ��•
❑ Duplex A" `
❑ Multiple Dwellings (Single Family and/or Duplex) —05 (";.:. l
3. NUMBER OF BEDROOMS: 3 S ,r z e`
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 ❑
Waiver/Variance request for: Distance:
Received by: Date: (17I4(i
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ W 29 Waiver Fee $
Date of Payment (O/t ?lr 2 Date of Payment
Receipt Number 231 Receipt Number
COSA# OS C( ( S CQ 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 10/18/18
OF � 7a
� 49Trt •
•
K' !
•
�0 0 0.0 0 • O O ..... .. .•
O O O O O O 0...
v. MICHAEL N. . .,' L
6. DSD SIGNATURE 7 �^• ANDERSON ;�:
``�� ��fes.• CE-9 69
System #1 Approved for J bedrooms. hi/
System #2 Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
cZn- "7510
ON-SI I E .
WATFR AN
WASTEWATER o
' PROGRAM .(;
By: j ��cd/ Original Certificate Date: I D �t ^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 Nitrate Advisory
Septic System Advisory Arsenic Advisory x
Well Flow Advisory Other
COSA blue sheet 10.10-12.doc
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: HIDDEN HILLS BLK 1 LT 4 Parcel ID: 011-121-29
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed_8-28-85 Sanitary seal (Y/N) Y Wires properly protected (YIN) Y
Total depth 313 ft. Cased to 313 ft. Casing height(above ground) 12"+
FROM WELL LOG AT INSPECTION
Date of test 8-28-85 9.11.18
Static water level 175 ft. 178 ft.
Well production 10.0 g.p.m. 3.6+ g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate 4.10 mg/L
Arsenic: 21.2 ug/L Date of sample: 9-11-18 Collected by: MNA
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEEL Date installed 10-6-18
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) N
Date of pumping NEW Pumper NEW
C. ABSORPTION FIELD DATA
Date installed 10-6-18 Soil rating (GPD/SF) 1.2 System type DEEP TRENCH
Length 40 ft. Width 2.5 ft. Gravel below pipe 5.0 ft.
Total depth 11 ft. Eff. absorption area 400 ft2 Monitoring tube Y Depression over field N
Date of adequacy test NEW Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test in. Water added gal. new depth in.
Elapsed Time: min. Final fluid depth _in. Absorption rate >= g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) If yes, give date
•
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 100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main 100'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 100'+ Holding tank NA
Animal containment areas 100'+ Manure/animal excrete storage areas 100'+
SEPTIC TANK ON LOT TO:
Building foundation /I.+ k9 Property line 5'+ Absorption field 5'
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Property line *2'+ Building foundation 10'+ Water main 100'+
Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 104
Curtain drain 50'+(None Known) Wells on adjacent lots 200'+
• OFA .,104
•+ r,
p,. •
F. COMMENTS ow c) .' 4r •+
IT: 49TH i
/ • MA\
,s*�MICHAEL N. ANDERSON:
G. ENGINEER'S CERTIFICATION CE,-9 69 .;`
•
rr'0▪.••,���I b ,.
I certify that I have determined through field inspections and +1°FD ••••.
review of Municipal records that the above systems are in �\ P�(IfFS�I�t' `
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name MIKE N. ANDERSON,PE
Date 1011812018
COSA canary sheet_2-6-15.doc
Municipality of Anchorage '..R
•, tri �P = <o
_ Development Services Department
Building Safety Division
SA err
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Arsenic Advisory
Certificate of On-Site Systems Approval # OSC 181560
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 1, Lot 4 of
Hidden Hills Subdivision. This inspection revealed an arsenic concentration
of 21.2 micrograms per liter (ug/L) for the property's well water sample.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/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. Information on arsenic is
available from the On-Site Water and Wastewater Program website
(www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
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WELL' /70 OF `\\
BobbyF. Burnett GRAPHIC SCALE: 1 Inch = 40 Feet CURVE CHART ` •
2941 Carriage Drive NO DELTA RADIUS LENGTH 1 r 8 ?" ' i
Anchorage, Alaska 99507 , „ ,, ss�ox� �
(907) 350-5541 20 0 20 40 80 10 51'33'58 50.00 45.00 \Iii.._-110:41".
Date Scale Legal Description
10/8/2018 1" = 40' I hereby certify that the property described hereon has been surveyed
Lot 4 Block 1 by me, or at my direction, and that the improvements situated thereon
Grid are within the property lines and do not overlap or encroach on the
SW 2222 AS-BUILT property lying adjacent thereto unless otherwise shown. That no
Drawn byField Book HIDDEN HILLS SUBDIVISION improvements on the property lying adjacent thereto encroach on the
\44:. PLAT# 70-338 premi%es in question and that there are no roadways, transmission
BFB ASB-2018 lines or other easements on said property except as shown.
Municipality of Anchorage
-� Development Services Department
Building Safety Division
/ Onsite Water and Wastewater Program
4700 Bragaw Street 3" `T•
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel l.D. 011-121-29 COSA# OLPOP T
Expiration Date: 9 -- .2 6 - Oto
1. GENERAL INFORMATION
Complete legal description Lot 4; Block 1; Bidden Hills Subdivision
Location (site address) 6350 Lost Cir.
Current Propertyowner(s) .rim & RAChP1 Flmnrr Day phone 243-7761
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone
Christy Rush Dayphone 441-6202
Prudential Anchora
Unless otherwise requested, COSA will be held by DSD for pickup. -7W Z Irz-a, r( Z4
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
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
titte (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 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.
NameofFirm S 5 S Enpineerinp Phone694-2979
Address 17034 N. Eaple River Loop Ste. 204 Eagle River, K995 7
Engineer's Printed Name Pbl364T C �oc.i,y,J Date F74-1,46
'f4tn� ROBERT G COWAN �Q
5. DSD SIGNATURE 'ft ftiy Cs -8801 r \ ,
Approved for bedrooms. +t1``<v''
Disapproved.
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: Gv. ✓-'tel Original Certificate Date: S�_ 12 & 06
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsde
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
7
Legal Description: I,oT "1 T /1;819110--) 4I LLS C�D Parcel ID:_O It - t a.! -a9
A. WELL DATA
Well" e--1 M -c -
Date compietedcw8G
Total depth 313' ft.
If A. B, or C provide PWSID # = Well Log& \rte
Sanitary seal (/ 4) Wires properly protecled(Y N) VES
Cased to 313 ft. Casing height (above ground) 1 Z °f- in.
FROM WELL LOG AT INSPECTION
Date of test Z S 5 /1 e%,
Static water level 17S ft. 17 /o ft.
Well production g.p.m. 6o( g.p.m.
WATER SAMPLE RESULTS:
Coliform _0_colonies/100 mL Nitrate 63J mg/L Other bacteria C7 colonies/100 mL
Arsenic: 14-'l mgll Date of sample: 5 15/% Collected by: Sn S ti! -,r I�76C/EIK7Co
B. SEPTICIHOLDING TANK DATA
Tank Type/Material S vnc. SSE Date installed i \'z3 86 - 1 ZY86
Tank size ICCO gal. Number of Compartments 2 Cleanouts /t) 7Eg
Foundation cleanout&N) AUX-Depression over tank (Yo A56 High water alarm (Y® ,UO
Date of pumping S/OLO(7 Pumper lEIP_tJICL�
C. ABSORPTION FIELD DATA
Date installed Z 86 Soil rating (g.p.d.M2r fe/ drm -17-5 System type 1 �
i
Length Z� ft. Width z 5 ft. Gravel below pipe q•s ft.
Total depth ft. Eft. absorption area Monitoring tube *5 Depression over field
Date of adequacy test $ 1$ O6 • Resufts as ail) i' S For -3 -bedrooms
Fluid depth in absorption field before test „in. Water added gal. New depth2din.
r�
Elapsed Time: 15 min. Final fluid depth N6 in. Absorption rate >= ItSO t g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y& type) 00 If yes, give date
D. LIFT STATION
Date installed
'Pump on' level at _ in.
E. SEPARATION DISTANCES
Size in gallons
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
i
Septic tankAift station on lot 9 2 tk
*X
Absorption field on lot � �
Public sewer main
Sewer /septic service line a s 4
Animal containment areas 501+
in. High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots /00 1,L
On adjacent lots l m r4�
Public sewer manhole/cleanout /0
Holding tank A-4or
Manure/animal excrete storage areas t 6o
in.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation t4 I Property line '16 1
161 Absorption field I Q r+
I 1
Water main � Water service line r'0 Lf Surface water
Wells on adjacent lots /Q'7 t4 -
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line IC) /+ Building foundation (64 -
Water main
1 1 1
Water Service line I t Surface water t' 00 LF Driveway, parking/vehide storage
fr�vAl.Q 0%1V�
Curtain drain K0tJE�tt7
Il-'6W4on adjacent lots /W II �0 i
F. COMMENTS
IA -512#
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 COSSA guidelines in effect on this date.
Engineers Printed Name /C ie ` Dw9,-,l
Date -f— /Z 3 A C
COSA Fee $ 4 3 0. e v
Date of Payment S Aa 3 1G b
Receipt Number �O��i %j
(Rev. 11/05)
521 - tarp- - of
as
Waiver Fee $
Date of Payment
Receipt Number
n
ROBERT 'C..COWAN �
CE -8801 > .
�tl e.
rW'r—t1-2LKi6 11:53 PRUDENTIAL UISTA REAL EST 907 562 5485 P.02
•—,
' S DO'oJ' Oo�V✓ +
' 39 8�r �AVSEME T
a
10 WELL.
VT11-1'CY
EA EM AIT I r
1 �
' to \� \•� // i� \ \
3' I
h �
u ` \
0 aoac.c h
lo1p� �IVA,L.thl
r
Or 44'
n,
r .: �r +qE �'+ •..'�j try o � 1 1
o 1 0
't P ? FIELd 1
rr A
A '• 224'3 4
•Ow +
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
" AS - BUILT ' SURVEY
FOLLOWING DESCRIBED PROPERTY:
LOT A. BLOCK 1
LOT 4. BLOC( 1
HIDDEN HILLS SVSOIVISKIN
HIDDEN HILLS SUBDIVISION
AS RECORDED IN THE ANCHORAGE RECORDING DISTRICT, ALASKA.
'
AND THAT THE IMPROVEMENTS SITUATED THEREON ARE AS SHOWN
ON THIS PLAT AND THAT THERE ARE NO ROADWAYS, TRANSMISSION
Bahama C. Kaaloevski
ONES OR OTHER VISIBLE EASEMENTS EXCEPT AS INDICATED HEREON,
Reglal•nd Lan4 Surveyor
4620 Emerald Court
DATED AT ANCHORAGE, ALASKA THIS
Anchorage, AK 99602-5120 49071243-5650
22nd DAY Of OCTOBER, 1087.
-
DATE: 10122/97 SCALE: 1• . 20•
TOTAL P.02
MAY -26-2006 12:39 S&S ENGINEERING 907 694 1211 P.02i02
SGS Ref. t.
1062417
Client Name:
S 3 S Engineering
Project Name:
Hidden Hills, L4, B1
Client Sample ID:
Hidden Hills, L4, B1
Matrix:
Drinking Water
SGS Environmental Services Inc
200 W. Potter Drive
Anchorage, AK 99518
Tel: (907) 562-2343
Fax:(907)561•S301
All dates/Umes are Alaska Standard Time
Printed Datemme:
0228M 11:00
Conecled Datcrrkne:
=me 9:50
Received DateMrrwt:
45/15106 10:19
Technical Director.
Stephen e
Parameter
Released
PGL
aempge nemarr<s:
-
Parameter
Results
PGL
Units
Method
Allowable
Limits
Prep
Oata
Analysis
Date
Init
Bacteria
0.00
9222B
05/15106
05115M
df
Nitrate
0.39
0.10
mV/kg
EPA 300.0
10.00
05/1510e
05/15r06
air
Arsenic
14.70
S.CO
ug/L
200.8
10.00
MOM
0522/06
act
TOTAL. P.02
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH HUMAN SERVICES
Division of Environmental Services
7 f
'On-SiteServices Section 1.
P.O. Box 1966507Anchor'age. Alaska i+89519-6650
zz.
CERTIFICATE OF HEALTH AUTHORITY;,,
APPROVAL FOR ASIkIGLiE FAMILY 'DWELON'Gi
Parcel LD. # 011
!',J
CIA f,
Z
'GENERALINFORMATION bAn z
-+,.-Complete legal description Lott 4; Btdck IrHiddek-Hitt4Sr bdiviscon
L
Location, (site address ordirections)' 6350 Lost CiAcle.
Anehwta
4
Property -owner., Bob .a Beth Atbina
Day phone 337-4653"• -
Mailing Pddre AK 99504
--ca . .... .
-agency.;
Day phone
Mailing address s
Z
"VdvZcs/ Dunami-
Day 27
-Agent
.0ho
._ - A
Address 71 i i ZASt)teet .Smue�100%I: n ch
—.o)ta^- 'AKev, 03
pip 3111 I1C
Unless otherwise requested, HAA will bi held for pickup'.
t
W14 U'iNl§ ER -be EEO R 6 0 MS -!t---1
3 -"*-TYPE OF WATER SUPPLY""'
-.,In ivAM
dual well XXX
ii.,L_ruDtic waxer.NOTE If ,
community wail system• provide written confirmation from S44AbE&attesi-"':,
g_Lq Ate legality and status of system
X.
TYPE F WASTEWATER DISPOSAL ;�
Individual on-site XXX
W
Holding tank;
Community on-site,,.
Public sewer
...... I
.
'"'''NOTE. If community wastewater system,'prOvide written6onfirmatiori from 'State AID'EC
attesting to the legality and status of system
72-MMw.1191) FWI 110016921
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 fu rther verify that based on the information obtalnedfr`0 from
the Municipality of Anchorage files and from my investigation and Inspection, the on-site water
supply and/or wastewaterdisposal system Is in compliance with all Municipal and State codes,
ordinances,and ie4ulations ln�effecton the date of this Ins ion.
Name of F1' an &SENGINEERI4r
g -
woop Road Pm
204
-..Address 7'
--,-Engineer's signatun Date 3 -7
Rs 0
1.7. y7-
-3, ROBERr r- cowAN
7 it
it T
DHkSISIGNATURE.
,pprovad or room
'X:
ts
approved: . N.A. wflvi 't -d V',-0 &*M
"
;onditional,appr6vd,',for .��'ll..-'�l,"-���,"J,-,;bedrooms ,',wfttt'�the'.following.sfipulatio7;
777777�_' (W'A ..
in
W
T. CAUTION
",.The Munkipality"WAti-o-rag'e D'e'partrnent of Health and Huma^n' Sarvic6s'(DHHS')'Iss'ues Health Authority
`.',,ARpTal CerVkokes based only upon the representations given In paragraph 5 above by an independent
professional engineer 're-giitii6din the State of Alaska. The DHHS does this 'as a courtesy 'topurchasers of homes
a6d"t'h"efr lending Institutioiiii Iriorderto satisfy certain federal and state requirements. Employeesof DHHSdonot -
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.
72-MM—AMI) era MOAm
Imp,
66mm
Additional
n
B
W
4
T. CAUTION
",.The Munkipality"WAti-o-rag'e D'e'partrnent of Health and Huma^n' Sarvic6s'(DHHS')'Iss'ues Health Authority
`.',,ARpTal CerVkokes based only upon the representations given In paragraph 5 above by an independent
professional engineer 're-giitii6din the State of Alaska. The DHHS does this 'as a courtesy 'topurchasers of homes
a6d"t'h"efr lending Institutioiiii Iriorderto satisfy certain federal and state requirements. Employeesof DHHSdonot -
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.
72-MM—AMI) era MOAm
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 • Anchorage, Alaska 995010 (907) 3434744
Health Authority Approval Checklist
�r
Legal Description: Ltrr e�e &*cA f� DDFro /%e-eS'% Parcel I.D.: O11 - 121 - ? 9 VPA
A. WELL DATA
Well type -i tt1swe If A. B. or C. attach ADEC letter. ADEC water system number
Log present &i) t%S Date completed 8 -24 - 85
Total depth 3 1'5P Cased to S t 3 Casing height (aboyc ground) t e r
Sanitary seal6/M Ve 5 wires properly protected QN) YIEs
FROM WELL LOG AT INSPECI7ON
Date of test 8 - •?'I - $5 S -15 - 1%,
Static water level 1'75-' 1'7q '
Well production 10 g,p_m. 6--7 -1- g.p.m.
A ieaira.crg• dY
WATER SAMPLE RESULTS:
Coliform - Nitrate . /0'0 era Other bacteria
Date of sample: 3 /a -o /46 Collected by: Zone Low
—r „
BJUMHOLDING TANK DATA
Date installed 1-66 Tadt size 1000 Number of Compartments ai Cleanows ON)ES
Foundation cleanout &N) Yr. b Depression (Y® NO High water alarm (ter- - NLA -
Date of Pumping 3' I'i' 4(r pumper OLo /NeV0"A L0S
C. ABSORPTION FIELD DATA
Dare installed /-a(. Soil rating (g.p.d.M2 or ft'/bdrm) !AS y- System type T4�rre N
Length 4/P a Width R. S Gravel thickness below pipe 'e- S Total depth / r
Effective absorption area 37 8 Monitoring Tube prescm0l)-Yel! Depression over field (YAM 1/0
Date of adequacy test -6-145-90 ResultsQM�Tail) `PASS For 3 bedrooms
Fluid depth in absorption field before lest (in.): 10 Imme diateiv after 869 gal. water added (in.):
Fluid depth 5 (ins.) Minutes later:` ` ' AiiSot`ption rate = ?5Z ¢.p.d.
Peroxide treatment (past 12 months) (YIN) A/oP�rS YPAXJM If yes, give date ���
D. LIFT STATION
Date iustallatL_
—r
Manhole/Access (Y/N)
High water alarm level at" _
Cvcles tested
E. SEPARATION DISTANCES
Size in gallons
level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holdin tank on lot 11r q ; On adjacent lots
Absorption Geld on lot tyo + ; On adjacent lots
Public sewer main
-75 +
off' level at*
/0.2 14
Public sewer manhole/cleanout 19 ;
Sewer /septic service line 25 * Lift station — NIA —
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation -7 t Property line /a+ Absorption Geld 10
Water mam/service line 10 * Surface water/drainage 100 '+ Wells on adjacent lots 100 14
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
t
Building foundation 35 Water main/service line r D
�
Surface water 100 i Driveway. parldng/vehick; storage area 3 t
Curtain drain "a"Ar k-Dwov
F. ENGWEER'S CERTIFICATION
Wells on adjacent lots /c>* '; Propem line /is/
SC'PARArnowj BR. 0 85a 1 - WA - 017
1't8-t'Sa
I certifv that / have determined thru field inspections and review of.Numcipal records tha1.414 systems are
in conformance wi 0.4 1f�L-0=guivhnesin effect on this date. (- OF ,44 %4
Signature �
Engineer 7Ir's Name P08i T c� w A / = r/7AL
P
Daze 3 /a 7 i 6o aoeteT C. Cowart .W
%-•L CE -8601
HAA Fee S J DO ' '�"V
Date of Payment - ?zL
Receipt Number re -6/ r;
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee S
Date of Payment
Receipt Number