HomeMy WebLinkAboutPOLLOCK HOMESTEAD BLK B LT 2Pollock
Homestead
Block B
Lot 2
#017-112-46
Municipality of Anchorage
On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP201236 PID Number: 017-112-46
Dwelling: I Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ■❑ Upgrade
Name
Jonathan Katchen
ABSORPTION FIELD
❑ Deep Trench Q Wide Trench ❑ Bed ❑ Mound
Site address
15210 Pollock Dr. `Anchorage, AK 99516
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
907-317-0720
3
1.2 GPD/SF
9 MAX Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
SEE DWG. Ft.
Gravel depth beneath pipe
4.03 Ft.
Subdivision Block Lot
Pollock Homestead B 2
Fill added above original grade
SEE DWG. Ft.
Gravel length
40 Ft.
Township Range Section
Gravel width
5 Ft.
Beds: Number of Lines
-
Distance between lines
- Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
400 Ft2
1
10'+ Ft.
Well
1001+
1001+
25'+
TANK IN Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer Capacity
GREER TANK 1000 Gal.
Surface Water
1001+
100'+
Material
Number of compartments
Lot Line
5'+
10'+
NA
HDPE
2
Foundation
101+
101+
LIFT STATION
Manufacturer
Capacity
Remarks Old tank decommissioned per UPC per contractor
Gal.
Information is only for new install
Alam, location
Electrical installed by
Installer
PIPE MATERIAL House to tank D3034 Tankto
D3034
A+ HOME SERVICES
Drainfield D3034 CO/MTD3034
Inspector TIM ECKLUND AND DAVID GARNESS
BENCH MARK (Assumed elevation) 98.39 ft
Inspection
es: Im 8/27/20 2"d 8/28/20
Location and description
3'° 8/28/20 4118/28/20
TOP O F MANHOLE
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's St p
oo6opp
Conditional Approval: Date
o� OF oaf
0
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D
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-
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Septic System
esf ey _ Gar ss:
Approved Date / Zv
Q9• CE 79 3 `p
0� S P c�ppAlo 2-
Note: this approval d s not include well permit requirements.
rL F..... �P O
uaecceo0000��0
PERMIT
OSP201236
RECORD
DRAWING
PREPARED FOR:
PHONE NUMBER:
PAGE NUMBER:
Jonathan Katchen
907-317-0720
2 OF 3
LEGAL DESCRIPTION:
/
/ I
A B
PNB
MH 48.3 56.2
\\
ST 49.6 54.7
/
9/10/20
DBL1 50.2 54.6
DBL2 50.7 54.7
If\
FD 51.0 54.5
/
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C01 63.6 . I
I /
\
MTI 65.7 70.3
1-_
100' WELL RADIUS \
CO2 67.9 55.5
\
MT2 66.4 53.7
1
100'IyE LL RAp/US \
CO3 38.3 46.0
j
i SHED
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NEW 1000 GALLON i \\ \ EXISTING 3
HDPE SEPTIC TANK I I \ BEDROOM
1
\ HOUSE
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CO 0H \ • DRIVEWAY
MT1 o T 3 —a+
THE 100' WELL RADII FOR THE WELLS F FD \�� j "I
GARAGE
ON TIMBERLUX #4; BLOCK 2, LOT 10 z 1
WERE FLAGGED BY A PROFESSIONAL �
LAND SURVEYOR PRIOR TO ¢ H.#I
CONSTRUCTION AND WERE 100'+ FROM
THE NEW SEPTIC SYSTEMS ON B
POLLOCK HOMESTEAD; BLOCK B, LOT 1 I MT2
& LOT 2 o I CO2 \-NEW OLD DRAINFIELD
DRAINFIELD
/
/
/
/
/
GARNESS ENGINEERING GROUP, Ltd
ENGINEER
3701E. TUDOR ROAD, SUITE -ANCHORAGE, AK99507- CONSULTING
(907)337-6179- (907)336-3246 9TE:9amessengim.fi,g.om
PARCEL ID NUMBER:
017-112-46
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1"=40'
PREPARED FOR:
PHONE NUMBER:
PAGE NUMBER:
Jonathan Katchen
907-317-0720
2 OF 3
LEGAL DESCRIPTION:
DRAWN BY:
Pollock Homestead-, Block B, Lot 2
PNB
TYPE OF WORK:
DATE:
Record Drawinqs
9/10/20
PARCEL ID NUMBER:
017-112-46
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1"=40'
LOT 10
S 00001'35" E 135.00'
0 15' 30'
AS -BUILT
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE LOT 2, BLOCK B, POLLOCK HOMESTEAD SUBDIVISION
RECORDED SUBDIVISION PLAT (69-76) ARE NOT SHOWN HEREON. ANCHORAGE RECORDING DISTRICT, ALASKA AND THAT
THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE
THIS DOCUMENT DOES NOT CONSTITUTE A BOUNDARY SURVEY AND IS WITHIN THE PROPERTY LINES AND NO VISIBLE
SUBJECT TO ANY INACCURACIES THATA SUBSEQUENT BOUNDARY ENCROACHMENTS EXIST EXCEPTAS INDICATED.
SURVEY MAY DISCLOSE.
DATED THIS 2nd DAY OF SEPTEMBER, 2020, AT
UNDER NO CIRCUMSTANCES SHOULD ANY OF THE DATA HEREON BE ANCHORAGE, ALASKA.
USED FOR CONSTRUCTION OF FENCES, IMPROVEMENTS, OR FOR
ESTABLISHING PROPERTY BOUNDARIES.
FIXED HEIGHT, LLC
NO CORNERS SET THIS DATE I SCALE 1" = 30' Land Surveying Services 907.290.8949
WWW.FIXEDHEIGHT.COM
JOB p 20108
unurArr �T �
10' UTILITY EASEMENT --x x PEOESL31�E�
— — — — — — — — — — (— — — — — — — — — — — —\
x
x
I w SHED
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SEPTIC
STANDPIPES
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+ DECK
z
SEPTIC
00
MANHOLE 300
00
LOT 2 =1
0
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Co
2 -STORY o
18,630 sq. ft. o
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Co
o FRAME
LOT 1 CN31
HOUSE
LOT 3
m
30.0' 26.7'
S`
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30.0'
N N
GARAGE
26.1' 30.0'
V GRAVEL
vn DRIVEWAY WELL (V_�,
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rr•.ry^
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-POLLOCK DRIVE- - - - - -:' L} "� i
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'i s '• LS -14837
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it A' ••.....•.
rlt��?of-ESS IONA``P.�
0 15' 30'
AS -BUILT
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE LOT 2, BLOCK B, POLLOCK HOMESTEAD SUBDIVISION
RECORDED SUBDIVISION PLAT (69-76) ARE NOT SHOWN HEREON. ANCHORAGE RECORDING DISTRICT, ALASKA AND THAT
THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE
THIS DOCUMENT DOES NOT CONSTITUTE A BOUNDARY SURVEY AND IS WITHIN THE PROPERTY LINES AND NO VISIBLE
SUBJECT TO ANY INACCURACIES THATA SUBSEQUENT BOUNDARY ENCROACHMENTS EXIST EXCEPTAS INDICATED.
SURVEY MAY DISCLOSE.
DATED THIS 2nd DAY OF SEPTEMBER, 2020, AT
UNDER NO CIRCUMSTANCES SHOULD ANY OF THE DATA HEREON BE ANCHORAGE, ALASKA.
USED FOR CONSTRUCTION OF FENCES, IMPROVEMENTS, OR FOR
ESTABLISHING PROPERTY BOUNDARIES.
FIXED HEIGHT, LLC
NO CORNERS SET THIS DATE I SCALE 1" = 30' Land Surveying Services 907.290.8949
WWW.FIXEDHEIGHT.COM
JOB p 20108
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
POBox 1g665 40DElmore Road
Anchorage, Alaska 8gO18-665o Phone: (9O7)343 -78U4 Fax: (907) 343-7997
On-Site Wastewater Disposal System Permit
Permit Number: OGP201236
Work Type: Septic Upgrade
Tax Code Number: 01711246000
Site Legal Address: POLLOCKHOMESTEAD BLK BLT 2 (3:3137
Site Mailing Address: 15218P(}LLDCKDR, Anchorage
Owner: KATCHENJONATHAN VV&
Design Engineer: GARNESSENGINEERING GROUP LTD
This permit is for the construction of:
Effective Date
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
7/15/2020
7/15/2021
0 Disposal Field Z Septic Tank 0Holding Tank 11 Privy [] Private Well 0Water Storage
All construction shall beinaccordance 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 1S.G5. Provide notification bycalling (BU7)343-7SO4(24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall beeither:
a. Opened and Closed onthe same day, or
b. Covered, sealed, and heated to prevent freezing
Received Z2Date: '
Issued By: Oobe 7
. .
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Fax: 907- 343-7997
On -Site Water & Wastewater Program
Mayor Ethan Berkowitz
On -Site Sewer/Well Permit Application
For A Single Family Dwelling
Parcel I.D. 017-112-46
Property owner(s) JONATHAN KATCHEN Day phone 907-317-0720
Mailing address 15210 POLLOCK DRIVE `ANCHORAGE, AK 99516
Site address 15210 POLLOCK DRIVE 'ANCHORAGE, AK 99516
Legal description (Sub'd, Block & Lot) POLLOCK HOMESTEAD; BLOCK B, LOT 2
Legal description (Township, Section & Range)
Lot Size Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
( ® all that apply)
Absorption Field
Septic Tank
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑�
APPLICATION IS AN:
Initial ❑
Upgrade
Renewal ❑
THIS APPLICATION INCLUDES A VARIANCE/ WAIVER REQUEST FOR:
N/A
TYPE OF DEWELLING:
Single Family (SF)
(w/wo AD U)
Duplex (D) ❑
Multiple Dwellings ❑
(SF and/or D)
Distance: -
I certify that the above information is correct. 1 further certify that this is in accordance with
applicable Municipal codes.
GARNESS ENGINEERING GROUP, Ltd.
(Signature of property owner or authorized agent)
Permit/Rush Fees:
Date of Payment:
Receipt Number: Oct 6S7Cs
Permit No. 0SP2'0123b
1J)_0—Iq Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
(Rev. 01 /11)
a+�
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201236, Rebecca Carroll, 07/15/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201236, Rebecca Carroll, 07/15/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201236, Rebecca Carroll, 07/15/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201236, Rebecca Carroll, 07/15/20
\ MUNICIPALITY OF ANCHORAGE
• t DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
j 825 L Street • Anchorage, Alaska 99501 Telephone 264-4720
ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
NEW
��
()
UPGRADE
MAILING ADDRESS /
�
LEGAL DESCRIPTION
(-oT a 41k, 13cmp S
LOCATION
oL�a Ste"
NO. OF BEDROOMS
O Y
DISTANCE TO:
We _I
'F
t
AbsorPuo�r
Dwellings
PEHMI�O,Da 7
5/
WQ
Manufacturer
Materia!5..
No. of compartments
H
r4
r7 / Q.
m
Lip, c �ji n gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
d0z
DISTANCE TO:
Wel*
Dwelling
PERMIT NO.
_?
Manufacturer
Material
Liquid capacity in gallons
G
W =
DISTANCE TO:
Well
Foundation
Nearest lot line
PERMIT NO.
w Z
No. of lines rt
Length o�c lin e�f G
Total le yI lines
A,
Trenc d
Distance bet n lines
f-?¢
eX•
�"
inches
H
Top of file to finish grade
Material beneath tile
Total effective so�)ypn area
O
inches
CCJJ
W
Length
Width
Depth
PERMIT NO.
v
11_
a.
Type of crib
Crib diameter
Crib depth
Total effective absorption area
W
N
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption steals)
OTHER
PIPE /f�y/�TERIALS
C� -(/d '
SOIL TEST RA NG
1J
'
INSTALLER
R MARKS s
a1f2CC f� Yo �S I /bon/
I
U
T
APP VED DATE LEGAL
'IV t o trtev. J/ I dl /
/1 ?—
rl i_1 tJ I C I F~' ._ I T' r• 1=1 F F1 r -a C H 0 1=1 E3 E
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PRufECTION
825 'L' STREET, ANCHORAGE, AIC. 99501
264-4720
ED V4 ITE in EL4EF<. �•y I T
PERMIT NO. C 7902x'7 )
APPLICANT
LOCATION
LEGAL
c. (—U%t_ uG
JOE SPEZIALY 8027 NADINE ST LARK.
POLLOCK S/D�r L � / 1
ll:l�
1:3U
IL .
344 2903
L2 ELK B POLLOCK .�
'rns LOT SIZE 18630 SQUARE FEET
TYPE OF SOIL AESORBTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING CSG! FT/BR)= 250
THE REQUIRED SIZE OF THE SOIL ABSORPTIONSYSTEM
C•SYSTEM IS:
F=F'TH= 11 LF=r-J1-T1-1 -5 Wit- GF< H'ti EL G•EF'TH=
THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION CIN FEET).
F? E�-!L 1 I REG GEF=TIC TF1r IF I �F 1%DC-1 =y f3F=1LLrlr-��-
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DUPING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
--- I-L4ED C } I I iClrJ I F:EC• ---
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN! A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELL; OR
150 TO 200 FEET FROM A PUBLIC WELL DEPENDING, UPON THE TYPE OF PUBLIC WELL.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F'EF=:r'1 I T EXF=' I F<:E -1 =I :- S4
I CERTIFY THAT
1: I AN FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
_. I UNDERSTAND THAT THE ON-SITE SEWER. SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS.
SIGNED:---------------- �-- ,
APPLICANT JOE EiIAL
ISSUEDi f--�-� S - �
ITE --1 � --
ll/ / Vs.
/00-4�
9" SOILS LOG
f
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
Pouch 6.660, Anchorage, Alan" 991502 2762221
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: J [. s GL" Zl, L y DATE PERFORMED: S*- 7 14
LEGAL DESCRIPTION: L SUB, er 4 /tz RLoGKL) Po LL OG IG /4asea 6.
DEPTH
SLOPE SITE PLAN
(FEET) O w G
2
3
4
6 S'/ 6/L, SQ
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18
19
CS irt G tO
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WASGROUND WATER Ala 0
P
IF YES. AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
/Z: voyow
vs
y'
Z,l
`/
G -s
: So
3S'
20
PERCOLATION RATE ..3 O /4N G// (minutes/inch)
TEST RUN BETWEEN FT AND FT
COMMENTS
PERFORMED BY: G�C/LY J �t-Q�/ CERTIFIEDBY: DATE: rj' 7�
72008 (7/76)
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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
OSC241508
Parcel ID 017 -112-46 Expiration Date:
Legal description POLLOCK HOMESTEAD BLK B LT 2
Site address 15210 POLLOCK DR
Current propertyowner(s) PETERS GLENN & POPIT BARBARA
X The On-site system(s) is/are approved for 3 bedrooms
By:
Conditional approval for bedrooms, with the following stipulations:
Comments or conditions:
No comments
Original Certificate Date:
12/10/2024
Xsyeelmopmen
icate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage,
t Service Department (DSD) issues COSAs based upon representations provided by an
independent professional engineer. The Municipality of Anchorage is not responsible for errors or
omissions in the professional engineer's submittal.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
MUNICIPALITY OF
Development Services Department \_
On -Site Water & Wastewater Section
ANCHORAGE RU5H
Phone: 907-343-7904
Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 01711246000
Complete legal description Pollock Homestead B -B L2
Location (site address)
15210 Pollock Dr. Anchorage AK, 99516
Current property owner(s) Glenn Peters & Barbra Popit
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
Day phone 572-218-9741
3. TYPE OF WATER SUPPLY: ❑■ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL:❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ■❑ Plastic ❑ Concrete ❑ Fiberglass
Age 4 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ■❑ Wide Trench ❑ Seepage Pit
Waiver request for: Distance:
Expedited review requested: ❑■
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ S 130 Waiver Fee $
Date of Payment
COSA # Of) C-2 915DS
Date of Payment
Waiver #
COSA Application—June 2022
COSA Checklist_June 2022
COSA Checklist
Legal Description: Parcel ID:
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes go to bottom of effective.
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Adequacy test date
Results Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
Comments/Deficiencies:
COSA Checklist_June 2022
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Phone
Engineer’s Printed Name Date
• Municipality of Anchorage
On -Site Water and Wastewater Program
(907)343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 017-112-46
1. GENERAL INFORMATION:
Expiration Date: 6
Complete legal description POLLOCK HOMESTEAD; BLOCK B, LOT 2
Location (site address) 15210 POLLOCK DRIVE `ANCHORAGE, AK 99516
Current Property owner(s) JONATHAN KATCHEN Day phone 317-0720
Mailing address
Real Estate Agent
15210 POLLOCK DRIVE *ANCHORAGE, AK 99516
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
❑
WaiverNariance request for: Distance:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date:
COSA Fee $ Waiver Fee $
Date of Payment !a - 3D'2DZ-0
Receipt Number
COSA#P-)5C- 2(91 320
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: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507 !
Engineer's Printed Name: Jeffrey A. Garness Date: ( Y -Zo
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system
in accordance with the guidelines and regulations established by the Municipality of Anchorage and
industry practices. The reported results describe the condition of the system/s on the date/s of the
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or
encroachments may exist that were not identified during the evaluation. The operational life of all wells ;�j
and septic systems depend upon a variety of variables, including but not limited to, soil conditions,
groundwater levels (that may Fluctuate during the year), quality of construction (materials and ;!
workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the
system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of ,`1
the well or septic system. GEG makes no representation whether an alternative well or septic system �'
can be installed on the property in the event either of the current systems fail to perform adequately in lll�t
the future. The content of this report is for the sole benefit of the person/party that retained GEG t4-i�rl
/
perform the evaluation. Reliance upon the information provided in this report by any other perparty (including subsequent property purchasers) is not authorized, nor will it confer any le
whatsoever. ` \V
`g ON.
6. DSD SIGNATURE WATE, -
—Ll' System #1 Approved for - bedrooms �a WASTtL•v''ATER 01
System #2 Approved for bedrooms PROGRAM
\�
Disapproved J'JI0,0,F1�/T SERv�GAO,��`
Conditional approval for bedrooms, with the followinNWW'10`ns:
By: ha,lav Original Certificate Date: - �U
The Municipality of Anchorageevelopment 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 Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10-10-12.doc
Legal Description: POLLOCK HOMESTEAD; BLOCK B, LOT 2
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled ""5/80
Total depth 200 ft
Cased to 47 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 6/12/20
Static water level at beginning of test 22.1 ft.
Comments
B. TANK DATA
Age of tank(s) New years
Tank type/material "'�101E
Measured operating fluid level in septic tank New
❑ Standpipes/foundation cleanout per record drawing
Date of pumping New
D. ABSORPTION FIELD DATA
Which system tested (date installed) 2020
®❑ ALL standpipes present per record drawing
Total measured depth from grade 9.36 ft (max)
Measured depth to pipe invert from grade 4.62 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 n/a gallons
Comments/Deficiencies: Information is for new system
COSA Checklist yellow sheet
-
Parcel ID: 017-112-46
Structure served by this system
Well production at time of test 3.0+ gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate 1.03 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by GEG, LTD.
Date of Sample 6/11/20
C. LIFT STATION
❑ Required maintenance completed
Age of lift station year
Lift station :material
Comments
Adequacy test date New
Results ❑Pass For 3 bedrooms
Fluid depth prior to test - in
Water added gal
New depth in
Elapsed time min
Final fluid depth in
Absorption rate - gpd
Any rejuvenation treatment (past 12 months) NIA
If yes, enter date n/a
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'
0
Yes
Community Sewer Manhole/Cleanout > 100'
Q Yes
if No
ft
[V Yes
if No ft
Neighboring Tank > 100' Yes
if No
ft
Private Sewer/Septic Line > 25' F-1 Yes
if No ft
Absorption Field on Lot > 100' Fv� Yes
if No
ft
Holding Tank > 100' 0 Yes
if No ft
Neighboring Absorption Fields > 100'
0 Yes if No ft
Water Main > 10'
Animal Containment > 50' P Yes
if No ft
M Yes
if No
ft
0 Yes if No ft
Water Service Line > 10'
0
Yes
if No
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway
Community Sewer Main ? 75' Q Yes
if No
ft
E] Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
0
Yes
if No
ft
Surface Water > 100'
Q Yes if No ft
Property Line > 5'
0
Yes
if No
ft
Wells on Adjacent Lots:
0
Absorption Field > 5'
F1
Yes
if No
ft
Private Wells > 100'
0 Yes if No ft
Water Main > 10'
F,71
Yes
if No
ft
Community Wells > 200'
0 Yes if No ft
Water Service Line > 10'
0
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'
Q
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'
0
Yes
if No
ft
Private Wells > 100' [j Yes if No ft
Water Service Line > 10'
Yes
if No
ft
Community Wells > 200' [j Yes if No ft
Surface Water > 100'
Q
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
/ 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.
COSA Checklist yellow sheet
i...........
J ffrey •, Godness
Q �� j • fj CE -7953
#AECC884
C_., 5 ,
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
Parcel I.D. big- 112-010 COSA#
Expiration Date: / - / 3 - fl 61
1. GENERAL INFORMATION
Complete legal description Pollock Homestead Lot 2 Block B
Location (site address) 15210 Pollock Drive
Current Property owner(s) Jody Hansen Day phone 350.6144
Mailing address
Lending agency
15210 Pollock Drive
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
(]
Individual On-site
(]
Individual Water Storage
❑
Individual Holding Tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
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 Onsite Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also Issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of 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.
Name of Finn Spurkland Engineering Phone 2793916
Address 203W. 15th Avenue, SuNe 203, Anchorage, AK 99501
Engineer's Printed Name Lars Spurkland Date 7/10/06
_z Approved for 3 bedrooms.
Disapproved.
-�NN\\\\
OF A.< \11
i �P•
: 49TH
.laas uaaAkil i
t1`oo
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: l7 Original Certificate Date: 7 — r 3 "oto
(P«. 11m)
Municipality of Anchorage
• Development Services Department
Building Safety Division
Onsite Water & Wastewater Program
4700 Bragaw Street
P.O. Bax 198850
Anchorage, AK 995198850
www.muni.org/onslte
(907)343.7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Pollock Homestead Lot 2 Block B Parcel ID: O / 7— / /a - 1/6
A. WELL DATA
Well type R IFA, B, or C provide PWSID#_:__
Date completed 10-15-O0 Sanitary seal (YM) Y
Total depth 200 ft Cased to 47 1t
Date of test
Static water level
Wen production
FROM WELL LOG
10.15-1980
50 ft.
1
WATER SAMPLE RESULTS:
Coliform 0 coloniesH00 mL
Arsenic: NO mgn
B. SEPTIQHOLDING TANK DATA
Well Log (YIN)1
Wires properly protected (YIN) Y
Casing height (above ground) 26 in.
AT INSPECTION
06.20.2008
<24 R
O.P.M. 1 9—
p.m-
Nitrate 0.201 mg►L
Tank Type/Materiel GREERI STEEL
Tank size 100D gal Number of Compartments 2
Other bacteria 0 colonies/100 mL
Collected by: CARS SPURKLAND
Date ftWled 6=1979
Cleanouts (YM) Y
Foundation cleanout (YIN) Y Depression over tank (YM) N High water alarm (YM) WA
Date of pumping 10/28/06 Pumper CHUGACH SEWER & DRAIN
C. ABSORPTION FIELD DATA
Date installed 101=1979 Soil rating (g.p.dJft o r fe/bdnn)250 System type DEEP TRENCH
Length 58 R Width 3 tt Gravel below pipe 8.0 ft
Total depth 11.4 R Effabsorption area 750' fts Monitoring tube Y Depression over field N
Date of adequacy test 640-2008 Results (Pass/Fall) PASS For 3 bedrooms
Fluid depth in absorption field before test 89 in. Water added gal. New depth 82 in.
Elapsed Time: 125 min. Final fluid depth 73 in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (pest 12 mo.) (YIN & type) NONE KNOWN If yea, give date
D. LIFT STATION
Date IledSize in on
`Pump on' in.`Pump Off" lei
Datum Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot 91.5
Absorption field on lot 100'
Public sewer main WA
Sewer /septic service kne >25'
in. High water alarm
Meets alarm a dram
On adjacent lots >100'
On adjacent lots >100'
Public sewer manhole/cleanout N/A
Holding tank N/A
Animal containment areas >50' Manure/animal excrete storage areas >100'
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
Building foundation V Property line >1C Absorption field 5'
Water main N/A Water service Ina >2V Surface water >100'
Wells on adjacent lots >IW
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property fine >1V Building foundation V Water main WA
Water Service line >25' Surface water >100' D*away, parkingivehide, saga 10'
Curtain drain N.O. Wells on adjacent lots >100'
F. COMMENTS: SEPARATION DISTANCE APPROVED BY DEC WAIVER 5-29-85. AMENDED 422-98.
G. ENGINEER'S CERTIFICATION
I car* that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSH guidelines in effect on this date.
Engineer's Printed Name LA'S SS46A a�
Date :*&(o
COSA Fee $ Yy Waiver Fee $
r�_
Date of Payment u,,/ A Data of Payment
Receipt Number O1101 Receipt Number,
(Rev. 1Ift)
�
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LEGEND,
A •ENERYFN!
THE INFORAATION HEREON IS FOR THE USE OF LENOND KNNSTTIIif1pN5 SPFOPtC LLY TO SNOW ANY CONFLICTS BEINEEN
EXISTING STRUCTURES AND PUTTED LOT LINES OR EASEMENTS AND IS NOT TO BE USED FOR POSITIONING ACOKTONAL
STRUCMESORFENCEUNES
EASEMENTS OF RECORD. OTHER THAN THOSE SNONN ON THE RECORDED PLAT. ARE NOT SHOLMI HEREON,
NOTE ANY FENCELNES SROM/ ARE LOCATEDAPPRW4ATELYANDARE NOT TO MUSED TO DETERMINE PROPERTY LINES
OR LOCATE STRUCTURES
AS -BUILT SURVEY
NO CORNERS SET THIS DATE
SCALE: 1" • SP
I HEREBY CERTIFY THAT I HAVE PERFCRMEDA
MORTGAGEES INSPECTION OF THE FOLLOIMNO
DESCRIBEDPROPERTY.
IDT; BLOCK B. PO LOCK HOMESTEAD SUB,
ANCHORAGE RECORDING DISTRICT. ALASKA AND THAT
TREPERTY LINES
AN NO VISIDTHEREONAREMTBETE
PROPERTY LANES AND NO N9BlE EWCRGNCMAENTS E%IST
OTHER THAN NOTED.
DATEDATANOHORAGF ALASKATHIS_YTIL_
DAYa fPRI 1• fB�
HOLT LAND 6URVEYI
TEL. ]LS]]1] ISM76
N B9058' 25" E. 138.00
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...............................
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4 SHANE A. HOLT: pOP
!, L6.6914 A�Q
0 • � o•Q
LEGEND,
A •ENERYFN!
THE INFORAATION HEREON IS FOR THE USE OF LENOND KNNSTTIIif1pN5 SPFOPtC LLY TO SNOW ANY CONFLICTS BEINEEN
EXISTING STRUCTURES AND PUTTED LOT LINES OR EASEMENTS AND IS NOT TO BE USED FOR POSITIONING ACOKTONAL
STRUCMESORFENCEUNES
EASEMENTS OF RECORD. OTHER THAN THOSE SNONN ON THE RECORDED PLAT. ARE NOT SHOLMI HEREON,
NOTE ANY FENCELNES SROM/ ARE LOCATEDAPPRW4ATELYANDARE NOT TO MUSED TO DETERMINE PROPERTY LINES
OR LOCATE STRUCTURES
AS -BUILT SURVEY
NO CORNERS SET THIS DATE
SCALE: 1" • SP
I HEREBY CERTIFY THAT I HAVE PERFCRMEDA
MORTGAGEES INSPECTION OF THE FOLLOIMNO
DESCRIBEDPROPERTY.
IDT; BLOCK B. PO LOCK HOMESTEAD SUB,
ANCHORAGE RECORDING DISTRICT. ALASKA AND THAT
TREPERTY LINES
AN NO VISIDTHEREONAREMTBETE
PROPERTY LANES AND NO N9BlE EWCRGNCMAENTS E%IST
OTHER THAN NOTED.
DATEDATANOHORAGF ALASKATHIS_YTIL_
DAYa fPRI 1• fB�
HOLT LAND 6URVEYI
TEL. ]LS]]1] ISM76
0
SCS Ret#
1062884001
All Dates/Times are Alaska Standard Time
Client Name
Tobben Spurkland P.E.
Printed Datdl'ime
06/162006 13:22
Project Name/a
Pollock Homestead L.2 BB
Collected Date rime
06/072006 10:25
Client Sample ID
Pollock Homestead L2 BB
Received Date rime
06/072006 11:30
Matrix
Drinking Water
Technical Director
Stephen C. Ede
Sample Remarks:
Allowable Prep Analysis
Paramcter Results PQL Units Method Container ID Limits Date Date Init
Nitratc-N 0.201 0.100 mg(L EPA 353.2 B 06/07'06 ALR
Nitritc-N ND 0.100 mg/L EPA 353.2 B 06/07.'06 ALR
Metals Department
I lardness as CaCO3
234
5.00
mg(L
SM20 23408
C
06108106 06/09.'06
SCL
Private Individual
Analysis
Aluminum
ND
20.0
ug/L
EP200.8
C
06/08/06 06/09.'06
SCL
Antimony
ND
1.00
ug/L
EP200.8
C
(<6)
06/08/06 06/09/06
SCL
Arsenic
ND
5.00
ug/L
EP200.8
C
(<10)
06/08/06 06/09'06
SCL
Barium
30.4
3.00
ug/L
EP200.8
C
(0000)
06/08/06 06/09'06
SCL
Cadmium
ND
0.500
ug/L
EP200.8
C
(<5)
06108/06 06/09106
SCL
Calcium
64900
500
ug/L
EP200.8
C
06/08106 06/09'06
SCL
Chromium
ND
1.00
ug/L
EP200.8
C
(<I00)
06108/06 06/09'06
SCL
Copper
17.6
1.00
ug/L
EP200.8
C
(<1300)
06108/06 06109'06
SCL
Iron
ND
250
ug/L
EP200.8
C
(<300)
06/08/06 06/0906
SCL
Lead
0.425
0.200
ug/L
EP200.8
C
(<15)
06/08/06 06/09.'06
SCL
Magnesium
17500
50.0
ug/L
EP200.8
C
06/08106 061%06
SCL
Manganese
9.78
1.00
ug/L
EP200.8
C
(<50)
06108/06 06109:06
SCL
Phosphorus
ND
200
ug/L
EP200.8
C
06/08/06 06/09:06
SCL
Chloride
68.6
0.100
mg(L
EPA 300.0
B
(a50)
06/08/06 06/08;06
DSII
Fluoride
ND
0.100
mg(L
EPA 300.0
B
(a)
06/08106 06/08:06
DSI I
Potassium
995
S00
ug/L
EP200.8
C
06/08/06 06/09:06
SCL
Selenium
ND
5.00
ug/L
EP200.8
C
(<50)
06/08106 06/09.'06
SCL
Sodium
16700
500
ug/L
EP200.8
C
(a50000)
06108106 06/09,06
SCI,
Silicon7770
200
ug/L
EP200.8
C
06/0&'06 06109'06
SCL
Silver
ND
1.00
ug/L
EP200.8
C
I< 100)
06108/06 06/0906
SCL
Thallium
ND
1.00
ug/L
EP200.8
C
(a)
06/08106 06/09,06
SCI,
Sulrate
12.5
0.100
mg/L
EPA 300.0
B
(a50)
06/0&'06 06/0806
DS1I
FM
SGS ReEN
1062884001
All Dates/nmcs are Alaska Standard Time
Client Name
Tobben Spurkland P.E.
Printed DatdPime
06/16/2006 13:22
Project Name/a
Pollock Homestead L2 BB
Collected Date/rime
06/07/2006 10:25
Client Sample ID
Pollock Homestead L2 BB
Received Date/Time
06/07/2006 11:30
Matris
Drinking Water
Technical Director
Stephen C. Ede
Paramctcr
Results
PQL
Units
Method
Contains ID
Allowable
Limits
Prep Analysis
Date Date
Init
Private Individual Analysis
Total Dissolved Solids
343
10.0
mg/L
SM20 2540C
D
(<500)
06/08/06
KP
Zinc
ND
5.00
ug/L
EP200.8
C
(<5000)
06/08/06 06/09/06
SCL
Nickel
2.24
2.00
ug/L
EP200.8
C
(<100)
06/08/06 06/09/06
SCL
11CO3 Alkalinity
182
20.0
mg/L
SM202320B
D
06/09/06
PLW
CO3 Alkalinity
ND
20.0
mg/L
SM202320B
D
06/09/06
PLW
011 Alkalinity
ND
20.0
mg/L
SM202320B
D
06/09/06
PLW
Conductivity
500
1.00
umhos/cm
SM202510B
D
06/07/06
KP
pil
6.99
0.100
piunits
EPA 150.1
D
(6.5-8.5)
06/07/06
KP
Alkalinity
182
20.0
mg/L
SM202320B
D
06/09/06
PLW
Total Coliform
0
coVI00mL
SM209222B
A
(<I)
06/07/06
TLF
Municipality of Anchorage
• Development Services Department
Building Safety Division
/ Onsite Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
wKw.ci.anchorage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING l�/
Parcel I.D. 0r7 (0 l -11Z -7S HAA 9- V F
Expiration Date: _ LO _ 3
1. GENERAL INFORMATION
Complete legal description 1 -of 2, S to c lc SO Pc floc lr 1k ole f%taa S /.p
Location (site address or directions)
16-Z10 io I/oc 1r
D rt �ie
❑
Current Property owner(s) I'11 t, e
4 V" !�z Sh run
Day phone
23a�6s-Y& cert
'341,f -979,f
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
/CZ10 flock 0.�.-Q, fwp, 4k 99s l,(
GtJGl1 Fu vee t34os Dayphone
AI an e- FS BO . Day phone
Unless otherwise requested,, HAA will be held byDSD;orpickup. plexly cart ou»r.
2. NUMBER OF BEDROOMS: 3 terhf.c�/� L r�xdy %. pvcl<•up,
3. TYPE OF WATER SUPPLY:' TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Individual On-site 12
Individual Holding tank ❑
Community On-site ❑
Public Sewer ❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
Me (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system Is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
NameofFirm Fla/-/" Tcctinrca/ S-erv�rtr Phone 3ys-13S"r
Address yti5-34 /=c%o Sl., Ak 919S-16-1
L.—o
Engineer's Printed Name 7-A ora c,'O -e F'. Mao�e Date_ 7/Z,9/ O.3
Additional Comments
ON-SITE
WASTEWATER
Attachments:
HAA Checklist X
Septic System Advisory .
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: tr%v ,/ Original Certificate Date: Z
(R«. DIM)
5. DSD SIGNATURE
••••••••.••.....:::.
✓ 3
�w
.^
Approved for
bedrooms. .......... •.. 4,..��;
rnEODORE F.
Disapproved.
Y.00RO 1
•, Cc - 35c 4
Conditional approval for
,r
bedrooms, with the following stipulations':,,...Sir
Additional Comments
ON-SITE
WASTEWATER
Attachments:
HAA Checklist X
Septic System Advisory .
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: tr%v ,/ Original Certificate Date: Z
(R«. DIM)
Municipality of Anchorage .,..
Development Services Department
Building Safety Division <
On -Site Water 6 Wastewater Program `
4700 South Bra9 aw SL
P.O. Box 196650 Anchorage, AK 99519-6850
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: G. f 2, 3 /oc k q13"
Pe rlo c k hf,, cr /baf Parcel ID:_
A. WELL DATA
Well type P v r
Date completed ro //16/60
Total depth ±np ft.
Date of test
Static waterlevel
Well production
If A, B, or C provide PWSID # _ Well Log (Y/N) Y
Sanitary seal (Y/N)—Y Wires property protected (YIN) Y
Cased to N 7 ft.
FROM WELL LOG
SO ft.
/-0 g p.m.
WATER SAMPLE RESULTS:
Coliform _-Q_ooloniesf100 ml.
Arsenic: = mg./I.
B. SEPTICIHOLDING TANK DATA
Nitrate G o. I mg.h.
Casing height (above ground) ? 2 in.
AT INSPECTION
/2//2ac)3
I* R
1. s;' g.p.m.
Other bacteria 0_ oolonies/100 ml.
Date of sample: 7/ 2 I /03 Collected by: Ft-h6p 7-ic4 .r -,f
Tank Type/Material SeA fic / S A.. l Date Installed 6 / 2 s- / 7 9
Tank size r oco gal. Number of Compartment Cleanouts (Y/N) Y ( r )
Foundation cleanout (YIN) Y Depression over tank (Y/N) IV High water alarm (Y/N) N. A
Date of pumping la /9 / a Z Pumper Mr- Denw/d c
C. ABSORPTION FIELD DATA
Date installed /2-5/7 Soil rating (g.p.d.ife or fe/bdrm) —2,5w_9—' System type TrrneS
tr441 .
Length S'18 ft. Width 7 ft. Gravel below pipe o ft.
Total depth f I ft. Eff. absorption area ,L,_fe Monitoring tube Y Depression over field N
opeon =71 e s
Data of adequacy test 7 / 21 /zoo 3 Results (Pass/Fail) Paz . For 3 bedrooms
Fluid depth in absorption field before test " in. Water addedAat� gal. New depth,,'- in.
Elapsed Time:2 ,r min. Final fluid depth _Ip!§ in. Absorption rate >= Ys0 9-p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N 8 type) No�c ko oz,& If yes, give date N• 4
D. LIFT STATION N• A.
Date installed
'Pump on" level at_ in.
Datum
E. SEPARATION DISTANCES
Size in gallons
'Pump ofr level at _ in.
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 9/. S
Absorption field on lot too'
Public sewer main W. A.
Sewer /septic service line ZS'
Manhole/Access (Y/N)
High water alarm level at
Meets alarm S dreuit requirements?
On adjacent lots -,x, r oo
On adjacent lots 7 rao'
Public sewer manholeldeanout A/. A.
Holding tank ti -A.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation S Property line D' Absorption field S
Water main N • A. Water service line 7 1&' Surfacewater roo'
Wells on adjacent lots > t00 '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ^-Y ZO' Building foundation 13 r •" Water main N• A•
Water Service line �> to' Surface water. --> too • Driveway, parking/vehicle storage 16 '
Curtain drain Nont S eopn Wells on adjacent lots '> t '
F. COMMENTS
in.
G. ENGINEER'S CERTIFICATION r •:! ;
I certifythat I have determined through field ' cfions and R.
r
9 rnspe r; ; /frQTH
review of Municipal records that the above systems are in
SY..T •H •.••1N.1H H.i,r�
conformance with MOA HAA guidelines in effect on this date.
. .:.......
C "'ecce F. a:ooxe t >!
Engineer's Printed Name 'ih¢Or-eOrY F• l`r�o C[ - ^539 ^r
`.. • ;rte,
Date J u (w Z 2 a o 3 ;F; _• • •' +
6p
HAA Fee $ 3'7S— Waiver Fee $
Date of Payment -77/ 7-0 /03 Date of Paymem
Receipt Number -ZQ zjcll C Receipt Number
(Rev. 12/01) ,
MUNICIPALITY OF ANCHORAGE
• ^' DEPARTMENT OF HEALTH R 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
RECEIVED
AAPR 151998
MUNICIPAUTY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
Parcel I.D. # —0114-0--'46 b HAA # -�fV% M, C
1. GENERAL INFORMATION f OA,1i; rEAO
A
Complete legal description �-r,1ZC��PoL_ucK - �1)
Location (site address or directions)
Property owner
Mailing address
Day phone
Lending agency Day phone
Mailing address 1�
Agent 4,yt I Pao�'F��rnas Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3 Y
QLL L� Ll.
3. TYPE OF WATER SUPPLY:
Individual well P1ctc-
v
Community well j1i�"Gr'
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site -�
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-=(P ..1/91) Front MOA41
S. 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
Address
Engineer's signature
S. DHHS SIGNATURE
do
X Approved for 3 bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Phone s 3 7—lL179
—Date 4 f %V
4 cc
r_ :7937
kkki Frss _
bedrooms, with the following stipulations:
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 purchasersof 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.
72-=(P«-1/91) 6. waw m
RECEIVED
e Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES APR 15 199
Environmental Services Division AaAVICIVAUIY OF
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907rj'� $uavas
f% [f Health Authority Approval Checklist
Legal Description: _/KGOCK HWJ�ST69s F1, /Z &e?parcel I.D.: e/9 -//?- v`
A. WELL DATA
Well type P12k ✓47E It A, B, or C, attach ADEC letter. ADEC water system number fi
Log present (YM) ! Date completed/Ag/yo
Total depth 200 —Casedto I/9 r Casing height (above ground) '/Y r*
Sanitary seal (J)N) xec Wires properly protected (YM) YES
FROM WELL LOG AT INSPECTION
Date of test
Static water level /3 r
Well production /to g.p.m. a.h g.p.m.
WATER SAMPLE RESULTS:
Collform -Nitrate o. TOther bacteria
Date of sample: yg Collected by: �] ,
B. SEPTIC/HOLDING TANK DATA
Data installed d L ?Tank size Number of Compartments Cieanouts &N) �-
Foundation cleanout &N)FYS Depression (Ye l6 High water alar (Y/6 N14
Date of Pumping a I ( 31 1 98 Pumper Al /L& �&a s
C. ABSORPTION FIELD DATA
Date installed oR" 6 .� Soil rating (g.p.dJ W o ft'/bdr �SO System type 7Rr r
Length 5$ Width 3r Gravel thickness below pipe
t Total depth
Effective absorption area Jae S Monitoring Tube present 49WAA Depression over field (Ye No
Date of adequacy test A)13 III Results (Pass/FaiqP4, For TSE bedrooms
to r,
Fluid depth in absorption field before test (in.); Immediately afterW3 gal. water added (in.): $�%r5
Fluid depth 181�5(ins) Minutes later: Absorption rate = SI50t c.p.d.
Peroxide treatment (past 12 months) (YO) l KJ&6z - if yes, give date N%A
72-026 (Rev. M6)•
D. ON
Date installed
Manhole/Access (Y/N)
High water alarm level at* _
Crorae
E. SEPARATION DISTANCES
'Datum
Size in gallons
at'
air level at'
9 S 1/l(4I11c2 O/ + FIDE ( 521 ' W14 " 173)
SEPARATION DISTANCES FROM WfLROI�LOi0T0:
VE II /
Septic/holding tank on lot 611.S'
t4ERSJ6Ag1 fd-7S On adja M lots too +
..O IFS- "Ic( Su2vry
Absorption field on lot 106 On adjacent lots 1 UO f
Public sewer main A/1A Public sewer manhola/cleanout /t%/�
i
Sewer /sepfic service line ;51 Lift station N14
SEPARATION DISTANCES ROM SEPTIC/HOLDING TANK ON LOT TO: V,
Foundation 5 r KProperty line 10 /' Absorption field 5 7M, , I(/n�
c/bc7
'r
Water main/service line LL4- Surface water/drainage /004 Wells on adjacentlots 106.4-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
r r FROM
Property line I6 + Building foundation ^ S 6 ktoldf. Water main/service line to /
Surface water NO r+ Driveway, parkingfvehicle storage area 10 4
Curtain drain %rje ka1eW4 Wells on adjacent lots 100
F. ENGINEER'S CERTIFICATION
I cerW that I he # determined field inspections and review of Municipal 1F�th�i10rk19tsystems are
in conJomrance th MOA rd i e it (fact on this date.
n�'1, •• •• •" • •• •S•t++
Signature . w %.R y 49� "/'�'J.
....... ...A
Engineer's q(me JA4df5 f W/C[ /fu t I 1U! �A w" xy ,• .
WILUAW
Data lilt `i 8 �j+ No. 9W
.(
AV
HAA Fee $ 2C_ndl� Waiver Fee $
DateofPayment
Receipt Number 4,°\S_1
72-026 (Rev. 3196)'
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
- P.O. Box 196650
Anchorage, Alaska 99519-6650
Date: April 22, 1998
To: File
From: Dan Roth, Civil Engineer, On -Site Services
Subject: Amendment to A.D.E.C. waiver issued on May 29, 1985, P.I.N. 017-112-
46, H.A.A. Number HA980090
During the recent H.A.A. the engineer discovered that the septic tank to well separation is
actually 91 feet and not the original approved separation of 95 feet waived by the Alaska
Department of Environmental Conservation.
After discussion with Keven Kleweno of A.D.E.C. about the geological conditions in the
well and negative water sample results from the well in question, it is okay to amend this
waiver to 91 feet by means of this memo to file.
CC:
i
Msc e. MOLT Tr. DY"W PRCPtXrld
PMW dais TIM IAM.1Y w
S
rRwiNou.e' q��� 8
�pul
iFK
mksTiWc
jo�d CAL --
w
040%
GOPWA4
Erie or
Guest` ;�
I
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MUNICIPALITY OF ANCHORAGE
• ^• .Department of Health 3 Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcell.D.# 0111 -112 -Clio HAA #— VA29-nLl9,�
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot.2, Blk B, Pollock Homestead Subdivisi
Location (address or directions)
15210 :Pollock Drive', Anchorage, AK.
(b) Property owner Joseph A. Spezialy Telephone: (home) Business
Mailing Address 8027 Nadine Street, Anchoracre, Alaska 99507-3222
(c) Lending Institution Commonwealth Mortgage Telephone 273-5229
Mailing Address 3333 Denali Street, Suite 110, Anchorage, AK 99503
(d) Real Estate Company and Agent Marston Real Estate/Dale Tyree
Address 2804 West Norther Lights Boulevard
Telephone 248-2804
(e) Mail the HAA to the following address: (or check here fVif hold for pick up.)
List contact person and day phone number below:
.fit% rVae i✓ zVp-Z>3Or
2. TYPE OF RESIDENCE
Single -Family IN Number of bedrooms 3
3. WATER SUPPLY
Individual Well ® Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ® Public ❑ Community ❑ Holding' ank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the Iegaiity and status.
72 -MS (R". 7/W) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
Ascertified by mysealaffixed heretoand as of thevalidation dateshown below, I verify that my investigation of this
Health Authority Approval 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.
Engineering Evaluation and 274_7611
Name of Firm Investigation Services, :Enc Telephone
Address 200 West 34th, Box 267, Anchorage, AK 99503
Date
6. DHHS APPROVAL ;
Approved for 3 bedrooms by Date
ApprovedDisapproved Conditional
Terms of Conditional Approval
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above byan independent professional engineer
registered In the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
Institutions in orderto satisfycertain federal and state requirements. Employees of DHHS do not conduct inspections
oranalyze data before a certificate is Issued.The Municipalityof Anchorage Is not responsible for errors oromissions
In the professional engineer's work.
MM )Rw. rrea) 8"k Page 2 of 2
j�6,10 MUNICIPALITY OF ANCHORAGE (MOA) -
g�� • Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744 rd
Legal Description: Lot 2, Blk B
�L`� Pollock Homestead Subdivision
A. WELL DATA
Well Classification individual If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) Y Date Completed 10/16180 Yield 1.3 aom
Total Depth 200' Cased to 471 Depth of Grouting N/A
Static Water Level 201 Pump Set At UNKNOWN
Casing Height Above Ground ' 36" Sanitary Seal on Casing (Y/ }. q
Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N) N
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot *151 ; On Adjoining Lots 1 100'
To Nearest Edge of Absorption Field on Lot 103' ; On Adjoining Lots >100'
To Nearest Public Sewer Line N/A To Nearest Public Sewer Cleanout/Manhole N/A
To Nearest Sewer Service Line on Lot N/A
Water Sample Collected by Alan Harala ; Date 10/21/88
Water Sample Test Results satisfactory AM, _ A /B "
Comments * D.E.C. Waiver of horizontal separation between Well and
Septic Tank on file with DIIIIS.
B. SEPTIC/HOLDING TANK DATA
Date Installed 6/25/79 Sizel, OOOga1.No. of Compartments
Standpipes (Y/N) Y Air -tight Caps (Y/N) Y Foundation Cleanot (Y/N) Y
Depression over Tank (Y/N) N Date Last Pumped S
Pumping/Maintenance Contact on File (Y/N) N/A ; for N/A
Holding Tank High -Water Alarm (Y/N) N/A Temporary Holding Tank Permit (Y/N) N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Weil , ` '951 To Building Foundation 81
To Property Line % 30 r To Disposal Field 7' to C.Q.'
To Water Main/Service Line N/A
To Stream, Pond, Lake or Major Drain a Course 1100'
Comments y4�L11fS�$
724rM (Re, 7/U) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating In Absorption Strata
Date Installed 6/25/79
Width of Field
36"
250 sq. ft.
/ BR Type of System Design
— Length of Field 58
Depth of Field
Gravel Bed Thickness
750 AS13
Ak—
3'
8r/
Trench
Square Feet of Absortion Area Per Statndpipes Present (Y/N) Y
Depression over Field (Y/N), N Date of Last Adequacy Test 10/21/88
Results of Last Adequacy Test Satisfactory
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well 103' To Property Line 20'
To Building Foundation 201 To Existing or Abandoned System on
Lot N/A ; On Adjoining Lots 100'
To Water Main/Service Line N/A To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course 2' 100'
To Driveway, Parking Area, or Vehicle Storage Area approximately 50'
Comments z = /G 6LI) = 9280
D. LIFT STATION
Date Installed N/A Dimensions
Size in Gallons Manhole/Access (Y/N) .
"Pump On" Level at "Pump Off' Level at
High Water Alarm Level at Vent(Y/N) _
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Pumping Cycles during Adequacy Test.
"Check Permitted Bedroom Rating Against HAA Request" .
certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
Inspection.
Signed
Company Engineering Evaluation and Investigation Sery
Date October 24, 1938 14
MOA No.
Receipt No. old 77,E _1 - -P77, Receipt No
Date of Payment, — d'� Waiver Fee: $ _
Amount: $ 7C! d Date of Payment
72-M (S". 7/88) Back Page 2 of 2
Richard G Bi
CE $031
Seal
/y n
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date - .15 "a-1 j
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
ifof Z enr a Fwtoc h- 17(nmes/m C sett
Location (address or directions)
—_r52/0 Pollock
(b) Applicant Name JCS S'P_ L Telephone: Home Business 5'62'Z'TYY
Applicant Address 15Z(o 1�6LLoc-k nl, 4ileja._41L
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder Buyer ❑ ; Other ❑ (explain);
Lending Institution L" S � (Z h1c 8+.= 11e
!TVIVI Telephone 7 r" '7311
Address o
'pf Real Estate Company and Agenl
Address Al
Telephone �r� A
Mail the HAA to the following address:
tjfl-L (C up w -z 1-114 11'0"z LAJC.
C—LU OE-7-PVLL54
2. TYPE OF RESIDENCE
Single -Family K Multi -Family ❑ Other
Number of Bedrooms 3
3. WATER SUPPLY
Individual Well 13 Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite g Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11,84)
n
r
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
a y
As certified by my seat affixed hereto and as of the validation date shown below, l verify that my Investigation of this Health
Authority Approval 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. l 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. 'X
Nsmeof Firm _F&a%e lecAns6t Strr:cti Telephone _ 3'/S— 13s'ti
Address -5. R. Box 73,50 —,Y /'/S30 Bcl o Sf. /}sr t/aryn:� 91Sln-
Date%1K Z /96S
>� (�(/ruvs� //o�► /ccs .�'f s'i�aarl4n•.
- CYY%lrar. yon' IUC(( �ie st�/dc
D.�•C.
,\',I r /IIS,
DHEP APPROVAL
Approved for � ' 3 bedrooms by Y Date
Approved Disapproved Conditional
Terms of Conditional Approval
I
16MI'll (I•I:l
Engineer's Seal
49T" •• •.y*
..........•..•..•••.•L.•.
'..o ....... Aa•6004..1
rHEODORE F. MOORED Ar
CE -3589 at'
vplatessw S\
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 engineers work.
Page 2 of 2
MUNICIPALITY OF AN1*HO.FACE
MUNICIPALITY OF ANCHORAGE (MOA) ENYIROr�M, HEALTH OTECTION
HEALTH AUTHORITY APPROVAL (MAA)
CHECKLIST - FEBRUARY 1984 I Ay 29
2944720
Legal Description:�_ O_��
Pollock Nomesktrd Sub
A. WELL DATA
Well Classification—ilciwre+!uG f If A. B, C. D.E.C. Approved (Y/N) N.A.
Well Log Present (Y/N) Y Date Completed !U /11S /BU Yield 1•0 aOT
Total Depth 2CV Cased to Hi Depth of Grouting H•A.
Static Water Level to it. Pump Set At On k
Casing Height Above Ground 3rr Sanitary Seal on Casing (Y/N) r
Electrical Wiring inC t (Y/N) Y Depression Around Wellhead (Y/N) -N
Separation Distances from Well:
r
To Septic/Holding Tank on Lot 'S ; On Adjoining Lots 100 1
To Nearest Edge of Absorption Field on Lot 103, ; On Adjoining Lots > too
To Nearest Public Sewer Line —N,I To Nearest Public Sewer
Cleanout/Manhole - -NIA. To Nearest Sewer Service Line on Lot N,A
Water Sample Collected by T F/•1 ; Date 512049
Water Sample Test Results -
Comments)���
foo -!fry," DEG
S. SEPTIC/HOLDING TANK DATA
Date Installed 6•IU179 Size --1020 No. of Compartments 2
Standpipes (Y/N) r Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N)
Depression over Tank (Y/N) N Date Last Pumped SIZI18J-
Pumping/Maintenance Contract on File (YIN) N• A • ; for N•A
Holding Tank High -Water Alartr�((Y/N) N•A • Temporary Holding Tank Permit (Y/N) tN•4-
Separation Distances from eptic/ olding Ta y'�
To Water -Supply Well 9.5 r To Building Foundation r
To Property Line >_� 301 To Disposal Field '2' G O.
To Water Main/Service Line N,A • To Stream, Pond, Lake, or Major Drainage
Course ? (l70 r
Comments
Page 1 of 2
72-026(11,84)
C. ABSORPTION FIELD DATA
r
Soils Rating in Absorption Strata ?SO *0146 ORh Type of System Design Trench
Date Installed 6'1" /79 Length of Field
Width of Field 36 r Depth of Field 3 r
r
Gravel Bed Thickness g
Square Feet of Absorption Area 76& per Standpipes Present (Y/N) i
Depression over Field (Y/N) —£( Date of Last Adequacy Test .
Results of Last Adequacy Test N',4
Separation Distance from Absorption Field:
�
To Water -Supply Well 103 To Property Line —�E
r
To Building Foundation 20 To Existing or Abandoned System on
Lot N114. ; On Adjoining Lots "7 too r
To Water Main/Service Line N• A, To Cutbank (it present) P.A.
To Stream/Pond/Lake/or Major Drainage Course i 100'
To Driveway, Parking Area, or Vehicle Storage Area 50'
Comments
D. LIFT STATION AA.
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
_ "Pump Off' Level at
.• Check Permitted Bedroom Rating Against HAA Request •,
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
I certify that I shave checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date
Company F(w* AtAA-cw(ro""MOA No. 9S ofc'
Receipt No. � 1 3�
Date of Payment �" J
Amount: $ y 5 oL
Page 2 of 2
72-026 (11, &4)
wiR
,4!. .........
• THEODORE F. MOORE • `Alf
CE -3589 ;
Prokssia�` � .
Engineer's Seal
STAH Ou F ALASKA"
BILL SHEFFIELD, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501 274-2533
Flay 29, 1985
Fir. Ted Moore, P.E.
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
SUBJECT: Waiver Horizontal Separation between Well and Septic
Tank, Lot 2, Block B, Pollock Homestead Subdivision
Anchorage, Alaska (8521 -WA -173)
Dear Fir. Moore:
The Department has reviewed the subject waiver request and hereby waives
the horizontal separation between the well and septic tank to 95 feet
on the subject property for a 3 bedroom single family residence only.
Sincerely,
Steven Fl. Eng, Pg5
District Engineer
S11E/msm
MUNICIPAUTY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
t ;AY 29 1985
RECEIVED
