HomeMy WebLinkAboutCHUGACH PARK ESTATES BLK 1 LT 21Chugach Park
Estates
Block 1
Lot 21
#051-481-34
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.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP231134
Work Type: SepticTank Upgrade
Tax Code Number: 05148134000
Site Legal Address: CHUGACH PARK ESTATES BLK 1 LT 21 G:1161
Site Mailing Address: 19436 KULLBERG DR, Chugiak
Owner: NEVELLS ROGER M JR &
Design Engineer: ARC TERRA CONSULTING INC
Effective Date
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
cnt
DelYn-tment
6/6/2023
6/5/2024
54552
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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
Received By: (S 5 uLD (� — TC (Z Date:
Issued By: �— Date: 6/2,0 2-
3
MUNICIPALITY OF ANCHORAGE
5, -1�1
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. 051-481-34
Property owner(s) Roger & Juliann Nevells Day phone
Mailing address 19436 Kullberg Dr. Chugiak, AK
Site address _19436 Kullber2 Dr. Chugiak, AK
Legal description (Sub'd., Block & Lot) Chugiak Park Estates Block 1 Lot 21
Legal description (Township, Range & Section)
Lot Size 54,552 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(N all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) X❑
Septic Tank
XX
Upgrade ❑X
(w/wo AD U)
Holding Tank
❑
Renewal ❑
Duplex (D) El
Privy
❑
Multiple Dwellings ❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION
INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
Dea Duffus
(Signature of property owner or authorized agent)
Permit/Rush Fees: Waiver Fees:
Date of Payment:
Receipt Number:
Permit No. OS P Z 3,1.1
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231134, Curtis Townsend, 06/06/23
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231134, Curtis Townsend, 06/06/23
!
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street • Anchorage, Alaska 99501 Telephone 264.4720
ON -.SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME JMHONE
u
i7`y-'`jp /
❑UPGRADE
MAILING ADDRE55 A
LEGAL DESCRIPTION
Lai
LOCATION
NO. OF BEDROOMS
J
WellG /
Absorption area
Dwelling r
PERMIT NO.
O Y
DISTANCE TO:
ADO 1
-��17Ari
'
2
Manufacturer /'
Materiel
No. of compa intents
W<
CJ7
!
ti
Liq. capacity in gallons
117 A
IF HOMEMADE:
Inside length
Width
Liquid depth
6OZ
DIST A 0:
We
Dwelling
PERMIT
_ FQ-
of urer -
Ma aria f �.i
Liquid capacity in'gallons
O
DISTANCE TO:
Well
Foundation
Neares 1 tone
PERMLy�O r�
d`j
W =
_
755
W Z
No. of lin
Length pf ach line
Total len th of lines
Trench widt
Distance between lines
F Z W
v Q inch.,
Q H
Top of the to finish grade
Material beneath the
Total affective bsorp�{ion area
p
inches
oZ 5 �!/"
L ngth
Width
Depth
PERMIT NO.
W
,7
Q f
Ty of crib
Crib !
Crib de th
To al effecti b rption a ea
wd
w
'ntner
Well
Build" g foundation
Nearest to ine
DIST NCE O:
j
Class Incl✓.
Depth
Driller
Distance to lot line
PERMIT NO.
`i
7
W
DISTANCE TO:
BuildiTngg1foun alion
Sewer line
Septic t n) �h
�i
Absorption
�
S
+�S
C
7/00areaddlsl
OTHER
L
PIPE MATERIALS
7)30 n
SOIL TEST RATING
INSTALLER
3
REMARKS
/ AeeA
41
D 3
1134
APP VED DATE LEGAL
�1Gle;-
72-013 IRevLB/781
1t_It-4 I C InF�L_ I _r 'r' Cl F= nr-4CF-^'F:HCaE
EPARTMENT , HEALTH AND ENVIRONMENTAL . FrOTECTION
825 'L' STREET, ANCHORAGE: AFC. 99501
264-4720
W r� Cor -7-:E3 I TE �E=r•-JEF: FsEF:r1 I -T-
PERMIT
PERMIT NO. C 820574 )
3: o� '/z
L/ -,T_
APPLICANT DENNIS JOHNSON PO BOX 795 CHUGIAK 99507 694-9557
LOCATION
LEGAL L21 61 CHUGACH PARK. ESTATES LOT SIZE 99_-+994 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAT.IMUM NUMBER OF BEDROOMS = ? SOIL RATING CSO FTlBF:)= 85
THE PEGUIFED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
C•EF TH= 12 .=1._• DEF•TH-
THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OP 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 FOP. TRENCHES.
THE GRAVEL DEPTH IS THE MININUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IF! FEET).
� F:E�_±t'_t I F:EC• =•EF'T I C TFit-.1F� � I �E= 1�-=*4-+t=r r- _-
- �FiL_Lr_,t-a-•
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DUPING THE
INSTALLATION INSPECTION= OF ANY HELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL HILL SERVE.
--- -Y-WI i C `? I J4f7-F•EC:T I 0r-4 s,7 F�vF!EE: FR: ECZ, �_, I REL> ---
BACKFILLING OF ANY SYSTEM MITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT IJILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS.
100 FEET FOR A PRIVATE WELL OF: 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UP014 THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F'EF:J1 I T E:<:F• I F:E=• C•ECEr•1E:ER -:1. 1_=+L= •
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REQUIREMENTS FOP. ON-SITE SEWERS AND HELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
FESIDENCE IS REMODELED TO INCLUDE MORE THAN = BEDROOMS.
SIGNED: -------------------
APPLICANT _NNIS JOHNSON
ISSUED BY_ _ SSSS-- /-DATE--------------- V4.0
5 l �-e
r%i
M U NJ I CT I F-- Fl L_ I T Y Q F Fl N4 CT VA FZ FA C3 E
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 'L' STREET, ANCHORAGE, AK. 99501
264-4720
IJ ELL F}EE: F2f1 I T
PERMIT NO. C 821126 )
APPLICANT DENNIS JOHNSON PO BOX 795 CHUGIAK 99567 6882141
LOCATION
LEGAL L21 61 CHUGIAK PARK ESTATES LOT SIZE 999999 SQUARE FEET
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.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F}EFZM I T EXF=' I FZES; E>ECEMEDFEE R 31r 1'g:s2
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM ,4 N ACCORDANCE WITH THE CODES.
SIGNED
APPLICANT PERF,lIS JOHNSON
ISSUED BY DRTE__� �� �_ v V4.0
by
DOC Co. Cba
SULLIVAN WATER WELLS
P.O. BOX 272, CHUGIAK, ALASKA 99567 a TELEPHONE 688-2759
OWNER OF LAND /i7 1O H".r0')
DEPTH OF WELL o? -� d
J
ADDRESS x 79 STATIC LEVEL OF WATER FT. /7,3
LEGAL DESCRIPTION -'J/ �< !' C�f/U� A� �/r DRAW DOWN FT.
DATE • Started Ended GALS. PER HR �4 O
PERMIT NUMBER KIND OF CASING do
KIND OF FORMATION:
From n Ft. to C Ft. e" Ud� Z /3 r/eOC pli
From Ft. to J Ft. J -x �
From -2 � Ft. to -3 ; Ft.
From 7F Ft. to L� Ft. __AV- 4 6425 va L
From Ft. to Ft. S� Ce 11f
From e, a Ft. to2,L_FL _5-4 -J-0 ! Cc a9 f £
From Ft. to Ft. C; Llz ,e
r
From_V Ft. to -LO -2 --Ft. FO4 el F l ex �F{
From ./0 Ft. to I-) A Ft. Ce *I f e_
From/�-�AFt. to�_Ft. T /, YT SFif-dl)
From 1L�Ft. to-L2LFt. ? M r
From Ft. to Ft. -S� t 0 C �{ d uf'L
From Ft. to Ft.
From % ! Ft. to IIFlFt.
From (,F'4 Ft. to / E Ft.
From Ft. to Ft.
From/tFrFt.to»O Ft. CJ' -q1
MISCL. INFORMATION:
From
Ft. to
Ft.
From
Ft. to
Ft.'
From
Ft. to
Ft.
- MUNICIPALITY OF ANCHORAGE
From
Ft. to .
Ft. prnT or , - - ,T . r.
ENVIRJI U.',:t:: A_ ; ..U. ECTION
From
Fl. to
Ft
From
Ft. to
' Ft. CCT 2 9 1932
From
Ft. to
Ft. MUM f��
�� LL YY LL 11��
From
Ft. to
Ft.
From
Ft. to
Fl.
From
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DRILLERS NAME
Russell Oyster
694-2774
Performed for.
O & E ENC VEERING & DEVEL•0.,MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
SOIL LOG
oec=,o R__St i o,C:'
Mailing Address: •
Legal Description: LC� 2
Depth (feet) Soil Characteristics
0
1 �Os.o�c � Kms., -•o �' ��.aNic ��
2-
3-
4 34
5 1:a>
.4
6
7
l I Lijj #&.4C -N L—
Earl Ellis
688-2280
—Tel. No. l2�_5 A
10
Lo-r 2/
11 —
4::�ZLnG /
12-
13
14_
15^T
16
Earl Ellis
688-2280
—Tel. No. l2�_5 A
PLOT PLAN
PERC.TEST
a {. G .AL�t:
Ground Water Encountered: Yes No --H yes, what depth—
Proposed
epth Proposed Installation: Seepage Pit— Drain Field c�
Comments:
Performed
Date:
Lo-r 2/
4::�ZLnG /
0,41.+ewnz4
/
Q
PLOT PLAN
PERC.TEST
a {. G .AL�t:
Ground Water Encountered: Yes No --H yes, what depth—
Proposed
epth Proposed Installation: Seepage Pit— Drain Field c�
Comments:
Performed
Date:
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
wwwmuni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. DSI -X181- 3 y COSA# ogo ((/5 -
Expiration Date:
1. GENERAL INFORMATION
Complete legal description Lot 21; Block 1; Chugach Park Estates
Location (site address) 19436 Kullberg Rd. Chugiak, AK 99567
Current Property owner(s) Debi s Jack Smith
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
same
Unless otherwise requested. COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
IZI
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Day phone 686-6878
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
IZI
Individual Holding Tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of 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 welts 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.
Name of Firm S a s Engineering
Address 15861 S. Birchwood Loop Chugiak. AK 99567
Engineer's Printed Name Robert A. Shafer
5. DSD SIGNATURE
" Approved for bedrooms.
Disapproved.
Conditional approval for
Phone 694'2979
Date // %
bedrooms, with the following stipulations//:"''"
\t`Y OF q
ON-SITE
yP.
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineets Report
Other
By: Original Certificate Date: q
(R. 11105)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OFF ON-SITE SYST APPROVAL CHECKLIST
Legal Description: Ldf'0CI',I-7"OfPJ+ li K 651 Parcel to: 051 - 4 SI -3y
A. WELL DAIA�
Well type 2tVtfE
Date completed
Total depth aao,ft.
If A. B, or C provide PWSID #_
Sanitary seal (Y/N) - '
Cased to o`oC0 fL
FROM WELL LOG
Date of test 6/89
Static water level ft.
s.
Well production 9—
p.m-
Well Logd! N)
Wires properly protected.(Zy N) q
w
Casing height (above ground) 12 t-- n.
AT INSPECTION
fo a7
fio • of g.p.m.
WATER SAMPLE RESULTS:
Coliform f 0� colonies/100 mL Nitrate a � ng/L Other bacteria � colonies/100 mL
1
Arsenic: �V ug/L date of sample: to —7107 Collected by:
B. SEPTICIHOLDING TANK DATA
Tank Type/Materiai J><m &L. Date installed 8
Tank size(ON) oOb gal. Number of Compartments a Cleanouts
Foundation cleanout�iN) J65 Depression over tank (�Y/& 1 High water alarm (Y/10)
Date of pumping R� Pumper -
C. ABSORPTION FIELD DATA
Date installed a Soil rating (g.p.d./f? oft' dr � System type 51>4f•Ul o t26tlX#�
Length 4to' ft. Width 5 ft. Gravel below pipe
'11
Total depth 7/0 r-- Eff, absorption area Z_6112 Monitoring tube _A5 Depression over field
Date of adequacy test l0 Result (Pa ail For _3bedrooms
g�nnu 11 Q
Fluid depth in absorption field before test v in. Water added_t/gal. New depth in.
Elapsed Time: M min. Final fluid depth in. Absorption rate >= y50t g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y6& type) �t5 If yes, give date
D. LIFT STATION N IR
Date installed
'Pump on' level at _in.
Datum
E. SEPARATION DISTANCES
Size in gallons
Cycles tested
at _ in. High water alarm level at in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
1
Septic tank/lift station on lot
I
Absorption field on lot 1049 '-
Public sewer main N /q
Sewer /septic service line 0q54-
Animal
q 4'Animal containment areas
Meets alarm ti circuit requirements?
On adjacent lots `F
On adjacent lots �� f
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas l�
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5 1'r Property line5 /f Absorption field s
/ I
Water main N �� Water service line lD -/- Surface water 100
1
Welts on adjacent lots /00 'f"
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
I I
Property line /0-1-- Building foundation ID 4- Water main _ N
I I I
Water Service line 10 � Surface water 100 'r<- Driveway, parkingfvehicle storage
Curtain drain N' M& KM%4 Wells on adjacent lots Imp
F. COMMENTS
)k F'iaw e13 F7)U, sr
herr Cw,4E)Wrc✓ — SU
G. ENGINEER'S CERTIFICATION
I certify that 1 have determine hro
review of Municipal record that t
conformance with MOA COS gu' it
Engineer's Printed Name 6
Date
COSA Fee $
Date of Payment I I
Receipt Number
(Rev. 11/05)
5A
h field inspections and
above systems are i4
Waiver Fee $
Date of Payment
Receipt Number
WIN
IS
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. O S 1 - `f 1 - 341 COSA#.�Q�3�q
Expiration Date: /O -,Z6 - OG
1. GENERAL INFORMATION
Complete legal description Lot 21: Block 1: Chugach Park Estates
Location (site address) 19436 Kullberp, Dr. Chupiak, AK 99567
Current Property owner(s)`:Luanne Urfer & Michael Bowd(nyphone 250-5890
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Caroline Streano
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
)m
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Day phone
Dayphone 350-1945
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
)m
Individual Holding Tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an Independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of 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, 1 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 Firm S a S EnginPPrinp Phone 694-7979
Address 17034 N. Ea le River LooD Ste. 204 Eagle River, AK,99577
Engineer's Printed Name 0,0e.27- C.
S. DSD SIGNATURE
Approved for 3 bedrooms.
Disapproved.
OciA.✓ Date 7�/e C
T ` ROBERT C. COWAN
'O 'tC.-8801
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory Other
By: / Irle? --1/ / Original Certificate Date: 7— 2 (o - O G
(R". 7 LOs)
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/onsits
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: I OT &e1r_K- (f l,++tl49 Jf t 06Z_k &&T, Parcel ID: 0571 " <jg 1 - 3q
A. WELL DATA
Well type&1/}TC
Date completed 42
Total depth . DL ft.
Date of test
Static water level
Well production
If A. B, or C provide PWSID # =
Sanitary seal (YjN) _\tLe-
Cased to VX ft.
FROM WELL LOG
r
11D g.p.m.
WATER SAMPLE RESULTS:
Coliform _0 colonies/100 mL
Arsenic: NTS mgA
B. SEPTIC/HOLDING TANK DATA
Nitrate Irb mg/L
Date of sample: 11-21/0(c
TankType/Matedal 5rMIC-1 �✓i�6L
Tank size 10a? gal. Number of Compartments 2
Well Log&) \1 �
Wires properly prolectedO N
Casing height (above ground) 12- + in.
AT INSPECTION
5.3 g.p.m.
Other bacteria 0 colonies/100 ml
Collected by: 574-5 r-iCC-(0-FEZAkXr
Date installed (o & &2-
Cleanouls(flf) `(cS
Foundation cleanout (SIN) IC5 Depression over tank (Y94>_E20 High water alarm (Y[IV lf,
Date of pumping `7 11fbG Pumper �M's +N1Pr1-26
C. ABSORPTION FIELD DATA 1
Date installed (o �%.2 Soil rating (g.p.d.lte or� i�5 0 System type �f1A[lL>� I r7F f
Length qbt ft. Width S ft. Gravel below pipe
Total depth 2X &. Eff. absorption area JbS ft2 Monitoring tube IL Depression over field NO
Date of adequacy test Resu Pad ail) i 1 For 3 bedrooms
Fluid depth in absorption field before test _!2L in. Water added5-73gal. New depth in.
Elapsed Time:,W min. Final fluid depth Q in. Absorption rate >= gSO4 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y(9 type) 00 If yes, give date
r
D. UFT STATION
Date installed Size in gallons
'Pump on' level at _ in. 'Pum
Datum Cycles tested.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot Ito 1
Absorption field on lot 1 CkP It
Public sewer main! i{
i
Sewer /septic service line
Animal containment areas 1;n.4 -
(YIN)
in. High water alarm level at
Meets alarm 8 circuit requirements?
On adjacent lots IDU +
On adjacent lots 1 Do 1.1 -
Public sewer manhole/cleanout
Holding tank AJh
Manure/animal excrete storage areas too -
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
1 1 1
Building foundation S + Property line 6 + Absorption field S 4
Water main ►a'ti Water service line 104 Surfacewater _ IQ'> r+
Wells on adjacent lots /m4
in.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /D,4- Building foundation -140(V Water main 1A
Water Service line /O 1'� Surface water 100+ Driveway. parking/vehicle storage '6f)1
Curtain drain AX'd?f Kk-00N Wells on adjacent lots t0 ta
F. COMMENTS
G. ENGINEER'S CERTIFICATION
/ certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSAA guidelines in elect on this date.
Engineers Printed Name I` 0 3 E A r C• CO wA""
Date -7 40 /0 G
COSA Fee $ A /30-00
Date of Payment 7 la •f /O C
Receipt Number O `1 31. 3 y
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
70 R06;C. COWbN`
`��•''. ceae8l'
Y
N (TI AAI
N'l EAS
ASSUILT
SEIIARU
6 ASSOCIATES LAND SU" VEYINC L94
I HEREBY CERTIFY •THAT I HAVE SURVEYED THE
SCALE: .,
FOLLOWING DESCRIBED PROPERTY=OF
i�a�e"�Y.ayr'� �L�f'✓
DATE, ..
-. A
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS
/ d
INDICATED. IT IS THE RESPONSIBILITY OF THE
���.` "��'' ''ter 4
OWNER TO DETERMINE THE EXISTENCE OF ANY
^Ty'v
EASEMENTS, COVENANTS OR RESTRICTIONS
GRID-
i/w//.� /
.
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
;
VISION PLAT, UNDER NO CIRCUMSTANCES SHOULD
FB`
C!'.. &-" M"' ^'•''a
�IX �`✓
ANY DATA HEREON BE USED FOR CONSTRUCTION
'x
r'. lY-912
OF FENCE LINES, OR FOR ESTABLISHING1
BOUND-
. A •..... •' `'`
ARY LINES.
DRAWNt
,
•� �'r,�y,t„L�
Municipality of Anchorage
�- Development Services Department
Building Safety Division �.
j On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ct.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
,FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-481-34 HAA# L4 R Q 3 O 2 -
Expiration
Expiration Date: R- 2 R- O 9
1. 'GENERAL INFORMATION
Complete legal description Lot 21; Block 1; Chugach Park Estates
Location (site address or directions) 19436 Kullberg Dr.
'Current Propertyowneir(s) Dennis Johnson Dayphone 949-4266
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone
16600 Centerfield Sr. Ste. 201 Eagle River, AK 99577
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
1TIt�RFIIRIaP
Individual Water Storage
Community Class Well
Public Water System
3
-7o'Z 4L,
TYPE OF WASTEWATER DISPOSAL:
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
Individual On-site
U
❑
Individual Holding tank
❑
❑
Community On-site
❑
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm S b S Engineering. Phone 694-2979
Address 17034 N. Eagle River Loop Ste 204 Eagle River, AK 99577
Engineer'sPrinted Name Robert C. Cowan Date_ s-za?A3
-07
_f--- ;n ROBERT C. COWAN
5. DSD SIGNATURE CE -8801
✓ Approved for �✓ bedrooms. f ,'tt`�i'� • :; �:�ti �'4
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
-V WATER AND
Additional Comments : R'=
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By, n /—U -C Original Certificate Date:
(Rw. 12M)
Municipality of Anchorage
• ~' Development Services Department
Building Safety Division -
On -Site Water & Wastewater Program S.
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST `'
Legal Description: L a� �`S fa'f K FST Parcel ID: 051- a'- 3Y
A. WELL DATA
Well type k�?4t If A, B. or C provide PWSID #� Well Log (2)N) y�S
Date completed �`6� Sanitary seal ®N) : Wires properly protected &N) Ys
Total depth aNLI'L Cased to 22L -ft.
FROM WELL LOG
Date of test CIO
Static water level N-5- ft.
Well production /0 9 -13 -m -
WATER SAMPLE RESULTS:
Casing height (above ground) Q.1. in.
AT INSPECTION
S �E-03
g.p.m.
Coliform O colonies/100 ml. Nitrate )-5-7 mg.A. Other bacteria 0 colonies/100 ml.
IS /� S i S ENGINEERING
Arsenic: mg.A. Date of sample: Collected by:iLoop,No. 404
B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99577
Tank Type/Material SrDficIZ6±'-1 Date installed
Tank size ,1000 gal. Number of Compartments t� Cleanouts (9/N) Y^s
Foundation cleanout &N) fL Depression over tank (YAQ 't High water alarm (Y/N)
Date of pumping 10h -31o) Pumper 1f>
C. ABSORPTION FIELD DATA
Date installed 6A15C Soil rating (g.p.dJft2 or =/bdrm System type 4,0—e%
Length 94 ft. Width # S ft. Gravel below pipe %P -Z ft.
Total depth �'�d" ft. Eff, absorption area L S ft2 Monitoring tube Y'S Depression over field Nd
Date of adequacy test 5' /F -a 3 Results (Pass/Fail) S For _L bedrooms
Fluid depth in absorption field before test OPS in. Water addedgal. New depth d in.
•• r
Elapsed Time: 60 min. Final fluid depth in. Absorption rate >= Z/ 5- g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) 0V k w�.. ,✓ If yes, give date
D.' LIFT STATION
DateInst
"Pump on" level at _ in.
Datum
E. SEPARATION DISTANCES
Size in gallons
Cycles tested
Manhole/Access (YIN)
at _ in. High water alar level at in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot /06'{"
Absorption field on lot too {
Public sewer main _ qlA
Sewer /septic service line a- S '4-
On adjacent lots 1c) F
On adjacent lots Lek) /
Public sewer manhole/cleanout A11/i
Holding tank MA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Sk Property line S* Absorption field S'*'
Water main /D h Water service line 0.4 Surface water /CUA
Wells on adjacent lots !J✓ Ir I -
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ICE Building foundation /a'* Water main /aF-
Water Service line 164- Surface water /d✓A Driveway, parking/vehicle storage
Curtaindrain Ak-f r, ,,. i Wells on adjacent lots /air
F. COMMENTS
OF
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and ` "7
review of Municipal records that the above systems are inJ. _
conformance with MOA HAA guidelines in effect on this date. Tei ROURT
—21
CE -8801
G. COWAN
Engineer's Printed Name feppaO't-er- C. C,)&,4,. +f���
tt i .• .1
�.
Date S- �a 3I0 j ! .............
HAA Fee $ 3 �� , y Waiver Fee $
Date of Payment S -1A 7 103 Date of Payment
Receipt Numbery" 3 S y t Al c,'S Receipt Number
(Rev. 12101)
r r MUNICIPALITY OF ANCHORAGE f '.
1 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 4/3/86
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 21 Block 1 Chugach Park Estates T15N R1W Sec. 15
Location (address or directions)
Kullber Drive
(b) Applicant NamaDennis JohnSOn Telephone: Home 688-9868 Business N/A
Applicant Address PO Box 795 Chugiak AK 99567
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder 0 ; Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution AK Paci fir Dlortgmpe Telephone 694-7780
Address Tzay a River. Alaska
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
2. TYPE OF RESIDENCE
Single -Family M Multi -Family ❑ Other
Number of Bedrooms
3. WATER SUPPLY
Individual Well m 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 11 Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the Stale Department of Environmental Conservation
attesting to the legality and status.
72.025 111,54)
,Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of thevalidation date shown below,) 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.
Name of Firm EAGLE RIVER ENGINEERING SERVICES Telephone
EAGLE RIVER, AK 99577
Address ^,-,^,•-DO%773294
DateZZY16a 694-5195
r �
.••-c' •.c.°,w°"•.,Engineer's Seal
t
C
Louis A. uc:a l i
.•
6. DHEP APPRO
Approved for bedrooms byLt f "L Date
Approved �- Disapprove Conditional
Terms of Conditional Approval
to
CAUTION
y 8�
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
72.025 111/84)
WNICIPAUTY OF ANCHORAGE
DEPT. OF HEALTH 6
MUNICIPALITY OF ANCHORAGE (MOAT EWPOt"NTAL PROTECTION
HEALTH AUTHORITY APPROVAL (HAA) APR 3M
CHECKLIST - FEBRUARY 1984
284-4720 EE
Legal Description: /�E'-"`SD`/
0,14 r Lr Er.14;l)cr T/1 N greIW fcr./S'
A. WELL DATA
Well Classification q 7'11F If A. B, C, D.E.C. Approved (Y/N) ni/4
Well Log Present (Y/N) y— Date Completed G /g -.a Yield 7%^n• t: ici Mrd
Total Depth 2s'' Cased to aaO ' Depth of Grouting N/</
Static Water Level /V0' &A, 7$p �f � � ^ s Pump Set At le,
Casing Height Above Ground /8" Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) y Depression Around Wellhead (Y/N) N
Separation Distances from Well
To Septic/Holding Tank on Lot /° > �s ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot /e2 = -2 : On Adjoining Lots
To Nearest Public Sewer Line W To Nearest Public Sewer
Cleanout/Manhole N ^L To Nearest Sewer Service Line on Lot
Water Sample Collected by Date e -
Water Sample Test Results Sc t,s aa��r
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed 19 SA Size /oco e-1 No. of Compartments -2
Standpipes (Y/N) k Air -tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/N) /✓//// Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) `�4 ;for —
Holding Tank High -Water Alarm (Y/N) 11171114f Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank
To Water -Supply Well 142 7 To Building Foundation
To Property Line */d To Disposal Field 05 -
To
STo Water Main/Service Line y /� To Stream, Pond, Lake, or Major Drainage
Course —i Alamt Pr
Comments
Page 1 of 2
72-026(11)84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 05- 0,8x Type of System Design l✓�fo i r�+✓c
Date Installed J5a Length of Field 4�' f — • —dr
i
Width of Field Depth of Field 7 ^< «1•'.r
Gravel Bed Thickness /z %--� R.•-er
Square Feet of Absorption Area 26 N Standpipes Present (Y/N) Y
Depression over Field (Y/N) N Date of Last Adequacy Test
Results of Last Adequacy Test So .1,;.
.i , fa , . 6s.• 6 t, . -, 7•`- 3
Separation Distance from Absorption Field:
To Water -Supply Well /`%a c= d' To Property Line
To Building Foundation Ys '
Lot
On Adjoining Lots
To Existing or Abandoned System on
3u•
To Water Main/Service Line */o To Cutbank (if present) yP^'e
To Stream/Pond/Lake/or Major Drainage Course /✓— • %7;L•^a i w '
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION�,�/A
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
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
'• Check Permitted Bedroom Rating Against HAA Request °°
I certify thattIhave checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed �/ ��� Date `vt40
Company -La.Pc • MOA No.
Receipt No. —B. L)
DateofPayment
ch
Amount: $ CpS
Page 2 of 2
72.026 (11,84)
itngineer's Seal
t ` lou& A. eufara
,�,,. c,J ee...e..N• . t..0
APPLY 'NT FILLS OUT UPPER HA[ ONLY
Property Owner e /7 /!/S /%L TUi7 /7S 0, -7 -
/iMailin
Time
Mailing Address PL) 13 W r]//c?S C t� + r Zip Code
Time \G�•�
Buyer
b O✓ 6.1'1—qS'�I
c! S Gl
Address Zip Code
Lending Institution �C2 G/E' .�i 6'1 n +� Phone
/
In nC cver
Address £ q C / P ( M 7 �iS% / Zip Coda
Realty Co. & Agent 1 Phone
C•(-a.v �.O t. �10�1uSM
Inspector
Address ZIP Code
ti aua
Legal Description L o -/ / O c. !C %l ✓G 4 C R i.� ES'f
J
Street Location fn
Type of Residence
JQ Single Family
❑ Multiple Family No. of Bedrooms
❑ Other
�U
ENVIE ;L! .1,.a..:.Ur T'.,1
Water Supply
�y Individual . !lO p��
LOG. A well log is required for all wells drilled since June 1975.
TAT7TACH:iL
��
weled prior to that date. give well depth (attach log If available).
❑ Community -
❑ Public Utility
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
Sewer Disposal Year Individual Installed: 1 i�
Individual
❑ Public Utility When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RECUEST BEFORE PROCESSING CAN BE INITIATED.
we 0 lh r
rn m/L p �� X
Time
Time
Time
Time \G�•�
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes: ,��' 0— wc-co &7
l
MUNICIPALITY OF ANCHORAGE
r --T r
�U
ENVIE ;L! .1,.a..:.Ur T'.,1
CC -1 T 1982
RECEIVED
( :3) APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
/D (''
DATE
`-
\ I
BY:
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
Septic Tank Size t OcJJ
S
Well to Tank
72e 3 C