HomeMy WebLinkAboutROCKHILL BLK 4 LT 5Rockhill
Block 4
Lot 5
#015-063-28
Municipality of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP191095 PID Number: 015-063-28
Dwelling: M Single Family(SF) ❑ with ADU ❑ Duplex(D) ❑Two Single Family Project: ❑ New 0 Upgrade
Name ABSORPTION FIELD
Basilio &Rosa Castillo
Site Address ❑ Deep Trench ❑Wide Trench ❑ Bed ❑ Mound
9825 Lone Tree Drive ❑ Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
907-230-5273 4 GPD/SF Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot Ft. Ft.
Rockhill 4 5 Fill added above original grade Gravel length
Township Range Section Ft. Ft.
Gravel width Beds:Number of Lines Distance between lines
SEPARATION DISTANCES Ft. Ft.
Septic Absorption Holding Sewer
From Total absorption area Number of trenches Dist.between trenches
To
Tank Field Lift Station Tank , Line Ft2 Ft.
,
Well 100+ TANK ®Septic 0 S.T.E.P. 0 Holding 0 Other
Manufacturer Capacity
Surface Water 100+ Anchorage Tank 1250 Gal.
Material Number of compartments
Lot Line 5+ i NA Steel 2
Foundation 9* LIFT STATION
i i Manufacturer Capacity
Remarks *septic tank is not within the foundation Gal.
soil bearing prism, see record drawing. Alarm location Electrical installed by
PIPE MATERIAL House to tank 3034Tank to 3034
Installer drainfield
ARM Services Drainfield CO/MT 3034
Inspector Crewdson Engineering LLC BENCH MARK (Assumed elevation) 100 ft
Inspection
1s' 4/17/2019 4/18/2019 Location and description
dates: 2b
3rd 4th bottom of siding, see record drawing
ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp1``�.•\‘‘
,==..4OF /44111t
Conditional Approval: Date •� Q► .• f• b
Iames
A.Crewdson:g• /
Septic Syste — 112-(0-1?'
/ C11 27 �,, �'
Approve 0^--t"'" Date `? �� l 6• •/... . \, ..
.
l\‘ 1170FESSON�-
Note: this approval does not include well permit requirements. A LLC )>a as ,/%N.%:".
(Rev 05/02/18)
•
SWING TIES(feet)
A B
FC 11.00 I 8.34
S1 15.79 12.73
4 BR SFH S2 21.87 j 19.37
DC 25.41 23.11
i1 A BM B
° FC
9.0' ` N SEPTIC TANK
/ DGK S1 It AT-1250
/./Z'/
I S2
o/ DC
coj
LOT 5
/ PLAN
SCALE: 1"=20'
J7—BM BOS ELEV: PROFILE •
_
ELEV: EG 99.3' •
,,,����,,���////// ASSUME 100' FG 99.6' — SCALE: 1"=5'
17=11I •
IIIIIIIIIIi IiIIIIIii1Iliill iiIII' )III-III III- I I 1
•
5.7'
8.7' LEGEND
(N)-new
----'"---------ELEV 94.83' BOS-bottom of siding
•
•• _ BR-bedroom
• AT-1250 SEPTIC TANK t— DC-double cleanout
1L.N. ELEV: EG-existing ground
1 \• TOT 93.93' ELEV-elevation
•
•` IN-INV 93.35' FG-finish grade
\\ OUT-INV 93.18' IAW-in accordance with
•
IN-inlet
•
•
INV-invert
•
•
OUT-outlet
••. TOT-top of tank
Crewdson Engineering, LLQ Rockhill, Block 4, Lot 5 ' ���\
r�P � nF A• SII
Septic Tank Upgrade Record Drawing rg '1,• -9'l
;:ii..‘, Plan and Profile * TM '� *��/
/ James A.Crewdson '
moo. ' # Cl 27 •..
Civil&Environmental Engineering Prepared for: Basilio Castillo Date: 4-18-19 4 •`•f-1F-1.9• ...!
' /
Permit: OSP191095 Page: 1 of 1
PO Box 671389 Chugiak AK 99567 • cellc.t(doutlook.wm
til ``��'
Cell/Text:907-280-9493 • Fax:907.688-2295
ALL INFORMATION SHOWN ON TUTS DOCUMENT IS THE PROPERTY OF CRCWDSON ENGINEERING,ILL AND SNAIL NOT RE USU.,OR ALLC#112279
ENGINEERING OR CONSTRUCTION PURPOSES WITHOUT WRITTEN PERMISSION FROM CREWOSON ENGINEERNG.U.0
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: OSP191095
Work Type: SepticTank Upgrade
Tax Code Number: 01506328000
Site Legal Address: ROCKHILL BLK 4 LT 5 G:2438
Site Mailing Address: 9825 LONE TREE DR, Anchorage
Owner: CASTILLO BASILIO & ROSA
Design Engineer: CREWDSON ENGINEERING, LLC
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date
ti/l1/l9
nt
V _
Department
Lot Size in Sq Ft:
Total Bedrooms:
4/12/2019
4/11/2020
53607
❑ 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
Special Provisions:
1) The tank shall be installed outside the soil bearing prism of the foundation (or 10 ft from the foundation).
2) The tank shall be installed at least 5 ft from any supports for deck or stair over 30" high.
Received B
Issued By:
Date:
Date:
4
MUNICIPALITY OF
0
Development Services Department
On -Site Water & Wastewater Section
f
/f
f
ANCHORAGE
ON-SITE SEPTICIWELL PERMIT APPLICATION
Parcel I.D. 015-063-28
Property owner(s) CASTILLO BASILIO & ROSA Day phone
Mailinq address 9825 LONE TREE DR, ANCHORAGE, AK 99507-6712
Site address SAME
Legal description (Sub'd., Block & Lot) ROCKHILL, BLOCK 4, LOT 5
Legal description .(Township, Range & Section)
Lot Size 53,607 Sq. Ft. Number of Bedrooms 4
Phone: 907-343-7904
Fax: 907-343-7997
APPLICATION IS FOR: APPLICATION IS AN:. TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑ Initial
❑
Single Family (SF) Q
(w/wo ADU)
Septic Tank Upgrade
Fx]
Duplex (D) F-1
Holding Tank ❑ Renewal
❑
Multiple Dwellings ❑
Privy ❑
(SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify hat the above information is correct. I further
certify that this
is in accordance with
applic le Municipal Codes.
-cv-t
( ig a re of property owner or authorized agent)
Permit/Rush Fees:. 3426
Waiver Fees:
Date of Payment: tlla.La
Date of Payment:
Receipt Number: aL �'�
Receipt Number:
Permit No. 65MI645,
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc
Civil & Environmental Engineering
M
April 10, 2019
Onsite Reviewer
Municipality of Anchorage
On-site Water & Wastewater Program
4700 Elmore Road
Anchorage, AI<99519-6650
Reference: Rockhill, Block 4, Lot 5
Septic Tank Upgrade
Design Narrative
James "Jay" Crewdson, P.E.
Email: CELLC.1@outlool<.com
Cell/Text: (907) 280-9493
Fax: (907) 688-2295
The owner of the 4 -bedroom home would like to replace the existing septic tank.
The existing septic tank will be abandoned in-place or removed from the property in accordance with the
code.
The new septic tank will be either an Anchorage Tank AT -1250 or Infiltrator IM -1530 located near the
location of the existing septic tank at roughly the same elevation.
No waivers are required for the proposed design.
Please feel free to contact me if you have any questions.
ar}a'es "Jay" Crewdson, P.E
OVA
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J m e s A. Crewdson
C11527
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PO Box 671389 ® 18368 Amonson Road ® Chugiak, Alaska 99567
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AS -BUILT SURVEY
SCALE: 1 • e 40'
LEGEND
I HEREBY CERTIFY THAT I HAVE PERFORMED A "----'---
MORTGAGEE'S INSPECTION OF THE FOLLOWING
DESCRIBED PROPERTY, 8 SEWER VENT
LOT 5, BLOCK 4, ROCKHILL SUB.
/•• .......�
/ J m . Crewdson '
C11527
�t F�pROFES510NP .�
Ll. 19 9L q
ANCHORAGE RECORDING DISTRICT, ALASKA AND THAT TH6 INFORMATION HEREON IS FOR THE USE OF LENDING INSTIYUTION8 SPECIFICALLY TO SHOW ANY CONFLI ETWEEN
THE VISIBLE IMPROVEMENTS SITUATED THtPI ON ARE EXISTING STRUCTURES AND PLATTED LOT LINES OR EASEMENTS AND IS NOT TO BE USED FOR POSITIONING AUDI AL
WITHIN THE PROPERTY LINES AND THAT NO VISI13LE STRUCTURES OR FENCELINES.
ENCROACHMENTS EXIST OYHER THAN NOTED. EASEMEiNT,$ OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED PLAT, ARE NOT SHOWN HEREON,
DATED AT ANCHORAGE, ALASKA THIS 8YN
DAY NOTE; ANY FENCELINE8 SHOWN ARE LOCATED APPROXIMATELY AND ARE NOT TO 0E USED TO DETERMINE PROPERTY LINES
,
HOLYL LAND PrUJUNERVEYINCI 8374, 2001 1`59355 OR LOCATE STRUCTURES.
TEL, 3x8.6613 ANY PAVING .SHOWN MAYBE APPROXIMATE DUE TO SNOW CONDITIONS.
TOTAL P.02
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SCALE: 1 • e 40'
LEGEND
I HEREBY CERTIFY THAT I HAVE PERFORMED A "----'---
MORTGAGEE'S INSPECTION OF THE FOLLOWING
DESCRIBED PROPERTY, 8 SEWER VENT
LOT 5, BLOCK 4, ROCKHILL SUB.
/•• .......�
/ J m . Crewdson '
C11527
�t F�pROFES510NP .�
Ll. 19 9L q
ANCHORAGE RECORDING DISTRICT, ALASKA AND THAT TH6 INFORMATION HEREON IS FOR THE USE OF LENDING INSTIYUTION8 SPECIFICALLY TO SHOW ANY CONFLI ETWEEN
THE VISIBLE IMPROVEMENTS SITUATED THtPI ON ARE EXISTING STRUCTURES AND PLATTED LOT LINES OR EASEMENTS AND IS NOT TO BE USED FOR POSITIONING AUDI AL
WITHIN THE PROPERTY LINES AND THAT NO VISI13LE STRUCTURES OR FENCELINES.
ENCROACHMENTS EXIST OYHER THAN NOTED. EASEMEiNT,$ OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED PLAT, ARE NOT SHOWN HEREON,
DATED AT ANCHORAGE, ALASKA THIS 8YN
DAY NOTE; ANY FENCELINE8 SHOWN ARE LOCATED APPROXIMATELY AND ARE NOT TO 0E USED TO DETERMINE PROPERTY LINES
,
HOLYL LAND PrUJUNERVEYINCI 8374, 2001 1`59355 OR LOCATE STRUCTURES.
TEL, 3x8.6613 ANY PAVING .SHOWN MAYBE APPROXIMATE DUE TO SNOW CONDITIONS.
TOTAL P.02
r'—" MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
1 ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
EW
K T
i SS22
❑UPGRADE
MAILING ADDRESS
K -D
LLE 1.1
LEGAL DESCRIPTION ^�
S
1_oT S �s OG KICK 411�� s7
LOCATION.,
tSZi �vJ r l Tt2 t E ^► L c. r
NO. OF BEDROOMS
Well
I
Absorption area
Dwelling
PERMIT NO.
HasaDtJm..tErJ
DISTANCE TO:
a A
L O
O Y
EZ
Manufacturer
Material
Material
STEE`
No, of
W
Q£E
Liq. capacity in gallons
Inside length
Width
Liquid depth
% SO
IF HOMEMADE:
d v
D
DISTANCE TO:
Well
Dwelling
PERMIT NO.
S
Manufacturer
Material
Liquid capacity in gallons
OWell
J
DISTANCE TO:
-`
1J1i�s
Foundation
^- Zg0
Nearest lot ltne .
'ILA
PERMIT NO.
H 13DsSiLst'TF
W=
LL Z
No. of lines
Length of each line /
TOIaI length Of lines
Trench width
Distance between lines
Z W
,
inches
H
WTop
cc 1-o
of tile to finish grade
Material beneath tile t
Total effective absorption area
4CA S
� Z'-6-115"
inches
Length Width
Depth
PERMIT NO.
W
H
Type of crib
Crib diameter
Crib depth
Total effective absorption area
W6
W
Well
Building foundation
Nearest lot line
a
DISTANCE TO:
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
J
W
Building foundation
Sewer line
Septic tank
Absorption area(s)
DISTANCE TO:
OTHER
_
PIPE MATERIALS
�v V
SOIL TEST RATI NG
l:
INSTALLER
TE �rZESH S
REMARKS
O
i
7 u
K �-
APPROVED DATE LEGAL
72-013 (Rev. 3178)
:-Ca
MUNICIPALITY OF ANCHORAGE-� 0
Departmen'�f Health and Environment. -Protection
825 L Street, Anchorage, AK. 99501
` 264-4720
* * * HAN WRITTEN PERMIT
Permit #Q3o(raa WELL ON-SITE SEWER PERMIT
Applicant:�i3.�/✓^�r//����W Mailing Address: 4,70/ % eu,,r A tea%
Location: �6— ¢' ���dGc/J Phone Number:
Legal Description: Lot Size: .s3�a --
Type of Soil Absorption System
Is:
Trench: Drainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: _� Soil Rating(sq.ft/br) //ki
The Required Size of the Soil Absorptions System Is:
DEPTH LENGTH _ .GRAVEL DEPTHS WIDTH
The length dimension is the length(in 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(in 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(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE _ �a� GALLONS
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED
Backfilling of any system without final inspection and approval by this departmer
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 fee
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 this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 3 3
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I pqderstand that the on-site sewer system may require enlar ement if
e residens o ed to include more tha bedroo c
Signe3: / Issued by:
Applicant
Date: L__.....__
SWP/024(1/81)
n SOILS LOG
• \ MUNICIPALITY OF ANCHORAGE 11 PERCOLATION
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST
825 L. Street, Anchorage, Alaska 99501 2644720
T1(�
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: 1`A' I`^)n DATE PERFORMED: &I
LEGAL DESCR
1 OL
2-
3-
4-
34 4' GP
ek
IOU a bedroon
/7
;
8
';.
h'_ gravel wib�ulder5
'
101 4.
IL -7 I
WAS GROUND
ENCOUNTERED? WATER No
12 e' "' , 1 V
12 Grl V� Ywel IF YES, AT WHAT . .
14-
15-
16-
17
4151617
18
19-
J" �
SITE PLAN
Reading
Data
Gross
Time
Net
Time
Depth to
Water
Net
Drop
20
PERCOLATION RATE
TEST RUN BETWEEN FT AND
COMM
(minutes/inch)
FT
(!o6b/ n o » w -2u
PERFORMED BY: Reid _CERTIFIED BY: DATE:
Moi 5TSs3-DZ�I
72008 (6/79)
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� MANS
MUNICIPALITY OF ANCHORAGE
• , ire
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section - Fax: 907-343-7997
Certificate of On-Site Systems Approval
Parcel I.D. 015-063-28 Expiration Date: 7- 2-62-1
1. GENERAL INFORMATION
Complete legal description Rockhill, Block 4, Lot 5
Location (site address) 9825 Lone Tree Drive
Current property owner(s) Basilic Sc Rosa Castillo Day phone
Mailing address same
Real estate agent Day phone
2. TYPE OF DWELLING:
Li Single Family (w/wo ADU)
LI Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Private Well 0 Private Septic El
Water Storage ❑ Holding Tank ❑
Community Well ❑ Community ❑
Public Water System [ Public Sewer ❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ .550 Waiver Fee $
Date of Payment glia/19 Date of Payment
Receipt Number OVALI4 Receipt Number
COSA# 03C1g11/7 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 Crewdson Engineering, LLC Phone 907-280-9493
Address PO Box 671389, Chugiak, AK 99567
Engineer's Printed Name James Crewdson Date 4/18/2019
A I-L.,.;. .LW' °1
OF ALq\1
i•t'' ..:. `r'F11)
..•• _ fr y
6. DSD SIGNATURE �i' tw, .„... ' ,, *,
System#1 Approved for 7 bedrooms • •!•• 1••' A!'
/F• Ja -- A.Crewdson
System#2 Approved for bedrooms '1 C11527
Disapproved 4• eb ••» aP• o
Conditional approval for bedrooms, with the following stip liNio'.$�"
• `oltll(((((((��
``\`\�t`\c fr 11 . o tie.
SON- o
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By: V'""Geoi.,____-(7 Original Certificate Date: q— ZGo—(
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other •
COSA Checklist blue sheet
COSA Checklist
Legal Description: Rockhill, Block 4, Lot 5 Parcel ID: 015-063-28
If more than 1 septic system on lot: COSA Checklist# of Structure served by this system
A. WELL DATA
IN Well log is filed with Onsite(or attached) Well production at time of test 3+ gpm
Date drilled 7/29183 Water storage tank volume none gallons
Total depth 56 ft Well disinfected for coliform test? ❑ Yes 0 No
Cased to 56 ft ® Coliform bacteria is Negative
❑U Sanitary seal is functioning correctly Nitrate ( `19 mg/L El Nitrate less than MRL (ND)
El Wires are properly protected Arsenic ug/L ® Arsenic less than MRL(ND)
Casing height(above ground) 18+ in. Collected by Crewdson Engineering
Date of flow test for COSA 41
181
2019 Date of Sample 4116!2019
Static water level at beginning of test 33 ft.
Comments
B. TANK DATA C. LIFT STATION
Age of tank(s) 0 years ❑ Required maintenance completed
Tank type/material s°°'""r Age of lift station years
❑ Standpipes/foundation cleanout per record drawing Lift station material
Date of pumping New tank, not required Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) "11983 Adequacy test date 4/168019
®ALL standpipes present per record drawing Results Q Pass For 4 bedrooms
Total measured depth from grade 11.5 ft(max) Fluid depth prior to test 36 in
Measured depth to pipe invert from grade 7.0 ft(min) Water added 600+ gal
El N/A—pressurized field New depth 44 in
Monitor tubes go to bottom of drainfield. If not, state Elapsed time 1200 min
depth into effective
® Code-required soil cover over field Final fluid depth 36 in
El System presoaked Absorption rate 600+ gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) No
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies:
COSA Checklist yellow sheet
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' Community Sewer Manhole/Cleanout> 100'
[Yes if No ft [Yes if No ft
Neighboring Tank > 100' [Yes if No ft Private Sewer/Septic Line> 25' [Yes if No ft
Absorption Field on Lot 100' Q✓ Yes if No ft Holding Tank > 100' [Yes if No ft
Neighboring Absorption Fields> 100' Animal Containment> 50' []J Yes if No ft
0 Yes if No ft
Manure/Animal Excreta Storage> 100'
Community Sewer Main > 75' [Yes if No ft EYes if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations> 10' []Yes if No 9.0*ft Surface Water> 100' Q Yes if No ft
Property Line> 5' ['Yes if No ft Driveway/Parking > 0' [Yes if No, comment
Absorption Field > 5' Q Yes if No ft Wells on Adjacent Lots:
Water Main > 10' [Yes if No ft Private Wells> 100' [Yes if No ft
Water Service Line > 10' [Yes if No ft Community Wells>200' [Yes if No ft
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' Q Yes if No ft Driveway/Parking > 0' El Yes if No, comment
Property Line> 10' [Yes if No ft Wells on Adjacent Lots:
Water Main > 10' [Yes if No ft Private Wells > 100' [Yes if No ft
Water Service Line > 10' [Yes if No ft Community Wells>200' [Yes if No ft
Surface Water> 100' El Yes if No ft
F. ENGINEER'S COMMENTS
*Septic tank is not within the foundation soil bearing prism, see record drawing.
-/OF A�q\l
G. ENGINEER'S CERTIFICATION itP� 1 _� ��'•�ftr'
/' •�' I . /\ a
/certify that 1 have determined through field inspections and review / '�it /
of Municipal records that the above systems are in conformance with •.*Ail
MOA COSA guidelines in effect on this date. / . 7��' -J .'g wdson i /
-ip • .
COSA Checklist yellow sheet " ' 4.L c t t 9
��LeRXA
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 995196650
www.muni.org/onsfte
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. 015-063-26
COSA# U0o6l3
Expiration Date: 1— a q — 7
1. GENERAL INFORMATION
Complete legal description Lot 5, Block 4, Rock Hill Subdivision
Location (site address) 9825 Lone Tree Drive Anchorage, AK 99516
Current Property owner(s) Robert K. Renke
Day phone 2400024
Mailing address 530 West 72nd Avenue
Anchorage, AK 99518
Lending agency
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: Four (4)
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well IZI
Individual On-site 0
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 On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of Onsite Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my 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 -she 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 Anderson Engineering Phone 522-7773
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
6. DSD SIGNATURE
Approved for _ bedrooms.
Disapproved.
Date 10/1=006
l 49th ,
KIMA , E_...$p(._„
Ar70ER
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: Ax Original Certificate Date:
(R«. 1IM5(
Municipality of Anchorage •.,
• Development Services Department
Building Safety Division
On -Site Water d Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.mLtni.org/ormke
(907) 3437904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Lot 5 Block 4, Rode Hill Subdivision Parcel ID: 015-063-28
A. WELL DATA
Well type Etge If A, B, or C provide PWSID # _ Well Log (YIN) Y
Date completed 7/29/1983 Sanitary seal (Y/N) Y Wires party P (Y/N) Y
Total depth 56 ft. Cased to 58 ft. Casing height (above ground) 24 in.
FROM WELL LOG AT INSPECTION
Date of test 7/29/1983 10/11/2008
Static water level 32.5 ft. 33.5 ft.
Well production 20 g.p.m. 6.88 9 -P.M.
WATER SAMPLE RESULTS:
Coitform 0 colonies/100 mL Nitrate •721 m9/L Other bacteria 0 colonkWI00 mL
Arsenic: NO mg/I Date of sample: 9/29/2008 Collected by: F. LeDoux
B. SEPTICIHOLDING TANK DATA
Tank Type/tlilaterial SeptidSteei Date installed 7/27/1983
Tank size 1,250 gal. Number of Compartments 2 Cleanouls (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alar (YM) N
Date of pumping 10118/2008 pumper Old MacDonald's Pumping
C. ABSORPTION FIELD DATA
Date installed 7r27/1983 Soil rating (g.p.d./ft= or ft=Ibdr)115 SFBDRM System type Deep Trench
Length 55 ft. Width 4.67 ft. Gravel below pipe 4.5 ft.
Total depth 11.5 fL Eft. absorption area 495 le Monitoring tube Y Depression over field N
Date of adequacy test 10/1 V2006 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 28 In. Water added954.5 gai. New depth 34.5 in.
Elapsed Tare: 720 min. Final fluid depth 28 in. Absorption rate >= 600 9-p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed Size in gafions Manhole/Aoeess (YM) .
'Pump on' level at _ in. 'Pump ofr level at _ in. High water alarm level at in.
Datum Cycles tested Meets alarm 6 circuit regrmaments9
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankllift station on lot >100' On adjacent lots >1W
Absorption field on lot >100'
Public sewer main WA
Sewer /septic service line >25
On adjacent Iota >100'
Public sewer manhole/cleanout WA
Holding tank
Animal containment areas None Manure/animal excrete storage areas None
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5 Property One >5 Absorption field >T
Water main WA Water service line >10, Surface water >100,
Wells on adjacent bts >100'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line >IV Building foundation >IV Water main WA
Water Service One >IV Surface water >I W Driveway, Pam storage >2S
Curtain drain None Noted Wells on adjacent bts >10T
F. COMMENTS:
G. ENGINEER'S CERTIFICATION
I ceRlly that I have determined through field inspections and
review Of Muntslpal records that the above systems are in
cWfOnnance wltb MOA COSA guidelines in effect on Mis date.
Engineer's Printed Name Michael E. Anderson, P.E.
Date 10/18/2008
COSA Fee S (t� Waiver Fee $
Date of Payment civ (g)(J (o Date of Payment
Receipt Number a f CJ J� Receipt Number
(Rev. 11/05)
SGS ReEN
1065894001
Client Name
Anderson Engineering
Project Name/N
Lot 5 Block 4 Rock dill
Client Sample ID
Lot 5 Block 4 Rock Ilill
8lairix
Drinking Nater
Sample Remarks:
All Dates/ hints are Alaska Standard Time
Printed Datelrime
10/062006 13:35
Collected Datelrime
09292006 14:58
Received Daleflime
09292006 15:20
Technical Director
Stephen C. Ede
Allowable Prep Anaysis
Parameter Results POL Units Method Container ID Limits Date Date ]nit
Metals by SCP/Ms
Arsenic ND 5.00 ug/L EP200.8
Haters Department
Nitmtc-N 0.721 0.100 mg/L EPA 353.2
Microbiology Laboratory
Total Coliform TNTC OB. No Coli coVl00mL SM20 92226
C (<10) 10/02/06 10/04/06 Mil
B (<10) 09/29/06 ALR
A (<I) 0929/06 DPT
OCT -17-2006 13:26 PRUDENTIAL VISTA REAL EST 907 562 5485 P.02
n
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AS-BUfLTSURM Q
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LtDEHD •p
1 HEAMY CERTYY THAT I HAVE ►fREOMaD A
WATOAGfrS ■1S+fCTON 0E THE FOLLOWING ■ ■[w[A vErT N
06SCAI8E0 PROPERTY.
COT E. BLOCK.. KOCKHILL SUS.
ANCHORAGE RECDADNG DISTNCT. ALAS" AND THAT
'^1171"'^'"•"""'••`^�", --- -- •"•�..._..._..._.._..__ __
STRUCTURES AND EI„ATTEO LOT LNES OR WEMENTS AND IS NOT TO BE USEDEOR pSITIONNG AO
THE VISIBLE PAPAOVEMENTS SITUATED THfAEON ARE
WITMN THEN MTY UNSO AND THAT NO VIS7LE
EKISTNG
STRUCTURES OR TENCELNES.
�OACHNENTS EXIST OTHEN THAN NOTED.
r,ASEMEHTS OE RECORD, OMER THAN THOSE SHOWN ON THE RECORDED PLAT, ARS NOT SHOWN HEREON.
DATED AT ANCHORAGE, ALASKA THIS
NOTE: ANY FENCEUNES SHOWN ARE LOCATED AEPROXIMATSLY AND ARS NOT TO St USED TO DETSRMBIi►110ESRTV
DAT OP AME 7001
HO LT LAND SV AV6Y� INL-G♦A. PWn 78
OR LOCATE STRUCNREA
ANY EAVNO SHOWN MAY BE ARKOXWATE DUE TO SHOW CONOMONS.
TfL. 346.6613
TOTAL P.02
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) on properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to home owners. 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 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.
(R..II"
5.": STATEMENT OF INSPECTION BYIENGINEER
As certified by my seal affixed heretoTand "as of tfie valld1.ation date shown below I venfy,that my investigation
based on procedures outlined.in the Health AuthdAY Approval guidelines for this Heaith'Authority Approval
application shows that the on-site water supppose
ly;andlor,wastewater.disl•system'is safe;-functional and
adequate for the number of btdiooms and type of;structuea ir�dJt ed herein. I further vedfy.that based on the
ma
infortion obtained from the Mumtiipa14 of Anglorage files and from'my'investgation and inspection, the
on-site watersupply'aril/or;,wastewater;disposalsystem is;in'compliance with-all'applicabie._Municipal and
State codes, ordinances, and regulations in effeet'at the time.of installation:
Name of Firm Pannone Ena.-Svc. Phone: 272218
Address _P.O. Box"j 02954.`Anch:'AK 99510
Engineer's Punted'Name Steven Rc Pannone.':P E. Date "6 t•i ec 1 '
Engineers Comments In cooductmg an adequacy test, l attampt to provide a Pugh oonaWenhous ��������� j
cngmcenng analysis of the syslm� m acconlai�ce H�Ut MOA DSD GwdeLces & RegiUnhoos The ��� -DC
reporter! results descnbe the pc+"fwrrwu�. of the syslean t the ootidiuoos eoi"gtpred at Uii time of , ,����P�� ..j
t'9
. nfiabkfealures 7heoperahomllifeofall t.GJ �j.
'-- acll atnd s< hcsyslcros d.-perd on the local soil condition gourd water levelsihet rtmytluc(uale - {s
4 TH
separet�on distanux measured to readily �drn
01
during U�c ya,r; and the water usage of the family bang srncd by systmti 17usc wnditions arc 9
• .outside U�c control of Um evaluator oCthis"system All systems cytntually fail ami se4efactory test 0 •
results do not guaranlce future j�crCormancc of the system, nor do ttieyguarantai that there me no 1 ' - .,i
h�ddcn d�f�tits or encroachments: PTS can therefore not prondc any waira»ty for fulme perfominnce Steven R Ponnor a
nor give any cshmate of how long the system will contmpe to meet the ali ' I icgwremrnts of No. GE 8149 1
ADHC or MOA DSD The content of this report is for the soli benefit of the owner listed
reliance upon or use oC this report by any dhet person or'pa�rtY is rkfthhc;iz d nor wdl rt cq�nfer eery • •••:., ,.... •--,n`'���
iejal right ehatsocver. ,, r ft
6. DSD SIGNATURE:
✓'. Approved for. bedrooms
„ .. Disapproved
Conditional approval for bedrooms; with the, following stipulations`.
`�tttttY OF�ir���i'.
Additional Comments J ON-SITE
Z-- TERAN
B m,
i,WASTEWATERROGRAM
.
R
Attachments: / 1111)1
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineers Report
Well Flow Advisory . Other
By: la'2L Original Certificate Date:_ iter
asi
Expiration Date: 17—/3-01 Reissue Date:
ma. ,,M1
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 190050 Anchorage, AK 99519-W50
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Well type Private
Date completed 7/2911983
Total depth _P—ft
If A, B. or C provide PWSID
Sanitary seal Y
Cased to JLG_ft
FROM WELL LOG
Date of test 7/29/1983
Static water level 32.8 ft
Well production 20 9 -p.m
WATER SAMPLE RESULTS:
Coliform�_colonies/100 ml Nitrate _�Z 'W
Well Log Y
Wires properly protected Y
Casing height (above ground) 24+ in.
AT INSPECTION
817/2001
33 ft
4.0 g.p.m
Other bacteria -t7— colonies/100 ml
Date of sample: 8!712001 Collected by: Laura Pannone
B. SEPTICIHOLDING TANK DATA
Tank Type/Material Greer Steel
Dale Installed 7/27/1883 Tank size 1260 gal Number of Compartments
Cleanouts Y Foundation deanout Y Depression over tank NQ High water alarm N/A
Date of pumping 6/7/2001 Pumper A+ Home Services
E
C. ABSORPTION FIELD DATA
Date installed 7/2711683 Soil rating (g.p.d./ft? or ft2lbdnn)115 ft salbd System type Deeo Trench
Length 55ft I OR Width X11• Gravel below pipe 4.6 _ ft
Total depth 1r 114 Effective absorption area 9' ft= Monitoring tube Y Depression over field No
Date of adequacy test�/ 001 Results (Pass/Faiq Pass For 4 bedrooms
Fluid depth in absorption field before test Qty in Water added§M gal. New depth2a In.
Elapsed Time: 0 min Final fluid depth Dry In Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) No If yes, give date
(Rev. 1IM)
D. UFT STATION
Date installed _
'Pump on' level at
Datum
Size in gallons
In'Pump off" level at
E. SEPARATION DISTANCES
Cycles tested
ManhoWAccess
_ in High water alarm level at _ in
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAifi station on lot 1001+
Absorption field on lot 106'+
Meets alarm & circuit requirements?
On adjacent lots 160'+
On adjacent lots 1601+
Public sewer main NIA Public sewer manhole/cleanout WA
Sewer /septic service line 4144- tdb �C Holding tank -lg -)!T'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10' Property line 70'+ Absorption field 7'
Water main ti0'+ Water service line 60'+ Surface water 'I 0W+
Drainage 100'+ Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 76'+ Building foundation 26'+ Water main _60'+
Water Service line 25'+ Surface water 100'+ Driveway. parkingtvehicle storage _30+
Curtain drain 60'+ Wells on adjacent lots 160'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I halve determbied through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines In effect on this date.
Engineer's Printed Name Steven R. Pannone, P.E.
Date o / '}/o (
HAA Fee
Date of Payment
Receipt NumberCi W Z
(Rev. I IM)
Waiver Fee $
Date of Payment
Receipt Number
�= 49 T"
Nc. CE 8149
�ESSt�i'
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH b 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
Parcell.D.N �ts-[�ln�i-aR HAA# V�pm I`ll
GENERAL INFORMATION &k
Complete legal description T S �� 44 Rout
Location (site address or directions) `%BZS 4o,4c- r- IN R lc -
Property owner $C -7j -4- L_ Day phone ?`«'- Z33(o
Mailing address
Lending agency
Day phone
Mailing address
Agent F Rr Un) E bwPar2 1CS Day phone
Address -N7 S • r It S-r&A=Wl-
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4 V
3. TYPE OF WATER SUPPLY:
Individual well X
Community well
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 x
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.
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'9
1:133NION3 AS N01103dSNl d0 1N3W31V1S 'S
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LOr 5 g7—��
lGR �ru Parcel I.D.
A. WELL DATA
Well type PIZIJB If A. B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Y,Date completed 7/Z9/6 s' Driller !�XJZ-521 9fl,1aS -
Total depth S'10 Cased to 57C Casing height 2
Y Sanitary seal (Y/N) ( Wires properly protected (Y/N) r
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
'7/7,173
ZO 9.p -m.
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
/ 3 t7J,UNIGPAUTY OF ANCHORAGE
&WIRONMENTAL SERVICES DIVISION
7 S'-1:"! 0 2 1993
tRECEIVED
Septic/' oldingtank on lot IDO r+ ; On adjacent lots 7 /5'0 ,
r
Absorption field on lot ��S r -f- ; On adjacent lots y/�
Public sewer main Af d Public sewer manhole/cleanout ^) /A
Sewer service line AIM Petroleum tank
WATER SAMPLE RESULTS:
1
Coliform
O Nitrate •
` 7
Other bacteria o
Date of sample:
fir/ /S 3 S_Z7 113
Collected by:
/),44M LA
B. SEPTIC/HOLDING TANK DATA
Date installed 71Z7Jh 3 Tank size 1Z TO Compartments Z
Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) N
High water alarm (Y/N) "Ai /�t Alarm tested (Y/N) N/A
Date of pumping
Pumper /(�pTp l�p"%>=�
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: /
i r
Well(s)onlot /400 -!- Onadjacentlots >/So Foundation /0-
r
To property line %O f' Absorptionfield % Water main/service line
i
Surface water/drainage
NO
72026 (Rev. 7191) From CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N)
1
Vent (Y/N) "Pump on" level at "Pump off' level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Cycles tested
Surface water —
D. ABSORPTION FIELD DATA //�� r
Date installed 7 %/27/b3 Soil rating /�5�7-Z n System type _bty —/ RteyJCN
11
Len $S ,
' Widtti /� Gravel thickness r� Total depth- 7Zr•
-Length"
Total absorption area PY' Z Cleanouts present (Y/N) _ Y
Depression over field (Y/N) Date of adequacy test. 93
Results(pass/fail)' PASS for V/L
bedrooms
Peroxide treatment (past 12 months) (Y/N) If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /0-S On adjacent lots 1J50 Property line 7 %$
To building foundation . Z 5 r To existing or abandoned system on lot
On adjacent lots>/dn r Cutbank N/
/6 Watermain/service line >SO
Surface water >/OD Driveway, parking/vehicle storage area > q0
_
Curtain drain NZA '
E. ENGINEER'S CERTIFICATION
/certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this Inspection.
0. L e
Signature % � p - au_ h:'• Q •'• )i
rt..•
Engineer's Name-MrGNat [. 15 A"O enISO.i i ••y'••'•°••� ••••• °»r..„. ' „�
�? I �Se :.. .• �e
Date - 6�Z%93 iO 1110 1. M;chaei E. Anderson
AlC: /�V.S4 �S g�7J %/A-Cw % - 0�)V"O. 4391.E �\
S w ex -
HAA Fee $ Waiver Fee: $ '
Date of Payment 6 -,-2 - 93 Date of Payment
Receipt Number -' 1-1 q Z Receipt Number
72-M(R-3N1)6"k MOA 21
ADEQUACY TEST REPORT
LOCATION
INSPECTOR: /
,� PROJECT •,
TYPE OF DWELLING:� <•
SEPTIC TANK SIZE: 1,.w
NO. OF BEDROOMS:
PEAK LOAD CALCULATION: d if
DATE �14jt
TYPE OF S.A.S. iG
Time
Flow
Rau
(gpel
Vol.
(gall
Como I.
Vol.
(gall
S.T.
S.T.
Liqvid
Level
S.A.S.
MTel
S.A.S.
MTe2
S.A.S.
M7e3
Coeeu le
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6
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TEST RESULTS �'�j'Fl(�/_
REVIEWED BY. -
DATE
WELL FLOW TEST
Loco Iion I LQf 5r C>4 fKyLF�Ilrli %[IGp
Well Dep th__5i(ft.I Costing Above Ground Y lfI.I
Stotic Water Level —AJC! (ft.)
t11wa1Ylwd from top of waltiw9l
ate
--a—
Inspector
Project e
y
Time
Water
Level
(ft.)
Volume
(gal')
Cum.
Volume
Igal.)
Meter
Reading
Sol/sec
Flow
1 m)
9P
Comments
7
5
let
—
1 qn
n
.y
300.E
n
p
----tt
�r
_---
AVERAGE FLOW RATE J 5 (qpm)
REVIEi1'ED BY:
Underground conditions ore subject to change over the course of time
DAILY DRILLING LOG
SYREN BROS. DRILLING. INC
Ie Street Anchonee. A13%ka 99503 274-6417
Ibn Tarringtan
OFLAND .............. _.... „........... ,.................................................. DEPTH Or WELL ........................................ ............. „_.......... _... _...........
5 ................. :jROl TaItr;„SRA IORl-R ............................
........... .. ....................
ITE ........9 R3
. 7....2....„.....
STATIC LEVEL OF WATER FT_ ......
:i"w: G::.. L.g.l» _._.._..__„.........
DRAW DOWN FT.
7/29/R3 GALS. PER NR , 20 I»)1/min.
7/29/83 G-' AM GRD B Steel w/sha• .5'(- Cr c
NDED........................ _................................................................ KIVnorCASING ......................................................................................
FORMATION:
_Q_... .......... FT. TO ........ i,R.............FT...f'.1 �tXL1� t�x:l...(harJpsn)
„„..„....„..FT. TO
FROM
........................ FT. TO..„...._„„...._ .FT....._..„„_.._----__....
FT. TO .....
�f'.............gravel
FROM
........ .......... „.... FT. TO....____....__..FT------------------
iG....FT.TO....53.....„......FT.»ur.....Silty
gravel
.._...
FROM
.... __................ FT.
i3
5G
sand/gravel/eater
...........
FT.TO................
..... .FT. .................... _.........
FROM......„„__..__»_FT.TO
............. „..... ...FT.
.......... ............. FT ........... _......... ..... _....
... _........ _.... FT. TO .......... ... _....... FT .... ...... _..... .... ...........
....... _.......... FT. TO..„.......„._.. _.FT._...._.._........„__^__..
...................FT. TO......».._.._...._.FT.................................
._-„••---....FT. TO_........_...........FT._......__..............„.....
...........„.....FT. TO .............. _....... FT...................................
..._ ..............FT. TO ............ „......... FT .............................. ...
FROM .............. _._..... FT.TO...._»..
FROM ........ ............. FT.
TO..___„_..___„FT.__
FROM....................... FT. TO.._»__...._„__FT._„____....__„_____-
FROM..„„.._ TO..„.....
FROM.................. ... FT. TO.._ ............... ...
FROM ................ »„.._FT. TO ......... „_...... ....FT
FROM........ __............ FT. TO ..................... FT.„.....-•-„_
...................FT. TO...._..„„..»_.....FT...... ................ ..... ..... FROM .... _.................. FT. TO._ ................. FT. ........ _..._ _._ .._....
YFOR.MATION:
1)RILLER'SNAME.....„Stephen D. Syron
Parcel I.D. k
MUNICIPALITY OF ANCHORAGE
• Department of Health & 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
HAA# /7�gr`l0/V3�
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
96 Zr t -one Tine Drive -
(b) Property owner gonad 74MI17/00 Telephone: (home) Business 27/-S7o/
Mailing Address 96?,S 4one Ir"t Dr, And+onya 6k 996-1
(c) Lending Institution N 4 Telephone
Mailing Address
(d) Real Estate Company and Agent6 ax
s
v
Address 6YOo tla�f se f/ Re<T h�c�o t� of cc 99so7
Telephone 3YY 10 -co/
(e) Mail the HAA to the following address: (or check here ®. If hold for pick up.)
List contact person and day phone number below:
Tao( t-(00re 3 HS' - r 33'S'
2. TYPE OF RESIDENCE
Single -Family Ii Number ofbedrooms —
3. WATER SUPPLY
Individual Well t9 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 Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (A". rrem 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 the validation date shown 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.
Name of Firm Flea h 6le Tech"Iea -Ce--"Z Telephone -7 lr-Iss`
Address. 1 YE30 Eclm Ijnchor'w A/r 99S/l<
Date- n�v 3 /969
6. DHHS APPROVAL
Approved for=bedrooms by
o,e,.;.......-qY -9
v :� CJTFI �:�� •tom*1
v ... ...............
�TeEOCO;: F. A..... 1
�,•,' C'c•35 9
Q�_rY.QttI�iW A^!
Engineer's Seal
Date l >
Approved Disapproved Conditional /
Terms of Conditional Approval
The Municipalityof Anchorage Departmentof Health and Human Services (DHHS) issues Health Authority Approval
cerificated based onlyupon 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 federaland state requirements. Employees of DHHS do not conduct inspections
oranalyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors oromissions
in the professional engineer's work.
72-025 (Ray. 7/88( Beck Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
OF P� Health Authority Approval (HAA)
P��6SE0.v\ CHECKLIST- FEBRUARY 1984 '
NMcxZ 3434744
Legal Description:
` V
Aor.(r /Fr 11 S/o
A. WELL DAIS����`
Well Classification Private If A, B. C, D.E.C. Approved (Y/N) N A.
Well Log Present (Y/N) r Date Completed 7/ P-9 / R? Yield2��n� ptc &&
Total Depth�V'_Cased to sK Depth of Grouting N'A'
Static Water Level 3y' Pump Set At ::z 5 +"
Casing Height Above Ground 2'Y" - Sanitary Seal on Casing (Y/N) r
Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N) N
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot 1610, ; On Adjoining Lots > roc"
To Nearest Edge of Absorption Field on Lot r GS' ; On Adjoining Lots �> r00
To Nearest Public Sewer Line MA. To Nearest Public Sewer Cleanout/Manhole N, A.
To Nearest Sewer Service Line on Lot > 2 r'
Water Sample Collected by t. F. moose — ; Date y / 2.9 89
Water Sample Test Results O calms` /100024 0' 77!7/-t_ 0' -*k -0
1,Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed 7r*'z71 E3 Size,z�No. of Compartments el
Y Foundation Cleanout Y/N I'
Standpipes (Y/N) Y Air -tight Caps (Y/N) ( )
Depression over Tank (Y/N)
Date Last Pumped 3/9/A9 61k No7 A lano(
Pumping/Maintenance Contact on File (Y/N) N. A ; for N• 14 -
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 Well 140' To Building Foundation
To Property Line > r0To Disposal Field _
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course �-- loo'
Comments
72-M(Rn. 7/U)From Page 1 of 2.
a '
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 11s a'lCdr.,
Type of System Design ]R=IC4i
Date Installed
Length of Field sr'
Width of Field S6"
Depth of Field 12'
Gravel Bed Thickness y,s '
Square Feet of Absortion Area N9s-
Standpipes Present (Y/N) Y
Depression over Field (Y/N) N
Date of Last Adequacy Test s/ F / A9
Results of Last Adequacy Test 4albua k crer
M bec(roor7y
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well I ('S-'
To Property Line sro'
To Building Foundation 2 B
To Existing or Abandoned System on
Lot N -A. ; On Adjoining Lots �, To'
To Water Main/Service Line 25"
To Cutback (if present) N, A.
To Stream, Pond, Lake, or Major Drainage Course
«o'
To Driveway, Parking Area, or Vehicle Storage Area
> sb'
Comments
D. LIFTSTATION r4,A.
Date Installed 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 Pumping Cycles during Adequacy Test.
Meets MOA Electrical Codes (Y/N)
Comments
"Check Permitted Bedroom Rating Against HAA Request"
I certify that I have checked, verified, or conformed to all MOA and HAA guidelg�,ig�ffect on the date of this
inspection. -W OF A It%
Signed � � h2o..� o�P•o .-0 ...,�qS°e
Company _F1466.7ec nic«/ 5erwrr:V aco
Of * : 49TH � y*�4
Date �K /969 � ••...,,I gineer'sSeal
MOA No. 69-0,-2 II. •.�..
T
Receipt No. 4
Date of Payment 4/ OPJ
Amount: $ Z 2A
0 NEODOKE F. MOORE �• O
CE.3589 W
ev
Receipt No. eak44pa�u 100
Waiver Fee: $
Date of Payment
M -0M (Aft. 71U) Beck Page 2 of 2
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 Q
Application Date 7-1 al -ad)
1. GENERAL INFORMATION
(a) LQgal Description (include lot, bIpck, subdivis! n, section, township, range)
t41
(b) Applicant Name Telephone: Home Zq 1 - S'7O 1 Business
Applicant Address ��
(c) Applicant is (check one): Lending Institution 13; Owner/builder Lf; Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(1) Mail the HAA to the following address:
Y. \� .���JG'Y�—c�[� ICI tGL�-LIE\ i
2. TYPE OF RESIDENCE
Single -Family a ENMulti-Family ❑ Other
Number of Bedrooms
3. WATER SUPPLY
Individual Well ®/Community O 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 B/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.
72-125 (11,84)
Page 1 of 2
n
em'�,
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION -
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 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 da
Name
Addre
Date
6. DHEP APPROVAL,. l �tnn,.Ln�
Approved for auC bedrooms by ,97 � It"
f" (/ ` .NW,
Approved Disapproved Conditional V
Terms of Conditional Approval
04M
CAUTION
Seal
The Muncipalily 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
o J.
Corwin•
o. CE-5499%��
� •. ••...N�.. Air w
6. DHEP APPROVAL,. l �tnn,.Ln�
Approved for auC bedrooms by ,97 � It"
f" (/ ` .NW,
Approved Disapproved Conditional V
Terms of Conditional Approval
04M
CAUTION
Seal
The Muncipalily 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
A. WELL DATA
Well Classification
MUNICIPALITY OF ANCHORAGE (1110^
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
284-4720
Legal Description:
If A. B. C, D.E.C. Approved (Y/N)
Well Log Present (Y�/N) U -b Date Completed %Zt9 t RD Yield Apr
Total Depth Cased to 5 1 1' Depth of Grouting Al
Static Water Level Pump Set At y
't p
Casing Height Above Ground �' � Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) 7�— Depression Around Wellhead (YIN) O
Separation Distances from Well:
To Septic/Holding Tank on Lot %�, ; On Adjoining Lots +�00 r
To Nearest Edge of Absorption Fielld n Lot 10 ' ; On Adjoining Lots �n0
To Nearest Public Sewer Line ry�-- — To Nearest Public Sewer
Cleanout/Manhole A/W To Nearest Sewer Service Line on Lot
A
Water Sample Collected by
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
(ltly�r[.r1
r7�;riZSO 2
Date Installed �TZ �� Size No. of Compartments Z
Standpipes (Y kir-tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/N) NO Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) f4r; for —
Holding Tank High -Water Alarm (Y/N) ---A /16— Temporary Holding Tank Permit (Y/N) 11 VA
Separation Distances from Septic/Holding Tank:
r ro'
To Water -Supply Well X t To Building Foundation
To Property Line 7�r .r To Disposal Field
�r
To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
72-02601,64)
C. ABSORPTION FIELD DATA
Soils Rating in Absorp yyion Str to �� Q Tye of System Design
Date Installed Length of Field �S r '�
Width of Field 5�n t r * Depth of Field '1 Z II 'K
`L,r*Gravel Bed Thickness Sy It 'IC
Square Feet of Absorption Area S S L Standpipes Present (Y/N) Q
Depression over Field (Y/N) 0 Date of Last Ade/au�a�cy Test Z
Results of Last Adequacy Test V -rt r1 rn { t n ..<n
Separation Distance from Absorption Field: U U I /
To Water -Supply Well to Sf To Property Line
t
To Building Fou dation To Existing or Abandoned System on
Lot ; On Adjoining Lots
To Water Main/Service Line To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area Z,51
Comments
D. LIFT STATION t V ( /A
Date Installed 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 Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
Check Perm' ted Bedr om Rating Against HAA Request •'
Icertify thatl echec verified, or conformed to all/ MOA and HAA guidelines ineffect onthe date ofthis inspection,
Signed to Z I . aM11 /%'eq
1
wrnpdny - cMa*No.
Receipt No. 3-) 9 3 S � O: J '.
Date of Payment 3-aI?3-43to
Amount: $ US -CC) •• �.' ' Engineer's Seal
rri E rn.., i
• N.Ci•___
Page 2 of 2 ��`r�9 ,
72-026111,84) ,, `�\0FES W)
