Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
HomeMy WebLinkAboutGLACIER VIEW HEIGHTS BLK D LT 15Glacier View
Heights
Block D
Lot 15
#050-501-02
Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP191494 PID Number: 050-501-02
Dwelling: ® Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ® Upgrade
Name:
JOSEPH CASEY
ABSORPTION FIELD - EXISTING
❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
23105 MYRTLE DRIVE, EAGLE RIVER, AK
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Fill added above original grade
Ft.
Gravel length
Ft.
GLACIER VIEW HEIGHTS D 15
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ft'
--
-- Ft.
Well
100'+
NA
100'+
NA
NA
TANK ® Septic ® S.T.E.P. ❑ Holding ❑ Other
Manufacturer
GREER
Capacity
1250 Gal.
Surface Water
100'+
NA
100'+
NA
Material
HDPE
Number of compartments
2
Lot Line
5'+
NA
5'+
NA
NA
Foundation
10'+
NA
10'+
NA
LIFT STATION
Manufacturer
ORENCO / GREER
Capacity
1250 Gal.
Curtain Drain
NA
NA
NA
NA
Remarks Existing tanks decommissioned
Pump on level at
108 in.
FROM TOP OF MH
Pump off level at
119 in.
High water alarm at
106 in.
per code, new STEP connected to existing
fields w/ valves.
Pump make and model
Franklin 2445040117 — 1/2HP
Electrical Inspections performed by
PLC
Tank to
PIPE MATERIAL House to tank 3034 3034
Installer DENALI EXCAVATING
d ainf eld
Drainfield CO/MT 3034.
Inspector FWCS / MNA
BENCH MARK (Assumed elevation) 100 ft
Inspection 1" 11/8/19 11/11/19
Location and description
2nd
3`d 4`"
DOOR SILL
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Conditional Approval: Date
®*
TH*
MICHAEL N. ANDERSON:
No. CE 9469
Approved 8/15/0
r 11/14/19..- C3 /
Date
'®%Pzssiol� "W
mspecuon mepon_y- i- i Z.00c
GLACIER VIEW HEIGHTS BLOCK D, LOT 15 PID: 050-501-02
ii PERMIT: OSP191494
„W
6\
S
SCALE: 1" = 30 208S�n'•
A -C=12.9'
B -C=48.9'
A -D=14.6'
B -D=51.6'
A -E=17.3'
B -E=55.5'
A -F=19.9'
B -F=58.4'
A -G=22.6'
B -G=60.4'
SEPTIC SECTION
SCALE NTS
SUPPORT SERVICES: _
PREPARED FOR: OF AZ
`4 \
JOSEPH & THARETH CASEY
GLACIER VIEW HEIGHTS BLOCK D, LOT 15&—I
/ �� 49 TH
*
23105 MYRTLE DR., EAGLE RIVER, AK 99577/�� 0
Michael N. Anderson P.E.
DATE: 11/14/2019 MICIIAEL C ANDERSON /
No. CE 9469
4661 Natrone Ave. e.0� AO
Anchorage, Alaska 99516
DRAWN: FWCS Sb 11/14/19 e tph'OFESSIC��'ti i
(907)727 8864/FAX: (907)345 1391 SCALE: 1" = 30' X'`__�
Electrical installation of Lift Station power and Control
PuUg BnG And EWkbM LLC
ISI DP Pr
Er r Rkw �- OW 77
�7P 22.5211
PFa�rrrreff;g`u mti
FrcWt MISS Vrnlo (Du arkaI hsahLbn d tA iutw I
Omirkx1an
TMpamhrira ramal+alma
inMUlYllvn vl 56.01111TYZI rnw L
inE!:mlk d �ovdn4 Ln Mh lalnol me
God! r4941r��G
t+N 15 241$ Moth I IYra Um ftr vm a a,++
i'dOM Ye M ft *W& Q.
Sent from my Phone
TM
S62`O8'4U L I JU.
MYRTLE DRIVE _
ANCHORAGE R CORDING DISTRICT ,ALASKA
AS -BUILT OF:
GLACIER SUBDIVISION
LOT 1.5 BLOCK 3 '
SURVEY CERTIFICATE: 1, John L. Schuller, Have conducted a
physical survey of this property as shown on this drawing and that the
improvements situated hereon are within the property lines and no
enchroachments exist other than noted, Under no circumstance should
any information on this drawing be used for construction offences,
structures, improvements, or for establishing boundary lines.
EXCLUSION NOTES: It is the owners responsibility to determine
the existence of any easements, covenants, or restrictions which
do not appear on the recorded subdivision plat.
WORK ORDER NUMBER: DATE sc"' E -MAIC
N0V 13, 2Q19 1"=3Q'
19-110 BY CHECKED BY CRA NUMBER: I BOOK/PA
JLS SV0159 1 190168
Q = FND 5/8" REBAR
Aw
x.....49 .CTi......
.JOHN L. SCHULLER.: �
LS -1040$
10J,
fession
LAND Zr �
44_4 �y 1
ma
1831 Talkeetna Street
Anchorage, Alaska 99508
(907) 227-1455 office
(907) 274-4992 fax
11/1/19
MUNICIPALITY OF ANCHORAGE
v
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. 050-501-02
Property owner(s) JOSEPH & THARETH CASEY Day phone 8034060045
Mailina address 23105 MYRTLE DRIVE, EAGLE RIVER, AK 99577
Site address 23105 MYRTLE DRIVE, EAGLE RIVER, AK 99577
Legal description (Sub'd., Block & Lot) GLACIER VW. HTS. BLOCK D, LOT 15
Legal description (Township, Range & Section)
Lot Size 23,139 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑ Initial El
Single Family (SF) Q
(w/wo ADU)
Septic Tank
Upgrade
Duplex (D) ❑
Holding Tank
❑ Renewal ❑
Multiple Dwellings ❑
Privy
❑
(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.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 01�S
Date of Payment: s 11/11/q
Receipt Number: ogig ! Lam%I
Permit No. 05p 1 q ! Lig i -i
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc
Michael N. Anderson, P.E.
Civil/Structural Engineering and Construction
4661 Natrona Ave. Anchorage, Alaska 99516
Phone 345 -3377 / Fax 345 -1391
Support Services
Brent M. Western
907-440-4601
October 30, 2019
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: GLACIER VIEW HEIGHTS BLOCK D, LOT 15
To whom it may concern:
The owner has requested we proceed forward to obtain a septic permit to upgrade the
aged septic tank and lift station on the subject lot. The proposed upgrade will serve the
existing 3-bedroom house.
The lot and area are served by private water. The proposed design will not impact any of
the neighboring properties due to the lot layout. Please contact Brent M. Western or me if
you have any questions.
Sincerely,
Michael N. Anderson, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191494, Rebecca Carroll, 11/01/19
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191494, Rebecca Carroll, 11/01/19
www.sullivanwaterwells.com
Pump Installation Log
Well Drilling Permit Number: SW Date of Issue
Parcel Identification Number:
Legal Description Property Owner Name & Address
Glacier View Heights Block D Lot 15 Joe Casey
Pump Installation Date:
2-4-19
Pump Intake Depth Below Top of Well Casing:
150 feet
Pump manufacturer’s Name:
F&W
Pump Model:
4F07P07301S
Pump Size:
3/4 hp
Pitless Adapter Burial Depth:
10 feet
Pitless Adapter Installer:
Unknown
Disinfected Upon Completion?
yes no
Method of Disinfection:
Chlorine 50 PPM
Comments:
Pitless Manufacturer: Unknown
Pump Installers Name:
Sullivan Water Wells
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Municipality of Anchorage Page Of�
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
%5 Q i l 2Cn_gj 66Oo5`DI,nZ.
Permit Number: PID Number:
Na a:
s Aad/� ✓ �
Wastewater System: ❑ New gvpgrade
Aut o. Bo l4j d e6AjikI q I I
ABSORPTION FIELD
Phone 10 I
No. of Bad rooms:
eep Trench O Shattow Trench ❑Bed ❑Mound ❑Other
LEGAL DESCRIPTION
Soil Rating:
O. &
Total Depth from original grade:
t ipr<
GPD/Sq FI
Lot: ,"J 8105 � Subdivision,
Depth to pipe bottom from ongmal g; e:
Gravel depth beneath pipe
I d /
14 y
Ft.
FI.
Township:
Range:
Section:
Filla ded above original grade:
Gravel length: /
. �f-.. --:50 FI
Ft.
WELL: ❑New ❑Upgrade
GravelOepne "7:>
/
Numberollines:
I
DOtance /en laws:
�7
Ft
F-1 Ft.
Cl e f cation (Private. A.B.C):
Total Depth:
Cased To:
Total absorption area //
Pipe material: 10-4r,2r-
f
Ft.
Ft.
100 SO Ft.
Driller.
Date Drilled:
Static water Level:
Istella 9r: � n` S
��•�
Date installs0:
�p -1
FL
Iw
yield:Pump
set at:
Casing Height Above Ground:
TANK
GPM
Ft.
Ft.
SEPARATION
DISTANCES
Asepti Ho i 0S.T.E.P.
To
Seplic
Absorplim
WI
Holding
blie/Pdvatw
Manufacturer.
Capacity Vn3aln
From
Tank
Filed
Stalion
Tank
m
Sawar Lia
��� .
Well
I D�. f
I CQ /
1167,
n t
!�� G.
Materiel:
Number o1 Compartments:
Surface
GYW4-
IC0/+
JCO�F
—
LIFT STATION
I
LOt
Line
10
3�
Size In gallons:
SOD
Mg§��nufactur
+ r: 14C+ E TAtiIIL
Foundation
/
� 1
/
1 G,
/
22
«�
"Pump on" [evel�t:
28
"Pump Ofl" level at:
✓
High water alarm at:
3 �r
Curtain
D
Pump Make 6 Moo el EI trical lnspectior)goerlormad by,
Drain
(•(
Alf
(y'j 0�
Remarks::
BENCH MARK
LOT dDescriQlion : D�
—DI 4.3Cpt l C-15 -:exc,7—noer -1
LVIr -, toti l
Assumed Elevation: Ft
Ob0
AL
F OOANI
ti
e %�Os��d
�'t?rf Q�► a%
Inspections performed b � Gly —I P14 Dates: is � �1
••«.«.1 « 60.0
I
2nd
r.RODE ,HAFER. W
�+
Department of Health and Human Services approval
J". No. 15 c�/
by: Urhv &It t7H Date: -7z :
Reviewed and approved '1
72-017 (1/91) MOA 25
IPermitl4o. G✓1��120G�i�
Page sof ?7 -
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
DescriotionZL_At-,tk: . 1-fa2a=- T��jLOlplAo; 6G.0�5b I DZ
ipo'
Ill
[b, IO 4l-
t1 lam° 14gG
Y- 1535 we WAV2¢oa1 to
hGALX_f 1-= 10'
nn
ptw.lEn
x,14-
\cr_ 1�rX� GSL. ��PriG�R'►�tL
5� 4Ac^
:R SMAFER
No. 215
1
72-017 A (2121) MOA 25
NORTHSTAR
*
ELECTRIC
COMPANY
June 29, 1992
To whom it may concern:
Northstar Electric Company has done the electrical wiring to a
newly installed sewage lift station and alarm at Lot 15,
Block D, Glacier Heights Subdivision in Eagle River, Alaska.
The wiring has been done in accordance with the 1991 National
Electrical Code.
Alaska State Contractor License AA17485
Sincerely,
V%'k Boone
Jw
P.O. 80x 772886 EAGLE RIVER. AK 99577 907-696.8608
HEALTHAWHORITY
APPROVALS
SEWER 8 WATER
MAIN DMNSIOIS
SEWER&WATER
DISPECTION
ENGINEERINGSTUDIES
ANDREPORTS
WELL INSPECTION
6 FLOW TEST
SITE PLANS
ROAD DESIGN
SOLTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
WPECTIONS
CN SITE
WASTEWATER
DISPCSAL SYSTEM
DESIGN
PA6E 1 of Z
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
Jul 11 19 9 6 CML ENGINEERS
Y . (907)694-2979
FAX(907)694-1211
oeZ10- Sol -On
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AR. 99519
. Lot 15, Block D, Glacier View Heights S/D
This letter is to inform you that a flow diverter has been
installed in between the existing 1000 gallon septic tank
and the existing 500 gallon lift station. The purpose for
this addition is to provide more leachfield for future use.
If you require additional information, please contact us.
Sincerely,
Robert C. Cowan, P.E.
RCC/gk
Attachment
RECEIVED
JUL 15 1996
Municipality Of Ancnuraye
Dept' Health & Human Sery)ces
17034 NORTH EAGLE RIVER LOOP • SURE 204 • EAGLE RIVER. ALASKA 99577
Permit No. Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: LOT 15, BLOCK D, GLACIER VIEW HEIGHTS PID No.: 05050102
72-017 A (Rw. 9/91( MOA 25
100'
YELL RADIU.
N
INSTALLED
FLO
DIVERTER
EXSI
BED
H
TING 3
OOM
USE
411003[A'
EXISTING
1000 GAL.
SEPTIC
TANK
EXISTING
500 GAL.
LIFT
STATION
QNSTALLE
8-10-87)
SCALE 1' -
'
,
e
.p ROBERT C. COWAN
ec� CE -8801
72-017 A (Rw. 9/91( MOA 25
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON—SITE WASTEWATER DISPOSAL SYSTEM
PERMIT NUMBER:SW920095
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:VICTORS CHRIS M & BONNIE
OWNER ADDRESS: P.O.BOX 1410
KENAI, ALASKA 99611
PARCEL ID:05050102
LEGAL DESCRIPTION: GLACIER VIEW HEIGHTS BLK D L
T 15
LOT SIZE: 23139 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1
�/y/rZ SIS
/0 tic) AV,
E/:j/4L SES
(UPGRADE) PERMIT li z, 5(5
DATE ISSUED: 5/22/9!'2
EXPIRATION DATE: 5/22/93
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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
IF THE EXISTING DEEP TRENCH IS TO BE ABANDONED, THE ABAND-
ONDEDMENT MUST BE SUCH THAH IT CAN BE RETURNED TO SERVICE
AT ANY TIME IN THE FUTURE THAT IT IS NEEDED TO SUPPLEMENT
THE UPGRADE SYSTEM. THE UPGRADE SYSTEM MUST BE INSTALLED
PER THE APPROVED ENGINEER'S DESIGN DATED 5/16/92. A WAIVER
TO THE 10 FOOT LOTNEr�SETBACK IS GRANTED UNDER WR920025.
RECEIVED BY: �("JDATE : Z_Z- 7z__
ISSUED BY: DATE: /
S 11 MUNICIPALITY OF ANCHORAGE 1
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
1 ENVIRONMENTAL ENGINEERING DIVISION
825 L Street -
Anchorage, Alaska 99501 Telephone 2644720
ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
OYs DI/ `off
PHONE
NEW
❑UPGRADE
MAILING ADDRES —1?� L S
/
P4 Ghi a SO
LEGAL DESCRIPTION
OT /5- 91K D r2ladet
View
LOCATION
Myrtle Drive
NO. OF BEDROOMS
& -►ort
Y
DISTANCE T0:
Well 1D� ��
Absorption area
Dwelling �
PERMIT NO.
W<
~L
Manufacturer
Materia lSTeC'
No, of compartments �J
to
U7capacity in gallons
6 0n
I IF HOMEMADE:
Inside length
Width
Liquid depth
d Y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
JD2
_ f
Manufacturer
Material
Liquid capacity in gallons
D
DISTANCE TO:
We
It a ion v
Nearest lot It eO
PERMIT NO.
W =
Y.
W Z
No. of lines
Length of each line
Total lengthf I' es
Trench wi
Distance between lines
Z W
i"
Inches
H
Top of tile to finish grade ^ n
Material beneath tile
Total ellect6 absarptkn area
Length
Width
Depth
PERMIT NO.
W
Q-
Type of crib
Crib diameter
Crib depth Total effective absorption area
W4
to
DISTANCE TO:
Well
Building foundation Nearest lot line
E
J
Class
Depth
Duller Ois �f !pa
PERMIT NO.
J
1N
DISTANCE TO:
Building foundation
Seer
wline 0I psepyrN
Absorption steals)
OTHER
PIPE MATERIALS
el
P vc
SOIL TEST RATING
#5 = f'Pc{roo
INSTALLER
144�r
REMARKS
y
6fT 2 3.6"c' SLOG w
f
t t
G e. S
r
•s
ew
r � ��
La�;tfi'o✓► O!C'ed �y
9
I
�,.
9
G
lLi
s Mmes L Thiso v .
APPHOV EDS Jf•.•• CE 5035 •:• `?W
=-f9fo'•••••••••' E„�js�
DATE LEGAL
BIK D, Glacier V;e4.P 14 s/
"'.► pRpF
wR�
72-M3 (Rev. 3/78) ow-
. aoaa
frr.afird Bri11i by
'}� ... • cot Ca err
SULLIVAN WATER WELLS 1 s`''�!
`?.0.K'%M. CHWIAK. ALASKA
�y;�•. a,.� = .. .
0%tN1tR0F LAND c Y �RR'/ G iSTF. DEPTH OF WELL ,] e�✓Pi�1 f!;
��'7PSa7' /rrOAl/f %/iwcc /%\/C! "T`JATICLEVEIOFWATERFT :Z"'`•I*L.-
•i %r .. (t`iS AcK O Gl.rcl�' ✓irN NC7J ! .` _ : �`,%7`,•+Sr�`'i.
LRGALDt1CkWflOI4 DIL%W DOWN ri
+ Or► 1fY111M ' ' 3 Eww—?�'F�i % GALS. PER HR
,
j Pt1RYtf M1Y!!i KIND OF CASING,
A
' KD7D OF FORlIATION �. •�, , S 1 Y}i 15' �'t\-i. r. l i :
,
01 F�'�<,Y, , e y .• s r•s.. +. . w� � ,w.l J i f� •.._ter .
Fran Ft to .t4 .' FL
t 6: �.0%a1 From , Ft IS Ft Q ' t
,•. Aj -� • �. ^ Ax. rnrrAlNV L•rt. •y..♦ 1
a�L1F1:_et 4 Y f,e.r v.rc •� Fran Ft. ro � Ft ' ^"� r :�•
to— � Frons Fl.roFe- -
i.
Id-,iYl.1�FL 0 ,<-AnG k From Fl.lo f F �!? is t•. ! ., ,...
w
,� t r'St •. ,:.11OGK F•%ltr•e{ O .i .i,: tint r•:�,at �) t-%r�< rl
rFrom FL to Ft t ,
�� F«•_."' �'` Fl. to FL (_ OM From Ft.to t .FL`'-s.,:.r::te{=i
Fwf4(' haiDe Ft LEOleaK sit From FL10 ' Ft
IF .".YL to Pt- Fran
'i' Fww hM FLFrew FL to Ft.•
Frew FLIa Ft • `�''' '� �-�ti'E:a
f.y FtMdi rr. b�Ft Fran -
FL le Ft.
From FL ►L From _FL to Ft
from FL Ie FL Front—Ft. to 1 F4
to—FL, Fran FL Io FL
Frere .w - j i4 N FL From
Pnw °�FttaFL Frow Fl.le Ft �
v
_ .I CAf..vL .. 4 I `'�.1 _ o.:.J<a- rli!i• .1.
'� -r�. i•3}V��,'/1' i01 01t. � r t[ art }fr •d. �4aii '7j
♦' /�... •'•if 1 syr+.
,
•F', r 4...
DRILLERS NAME •N t 'C3:°s
by
DOC Co. dba
SULLIVAN WATER WELLS
P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 6882759
OWNER OF LAND fl /! 'i G yS t E.- DEPTH OF WELL
ADDRESS Jr".�C �r+0+'jri� v�rSTATICLEVEL OF WATER FT.
LEGAL DESCRIPTION
[- /S PLIC O 6L64t lE.M fLf"J J t6DRAW DOWN FT.
DATE -Started ct'4a /'F'' Ended /��r GALS. PER HR �< <'
PERMIT NUMBER
KIND OF FORMATION:
KIND OF CASING 1, !i� OQ
From n Ft. to 12 Ft. --/'t ' ✓ 4,6 "54- From Ft. to Ft.
From = Ft. to � Ft. dd✓lO X141 From Ft. to Ft.
r
From :SLS' Ft to L�LFt. Ci_ Al /•s N�(< From Ft. to Ft.
From
Ft. to Ft.
X?o
From
Ft. to
Ft,
From ` ' 7
Ft. to /�Ft.
A e," ° ° /' From
Ft. to
Ft.
From
Ft. to /s' �Ft.
/_11<71j/ "From
Ft. to
Ft.
From
Ft. to Ft.
" C F n7
From -
Ft. to
Ft.
From ' `>
Ft. to_f`' o Ft.
0 C
) c. 'O From
Ft. to
Ft.
From
Ft. to Ft
From
Ft. to
Ft.
From
Ft. to Ft.
From
Ft. to
Ft.
From
Ft. to -Ft.
From
Ft. to
Ft.
From
Ft. to Ft.
From
Ft. to
Ft.
From
Ft. to Ft.
From
Ft. to
Ft.
From
Ft. to Ft.
From
Ft. to
Ft.
From
Ft. to Fl.
From
Ft. to
Ft.
From
Ft. to Ft.
From
Ft. to
Ft.
From
Ft. to Ft.
From
Ft. to
Ft,
MISCL. INFORMATION:
yo -7 / ioirl<
DRILLER'S NAME
O
MUNICIPALITY OF ANCHORAGE
Department^f Health and Environment,`)Protection
825 Street, Anchorage,.AK. X9501
264-4720
Permit# f * * * HANDWRITTEN PERMIT
WEL ANDAV ON-SITE SEWER PERMIT
Applicant: Mailing Address: Z� �di�lL
&qcA a 7c
Location: Phone Number:
Legal Description: zo7`- /5 zo_e l l/� -fLl.0 Lot Size:
Type of Soil Absorption System Is:
Trench:_ Drainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: _ Soil Rating(sq.ft/br) /Y,5-
The Required Size of the Soil Absorption System Is:
DEPTH LENGTH . GRAVEL DEPTH XII�DooTooH o,v
s
The length dimension is the�ength(in feet) of the french 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(fi6) TANK SIZE _ /DOO 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 departmen
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 8 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 understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 bedrooros..
Signed: Issued by:
A 1'can
Date: 67
Date:
.S/,44tzacu�'/dam
SWP/0244 (1�/8�1) �7 S� 3to
jae�.uu�•ti.� � •a%�o-
to� /�-'
9 SOILS LOG
MUNICIPALITY OF ANCHORAGE
\
ri
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 0 PERCOLATIONTEST
825 L Street, Anchorage, Alaska 99501 2643720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: 7,qQ7 DY --57-f P— DATE PERFORMED: S/-22-183
LEGAL DESCRIPTION: LOT IS', GL//C/E/L ✓/E K/ NTS. Sd 8. SEG /61_T/VN, p/K/ . 5, M.
DEPTH SLOPE SITE PLAN(No 6 - CE)
(FEET)
Sic_r
2
3
4
5
6
7
s
9
10
11
12
13
14
15
16
17
16
19
2D
S/LTS/ SANOYG�AVE_G�
SAND /R/ Pct,L'e7s ff
SE,gi7ff / L005E
5/LT� SRNoY WAS GROUND WATER '. // S
h ENCOUNTERED? NO L
GQ7/�i✓tet . ✓EKY O
J CNS P
IF YES, AT WHAT E
DEPTH?
MG 517- 664vE)
146or-rv,#f eF Pr -
Reading
Data
Gross Ti Depth to
Time ,��� (C
[Jl `' Water
Net
Drop
�P • •� ....,e*a s•L
x; 49 i
I$,* •aa INN N .NN .N• •a,
l
a•• HI1N • •••.•
W%
%1�
T% I P. Ellis
•t
s •e '
f•IN
a•M•
�At•a,•F��
I I PERCOLATION RATE (minutes/inch)
11�� TEST RUN BETWEEN FT AND FT
COMMENTS NO .6&02oc1,-1 _r--1yc0c Al ,F2E0 g SL oiE C> P,,r = f;S-- 40%.' OEt/ECOO SEE/�GE
�fE!J 1,V A4 6,5 no ecv /Y2- Fao7- PEPTN.,EXCA✓,?7-a2 61?410.vD dP (o Ali T.
PERFORMED BY: E/1.2c. �LL/S CERTIFIED BY:___ -13
72-008 (6/79)
q
G �p G/ut.<.1 A�
r.,
municiA- lity of Anchorage
Department of Health and Human Services
825 "L" Street
Tom Fink,
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
February 1, 1989
Robert A. Shafer, P.E.
S & S Engineering
17034 Eagle River Loop Road
Suite 204
Eagle River, Alaska 99577
Baa=
Subject: Waiver Request for Lot 15 Block D Glacier View Heights
Waiver Request #WR890005, PID #050-501-02
Dear Mr. Shafer:
Your request for waiver of the required 100 foot separation'of
a septic system to a private well has been approved. The
approved separation distance is 92 feet.
This waiver approval applies to the existing septic system to
well separation only. Any future upgrade to either will
require all separation distances be met or another approval
from this department.
Sincerely,
Daniel J. Roth
Civil Engineer
On-site Services
DJR/ljw#6
HEALTH AUTHORITY
APPROVALS
SEWER! WATER
MAIN EXTENSIONS
SEWER A WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURALS
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
Januarty 30, 1989
Municipaefity o6 Anchortage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Strteet
Anchorage, A aAa 99501
ROBERT A. SHAFER
CIVIL ENGINEER
694.2979
REFERENCE: Lot 15; Btock D; Gtaciert View Heights Subdivision
Request you grtant a waivert bort the hortizontat aepatation distance
between the prtivate weft and the teach6ietd Located on the rte6ertenced
prtopertty at a distance o6 92 beet.
The septic system was insta ted under a Muni.cipa.t pertmit .issued
May 25, 1983. A aepartation distance uaivet was approved by the
Municipaeity o6 Anchorage (MOA) durting the instattation to 96 beet.
A aurtvey done rtecentey shows the hortizontae 6epartation to be c[osea
to 92 beet.
A 2iak anatyaia has been pert6okmed and it appearta that no bacten.iatogicaf
pottution is poaaibee 6rtom this aounve. Attached boa yours Aeview
ane the 6ot.towing documents:
1. A plot pian showing the rtetative distance between the we t
and septic system.
2. A aiak anatys4s work sheet.
3. Satis6actorty coti6ortm and nitna.te anatyaia rtesueta 64om the
rte6etenced wee£.
4. A we t, .Cog bort the 4e6ertenced weee.
It is out opinion that the hoaizontat aepartati.on distance prtescnibed
by 18AAC72.021 is not rtequirted in this case.
16 you rtegcr�lA,' a additional in6o, mation, please contact us.
VASHAFER, P.E.
as0-5 o F33
��� F�liJQ111-P-1�
17034 EAGLE RIVER LOOP. SUITE 204. EAGLE RIVER. ALASKA 99577 SO 7/
SCALE
i
A
t,{LI't F1
�. (icy-. '� � 'C�-��1'fl--. Gcv�C�-��•�r, � � •r
�{ 1 �C.. X7.7' 1R�w�jV 1� �f�a'h•� Z
l�G sti, or-
2 7 ?,e,. , >
tm �
N
2
—1
•A
�•'d.L'4.Y S.. Y
municipality of Anchorage
Department of Health and Human Services
Tom Fink, 625 "L" Street
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
May 22, 1992.
Roger A. Shafer, P. E.
S & S Engineering
17034 Eagle River Loop Road
Suite 204
Eagle River, Alaska 99577
Subject: Waiver Request for Lot 15 Block D Glacier View Heights S/D
Waiver Request fWR920025, PID #050-501-02, SW920095
Dear Mr. Shafer:
Your request for waiver of the required 10 foot separation
between a septic system and a lot line has been approved. The
waived distance is 1 foot from the west property line to the
leachfield.
This approval applies to the existing septic system lot line
separation only. Any future upgrade to the septic system will
require all separations be met or another approval from this
department.
Sincer,9ly,
C�
Robert W. Robinson
Civil Engineer
On-site Services
ljw#7
CPrt
ohn Smi
Program Manager
On-site Services
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR# PID# 050-501-02 HA# Permit # ri a[ylq�
Date Received: May 19, 1992
Legal Description: Lot 15 Block D Glacier View Heights
Engineer: Roger A. Shafer, P. E. S & S Engineering
17034 Eagle River Loop Road, Suite 204 Eagle River 99577
Applicant: Chris Victors
Waiver Requested: Lot line waiver - west property line - 1 foot
Criteria: 1. Geology: Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
2. Special Conditions:
3. Other:
Waiver is Granted: Waiver is NOT Granted:
List Conditions or Reasons for above: -/4 D/0.1r.Z /ni ..,
Date:
By
or xeviewer
Rec #: 23700.2167 Amount: $ 70.00 Date Paid: May 19, 1992
1/,
May 19, 1992
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX 6941211
HEALTH AUTHORITY
APPROVALS
Municipatity o6 Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
P.O. Boz 196650
Anchorage, AWka 99519-6650
SEWERBWATER
MAIN EXTENSIONS
REFERENCE: Lot 15; Bloch D; GtacieA View Heights Subdivision
Request you issue a permit to upgrade the septic system serving the
re6erenced propeAty.
SEWERSWATER
INSPECTION
The existing system was tested and a Heatth Authority Approval .issued on
Manch 20, 1992 (w/COMMENTS). Due to questions o6 the existing systema'
adequacy. (SEE FILE) .lending institutions wilt not accept the Heattth
ENGINEERING STUDIES
CeAtijicate. TheAe6ore, an upgrade to the system is proposed.
AND REPORTS
As can be seen 6 -tom the attached site pian/design there .is tittCe room on
the p)topeAty 6or an upgrade. To maintain a 100 6t. separation distance to
the wet aerving the propeAty, we propose encAoaching the west propWy
WELLINSPECTION
.tine. There6ore, we request a waiver 6or the distance between the west
a PLOW TEST
prope)tty .Line and the propo6ed teach6ield trench at 1 6t. This encroachment
ahoud not e65ect the adjacent property since the system is on the west side
o6 Lot 14.
SITE PLANS
16 you have any questions or require additionat in6ormation 6or your review,
ptea6e contact as.
SinceAely,
ROAD DESIGN
vv
ROGER J. SHAF R, P.E.
soaTEsr
QJS/gm
PERCOLATION
TEST
STRUCTURALS
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSALSVSTEM
DESIGN
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR:y�
LEGAL DESCRIPTION: L
2—IF
3 i
"C
4-
5-
6 5
7 b
o.
8-
9-
10-
11 9 10 11 / 'd
12 ,O
13-
14-
15
3 14 15 r
16
�ld
17 U
18-
19-
20-
COMMENTS
81920COMMENTS
610
T/•fl irt.
DATE PI
Township, Range, Section:
1 ' SLOPE
WAS GROUND WA'
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Depth to Water
MoniWrinpT
PERCOLATION RATE `A1' h)
(minutesanch) PERC HOLE DIAMETER �l
TEST RUN BETWEEN K FT AND i FT
PERFORMED BY: S & S ENGINEERING( CERTIFY THAT THIS TEST WAS PERFORMED IN
20
17034 Eagle River Loop Rood No. 4�j
ACCORDANCE WITHIN EFFECT ON HIS DATE. DATE:
72-008 (Rev. 4,851
Er(alllls
MUNICIPALITY OF ANCHORAGE
0
�`
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. 050-501-02
1. GENERAL INFORMATION
Expiration Date:" 15, c'� O a
Complete legal description GLACIER VIEW HEIGHTS BLOCK D, LOT 15
Location (site address) 23105 MYRTLE DRIVE, EAGLE RIVER, AK 99577
Current property owner(s) JOSEPH & THARETH CASEY Day phone
Mailing address
Real estate agent
23105 MYRTLE DRIVE, EAGLE RIVER, AK 99577
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
®
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ g5o
Date of Payment k 1 _rc_lc�
Receipt Number OTGoa
COSA # osc1115� 1531A
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm ANDERSON CONSTRUCTION & ENGINEERING Phone 345-3377
Address 4661 NATRONA AVENUE, ANCHORAGE, AK 99516
Engineer's Printed Name MICHAEL N. ANDERSON, PE Date 11/7/2019
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic+
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use, � A or
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the ! '
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the *
well and septic system. Therefore, any estimate of how long a system will function satisfactory }
for current or future occupants or guarantee that no unseen encroachments, deficiencies or F
discrepancies exist can be given by FWCS and Anderson Construction & Engineering.
o, CE QQIQ
6. DSD SIGNATUREk . 11/7/19.•
Aw
./ System #1 Approved forbedrooms *�ti'
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
,�tlllll((((ftfr..
v W ER A�1� tM
�17J
WA Ar
PR
OG
J�o R R,y,l
By: Original Certificate Date: -1 15 1
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: GLACIER VIEW HEIGHTS BLOCK D, LOT 15 Parcel ID: 050-501-02
If more than 1 septic system on lot: COSA Checklist #
of
Structure served by this system
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled 8/4/1983
Total depth 200 ft
Cased to 130 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 24+ in.
Date of flow test for COSA 10/25/2019
Static water level at beginning of test 74 ft.
Well production at time of test 0.92 gpm
Water storage tank volume gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date of Sample 10/25/2019
Comments __________________________________________________________________________________
B. TANK DATA – NEW TANK
Age of tank(s) 0 years
Tank type/material STEP/ HDPE
Measured operating fluid level in septic tank
Standpipes/foundation cleanout per record drawing
Date of pumping NA – NEW TANK
C. LIFT STATION – NEW TANK
Required maintenance completed
Age of lift station 0 years
Lift station material HDPE
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 8/5/1983
ALL standpipes present per record drawing
Total measured depth from grade 8.7 ft (max)
Measured depth to pipe invert from grade 4.7 (min)
N/A – pressurized field
Monitor tubes go to bottom of effective. If not, state
depth into effective Appears to
Code-required soil cover over field
System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Adequacy test date 10/25/19
Results Pass For 3 bedrooms
Fluid depth prior to test 0 in
Water added 600 gal
New depth 7 in
Elapsed time 1200 min
Final fluid depth 0 in
Absorption rate 450+ gpd
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Comments/Deficiencies:
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100’
Yes if No
ft
Neighboring Tank > 100’ Yes if No
ft
Absorption Field on Lot > 100’ Yes if No * 92 ft
Neighboring Absorption Fields > 100’
Yes if No
ft
Community Sewer Main > 75’ Yes if No
ft
Community Sewer Manhole/Cleanout > 100’
Yes if No
ft
Private Sewer/Septic Line > 25’ Yes if No
ft
Holding Tank > 100’ Yes if No
ft
Animal Containment > 50’ Yes if No
ft
Manure/Animal Excreta Storage > 100’
Yes if No
ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No
ft
Property Line > 5’ Yes if No ft
Absorption Field > 5’ Yes if No
ft
Water Main > 10’ Yes if No
ft
Water Service Line > 10’ Yes if No
ft
Surface Water > 100’ Yes if No
ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No
ft
Community Wells > 200’ Yes if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10’ Yes if No
ft
Property Line > 10’ Yes if No **1’ ft
Water Main > 10’ Yes if No
ft
Water Service Line > 10’ Yes if No
ft
Surface Water > 100’ Yes if No
ft
If absorption field is under driveway comment below
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No
ft
F. ENGINEER’S COMMENTS
*1983 Trench (WR890005) **1992 Trench (WR920025)
G. ENGINEER’S CERTIFICATION
I certify that I have determined through field inspections and review
of Municipal records that the above systems are in conformance
with MOA COSA guidelines in effect on this date.
11/11/19
• '� Municipality of Anchorage =
On -Site Water and Wastewater Program
(907) 343-7904 s n E T
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 050-501-02-000
1. GENERAL INFORMATION
Complete legal description Glacier View Heights Blk D Lt 15
Location (site address) 23105 Myrtle Dr; Eagle River AK 99577
Expiration Date: I Z -,;2-- /
Current Property owner(s) Joseph & Darmaly Williams Day phone
Mailing address
Real Estate Agent
23105 Myrtle Dr.; Eagle River AK 99577
Les Baily Office Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual
Individual Water Storage
❑
Holding Tank
❑
Corrn unity Class Well
❑
Commui Community
❑
Public Water System
❑
Public Sewer
❑
WaiverNariance request for: Distance:
Received by: «,,-"
COSA to be released to the engineer, unlessb 116V
requested by the engineer.
COSA Fee $ 490.00
Date of Payment
Receipt Number
COSA # O�C- 1313"11
Date ;', - ' / �;
Waiver Fee $ _
Date of Payment
Receipt Number.
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING, INC. Phone 696-6111
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 7/26/2013
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the
condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to
subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that
may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic
systems are subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore, -
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future r OFoccupants or can ArcTerra guarantee that no unseen S� Z
encroachments, deficiencies or discrepancies exist. / � 4S,
C)TH *4,
6. DSD SIGNATURE
P„
KENNETH N\�DU S x /
System #1 Approved for _ bedrooms. 6/
System #2 Approved for 3 bedrooms. , �o .7 1;2 AW
P FE5510 �vPL
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
By: /'&1L/( Original Certificate Dater
The nicipa �y ® Q, c�rage 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 X Other
COSA blue sheet 10-10-12AM
If more than 1 septic system is on the lot:
COSA Checklist # _of _
Structure served by this system _
Certificate of On -Site Systems Approval Checklist
Legal Description: Glacier View Heights Blk D Lt 15 Parcel ID: 050.501.02-000
A. WELL DATA
Well type PRVT If A. B, or C provide PWSID #
Date completed 81411983 Sanitary seal (Y/N) Y
Total depth 200 ft. Cased to 130 ft.
FROM WELL LOG
Date of test 814183
Static water level 60 ft.
Well production 6 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate ND mg/L
Arsenic: ND ug/L Date of sample: 7/1212013
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC 1 STEEL
Tank size 1000 gal. Number of Compartments 2
Well Log (Y/N)
Wires properly protected (Y/N) Y
Casing height (above ground) 12+ in.
AT INSPECTION
711212013
ft.
g.p.m.
Collected by: ARCTERRA
Date installed 8/10/1983
Cleanouts (Y/N)
Foundation cleanout (Y/N) Y Depression over tank (YIN) N High water alarm (Y/N) N
Date of pumping 7/11/2013 Pumper JR's
C. ABSORPTION FIELD DATA ** TESTED 1983 SYSTEM" Directed Diverter to 1983 system
Date installed 616-9192&"815183 Soil rating (g.p.d./f:2 or ff/bdrm) 0.61 145 System type Trench
Length 381** 55 ft. Width 31**2 ft. Gravel below pipe 10.01"4.0 ft.
Total depth 17.61 **13.7 ft. (Meas. 7/13/13) Eff. absorption area 440 ftz Monitoring tube Y Depression over field N
Date of adequacy test **711312013 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0_0 in. Water added 600 gal. New depth 24 in.
Elapsed Time: 1,440 min. Final fluid depth 5 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date
D. LIFT STATION
Date installed 61511992 Size in gallons 500 Manhole/Access (Y/N) Y
"Pump on" level at 28 in. "Pump off' level at 18 in. High water alarm level at 31 in.
Datum Bottom of Tank Cycles tested 3 Meets alarm & circuit requirements? Yes
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+
Public sewer main NIA
Sewer /septic service line 25'+
Animal containment areas 504
SEPTIC/HOLDING TANK ON LOT TO:
On adjacent lots 100'+
Public sewer manhole/cleanout NIA
Holding tank NIA
Manure/animal excrete storage areas 1004
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main NIA Water service line 104 Surface water 1004
Wells on adjacent lots 1004
ABSORPTION FIELD ON LOT TO:
Property line 10'+11' Building foundation 104 Water main NIA
Water Service line 104 Surface water 100'+ Driveway, parking/vehicle storage 3'
Curtain drain 50'+ (NONE KNOWN) Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name KENNETH M. DUFFUS
Date 7/'/-1
COSA brown sheet_10-10-12.doc
OF ALS
i4.ATH I*+,
+ NKENNETH71M. D S /
+gymAlf
q 16
a16
� �r
\`� P FE551DNaV
Municipality of Anchorage
Development Services Department
Building Safety Division a 5 , t. r c
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ei.anchorage.ak.us
(907)343-7904
Water Well Advisory
Certificate of On -Site Systems Approval (COSA) # 131377
During a recent COSA on-site inspection and test of the potable water
supply well on Block D, Lot 15 of Glacier View Heights subdivision, the
well's productivity was determined to be 0.68 gallons per minute. The
minimum well productivity required by this Department (AMC 15.55) for a
3 -bedroom residence is 0.31 gallons per minute. Although the subject well
currently exceeds this minimum requirement, all parties concerned are
advised that the production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering lawns and
gardens may be required.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water 8 Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS
/ _:�G/Gt
APPROVAL j -
FOR A SINGLE FAMILY DWELLING
Parcel l.D._056'Jrl /-n,P COSA#
1. GENERAL INFORMATION Expiration Date: / % - 0 CI
Complete legal description GLACIER VIEW HEIGHTS SUBDIVISION; LOT 15 BLOCK D
Location (site address) 23105 MYRTLE DRIVE + EAGLE RIVER AK 99577
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
JOHN GILLMORE Day phone 980-5068
23105 MYRTLE DRIVE • EAGLE RIVER AK 99577
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
Day phone
Day phone
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well
N
Individual On-site
N
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 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 samples. (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 application,
investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this app
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 (les and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Finn GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, VD. attempted to provide a thorough,
conscientious engineering analysis of the system In accordance with ADEC and MOA
DSD Guidelines d Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily Identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory
atictoy test
results do not guarantee future performance of the system, nor do they guarantee
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
S. DSD SIGNATURE
V Approved for bedrooms.
Phone 337-6179
Date
Disapproved.
Conditional approval for bedrooms, with the fllowing stipulations:
Attachments: V
COSA Checklist Arsenic Advisory
Septic System Advisory Maintenance Agreements
(Z'16/O tU
rn1�®fYfi
A. G ness:
CE— 3
dZ ,l
aD t111,.,,,,
QQy��Y OF giy�y
' 0 '
ON-SITE G7's
WATER AND
WASTEWATER
PROGRAM '
"J"mil l
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory Other - 7
By:4
Original Certificate Date: /o'7-- / / - g
(Rev. 11105)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Waler & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage. AK 99519-6650
www.muni.org/onsite
(907)343.7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: GLACIER VIEW HEIGHTS SUBDIVISION: LOT 15 BLOCK D Parcel rOL02
A. WELL DATA
Well type PRNATE If A. B, or C provide PWSID# N/A
Date completed 8/4/1983 Sanitary seal (Y/N) YES
Total depth 200 ft. Cased to 130 ft,
FROM WELL LOG
Date of test 8/4/1983
Static water level 60 ft.
Well Log (Y/N) YES
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ _in.
AT INSPECTION
4/22/2008
70 ft.
Well production 6.0 g,p,m. 0.70 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate ND mg./L. Other bacteria 0 colonies/100 mi.
Arsenic: ND ug./L. Date of sample: 12/2/2008 Collected by: _ GEG, ltd.
4 22 2008 B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEEL/S.T.E.P. Date installed _ _8/10/83 & 6/9/92
1000/ —
Tank size 500 gal. Number of Compartments 2 Cleanouts (Y/N) YES —
Foundation cleanout (Y/N) YES Depression over tank (YIN) NO High water alarm (Y/N) YES —
Date of pumping 5/19/2008 Pumper JRs PUMPING _
,C. ABSORPTION FIELD DATA Fe - LOW EXISTING GRA
6/6-9/92 0.6
Date installed - 8/5/83 Soil rating (g.p.dAt'or ft'/bdrm) 145 System type TRENCH _
Length 38/55 ft. Width s 3/2 ft. Gravel below pipe 10/4 ft.
760/
Total depth '17.s 10.1 ft. Eff. absorption area 440 ft' Monitoring tube YES Depression over field NO
Date of adequacy test "12/15/2008 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth In absorption field before test 40 in. Water added 450 gal, New depth 50 ir.
Elapsed Time: 900 min. Final fluid depth 38 in, Absorption rate >= 450+
P g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date
**TESTED THE 1992 TRENCH
***NOTE: ON (12/15/2008) LIQUID LEVELAN THE 1983 TRENCH WAS 1 FOOT BELOW THE INVERT
NOTE: DO TO WINTER CONDITIONS THE CLEANOUT IN THE 1992 TRENCH COULD NOT BE
FOUND. ON OUR 2003 INSPECTION IT WAS FOUND. THE TRENCH CAN BE CLEANED OUT BY
USING THE CLEANOUT ON THE OTHER END OF THE TRENCH AND FROM THE LIFTSTATION.
D. LIFT STATION
Date installed
6 5 1992 Size in gallons 500 Manhole/Access (Y/N) YES
'Pump on" level at 28 in. "Pump off" level at 18 in. High water alarm level at 31 in.
Datum BOTTOM OF TANK Cycles tested 3 Meets alarm & circuit requirements? YES
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankA!ft station on lot
100'+
Absorption field on lot '927••100.38'
Public sewer main N/A
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout N/A
Sewer /septic service line 25'+ Holding tank N/A
Animal containment areas
50'+ Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
5'+ Property Ime 5'+ Absorption field 5'+
Building foundation P rtY
Water main
N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
N/A
P
Pro a rtY •+10'+/••'•1' 10'+
line ' Building foundation Water main
"' 1
100'+ Driveway, parking/vehicle storage "0'+
Water service line 10'+ Surface water Y. P 9
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
*WAIVER GRANTED TO 1983 TRENCH (WR 890005).
F. COMMENTS* DI 19A83 FROM THE EDGE INSPECTION REPORT. • '9WR9 0025 (12 TRENCH 9920TRENUT OCH). ••' EDGE 0'0' (1983 F WELL ET TRENCH)
D. PER
G. ENGINEER'S CERTIFICATION
1 certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date 12'1 L //o &
COSA Fee
Date of Payment
Receipt Number
(Rev. 11105)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
I Development Services �Division
Department
Building "�•: I'� � . 4:
g Safet y Di vision
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchomge.ak.us
(907) 343-7904
Water Well Advisory
Health Authority Approval # 080153
During a recent Health Authority Approval on-site inspection and test of the
potable water supply well on Block D, Lot 15 of Glacier View Heights
subdivision, the well's productivity was determined to be .70 gallons per
minute. The minimum well productivity required by this Department (AMC
15.55) for a 3 -bedroom residence is 0.31 gallons per minute. Although the
subject well currently exceeds this minimum requirement, all parties
concerned are advised that the production capacity of the well may fluctuate.
Restriction of non-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory must be attached to all copies of the subject Health Authority
Approval.
U
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/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING {�
Parcel I.D. nrC' ,Q 1-Qa D COSA# O I53
1. GENERAL INFORMATION Expiration Date: -� a rs
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
GLACIER VIEW HEIGHTS SUBDMSION• LOT 15 BLOCK D
23105 MYRTLE DRIVE • EAGLE RIVER AK 99577
JOHN GILLMORE Day phone 980-5068
23105 MYRTLE DRIVE • EAGLE RIVER AK 99577
Day phone
Real Estate Agent Day phone
Mailing address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
■
Individual On-site
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 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 samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the
information obtained from the Municipality of Anchorage riles and from my Investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE. AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date s -/ z C/0 6
Engineer's Comments:
In conducting this evaluation, GEG, LID. attempted to provide a thorough,
conscientious engineering analysis of the system In accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily Identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outsido the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report Is for
5. DSD SIGNATURE
Approved for 3 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the fllowing stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory ✓
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Reort
Other
vr� .................
• ON-SITE
WATER AND
WASTEWATER
PROGRAM •'
11
By:� 14-1. ' �� Original Certificate Date:
(R. 11*5)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water 8 Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.orglonsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: GLACIER VIEW HEIGHTS SUBDIVISION; LOT 15, BLOCK D Parcel ID:
A. WELL DATA
Well type FRNATE If A. B, or C provide PWSID# NIA Well Log (YIN) YES
Date completed 8/4/1983 Sanitary seal (YIN) YES Wires properly protected (YIN) YES
Total depth 200 ft. Cased to 130 ft. Casing height (above ground) 12+ In.
FROM WELL LOG AT INSPECTION
Date of test 8/4/1983 4/22/2008
Static water level 60 ft, 70 ft
Well production 6.0 g.p.m. 0.70 - 9—
p.m-WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate —)J ---O mg./L. Other bacteria 1 n colonies/100 mi.
Arsenic: 1J Q ug./L. Date of sample: 4/22/2008 Collected by: GEG, Ltd.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEEL/S.T.E.P. Date installed 8/10/83 do 6/9/92
1000/ YES
Tank size 500 gal. Number of Compartments 3 Cleanouts (YIN)
Foundation cleanout (YIN) YES Depression over tank (YIN) NO High water alarm (YIN) YES
Date of pumping5/19/2008 Pumper JRs PUMPING
C. ABSORPTION FIELD DATA BELOW EXISTING C.6 ?E
6/6-9/92
Date installed 8/5/83 Soil rating (g.p.d./Wor felbdrm) 145 System type TRENCH
Length 38/55 ft. Width3/2 ft. Gravel below pipe 10/4 ft.
760/
Total depth *17.6 /10.1 ft. Eff. absorption area 440 ft= Monitoring tube YES j Depression over field NO
Date of adequacy test "9/26/2006 Results (Pass/Fail)PASS For 3 bedrooms
Fluid depth in absorption field before test"_4 In. Water added 450 gal. New depth 21 in.
Elapsed Time: 120 min. Final fluid depth 19 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date
TESTED 1983 TRENCH ***NOTE: ON (4/22/2008) LIQUID LEVEL IN THE 1992 TRENCH WAS 1 FOOT
BELOW THE INVERT AND IN THE 1983 TRENCH LIQUID WAS 1 FOOT BELOW THE
INVERT i
D. LIFT STATION
Date installed 6/5/1992
Size in gallons
500
Manhole/Access (Y/N) YES
"Pump on" level at 28 in.
"Pump off" level at
18 in.
High water alarm level at 31 in.
Datum BOTTOM OF TANK
Cycles tested
3
Meets alarm & circuit requirements? YES
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
100'+
On adjacent lots
100'+
Absorption field on lot '92'/••
100.36'
On adjacent lots
100'+
Public sewer main N/A
Sewer /septic service line 25'+
Public sewer manhole/cleanout N/A
Holding tank _ N/A
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line "•10'+/*"•*1'
Building foundation
10'+
Water main N/A
Water service line
10'+
Surface water
100'+
Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS ,WAIVER GRANTED TO 1983 TRENCH (WR 890005).
DISTANCE FROM THE EDGE OF 1992 TRENCH CLEANOUT TO EDGE OF WELL HEAD.
***PER 1983 INSPECTION REPORT. 04+•WR920025 (1992 TRENCH).
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and per* 4 I 9*
review of Municipal records that the above systems are in �......"" .. ....... •••••.•••
conformance with MOA COSA guidelines in effect on this
date. f A. G nese:
Engineer's Printed Name JEFFREY A. GARNESS �Q �. C 3 6M,
Date S/2olo8 �4p e� ' •S.?a�o�da
v oresso.• o
�4000p0o
COSA Fee $ / 2> U. uy Waiver Fee $
Date of Payment ZU ) V Date of Payment
Receipt Number Receipt Number
(Rev. 11/05)
Municipality of Anchorage e ,;
• Development Services Department
Building Safety Division „
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
Nater Well Advisory
Health Authority Approval # 080153
During a recent Health Authority Approval on-site inspection and test of the
potable water supply well on Block D, Lot 15 of Glacier View Heights
subdivision, the well's productivity was determined to be .70 gallons per
minute. The minimum well productivity required by this Department (AMC
15.55) for a 3 -bedroom residence is 0.31
minute. Although the
subject well currently exceeds this minimum requirement, all parties
concerned are advised that the production capacity of the well may fluctuate.
Restriction of non-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory must be attached to all copies of the subject Health Authority
Approval.
Municipality of Anchorage
• Development Services Department °
j Building Safety Division .. .,.
On -Site Water 8 Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904 \ill
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. 0-50 x.02 COSA# 0,61
1. GENERAL INFORMATION Expiration Date: 3 — Z 1— 0 %
Complete legal description
Location (site address)
Current Property owners)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
GLACIER VIEW HEIGHTS SUBDIVISION; LOT 15, BLOCK D
23105 MYRTLE DRIVE • EAGLE RIVER. AK 99577
DANA do STACEY PRATT Day phone 622-9599
23105 MYRTLE DRIVE • EAGLE RIVER, AK 99577
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
N
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
0
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 samples. (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 engineers 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. 1 further verify that based on the
information obtained from the Municipality of Anchorage files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) In compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines 8 Regulations. The reported results described the performance of the
system under the conditions encountered of the time of the test, and separation
distances measured to readily Identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
.__L Approved for `3 bedrooms.
Disapproved.
Phone 337-6179
Date 1.2 Lo /of,
®Wws —
Conditional approval for bedrooms, with the filowing stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Reort
Other
1..............
CE -795
1.Z'ZcDb
ON-SITE
WATER AND
WASTEWATER
PROGRAM
By:/��y// rl/ i✓, �1 Original Certificate Date:
(Rm. 1115)r//J
Municipality of Anchorage
Development Services Department
Building Safety Division
OnSke Water & Wastawater Program
4700 Sragew Street
P.O. Scor 190850
Anchorage, AK 995196850
www.muni.orglonsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: GLACIER VIEW HEIGHTS SUBDIVISION; IAT 15, BLACK D Parcel ID:
A. WELL DATA
Well type PRIYAn If A. B, or C provide PWSID# N A
Data completed 8/4/1983 Sanitary seal (Y/N) YES
Total depth 200 ft. Cased to 130 ft.
FROM WELL LOG
Date of test 8/4/1983
Static water level 60 ft.
Well production 6.0 g.p.m.
WATER SAMPLE RESULTS:
Well Log (YM) YES
Wires property protected (Y/N) YES
Casing height (above ground) 12+ in.
AT INSPECTION
9/26/2006
72 ft.
0.83 g.p.m.
Coliform 0 colonies/100 mi. Nltmte d mgJL. Other bacteria 0 colonies/100 ml.
Arsenic: r. v ugA. Data of sample: 9/26/2006 Conected by: GEG. Ltd.
B. SEPTICIHOLDING TANK DATA
Tank Type(Materlel STEEL/S.T.E.P. Data installed 8/10/83 & 6/9/92
1000
Tank sizel 500 gal. Number of Compartments 2 Cleanouts (VIN) YES
Foundation cleanout (Y/N) YES Depression over tank (YIN) NO High water alarm (YM) YES
Date of pumping x0/5/2006 Pumper JRs PUMPING
C. ABSORPTION FIELD DATA 8 OW EXISTING 2
Date installed s e� 83 Sob rating (g.p.d./ft'0r ftlbdrm) 011 .6 System We TRENCH
Length 38/55 ft. Width 3/2 R. Gravel below pipe 10/4 ft.
Total depth 017.6/10.1 ft. Eft. absorption area446 76O ft' Monitoring tuba YES Depression over field NO
Date of adequacy test 009/26/2006 Results (Pass/Fab) PASS For 3 bedrooms
Fluid depth in absorption field before test 4 In. Water added 450 gal. New depth 211 in.
Elapsed Time: 120 min, Final fluid depth 19 in. Absorption rate >= 450+ g,p,d,
Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date —
•• TESTED 1983 TRENCH
D. LIFT STATION
Date installed 6/5/1992 Size in gallons 500 Manhole/Access (Y/N) YES
"Pump on" level at 28 in. "Pump ofr level at 18 in. High water alarm level at 31 in.
Datum BOTTOM OF TANK Cycles tested 3 Meets alarm 8 circuit requirements? YES
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot 100'+
Absorption field on lot '92'/"100.36'
Public sewer main N/A
Sewer /septic service line 25'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/deanout N/A
Holding tank
Animal containment areas 50'+ Manurelanimal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 1000+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 'ee10'+/et•et' Building foundation 100+ Water main N/A
1'
Water service line 10'+ Surface water 100'+ Driveway, parkinglvehide storage+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS *WAIVER GRANTED TO 1983 TRENCH (WR 890005).
DISTANCE FROM THE EDGE OF 1992 TRENCH CLEANOUT TO EDGE OF WELL HEAD.
•••PER 1983 INSPECTION REPORT. 0•e8WR920025 (1992 TRENCH).
G. ENGINEER'S
I certify that I have determined through field inspectlons and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date 17 rhy/66
COSA Fee S `/3C� . C O Waiver Fee $
Date of Payment
Receipt Number.
(Rev. 11M5)
Date of Payment
Receipt Number
Municipality of Anchorage ,.• _•.
Development Services Department
Building Safety Division $
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
Water Well Advisory
Health Authority Approval # 060599
During a recent Health Authority Approval on-site inspection and test of the
potable water supply well on Block D, Lot 15 of Glacier subdivision, the
well's productivity was determined to be 0.83 gallons per minute. The
minimum well productivity required by this Department (AMC 15.55) for a
3 -bedroom residence is 0.31 gallons per minute. Although the subject well
currently exceeds this minimum requirement, all parties concerned are
advised that the production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering lawns and
gardens may be required.
This advisory must be attached to all copies of the subject Health Authority
Approval.
Sep 22 06 12:30p THE STEPHENS TEAM P. WV 19072737205 p.2
M -W Drifting. iac.
resrPLw fts Iwr
Conducted
Sheet of
Date: 04
-Alm, 24QIo-
M-W Job No W D* 0461
Well Location: J4�' Arit Mgr4if . 15' L .#Vt ,d bie, c, U'd of Ar" lin/. LE. pap&fu l'
Well InformDePthey{p' Dation: Tatai ' 1 Screen: From—TTT�
Depth of Casl^9'1�._
Casing Sizer Screen Diameter.-:_- Screen Slot:
Aemarks:
Pump Information: Intake dept : — Pump Size:. -Z --Water LeveJ AAeos.:
Static water level:Ii.V Arg. discFw Ve: — GPM, max, drawdown:
Misc. Pump Info.: Pump On: DGte! At&!6 Time 1 :00 Mtr. Reading:
Pump Off: Date:0k-jD1—v*Tirme:l3.8D Mtr. Reading:
_-�
R WE • ..
r
�_�-
Sep 22 06 12:31p THE STEPHENS TEAM PJM
19072737205 p.3
L
"Cr
�Z
N
W
�
wj�
u
k
N
Q
Y
Q
O
an
I
e
ww
l\
I
8
19072737205 p.3
r�r
an
I
I
GrAllc.Bull
e
r�r
Municipality of Anchorage T
• 'i-'' Development Services Department ► = • t`•
Building Safety Division "
On -Site Water & Wastewater Program
4700 South Bragaw St. W�
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING r
Parcell.D. 050-501-02 HAA# W15L �-5
1. GENERAL INFORMATION Expiration Date: :;%42 r10 t
Complete legal description GLACIER VIEW HEIGHTS SUBDIVISION; LOT 15, BLOCK D,
Location (site address or directions) 23105 MYRTAL DRIVE • EAGLE RIVER, AK 99577
Current Property owner(s) HARRY & HILDEGARD SPEAKMAN Day phone 622-5840
Mailing address 23105 MYRTAL DRIVE • EAGLE RIVER, AK 99577 _
Lending agency Day phone
Mailing address
Real Estate Agent ROLF MILTON w/ PARTNERS REAL ESTATE Day phone 694-4994
Mailing address 11940 BUSSINESS BLVD. • EAGLE RIVER, AK 99577
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
B
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
0
Individual Holding tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of 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 samples. (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.
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $ at, or prior
to closing for the engineering services provided.
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 riles 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 ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone 337-6179
Address 6901 DEBARR ROAD, SUITE 2B • ANCHORAGE, AK 99504
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines 8 Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. AKW WC, Inc. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
Date 3
✓ Approved for 3 bedrooms.(,;r(;:((rFrr rrir
1,1tZY OFq�,',�i�
Disapproved. ���r�: rte• ' ' 'C,f
Conditional approval for bedrooms, with the fllowing stipns: ON-SITE
' WATER AND : m
PROGRAM
it„/1/1(111''
Attachments:
HAA Checklist Manitenance Agreements
Septic System Advisory Supplemental Engineer's Reort
Well Flow Advisory Other
By: r �^ Original Certificate Date: 1z 1/01
1
(Rm. I
Municipality of Anchorage
• Development Services Department
Budding Safety Division
On -Ste Water 8 Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-66W
www.ci.anahorsge.skus
(907)343 -79tH
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: GLACIER VIEW HEIGHTS S/D: LOT 15, BLOCK D. Parcel ID: 050-501-02
A. WELL DATA
wen type PRIVATE it A, B, or C provide PWSID# N/A
Date completed 8/2-4/1983 Sanitary seal (YIN) YES
Total depth 200 ft. Cased to 130 ft.
FROM WELL LOG
Date of test 8/2-4/1983
Static water level 60 R.
Well production 8 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0_ colonies/100 ml. Nitrate _.QmgJL.
Well Log (YIN) YES
Wires property protected (YIN) YES
Casing height (above ground) 12+ in.
AT INSPECTION
4/1/2003
59 ft.
1.2 g.p.m.
Other bacteria _0_oolonies/100 ml.
Arsenic: N/A mg./L. Date of sample: 4/2/2003 Collected by: AKWWC. INC.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEEL/S.T.E.P. Date installed 8/10/83 & 6/9/92
1000,
Tank size 50o gal. Number of Compartments E Cleanouts (YIN) YES
Foundation deanout (YIN) YES Depression over tank (YM) NO High water alarm (YIN) YES
Date of pumping 4/1/2003 Pumper JR'S PUMPING
C. ABSORPTION FIUNR
ELDDA— A
/9 0.
Date installed �� Son rating (g.p.dJR'or ftlbdrm)`
System type TRENCH
Length 38/55 R. Width 780j 3/2 R. Gravel below pipe 10/4 R.
Total depth •17.e 10. ft. Eft. absorption area 440 R= Monitoring tuba YES Depression over field NO
Date of adequacy test "4/312003 Resutts (Pass/Fan) ***PASS For 3 bedrooms
Fluid depth in absorption field before test _221 In. Water added 768 gal. New depth 38 in.
Elapsed Time: 969 min. Final fluid depth 21 In. Absorption rate >= 450+ g.p,d.
Any rejuvenation treatment (past 12 mo.) (YM & type) NONE KNOWN If yes, give date —
**TESTED 1983 TRENCH. PRE—SOAK PERFORMED ON 4/2/2003.
***1992 TRENCH SURCHARGED.
D. LIFT STATION
Data installed
"Pump on" level at _in.
E. SEPARATION DISTANCES
Size In gallons
High water alarm level at
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankllift station on lot 100'+
Absorption field on lot $927"100.36'
Public sewer main N/A
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/deanout N/A
Sewer /septic service line 25'+ Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water 100'+
Wens on adjacent lots too'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 100'+ Driveway, parkingivehide storage 0'
Curtain drain NONE KNOWN Wells on adjacent lots 1000+
F. COMMENTS *WAVER GRANTED TO 1983 TRENCH (WR890005). **DISTANCE FROM EDGE OF,41992 TRENCH
CLEANOUT TO EDGE OF WELL HEAD. ***PER 1983 INSPECTION REPORT. 'N+WR920025/11992 TRENCH
G. ENGINEER'S CERTIFICATION
1 cerW that I have determined through field inspections and.; .-"
! ri
review of Municipal records that the above systems are in "
conformance with MOA HAA guidelines in effect on this date.
. ................
e as.,
Engineer's Print N% JEFFREY A. GARNESS a E-79`
Dategra/ j 'IP. .... b►
�orsssWo
HAA Fee $ 3175- — Waiver Fee $ _
Date of Payment 3 Date of Payment
Receipt Number. Receipt Number,
(Rev. 1?101)
04/07/2003 10:09 FAX 6944993 PARTA•ERS REAL ES Q02
•e:
•J � r I
SCK' ` —i,/�. �\a 1• •.
0--f!
WC
Rc: v =.... .. �.
�%i ••• fit). eC.v
�, ti YV Gt•r•-6
.. ASBWLT
I hereby artily ilue 1 haee naveycd the fo&mkq'desr&a
Popery. Lel- [fes
1/f.CW .%lr-f i17fT iL/�,N. a urc ,�• pet•.
I,n,m aitualed tLe�ed� am wihin propert
ovoUp each a the ptopag a y �ill3 W do m[
aotlratoem Ad
DO an
Ord
tt thee!+! ptmraes 8ogrgnutels�t�eim atd m o0 loedwsls.
e6+dk steed M.oe visile encenee on said peppery'
Dated et Emee Rma. Alaska
this '7 n �y u(_AA r r � ag
SCALE: Mal - pwad S SON
I raw f9�mf 69f�30�'
Municipality of Anchorage
Development Services Department
Building Safety Division .
On -Site Water and Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK.,'99519-6650
www.ci.anchorage.akus
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-501-02
9.' GENERAL INFORMATION
HAA # F/A DltQ 2 4
Expiration Date: 8- .2 9 - O
Complete legal description Lot 15 Block D, Glacier View Heights
Location (site address or directions) 23105 Nyrtle Drive
Current Propertyowner(s) John Emmi Dayphone 694-0371
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
23105 Myrtle Drive, Chugiak. AK 99576
Day phone
Day phone
Unless otherwise requested, HAA will be held by DSD for pickup. _'WG _ 1fzr-X' S Ac !0/
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Individual On-site
Individual Holding tank ❑
Community On-site ❑
Public Sewer ❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of 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
neer 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(aie) 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. C [{ % q
Name of Firm Robert C. Cowan, P E. Phone'
Address
Engineer's Printed Name
ENGINEERING
1 Eagle River Loop K04 .
9957/ Date'
5. DSD SIGNATURE
1/ Approved for 3 bedrooms.
Disapproved.
p ROBERT C. COWAN
/f`i3� .� CE • E 301
++tl�i<p • ��,�
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: a , ( In Original Certificate Date:
(Rev. 12LC(
N
Municipality of Anchorage
•' '�'} Development Services Department
Building Safety Division s
On -Site Water & Wastewater Program • �'
4700 South Bmgaw St.
P.O. Box 196650 Anchorage, AK 9951M650
www.dAnchorage.ak,us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L/67; FS `ipt i✓C,a 645 Parcel ID: DSD - Sal
A. WELL DATA
Weil type IiAA' If A, B, or C provide PW SID #
Date oompteted19 Sanitary seal �J)
Total depth A@ft. Cased to ±40fft.
Well Log (Y/N)
Wires property protected (YM)
Casing height (above ground) __Z tgtin.
FROM WELL LOG AT INSPECTION
Date of test
Static water level 4O ft.
Well production co g.p.m. / Z g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 ml. Nitrate o• 5 mg -fl. Other bacteria D colonies/100 mi.
Date of sample: O / Collected by:
B. SEPTICIHOLDING TANK DATA
Tank Type/Material G Date installed J61101,03ta�9 'i i
Tank size /QAi gal. Number of Compartments _.3 M Cleanouts (Y/N) YGrd
Foundatio�00 eanout (Y/N) t 1l Depression over tank (Y/N) �J High water alarm (Y/N)
��,d��� t
.Date of pumping � Pumper L % � S
C. ABSORPTION FIELD DATA
__.D-,ta Inq!alie / v.`Sod rating (g.p.dJft2 orf 2/bdrm)66 Svstwm type �LENG h
Length 3 ft. Width 3 ft. Gravel below pipe ft.
Total depth lo ft. Eff. absorption areaavue Monitoring tube 45 Depression over field MO
Date of adequacy test S 110 0 / Results (Pass/Fad) P* c For bedrooms
Fluid depth in absorption field before test in. Water added gal. New depth 'n.
/ r
Elapsed Time: !(Q min. Final fluid dep 4 in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) /V ONE I&IWW If yes, give date '—'
D. LIFT STATION
Data Installed G S QZ
"Pump on" level at .8 in.
Datum
E. SEPARATION DISTANCES
Size in gallons
"Pump oft level at ZE in.
Cycles tested Z
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankfilff station on lot
Absorption field on lot /00 f -F
Public sewer main N 1h
S%W-fseptic service line -PS r4"
Manhole/Access (Y/N)
High water alarm level at _ 3 f-_ in.
Meets alarm b circuit requirements? C 5
On adjacent lots 1/00 1'F'
On adjacent lots i eVp r 06 -
Public sewer manholaldesnout N�h
Holding tank A( /4
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: /
Building foundation f Property line 5 /f f ,3 (4L51Absorptk)n Heid S ry"
i
Water main N A Water service line r, Surface water /OD r
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundation �� f Water main N
r f
Water Service line 0 f Surface water 00 1` Driveway, parkinyvehide storage
Curtain drain MIME A/M(W Wells on adjacent lots OD 1,
F. COMMENTS
* H!Q t1
G. ENGINEER'S CERTIFICATION
I certify that I have determined through Reid inspectlons and
review of Municipal records that the above systems are in
conformance with MOA HAAvgurdelines in effect on this date.
Engineer's Printed Name /c d Q't =%/ C. Co w A. -J
Date
HAA Fee $ 3 a 0
Date of Payment 1/26 1 A /
Receipt Number O 0 V 6 3
(Rev. 12100)
Waiver Fee $
Date of Payment
Receipt Number
At
\A,\ pc�@F�OWAN
C .0601
...;,,nom
MUNICIPALITY ANCHORAGE
- - • '� .DEPARTMENT OF HEALTH 8 HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # C SO S`c I -0 2
1. GENERAL INFORMATION
HAA# 4l(�glnr,ISS'R
Complete legal description Lot 15; Stock D; Gtaciek View Heights
Location (site address or directions) 23105 Mytttc Dntve
Eaqte RiveA, AK
Property owner Chattes b Stacy St><Lcktand Day phone 696-1340'
Mailing address 23105 Hyxtte DaLvo Eagtp Rivp2. AK 99977
Lending agency
..Mailing address.
Agent
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3
XXX
Day phone
Day phone
fly C 04l 11'1yOF
EPMq`SERVI� pl�sON
R 04 1986
E�El QED
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 XXX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-0ri1R".1/91) Front MOAR21
5. - STATEMENT OF INSPECTION BY ENGINEER.
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system Is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and Inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations In effect on the date of this inspection.
Name of Firm S & S ENGINEERING Phone G 4 y' 2-9 -7 "f
17034 Eagie River Loop Road No. 204
Address Eagle River Ales a 995
Engineer's signature Date 7
6. DHHS SIGNATURE
By:
%C Approved for -_ bedrooms.
Disapproved.
Conditional approval for
Additional Comments
bedrooms, with the following stipulations:
i
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an Independent
professional engineer registered In the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct Inspections or analyze data before a certificate Is issued. The Municipality of Anchorage is not
responsible for errors or omissions In the professional engineer's work.
rI'M Vh- W1 eo UOA.
'PAUTY OF ANrHO4A(�..
YAEWAt StgviU-S Dryig
,., Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICE6"p 04 1996
Environmental Services Division r r t
825 L Street, Room 502 • Anchorage, Alaska 99501 • (90 C&, , E
Health Authority Approval Checklist
Legal Description: S Parcel 1. D.: 06- © 5 0 1 02
A. WELL DATA t4 Lz i4vs.
Well type FP -kJ &T -C, If A, B, or C, attach ADEC letter. ADEC water system number A
Log pmsent&l)
Date completed 4b -4 — S-5
Total depth 'Lo®I Cased to 1$ . f 3,2 7 N Casing height (above ground) 12- k(
Sanitary seal &) q Wires property protectedON) J
FROM WELL LOG
Date of test `3 - LA -9 3
Static water level
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform O Nitrate j / O
AT INSPECTION
°b L`1 —9 L.
1.3 g.p.m.
Other bacteria
Date of sample: g .20 -9 V Collected by: .S/S &14g=
S. &EMrCIHOLDING TANK DATA
0
Date installed 'd-10Tank size Imo Number of Compartments Z Cleanouts ON)_
Foundation cleanout O1) N( Depression (1;W_ ! High water alarm (YM) 0 A
Date of Pumping Pumper .ZZ. 4zMt'_"j
C. ABSORPTION FIELD DATA
Date installed (n - 9--'7Z Soil rating (g.p.dAI* or ft'/bdrm) 0• to System type 7 "e f-/
Length •39 r Width 4 r Gravel thickness below pipe D r Total depth 7-2 \r
Effective absorption area 7fb Monitoring 7iibe present(VN)__Y_ Depression over field (Yt� zf
Date of adequacy test Results ssRFal9 &ng For 3 bedrooms
Fluid depth in absorption field before test (In.); G2'` Immediately after(.(2 gal. water added (in.):
Fluid depth g� r (ins) Minutes later: /Q� Absorption rate = 7SD;d•
g•R
Peradde treatment (past 12 months) (TLY jr yes, give date
72-028 (Rev. 3/98)•
D. UFT STATION
Date Installed L-11 -I -Cl Z Size In gallons 15-00
Manhole/Access&04) V "Pump on" level at' of 00� "Pump oft" level at' �� N
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
'Datum a FF t%Irti'n
SEPARATION DISTANCES FROM WELL ON LOT TO:
Se olding tank on lot 1 b"1 On adjacent lots 1 do L
Absorption field on lot tom t On adjacent lots U t 4 -
Public
Public sewer main .1(or Public sewer manhole/cleanout
t -4 -
Sewer /septic service line IS Litt station 1 0=.% 4
SEPARATION DISTANCES FROM&M!rVHOLDINGTANK ON LOTTO:
Foundation l p t Property line t o Absorption field
Water main1service line __J'� Surface water/drainage Wells on adjacent lots 14=0 t+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line j t (nmLo Building foundation tS I Water main/service line lc7
Surface water to C> k 1- Driveway, parkingNshicle storage area I o k
Curtain drain t 104- 0-r34 ,tel r: Wells on adjacent lots too %+
F. ENGINEER'S CERTIFICATION
1 cerW Mat 1 have determined thru 116M Inspections and review of Municipal
in conformance with MQAt�del�tiect on this date.
Signature
Engineers Name t� b Q i AL;- C
Date
9 /3/d?
HAA FeeW
$C� '�/
Date of Payment / 7Z 9r.
Receipt Number
72.026 (Rev. 3/98)•
Waiver Fee $
Date of Payment
Receipt Number
AMM C, COWAN
CE -8801
are
MUNICIPALANCHORAGE
• :' DEPARTMENT OF HEALTH
& HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcell.D.# 11�-_1421 -C)Q HAA# �An�l��aR
1. GENERAL INFORMATION
Complete legal description Lot 15: Bloch D: Gtaciea View Heights
Location (site address or directions) N.H.N. MyUte Drive
Property owner
C.
V.ictoka
Day phone 283-1017
Mailing address
P.
0. Sox 1410
Kenai, A£aaha 99611
Lending agency
Mailing add
Day phone
Agent-Tnnn inrbe_1XIM if 7TF aFAI FCTATF Day phone x9-
13135 OCd Gtenn Highway 0100
Address —€ag8e 91ver-4&6ka 995571
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3 y
3. TYPE OF WATER SUPPLY:
Individual well XK
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 XX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(Aa 1/91( Front MOA121
5.
6.
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I furtherverify 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 e IS ENG `-__RING Phone
77034 Eagle River Loop Road No. 204
Address —Etg;e Rivet, Alaska 99j/1
Engineer's signature
DHHS SIGNATURE
Approved for 3 bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Date 0-2-1-611—
bedrooms, with the following stipulations:
By:
—)OR tJ 's"m f TI -F Date 5,11. C?Z
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and thei r lendi ng institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025(11«-1191) 8+ k MOA.21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L.,=:,,r IS -&L-Y, i7 Parcel I.D.
A. WELL DATA
Well type ,Sal ^ ,. L - If A. B, or C, attach ADEC letter. ADEC water system number
Log presentON) U Datecompleted 0-4'-63 Driller
Total depth; % Casedto 13017. Casing height- 12��
Sanitary sealdl?N) / Wires properly protected�Y N)
Date of test
Static water level
FROM WELL LOG
it E3
lOo
AT INSPECTIP#UNICIPAL11 OF ANCHORAGE
IRONMENTAL SERVICES DIVISION
SZ ^ 1 1992
Well flow (.0 g.p.m. t I VE D
Pump level U�. 1(02
'F tiow TFT 'f�—Ra'r�M�D 8y a✓.�-.E.S.
SEPARATION DISTANCES FROM WELL TO: %I-"%, f%iWLwS t%AoAr.
Septic/holding tank on lot f o7 ; On adjacent lots
Absorption field on lot t 1 ; On adjacent lots 1 A_
Public sewer main a A, Public sewer manhole/cleanout <'
r 1�
Sewer service line ZS Petroleum tank -A C" er,
WATER SAMPLE RESULTS:
Coliform Nitrate t,1M Other bacteria
Date of sample: Collected by: S 5[ sz
B. SEPTIC/HOLDING TANK DATA
Date Installed B-10' e2 Tank size tom Compartments
2
Cleanouts4VN) T_ Foundation cleanouk�?JN) `/ Depression Y -�J
High water alarm (Y/N) Alarm tested (Y/N)
Date of pumping. — 13 — 9 2 Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
1.
Well(s) on lot J 17 - On adjacent lots Foundation 101
1
Topropertyline " 1':� Absorptionfield S Watermain/serviceline 111 a
Surface water/drainage - I <nr,� t {
72-026 (Rev. 7/91) Front .. CONTINUED ON BACK PAGE
C. LIFT STATION
Date Installed "") 2 Manufacturer
Size in gallons Manhole/AccessXPN) T
M y
VentQV'N) "Pump on" level at 121e> "Pump off' level at
1 . . 11
High water alarm level Cycles tested
Meets MOA electrical codeso7N) —!�
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot `� 4 On adjacent lots (� Surface water fit+
D. ABSORPTION FIELD DATA
•Date installed Soil rating �•�/tt System type
1 3t r
Length 38 Width Gravel thicknes s (cai Total depth 22
Total absorption area —7 to O Cleanouts presentd77.N)
Depression over field (YM5 N Date of adequacy test
Results�laii) for bedrooms
Peroxide treatment (past 12 months) (Yea,>. tJ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
.t 1t
Well on lot Oo On adjacent lots 3 '� Property line
To building foundation S To existing or abandoned system on lot
Onadjacentlots 301 k Cutbank t4 A Water main/service line �cI
Surface water tk Driveway, parking/vehicle storage area (dt
Curtain drain �o�� Y=:��
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this Inspection.
.� 01 AL 1%%
S ti S ENGINEERING i�.Q�•••'�•,,,•ti��n� a,
Signature 17034 Eagle River Loop Road No. 204
g age rver, as a / *?QGin 3
Engineer's Name •• «•«• .•..• ••.
G� O
Date g— 21� `Z ��;•R04 • J-76AFER : W�+
`OF 'Ns
HAA Fee $ %7 Waiver Fee: $
Date of Payment 'z/- L Date of Payment
Receipt Number P57131 (-5S Ur Receipt Number
72.ON(Aw. 1191)Bwk MOA 21
MUNICIPALITY ANCHORAGE
O DEPARTMENT OF HEALTH t£ HUMAN SERVICES M
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.# JOL�:�l'n� HAA# 1AIDg2011^3
1. GENERAL INFORMATION
Complete legal description
2.
Lot 15; Bt.och D; G4ac.ien View Heights
Location (site address or directions)
N.H.N. Mytae Dtive
Property owner
Ch)tistophen Vi toaa Day phone 283-1020
Mailing address Ht s4 Sr,Y i546 Eag�v—BsvP)t. AfaAhn 99577
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 V
3. TYPE OF WATER SUPPLY:
Individual well XX
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 XX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
. attesting to the legality and status of system.
72-025 (Ft".1/91) Front MOA h1
5. STATEMENT OF INSPECTION BY ENGINEER
6.
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this Inspection.
Name of Firm Phone
Address 17034 Eagle River Loop Road No. 204
Ecnle River. Alaska 99577
Date—t3-`i2
Engineers signature
DHHS SIGNATURE + //� I' /
Approved for bedrooms. JCC GOnww?ePn7`I 4 h4WWsd/
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
By:
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given In paragraph 5 above by an Independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is Issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineers work.
non (R«. w1) SKk MOA#21
Health Authority Approval
Lot 15 Block D Glacier View Heights Subdivision
HA920163
March 25, 1992
Following an extended period of vacancy, the on-site wastewater
disposal (septic) system marginally satisfied the minimum
adequacy requirement or handling 950 gallons of wastewater per
day. Even after the extended period of vacancy and non-use, the
subsurface disposal field continues to have over 50% of the
absorption area standing full of water. At best, this
absorption system is in the final stages of failure and has a
limited remaining effective life expectancy. Additionally, the
subsurface disposal field is installed or a severe
(approximately 50`s) slope which could result in the septage
effluent day lighting at any time during the remaining life of
the system.
y Municipality of Anchorage AUL
Department of Health & Human Services
low
HEALTH AUTHORITY APPROVAL CHECKLIST GODS
Legal Description: Parcel I.D.
bat-�,eq_, q%&V]
A. WELL DATA
Well type'`) If A, B, or C, attach ADEC letter. ADEC water system number
Log present ON) �� Date completed 8-x-63 Driller-SJL- ►-1
Totaldepth � Casedto X30) :70 Casing height Wt
t4-
Sanitary seal ON) Wires properly protected( /N)
Date of test
i
Static water level
Well flow
Pump level
FROM WELL LOG
6-��f33
(oo
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION Zo
147 g.p.A
lLog
C
Septic/hohiing tank on lot k On adjacent lots 14 -
Absorption field on lot On adjacent lots ( ct�:> 1 4�
/ Z -I-el
Public sewer main n/��F, Public sewer manhole/cleanout
Sewer service line S' Petroleum tank 4DAI6 KribWd
WATER SAMPLE RESULTS:
Coliform 0 Nitrate .0 tom. t /�_ Other bacteria
Date of sample:kk-2'I -9 t-2�1t Collected by:
B. SEPTIC/HOLDING TANK DATA
Dateinstalled-to"t33 Tanksize tC%-,o Compartments
2
Cleanouts (AN) Foundation cleanoutV?N) Depression (Ydlp t -I
High water alarm (Y/N)
Date of pumping
Alarm tested (Y/N)
_ Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot 1 5)� A' On adjacent lots l I ( Foundation (o)
To property line tol.Ir Absorption field ::I� Water main/service line to'�
Surface water/drainage 1C)r,>t•1'
(3
i
72-026 (Rev. 7191) From CONTINUED ON BACK PAGE
C. LIFT STATION
DataIn ed
Size in gallons
Vent(Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access(Y/N)
at "Pump off" level at
(Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
On adjacent lots
Surface water
Date installed
Soil rating System type��•��
Length 45S Width 2 Gravel thickness ¢ Total depth 9 -17 VN -16:5
Total absorption area 440 Cleanouts present(IIYN) y
Depression over field (Y/g Date of adequacy test 7-. 7 A 2
Results ((�N/fail) '{���`� for'� Fad bedrooms
Peroxide treatment (Past t2 months) (Y �otit �-► 0101.1 If yes, give date
SEPARATION DISTANCE FROM A13SORPTION FIELD TO:
Well on lot 2 On adjacent lots �I �' Property line I btk
2-1- 511 )
To building foundation 20 '} To existing or abandoned system on lot �oN/t;
On adjacent lots �� t Cutbankt�Water main/service line
Surface water I 'Iri �=
Driveway, parking/vehicle storage area
Curtain drain
E. ENGINEER'S CERTIFICATION
1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
S & S ENGINEERING "rQ�0 .••"••••.;1s'a�
Signature 17054 Eagle River Loop Road No. 2(14 or Gj� . ~•. �Z+e�
Eagle River, Alaska 99577
SC3�►�3�;
Engineers Name /' NJN.M . NwiN•,
r,
Date �� �3 X92 j1 F �� •F •••EF, d. CHAFErI':
C . No. 8215
r1. n
HAA Fee $
Date of Payment /,
Receipt Number Sa' MOO
`T
72-026(A". 3/91) Suk MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
p�3
I
TA
c
Q
l9
,_or
14
W
LCt /5 , SloCk
Glacier
Anchorage Recordir
T.V. o� SLATE
�f WELL CAS/NCaS
cM�1
770,V ' 9AB/OW N RMIMAIG WALLS CTYR1
OffCK
141i .S%ANn #-1115-S57RUCTUREr, ni
P/A:eS
YRT05 40 t
CE OR.
1 weal ewlar the, IMee ewoom the►roprtr ohard and Meorl►e1
her0en, M1 tdel M I►grM ere, 01114140 Owl" we o11Me the Mee•
ctrl NM/1Me eo ee1 M•rle e1' ederoeM ed oelae.M erelerfr O,a t1e1
eI tmprewreeM14 M M1eoI M40wry evwlw M edereeM M fM ►reellee
td evee,lM era Ides theM I Ne neawre, eHHry IMw, e1' Mhw det►4
eeunldls M MII Pro Y m"I w W1016e sweet.
SCale /'� Date
Ret. SVv 59 F. B. No.
c
eeIIMM14 of mor/ ettw thM thee. ehe+d M
the Net of fNw1 we pot eeeVN Mreud "lose
�EGENeMen14eo hwN. 40
0 Bross of Aluminum capped monumor
o Iron pipe OW01' 11041' recovered.
17 2112 hub & tock recovered
• • 5/9"jt3 dttbar 11t this survey
OT
16
r
�t
d� 4 Y Ataww�,V'7t� r
Prepored by. It. L. BUTTON
R001,tr1nC Lmd SLrriyor
(907J279.6200 b/9 W. £iyhlhArl. AnOwW A/mko99501
Property ot:/ChrisfOP% r Vl%C740/S
11
DEC -27-91 FRI 10:29 FORTUIJE PROPERTIES
DEC -23-'91 13:13 ID:Pfa�MAL PF1AC 1713-T9-2 "1
Wk Buten, P.E.
Rgl tcrcd Civil Ens;accr
D=Mber 11, 1991
HoukNuTfs
!~31101111 Arced
421 West Union Avenue
Bound 8fook, NY 08805
itc. Glacier Ylow Heights, Lot 15, Block D
NHN Myrtle Dr.
MGI 9393
Dew Ms. Arcud:
P.02
tt2W P02
1 - , i.. r• -i.
At your request we have perrormod a acpde adequacy tat, well now telt end p0tabl1lty testins
for the above rafueneed home.
The well was found 10 produce at a sulttlnbd rase of 4.3 OPM over t e hour tett pt:riod as
required by FHA guideIInes and meets Municipal Hulth criteris with 111,11fsetory water quality
ana'ysis for coliform and nitrates. The well wire sheathing docs not meet code requirements And e --
will require rglhRSns tI an esdmaccd cost of 3100, Tho well is loattd 92' from the existing
lachfield under a wavier of 100' separetinn disuce and if upgraded this wavl:r would bcco'nc
invalid and would require respplicilion and rapproval by HeAllh AuthudI10•
The optic system was sulljectod to an adequacy lestlng for acceptance ntc es required to coact
1`funlclpal Guidelines for Health Approval Cettificatlon, The Uachfield was delermtrod to
e:cep: 430 gallons per day, howevef, the field did back up e(ltef approxirrately 90 gallons wa1
added and was found to be in a flooded of full state at the beginning of *e test. As per
Municipal guidelines a lcuhAtld operad`g in a iW Health Aon Is c end n+aa tQ be limit to g teral
Improperly and therefore would 1 Wj&A 5sAL. pp y
financins. There is also a camera wlth the avallablltry of area for a rcplsccr..cnt icachf�etd due
to extreme slope and driveway location in relation to potentia! replacemenr Ern. If Icachficld
replacement is possiblo it would be very expensive. The deter4nallon of tltc flooded conditlun
was made through surface inspection tubes. A better detg.rhinstion c0-s1d be srsde by excxvAtion
into !tie field if so desired. 'Che cost of th;x excavation is estirrvtd at 5700.00.
If you rave any quc3tion3 place call our office at 694.5195.
slncenly,
Loult Auters, P.E.
... Y.. tnr..� . 1'.+. Y..... �..... IYi �: . 6LJw.r Jin!, JELL.{w{ • rw 94C,1,0.1.1tq]
1-0 2x PRUDENTIAL RILOC 12-23-91 02!0A!4 P002 4'25
DEC—=7-91 FRI 10:`,.59 FORTUNE PROPERTIES
P. OS
. - DEC -23-191 13113
12-10-1921 10:50
TEST DATE'
LEGAL.
1D1PFOOO�NTIFL F9 -CC a :713-7M-2300M*� 1120e P03
806 489 8560 - .... • . -;CjS6 rA T5M- S • ,.+ � "r r a op " IV
EAGLE RIVER ENOINEER= SERVICES
V.O. BOX 773294
BAOt F RIVER, AN 99577
wELL & SEPTIC ADEQUACY TEST REPORT
Dewrabar 12.16, 1991
Oluicr View l;elghts, Lot 13, Block D
LOCATION; N1IN I•tyras Drive
RESIDENCE: Single Family, 3 1lsdrOoms
PUMP YIELD: 4.5 01MODs per Minute
WATER SYSTEM: private Wrll
SEPTIC SYSTEM: From Munlclpal R000rds
Tank: 1,000 011104
Absorption System: Trench Type
INSTALLATION DATE; 1903
INSTALLED ABSORPTION AREA: 440 Square Peet
ORIGINAL SOIL RATING: 145 (FtOm Odglaat Sotl Loa)
TEST PROCEDURE
SF.EI'IC: The luthGeld was initially charged with water from rho on -slit at a neo of UGpbt.
The saptle unk and leachfield liquid levels were monitored referencinS r. mtswremcnt below
the top of the standpipe. During the test, Water was added through the 10 clan cut tube Rnd
the leach field water level Was monitored as water was added and then absorbed Into the
altrro,tltdlvg soil.
ons of water showing that
the water level In the septic k
leochfield was ra Icceptl nat fl u flow rate.% The Septic addNOn Uk Ie el c ctlnued to rise 3.50
aflor 3V gallons of *stat was added, A total rise in liquid ltvel in the IachGcld was recorded
The A else in tacbneld level of 14.5". Mwow rate was tbgn u e;nentS were taken of the lover 49 hours to ar hfiold letllonl vel sifter 24
hour% with a serum to edema sttrdng�liquidYevel. The mordtorood catc-5 the however becsuse4the
i *111 atUpt the requlred 130 91110" tda of tflluent, per
R092% PRUDENTIAL RELOC 12-23-91 09:13AM POC3 025
DEC -27-91 FRI 10:.59 FORTUNE
• DM -23-'91 1314 IDIPRt"*14ilAL PF1AC
PROPERTIES P.04
a 1713-789-23c� i120B PO4 ..
.. �.��..rtw a da
.• ske 463 6550-• • • •may •��= 1WSTtR3
system was inl6eIly, to a Hooded condition It will not meet Municipal approval.
WFT L: 'It,c well was pumped at aets�dy flow rate of 0 ()PM' There µ•ms no ehinje in the
fate of pressun afteJ 45 mints. The ykld or flow nes of the well wu monttered and
ra
fThe well win will require lashcathlr¢ with conduit
atculrted at a maximum rasa of 11 GPM'
Connecilons to meet Code requirements. The well
operate, under a waiver of stalca:ion distance
whIeh expitea upon any apgnde.
TEST RIMULTS
The well ylcld or flew rate meets the Tequiremcnts of the Municipality of Anchors je (MOA) foc
It 3 Wrtoom single latnily rafdcnce ss of the day the system was tested' The well (low rate
eAterit Meets the FHA 4 hour well nw n4ulremtnts.
furher inveedjadon and possible tcplacemerthe pdC system v 1_ l craw meet MOA
Mtessment of existinj subsuffeca condidoot by the inspccdng engineer is linlitcd to infurlr•stion
obtained from *..e available monitoring tuba and Municipal second X=h• We do rot guarantee
the vallERy or quality of subsutfs: a IOU ssd IrspeCtions perfotmed by the ordinal insrPe"S
enginoer or authority. T1111:100!1- Is Lm,itod to absorption tale testing sand surfnCc itpRrenan
musaraments a our �'Y1oAw'� by P Y Murd� water Quality othuOf 'the t the bee cltia: teal n verify
Integrity of the plping
content.
The operadonsl life and the natter of Complianco with State and hsunlelpsl codes, for all watcr
and septk systems de`Q�nds on the local 3011 Wditions, Wondwatu levels that may Pat be
wobitrvM fm, the ho s)' umroard theudetslt of tequlrCdtw<rsdnjeprnOced=. Septic aystcros cxphs wb
cral with use ed
future cnvironment2l eoneems may require more extensive WIN, which could rendor the
leachfaeid unusaable. Ibis is true of all septie systems.
Thtre is no gut" "t the well and septic system tested will mat the requirements
our
apptoval in the future. The best date a'td inves:;gation of existing e0nditiohs is p•
anent for submil� em�f wMl'�+ 1�Isakry HWtpoo Dould be ciartmenes teased wifor thtlf t hlthe testa enginee'.
approval. Any
If it Is requested we w1il submit the report dlroCpy to the Mlmtctpetity'
R-929 PRUDIt1TIAL F?' -CC 12-23-91 C9:13AD1 PC04 1:25
FED -23-92 TUE 14:43 McCI_ZNTOCK L -S -ER ENGINEER
P. 01
Eagle River Engineering Services
11940 Business Blvd, Suite #205
P.O. Box 773294 694-5195
Eagle River, A. 99577 Fax 694-3297
Legal:
Owner: .tet. Date:
Time
Meter
Reading
Well
Level
GPM
��►t..;i
.,.e/
we_ d -moi ..�rr re,.,,o..G e.r
i-e.c.{...: F/�..� r..ta c�!<✓
qir�� //i..%*>� S.i,'�e
NY+ L[CL/MGIC ootr
73,30 • /i..r1 pf p i.✓
/:,w.?
3• ! o
74.r.
/i..i
Y1 � Yew GGA w f
fn %4 i✓�i /�•� c -f/ N
e Go
• e i' ir..+. F. e 4/
Time Meter Well GPM
Reading ILevell I
REMARKS: �Y-
p., a fa wC//
��►t..;i
.,.e/
we_ d -moi ..�rr re,.,,o..G e.r
i-e.c.{...: F/�..� r..ta c�!<✓
qir�� //i..%*>� S.i,'�e
NY+ L[CL/MGIC ootr
73,30 • /i..r1 pf p i.✓
pv-^
A Z ./— rs o✓Cr
/i..i
Y1 � Yew GGA w f
fn %4 i✓�i /�•� c -f/ N
e Go
• e i' ir..+. F. e 4/
Post -It" brand fax transmittal memo 7671
uwr eee� woiuum ® _ OZ l . .
ill of—deyr aoueje/ey ea,y „ej6n4p/ieeJy e16e3
69 MS
N�v3nvro r` ,
T
/,,n /"PY 0460 A��
y
ce/r
%f -
7 5"YZ -
LIL
o�g o
' L -IV / r// 1/117 Stl
✓ fyf�G',`v/,/�7�/ate � `d717/i
yM 6v/
MAR -13-92 FRI 10:36 MaCLINTOCK L£—ER ENGINF_ER P.02
Eagle River Engineering Services //;t-
11940 Business Blvd, Suite #205
P.O. Box 773294 694-5195
Eagle River, A. 99577 Fax 694-3297
Legal: L.r Jt iSisr 0 IYIT
Owner: �,r'af Date: -j /,
Type of test:
Well Flow Test 0 Septic Test Only 0 Well & Septic Test 0 Other:
Time
Meter
Reading
Monitor
Level
Well
Level
Tank
Level
GPM
PSI
Remarks
q
Re, r.. rr te,r Y.n .Y..✓
/: r(./
•
I: Ali
5
`gip
_—
1:53
?65"3 0
/oo'
?•t
frd+lr / F/.. rsk
y:
?70
?
.777/0
'
Sre Yom, r-
t: fs
l/L'
7:0s
/
e
2 7.2 /v
/i1
+. r
we/: �...r
zio
.t wo
/ r
3f/1'
777rb
F'J
�•J'
/.:s r. F•... r.
7'7W0
7tlse
So
Z.70
/'r
/.
MAR-1Z—S'2 FR I 10:37 McCL I 1JTOCK L.S—ER Ef/G 11IEER P. O?
Eagle River Engineering Services zlb-
11940 Business Blvd, Suite x(205 594_5195
P.O. Box 773294
Eagle River, Ak. 99577 Fax 694-3297
Legal: /wt W O G/tie v/r / N/>•
Owner: 111f r pate' 3 /1 Z -
Time I Meter 11-evell Well GPM
Reading
/:
JfJr✓
7�
0.7
/1:r5
2f3tS
Sr
S'�
:/♦
?4 yao
/1�
N,o
.1 :Y7:r•
1 Jo
3;i01r)
h Y
l' 74
.T F rev
/ fe
3. N
.Z P •a
<v
/ L •
.O
Fhr♦�K i/r e�.HrJ
2:/7
GPM
/fr2
Reading
level
3;sv: 14
/
.1 :Y7:r•
1 Jo
3;i01r)
h Y
3:uH
.7$6/r
/7H
�. 11
.Z P •a
/Lp
/1p
oN
U:ob
�ri 760
/Go
.+c•/ "1p
7:so: r9
y:ob: YJ
/To
Meter
Well
GPM
lime
Reading
level
3;sv: 14
/
If
�53
18670
/1p
oN
U:ob
�ri 760
/Go
.+c•/ "1p
y:ob: YJ
/Sy
Y; 13;
/t -O
1�v
�r't'i
2F V1
S & S ENGINEERING I'-22
17034 Eagle River Loop Road 14o.204
Eagle River, Alaska 99577
1%=-7
J
"ID *•'-� U
!! 2-6-92
z 1 bi44"7
Q
10 MT'
►� 06 off-, Diss �1-
C17-
Tt
11 =�v M��z I D�hY>S 33 `� ►►� MT
I
2�3
S 8 S ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Z-1c>-el2
L4
i I �t�l..l Cb�-� or� '� TL � 14R� Ei ►�
Ip.2�a MESS -n.= o
2-12
4 r�bll
PPP�� _ ''o cotes 4 � PD
2 -k4 -92
-'.2o P �� 1 L a 1_� c> I 1 10 M ,'T
s
S 8 S ENGINEERING 3 /�
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
i)
M���I1I207
11 4
-- '11i � l5 l.�o SSP-E+e✓._ f<��b��—t� ffAh�
1�JI-r��-�,' 'amu-�-�,-I ►�T� �rL-�z,��.
I`✓ v
6V //RNs
�14Y7
.87-
la;ro RY
/07.SA5'
TO
3
to;2o.
1013/0.
A97.
l �s �ii ti.5
"
4FI
IDS 10
ff
.:
4
zl.
at'
2'•%'�
nLf 'C `ILt(i?p
II I D I I
SOI
35j �lG�.��J
-
Q6
.3'. ;Lo
' I1 1 �0� ;
14 6
�l
bo
sl'
3g1 �7°•�'I��
loz
ASL- .�• I .c�-jl �,': s�,r�..-: �,��
3g3y '�a�/�,�J 0-1
pP"^:Ovfhv Ovt�/��
'o 5qp
ell 0/
:
'7*; %•�. f
T. -e' cr'yf�G.s.uk�S ./✓tGht f.e (� :
/.' ' ��
1
l4a72:
U).
k
50 ��/vC—(
�o
53 I ��
,-
w l4G .r�rrdc-1 Get r�n."
ot
& pic"N G GSvA
V\.UG\PPS\
`\RpNME MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services a
iDDIVISION OF ENVIRONMENTAL SERVICES
(� C 343-4744
?'CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # 0 Sn -5'0 / C y HAA # A� g9 t^
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
P
Lot 15 Block Q Glacier View Heights
Location (address or directions)
(b) Property owner AHI' Telephone: (home) 'Business
Mailing Address sen . A4rh, Anrhnragp, AK
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent rack Mite ro -_Kath, Olmstead
Address
e •- - =
Telephone _69,4 �6,X
(e) Mail the HAA to the following address: (or check her` if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
—t7034-Esg k-RLver-Loop4ioad-N*AQ 4
Eagle River, Alaska 99577,
2. TYPE OF RESIDENCE
Single -Family IR Number of bedrooms g
3. WATER SUPPLY
Individual Well q 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 G} Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the Iegailty and status.
72-0251R". 7/88) 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. / ' `-
NameofFirm Telephone
S & 5 ENGINEERING
Addre
Date
6. DHHS APPROVAL
Approved for 3 bedrooms by
`' Date n l s
Approved 9, Conditional
Terms of Conditional Approval
CAUTION ' ', . , .
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Ray. 7:88) Back Page 2 of 2
G [�
G O
o�P MUNICIPALITY OF ANCHORAGE (MOA)
\tt 5 • Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
4 343-4744
Legal Description: S
A. WELL DATA
Well Classification If A, B, C. D.E.C. Approved (Y/N)
Well Log PresentI'N) Date Completed 8— �'� Yield
Total Depthl-_422�Cased to L22� Depth of Grouting
Static Water Level _ gy� Pump Set At
Casing Height Above Grourid t2 u+ Sanitary Seal on CasingONq
Electrical Wiring in Conduitdl%) Depression Around Wellhead
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot 11!2� -- ; On Adjoining Lotsi—
To Nearest Edge of Absorption Field Lot �� ZI ✓ ; On Adjoining Lots
To Nearest Public Sewer Line �°r� To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by j tx6Ld 0`-Y; Date — "—g9
Water Sample jest Results
B. SEPTIC/HOLDING TANK DATA
Date Installed 'B0- ' Size `rn-2<2 No. of Compartments ?�
Standpipes CON) _Air -tight Caps4n7N) FoundationCleanouta7N) -
Depression over Tank (Y/® tJ ate Last Pumped q --ZS- ) ✓
Pumping/Maintenance Contact on File (Y/Nx for
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well ` �� I'I' To Building Foundation 1 of ... ;
To Property Line r�A To Disposal Field 1 I
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course l o�X
72-M (11".71W) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Stratayrc�; , �Type of System Design '�1(
Date Installed Iv' g'� Length of Field
1
Width of Field Z Depth of Field 4�
Gravel Bed Thickness
Square Feet of Absortion Area �- f v Statndpipes Presentg5%)
Depression over Field (Y/Q ���� Date of Last Adequacy Test
Results of Last Adequacy Test �r^►�� i°-�'`� 'w=5 -Fx-2_-
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Wellg2
To Building Foundatiop
�f
Lot I"
To Property Line . kc::,
; On Adjoining Lots
To Existing or Abandoned System on
tJo
To Water Main/Service Line Ic> l-( To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, P
Comments ly
D. LIFT STATION
D to Installed
Size lions
"Pump On" Lei
Area, or Vehicle Storage Area
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
J N
� u _ f=tLEr--1 •4�-aY�
Dimensions
_ Manhole/Access (Y/N)
"Pump Off' Level at
Vent(Y/N)
Cycles during Adequacy Test.
"Check Permitted Bedroom Rating Against HAA Request"
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines
inspection.
Signed
Company 17034 Eagle River Loop Road No. 204
Eag a r, •Ka 99377
Date p ff9
MOA No. f a Ob–z
Receipt Noo:2 lhh L D L (e
Date of Payment �Z_,)/' o e—a
/ ., [/ c3
Amount: $
Receipt No.
Waiver Fee: $ _
Date of Payment
n -02e (Ra.7/U) Back Page 2 of 2
s.n A. Shwhr
No. 1457E
dafW6II->his
Ely, �l
a I a` ,9 � L �a4z. y
�L .0 Q
Time
APPLICy" NT
FILLS OUT UPPER HAL,',ONLY
Props..; Owner
/ 2 y G c
`7
I �✓F F. y/S?:F 2, `/r / 'N, %✓�/ G 3—
q
Mailing Add ess
7R 7o it b4 Sf!
PL . zip code 99
Bu')!
Date
— %/-- ZIP Code
Address
TInspwtor
Inspector
InspectorInspector
Phone
Lending Institution
�JtASKn SIA TE
QAN� .`
z7 *2-56W,/
Address
iG0+fl- A
r H ZIP Codei
Field Notes: k C� O .
Realty Co. d Agent
--�-
r
Phone_
1
/v/ _.
: ZIP Code !
/
Address
.•r
Legal Descriptbnr'
I LK• �. Mr.)) -A r'IfR✓If Gal 1416H74'11..
/-/_ ,, '
( ) APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
Street Location
7 t i !
( ) CO���^N111DITIONALQAPPROVAL'
I t5
Type of Residence
(Single Family
Q
❑ Multiple Family
_. No. of Bedroom
Well To Absorption Area
❑ Other
Well Log Received L___�
Septic Tank Size I
no CD'
e— I C;) —83
Water Supply
VIndlvidual
J�For
CH WELL LOG. A well log Is required for all watts drilled since June 1975.
ellsdrilled prior to that date, give well depth (attach log if available).
0 Community
"> i
❑ Public Utility
Sewer Isposat
Year Individual Installed:
Individual
❑ Public Utility
When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
a I a` ,9 � L �a4z. y
�L .0 Q
Time
Time ry
Time
Cl b \I tAnDate
Date
Dare
TInspwtor
Inspector
InspectorInspector
Field Notes: k C� O .
1
)o
/
V C)
.•r
( ) APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CO���^N111DITIONALQAPPROVAL'
I t5
DATE —p,'
BY: �lCAA
Solis Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received L___�
Septic Tank Size I
no CD'
e— I C;) —83
Well to Tank 91
xxan rven