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HomeMy WebLinkAboutCHANDELLE ACRES LT 2Chandelle Acres Lot 2 #051-063-81 Municipality of Anchorage Community Development Department Page 1 of 3 On-Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP141369 PID Number: 051-063-81 ❑ New ❑✓ Upgrade Name: Gordon and Sue Ellen Kenyon ABSORPTION FIELD Deep El Trench ❑ Dee Trench ❑ Bed ❑ Mound Address P.O. Box 672047 Chugiak, AK 99567 ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 903-3614 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot Chandelle Acres 2 Ft. Ft. al grade Gravel length Township Range SectionFL EE FtBeds: Number of Lines Distance between lines SEPARATION DISTANCES Ft. Ft To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Fe Ft. Well >100, qy� X67 >100' >75' >25' TANK 171 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Anchorage Tank Capacity 1,OOOGal. Surface Water >100' >100' >100' N/A Material Number of compartments Lot Line >5' >10' N/A N/A Steel Two NA Foundation >5' >10' N/A NIA LIFT STATION Manufacturer Capacity Curtain Drain None Noted Gal. RemarksTank Only Replaced Under This Permit. Pump on level at Pump off level at High water alarm at Existing Tank Decommissioned in Accordance With in n. in. Municipal Code. Pump make and model Electrical Inspections performed by Installer PIPEMATERIAL Housetotank D3034 Tankto drainfield D3034 Stuart Gilbert Drainfield F810 CO/MT D3034 Inspector W Roberts BENCHMARK (Assumed elevation) 100.Oft Inspection „ dates: 1 9/12/14 2� 9/12/14 Location and descri tion p 3`° 4" Garage Slab COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL It ��E Conditional Approval: Date .'4E,,...... � ��P: 'S ® �•Gj1 49?H a� iA; Soto- . ...:....... +.... ..... ' %•M1%lAEL E. ANDERSON•: �• �� CE .4381 ''p` I��yF•.s��y� Approved Date-e? t'i- "Po 4* ` ``' Inc..Hmn Ru t_ Z 11 -- - — - -- — -- - — -i — -- -- - — - — - — - — CLOVERLEAF ROAD S 00'07'10"E 269.58' 10UTILITY EASEMENT~, 00 J� Q Go �. zMLu it �� J F O w H m¢m M and 09 H y V a ^ M o o0� 0 n co rn M 3 w a� OZ E W O W L .EWa U ^ z w� 13 2 N W v; E I -'Jo a O pW T � C Q Jp z w of Q EQ 2 0.5 U •E m c -c ao co Q) N j ♦ co .. b♦ 4 Wo j LO Ea /u -i v w� wO 0)0O 00-41 N G z Z W C U fI�S. : w m z€ ~O Q I��d : v? .•'meq a a a z w .� ��j�S •.. £G`5���� Municipality of Anchorage Page 3 of 3 DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-0655 - 343-7904 On -Site Wastewater Disposal System or Well Inspection Report Permit Number: OSP141369 PID No. 051-063-81 96.3 y �y UU 1,250 Gallon Septic Tank 1.6—/191.45 Tank Only Replaced Under This Permit. Existing Tank Decommissioned in Accordance with Municipal Code. PROFILE AS -BUILT No Scale On -Site Water and/or Wastewater System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP141369 Tax Code Number: 05106381000 Work Type: SepticTank Upgrade Permit Effective Dates: September 10, 2014 to September 10, 2015 Design Engineer: ANDERSON ENGINEERING Subdivision: CHANDELLE ACRES Site Legal Address: CHANDELLE ACRES LT 2 G:1460 Owner/Address: KENYON SUE ELLEN & GORDON S PO BOX 672047 CHUGIAKAK 995672047 Site Mailing Address: 21818 CLOVERLEAF RD, Chugiak This permit is for the construction of: N Disposal Field Y Septic Tank N Holding Tank N Privy Lot Size in Sq Ft: 41504 Total Bedrooms: 3 N Private Well N Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received Issued By: MUNICIPALITY OF ANCHORAGE Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION UBMITTA SEP 022014 Parcel I.D. 051-063-81 Gratchen swiler Property owner(s) Sue and Gordon Kenyon Day phone Mailing address P.O. Box 672047 Chugiak, AK 99567 Site address 21818 Cloverleaf Road Chugiak, AK 99567 Legal description (Sub'd., Block & Lot) Chandelle Acres, Lot 2 Legal description (Township, Range & Section) Lot Size 41,504 Sq. Ft. Number of Bedrooms Three (3) APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑x (w/wo ADU) Septic Tank 1ZUpgrade 19Duplex (D) ❑ Holding Tank ElRenewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. 'L (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: qlapq Receipt Number:ogs�/a9� Permit No. l//�� C<gPj /l3leR Permit App__- : Waiver Fees: Date of Payment: Receipt Number: Waiver No. ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 522-6779 FAX August 29, 2014 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: Lot 2, Chandelle Acres Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer The septic tank on Lot 2, Chandelle Acres Subdivision has failed and must be replaced. We are therefore requesting a permit be issued for the construction of a new 1,000 gallon steel septic tank to serve the home. The attached Site Plan and backup documentation identify the location and configuration of the existing septic system and the location of the new tank. Also identified on the plans is the existing well on the lot and those on the adjacent properties. No conflicts existing between the well separation distance the septic system on this or the adjacent lots. The existing tank on the lot will be properly disposed in accordance with Municipal Code. The existing absorption system will remain in place for Continued service. The ground surface on the lot slopes slightly to the southwest in the area of the septic tank. The tank will be constructed near the location of the old tank and in conformance with Municipal requirements. If the tank is constructed in accordance with our design the following statements apply: The tank, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. 2. The tank, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. The tank, if constructed as designed, will have no adverse impact on reserve Lot 2, Chandelle Acres August 29, 2014 Page 2 of 2 space, either surface or subsurface, on any lots located in the area. 4. The tank if -constructed as designed, will -have no -adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, Vj'L't z Michael E. Anderson, P.E. Attachments . L.�. , -•. .L Srn/��VJ q P'• 49th s=�} MICHAEL E. ANDERSON No. CE 4381 i ® Existing Well CHANDELLE ACRES �\ LOT 2 \\ 41,504 S.F. �. LOT 3 Three Bedroom Home 1,000 Septic Gravel Driveway Existing Absorption Trench.w J Z / i w � / I I I . I j Existing / Well 4 LEGEND S1 — Septic Vent CO — Clean Out M1 — Monitor Tube TH — Test Hole FCO — Foundation Clea T �? y '-.MICHAEL E. ANDERSON •; 1' No. CE -4381 J /l / I / / Existing ist ng LOT 1 SITE PLAN SCALE V = 50' SCOPE OF WORK Decommission Existing Septic Tank in Accordance with Municipal Code. Place New 1,000 Galion Septic Tank and 2 — Post Tank Clean Outs. Tie In Existing Absoorption Trench. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME GG PH ONE EW C-�"•J ✓%� — s' ❑UPGRADE M1tAI LIN. DRESS p/ LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS UY Well D Absorption read DISTANCE TO: Q Dwelling / SO PEHIyuT O. tJ 2 � Manufacturer Mat eya7� ` �� No. of compartments 7- L iq. apaCit in Ilons IF HOMEMADE: Inside le�tn Width Liquid depth D Y J10 Z DISTANCE TO: Well Dwelling PERMIT NO. =? I-. Manufacturer Material Liquid capacity in gallons I DISTANCE TO: Well / O Foundatiop Nearest lot bn /j, & PEHp1f>7,y0 m Z h No. of lines Lengt f a h / Z y Total len h f li s Trench wi Distance between lin s / t. Top of the to finish grade /1 / Material beneath rile inches _ SL 0 Total eilective absorpti rea r inches W Length Width Depth PERMIT NU. U Ali d - W Type of crib Crib diameter Crib depth Total effective absorption area DISTANCE TO: Well Building foundation Nearest lot line J J W Class Depth _ V -�1 Driller Distance to lot line PERMIT NO. 3 DISTANCE TO: wilding foundation Sewer line Septic t tGiafsl DEPT. CF I ALTH OTHER IkCNhJ._NfAL PROTECFICN PIPE MATERIALU� , J SOIL TEST RATING 2415 INSTALLER G7L/ _/SIV L5-XC REMARKS /vc , o v IN co o F/Ld. F."4w, 22av //V4 ON if / y/N / Of aL.a_ soh_ ••• , �i i ham+ A. Illi Al t APPROVED SF,1y` IES:RIi%IQ •. E LEGAL Y'1 < \n <K \2 g° 5 � � § kla � ) B i f ,G: \ o \ q@.!% 5` ! 0«\ % ! ♦ W\! .J§ / § § ( � § [ } k j \ J k § k § � \CK / / _ Zdk » >} ( -3 § § § �/ < \n <K \2 g° 5 � � § kla t: / k §) k k §kkk§ k k ]§| ) § i f ,G: \ o \ q@.!% 5` ! qx| % ! 7|LA4 .J§ / § § ( � § [ } k j \ J k § k § t: / k §) k k §kkk§ k k ]§| & / i f ,G: % Ln ; 5` qx| % ! 7|LA4 q |■| ! g3| q \CK / / k » ( -3 § § § t: / k §) k k §kkk§ k k f ,G: \ ( % ! 7|LA4 |■| \ t: / k §) k k §kkk§ k k § k k k \ G y § } � § / k j � g \ / § E f ,G: \ ( % ! |■| q » : / m.« -! �(a ! (a m a En: U) o » & ( ( ( ( ( ( ( / \ r- M: / \ 5 al: / ( ( ( \ ( ( ( / / 0: % ®!®: © ® R / \ } = ° / 0 e E 2 2 § k k k \ G y § } � § / k j � g \ / § E tlU" I C I F. _4L- I TY OF: Ffr,1CHL.,RRGE DEPARTMENT,OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, At'. 99501 n - 264-4720 �✓� Ohl—S I TE EWER $: 4JELL PERM I T PERMIT NO: 840459 DATE ISSUED: 06114/84 APPLICANT: S & S ENG'G AMERICAN EXCAVATION ADDRESS: SRS 196X EAGLE RIVER„ AK 99577 CONTACT PHONE: 694-2979 .LEGAL DESCRIP: SUBDIVISION: CHANDELLE ACRES LOT: 2 BLOCK: NA SECTION: 3 TOWNSHIP: 15N RANGE: 1W LOT SIZE: 41504 (SQ.FT: OR ACRES) ,MAX BEDROOMS: 3 .LISTED BELO14 ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR. SEPTIC 'SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR SITE. I TF2ErJCH - - - EEI> W C>RFi tJ - DEPTH TO PIPE BOTTOM (FT.) 4.0 4.0 4.0 GRAVEL DEPTH (FT.) 6.0 0.5 3.'5 TOTAL DEPTH (FT.) 10.0 4.5 7.5 GRAVEL WIDTH (FT.) 2.5 24.0 5.0 GRAVEL LENGTH (FT.) 67.0 45.0 87.0 ** GRAVEL VOLUME (CU. YDS.) 40.3 40.0 64.4 TANK SIZE (GALS) 11000.0 ** 10000.0 ** 1,000.0 ** SOIL RATING (SQ. FT. /BR) 268 239 268 ** GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH) ** TANK, MUST HAVE AT LEAST TWO COMPARTMENTS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I CERTIFY THAT: I. I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE (MCA) AND THE STATE OF ALASKA. 2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS, AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. 3. I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL SYSTEM OR•PUBLIC SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT. 4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 3 BEDROOMS AND ANY ENLARGEMENT 14ILL REQUIRE AN ADDITIONAL-PERMIT. 'IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOR BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT,AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS CTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED DRTE: APPLICANT:'S&�G A� MERICAN EXC ATION - - ,ISSUED BY -DATE: /__-voL ----------------Y_�z----- �S�o s4-1 .� - �' ❑ SOILS LOG MUNICIPALITY OF ANCHORAGE \, DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION 825 L. Street, Anchorage, Alaska 99501 2644720 TEST SOILS LOG - PERCOLATION TEST PERFORMED FOR: AM LICA /rC Allem, I DATE PERFORMED: LEGAL DESCRIPTION: Lor Z La LfBn/OFt. CE P_E pp1(} tt}1/1 SLOPE - -- IFCEI\ I I i T-1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 G M - z30) 0iaie 130rr OT= NCLr- WAS GROUND WATER S ENCOUNTERED? In L —NfO P IF YES, AT WHAT E DEPTH] Reading Date Gross Time Net Time Depth to Water Net Drop Zo p Z 1!5-0 73o klig. 3V ti 3 2.1 .one— t, h N µ 21 10i D " 08� i S 2 2p r /0 1 // y� `� 4 8 PERCOLATION RATE 7'7 (minutes/inch) TEST RUN BETWEEN i(0 FT AND / FT 72009 (6/79)_ GARNESS ENGINEERING GROUP, Ltd. — CONSULTANTS & GENERAL CONTRACTORS February 8, 2007 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650, Anchorage, Ak 99519-6650 (907)343-7904 Ref: Waiver Request and COSA for Chandelle Acres Subdivision; Lot 2. The existing 3 bedroom house is served by a private well and septic system. We request you grant a 86 feet separation distance waiver from the well on the referenced property to the drainfield on referenced property and a 96 feet waiver from the well to the septic tank on the referenced property. The following items are justification for the waivers: • The lot is sloping from the septic system away from the well head. If the septic system was to overflow, it appears that the effluent would not travel toward the well head. • The location of the septic system is in a very visible area so that if any effluent was to surface, it would be noticed and the problem corrected. The other path of contamination is subsurface migration wastewater. As can be seen on the attached well logs, the static water levels range from 85-160 feet and well depths ranging from 112-180 feet. The silt, sand, clay, and hardpan soils above the aquifer have served to inhibit the migration of untreated wastewater into the aquifer. Recent water sample results indicated nitrate levels to be 0.1 mg/L and coliform bacteria results to be undetected. Based upon the aforementioned facts, it appears that there is minimal risk associated with granting the requested waiver. If you have,lny questions, please contact us at 337-6179. Thank you for your assistance. P.E., M.S. 3701 E. Tudor Road, Suite 101 • Anchorage, AK 99507-1259 Ph: (907) 337-6179' Fax: (907) 338-3246' Website: www.gamessengincering.com EXISTING / GARNESS ENGINEERING GROUP, Ltd. CONSULTANTS b GENERAL CONTRACTORS ...... 3701 [ 111001 11010. lIIC 101 • MC OP E M1 99101 • 11OIC (1011111-e11e • r" (101}1L-314 • \RSRL ew.,enlllwyYr�,t.een, a PREPARED FOR: PHONE NUMBER: PACE NUMBER: KEN KASTNER 229-3013 1 OF 1 A.o't CHANDELL ACRES SUBDIVISION: LOT 2, C.J.G. OF WORK: DATE' SITE PLAN FOR WAIVER PACKAGE 1/23/20 (Rev. 01M) 45 / •�•. Via: r $J(�'� / GARNESS ENGINEERING GROUP, Ltd. CONSULTANTS b GENERAL CONTRACTORS ...... 3701 [ 111001 11010. lIIC 101 • MC OP E M1 99101 • 11OIC (1011111-e11e • r" (101}1L-314 • \RSRL ew.,enlllwyYr�,t.een, a PREPARED FOR: PHONE NUMBER: PACE NUMBER: KEN KASTNER 229-3013 1 OF 1 A.o't CHANDELL ACRES SUBDIVISION: LOT 2, C.J.G. OF WORK: DATE' SITE PLAN FOR WAIVER PACKAGE 1/23/20 (Rev. 01M) Municipality of Anchorage O V0. @xr 1!1('Ai,M) • Anchora(;c. Aluskn �J!451!)•fif:�0 • Tcliphrmc (!1(YI) &1.4R'i0I • ras (Otr/) 34,s"M) 4700 nrapw Street • Anchnmge, Alaska J<4W w�mmuni.org Mayor Mark 73c�yicll Building Safety Division February 23, 2007 Jeffrey Garness, P.E. Garness Engineering Group 3701 E. Tudor Road, Suite 101 Anchorage, AK 99507 Subject: Waiver Request for Chandelle Acres, Lot 2 Waiver Request WR#: 070009 Parcel ID # 051-063-81 IIA070034 Dear Jeffrey Garness, P.E.: Your request for a waiver of the required 100 feet horizontal separation from the septic tank to the private well has been approved. The approved separation distance is 96.0 feet. Also, your request for a waiver of the required 100 feet horizontal separation from the disposal field to the private well has been approved. The approved separation distance is 86 feet. This waiver approval applies to the existing septic tank to private well separation and existing field to well separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-7904. Sincerely, Deb Wockenfuss Civil Engineer On -Site Water & Wastewater Program Community, Security, Prosperity 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 Waiver Review Worksheet WR#:O70009 PIDq:051-063-81 HA/Permitk HAO70034 Date Received: February 23, 2007 Legal Description: Chandelle Acres, Lot 2 Engineer. Jeffrey Garness, P.E. Garness Engineering Group 3701 E. Tudor Road, Suite 101 Anchorage, AK 99507 Applicant: Ken Kastner Waiver Requested: 96' from well to tank and 86' from well to field Criteria: Geology A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Points: 8 3.4 1.8 4.5 2.4 Total: 20.1 r ... °....... .....°..°..e..e°..... .°°..°..°... ..°°....°°...°..... °..°e..... Waiver Is Granted: X Waiver Is not Granted. List Conditions or Reasons for above: Dale: 2123107 By: Deb Wockenfuss Name of Reviewer reeee.e.ee......... .eeeeeeeeeee......eeeeee........ °....°°°..°...... .eeeee Rec#: 37134 Amount: $JIM Date Paid: 2/23/2007 Chandelle Acres, Lot 2 Parcel ID: 051-063-81 Waiver for 96 feet from septic tank to well and 86 feet from disposal field to well Issued February 22, 2007 General 1. From the water sample, total coliform was 0, and total nitrates was .1 mg/L. 2. The well on the subject property was installed on June 1, 1984 at a total depth of 120 feet. The well is cased with 40' plus. The well log for this property and other surrounding properties identifies numerous layers of silt, sand, clay and hardpan soils. 3. The lot is sloping from the septic system away from the well head. 4. The location of the system is In a visible area and any surfacing effluent will be seen and corrected. ADEC Criteria Points Water Table 8.0 Depth of water bearing zone In well 113 feet Assumed bottom of septic tank -10 feet 103 feet x = 1'(3/190) + 8.0 x =8 Soil Sorption 3.4 Soil descriptions from neighboring well log for subject property silty gravel 4 10-75 feet fine sand/gravel 1.5 75-136 (65/103'4)+(38/103'1.5) Permeability 1.8 Soil descriptions from neighboring well log for subject property silty gravel 2 10-75 feet fine sand/gravel 1.5 75-136 (65/103'2)+(38/103'1.5) Water Table Gradient 4.5 Lot slopes away from the well head Assume 5% slope Horizontal Separation 2.4 86 feet between drain field and well x=11/25+2.0 x=2.4 Total Points 20.1 As per ADEC waiver guidelines a point value of 20.1 is almost sure to be free of any form of contamination from household sewage. #ire Drtlltng. Doc ca e•• SULLIVAN WATER WELLS • P.0.RORpOtfLCMWUtK.AtAtKAHMt•TLL!►IIOMIt�t•!!Y OWNER OF LAND !�WjTA7.4cf '/n) GDEPTHS OF WELL ADDRESS'' STATIC LEVEL OF WATER FT. � LECAl. DFSCAIF[IOW / 1 I C%NA.aOt !t t_� /Tr'�ErDRAW DOWN FT., r EMM t/ GALS. PER Hilt a DATE-awtta PEAmrr NUMBER KIND OF CASING, KIND OF FORMATION: From Ftlo�_Ft �'AJ���i .irrt w' J� From PL to Ft. From -Ft. toA--pt From -:—FI. b Ft. From-4Ft l6 d 4.1 ' �riwn Ft. b Ft. TlE.r/ i 'S/c: ��GAFina� ` Ftte Ft, •FmmFt.ta- y� Cc. ^, ' Fre1e��Ft.ta Ft Prom��. FL lo.�S—.Pt. r� From As' to li 7 -Ft. ^I ^ Q/ From Ft. to Ft. From / 1 3 . Ft to Pt /?r Dtro K Fram Fa a Ft From Ft to Ft From Ft b F Fpm FY.Ie Ft - • From Pt. ta• —pt. From Ft. to_ Ft: From RL Ft. Froin Ft t. Ft. From ft la Ft_ From Ft to Ft ' Prom • ' Fl to Ft. prom Ft to Fl. From ft. to Ft• '. From Pt. prom FLto Ft. C F' FpmFtlO__FL F V E (Z..__ ppm Plb F4 Pram Ft le f L From h b Ft M-U-nrc—lpahty of Anchorage Fran Pl te. pt From MISCL.INFORMATRINI T erf.f irb Drilling Dnp by OOC CO. dba SULLIVAN WATER WELLS P.O. BOX 272. CHUGIAK. ALASKA 99567 • TELEPHONE 6882759 OWNER OF LAND KF_ [G Y rc a uw K � ADDRESS ,QS -SO %de:E.✓ mlxe- LEGAL DESCRIPTION 4 &Adj)'DEc c- F DATE • Started � Ended 0!!� PERMIT NUMBER FfP,l1xild ial'7L 1111N);p DEPTH OF WELL /77 -7 STATIC LEVEL OF WATER FT. 14 D DRAW DOWN FT GALS. PER IiR KINDOFCASING G OQ FromFt. to -12 Ft.6LEa4,IA0O"''y From Ft. to Ft. From �` Ft. to-j��Ft. NiOPDP*-J r QJJI 9904rom Ft. to Ft. From7r Fl.to-L?S_Ft._ fiwE X-4.20- XZ From Ft. to Ft. From Ft. to Ft. ,lir✓BL From Ft. to Ft From -a -C -Ft. to Lf -X FL ri-JO .r-4wa 6OXT From Ft. to Ft From / r P Ft. tof,'�Ft. h�'o 6 t aR U�'L From Fl. to Ft. Fron��Ft. to -Lys PL S ! C<-47' From Ft. to Ft. From 17< Ft. to1]r.Ft. 7:1& H7 1�/F'-Xe,4 From Ft. to Ft. From FL to Ft_ r A-140 t G 4Nd4L From Ft. to Ft. From Ft. to FL "IrFrom Ft. to Ft. From_[)—Ft. to Ft. 89,040S< From Ft. to Ft. From Ft. to Ft. From Ft. to Ft, From FL to FL From From Ft. to Ft. Ft. to From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. MISCL. INFORMATION: / -77 , 7 .r o From Ft. to Ft, From Ft. to Ft. From Ft. to Ft. From Ft. to Ft From Ft. to Ft, C RS/AJ6 DRILLERS NAME Zk *C�� FROr! COIRJTRY REALTY PHONE NO. : 9076881310 Feb. 09 2000 09:14M P1 FRC -1`1 : AUr0RA PROPERTIES FI.&E No. : 9076881310 Nov. 19 1999 11:27AM P2 (1ZExtifiE� rjl�ixti Jung by ooe C.. &A SULLI VANrWATER 'WELLS P.O. BOX 670271• t HUOtAK: ALASKA 99687.4 E1 Ei'HONE 688.2759 l AAoAJ �� ,. DORS HOl!FDATA Oy�tEROFLAND .�DEPTH:'.• ` �o• 3 Wrccovl' •ADDRESS' F o et•` ��f1r�'—(`l �`—r'�p - LEGAL DESCRIPTION t `v.:. ; 4 of r444 E- o} Issue ee PERMIT NUM13ER� Date o� ^�- TAX INDENTIFICATION NUMBER �L `6 ' T* . Is watt loo C3 f-, at approved permit location? E�res Q N Ll cable tool •� Method of Drilling: air rotary Depth of well: Wall ThicknessS� 'aches Casing Typed S- ` f! Inches• depth i3 feet piameter : % , Liner TYDP- _ feet Casing Stickup Above Ground: cR feet. Static Water Level (from ground level): m Pumping level:.feet after hrs. pumpit;9 P Recover Rate:- gpm - t Method of Testing: "' �' • �' open End 0 Sen H _ Well intake OpeMrrg TYPjq�� � p 'feet p Screened: Sta --feet Stopped Perforations star[ Id f/r)' Stoppedri��, ifeFA. ,.. `�• rt—Vclume o2tJJ Ly r_= Grout Type: ^" a� ... feel Depth: from �� _. —feet. to feet Pump Intake Depth: PUMP Size Brand Name �-•— Well Disinfected Upon Completion? s No S � Method of Disinfection: t Jif comments: s/4/4;,1 EB 09 2000. Dept. Healthy& Hof umnnhc rage BFyjcgg Drillet's Name r Cf1 1 � r FOD / L! q i /lI A� Q KK Afl4�+ ' � OIAJ c E2 r.k rt j v f�l4�c� EB 09 2000. Dept. Healthy& Hof umnnhc rage BFyjcgg Drillet's Name ■i-epr0uue 2euijb Fj?iurn Ilff ■ f ■ I` 073383246 bItWFIKI Ia1Lt nn1.nUKnVC avT/ O:2oo 'roao A&BUMT I hereby certify that 1 have surveyed the lollowln jtpqcrib&4 Androras— Predtd• Alnico, and that the bnprove- alenb ahuebed ebereon are *%4 hin the Vvpvty Ltre AM do not oeeliap or eouoath oe tha propeitym4mcenth t ereto, dw r no kttptovements on pro hmrt� Mento efu:rl? . PR Hta Premlaet In nand t lug no roadWJye% • • tralaanitalon Glres or other vi ecoffb nls on r>.Id• pm" ' cDated imr ad kwdkAk at Fable Wvf : Jllaaki tr �f�� J Qil! 4ay pl i1 c/�c ''1; ROBERT C. JOHNSON /► r. SCALE Vred LAM Reffilt. 7 : if ! • . urveyor bo Eagle River, Al a 94511 Phone (9Vn 69¢ n , 14 7�u. NW1M••� •t , •/y.,. A&BUMT I hereby certify that 1 have surveyed the lollowln jtpqcrib&4 Androras— Predtd• Alnico, and that the bnprove- alenb ahuebed ebereon are *%4 hin the Vvpvty Ltre AM do not oeeliap or eouoath oe tha propeitym4mcenth t ereto, dw r no kttptovements on pro hmrt� Mento efu:rl? . PR Hta Premlaet In nand t lug no roadWJye% • • tralaanitalon Glres or other vi ecoffb nls on r>.Id• pm" ' cDated imr ad kwdkAk at Fable Wvf : Jllaaki tr �f�� J Qil! 4ay pl i1 c/�c ''1; ROBERT C. JOHNSON /► r. SCALE Vred LAM Reffilt. 7 : if ! • . urveyor bo Eagle River, Al a 94511 Phone (9Vn 69¢ n j eb•23. 2001; 1:35R'07-7,Garness Enaineerins Gtoo , Ltd -ow NO -7157 F? - 1 We4 MATANUSKa ELECTRIC ASSOCIATION, INC. �GHT OF WAY ENCROACHMENT EASEMENT THIS AGREEMENT Is made and entered Into this doy of b_WL_c 2o-0:7, by and between MATANUSKA ELECTRIC AS OCIATION. INC., an Alaska norrprofk member owned electric cooperative. whose post office address Is Box 2929, 'Palmer, Alaska. 99847 hereinafter coiled'MEA', and Kannnbe7DFaoiK_r J!A A. Ka m— Post whose address Is tost 0.x=2 B0-- Alaska 895 _ . hereinafter caged 00wncr'. WHEREAS. Owner covenants that owner is the legal owner of the real property described as: Lot 2, CHANDELLE ACRES SUBDIVISION, according to Plat No. 79190, Anchorage Recording District WHEREAS, Owner further covenants that the said property is owned free and clear of encumbrances and Pens of whatsoever character that in any way Amit Owner's authority to enter Into this Agreement with MEA; WHEREAS. Owner and MEA hereby covenant that MEA is lawfully authorized to . occupy the 30 foot wide and depicted oneasement dFlatnNoa7within 190 Anchorage Recording rtion Of the Above-described property, District, Third Judicial District of Alaska; and WHEREAS.Own r acknowledges t is that there I an existing encroachment In this utility easement. Th Septic leach field and monitoring tube encroaching utility easement approximately 10 feeL NOW, THEREFORE, for and In consideration of these mutual agreements: s. does hereby t, Owner, for Own nd to lisiuocees orsaocuce"rore and r assigns the tight to enter upon the grant to MEA the Anchorane Recording District. State of Alaska, property of owner situated in and more particularly described as follows; Lot 2, CHANDELLE ACRES SUBDIVISION, according to Plat NO. 79.180. Township 15N . Range 1w S.M., and to construcL being In Section 3 , rephase, repair, operate and maintain ZO . aver or under the above reconstruct described lands and/or In, upon or under an streets, roads or highways abutting said lands, and electric transmission and/or distribution Ane or system: to inspect and make such repairs, changes, alterations, improvements, removals from, substitutions and additiona to as factOtisa as MEA Way from l rnR boil° the right time m advisable. including by Way of example and not by Y ables, hand holes. increase or decrease the number otrandformer enctosto wIres rurres: to cut, hint and manholes, connection boxes, pedestals.lociated of olherAst of control the growth becfi Ayndescrbed ebove orees and thatmay interfere with Or within the lands ap of sold line or threaten to endanger the operation f otheand r vegetation in the right of way system (neJuding airy control of the growth may incidentally and necess" result from the mens of control employed): to keep the encroachment easement dear of all buildings, sticteudre;�°toer obstructions, other then the existing and dencroachment' ie remainder of said parcel as Wall MEA rho fight of ingress reasonably necessary to conduct the above aetivlt es t+11hfi the encroachment easement. e:Feb•23. 20071: 1:35PM07-7Garness Engineering Grouo, Ltd -PA No -7157 FP Encroachment Easement Page 2 2. MEA, for itself. Its successors and as hereby waives its objections to owners existing encroachment as described above on the following conditions *which crept%%Owner mvenanfor � at Mt wrs self 'ithlus theOwners perty described successors assigns, Y A. Owner, owners successors and Owners assigns, shag Indemnify and hold MFA, s successors assigns, harmless rarwR from ury or damage toany Person orproperty that may esaid encroachment. g, Owner, for Owners self plus owners successors and assigns, hereby agrees that the continued existence of the encroachment described above oy tell 60t restrict or limit the current or future ny benefits of this encroachment chment easement for aand alof l utility Purpoto fully ses the es consistent with paragraph 2 above. C. Owner, for Owners self, plus Owners successors and assigns, hereby stipulates and agrees that they shat each hold MEA. its successors end assigns, harmless from liability for any and an damages to the encroachment that may result from he existing and future tors utility succLme Of said encroachment easement by agents, licensees, or assigns. 0. Any facilties or property of MFA, is successors and assigns, located with the oncroarhmant easement granted herein that are damaged or destroyed as aes rult of actions undertaken by Owner. or Ownefs successors and repairs or rreptaceell be mpm shall red or replaced be paid for by aOwne�r• or Owners on and such reD � P successors and assigns. E. Any facilities or property of MEA, its sue hereon that must assigns relocated , located within the encroachment easement granted or modified to accommodate actions undertaken by owner, or Owners successors and assigns, in order to remain in compliance with oppric able codes andprudent utility expense of owner, or Owner's successors end assice shon be relocatedg^ modified at the sole F. Owner, Owners aucessors and assigns, and their contractors or agents, will not perform work on the encroachment described above with governing the operation able of violating fnequipmentte or nearFeneral rgizedwregulation electricUti ty Infrastructure. By execution of this Agreement, owner further agrees for owners self, plus owner's successors and assigns: placed in the said (a) that any septic monitoring easement be vlsble at n times sfor dista hce of at least ten feet from any direction. 2 03/04 a:Feb•23. 20011: 1:36%7-713arness Engineering Grouc. Ltd• I No .7157 IP. 3 Ba/ea EncroaUvnerA Eesement Pape 3 IN WrrNESS WHEREOF, the parties have caused this Agreement to be executed by their duly authorized representatives and agents as of the day and year first above mentioned. MATAN S E ;Ma ;ASSOC N INC. BY: U rescnwt General Mr or his Rep STATE OF ALASKA : SS. THIRD JUDICIAL DISTRICT The foregoing agreement was acknowledgedbefore moo this _day 20 Z—Z by My c&nmlasian STATE OF ALASKA : SS. THIRD JUDICIAL DISTRICT : of Patncia A. Kastner The foregoing agreement wasacknowledgedbefore me this day by Notary Pubic for the a of Alaska my commission expir. . II /a--T— RETURN TO: MEA P.O. BOX 2929 9964E PALMM ALA3KA MUNMPAU7Y OF Development Services Department On -Site Water & Wastewater Section Parcel I. D. 051-063-81 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Complete legal description CHANDELLE ACRES LOT 2 Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date: ) 1-1 3-Z) Location (site address) 21818 CLOVERLEAF ROAD, CHUGIAK, AK 99567 Current property owner(s) COREY GILLESPIE & KERRY DUKEHEART Day phone Mailing address Real estate agent 21818 CLOVERLEAF ROAD, CHUGIAK, AK 99567 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: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ -5.56 Date of Payment 7h2g12.� Receipt Number 8092 9 S COSA# Date: Waiver Fee $ Date of Payment Receipt Number Waiver # Distance: 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY, ANCHORAGE, AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 7/24/2021 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to Amp, 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 �••• �� f�J for current or future occupants or guarantee that no unseen encroachments, deficiencies or * • ` TM ••* I discrepancies exist can be given by First Water Consulting & ' ' • ' ' • • ' • • ' • ' • • • • • • r! FWCS .. .... ........ 6. DSD SIGNATURE JJ Curtis Huffman . system #1 Approved for bedrooms rF � CE 128991 ;01' Ae �,, s System #2 Approved for bedrooms RF�PROFESSI��P�- 0\\\ ESSO� Disapproved Conditional approval for bedrooms, with the following stipulations: t9-ecaS e see 1=MtvLaOYS {'�cAe a-,, —f'.e Yb6'il,,� J ti's. O � o WATER A PR'AT�' ER ))hSERVICR��.��, � ►�•� Original Certificate Date:— / S"20 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 L,, r Legal Description: CHANDELLE ACRES LOT 2 Parcel ID: 051-063-81 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 6/1/1984 Total depth 120 ft Cased to 120 ft ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 7/21/2021 Static water level at beginning of test 82 ft. Well production at time of test 4.4 gpm Comments B. TANK DATA Age of tank(s) 7 years Tank type/material SEPTIC / STEEL Measured operating fluid level in septic tank 49" ® Standpipes/foundation cleanout per record drawing Date of pumping 7/21/2021 Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ® No ® Coliform bacteria is Negative Nitrate mg/L ® Nitrate less than MRL (ND) Arsenic ug/L ® Arsenic less than MRL (ND) `� Collected by FWC Date of Sample: 7/21/2021 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA – SEE NOTE BELOW UPPER / MIDDLE / LOWER - MTS Which system tested (date installed) 9/15/1984 Adequacy test date 7/21/2021 ® ALL standpipes present per record drawing Results R Pass For 3 bedrooms Total measured depth from grade 6.8 / 7.2 / 5.8 ft (max) Fluid depth prior to test 27 / 0 / 8 in Measured depth to pipe invert from grade 2.8 / 2.0 / ? Water added 500 gal ft (min) F-1N/A – pressurized field New depth 47 / 11 / 39 in ❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 1440 min depth into effective 4' / 5.1 / UNKNOWN Final fluid depth 27 / 0 /8 in ❑ Code -required soil cover over field NO KNOWN ISSUES Absorption rate 450 gpd ❑ System presoaked Any rejuvenation treatment (past 12 months) N (Required if vacant for greater than 30 days prior to date of test) If yes, enter date F(, Gallons introduced gallons Comments/Deficiencies: MEASUREMENTS WERE BASED ON ELEVATIONS TAKEN, VISUAL OBSERVTIONS & ASSUMPTIONS PER MOA RECORD DRAWINGS. 4' ED MEASURED IN UPPER MT PER SUMP INVERT. 5.1' ED PER THE PERF PIPE VISIBLE & BOTTOM OF PIPE IN THE MIDDLE MT. LOWER MT MEASUREABLE ED COULD NOT BE DETERMINED WITH NO PERF VISIBLE...ELEVATIONS SHOW THAT THE MIDDLE MT IS 1.5' LOWER THE BOTTOM OF PIPE MEASURED IN THE UPPER MT & T ABOVE THE LOWER MT BOTTOM OF PIPE. THIS IS A CASCADING ORIGINAL FIELD & APPEARS THE LOWER PORTION IS RECEIVING THE MAJORITY OF THE EFFLUENT. THE SYSTEM SEEMS TO MEET MOA COSA TESTING STANDARDS AT TIME OF TESTING, BUT APPEARS TO BE OPERATING AT THE END OF ITS USEFUL LIFE & NO GUARANTEE CAN BE GIVEN ON HOW LONG THE ORIGINAL 1984 FIELD INSTALLED IN SILTY SOILS WILL CONTINUE TO DO SO. 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 Wells on Adjacent Lots: Community Sewer Manhole/Cleanout > 100' ® Yes if No ft ® Yes if No Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No Absorption Field on Lot > 100' ❑ Yes if No *97 ft *95'+ Holding Tank > 100' ® Yes if No Neighboring Absorption Fields > 100' Surface Water > 100' ® Yes Animal Containment > 50' ® Yes if No ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft ® Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ft ft ft ft ft ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ® Yes if No ft Private Wells > 100' ® Yes if No _ Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No _ ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No —ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS *WAIVER ISSUED PREVIOUSLY. CONFLICTING DATA IN MOA FILE. RAG TAPE SHOWS 96.5' PLEASE AMMEND WAIVER TO 95'+ PER CONVERSATION WITH MOA ONS IS TE_STAFF TODAY G. ENGINEER'S CERTIFICATION l certify that l have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. p i . 'TH ....�: Curtis Huffman �'CIO •. 7�2484�}.•������ pROFESSIO X M III Mtuiieip► di y of Anehorage 1'0. DA 19CA;7)() • Ancborage, Alaska 99519-6(r)0 0 Teleph(me (1x)7) M-!3,`301 • Caa (x)7) 3X.3_&o(x) 4700 BnIWLW Strcet • Anchorage, Alaska EMM n�t�t:mtcnLorg Mayor Mark I'3cgicl: Bttilding Safety Divisioii February 23, 2007 Jeffrey Garness, P.E. Garness Engineering Group 3701 E. Tudor Road, Suite 101 Anchorage, AK 99507 Subject: Waiver Request for Chandelle Acres, Lot 2 Waiver Request WR#: 070009 Parcel ID # 051-063-81 IIA070034 Dear Jeffrey Garness, P.E.: Your request for a waiver of the required 100 feet horizontal separation from the septic tank to the private well has been approved. The approved separation distance is 96.0 feet. Also, your request for a waiver of the required 100 feet horizontal separation from the disposal field to the private well has been approved.. The approved separation distance is eet. 9 This waiver approval applies to the existing septic tank to private well separation and existing field to well separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-7904. Sincerely, Deb Wockenfuss Civil Engineer On -Site Water & Wastewater Program Community, Secilrity, prosperity L a Parcel I.D. 051-063-81 Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Complete legal description Chandelle` Lot 2 Expiration Date: P 5t07 -WT OVA QT - Wins, Location (site address) 21818 Cloverleaf Road Chuglak, AK 99567 Current Property owner(s) Gordon & Sue Ellen Kenyon Day phone 903-3614 Mailing address P.O. Box 672047 Chugiak, AK 99567 Real Estate Agent 2. TYPE OF DWELLING: E] Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: Three Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual El Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request Received by:�— COSAto be released to COSA Fee $ LIZ? -&O Waiver Fee $ Date of Payment 5�a01�5 Date of Payment. Receipt Number Receipt Number COSA# t35CJ6/a30 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 Anderson Engineering Phone 522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. Date 5/20/201 �a. W. 49TH 6. DSD SIGNATURE ,, _ System #1 Approved for bedrooms ®® 01 MICHAS-MWDERSON CE -4381 \fie System #2 Approved for _ bedrooms Disapproved �@ �f� '°R0 � 510 • e� Conditional approval for bedrooms, with the following stipulations: By: Original Certificate Date: S-�- 2 0 -/s-- The 144hidp It nchorage 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 Stale of Alaska. The Municipality of Anchorage is not responsible forerrors or omissions in the professional engineer's work. - - ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSAbluesheer( f- .., e 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: Chandelle, Lot 2 Parcel ID, 051 -063-81 A. WELL DATA Private Y Well type If A, B, or C provide, PWSID # �_ Well Log (YIN) Date completed 6/1184 Sanitary seal (Y(N)_Y Wires properly protected (Y/N) Y Total depth 120 ft. Cased to 120 ft. Casing height (above ground) >12 in. FROM WELL LOG AT INSPECTION Date of test 6/1/84 5/2/15 Static water level 90 ft. 81'2 ft. Well production 5 g,p,�n, 4.5 9 -P.M. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate ND mglL . Arsenic ND ug/L Date of sample: 5/4/2015 Collected by: Anderson Engr. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Tank size 11000 gal. Number of Compartments 2 N Date installed 9/12/14 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) _ High water alarm (YIN) Date of pumping New Pumper Construction N C. ABSORPTION FIELD DATA Date installed 9/15/84 Soil rating (g.p.d./ft2 or ft2/bdrm) 268 SF/BDRM System type Deep Trench Length .64' ft. Width 2'5 ft. Gravel below.pipe 7 ft. Total depth 11-12 ft. Eff. absorption area 896 ft2 Monitoring tube Y Depression over Feld N Date of adequacy test 5/14/15 Results (Pass/Fall) Pass For 3 bedrooms Fluid depth In absorp(ioh field before test 43/0 in. Water added 510 gal. New depth 43!23.5 In Elapsed Time: 1,440 min. Final fluid depth 43/0 in. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level of in. "Pump off' level at in. High water alarm level at in. Datum E. SEPARATION DISTANCES Cycles tested WELL ON LOT TO: Septic tank/lift station on lot DOS Absorption field on lot 97'** N/A Public sewer main Sewer /septic service line >25' Animal containment areas >50' SEPTIC/HOLDING TANK ON LOT TO Meets alar & circuit requirements? in 6n adjacent lots >11 00' On adjacent lots >100' Public sewer manhole/cleanout N/A Holding tank N/A Manure/animal excrete storage areas >100' Building foundation >51 Property line >5' Absorption field >51 Water main > 10' Water service line >10' Surface water >1 00' Wells on adjacent lots >100' ABSORPTION FIELD ON LOT TO Property line >10' Building foundation >10' Water main >10' Water Service line > 10' Surface water, Driveway,>100' parking/vehicle storage Curtain drain None Noted Wells on adjacent lots >100' F. COMMENTS "Waiver Issued. System Operates as an Overflow Trench. The Middle Cleanout is the Overflow to the Remaining Trench. G. ENGINEER'S CERTIFICATION I certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this.date. Engineer's Printed Name Michael E. Anderson, P.E. Date 5/20/15 COSA brown sheet_10-10-12.doc I tse„MICHAEL E. ANDERSON %W s CE -4381 ✓fgt�AROFE , F v_ n n PLOT PLAN AS BUILT X SCALE 1" = 50' GRID NW 1460 Project No. 15-127 Lang & Associates, i l i C. 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 (907) 522-6476 Phone Registered Land Surveyors (907) 522-4625 Fax -9"Oq � kenOiongsurvey.com / jonathan*langsurvey.com .` ,.• ""° •` � I hereby certify that I have surveyed the following described property: �Q ' LOT 2, CHANDELLE ACRES (PLAT 79-190_) * 49TH�* Anchorage Recording District, Alaska, and that the improvements situated thereon are -• •. • • • • within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed ,, „ premises and that there are no roadways, transmission lines or other visible NEHNETH . easements on said property except as Indicated hereon. Dated this the t�" Day of }V b� _, 711 s , at Anchorage, Alaska O� w^-520 FESg�all�c It is the responsibility of the owner to determine the existence of anyeasements, wl covenants, or restrictions which do not appear on the recorded subdivision plat. •4S_ Municipality of Anchorage Development Services Department Building Safety Division Onsite Water & Wastewater Program 4700 Bragaw Street Q P.O. Box 196650 u Anchorage. AK 99519-6650 ^� www.muni.org/onshe (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 1)61 0tyS, I 1. GENERAL INFORMATION cosau D; Obi Expiration Date: Complete legal description CHANDELLE ACRES SUBDIVISION LOT 2 Location (site address) 21818 CLOVERLEAF ROAD • CHUGIAK AK 995-- Current Property owner(s) KEN KASTNER Day phone 229-3013 Mailing address 2181 B CLOVERLEAF ROAD • CHUGIAK AK 99567 Day phone Lending agency Mailing address BROOKE STILTNER Day phone 694-4804 Real Estate Agent Mailing address 16600 CENTERFIELD DRIVE • EAGLE RIVER AK 99577 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 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 independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Apprrooval 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. TYPE OF WASTEWATER DISPOSAL: 3. TYPE OF WATER SUPPLY: Individual Well 0 ❑ Individual Onsite Individual Holding tank 0 0 Individual Water Storage ❑ Community On-site Community Class Well C1Public Sewer ❑ Public Water System 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 independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Apprrooval 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 axed hereto and as of the validation date shown below, l verify that my Investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the onsite water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. l further verify that based on the Information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(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. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date p+ 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 & Regulations. The reported results described me Performance ofthe System under the conditions encountered at the time oflhe lest, and separation distances measured to readily Idenlfiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels Met may fluctuate during the year, and the waterusage of the family being served by the system. These conditions are outside the control ofthe evaluator of the system. Satisfactory lest results do not guarantee future Pedormance of Me system, nor do May guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimato 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 X Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the (flowing Attachments: OF AN& , W S EPnD WATM PROGRE` •:` COSA Checklist X Septic System Advisory Arsenic Advisory Well Flow Advisory Maintenance Agreements Nitrate Advisory Supplemental Engineer's Reort Other By: Original Certificate Date: Z 0 (R•, IIps) Municipality of Anchorage e Development Services Department f Bulater Safety Division water Or�Ke 4700 Brege Wastewater prem P.O. Bot 196650 Anchorage, AK 99519.6650 www.muni.orglonsite (907) 943.7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: CHANDELLE ACRES SUBDIVISION- LOT 2 parcel ID: A. WELL DATA Well type yA If A. B, or C provide pWSiD# N A Date completed 6 1 1984 Sanitary seal (YM) YES Total depth 120 ft. Cased to 120 ft. FROM WELL LOG Date of test 6/1/1984 Static water level 90 ft. Well production WATER SAMPLE RESULTS: Coliform _4 colonies/100 mi. Arsenic: mug.&. Nitrate N'0 mgJL- Wen Log (YIN) YES Wires Properly Protected (YIN) YES Casing height (above ground) 12+ in. AT INSPECTION 1/14/2007 84 ft. Other bacteria --6—colonies/100 mi. Date of sample: 1 18 2007 Corrected by: GEG Ltd. B. SEPTICIHOLDING TANK DATA Date Installed a i r �/ 1984 Tank TypelMeterial STEEL 2 Geanouts (YM) YES Tank size 1000 gal. Number of Compartments _ N/A YES Depression over tank (YIN) NO High water alarm (YIN) Foundation dearrout (YIN) JR'S PUMPING Date of pumping Z b7 Pumper C. ABSORPTION FIELD DATA HOWME93M TRENCH Date installed 6LrsLrss4 Son rating (g•P.d.�2� 268 System type Width 2.5 ft. Gravel below Pipe Length �—ft. NO Total depth •s.0 ft. EfF. absorption area 896 ft' Monitoring tube YES Depression over el bedrooms Date of adequacy test 1215/2006 Results (PasslFail) PASS For Fluid depth in absorption field before test DRY in. Water added 915 gal. New depth 14 in. DRY In. Absorption rate >= 450+ g.p.d. ��� Tom: 980 min, Final fluid depth _ NONE KNOWN If yes, give date Any rejuvenation treatment (Past 12 mo.) (YIN & hype) *SUMP ONLY OCK. THE WAS NOT FOUNXDTENDS 6 FEET INTO R . OK. PER CONVERSATION JEFF POET SOUTHERN /18/07• Sy ST _Aj (.✓n.S fy�£SOMGF� D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N 'Pump on' level at _in. -pump oft' leve High water alarm level at in. Datum CYdes tested � Meets alarm 8 drrwit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAift station on lot '86' Absorption field on kri '97' Public sewer main VA Sewer /septic service line2�+ Animal containment areas 5_, 0 + On adjacent lots 100'+ On adjacent jots 100'+ Public sewer manhole/deanout N/A Holding tank N i Manure/animal excrete storage areas 1004 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line rp --5'+� Absorption field 5'+ Water main N/Water service fine 10'+ water --___l 00'+ Wells on adjacent lots 100'+ Surface SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water __1�_=DrIvI pa�ng/vehide storage 10'+ Curtain drain NON_ E i(NOWN Wells on adjacent lots 100'+ F. COMMENTS (Rev. 11/05) -- 11•••.•.owe MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 19 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING HAA # s -i �r � fir•.. Parcel I.D.It GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property owner Telephone : (home) Business �'ye- Mailing Address e%ATelephone (c) Lending Institution ✓� Mailing Address (d) Real Estate Company and Agent Address • � � _ $SG70 Telephone hone ncheck ere if hold for pickup.) (e) Mail the HAA to the following addrs: (or List contact person and day p umber below S & S ENGINEERING 7: Eagle River, Alaska 99S77 2. TYPE OF RESIDENCE Single -Family K Number of bedrooms `-' 3. WATER SUPPLY Individual Weliy Community 13 Public O Note: If community well system, must have written confirmation from the State Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site Public O Community 0 Holding Tank ❑ Note: If community well system, must have written confirmation from the State Conservation attesting to the legality and status. Page 1 of 2 72-0251Rn. 71881 Department of Environmental Department of Environmental Z 10 Z a6ed suolsslwoJosIaJaJolelglsuodsaiIOU sla6eJo ou oAledlolun a •> OMSdaaul6ualeuolssa;wdeylul suolloadsullonpuoolouo 4 ua 71 W 41'Pansslsleleo!!!Uaoee�olage;epezAleue�0 OP s;uawa�lnba�elelspuele�apalulelraoA;sl;eso;japjoulsuollnll;sul 6ulpual play; pue saw0y ;o siaseyoind O; AsaUnoo a se s141 SaOP SHHO 841 'e�Isely 10 ele;S eyl ul paja;sl6aj i0aul6ua leuolssalad luepuadepul ueAq anoge S ydei6eied ul u9nl6 suol;e;uasaidaj eyl uodn Aluo paseq pa;eo1l' IenaddyA3!Jo41ny y3leaH sanss! 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Health Authority Approval (HAA) CHECKLIST. FEBRUARY 1984 w:•is,cr: _ 343-4744 Legal Description: ` T 1Z_ • 1 V ',2139 A. WELL DATA' ` E C E I V E D A P%J 1 p fib-, If A, B, C. D.E.C. Approved (Y/N) Well Classification Well Log Present�l) —�- Date Completed ' Yield Total Depth_2,!—Cased to Depth of Grouting Pump Set At r1 Static Water Level tl Casing Height Above Ground �% X Sanitary Seal on Casing¢WN) Electrical Wiring in Conduit6%N) ' Depression Around Wellhead mp SEPARATION DISTANCES FROM WELL: t `f4 - To Septic/Holding Tank on Lot 1 d3 -;On Adjoining Lots r To Nearest Edge of Absorption Fielq 01,, Lot o S t ; On Adjoining Lots To Nearest Public Sewer Line rl_-1— To Nearest 1 Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot __2_05 4_ \ _ gq S Water.Sample Collected by � Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA 2_ Date Installed t^� Size 142 � No. of Compartments Standpipes�LhJ)_.Air-tight Caps(YrN) v Foundation Cleanout (=) — Depression over Tank (YANP ate Last Pumped Pumping/Maintenance Contact on File N (Y/IU P Temporary Holding Tank Permit (Y/N)P ;for Holding Tank High -Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: fTb r To WaterSuppIy Well - ` To Building Foundation 1 � To Property Line To Disposal Field o To Water Main/Service Line �k To Stream, Pond, Lake or Major Drainage Course vv Comments T C1 1 Pagel of 2 r2.0M (S". Vaal Frml C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata %%08 �rset� Type of System Design _T�4rS Date Installed L-^ \S i Length of Field Width of Field ? S Depth of Field 11 Gravel Bed Thickness '7 Square Feet of Absortion Area 'Y1, Statndpipes PresentjYlN) y Depression over Field (Ya tJ Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Wello To Bung Foundation Lot N Date of Last Adequacy Test k.(S. — -�2, 2n To Property Line A C�lk-4-- To Existing or Abandoned System on On Adjoining Lots p I -f - To Water Main/Service Line. 1 '4 To Cutback Sif present) ,+ To Stream, Pond, Lake, or Major Drainage Course t E2. 4 To Driveway, Parking Area, or Vehicle Storage Area 20 (-1' Comments D. LIFT STATION D to Installed . Size in Ions "Pump On" Lev 0 High Water Alarm Level at Tested for — Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at cVent(Y/N) _ Cycles during Adequacy Test. "Check Permitted Bedroom Rating Against HAA Request" I certify that I have checked, verified, or conformed Inspection. to all MOA and HAA guidelines In effect Signed S & S ENGINEERING 204Company sk° 99577 Date . MOA No. Ddb Receipt No. 41ol� Receipt No. _ Date of Payment G - % Waiver Fee: $ _ Amount:$ Date of Payment 72-M(Fift 7/Ba) Beck Page 2 of 2 �te of this It b" A. S,.I, ...j. Na. I437 -E • e` ' MUNICIPALITY OF &NCUOILIGE DIVISION OF Eh'VIROh:4ENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date �� G (a) Legal Descrlptl9n (include lot, block, subdivision,�,section, township, range) Location (address � or directionss) , , y r UUG -7-s % 17 d 3- v"':v 'a v . (b) App Telephone - Home Busi Applicants Name ��"ness T Applicants Address S'R (c) App Owner/builder Applicant is (check one) Lending Institution � ; Buyer E=l ; Other E= (explain); Telephone (d) Lending Institution Address (e) Real Estate Co. b Agent Address Telephone (f) Mail the HAA to the following address,:/ 2. Type ofResidence Single -Family � Multi -Family Other (describe) Number of Bedrooms 3. WaterluPply Individual Well rM Community Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite Public Community F—D Holding Tank Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 21 rm Providing Inspections, Tests, File Search, Data 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 regula- tions in effect on the date of this inspection. Telephone Name of Firm Address a Date / (ENGINEER SEAL) �kr 4,. .2 �% No. 1457.E 6. DHEP Approval , `i�•`ppp,�:' w 7 i f 3 bedrooms By ' b Da�Q�.. Approved for � / Approved _;gv— Disapproved conditiol+ Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- PARAGRAPHATIONS GIVEN IN 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER IN THE STATE OF ALASKA.THEJXIE DOES THISAA COURTESYTO PURCHASERSOF HOMESEAANND THEIR TENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- RE A CERTIFICATELISEES OF ISSUED.EPDO NOT THE MUNICIALITYTOFINS ANCHORAGE SISRNOT YRESPONS RESPONSIBLE FOR ALYZE D&TA FOERRORS OR OaISSIONS IN THE PROFESSION:IL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 21 7-19-84 r'1 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 A. WELL DATA NIMCIP?LITY 07 AP:CHOVGE C"T. OF HEALTH & E"NI:CF::J:NTi.L i'OrECr:G;J OCT RECEIVED Well Classification /UQ If A, B, or C, D.E.C. Approv�ed(Y/N) Well Log Present ( Date Ccupleted G -/ -'i� Yield�<., Total Depth /Z a Cased to f Depth of Grouting Static Water level .3a PuM Set At t4 Sanitary Seal on Casing Casing Height Above Ground 30 N Depression Around Wellhead ('� Electrical Wiring in Con(Y Separation Distances frau Well: ,� t pdjoinirg Lots To Septic/Holding Tank on Lot Z Adjoining Lots To Nearest Edge of Absorption Field on Lot��_' on To Nearest Public Sewer To Nearest Public Sewer Line � � Clearcut/Manhole � Ze To Nearest Sewer Service Line on Lot Water Sample Collected By -5'- �/lfr�� �� G �y Water Sample Test Results SFA 7 Canments N B. SEPTIC/HOLDING TANK STA Date Installed 6 g� Size j! 0 No. Cp�p�l�nents Z 4Z--�� Standpips ( Air -tight Caps ( Foundation Cleanout Y ) Depression over Tank Date Last Pumped /y c l punping/Mai .tenanee Contract on File (Y )w /� f� 7 s'J Holding Tank High -Water Alarm (Y )w I1 Tbmperary Holding Tank Separation Distances from Septic/Holding Tank: To Water -Supply 511 /D i To Building Foundation 3Z To Property Line 111F�_ To Disposal Field /� To Water Mair,/SeJoe Line-�„— �_2 '_ To Stream, Pond, Lake. or Major Drainage ry4- Course Ccmmnts N O N [Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Stratav/�' lap Type of System Design Date Installed 8 Length of Field Ir Width of Field `' 3v Depth of Field _ /D Gravel Bed Thickness 7e- Square LSquare Feet of Absorption Area 10 Sta /�' ndpipes Present E'er Depression over Field _(Y19Date of Last Adequacy Test -,c/e�l✓ /✓ a Results of Last Adequacy Test _ ej Separation Distance from Absorption Field: To Water -Supply Well To Property Lina /o ,� To Building Foundation J D To Existing or Abandoned System of Lot_ • /J Ig On Adjoining Lots /v o e Mier' ter NaWService Line SD 1 To Cutbank(if present) "i To Stream/Pond/Lake/o" Major Drainage Corse N / h To Driveway, Parking Area, or Vehicle Storage Area .Sd Ccaments D. LIFT STATION Date Installed Dimensions Size in Gallons nhole/Access (Y/N) "Pump On" level at Off" Level at High Water Alarm Level at G ` Vent (Y/N Tested for Electrical Comments Pumping Cycles during Adequacy Test. Meets MDA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA on the date -scare ftR@ t 4P. SRB 19G:: Signed—_—RIVE R, ALAS_,C1 T_, X Company MOA No. KB1/d5/s RW. 3oZ� ss y uv (Page 2 of 2] Liol1rlsq in effect 2-15-84