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HomeMy WebLinkAboutSKYLINE VIEW BLK 2 LT 1940 Skyline View Block 2 Lot 19 #051-192-08 �fl�Q GREATER r1� ANCHORAGE AREA BORvUGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME !/I/ MAILING ADDRESS SA' ,e?pel y u Z-, X, PHONEC'//qy / c7 / y� LOCATION l'1-- [ / D L" o'S+/ 121f(y LEGAL DESCRIPTION''' T / Cl /j�d CA- .7 Sky�r�. SEPTIC TANK: DISTA(CE /e NUMBER OF FROM WELL `�a� MANUFACTURER JE A'"r/Ar6L'FMATE R IAL 6/' --Cr x`115* COMPARTMENTS_ INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY/"_ U GALLONS. SEEPAGE PIT: r NUMBER OF PITS DIAMETER OR WIDTH_2 f, LENGTH_, DEPTH , LINING MATERIAL v/ l CRIB SIZE: DIAMETER _DEPTH ZDISTANCE FROM: WELL lUa � TOTAL EFFECTIVE�QQ�� I� _ BUILDING FOUNDATION, NEAREST LOT LINE,.t�r. ABSORPTION AREA (WALL AREA) 01%10 FT. ADDITIONAL ABSORPTION /9"ie� s S >'t WELL: TYPE CONSTRUCTION DEPTH DISTANCE FROM: BUILDING NEAREST NEAREST SEPTIC SEEPAGE FOUNDATION -,LOT LINE SEWER LINE TANK SYSTEM. CESSPOOL , OTHER SOURCES APPROVED DISAPPROVED DISTANCES: INSTALLED BY: t^'rNAle±1 9/h PIPE MATERIAL: ���Sti C LOT SLOPE: REMARKS: Form No. E0-031 REMARKS DIAGRAM OF SYSTEM 0 rrc�'-;fN / N p DATE .e -/J- %/ APPR l'11_It I I r i 'HL I TV Cl F::' Ht-Jf--I =o FRf=11L-jE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PF,'OTECTION 825 'L' STREET, ANCHORAGE, AK. 99501 279-2511 WELL FIVJC• CAt4`> I TE _.EIJEF: F•EF:t•1 I T PERMIT NO. ( 77297 ) APPLICANT PHIL SWAN SR BOX 87 694-9143 LOCATION IIILDbIGUQ ,': LEGAL L19 B2 SKYLINE VIEW SUED LOT SIZE 15120 SQUARE FEET TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SQ FT/FR)= 85 THE REQUIRED SIZE OF THE SOIL AB_,ORPTION SYSTEM IS: C -QEF TH= 1C2 LEt-JGTH= 22 CiFZ:f:'J •. EL C=•EF TH= r_=. THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR, DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR, TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION CIN FEET). F:EGti_1 I F:EG� _.EF•T I 1_- T1=1t4l-r _. I E_ fILCI -193 iGr=iLL�=�tJE TIJCl C J I t11_.F•ECT I Ci" FIFE F:E17�_1_1 I r I--- r> BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 1001 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F* E=_ I T •Y F-1 L- I O F -CIE• r—it-JE YEi=1F: F'F:CDt•1 I __L.1E I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES- !: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS 10DELED TO INCLUDE MORE THAN 3 BEDROOMS. SIGNED: --- c 111=11n _ AP`1P\LIC nT PHIL SWAN ISSUED BY_L`.0"-- -1 14 /Z_ i_ r,HTP I 0 & E GEG�ECHNICAL Et DEVELOPMENT CO. r Box 90, Davis St., Eagle River, Alaska 99577 6942774 or 688-2280 Russell Oyster Earl Ellis 6942774 SOIL LOG 688-2280 Soils Et Foundations Land Development Performed for: Name: N'�N�. \y�� vJ qJ Tel. No. Mailing Address: Legal Description: V\ �y�•,�*- \!,•,o SUr, Depth (feet) 0 1 2 3 4 5 6 7 8 9. 10 11 12 13 14 15 16 Soil Characteristics S.�Yti - Csc3a,.,is •.-� `� �acH�s S \—mw.i. . I S(Va Zlz Ground Water Encountered: Yes No If yess what depth Proposed Installation: Seepage Pit Drain Field Comments: �� 20 �,� �. 1 -St �\\C4° Performed by:« l 1��51"tDate:- to- i\- 77 K - - - - -- P�r�R �,zG�o c�r7/• Y STTc,all rew L t 4X f-, 0.: c rrr �S G.PMy /a° / //0 -7 YJ j7 a Gin-'"] rte. rtiT2+l..tiif of pf rZ _ <DO89 707 • 'ti �' n. 7"` 1, •-f Municipality of Anchorage is On-Site Water and Wastewater Program (907)343-7904 SA ETY tea. ti C h� Certificate of On-Site Systems Approval a 6 i3 L. 9 Parcel I.D. 051-192-08-000 Expiration Date: 9 -`f ^` 1. GENERAL INFORMATION Complete legal description Skyline View B2 LI9 Location (site address) 19410 Wildwood Dr. Chugiak, AK 99567 Current Property owner(s) Taylor & Morgan Holley Day phone 832-564-5867 Mailing address . P.O. Box 670370 Chugiak, AK 99567 Real Estate Agent Shelley Schneider-Fox Day phone 907-229-1500 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 ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: G t Date: (o - `-/ - COSA to be relea d to the enginee, less otherwise requested by the engineer. COSA Fee $ k5Zito Waiver Fee $ Date of Payment 6`30/1 Date of Payment Receipt Number aiA61/5' Receipt Number COSA# 660S7ia1 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 Alaska Rim Engineering, Inc. Phone 907-745-0222 Address 9131 E. Frontage Rd. Palmer, AK 99645 Engineer's Printed Name Norman K. Gutcher Date 5/30/2018 • OF � ��fl Or vi �T 1 ° y 0 60 a60* • •SPI l 7• iy° •�7C r0.• 0•.YU••0•.•00 •••O••• 6. DSD SIGNATURE •� }� •...• System #1 Approved for 3 bedrooms itPtormon'K.Gutcher :�� �c!' ®°• i ° CE-4919 System #2 Approved for bedrooms , Disapproved ®®®R®a '— e �\ Conditional approval for bedrooms, with the following stipulations: 71-fkA Li 1 /v.e.a.e.c. ,,o-ed fwAr,y) cic) 2z9 (Y UF4iN�y ON..siTE. WATER AND rn WASTCW PROGRAM R o n,) c C`. By: _ - _ Original Certificate Date: Cc:,—11 / 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 blue sheet_C '• :. C 1 ��c.:, 1 " 9 70 1 If more than 1 septic s, - m 't e tit: 1. COSA Che l st . o 8 Structure served b WI s `t�m m // ^^V� 4 'v Certificate of On-Site Systems Approval Che.` . ' c,"w Y pp `/ 62L9 Legal Description: Skyline View B2 L19 Parcel ID:051-192-08-000 A. WELL DATA Well type Private If A, B, or C provide PWSID# Well Log (Y/N) Y Date completed 7/1/1977 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth 295 ft. Cased to 215 ft. Casing height(above ground) 12 + in. FROM WELL LOG AT INSPECTION Date of test 7/19/1977 5/17/2018 Static water level 195 ft. 153.5 ft. Well production 5 g.p.m. 4'7 g.p.m. WATER SAMPLE RESULTS: Coliform A colonies/100 mL Nitrate 2.66 mg/L Arsenic ND D ug/L Date of sample: 5/17/2018 Collected by: Kaley Lyles B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Fiberglass Date installed 6/13/1977 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 5/14/2018 Pumper JR's Pumping C. ABSORPTION FIELD DATA Date installed 6/13/1977 Soil rating (g.p.d./ft2 or ft2/bdrm) 85 SF/BR System type Deep Trench Length 23 ft. Width 3 ft. Gravel below pipe 6 ft. Total depth 11 ft. Eff. absorption area 282 ft2 Monitoring tube Y Depression over field N Date of adequacy test 5/17/2018 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 25 in. Water added 487.4 gal. New depth 28 in. Elapsed Time: 104 min. Final fluid depth 25 in. Absorption rate >- 487.4 g.p.d. Non Known Any rejuvenation treatment(past 12 mo.)(Y/N &type) If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm&circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 1001+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main 751+ Public sewer manhole/cleanout 100'+ Sewer/septic service line 251+ Holding tank 1001+ Animal containment areas 501+ Manure/animal excrete storage areas 100'+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 51+ Property line 5'+ Absorption field 5'+ Water main 101+ Water service line 10'+ •Surface water 100'+ Wells on adjacent lots 1001+ ABSORPTION FIELD ON LOT TO: 7* 10'+ '+ Property line Building foundation Water main Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage_ 10'+ Curtain drain 501+ Wells on adjacent lots 100'+ F. COMMENTS * Waiver on file #WR070020 ***Survey on file G. ENGINEER'S CERTIFICATION '`'S 4 11 I certify that I have determined through field inspections and j��▪'• • ••••J�es review of Municipal records that the above systems are in / 't:49 TN ; * P conformance with MOA COSA guidelines in effect on this date. ge•• ••'•" ""' Norman K. Gutcher ▪ •' •�..•-• Engineer's Printed Name 0 . Norman K. Gutcher ;,e� Date 5/30/2018 I�.`��9••• CE-4919 ••• ��� •••••..•.•••• ��— COSA canary sheet_2-6-15.doc _gUSAWITT i UG 07 2015 Qj Municipality of Anchorageuret.I, stug On -Site Water and Wastewater Program (907)343-7904 Certificate of On -Site Systems Approval -Parcel LD. 051-192-0$ 1. GENERAL INFORMATION Expiration Dater f / / ,7 ' 1 Complete legal description Skyline View, Block 2, Lot 19 Location (site address) 1941.0 Wildwood Dr. Current Property owner(s) Gretchen Courtney Day phone Mailing address19410 Wildwood St. Chugiak, AK 99567 Real Estate Agent 2. TYPE OF DWELLING: ❑ Single Farniiy(w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Fx I Individual F� Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 52,60 Waiver Fee $ Date of Payment g1; qs5 Date of Payment Receipt Number l4� 2516 Receipt Number COSA # ©t)C16/41 B 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 ver4.3hat based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site wafersupply 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe 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 soil condition, ground water 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 this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we. estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Alk. 99510 Engineer's Printed Name Steven R Pannone Date 7/24/2015 6. DSD NATURE E1 System #1 Approved for —a— bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, with the following stipulations: WASTEWATER ?= By:� Q, �Original Certificate Date: The nici Ity A ge Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based- only upon the representations given in paragraph 5 by 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 blue sheet E .., c If more than 1 septic system is on the lot: COSA Checklist # + of Structure served by this system 1 Certificate of On -Site Systems Approval Checklist Legal Description: Skyline View, Block 2, Lot 19 Parcel ID: 051-192-0$ A. WELL DATA Well type Private If A, B, or C provide PWSID # * ^ Well Log (Y/N) Y Date completed 7/1/1977 Sanitary seal (YIN) Y Wires properly protected (Y/NJ x Total depth 295 ft. Cased to 215, ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 7/1911977 7122/2015 Static water level 195 ft 19fl ft Well production 5 g.p.m. 4.0 g.p.m. WATER SAMPLE RESULTS: Coliform Negcolonies/100 mL Nitrate 3.30 mg1L. Arsenic ND ug/L Date of sample: 7/22/2015 Collected by: PES R. SEPTICIHOLDING TANK DATA Tank Typelmaterial Septic/Fiberglass Date installed 5/13/1977 Tank size 1,000 gal. - Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) NN Date of pumping 5/29/2015 Pumper ` R's Pumping C. ABSORPTION FIELD DATA Date installed 6/13/1977 Soil rating (g.p.d./ft2 or ft2/bdrm) 85'SFrBR System type Deep Trench Length 23.5 ft. Width 3 ft. Gravel below pipe 6 ft. Total depth 7`4** ft.-':Eff..absorptlon.area 282 ft2 Monitoring tube Y Depression over field N Date of adequacy test 7/22/2015 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 31 in. Water added 470 gal. New depth 42 in. Elapsed Time: 220 min. Final fluid depth 31 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date D. LIFT STATION Date installed Size in gallons "Pump on" level at in. "Pump off' level at _ in. Datum Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO Septic tank/lift station on lot 100+ Absorption field on lot 100+ Public sewer main 75+ Sewer /septic service line 25+ Animal containment areas 50+ SEPTIC/HOLDING TANK ON LOT TO: Manhole/Access (WN) High water alarm level at -in. Meets alarm & circuit requirements2. On adjacent lots 100+ On adjacent lots 100+ ' Public sewer manhole/cleanout 100+ Holding tank 100+ Manure/animal excrete storage areas 10()+ Building foundation 5+ Property line 5+ Absorption field 5+ `.i Water main 10+ Water service line 10+ Surface water 100+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 7* Building foundation 10+ Water main 1 Q+ Water Service line 10+ Surfacewater100+ Driveway, parking/vehicle storage+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS *Waiver_on File #WR070020 ***Survey on -File **Monitor tube extends 41" into the top of the drainfieid. G. €N61N8ER'S CERTIFICATION I certify that t 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. Engineers Printed Name Steven R. Pannone Date •i"': COSA canary sheet 2-6-15.doc 7/31/201.5 4t Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 j �,-i r e qr 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. 05519a-rA COSA# O % 0 /3 9 1. GENERAL INFORMATION Expiration Date: 9 — I q' O % Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address SKYLINE VIEW SUBDIVISION, LOT 19, BLOCK 2 19410 WILDWOOD DRNE • CHUGIAK. AK 99567 JENNIFER & WILLIAM HOBBINS Day phone 688-6890 P.O. BOX 672462 • CHUGIAK. AK 99567 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well E Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ Day phone Day phone TYPE OF WASTEWATER DISPOSAL: Individual On-site E 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 engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER 5. As certified by my seal affixed hereto and as of the validation dato 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 andlor 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. I Phone 337-6179 Address 3701 E. TUDOR ROAD. SUITE 101 • ANCHORAGE, AK 99507 Engineers Printed Name JEFFREY A. GARNESS, P.E. Date S t6 /D-' Engineers Comments: In conducting this evaluation, GEG, Lt D. attempted to provide a thorough, 1. conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines B Regulations. The reported results described the performance of the system under the conditions encountered at the time ofthe 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 lluctuate 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 ownerlisted above. Any reliance upon or use of this report by any other person or party Is not authorized, nor will R confer any legal right whatsoever. Conditional approval for Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory bedrooms, with the Hlowing stipulations: Arsenic Advisory .Maintenance Agreements Supplemental Engineers Reort Other WASTEWATER PROGRAM o• By: /t/. Original Certificate Date: (Ray. 11A5( Municipality of Anchorage Development Services Department Building Safety Division < On -Site Water & Wastewater Program ' `• 4700 Bragew Streat P.O. Box 196650 Anchorage, AK 995196650 www.muni.org/onsf (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: SKYLINE VIEW SUBDIVISION, LOT 19, BLOCK 2 Parcel ID: A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 7/l/1977 Sanitary seal (Y/N) YES Total depth 295 ft. Cased to 215 ft. FROM WELL LOG Data of test 7/19/1977 Static water level 195 ft. Well production 5 g.p.m. WATER SAMPLE RESULTS Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 4/18/2007 195 ft, 4 g.p.m. Coliform 0 colonies/100 mi. Nitrate 4.14 mg./L. Other bacteria 0 colonies/100 ml. Arsenic: ND_ug./L. Date of sample: 4/18/2007 Collected by: GEG Ltd. B. SEPTICIHOLDING TANK DATA TankType/Material SEPTIC/STEEL Date installed 6/1/1977 Tank size 1000 gal. Number of Compartments E Cleanouts (Y/N) YES Foundation deanout (YIN) YES Depression over tank (Y/N) NO High water alarm (YIN) N/A Date of pumping 4/19/2007 Pumper JR's PUMPING C. ABSORPTION FIELD DATA Date installed 6/1/1977 Soil rating (g.p.d./f 2orj� 85 System type DEEP TRENCH Length 23.5 ft. Width 3 ft. Gravel below pipe 6 ft. Total depth *_ft. Eff. absorption area 282 fe Monitoring tube YES Depression over field NO Date of adequacy test 4/18/2007 Results (PasslFail) PASS For 3 bedrooms Fluid depth in absorption field before test"0 in. Water added 470 gal. New depth "20 in. Elapsed Time: 330 min. Final fluid depth"8 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date — **MT ONLY EXTENDS 2.75' BELOW INVERT D. LIFT STATION Date installed Size in gallons Manhole/Access(YIN) 'Pump on" level at _in. 'Pump ofr leve High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot too '+ Absorption Held on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Holding tank 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 t0'+ Surface water t 00'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line '7 Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicie storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS 'SEE ATTACHED WAIVER REQUEST LETTER 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 JEFFREY A. GARNESS Date <-It 6�0?— COSA Fee $ Waiver Fee $ Date of Receipt Number (Rev. 11*5) Date of Payment Receipt Number GARNESS ENGINEERING GROUP, Ltd. . - - - CONSULTANTS & GENERAL CONTRACTORS -- - -„--= r, May 3, 2007 Municipality of Anchorage Development Service Department Building Safety Division On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref: Lot Line Waiver for Skyline View; Lot 19, Block 2, To whom it may concern: We request that your department issue a 7 -foot lot line waiver from the west property line to the existing drainfield. The adjacent septic system on lot 12 is 10 feet plus from the lot line. I am unaware of any adverse impacts this waiver would have on adjacent wells or septic systems. If you have any gyresAons, please contact us at 337-6179. Thank you for your assistance. .E., M.S. 3701 E. Tudor Road, Suite 101 • Anchorage, AK 99507-1259 Ph: (907) 337-6179' Fax: (907) 338-3246' Website: www.gamcsscnginccring.com Municipality of Anchorage �°`` 1'(). Ik1.0 I9(iGiO • Anchomgc, Alnskn!)!�i19•fifsi0 • Tcicphnnc CJ()7) 34.4R'!01 •1'ac ((N)7) 34.9-fi'Nx) i \ 470011mgaw Stmct • Anchmagc, Alnskn !)!)R)7 a�mmuni.nrg Mayor MarkJ3cgich Building Safety Division 5/14/2007 Jeffrey Gamess Gamess Engineering Group, Ltd. Subject: Waiver Request for Skyline View Block 2 Lot 19 Waiver Request #WR070020 Parcel ID #051-192-08 HAA# 070138 Dear Engineer, Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the property line has been approved. The approved separation distance is 7.0 feet. This waiver approval applies to the existing absorption field to property line 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, Jeffrey W. Poet Engineering Technician 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 Stmt P.O. Box 196650 Anchorage. AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Waiver Review Worksheet WR#: 070020 PID#: 051492-08 HAM 070138 Permit#: Date Received: 5/10107 Legal Description: Skyline View Block 2 Lot 19 Engineer. Jeffrey Gerness Waiver Requested: 7 feet separation distance absorption field to property line. Criteria: Geology Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: ............................................................................... Waiver is Granted: Waiver is not Granted. Ust Conditions or Reasons for above: Date: !q -- By: Rec#: 5/10107 Amount $175.00 ...dr.A.............................. Date Paid: 5/10/07 i NOV 01 2001 12:5GPM HP LRSERJET 3200 '' LiA 1G^ zy: rg".7 0 l/ y= :: T " aawnew h A"5WIATES LAND SURVEYING', 694-0829 1 HEREBY CERTIFY THAT 1 HAVE SURVEYED THE SCALE, FOLLOWING DESCRIBED PROPERTY= t.�uv`y/<rvf!/cl<or�9 �yDLe .�qWW%%•N , : OF At '05wZ DATE, r ,......,,,q � AND THAT NO FNCR44L 4ENTS &IST CEAS EXPT r hQ'•'' :sof INDICATED. IT IS THE RESPONSIBILITY OF THE .d�� M OWNER TO DETERMINE THE EXISTENCE OF ANY .... ,• ...... , { EASEMENTS, COVENANTS, OR RESTRICTIONS%YG/�!/Si WHICH DO NOT AR ON THE RECORDED SUBOI- YISION PLAT. U NO CIRCUMSTANCES �/ Dvn. Mnk >•+..M R �'�� �` SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OF fl�l`f � �,, 15-6918 �1 �°r .... FELE LINES, OR FOR ESTABLISHING BOUND. DRAWNs 6�' +r A\9ck�• ART LINES. SGS Ret.N 1071596001 Client Name Garness Engineering Group, Ltd. Project Name/N Skyline View L19 U2 Client Sample ID Skyline View L19 D2 Matrix Drinking Water PN'SID 0 Sample Remarks All Dates rimes are Alaska Standard Time Printed Date2'ime 04/30/2007 9:04 Collected DateMme 04/182007 11:15 Received Dale/Time 04/182007 16:14 Technical Director Stephen C. Ede Allowable Prep Analysis Parameter Results POL Units Metlad Container ID Limits Date Date ]nit Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 0420/07 0428/07 TK Waters Department Total Nitratc/Nitritc-N 4.14 0.100 Microbiology Laboratory Total Coliform 0 mg/L Sh1204500NO3-F 0 (<10) col/IOOmL SK1209222B A (<I) 0423/07 JDS 04/18.'07 DLC tfayor 11"etrk Begicll Nlay 10, 2007 .Municipality of Anchorage N),IA-a 1!xMo •.tnchnni•�r..ticisk" k471114 i(R)- %INI Iln;!a�c SI rt'a9 Ulli.x: 1!Nl7l343.t+gll - Flip: 1!Nli 1:N:1�R21N1 hll r//uxw I . mu'lli ory! Dei,eloptncnt Services Delrtrtment William B. Jlobbins and Jennifer D. Church P.O. Box 672462 Chugiak, Alaska 99567 Dcar Property Owners: `o'. C n [ Sc c o Q c Department Encroachment: Septic Leach Field Monitor Tube and Fence in Utility Easement Skyline View Subdivision, Block 2, Lot 19, Grid NIV1159,19410 %Vildwood Street The Right of Way Division reviewed a request for a letter of nonobjection to an existing chain link fence encroaching one foot, and a septic leach field monitor tube encroaching two feet into the 10 -foot utility easement on the western side of the lot. On the as -built survey dated 10/29/01, submitted with the request, the petitioner has shown the fence and the monitor tube. This letter of nonobjection is issued with stipulations, and by using it the petitioner is ageeing to the following: 1. Municipality of Anchorage (MOA) will be held harmless, now and forever, for any damages or injury to any person as a result of the encroachments. 2. All applicable codes and regulations will be observed and maintained within the easement. 3. This letter of nonobjection will in no way preclude MOA from full use and enjoyment of its rights within any portion of the easement. 4. Additional and extraordinary costs incurred duri reconstruction ng any future required construction, repair or of MOA improvements to accommodate any or all of the encroachments shall be paid by the property owner. 5. Obtain letters of nonobjection from the following utilities: ❑ ❑ Anchorage Water & Wastewater Utility Chugach Electric Association, Inc: ❑ ® Alaska Communications Systems Matanuska ® ❑ Matanuska Electric Association, Inc. Municipal Light & Power ® Telephone Association Enstar Natural Gas Company ❑ Eyecom (Girdwood Cable TV) ® ❑ GCI Cable of Alaska No letters required All letters of nonobjection should be retained in your permanent files. If you have any questions, please call the at 343-8240. �Sincerely, 2 lack L. Frost, Jr. Right of way Supervisor Community, Security, G:WeKk-ffl'1'*-1R0H%2v/Gr tMe 8112. Lot 19 Hobbll d, Concur Y "ny cr(s) Prosperity MATANUSKA ELECTRIC ASSOCIATION, INC. RIGHT OF WAY ENCROACHMENT EASEMENT THIS AGREEMENT is made and entered into this day of JR/ TJ 20_0Z, by and between MATANUSKA ELECTRIC ASSOCIATION, INC., an Alaskan non-profit member owned electric cooperative, whose post office address is Box 2929, Palmer, Alaska, 99645, hereinafter called 'MFA', and WILLIAM B. HOBBINS 8 JENNIFER D. HOBBINS whose address is POST OFFICE BOX 672462 CHUGIAK, ALASKA 99567hereinafter called "Owner". WHEREAS, Owner covenants that Owner Is the legal owner of the real property described as: Lot 19, Block 2, SKYLINE VIEW SUBDIVISION, according -to Plat # P-508, Anchorage Recording District WHEREAS, Owner further covenants that the said property is'owned free and clear of encumbrances and liens of whatsoever character that in any way limit Owner's authority to enter into this Agreement with MEA; WHEREAS, Owner and MEA hereby covenant that MEA is lawfully authorized to occupy the 10 foot wide utility easement designated along the west portion of the above-described property and depicted on Plat No. P-508, Anchorage Recording District, Third Judicial District of Alaska; and WHEREAS, Owner acknowledges that there is an existing encroachment in this utility easement This encroachment is described as follows: Septic leachfield monitor tube encroaching approximately 3 feet, and chain link fence encroaching approximately 1-2 feet ,NOW, THEREFORE, for and in consideration of these mutual agreements: . Owner, for Owner's self, plus Owner's successors and assigns, does hereby grant to MEA, and to its successors or assigns the right to enter upon the property of Owner situated in the _Anchorage Recording District, State of Alaska, and more particularly described as follows: Lot 19, Block 2, SKYLINE VIEW SUBDIVISION, according to Plat # P-508, Anchorage Recording District being in Section 16 , Township 15N, Range 1W. S.M., and to construct, reconstruct, rephase, repair, operate and maintain on, over or under the above described lands and/or in, upon or under all streets, roads or highways abutting said lands, and electric transmission and/or distribution line or system; to inspect and make such repairs, changes, alterations, improvements, removals from, substitutions and additions to its facilities as MFA may from time to time deem advisable, including by way of example and not by way of limitation: the right to increase or decrease the' number of conduits, wires, cables, hand holes, manholes, connection boxes, pedestals, transformer enclosures; to cut, trim and control the growth by machinery or otherwise of trees and shrubbery located within the lands specifically described above, or that may Interfere with or threaten to endanger the operation and maintenance of said line or system (including anycontrol of the growth of other vegetation in the right of way which may inddentaily and necessarily result from'the means of control employed): to keep the encroachment easement dear of all buildings, structures or other obstructions, other than the existing encroachment specifically noted above, and to allow MFA the right of Ingress and egress over the remainder of said parcel as reasonably necessary to conduct the above activities within the encroachment easement Encroachment Easement Page 2 2. MFA, for itself, its successors and assigns, hereby waives its objections to Owner's existing encroachment as described above on the following conditions which Owner, for Owner's self, plus Owner's successors and assigns, hereby accepts as covenants that run with the property described above: A. Owner, Owner's successors and Owner's assigns, shall indemnify 'and . hold MEA, its successors and assigns, harmless from liability for any injury or damage to any person or property that may result from said encroachment. B. Owner, for Owner's self, plus Owner's successors and assigns, hereby agrees that the continued existence of the encroachment described above shall not restrict or limit the current or future ability of MEA to fully enjoy. the benefits of this encroachment easement for any and all utility purposes consistent with paragraph 2 above. C. Owner, for Owner's self, plus Owner's successors and assigns, hereby stipulates and agrees that they shall each hold MEA, its successors and assigns, harmless. from liability for any and all damages to the encroachment that may result from the existing and future utility use of said encroachment easement by MFA, its contractors, .successors, agents, licensees, or assigns. ' D. Any facilities or property of MEA, its successors and assigns, located with the encroachment easement granted herein that are damaged or destroyed as a result of actions undertaken by Owner, or Owner's successors and assigns, shall be repaired ordeplaced at MEA's discretion and such repairs or replacement shall be paid for by Owner, or Owner's successors and assigns. ' E. Any facilities or property of MEA, its successors and assigns, located within the encroachment easement granted herein that must be relocated or modified to accommodate actions undertaken by Owner, or Owner's successors and assigns, In order to remain in compliance with applicable codes and prudent utility practice shall be relocated or modified at the sole expense of Owner, or Owner's successors and assigns. F. Owner, Owner's successors and assigns, and their contractors or agents, will not perform work on the encroachment described above with equipment capable of violating any State or Federal law or regulation governing the operation of equipment near energized electric utility Infrastructure. By execution of this Agreement. Owner further agrees for Owners self, plus Owner's successors and assigns: (a) that any septic monitoring tubes placed within the said encroachment easement be visible at all times for a distance of at least ten feet from any direction. Encroachment Easement Page 3 IN WITNESS 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. MATANUSKA ELECTRIC ASSOCIATION. INC. l (MEA) BY:laww—�l • Gam` " General Managerorhis Repre ntativ STATE OF ALASKA SS. THIRD JUDICIAL DISTRICT : of The foregoing agreementwas acknoo�wl%dged before me this day by �•� "n L 7J� es_7t,., v,• yA/ltL- tyo ru�y Al Notary Public for the State of Alasl My'commission expires: N/a & OWNER STATE OFALASKA : SS. THIRD JUDICIAL DISTRICT : The foregoing agreement was acknowledged before me this '?L/ day of 200 , by W 1,ICam 6 and 5�nn i 4e b #Oblx4s. *S Notary Public for the Gtate of Nqska My commission expires: 10A 108� RETURN TO: MEA P.O. BOX 2929 PALMER, ALASKA 99645' April 25, 2007 William and Jennifer Bobbins P.O. Box 672462 Chugiak, AK 99567 Re: Letter of Non -Objection Grid: NW1159 To whom it may concern: ENSTAR Natural Gas Company A DIVISION OF SEMCO ENERGY Engineering Department 401 E. International Airport Road P. O. Box 190288 Anchorage, Alaska 99519-0288 (907)334-7753 FAX (907) 334-7798 ENSTAR Natural Gas Company has no objection to a drain field monitoring tube encroachment into the Ten Feet (10 ft) wide utility easement, situated on Lot 19, Block 2, Skyline View Subdivision, according to Plat No. P-508, Records of the Anchorage Recording District, Third Judicial District, State of Alaska. Acceptance and use of this letter of nonobjection by yourself, your heirs, your assigns, or your successors, will constitute agreement to the following stipulations: • ENSTAR will be held harmless, now and forever for any damages or injury to any person or property as a result of this encroachment • Any ENSTAR facility damaged or destroyed, as a result of this encroachment will be repaired at no cost to ENSTAR. • Any costs incurred by ENSTAR for special construction necessitated by this encroachment will be home by the property owner. • All applicable safety code regulations will be observed and maintained. • This letter of nonobjection will in no way preclude ENSTAR from full use and enjoyment of its rights within any portion of its right-of-way. Sincerely,���J�� Andrew Fraiser� Right -of -Way Assistant ENSTAR Natural Gas Company cc: File �T/A NON -OBJECTION TO EASEMENT ENCROACHMENT DOCUMENT By this document Matanuska Telephone Association, Inc. (MTA) declares that it has no objection to the encroachment of a monitor tube within the platted utility easement located upon and within Lot 19, Block 2, Skyline View Subdivision, Plat No. P-508, Anchorage Recording District, Third Judicial District, State of Alaska, situated in Section 16, Township 15 North, Range 1 West, S.M., Alaska. Please be advised that MTA through the issuance of this document does not forfeit any of its rights to the use of the area cited. In the exercise of these rights MTA will, if needed, upgrade, maintain, repair, and/or replace buried or aerial tclecommunications facilities within the easement. Any repairs that may be required to the encroachment as a result of utility construction will be bome by the property owner of record. This document does not authorize the placement of any additional encroachments within the easement area. Property owners are required to obtain utility locates before doing any kind of work in the utility easements and will be liable for any damages caused by their construction work in the easements. This document is, in no way, an agreement to vacate anv portion of the utility easement and should not be interpreted as such. Issued for Matanuska Telephone Association, Inc. this 25th day of April, 2007, by, Real Estate &: Properties Supervisor THIS IS TO CERTIFY, that on this 25th day of April, 2007, before me the undersigned, a Notary Public in and for the State of Alaska, duly commissioned and sworn as such, personally appeared Bonnie Bailey known to me and to me known to be the individual named in and who executed the foregoing instrument and acknowledged to me that he signed and sealed the same as a voluntary act and deed for the uses and purposes therein mentioned. IN WITNESS WHEREOF, I have hereunto set my hand and official seal the day and year first above written. Notary.Asublic Wand Tor ee- My commission expires: //- g0 -/O GRANTOR: ;ru i; Matanuska Telephone Association, Inc. P.O. Boz 3550 0n .�� Local MiRakns�ra A&% P( WAssoclation Inc. - Long Distance P.O. Box 3550 Wireless Pain a . Alaska 99CAS•3550 . 800.748.9510 Business Solutions 907.781.2510 Internet 907.781.2848 (fax) Directory www.mtasolutions.eom DN April 25, 2007 William and Jennifer Hobbins (Owners) 19410 Wildwood Street Chugiak, AK. 99567 To whom this may concern, Subject to your agreement to indemnify the company as set forth below, GCI Cable Inc. of Alaska has no objection to the monitoring tube for drainlield encroaching a utility easement in the Southwest portion of Lot 19, Block 1, Skyline View Subdivision. Known as (194 10 Wildwood Street, Chugiak, AK. 99567) in city grid # NW1159. This letter of non -objection in no way precludes GCI Cable from full use and enjoyment of any rights it may have within any portion of the utility easement and or the right -of. way, including unlimited access for servicing its facilities. Also any additional and extraordinary costs incurred during any future required construction, repair or reconstruction of GCI's facilities to accommodate any or all of the encroachments shall be paid by the property owner. By signing below, you agree to indemnify and hold GCI Cable harmless, now and forever, for any damage, costs, expense (including reasonable attorney's fees), liabilities and injury to any person or property occurring as a result of the encroachment. Please indicate your acceptance by signing and returning this letter to myself at the address below. If not signed and returned to (CI within 30 days of issuance this letter of non-ohlection becomes void for all intents and purposes Sincerely, Pro y Own s signature (Void until signed by the Property Owners and returned.) Rob Hansen CAD Operator Level 1 E -Mail- RHANSENI na GCI.COM Office # (907) 868-6168 Fax # (907) 868-8580 5 S -o-) Date Municipality of Anchorage e'er syr! -� Development Services Department % Building Safety Division _ On -Site Water and Wastewater Program S I-„ 4700 South Bragaw St. 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 Parcel I.D. 051-192-08 HAA #_ f F1 ( O t- 5 - Expiration Expiration Date: )/-/6-01 1. GENERAL INFORMATION Complete legal description Lot 19 Block 2 Skyline Yew Subdivision Location (site address or directions) Wildwood Drive Current Property owner(s) Thomas Beesino Day phone 694.6646 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address P.O. Box 672226 Chuoiak, AK 99567 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class_ Well Public Water System Three 3 Day phone Day phone TYPE OF WASTEWATER DISPOSAL: ® 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 We (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seat affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system ts(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, RE Date 8/10/2001 . ......... ••A • .•` ` 4916fjj l jEER`St {� MICHAP E ANDERSCN :v p dpi'.' CE -4381 •:��� 5. DSD SIGNATURE di4leyF•.• " •••••.••�a`y t�' Approved for bedrooms. Disapproved., Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineers Report Other By; 6!J � Original Certificate Date: S - / 3 - O 1 (ra.. +zco) Municipality of Anchorage ,,._ •. • Development Services Department Budding Safety Division Oro -Sao Water & Wastewater Program : 470D South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage,ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lot 19, Block 2. Skyline View Subdivision Parcel ID: 051.192-08 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 7111`1977 Sanitary seal (YM) Y Total depth 295 ft. Cased to 215 ft. FROM WELL LOG Date of test 711911977 Static water level 195 ft. Well production 5 9 - p.m -WATER SAMPLE RESULTS: Coliform 0 colanies1100 not. Nitrate j mgA. Date of sample: 78912001 Collected by: MEA B. SEPTICAIOLDING TANK DATA Tank TypefMatenal Seotic/PJ&M.4"ss Tank size 1,000 gal. Number of Compartments 2 Well Log (YIN) Y Wires property protected (Y/N) Y Casing height (abs gond) >24 in. AT INSPECTION 6!4!2001 192 ft. 4.7 g.p.m. Date installed 6MR977 Ctearwuts (YIN) Y Foundation deanout (YM) It Depression over tank (YIN) N High water alarm (YIN) X N Date of pumping 8!!81101 ` Pumper AR's C. ABSORPTION FIELD DATA Date installed 611n977 Sol rating (g.p.dAftor fPlbdnn) 85 SFBDRM System type Deep Trench Length 23 ft. Width 9 ft. Gravel below pipe 6 ft. Total depth 11 ft. Eft. absorption area 282 fN Monitoring tube Y Depression aver field N Date of adequacy test 8148001 Results (Pass/Fed) Pass For 3 bedrooms Fluid depth in absorption field before lest' U— in. Water added450 gal. New dep#40 in. Elapsed Time: 0 min. Final fluid depth' 4�.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 Size in gallons "Pump on* level at _ in. "Pump off' level at _in. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic lank/lift station on lot >11V Absorption field on lot MW Public sewer main WA Manhole/Access (VM) High water alarm level at Meets alarm b =cult requirements? On adjacent lots >1001 On adjacent lots Public sewer manhole/cleanout WA Sewer /septic service One >25 Holding tank WA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Budding foundation >S Property One >S Absorption field >S Water main WA Water service line >117 Surface water Aw Wells on adjacent lots MW SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line >IW Budding foundation >17 Water main WA Water Service line >1C Surface water. >IW Ddveway, pa*mWvehkle etmW >25 Curtain drain None Noted Weds on adjacent lots >100' F. COMMENTS HAA Fee $ .300 -ma Date of Payment 94/3-6/ Receipt Number g 6/ (Rev. 12/00) Waiver Fee S Date of Payment Receipt Number G. ENGINEER'S CERTIFICATION r•. A I cer* that 1 have detenNned duough field kquectlorrs and . 4 9 i 'v `� review of Municlpal records drat tae above systems are in „ .. . .. oon/ormance with MOA HAA guidelines in effect on dds date. ..- ...... so Engineer's Printed Name Michael E Anderson. P.E.Od �'• CT -4- l n �O` FSE... .,�'�r-,< Date 111`10M1lOM10 • HAA Fee $ .300 -ma Date of Payment 94/3-6/ Receipt Number g 6/ (Rev. 12/00) Waiver Fee S Date of Payment Receipt Number ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 522-6779 (FAX) August 10, 2001 Mr. Tom Beesing P.O. Box 672226 Chugiak, AK 99567 Subject: Lot 19, Block 2, Skyline View Subdivision Well and Septic System Inspection and Certification Dear Tom: On August 4, 2001, we inspected the septic system serving the three-bedroom home on Lot 19, Block 2, Skyline View Subdivision. Prior to the inspection we researched the information on the system located in files maintained by the Municipality. These files indicate the system was originally constructed in June of 1977 when the house was originally built. The current system consists of a 1,000 -gallon fiberglass septic tank and a deep absorption trench with a length of 23', a total depth of 11' and an effective depth of 6'. Water was found in the sump at the end of the trench at a depth of 54.5" indicating the trench is approximately 75.5% submerged with 17.5" of working absorption area remaining. A total of 450 gallons of water was injected into the trench to determine the absorptive characteristics. No rise in the water level in the sump was detected indicating the trench was absorbing the water as fast as it was being injected. We are confident the system is currently capable of absorbing more than 450 gallons of water per day and meets the Municipal requirement for certification. We make no guarantees, however, of the ability of the system to sustain this rate in the future. The well was allowed to flow freely for 5 hours. Flow from the well was measured at 4.8 gallons per minute during this period. The static water level was measured at 192' below the surface and remained at that level during the entire test. The well produces sufficient water to meet the Municipal requirement for a 3 -bedroom home. A sample was taken from the well and found to contain no coliform or other bacteria and only 2.98 mg/liter of nitrates. - The water quality also meets Municipal criteria. Sincerely, i1 (f aLc� Michael E. Anderson, P.E. r Q i O. N O { O UU � W W W CL m KU) O CL — sc G C R. r O a m H 0 N i _m d E E 8 O T N o U A 7 J p U 0 4) O to Y W CL O 9 LL U N N W N N N y c C E m z u n2 E U CL o d m u c T O d �C- as C U H �I N C CLA U M j n. C 3: V) ik N m C - N 3 m N N S N _� 76 U)w Q ui c Y c z 0 o O N Q N 110 R' w N � — n c F- Cr m J — Z � t Q c 4 fA c t7 O — c > u Q Z U o N V c Z J Z Q C d (n v { o y c9i As J S G 0% L c d V Q d C V V V j J L N c C OI O 01 O O ONi 0 m On N N go 0 Nn 0 p 0 O m 7 0 { NN NN 1n co na0 na0 � m rn v e v < v oo�n000 E N N c7 V O F 00 0 N N N N W N N N y c C E m z u n2 U CL o d m u c T O d �C- as C �I N C CLA U M j n. C 3: V) ik N m V) - N 3 m N N S N _� 76 N W o N E m z u U o Z Z U V) Q ui Y c z mN o E ~ iv R' MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIR=MNTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRO&%ENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information (a) Legal Des Application Date (include lot, blockJ subdivision, section, township, range) Location (address or directions) 111,0"41" ,�J'o (b) Applicants Name / /h X41" Gree C / Telephone - HomesycBusiness Applicants Address -7,0.5-1 L,,- !rr' <% 7�;c %- /l -.J e"; rc-� AX.i Sir (c) Applicant is (check one) Lending Institution ; Owner/builderAE�l ; Buyer E:j ; Other [-�:J (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. S Agent �V"e m "r Address oD X —7 i h 6 7 0 e-, ✓r► 95s7� Telephone (f) Mail the HAA to the following address: AeII! esr -+.A.✓-P 2. Type of Residence Single-FamilqMulti-Family Q Number of Bedrooms- oZ 3. Water Supply- Individcal Well Community Other (describe) 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 Oudllp,� 1'uLlle � l;ununuully � II��l�ltu6 1'uub. Note: If community well system, must have written confirmation from the State Department of Enviro=ental Conservation attesting to the legality and status. [Page 1 of 2] 1 f 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 regula- tions in effectonthe date of this inspection. Name of Firm T66e., Sac,. r-���� �F r Telephone Address Date 1 1 6. DHEPApproval (ENGINEER SEAL) Approved for -;90 -z) bedrooms By 1 - Approved X Disapproved Terms of Conditional Approval CAUTION *:A 9TH Conditional 00"225-E '^- It S/ONAL Da tie THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL LND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSION'S IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 (Page 2 of 21 7-19-84 • n n Linda Wetzel Tobben Spurkland, P.E. 7051 Lake 0' The Hills Circle 203 W. 15th Ave "C" Suite 203 Anchorage, AK 99516 Anchorage, AK 99501 September 12, 1984 WELL INSPECTION LEGAL: Lot 19, Block 2, Skyline View TYPE OF WELL: Private CASING ABOVE GROUND: 24" WIRES IN CONDUIT: Yes SEPARATION DISTANCES: 100+ to septic and trench SURFACE GRADING: Satisfactory LAB TEST: Satisfactory WELL STATIC LEVEL: 195' (well log) The sustained 4 hour yield of this well is adequate for the residence described on this date. n Linda Wetzel 7051 Lake 0' The Hills Circle Anchorage, AK 99516 Tobben Spurkland, P.E. 203 W. 15th Ave "C" Suite 203 Anchorage, AK 99501 September 11, 1984 SEPTIC SYSTEM ADEQUACY TEST LEGAL: Lot 19, Block 2, Skyline View LOCATION: Eagle River OWNER: Linda Wetzel RESIDENCE: 3 bedroom home, single family WATER SYSTEM: On site well SEPTIC SYSTEM: From municipal records. A 1,000 gallon septic tank and trench type leachfield DATE OF TEST: September 11, 1984 TEST PROCEDURE: The septic tank was pumped and verified to have a capacity of 1,000 gallons. The trench was charged with 450 gallons of fresh water and after a period of 24 hours all the water which had been added to the trench had percolated out as recorded by sump measurements. TEST RESULT: The septic system is adequate for the described property on this date, September 11, 1984. APPLIf"NT`''FILLS OUT UPPER HAI", ONLY PrCperlY owner &orC�01� + L� �Ci(l VV eA Za1 Phone 563 8315 Mailing Address i (oo w Vr h Vp )knN o(ci 1g, zip code gtSO Buyer rnUnGe �, Address ZIP Code Lending Institution n -)c YiAL-nl, tL Lo 0C �C L` Phone Address / Zip Code Realty Co. d Agent Phone Address ZIP Code Date - / Legal Description SKy1,ne V l e1� �•1�- 1< Z L`'" 19 Street Location Type of Residence Single Family 2 ❑ Multiple Family No. of Bedrooms ❑ Other Water Supply Inspector Individual ATTACH WELL LOG. A well log Is required for all wells drilled since June 1975. �j Community For wells drilled prior to that date, give well depth (attach log if available). ❑ Public Utility Ny O Sewer Disposal Individual Year Individual Installed: Public Utility When Connected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Tim Tima \\ � ciCr n Date Date Dat GC.Qo ^ tY- � Date Inspector Inspector Inspector Insp r ��nNS Field Not Ny O MUNICIPALITY OF ANCHORAGE GD6/ DEPT. OF HEALTH S. ENVIRONIA=NTAL PROTECTION t -r MAR 10 t�o3 RECEIVED ( ) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( I DISAPPROVED ( ) CONDITIONAL APPROVAL' DATE BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Septic Tank SIZe /O a sj S G' A 3- % /ll 1 Well to Tank /00 j7 2o» OM March 17, 1903 Gordon & Linda Wetzel 066 Westbury Drive Anchorage, Ai: 99503 Subject: Skyline View Falk 2 Lot 19 Approval for the individual sewer and water facilities cannot be granted until the following item have been completed: A well log submitted to this office for our files and review. ° The top of the well casing should be scaled so that it is water tight. b�I1H ° Lxposed electrical vires to the well head are in violation E of the Municipality of Anchorage codes and must be encased in conduit. � p j The water analysis report needs to be sub:.iitted to this office from the Chem Lab, 5633 D Street, for our review. The septic tank pumped with a receipt sub:aitted to this department. U a° The standpipe to the sewer system need caps on them. Please notify this Department for a reinspection when the noted discrepancies have been corrected. If there are any further questions, please call this office at 264-4720. Sincerely, Jim Roberts Associate L'nvironnental Specialist JR169/ej/El hc4a MUNICIPALITY OF ANCHORAGE &ILL' PL[_ V Nim DEPARTMU"F HEALTH AND ENVIRONMENT'�)PROTECTION 825 L Street, Anchorage, Alaska" 99501 Vtir 279-2511, ext. 224 or 225 Date Received: Au_gust__5_, 1977 #1: Time ILLY-) An)- #2: Time f3: Time Date 9-- /,(}.`17 I , 3�' Date Date Insp Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES % Florence Wegner 1. Lending Institution Request: First National Bank of Anchorage Mailing Address: Post Office Box 4-2090 99509 Phone: 275-1521 2. Property Owner: Max :bevins flailing Address: 640 West 36th Avenue 99503 3. Legal Description: Lot 19 Block 2 Skyline View 4: Single Family Residence: (yj Multiple Family Residence: ( ) Phone: 279-2491 Number of Bedrooms: Two Number of Bedrooms: 5. Well System: Individual 1.7011 kX) Community/Public System ( ) Permit # Construction Depth of Well Well Log on File ( ) Bacterial Analysis 6. Sewage Disposal System: On-site System :kxk Public Utility ( ) Permit # Installed Septic Tank Size Absorption Area Installer Manufacturer Soils Rate 7. Distances: Well to Septic Tank to Sewer Line to Nearest Lot Line Nearest Lot line Material to Absorption Area Absorption Area PS R� Tcro Department of Health and Environmental Protection Request for Approval of Individual Seiner and Water. Facilities Legal Description: Comments: Lot 19 Block 2 Skyline View Subdivision Affadavit Attached: ( ) Letter Attached: ( ) Approved:+' Date: Disapproved: Date: Department Worksheet: Municipality of Anchorage DEPART.., AT OF HEALTH & ENVIRONMENTAL PR, CTION t J J '.'7 ll POUCH 6-650 ANCHORAGE, ALASKA 99502 279-2511 ;: ,y• C REQUEST FOR APPROVAL OF INnIVInUAL SEWER ANO WATER FACII ITIFS 1. TYPE OF LOAN 2. ASSESSORS PARCEL NUMBER ❑ VA ❑ F.H.A. [N CONV ❑ 3. LENDING INSTITUTION 4. REALTOR OR AGENT , .[ First National Bank of Anchorage flax Bevins P. O. Box 4-2090 aoo�r.s, Star Realty South Center Branch 640 W. 36th Anchorage, Alaska 99509 Anchorage, Alaska 99503 Florence hlegner n, r;; 274-1521 ATT'.; ri r,::_ 279-2491 5. SELLER 6. BUYER Max Bevins ':'V C: Steven f•hirto 640 W. 36th AL 'U, SPA 196A Eagle River, Alaska 99577 o,.'";WY 279-2491 HA 279-3114(work) or 694-9026 (hole) 7. LEGAL DESCRIPTION 8. LOCATION/STREET ADDRESS Int 19, Block 2, Sk.yline View TUDI Wildtvod, Chugiak 9. TYPE OF DWELLING 10. WATER SUPPLY 11. SEWAGE DISPOSAL SYSTEM XXSINGLE FAMILY RESIDENCE 2 BDRMS ❑ PUBLIC UTILITY ❑ PUBLIC UTILITY ❑ MULTI -FAMILY RESIDENCE BDRMS 11 PRIVATE ON XK ON-SITE YEAR INSTALLED INSTRUCTIONS TO REQUESTOR 1. Complete Items 1 to 11 above 3. Send to address above 5. Response will be returned to lending 2. Remove the carbon 4. Please allow 10 days for processing institution DATE RECEIVED DATE OF INSPECTION TIME OF INSPECTION INSPECTOR 8-10- `1� I�rz1�T TYPE DEPTH YEAR DRILLEEDs1 PERMIT REFERENCE FT. W 3 CONSTRUCTION BACTERIAL ANALYSIS LAB REFERENCE NO. YEAR INSTALLED INSTALLER TANK SIZE MANUFACTURER 1911) t 000 DIMENSIONS CRIB CONSTRUCTION IW ❑ PIT N } N TOTAL LINE LENGTH TRENCH DEPTH GRAVEL DEPTH � .DISPOSAL h FIELD + � t 8S aQl1RT. FT. FT. TOTAL ABSORPTION AREA PERMIT REFERENCE ��— I SO. FT. 72010111/761 - - SEPTIC TANK ORPTION AREA I SEWER LINES'' LOT LINES OTHER W WELL T0: U 2 SEPTIC TANK ABSORPTION AREA WELL LOT LINE _ - — FOUNOAT16N TO W U ❑ APPROVCD ❑ CONDITIONAL APPROVAL ❑ DISAPPROVED ❑ UNABLE TO INSPECT DATE INSPECTOR DIAGRAM OF SYSTEM I I t .. .. t f I i I I I � — t — — I , I I S! 1 I 11 I I I I I 1! 1 I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. DATE SIGNATURE -- GREATER ANCHORAGE AREA BOkUUGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME ' MAILING ADDRESS - ' ' PHONE:' LOCATION �' ' �/ //"L" LEGAL DESCRIPTION SEPTIC TANK: DISTANCE NUMBER OF FROM WELL MANUFACTURER -'MATERIAL /."' ' COMPARTMENTS INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY GALLONS. SEEPAGE PIT: 1 NUMBER OF PITS DIAMETER OR WIDTH LENGTH n�Q"' DEPTH i LINING MATERIAL' '' CRIB SIZE: DIAMETER_DEPTH DISTANCE FROM: WELL . TOTAL EFFECTIVE r• %; BUILDING FOUNDATION(_, NEAREST LOT LINE ABSORPTION AREA (WALL AREA) "' SQ. FT. ADDITIONAL ABSORPTION WELL: TYPE BUILDING FOUNDATION _CONSTRUCTION NEAREST NEAREST LOT LINE SEWER LINE , CESSPOOL , OTHER SOURCES APPROVED DISAPPROVED REMARKS DISTANCES: i I� I( INSTALLED BY: k • F PIPE MATERIAL: ~ ' LOT SLOPE: 1 REMARKS: a i DEPTH _ SEPTIC TANK. DIAGRAM OF SYSTEM r .rhY IAS DISTANCE FROM: SEEPAGE SYSTEM I DATE APPROVED" r G.A.A.B. Form No. EQ -031 a I. -or zo Lor 16 o rN p 'RQt3 d l -N* F5Rt.Pcf5D W LOT SURVEY CERTIFICATION: 1 HEREBY CERTIFY THAT 1 HAVE SURVEYED THE PROPERTY SHOWN AND DESCRIBED HEREON AND THAT THE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO ENCHROACHMENTS EXIST. PR•wI[D �r. GERALD V. RANDALL A REG. L o SURVEYOR AN AGE W4, of A14" -%1n - Gerald V. Randall Jr. f o NO. 405y{1[_ `Q rFROFfSSICh AL LpA�e rr IS THE CONTRACTORS RESPONSIBILITY TO CHECK TOP OF FOUNDATION IN RELATION TO FINISH GRADE LEGAL DESCRIPTION: FLaT' ?1-A� Loi 1'7 SLK Z- -5 sK-YL_►N15 V15N SID LEGEND: • e/[ REAR RECOVER[D O e/R REBAR [[T T NiRV[T a tYt- we R •ACK [ET CMI ■[I[TNG ELEVATp s DAT1M A331MED 1 KAl[ 111 C � O I zOl,1 n r C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata S 0 Type of System Resign Date Installed /9 7 7 Length of Field 3 Width of Field T / Depth of Field Gravel Bed Thickness y ' Square Feet of Absorption Area Standpipes Present (Y/N) Depressior. over Field (YIN) AJ Date of last Adequacy Test 511r z/ Results of Last Adequacy 'I':�st Tv T;A. firs Separation Distance frau Absorption Field: To Water -Supply Well /ov To Property Lire / e To Building Foundation ar,-? To Existing or Abardcned System on Lot N+^ t ; On Adjoinirg Lots 3,o t To Water Main/Service Line .2 s- f_ _ To Cutbank (if present) To Stream/Ford/Lake/or Major Drainage Course w - To Driveway, Parking Area, or Vehicle Storage Area /o f Comments D. LIFT STATi0.1' /✓/� Date Installed Size in Gallons "Pump Or." Level at Dimensions Mard.ole/Access (YIN) "Pump off" Level at High Water Alarm Level at Vent (YIN) Tested for Pumping Cycles airing Adequacy Test. Meets MOA Electrical Codes(Y/N) Comments ** Check Permitted Bedroom Rating Against HA.4 Request **- I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the date of this inspection. Sigred :50, Date 9/• //r V Company MOA No. 5-j S-7-- 1) Y.B1/d5/s (Page 2 of 21 IrEF.'nntS, .. 2-15-54 + MUNICIPALITY Cf DEPT. OF WALT: i 3 ENVInONh1 NTAL F v:.TLCi.UN MUNICIPALITY OF ANCHDRAGE (MGA) SEP_ 17 1984 HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 RECEIVED A. WELL DATA Legal Description: LQ± Ig Alk 2 5Kytnee \AeLk) 53b. ch Well Classification If A, B, or C, D.E.C. Approved(YM) Nf¢ Well Log Present (Y/N) Date Completed 7/7> Yield 5'Gprn Total Depth .-25 5- Cased to .2"5- ' Depth of Grouting yl,, Static Water Level 795- Pump Set At 6-a Casing Height Above Ground -Z / Sanitary Seal on Casirg (YM), y Electrical Wiring in Conduit (Y/N) 1/ Depression Arcund Wellhead (Y/N)Atl Separaticn Distances from [loll: To Septic/Holding Tank on Lot /OD * , On Adjoining Lots�ou�` To Nearest Edge of Absorption Field on Lot &e r ; On Adjoirirg Lots To Nearest Public Sewer Lire /✓ To Nearest Public Sewer Cleancut/Manhole ws. a TO Nearest Sewer Service Lire on Lot a 5 -JO-- Water Sample Collected By A Ir, P Water Sample Test Results czJl3 7�r�7,+e ✓ Comments i4-lL-// /as /-'r'te /j74n I B. SEPTIC/HOLDING TANK DATA Date Installed 6y7 7 Size /oov G< //^rNo. of Compartments ?' Standpipes (Y/N) y Air -tight Caps (Y/N) t Fcundation. Cleanout (Y/N) Depression over Tank (Y/N) W Date Last Pumped /Pg Pumpirg/Mainterance Contract on File (Y/N) N/j ; for Holding Tank High -Water Alarm (Y/N)A✓/¢ Temporary 8oldirg Tank Per -it (Y,^.) Separatior. Distances from Septic/Holding Tank: To Water -Supply Wall /on 7'- To Bjilding Foundation /'g. To Property Line /0 To Disposal Field &/ To Water Mair/Service Linz LS JA- To Stream, Pond, Lake, cr Major Drainage Course /v... Comments Receipt Date Paid: t Amount: yT.11� [Page 1 of 21 2-15-84