HomeMy WebLinkAboutTERRACE HEIGHTS BLK 1 LT 4 Municipality of Anchorage Page I, of-'-/--~
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~_ ' ~ ~'~.- ~:~ '~------ff PID Number:
Name:¢~ i ~[ ¢ ~ ~~~ Wastewater System: ~ New ~pgrade
~ss~ (o%~ ~ ~V,~ ~ ~[[~ ABSORPTION FIE~
Phone: 5HS~&7~Nc. or, rooms: ~ DeepTrench ~ Shallow Trench ~ Mound ~Other
LEGAL DESCRIPTION sci, Rating: ~al Depth from original grade:
GPD/Sq.
Lot:~ Block: j ~~ Subdivisio~~ Depth to pipe bottom from original/Ft. ~ Gravel depth beneath pipe Ft.
Township: ~ Range: Section: Fill added above origi~de: Gravel length:
Ft. Ft.
WELL: ~tg~2w ~ Upgrade Gravelwidth: / Number of lines: ~ Distance between lines:
Ft. Ft.
~Classif~ti°n/~ ~Pri~ate'~A~'C): Total Depth: Ft. Cased To: Ft. Total abs~on area: SQ. Ft. Pipe material:
Driller: Date Drilled: Static Water Level:Ft. InstaHer:~~~ ~. Date installed:
Yield: Pump Set at: Casing Height Above Ground:
GPM Ft. Ft. TANK
SEPARATION DISTANCES ~ Septic ~olding ~ S.T.EP.
TO Septic Absorption Lift Holding ~ublic/Private Manufacturer: I Capacity in gallons:
From Tank Field Station Tank Sewer Lines.' . _ ~E~ ·
Well ~ __ __ ~l ~ ~ Mater~~ ~ Number °f
Compartments:
Surface
Water ~ ~ -- ~ ~ LIFT STATION
LineL°t ~ ~ _ ~/ ~ Size in gallons: ~ Manufacturer:
Foundation .... I~' -- "Pump°n"levelat: ~~lat: [High water alarm at:
Curtain ~ectrical Inspections performed by:
Drain ~ ~-¢~ ~¢O~ PumpM
Remarks: ~/~ ~ ~~7¢¢ ~171¢ BENCH MARK
Location and Description:
Assumed Elevation:
ENGI~EAL
S & S ENGINEERING
.nspect ons performed ,7.4 '
Department of Hea!~ and ~uman ~ervices approval
Reviewed and approved by: Date' N-/~- ~2
72-013 (Rev. 9/91) MOA 25
Permit No. ~ ~'-[~'"~) '~'"'~' Page
~ of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: I~ ~ PID No.:
..,?~ -¢~' ~2-'
72-013 A (Rev. 9/91) MOA 25
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF
~9,~
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920278
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:BEEGLE PHILLIP P &
OWNER ADDRESS:7861 COX DR
ANCHORAGE, AK 99516
DATE ISSUED: 9/11/92
EXPIRATION DATE: 9/11/93
PARCEL ID:01707314
LEGAL DESCRIPTION: TERRACE HEIGHTS BLK 1 LT 4
LOT SIZE: 20700 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT:
THIS PERMIT IS FOR THE CONTRUCTION OF:
HOLDING TANK SYSTEM
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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
DATE:
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
August 28, 1992
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
Anchorage, AK 99519-6650
REFERENCE: Terrace heights Subdivision, Block 1, Lot 4
We request you issue a permit to upgrade the septic system
serving the referenced property.
An adequacy test was performed on the existing system and the
absorption capacity of the system was found to be inadequate.
A test hole was excavated and a percolation test performed.
The approximate location of the test hole is located on the
attached site plan.
Due to the poor permeability of the soils and the notorious
high groundwater levels in the area we feel the only
possibility for on-site wastewater disposal is a holding tank.
We do not anticipate any adverse effects on neighboring
properties by the installation of the proposed holding tank.
If you have any questions, or require additional information
for your review, please contact us.
Sincerely,
Roger J. Shafer, P.E.
RJS/LSU/lsu
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
SCALE
UPGRADE
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
~ ~)Township, Range, Section:
SLOPE
WAS °ROUND WATER Y~-.S
ENCOONTERED?
S
IF YES, AT WHAT ~ ~
OEPt,? )O'/~ p,
Depth to Water Alter, e
Monitoring? Date: I
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
~-,,?.~ S(/2'~
PERCOLATION RATE '~Z~minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN r-~ F~_FT AND
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE:
c, .~-~t cs,/1L- ~ ~.~ ~
O MENTS ~ v(2( !
~_~. 2,,~0o ~
PERFORMED BY: S & s EN~INFF~]NG
17034 Eale~Rle i,
ACCORDANCE WITH &LL.¢T~T~A~ ~¢~~'~N EFFECT ON T"IS DATE.
=agle KIver¢ AlaSKa
72-008 {Rev. 4/85)
~3NICIPALITY OF ANCHORAGE
Hea~and Environmental Pr(
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
264-4720
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION
SEPTIC TANK: "
FROM WELL MANUFACTURER ~ __.'MATERIAL f COMPARTMENTS
INSIDE LENGTH
INSIDE WIDTH
LIQUID DEPTH
__ LIQUID CAPACITY ,/(-~'7'~ALLONS.
TILE DRAIN FIELD:
DISTANCE FROM WELL
~ of Lines
OEP]
i TOTAL LENGTH
__FOUNDATION__ NEAREST LOT LINE OF LINE -~-~-
DISTANCE BETWEEN LINES ~///~ TRENCH WIDTH~¢' IN. TOTAL EFFECTIVE
SQ. FT. LENGTH OF EACH LINE ,
DEPTH OF FILTER
TOP OF TILF TO FINISH GRADE "~/ MATERIAL BENEATH TILE_ ~ I~. ABOVE TILE '¢"/~' IN.
SEEPAGE PIT:
Log Crib- Rings
BUILDING FOUINDATION __.
DI/-',METER ~ OR WIDTH __
·
Crib Szze:] DIAMETER___
NEAREST LOT LINE__
ILENGTH , DEPTH
DEPTH~ DISTANCE FROM: WELL__
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA)
,SQ. FT.
Well
Class: ,,~M); Depth:
v-
Well Dzstance To: Lot Line
Bldg: Sewer Line:
Pipe Materials:
# of Bedrooms:
Installer:
Remarks:
DATE//-"~'i/~'/''' 7 ./APPROVED
L '3'T'.-.-,4- Fd. EIi i.:; :t. 'T' iii: i:;;: i:;::' i::. i'" .:.::; H '"" :!ii;.
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T H E [;:, i::: P T H O i:' t:::i T i-';;t E; i'-,t E: H O FR i:::' ;iL "i" i '_:i; 't" H E D i '_::;"i" F:I i'.4 l..'::iE B E T HiE ii!-: i'-,i T H ii:-:; :iii; Li J:;:': F:' F:! {3 L::_-'; O i:::' T H
{3 l:;i: {Zi U J'-,i D ¢.:i N i::, T H Ei; E~ El T'i" O H O F:' T H E EZ ;,.:; E: I::t V F:!"t" i O 1'.4 < i l'q F' E: E'i" >.
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THiii._. EiRF::tVE:'L. J;;:,iEi::'"l-i..-i iS 'i"t--.tiiii; J'qiNtt'qUt"'i DEPTH OF:' GF;:f:I:v'EI .... Efi:::.Ti-,.JE;E;i'.,I 'T'J..-iE OUTF'ffJLJ_. F'tF::'i:-"
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F:' Oi.... L. Ed.,-i i N C:i E:O N E:, I 'T' t {::IN'_:£;:
2.. Et'T'i-JiER F:I Ii:J....t:::I'"'::';S ]: {::ii:::: ]:I N:E;F' F:ff:'PF:::O',,"EE:, F'L..F:INT i'"il::l'T' Ed:i: :NSTRLL..E:i:::'.
;;;::.i::l E:ONT I j'-,Jt..iiilU'J:; tV[l::l .t: N'!"iENfftNC:iE F:ff3i:;::t"EEHE:NT i S f;:: E: l:;:¢_t :[ t:;:::ED, i F' t:! J"'it:::l ]Z N'T'E:?,IF:!i'.,iE:Ei:
F:IGi:;:tEff.'i"!ii.::N'T' I'.:-:i; NO'T' !< ii:-:: F' "i" E:U~:;::i:~:t!.:i'.,I'T :r'(:.'ll_i i"'lR"r' li.:'~E t::::E:L::¢_IIi:::".ED TEI El",il_l::ff;::GE ~FJ"'iff: SOIL.
F::IE:SOi:;.tF:"T'iON 9.';'-r'STiiii:i'"! F:INC,,--"Cd:;;: h"OU Jq!::l'T' 8E :'3UE:..:i'EC't .... ['El F:'F;::OSE:E:i...iTiON.
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME /~"~>/J'~'//~ '~ '~
~'~J-/,~,~ MA ILl NG ADD RESS
SEPTIC TANK:
FROM WELL/Z2~' " MANUFACTURER
INSIDE LENGTH
MATERIAL
INSIDE WIDTH
LIQUID DEPTH
NUMBER OF
COMPARTMENTS
LIQUID CAPACITY ./~:~/~ GALLONS.
SEEPAGE Pit:
NUMBER OF PITS
LINING MATERIAL
BUILDING FOUNDATION
ADDITIONAL ABSORPTION
DIAMETER ~ OR WIDTH
CRIB SIZE: DIAMETER ~'
NEAREST LOT LINE-~' ~7
LENGTH/? DEPTH ,-/'~-~' /
DEPTH ~; /'
DISTANCE FROM:
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA) -~/~,,~/ SQ. FT.
WELL:
TYPE //~/'-~//J/~://<.,-~'~:% CONSTRUCTION
BUILDING NEAREST
FOUNDATION_ , LOT LINE
CESSPOOL
, OTHER SOURCES
APPROVED
DISAPPROVED
NEAREST
SEWER LINE
DEPTH DISTANCE FROM:
SEPTIC SEEPAGE
, TANK __ , SYSTEM
REMARKS
DISTANCES:
INSTALLED
PIPE MATERIAL:
LOT SLOPE: ~--~=-~_.L_
REMARKS:
Form No. EQ-O31
DIAGRAM OF SYSTEM
~.~z. ~. ~ ~ .~
Grl~aTEr ANCHORAGE Area Borough
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-4561
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
PERMIT NO.
NAME OF APPLICANT / ~.~//~/ ~/~__L~
INSTALLATION LOCATION
iNSTALLATION OF: SEPTIC TANK
SEEPAGE PIT DRAIN Field . OTHER
FINANCED THROUGH TO BE INSTALLED BY
SOIL TEST RESULTS , .~
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK ~
FOUNDATION TO SEEPAGE Pit. '~/''; /'
DRAIN FIELD
SEPTIC TANK TO SEEPAGE PIT WALL /~'~ /'
SEPTIC TANK ~ , SEEPAGE PIT~/;'~' / ., DRAIN FIELD
TO NEAREST LOT Line.
WeLL tO SEPTIC TANK. / ~/'/' ~" SEEPAGE PiT /~/~///' /
DRAIN FIELD ALSO CONSIDEr AREA WELLS.
water Main tO SEPTIC TaNK ~'~ f SeEPage PIT Jz~' :
DRAIN FIELD
SEPTIC TANK,~~ ~/~ {~' SEEPAGE PIT ~"'('~: DRAIN FIELD
TO RIVER, LAKE, STREAM.
SEEPAGE AREA SIZE '/~/~J'-~ TYPE
DIAGRAM OF SYSTEM
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE Pit
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
OR
LICENSED DESIGNER
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH OrdiNANCE NO. 28.68 AND THAT THE ABOVE
DATE APPLICANTS SIGNATURE ~ ~ ~.~C.-
FORM NO. EQ-016
SOILS LO(] - PEROLATION TEST
Performed for Bear Cat Construction
Legal Description: LO~'LF~--B%-obk i, Terz~ac-e-Heigh~s
This form reports: Soils log
GREATER ANCHORAGE AREA BOROUIIIi~ It~ ~ ~D
Department of Environmental QuWty
3330 "C" Street ,.iii(. 2 ~ ]9~74 ~l/Ni
Anchorage, Alaska 99503
GREAI'ER ANCHORAGE AREA BOROUGH
DFPT, OF ~, FNTAL ~UALIIY
Date Performed 7/23/74
Percolation test
Depth
Feet
I ';,, Black
5-
6-
7-
8-
9
Silty Sand 200 S.F./B.R.
Well gradedsand 150 S.F./B.R.
10-
I~13-
Silb~ sand 250 S.F./B.R.
Was ground water encountered? Yes
If yes, at what depth?
Reading Date Gross Time
Net Time
Depth to Water
Net Drop
Percolation rate minute.
.Proposed installation ~ecpaje Pit Yes Drain Field
:)cpth of Inlet . Dept~i--t-O--U~-~;-~n--o-f--pit or trench ...... ~T ....................
EQ--' 040 (6/74)
•
(74---- Municipality of Anchorage
On-Site Water and Wastewater Programmal1
(907) 343-7904 , ,, rF
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 017-074-19 Expiration Date: ) J -1 7 -/e
1. GENERAL INFORMATION
Complete legal description _TERRACE HEIGHTS BLK 1 LT 4
Location (site address) _7861 COX DRIVE ANCH,AK
Current Property owner(s) _SHAWN MCALPIN Day phone
Mailing address _SAME
Real Estate Agent Day phone
3L56
2. TYPE OF DWELLING: � �,,
® Single Family (w/wo ADU) e i
v
❑ Duplex uCT 0 4 ��
1, a
ElMultiple Dwellings (Single Family andlor Duplex} �L
3. NUMBER OF BEDROOMS: q a q. s s j,J
L9
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 E
WaiverNariance request for: Distance:
Received by: Date: /P// -/J9
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 5a io Waiver Fee $
Date of Payment !U/LW? Date of Payment
Receipt Number a 13-109 Receipt Number
COSA# O C'J ?-/Lf(D% 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 MIKE N ANDERSON. P.E. Phone 727-8864
Address 4661 NATRONA AVE.
Engineer's Printed Name MIKE N ANDERSON, PE Date 10/3/17
11 .14 ° 49r1-1 �y-°rY ',
�ro o ° ne.° .•en..
6. DSD SIGNATURE t' Q MICHAEL N. ANDERSON :°'.A'
e CE-9469 ,:;�
System #1 Approved for1-7bedrooms. fr',•�. (rJ
Syste �;:;;'': ved for bedrooms. � PltOFE
Disap 'oved. �Q@
Conditional approval for bedrooms, with the following stipulations:
. .� oFAr�+,
py'1
�p,TE i*ID
ER OO
WpS t
A
PROGRAM
,,,,,,,,,,
By. f^-- C � � Original Certificate Date: fa H 7^17
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 10.10.12 doc
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: TERRACE HEIGHTS BLK 1 LT 4 Parcel ID: U17-1>74-I ')
A. WELL DATA
Well type Private If A. B. or C provide PWSID # Well Log (YIN) N
Date completed UNK Sanitary seal (Y/N)Y Wires properly protected (Y/N) Y
Total depth 106 ft. Cased to >40 ft. Casing height (above ground) 18"+
FROM WELL LOG AT INSPECTION
Date of test 912612017
Static water level ft. 72 ft.
Well production g.p.m. 2+ g.p m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate 0.422 mg/L
Arsenio ND ug!L Date of sample 9-26-17 Collected by: Mike Anderson
B. HOLDING TANK DATA
Tank Type/Material STEEL Date installed 912811992
Tank size 2500 gal. Number of Compartments 1 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (YIN) Y
Date of pumping SEE RECEIPT Pumper ISAACS
C. ABSORPTION FIELD DATA— HOLD TANK
Date installed Soil rating (sf/bedroom) System type
Length ft Width ft. Gravel below pipe ft.
Total depth _ft. Eff. absorption area ft2 Monitoring tube_ Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before test in. Water added_gal_ New depth in.
Elapsed Time: min. Final fluid depth _ in. Absorption rate >= g.p d.
Any rejuvenation treatment(past 12 mo.) (Y/N & type) If yes. give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YIN)
"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 NA On adjacent lots 100'+
Absorption field on lot NA On adjacent lots 100'+
Public sewer main NA Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field NA
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 75'+
ABSORPTION FIELD ON LOT TO:
Property line Building foundation _ Water main
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
F. COMMENTS
lli kbw► 'S 3 '6 me S
OF At fkk
G. ENGINEER'S CERTIFICATION ,:'gyp:•'• ..•`:13.
,���
1 certify that I have determined through field inspections and ; 4 9TH • ••;• ,!
review of Municipal records that the above systems are in /
conformance with MOA COSA guidelines in effect on this date. �••••.
MICHAEL N. ANDERSON . d
Engineer's Printed Name MIKE N. ANDERSON, PE ���.'• +CEE- 4o9
Date 10/312017 +,k•FQ/" �,�' •••S..
COSA canary sheet_2-6-15.doc
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. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DVVELLING
Parcel I.D.
GENERAL INFORMATION
Complete legal description
COSA# 0'~C )i IO)D
Expiration Date: Z_// -~ o .- II
TERRACE HEIGHTS,, BLOCK 1, LOT 4
Location (site address) 7861 COX DRIVE, ANCHORAGE, AK 99516
Current Property owner(s) LEE & MERRILEE ROHWER
Day phone
Mailing address
7861 COX DRIVE, ANCHORAGE, AK 99516
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class __ Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site [~
[] Individual Holding Tank ~]
r"] Community On-site E~]
[] 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 forthe 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 pdvate or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of 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 vedfy that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3792
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 01/13/2011
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic apPlies :on!y= to the conditions.as of the day tested. The flow
and absorPtion rates may Change due to SubSurface conditions that may not be, obsen/ed from the surfaceI
changes inland use, local Soil characteristics, groundwater 'levels that may fluctoate during the Year and the
water usage of the family being sewed by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how Iong a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen .~~:
encroachments, deftciencies or discrepancies exist. ~d~~i:"
DSD SIGNATURE
~/ Approved for bedrooms. ~~'
Disapproved. '~~:" '
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water& Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: TERRACE HEIGHTS, BLOCK If LOT 4
A. WELL DATA
Well type P .]{J~VATE IfA~ B, or C provide PWSID #
Parcel ID: 017-073-14
Date completed UNK Sanitmy seal (Y/N) _Y
Total depth 106+ f. Cased to 40+ f.
FROM WELL LOG
Date of test -
Static Water level -
Well =production -
WATER SAMPLE RESULTS:
Coliform N~.G colonies/100mL
g.p.m.
Welt Log (Y/N) _N_
Wires properly protected (Y/N) ~
Casing height (above ground) 18+ in.
AT INSPECTION
01/07/2011
2.50 g.p.m.
Nitrate 0.227 mg/L
Date installed 09/2811992
Arsenic: ND rng/I Date of sample: 01/07/2011
SEPTIC/HOLDING TANK DATA
Tank Type/Material I-IeldSn_~Steel.
Collected by: ArcTe~ra
Tank size Z500 gal.
Number of Compartments ! Cleanouts (Y/N) ~ Foundation cleanout (Y/N) Y Depression over tank (Y/N) __N
High water alarm (Y/N) Y Date of pumping Pumper Isaac's Pumping
C. ABSORPTION FIELD DATA
Date installed --__ Soil rating (g.p.d./ff2 or ff2/bdrm) --
Length -- ff. Width -_~-f. Gravel below pipe --_~ff.
Eft. absorption area --~ Monitoring tube --
Date of adequacy test --
Fluid depth in absorption field before test __
Elapsed Time: --__ min. Final fluid depth __
System type --
Total depth -- ft. (Measured 5/21110)
Depression over field -_-
Results (Pass/Fail) ~- For -- bedrooms
-- in. Water added --gal. New depth -- in.
-- in. Absorption rate >= -- g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) ---If yes, give date -_~-
LIFT STATION
Date installed
~Pump on" level at
Datum
in.
E. SEPARATION DISTANCES
Size in gallons
'Pump off" level at~
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/li~ station on lot NA
Absorption field on lot NA
Public sewer main NA
Sewer/septic service line 25'+
Animal containment areas 50'+
in.
Manhole/Access (Y/N).
High water alarm level at in.
Meets alarm & cimuit requirements?
On adjacent lots 100'+
On adjacent lots lo(Y+
Public sewer manhole/cleanout 100'+
Holding tank 75'+
Manure/animal excrete storage areas
100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation $'+ Property line 5'+ Absorption field NA
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent loll 75'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line -- Building foundation -- Water main --
Water Service line -- Surface water -- _ Driveway, parking/vehicle storage
Curtain drain -- Wells on adjacent lots -
F. COMMENTS _/~ ~4)~--~ E/.~-- --~~ U~L~ ~ ~ ~-L~:~
G. ENGINEER S CERTIFICATION
·
review of Munidpal records that the above systems are in !:'~'~::'~'~.
conformance with MOA COSA guidelines in effect on this date
Engineer's Printed Name :K"ENN~T~ NJ. DU~-LTS
Date 1/:t3/2011 ' "::~:'
COSA Fee $490.00
Date of Payment
Receipt Number 0
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
AS-BUILT SURVEY
BorroWer: N/A File No.: WL01578
Property Address: 7861 Cox Drive Case No.:
City: Anchorage State: AK Zip: 99516
Lender: Alaska USA, Mort,gage
kl
· //,/ELL, '
LOT
$
b
I
I'
I
I ·
I
!
LOT
COX
· o, 4 , B~oc~ !
Anchorage Recording Oistricf~AloskO
LOT SURVEY CERTIFICATION
4bell[~ ~d IhQI Ihffl afl flO ~odwaylt utility IbN, ~ Of~ vlllbll
the plat of rooord ore flat thogn ~rKn unlett
otherwise noted,
LEGEND
~ Brae~ or Aluminum eo~ed monument recovered
0 Iron pipe an~or rebar recovered
~ 2x2 hub &tack recovered
~ 5/8"x ~" rebor net t~is survey
Ret.
Prepc~red by:
R. t. BUTTON
~.gisfm~m:f &ond Surveyor
6/9 IE, E. ighfh Av~. Anchor~e Aloska ;~J~O,
3040 Lakeshore Drive, Suite 102, Anchorage, Alaska 99517 907-243-4215
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak, us
(907) 343-7904
Parcel I.D. 017-073-14
1. GENERAL INFORMATION
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Expiration Date: J
Complete legal
deScription
'TERRACE
Location (siteladdress or directions)
HEIGHTS S/D; LOT 41 BLOCK 1,
7861 COX DRIVE * ANCHORAGE, AK 99516
Current Property owner(s)
Mailing address
GINA POTHS Dayphone 545-6725
7861 COX DRIVE * ANCHORAGE~ AK 99516
Lending agency
Mailing address
Day phone.
Real Estate Agent
Day phone,
Mailing address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY: "
Individual Well []
Individual Water Storage [--]
Community Class Well []
Public Water System []
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 title (except between spouses) for properties served by a single family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a pedod of
up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B
wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $800.00 at, or prior
to closing for the engineering services provided.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
invesb'gation, 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 verffy 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 v~th all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone 557-6179
Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504.
Engineer's Pdnted Name JEFFREY A. GARNESS, P.E. Date
Engineer's Comments:
In conducting this evaluation, AWWC, Inc. attempted to provfde a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the b'me of the test, and separation
distances measured to readi(y idenEfiable features. The opera#onal life of all wells and
sep~c systems depend on the local soils condi#on, groundwater levels that may
tTuctu~te during the year, and the water usage of the family being se.,vcd by the system.
These conditions are outside the control of the evaluator of the system. Sa§sfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. AWWC, Inc. can therefore not provfde
any warranty or future estimate of how long the system ~11 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 authofized, no~ will it confer any legal fight whatsoever.
DSD SIGNATURE
t~ Approved for L~
Disapproved.
Conditional approva_,l for
bedrooms. .~'~.'
~: ON-SITE
j WATER AND
~ ~ WASTEWATER
bedrooms, with the fllowing stipulations:~ % PROG~M
-~, 0<~ ~ .... "
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
By: ~/~--~....
(Rev. 12/00)
Manitenance Agreements
Supplemental Engineer's Reort
Other
Original Certificate Date:
Municipality of Anchorage
lopment 'ServiCes Department
Building Safety Division
On-Site Water & Waslm, mter Program
4700 South Bragaw St.
P;O. Box' 196650 Anchorage, AK 995196650
www.cLanchorage.ak.us
(9O7) 343-79O4
B;
Legal Description:
WELL :DATA
Well type ,PRIVATE
Date completed UNKNOWN
Total depth 106'+ R.
HEALTH AUTHORITY APPROVAL CHECKLIST
TERRACE~ HEIGHTS S//D; LOT ¢~ BLOCK 1~ Parcel ID:
If A, B, or C provide PWSI'D~ N/A
Sanilerysoel (Y/N) YES
CaSedto 40'+ ft.
FROM WELL LOG
N/A
N/A ft.
N/A g.p.m,
Date-of tast
Static water level
..Well :production
WA'r~SAMPLE RESULTS:
Coliform 0 colOnies/lO0 mi.
Date of sample: ~ 8/16/01
8EPTIC~AHK DATA
Tank Type/Matariel
Nitrate 0.6 mg./L.
ColleCted by:
STEEL
017,073-14
Well Log (Y/N). NO
wires properly p~ (Y/N~~
Casing height (above ground) 12+ in;'
AT INSPECTION
8/16/01
73 ft.
3.6 g.p.m.
Other bacteria 0 colonieS/lO0 mi'.'
AWWC, INC.
Date installed
Cleanouts (Y/N)
Tank r~ . 2500 gal-' Number of Compartments 1
FOundation cleanout~. ~(?-/N) YES DePression :over tank (Y/N) NO High water alarm (y/N)
· .
Date of pumping '. ~ ~ Pumper ~ ~S~/~c'~ ,.~u,~P-v G
A~N FIELD DATA
9//28/92
YES
YES
Date installed Soil rating (g.p.d./ft=or ff~/bdrm) ~System type . , ~
Length . ff. Width ff. ~pe , :. ".ff.
Total dePth ff. Eft. absorption ama ft' ~ Depr',~dOn over field :
Fluid depth in absorption field ~fo~:~e.M~ in. Water added gaL New dePth /in.
Elapsed Time: ' . Final fluid depth in. Absorption rata' >= ' g.p;d.
~treatment (past 12 mo.) (YiN & type) If yes, give data
LIFT STATION
Data installed
'Pump on' level et .
in.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in gallons ~
"Pump ~ ,n. High water alarm level at
Cycles tested. Meets alarm & circuit requirements?
Holding tank
Septic tank/lilt 8taUon on lot N/A
AbserpUon field on lot N/A
Public sewer main N/A
Sewer/septic service line 25'+
On adjacent lots 10o'+
On adjacent lots N/A
Public sewer manhole/cleanout
75'+
SEPARATION DISTANCES FROM SEPTI~TANK ON LOT TO:
Building foundation 5'+
Water main N/A
Wells on adjacent lots 75'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Absorption field
Surface water
Water main
Property line
Water service line
COMMENTS
Property line 5'+
Water service line 10'+
Building foundation.
Surface w~-------------
Wells on adjacent lots
N/A
1 oo'+
Driveway, parking/vehicle storage
in.
G. ENGINEER, S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records ~rat the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name,
Date
,
JEFFREY A. GARNESS
HAA Fee $ ~'~)0.
Data of Payment
/ /
Receipt Number ~1,,.~ ! t. Tr
(Rev. 12/oo)
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
Lot
4;~.Block, 1; T~rr~ Heights
Location (site address or directions)
7861 Cox Drive'
Anchorage, AK
Property owner
Mailing address
Lending agency
Mailing address
PHH/HOMEQUITY Day phone (214) 506-8808
400 East Las Colinas Blvd., Suit~ 100, Irving, T~xas 75039
Day phone ·
Agent J~an Hohnstei~/ MARSTON REAL ESTATE Day phone 248-2804
Address 2804 W. No,thorn Liqhts Anchoraq~, Ak
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4 ~/' 'w
TYPE OF WATER SUPPLY:
Individual well
XXX
jr
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
Se
· As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
S & s ENGINEERI ~Nc,.~? Phone
Name of Firm 17034 Eagle R~oep .l~d No. 204~
Address Eagle River/~..1~_
Engineer's signature ~ Date
DHHS SIGNATURE
Approved 'for
Disapproved.
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professicnal engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:/4:)7-~
A, Well Data
Well type }~'~/~'/A ~
Log present (Y/~) /~'O
Total depth //~.~ r
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed /~-'~' ~/'~-Driller
Cased to ~ r -F Casing height
Wires properly protected)
AT INSPECTION
Sanitary seal ~1) T"E-_~
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
S~/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line ~--~' ~'-
g.p.m. ,~ ~ g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample: ~, f/~/~--~
Nitrate
~-~'/~-~ ~"/~--- Other bacteria ~__~//~0~-~
Collected by: .-~'¥'.-~
Date installed ¢/~ °c~/? ~--' Tank size Z-~'-O(--) ~'~---
Cleanouts~_~N) ~'~_~ Foundation cleanoq~N) y~.~_jr
High water alarm(~N)
Date of pumping /~//~
Compartments
Depression (Y~
'~_~ Alarm tested(~)
-/L/Et/-] 77~M/<' ~ / ¢E7~i~) Pumper
SEPARATION DISTANCES FROM ,?~I,T,,I~HOLDING TANK TO:
Well(s) on lot ~./.~ r On adjacent lots
To property line 47__. t Absorption field
Surface water/drainage /OO ~
/0 0 ~'- Foundation (Zr
,~Y/~91- Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION //~/,JE-
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Manhole/Access (Y/N)
"Pump on" level at r ~ off" Level at
~ested
Meets MOA electrical codes (Y/N?~/
SEPARATION DI~E FROM LIFT
STATION
TO:
~ On adjacent lots
Manufacturer
Surface water
D. ABSORPTION FIELD DATA /k~ ~ /'~/~-~...~--~7,<J,'/--
Date installed Soil rating (GPD/FF) System type
Length Width Gravel thickness
Total absorption area .Cleanout present (Y/N) . ---~/Depression over field (Y/N)
Date of adequacy test ~esaits~'~fail)
Water level in abso~test -- ..... After test
(past 12 months) (Y/N) ____ __ If yes, give date
EPARATION DISTANCE FROM ABSORPTION FIELD TO: ,,~J'~,t/~'~
Bedrooms
Well on lot
To building foundation
On adjacent lots
Surface water
On adjacent lots Property line
To existing or abandon~ s~
Cutbank ~ Water main/service line
~parking/vehicle storage ama
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect.~ ~_ ~h~is inspection.
~,,..~ ',, ~.o~ '~,.
Signature S · S E~INEERI
Engineer's 17~ Eagle Ri~
Date
HAA Fee $ /7° ' ~
Date of Payment
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.# ~__~ - ~%_%-t4-/
1. GENERAL INFORMATION
Complete legal description
Lot 4; Block I; Terrace Heights Subdivision
Location (site address or directions) 7861 CrC× D4x'.v~,.; Anchorage.; Alaska
Property owner
Mailing address
Phillip and Linda Beeqle
7861 Cox Drive, Anchorage, Alaska
Day phone. 345-1695
99516
Lending agency
Mailing address
Day phone
Agent
Address
Mike
Lewis/HOMEQU ITY
400 East Las Colinas
Day phone 214-506-8808
Boulevard, Suite 100, Irving, Texas 75039
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~ 'k4
TYPE OF WATER SUPPLY:
Individual well XXX
Community well
Public water
NOTE: If community W~de written confirmation from State ADEC attest-
ing to the legality and status of s~m.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Hold k~n k ~( X/~.
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY
ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm $ & $ ENGINEERING Phone
170:34 Eagle River Loop Road No, 204
Address Eagle River, Alaska 99577
Engineer's signature Date
DHHS SIGNATURE
X~' Approved for
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By: ~
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
( Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~.~'T ~,,/~)r.. / ,/ T~)~/~ //--~/cc~.y.?~ Parce I.D.
A. WELL DATA
Well type '.~. t(
Log present (Y/~
Total depth
Sanitary seal ~N)
If A, B, or C, attach ADEC letter. ADEC water system number "-"'
Date completed ~-:~-.~-- '~l'~ Driller
Cased to ¢0 ~4
Casing height
V~----$ wires properly protected ~'N)
FROM WELL LOG
Date of test
/
Static water level //
Well flow ~.
Pump level
SEPARATION DISTANCES FROM WELL TO:
~/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
AT INSPECTION
g.p.m. 4-,~
/fi'C-
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank ~'U()/~F~
g.p.m. ~
~o
/oo 'F
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
Date of sample: C~_~,. ~ c~ 2_
J~O/k'~- ~7'~c-7'/~'/o Other bacteria Collected by: L_~ ~ --~
B. ~BIBIIII~/HOLDING TANK DATA
Date installed ~-,~--~- ~
Cleanouts ~1) ~ %C(/'&/O
High water alarn/q ~/N)
. .~/~ - ~
Date of pumping I ~ ~
Tank size
Foundation cleanout
Compartments I
DePression (V/~[~
Alarm tested~N) y~ ~'
Pumper /~//~
SEPARATION DISTANCES FROM~HOLDING TANK TO:
Well(s) on lot ~ ~'- ~ On adjacent lots [00 ~ Foundation
To property line ~"~'- ( Absorption field /~/A- Water main/serviCe line
Surface water/drainage /~(~
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
LIFT STATION
Date installed Manufacturer
Size in gallons ~'-,,, ~ M an h ole/Access (~,~N_~/,../
vent (Y/N) Pump on" le~l. at /'"';'Pump off" level at
High water alarm level ~, ,-/'~Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FR~N TO:
~On
· Su~ace water
Well on lot adjacent lots
ABSORPTION FIELD DATA
Date installed /~J/~ (~ ~..~.
Length Width ~--..
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Soil rating ~e
Gravel thickness / Total depth
-"'~t (Y/N)
~...----/- f:~y ter ~..~t
If yes, give date~"~
SEPARATION ?,~/~/~TANCE FROM ABSORPTION FIELD TO:
Wellon lot ~J/4 '-.. On adjacentlots
~_~ Property line
To building foundation
bedrooms
On adjacent lots
Surface water
Curtain drain
'"'~-, ..~, To existing or abandoned system~R-tO~_'
: .Cutbank '~""~~____~~celine__
- -~----:_~D~'~'P'-ark'mg/~orage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspecti~)n.
Si.nature 17034 Eagle Riv. L~ E~ ~
Date ~-~ ~ ~
HAA Fee $ / ~ ~ ~ Waiver Fee: $
Date of Payment /~ ~- ~ ~ Date of Payment
Number ~/~ ~ ~ ~ / ~
Receipt
Receipt
Number
72~26 (Rev. 3/91) Back MOA 21
E. ENGINEER'S CERTIFICATION
Bate Receivea ~-
Time of Inspection
Date of inspection
..... ~r,
fNDIVTDUAL~ ~EI:ER & W/~,'r~p, ,,~, .FAC*~,IEb
Mailing Address:
Property Owner:
Mailing ,Address:
Phone:
Phone:
' ,., F~c~'i~+,,, ,.., t,c ?e inspected - No. of bedrooms
Well r .....
A. Type .~¢~2 B. Depth
D. Bacterial Analysis
A, Instal'Ia:! ·
Septic. ~anK; ]. ol¢"ze ×i'"" s .....
2. Manufacturer '
Seepage Pit: I. Absr:mptir.:,n Area ' __~: ? 2. Material .... .:~ ./..,..
A. We'll to; Septic tank. ~/~,' Abso'roc~,on area
.?.4ea re.; t TM
g. FoundatioF; to se~:'t, ic tsnk ~ Absorption area _..~,~
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Sewer Lines
Page 1 of t~,~o pages
TER ANCltORAGE ARL~../, BO I
Department of Environmmntal Quality
3330 "C" st., Anchorage, Alaska 99503 - 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
Type of Inspection- CMRO VA ' FHA
Property Owner: Ron Hawley (Klondike Construction)
CO N V xxxx
Mai 1 i ng Address: 4521 Klondike Ct.
Name of Buyer: John A. Reimer
Day Phone 333'1635
Ilailing Address: 925 E. 20th Apt. B D_ay Phone 274-3611
Name of Lending Institution: l~irst National Bank of Anchorage
n
Mailing Address:
P.O. Box 720 Phone 279-448'1
5.. Name of Realtor or Agent:
Mailing Address:
Phone
Legal Description- Lot 4; Block 1, Terrace Heights Subdivision
Location: .NHN Cox ..Drive
Type of Facility to be inspected: s~l ~
Water Supply
Type of Supply: Public Utility Individual xx
If Individual, number of dwellings presently served xx
If Individual, depth of well
Sewage Disposal'System
Type .of S~stem: Public Utility
if Individual, date of~ installation
No. Bdrms. 2
Individual (on-site) xx