HomeMy WebLinkAboutNORTH SLOPE BLK 1 LT 2nts,40K su)ot.
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Municipality of Anchorage
On-Site Water and Wastewater Program • (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP181063 PID Number: 050-511-29
Dwelling: ® Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ® Upgrade
Name:
JENNY L. BAILEY ABSORPTION FIELD - EXISTING
Address ❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
30714 PRUDHOE BAY AVE, EAGLE RIVER, AK ❑ Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
3 GPD/SF Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot Ft. Ft.
NORTH SLOPE 1 2 Fill added above original grade Gravel length
Township Range Section Ft. Ft.
Gravel width Beds: Number of Lines Distance between lines
SEPARATION DISTANCES Ft. -- -- Ft.
To Septic Absorption Holding Sewer Total absorption areaNumber of trenches Dist.between trenches
From
Tank Field Lift Station Tank Line Ft2 -- -- Ft.
Well 100+ -- -- NA -- TANK Z Septic ❑S.T.E.P. 0 Holding 0 Other
Manufacturer Capacity
Surface Water 100'+ -- -- NA Anchorage Tank 1250 Gal.
Material Number of compartments
Lot Line 5'+ -- 5'+ NA Steel 2
NA
Foundation 10'+ -- 5'+ NA LIFT STATION
Manufacturer Capacity
Gal.
Curtain Drain NA -- NA NA
Pump on level at Pump off level at High water alarm at
Remarks *None known. New 1250-gal S.T.
Installed per code. in. in. in.
Pump make and model Electrical Inspections performed by
PIPE MATERIAL House to tank 3034Tank to 3034
Installer Northern Excavation
drainfield
Drainfield CO/MT 3034
Inspector ARCTERRA BENCH MARK (Assumed elevation) 100 ft
Inspection "
14/27/18 2nd 4/28/18 Location and description
dates:
3`d 4th Door Sill
COMMUNITY DEVELOPMENT DEPARTMENT APPROVALEngin
Conditional Approval: Date Air���, -I ,�
* '
r -
49Ti1
Gj 7116 /
Approved t__- ---- ,7. ���� Date S�� t l PRopEsS101:4,ZNET4_1-1 /MI. ' .i
eer's Stamp
Inspection Report_9-1-12.doc
AS-BUILT SYSTEM DETAILS/SITE PLAN Permit ❑SP181063
NORTH SLOPE SUBDIVISION LOT 2 BLOCK 1 PID# 050-511-29
GRAVEL
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:§B—D=51.2' & -
VARIES
0+0 A --11250 GAL -
30 SEPTIC
& Zr TANK EXISTING TRENCH 5'
(77 86.50) 86.33 —
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N —'_`\ I 31' I SCALE' NTS
� AP-Airis. 4 1 PREPARED FOR: 7cCTERR
`, JENNY L. BAILEY ifilikilm/ `71 P❑ B❑X . B ;�� ro / L� • TH �� . * T B❑ALSBURG, PA 16827
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ACAD Fly` FILE JOB No.: 8129 R• AK.99577--
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ARC TERRA
CONSULTING, INC
212 E. 51st Ave, Anchorage,AK. 99503
Office(907)868-3791, Fax(907)868-3793
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May 1, 2018
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: WELL TO FIELD WAIVER—NORTH SLOPE B1, L2
The new 1250-gallon tank was installed outside the 100' well radius. Per
previous discussions with you regarding the existing leach field, which appears
to be between 98.5-100' from the existing well —we respectfully request a waiver
of 98' from field to well be issued. We believe a waiver is justifiable because the
well is on the opposite side of the house, 10-20' up gradient in elevation from the
septic, nitrate results are less than 1 mg/L, the MOA has issued a HAA for this
property previously, there have been no known issues with this encroachment
over the past 40 years and we do not expect there to be any adverse effect on
adjacent lots by the issuance of this waiver. If you have any questions, please
contact me at 868-3791 / FAX 868-3793.
Respectfully submitted,
ArcTerra Consulting, Inc.
Kenneth M. r.E.
Attachments: COSA w/ SGS Results
MOA Inspection Report
As-Built Survey
20441 PTARMIGAN BLVD • EAGLE RIVER,AK 99577-8736 • PH(907)868-3791 • FAX(907)868-3793
.*%ciPALIr). MUNICIPALITY OF ANCHORAGE o�enc ,
• On-Site Water&Wastewater Program \O Sh„
' . rPO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
S +s http://www.muni.orglonsite "'t':
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On-Site Wastewater Disposal System Permit
Permit Number: OSP181063 Effective Date: 4/26/2018
Work Type: SepticTank Upgrade Expiration Date: 4/26/2019
Tax Code Number: 05051129000
Site Legal Address: NORTH SLOPE BLK 1 LT 2 G:0703
Site Mailing Address: 30714 PRUDHOE BAY AVE, Eagle River
Owner: BAILEY JENNY L Lot Size in Sq Ft: 141265
Design Engineer: ARC TERRA CONSULTING INC Total Bedrooms: 3
This permit is for the construction of:
❑ Disposal Field El Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
y7Ae
Received By: Date:
Issued By: leJL.VltAl. C� ' Date: 9 acoi
MUNICIPALITY OF ANCHORAGE
VI
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Community Development Department ::5Phone: 907-343-7904
Development Services Division - Fax: 907-343-7997
On-Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D.
050-511-29
JENNY L. BAILEY 694-5050
Property owner(s) Day phone
Mailing address
PO BOX 268 BOALSBURG, PA 16827
Site address 30714 PRUDHOE BAY AVE, EAGLE RIVER, AK 99577
Legal description (Sub'd., Block & Lot) NORTH SLOPE BLOCK 1 , LOT 2
Legal description (Township, Range & Section)
Lot Size 141 ,265 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field n Initial Single Family (SF)
(w/wo ADU)
Septic Tank I>I Upgrade >
Duplex (D) n
Holding Tank Renewal I
Multiple Dwellings
Privy n (SF and/or D)
Private Well I i
Water Storage U
THIS APPLICATION INCLUDES A VARIANCE /WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signattare f roperty owner or authorized agent)
PeFmit/Rush Fees: a 16-.49 Waiver Fees:
Date of Payment: caa513 Date of Payment:
Receipt Number: vaiciD Receipt Number:
Permit No. O3P Ig`b(pa Waiver No.
Permit App_9-1-12.doc
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t4RCTER",q ^w
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ARCTERRA
n' Y
1 CONSULTING, INC
,. s . 1 j 212 E.515t Ave,Anchorage,AK.99503
�.` �` Office(907)868-3791,Fax(907)868-3793
April 25,2018
Municipality of Anchorage
Development Services Department
On-Site Water &Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Emergency Septic Tank Upgrade Permit- NORTH SLOPE B1, L2
The owner has requested we proceed forward to obtain a septic permit to
upgrade the failed septic tank. The tank appears to be ready to collapse and we
request an expedited permit.
We propose to decommission the existing 1000-gallon septic tank per code and
install a new 1250-gallon tank outside the well radius. This will take some
exploratory excavation at installation. If unable we will submit waiver request
and the associated fee. We believe a waiver is justifiable because the well is on
the opposite side of the house, 10-20' up gradient in elevation from the septic,
nitrate results are less than 1 mg/L, the MOA has issued a HAA for this property
previously and there have been no known issues with this encroachment over
the past 40 years.
The adjacent lots are served by private water. There is no surface water within
100' of the proposed tank. We do not expect there to be any adverse effect on
adjacent lots by the development of this tank. If you have any questions, please
contact me at 868-3791 / FAX 868-3793.
Respectfully submitted,
ArcTerra Consulting,Inc.
Kenneth M. Du ' .
Attachments: On-Site Sewer Application
20441 PTARMIGAN BLVD • EAGLE RIVER,AK 99577-8736 • PH(907)868-3791 • FAX(907)868-3793
WELL & WASTEWATER DISP❑SAL SYSTEM DETAILS/SITE PLAN
NORTH SLOPE SUBDIVISION LOT 2 BLOCK 1
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FLAG PROPERTY LINES Scale: 1"= 1o0'
PAGE 1 OF 2
WELL RADII & EASEMENTS
1 PRIOR TO CONSTRUCTI❑N
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O.
t DESIGN DETAILS
NO PUBLIC WELLS WITHIN 200' OF DECOMMISSI❑N EXISTING SEPTIC TANK PER CODE &
o PROPOSED SYSTEM. INSTALL NEW 1250-GALLON SEPTIC TANK
O NO PRIVATE WELLS WITHIN 200' OF
II PROPOSED SYSTEM EXCEPT AS NOTED.
PROPOSED WELL EE C PT HAS 2NOTED.F NOTES:
1, INSULATE TANK IF <4' COVER.
2. CONTRACTOR WILL ENSURE MINIMUM 2X SLOPE INT❑ SEPTIC TANK.
1 3. CONTRACTOR WILL ENSURE ALL SEPARATI❑NS TO ADJACENT
WELLS, SEPTICS EASEMENTS, PROPERTY LINES, ETC...
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L' �+ JENNY L. BAILEY
' � P❑ BOX 268 a°� ,i,
c /* • TH ,\ * BOALSBURG, PA 16827 ;° , ION llit \ �
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< \`_ AC AD FILE: FILE NO' 1 81 29 FR AK.99577��3
WASTEWATER DISP❑SAL SYSTEM DETAILS
NORTH SLOPE SUBDIVISION LOT 2 BLOCK 1
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PRIOR TO CONSTRUCTION Scale: l'= 60'
g .674 "\\ PAGE 2 OF 2
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W / _ OF 4,�1 PREPARED FOR: gCTER
/A�' �* 1 JENNY L. BAILEY
!:. —J� .� PO BOX 268 7 ptiI* ^ • T 1\ / BOALSBURG, PA 1682 (ØT\b / KENNE .., D .if / FIELD BOOKS COMPUTED:` `�� CE-71 a' / BOUNDARY:N/A DRAWN: BMW z \
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FSSIO ' I ASBUILT: SLS DATE 4/23/18 �'9 \�,�///G' ^,tr
E \`_'� DWG. FILE �D: SE0703 �'��I.�`VSU[TING > %-l°P
Z "CAD Fl� FILE 10B"°'` 18129 R• AK.99577-''
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SGS Ref.# 1181622001
Client Name ArcTerra Engineering and Surveying Printed Date/Time 04/23/2018 14:25
Project Name/# Spigot Basement Nor-ON S\ope &Ik 1 L'L Collected Date/Time 04/17/2018 16:30
Client Sample ID Spigot Basement Received Date/Time 04/18/2018 9:47
Matrix Drinking Water Technical Director Stephen C.Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date !nit
Metals by ICP/MS
Arsenic ND 5.00 ug/L EP200.8 C (<10) 04/20/18 04/20/18 VDL
Waters Department
Total Nitrate/Nitrite-N 0.860 0.100 mg/L SM21 4500NO3-F B (<10) 04/18/18 AYC
Microbiology Laboratory
E.Coli Negative 1 100mL SM21 9223B A 04/18/18 K.W
Total Coliform Negative 1 100mL SM21 9223B A 04/18/18 K.W
Page 2 of 5
.~ MUNICIPALITY OF ANCHORAGE
~ J Y~I~--~ --- DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
~ ENVIRONMENTAL ENGINEERING DIVISION
I 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
~ UPGRADE
MAILING DDRESS
Well bsorption area Dwelling ~1 PERMIT NOw ~070 ~
Man ufacturor M~rta~+[ ~ No. of compartments
Liq. capacity in galJons Liquid depth
[~0~ IF HOME.DE: ' '
~OZ~ ~ DISTANCE TO: Well ~ ~ Dwelling
~ ~an~facturer~ Material Liquid capacity in gallons
r
~ ~ Well Foundation Nearest lot line PERMIT NO.
'~-- ~ TopN°' of lineSof tileC~to finish' gradeLength of eac~i~e,, TotaIMaterial beneath; tileIO~'~ inchesinChes T°ta' effective ab~r[t3n area
~ ~ Type of cri~ Crib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
m Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO: i O0
OTHER
REMARKS
i
· 3/78)
PERMIT NO.
APPLICANT JAMES GRBNTHAM
LOCATION MI 10. 5 ER RD
LEGAL L2 Bi NORTH SLOPE
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH
MFt~(It'IUM NUMBER OF ~.EDROOMS = ~ SOIL RATING (SQ FTZBR)=
DEF AE. TMENT · HE8ETH ~i'.lD ENVIRONMENTAL~II~..OTECTI
·- '--' ~5oi'/)'~
~, ,925 "L" STREET., ANCHuEM.E~ BK.
264-4?20
O~--S I TE S E l---I E E.' F"ERI'II T
LOT SIZE 0 SLLIARE
100
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
[:,EF"TH-- 10 L Er-I]3TH'-- 31 G RFt"./EL DEPTH-- 5
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF' THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
REL~IJ ~ RE[-'. SEPT I L--; TFtr-~kC S I ZE= ~LOO£" F3F~LLC,~-~S
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS [)EPARTMENT DURING THE
INSTALL8T~ON INSPECTIONS OF 8NY WELLS'ADJACENT TO THIS PROPERTY 8ND THE
~UMBER OF RESIDENCES THAT THE WELL HILL SERVE.
T~-~O (2) I NSPE~]TICi~S FiRE E:EC4UIREC,
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BM THIS
}EPARTMENT WILL BE SUBJECT TO PROSECUTION
~INIMUM DISTANCE BETWEEN 8 WELL AND ANY ON-SITE SEHRGE DISPOSAL SYSTEM IS
FEET FOR A PRIVATE WELL; OR
TO 200 FEET FROM A PUBLIC HELL DEPENDING UPON THE TYPE OF PUBLIC HELL
DTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS 8ND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F'E Rt-11 T E)~P I RES C-,EE:EMBER
CERTIFY THAT
,I BM ,FAMILI8R HITH THE REQUIREMENTS FOR ON-SITE SEWERS AND' HELLS AS SET
~ORTH B~ THE MUNICIPALITY OF ANCHORAGE.
I WILL INSTALL TAE SYSTEM IN 8CCORDANCE WITH THE CODES.
I UNDERSTAND THBT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
~ESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS.
......
O ~ E GEC~rEC1-1N'fCAL 8. DEVEL~)PMENT CO.
Box 00, Davis St,, Eagle River. Alaska ~577
694-2774 or 688-2280
Russell Oyster
694-2774
Soils Et Foundations
Earl Ellis
S0[L L~ ~8~-2~0
Land DeveloDmedt
Hame: ~/-/~/ ~,~-/,~-,4q Tel. NO. ~ ~- z7~4
Hatltng Address: ?~ ~. ~(~ ~r ~c~ ~
Performed for:
Legal Description:
Depth (feet)
Sotl Characteristics
o
1
2
3
""~ 5
6
7
8
9,
12
13
15
16
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit
Con~ents:
No .V If yes, what depth
Drain Field
PERMIT NO.
APF'LICANT
LOCATION
LEGAL
JAMES GRANTHRN
NORTH SLOPE S/D
L2 Bi NORTH SLOPE
900 W.
FIREWEED LN
LOT SIZE
694 2756
1~i088 SQUARE FEET
MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
i00 FEET FOR A PRIVATE WELL~ OR
i50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PERr~ I T EXPI RES E-'ECEFIBER --~<l.- 1978
I CERTIFY THAT
i: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
~ APPLICANT JAMES GRANTHAN
.......... ....
RS SET
DSC Compo, nbl, Inc.
P.O.BOX 10-298 SOUTH STATION, ANCHORAGE, ALASKA99511
PHONE (907) 344--9158 / 274- 4214/279- 3138
LICENSED
NATURAL RESOURCE D£VELOPMENT, MANAGEMENT AND SUPt~ORT CONTRACTING BONDED
WORK GUARANTEED
~ATE ~O~,~LETED ~.~ ~ /7., ''f--' CRE~ Z-. :.~.-:,....,,:..... -.
TOTAL DEPTH OF WELL .~;r~,b'- FT. CASING INSTALLED oc~-5'' / '"/
· DIAHETER
GROUT SCREEN SIZE ' HFG
STATIC ~A~R L~VEL ~ ~ / HRS. PUUPED
~ : .5~/'~~ ~/b'~'r
~ATER F!E~ TES~
TASTE ~o c,/ APPEARANCE
CHLORIDES TDS
/'~ ,.5'~-' AFTER 24 HOURS
ALKALINITY __pH.
IRON
•
80
•
•, r Municipality of Anchorage °
On-Site Water and Wastewater Program
(907) 343-7904 SA ETY
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 050-511-29
Expiration Date: – I S---(
1. GENERAL INFORMATION
Complete legal description NORTH SLOPE BLOCK 1, LOT 2
Location (site address) 30714 PRUDHOE BAY AVENUE, EAGLE RIVER,AK 99577
Current Property owner(s) _CJM PROPERTIES LLC Day phone
Mailing address 5300 CAPE SEVILLE DRIVE,ANCHORAGE,AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Individual 121
Individual Well ® Holding Tank ❑
Individual Water Storage ❑ Community ❑
Community Class Well C Public Sewer n
Public Water System ❑
WaiverNariance request for: Distance:
Received by: Date: —
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5S 0. 0vr Waiver Fee $
Date of Payment �<< LO 1O 1 Date of Payment
Receipt Number 0 7 -I 2 0 Receipt Number
COSA# OSGI°I 10 (01 Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation. I acknowledge that On-Site staff may visit the
site to verify the information submitted.
Name of Firm ANDERSON CONSTRUCTION & ENGINEERING Phone 345-3377
Address 4640 SHOSHONI DRIVE,ANCHORAGE,AK 99516
Engineer's Printed Name MICHAEL N. ANDERSON, PE Date 3/9/2019
eaad\dpi
� 0
���., OF gl,4s�'`1P
6. DSD SIGNATURE
•' rH •••v r�
.� 49. • ,� 1C
System #1 Approved for -.3 bedrooms. 1���14-4. f
System #2 Approved for bedrooms. / •v.-2s%% MICHAEL N. ANDERSON:-.Z,...:
r l< CE- 4o :"
Disapproved. �d4 fb' •r ••3J •4�,� .,.
Conditional approval for bedrooms, with the following stl� b7i$SSIOti�'��
000���
V'N Vr
1tv ,
ON-SITE Q
WATER AND
v WASTEWATFR o
PROGRAM
O�
up
__....j
By: - "
Original Certificate Date: 3—�5 �i
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 olue 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: NORTH SLOPE BLOCK 1, LOT 2 Parcel ID: 050.511.29
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID# _ Well Log (Y/N)Y
Date completed 7/27/1978 Sanitary seal (Y/N)Y Wires properly protected (Y/N)Y
Total depth 85 ft. Cased to 85 ft. Casing height(above ground) 24+ in.
FROM WELL LOG AT INSPECTION
Date of test 7-27-1978 411712018
Static water level 60 ft. 77' ft.
Well production 30 g.p.m. 10+ g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate 0.86 1 0.94 mg/L
Arsenic: ND ug/L Date of sample: 4117118&2125119 Collected by: FWCS
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC 1 STEEL Date installed 4127/2018
Tank size 1250 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 NA-NEW TANK Pumper
C. ABSORPTION FIELD DATA
Date installed 1011978 Soil rating (g.p.d./ft2 or ft2/bdrm) 100 System type DEEP TRENCH
Length 31 ft. Width 3 ft. Gravel below pipe 5 ft.
Total depth 9.4 ft. Eff. absorption area 310 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 411712018 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 7 in. Water added 600 gal. New depth 13 in.
Elapsed Time: 1310 min. Final fluid depth 6 in. Absorption rate >=450 g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) N If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level 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 100'+ On adjacent lots 100'+
Absorption field on lot 98'+ (Waiver) On adjacent lots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 100'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 100'+
F. COMMENTS
Previous testing done within 2 years-new water samples attached. MT had 4 inches of fluid.
G. ENGINEER'S CERTIFICATION
OF Ap4‘ 1
I certify that I have determined through field inspections and tiG '° °•:'�d;
review of Municipal records that the above systems are in ' 41•° � •'1 I
conformance with MOA COSA guidelines in effect on this date. 0 4. F:t ' % 4
Engineer's Printed Name MICHAEL N.ANDERSON,PE el, •
r .mss: MICHAEL N. ANDERSCN :<<±0
Date 3109119 �• c2E 9 9
COSA canary sheet_2-6-15.doc gf rD •a •• `•°�..:d�
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Municipality of Anchorage °4*
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On-Site Water and Wastewater Program s ®9_I�` ,'
(907) 343-7904 s A cry
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 050-511-29 Expiration Date: IF- 3 0
1. GENERAL INFORMATION
Complete legal description NORTH SLOPE BLOCK 1, LOT 2
Location (site address) 30714 PRUDHOE BAY AVENUE, EAGLE RIVER, AK 99577
Current Property owner(s) JENNY L. BAILEY Day phone
Mailing address PO BOX 268, BOALSBURG, PA 16827
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Individual
Individual Well ® Holding Tank ❑
Individual Water Storage ❑ Community ❑
Community Class_Well El Public Sewer ❑
Public Water System ❑
WaiverNariance request for: Distance:
Received by: G/'/Z�'rDate: //,l
(/
COSA to be released to the engineer, unie s oth rwi a requested by the engineer.
COSA Fee $ 5.9,6 Waiver Fee $
Date of Payment 5141$ Date of Payment
Receipt Number 0/67 D Receipt Number
COSA# One(YI(26 Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING,INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD.,EAGLE RIVER,AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 5/1/2018
THIS COSA DOCUMENT CANNOT BE USED TO TRANSFER TITLE UNLESS ALL VENDORS(ENGINEERING,SURVEYING,CONTRACTORS,ETC...ASSOCIATED
WITH THIS COSA ARE PAID IN FULL AT OR BEFORE CLOSING. Engineer's Comments: This investigation was completed in compliance with
ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested.
The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use,
local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the
system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system. Therefore,ArcTerra can not give any estimate of how long a system will function
satisfactory for current or future occupants or can ArcTerra guarantee that no unseen +��\
encroachments,deficiencies or discrepancies exist. OFA x/
tyr
_ 4 THS /N
6. DSD SIGNATURE
System#1 Approved for 3 bedrooms. `
r hTNi\`E7'H A1. llUFFU/�� /
System #2 Approved for bedrooms. �sT 7 s Ase
�:�
Disapproved. \ `'� essto
Conditional approval for bedrooms, with the following stipulations:
\\�NI, OF �/>.
Jam' ON SITE %,
•
WATER AND fi
Frk WASTEWATER
PROGRAM C
0h „. �r��nv�cF
Original Certificate Date: 57--3- 1
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA 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: NORTH SLOPE BLOCK 1, LOT 2 Parcel ID: 050.511.29
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID#_ Well Log (Y/N) Y
Date completed 7/27/1978 Sanitary seal (Y/N)Y Wires properly protected (Y/N) Y
Total depth 85 ft. Cased to 85 ft. Casing height(above ground) 24+ in.
FROM WELL LOG AT INSPECTION
Date of test 7.27-1978 4/17/2018
Static water level 60 ft. 77' ft.
Well production 30 g.p.m. 10+ g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate 0.86 mg/L
Arsenic: ND ug/L Date of sample: 4/17/18 Collected by: ARCTERRA
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC I STEEL Date installed 4/27/2018
Tank size 1250 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 NA-NEW TANK Pumper
C. ABSORPTION FIELD DATA
Date installed 10/1978 Soil rating (g.p.d./ft2 or ft2/bdrm) 100 System type DEEP TRENCH
Length 31 ft. Width 3 ft. Gravel below pipe 5 ft.
Total depth 9.4 ft. Eff. absorption area 310 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 4/17/2018 Results(Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 7 in. Water added 600 gal. New depth 13 in.
Elapsed Time: 1310 min. Final fluid depth 6 in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) N If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level 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 100'+ On adjacent lots 100'+
Absorption field on lot 98'+ (Waiver) On adjacent lots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 100'+
Animal containment areas 50'+ Manure/animal excrete storage areas 1001+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 100'+
F. COMMENTS
Vacant system presoaked prior to testing.
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. �� °F AZ4Aar
Engineer's Printed Name KENNETH M.DUFFUSEQ ,
Date 5/1/2018
4 9 TH �* ,
COSA canary sheet_2-6-15.doc p
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Municipality of Anchorage
P.O. Box 196650 • 4700 Elmore Road
Anchorage, Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997
http://www.muni.org/Onsite
Development Services Division
On-Site Water and Wastewater Program
**** VARIANCE/WAIVER REVIEW ****
Waiver#: COSA#: OSC181180 Permit#: OSP181063
PID#: 050-511-29
Legal Description: North Slope Blk 1 Lot 2
Engineer: ArcTerra
Applicant: Jenny Bailey
Your request for a waiver of the required 100 feet horizontal separation from the absorption field
to the private well has been approved. The approved separation distance is 98 feet.
This waiver approval applies to the existing absorption field only. Any future upgrade to the on-
site wastewater disposal system will require all separation distances be met or another approval
from this department.
❑ The affected adjacent property owner(s) have been given a 7 day notice regarding this
waiver.
❑ Notarized letter(s) of nonobjection have been received from the owner(s) of the affected
adjacent property.
® Adjacent properties are not affected by this waiver.
Waiver is Granted: X Waiver is not Granted:
Date: 5-3—1 Approved by:
Name of Reviewer
**** VARIANCE/WAIVER REVIEW ****
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ANCHORAGE RECORDING DISTRICT,ALASKA
ASBUILT OF:
NORTH SLOPE SUBDIVISION OO =FND REBAR
LOT 2 BLOCK 1 PLAT 69-131 `�"`
SURVEY CERTIFICATE:I,John L.Schuller,Have conducted a i O F A \�` 4V 1,,,-0
LAND v4)
physical survey of this property as shown on this drawing and that the �/ ��..••. •..<Q�11 �4,�N.° r,, r
improvements situated hereon are within the property lines and no 0 A,,.•'• `) , w t`�'
enchroachments exist other than noted.Under no circumstance should % �j.' 49TH )N •' 4 N iG1
any information on this drawing be used for construction of fences, * • * ,/ 0. G�r
structures,improvements,or for establishing boundary lines. , 0 ,
rp ,
- �� 0
EXCLUSION NOTES:It is the owners responsibility to determine i 73 .
A •.J L. SCHULLER. c/
the existence of any easements,covenants,or restrictions which ,a LS-10408 ��
do not appear on the recorded subdivision plat. $ / -`v'�-+•--�"
WORK ORDER NUMBER: DAIE E- At e ' �o�� 1831 Talkeetna Street
APR 28, 2018 1"=60' ,,,o '44:a•1. 6/ Anchorage, Alaska 99508
18—01 7 I+BY:CHECKED BY ORD mem BOOK/PACE t! fessiono` �'� (907) 227-1455 office
JLS SE0703 180135 AN."'• (907) 274-4992 fax
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. #
1. GENERAL INFORMATION
Complete legal description
CERTIFICATE Of HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~; .:.~ ,. ,.. ~ .: .. HAA#
Lot 2; Block I ; North Slope Su§divi~ion
Location (site address or directions)
Pr~dho~ BaN Road
Eagle River, AK
Property owner
Mailing address
Lending agency
Mailing address
Ra~ Atnip Day phone 694-6189
2418 Ea~l~ River Road Ea~l~ Riv~r~ AK 99577
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
cornmUnit W jl
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 XXX
Holding tank --~
Community on-site
- Public sewer
NOTE: If community waste(rater system; provide written confirmation from State ADEC
attesting to the legality and status of system. , .. ...
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 verifythat 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 ~laai~lsl~lim[~Ct on the date of this inspection.
.... '~ ~7034EagleRi~arLoepReadNo. 204 .~ '
Name of Firm Earn_la R;~,. A;..~.._ _~_ _=.~7. Phone
Address .... ~/~
Engine,s signature l~'~ ~~
6. DHHS SIGNATURE
Date
ApProved for 5 bedrooms. -
Disapproved,
Conditional approval for bedrooms, with the following ~tipulations:
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 indepandent
professionalengineerregisterad intheStateofAleska. TheDHHSdoesthisesacourtesytopurcheseraofhomes -
and their lending institutions in order to satisfy certain federal and state requirarnents. Employees of DH HS do not
. :~Onduct inspections or analyze data before a certificate is issued. ~The Municipality of Anchorage is not
· ~ .-.' res..P~. ~nsible for errors or omissions in the professional engineer's ~i'l~,*~i"~.;~. :.~:. ~ ~ ~.~i?:,~:~ "'~
..-. ;. ~:~'_-'/a.~S'~r~.:l~l) Cae, MOA~ :, i ,-'.": ]~'..,',~ '. '~,~;'~? ~; :~' ::~."--':._'... :-
MUnicipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescription:~,~'Tj~c~.~v__~ r~od.4.~:~.(.... ParcelI.D. 05-0 5'- Jl~.~
A. Well Data
Log preset)
Total depth
S, anitary seal.N)
If A, B, or C, attach ADEC letter. ADEC'water sY~!~m number
Date completed '~ -~-'/~ '7 b Driller
Cased to ~5''~ Casing height
y wires properly protected (~N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot /o~3 !
Absorption field on lot f00 i~-
Public sewer main
Sewer service line ~ 5" I~*
AT INSPECTION
g.p.m. 7.7 '~
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~) ~ Nitrate
Date of sample:
~,-~7 '~' Other bacteria
Collected by: .,~" ?/,.~' ~-~,J'/--/~.
B. SEPTiC/HOLDING TANK DATA
Date installed
Cleanouts (~1)
High water alarm (Y~
Date of pumping
Tank size / 4a e Compartments.
Foundation cleanout(l~3N) ? Depression (Y,~)
Alarm tested (Y/N) ~'~
~"~"~ ~?~ "~ Pumper .~-~,E~ ~'~'~o ~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surface water/drainage
/ ' On adjacent lots /~,~ / ~'' Foundation
Absorption field ~'~'~ Water main/service line
72-o2s(3~3)*From CONTINUED ON BACK PAGE
C. UFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N) _
Vent YIN ' "Pump on" level at "Pump off" Lev
High water alarm level at~ ~_
Meets MOA elect~cal codes (Y/N) ~
¥o: ·
w~r6n lot On ediacent lots .~urtace watsr.
D. ABSORPTION FIELD DATA
Date imtalled /~ - 7z~
Length ..~/~ Width
Total absoq3tion area ..?/6
Date of adequacy test '~ -~2
Soil rating (GPD/F~ /a~ ~/~- System type
Gravel thickness .5-/ Total depth
Cleanout present ~) V' Depression over field (Y,~
Results ~a'a'a'a'a'a'a'a'a'~ a il } ~,.5 for .~ Bedrooms
'7 ~ ~ ~ .Nter test
~ ~,~._ ~z-,~o~j,J If yes, give date
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y~-
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on iot /0<3 / ~
To building foundation
On adjacent lots .~o ' *
Surface water /ag / '~
Curtain drain ~///~
On adjacent lots / oo [~- Property line /o
/'0 (~' To existing or abandoned system on lot
Cutbank ~J~ Water main/service line /o
Driveway, perking/vehicle storage area
F_ ENGINEER'S CERTIFICATION
HAA Fee $
Date of Payment
R~,. Numar
=~ (~)* ~k
I cerEfy that I have checked, verified, or conformed to all MOA and HAA guide/in.es in eff~this inspection.
Signature y~ ~7'~~ ....... ~
Engineers Name ~0d~'~-- C C~ ~8-~J ~~
Waiver Fee $
.~ L~ Date of Payment
Receipt Number
~ APPLIC~JT FILLS dl~T uPPER HAL~ONLY
Buyer ~y~ '~/~ ~'~- ~~ ~ ~S~
Address /~~7~7~ ~/~ ~/~g~ ~t~z~.co~ ~.~
Lending l~stitution ~Z~S~ ~*~ ~ d~e~7 ~ ~tUe~ ~ Phone
Address ~ ~ ~ ~ ~ ~/~ ~ ~
Legal Descript~, ~ ~ ~ '~ / ~d~ X~O~ ~U~-
Type of Resi~nce -
~ Multipl~ Family :. No. of Bedroom~ ~ ~ ~
~ Other
Wate~ Supply
~ Individ~l A~ACH ~LL LOG. A w~l I~g is required for all wells drilled since June 1975.
~ Community For wells ~illed prior to that d~te, give well depth (attach ~g if available).
- ~ Public Utility
Sewer Disposal
~ Individual Year IndivMual Installed:
~ Public ~ility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
~ ~APFSOVED ~DSOOMS q .~o.~,,,o., o~ ~.ow~
( ) DISAP~OVED
( ) CONDIT~NAL AP~ROVALf
Soils Rating Da~e ~ er installed Well To ~sorption Area Well Log Received
/;7~ Well ,o Tank Septic T~k Size
EXCAVATION
WORK
September 5, 1983
ROBERT A. SHAFER
CIVIL ENGINEER
694-2979
Century 21, Sleeper
ATTENTION: Sue Gallion
Reference: Lot 2: Block 1: North Slope subdivision
A sewer system adequacy test was performed on the system located
on the referenced property as you requested. The septic tank was
pumped by A-1 Pumping Services and verified to have a capacity of
1000 gallons. The absorption trench was tested by a continuous
flow of water over a period of 48 hours without any adverse effects
on the system.
It can be concluded from this test that the waste water disposal
system serving the three'bedroom residence located on this property
is currently functioning adequately. However, the system cannot
be guaranteed against subsequent failure.
If we may be of further service, please do not hesitate to call.
,~KO~ERT A. S~AF~'P.E.
~'~c~c.'S/S~unicipa/lity of Anchorage
Department of Health and Environmental Protection
SR9 196X EAGLE RIVER, ALASKA
5TACKS
LOT 2
lATE ~ DRAWN BY '
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ZONING
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~ ,.:/.~ .,'' ,-, ,. ,,, ,,
SURVEYOR'S CERTIFICATION
I HEREBY CERTIFY THAT I HAVE
SURVEYED THE DESCRIBE9 PROPERTY
ON THIS PLAT AND THE IMPROVEMENTS
~!ISUATU) TrlEREON ARE LOCATED AS
SHOW;I SN THIS PLAT./ ~S
,~-/_.~:,~.~_~.._.__: _~ _~,~-,~,~_ .....
~/--
LOT 2,BLK.t
NORTH SLOPE SU~
ISCALE 'l (3RID
I": 80' SE 705
5
/
" _D_A~ E RECEIVED
· - ~ · INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECT(~
~UNICIPALI~ OF ANCHORAGE
~UNICI~ALITY OF
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC~RONMENTAL PROTE~ION
( ) ENVIRONMENTAL SANITATION DIVISION SEP 1 5 1980
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
MAILING ADDRESS
4. R~ALtOR/AGENT I PHONE
I
MAILING ADDRESS
5. LEGAL DESCRIPTION
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
~ SINGLE FAMILY [] One [] Four [] Other
[ Two [] Five
[] MULTIPLE FAMILY Three [] Six
7. WATER SUPPLY
[~ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
S, SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE** .YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTI LITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72 010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBEROFBEDROOMS
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SIX
[] OTHER
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTI LITY
Connection Verified
[]Sep~[q Tan~ or [] Holding Tank
Size:/~?C¢~) If Tank is homemade
give dimensions:
TYPE OF TANK
TOTAL ABSORPTION AREA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOILS RATING
Sewer Line Nearest Lot Line
5. COMMENTS
DATE
E]~-~APPROVED FOR __7 BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 ( Rev. 6/79}