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SAMPSON ESTATES BLK 3 LT 2
Sarnpson Estates Block 3 Lot 2 #051-811-28 Municipality of Anchorage Community Development Department Page 1 of 3 On -Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904 ONSITE WASTEWATER INSPECTION REPORT Permit Number: OSP121219 PID Number: 051-811-28 ❑ New ❑✓ Upgrade Name: Janet Hagensieker ABSORPTION FIELD Ej Deep Trench ❑Shallow Trench Q Bed ❑Mound Address P.O. Box 772162 Eagle River, AK 99577 ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 AGPD/SF 3-5 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe .SFt. Subdivision Block Lot Sampson Estates 3 2 Fill added above original grade 0-1 Ft. Gravel length 47 Ft. Township Range Section Gravel width 24Ft. Beds: Number of Lines 4 Distance between lines 6Ft SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 1,128 Fe I Ft. Well >100' >100' N/A N/A >25'TANK Septic I] S.T.E.P. ❑ Holding I] Other Manufacturer❑ Existing Capacity I Gal. Surface Water >100' >100' N/A N/A Material _ Number of compartments Lot Line >5' >10' N/A N/A NA Foundation >5' >10' N/A N/A LIFT STATION Manufacturer Capacity Curtain Drain None Noted Gal. Remarks Existing Septic Tank Inspected and Found Pump on level at in. Pump off level at in. High water alarm at in. Suitable for Continued Use. Flow Diverter Valve Placed and Existing Absorption Bed Tied Pump make and model Electrical Inspections performed by In For Future Use. Installer PIPEMATERIAL Housetotank Tank to dminfeld D3034 Jim Walker Drainheld HDPE COrMT D3034 Inspector MEA BENCH MARK (Assumed elevation) 100.011 InspectionLocation dates: .is 8/20/12 2- 8/22/12 and description 3'd Garage Slab. COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL �� ?�E .....;44� 1l ••��:S�* 'sLjp'��• Conditional Approval: Date10 49m :v �i ... rn ;MIt7lA9. E ApM : 4 � � Date i9hFF�o••• Approved %� 1 46t�e mvvul I_ I -1-14I/ / Municipality of Anchorage DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 Page 2 of 3 PID No. 051-811-28 Permit Number: OSP121219 el TH3 M2 80.0' 92.4' i Mz\ LOT 1 c7? ®TH2 ��cs7 / y Mt 9} 10' ELEC. & TELECOM _ EASEMENT Existing 3 s 10' DRAINAGE Absorption Bed DV s9 EASEMENT TH1 Exisiting 1,000 Gallon Septic Tank A 04%0N \ N 'hree Bedroom House \ LOT 2 40,513 S.F. \ v� a� LEGEND M1 — Monitor Tube FCO — Foundation Clean Out TH — Test Hole N) C4 — Clean Out FDV — Flow Diverter Valve H ® 1 Existing Well LOT 3 s 10' DRAINAGE s9 EASEMENT PLAN AS BUILT SCALE 1" = 40' V' 0 Municipality of Anchorage Page 3 of 3 DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 On -Site Wastewater Disposal System or Well Inspection Report Permit Number: OSP121219 1000 Gallon Septic Tank EXISTING PID No. 051-811-28 �U No Groundwater 8-22-12 93.3 49th \* PROFILE AS -BUILT / '•MICHAEL E. ANDERSON �# No. CE -4381 No Scale MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 4700 BRAGAW STREET ANCHORAGE, AK 99519-6650 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: LOT 2, BLOCK 3, SAMPSON ESTATES SUBDIVISION PERFORMED FOR: JANET HAGENSIEKER DATE: 8/15/2012 PROJECT No.: PARCEL ID#: TECHNICIAN: M. ANDERSON DEPTH (feet) 1 — 2 — 3 — 4 — 5 — 6 — 7- 8 — 9- 10- 11- 1 1 1 1 1 1 OB/OG TEST HOLE # 3 d a SILTY GRAVEL a GM 0 MICHAEL E. ANDERSON NO. CE -4381 SITE PLAN _ SEE SITE PLAN t WAS GROUND WATER ENCOUNTERED? NO IF YES @WHAT DEPTH? ,S DEPTH OF WATER AFTER MONITORING: NONE LL DATE OF MONITORING: 8/23/2012 p SEE SITE PLAN BOTTOM OF HOLE DATE READING GROSS TIME (MINUTES) NET TIME (MINUTES) DEPTH To WATER (INCHES) NET DROP (INCHES) PERCOLATION RATE(MIN/INCH) PERC. HOLE DIA. (INCHES) TEST RUN BETWEEN:—FT. and—FT. COMMENTS: TEST HOLE FOR GROUNDWATER MONITORING. NO GROUNDWATER DEVELOPED. TEST PERFORMED BY ANDERSON ENGINEERING TECHNICIANS. I, MICHAEL E. ANDERSON CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS DATE: 8/23/2012 On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP121219 Tax Code Number: 05181128000 Work Type: Septic Upgrade Permit Effective Dates: August 03, 2012 to August 03, 2013 Design Engineer: ANDERSON ENGINEERING Subdivision: SAMPSON ESTATES Site Legal Address: SAMPSON ESTATES BILK 3 LT 2 G:1560 Owner/Address: HAGENSIEKER JANET M PO BOX 772162 EAGLE RIVER AK 995772007 Site Mailing Address: 22727 SAMPSON DR, Chugiak Lot Size in Sq Ft: 40513 Total Bedrooms: 3 This permit is for the construction of: Y Disposal Field N Septic Tank N Holding Tank N Privy N Private Well N Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Special Provisions: The Engineer must perform groundwater confirmation prior to the construction of the septic field. Construction may proceed at your own risk before the 7 day water monitoring is complete. Please submit stamped and signed results with the As -built Inspection Report. If the results require a design change, construction of the system will stop pending Onsite review and approval. Received Issued By i Community Development Department_ Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program Mayor Dan Sullivan ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcell.D. 051-811-28 Property owner(s): Janet M. Hagensieker Day phone: Mailing address : P.O. Box 772162 Eagle River, AK 99577 Site address: 22727 Sampson Drive Chugiak, AK 99567 Legal description (Sub'd., Block & Lot): Sampson Estates, Block 3, Lot 2 Legal description (Township, Range & Section) Lot Size: 40,513 Sq. Ft. Number of Bedrooms: Three (3) THIS APPLICATION IS FOR: THIS APPLICATION IS AN: (® all that apply) Initial ElAbsorption Field X Septic Tank ❑ Upgrade X Holding Tank ❑ Renewal ❑ Privy ❑ Private Well ❑Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. ny owner or aurnoi Permit/Rush Fees: A 5,D Date of Payment: 7126 z Receipt Number: 0080567 Permit No. OSP 121Zt� Waiver Fees: Date of Payment: Receipt Number: Waiver No. C:\UserslAndEng\Desktop\MikelSampson Estates\Permit Application Lot 2.docC:\Users\AndEnglDesktop\MikelSampson EstatesTermit Application Lot 2.doc ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) MEMORANDUM DATE: August 1, 2012 TO: Deb Wockenfuss FROM: Mike Anderson. P. E. SUBJECT: Sampson Estates Subdivision, Block 3, Lot 2 Well and Septic System Permit No. OSP121219 We have reviewed your comments regarding the design and permit application for Lot 2, Block 3, Sampson Estates Subdivision and offer the following comments: 1. A test hole will be placed prior to the construction of the new absorption bed and the water table verified and monitored over 7 day. Two test holes completed in 1992 indicate groundwater at 10'. The bottom of the new bed is proposed for 4' below the surface. We anticipate a minimum of 6' of separation between the bottom of the bed and the groundwater. 2. The cleanouts in the new system will be connected to meet current code. I am unsure why this comment has been included. 3. The existing absorption bed on the lot was constructed to a 24' width. It has been in service since 1992. Longevity is the best indicator that a 24' width is suitable for this property. In addition, very little area remains for the construction of a new bed and 2 — 15' wide beds will encroach into the lot line setback, the T & E Easement and the driveway. 4. The Site Plan is drawn to scale and shows the location of wells, septic systems, roadways and other features pertinent to the design of the new absorption bed. In addition, a note has been added regarding conflicts with adjacent systems. 5. The application form has been modified to the format requested. 6. A description of the topography on the lot has been added to the Site Plan. No breaks in grade greater than 25% are within 50' of the new bed and no surface water is within 100'. 7. The two test holes placed in 1992 were located over 60' apart. The groundwater level was measured at 10' below the surface in each hole. That documentation indicates the water table is at the same gradient as the ground surface and appears to be flowing to the west at a slope of 3%. A profile would show the depth of groundwater below grade to be constant over the proposed absorption bed area. ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 FAX July 25, 2012 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: Lot 2, Block 3, Sampson Estates Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer: The existing absorption bed on Lot 2, Block 3, Sampson Estates Subdivision is in a state of failure and must be replaced so that a COSA can be issued and the property title transferred. We are therefore requesting a permit be issued for the upgrade of the septic system to accommodate the three-bedroom home on the lot. The attached Site Plan and backup documentation identify the location and configuration of the upgrade to the proposed septic system. The existing septic tank will be exposed and inspected and verified suitable for continued use. A new 1,000 gallon septic tank will be placed near the same location if the existing tank is found to be leaking. Also identified on the plans are the locations of the existing well and the well on the lot to the south. No conflicts exist between the existing septic system and the systems on adjacent lots. The wells on this and adjacent lots are more than 100' from the proposed improvements. Drainage arrows are shown indicating the current drainage patterns. The drainage patterns will be maintained after construction. The test hole placed on the lot when the original system was constructed indicated silty gravel with some sand (GM). The application rate was determined to be .4 GPD/SF. The original permit was issued for a primary absorption bed and an alternate site. Both beds were 24' wide and 47' long. We are proposing to follow the original permit and construct a new 47' long by 24' wide absorption bed at the location designated under the original permit. The distribution pipe in the trench will be placed at 3.5' below the surface with the total depth at 4'. A test hole will be placed prior to construction to verify the percolation rate, water table and bedrock locations. If conditions are found to be different than anticipated work will stop and a new design completed and submitted for approval. It is imperative the septic system be reconstructed soon as the existing Lot 2, Block 3, Sampson Estates Subdivision July 25, 2012 Page Two system is currently backflowing into the house. The ground surface on the lot slopes slightly to the southwest at very shallow grades approaching 1 %. The bed will be constructed parallel to the contours of the ground as much as possible and in conformance with design criteria. A minimum of 100' will be maintained between all components of the septic system and the existing wells and surface water in the area If the system is constructed in accordance with our design the following statements apply: The system, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. 2. The system, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. 3. The system, if constructed as designed, will have no adverse impact on reserve space, either surface or subsurface, on any lots located in the area. 4. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, _D Michael E. Anderson, P.E. Attachments I I I I ------------------------------------- --- 1 REESE ROAD -------------------------------- ! 1I I �\ I Existing Well! I 1 I l rl I / % I \\ l l / Ev ng Well / l Existing Well ; 4 ---- - CF ♦ .......... 111 5 •. � 49th . SITE P AN ::::::':...... ` MICHAEL E. ANOERSON•t SCALE I' = 60'No. CE -asst y�� IIII�p�FES„�� ♦♦ � Existing Well NOTE No Conflicts with Existing Wells or Septic Systems in the Area. No Slopes >25 R Within 50' or Surface Water within 100' of Proposed Septic System. SAMPSON ESTATES SUBDIVISION deo Sy�i�t 47' Long x 24' Wide / sorption Bed '\MI \\ \\ / R LOT3, BLOCK 3 LOT2, BLOCK 3 40,152 S.F. NOTE Contractor Shall Have No Wheeled or Tracked Traffic on the Bottom of the Excavated Bed, Bedroom House MT — Monitor Tube FCO — Foundation Clean Out TH — Test Hale CO — Clean Out 2CO — Double Clean Out LOT1, BLOCK 3 ?3693 Exisiting 1,000 Gallon Septic Tank \ I \ I I SCOPE OF WORK �\II r Expose and Inspect Existing Septic Tank. Replace if Necessary. Place Flow Diverter l Valve and Construct New 24' Wide x 47' Long Absorption Bed. I Connect Existing Bed for Future I Use. I I I `w I E I y ® L1 Existing I a, Well I 1 'o Io to I� I I I � I/ I I I � I � I I I I I SITE PLAN SCALE 1" = 40' LOT 2, BLOCK 3, SAMPSON ESTATES SUBDIVISION DESIGN FACTORS: SYSTEM REQUIREMENTS 3Bedroom Home Shallow Bed System Perc. Rate: 16-20 Min./Inch 1,000 Gallon Septic Tank (Verify Existing) Application Rate: .4 SF/BDRM 5 Effective Depth 3 Bedrooms X 150 GPD/Bedroom = 450 Gallons 450 Gallons/,4 GPD/SF/24 LF (Width) = 46.9 LF Bed Length THEREFORE: Construct a 47' Long x 24' Wide Shallow Bed as Shown Below. Place Distribution Piping at 3.5' Below Original Ground Surface. Total Depth to be 4' Below Existing Ground. Minimum T of Cover Required Over Bed. In lieu of Cover Place 2" Insulation and 2' of Cover. Expose and Inspect Existing 1,000 Gallon Septic Tank. Replace if Required. Maintain 100' Separation From all Wells in the Area. Ground Existing Ground Natural Backfill 3.0' Geotextile Fabric 5' O O O O 5Drainfield Rock T-4" PVC In Situ GM Soil 3' 6' 6' 6' 3' TYPICAL BED SECTION (NO SCALE) NOTE: Grade Area Surrounding Bed to Drain Away. Minimum 6' Separation From Bedrock. i Minimum 4' Separation From Groundwater. i Minimum 100' Separation From Private Wells in the Area. i Minimum 100' Separation From Surface Water or Streams. . Minimum 10' Separation From Water Service Line. QO zz 0 0 D _ m O O O Q Q —I < C7 T Q N Gi UPJ CC) Q O C O Q X J O O (TI U) 0 N COX C) < p CD (n D C) m Q fi F m < m Q CO � G7 CO F- 0 (D ' 0 Irl ° Q a o � //�•ysl9�• '*.STM \W\o �' ••'• Z � �,� � X11 BOP r; ;h 1 n S �O of 11� ar m m me e . rh Municipality Anchorage DEPARTMENT OF HEALTH &HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMEDFOR: i� '-Y�/�M %�U�J DATE PERFORMED: LEGAL DESCRIPTION: fiCl(i ;�1 � —.7 . wnship, Range, Section: SLOPE SITE PLAN 7 7 8 9 10 11 12 13 14 15 16 17 16 19 d '' 6H WAS GROUND WATER ENCOUNTERED? CJ ' MA mffl� 'lI�®z� S IF YES, AT WHAT L D DEPTH? P E Depth to Water After r I �. Monitoring? WD Date: 20 { I / Iul PERCOLATION RATE 1 (/J (minutes inch) PERC HOLE DIAMETER TEST RUN BETWEEN T AND -F -T COMMENTS PERFORMED BY: S & S ENGINEERING I CERTIFY THAT THIS TEST WAS PERFORMED IN 17034 Eagle River Loop Road No, Z2 ACCORDANCE WITH , dwKI fO90TOUIDELINE EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) MA mffl� 'lI�®z� �LT1e�©�. 20 { I / Iul PERCOLATION RATE 1 (/J (minutes inch) PERC HOLE DIAMETER TEST RUN BETWEEN T AND -F -T COMMENTS PERFORMED BY: S & S ENGINEERING I CERTIFY THAT THIS TEST WAS PERFORMED IN 17034 Eagle River Loop Road No, Z2 ACCORDANCE WITH , dwKI fO90TOUIDELINE EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) PERFORMED F LEGAL DESCRI Ori Municipalily of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 •'L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST MEMO 13 14 15 16 17 18 Rance, Section: WAS GROUND WATER l I^ ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water Alt r / MoniterinII7 10 Data: 19 20 /f PERCOLATION RATE v4� (minutes inch/) P'ERC HOLE DIAMETER TEST RUN BETWEEN --I— FT AND `� FT COMMENTS' "'""T'• �'�� SITE PLAN PERFORMED BY: S & S ENGINEERINGQ�I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH 17034 Eaglea�� �c L TT ,�t1 AAr� �nw a ND@[fln�9Au EFFECT ON THIS GATE. DATE: �^ 72-008 (Rev- 4/85) Municipality of Anchorage Page of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ��� �� I �'� PID Number: 0& 1i 9M L Name: Imo, Wastewater System: ew ❑ Upgrade Address: !�{ ABSORPTION FIELD Phone: No. of Be rooms: ❑ Deep Trench ❑Shallow Trench ed ❑Mound ❑Other LEGAL DESCRIPTION Soil Rating: 0• Total Depth from original grade: GPD/S . Ft. Lot: Block ) Subdivision: G.JJ�,j Depth to pipe bottom from original g/rade: �/in. :✓ Ft. Gravel depth beneath pipe O �'Ft. Township: Range: Section: Fill added above original grade: Gravel length: �y r 4.1 D Ft. Ft. WELL: ❑ New ❑ Upgrade Gravel 4eptI;4,W Number alines: Distance//be__twlen lines: i_V Ft. Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: �l I Pipe material: IIff_40 r Ft. Ft. !i� SQ. Ft. Driller: Date Drilled: Static Water Level: Installlleerr:, Date install d: qZ - Ft. Yield: Pump Set at: Casing Height Above Ground: TANK GPM Ft. Ft. SEPARATION DISTANCES ptic ❑ Holding ❑ S.T.E.P. To Septic Absorption Lift Holding Public/Private Yanu��faa�c,turer: Capacity in gallons: 4 1 From Tank Field Station Tank Sewer Lines {'C1�K�'%{'%,2 Well ��jG}- IIIA �_ _- Z�Jt Material: Number otCompartments: Surfac 1470 lao'+ _ LIFT STATION Water -j- Lot ' i D + r fd f - �— Size in gallons: Manufacturer: Line Foundation / t0� 1 i2 ..� "Pump on" level at: "Pump vel at: High water alarm at: Curtain 1 1 N Pump Make & Mo Electrical Inspections performed by: Drain {moi Remarks: BENCH MARK Location and Description: f, . Assumed Elevation: _ �CQa ENC 44h of Al. �pp�p►'4 e�saeamasaa®�� �® top daaa .. 9 7. S & S ENGINEERING4 17034 Eagle River Loop Road, N Inspections performed by: i9ates: 1st Eagle River, S i� a2nd afl fiPpti ANo_ riOC>S"1AFEF1 15 Department of Health dHuman rvicesapproval if9�'9 F 60e, ee6' s Reviewed and approved Date: 72-013 (1/91) MOA 25 Permit No. l'Jl� ctZOi 1 Page __Z__ of _Z_ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 0 Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: �4- 1 5�5 , l�T �� PID No.: 0510117 Goti! P, t._ q1`1 is I— 4POO kL, Q�a Bla- 3.�.t�� N ) co • �y Gey � I rJ>vrJ (acto 4D-�-- 72-013 A (2191) MOA 25 Q (4ic,�av sol Goz wl htf P 16° 195 its � �v MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW920151 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:SLAYMAKER RONALD F & OWNER ADDRESS:5761 SILVERADO WAY ANCHORAGE, ALASKA 99518 PARCEL ID:05181128 LEGAL DESCRIPTION: SAMPSON ESTATES BLK LOT SIZE: 40513 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 3 LT 2 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: PAGE 1 OF 1 DATE ISSUED: 6/23/92 EXPIRATION DATE: 6/23/93 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ISSUED BY: U), 6)"t DATE: Q4�iv_ DATE: 6 ` _)' 3 - rJ Y HEALTH AUTHORITY APPROVALS June 18, 1992 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street SEWER&WATER Anchorage, AK 99519-6650 MAIN EXTENSIONS REFERENCE: Sampson Estates, Block 3, Lot 2 SEWER & WATER INSPECTION ROBERT SHAFER, P.E. ROGER SHAFER, P.E. CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 We request you issue a permit to drill a well and install a septic system to serve the proposed 3 bedroom house on the referenced property. ENGINEERING STUDIES AND REPORTS Test holes were performed on the property on June 9, 1992. The approximate location of the test holes are located on the attached site plan. On June 16, 1992, the monitoring tubes within the test holes were checked and water was found at 101. WELL INSPECTION & FLOW TEST This property has enough area for a septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring properties by the installation SITE PLANS of the proposed septic system. If you have any questions, or require additional information for your review, please contact us. ROAD DESIGN Sincerely, SOIL TEST Roger J. Sh RJS/LSU/lsu PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ONSITE WASTEWATER DISPOSAL SYSTEM DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 r=42 SrALE OT £§z 2 VAC�ANT vs -Tj Do M R > > P oma p \ d (n rTl 6 rri (.r) Ph 17" 0 (3) -4 - CO rT ) C)%25/ w\\\ > 4 m rri \� / ». rl:r 1 • � C-- cn -Tj x Igo rn mg e Municipality of Anchorage t DEPARTMENT OF HEALTH & HUMAN SERVICES C >Oca LLS 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: 4--� V ( I�-I `/�ll�-1 :i�Ci�-�61� DATE PERFORMED: § v LEGAL DESCRIPTION:' i — ry/ �%) (,�T "-T-ownship, Range, Section: r—� SLOPE SITE PLAN F E LI) 1 ^— t 3 4 5 c . c`v 6 p�d 7 Grr �1 8 e 9 a 10 r o d 11.�.� . 12 13 14 15 16 17 18 19 WAS GROUND WATER I r ENCOUNTERED? _ IF YES, AT WHAT DEPTH? Depth to Water After 1 Monitoring? � Date: 20 I� PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER f ( TEST RUN BETWEEN T AND -FT COMMENTS �7 PERFORMED BY: S & S ENGINEERING I CERTIFY THAT THIS TEST WAS PERFORMED IN 17034 Eagle River Loop Road No. 204 ACCORDANCE WITHW jtTWJJIW C0ftPUIDELINES'I EFFECT ON PHIS DATE. DATE: 72-008 (Rev. 4/85) �1�•�a�};"bbd "' ' Municipality of Anchorage • a.r 6�. DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 c, sy0�� ;it.:• " ''-41 SOILS LOG — PERCOLATION TEST "s �f,`nE•OO rs G08a@s33Vls FF S PERFORMED FOR: ,,�i1rJ/Y�+�Lt"� 1*`—DATE PERFORMED: LEGAL DESCRIPTION -s„ 2/' ,?-"iownhip, Range, Section: SLOPE SITE PLAN DEPTH 1 a _v N 2 9 , D 3- 4- 5- 4 5 d a 2- 6 - La d �l 7 0 1 I .d 8 9 a WAS GROUND WATER P� 10 o ENCOUNTERED? i z� 11 IF YES, AT WHAT DEPTH? 1 z �,�.ik• 13 14 15 16 17 18 19 Depth to Water Aft r / Monitoring? . Date: 20 I PERCOLATION RATE—: (minutes/inch) P'ERC HOLE DIAMETER TEST ,�--RUN BETWEEN —!!t— FT AND FT COMMENTS' �J PERFORMED BY: S & S ENGINEERING I CERTIFY THAT THIS TEST WAS PERFORMED IN 17834 Eagle River Loop Rp��[ ��9q- ACCORDANCE WITH JPRT, 1Cd &N.IC�29LS�UlU S�tl�`.YTN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) a+`�5777 `�M�607 �1=r/ll�S���-- III 10 20 I PERCOLATION RATE—: (minutes/inch) P'ERC HOLE DIAMETER TEST ,�--RUN BETWEEN —!!t— FT AND FT COMMENTS' �J PERFORMED BY: S & S ENGINEERING I CERTIFY THAT THIS TEST WAS PERFORMED IN 17834 Eagle River Loop Rp��[ ��9q- ACCORDANCE WITH JPRT, 1Cd &N.IC�29LS�UlU S�tl�`.YTN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) a+`�5777 RECEIVED July 13, 1992 JUL 131992 Municipatit a Municipality of Anchorage pePt. Health &HumanSerr lice,, On -Site Services 825 L Street #502 Anchorage, Alaska Subject: Well & Septic Permit Application, Addendum to This letter is to provide On -Site Services with information that I intend, as an owner -builder, to install a septic and waste disposal system as per design on lot 2, block 3, Sampson Estates, near Peters Creek. Further, I am familiar with MOA installation requirements and regulations. The project will be supervised by a licensed and MOA approved civil engineer. Sincerely l evK in R(Ha nsi e B 9 • '� Municipality of Anchora AU6 32016 = On -Site Water and Wastewater Progra (907)343-7904 A E T Y d w Certificate of On -Site Systems Approva °C Parcel I.D. 051-811-28-000Expiration Date: _/ 2 —16o 1. GENERAL INFORMATION Complete legal description Sampson Est. Block 3 Lot 2 Location (site address) 22727 Sampson Dr. Current Property owner(s) Wesley & Kim Planing Day phone Mailing address 22727 Sampson Dr., Chugiak, AK 99577 Real Estate Agent Steve Cook Day phone 346-7215 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 Q Individual IX Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request Received by: �Date: u�toi I l� COSA to be released to the engin rnl s otherwise requested by the engineer. _ l COSA Fee $ Waiver Fee $ Date of Payment gI3I (2-0I (0 Date of Payment Receipt Number C)/t-LV— 4 Receipt Number ' COSA#�SGI�13�� . Waiver# 5. STATEMENT 61iiNSPECTION 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. Address 9131 E Frontage Rd., Palmer, AK 99645 Engineer's Printed Name Gtr 17�h GL ES 6. DSD SIGNATURE System #1 Approved for 9 bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, with the follow Phone 745-0222 Date 3D `®,eoeeeaaaa a a �..OF A� apes A. OTH SIF�*'�� By: Original Certificate Date: The Municipality of Anchorage Development Services Divislon (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 f c 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: Sampson Est. Block 3 Lot 2 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 7/20/92 Sanitary seal (Y/N) Y Total depth 165 ft Cased to 165 ft. FROM WELL LOG Date of test Static water level ft. Well production g.p.m. WATER SAMPLE RESULTS Coliform A oolonies/100 mL Nitrate 4.07 mg/L Arsenic ND ug/L Date of sample: 8/9/16 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Tank size 1000 gal Number of Compartments 2 Parcel ID: 051-811-28-000 Well Log (Y/N) N Wires properly protected (Y/N) Y Casing height (above ground) 19 in. AT INSPECTION 8/9/16 138.3 ft. 8.0 g.p.m. Collected by: Brandon Jones Date installed 7/17/92 Cleanouts (Y/N) Y Foundation cleanout (Y/N) YDepression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 7/7/16 Pumper JRs Pumping C. ABSORPTION FIELD DATA Date installed 8/22/12 Soil rating (g.p.d.e orft2/bdrm) .4 gpd/ft2 System type Bed Length 47 ft. Width 24 ft. Gravel below pipe •5 ft. Total depth :3-5 ft. Eff. absorption area Ll28 fe Monitoring tube Y— Depression over field N Date of adequacy test 8/9/16 Results (Pass/Fail) Pass For 3 bedrooms Fluid depthin absorption field before test 4 in. Water added 450 gal. New depth 4.5 in. Elapsed Time: 105 min. Final fluid depth 4 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 °Pump on" level at Datum — _ . Size in gallons_ in. "Pump off' level at Cycles tested_ E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption Feld on lot 100'+ Public sewer main 100'+ Sewer /septic service line 254 Animal containment areas 50'+ SEPTIC/HOLDING TANK ON LOT TO: Manhole/Access (Y/N) in. High water alarm level at in. Meets alarm & circuit requirements? On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manholetcleanout 100'+ Holding tank 100'+ Manure/animal excrete storage areas 100'+ Building foundation 51+ Property line 5T+ Absorption Feld 5'+ Water main 10'+ Water service line 107+ Surface water 100'+ Wells on adjacent lots 100'+ ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 101+ Water main 10'+' Water Service line '+ Surface water 100'+ 25't — Driveway, parking/vehicle storage Curtain drain none known Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA,,g��uAAid__elines in effect on this date. Engineer's Printed Name Date Vii! COSA canary sheet_2-6-15.doc Mary I.UShreves CE 9351 0 }LEA /CN CLEANOUT b' Q Ci r \\\\ G `10• ELEC. 8 TELECOM J EASEMENT ry .01 W LOT 1 WALL \ r\ LOT 3 e. WOODEN FENCE I FENCE LOT 2 ' I 40.513 S.F. y O x WELL QUO I �� CHAIN—LINK FENCE I I x 10' DRAINAGE EASEMENT W J M Q O m I= I 1 0 PLOT PLAN AS BUILT X SCALE 1'= 440' GRIDNW 1560 Project No. 16-218/All Associates, � 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Ass 0 c i a 1j e s, inc. (907) 522-6476 Phone (907) 522-4625 Fax Professional Land Surveyors kenolangsurvey.com c! i jonothonOlongsurvey.com I hereby certify that 1 have surveyed the following described property: 0 • �O 49L LOT 2, BLOCK 3, SAMPSON ESTATES (PLAT 84-10) 0 * .- �* Anchorage Recording District, Alaska, and that the Improvements situated thereon* ore within the properly lines and do not encroach onto the property adjacent thereto, that no Improvements an the property lying adjacent thereto encroach on the surveyed' ' ' KENN promises and that then are no roadways, transmission lines or other visible o M easements on sold property except as indicated hereon. Q $l9l�co •..j.S-5202. • •'• SaQr Dated this the '� Day of at Anchorage, Alaska p� ••••••o 0 Op Atsswwa-o4� N Is the responsibility of the owner To determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. AECC983 Parcell.D. 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 DWELLING 051-811-28 1. GENERAL INFORMATION c COSA # OSC VDI V8 Expiration Date: //—a'/ — I a Complete legal description Lot 2, Block 3, Sampson Estates Subdivision Location (site address) 22727 Sampson Drive Chugiak, AK 99567 Current Property owner(s) Janet Hagensieker Day phone Mailing address P.O. Box 772162 Eagle River, AK 99577 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless_ otherwise requested, COSA will be held by DSD for pickup 2. NUMBER OF BEDROOMS: Three (3) 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ✓❑ Individual On-site ❑✓ Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water 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 verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Engineering Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for Phone 522-7773 Date 8/23/2012 bedrooms, with the following stipulations: Attachments COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By. fid Original Certificate Date: <✓ "7 Jit (Rev. t VMS) Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www-muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lot 2, Block 3, Sampson Estates Subdivision Parcel ID: 051-811-28 A. WELL DATA Well type Private If A, B, or C provide PWSID # _ Well Log (Y/N) Y Date completed 7/20/92 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth 165 ft. Cased to 165 ft. Casing height (above ground) >18 in. FROM WELL LOG AT INSPECTION Date of test 7/20/92 7/20/2012 Static water level 75 ft. 138.3 ft. Well production 15 g.p.m. 6.0 g.p.m. WATER SAMPLE RESULTS: --- Coliform 0 colonies/100 mL Nitrate 2.63 mg/L Arsenic: N/D ug/I Date of sample: 6/7/2012 Collected by: JKB B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 7192 Tank size 1,000 gal. Number of Compartments Two Cleanouts (Y/N) Y Foundation cleanout (YIN) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 8/20/2012 Pumper JRs Pumping C. ABSORPTION FIELD DATA Date installed 8/20-22112 Soil rating (g.p-cl-e or ft2/bdrm) .4 GPD/SF System type Shallow Bed Length 47 ft. Width 24 ft. Gravel below pipe .5 ft. Total depth 3-5 ft. Eff. absorption area1226 ftz Monitoring tube 2 Depression over field N Date of adequacy test New const. 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) 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: Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? r1l Septic tank/lift station on lot >100, On adjacent lots >100' Absorption field on lot >100' On adjacent lots >100' Public sewer main N/A Public sewer manhole/cleanout N/A Sewer /septic service line >25' Holding tank N/A Animal containment areas >50' Manure/animal excrete storage areas >109 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' Property line >5' Absorption field >5' Water main N/A Water service line >10' Surface water >100' Wells on adjacent lots >1W SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line >19 Building foundation >10' Water main >10' Water Service line >10' Surface water >100' Driveway, parking/vehicle storage >25' Curtain drain None Noted Wells on adjacent lots >1W F. COMMENTS: G. ENGINEER'S CERTIFICATION 1 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. Engineer's Printed Name Michael E. Anderson, P.E. Date 8/23/2012 COSA Fee $.2-5-62 ✓� o y /5 6- /y Z Date of Payment Receipt Number Com% 2,2 61 (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number �r ��• int:;- *? 49ZJ t -23 N t - O J W J M in f- Z O m 0 M PLOT PLAN AS BUILT X SCALE 1" = 40' GRID NW1560 Project No. 12-151A1 Lang & Associates, InC. 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 (907) 522-6476 Phone Registered Land Surveyors (907) 522-4625 Fax pF q�°pp4 ken®langsurvey.com / jonathan®langsurvey.com I hereby certify that I have surveyed the following described property: D LOT 2, BLOCK 3, SAMPSON ESTATES (PLAT # 84-10) [�./_0� Anchorage Recording District, Alaska, and that the improvements situated thereon are 49IN mit 0 within the property lines and do not encroach onto the roe adjacent P' property rc adjacent thereto that :h no improvements on the properly lying adjacent thereto encroach on the surveyed �i�y, � r j__ premises and that there are no roadways, transmission lines or other visible M • ; • • •I• • of • • . • •; •o 0 easements on sold property except as Indicated hereon. t7 KENNETH G. LANG „ LS -520200 Dated this the B Day of 4.aP uST 2olZ , at Anchorage, Alaska � SAS,( .( - ,.•0��0 It is the responsibility of the owner to determine the existence of any easements, 44p4R��SSIONPlpc covenants, or restrictions which do not appear on the recorded subdivision plat. 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. # b 5 -� i 1 - �� HAA # 1. GENERAL INFORMATION Complete legal description Lot 2 Bloch 3• Sampson E3tate3 Location (site address or directions) Sampson D i.ve Property owner Kevin Hagen6iekm Day phone 696-0901 Mailing address P.O. Box 772002 Eagte Riven, AK 99577 Lending agency Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3 4 Day phone Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XXX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA#21 �aavow NMEJ (L6it'AO8)9zo-ac -NioM s,aaaul6uo leuolssalo.)d aql ul suoisslwo Ao saoaaa aol elglsuodsaa lou sl obeaogouy to Al!led!o!unW aql •panssl sl aleoigino a aaolaq lelep ozAleue ao suolloodsul lonpuoo IOU op SHHG 10 saa/oldw3 •sluowaalnbaa alels pue leaapal ule}jao Alslles olaapao ul suolln}llsul 6ulpual alagl pule sawog to siesegoand of Aselanoo a se slgl scop SHHa agl'2Nsely to alelS aql ul paaalsl6ai iaeul6ua leuolsseloid luapuadapul ue Aq anoge S gduibujud ul uanl6 suoljeluoseiclai ail uodn Aluo paseq saleollRaao lenoaddy Allaoglny glleaH sonss! (SHHd) saolnaaS uewnH pue q}leaH l0 1uawjjed9Q aBeaogouy to AllledloluniN oq.L • -suollelndlls BulMollol aql gIIM 'swooapaq h G 2 b % ouogd sluawwo0 Ieuolllppy aol lenoadde leuolllpuoO panoaddesla •swooapaq � aol panoaddy 3unIVNJIS SHHO Mill 816e3 4EOLL 2133NION3 S I S ainleuBls s,aaaulBu3 ssaa ppy wall to aweN •uo1loadsul slgl jo alep aql uo loalla uI suolleln6ai pue 'saoueulpao 'sopoo alelS pue ledlolunw Ile g11M aouelldwoo ul sl walsAs lesodslp aaleMalseM Ao/pue Alddns aaleM alls-uo aql 'uolloadsuw pue uo!lefi!lsanul (w woal pue salll aBeaogouy to Al!led!o!unW aql woa} poulelgo uollewao}ul oql uo paseq legl Aluanaaglanl I •ulaaaq paleolpul aanlonals to adAl pue swooapaq;o aagwnu aql aol alenbape pue leuollounl'ales sl walsAs lesodslp aaleMalseM ao/pue Alddns Aalum olls-uo aql legl smogs uolleolldde lenoaddy Al!aoglnV glleal-1 slgl }o uo!leB!lsanul Aw legl Allaan I 'Molaq uMogs alep uollepllen agl to se pue olaaaq paxille leas Aw Aq paipliao sy Trz E H33NION3 A8 N011O3dSNI d0 1N3W31b'1S 'S Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Li- -I- Es -r Parcel I.D. A. WELL DATA Well type k:sl If A, B, or C, attach ADEC letter. ADEC water system number �' P Log present/N) q Date completed - 20 1- Driller Total depth � L'`F Cased to \ 1-5% Casing height t2 Sanitary seal (. N) J Wires properly protected (VN) — FROM WELL LOG AT INSPECTION Date of test°'� 2 Z.I esu . Static water level S Well flow ,�' D g•p•m• g.p.m. Pump level 0� M : - o z 3:__ (01 M v_ SEPARATION DISTANCES FROM WELL TO: rr, r m T Septic/holding tank on lot \ D A % On lots ;adjacent N d'ti°1 , c,4 Absorption field on lot Nil ; On adjacent lots Public sewer main's Public sewer manhole/cleanout Sewer service line 2s \k Petroleum tank WATER SAMPLE RESULTS: f Coliform -0' o L1/1 6b Nitrate 2 6 `� Other bacteria da"li= Date of sample: 5v" S - 173 Collected by: S & S ENGINEERING 17034 Eagle River Loop Road No. 204 B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99577 Date installed I - q�L- Tank size \ u'Z� 0 Compartments Cleanouts (21N) T— Foundation cleanout &N) S/ . Depression (Y&N' tj High water alarm (Y® IS Alarm tested (WN) Date of pumping �f Pumper /rESs %lei 1l K SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot D On adjacent lots i 60 ' 4- Foundation .S' To property line _F.asorption field S Water main/service line /0' } Surface water/drainage /6(3 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes — Manufacturer Manhole/Access (Y/N) ump off' level at Cycles tested SEPARATIO-N-DISTANCE FROM LIFT STATION TO: on lot On adjacent lots D. ABSORPTION FIELD DATA Surface water Date installed 1 -1 Z Soil rating 0, ¢ �*' System type 13 ED i Length 4% Width Z+ Gravel thickness Total depth Total absorption area L 2 3 Cleanouts present aN) J / Depression over field (Y& v Date of adequacy test !/a Results (pass/fail) a for IJE bedrooms Peroxide treatment (pas, 12 mon,hs) (YH�1 If yes, give date �fp ,-vZ i .�,LL f(-aDED a l sy9T��'1 SEPARATION DISTANCE FROM ABSORPTION FIELD TO: r� Well on lot l (I r On adjacent lots 1 o d Property line 6 To building foundation 17-f To exi ting or abandoned system on lot la/a, r� ~f� to �d On adjacent lots 5-D Cutbank k Water main/service line Surface water 1 �� r Driveway, parking/vehicle storage area 2-0 r Curtain drain E. ENGINEER'S CERTIFICATION I certify that t have checked, verified, or conformed to alr?�OA and HAA guidelines in effect on the date of this inspection. S & S ENGINEERING Signature Eagle River, Alaska Engineer's Name Date HAA Fee $ / h `OC) Date of Payment 3 Receipt Numbertl Waiver Fee: $ Date of Payment Receipt Number in,:r lunll 1'tC,,rWii1 Chemlab Ref.# x93.2027-1 client Sample ID :L2 N3 SAMPSON EST. Matrix ;WATER client Name :S & S ENGINEERING Ordered By ;R..SHAFER project Name Project# PVSID :UA Sample Remarkst COc3'ED BY : RAY. 5833 B STREET ANCHORAGE. AK 99518 TEL: (907) 5622343 rAA: (907) 551-5$03 WORK Order :65793 Report completed .05/10/93 Collected :05/05/93 @ 1100 hrs. Received :05/06/93 @ 14:30 hrs.l Technical Director tS EDE Released By s __ Qc Parameter Results Qu5l. Units Method ---RATE---------..�2 2 1 0 - 0 --_._---- NITRATE_N 2.4mS±/L EPA 353.2/300.0 Allowable Ext. Anal Limits oat;e date Init ------------------------ 10 05/07 LLH ' le�esxn=====�=5ffis I -- UA Unavailable— I See:Special`Instructions '.Above '.NA = Not Analyzed-- ** See'Sample.Remarks-Above, Lm s Less 'Than U:= Undetected,_. Repo. ted.valLie is the practical quentifi+8ti�►rt`limit. GT = Greater.Than: D Secondary dilution. Member of the SGS Group (SocidtA G9�6rale d® Survvillance) — '.t - _ 1 MARYLAND, WEST VIRGINIA NEWJERSEY, SOUTH GAROLINA'.- �u.n!\AAI\AC A:TdI aFa�nr.Fv w Ai ASK.4.�. COLORADO—UTAH, ILLiM1UIS;-O!iIQ,, ' e "" "