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BLUEBERRY HILL BLK 1 LT 4
a IP 1 144 IdOLM 0 ��imxldj #050-202-22 (Kev Ub/U2/16) Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201411 PID Number: 050-202-22 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade Name NameS CHO DONGSite ABSORPTION FIELD - EXISTING ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Address 21812 SHEPPARD DRIVE ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot Fill added above original grade Ft. Gravel length Ft. BLUEBERRY HILL 1 4 Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft' Ft. Well 100'+ -_ 25'+ TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1250 Gal. Surface Water 100'+ -- Material HDPE Number of compartments 2 Lot Line 10'+ -- NA Foundation 10'+ __ LIFT STATION Manufacturer Capacity Gal. Remarks Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 drainfield Tank to 3034 Installer RPC Drainfield CO/MT 3034 Inspector FWC BENCH MARK (Assumed elevation) 100 ft Inspection Vt 10/12/2020 10/13/20 Location and description da:3`d 2nd 4`" TOP OF CEMENT DECK SUPPORT ON-SITE WATER AND WASTEWATER SECTION APPROVAL pF 1 Conditional Approval: Date ,.,. • • . tp,�,,� �AwOF .�Q A� • '. Curtis Huffman• : • j �� �'c�G, • CE 128991 • <4`�r Septic System Approv - DateislF�FO plz�sl�QzN���': r �1 ROFESSIO .. Note: this approval does not include well permit requirements. (Kev Ub/U2/16) PID: 050-202-22 PERMIT: OSP201411 ipgwm�g �FpPgRO SEPTIC SECTION BLUEBERRY HILL BLOCK 1, LOT 4 ��rrvni �trcvi�ta: PREPARED FOR: DONG S. CHO 21812 SHEPPARD DRIVE EAGLE RIVER, AK 99577 FIRST WATER CONSULTING DATE: 12/01/2020 SURVEY: RJF 13030 SUES WAY DRAWN: FWCS 12/01/2020 ANCHORAGE, AK 99516 SCALE: 1" = 30' 907-350-9566 firstwaterAK@gmail.com —A- \ \ 1 END: UTnuTY (C)=CALCULATED DATA POLE (M)=MEASURED DATA (R)=RECORD DATA PER PLAT ohu=OVERHEAD UTILITIES U.G.=UNDERGROUND NA .=NATURAL �(TYP.)=TYPICAL S72:20's'5.'�'p \ 0\ 3oAo R Ay CONCRETE LOT 3 WELL )- goo \ PARKING PAD BLOCK 1O 1a z( NAT. GASEC. RETAINING \` 1 w U.G. ELEC. /-WALL 1Z7 Lu sg.ZL DECK w/ 1 J(� 2> T4>• ,Q% STEPS 1 to 1 \ 40 4"®LASTiC LOT 111 u 1 �RADIUSE� FENCE- ' RISER (TYP.) I 1 ' 0 1( LOT 4 t 1 1.92 Ac. 1 0 1 ^ I al = 1 1 1 1 1 1 ( ------1 -- — — — — — -- — - LOT 5 1"=60' NOTES: 1. EXCEPTING FOR GROSS NEGUGENCE, THE LIABIUT' FOR THIS SURVEY SHALL NOT EXCEED THE COST OF PREPARING THIS SURVEY. 2. THIS SURVEY REPRESENTS VISIBLE IMPROVEMENTS & CONDITIONS ON THE DATE OF SURVEY. 3. THIS DOCUMENT DOES NOT CONSTITUTE A BOUNDARY SURVEY & IS SUBJECT TO ANY INACCURACIES THAT A SUBSEQUENT BOUNDARY SURVEY MAY DISCLOSE. 4. THIS SURVEY PERFORMED FOR DONG CHO, IT SHOULD ONLY BE USED FOR A SINGLE PROPERTY TRANSACTION. EXCLUSION NOTE: IT 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. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OR FOR ESTABUSHING BOUNDARY OR FENCE LINES. R,F FARMER SURVEYING OF A AS -BUILT 9131 E. FRONTAGE RD. �F� °°° °• Lqf PALMER, ALASKA 99645 S e°•• f9 PH: (907)745-0222 9TH bob®formersurveying.com www.formersurveying.com *°•4 — °..° °..°. ..........°.: W0: 20-00331..° LLt� FB: 20-07 .°• °°• PAGE: 1 of 1 Obert J. Farmer .� Surveyors:Planners SCALE: 1" = 60' FILE: 2000331AS �, :• ; ,o 10615-S e I HEREBY CERTIFY THAT A MORTGAGE INSPECTION WAS PERFORMED `�� °•°° .• s° UNDER MY DIRECTION ON THE FOLLOWING DESCRIBED PROPERTY: Fo pRDfESSiUNAL �'P�9 BLUEBERRY HILL SUBDIVISION, BLOCK 1, LOT 4, PLAT No. 66-84, ANCHORAGE RECORDING DISTRICT, ALASKA. j�-Z�•��; SURVEYED ON THE 23rd OF OCTOBER, 2020. ©2020 274.00'(R&C) 15' UTILITY EASEMENT - — S89.55 OS"W 1319.39'(R) 1318.30'(M) 15' UTILITY EASEMENT — — -- — — — — — — — — --------------- ---- 2.5" BRASS BASIS OF BEARING CAP MONUMENT MILE, HI ADD. 1 TYP LOT 1 BLOCK O8 1"=60' NOTES: 1. EXCEPTING FOR GROSS NEGUGENCE, THE LIABIUT' FOR THIS SURVEY SHALL NOT EXCEED THE COST OF PREPARING THIS SURVEY. 2. THIS SURVEY REPRESENTS VISIBLE IMPROVEMENTS & CONDITIONS ON THE DATE OF SURVEY. 3. THIS DOCUMENT DOES NOT CONSTITUTE A BOUNDARY SURVEY & IS SUBJECT TO ANY INACCURACIES THAT A SUBSEQUENT BOUNDARY SURVEY MAY DISCLOSE. 4. THIS SURVEY PERFORMED FOR DONG CHO, IT SHOULD ONLY BE USED FOR A SINGLE PROPERTY TRANSACTION. EXCLUSION NOTE: IT 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. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OR FOR ESTABUSHING BOUNDARY OR FENCE LINES. R,F FARMER SURVEYING OF A AS -BUILT 9131 E. FRONTAGE RD. �F� °°° °• Lqf PALMER, ALASKA 99645 S e°•• f9 PH: (907)745-0222 9TH bob®formersurveying.com www.formersurveying.com *°•4 — °..° °..°. ..........°.: W0: 20-00331..° LLt� FB: 20-07 .°• °°• PAGE: 1 of 1 Obert J. Farmer .� Surveyors:Planners SCALE: 1" = 60' FILE: 2000331AS �, :• ; ,o 10615-S e I HEREBY CERTIFY THAT A MORTGAGE INSPECTION WAS PERFORMED `�� °•°° .• s° UNDER MY DIRECTION ON THE FOLLOWING DESCRIBED PROPERTY: Fo pRDfESSiUNAL �'P�9 BLUEBERRY HILL SUBDIVISION, BLOCK 1, LOT 4, PLAT No. 66-84, ANCHORAGE RECORDING DISTRICT, ALASKA. j�-Z�•��; SURVEYED ON THE 23rd OF OCTOBER, 2020. ©2020 rI UN IC IPALITY OF ANCHORAGE 'Dn-Site Water & Wastewater Pr"Vgim PO Box 1517 4700 ElMOM r;&y AncWrege, AJ&sk& 99519 ,1 Phone: (907) 3.43-7904 Fex: (907) W-7"7 hE:p.rNmv.muni.onVonsft Ori -Site Wastewater Disposal System Permit Permit Number. 08P201411 Work Type: SepticTank Upgrade Tax Code Number, 05020222000 Me Legal Address,. BLUEBERRY HILL BLIP I LT 4 x,:0058 Site Mailing Address: 21812 SHEPPARD DR, Eagle Myer tOwnnr: CHO 00 NO Design Engineer, FIRST WATER CONSU LMNG This permit is for the congtructio n of: Effective Date: Expiration Data: Lot Size In Sq Ft; Total Bedroom, 10V020 14)5(2021 83635 ❑ Disposal Fuld 0 6eptiG Tank C Holding Tank ❑ Mq ❑ Private Well ❑ Water Storage AN construction sha3l be in accordance with: 1. The etteched approved design. 2. All requirements specified in Anchorage Muniapal code Chapters 15-:55 and 16.66 and the State of Alaska Wastewater Disposal Regulabons �18AAC ) and Drinking vVaW Regul ions (18AACBOj 3. The wast ler ode requires inspections during the installation}. The Emgi neer shall notify the Development Services Departnient per AMC15.65. PreMde notification by calling (907) 343-7904 (24+7). 4. From October 15 to April 15, a subsurface soil absorption system under const teon during freezing weathar shali he either: a. Opened and Chased on the same day, or b. Covered, sealed. and heated to pmerrt freezing Spacial Provisions. Contractor shall ensure minimum 5 ft separaTion between new ueptac tank and existing dock tuppmrta and 43 ft long abk5alptlon held. Received By: Issued By: PC Lteir-4 1 O1i0512020 Date- Date: /0 .0 4 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 050-202-22 Property owner(s) DONG S CHO Day phone 903-578-0555 Mailing address 38485 MADDY LANE, PONCHATOULA, LA 70454 Site address 21812 SHEPPARD DRIVE, EAGLE RIVER, AK 99577 Legal description (Sub'd., Block & Lot) BLUEBERRY HILL BLOCK 1, LOT 4 Legal description (Township, Range & Section) Lot Size 83,635 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) FE (w/wo ADU) Septic Tank El Upgrade Z Duplex El (D) Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: Receipt Number: % L9 5 Permit No. ©Sp `-11 Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc 13030 Sues Way, Anchorage, AK 99516 907-350 -9566 / firstwaterAK@gmail.com September 29, 2020 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: BLUEBERRY HILL BLOCK 1, LOT 4 PHYSICAL: 21812 SHEPPARD DRIVE, EAGLE RIVER, AK 99577 The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic tank on the above referenced lot. We propose to install a 1250-gallon HDPE tank outside any deck supports to serve the existing 4-bedroom residence. The lot and area are served by private water with no wells within 100' of the proposed tank. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201411, Rebecca Carroll, 10/05/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201411, Rebecca Carroll, 10/05/20 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division J 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES SEPTIC ABSORPTION Address FROM TANK FIELD WELL Phone(s) Permit No. No. of Bedrooms WELL 1 %C) t 1 i I -5193 oZ143 LEGAL DESCRIPTION LOT LINE to tpl't- Lot Block Subdivision FOUNDATION '�Zt I � -------- Township, Range, Section (Show location of well, septic system, property lines, foundation, f)', , 1 n AS -BUILT DIAGRAM `j 1` w G driveway, water bodies, etc.) TANKS N X SEPTIC ❑ HOLDING Manufacturer Capacity in gallons Material No. of Compartments r I r TYPE OF SYSTEM TRENCH ❑ BED ❑ W. DRAIN ❑ OTHER t I 1 a Depth to pipe bottom from Total depth from original grade original grade "1 FT IIJ FT ,I Fill added above original grade Gravel depth beneath pipe N 1 ti FT FT Gravel length Gravel width 3 FT 2 S FT Total absorption area Distance between lines 01 LeD() SQ FT FT . S ►' Number of lines Soil rating Pipe material �j 0 SQ FTFV L A!Sr?'&-p3c>34 N 3 �o 1 .41 le t Installer n Date Installed p, {� -0 Pm h I row tstt WELLS PRIVATE ❑ OTHER (Identifv) % -�' Classification (A,B,C) Total DepthC to FT `7ased,, VIV FT1451 d 1 D I U qI N 2t� Installer I Date Installed: 11 1 VLIF�t�I.S REMARKS: , Scale: 1° GINEETf g, L z Inspection orm@d by: Date: i;. 5 S ENGINEERING IY a -97034 Eagle River Loop Road No. 204 r4e 99577 ertil th t this inspection was performed accordingto all Eagleveo, Municipal and State guidelines in ellect his date: O Health Department Approval: •AE Date: 72-013 (3/85) by DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 • TELEPHONE 688.2759 OWNER OF LAND J ,fyE ITO,(1 Z ADDRESS 000 -t3oK 17 4153 C 09 LEGAL.DESCRIPT ION ( at -4 a<tJE'aeef A/141. DATE • Started Ended �Q PERMIT NUMBER DEPTH OF WELL �0 0 STATIC LEVEL OF WATER.F'r. DRAW DOWN FT. GALS. PER HRd 0 KIND OF CASING 6 ;o0 KIND OF FORMATION: From Ft. to 2 Ft. l� G �� ta' STI G Ky From l7 Ft. to ltd Ft. From o2 to- --$—Ft. OUER diea,%) From. Ft. to Ft. From Ft. to C Ft.��f0j& •l t-&kNYT From Ft. to - Ft. From 021 Ft. to -3-L- Ft. %�O Z t e—,l'JQ From Ft. to - Ft 3 Ftom�Ft. to�Ft. eL r+ �C C��IQ���G From, Ft. to MYN,.ICIPALITY OF ANCHOR. t�ERT `- From -33 Ft. to �_ Ft.—FDS o�ic l3Ra�� From Ft. to OF E%t. O HEALTH � t, NMENTgL pRo� ,,,�_ G From_ . g Ft. to g —Jft Q6d/ld. (. AC GWAit From Ft. to Ft. &I ]1.4 pp From r s 000 Ft. to !.FY L3rdQa-w,� 44647,n J (r(oKClJFrom Ft. to Ft. VL I a r From - Ft. to Ft 10—� From - Ft. to Ft. E' V E,IJ From Ft. toUS*�Ft. %jtD�'a�rC, �JeJFZtJ From Ft. to Ft. From Ft. toid? Ft. QC 4065, /31e04J#J From Ft. to Ft. Fromm—Ft. to13-3 Ft. L?-4en(-V 6A From Ft. to Ft. From f�Ft. to $ Ft. %, 60,06CA 4+0t S d a+9/Cr`Z From.—Ft. to Ft. From Ft. to Ft. I.C. pm. From Ft..to Ft. From YJJ Ft. toZsq Ft. Q['df 0'Sk 16R�byJ'N From . Ft. to Ft. From XI_Ft. to16T�Ft., 48" 401 K �, J ��Ei"" From Ft. to Ft. !f �.�r�-� From Ft. to1_71 Ft. Alf3��0S-K- 8�t!^� p From � � Ft. to MISCL. INFORMATION: C/ /�16 DRILLER'S NAME SULLI"N WATER WELLS P.O. BOX 670272 CHUGIAK, ALASKA 99567 TELEPHONE 688-2759 a3AHAN Municipality of Anchorage 0661 Se T1(' Department of Health & Human Services NOISIAIO S9DIAnS WiN3WNNIAN9 3JVMOHDNV d0 AIIIVd0INnW July 25,1990 To whom it may concern: As per telephone conversation on July 24 with John Smith, I will clarify why I drilled a well on Lot 1 block 4 Blueberry Hill for Steve Stortz without first obtaining a well permit. I had talked with Mr. Stortz about drilling said well last year. At that point in time I was led to believe that Mr. Stortz had a well permit. When he con- tacted me this summer to go ahead and drill the well, I assumed the proper paper- work had been done. After I pulled my equipment on the site and drilled the well, I learned that there was no well permit. I hope this statement will explain to your satisfaction why the well was drilled before the permit was issued. Thank you for your attention to the matter. Sincerely, i� ll Sullivan MUNICIPALITY OF ANCHORAGE Department of Health & Human Services 825 L Street, Anchorage, Alaska 99501 343-4720 ON-SITE SEWER & SEPTIC TANK & WELL PERMIT A ^�} «�cl� |�,erPermitNumber: 9O0218 ��\ ��^�-' '�-�-���[ Date Issued: 07/25/90 Engineer Designed Owner Name: STEVE STORTZ Day Phone: Owner Address: PO BOX 774153 694-5183 EAGLE RIVER, AK 99577 ENGINEER MUST CONTACT DHHS PRIOR TO EACH INSPECTION SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH APPROVED DESIGN THIS PERMIT EXPIRES 12/31/90 I CERTIFY THAT: i. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater disposal system or public sewerage system on this o, any adjacent or nearby lot, 4. I understand that this permit is valid for a maximum of 4 bedrooms. I also understand that the capacity of the total system is 4 bedrooms and any enlargement will require an additional permit. Signed: �«- DATE: .... ..... ... ___... ..... ..... .... .... ... ..... .... (Owner) STEVE STORTZ Issued By: DATE: ^7 / Parcel Id: 050-202-22 Lot Legal: Subdivision: BLUEBERRY HILL Lot: 4 Block: 1 Section: 9 Township: 14N Range: 1W Lot Size 83635 (sq.{t. or acres) Max Bedrooms: This Permit: 4 Total Capacity: 4 SEPTIC TANK: Minimum total septic tank capacity: 1,250 gallons. Each septic tank must have at least 2 compartments. Depth to top of septic tank(s) < 4.0 feet requires insulation over tank(s). ^ WELL: Log must be submitted to Municipality of Anchorage Department of Health and Human Services within 30 days of well completion. ENGINEER MUST CONTACT DHHS PRIOR TO EACH INSPECTION SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH APPROVED DESIGN THIS PERMIT EXPIRES 12/31/90 I CERTIFY THAT: i. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater disposal system or public sewerage system on this o, any adjacent or nearby lot, 4. I understand that this permit is valid for a maximum of 4 bedrooms. I also understand that the capacity of the total system is 4 bedrooms and any enlargement will require an additional permit. Signed: �«- DATE: .... ..... ... ___... ..... ..... .... .... ... ..... .... (Owner) STEVE STORTZ Issued By: DATE: ^7 / •gkrim�; AV / Q00 ;� !w � o 72 4z � � � v w� `� f I S -►- yam.. Qj i II Cl w II Q Z J O • o cQ '� � yam-- 4+-. 31VOS 7 e Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST w� PERFORMED FOR: ���� `-��OV l Z DATE PERFORMEEII♦�liz'R o LEGAL DESCRIPTION:Lf4 Ajo,1 8(��(/v (-i�'IlTownship, Range, Section: E T SLOPE SITE PLAN ( E ) 1 pr jAfJ1cc Fill 2- 3 4 O. 5 •O O 6 O O° G W g'57 7 � Q o, 8 O 9`O \a sPcsa 10-0 O. 11 12-0, 0 �• 13- 14 3 14 <•� O D' 15 P5oH 16- 17 18 19 20 WAS GROUND WATER ENCOUNTERED? NO S IF YES, AT WHAT L O DEPTH? P E Depth to Water After J - Monitoring? Date:'io J�o Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN AND FT COMMENTS ENGINEERING 17034 Eagle River Loop Road No. 2Qr� PERFORMEDhyiI r _ ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES 1 72-008 (Rev. 4/85) CERTIFY THAT T IS TEST WAS PERFORMED IN ECT ON THIS DATE. DATE: V MUNICIPALITY OF ANCHORAGE 0t Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 050-202-22 1. GENERAL INFORMATION Expiration Date: -3 — ZZ — 2,0 Z/ Complete legal description BLUEBERRY HILL BLOCK 1, LOT 4 Location (site address) 21812 SHEPPARD DRIVE, EAGLE RIVER, AK 99577 Current property owner(s) DONG S CHO Mailing address Real estate agent Day phone 38485 MADDY LANE, PONCHATOULA, LA 70454 2. TYPE OF DWELLING: Z Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ $412.50 (COVID-19) Waiver Fee $ Date of Payment /21.6120 Date of Payment Receipt Number 7 /- 10-3 Receipt Number COSA 4 OSC201677 Waiver # Distance: 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY, ANCHORAGE, AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 12/8/2020 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & FWr..S 6. DSD SIGNATURE ySystem #1 Approved for q bedrooms System #2 Approved for bedrooms Disapproved �- • is i •49 TH •.yt r • Curtis Huffman r����'cG,�j. • •CE 128991 ••��``r Conditional approval for bedrooms, with the following stipulai<i ku(((((f(( gff Y op 6,t, By LZWAO' T ER AND m �VVA C% r ER PRO g. A. . A. - Original Certificate Date: 12--22- -20 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other a Legal Description: BLUEBERRY HILL BLOCK 1 LOT 4 Parcel ID: 050-202-22 If more than 1 septic system on lot: COSA Checklist # —of Structure served by this system _ A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled 7/25/1990 Total depth 180 ft Cased to 38 ft (INTO BEDROCK) ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 24+ in. Date of flow test for COSA 9/17/2020 Static water level at beginning of test 100 ft. Comments B. TANK DATA Age of tank(s) NEW 0 years Tank type/material SEPTIC / HDPE Measured operating fluid level in septic tank NEW ® Standpipes/foundation cleanout per record drawing Date of pumping NA - NEW D. ABSORPTION FIELD DATA Which system tested (date installed) 8/1/1990 ® ALL standpipes present per record drawing Total measured depth from grade 11.7 ft (max) Measured depth to pipe invert from grade 4.7 ft (min) ❑ N/A — pressurized field ® Monitor tubes o to bottom of effective If not state Well production at time of test 3.3+ gpm Water storage tank volume_ gallons Well disinfected for coliform test? ❑ Yes ® No ® Coliform bacteria is Negative Nitrate 0.767 mg/L F-1Nitrate less than MRL (ND) Arsenic ug/L ® Arsenic less than MRL (ND) Collected by_ FRES Date of Sample 121412020 C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: Adequacy test date 911712020 Results Z Pass For 4 bedrooms Fluid depth prior to test 2 in Water added 600 gal New depth 15 in g I Elapsed time 1330 min depth into effective ® Code -required soil cover over field Final fluid depth 0 in ® System presoaked Absorption rate 600 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) Gallons introduced 2000 gallons If yes, enter date Fwcs Comments/Deficiencies:.. E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ® Yes if No Community Sewer Manhole/Cleanout > 100' ® Yes if No ft ® Yes if No Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ® Yes if No ® Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft ® Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No _ Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: ® Yes Absorption Field > 5' ® Yes if No ft Private Wells > 100' ® Yes if No _ Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No - Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No _ ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No —ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION l certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. ,law .W1... . TH •. .. ... . ....... .. .... .......... Curtis Huffman 9' CE 128991 `�slFq' l;/8/202Q . •��G�,d ft ft ft ft ft ki ft ft Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 Certificate of On -Site Systems Approval Parcel I.D. 050-202-22 1. GENERAL INFORMATION Expiration Date: (:o —g'— 6 Complete legal description Blueberry Hill Subdivision; Lot 4 Block 1 Location (site address) 21812 Sheppard Drive Eagle River, AK 99577 Current Property owner(s) Dong Cho Day phone 903-578-0555 Mailing address 4413 Leland St. Marshall TX 75672 Real Estate Agent Lindsey Bergeron Day phone 907-952-7222 2. TYPE OF DWELLING: Sing amity (w/wo ADU) ❑ Duplex Multi Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: Individual Well IN Individual Water Storage ❑ Community Class _ Well ❑ Public Water System ❑ WaiverNariance request for: Received by: j yyy ax Od COSA to be released to the engineer, unless TYPE OF WASTEWATER DISPOSAL: by the engineer. Individual Holding Tank ❑ Community ❑ Public Sewer ❑ Date: COSA Fee $��p e Waiver Fee $ _ Date of Payment 44c. c.k as4 Date of Payment Receipt Number Receipt Number COSA # 0%,j (p p 0.1 Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Alaska Rim Engineering Address 9131 E. Frontage Rd. Palmer. AK 99645 Engineer's Printed Name // 6. DSD SIGNATURE System #1 Approved for 4 bedrooms System #2 Approved for _ bedrooms Disapproved Phone 2/26/2016 Date _5/y%iC Conditional approval for bedrooms, with the following stipulations: OFA1VO - jam'\ ON-SITE �9m. WATER AND :a WASTEWATER o PROGRAM _RT lo�'-A/T SER\AG_ By: �� Original Certificate Date: -3 —12 —6 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 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: Blueberry Hill S/D: Lot 4, Block 1 Parcel ID: 050-202-22 A. WELL DATA Well type Private If A, B, or C provide PWSID # N/A Well Log (Y/N) YES Date completed 7!35'1990 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 180 ft. Cased to 40 ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 1990 2126116 Static water level 93 ft, 102.9 ft. Well production 5 g.p.m, 4.1 g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate 1.0 mg/L Arsenic fif D ug/L Date of sample: 2122/16 Collected by: Brandon Jones B. SEPTIC/HOLDING TANK DATA Tank Type/Material Steel Tank size 1250 gal. Number of Compartments 2 Date installed 8/1/1990 Cleanouts(Y/N) Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 7/8/2015 Pumper JRs Pumping C. ABSORPTION FIELD DATA Date installed 8/1/1990 Soil rating (g.p.d./ftz or felbdrm) 150 System type Trench Length 43 ft. Width 2.5 ft. Gravel below pipe 7 ft. Total depth 11:76 fr., Eff. absorption area 600 fe Monitoring tube YES Depression over field NO Date of adequacy 'test 2/26/2016 Results (Pass/Fail) Pass For 4 bedrooms Fluid depth in absorption field before test 0 in. Water added 618 gal. New depth 0 in. Elapsed Time`:, 150 min. Final fluid depth 0 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (pas'. 12 mo.) (YIN & type) N If yes, give date D. LIFT STATION Date installed "Pump on" level at in Datum E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer /septic service line Animal containment areas Building foundation 51+ Water main NIA Size in gallons_ Pump ofr' level at Cycles tested 0 Manhole/Access (YIN) _ High water alarm level at Meets alarm & circuit requirements? 1001+ On adjacent lots 100'+ 100'+ On adjacent lots 100'+ 25'+ Public sewer manhole/cleanout 1001+ 251+ Holding tank 1001+ 100'+ Manure/animal excrete storage areas 1001+ Property line 51+ Water service line 10'+ Wells on adjacent lots 100'+ ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water Service line 10'+ Surface water 1001+ SEPTIC/HOLDING TANK ON LOT TO: Curtain drain None Known Wells on adjacent lots 1001+ F. COMMENTS G. ENGINEER'S CERTIFICATION Absorption field 51+ Surface water 1001+ Water main NIA Driveway, parking/vehicle storage 101+ I certify that i have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Date ; Xq// C COSA brown sheet 10.10-12.doc in. \ UTILITY POLE LEGEND: (C)=CALCULATED DATA (M)=MEASURED DATA (R)=RECORD DATA PER PLAT ohu=OVERHEAD UTILITIES U.G.=UNDERGROUND ELEC.=ELECTRIC NAT.=NATURAL (TYP.)=TYPICAL FCO=FOUNDATION CLEANOUT 1 11 n 0 00 h' LOT 3 z I WELL qy o CONCRETE O I w I �n \ `PARKING PAD BLOCK Lu I U.G. TE ECS / RETAINING I QI b' 2 '11''Y F FCO LOCATED UNDER DECK I W 59.* .6. D 298.. ; 2.1• IZo �I ry32j'�<7. 4q� STEPS DECK W/ I LOT 11 I I I 1 I I 1 I � �nl 4.0' I x �I x I � 4" PLASTIC I FENCE " RISER (TYP.) �I I LOT 4 �I I 1.92 Ac. C)f zl L— — — — — — — — — — — — — — — — — — — — — — 274.00'(R&C) 15' UTILITY EASEMENT S89'55'05"W 1319.39'(R) 1318.30'(M) 15' UTILITY EASEMENT — — — — — — — — — — — — — — — — — — — — — — — — — — k2 -1/2 - RECOVERED BASIS OF BEARING BRASS MILE HI ADD. 1 CAP MONUMENT (TYP.) LOT 1 BLOCK ( CV LOT 5 NOTES: 1' = 60' 1. EXCEPTING FOR GROSS NEGLIGENCE, THE LIABILITY FOR THIS SURVEY SHALL NOT EXCEED THE COST OF PREPARING THIS SURVEY. 2. THIS SURVEY REPRESENTS VISIBLE IMPROVEMENTS & CONDITIONS ON THE DATE OF SURVEY. 3. THIS DOCUMENT DOES NOT CONSTITUTE A BOUNDARY SURVEY & IS SUBJECT TO ANY INACCURACIES THAT A SUBSEQUENT BOUNDARY SURVEY MAY DISCLOSE. 4. THIS SURVEY SUBSTANTIALLY COMPLIES WITH ASPLS MORTGAGE STANDARDS. 5, TIES TO PARTIALLY MONUMENTED OR UNMONUMENTED PROPERTY LINES ARE t1 FT. 6. THIS SURVEY PERFORMED FOR DONG CHO IT SHOULD ONLY BE USED FOR A SINGLE PROPERTY TRANSACTION. REUSE OF THIS DRAWING FOR ANY PURPOSE NOT STATED ABOVE WITHOUT THE EXPRESS WRITTEN CONSENT OF ALASKA RIM ENGINEERING, INC. IS A VIOLATION OF FEDERAL COPYRIGHT LAW. EXCLUSION NOTE: IT 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. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES. S� ^ q :'49TH � �,.� ... Robert JOeFarmer ^moo �'^r. s10615a S Pd PROFESS IONpV \"p�C AS—BU ALASKA RIM ENGINEERING, INC. 9131 E. FRONTAGE RD, PALMER, ALASKA 99645 PH: (907)745-0222 : FAX: (907)746-0222 EMAIL: akrim®alaskarim.com : WEB: www.alaskarim.com W0: 1600125 FB: 16-03 PAGE: 1 of 1 GRID MAP: NW0058 SCALE: 1" = 60' 1 FILE: 1600125AS I HEREBY CERTIFY THAT A MORTGAGE INSPECTION WAS UNDER MY DIRECTION ON THE FOLLOWING DESCRIBED BLUEBERRY HILL SUBDIVISION, BLOCK 1, LOT 4, PLAT ANCHORAGE RECORDING DISTRICT, ANCHORAGE, ALASKA. SURVEYED ON THE 3rd OF MARCH, 2016. PERFORMED PROPERTY: No. 66-84, ©2016 Municipality of'Anchorage .. .. ' Development Services Department Building Safety Division G wf) On -Site Water & Wastewater Program U� 4700 South Bragaw SL \\\ P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchorage.sk.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. D 5-0 — 2.07. - ZZ HAA# 1. GENERAL INFORMATION ExpiretionDate: Z.12Zlor . Complete legal description BLUEBERRY HILL SUBDIVISION* LOT 4. BLOCK 1. Location (site address or directions) 21812 SHEPARD DRIVE • EAGLE RIVER, AK 99577 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address LYNN STIMLER Day phone c/o AGENT c/o KAREN FOSTER w/ DYNAMIC PROPERTIES Day phone KAREN FOSTER w/ DYNAMIC PROPERTIES Day phone 3111 "C" STREET • ANCHORAGE, AK 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well N individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ 261-7662 TYPE OF WASTEWATER DISPOSAL: Individual On-site 0 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 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of fide (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 samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions In the professional engineers 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 Health Authority Approval Guidelines for this application, shows that the onsite water supply and/or wastewater disposal system Is(are) safe, functional and adequate for the number of bedrooms and type of structure Indicated herein. 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 GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SURE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily Identsable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ltd. can (herefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party Is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE I/ Approved for _4-1 bedrooms. Disapproved. Conditional approval for bedrooms, with the fllowing Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Phone 337-6179 Date it 11�— g : WATER ANu ; -- ,., BTP�tiaTER . c • PROGRAM Manitenance Agreements Supplemental Engineer's Reort Other By: AA Original Certificate Date: ZZ a (Rw. 17101) Municipality of Anchorage Development Services Department Building Safety Division OnSRe Water & Wastewater Program 47W South Bragew St. P.O. Box 196650 Anchorage. AK 99519-6650 www.dArotorage.akus (907) 3437904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: BLUEBERRY HILL S/D: LOT 4. BLOCK 1. Parcel ID: 050-202-22 A. WELL DATA 'CASED TO BEDROCK Well type MAX If A, B, or C provide PWSID# N/A Date completed PRE 7/25/1990 Sanitary seat (Y/N) YES Total depth 180 ft. Cased to •38 ft. FROM WELL LOCI Date of test 1990 StatIc water level 93 ft. Well production 5 9— p.m-WATER SAMPLE RESULTS: Cdfforn O colonies/100 ml. Nitrate •35110 m9JL. Well Log (Y/N) YES Wires property protected (YM) YES Casing height (above ground) 12+ in. AT INSPECTION 11/16/2004 99 ft. 4.9 9— p.m- Other bacteria 7_colonlW100 ml. Aran6: N/A mgJL. Date of sample: t 1/16/2 Collected by: GEG. LtD. B. SEPTIC/HOLDING TANK DATA Tank Type/Matertal STEEL Date Installed 8/1/1990 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation deanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (YM) N/A Data of pumping 7/29/2004 Pumper JR'S PUMPING C. ABSORPTION FIELD DATA FARM DWNG EM Date installed 8/1/1990 Soil rating (g.p.dJftiDr® 1150 System type TRENCH Length 43 ft, Wiry 2.5 ft. Caravel below pipe 7 ft. Total depth •11.75 fL Eft. absorption area 600 ft' Monitoring tube YES Depression over field NO Date of adequacy test 11/16/2004 Results (Pass/Fall) PASS For 4 bedrooms Fluid depth in absorption field before test 0 in. Water added 10?5gal. New depth28 In. Elapsed Time: 138 min. Final fluid depth 21 in. Absorption rate » 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed "Pump on" level at _in. L SEPARATION DISTANCES Size in gallons High water alarm level at in. Cycles tested Meets alar & circuit requirements?, SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAitt station on lot 100'+ Absorption field an lot 1000+ Public sewer main N/A On adjacent lots 1008+ On adjacent kits 100'+ Public sewer manhole/deanout N/A Sewer /septic service line 25'+ Holding tank N/A 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 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Properly line 100+ Building foundation 10'+ Water main_ N/A Water service line 101+ Surface water 1001+ Driveway, parkinglvehide storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I ceAify that I have determined through field inspections and * `N review of Municipal records that the above systems are in . • • • • • •"• • .. • • • • • • • • • • •. conformance with MOA HAA guidelines in effect on this date. ........... Engineer's Printed Name JEFFREY A GARNESS •� 79 ass Date 1('tt/aF .• �• HAA Fee S 430 'f � ",4WI k Date of Payment I l II ] Receipt Number QbQ97Y (Rev. Mtn) Waiver Fee $ Date of Payment Receipt Number 5 04,10:38a Karen Foster JU'/-X61-rogi p,e S '93 10733 fafyrlCOC Ot EAr3.4 RYYl1' '"•:r :> ra; ..e.• .�1. r. �- ..._.� SH§!PA ----Rfl oR1Vt: Ale at -Wer\•ry Lr { b.r.Dy e.neryy t"t cn m444o•a4o• wvrWy of thw ; :. Vnprovomonto bn tho fanoWInp "de*cft4d NOfE W*i i%Cda'wn Oec*mber 1. th4t sold »■ Is a ret"flootton s+avii trnprovwmwalw Sltvoted thgro6n.W% 'WRhtn 1MV17 No aornere were act uh &L-*.% property ,mos and do not overtop or encroach-..:.. an r the p'opwrty,tyMlp eaJ=*At_ thorsto and that ;. it►42rtti: +r,t" m '; :� (nan�enitfltA tinea er laisr+Itn4S ;of .ewoc ;Dol«" ilk�A e7MM 1..... ., .. 41o!pt 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 AW141UPALITY Of AN, r1%J"tvL ENVIRONMENTAL SERVICES DIVISION CERTIFICATE OF HEALTH AUTHORITY NOV 10 1997 APPROVAL FOR A SINGLE FAMILY DWELLING - Parcel I.D.-# OSO HAA # n2 1. . GENERAL INFORMATION Complete legal description __l. F3 y r1i« S1O1' LTA) l3C 1 Location (site address or directions) a _,L S1�EPPAR+D l`�vi= Property owner MICf(flr:'—' %F7t>`EILINFL bF2sa Day phone 676-•130' Mailing address Lending agency Mailing address Day phone Agent AUDI /W#soN Day phone 69y - Li'!X03 Address REutA-x OF FPO&( -c Z1L)iI Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: F- u 3. TYPE OF WATER SUPPLY: Individual well 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 a 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. 1191) 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 ALASV-.., WAu Ie�e. � ` Address -V302 E . Engineer's signature 6. D�SIGNATURE 7Approved for bedrooms. Disapproved. Conditional approval for Additional Comments 111Th Phone 33^7—(617 0 022E - =Jq s04 - Date Wto C o f= .... diu °*'r;.. gyp• i 00 iQ9+ y A. Garness �Lu n , a .. r a CE -7453 bedrooms, with the following stipulations: Date /`/ ./?_.97 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) Beck MOA #21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 Anchorage, Alaska 99501 • (907) 3435 *WWWWON Health Authority ApprovaHChecklist, MY 10 As? Legal Description: IWL_ui _ a&_ � l�t ►i L S�(� , Z-�1 � 131 Parcel I.D.: O S 0 — a OD. -off 2 A. WELL DATA RECEIVED Well type RivA--rE_ If A, B, or C, attach ADEC letter. ADEC water system number IVIA Log present O/N) & Date completed I LZ�o O 1 a_5 9 D 4 AA Total depth $O Cased to 3E0-or_K Casing height (above ground) Sanitary seal (S)N) Wires proper!y protected (Y/N) `l.S FROM WELL LOG AT INSPECTION Date of test I I R 6fl_ D /0/30/9 �. Static water level 93' Well production s g.p.m.g.p.m. FUS /.52 tiwu^,f5 ; 6q5 6A"ODS WATER SAMPLE RESULTS:L,,, r�"l-F A pQ-'Wi00w►./ Coliform Nitrate { Other bacteria Date of sample: _2z) I i Collected by: w B. SEPTIC/HOLDING TANK DATA Date installed 08,10 1 190 Tank size IASOGRL Number of Compartments _A Cleanouts 6/N) -,2, Foundation cleanout 9N) S Depression (YAP L" High water alarm (Y19 !�VA S. �R , S Date of Pumping D6�ly 191- Pumper fUA^PI N fr C. ABSORPTION FIELD DATA Date installed 08 f 0I ) cl`o Soil rating (g.p.d./ft2 or /bd m) 150 System type b6slo l /01 DEEP Length 3 Width a.5 Gravel thickness below pipe Total depth Fie, o /WSAs (9 -AAT Effective absorption area Oa Sr Monitoring Tube present O/N) yaJ Depression over field (Y/@ 1'06 Date of adequacy test _ _ WI9019�- Results (Isbs/Fail) ASS For F0CAR, bedrooms �;1 eFluid depth in absorption field before test (in. - D Immediate) after gal. water added (in.): as Fluid depth 16 (ins) Minutes later: NO Absorption rate = 600 t g p d Peroxide treatment (past 12 months) (Y/GI) N13T LrKs`� If yes, give date /_V%1 72-026 (Rev. 3/96)* ® _Au Wazcn R�� -r sySTi�w (Wgf<n OF TIM -NC 64 � MOP" " M &UP TµRu. M'(. D. LIFT STATION N/A- Date installed Manhole/Access (Y/N) High water alarm level at* _ Cycles tes *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer. /septic service line Size in gallons go f On adjacent lots On adjacent lots "Pump off" level at* /00 �4- Public sewer manhole/cleanout 014 c� �4- Lift station NIA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation C4 �� Property line Absorption field S "� Water main/service line l �� Surface. water/drainage /oU Wells on adjacent lots /yO f SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water /0 /oo�t .1 Building foundation /0 + Water main/service line Driveway, parking/vehicle storage area I a V - /,q !L Curtain drain i)oNF kr�wN Wells on adjacent lots W4- F ENGINEER'S CERTIFICATION 1 certify that I have de mined t r field inspections and review of Municipal reco �tt` �ms are in conforman w th A 9 'delines in effect on this date. �'u�"� * ? � y Si nature: A n •• • ••Na•e s• Engineers Name`-/ > c� y A0artt+ �s ' S. �w � R CE=7953,E Date / ! �!oLf-7;:7- HAA Pee; $ Date of Payment 11 %/al9 Receipt Number 32�� 72-026 (Rev. 3/96)* 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. # - -1•;� HAA# �� i -N) ��_S,2) � 1. GENERAL INFORMATION Complete legal description 40T¢ lac- 1414e- SuQp Location (site address or directions) Property owner -5-FE U C 37-0 /1 Z- Day phone 6 51 S'2 Mailingaddress Po, 60X 77'/:/r3 6467c'e- 95-72 Lending agency ^�4 2^�G`" Day phone Mailing address Agent 42C_1"AtXa, Aze - Day phone 614 4�2-1952 Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: y 3. TYPE OF WATER SUPPLY: Individual well l� 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 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 regulcVWr 0.nCpa t pg. the date of this inspection. 20210 Donalar St. Name of Firm 4wg* Alaska M Phone Address Engineer's signature 6. DHHS SIGNATURE �_ Approved for Disapproved. Conditional approval for Additional Comments ®r bedrooms. Date 'a, L /y7 L -�ta .�9q.Coe•rww.:c. ne�%yy �-. �.. nt1F�g�si�?� N+�,, bedrooms, with the following stipulations: Date izyr/ 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 orderto 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: �� ¢ �GcY�c� Parcel I.D. e6__6-,4 2`ZL- /xuG��ay A. WELL DATA Well type 04044'0- If A, B, or C, attach ADEC letter,, ADEC water system number Log present (Y/N) — Date completed LH_Z1Z990 Driller Total depth A90 Cased to � 11 Casing height Sanitary seal (Y/N) Wires properly protected (Y/N)_ �z FROM WELL LOG AT INSPECTION Date of test 19910 :m Static water level rn < z Well flowg.p.m. �o, �' g.p.m. IIS N < Pump level G1�/,r.�rv��J G�iyr,vr��.o✓ o m SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ( /,0 ; On adjacent lots '100 f-_ Absorption field on lot I 10 4- ; On adjacent lots ) (>0 -f- Public t Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform ^'-�3 Public sewer manhole/cleanout 14,� a a Petroleum tank 41...,z #Q o -r, %r f Nitrate 01 t!5' Other bacteria Date of sample: rzl3 14 7- B. B. SEPTIC/HOLDING TANK DATA 6) Collected by: �J►-�-� -J `� Date installed —/9 n -Tank size L Compartments - 2- f Cleanouts (Y/N) Foundation cleanout (Y/N) y Depression (Y/N) A/ High water alarm (Y/N) Alarm tested (Y/N) !;_A, ate of pumping &A Pumper �YsTLriI i sTfk�� z 1990, u5 is ar T cs w.P c �. , o wa &y 1 To s t T --SENARATIVN MST-CNCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 1 l b On adjacent lots I ©o +- Foundation 3© To property line 10-F- Absorption field °I 4 Water main/service line N Surface water/drainage I +-- 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Surface water Date installed �s���go Soil rating 1;529sF650- System type e Y Length Width 2 S Gravel thickness 7 r Total depth Total absorption area Depression over field (Y/N) Results (pass/fail) O 2-- Cleanouts present (Y/N) 1�z V' Date of adequacy test ii�t��9Z for EM Peroxide treatment (past 12 months) (Y/N) �J If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 1/0 t On adjacent lots I ©p f" Property line ZS'::t To building foundation To existing or abandoned system on lot On adjacent lots gwo 4,-J Cutbank Water main/service line Surface water t t> v 'r` Curtain drain 0,,J_ -S E. ENGINEER'S CERTIFICATION Driveway, parking/vehicle storage area So ' bedrooms Alo—� 1 certify that ! have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. David R. Dayton P -E. ," n 20210 Donalar St. �' Signature 67 r�"* .,. , Engineer's Name �" 17 / �% i°.ieawBeBo*aews�ees Date )R-cs�vij R. Dayton 0FESSI��P,.4' HAA Fee $ / 76, CTD Waiver Fee: $ Date of Payment l2 `"66 Z- Date of Payment Receipt Number Receipt Number 72-026 (Rev. 3/91) Back MOA 21