Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
HomeMy WebLinkAboutR & R BLK 3 LT 24'cx0- 331- VO
Mark Begich
Mayor
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www. mu ni.orq/onsite
(907) 343-7904
Pump Installation Log
Well Drilling Permit Number: SW
Parcel Identification Number: E(.O `331-10
Date of Issue:
Legal Description
IG^i'1\
f3 L2.
Property Owner Name & Address:
SY / lra',n /Yoli,,; o,)
1g333 Sfa1c4;/(
Pump Installation Date: 5^_ u (^ r 6
Pump Intake Depth Below Top of Well Casing:
Pump Manufacturer's Name: Rec J "ked.
Pump Model: 1.5-62.,1 %Si6
Pump Size )1 -hp
Pitless Adapter Burial Depth: . (0 feet
Pitless Adapter Manufacturer's Name:
Pitless Adapter Installer:
Well Disinfected Upon Completion? r Yes ❑ No
?a !'/Z
Method of Disinfection:
Comments:
G7d t� c c 2: vcne, A K
feet Zpr
Pump Installer Name: Coif C0-1-4
ANCHORAGE WELL & PUMP SERV.
330 EAST 76111 AVENUE
ANCHORAGE, AK 99518
PHONE: 907-243-0740
AWPS.COM
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Anchorage Page of 2.
Municipality 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
PID Number' 04033//0
Permit Number: sWg30401
Name:
ess/6- N. /4,4z_ r_ j-
Wastewater System: Ig New ❑ Upgrade
Addreaa:
/7// ? CG/20N4-Do
ABSORPTION FIELD
.Shone.,
EA6-Z.E 12.f Vf✓ /Z , k 99x77
No. of Bedrooms:
3
(-Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other
LEGAL DESCRIPTION
Soil Rating:
0. 6, GPD/Sq. Ft.
Total Depth from original grade:
7
Lot: Block: Subdivisiori:�
Z / 7 F /Z 5�/.)
Depth to pipe bottom from original grade:
/. SFt.
Gravel depth beneath pipe
S. 6 -Ft.
Township:
—.
.�
Range:
--
Section:
--
Fill added above original grade:
/ Ft.
Gravel length:
'7 S Ft.
WELL:
New ❑Upgrade
Gravel width:
3 Ft
Number of lines:
/
Distance between lines:
— Ft.
Classification (Private, A,B,C):
&
Total Depth:
Z2O Ft.
Cased To:
(fl? r Ft.
Total absorption area:
72$ SQ. Ft.
Pipe material: FP'o PELF
AsrAs P2°39 P.Y.c.
j2/VAi
Driller:
I/e�
S"v4`(v/4) WA%t�
Date Dried:
y 9N
Static Water Level:
z- FL
Installer:
l/714,1/swill CONST •
Date installed:
'l - f - 9 `i
Yield:
3 GPM
yy��ELLS
Pump Set at:
UK -JJ Ft.
Casing Height Above Ground:
2- Ft.
TANK
SEPARATION DISTANCES
-Septic ❑ Holding ❑ S.T.E.P.
To
From
Septic
Tank
Absorption
Field
Litt
Station
Holding
Tank
Public/Private
Sewer Lines
Manufacturer:
A,uc,1O ,o -E TAN 1e-
Capacity in gallons:
/000
Material:
Number of Compartments:
Welt'
/22'
/2St
25
5 -re cz-
2-
Surfac
'i-
'
LIFT STATION
Water
/00
/00 I--
LotSize
,
•: •.s:
Manufacturer:
Line
/0 '+
/O i-
"Pump on" level at:
"Pump off' lev: ..
High water alarm at:
Foundation
-7'
2.31
-
Pump Make & Model
Electrical Inspections performed by:
Curtain
NO/tie
f«p
W /J
Drain
Remarks:
BENCH MARK
Location and Description:
TOP Of /'vU'vaA'Tip.0 FOOT//U6- @ (VORTN
-S-/.DE Or' Nor/So.
Assumed Elevation:
J /00.00
ENGINEER'S SEAL
^a to 'ycl i4
r3�_
43
'z r r l 3 J
17034 Eagle River Loop Road, No. 204
River,Alaska 99577 Dates: 1st s"7(-99
; u .^'•( „ t.
"' n o."s a 0 4i
Inspections performed by: Eagle
2nd r, -/-9ii
., r
'•-..�_,s.�,,•�n-t
Department of Health and Human Services approval
Mg /�� C`�- Date: 9'26 ' 9'/
` 3.rt A. $1104u -
•
,.
r iJ., ,J
Reviewed and approved by:
��l a, C.•p
79-n19 IRay. 9/911 MOA 25
Permit No. SW930401 Page 2 of
2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
R & R SUBDIVISION, BLOCK 3, LOT 3 06033110
Legal Description: PID No.:
CO1 CO2
r 97.6'
6
NEW
1000 GAL
SEPTIC
TANK
A
B
FCO
CO1
CO2
CO3
C04
MT
24.0
25.0
29.0
39.0
54.0
50.0
29.0
31.5
37.0
39.0
101.0
98.0
FINAL GRADE
92.5'
♦ 80.5' NO WA'T'ER FOUND
NEW 1000 GAL.
SEPTIC TANK
SCALE C' = 40'
NEW TRENCH
72-013 A (1/93)'
0 b. 2 7. 94 0' ri1V1 :I.4_yE!4 S C0 AK 9J 7 2 rjt4 5 2 5 F'
From : R A VRANCKRERT SAND POINT
PHOE No, 94.173E1:5SS65 Jun, 24 1994 1:52A11 fol
,Jq 3 0401 10,
(1,1ertifid Ortilitto
by
DOC Ca, am
SULLIVAN WATER WELLS
C.h. B4>t trtJ . 0111/r81t,14, ALAKKA OW/ i 'rl:l.tr 1vaNN EL6wn
OWNER O11 LAND I....
DEPTH OF WI: LL, �..a 1-f
STA1'It' I.FVI I t!!' WAnk 1 I .
r C
LEGAL DESCRIPTION �W • ar4� ._�L�LL}�1, ._ DRAW )014'NET,
DATE •Eterta _._._.. - Fngtltf . l''''/61 c L$ 1'c€ Hit e,i
PERMIT NUMBER ..., _. ___ ..... .........« t..,.d.,,a..i.„,... „ KIN!) (11 CAIN( . ,,.trl1:...k.C. ..
KIND OF FORMATION: -
Frorn. -Et In ..,.Ft. :! a/4.0„4-..._ _.(..rc.r', li.._
From a
From_
Et to
1't, Ft --
1°-
1°- e, I.
� r
FL if) b! _1_- rt i_� ! �' bfl . �_ � i� �c.iF{it Iri �._. n. lrt�.. ._ , rt.
From. Ft loR1 Ft. _ %�✓�?t�:rsC� _ css;t.- I torr rt. to
-Front .._4.- Ft. to-1�� __}t _/:, 1&'_.G.A- 6K,c c1,1_. 11.,/ 4', ),6..er4-
fltrom ./,;‘)S1.- pt to 1 7 '' Ft. 6i k .c,'..k.tw.i`=.....4.g.r. _ (1. 4 ($4,1_____ _ i ( u, t t .. .
Prom./..7___Ft, lu,J 1.,i .Pr.__A.4i tlig,'>Cr/._..„6_,t+ai'i">) FrOl,i ft 10 .....ry....b'E.__
rronifl ..Fr.li,2,1 Ft. ,c,..�C�eZL1��, .-ri.WJ- i Firdo----._.___Ft 1.,.„ .... .._....F .-. R� �
Ft
,..06b_
<:%� r 0
Ytutn Ft. to. -�i?V_ r?hi-._37"-&1..),--Irom......w.,...-FI,:c....-.---F1.-- =W.___ ,; --k: tr-___.....
Front ..Z_,)41. Ft i rt „g.k._1,,J.. .__..... Pram, ..._ k E tv_ . tt. I-1 _. .....': cTS.....-_.,...._•
(,1 <2 _:.G
IFraa+ FY. to rt.-_. return._..-----_ Fi. ti . ,.,. ,.,iit. id- t--_-- __,) i
1 a.." ":`r
From Pr to Ft - Prom_ .____.rr,ra..- ...Ft... ..._.
f't
to
- {h
--ro
ai 0
Froln.---- --FI. 1110 41,-.• Vt• x...
From -- - - IPL Io _ _-Ft. _
From t"t to _
!Fran® _Pi tc�.�_. ,.Ft. _._. W_
From ___._-Pr
M1SCL. INFORMATION;
4$,�E�
�ra�11'!a/ J/141444 lei
Frum_a_ _._rt.th...��,.
FNMA __.... _Ft . ro
From,-_ I t. t 4 ' l t..
141
744
ra
rit c:--Ja•�r,
PAGE 1 OF 1
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
DATE ISSUED: 9/29/93
EXPIRATION DATE: 9/29/94
PERMIT NUMBER:SW930401
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:HALL JESSIE H JR
OWNER ADDRESS:17118 CORONADO
EAGLE RIVER, ALASKA 99577
PARCEL ID:06033110
LEGAL DESCRIPTION: R & R BLK 3 LT 2
LOT SIZE: 46405 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY: �t
DATE: 7/2<? /9.7
,1 _6 C
DATE: C:_.
HEALTH AUTHORITY
APPROVALS
SEWER 8 WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
September 25, 1993
unicipality of Anchorage
EPARTMENT OF HEALTH AND HUMAN SERVICES
25 'L' Street
.0. Box 196650
nchorage, Alaska 99519-6650
EFERENCE: R & R Subdivision, Block 3, Lot 2
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
equest you issue a permit to drill a well and install a
septic system to serve the proposed three bedroom house on
the referenced property.
Test holes were excavated and percolation tests performed.
The approximate location of the test holes are located on the
attached site plan. The monitoring tubes within the test
holes have been checked and found to be dry.
This property has enough area for a future septic upgrade
which can be seen on the attached site plan. We do not
anticipate any adverse effects on neighboring properties by
the installation of the proposed septic system.
If you have any questions, or require additional information
for your review, please contact us.
Sincerely,
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
A. Shafer, P.E.
S/LSU/lsu
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
LL
O
1-
4 N
=y �
d
c U
w
J
w
J
z
0
oM >U(n2
U Q et
Lu
Ld0n=www
CK H CC Z_
O Z?,. Z LO 0-I OH
Z
N J w r(Y H 0 0
H O J w Ld w Q
LLJ w> CO I- p 0 Q Q
H w In — Z U
PNCC 0ZwaSOX
Qcn ZOW _JLi.-.
wzvi 5NNZ — Ld
0 J W� w Q O 1Y J Q I—
Li
O m w)- w U O D O Q
D 1 I U r Q Z H
U (n wZ /— -
cn>au) '- Qom 0
z
F — O O
I 0 U
0
w
Ln
0
H
d
S i ONEHILL ROAD
Oo O
v (J < 00a -
z0 Q
H
LL_ p2
V_
0
H O 0 0
Cl -0
OM U � C
Loh- Z w\
II0II W
'--4- (4UO
I I CO E-, W uj Z
0
a✓ 00 m _J Q w J
F4 MV) CMN
al
0
Z
0,
-~�
1000 GAL SEPTIC TANK
Z9 t
J
S
0
0
U
a j
4
'Nb
' b
jo&
31VJS
NVld 31IS
017
Page Two
R & R Subdivision, Block 3, Lot 2
September 25, 1993
5. A foundation cleanout shall be installed one to four feet
from the building foundation. In the line between the
tank and the leachfield there shall be two adjacent
cleanouts (unless an effluent pumping system exists
within the septic tank). These cleanouts shall be
located on undisturbed soil not more than 10 ft. from the
tank. The first cleanout, in line, shall be to clean
toward the leachfield. The second cleanout shall be to
clean toward the septic tank.
6. Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
1. Excavate the proposed trench to the dimensions shown on
the design. The bottom of the excavation shall be within
2 inches of level. If the sidewalls of the excavation
become smeared, they must be raked or scratched (ruffed -
up) before gravel (sewer rock) placement.
2. Once the gravel is installed, the distribution pipe is to
be installed level with the perforations faced downward.
Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
3. A silt barrier must be installed between the final gravel
layer and the native soil backfill. Ensure the silt
barrier covers the entire gravel surface before placing
backfill.
4. Monitor tubes shall be of four (4) inch diameter and
installed approximately in the locations shown on the
design. The portion of the monitoring tube extending
through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This
is equivalent to the effective depth of the gravel as
noted on the design.
5. Backfill over the final gravel layer must not be less
than twenty-four (24) inches. Insulation must be
installed when the backfill depth is less than thirty-six
(36) inches. The finish grade over the trench must be
mounded to prevent the formation of a depression after
settling.
Page Three
R & R Subdivision, Block 3, Lot 2
September 25, 1993
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
2. The following pipe materials are approved for use in
septic system installations in the Municipality of
Anchorage:
Type of Pipe Perforated Solid
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F810 (HDPE) Yes No
ASTM D2662 (ABS) Yes Yes
Use of a type of pipe other than listed above must be
approved by the inspecting engineer.
3. Insulation shall be at least 2" thick extruded direct
burial polystyrene (Dow Chemical Company Styrofoam HI or
equal).
4. Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mirafi
140N, or equal) must be installed between the final
leachfield gravel layer and the native soil backfill.
6. All leachfield gravel (sewer rock) shall be 0.5"-2.5"
screened gravel with less than 3% passing the #200 sieve.
7. When sand is being used as a filter material, it's
gradation specifications must conform to current M.O.A.
or D.E.C. requirements.
Page Four
R & R Subdivision, Block 3, Lot 2
September 25, 1993
INSPECTIONS:
Typically there will be a minimum of three (3) inspections
required during the installation of the wastewater disposal
system. These inspections will occur as follows:
1. The first inspection must be conducted after the
excavation of ditches, pits, trenches, or beds and
before the installation of any gravel. A septic
tank may be set in place, but may not be backfilled
before this inspection.
2. The second inspection must be conducted after the
placement of the silt barrier, gravel, distribution
lines, standpipes, cleanouts, and insulation, but
before the placement of any other backfill.
3. The final inspection is to occur upon final grading
of the property.
Often there will be more than these 3 inspections required.
Especially with the installation of multiple trenches, sand
filters, pressurized distribution systems, etc. Thus, the
inspecting engineer is to be contacted at least 24 hours prior
to the start of construction. If necessary, a pre -
construction meeting will take place on-site.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: SSI 4pt/_(__
LEGAL DESCRIPTION: La`1 IJ� g- 4 I`
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
r.
Jab
The
lit
ai
s
NNW
at
S�)
Township, Range, Section:
bRC,
6411
COMMENTS (.lsi- 9 / Pp 125NCi"I
SLOPE
WAS GROUND WATER
ENCOUp/'t"ERED?
IF YES, AT WHAT
DEPTH?
Depth to Water Allern
Monitoring? YfL
AID
S
L
0
P
E
Dale. 61/2-41",
SITE
/2 -
SITE PLAN
Reading
l
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
9'p0
—
y),1i"
—
•.10
10 Ag,,,,
S%-
sc�, ,,
:ao
,I
6 y
vs,,
:3�6)y
4
S/g"
Yo
l .
7 348
5/8"
PERCOLATION RATE
6
/�(m(minutes/inch) PERC HOLE DIAMETER "
TEST RUN BETWEEN ti -S P 5`-5 FT
w/ 1 EF -H RJ
S ENGINEERING
PERFORMEgAf$
Oe ®,
TU FGGC-0k)
CERTIFY THAT THIS TEST WAS PERFORMED IN
�
ACCORDANLEWtlt PHd�Lhc MaAlEaA9SZt!°1NICIPAL GUIDELINE- EFF' CT ON THIS DATE. DATE
72-008 (Rev. 4,85)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG - PERCOLATION TEST
PERFORMED FORS\•=4551.E.—
Ru.-,
LEGAL DESCRIPTION:
3
4 -
12
P
FIE T
D
19-
20 -
COMMENTS
(ENGJNEERS SEAL);
DATE PERFORMED:
Township, Range, Section:
O2G
3.(,4,
SLOPE
WAS GROUND WATER 1 ,,
ENCOUNTERED? �_
IF YES, AT WHAT
DEPTH?
S
L
0
P
E
Depthto Water Alter
Montt/ (
Monitoring? gale• T�
PLAN
Li
`E
Reading
Date
Ifo
1
Gross
Time
Net
Time
I__
Depth to
Water
Net
Drop
PERCOLATION RATE
TEST RUN BETWEEN
(minutes inch) PERC HOLE DIAMETER
AND SFT
S & 5 ENGINE
PERFORMED BY170034 Eagle RiveraLoopj1zoad nr nAA 1 CERTIFY THAT THIS TEST WAS PERFORMED IN
E9577
ACCORDANCE WIa7Hl ALL SRiveTATE ANBD MUNICIPAL GUIDELINES IN EFF CT ON THIS DATE. DATE
72-008 (Rev. 4185)
0 E- E GEM .CHNICAL a DEVEL.. E NI CO.
Russell Oyster
694-27740%L L6N r Earl Ellis
Soils & Foundations �' 0 688-2280
Land Development
Box 90, Davis St., Eagle River, Alaska 99577 ��
694-2774 or 688-2280
Performed for: Name: Mr. Donald Combs Tel, Noo 694-..9389
Mailing Address: Star Route Box 9-239 Eagle River, Ak. 99577
Legal Description: Lot 2 of Block 3 of R & R SubdivisionDgEklattl_
AArtOeristi_C$
0
1 ML - Silt topsoil with roots and organics. 275 sq. ft./Br.
2
5
6
8
10
GP -GM - Silty Sandy Gravel with cobbles and boulders to 24
inches. Material very loose. 165 sq. ft./Br.
PERCOLATION DATA
Net Time Net Dro
10 1 1 8" PERCOLATION RATE
20 1"
30 1" 10 Minutes/inch
40 1"
11_ 50 1"
60 1.11=165 sq. ft./Br.
16
3ottom of pit
Ground Water Encountered: Yfl
Proposed Installation: SeemP t_
Comments:
Pdij...,_)cX_._... If yes s what depth
—__
proin Field xx
Performed by: Date: 25 July 1976
MUNICIPALITY OF ANCHORAGE
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. 060 331 10
1. GENERAL INFORMATION
Complete legal description R&R Block 3 Lot 2
Location (site address) 19333 Stonehill
Current property owner(s) Nouvion
Mailing address
Real estate agent
2. TYPE OF DWELLING:
F-1 Single Family (w/ADU)
F-1 Duplex
R Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Expiration Date:. I -,' ' '2 q -2-6 ZZ
Day phone
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
El
Private Septic
El
Water Storage
11
Holding Tank
F-1
Community Well
El
Community
F1
Public Water System
El
Public Sewer
1-1
Waiver request for: NONE Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee$
Date of Payment_ 1011q1z I
Receipt Number n?Z2q I JD
COSA # 0.5c,2-1 1
Waiver Fee $
Date of Payment
Receipt Number
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 C&M ENGINEERING Phone 8545558
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI Date 10/18/21
OF A� -kk
,low
49 TH
6. DSD SIGNATURE ... .. . ... ......
�0_
System #1 Approved for bedrooms .. ...... .. jl!
t;HARLES G BALZARINI �o
. ',,- " W
System #2 Approved for bedrooms 67
CE -13854
Disapproved
Conditional approval for bedrooms, with the following stipulations:
WAST!1_-_-VVATER Z_
FJHU(3KAM
J. SFN N'\
By: Original Certificate Date:
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 SahC A�,
COSA Checklist blue sheet
��M ��
Legal Description: R&R BLOCK 3 LOT 2
If more than 1 septic system on lot: COSA Checklist # 1 of 1
A. WELL DATA
FEI Well log is filed with Onsite (or attached)
Date drilled 4/94
Total depth 220 ft
Cased to 68.4 ft
RE Sanitary seal is functioning correctly
RM Wires are properly protected
Casing height (above ground) +12 in.
Date of flow test for COSA 10/17121
Static water level at beginning of test 80 ft.
Comments
B. TANK DATA
Age of tank(s) 27 years
Tank type/materia I SEPTIC STEEL
Measured operating fluid level in septic tank 49
01 Standpipes/foundation cleanout per record drawing
Date of pumping 10/19/21
D. ABSORPTION FIELD DATA Trench
Which system tested (date installed) 1994
F01 ALL standpipes present per record drawing
Total measured depth from grade 7.9 ft (max)
Measured depth to pipe invert from grade 3,5 ft (min)
F-1 N/A — pressurized field
F] Monitor tubes go to bottom of effective. If not, state
depth into effective 4.4'
N Code -required soil cover over field
El System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
Parcel ID: 060 331 10
Structure served by this system 1
Well production at time of test 3 gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? El Yes MR No
FE1 Coliform bacteria is Negative
Nitrate 1.32 mg/L El Nitrate less than MRL (ND)
Arsenic_ ug/L MR Arsenic less than MRL (ND)
Collected by C.Balzarini
Date of Sample 10/17/21
C. LIFT STATION
El Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 10/17/21
Results 91 Pass For 3 bedrooms
Fluid depth prior to test 3 in
Water added 450 gal
New depth 0 in
Elapsed time 0 min
Final fluid depth 0 in
Absorption rate 450 gpd
Any rejuvenation treatment (past 12 months) NA
If yes, enter date NA
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'
Lj�j
Yes
Community Sewer Manhole/Cleanout > 100'
ry7( Yes
if No
ft
M Yes
if No ft
Neighboring Tank > 100' [Z] Yes
if No
ft
Private Sewer/Septic Line > 25' 177� Yes
if No ft
Absorption Field on Lot > 100' El Yes
if No
ft
Holding Tank > 100' 0 Yes
if No ft
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' 0 Yes
if No ft
F/1 Yes
if No
ft
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' F71 Yes
if No
ft
n,/ Yes
if No ft
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 ft
I
Property Line > 5
Lj�j
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
Yes
if No
ft
Private Wells > 100' F71 Yes if No ft
Water Main > 10'
Yes
if No
ft
Community Wells > 200' n,/ Yes if No ft
Water Service Line > 10'
F71
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'
F71
Yes
if No
ft
Community Wells > 200' Yes if No ft
Surface Water> 100'
E]
Yes
if No
ft
F. ENGINEER'S COMMENTS
TANK IS OLDER BUT LEVELS NORMAL. RECOMMEND PRO -ACTIVE.
REPLACEMENT IN THE FUTURE. ALL SEPTIC PIPES VERIFIED DURING CONSTRUCTION.
NO DECK SUPPORTS WITHIN 5'OF SEPTIC TANK
G. ENGINEER'S CERTIFICATION
i certify that / 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. 10/28/21
COSA Checklist yellow sheet
k
49 TH
... .. .. .. .......
;0,
... ....... —
C ARLE G BALZARINI ;t'
%,w
CE -13854 . - *�', ,
Ar
z
e2o
PROFEW
Septic Tank Advisory
Certificate of On -Site Systems Approval #OSC 211629
Subdivision: R&R Block 3 lot 2
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this property is 27 years old. Typical replacement costs range from $9,000 to $12,OGO
This advisory must be attached to all copies of the subject Certificate of On -Site Systems
Approval.
This is an example of what the metal of a 20 -year-old steel tank MAY look like.
de,
Municipality of Anchorag
On -Site Water & Wastewater Program
(907) 343-7904
0/ 6 8
CERTIFICATE OF ON-SITE SYSTEMS APPRO L
Parcel I.D. 060-331-10
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Real Estate Agent
R&R; BLOCK 3, LOT 2
19333 STONEHILL DR.
Expiration Date: 5
f C,
DON & ETHANN OLDHAM
1933.3 STONFHII J DR.
RANEY HARDMAN
Day phone 242-0337
2. TYPE OF DWELLING:
• Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
W aiverNariance request for:
N/A
3
Day phone 440-7257
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
❑ Individual Holding tank
❑ Community On-site
❑ Public Sewer
•
Distance: —
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date: 2/3�1lQ
COSA Fee $ S-010
Date of Payment 1 %l&
Receipt Number 619.- S(1,
COSA # 05GI 6 ! o l g
Waiver Fee $
Date of Payment
Receipt Number
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 GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 *ANCHORAGE, AK, 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the
guidelines and regulations established by (he Municipality of Anchorage and industry practices. The reported results describe the
condition of the system's on the dates of the evaluation. Separation distances were measured to readily identifiable features.
Hidden defects or encroachments may exist that were not identified during the evaluation.The operational life of all wells and septic
systems depend on a variety of variables including, but not limited to, soil conditions, groundwater levels ((hat may fluctuate during
the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system's. These
conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the
system's; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system.
GEG makes no representation whether an alternative well or septic system can be installed on (he properly in the event either of the
current systems fail. The content of this report is for the sole benefit of the person/party who retained GEG. Reliance upon the
information provided in this report by any other person or party, including but not limited to subsequent property purchasers, is not
authorized. In short, GEG disavows any legal duty to anyone other than the person/pady who paid for this report.
6. DSD SIGNATURE
System #1 Approved for 3 bedrooms.
System #2 Approved for
Disapproved.
Conditional approval for
bedrooms.
Date 11 2 J r'6
bedrooms, with the following stipulations:
\\( OF�;�
ON-SITt m
WAND
v+tAS1 t=vATER R
PROGRAM
By:
Original Certificate Date: 3 _1 Cr
The Municipality or Anchorage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenatations 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. ATTCHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
(Rev. 10112/12)
Nitrate Advisory
Arsenic 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:
A. WELL DATA
Well type PRIVATE
R&R; BLOCK 3, LOT 2
Parcel ID: 060-331-10
If A, B, or C provide PWSID# N/A Well Log (Y/N) YES
Date completed 4/1994 Sanitary seal (Y/N) YES Wires properly protected (YIN) YES
Total depth 220 ft: Cased to 68.4 ft. Casing height (above ground) 12+ in
FROM WELL LOG AT INSPECTION
Date of test 4/1994 1/20/2016
Static water level 72 ft. 72.9 ft.
Well production 3 g.p.m. 2.5+ g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate " mg.IL. Collected by: GEG. Ltd.
Arsenic: N 0 ug./L. Date of sample: 1/20/2016
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size 1000 gal.
SEPTIC/STEEL
Number of Compartments 2
Foundation cleanout (Y/N) YES
Date of pumping !%Z I % to 16
C. ABSORPTION FIELD DATA
Depression over tank (0N) NO
Pumper
JR'S PUMPING
Date installed 5/31/94-7/1/94
Cleanouts (Y/N) YES
High water alarm (Y/N)
N/A
*BELOW EXISTING GRADE
Date installed 5/31/94-6/1/94 Soil rating orft2/bdrm) 0.6 System type DEEP TRENCH
Length 75 ft.
Width 3 ft. Gravel below pipe 5.5 ft.
Total depth *8+ ft. Eff. absorption area 825 ft2 Monitoring tube **YES Depression over field NO
Date of adequacy test 1/20/2016 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 610 gal. New depth E in.
Elapsed Time: 3 min. Final fluid depth E in. Absorption rate >= `' .450+ - g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE If yes, give date
**MT ONLY EXTENDS 4.84' INTO EFFECTIVE
D. LIFT STATION
Date installed Size in gallons
"Pump on" level at in. "Pump off' level
Datu Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
100'+
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
100'+
75'+
25'+
Animal containment areas 50'+
Manhole/Access (YIN
High water alarm level at in.
Meets alarm & circuit requirements?
On adjacent lots
100'+
On adjacent lots 100'+
Public sewer manhole/cleanout 100'+
Holding tank 75'+
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+
Water main
Property line
5'+ Absorption field 5'(ASSUMED)
10'+ ( Water service line 10'+
Wells on adjacent lots
100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+
Water service line 10'+ Surface water 100'+
Curtain drain NONE KNOWN
F. COMMENTS
Surface water 100'+
Building foundation 10'+ Water main 10'+
Driveway, parking/vehicle storage 10'+
Wells on adjacent lots 100'+
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Pr nted Name
Date l Zcj,I(o
(Rev. 11105)
JEFFREY A. GARNESS
b
a
VA
y A. Garness.
CEr 79 m0
-ft (ovefe
fp,-of ession:\
v
�Opoo�a
Block 2
Lot 1
12.0.x12.01
SEPTIC PIPE
DECK
SEPTIC PIPES
ROW -CANT -- -
9.7'
Tract 2
46,405 s.f.
10.0'x10.0'
21.8'x23.3'
.0'x30.3'
BALCONY
10' UTILITY
EASEMENT
PLOT PLAN
S 89'56'30W 309.41'
—ate— —ore—arc—arc— Ott —aA—ate— EVE — EVE -..-
STONEHILL DRIVE
A5 BUILT X SCALE 1' = 60' ORID SW 255 Protect No 15-351/A1
Lang & Associates, Inc. 11500 Daryl Avenue, Anchorage, Alaska 99515-3049.
(907) 522-6476 Phone gyp© %
Registered Land Surveyors (907) 522-4625 Fax
OFq
kenOlangaurvey.oam / JonathanOlangeurvey.aom �,�,.•••
1 hereby certify that I have surveyed the following described property: p+`;'
LOT 2, BLOCK 3, R&R SUBDIVISION (PLAT 76-246) P / 49
Anchorage Recording District, Alaska, and that the Improvements situated thereon a
within the property lines and do not encroach onto the property adjacent thereto, th
no improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission lines or other visible
easements on said property except as Indicated hereon.
Dated this the i tell Day of ihacnanPnbr-
at Anchorage, Alaska
It Is the responsibility of the owner to determine the existence of any easements,
covenantee. or restrictions which do not annenr nn the recorded subdivision Dint.
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
i-CEIVLV
I1.1N 0c 1999
..tNk_trkuir ur ANCHORAGE
N IRUNAALN1AL SERVICES DIVISION
i/tc.E,.,Ce ,p
rig
Parcel I D # 060-331-10 HAA #
1. GENERAL INFORMATION
Complete legal description Lot 2, Block 3, R & R Subdivision
Location (site address or directions) NHN Stonehall Road
Property owner Marjorie Hall Day phone 694-8817
Mailing address
PO Box 773244, Eagle River, Ak 99577
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3 -
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
XXX
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
xxx
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 1121
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 S & S ENGINEERING Phone `i — 67
17034 Eaale River Loop !load No. 2'4
Address EaaJe River, Alaska 99577
Engineer's signature17..-
6. DHHS SIGNATURE
v Approved for l /-/PES bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
/ /c1 1
Date
Additional Comments
By:
Date (7 - ( �
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA x21
JUN 0 1999
Municipality of Anchorage rvrUNIUPALI1Y OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN sa\ackgallAi SERVICES DIVISIO
Environmental Services Division
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: Ln'\ --6 n'Z Y-. 3 r.4 e Ie Parcel I.D.: btpc, (t
A. WELL DATA
Well type Pe -01 A --CE- If A, B, or C, attach ADEC letter. ADEC water system number
Log present/N) '/ Date completed 14"1 ql r rr rr %
Total depth � Cased to 6 k Casing height (above ground) /d
Sanitary sealON) `/ Wires properly protected 6N) y
FROM WELL LOG AT INSPECTION
Date of test -61,'f ri ,2 1 1
Static water level 12.i 7 yl
Well production 5,o g.p.m. LI • Z g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 Nitrate I L G`' 1L Other bacteria
Date of sample: •- 2 3 -91
Collected by:
O
B. SEPTIC/HOLDING TANK DATA
Date installed /-I 4 Tank size 1 ✓0 U Number of Compartments 2 Cleanouts jN) l/
Foundation cleanout ON) \f Depression (Y/60 High water alarm (Y/N) `,Ifr
Date of Pumping 6-19 Pumper V _ . eUM.P I rs -i
C. ABSORPTION FIELD DATA
Date installed 7 -1 -1 Soil rating (g.p.d./ft2 or ft2/bdrm) b, to System type 72(vrJc.4-(
Length 75 ' Width 3 / Gravel thickness below pipe S, 5.-- Total depth 2''SY
Effective absorption area �°�� Monitoring Tube present10VN) Depression over field (Y,b) 'N-)
Date of adequacy test 5-'13 .-5 cl Resul •.Fail) f/V3 For 3 bedrooms
Fluid depth in absorption field before test (in.); O u Immediately afterGg/ gal. water added (in.):
Fluid depth 6 (ins) Minutes later: U Absorption rate = 4/6-0 9•p d•
Peroxide treatment (past 12 months) (Yg /)udr` (--A'° Ai If yes, give date ij/"}
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N) "Pump on" level at* _ imp o evel at*
High water alarm level . * *Datum
s tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holdingSeptic/holding tank on lot
tZZ On adjacent lots lav;k
Absorption field on lot \ ?2'> On adjacent lots
Public sewer main Public sewer manhole/cleanout
Inv r. --
Sewer /septic
�� Lift station
SEPARATION Ui ;i'.;. L FROM S� EnG/HOLDING TANK ON LOT TO:
Foundation
— l
Property line
I0r�
Water main/servic line ?n `-fr Surface water/drainage PPO 1
,r
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
4-
Property line Building foundation 3
Absorption field
Wells on adjacent lots /moo 14.
Water main/service line
/r .f
U
Surface water / Driveway, parking/vehicle storage area Sb
Curtain drain r /x Wells on adjacent lots /00 ( F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal
in conformance with MO I H4�,guidelines in effect on this date.
Signature
Engineer's Name
I 403 t-tr C, 0) 4/�
Date 40 a �)
records 4t% fiku
�urV�iy
a.'
10
T • ROBERT.C..COWAN r o;
o
• CE - 8801 /' >-
s are
V .e,
HAA Fee $ 3 t7f7 (-)0
Date of Payment bu 1
Receipt Number CI" 9 o 9 C
72-026 (Rev. 3/96)*
�vcy
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. # OGo _' 3 I - J0
1. GENERAL INFORMATION
HAA # \A cc'1 to \��
Complete legal description Lot 2; Block 3; R & R Subdivision
Location (site address or directions) NHN Stonehill Rd.
Eagle River, AK
Property owner Jessie and Marjorie Hall Day phone 696-8646
Mailing address P.O. Box 773244 Eagle River, AK 99577
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well XXX
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
XXX
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev ' 91 ( = r. MC.: X21
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.
S & S ENGINEERING
Name of Firm 17034 Eagle River Lnop Rnad kin 404 Phone C % - `% 7 `%
Address Eagle Riivve�err, Alaska 99577
Engineer's signature 7/7
6. DHHS SIGNATURE
X Approved for 3 bedrooms.
Date �S 9 E
•'')t'1-7 io
vi •t ROBERT C. COWAN r •��
r • ; Cc „
•8o1 '�-p+�`
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
By A/,P
Date 1 - 25—
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. 1/91j Bacx MCA 421
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: /---07' Z /3(.4e 3 R 40
%O
Parcel I.D.: -0/".5.33 /to r o m G,
ew Cid �L -2
A. WELL DATA ®®�*s(•
I N
Well type pg.,../.r If A, B, or C, attach ADEC letter. ADEC water system number JE A '411o G
Log present ON) y Date completed 1/- 5 `i
,n -F
Total depth a' o / Cased to be ' S y Casing height (above ground) /Z
Sanitary seal N) .s./ Wires properly protected ai=/N)
FROM WELL LOG AT INSPECTION
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
7 2'
3,D
PoT-
1,V-;o csP.-
g.p.m. / g.p.m.
Coliform
0 Nitrate j.1\ Other bacteria D
Date of sample:
1-/-61 /1/-22 -n Collected by:
B. SEPTIC/HOLDING TANK DATA
S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Date installed 7 --1 -' I Tank size lex O Number of Compartments 2— Cleanouts
Foundation cleanout 1 'N) Depression (Y® ,S High water alarm (YIN)
Date of Pumping t .- -1...W t2 -Pumper
C. ABSORPTION FIELD DATAr
Date installed 1- 1-� `I Soil rating (g.p.d./ft2 or ft'/bdrm) t' System type
vl
DN)y
Length 73— Width 3 Gravel thickness below pipe SS Total depth
Effective absorption arca 9225 Monitoring Tube presenlaiN) / Depression over field (Yap
.(6 t y,[- PP -r -
Date of adequacy test AIM "3 r° ash Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before test (in.); - Inunediately after —gal. water added (in.):
Fluid depth ms.) Minutes later: Absorption rate = — /g.p.d•
Peroxide treatment (past 12 months) (Y/N) J�-/ If ycs, give date
,//.4.
/ 4
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
sled
Size in gallons
„Pump on" lev
E. SEPARATION DISTANCES
*Datum
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Se tic bolding tank on lot
Absorption field on lot
Public sewer main
/22
las t
/J/A,
Sewer /septic service line
; On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
1c>0 /'4
/op i4"
SEPARATION DISTANCES FROM(SEPTIC7HOLDING TANK ON LOT TO:
Building foundation
7'
Water main/service line
Property line 119 / Absorption field
/o (4- Surface water/drainage
14- Wells on adjacent lots /oa /
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation
023' Water main/service line
Surface water /06 / -{-
/ 0 „`"
Driveway, parking/vehicle storage arca
Curtain drain de,14 I ' J0 h1 wt Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
So �'L
/0041' Property line /o
1 certify that 1 have determined thru field inspections and review of Municipal r
in conformance with A, )A 1M -1A guidejines in effect on this date.
Signature
Engineer's Name let}. “2 T C
Date
ecords thag \
`4P
HAA Fcc $
Date of Payment
Receipt Number
Rev. 8/95 OSS: haa.wk.doc
360 'd
L -
Waiver Fee $
Date of Payment
Receipt Number