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HomeMy WebLinkAboutHIGHLAND HILLS #1 BLK 1 LT 5Hi'mghlcind Hills Block 1 Lot 5 #050-382-26 MUNICIPALITY OF ANCHORAGE \ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION I>> ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME �-�, I PHONEoe-NEW 1CG�A�.�'�- �� ❑UPGRADE MAILING AD DRESS LEGAL DESCRIPrrION � � LJ � 7 f �I fes" ✓ r' ! � LOCATION NO. OF ROOMS/ Well Absorq 'oryarea Dwell' DISTANCE TO: / � - f /2 PE MIT N MW c) y - -y � i' F Z Manufacturer � r66`t'pi'1 yJ C- No. of compartments Liq.FapaicityIlons IF HOMEMADE: Inside length Width Liquid depth z DISTANCE TO: Well Dwelling - PERMIT NO. 02 N Manufacturer Material Liquid capacity in gallons $1-•j DISTANCE TO: ,�) Weye' 0 • f- Foundati Nearest Ipyline �� "Distance Z No. of lines Lengt f e c'r(Ine Tota le i�. li fes Trench idth f; vLee lines �" b I- _�1.) Top of tile to fi i h grade inches Materia beneath theLU // /'}- Total eft -�bsor io ryareea inches 5 d � �L Length Width Depth ��'=� PERMIT NO. t9 t- 0. Type of crib Crib diameter �rde Total effective absorption area IL w (n DISTANCE TO: Well Building foundation Nearest lot line _j LU ClassDepth Dr'!"r Distance to lot line PERMIT NO. � DISTANCE TO: Building foVIndation Sewer line Septic tank Absorption area(s) OTHER 'I. PIPE MATERIALS V C' Lo ® C. SOIL TEST RATI G % INSTA R REMARKS K9 ♦f K -9 6 �A •. rd •T . ff h. p Rwl>fr1eA. '%Wiar• r _ fi�`t',A a Y"� �(e •rte APPROVED DATE LEGALPZK,nZ1% f 11 i g kill. PERMIT NO: DATE ISSUED: APPLICANT: ADDRESS: CONTACT PHONE: �����I IF::,,, IL-, :1 �IFI­I, DEPHRTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION / '/��\ 825 L STREET� ANCHORAGE, AK 99501 \ \ 264-4720 IE30"'q^�fEE'; 1 UF -.'-E, 1E.3 11,n,11UE t7�; 340729 08/27/84 C/O S & S ENG/G. BOB DEAN S R B 196X EAGLE RIVER, Al...': 99577 694~2979 LEGAL DESCRIP: SUBDIVISION: HIGHLAND HILLS SECTION: 72113 TOWNGHIP: 14N LOT SIZE: 50000 (SQ"FT. OR ACRES) MAX BEDROOMS: 3 LOT: 5 RANGE: 1W Listed below are the options available to you in designing system" Choose the option that best fits your site., EE 11 1!, _1 E]� DEPTH TO PIPE BOTTOM (F -l". ) 4"0 4.0 GRAVEL DEPTH (FT"> 4.0 ' 0.5 TOTAL DEPTH (FT.8"0 4"5 GRAVEL WIDTH (FT") 2"5 17"0 GRAVEL LENGTH (FT") 47"0 34"0 GRAVEL VOLUME (CU.YDS.) 19"6 21"5 TANK SIZE (GALS) 1,000"0 ** 1,000"0 ** SOIL RATING URI. FIT. MR) 125 125 BLOCK: 1 your septic 4^0 3.5 7^5 5,0 41"0 30"4 1,000"0 ** 125 ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS .... .... ... ~__~ I certify that: 1" I am familiar, with the requiPements for and as set forth by the MunicipMlity of Anchorage (110A) and the ol' Ala�ka" 2" I Will install the sySit eill in accordance with all MOA codes and regulaticns, and in ccm)pliance with the design criteria oIF this permit. 3" I will adhere to all MOA and 13tate of Alaska requiremqnts for the set back distances from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot" 4" I understand that this permit is valid for a maximum of 3 hedrooms and any enlargewent will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS~BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL D ELECTRICIAN" SIGNED DATE: ^/'l -~��~�^-- APPLICANT:AN-r ~ —`~ ~^ ~~~ � � ISSUED BY DATE: -........... ..... _.-._�-~~~__�. ..... .~__�~...... .~ MUNICIPALITY OF ANCHORAGE� 7� c, Department 7 Health and Environmenta 'rotection 1 825 L Street, Anchorage, AK. y9501 264-4720(�U Permit # #HANDWRITTEN PERMIT Q /�C < ) �JE,L AND/OR ON-SITE SEWER PERMIT T�Tr Applicant: (Q. C.L) �__ Mailing Address: _ l� �1 �-�v*z Location: Phone Number:---- Legal Description: t_ j��` I uQ �t of Size: Type of Soil Absorption System Is: Trench: L--_ Drainfield: _ Seepage Bed: Holding Tank: Maximum Number of Bedrooms: Soil Rating(sq.ft/br) If/_l The Required Szthe Soil Absorption System Is: DEPTH LENGTH GRAVEL DEPTH = WIDTH _ The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no :set width for trenches. The gravel depth is the minimum depth of gravel be wT t a outfall pipe and the bottom of the excavation(in feet). REQUIRED SEPTIC(HOLDING) TANK SIZE _ _L `_� _ GALLONS # # Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. .# TWO(2) INSPECTIONS ARE REQUIRED # Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet: and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 u 3 # # I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) T understand that the on-site sewer system may require enlargement if h� residence is remodeled to include more that 3 b d ooms. Signed: Id by: , ? Applicant Date: SWP/024(1/81) �4- SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION E-1 PERCOLATION " l TEST 825 L. Street, Anchorage, Alaska 99501 2644720 - SOILS LOG — PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION:_ , kkrY I DEPTH (FEET) 1 2 - - 3- 4 �� �,9nl�y �,QAJ� � rt9�•r-x� 5 6 7 8 ) 9- 10 S DATE PERFORMED-LA)t"— /2 SITE PLAN 11 WAS GROUND WATER /I S ENCOUNTERED? O 12_ P ///��� IF YES, AT WHAT E 13 M 0/ ' r ' ir' DEPTH? 14 15 16- 6F Ak i5'yjv `�V�oe o0`)49� ieo 4� 17 09' of ;3 o 0000000 0u00 QuoO oa0 18 Po oVtl7R�fME',o o� o bb�mG� Russell L. Oyster ;<'f 19 © '6)% No. 4286-E �c 20 PERCOLATION RATE__ TEST UN BETWEEN COMMENTS IN Reading Date Gross Net Depth to Net Time Time Water Drop c� '3 V PERFORMED BY: 72-008 (6/79) CERTIFIED -(minutes/inch) FT AND FT DATE: 69-e .To 1T Vj I A, J-1 I C, 2 7 C 1 L J G I A'(, A I J� S Kf-, :J' PITN CIA! - k F) l" Ji L o,"IM T- 1 ej 1 1-:- -------- -- 1j f Min -1kyj V0111 - --- - ------ rom l-1 . - - - - Al 0— Municipality of Anchorage, Department of Health and Human Services Tom Fink, 825 "L" Street Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 November 3, 1988 Engineering Evaluation & Investigation Services, Inc. 200 West 34th, Box 267 Anchorage, Alaska 99503 Attention: Richard Button, P.E. Subject: Waiver Request for Lot 5 Block 1 Highland Hills S/D Waiver Request #WR88-069 Dear Mr. Button: A Your request for waiver of the required 10 foot separation between a septic system and a lot line has been approved. The waived distance is 8.5 feet. This approval applies to the existing septic system lot line separation only. Any future upgrade to the septic system will require all separations be met or another approval from this department. Sincerely, PGY q_ A;--rt— Daniel J. Roth Civil Engineer. On-site Services DJR/ljw#7 ENGINEERING EVALUATION INVESTIGATION SERVICES, INC. October 26, 1988 Mr. Dan Roth Municipality of Anchorage Department of Health and Human Services 925 "L" Street Anchorage, Alaska 99501 P� 1 OF NI CNORAOE LrN1[.�S DIVISION Document No: 8274BC3.001 Subject: Waiver for Required Separation Distance Highland Hills Subdivision, Lot 5, Blk 1 Dear Mr. Roth: This letter is written in an effort to get the Municipality of Anchorage, Health and Human Services, On—site Services Section (Municipality) to grant a waiver for the ten—foot separation distance between an absorption trench and the property line. Engineering Evaluation and Investigation Services, Inc. (EEIS) contacted Gerald and Carol Krieter. The purpose of the contact was to ask Mr. and Mrs. Kreiter to sign a letter of non—objection to allow the Municipality to grant the Waiver of Separation Distance. I contacted the Kreiters on two occasions, and explained to them that the violation of the ten—foot separation between absorption trench and the property line would not impact their ability to develop their lot at some future date. The Krieter's lot is large, and the well on the developed property on the other side of their lot (Lot 3) is located near the property line with the Krieters. This works out well since the lot Fannie Mae owns (Lot 4) is on the downhill side of the Krieter's lot, so it would be logical for the Krieters to locate their septic system on the side of their lot nearest Lot 4 and their well on the side of the lot nearest Lot 3. The Krieters indicated to me in conversation that they were not anxious to sign the waiver because they felt the original developers of Lot 5 had trespassed on their property by pushing dirt and debris over the property line. They stated that they felt they could not be responsible for the mistakes of someone else. I asked them to return the Letter of Non—objection sent to them indicating their objection. A copy of that letter is attached to this letter for your information. Under the circumstances, I would ask that the Municipality grant the Waiver of Separation Distance for Lot 4 over the objections of the Krieters since the waiver will not adversely impact or restrict the development of their property. 200 West 34th, Box 267 ® Anchorage, Alaska 99503 ® (907) 274-7611 Dan Ross October 26, 1988 Page Two If you have questions, or if I may be of further service, please do not hesitate to call. � p elrichard§Ori4,P C.. RCB:Iwh attachments 8274BC3.001 200 West 34th, Box 267 a Anchorage, Alaska 99503 • (907) 274-7611 NON -OBJECTION TO GRANTING OF A WAIVER FOR LOT LINE SEPARATION FOR THE ABSORPTION FIELD OF LOT 5, BLOCK 1 HIGHLAND HILLS SUBDIVISION W __t -he- owners of Lot 4, Block 1 Highland Hills Subdivision DO OBJECT to the granting of a waiver allowing the existing absorption trench for Lot 5, Block 1 Highland Hills Subdivision to remain within the 10 foot setback. The existing system terminates approximately 8 1/2 feet from our prgperty line. If'the absorption field is upgraded or reconstructed in the fYtPPP? UP request that it be placed at least 10 feet from our property line. Gerald Kr'eter Carol rr' t D• e .. .......... Date ZJQ woulp COQ-, W5• � ;s wa�I eb s� iou WQf� �rov G 6 f so rn C O N fv E-A 5 'm w � 200 West 34th, Box 267 • Anchorage, Alaska 99503 w (907) 274-7611 Municipality of Anchorage On -Site Water &Wastewater Program 6 :� 8 9 <I (907) 343-7904 tVAL CERTIFICATE OF ON-SITE SYSTEMS APP Parcel I.D. 050-382-26 1. GENERAL INFORMATION Expiration Date: Complete legal description HIGHLAND HILLS S/D #1; BLOCK 1, LOT 5 Location (site address) 5540 HILAND ROAD, EAGLE RIVER, AK 99577 Current Property owner(s) RANDY MUNTZ Day phone 953-9011 Mailing address Real Estate Agent 5540 HILAND ROAD, EAGLE RIVER, AK 99577 JAYME LEMBKE W/ PRUDENTIAL Day phone 2. TYPE OF DWELLING: E Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 2 4. TYPE OF WATER SUPPLY: 360-1906 TYPE OF WASTEWATER DISPOSAL: Individual Well E Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ WeiverNeriance request Received by: 7 Ill Date: 1 L2 3 h (a COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ J ,),� , Waiver Fee $ _ Date of Payment I I Gl Date of Payment Receipt Number bbaG Receipt Number COSA # o sc «i �ti3 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. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK, 99507 Engineer's Printed Name Engineers Comments: JEFFREY A. GARNESS, P.E. In conducting this evalumlon, GEG provided an engineering evaluation of the welt andlerm plic system in accordance with the guidelines and regulations established by the MunicrpalityofAnchmage and industryprectices. The reported results describe the condltion oflhe sysfemis on the dates of the emi atfan. Separation distances weremeasured to madilyfdenfiflable features. Hidden defects orencroachmenfs mayexisf that were not Mengrad during the owhetion.The operetionellde of all wells andceptic systems depend on a variety of variablesindeding, but not gmgedlo, sorioonothons, groundwaterlmma (that maylluclume during the year), quality of constriction (materials and workmanship), and the water usage onhe lamrTyideldng the systerns. These condgms can nary, and are oulside the controlOGEG. Satisfactory test resulfs do not guarantee futureperformance of the systen✓s; therefore, GEG makes no wanamy(express orlmplled) regarding the lutureperformance of the well orsepticsystem. GEG makes no representation whether an altamatke well orseptic system can be installed on the property in the event edheroflhe current systems fa. The content of this report is forthe sole benerd of the personrpady who retained GEG. Reffence upon the information provided in this report by anyofharperson or party, kch ding but not Wad to subsequent property purchasers, is not authorized. In shod, GEG disavows any legal duty to anyone other than the persoeparty who paidfurtidsmport. 6. DSD SIGNATURE System #1 Approved for Z-- bedrooms. System #2 Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following Phone 337-6179 I Date 100 >f PROFESS\t.4 LICENSE IVAECC854 �y(Y OF4crrrry. yL) —M SIM— eve.;: WATER AN D The Municipality or Anchorage Develop,emt Services Division (DSD) issues Certificates of Onsite Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineerregistered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engine/'s work. 7. ATTCHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory (Rev. 10117112) Nitrate Advisory Arsenic Advisory Other r 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: HIGHLAND HILLS SID #1; BLOCK 1, LOT 5 Parcel ID: 05-382-26 A. WELL DATA Well type PRIVATE If A, B, or C provide. PWSID# N/A Date completed 10/24/1983 Sanitary seal (Y/N) YES Total depth 140 ft. Cased to "20.3_ ft. FROM WELL LOG Date of test 10124/1983 Static water level 60 ft. Well production 30 g.p.m. WATER SAMPLE RESULTS: Coliform O colonies/100 ml. Nitrate -3 8 mg./L. Well Log (Y/N) YES Wires properly protected (YIN) YES Casing height (above ground) 18+ in. AT INSPECTION 9/1/2016 4.5 g.p.m. Collected by: GEG, Ltd. Arsenic: mo—ug./L. Date of sample: 9/1/16 & 917/16 B. SEPTIC/HOLDING TANK DATA NOTE: 32 YEAR OLD STEEL SEPTIC TANK IS APPROACHING THE END OF ITS USEFUL LIFE. Tank Type/Material SEPTIC/STEEL Date installed 9/26/1984 Tank size 1000 _ gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (YIN) YES Depression over tank (YIN) NO High water alarm (Y/N) N/A Date of pumping 9/2!2016 - I SANITARY PUMPERS C. ABSORPTION FIELD DATA • BEL OW EXISTING GRADE TO BOTTOM OF 2" Mr Date installed 9/26/1984 Soil rating (g.p.d./ftor bdrm725 System type TRENCH Length 47 '_ft. Width 2.5 ft. Gravel below pipe 4 ft. Total depth "8.98 ft. Eff. absorption area 375 ft2 Monitoring tube YES Depression over field NO Date of adequacy test 9/1/2016 Results (Pass/Fail) PASS For "2 bedrooms Fluid depth in absorption field before test 6.75 in. Water added 543 gal. New depth"36_75 in Elapsed Time: 295 min. Final fluid depth"`32.75 in. Absorption rate >= 300+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date "HOUSE IS ONLY 2 BEDROOMS, BUT SEPTIC SYSTEM SIZED FOR 3. LIQUID LEVEL DURING TEST REMAINED AT 36.75" AFTER 166 GALLONS ADDED TO SYSTEM. IN SHORT, 377 GALLONS WAS ABSORBED AT THIS LEVEL. NOTE: THERE ARE NO CLEANOUTS IN THE DRAINFIELD, ONLY SINGLE MONITORING TUBE. APPROVED PER 2012 & 2014 COSAS. 6.72 FEET ELEVATION DIFFERENCE BETWEEN POST TANK CO AND THE BOTTOM OF THE 2" MONITORING TUBE. D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N)_ "Pump on" level at in. "Pump off' level at wa er alarm level at Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO Septic tank/lift station on lot 100'+ On adjacent lots 1001+ Absorption Feld on lot 1001+ On adjacent lots 1001* Public sewer main 75'+ Public sewer manholelcleanout 100'+ Sewer /septic service line 25'+ Holding tank 751+ Animal containment areas 50'+ Manure/animal excrete storage areas 1001+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: --- Building foundation *5'+ Building Property line 5'+ Absorption field 5'+ ( ASSUMED) Water main 10'+ Water service line 104 Surface water 100'+ Wells on adjacent lots **1001+ NOTE: A STEEP SLOPE (>25%) EXISTS -10 FEET DOWNHILL FROM SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: THE DRAINFIELD. NO INDICATION ("' SEE WR88-069) OF DAYLIGHTING OF EFFLUENT. Property line ***6.5' Building foundation *10'+ Water main 10'+ Water service line 10'+ Surface water 1004 Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots **100'+ F. COMMENTS *THERE IS A DECK LOCATED NEXT TO THE SEPTIC TANK AND DRAINFIELD. DECK IS SUPPORTED BY PIER BLOCKS. -THE ADJACENT LOT TO THE SOUTH ( LOT 4) IS VACANT, BUT HAS A WELL DRILLED ON IT. SEVERAL ATTEMPTS WERE MADE TO FIND THIS WELL THAT WERE UNSUCCESSFUL. THE WELL IS BELIEVED TO BE LOCATED ON A -EXISTING EXCAVATED PAD PER THE OWNER OF LOTS ( SEE ATTACHED PICTURE) THIS PAD IS OVER 100' FROM THE SOUTH '„", LOT LINE OF LOT 5, HOWEVER WE CANNOT CONFIRM SEPARATION DISTANCE TO THIS WELL. ��� nC INIII , G. ENGINEER'S CERTIFICATION 1 certify that t have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Nam JEFFREY A. GARNESS Date 7[/ 9 7/L LICENSE #AECC884 (Rev. 10112112) • Municipality of Anchorage =p On -Site Water and Wastewater Program (907)343-7904 sn Err ry 3$a- �Certificate of On -Site Systems Approval Parcel I.R`- Expiration Date: r 1. GENERAL INFORMATION Complete legal description Highland Hills #1, Block 1, Lot 5 Location (site address) 5540 Hiland Road Eagle River, AK 99577 Current Property owners) Jeffrey & Carrie Chisholm Day phone _ Mailing address 5540 Hiland Road Eagle River, AK 99577 Real Estate Agent Day phone 2. TYPE OF DWELLING: SUBMIT ix Single Family (w/wo ADU) 71r ❑ Duplex FEB 18 2014 L t� �,;/ ❑ Multiple Dwellings (Single Family and/or Duplex) i 3. NUMBER OF BEDROOMS: Three 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual 7X Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: F 1 Received by: `: " ` J t' ✓` Date COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ II '23Is K-L(5h Waiver Fee $ Date of Payment 211 � i I C4 Date of Payment Receipt Number (5 [N�' Receipt Number COSA # OSL I `� l043) 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 Anderson Engineering Phone 522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. 6. DSD SIGNATURE ? System #1 Approved for J bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, Date 2/7/2014 4's, rr o 49 if, CE -4231 with the following stipulationts: By: Original J ilYX��i� Original Certificate Date: /INfC' The 10"I pality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet f .., c If more than 1 septic system is on the lot: COSA Checklist # of _ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: Highland Hills #1, Block 1, Lot 5 Parcel ID: 050-382-26 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 10/24/83 Sanitary seal (YIN) Y Total depth 140 ft Cased to 20.3 ft. FROM WELL LOG Date of test 10/24/83 Static water level a A Well production 30 g,p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate mg/L Arsenic UZIL ug/L Date of sample: 1/30/14 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Tank size 1,000 gal Number of Compartments 2 Well Log (YIN) Y Wires properly protected (Y/N) Y Casing height (above ground) >12 in. AT INSPECTION 6/13/12 37 ft. 3.41 g.p.m. Collected by: Anderson Engrg. Date installed 9/26/84 Cleanouts(Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High /water alarm (Y/N) N Date of pumping%1 L li Pumper C. ABSORPTION FIELD DATA Date installed 9/26/84 Soil rating (g.p.d./ftZ or ftZ/bdrm) 125 SF/BDRM System type Deep Trench Length 47 ft. Width 2.5 ft. Gravel below pipe 4 ft. Total depth 8.7 ft. Eff. absorption area 375 ft Monitoring tube Y Depression over field N Date of adequacy test 6/13/12 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 450 gal. New depth 0 in. Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 450 g p d Any rejuvenation treatment (past 12 mo.) (Y/N & type) �J If yes, give date Drainfield Checked on 1/5/2014. No Water Noted in Monitor Tube. No Clean Outs are Located in the Drainfield. The Monitor Tube is the Only Vent Present. D. LIFT STATION Date installed Size in gallons "Pump on" level at in. "Pump off"level at in. Datum Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: >100' Manhole/Access (YIN) High water alarm level at in. Meets alarm & circuit requirements? Septic tank/lift station on lot On adjacent lots > 100 Absorption field on lot >100' On adjacent lots >100' Public sewer main N/A Public sewer manhole/cleanout N/A Sewer /septic service line >25' Holding tank N/A Animal containment areas >50 Manure/animal excrete storage areas >100, SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' Property line >5' Water main > 0, 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 >100' Curtain drain None Noted Wells on adjacent lots >100' F. COMMENTS 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 Printed Name Michael E. Anderson, P.E. Date 2/7/2014 COSA brown sheet 10-10-12.doc Absorption field >5' Surface water >100, Water main N/A , Driveway, parking/vehicle storage > 10 ot-,•q V* *�„' MICHAPL E. AIvDER56N �� e ��sfF CE -4381 • •�=_s Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 �. www.ci.anchorage.ak.us (907) 343-7904��u CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-382-26 COSA# C;�D_ C� I d 1. GENERAL INFORMATION Expiration Date: Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address HIGHLAND HILLS #1 S/D: BLOCK 1, LOT 5 5540 HILAND ROAD *EAGLE RIVER, AK 99577 HOLLY SUOZZO Day phone 830-8866 5540 HILAND ROAD *EAGLE RIVER, AK 99577 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 13 Day phone Day phone 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site 0 Individual Water Storage ❑ Individual Holding tank ❑ Community Class - Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served_ by a private or Class C well and may be reissued with new water 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 engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seai affixed hereto and as of the validation date shown below, t 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. t 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 system under conditions Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date2� septic systems depend on the local soils condition, groundwater levels that may /2 Engineer's Comments In conducting this evaluation. GEG, LtD. attempted to provide a thorough, the in with ADEC and MOA 00060�� conscientious engineering analysis of system accordance The described the of the DSD Guidelines& Regulations. reported results performance the encountered at the time of the test, and separation j system under conditions distances measured to readily identifiable features. The operational life of all wells and * ;' 4 T,�* septic systems depend on the local soils condition, groundwater levels that may Q . . . • . . .. .. . . . . . . • . . • . 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 OOP -fey A. G rness: there are no hidden defects or encroachments. GEG, LTD. can therefore not provide or future estimate of how long the system will continue to meet the Q " CE -7 o4d4P I any warranty ,12 Eo�O operational requirements of the ADEC or MOA DSD. The content of this report is for & dprof es slogo ��0400��60 the sole benefit of the owner listed above. Any reliance upon cruse of this reportby any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. j pN-SiTE _Z WATERAND Conditional approval for bedrooms, with the following stipulations:%d WAS[EWATER SO PROGRAM Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other gy;Original Certificate Date: �- (Rev. 11105) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: HIGHLAND HILLS #1 S/D; BLOCK 1, LOT 5 Parcel ID: 0 SO - 3 L A. WELL DATA *BEDROCK ® 10' Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 10/24/1983 Sanitary seal (Y/N) YES Total depth 140 ft. Date of test Static water level Well production Cased to *20.3 ft. FROM WELL LOG 10/24/1983 WATER SAMPLE RESULTS: Coliform colonies/100 ml. Arsenic: OA ag./L. B. SEPTICIHOLDING TANK DATA Nitrate LS!mg./L. Date of sample: 6/13/12 Tank Type/Material SEPTIC/STEEL Tank size 1000 gal. Number of Compartments 2 Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 6/13/12 37 ft. 3.41 g.p.m. Collected by: GEG. Ltd. Date installed 9/26/1984 Cleanouts (Y/N) Foundation cleanout (YIN) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 10/25/11 Pumper SANITARY PUMPERS C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE Date installed 9/26/1984 Soil rating (g.p.d.lft`or /bdrm 125 System type TRENCH Length 47 ft. Width 2.5 ft. Gravel below pipe 4 ft. Total depth *8.66 ft. Eff. absorption area375 ft2 Monitoring tube YES Depression over field NO Date of adequacy test 6/13/12 Results (Pass/Fail) PASS For bedrooms Fluid depth in absorption field before test 0 in. Water added 450 gal. New depth E in. Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 300+ g,p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE If yes, give date NOTE: THERE ARE NO CLEANOUTS IN THE DRAINFIELD, ONLY A SINGLE MONITORING TUBE. D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N "Pump on" level at in. "Pump off" levela� I . High water alarm level at Cycles tested Meets alar & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ Public sewer manhole/cleanout Holding tank N/A Animal containment areas. 50'+ Manure/animal excrete storage areas 100'+ 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: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION 1:57<1- I :57G v'r.•' certify that t have determined through field inspections and p 9 review of Municipal records that the above systems are in Q •' """ .. conformance with MOA COSH guidelines in effect on this 0 date. 9 '•.J f A. ness Engineer's Printed Name JEFFREY A. GARNESS Data 6121112 COSA Fee $ t b n Date of Payment`�- Receipt Number (Rev. 11/05) Waiver Fee $ Date of Receipt Number SGS Ref.# 1122267001 Client Name Garness Engineering Group, Ltd Project Name/# Highland Hills 1 B1, L5 Client Sample ID Highland Hills 1 B1, L5 '-Matrix Drinking Water Printed Date/Time Collected Date/time Received Date/Time Technical Director 06/21/2012 8:51 06/13/2012 12:15 06/13/2012 14:29 Stephen C. Ede Sample Remarks: Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 06/[8/12 06/20/12 ACF Waters Department Total Nitrate/Nitrite-N 1.58 0.100 mg/L SM21450ONO3-F B (40) 06/15/12 AYC Microbiology Laboratory E. Coli Negative 1 100mt, SM21 9223B A 06/13/12 DLC Total Coliform Negative 1 100mL SM21 92236 A 06/13/12 DLC Municipality of Anchorage a �. • "-° Development Services Department2 °s Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-382-26 COSA# ®S C` /0 �� ✓� 1. GENERAL INFORMATION Expiration Date: 1 Complete legal description HIGHLAND HILLS #1 S/D; BLOCK 1, LOT 5 Individual Water Storage ❑ Individual Holding tank Location (site address) 5540 HILAND ROAD * EAGLE RIVER, AK * 99577 ❑ Public Water System ❑ Current Property owner(s) HOLLY & VINCENT SUOZZO Day phone 830-8866 Mailing address 5540 HILAND ROAD * EAGLE RIVER, AK * 99577 Lending agency Day phone Mailing address Real Estate Agent HENNIE VINCENS W/ DYNAMIC Day phone 261-7600 Mailing address 3111 C STREET * ANCHORAGE, AK * 99503 - = -Unless otherwise requested, COSA will be held by DSD for pickup. - 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well N Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water 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 engineer's work. 4. STATEME14T OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, l 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. l 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, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name Engineer's Comments: JEFFREY A. GARNESS, P.E. 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 identifiable 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 therefore 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 h Phone 337-6179 Date (8 � *� ... .. . . ....... ....... r-79 �arngss. 5 I • �� v fessio— of er person or party rs not authorized, nor will it confer any legal right whatsoever. t(t (((I < If; 1, 5. DSD SIGNATURE V Approved for bedrooms. Disapproved. Conditional approval for Attachments: COSA Checklist Septic System Advisory Well Flow Advisory OF r�rr i pv,�,.....Cy�;� Jam: ON-SITE X ; WATER AND : �- WASTEWATER bedrooms, with the following stipulation ��• PROGRAM Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Nitrate Advisory Other By: Original Certificate Date: 5_` (Rev. 11105) Municipality of Anchorage G Q L '-� Development Services Department Building Safety Division 5 "1 On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLEFAMILY DWELLING Parcel I.D. 050-382-26 COSA# 1. GENERAL INFORMATION Expiration Date: Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent HIGHLAND HILLS #1 S/D; BLOCK 1, LOT 5 ILAND ROAD * EAGLE RIVER. AK * 99577 HOLLY & VINCENT SUOZZO Day phone 830-8866 5540 HILAND ROAD * EAGLE RIVER, AK * 99577 Day phone HENNIE VINCENS W/ DYNAMIC Day phone 261-7600 Mailing address 3111 C STREET * ANCHORAGE, AK * 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 2 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site Individual Water Storage ❑ i Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water 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 engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. 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, 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 identifiable features. The operational life of al/ 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 therefore 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 Approved for bedrooms. Disapproved. Conditional approval for Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory t-� Phone 337-6179 Date /11/6 M OF •A 4TH �t r A I arrt ss: CE —79 .��_ro f e s siol!ovo �V��� OFq , t,,, P. ON-SITE • WATER AND WASTEWATER PROGRAM bedrooms, with the fllowing stipulations : ~ J//.OAXS:APt Cc\I�f"' Arsenic Advisory, Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date:9-217-17) Z'/ (Rev. 11105) Municipality of Anchorage • Development Services Department z� �x Building Safety Division - S 4 ! T Y On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: HIGHLAND HILLS #1 S/D; BLOCK 1, LOT 5 Parcel ID: n,�rO- 3S3 o - 6Z6 A. WELL DATA *BEDROCK 0 10' Well type PRIVATE If A, B, or C provide PWS1D# N/A Date completed 10/24/1983 Sanitary seal (Y/N) YES Total depth 140 ft. Cased to *20.3 ft. FROM WELL LOG Date of test 10/24/1983 Static water level 60 ft. Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 5/10/2010 69 ft. Well production 30 g,p,m, 5.37 g,p,m, WATER SAMPLE RESULTS: Coliform colonies/100 ml. Nitratet •5mg./L. Other bacteriacolonies/100 ml. Arsenic: N ug./L. Date of sample: 5/13/2010 Collected by: GEG Ltd. B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Date installed 9/26/1.984 Elapsed Time: 1238 min. Final fluid depth Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 8/18/2009 Pumper SANITARY PUMPERS C. ABSORPTION FIELD DATA *BELOW EXISTINGGRADE Date installed 9/26/1984 Soil rating (g.p.d./Wo 2/bdr 125 System type TRENCH Length 47 ft. Width 2.5 ft. Gravel below pipe 4 ft. Total depth *8.6 ft. Eff. absorption area 375 ft' Monitoring tube YES Depression over field NO Date of adequacy test 5/10/2010 Results (Pass/Fail) PASS For 2 bedrooms Fluid depth in absorption field before test 8 in. Water added 500 gal. New depth 17 in. Elapsed Time: 1238 min. Final fluid depth 10 in. Absorption rate >= 300+ g,p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date - NOTE: THERE ARE NO CLEANOUTS IN THE DRAINFIELD, ONLY A SINGLE MONITORING TUBE. D. LIFT STATION Date installed "Pump on" level at in. E. SEPARATION DISTANCES Size in gallons Manhole/Access "Pump off" level_ atHigh water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Sewer /septic service line 25'+ Public sewer manhole/cleanout N/A Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ 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. Wells on adjacent lots 100'+ 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENOINEER'S CERTIFICATION I cert/fythat 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. Engineer's Printed Name JEFFREY A. GARNESS Date w COSA Fee $ V7 Q Waiver Fee $ Date of Payment Q I I I 1 © Date of Payment Receipt Number o%IMS Receipt Number (Rev. 11/05) Yv1 fit i ,�,.✓z q.0.VY �u SGS Ref.# 1102162001 Client Name Gs En tr�eering Group, Ltd Project Name/# Hiland Hill I,LS Client Sample ID Hi land Hil IN1,L5 Matrix tDrinking{ Water l PWSID 0 Printed Date/Time Collected Date/Time Received Date/Time Technical Director Sample Remarks: 4500NO3 - Total Nitrate/Nitrite, - MS did not meet QC criteria, biased low. LCS meets QC criteria. 05/21/2010 14:54 05/13/2010 18:00 05/14/2010 15:20 Stephen C. Ede Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 05/17/10 05/18/10 KDC Waters Department Total Nitrate/Nitrite-N 3.25 0.100 Microbiology Laboratory Colony Count 0 Fecal Coliform 0 Total Coliform 0 mg/L SM20 4500NO3-F B (<10) col/100mL SM20 9222B A (<200) col/100mL SM20 9222B A (<I) col/IOOmL SM20 9222B A (<1) 05/14/10 AYC 05/14/10 DLC 05/14/10 DLC 05/14/10 DLC ...SGS._ SGS Ref.# Client Name Project Name/# Client Sample ID Matrix Sample Remarks: 1104313001 Garness Engineering Group, Ltd Highland Hil1S1,1-5 Highland Hills N1,L5 Drinking Water Printed Date/Time Collected Date/Time Received Date/Time Technical Director 08/24/2010 11:09 08/20/2010 9:09 08/20/2010 13:15 Stephen C. Ede Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 A (<10) 08/20/10 08/23/10 KDC 33' Sectio,; Line s f ._ ...-- ._- - _o "' °�{ ...... .s — .... ._.®... — •.r.v .-.a�•w.�a�. n.r°.....—... . i -_ ... ve 1. .—tea. . ..a OD t • o o � O -}� ;o �z�' o r4 owr amm • :4� � �N � v n z � �8 ;N /* mmO m re Ito Nr, Li zr LAWH MAG M,f 30 s y Rt[ c 07 10 10:27a Betty J. Van B SAMMY PUMPERS 20627 UPPER BOWERY LANE CHUGIAK, AK 99567 907-688-4602 CUSTOMER'S ORDER NO. PHONE DATE 14111 a�� L, �-� -:� 1 3 n Z2: ADDRESS 55 aE U <14 - SOLD BY J CASH C.O.D. CHARGE ON ACCT. NIOSE.RET'D. PAID OUT OTY. DESCRIPTIO AWUNT LP Ivi DAY L TAX RECEIVED BY TOTAL All claims and returned gogds. 10955 MUST be accompanied by this bill - PRODUCT 2531 Thank You! L-151 \ Municipality of Anchorage Development Services Department / Building Safety Division On-Slte Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsfe (907) 343-79(4 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel l.D. t 13) 3S a, - al f, COSA # r)(r l" l l$D Expiration Date: 0 -'0 G ,1. GENERAL INFORMATION Complete legal description Lod 5 131ock 1 0iu004 14;IL5 �i Location (site address) 5540 k;Roads L Current Property owners) 1i 1%.4n AcA4gQ. Corin li'UST Day phone Mailing address 3 ADA, -Iru;ne- ICA 9yom Lending agency Day phone Mailing address Real Estate Agent Bob B roc.k Day phone 2roI -1603 -Mailing Address 24asm;L Proptnt;eb I Inc.. 3111 i SF. , Ste. 100 Arcllpra�etAK Unless otherwise requested, COSA will behold by DSD /or pickup. qq 541,3 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given In paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also Issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below. I verify that my Investigation, based on procedures outlined in the Certificate of On. -Site Systems Approval Guidelines for this application, .shows that the 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 pka- Anel znaineeri^4- Phone 277-341(0 Address 203 W. t5" i Sul 203 Aneho-4.. Al( 99501 Engineer's Printed Name -r,� in So�lancA atQ Mar 'Zook 491. * S. DSD SIGNATURE ��" CE 2M _� Approved for bedrooms. '� Disapproved. tl,l\\\\0 Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By:Original Certificate Date: 3 —a o" 0 6 V11f ';0000 Municipality of Anchorage • Development Services Department BWding Safety Division.. On -See Water &Wastewater Program 4700 Bragew Street P.O. BOX 198650 Anchorage, AK 995198850 www.muni.orylonske (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lot 5 La la ck 1 p jAl lab j Parcel ID: OS A. WELL DATA Wap type±r:?4 fie. If A, B, or C provide PWSID f = Well Log (Y/N) iI Data completed =L"r 1 S3 Sanitary seal (YIN) 'Y Wires properly protected (Y/N) Y Total depth _L40 ft. Cased to ! 9" R. (BMJ ga.k) Casing height (above ground) _LZ—In. FROM WELL LOG AT INSPECTION Date of test10 14 83 r 3 O fo Static water level b0 rt. '(07, rt. Well production i60D b. F. k 9,pm. 2 • `i g.p.m. WATER SAMPLE RESULTS: C 1dorm _$ 100 ml Nitrate AID mg1L DOW bacteria __V_ c0ionies/100 mL Arsenic: +"ff– Date of sample: _16�0(4 Collected by: _ LArS So4rk�a�c` B. SEPTICIHOLDINO TANK DATA Tank TypelfMaterial irreer I S%e Date Installed 5Q B'1 Tank size 1000 gal. Number of Compartment 2 Cleanouts (YM) Y Forndallon deanoL*(Y/N) Y Depression over tank (YM) /f High water alarm (Y/N) T— Date of pumping I 0 {n Pumper JR 'S Sea 4,e– Pu nhAZ9 C. ABSORPTION FIELD DATA Data Installed 9 16 Sail rating (g.p.d./f ? or felbdrm) 115 System type Deep Tan.1 Length H_' ft. VNtlth Z. ri ft. Gravel below pipe _ I 8 - Total depth —B—_R. Eff. absorption area11.5_fe Monitoring tube Y Depression over field Y Date of adequacy beat I b Results (Pass/Faii) 8466 For 3 bedrooms Fkdd depth in absorption lfeld before teat --Q—in. Water added 450 gal. New depth O in. Elapsed Time: O min. Final fluid depth __Q_in. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) None knoon If yes, give date -- D. LIFT STATION Date instatled Size in gallons Manhole/Access (Y" 'Pump on level _ in. 'Pumpofi kivel lo. High water alar 1 at In. Datum Cycles Meetsaknn mwnrrertb9 E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanklUfi station on lot + (°o' Absorption field on lot + 100' Public sewer main /V/A sewer /septic service line 4100, Animal containment areas 41001 On adjacent kits + 100 On adjacent kits +1001 Public sewer manhole/deanout � Holding tank N/A Manurelardmal excrete storage areas f tom' SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building foundation +101 Progeny fine + 10 n - Absorption field %10 t Water main A Water service line k �� Surtaoe water Wens on adjacent lots 1 00' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line +' y ^'� E?5 Building foundation t _ _j water main /1//A MW Service Una { 0' Surface water Al,veway, , 0 , Dr, parkirWahide storage + 10 ' Curtain drain N. D • Wens on adjacent lots 41001 F. COMMENTS: G. ENGINEER'S CERTIFICATION i Ono... '•t:ll I carry Mat I have determined through field inspecxlons and review of Municipal records that the above systems are in ........... 1 cwkvmance with MOA COSH guAdalines in off on this date. / • . ; ' r 1 % T b7�1RKLi1ND;r i Engineer's Printed Name Toto bar. Date A1311010AV .c' .: COSA Fee S(42�o . d O Date of Payment 3115 l e(k Receipt Number (rtsv. tvoe) CM Waiver Fee S Data of Payment Receipt Number Municipality of Anchorage • Development Services Department Building Safety Division ' On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Arsenic Advisory Certificate of On -Site Systems Approval # 060080 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 1, Lot 5 of Highland Hills #1 Subdivision. This inspection revealed an arsenic concentration of 11.7 micrograms per liter (ug/L) for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Information on arsenic is available from the On -Site Water and Wastewater Program website (www.muni.org/onsit or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. 8 2.95;9 1 23-5.00 33' Section Line Es►�,f 03-05-:6;13:33 EMI SCS AeCN 1067855001 C11eac Name Tobben SpurkL-nd AE ProiectName!r' Lot 5Block IHllandHills Cl;cat Semple ID Lot S Block I Hiland Hills :Natrla Drinking Wates PWSID 0 M7 561 5:01 tt 3/ 5 All Ntr.%Tlmca aro Ak,b SmaJard Time Printed DaIdTime 03108/2006 11:40 Collected Datollme 0122!.'006 14:00 Received Valentine 0:.211006 15:36 Tecks"l Director Scenbea C. Ede pw4mon• R=Ju POL Udn "Idea Coemhwr to A:blwble Limits Prue Anutysis Don Dau W1 Private yndividual AraSYaia Zin. 824 5.00 e8lL EP200.8 C (10-5000) 0223106 0263106 SCL Toa: Duorol•cd Sclida 249 10.0 mt/L SNC'02540C D (¢500) 0267106 ICP Nickel ND 2.00 UZIL EP200.8 C ("100) 0122106 02/23/06 SCL FIC03Alka!(rity 124 20.0 m8P_ SNC'023200 D 03111/06 PLW CC3A3win;ty ND 20.0 mit/l, Sh12023203 D 03/01106 PLW OHA;kolinhy ND 20.0 mt/L SN1201320D D 03101/06 PLW Conduct:viy 400 1.00 wnhos/em SM1t<025103 D 03/01106 KI' PH 7.50 0100 PH urita EPA 150.1 D (6.5-9.5) U2l22/06 AZS AIKa!Inlly 124 20.0 mill. Sh12023208 D 03/01/06 PLW Total Coliform QOB.NoColi eoV:00mL Sh12092223 A (o-1) 0261'06 TLF Page 3 of 5 SCS Rets 1060815001 CEeet Name Tobbdn Spurkland P.E. rrojeet.Name/a Lot S Block 1 Hilond Hilk Client Sample LM 5 Block I Hiland Hills hlatrla Drinkinu Watts PwSID 0 SarDlc Rcmaris: 922213- Duc to turbidity the sample wa+ondyzcd in two 50m1 slIquou. ;907 561 5301 x 2/ 5 All Dates/Tlmn arc Alesla Standard Time Printed DateMme 0101/2006 11:40 Collected Datc113me 02/22/2006 14:00 ReceivedDatOTime 02/22/200615:36 Technical Director Stepbsn C. Ede AAmublc Pico Ancheit Purenctcr Rrndu PDL Unu Mahod Ca+aincriD Link Data Date Init Nitrile -N ND 0.100 howl EPA 353.2 B 021=6 1C Nitrate -N ND 0.100 m2/L EPA 353.2 B 02/22/06 SC Natal• Depart:seent Hardness &3 CnCO3 155 Private 2ndividual Analvsis Altuninum 38.0 Andrnony ND Arsco.c 11.7 Barium ND C:dnuum ND Calcium 49100 Chmmlum 2.32 Copps Ili Iron 3510 Lead 224 Mcgne3ium 7810 Musgancx 65.8 Phospborw ND Flwridc 0.101 Chloride 2.30 Potarliunt 695 Solomum ND Sodium 4720 Silicon 1300 Silver ND SOINto 79.2 ThJlium ND s.00 m6r_ S\420 23400 C 02/23/06 0223106 SCL 20.0 ug/L EP200.1 C 0727/06 02/23/06 SCL 1.00 uyL EP200.8 C (<.6) 02123106 0223/06 SCL • 5.00 uyL EP200.8 C (male) 022106 0223/06 SCL 3.00 uyL EP200.8 C (<a2000) 0=3106 O^ WO6 SCL 0303 uyL EP200.8 C (<-51 02/23/OG 02/23/06 SCL 500 uyL EP200.8 C 02/2106 0223106 SCL 1.00 uyL EP200.8 C (<a100) 0123M6 0223/06 SCL 1.00 uz(L 0P200.1 C (x1300) 0223/06 022M6 SCL a 230 ug(L EP200.8 C (o-)(+0) 022106 022106 SCL • 0.200 ugrL EP200.1 C Id15) 0223106 02/23.66 ECL $0.0 uZIL EP200.8 C 0283106 C22106 SCL n 1.00 ug/L EP200.8 C (x50) OVUM C2/2106 SCL 200 uyL EP200.8 C 01=6 0223106 SCL 0.100 my/l. EPA 303.0 B (<n2) 0223!06 DS4 0.100 mzlL EPA 300.0 8 (<a250) 02/28/76 DSH 500 uyL EP200.1 C 0223/06 02t" SCL 5.00 uyL EP200.8 C (<-50) 02/23/06 0223106 SCL 500 uyL EP200.1 C (<-2500001 0223106 022106 SCL 200 uyL EPSOC.1 C 0=06 03 U06 TK 1.03 uyL EP200.5 C (<-100) 022106 02113/06 SCL LOD mglL EPA 300.0 0 (<a233) 03/01106 DSH 1.00 cc& EP200.8 C (<n21 0223106 0223106 SCL Page 2 of 5 03-06-06:11:39 ; 907 561 5301 0 4/ 5 ^�_GQ� 200 W. POTTE13 DRIVE, /11J ANCNORAGF,A-43KA0351a SGSICTBEEWRONMENTALSERIACES T04$C7.30xx347.' Feld 977.SS1.SS01 Drinking Water Analysis Report for Total'Coliform Bacteria 1 II 06J 0B55q-* REAM WAU=ONa ON R1MSt IC[B&r01tC COLLECTING SWL1 ! 111IIIMUST St!COMPLETMBYWATMt3UI-PUBA.....•• . • •....•.•• • .. - . •.. .-� IILI PRrvATZ WATER SYSTMA ❑ Sena Raw" ❑, senauann p AsadAA&ft' Qs.nawNaw . ri u .n • a�e4 v sant n Acem sAMPLC COLLCCMN: I. W.. Yom..•\• •.•V\ mw � Zz o 6 tr INITYPE: XAadtlne 11 Treated Water Tone: Z ao AM 9 0 ." 0Repeet Sempla treated Water Locadenl• to{' S elk wuA N;lk s/A (ratertotabno. Ca4dor.R(b� d $�1 •�hl,�g� Specht Purpose - FIIao«. rransporad le Las M WIPM& K CdMdtar Other. TO BE COMPLETED BY LABORATORY BagEll ReulYlnr. Data: ,-2 ❑Saiqpkov30Mumdd: • ❑ RUSHSAMPLi • Time: n, RwbmaY ee unnlhbY Tamp: 61 ❑ w wawar Q,'ioro M: . For Lealore ''� Odvery Method: c Faxit ReteMad by: —T•7 <- Camra+oda: • • V � ...................................................»............................».......................................................... rbl r Yalf fteord: sant n Acem • MMO•MUG pW RESULTS: ANC PSK AM Ana"Lat.Man: mto TdalrpL6.a �� naa.R6Ye• A,Wyat: 7F' • E Cot: �- Sart to Cart Aealyscal Se "L VEMSOME FILTZK REYJLTS: Phoned Q find Q OindCaeR L�$ Cp'oNr✓iMb.i.'. ��amhrans filter v daaso: IVa 4-0/" soya%br, LJ anb= (NA.) ......: r ``. ICZ SaLsfactory ,e Unaabafeetory Cz 1MK.T..M�v.t.w ✓-- RportdS)r OatoRlrne: )y��� /,Kr" de.a..e...r earraa Iwaeawaotww�ao.po.a•aaal�nocuueNnToants.r Pp�eeat wrm txnos�aa Farm S FW -0453 12!:7,03 Page 4of5 MUNICIPALITY OF ANCFIORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services Ak On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D.�'u-q(o HAA #_1� P( S\SL 1. GENERAL INFORMATION Complete legal description Lot 5; Block 1; Hightand Hitt,5 III Location (site address or directions) Haand Road Property owner Patki.ck Munphy Day phone Mailing address C/O REMAX OF EAGLE RIVER 16600 Centen62.e2d Dk ve Lending agency Mailing address Agent EVA LOKEN/ Remax Eag2e RiverL Address 16600 Cen-ten6iad Dn i.ve Eag2e Rivek, Unless otherwise requested, HAA will be held for pickup 2. NUMBER OF BEDROOMS: 2 3. TYPE OF WATER SUPPLY: Individual well —XXX_ Community well Public water Day phone Day phone 694-4200 AK 99577 G-4(, Rive#., AK 99577 NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. h. TYPE OF WASTEWATER DISPOSAL: Individual on-site XXX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Franl MOA 921 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 17034 Eagle River Address Engineer's signature 6. DHHS SIGNATURE Approved for Z bedrooms. Disapproved. Conditional approval for Additional Comments 4 I Phone_' Date 12' 73 bedrooms, with the following stipulations: By: _—waif _ Date aUTIC 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 (Rov. 1191) Back MOA #21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LoT S SLG,(- i J41(�t-IC11IJb HCCS _Parcel I.D. 6* S A. Well Data Well type If A, B, or C, attach ADEC letter. ADEC water system number Log presen (Y% ) Date completed &Z b'3 Driller SVLL fyrVN WfhT�J2 G�c`CLS Total depth /40( Cased to Casing height % Sanitary seal/N) Wires properly protecte6Y l) '7�3 Date of test Static water level Well flow Pump levell FROM WELL LOG AT INSPECTION jr�124 / �3 /z Z z t - r s r () YjCLo�1 mor=C.�slti� -. a v z g.p.m. _ � �; �.., OPI(Nor. )N SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line 00(1- / b (D (-/- WATER SAMPLE RESULTS: Coliform 0 Nitrate IJI Jy,k�l` I dYG v ; C ,„ �. I /UU X d N i On adjacent lots On adjacent lots z C r� R Public sewer manhole/cleanout 160 Petroleum tank NoNLf Kl-)Cv.lM 2 , o Other bacteria 6 Date of sample: /2- Z —93 Collected by: E3. SEPTIC/49te}N&TANK DATA S � S �,AA. Date installed Tanksize ZOO() 6AL Compartments Cleanout(Y N) Foundation cleanou Y/) (CrJ Depression High water alarm (Y6)7 /%�> Alarm tested (Y/N) Date of pumping / 2/ � 3 Pumper C S F/mell ib SEPARATION DISTANCES FROM SEPTIC/TANK TO: r � Well(s) on lot /C.) -f On adjacent lots //Uy /- Foundation To property line /0 t_ _Absorption field r Water main/service line Zo 1,4- Surface fSurface water/drainage 1'6 YL IIJS/2ECTIO/.J i26xbn_ 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION NDIJ `" Date installed Manufacturer Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DIST, PiRal' D. ABSORPTION FIELD DATA LIFT STATION TO: On adjacent lots Manhole/Access (Y/N) tested off" Level at Surface water Date installed �/ Z� �� Soil rating (GPD/FtZ) 2S �� System type �K 4 ICH Length 4-9 / ?Width S GravelthicknessTotal depth Total absorption area 3%S �-Cleanout present�Y Pel) (D Depression over field (YoI Date of adequacy test /Z � 2-1/ 93 Results (pass/fail) for Bedrooms Water level in absorption field before test U After test C) Peroxide treatment (past 12 months) (Y/N) N UI\)e r\A)0t./1,J If yes, give date A)14- SEPARATION )1 - SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ��iv /� On adjacent lots / U U t Property line To building foundation %S _X To existing or abandoned system on lot N 011JE P1'eCSEe-q_- On adjacent lots 20l-,7tCutbank�/A Water main/service line �U Surface water %�(� ('- Driveway, parking/vehicle storage area 20 /- Curtain drain �ioN� r4J P6rr, s, ,��,./ � �zl < b)A ��2 ON i l�C �J MCA, E. ENGINEER'S CERTIFICATION I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date_of this inspection 1 i), , HAA Fee $ 3Gn� Date of Payment 1 (�- Receipt Number 72-026 (3/93)' Back Waiver Fee $ Date of Payment Receipt Number COMMERCIAL, TESTING & ENGINEERING CO. ENVIRONMENTAL LABORATORY SERVICES Samp-Le Kemarxs: ROUTINE SAMPLE COLLECTED BY: S.S. QC Parameter Results Qual Units ------------------------------------------- Nitrate-N 2.0 mg/L Allowable Ext. Anal Method Limits Date Date ----------------------------- EPA 353.2/300.0 10 12/03 * See Special Instructions Above UA = Unavailable ** See Sample Remarks Above NA = Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT = Less Than D = Secondary dilution. GT = Greater Than (DN SGc Member of the SGS Group (Societe Generale de Surveillance) ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA Init CMR REPORT of ANALYSIS Chemlab Ref . # :93.6489-1 5633 8 STREET Client Sample ID :L5 B1 HIGHLAND HILLS S/D lo- f ANCHORAGE. AK 99518 TEL: (907) 562-2343 Matrix :WATER FAX: (907) 561-5301 Client Name :S & S ENGINEERING WORK Order :73770 Ordered By :R. SHAFER Report Completed :12/06/93 Project Name Collected :12/02/93 @ 13:15 hrs. Project# PWSID Received :12/03/93 @ 09:30 hrs. :UA Technical Director:STrE,PH N C. EDE Released By X41 Samp-Le Kemarxs: ROUTINE SAMPLE COLLECTED BY: S.S. QC Parameter Results Qual Units ------------------------------------------- Nitrate-N 2.0 mg/L Allowable Ext. Anal Method Limits Date Date ----------------------------- EPA 353.2/300.0 10 12/03 * See Special Instructions Above UA = Unavailable ** See Sample Remarks Above NA = Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT = Less Than D = Secondary dilution. GT = Greater Than (DN SGc Member of the SGS Group (Societe Generale de Surveillance) ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA Init CMR MUNICIPALITY OF ANCHORAGE CA1411iDepartment of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL Of: ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # fes. -.''92 - aU HAA # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 5, Block 1 Location (address or directions) 1 Hiland Rd Hills 41 T14N RlW Sec. 28 (b) Property owner _-_Danyl Thompson Telephone : (home) 696-1057 Business2-7�Q�2� Mailing Address 1007 West 3rd Suite 301, Anchorage, Ak 99501 (c) Lending Institution City Mortgage Telephone — 563-0700 Mailing Address 405 W 36th Suite 100 Anchorage, Ak 99503 (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here ❑, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single -Family KI 3. WATER SUPPLY Number of bedrooms 3 Individual Well 0 Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department.of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site 0 Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 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 Eagle River Engineering Services Telephone 694-5195 Address Town Square -Professional Building, 11940 Business Blvd Suite 205, P.O. Box 773294 Date y�6/�G Eagle River, Ak 99577 Lfr.�l' i i�J�J'\�• b� •.r 9m�c Louis A. Butes s 0 '. C8 -573u 6. DHHS APPROVAL/G�,C /�� Approved for bedrooms by /� �� 2 Date C _ Approved Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 7/88) Back Page 2 of 2 S � PSG \v 05���\G ��Q P� MUNICIPALITY OF ANCHORAGE (MOA) ltt��vC�aa``� �o • '� Health Authority Approval (HAA) A�I� 91b CHECKLIST - FEBRUARY 1984] 343-4744 Legal Description: / Tiv �✓ ,�iw �.�, as A. WELL DATA Well Classification _�y'�G'`� If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) y Date Completed /yam%' AJ 2 i-y� _ Yield Total Depth /`�� Cased to'R �` i epth of Grouting Static Water Level 5 ' r Pump Set At Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot /yv To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line �"�`F Sanitary Seal on Casing (Y/N) l _. _ Depression Around Wellhead (Y/N) Al On Adjoining Lots —1 1e.'o lo / ; On Adjoining Lots �' To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by /7''si °er ; Date Water Sample Test Results - ��� e iv,n� c r 5A Comments /.�' />f B. SEPTIC/HOLDING TANK DATA Date Installed % gzs V Size 91 No. of Compartments Standpipes (Y/N) z Air -tight Caps (Y/N) % Foundation Cleanout (Y/N) Depression over Tank (Y/N) N Date Last Pumped Z!e � ✓ s Pumping/Maintenance Contact on File (Y/N) V/' for ^ / Holding Tank High -Water Alarm (Y/N) -Vld Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well /xl: To Property Line 410 / _ To Water Main/Service Line 'Soy To Stream, Pond, Lake or Major Drainage Course Comments To Building Foundation To Disposal Field 72-026 (Rev. 7/80) Front Page 1 of 2 /.. a r C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata / ---:)5 Date Installed Width of Field 5 Type of System Design Length of Field i Depth of Field rel—I C_ 4 Gravel Bed Thickness Square Feet of Absortion Area X75 Statndpipes Present (Y/N) Depression over Field (Y/N) w Date of Last Adequacy Test Results of Last Adequacy Test fir ,_4 r,.% C ;e& 2 SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well Jl� T Pr ert Line _R,J �'cz To Building Foundation / Lot To Water Main/Service Line 0 op y On Adjoining Lots To Stream, Pond, Lake, or Major Drainage Course . To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION /�11/ Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments To Existing or Abandoned System on fi 3a ' To Cutback (if present) N /A F;o Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent(Y/N) S� Pumping Cycles during Adequacy Test. '*Check Permitted Bedroom Rating Against HAA Request" I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Eagle R:vm Engineering Services Company ox a m s --Engineer's Seal Date Eagle River, Air 99577 <- MOA No. i Receipt No. �3 C 3 3 Date of Payment Amount: $ ? - c--) Receipt No Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 NORTHERN TESTiNU LABORATORIES, INC. 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907.2778378 • FAX 274.0645 3330 INDUSTRIAL WAY FAIRBANKS, ALASKA 99701 907-466-3116 . FAX 456.3125 .Eagle River Engineering PO. Sox 773294 Eagle River AK 99577 Attn: Louisa Butera Our Lab 0s A205333 Location/Project: e Your Sample ID: Highland Hills #1 5/1 Sample Matrix: water commantb: Method Parameter _r EPA 300.0 Nitrate• -N Reported Sy: Francois Rodiga Anchorago Operations Manager Report Dates 09/26/90 Date Arrived: 09/21/90 Date Sampled: 09/22/90 Time sampled.: 1200 Collected By: Y%MA Flag Definitions U - Below Detection Limit DL Stated in Result a - Below Regulatory Min. iI � Above -Regulatory Max. F = Below Detection Limit Estimated values Date Unite Result Flag Analyzed Y mg/l 2.7 09/24/90 (,I Fiji U] I I Cea i e n- I C C S 11940 #10r� 940 5usiness Blvd, Suite Z J P.0, Box 773294 Eagle River, Ak. 99577 694-5 195 Fax 694-3297 egol. Y;ner: fL-�-rffl -L— Dote: 9 a/ ,pe of test: I V,'ell now Test El Septic Test Only XWell & Septic Test 13 Other: Time Meter Reading Monitor Level Well Level Tank Level GPM PSI Remarks' ------------------ Ic-C Y ?J- 2.; 4- R vi I gV Department of Health and Human Servicer Tom Fink, 825 "l." Street Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 i��• November 3, 1988 Engineering Evaluation & Investigation Services, Inc. 200 West 34th, Box 267 .Anchorage, Alaska 99503 Attention: Richard Button, P.E. Subject: Waiver Request for Lot 5 Block l Highland Hills S/D Waiver. Request #WR68-069 Dear Mr. Button: Your request for waiver of the required 10 foot separation between a septic system and a lot line has been approved. The waived distance is 8.5 feet. This approval applies to the existing septic system lot line separation only. Any future upgrade to the septic system will require all separations be met or another approval from this department. Sincerely, Daniel J.' Roth Civil Engineer- On-site Services DJR/ljw#7 MUNICIPALITY OF ANCHORAGE MEN l OF HEALTH AND ENVIRONMENTAL PROTIEG t iuN DIVISION OF E14VIRONMENTAL HEALTH CE:HI (FICA I E OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF UN -SITE SEWER AND WATER FACILITY 264-4720 Application Date ___— If/10/a I. GEFIERAL IN OHMATION (a) Legal Description (include lot, block, subdivision, section, township, range) 1.:;u 5� Block I , Hi-gtiland Hills #1 T15N R1W Sec. 28 Location (address or directions) iiyatid Road (i?; �.rni;:arr? name __ Paul FirikelstienTelephone: Home(59rf-7783 ._ Business N� Applicant Address __:)R-91111 Ililand Drive, Rale River, AK 99577 (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ®; Buyer ❑ ; Other LI (explain); (d) Lending Institution Alaska Pacific Mortgage Telephone_ 69y-7780 Address Eagle River, AK (e) Real Estate Company and Agent NSA _ Address _ Telephone (f) Mail the HAA to the following address: aPPJ_cJmp _by applicant 2. TYPE OF RESIDENCE: Single -Family El Multi -Family ❑ Other Number of Bedrooms 3 3. WATER SUPPLY Individual Well ® Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite ® Public ❑ Community,❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025111,84) -�' ;;rIUIN 04St f.: r ONS, TESTS, FILE SEARCH, DA I A ANU IiYi= RIMA i i0N ;c- d hereto and as of the validation date shown below, I verify that my investigation of this ' IcaIth �r�;;; •;.; :` �i sflo•Hs that the on-site water supply and/or wastewater disposal system is safe, functional and adequate and type of structure indicated herein. I further verify that based on the information obtained i;.;r ttx limic,imality of Anchorage files and from my investigation and inspection, the on-site water supply and/or n: rtl system is in compliance with all Municipal and State codes, ordinances, and regulations ir; effect on n,.Q EPGl_E RIVER ENGINEERING SERVICES kJ1tzL6liIVFR, F1K99577 Telephone P-0.-130X-77� 694-5195 6. [)HEP APPROVAL -'J Approved for bedrooms by Approved Disapproved Terms of Conditional Approval Conditional d�tE..p CAUTION ate��) The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in or to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAGE (MOA) MUNICIPALITY OF ANCHORAGEHEALTH AUTHORITY APPROVAL (HAA) DEPT. OF HEALTH & CHECKLIST - FEBRUARY 1984 ENVIRONMENTAL PROTECTION 264-4720 APR1Legal Description: Z 0 7 S CIcIt 1 %"X(_Af 0 ATCiJ SuAo, Ti`/ A/ C Z8 A. WELL DATA E Ci EIV ED Well Classification _ P+2�: If A, B, C, D.E.C. Approved (Y/N) "�,'T Well Log Present (Y/N) `% Date Completed Yield 99 GPM Total Depth /'7o Cased to ao 16F" Depth of Grouting Nll Static Water Level 7s + — Pump Set At'%r"' Casing Height Above Ground */� �+ Sanitary Seal on Casing (Y/N) Y Electrical Wiring in Conduit (Y/N) V Depression Around Wellhead (Y/N) N Separation Distances from Well: To Septic/Holding Tank on Lot`IC' ; On Adjoining Lots /b } To Nearest Edge of Absorption Field on Lot �� �� ;On Adjoining Lots /UOQ To Nearest Public Sewer Line tia,Ie To Nearest Public Sewer Cleanout/Manhole J°"' To Nearest Sewer Service Line on Lot Water Sample Collected by DateSG Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed '/-g,/ Size / (fWl ` No. of Compartments — 2 Standpipes (Y/N) — yf — Air -tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (Y/N) N Date Last Pumped _ 9- u",96 Pumping/Maintenance Contract on File (Y/N) SIA ; for — Holding Tank High -Water Alarm (Y/N) J�� Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: ,tia To Water -Supply Well / Vo To Building Foundation 1 4 ( F To Property Line — la To Disposal Field G To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course N A — Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata / Z Date Installed 9 "g y Width of Field �x 2 z Square Feet of Absorption Area —13,7s- '0 Depression over Field (Y/N) N Results of Last Adequacy Test •S�7 r rs—le'y Separation Distance from Absorption Field: To Water -Supply Well /0% To Building Foundation /S Lot N0,�e To Water Main/Service Line (,g To Stream/Pond/Lake/or Major Drainage Course _ To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION 10//a Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Type of System Design Length of Field �/ 7 Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Y — Date of Last Adequacy Test , y,.A � E -A49-r,I //i✓.N le - )'c fur 3 eSeafrvj n To Property Line /O fi To Existing or Abandoned System on On Adjoining Lots f Do F To Cutbank (if present) Vl� t — Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Date Company MOA No. Receipt No. Date of Payment Amount: $ (�c>Engineer's Seal ` S �o i -; t ��. r°,•+ `'� ti �J^O Page 2 of 2 72-026 (11/84) MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL 11KALT11 DEPARTMENT Of HEALTH AND ENVIRONMENTAL, PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL. CERTIFICATE le _General Information Application Date (a) Le al Description (include Lot, block, subdivision, section, A, :' t'.) Crange) Location (address or directions) Home Business (b) .Applicants Name ecs f ___� /Sl t" / el hone Ic- Applicants Address - r�3�'o�- _7 7 .i i-- (c) Applicant is (check one) Lending InstitutionBuyer. �� ; Other F---1 (explain); (d) Lending Institutionril Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the 11AA to the following address: 2. ape of Residence Single-Family� Mu ti -Family 13 Number of Bedrooms 3. water Supply Individual `dell rX Community I-----.-1 ; Owner/builder ; Other (describe Public Telephone Note: If community well system, must have vritten confirmation from the State Department of Environmental Conservation att2sti.ng "_o the legality and status. 4, ;sewage Disposal. -�`Public-� HoldiTank Onsng i.t,e Y� Community ._ �- .�S Note: If community well, system, must have w[:itten confirmation from the Slate Department of Environmental Conservation attesting to the legality and status. rv�«a 7 of 21 5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information 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 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 regula- tions in effect on the date of this inspection. Name of Firm J �� �; X, S/_9,fr-elei rr-�� ' z� Telephone Address �; �•tf� vcJ �2/ F s f� ,. = < Date oc a rr,s� `} `i (ENGINEER SEAL) {jjj 6 Y e i' % t t ; 1k o.e e/n e n a - • rs . i No. 27�` C DHEP Approval. All'. JUNF ZS, 1371 Approved iorj,-_=,rbedrooms � J 13y e_r - �.. _/.in Approved � Disapprove(] Conditional Terms of Conditional Approval ....... CAUTION TILE 0NICI.PALITY OF ANCHORAGE DEPARTMENT OF HEAI.;1'H ANII ENVIRONMENTAL PROTECTION (DH P) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESE'NT'- ATIONS GIVEN IN PARAGRAPII 5 ABOVE BY AN INDEPENDENT PROFESSIONAL. ENGINEER REGISTERED IN THY STATE OF ALASKA. THE DEEP DOSS THIS AS A COURTESY TO PURQIA RS OF HOMES AND T':IEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHL'P DO NOT CONDUCT INSPECTIONS OR ANALY& DATA BEFORE 11, WIR` IFICATE IS ISSUED. THE MUNICIPALITY OF AFCHORAC E IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DIIEP SEAL) RR4001S [VW;e 2 & ' ] 1--1.9.84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 A. WELL DATA Legal Description: 6- 1?//i / 1- /fie cln lce..,x Well Classification �Yiyev If A; B, or C, D.E.C. Approved(Y/N) y% Well Log Present (Y/N) Date Completed n)ov'z: eaYie1d Total Depth�ltr ! Cased to t "i�,,4 ')ppth of Grouting �/� Static Water Level Q Pump Set At .f Casing Height Above Ground '9 N "I Sanitary Seal on Casing Electrical Wiring in Conduit (Y/N) �/ ^ Depression Around Wbl]head (Y/N) 1!L/ Separation Distances from Well: To Septic/Holding Tank on Lot lee 'z On Adjoining Lots /Ulo To Nearest Edge of Absorption Field on Lot iDo f ; On Adjoining Lots led To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole_ To Nearest Sewer Service Line on Lot Water Sample Collected By L--�21, , �;� _ Date ✓��r�� �r _s Wager Sample Test Results S 7` Convents B. SEPTIC/HOLDING TANK DATA Date Installed Size����� la/ No. of Compartments Standpipes (Y/N) Air -tight Caps (YM) i Foundation Cleanout (Y/N) Depression over Tank (Y/N) j✓Date Last Pumped 71/��G✓ Pumping/Maintenance Contract on File (Y/N) ft for ___ A/ f- Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit Separation Distances from Septic/Holding Tank: To Water -Supply Will lazy 71- To Building Foundation To Property Line /0)- . To Disposal Field To Water Main/Service Line 6`6 '� To Stream, Pond, Lake, or Major Drainage Course 4A Comments [Page 1 of 21 ,�. J 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata �� - Type of System Design %!^e -1 c . Date Installed Length of Field Lf 7 Width of Field Depth of Field 9 Gravel Bed Thickness of f Square Feet of Absorption Area 3'7T 16 Standpipes Present (Y/N) Depression over Field (Y/N)/L/ Date of Last Adequacy Test /1/& 4,J Results of Last Adequacy Test A�C c,/ Separation Distance from Absorption Field: To Water -Supply Wall /, f To Property Line To Building Foundation /-5-0--- To Existing or Abandoned System on Lot A',O-W - ; On Adjoining Lots -? o ;4 - To To Water Main/Service Line 4evalbr- /d �L- To Cutbank(if present) IZ1/4 To Stream/Pond/Lake/or Major, Drainage Course /t-/-/,4 To Driveway, Parking Area, or Vehicle Storage Area /d 3- Convents ACcwcCS 7+c+v. Ac 4ihi et/k,,- �x^-%— 54 (' D. LIFT STATION Date Installed Siva in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(YM) Convents J Dimensions Manhole/Access (YM) "Pump Off" bevel at Vent (YIN) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conforrred to all MOA HAA Guidelines in effect on the date of this ss /in9jpeecction. p..� Signed Le Date l 11��„e.a...aa •�' �� Company Yc'l)/) MOA No.0 1/ t, >c 49 Rs a �'. (,ire s_ ...s,.iy • •a •a •w KB1/ / d5 s .......... n. 7• o. 222 F )UNE 7.5, 1971 (Page 2 of 21 �n 2-15-84