No preview available
HomeMy WebLinkAboutROCKHILL BLK 4 LT 4.. 'I 11 ► 1 k,.ch4 4004I � �l"31 -mo Lln?a -1(n Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP231230 PID Number: 015-063-16 Dwelling: ❑■ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New A Upgrade Name David Payer A ORPTION FIELD EDDD Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 9835 Lone Tree Dr Other Phone Number of Bedrooms Soil Rating Total depth from original grade 907-699-1236 3 /sF Ft. LEGAL DESCRIPTION Depth to pipe invert from original a Gravel depth beneath pipe F . Ft. Subdivision Block Lot Rockhill 4 4 Fill added above original grade Gra length Ft. Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Dista between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between tre es From Tank Field Tank Line Ft2 Well >100' >100' N/A N/A >25 TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1250 Gal. Surface Water >1 >1 00' N/A N/A Material Plastic Number of compartments 2 Lot Line >5' >6' N/A N/A NA Foundation >10' >10' N/A N/A STATION Manufac Capacity i Remarks Tank upsized at homeowner's request Gal. Insulation placed over tank Alarm location Elec ailed by PIPE MATERIAL House to tank D3034Tank to D3034 drainfield Installer A+ Home Services Drainfield D3034 CO/MTD3034 Inspector B Schiller BENCH MARK (Assumed elevation) 100 ft Inspection 1m 9/g/23Location and description dates: 2nd m th Threshold back man door 3rd 4 ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Q,,�i F� AC,q l��l Conditional Approval: Datelow �G is o*:47 •*/ Septic System�F�, Benjam(n=Schiller •, CE 12592 Approved Dat �!'srF�• /- /19 •��C��,,: lll;0 pROFESSlO�� aroval o�.thiis does not include well permit require ents ®\®dam ROCKHILL SUBDIVISION, BLOCK 4 LOT 4 PERMIT # OSP231230 PID # 015-063-16 I �ALLI VALLI VUE ESTATES LOTS TO THE SOUTH ARE ON A COMMUNITY WATER SYSTEM) LOT 20 LOT 21 ENGINEERING *j.. `I�� 497H . .. ....... Be* i Schiller CE 2592 9/22/23, C\ AS -BUILT PLAN 0 50 100 hM EM FEET 111=50' A B FCO 6.3 1 64.6 MH 15, - 62.3 SV 18AE 6-4-.6 F 2C0 6 66.7 6 7 LEGEND CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEAN( FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE �• • ••ma ul PERMIT # OSP231230 ENGINES R PID # 015-063-16 PROFILE AS -BUILT (NO SCALE) AW • • ' • Benja•'n Schiller • • • 1 �Fc CE 12592 •���i ���Ole�pROFESSIONP�.®!^'�" MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP231230 Work Type: SepticTank Upgrade Tax Code Number: 01506316000 Site Legal Address: ROCKHILL BLK 4 LT 4 G:2438 Site Mailing Address: 9835 LONE TREE DR, Anchorage Owner: PAYER DAVID C & Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date: Expiration Date c rh_ S, m Q f Department Lot Size in Sq Ft Total Bedrooms: 8/3/2023 8/2/2024 55190 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: The tank is required to be 10' from the foundation. 7 - aro � : ,Urclon 1 . - Issued By: Date: g -� 3 c, ., r; Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 015-063-16 Property owner(s) Dave Payer Mailing address 9835 Lone Tree Drive, Anchorage, AK 99507 Site address 9835 Lone Tree Drive Day phone (907) 699-1236 Legal description (Sub'd., Block & Lot) Rockhill Subdivision, Block 4 Lot 4 Legal description (Township, Range & Section) Lot Size 55,190 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank ❑X Upgrade ❑ (D) E]❑ Holding Tank ❑ RenewalDuplex Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 0 22 Waiver Fees: Date of Payment: 7,63th-3 Date of Payment: Receipt Number: 057 413 D Receipt Number: Permit No. 05P Z3 12 30 Waiver No. Permit App_'-'-:. ._.,:c July 25, 2023 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Rockhill Subdivision, Block 4 Lot 4 - 9835 Lone Tree Drive Septic Tank Replacement Dear On-Site Services Engineer: The owner of the above lot has a septic tank that has reached its end of useful life, so we are submitting this permit application for its replacement. The attached site plan identifies the location of the home as well as the wells and septic location. No conflicts exist between this proposed system and any other wells or septic system, whether on this lot or adjacent lots. We are replacing the septic tank with the same size designed for 3 bedrooms. The new septic tank will be a minimum of 100’ from all wells and surface water. Please refer to the attached plan for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231230, Deb Wockenfuss, 08/03/23 // // // // // // // // // // // // // // // // // // // // // // // // // // // / / / / / / / / / / / / / / // // // // DECOMMISSION EXISTING TANK PER UPC Benjamin Schiller CE 12592REGISTEREDPROFESSION A L E N GINEER 1"=50' CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND 2CO ROCKHILL SUBDIVISION, BLOCK 4 LOT 4 FEET 0 50 100 FCO 3-BDRM HOME SEPTIC PLAN 7/25/23 10' UTILITY EASEMENT NEW 1,000 GAL SEPTIC TANK EXISTING TRENCH TO REMAIN IN SERVICE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231230, Deb Wockenfuss, 08/03/23 X X X X X X X X X X X X X X X X X XXX X X X X X X X X X                                  L =5 2 .3 6 R =5 0 .0 0 N 4 8 ° 0 5 ' 2 4 " W 3 4 0 . 8 1 N0 0 ° 0 4 ' 4 0 " W 7 6 . 6 3 S89° 53' 24"E 269.58 S 1 2 ° 3 3 ' 2 4 " E 1 4 7 . 0 0 S0 0 ° 0 6 ' 3 6 " W 1 4 4 . 7 5 3 $ 9 ( '  ' 5 , 9 ( : $ < T E SS S S S S W /27 /27 /27 /2 7    75 $ & 7  % /27 /27 /RW%ORFN 5RFNKLOO6XEGLYLVLRQ 6T)W /RQH7UHH'ULYH 6WRU\:RRG)UDPH+RXVH :LWK$WWDFKHG&DU*DUDJH ℄  / 2 1 (  7 5 ( (  ' 5 , 9 (      &+,&.(1&$*( 6+(' 6+(/7(5/2*,& &29(5('6725$*(    G E     : ( / /  5 $ ' , 8 6  87,/,7<($6(0(17 (' * (  2 )  3 $ 9 ( 0 ( 1 7 T    PROFESSIONAL SEAL Date:Frontier Surveys, LLC Project No: 650 W. 58th Ave. Suite E Anchorage, Alaska 99518 As-Built Survey of: www.frontiersurveys.com Frontier Surveys, LLC I, Pierre Stragier, hereby certify that this Mortgage Inspection Survey was performed by me, or under my direct supervision on Plat:Grid:Ordered By: 907.460.1686 - info@frontiersurveys.com This survey complies with the ASPLS Mortgage Location Standards. The survey represents visible improvements and conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances should this document be used for construction or for establishing a boundary or fence line. July 12th, 2023. Legend: Scale 1" = 50' Gas Meter Electric Meter/Outside Power Deck Septic Fence Lot 4, Block 4 Rockhill Subdivision David Payer 23-281 07/13/2023 80-9 SW2438 Elec. Pedestal Water Well Tel. Pedestal Culvert -XO R E GISTEREDPROFESSIO N A L L A N D S URVEYORPierre M. Stragier No. L.S. - 9812 G E S W x T E General Notes: 1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright Laws. 2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey. 3. All measurements/setbacks are to the visual/apparent building footprint. 4. All dimensions to property lines are plus/minus 0.1ft. Frontier Surveys, LLC Project No: 23-385 Date: 09/20/2023 Ordered By: David Payer Plat: 80-9 Grid: SW2438 Scale 1"=50' LOT 6 .\ FpGFOF �<� pq�F,trFNr OZ / \ O j ti360 �\ LOT 5 O 1 d gyp° I \ � O \ .�.3n m �a r 30.3 23 `c tij A \ y 3.0 � \\� �hf�4s5 121 699 r LOT � o• 4 Lot 4, Block 4 k 00 34.9 12 Rockhill Subdivision / U 55,190 Sq. Ft. COVERED STORAGE 9835 Lone Tree Drive / 2 Story Wood Frame House i With Attached 3 Car Garage k � 3 e �x 3 0 0 ur 0 x x_ x— x 2 10' UTILITY EASEMENT — — — — — — ---- S89* 53'24E —S89°53'24E 269.58 .Legend: __ --- — _ - ----- Electric Meter/Outside Power a Culvert Je Elec. Pedestal y Gas Meter ® Deck -x- Fence LT_1 Tel. Pedestal LOT 21 c .S; Septic w; Water Well 1'7" Septic Tank M.H. General Notes: 0 2 11 5 50 100 1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright Laws. 2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey. - 3. All measurements/setbacks are to the visual/apparent building footprint. 'r' r 4. All dimensions to property lines are plus/minus 0.1fL ®®� This survey complies with the ASPLS Mortgage Location Standards. The survey represents visible improvements and „�-a- l conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any �,�� OF A(,q kl inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the '®' S , existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances should this document be used for construction or for establishing a boundary or fence line. 9 TH :* �� As -Built Survey of., ,® Lot 4, Block 4 Rockhill Subdivision 9 Pierre M Sirper • j 1, Pierre Stragier, hereby certify that this Mortgage Inspection Survey was performed by me, or No. L.S. - 9812 ® under my direct supervision on September 19th, 2023. Sep 21. 2023 klj IOFESS10tlN �Pa� Frontier Surveys, LLC FRONTIER, ® 650 W. 58th Ave. Suite E Anchorage, Alaska 99518 W�� 907.460.1686 - info@frontiersurveys.com PROFESSIONAL SEAL www.frontiersurveys.com 6- I6- �' 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL. PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 2.64-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME 66A)ST PHONE ?41 el ❑ UPGRADE MAI LIN ADDRESS ��f,���7 7 e LEGAL SLCC•RIIPTIION act, h-21 LOCATION •---.�„ be �- NO. OFULDROOMS Uy DISTANCE TO: W `�® Absorption area C 5— Dwelling / !� PER 0. B/6 wQ I- Manufacturer Materi.y ! No. oj�ompartments c.L- U) Liq. 768n gallons IF HOMEMADE: Inside length Width Liquid depth 6 YDISTANCE _j 02 TO: Well Dwelling PERMIT NO. 2 z H Manufacturer Material Liquid capacity in gallons O w DISTANCE TO: Wel= G6®' Foundation Nearest I t i e /� PERM N �°' dtS`� J LL Z F Z w No. of li Lengt each e t3 Total I links Trench- ' th �j inches Distancy be a lines 4 / HTop p of the to finish grade Material beneath tile A. inches Total ff c ive bsorption area w Length Width Depth PERMIT NO. Q F wd Type of crib Crib diameter Crib depth Total effective absorption area LU DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERMIT NO. W DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST R//A (T(S�I N 45-0 INSTALLER 44/..••i` REMARKS e - d .Aj G I 04a > OkA / APPRO DATE LEGAL THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: a.0 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD- THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. ` THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCHVHTION (IN FEET). �UE. 0 U I F-2 E=_ E-0 �� �1���­- jLt2i 0:3 F=1 L_ I CH r -4!F3 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. �:an > ��������������� ����� ����������� BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL HND 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 H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND TO H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 2:0 DAYS OF THE WELL COMPLETION. OTHER REIDUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIH13R8MS ARE AVAILABLE TO INSURE PROPER INSTALLATION. �LEE F�:.Pl 1 "7- �F-0 1 lFZ"E=_!E"- �������F---4 3:JL , �a-:31_ I CERTIFY THAT 1: I HM FAMILIAR WITH THE REQUIREMENTS FOR 8N -SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3' I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS. SIGNED:~�_�_~_~�__~~~_���~�-~--~~-�~^~-~��~--��� JF*-,*.' CONST. ISSUED BY- F V4. 0 q'�h ��n jr-4 ���` E/�u1L'9 DEPARTMENT HEALTH AND ENVIRONMENTAL ! TECTION / ^ 825 'L' STREET, ANCHORAGE, GK 99501 /) u/�4 ° 264-4720 ���� "r -4C> (J��F� �������� ������/ &. / PERMIT NO ( 810515} Uwm APPLICANT JAK CONST. ]511 CHIO<HT ST. 694�21"� / #��/ LOCATION LONE TREE DR SUB ` LOT SIZE 40000 SQUARE FEET LEGAL. LOT 4 BLK 4 RQCKH%LL TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS =; 3 SOIL RATING (S{) FT/BR)= 150 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: a.0 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD- THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. ` THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCHVHTION (IN FEET). �UE. 0 U I F-2 E=_ E-0 �� �1���­- jLt2i 0:3 F=1 L_ I CH r -4!F3 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. �:an > ��������������� ����� ����������� BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL HND 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 H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND TO H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 2:0 DAYS OF THE WELL COMPLETION. OTHER REIDUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIH13R8MS ARE AVAILABLE TO INSURE PROPER INSTALLATION. �LEE F�:.Pl 1 "7- �F-0 1 lFZ"E=_!E"- �������F---4 3:JL , �a-:31_ I CERTIFY THAT 1: I HM FAMILIAR WITH THE REQUIREMENTS FOR 8N -SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3' I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS. SIGNED:~�_�_~_~�__~~~_���~�-~--~~-�~^~-~��~--��� JF*-,*.' CONST. ISSUED BY- F V4. 0 DEPARTMENT' ry HEAL TN FWD rJiv Li?""T AL PROTECTION 825 ''L-' STR ET- # 54C, -50t PERMIT fl a. K et is APFLIJDANT FIX CNW3C_ T-5tt CHILKHT St. b9$ 313t LE138Lor 4 SLK 4 Pf:PrKH ILL '9J8 Liar .S i Ze 40000 a'r UFW. €= $, TITIFE Or -:-OIL fW33ORP'T I ON *�TEM IS. T t a i tM WJN NUMBER OF SEC4")Y*$°a` = 3 -"(L RAT UM C a9 � i'1i3R3 = 3.:59 TW REQ I D °5 I OF 11-tE `-+O TL H si r i om SYSTEM IS: THE Lr# -R #J rH ofpEji S I ON IS THE LCMTtf (IN FE( rp t)r THE T ir;H 12R 4�1 ilk If=tTi THE DCP TH OF R Ti'.Etlr:li OR PIT IS TW D 4T NS Imo. nW-EN TW- ��!'tt3FTHE '- # THE BOTTOM rip= 'rl* EST ION ( LN F r)- THERE 15 NO SEr IJIDTai FOR TM. K- !el THE 11MVVEL DEPTH I°3 n V- 14I N Iiir3Ti LFP rH CIRRYEL BETWEEN Ttie OUTF A .1 P1 AND TW 80TT011 13- THE rFWM*AT'TOH t IN FEED. PERM € T l- L # Cid r HRS Ti #- FR'E IW3 I B f Iry to lWoRN TH I'4 I FR TP04 C [UR IM T ti err iTI= tt rTI: ry My ��t�b� RDJR--NT TO This FsRopeirty AW n -E #-N-i''�.F ILL IW -v +3F WWW 'FT'STE€! Id I TM`viC raw. IRSPECT ION AND fVPFTfO SY THIS c*f4jRrpj04r N ILL13€•IEt; T T► t4 I ii URA Ca t'STAWDE 2J-xrWEEN R i°ELL Am e im- a i Td -siame D I SPrjsflL SYSTEM I i Fir FOR A 3-'RUMrL GELL OR VW To Zee Fe y` FA13m A Fus Icf b*LL moalol a t.pN TM r�ft t>f PLO...Iu WELL. IitNEfVjM I}€° it pROii n PRIvATE fjEU_ To a PRIYA SaAJER LINE IS 25 F&EY AM TO €8 !_`iNVUNI TY S%L IW- IS 75 FEET. W -LL LIXt3 RRE REQUIRED AND ws r BE RETIJRWO TO Ti- OEPARTHE14T W I ni IN 30 We; OrWR t AROW-Hrs FW WPLY. AIS' #:�awrkfjc r loll DiffiRRM fRE I 1:"I T LF Y THRY L. I viii FAM IL t HR t4 I rH Tw, w3FJ-WJ6 Apio WELLS S w T FIV.TH Y THE Ml ICIFa IT'0 riF a� � � : L WILL t05T l- THE 5 v"-; T ii IN WI FST T148 'C 's. I mic i io 'WT THE ON -S I Tse �`� rEm I m f?Et- ! - I spr lmt LF Tf ! t `a i lyEt A TO I F�"�. UDE THAN 3 BEORMNS. 0 SOILS LOG MUNICIPALITY OF ANCHORAGE ae^. DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST \\ % 825 L. Street, Anchorage, .Alaska 99501 264-4720 SOILS LOG -PERCOLATION .TEST PERFORMED FOR: / G0 100 ( DATE PERFORMED: J Uyk �' / LEGAL DESCRIPTION: t` DEPTH (FEET) 1 Z- , LA-)__ �5 SLOPE -1� �o f313C..Cs Som 5,111— WAS ,111WAS GROUND WATER A -A) ENCOUNTERED? V� J IF YES, AT WHAT DEPTH? NQ. 1732-E June 22, 1968 COMMENTS PERFORMED BY: (��N✓ / CERTIFIED BY: tea/ DATE: SITE PLAN MEN MENEM �om®■m®■®® SENO ®®®M®® MEN ENO 0 ON ONE M ONE ��sr®loom ■111M®1011011 ® ONO MENEM SOMEONE INNMENEEN Lome 7W EE- DR, C/2, i L D D E Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT Wei I Log For..,.. ........ ...........it .......... I ........ .......... ...... ...... .1, .......... Location ..... �,o,-r .... 4,,..g L K.4 ........ F- 65 c- k,,- Hitt- SuZ3 .... .... .... I ... .... 11 ... I .... 1. ................... 11111 .... .................... 6 - zz - 1q, I Datecompleted ................... ............................................................ Depthof well............ ............... ................ .................... Size of casing........ ..................... ................ Distance to water ......... .............................. o ............................... Distance to water while pumping. ........-.Z7.'.i ................... ............... at rate —Z-4+ of ................... .............................. gallons per hour. Formation —from--- to G i C -i54 : 4C, 1 76 �s fZ4 VZE� Drillu DELTA DRILLINO COMPANY ORA @QX 304 @ ANCHORAG9, AI=A@KA 0@007 MUNICIPALITY OF ANCHORAGE Development Services Department T Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 015-063-16-000 Expiration Date: Legal description ROCKHILL BLK 4 LT 4 Site address 9835 LONE TREE DR Anchorage AK 99507 Current property owner(s) PAYER DAVID C &MATZ ANGELA C 1/6/2023 X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 10/6/2023 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval—June 2022 MUNICIPALITY OF ANCHORAGE 0 Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 015-063-16 Complete legal description Rockhill Block 4 Lot 4 Location (Site address) 9835 Lone Tree Drive, Anchorage, AK 99507 Current property owner(s) Dave Payer Day phone (907) 699-1236 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: 0 Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: 0 Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel 0 Plastic ❑ Concrete ❑ Fiberglass Age < 1 yr - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed 0 Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ S Waiver Fee $ Date of Payment � 2 fo202 Date of Payment C COSA # O S 2� �3 Waiver # COSA Application—June 2022 Legal Description: Rockhill Block 4 Lot 4 Parcel ID: 015-063-16 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached), Date drilled 6/22/81 Total depth 70 ft Cased to 70 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA 7/10/23 Static water level at beginning of test 35 ft. Comments B. TANK DATA Measured operating fluid level in septic tank N/A Date of pumping New Installation ❑ Required maintenance completed, if AWWTS Comments: 1.250 -gal tank installed D. ABSORPTION FIELD DATA Which system tested (date installed) 6/16/81 ❑ ALL standpipes present per record drawing Total measured depth from grade 7.9 ft (max) Measured depth to pipe invert from grade 4.6 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ❑ Monitor tubes go to bottom of effective. If not, state depth into effective 3.3 ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced N/A gallons N/A date Any rejuvenation treatment (past 12 months) N/A If yes, enter date Comments/Deficien COSA Checklist June 2022 Well production at time of test 8.4 gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes ❑ Nc ❑ Coliform bacteria is Negative Nitrate 0.869 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L FE-1Arsenic less than MRL (ND) Collected by Forge Engineering Date 9/8/23 C. LIFT STATION fired maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 7/10/23 Results ❑ Pass Fluid depth prior to test _ Water added 894 gal New fluid depth 29 in Elapsed time 1440 min 15.5 in Final fluid depth 13 in Absorption rate ' 450 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 72 in Effective depth used 45 in Effective depth remaining 27 in E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100' F-1 Yes if No 98 ft Q Yes if No ft Neighboring Tank > 100' ❑ Yes if No 83 ft Private Sewer/Septic Line > 25' FE� Yes if No ft Absorption Field on Lot > 100' E] Yes if No ft Holding Tank > 100' Q Yes if No ft Neighboring Absorption Fields > 100' 86 Animal Containment > 50' R Yes if No ft ❑ Yes If No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Q Yes if No ft Q Yes if No ❑ N/A - Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' Fm_1 Yes if No ft Surface Water > 100' Yes if No Tank to Property Line > 5' Yes if No ft Wells on Adjacent Lots: Field to Property Line > 10' ❑ Yes if No 6 ft Private Wells > 100' Yes if No Water Main > 10' Yes if No ft Community Wells > 200' Q Yes if No Water Service Line > 10' Fm� Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS Waiver #WR85-053 ft ft ft ft G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Forge Engineering Engineer's Printed Name Benjamin Schiller, P. E. COSA Checklist—June 2022 Phone (907) 522-7773 Date 9/22/23 i ..w_-...... �� . �•,. BenjakrrySchiller •:� F CE 12592 •0 i k�PROFEWONt , vvZ: X X X X X X X X X X X XXX X X X X X X X X X                              L =5 2 .3 6 R =5 0 .0 0 N 4 8 ° 0 5 ' 2 4 " W 3 4 0 . 8 1 N0 0 ° 0 4 ' 4 0 " W 7 6 . 6 3 S89° 53' 24"E 269.58 S 1 2 ° 3 3 ' 2 4 " E 1 4 7 . 0 0 S0 0 ° 0 6 ' 3 6 " W 1 4 4 . 7 5 3 $ 9 ( '  ' 5 , 9 ( : $ < T E S W /27 /27 /27 /2 7    75 $ & 7  % /27 /27 /RW%ORFN 5RFNKLOO6XEGLYLVLRQ 6T)W /RQH7UHH'ULYH 6WRU\:RRG)UDPH+RXVH :LWK$WWDFKHG&DU*DUDJH ℄  / 2 1 (  7 5 ( (  ' 5 , 9 (      6+(' &29(5('6725$*(    G E     : ( / /  5 $ ' , 8 6  87,/,7<($6(0(17 (' * (  2 )  3 $ 9 ( 0 ( 1 7 T    SC S S SSS S PROFESSIONAL SEAL Date:Frontier Surveys, LLC Project No: 650 W. 58th Ave. Suite E Anchorage, Alaska 99518 As-Built Survey of: www.frontiersurveys.com Frontier Surveys, LLC I, Pierre Stragier, hereby certify that this Mortgage Inspection Survey was performed by me, or under my direct supervision on Plat:Grid:Ordered By: 907.460.1686 - info@frontiersurveys.com This survey complies with the ASPLS Mortgage Location Standards. The survey represents visible improvements and conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances should this document be used for construction or for establishing a boundary or fence line. September 19th, 2023. Legend: Scale 1" = 50' Gas Meter Electric Meter/Outside Power Deck Septic Fence Lot 4, Block 4 Rockhill Subdivision David Payer 23-385 09/20/2023 80-9 SW2438 Elec. Pedestal Water Well Tel. Pedestal Culvert 6HS R E GISTEREDPROFESSIO N A L L A N D S URVEYORPierre M. Stragier No. L.S. - 9812 G E S W x T E General Notes: 1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright Laws. 2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey. 3. All measurements/setbacks are to the visual/apparent building footprint. 4. All dimensions to property lines are plus/minus 0.1ft. SC Septic Tank M.H. Parcel I.D. 015-063-16 Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Complete legal description Rockhill, Block 4, Lot 4 Expiration Date: —� f � Location (site address) 9835 Lone Tree Drive Anchorage, AK 99516 Current Property owner(s) Kevin & Nicole Mitchell Mailing address Real Estate Agent Day phone 562-2336 9835 Lone Tree Drive Anchorage, AK 99516 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: Three Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well El Individual F Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver/Variance request Received by: l /.X11 (/L&q a VI/ U Date: COSA to be released to the engineer, unless otherw a req ested by the engineer. COSA Fee $ 5a (I — Date of Payment 319 /1(0 Receipt Number do2.s'a' COSA# SGIIy0_F 6 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 Anderson Engineering Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. 6. DSD SIGNATURE 0 System #1 Approved for System #2 Approved for Disapproved Conditional approval for bedrooms bedrooms Phone 522-7773 Date 3/2/16 aLvV � . 49th ..'�'� MICHAEL E. ANDERSON No. CE -4381 bedrooms, with the following stipulations: Original Certificate Date: -,5 '—� 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. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSAblueshee[r'- L, c c If more than 1 septic system is on the tot: COSA Checklist # Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: Rockhill, Block 4, Lot 4 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 6/22/81 Sanitary seal (Y/N) Y Total depth 70 ft. Cased to 70 ft. Date of test Static water level FROM WELL LOG 6/22/81 27 ft. Well production 40 9 - p.m -WATER SAMPLE RESULTS: Coliform 0., colonies/100 mL Nitrate '704 mg/L Arsenic ND ug/L Date of sample: 2/3/16 B. SEPTIC/HOLDING TANK DATA Parcel ID: 015-063-16 Well Log (Y/N) Y Wires properly protected (YIN) Y Casing height (above ground) >18 in. AT INSPECTION 2/8/15 43 ft. 7.25 Collected by: Anderson .Engrg. Tank Type/Material Septic/Steel Date installed 6/1981 Tank size 1,000 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 7/14/15 Pumper Northland Pumping C. ABSORPTION FIELD DATA Date installed 6/1981 Soil rating (g.p.d./ftz or a/bdrm) 150 SF/BDRM System type Deep Trench Length 39 ` ft. Width 3 ft. Gravel below pipe 6 ft. Total depth 11.25 ft. Eff. absorption area 450 ftp Monitoring tube Y Depression over field fnJ Date of adequacy test 2/15/2016 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 465 gal. New depth 20 in. Elapsed Time: 1,440 min. Final fluid depth 0 in. Absorption rate >= 450 g p d Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed Size in gallons _ "Pump on" level at in. "Pump off" level at Datum Cycles tested _ E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot _ Absorption field on lot 98'* >100, Public sewer main >75' Manhole/Access (YM) in. High water alarm level at in. Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout >100, Sewer /septic service line >25 Holding tank >75' Animal containment areas >50' Manure/animal excrete storage areas >100, SEPTIC/HOLDING TANK ON LOT TO: Building foundation > Property line >51 Absorption field >5F Water main >10' >10' >100, Water service line Surface water Wells on adjacent lots >100, ABSORPTION FIELD ON LOT TO: �* Property line 6 Building foundation >10' Water main N/A Water Service line >10, Surface water >100, Driveway, parking/vehicle storage >1 O' Curtain drain None Noted Wells on adjacent lots >100, F. COMMENTS *See Waiver No. WR85-053. G. ENGINEER'S CERTIFICATION l certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Michael E. Anderson, P.E. Date 3/2/16 COSA brown sheet 10-10-12.doc MICHAEL E. ANDERSON a Municipality of Anchorage • "� Development Services Department o Building Safety Division SA On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage; AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY .DWELLING Parcel I.D. 015-063-16 HAA# { �� .1. GENERAL INFORMATION Expiration Date: Complete legal description LOT 4, BLOCK 4; ROCK HILL SUBDIVISION Location (site address or directions) 9835 LONE TREE DRIVE * ANCHORAGE, AK 99516 Current Property owner(s) MATT WARD Day phone 562-1025 Mailing address 9835 LONE. TREE DRIVE * ANCHORGE, AK. 99516 Lending agency Mailing address Real Estate Agent Mailing address ALBERT CIRCOSTA w/ PRUDENTIAL Day phone Day phone 563-5500 3201 "C" STREET SUITE 200 * ANCHORAGE, AK. 99503 - - - ---- -----Unless otherwise -requested; -HAA will be held by DSD for -pickup.- --- - - --- -- -- - 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 Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to *homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. _(Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional 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 Health Authority 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 tiles 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 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 other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE -Approved-for- � -.bedrooms. - ----- ----- ------- .Phone 337-6179 Date Zv d J ffr y A. Gam SS. - Prof esqlol s.-Professiol °, � Disapproved. Conditional approval for bedrooms, with the fllowing stipulations: <<<�� i-cy OF A A!16 `J ON-SITE •� ' 1AIA- AIr1 _ : rn C WASTEWATER : ... • DDnrPA111 • Attachments: � HAA Checklist Manitenance Agreements JJJJ�O • • • • • .. •��``````�� Septic System Advisory Supplemental Engineer's Reort �l/IJI)ttt1� Well Flow Advisory Other By: 'Original Certificate Date: r (Rev.12101) Municipality of Anchorage Development Services Department _.. Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. I P.O. Box 196650 Anchorage; AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 i HEALTH 'AUTHORITY APPROVAL CHECKLIST Legal Description: LOT 4, BLOCK 4;'.ROCKHILL SUBDIVISION Parcel ID: 015-063-16 . A.' WELL D ATA Well type' `PRNATE If A,'B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 6/22/81 Sanitary se YES Wires proper) al WN) y protected (YIN) YES Total depth 70 ft. Cased to 70 ft.'Casing height (above ground) 12+ in. j 'FROM WELL LOG . AT INSPECTION Date of test 6/22/81 4/15/2004 Static water level 27 ft. } 42 ft. x Well production 40 g.p.m 9.0+1g.p.m. WATER SAMPLE RESULTS: Coliform !I ` 0colonies/100 mL Nitrate •508 mg./L. Other bacteria 0 colonies/100 ml. Arsenic: I N Amg./L. Date of sample:4 16 2004 Collected by: GEG, ltd. 'B. 'SEPTIC/HOLDING TANK DATA" *IN CRAWL SPACE Tank Type/Material STEEL Date installed 6/1981 E Ij Tank size 11000 gal. Number of Compartments 2 Cleanouts'(Y/N) YES r; N/A Foundation cleanout (Y/N) *YES Depression over tank (Y/N) NO High water alarm (Y/N) " Date of pumping 4/15/2004 Pumper McDONALDS PUMPING C. ABSORPTION FIELD DATA s. Date instailed 6/1981 Soil rating i p.d./ r itlbdrm) 150 System type TRENCH Length i 39 ft. .Width 36 ft. Gravel below pipe 72 ft. Total depth 11x5 ft. Eff.'absorption area 450 ft Z Monitoring tube **YES Depression over field NO Date /2004 ,Resultsf(Pass/Fail) PASS For 3 bedrooms D to of adequacy test 4/15 G Fluid depth in absorption field before test 0 in. Water added 606 gal. New deptif12.5in. k Elapsed Time: 1234 min. Final fluid depth 0' in. Absorption rate >= 450+ g;p,d, s i ' E Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date — **SUMP ONLY EXTENDS 9.5" i BELOW INVERT OF LATERAL I ***AT TOP IOF LATERAL D. LIFT STATION Date installed "Pump on" level at in. Size in gallons Pump off' High water alarm level at in. Cycles tested Meets alarm & circuit r6quiremenis? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on loti *98' On a'djic6n't lots *83' Absorption 100'+ bs rption field on lot On adj&dn't lots' *86' Public sewer main Public sewer ma'nhbIelcI6*ah6ui ISI/A, Sewer /septic service line 25'+ Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Prop 1* Building foundatioh 5'+ Property ine 5+ 5+ Absorption field Water main N/A- - Wa'ieir 's&vide line 10'+ Su6ce Water 100'+ Wells on adjacent lots 106'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line - *6'+/—, Build ihg foU nidatioh ,lb'+ Water main— N/A Water service line 10,+ Surface water 100,+ -Driveway, par'kind/vehicle storage 20'+ Curtain drain NONE KNOWN Wei s on adjacent 166 100'+ F. -COMMENTS *WAIVER #WR85-053 G. ENGINEER'S CERTIFICATION I certify that I have d6i6iihine'd through Feld inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESt Date 4-�Zo%4 HAA Fee $ q Date . of Payment l l as 10� Receipt NU , mber .(Rev. 12101) Waiver Fee $ Date of 0ayrrien't Rkbio't Number. f y Aess: N jr C 77953• 4-g' ROO, 4-20-04; 3:15PM; GS Ref./i 1041811001 Tient Name Garness Engineering Group, Ltd. 'roject Name/# Lot 4, Block 4 Rockhill Drive Vent Sample ID Lot 4, Block 4 Rockhill Drive fatrix Drinking Water ample Remarks: ;907 5615301 :9 2/ 3 All Dates/Times are Alaska Standard Time Printed Date/Time 04/20/2004 8:57 Collected Date/Time 04/16/2004 14:33 Received Date/Time 04/16/2004 15:20 Technical Director Ste en C. Ede Releas y�`� nrameter Results L Units Method Container ID Towable Prep Analysis � Limits Date Date I It aters Department Nitrato-N 0.508 0.100 larobiology Laboratory Total Coliform 0 mg/L EPA 300.0 B (<=10) 04/16/04 JJB col/100mL SM18 9222B A (<=1) 04/16/04 DKC 4-20-04; 3:15PM; SGS/CTBE ENVIRONMENTAL SERVICES ' Drinking Water Analysis Report for Total Coliform Bacteria READ PMMUC71ONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE MUST BE COMPLETED BY WATER SUPPLIER ❑ PUBLIC WATER SYSTEM toy .ATE WATER SYSTEM send Results t'1 • Send Rosana ❑ Send Invoice' ❑ water Sewn N.rnbt:..P•ny N. Tw F IM.nb.r pswe Nunber Nyyiy Atld". •� '�. C1 SAMPLE COLLECTION: r...W ...ly.4.vr b'd�.40w 30 hr- [-d.�ob Date* NLI ;907 5615301 tC 3/ 3 200 W. POTTER DRIVE ; ANCHORAGE, ALASKA 99518 Tel: -907-562-2343. fax 907-561-5301 Leb Rd No. 1041 81 rk SAMPLE TYPE routine I] Treated Water .[].Repeat Sample ❑ Untreated Water.. (refer to lab no. ' 1 ❑ Speclal Purpose Transported to Lab By:' . ?(-Rame 05 Collector Other: TO BE COMPLETED BY LABORATORY : Sample Receiving: (� 1 Date: i— l 'C�� : ' ❑ Semple over So Moue dd Results may be 6rvdisble Time: / S2d Temp: L I .. - ❑ 4b How waiver Delive Ri Comments: ❑ RUSH SAMPLE: Phone #: *Saba .........................................:...:..... boa .............................. ..:...... ................:......................... Bacteriological Water Analysis Record: Sent bo ADEC: MMO-MUG (PIA) RESULTS: ANC FBK JUN j �{'rr0 t ��E? - Total Col'dorm: DatdTirne: Analysis Begans 1 Analyst: ' E CoFc Sent to Client • MEMBRANE FILTER RESULTS: Phoned ❑ Faxed ❑ Analyftal Method: DlmdCount _:. Coloniesl1004viL OatelTme� Membrane Filter Verification: Spoke Wier ' MMO-MUG (P/A) T�c.a.�B 8------ (g Satisfactory EC; ❑ Unsatisfactory ' TNTC! Teo N.m«ous to covM DateTme• q1,11" Oe'0ew�*�! Reported By: slgnetus I' ; _ ...FVII Form - 0053aY 12/17103.. . ..... .. . � . ' . '. �'.:.�::.'..' _ .... - . •� - .... _.... .. .. .. �� .- •.. ... - _ . 04/12/2004 06:38 3335023 I '. P M4M N YUKNIS PAGE 02 1 � j m 1 Municipality of Anchorage .. Development Services Department i Building Safety Division Onsite Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. 015-063-16 HAA# Ila el 1. GENERAL INFORMATION Expiration Date: 8 - % (G - 02 Complete legal description LOT 4. BLOCK 4; ROCK HILL SUBDIVISION Location (site address or directions) 9835 LONE TREE DRNE " ANCHORAGE. AK 99516 Current Property owner(s) CAROL SMITH Day phone 334-2121 Mailing address Lending agency Mailing address Real Estate Agent Mailing address 9835 LONE TREE DRIVE * ANCHORGE. AK. 99516 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 Day phone Day phone 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 Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $ 0 Ct, or prior to closing for the engineering services provided. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my investigation, based on procedures outlined in the Health Authority 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 riles and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Address 6901 DEBARR ROAD, SURE 28 • ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: in conducting this evaluation, AWWC, Inc. 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 evaluatorof 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. AWWC, Inc. 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 V Approved for 3 bedrooms. Disapproved. Phone 337-6179 Date Z2 Q2 a�OF � o0 4 rr : �...... .... ................. of 9 a A. 7953 ess� i °O Conditional approval for bedrooms, with the fllowing stipulations: Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other 'Gv.,• ••.ryQ WA---aN�17�-• AND rn PROGRA By: / Original Certificate Date: 5 ( (r (R". 14101( Municipality of Anchorage , ' Development Services Department Building Safely Dtvislon s On-site Water & Wastewater Program • " 47W South Sragaw St. P.O. Box 196650 Anchorage, AK 995198850 www.d.onehorage.ak.us (907)343.7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LAT 4, BLOCK 4: ROCKHILL SUBDIVISION Parcel ID: 015-063-16 A. WELL DATA Well type PRIVATE If A. B, or C provide PWSID# N/A Date completed 6/22/81 Sanitary seal (YIN) YES Total depth 70 ft. Cased to 70 ft. FROM WELL LOG Date of test 6/22/81 Static water level 27 ft, Well production 40 g,p,m, WATER SAMPLE RESULTS: Well Log (Y/N) YES Wires property protected (YIN) YES Casing height (above ground) 12+ in. AT INSPECTION 4/4/2002 38 ft. 7.5+ g.p.m. Coliform 0 colonies/100 ml. Nitrate 1.37 mg./L. Other bacteria 0 colonies/100 ml. Arsenic: N A mgA. Date of sample: 4/5/2002 Collected by: AWWC. INC. B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Date installed 6/1981 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (Y/NCYEDSDepression over tank (YM) NO High water alarm (YM) N/A Date of pumping 4/3/2002 Pumper OLD MCDONALDS C. ABSORPTION FIELD DATA 1,j G?A""'k. VAf-& Date installed 8/19111 Soil rating .p.d ftlbdnn) 150 System type TRENCH Length 39 ft. Width 36 ft. Gravel below pipe 72 ft. It. 25 Total depth eft. Eft. absorption area 450 fe Monitoring tube *YES Depression over field NO Date of adequacy test 4/4/02 Results (Pass/Fall) PASS For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 770 gal, New depth" -13—.5 in. Elapsed Time: 112 min. Final fluid depth 0 in. Absorption rate >= 450+ g.p,d, Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN if yes, give date - *SUMP ONLY EXTENDS 9.5' BELOW IN47 OF LATERAL **AT TOP OF LATERAL R D. LIFT STATION Date installed Size in gallons "Pump on" level at _in. E. SEPARATION DISTANCES High water alarm level at Cycles tested Meets alarm 8 circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankflift station on lot '98' Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ *SEE ATTACHED LETTER REGARDING WAIVER REQUEST AND AMENDING EXISTING WAIVER. On adjacent lots '83' On adjacent lots •86' Public sewer manhole/cleanout N/A Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water service line 10'+ 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 6'+/– Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 20'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION Afiksc-:,_ A•'-, I certify that I have determined through field inspections and e 4 �► review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. ............ f y es Engineer's Printed Nme JEFFREY A GARNESS Date 1=— 0Z K,90"brofssslo�d HAAFee$ 3-76'00 Date of Payment 7;0 hD Z Receipt Number /�TD�7 (Rw. 12101) Waiver Fee $ Date of Payment Receipt Number DATE: 5-15-02 TO: FILE FROM: Jeff Poet MUNICIPALITY OF ANCHORAGE Building Safety Division MEMORANDUM SUBJ: WR85-053 to Rockhill Subdivision Block 4 Lot 4 The existing waiver is amended to the following: 1. The well on Lot 4, Block 4, Rockhill S/D to the septic tank on Lot 3, Block 4, Rockhill S/D: 83 feet 2. The well on Lot 4, Block 4, Rockhill S/D to the drainfield on Lot 3, Block 4, Rockhill S/D: 85 feet 3. The well on Lot 4, Block 4, Rockhill S/D to the septic tank on Lot 4, Block 4, Rockhill S/D : 98 feet 4. Absorption field on Lot 4, Block 4, Rockhill to the lot line on Lot 4, Block 4, Rockhill S/D: 6 feet See Alaska Water & Wastewater Consultants letter of justification of April 18, 2002 Revised 5-14-02 ALASKA WATER & WASTEWATER CONSULTANTS, INC. April 18, 2002 REVISED ON 5/14/02 Municipality of Anchorage Development Service Department Building Safety Division On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, Alaska 99519-6650 A-r-� = 3 ori Ref: Waiver Requests and Health Authority Approval for Rockhill Subdivision, Lot 4, Block 4 The existing 3 bedroom house is served by a private well and septic system. During our HAA inspection it was noted that the well is too close to the septic system on the property and the septic system on an adjacent property. These encroachments are as follows: * The well on Lot 4, Block 4, Rockhill S/D to the septic tank on Lot 3, Block 4, Rockhill S/D: 83 feet. * The well on Lot 4, Block 4, Rockhill S/D to the drainfield on Lot 3, Block 4, Rockhill S/D: 85 feet. * The well on Lot 4, Block 4, Rockhill S/D to the septic tank on Lot 4, Block 4, Rockhill S/D: 98 feet. The well that serves the subject property was drilled on June 22, 1981, and the septic system on Lot 3, Block 4 was installed on June 8, 1981. The septic system on Lot 4, Block 4 was installed on June 16, 1981. In short, both septic systems were in place prior to the well being drilled. We are requesting that the required 100 foot separation distance be waived in this case. Justification for the waivers is summarized as follows: A waiver was previously granted for the separation distance between the subject well and the septic tank on Lot 3, Block 4 (86 feet), and the drainfield on Lot 3, Block 4 (89 feet). The topography slopes generally from southeast to northwest at a grade of less than 10%. There is a slight mound and heavy vegetation between the well on the subject property and the neighboring septic system. If the septic system was to overflow, it appears that the effluent would not travel toward the well head. The location of the septic system is in a very visible area so that if any effluent was to surface, it would be noticed and the problem corrected. The other path of contamination is subsurface migration wastewater should the tank begin to leak. As can be seen on the attached well log, the aquifer is confined below 64 feet of 6901 Debarr Road, Suite 2B * Anchorage, AK 99504 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com ,clay/gravel and clay/sand soils that have served to inhibit the migration of untreated wastewater to the aquifer. Recent water sample results indicated nitrate levels of 1.37 mg/L and no coliform bacteria. In short, the water quality appears to be unimpaired by this encroachment, which has existed for over 20 years. Based upon the aforementioned facts, it appears that there is minimal risk associated with the requested separation distance waivers. In addition to the well/septic separation distance issues, it was noted that the drainfield is closer than 10 feet from the lot line (see the attached as -built survey). There are no wells or septic systems that are being impacted by this encroachment; therefore, we are requesting that you waive the required separation distance to 6 feet. If you have any�quAstions, please contact us at 337-6179. Thank you for your assistance. .E., M.S. 6901 Debar- Road, Suite 2B • Anchorage, AK 99504 Ph: (907) 337-6179 " Fax: (907) 338-3246 " Website: akwwe.com r R .4�rC97 An AIV Ic - H� I co r E►�;,SaisE } I of 3 •� � SL' m its i•� y I W _i'd_6S9E'ON - —•. ' � l9li-6EE �Ntl-1HdS AV91:0I i001'El -pA 0 1 / 1 i LOT 3, BLOCK 4 — — — — — — — — — — — — 0 ` \ LOT 5,1 BLDCK4 LOT 4, BLOCK 4 4/8/2002 0 �OF� pp RBRAWN BY: ALASKA `WATER & `VASTEIVATER SCALE: J.L.M. CONSULTANTS, INC. C Q ,r 6901 DFRARR ROAD. SUITE 78 • ANCHORAGE. AK 9004 • PHDNF (00))33)•6170 • FAX (001)338.3746 1 50. ""' "' . ...... ........ PREPARED FOR: PHONE NUMBER: PAGE NUMBER: Q CAROL SMITH (907) 346-2379 1 OF 1 A. LEGAL DESCRIPTION: a .• e ess.- 4 LOT 4, BLOCK 4; ROCKHILL SUBDIVISION ADO • 7953 o TYPE OF WORK: ��•e •'' • •... • •''' ��.qp SITE PLAN FOR WELL WAIVER VERIFICATION Pro f OSS1014 pp400oSS1014 10 2 Fo L 4-12-02; 5:31PM; ;907 561 5301 0 3/ 3 PRtCT&E Environmental Services Inc. Laboratory Division Drinking Water Analysis Report for Total Coliform READ INSTR UCTIONS ON REVERSE SIDE BEFORE COLLECTING MUST BE COMPLETED BY WATERSUPPLIER ❑ PUBLIC WATER SYSTEM I.D. R • PRIVATE WATER SYSTEM ❑ SendRetxfra ❑ Sendlnvolce 41 "<" "•" WATER & WASTEWATER « 6901 DBBARR RD.. Sim'E 2B o sendtietatrr KA WATER 6901 DF.BARR RD.. SUITE 2B W, w .Y SAMPLE DATE: Eg b m Month Day Year SAMPLE TYPE: ❑ Routine ❑ Repeat Sample (for routine sample with lab ref. no. ) O ' Special Purpose SAMPLE LOCATION g' --tall xoO;� bl V -q Comments: O Treated Water A Untreated Water Time Collected Collected ' By 8' S Lak4(..,1 � rkw Prim _200 W. Potter Drive L Bacteria Anohon0e, AK 99618.1606 Tel: (907) 562.2343 SAMPLE Fax: (907)661.5301 TO BE COMPLETED BY LABORATORY An lysis shows this Water SAMPLE to be: Satisfactory O Unsatisfactory O Sample over 30 hours old, results may be unreliable O Sample too long in transit; sample should not be over3lDhours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received Time Received 1040 Analysis Begany Analytical Method: �( Membrane Filter MMO- • Number ofeolonies/100ml. Lab Ref. No. Result' An2lyst )DuI A��P f751kQ Sent to A.D.E.C. Aneh Fbks Jun ❑ Fd Date: Time: Client notified of unsatisfictory results: ❑❑ Phaned •Spoke with - Faxed Date: Time: BACTERIOLOGICAL WATER ANALYSIS RECORD M%lO-MUG Result: Total Coliform MemAnneFilter: Direct count E. Cell Verification: LTB CCB COLIFIRM colonies/too ml Fecal Coliform Confirmation Final Membrane ,Filter �Results Coliform/100 ml 'Reported By _1�-L--. Date Uti Time 1 7 hrs nvrC.TM N..eY..1 re c"W os-0<ae.s.:1..t4 � MN-' ei� Member 0l the SGS Group ISocidt1G6nerate de Surveillance) ENVIRONMENTAL FACILITES IN ALASKA, CAUFORNUL FLORIDA, ILLINOIS, MARYLAND. MICHIGAN. MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA 4-12-02: 5:31PM: ALCT&E Environmental Services Inc. CT&E Ref.# 1021746001 Client Name AK Water & Wastewater Consultants Inc. Projtct Name/# Rockhill S/D Lot 4. Block 4 Client Sample ID Rockhill S/D Lot 4, Block 4 Matrix Drinking Water Ordered By PWSID 0 :907 551 5301 0 2/ 3 All Datesaltnes are Alaska Standard Time Printed Date/time 04/12/2002 16:19 Collected Dat&Tlme 04/05/2002 8:53 Received Date rime 04/05/2002 10:40 Released Sample Remarks: EP300 - Bracketing CCV recovered outside of acceptance criteria for Nitrite. Sample results were ND for nitrite. No further action taken. Parameter Results Allowable Prep Analysis PQL Units Method Limits Date Date lnit Waters Department Total Nitrate/Nitrite 1.37 1.00 nWL EPA 300.0 Microbiology Laboratory Total Coliform 0 coUl00mL SM189222D (<1) 04/10/02 1DT 04/05/02 KAP _• MUNICIPALITY OF ANCHORAGE • '� Department 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. # d S 0 3/ 6 HAA #� 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 4, Block 4, Rockhill 4 Location (address or directions) 9835 Lone Tree Cr. (b) Property owner James L. Swartz Telephone: (home) Business Mailing Address 9835 Lone Tree Cr.., Anchorage, Ak. 99501 (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent Jack White Co./ Dale Murphe Address 3201 C st Suite 201, Anchorage, Ak. 99503 "S" Telephone 563-5500 ' (e) Mail the HAA to the following address: (or check here -$1, if hold for pick up.) List contact person and day phone number below: 5 & 5 ENGINEERING 17034 Eagle River Loop Read NQ 204 Eagle River, Alaska 99577. '2..TYPE OF RESIDENCE Single -Family 11 Number of bedrooms 3— 3. WATER SUPPLY Individual Well Z 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-sitekk Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty 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 Telephone l> `� �-2y S & S ENGINEER Address 17034 Eagle River Loop Road No. 204 Eagle River, A as a Date s 6. DHHSAPPROVAL j Approved for 3 bedrooms by Date .ApprovedDisapprovedConditional 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 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. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) • Health Authority Approval (HAA) C gCKLIST - FEBRUARY 1984 MUNI OF ANCI IO.If 343-4744 ENVIRONMENTAL SERVICES P'INISION Legal Description: A. WELL DATA R E CE 1 E LJ J J Well Classification ) D a`I— If A, B, C, D.E.C. Approved (Y/N) Well Log Preseent(,Y?N) Date Completed 1P-22- `bl Yield Aa, QPM - I2 Total Depth _Cased to l� Depth of Grouting Static Water Level 37 ( Pump Set At Lk_- Casing Height Above Ground �2 '� Sanitary Seal on Casing' N) Depression Around Wellhead (YAtY> Electrical Wiring in Conduit (tel) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot ( OS I ; On Adjoining Lots r To Nearest Edge of Absorption Field on Lot 1 k y ; On Adjoining Lots N To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole A To Nearest Sewer Service Line on Lot Water Sample Collected by '!!�7SC IDate Water Sample Test Results ��`���' Comments" B. SEPTIC/HOLDING TANK DATA Date Installed lo-tlo"81 Size No. of Compartments Standpipes¢" /N) -T Air -tight Caps (PN) `I Foundation Cleanout (DN) — --- Depression over Tank (Y/W aDate Last Pumped A5-- Ix -el Pumping/Maintenance Contact on File (Y/N) ;for N Holding Tank High -Water Alarm (Y/N) r- P Temporary Holding Tank Permit (Y/N) ' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: t � To Water -Supply Well �S To Building Foundation To Property Line � k4- To Disposal Field t� To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata1 �i �1i Type of System Design— I Date Installed L42 - 1 - 1 Length of Field Width of Field Depth of Field Square Feet of Absortion Area Depression over Field (Y/V- Gravel Bed Thickness Lo Statndpipes Present ON) Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well To Building Foundatic Lot r� J 5-11- Sri ( To Property Line t C�> 4 - To Existing or Abandoned System on On Adjoining Lots To Water Main/Service Line 10(-i To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course _ \ r�)� To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION r^ Date'knstalled I Size in "Pump On" Level High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments -Lo ) T- Dimensions Manhole/Access (Y/N) ""Check Permitted Bedroom Rating Against HAA Request" "Pump Off" Level at Vent(Y/N) ng Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed c x s ENGINEERING P A�� QR q Y, a5t Company 17034 Eagle River Loo Road No. 204 way oaf.*a 00 .,'� age F Date �7 0 �' En s ajy MOA No, •0 : baa A. Hha�fer Receipt No. C / ���°a PIR. ICY•:- sya! Receipt No. Date of Payment J� _ ti:�eyati�. Waiver Fee: $ Amount: $ 176 Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 V71 AUM4 P.O. BOX 6650 ANCHORAGE ALASKA 90502-M (907 26"111 roNy KNOWLES. MAYOR �q OPANT&UM OF "gal" & "w" saftwo bsr 27, 1985 Bract. P.R. fr-°,.Stamey '"Brusr jmd'Asaociat*8 V11,1610,blumid Drive ,.,Ancbor&V# Alaska 99507 i' jectt',Lot 3 Block 4 Rockhill Subdivision. WR85-053 ..Review of 1983 Waiver for the Separation Distance Between the Well, on Lot 4 and the Septic System on Lot 3 D"t" Mr. Brus t I `-"Thist'Depaitment has reviewed a waiver issued June 16. 1983 using separation distance waiver guidelines established by Alaska State 4n, "Department of Environmental Conservation. This evaluation indicated tbatthor* is little If any potential for contamination of the well on Lot. i ?lease consider this letter to be an affirmation of the "wsiver,lasued by this Department in 1983. J ii p' V'Si6jisli S.° !orris Civil Engineer "n - ft -site Services ,,I;Wljw �q ANALYSIS REPORT BY SAMPLE fox Work Order # 13261 Date Report Printed: MAY 12 89 @ 11:46 iS OF ALASKA, INC. DNE (907) 562-2343 Client Sample ID:L4, B4, ROCK HILLS Client Name S & S ENGR PWSID :UA Client Acct SNSENGP Collected MAY 11 89 @ 10:15 hrs. P.O.# NONE REC D Received MAY 11 89 @ 10:45 hrs. Req # Preserved with :AS REQUIRED Ordered By : RJS Analysis Completed :MAY 12 89 Send Reports to: Laboratory Supervisor g:STEPHEN C. EDE 1)S & S ENGR Released By : V, . / `�—, 2) ............•I ................................. ....=...................... b. ...... ...... ......,..... ,.. . . Special. Instruct: Chemlab Ref +#: 5239 Lab Smpl ID: 1 Matrix: WATER Parameter Tested ---------------------------- NITRATE-N Sample ROUTINE SAMPLE. Remarks: SAMPLE COLLECTED BY RJS. 1 Tests Performed ND- None Detected NA- Not Analyzed Result/Units ------------------------------------- 0.18 mq/l '— Method EPA 353.2 See Special Instructions Above UA -Unavailable " See Sample Remarks Above LT -Less Than. GT -Greater Than Allowable Limits 10 M CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street 4$ Anchorage, Alaska 99518 �•^�^°• Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER II TO BE COMPLETED BY LABORATORY 11# I I PUBLIC WATER SYSTEM I.D.I I I I h' W t SAMPLE to b � e- pPRIVATE WATER SYSTEM Name Phone No. S $ S ENGINEERING 17A9 I Mailing Ad es 5916 Over Loop Road NCI Eagle Riyer, Alaska 99577 Wj City State Zip Code SAMPLE DATE: Mo. Day Year SAMPLE TYPE: ,Z Routine El Check Sample (for routine sample with lab ref. no. ) ❑ Treated Water El Special Purpose EJ Untreated Water SAMPLE Time Collected NO. LOCATION Collected By 1 I L� 4 4 I/ 2 1 FVGK N7�� 3 4 5 Anal is shows t Is a er Satisfactory ❑ Unsatisfactory ❑ Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received S- / Y L_ Time Received Analytical Method: Membrane Filter ' No. of colonies/100 ml. Lab Ref. No. Result* Analyst 2` ED m U m I m BACTERIOLOGICAL WATER ANALYSIS RECORD j4bGC� s READ INSTRUCTIONS Membrane Filter: Direct Count Coiiforml100ml BEFORE Verification: LTB Bus COLLECTING SAMPLE Final Membrane Filter Results �D Coilform/100m1 Reported By to S r1Z 1 Time: f���� a.m. p.m. TNTC = Too Numberous To Count OB =Other Bacteria PART f OF 2 REMAINDER TO FOLLOW p. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) 1-4 3-4 Location (address or directions) i (b) Applicant Name ��/Ju'� �"✓�Y�= Telephone: Home -F z75 -l' Business 27/����Z Applicant Address `Fg':�5 (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder Buyer ❑ ; Other ❑ (explain); (d) Lending Institution��%7e� '1�� ��y {� Telephone Address (e) Real Estate Company and Agent Address 3. WATER SUPPLY Individual Wello 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)Rf 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 72-025 (11/84) W/L 09Z0-ZL Z 10 Z abed •�aoM s,aaau!6ue leuo!ssa}oid ay1 u! suo!ss!wo Jo saoaaa a01 alq!suodsaa lou s! a6eaoyouy;o �(l!led!o!unln} ayl *panssi s, aleo!l!Uao s aaolaq elep azAleue ao suo!loedsui lonpuoo lou op d9H0;o saaAoldw3 -sluawaa!nbei alels pue leaapa; u!elaao (ls!les o1 aapao u! suo!lnlpsu! 6u.pual A!ayl pue sawoy ;o sieseyoand of Rs%inoo a se s!y1 saop d3H4 ayl TNsely }o 01e1S ayl ut paaals!6aa aaau!6ue �euo!ssa;oid luapuadepu! ue (q anoge g gdeifted u! UOA16 suo!leluasaidai ay1 uodn Rlelos paseq saleo!;!uao lenoaddy A1!aoylnd y11eaH sanss! (d3H4) u0110910ad le1u9wu0A1Au3 pue y11eaH ;o luawlaedaa a6eaoyouy ;o (1!led!ounlnl ayl NOI1f1VO lenoaddy leuo!1!puoO 10 swial leuo!l!puoO panoaddes!Q panoiddy 8—$ S also e""o /Cq swooaPa9£� eai A ao} panoiddy -1VA0HddV d3H4 '9 POS s,aaau!6u3 ssaippy auoydalal -,/-S 4P Olt 2wa!3 ;o aweN -/ASle'15C�l •uo!loadsui s!y1;o alep ayi uo;oa49 ui suo!leln5ei pue'saoueu!pao'sapoo a1elS pue led!o!unyq Ile yl!M eouepdwoo ui si wals(s lesods!p aaleMalsem ao/pue (lddns Aa1eM a1!s-uo 9y1 'uo!laadsui pue uo!}e6!lsanu! Aw woal pue sal!; a6ejoyouy ;o (l!led!o!unlnl ayl woa; pou!elgo uo!lewao}u! ayl uo paseq leyl AI!aaA jegpn; I •u!aaay paleo!pui ainlonils;o adAl pue swoojpaq }o aagwnu ayl ao; alenbope pue leuo!1oun;'a;ss si welsAs lesods!paalemalseM ao/pue Alddns jejuni al!s-uo ayl leyl snnoys lenoaddy Aluoylny ylleal-I s!y1;o uo!1e6!lsanu! (w leyl (;!aaA I 'nnolaq UMoys alep uo!leplleA ayl;o se pus olaaay pax!;;e leas �(w (q pa!;!1aao sy NOIIVWHOdNI (INV V1V4 `HOHV3S 3l1d `S1S31 `SN01103dSNl E)NI01A08d WHId UNIH33NION3 '9 A. 0 MUN�IICyW,LITY OF ANCHORAGE (MOA) i(1�Tkj�¢�*+HORITY APPROVAL (HAA) \G\QPM\�yPOS�RHi}}'ECKLIS264�4744UARY 1984 Legal Description: WELL DATA Well Classification % If A, B, C, D.E.C. Approved ,&/N) l Well Log Present /I I) Date Completed � YZ� ` Y� Yield 4' to o %m Total Depth ✓�� Cased to Depth of Grouting Static Water Level t3 a<l ei' Pump Set At Casing Height Above Ground w Sanitary Seal on Casing &N) — Electrical Wiring in Conduit (1VN) Depression Around Wellhead (Y V' Separation Distances from Well: J-mr-V%0 " S To Septic/Holding Tank on Lot On Adjoining Lots To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots' wa:vr�s a To Nearest Public Sewer Line /./{ To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by Date 52 Water Sample Test Results ery—e ' Comments Z-�S'oq 1-?ef4 -*-eJ- A- Ilyi. !10iBfe_ Ccy�rar�°a G � tr/ iq Gn /k too c<yca�� �vasir"yrf�•� r !0IV �v>1 MC v B. SEPTIC/HOLDING TANK DATA -6x44 S O` ' e6 /Jrp4ileAV, Date Installed Size —�— No. of Compartments StandpipespN) Air -tight Caps CDN) Foundation Cleanou (f N) Depression over Tank (Y(9 Date Last Pumped �`� _'P ? Pumping/Maintenance Contract on File (Y/N) _ Holding Tank High -Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well LL7 To Property Line 3S� ;for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field M To Water Main/Service Line AJA To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026 (Rev. 8/861 Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed (O -/6 -? Width of Field /50 Type of System Design Length of Field 0 r Depth of Field 1Q� Gravel Bed Thickness Square Feet of Absorption Area ' Standpipes PresentS9N) Depression over Field (Yft Date of Last Adequacy Test Results of Last Adequacy Test pa's -7 & el Separation Distance from Absorption Field: To Water -Supply Well To Property Line To Building Foundation s� To Existing or Abandoned System on Lot Ailk :On Adjoining Lots 75 To Water Main/Service Line PJ�� To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments To Cutbank (if present) U — 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. O Date of Payment 5 D Amount: $ 1 D D Page 2 of 2 72-026 (Rev 8/86) Back Engineer's„Sealjc BESSE, E7PS & POTTS May 71 1987 Mr. Stephen S. Morris Civil Engineer Department of Health and Human Services Municipality of Anchorage Anchorage/ Alaska 99501 Re. Health Authority Approval Lot 4 Block 4 Rockhill Subdivision Dear Steve: MUNICIPALITy OF ENV/SEPT. OF RONMAL ENTAL E RO & � oE MAY 8 1987 RECEI QED I am submitting the attached Health Authority Approval for Lot 4 Block 4 Rockhill Subdivision/ which because of separation distance problems with Lot 3 Block 4, required a waiver because the well on Lot 4 was 86 feet and 89 feet from the septic tank and drainfield on Lot 31 repectively. I found by researching the files at your office that a waiver had previously been granted for this same problem on November 27, 1985. Upon discussing this matter with you today you indicated the waiver was in place and another waiver would not need to be pursued. Y/ Merrell, PE cc: Raquel M. Edelen United Bank of Alaska Jmm ENGINEERING, PLANNING, SURVEYING 2220 E. 88th Ave. / Anchorage, Alaska 99507 / Telephone 907-349.6451 / 344-1352 "Providing a quality personalized service to those building Alaska's future" 6 G 2- 7 �, n; .Locztt-; on. BESSEr L•'PPS & P:/1.'1'5 2220 E:A.`i1' 88 AVE'Ur,- A\CHO':ZA'..3r A:K 99501 (90'7) 3219-6-451 NXTER S:'rL,L 'PEST Pa t:e : Subdivision: Lot: Block: Client's Ttama-: Act mess: Initial Reading en Mater: 6-2'� -3 _ _. �___ Production Rate: Gii GPM ritt,�uC. 24 -:lour Caoaci tyiZ2 Gallons J �r ,,. �w�III ■1 ,,, Production Rate: Gii GPM ritt,�uC. 24 -:lour Caoaci tyiZ2 Gallons MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIION DEPT. OF HEALTH 8< 825 L Street - Anchorage, Alaska 99501 • ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION JUN 14 0 Telephone 264.4720 NUMBER OF BEDROOMS REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE f*66 f I1SE DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTYOWNER J. S. Frazier and Shirley D. Frazier ❑ MULTIPLE FAMILY PHONE MAILINGADDRESS PROPERTY RESIDENT (If different from above) James L. Swartz and Frances J. Swartz * ATTACH WELL LOG. A well log is required for all wells drilled PHONE 349-1757 2. BUYER James L. Swartz and Frances J. Swartz ❑ PUBLIC UTILITY PHONE 349-1757 MAILING ADDRESS 9835 Lone Tree Circle, Anchorage, Ak. 99507 3. LENDING INSTITUTION **If individual/on-site, give installation date 9-81 4. P 2 /6E 1911 United Bank Alaska ❑ PUBLIC UTILITY by this Department. MAILING ADDRESS Pouch 7-059, Anchorage, Ak. 99510 4. REALTOR/AGENT PHONE 561-1667 ERA Crown Realty MAILING ADDRESS 1205 E. International, Anchorage, Ak. 99503 5. LEGAL DESCRIPTION Lot 4, Block 4, Rockhill Sub. STREET LOCATION 9835 Lone Tree Circle, Anchorage, Ak. 99507 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS ❑ One ❑ Four ❑ Other ® SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY Xu Three ❑ Six 7. WATER SUPPLY r HCl INDIVIDUAL*_ P't' * ATTACH WELL LOG. A well log is required for all wells drilled ` ❑ COMMUNITY / since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM **If individual/on-site, give installation date 9-81 KI INDIVIDUAL/ON-SITE** If system is over two (2) years old an adequacy test is required ❑ PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY r DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS _ E:1 ONE LM"/THREE ❑ FIVE ❑ OTHER ��SINGLE FAMILY ❑ MULTIPLE FAMILY ❑ ' TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY PERMIT NUMBER© I m� S INDIVIDUAL DEPTH OF WELL V ❑ COMMUNITY DATE DRILLED ED UTILITY 22 _ Connection Verified LOG RECEIVED 3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER Jf EE NDIVIDUAL/ON -SITE L DATE INSTALLED ❑PUBLIC UTILITY Connection Verified INSTALLER 1 V l� El Septic Tank or E] Holding Tank Size: If Tank is homemade SOILS RATING, give dimensions: 1 v TYPE OF TANK C 0 0 D MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line WELL TO: Absorption to nearest Lot Line���� 9 A. 5. COMMENTS 0 ❑ APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) LK DISAPPROVED DATE ( - (6-'-) BY (Title) 6 r l b V, Nr►'v' LEGAL DESCRIPTION 72.010 (Rev. 3/78) rN dune 21, 1983 j. S. P,razier and Shirley T). FraZiPr 910135 Lone Tree Circle Anchorage, AK 99507 Subiecto Lot 4t Block 4. Rockilill Subdivision AD roval for tile individual GeWel- and water facilities cal"10t 'P ix� granted until the following items have been coMPlet0d: The tOT) Of the well casing should be sealed so that it B water tight. Tile water analysis report needs to be submitted to this office from, the Chem -Lab, 5633 3 Street, for our reviek,'. 0 The �>eptic tank pumpe(A %qith a receipt sub--Mitte(i to this department. kilease 110tify this 1)epartment for a reinsPectiOn "e" the noted discrepancies have been corrected. If them are any ase call thi- office at 264-4720. further questionso plC sincerely, Cory --jillis } 5. LEGAL DESCRIPTION ,._ DATE RECEIVED y INSPECTION APPOINTMENTS TIME NUMBER F,BEDROOMS ❑ TIME 4 TIME DATE ❑ Two ❑ Five DATE '�� n DATE n 4 7. WATER SUPPLY 19 INDIVIDUAL* *ATTACH WELL LOG. A well log is required for all wells drilled COMMUNITY "l — L �9 INSPECTOR depth (attach log if available.) INSPEC R, INSPECTOR c� INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. A% NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. MUNICIFfAhITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPT. OF H! - ALT I & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIQ%VIRONMENTAL F' iOT ECTION 825 L Street - Anchorage, Alaska 99501. • 3J 4 L?� G r� v�'.'`' 8 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 �J s - j D WATER AND SEW\1�/ REQUEST FOR APPROVAL OF INDIVIDUAL DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER _ In PHONE 6 3vgl MAI LINGADDRESS PHONE PROPERTY RESIDENT (If different from above) PHONE 2. BUYEER� MAILING ADQD�RESS 3. LENDING INSTITUTION PHONE MAILING ADDRESS 4.REALTOR/AGENT PHONE MAI LING ADDRESS ®� 5. LEGAL DESCRIPTION STREET LOCATION 4e 6. TYPE OF RESIDENCE NUMBER F,BEDROOMS ❑ ❑ One ❑ Four Other SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY Three ❑ Six 7. WATER SUPPLY 19 INDIVIDUAL* *ATTACH WELL LOG. A well log is required for all wells drilled COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM c� INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) ?_ THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED �yt INSTALLER ❑Septic Tank or ❑ Holding Tank Size: r000 If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION. AREA MATERIAL 4. DISTANCES WELLTO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS Its APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY Ls XkAU ,�(n - T/ 0re 80-9' .78 Adjoining P®qe No.0 ') G -2.2-7V iT u-77 Adjoining Tax Book NO.0 �$i K Assessors Parcel No. (o Assessors Block No. t i