HomeMy WebLinkAboutKNIK VIEW BLK 2 LT 4COSI - X31-35
0
Municipality of Anchorage P Page 2 of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 0 Anchorage, Alaska 99519-6650 i Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ���� 0 2 a_� PID Number:
Name:
jjflV 1� Tl-)-c7M t�S � rJ
Wastewater System: New ❑
� NY Upgrade
Address:
ABSORPTION FIELD
Phone: _ _
No. of Bedrooms:
p Deep Trench ❑ Shallow Trench 39 Bed ❑ Mound ❑ Other
LEGAL DESCRIPTION
Soil Rating:
0' ?
Total Depth from original grade: ,
5 Ffi
GPD/Sq.
.-7
Lot: Block: ZSubdivision:
PT
K VIEW
_
Depth to pipe bottom from original grade:
!)r-2-
Gravel depth beneath pipe
Z.f SAW,?
KN
Ft.
6'tr6VAVEL- Fl.
Township:
Range: /
Section: [gyp
Fill added above original grade:
U. S r
Gravel length: /
Ft.
Ft.
WELL: ❑ New ❑ Upgrade
Gravel width:
Numberoflines:
Distance between lines:
6
15 Ft.
_ _
Ft.
Classification (Private, A,B,C)%•. c,wrrtu n l' f
Total Depth:
Cased To:
Total absorption area:
Pipe material:
(,J&TV2 'Lh3,A
Ft.
Ft.
9Lf5_ SC. Ft.
Driller: ^
Date Drilled:
:
Static Water Level
Installer:
C_`CL',
Date installed: / /
3D 96-
ADC . 2« 1q 2c
Yield:
I Pump Set at:
Casing Height Above Ground:
TANK
GPM
Ft.
Ft.
SEPARATION
DISTANCES
g Septic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift
Holding Public/Private
Manufacturer:
Capacity in gallons:
From
Tank
Field
Station
Tank Sewer Lines
At-3e"I}ra(Pew_ 'FAI`JK-
12vD („a
Welh
..�
__--
�
— —�
Material:
Number of Compartments:
Surfac
�
%0t%'`h
LIFT STATION
Watere
Lot
��
f p
_.
Size in -gallons:
Manufacturer:
Line
N
Foundation
,� f
-�
__. .�_
"Pump on" level at:
.'Pump off' level at: High water alarm at:
0
Curtain
�_-.
Pump Make & Model
Electrical Inspections performed by:
Drain
Remarks: LOT Lt �1-yE-1D Pti( cr�r, -mie
_ BENCH MARK v
LV/}ii�
Location and Description:
fZ7i� CSF FUVNr
-7' aF cxC , 11 0ej
Sly CO2.fvE2 I+v
Assumed Elevation:
r
ENGf[JEEf1'SSEAL
3.1 `-oi'� (f P i fi To f3t�( vM OF Q> Z1 .
Inspections performed by:P. C, Dates: 1st AU64
2nd 1U(, .30
th and ervices approval
Department of
7ea
�jn
Reviewed and approved 1 '� Date: c' L
s
72-013 (Rev. 9/91) MOA 25 \1
Permit No.
Page _ ) of 's
Municipality of Anchorage
DEPARTMENT OI' HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: L63T q, BLoc- le_Z, VNtK VIrvJ 5u6b. PID No.
Elevations relative to top of foundation
Foundation
100.0
Tank Inlet
95.3
Tank Outlet
95.1
Bed Point 5
92.0
Bed Point 6
92.0
Bed Point 7
92.0
Monitoring Tube
Bs- -t 9LI CAV
Bed Point 10
92.0
Bed Point 11
92.0
Bed Point 12
92.0
Ground surface
83.8
Over Bed
95.2
Over Tanks
98.9
0--
01 6
f3 6
S
__......___..._._ ..... :.... ...................
.......
Tank Cleanout 1
Tank Cleanout 2
Effluent Cleanout
Effluent Cleanout
Bed Cleanout 5
Bed Cleanout 6
Bed Cleanout 7
Monitoring Tube 8
Monitoring Tube 9
Bed Cleanout 10
Bed Cleanout 11
Bed Cleanout 12
72-013 A (1193) -
A
B
C
32.0
30.3
40.0
29.6
47.3
30.3
47.9
30.2
76.7
58.8
80.2
60.3
83.8
62.4
86.1
64.6
10.8
37.1
13.0
35.7
17.9
37.9
22.1
40.8
A=Southeast corner of foundation
B=Southwest corner of. foundation
C=Nor.thwest corner of foundation
Z5- sU 1
Municipality of Anchorage
Department of Health and Human Services
P.O. Box 196650
825 "L" Street, Room 502
Anchorage, AK 99519-6650
Re: Construction Report for Lot 4 Block 2 Knik View Subdivision
Dear Sir:
Attached is a final construction drawing for the above referenced property.
Two construction inspections were performed during the construction of this system. In
addition, two more site visits were conducted to observe progress and take
measurements.
The first inspection was performed the evening of August 25, 1995. During this
inspection, l verified the length and depth of the bed, plus all offsets from the building
and lot lines, plus verified that the bottom of the trench was level.
The second inspection was performed the evening of August 30, 1995. During this
inspection, I verified that the piping was installed level, that monitoring tubes were
installed, filter fabric was in place, and that the amount of sewer rock and sand bed under
the perforated pipe was one-half foot and 2 feet respectively as specified. Elevations of
the various points on the system were measured to ensure that septage would flow from
the structure to the tank and on to the bed. Elevations of the various components and
offset distances to two permanant references are presented in the attached drawing.
The Installation of this system varied from the approved system in that:
- The septic tank that was installed had a capacity of 1250 gallons rather than 1500
gallons as was specified. A 1250 gallon tank is appropriate for 4 bedroom house.
- The bed was installed parallel to the northwest property boundary rather than the
southwest boundary as shown in the application.
If you have any questions, or need additional information, please give me a call at 753-
5520 (wk) or 688-1505 (hin).
Sincerely,
a1
r ;
�f+M
Iij(q/
y
urtis King, P.E.,
L
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON- SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW950231 DATE ISSUED: 8/22/95
DESIGN ENGINEER:CURTIS KING, P.E. EXPIRATION DATE: 8/22/96
OWNER NAME:THOMPSEN DAVID A & SANDRA K
OWNER ADDRESS:21908 GRASSER ROAD
PARCEL ID:05103135
LEGAL DESCRIPTION:
KNIK VIEW BLK 2 LT 4
LOT SIZE: 21524 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
FILTER MATERIAL MUST CONFORM TO ATTACHED BULLETIN
SEE ATTACHED r
RECEIVED BY:
ISSUED BY:
DATE:_ �S��Zh5'
DATE:
y ((-(2S� �ivsp. cnrc.l-a[c.%3-cF+ucr� MuwR_�d SIT F_,
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d
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- (ilsc�bsEi� /�r3sa,¢('Zro>J r3E'n L.�-%buI
- (�'&D To Ru,r �/ %o eo vrc2 IvaT Ac�+ws7 -•RS saow,� v/� p" .
( H L xagi� Cl as /t, Z -a n i S W Cuan En, 74 A�,) SOP" v& Desiy ✓•
L cXA-TcoNS A2E /NllaCw".47 U^' S«N //C.
A 4--;f5 T. S is Fx i�cax _(L�
Municipality of Anchorage 0509
Department of Health and Human Services
Tom Fink, 825 "L" Street
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
ENGINEER BULLETIN 94-3
June 1, 1994
TO: Engineers Involved with Design, Inspection and Construction of On-site Water
and Wastewater Disposal Systems
SUBJECT: Clarification of some design considerations.
1. Per AMC 15.65.060.H.4, the width of an absorption bed must not exceed 15 feet.
Recently, the On -Site section routinely approved changes to this requirement. In the future, an
exception to this requirement will be approved only after a thorough review and justification
submitted by the engineer.
2. Any absorption systems with a design length greater than 50 feet shall be entered at the
midpoint, unless otherwise approved by DIMS.
3. No absorption systems will be allowed which are designed on a "spill-over" concept, i.e.
two trenches with the second trench only receiving effluent after the first trench has been
filled.
4, Approved sands used to raise mounds or bed systems to insure the 4 foot separation from
the bottom of the absorption field to the water table are:
a. Road sand from Central Paving Products (Palmer).
b. ASTM D 33 concrete sand available from Quality Sand (Wasilla).
c. Pit run sand from Beaver Lake ,Sand & Gravel (Wasilla).
d. Any sand from a source other than a, b, & c above must have a sieve analysis
performed which indicates that the product is a sand and has less than 4% passing the
#1100 sieve and less than 2 % passing the /#200 sieve.
Sinely,
Jac ies Cross
Civil Engineer
On-site Services
August 18, 1995
Municipality of Anchorage
Department of Health and Human Services
Environmental Services Division
P.O. Box 196650
Anchorage, Alaska 99519-6650
Re: Resubmission of Lot 4 Block 2 Knik View Subdivision wastewater disposal
system permit application.
Dear Sir:
Enclosed please find the following:
- Sewer Permit Application
- Application Fee
- Site Plan
- System Detail
- Construction Specifications
- Perc Test
- Results of Mechanical Analysis of Soil Sample
A simple mechanical analysis of soils taken from this property indicates that a filter layer
will be required. Please note that this design now specifies a two foot sand bed be placed
in the bottom of the trench.
If you have any questions or comments about this application, please contact me at 753-
5520 (wk) or 688-1505 (msg).
Sincerely,
Curtis King, P.E.
Lot 4, Block 2 Knik View Subdivision,
A narrative description of the probable impacts to properties adjacent to lot 4, block 2
Knik View Subdivision, is provided below:
General
Knik View Subdivision is located within Peters Creek, Alaska, approximately 10 miles
north of Eagle River. The subdivision is located adjacent to and to the east of the Alaska
Railroad as shown in Figure 1. The general topography is one of gently rolling hills with
elevations ranging from 70 to 150 feet.
A soils investigation was performed in the summer of 1984 by Baxter Engineering and
Soil Testing. In general, the soils investigation found that the area was "well suited for
septic disposal." A total of 1 l test holes were dug in the Knik View Subdivision. The
investigation found that the soils were generally sandy gravels and gravelly sands.
The soils investigation rated the soils in this area at 85-330 square feet per bedroom.
Water Wells
There are no water wells within 200' of the proposed septic system. The subdivision is
served by public water and a service line from Inlet Vista Drive will supply water for this
lot.
Wastewater Systems
There are no septic systems within 200' of the proposed septic system.
Reserve Space
The proposed wastewater disposal system will be located such that the alternate disposal
site for this lot and the alternate disposal sites for adjacent lots will not be compromised.
Drainage
The entire lot is essentially flat with just the northwest portion that boarders the Alaska
Railroad sloping moderately down toward the railroad right of way. There is no slope in
the immediate vicinity of the two test holes. The majority of the rainwater and meltwater
should enter the groundwater with 1 ittle or no surface runoff due to the good percolation
rates of the soil.
The proposed wastewater disposal system should not impact, nor be impacted b�fHe ��tte
5.
drainage.
�Q'o, taurtl. A. King 7
System Detail (Revised 8/21/95)
Lot 4, Block 2, Knik View Subdivision
System Size Calculations:
Four bedroom house:
From percolation rates, the application rate is 0.7 gpd/ft2 (for system using two feet of
filter material):
Reduction Factor = (W+2)/(W+1-F((.5)" 2)) = (W+2)/(W+2) = 1. Where .5 is the depth of
drainfield rock below the perforated pipe in feet.
Square footage per bedroom = 150/.7 = 215 ft2/bedroom:
Total square footage required for system = 215ft2per bedroom*4 bedroom= 860ft2
For a bed system 15 feet wide, the length of the drainfield is given by 860ft2/15 feet, or
57.5 feet long.
Therefore, construct on(t 15' wide x 6 feet deep x 57.5 feet long (see detail below).
b�c(l
i I y� 5r 31
.3' I " P
-Q-
2 -
" 15'
F LJEe FAG(?-Ic
Lot 4, Block 2, Knik View Subdivision
Construction Specifications (Revised 8/21/95):
Tank:
- 1500 gallon capacity, two compartment septic tank.
- Setback a minimum of 5 foot from foundation.
- Maintain 2% grade on septic pipe immediately preceding septic tank.
Cleanout Pipes:
- Install one cleanout pipe one to four feet from foundation.
- Install one cleanout pipe on each compartment of the septic tank.
- Install two cleanout pipes one to four feet past the septic tank oriented in opposite
directions.
- Install six cleanout pipes, one at each end of each drainfield lateral pipe.
Absorption Field:
- Excavate at 57.5 feet long, 6 feet deep, 15 feet wide.
- Maintain 10 foot setback from property line and foundation. Maintain 10 foot setback
from water service line. Maintain 5 foot setback from septic tank.
- Install two Monitoring tubes, one at each end of the bed.
- Backfill with 2 feet of filter material (64 yards).
- Backfill with 1/2 foot of drainfield rock (16 yards)
- Place three 57.5 foot laterals of perforated septic pipes, on 4.5 foot centers, centered in
trench, perfs down.
- Manifold the laterals together at the center of each 57.5 length.
- Backfill with 1/2 foot of drainfield rock (16 yards).
- Cover entire surface of drainfield rock with filter fabric. Backfill with native material.
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51/b
a Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L•' Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: DAdin T 0HP6i^-r%3
(( r
\ , C
O A•
uu �4001, n0"0.00 V onoa Lf
ee tt
r000 n �yUnno auov oo onv�voc ��
, y o
Curtly A. KhnV
DATE PERFORMED:
L3LOC.V Z C -DT 41
LEGAL DESCRIPTION: KNI K VIEW 5t1ig171✓t5I00wnship, Range, Section:
SLOPE ^ SITE PLAN
�p��T�
1
2
3-
13eswr� GwJ
4 p '
5 O
6
• , W1'71} l.l'f'fLtz o� ruC�
6 o I 5i�r
7
15
16
17
18
19
20
WAS GROUND WATER
ENCOUNTERED?
N,
S
IF YES, AT WHAT L
DEPTH? 0
s P
E
Depth to Water Atter
MonitorinD? r"O6'E . Dale:.8h5-(q1
Reading Date Gross Net Depth to Net
Time Time Water Drop
e
I PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
—J TEST RUN BETWEEN _ FT AND FT
COMMENTS SOILS IN 7lcST H-OLiE FAL I pCNT1CA-C 7-0 'j'} 0&F- FL')0A"D rr.J T4
ND PE2G QST 2L)N) L —1-H t*
PERFORMED BY. _
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
ECT ON THIS DATE. DATE.2 C
S
Pxqc, k: 6/$
8
p �-
i
C>
9
to
11
-C"
r)
12'
13
10 <
: lJ
14��
�
�;-�
i I D
15
16
17
18
19
20
WAS GROUND WATER
ENCOUNTERED?
N,
S
IF YES, AT WHAT L
DEPTH? 0
s P
E
Depth to Water Atter
MonitorinD? r"O6'E . Dale:.8h5-(q1
Reading Date Gross Net Depth to Net
Time Time Water Drop
e
I PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
—J TEST RUN BETWEEN _ FT AND FT
COMMENTS SOILS IN 7lcST H-OLiE FAL I pCNT1CA-C 7-0 'j'} 0&F- FL')0A"D rr.J T4
ND PE2G QST 2L)N) L —1-H t*
PERFORMED BY. _
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
ECT ON THIS DATE. DATE.2 C
S
Pxqc, k: 6/$
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: DAP D-Mcl`1PZ>613 DATE PERFOR
LEGAL DESCRIPTION. BLoC-r- Z eeor 4( Township, Range, Section:
ECIV V IrvCCM1 J JCHI.)
Cue41s
n /rG'�i 0 rrn°000
,slSt�,' ROF+.s
0, ,P I-wvlle- VIF'LJ 5oe"i)IVI's f\} SLOPE SITE PLAN
1 ' 02,C-)ANIC-,S CZ1 111-7[7
2
3 jLi llaLl< Nd.
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6 _ 6 Vi
7 D
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8 I /
1,t3 L. i ij(r r7Q f3 t�1� i /I
9 li 0,.
1D 0WAS GROUND WATER
CTF�t ( ENCOUNTERED? PC)
11 S
IF YES, AT WHAT L
O
12 DEPTH? P
p E
Depth to Water Atter
13
V Monitoring? NONE. Dale: 81,51c)
14-
15 0 .
16
17
18
19
Reading Date Gross Net Depth to Net
Time Time Water Drop
20� rn�J2�min�t�
PERCOLATION RATE (minutesnnch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND 7 FT
COMMENTS /U 6A- OloS c1= WA`I- 17oofzltD Ll_ P (IGOL-i\IZUA)
IJAS F'JJ2kli T n Cu SYtniT ( 1?- �il�iUl JCC/ -'P (%)lk2 IJF-q 2U.St- NU2� T)4AtJ III
PERFORMED BY: - ('�,T1`� :L -I A)G I �✓ E CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE.
72-008 (Rev. 4185) ���
Sieve Analysis Lot 4, Block 2, Knik View Subdivision
On August 18th, a basic mechanical analysis of the receiving soils was conducted. A
total of 55 pounds of clean gravel was collected at the site and screened through a
number four sieve. The net results were as follows:
Weight of Sample 55 pounds
Weight of Sample Passing #4 sieve 22 pounds
Weight of Sample Retained by #4 Sieve 33 pounds
Percent passing #4 sieve 40%
Percent Retained 60%
Because less than 51% of the soil passes the #4 sieve, a filter layer will be required.
oc n
• Municipality of Anchorage
On -Site Water and Wastewater Program `
(907)343-7904 s,,,,--,.
Certificate of On -Site Systems Approval
Parcel I.D. 051-031-35 Expiration Date:
1. GENERAL INFORMATION
Complete legal description Knik View Subdivision, Lot 4, Block 2
Location (site address) 422620 Inlet Vista Drive, Chugiak, AK 99577
Current Property owner(s) David & JOani ThompSen Day phone (907) 575-9494
Mailing address 22620 Inlet Vista Drive, Chugiak, AK 99577
Real Estate Agent Day phone
2. TYPE OF DWELLING:
❑i Single Family (w/wo ADU) D
F-1DuplexJ\ g 4 2 S s
❑ Multiple Dwellings (Single Family and/or Duplex) C
2�`C �95A
3. NUMBER OF BEDROOMS: 4 01 5 a
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual Q
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑■ Public Sewer ❑
Waiver/Variance request for: Distance:
Received by: Date: 6 ��
CCSA to be released to the engMear, unless otherwise requested by the engineer.
COSA Fee $ 5Z(0-00 I MIS _#-32_q 6 Waiver Fee $
Date of Payment U 1151201 (0 Date of Payment
Receipt Number Zo1835 Receipt Number
COSA # ()S ci i b ( L$ 0 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 VEI Consultants Phone 907-337-3330
Address 1345 Rudakof Circle, STE 201, Anchorage, AK 99508
Engineer's Printed Name Aaron D. Jarnagin
6. DSD SIGNATURE
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for
Date
bedrooms, with the following
BY �� f Original Certificate Date: �' b
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet S ! >
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: Knik View Subdivision, Block 2, Lot 4 Parcel ID: 051-031-35
A. WELL DATA
Well type PUBLIC If A, B, or C provide PWSID # Well Log (YIN)
Date completed Sanitary seal (Y/N)_ Wires properly protected
Total depth ft. Cased to ft. Casing height ove ground) in.
FROM WELL LOG AT ECTION
Date of test
Static water level
Well production g.p.m.
WATER SAMPLE RESU
Coliform colonies/100 mL Nitrate mg/L
Ar ug/L Date of sample: Collected by:
ft.
g.p.m.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEEL Date installed 8/30/95
Tank size 1250 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 11/19/15 Pumper Sanitary Pumpers
C. ABSORPTION FIELD DATA
Date installed 8/30/95 Soil rating (g.p.d./ft2 or ft /bdrm) 0.7dgp /SF System type BED
Length 63 ft. Width 15 ft. Gravel below pipe 6" GRAVEL, 2' SAND
Total depth 6.2 ft. Eff. absorption area 945 112 Monitoring tube YES Depression over field NO
Date of adequacy test 6/13/16 Results (Pass/Fall) PASS For 4 bedrooms
Fluid depth in absorption field before test 0.0 in. Water added 650 gal. New depth 1.0 in.
Elapsed Time: 60 min. Final fluid depth 0.0 in. Absorption rate >= 650+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE If yes, give date -
D. LIFT STATION
Date installed
"Pump on" level at
Size in gallons
in. ,Pump off" II
Cycles tested.
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/]ift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service
PUBLIC WATER
Manhole/Access
water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
On adjacent
sewer manhole/cleanout
Holding tank
ontainment areas Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 54 Property line 6+ Absorption field 54
Water main 100'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 100'+
Water. Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 1001+
F. COMMENTS
Engineer verified all septic standpipes are present. Verified system components include a two way
cleanout between the septic tank and absorption bed.
G. ENGINEER'S CERTIFICATION
I certify that l 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 AARON D. JARNAGIN
Date ;;rfid
COSA canary sheet 2-6-15.doc
�40;�OF A —•R
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ral
1) 1w
ASBUILT-NO CORNERS SET THIS DATE. SEWARD
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
WeC74/ Gor y df; r
AND THAT NO ENCROAG IMENTS EXIST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONSTRUCTION
ARY LINES.
SCALE.
Of A4
DATE- � ..... 4S
9��l9�
GRID:
6v iss7
D.an. Mark Sawsrd
LS -6918 a
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DRAWN: k4�sdxa�L
A
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES p}i
Division of Environmental Services r
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519.6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # CS I L ,L 13 Sl
HAA # ��` 1 f ;)-1 1 1
1. GENERAL INFORMATION
\/ 11= uJ
Complete legal description Lo IzL W or --j
Location (site address or directions) P'L);tl � 5. -L•! ? _"IZO
TAf=L U13w2C, /Zo'1 7 TC L'+I -A t "t2 TL Krv,lL x'171 Ai` 7"O (N61L l ✓IS71-i
Property owner Dov' ID 1-t6m PC> * IL; Day phone __g!E%8 - `i 3 s c"
Mailing address 21C9c ; L','L`aL :2- kcr I y C'(i�c,l al' y S E>7
Lending agency Day phone
Mailing address—
Agent
ddress Agent Day phone
Address
Unless otherwise requested, MAA will be held for pickup.
2. NUMBER OF BEDROOMS: r,
3. TYPE OF WATER SUPPLY:
72-025 (Rev. 1/91) Front MOA N21
-r
o
Individual well
- `— z
Community well _
r -r(
N
Public water
Fn G'
oR
NOTE: If community well system, provide written confirmation from .State
ADE5attest-
ing to the legality and status of system.
z .z
o
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site ✓
�`a
h,
Holding tankLO
Community on-site
t -r -t
t„ G a
Public sewer
O
NOTE: If community wastewater system, provide written confirmation
from State AbE.0
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA N21
LH 113;-, K,"\ -''r, v'f? IL '/0
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 furtherverify 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 ia v2 Tl', ,JC Phone
Address
Engineer's signature
6. DHHS SIGNATURE
L
Approved for ' bedrooms.
Disapproved.
Conditional approval for
Additional Comments
411TIC
Date'94? 5 11 !�
bedrooms, with the following stipulations:
Date (S
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Beek MOA x21
4.
`rt1
/
Zi
f i
n
•3' A
aff
bedrooms, with the following stipulations:
Date (S
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Beek MOA x21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 ® Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: KNIT VI CO SD6D, Parcel I.D.: 0�
A. WELL DATA
e0Mr'1JNjtq wokma CLP'T a o
rr
Well type d4- If A, B, or C, attach ADEC letter. ADEC water system number # 2101409
Log present (YIN) _ N/,�'� Date completed tj1F PT'I
,✓�
r`ry
7 ?5
iz y
Total depth ti- Cased to N FSC Casing height (above ground) r l
O
- rax'
Sanitary seal (Y/N) fj Wires properly protected (Y/N) fl
-
A
R
_
i
FROM WELL LOG AT INSPECTION
Date of test NJ/ r>r
T
O "
z
Static water level _ N,1o�
Well production g.p.m._ N r� _ g.p.m.
WATER SAMPLE RESULTS:
Coliform W/ Nitrate Nj) o — Other bacteria t)/A
JJ
Date of sample: N Collected by: iV ! A
B. SEPTIC/HOLDING/ TANK DATA
Date installed 0 /30/g50`Tan k size L%_�. Number of Compartments 2- Cleanouts (YM)
Foundation cleanout (Y/N) y Depression (YM) N High water alarm (YIN) t\J
Date of Pumping 0 LA _ Pumper N
C. ABSORPTION FIELD DATA
Date installed 8/8D/95- Soil rating (g.p.d./ftz or ft2/bdrnr) 0,7_ System type _: ac -D
Length 63 _Width 1,5 _Gravel thickness below pipe Ci.'S Total depth 6. z
Effective absorption area 944S- Monitoring Tube present(Y/N)Y Depression over field (Y/N) f\1
Date of adequacy test NC0 CoN -K--rlai6ults (Pass/Fail) Q,& For 1J/,ft bedrooms
Fluid depth in absorption field before test (in.); IJImmediately after N)f gal. water added (in.):
Fluid depth tJA (ins.) Minutes later:._ V� 1A Absorption rate = fJ ✓'f'� g.p.d.
Peroxide treatment (past 12 months) (YIN) N f# If ves, give date
D. LIFT STATION
Date installed 1A Size in gallons 1A
Manhole/Access (Y/N) 01A "Pump on" level at* ,T N "Pump off' level at* IA
High water alarm level at* 01A} *Datum N If+
Cycles tested N
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/bolding tank on lot N I /k On adjacent lots
Absorption field on lot P4 I A : On adjacent lots
Public sewer main N I A Public sewer manhole/cleanout
Sewer /septic service line W 1 lk
rJJA
0 IN
Lift station 1i
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
Building foundation 22 Property line Absorption
Water main/service line 3504. 1 Surface water/drainage N(A Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
f
2C�
N /fl -
t {-
Building foundation 0 Water main/service line 5-0 F -
Surface water �(i®r >'�y Driveway, parking/vehicle storage area 20' 1-E.
Curtain drain C11V— Wells on adjacent lots Property line 10
F. ENGINEER'S CERTIFICATION
I certi%v that I have determined thru field inspections and review ofUunicipal rec RI'VIN hat jie. abo1, '1 erns are
in conformance withOA HAA guidelines ria effect on this (late. biz
Signature � { �
dhA�effi
T/V :n
f ��pEngiuecr's ine Cu2�t l�t NCS �{gmeermg Seal ' ore
_ 5 /!
Date � G-,� �) \.-�._ �1 � ' - l iC�
HAA Fee $ e:
Date of Payment?
Receipt Number
Rev. 8/95 OSS: baa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number