HomeMy WebLinkAboutGROLL BLK 2 LT 1&roll
Lot 1
Block 2
#050-521-32
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP221038 PID Number: 050-521-32
Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New X Upgrade
Name
Christopher Devine
ABSORPTION FIELD
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
25310 Eagle River Road, Eagle River, AK 99577
❑ Other
Phone
(360) 601-7774
Number of Bedrooms
3
Soil Rati
Existing
Total depth from original grade
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert fro riginal grade Gravel depth beneath pipe
Ft. Ft.
Subdivision Block Lot
Groll 2 1
Fill added above original grade Gravel length
Ft. Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
tance between lines
Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between ches
From
Tank
Field
Tank
Line
Ftz
t.
Well
>100'
N/A
N/A
N/A
>25
TANK p Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Greer
Capacity
1000 Gal.
Surface Water
*94'
N/A
N/A
N/A
Material
Plastic
Number of compartments
2
Lot Line
>5'
N/A
N/A
N/A
NA
Foundation
>1o,
N/A
N/A
N/A
LIFT STATION
M 3rnrfa urer
Capacity
Gal.
Remarks *See plan as -built
5' separation from tank to property line confirmed at construction
Alarm location
installed by
Installer
PIPE MATERIAL House to tank D3034 Tankto
D3034
JR's Septic
Drainfield Existing Co/MTD3034
Inspector J. Millette
BENCH MARK (Assumed elevation) 100 ft
Inspection 1St 3/4/22
Location and description
dates: 2 nd
3rd th
Bottom of sidding @ point B
4
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
OF q�q ill
Conditional Approval: Date
AEW'
*. TH
• . ....:.
Septic System
% Benjarrl"noSchiller
�� �'c�`•• CE �`���
Approve Date,. - ZZ
12592 .•
�����lF�• . 3/8/22 . •����
PROFESS00
v
Note: this approval does not include well permit requirements.
\®�®®a�"Z-
krCCv VU/UL/ 10)
GROLL, BLOCK 2 LOT 1
PERMIT # OSP221038 PID # 050-521-32
EXISTING WELLS lop
W 0 '0' R�DII 11 N\�660
1
toy,
TRACT 4B
B I
/POTE`NfiAL �A PGS
OVERFLOW-PATH V sv
2CO
->10
50' -DRAINA EASEMENT630—,
1zX, NEW 1000-GAL —
/SEPTIC TANK
W/ 20' MANWAY!,
100, SEPARATION
�� / j/ GRAVEL DRIVEWAY
LINE7ROM CREEK
(SERVES
610\ & TRACT, 4C)
O----�`OVVER -LINE,_
VERHEAD P
/ 7
TRACT 4C
jj, j \ 600
'EXISTING WELL
CK (LOT 2A)
// �— t V
f I
A
MH 1 50.2 118.
SV 1,, 47:8
GE BLOCK 2A 2C-0- 1 4 123.7
)IR
E 'N G I N E E R I N G
LEGEND
Cf- Aw A
CO - CLEANOUT
2CO -DOUBLE CLEANOUT
TH PLAN AS-BUILT
49
FCO - FOUNDATION CLEANOUT
0 50 100 FS - FLOW SPLITTER VALVE
•
•
•
Benja i SchillerC MH - MANHOLE
*t FFG ;00, FEET
CE 2592 MT - MONITORING TUBE
��il%W2022
Aw 1"=50' SV -SEPTIC VENT
PROH�SO TH - TEST HOLE
GROLL, BLOCK 2 LOT 1
PERMIT # OSP221038
PID # 050-521-32
PROFILE AS -BUILT
(NO SCALE)
of A
: 49 TM+
.
..........
• ' • ' • • •
Benja 'n Schiller '
•. CE 12592 .• 4`�%
,p ...
. 31.W22 . • •�C��
t�>1`� pROf E5 SIONP�'4
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: OSP221038
Work Type: SepticTank Upgrade
Tax Code Number: 05052132000
Site Legal Address: GROLL BLK 2 LT 1 G:0263
Site Mailing Address: 25310 EAGLE RIVER RD, Eagle River
Owner: DEVINE CHRISTOPHER
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
Effective Date:
Expiration Date
Lot Size in Sq Ft
Total Bedrooms:
,iltcnt
G fir.
c
Del3al'tment
2/16/2022
2/16/2023
72640
❑ 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
Date:
Date: �b r�.0�
3
Veronica Pope
Received By:
GE
2022.02.16
16:12:39 -09'00'
Issued By:
/
Date:
Date: �b r�.0�
3
MUNICIPALITY OF ANCHORAGE
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. 050-521-32
Property owner(s) Christpher Devine Day phone (360) 601-7774
Mailing address 25310 Eagle River Road, Eagle River, AK 99577
Site address Same
Legal description (Sub'd., Block & Lot) Groll, Block 2 Lot 1
Legal description (Township, Range & Section)
Lot Size 72,640 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
n
Upgrade ❑X
❑
(D)
Holding Tank
ElRenewal
ElDuplex
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: -5 Waiver Fees:
Date of Payment: Z//,,5h-7 Date of Payment:
Receipt Number: C)Y 3)6D Receipt Number:
Permit No. OS Pia 103 Waiver No.
Permit App__- : ._..:c
February 14, 2022
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
2/14/22
Subject: Groll, Block 2 Lot 1 – 25310 Eagle River Road
Septic tank replacement
Dear On-Site Services Engineer:
The septic tank on the above lot has reached the end of its 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 proposed septic tank location and existing well. No conflicts exist between this
proposed system and any other well or septic system, whether on this lot or adjacent lots.
Crystal Creek runs through the center of the property from North to South. Because of the creek’s
location, it is impossible to maintain 100’ separation to a new septic tank site. However, although
the proposed tank location is 90’ from the creek, the path of travel from the septic tank to the creek
exceeds 100’.
Wells on this and adjacent lots are shown. The new septic tank will be a minimum of 100’ from
all wells and surface water (other than noted), and more than 5’ away from the property line.
Please refer to the attached plan page for the septic design and tank to creek proximity justification.
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
OSP221038, Rebecca Carroll, 02/16/22
Benjamin Schiller
CE 12592R
EGISTEREDPROFES S I O N ALENGINEER
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
GROLL, BLOCK 2 LOT 1
FEET
0 50 100
NOTE:
SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC TANK IS
SHOWN. PATH OF OVERFLOW FROM TANK IS OVER 100'.
ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC
SYSTEMS.
3-BDR
M
H
O
M
E
2/14/2022
600
5
9
0
610
620
630 640650660
670 680OVERHEAD POWER LI NECRYSTAL CREEK50' DRAINAGE EASEMENT
DECK (LOT 2A)
SHED
GRAVEL DRIVEWAY
(SERVES LOTS 1
& TRACT 4C)
>100'
EXISTING WELLS
w/ 100' RADII
EXISTING WELL
100' SEPARATION
LINE FROM CREEK
INSTALL NEW
1000-GAL SEPTIC
TANK w/ 20" MANWAY
REMOVE & DISPOSE
OF EXISTING TANK
POTENTIAL
OVERFLOW PATH
5'
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221038, Rebecca Carroll, 02/16/22
NOTES:
1) THE 50' DRAINAGE EASEMENT AS SHOWN ON PLAT 74-60
IS NOT MATHEMATICALLY FIXED AS SHOWN ON LOT 1.
THE INTENT APPEARS TO BE TO PROVIDE A 50' WIDE EASEMENT
CENTERED ON THE CREEK THREAD. THEREFORE, THE CENTER OF
THE CREEK WAS LOCATED FOR THIS SURVEY AND IS SHOWN HEREON
AS SUCH.
2) THERE ARE ERRORS IN THE RECORD PLAT (74-60) REGARDING
MATHEMATICAL CLOSURE. THE LOTS LINES AND CORNERS
SHOWN FOR THIS SURVEY ARE COMPUTED USING THE MONUMENTATION
AS SHOWN HEREON.
TRACT 4 B
FOUND 112" REBAR
N 87000'S W 214.27'
o�000000O
O F A
co' 49 TH* �O
---------------------------------0
SHANE A. HOLT
)O N LS -6914 OD
00
°ressional
-------
O�POWER�INE (Ap�ROX.I� � � -
/CK
FOUND 112" REBAR
S
' W
J
LL'
O
a
IO
1/2" REBAR
Qj� GR9
SFR 4D
SAOr
s n'A
qN0 TR9
�O c�4oJ
0
O
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN
EXISTING STRUCTURES AND PLATTED LOT LINES OR EASEMENTS AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL
STRUCTURES OR FENCELINES.
EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED PLAT, ARE NOT SHOWN HEREON.
NOTE: ANY FENCELINES SHOWN ARE LOCATED APPROXIMATELY AND ARE NOT TO BE USED TO DETERMINE PROPERTY LINES
OR LOCATE STRUCTURES.
TRACT 4 C
FOUND 1 1/2" ALUMINUM CAP
(S.E. CORNER TRACT 4C)
AS -BUILT SURVEY
NO CORNERS SET THIS DATE SCALER" = 40'
I HEREBY CERTIFY THAT I HAVE PERFORMED A
MORTGAGEE'S INSPECTION OF THE FOLLOWING
DESCRIBED PROPERTY.
LO T 1, BLOCK 2, GROLL SUB.
ANCHORAGE RECORDING DISTRICT, ALASKA AND THAT
THE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE
PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST
OTHER THAN NOTED.
DATED AT ANCHORAGE, ALASKA THIS _20TH_
DAY OF -NOVEMBER 2002_.
HOLT LAND SURVEYING 8786, FB102-3
TEL. 345-5513
MUNICIPALITY OF ANCHORAGE s
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
NEW
`/4y�4r�>1 �o--•J'fr.,�f.,�+.
26
1 ❑UPGRADE
MAILING ADDESS
aX 617-z' Yle X1/
LEGAL DESCRIPTION
Ci=roLf / /%C /u' cu Se Q
LOCATION
NO. OFBEDROOMS
4 /e ,cevcY /Q'el
3
Well .�
Absorption area
Dwelling
PERMIT NO.
U Y
DISTANCE TO:
RY
t- z
CL F
Manufacturer
/ k
Material
5/ E/
No. of com arVnents
p
he/,o,-4:,
�C
w
Liq. capacity in gallons
/ a v o
IF HOMEMADE:
Inside length
Width
Liquid depth
�JZ
DISTANCE TO:
Well
Dwelling
PERMIT NO.
2
s F
2
Manufacturer -
Material
Liquid capacity in gallons
DISTANCE TO:
Well /OO f
Foundation
Nearest lot line r
PERMIT NO.
ZLu
No. of lines
Length of each line
Total length of lines
I
Trench width
Distance bejween lines
N L
3
-
30 inches
I—
Top of tile to finish grade / ,
Material beneath tile
Total, -effective absorption are
CC')-%- �,, f�1
Length
Width
Depth
PERMIT NO.
ua
C7
4 h
La
LU
Type of crib
Crib diameter
Crib depth
Total effective absorption area
Lu
DISTANCE TO:
Well
Building foundation
Nearest lot line
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
LU
�
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absor tion a-ea(s)
P
OTHER
Fi
PIPE MATERIALS
Ile r c, vC&t
SOIL TEST RATING
INSTALLER
REMARKS
A
t
tl, r'
/ ll
�7' t -'ti h %i Zl / r L' h G fy � � CJ / 6—/ ✓1
1
Oh,
Cr
wef" P! .Aj, \A
f 9
(fYr«
.,, ��• a •.• a.
(„
r, do. 2225-E'
i
APPROVED-�f.•f11A� ,��� DATE LEGAL
MUNICIPALITY OF ANCHORAGE � 't
Department Health and Environmenta ?rotection
825 L Street, Anchorage, AK. y9501'' k�
264-477_0
Permit 0 360 # HANDWRITTEN PERMIT
WELL AND/OR ON-SITE SEWER PERMIT
Applicant: �Ik; sf.�,, Mailing Address:��X 602L
D
01_ L /< I G Ro�� �- 1 �f Al R/ �.,� -mac a
.Location: Phone Number: -^654i ---272e _
Legal Description: % s -froom - Lot Size: m /� 7 ^c
Type of Soil Absorption System Is:
Trench: 'x__ Drainfield: _ Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: _ Soil Rating(sq.ft/br) �2o ®
The Required Size of the Soil Absorption System Is:
���
DEPTH —Z!Z LENGTH GRAVEL Lam. GRAVEL DEPTH WIDTH U
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE _ GALLONS ;E
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* # * TWO(Z) INSPECTIONS ARE REQUIRED
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 QS # #
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 bedrooms.
Signed: Issued by:-L�L �„�,
Applicant
Date: j
SWP/024(1/81)
n 6 I11 -,I u 1OX. '/L
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCPERCOLATION
825 L. Street, Anchorage, Alaska 99501 2644720
��--/ SOILS LOG - PERCOLATION TEST
PERFORMED FOR: / ����J /�'��i h C -U>` S # T a c, f-7r� ( DATE PERFORMED: A111
LEGAL DESCRIPTION: 7 �eAc / C C//PL eI:Az-✓e /y leC :� 3
DEPTH / —�- ; SLOPE SITE PLAN
(FEET) i p/f G/livlC
2
Q(/Fir lJ r1r�+�
4
5
6
7
8 1
9 S,) h/ - S �ly
10 (60v1 re -C.
11
12
13
14
15
WAS GROUND WATERS
L
ENCOUNTERED? ��/
0
P
IF YES, AT WHAT E .� "
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Milo
'•
r_��
17
NEI
iell*
9TH
•, _ .,
18
IN
INN
'14 6,
19
o. 2tti
VE L
Q4
JUNE 2S,
1971 -
WAS GROUND WATERS
L
ENCOUNTERED? ��/
0
P
IF YES, AT WHAT E .� "
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Milo
�j
NEI
In,
IN
INN
'14 6,
ONE
WAS GROUND WATERS
L
ENCOUNTERED? ��/
0
P
IF YES, AT WHAT E .� "
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
�j
'14 6,
106
a Y1G
■
■■■R
PIPM-
■
-
No
MAN
WAS GROUND WATERS
L
ENCOUNTERED? ��/
0
P
IF YES, AT WHAT E .� "
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
�j
'14 6,
106
a Y1G
20 -H^
L C
18�+'�._ �,•'= H,, 1e PERCOLATION RATE_ (minutes/inch)
// TEST RUN BETWEEN FT AND ? FT
COMMENTS /)e - C
PERFORMED BY: �- CERTIFIED BY:
72-008 (6/79)
DA
MUNICIPALITY OF ANCHORAGE
Development Services Department p p Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 050-521-32
1. GENERAL INFORMATION
Expiration Date: & 1-1- 2 D Z Z.
Complete legal description Groll Block 2 Lot 1
Location (Site address) 25310 Eagle River Road, Eagle River, AK 99577
Current property owner(s) Christopher Devine Day phone
Mailing address 25310 Eagle River Road, Eagle River, AK 99577
Real estate agent -April-Shane
2. TYPE OF DWELLING:
❑� Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone (360)601=7774—_._._...__ -
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Private Septic
❑■
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ -6-SO
Date of Payment 11 Zq, o,/2 9
Receipt Number 0`7 11 (,.h
COSA # OSC'Z Zl0 7R
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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Engineering (M.J•) Phone (907) 522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503
Engineer's Printed Name Benjamin Schiller, P.E. Date 3/8/2022
• — */
6. DSD SIGNATURE
System #1 Approved for 3 bedroomsI
. BWSchiller f
---System.#2 Approved for bedrooms ����sTFq.,Cs 125
Disapproved ,�,FapR0 ES510NP
Conditional approval for bedrooms, with the following stipulations:
`�`� �? � •ori
0
taA
e5
�J
��J�i,FAST
By �C Original Certificate Date: '3— Ll' ZZ
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 Checklist blue sheet
Legal Description: Groll Block 2 Lot 1
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
0 Well log is filed with Onsite (or attached)
Date drilled 6/10/1984
Total depth 405 ft
Cased to 137 ft
0 Sanitary seal is functioning correctly
0 Wires are properly protected
Casing height (above ground) >18 in.
Date of flow test for COSA 2/14/22
Static water level at beginning of test 218 ft.
Comments
B. TANK DATA
Age of tank(s) <1 years
Tank type/material Septic/Plastic
Measured operating fluid level in septic tank New
no Standpipes/foundation cleanout per record drawing
Date of pumping Installed 3/4/22
D. ABSORPTION FIELD DATA Deep Trench
Parcel ID: 050-521-32
Structure served by this system
Well production at time of test 1.6 gprn
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate •555 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date of Sample 3/9/22
IFT STATION
❑ Requir aintenance completed
Age of lift station years
Lift station material
Comments:
Which system tested (date installed) 7/30/1984 Adequacy test date 2/14/22
0 ALL standpipes present per record drawing Results ®Pass For 3 bedrooms
Total measured depth from grade 13.2 ft (max) Fluid depth prior to test 24 in
Measured depth to pipe invert from grade 6.4 ft (min) Water added 479 gal
❑ N/A — pressurized field
New depth 27 in
❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 1440 min
depth into effective 6.8 p
R Code -required soil cover over field Final fluid depth 21 in
Absorption rate '450 d
Q System presoaked p gp
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months)
date of test)
Gallons introduced 1400 gallons If yes, enter date
Comments/Deficiencies:-5.1(available effective) x 34 x 2.5 = 433.5(cubic feet) 433.5 x .3 x 7.5 = -975 Gallon Presoak
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
L,�J
Yes
Community Sewer Manhole/Cleanout > 100'
✓7v Yes
if No
ft
Q Yes
if No ft
Neighboring Tank > 100' El Yes
if No
ft
Private Sewer/Septic Line > 25' E] Yes
if No ft
Absorption Field on Lot > 100' F71 Yes
if No
ft
Holding Tank > 100' R Yes
if No ft
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' R1 Yes
if No ft
[D Yes
if No
ft
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' El Yes
if No
ft
0 Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' 0 Yes if No ft Surface Water > 100' R Yes if No ft
Property Line > 5
L,�J
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
Q✓
Yes
if No
ft
Private Wells > 100' 0 Yes if No ft
Water_Main.>_ 10'._.
,(]
Yes
if No
ft
Community Wells > 2nn' M/ Yes if No ft
Water Service Line > 10'
Q
Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' .
Yes ..
if No
ft
If absorption field is under driveway comment below
Property tine >.10'
✓
Yes
if No
ft
Wells on Adjacent Lots:
Water Main> 10'
Q
Yes
if No
ft
Private Wells > 100' QQ Yes if No
Water Service Line > 10'
Yes
if No
ft
Community Wells > 200' ❑✓ Yes if No
Surface Water > 100'✓Q
Yes
if No
ft
F. ENGINEER'S COMMENTS
Trench extends under gravel driveway, MT protected by trees/rocks in
miaale of ariveway. No past issues with freezing of the trench.
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
COSA Checklist yellow sheet
co
TH •r
~'^'Benjarrr5chiller
�� •. CE 12592
�S'l • . 3/8/22 • •���
PROFESS00-AMV-
lil
ft
h
h
h ZW
�S
V
i n
eQ
�
IS, OW
eW
T
W~
COQ
eoW
0
z
0 olio
>�w
° Ez,
s h
w
"�
aem
WOC
h
e�ch�
m o�Wr
2w
1. `-
xOW
2i20�
�ptiH
O
eeOW
�n1
A
V �
0; � -/l/
WCLL
SITF
JIV-1 r/l'. /VeerJf c�
X2.1 `t �rE S C /, Y r.Fr„
L-
�s;rs
T_
i
`�• OF
A
1 a
•'
�.eeOd •.• `-E�-:•
Q�'�•,.) NE 25. 1971 •
�X"
!, / c., ,, 0
r ; r,e , ," ,. ,_.
i
z1-
LOCATION
LOCATION OF WELL (Please complete either to, Ib or Ic.)
—/sDT
1a. Borough Subdivision 4 Rlev-k-- F
F -r ,. ..
I/agtre. Section No, Township NQ Range EQ Meridian`-
Anch of�of—of ® SQ w[j
--- —
Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS
3. OWNER OF WELLM,'o Bob 4W germ '-ior
Eagle River Rd.
Address; Mr.` John-Pul.e]awider
SR'.' -Box 16.98' River R
Street Address and Area of Wall Location
t0a'le
:Efa�g AX. - 995
2. WELL LOG
_
Foot Below
Surfoco
A, \4ELI,r8FT ft'(finalI S. Mg OF CQMMPLETIO�,NA- .
dd �j__ 't_
Top
Bottom
Material Typo
ww
- _ -
-^
—_�
g, QCable fact ,.)fi)jLtoturW QDrjv,n' -QDug
[j Auger QJetPoA ❑9nrd QOther 1
Clay and boulders
1
3
}30t]�Cifa]^a av�Ij_,�3
7,
'r.u8 .0Domestic QPublla'Supply loduntry
Q Irrigation Q iisoharge Q Commerical
Q Toe'War" .. 00
Other• '
Gravel.—} l_ _
5
Gravel, silt, boulders
€3.1
105-
Gravel, silt sand
10�
� 1 r�
B. CASINO: Q Threads d(-�Y�Ided�„ '-
dlam.6 In. to_M, ft. Depth Welght_1-7-_I ba./ ft.
diem. In. to '- ft. _Depth Stickup 'ft_
.t„00k
137
G�
250
—_
_Rla.nk "r -ink AY,a \ter
250
405
D. FINISH OF WELL,I -
_
Type; ...r pldmetert
T—._
Slot/Mesh BlleI Langth: -
Set between ft, apd' ft.
,
Or
8tr
Dockfllling Grovet pack
"�
--
10. STATIC WATER LEVEL.; _150 ft. 6 1 Q
Q Above or XAlpw londnurtaae Date
`
Equipment used:
---
-
'^ �^
II. PUMPING LEVEL below land surface and YIELD.-
It 1. -after _ -„hrs. pumping____-.a.p.m.
it. after - hre, pumping --a. p. M.
- — -
12. GROUT ING - Wall Grouted; Q Yeas' Q No
Material; Q Neat Coment Q Other' -
TT
13, PUMP: (if Ovgllobie) - HP
— — --
Length of Drop Pipe -ft. capacity q.p.m.
Q Subm. Q Jet : Q Cantrifloat _' Q Other
— --_-- —
14. REMARKS:
.Product,ion of;1/,2_ GPM
18. WATER WELL CONTRACTORS. CERTIFICATION:"t-"-t—
_ 15. Water Temporature IJ ®_F �.C
This well was drilled under my jurisdiction and this report Is true to the beet
of my knowledge and bollefi
Magnuson Drilling .AA_ 5385
Registered Business Name Contr(a]ctt]
License Number' ..-
,t�
Address: P.O. Box f 701504 Eagle. River, Aka
9577 .
Signed:
Date:
Authorized Representative
Form 02-WWR (11/81) Copy Distribution; WHITE-Stoto DGGS, FINK - Driller, CANARYCustomer
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 1 J.
264�4720 `
....
APPLICA
ISSUED BY
v�------v-��---------�'—���-~~~
DATE:
�.... ....
��
PERMIT NO:
0140950
DATE ISSUED:
11/19/84
APPLICANT:
ALASKA HYDRO^SYSTEM
ADDRESS:
BOX 773244
EAGLE RIVER, AK 99577
LEGAL DESCRIP:
SUBDIVISION: GROLL SUB
LOT: 1
BLOCK: 2
SECTION: 23 TOWNSHIP: 141\1
RANGE: 1W
LOT SIZE:
1A (SQ"FT. OR ACRES)
I certi
that:
1^ I am
��miliar with the requirements {or
on-site sewers and
wells as sclt
forth
by the Municipality of Anc:horage (MOA)
and 1.1-1e State
of Alaska,
2" I will
install the system in accordance
with all MOA codes
and regulations,
and in
compliance with the design criteria
o[ this permit.
3" I will
adhere to all MOA and State o[ Alaska
PCO quiroments
1,or the set back
distances
from any existing well, wastewater disposal system
or public
sewerage
syst( m on this or any adjacent
or nearby ldt.
....
APPLICA
ISSUED BY
v�------v-��---------�'—���-~~~
DATE:
Municipality of Anchorage
On -Site Water and Wastewater Program
(907)343-7904
JUL
CERTIFICATE OF ON-SITE SYSTEMS
Parcel I.D. 050-521-32 Expiration Date:
1. GENERAL INFORMATION
Complete legal description DROLL B2 G/
Location (site address) 25310 Eagle River Rd
Current Property ownef (,$) Martinet Day phone 346-4111
Mailing address Same
Real Estate Agent Muldoliado, Homes Unlimited Day phone 346-4111
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
❑
Community Class C Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual
Holding Tank
❑
Community
❑
Public Sewer
❑
Received by: Date: PA11,6
COSA to be released to the engineer, unless o erwise requested by the engineer.
COSA Fee $�4
Date of Payment�a�7 f%
Receipt Number C163710
��
COSA # Q "1101,51V
Date of Payment
Receipt Number
Waiver
5. STATEMENT OF INSPECTION BY ENGINEER
As cAille6 • y 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 NorthRim Engineering Phone 694-7025
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve lnr.. �. irsawernrcra ■+ Date
„mow^: �'-'c.�;;r••_
7/20/2016
6. DSD SIGNATURE Cf]:
- �4 E:avan W. in;1
System #1 Approved for bedrooms. zsE
System #2 Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
WASTE
qrQ\
Original Certificate Date: 'I
The Municipality of Anchorage Devlopment 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 5-1-12.doo
If more than 1 septic system is on the lot:
COSA Checklist # _of
Structure served`by this system
a
Certificate of On -Site Systems
Approval Checklist
Legal Description: GROCL Sa G/
Parcel IDOSOS2/32
A. WELL DATA
Well type If A, B, or C provide PWS ID #
Well Log (Y/N)
Date completed 7 /2rl4S Sanitary seal (Y/N)/
.
Wires properly protected (YIN)_
<
Total depth OQ ft. Cased to /37 ft.
Casing height (above ground) 36 in.
FROM. WELL LOG
AT INS;PyE'CTIION,
Date oftest . 719$
---�J
Static water level 336 ff.
Z S7 ft.
Well projpctlon Q. g.p.m;.
3 fr.. g:p.m.
WATER SAMPLE RESULTS:
Coliform O colonies/100 mL Nitrate O. 8S6mg/L
Arsenic /✓b ug/L Date of sample:
Collected by: ZO
E.„ SEPTIC/HOLbING TANK DATA
Tank Type/Material .SE/d7"( �A/ �C Few
Date installed ' 7
Tank size joao gal. Number of Compartments Z
Cleanouis YY/N)
Foundation cleanout (Y/N) Depression over tank (Y/N) High water alarm (Y/N) /y
Date of puMping '-7 TS / Pumper flit//-ift�V
a'
C. ABS®RPTIaN 04ELD DATA'
Date installed 3O Soil rating (g.p.d./ft2 o ftz/bdrm 2�
rf System type TieE+ilCif
Length IL Width z s ft. Gravel below pipe i ft.
r
Tota depth ; ` 3 ftr absorption area �!Z ft2 ` MonitoringtubeDepression over field
Date•of adequacry test hr Results (Pass/FaII),
r For bedrooms
t-
Fluid'depf!rin a�dptioq At before test in. Water added 5oa g�I.k New depth 30 in.
Elapseddin §' �0 `' Final fluid depth _ in.
ti
Absorption rate >= Se-7g.p.d.
E
Any rejuvenatioN:tgW'ent (past 12 mo.) (YIN & type)
if yes, give date
D. LIFT STATION /JA
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump "off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO
Septic tank/lift station on lot /QO ►` On adjacent lots
Absorption field on lot /06 t On adjacent lots /DO It,
Public sewer main Public sewer manhole/cleanout
Sewer /septic service line Z S to Holding tank hin r f
r
Animal containment areas SQ rf Manure/animal excrete storage areas f04 t
SEPTICIHOLDING TANK ON LOTTO`
Building foundation 3 Property line Jr Absorption field S
D ' F f rE
Water main / Water service line /O Surface water /0a
Wells on adjacent lots /DD`�f
ABSORPTION FIELD ON LOTTO:
Property line 5' +1 Building foundation /4P Water main / Q '*-
Water Service line /40 Surface water �f Driveway, parking/vehide storage Q
Curtain drainyAK' Wells on adjacent tots /OQ'
F. COMMENTS
Jr 'TRg r f L 06;*'r<d a -410,5e V COA/ST,P 0
�i � E� �'R roup cane R Gt�i�F�r Ae Z X56
G. ENGINEER'S CERTIFICATION ��c�l^►19 saw
I 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
Date 1-0 !//ro
COSA yellow sheet_2-6-15.doc
6600n W. Eng.
Municipality of Anchorage
P.O. Box 196650 0 4700 Elmore Road
Anchorage, Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997
hftp://www.muni.org/Onsite
Development Services Division
On -Site Water and Wastewater Program
Tear
�p S
� Ni.
i S m
e
Department
**** VARIANCE/WAIVER REVIEW ****
Waiver#: OSV161087
PID#:050-521-32
COSA#:OSC161318
Legal Description: Groll B2 Lot 1
Engineer: North Rim
Applicant: Martinet
Your request for a waiver of the required 10 feet horizontal separation from the absorption field
to the property line has been approved. The approved separation distance is 5 feet.
This waiver approval applies to the Existing absorption field only. Any future upgrade to the on-
site wastewater disposal system will require all separation distances be met or another approval
from this department.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I
Waiver is Granted: X Waiver is not Granted:
Date: Approved by:
Name of Reviewer
...............................................................................
w-
fj S✓ lal.F.P '1,4'
1
-fo - Preri
�'f•e-ae�` k -G _ v. - Sgt„f _
s � / A5 -BUILT
I hereby certify that I have surveyed the following described
property: Z o J f
,rf 2-6z,rs' o.l % rc 'x3y 7—/ M, R IW S
-� -
Anchorage Recording -Precinct, -AI S
g asks„ and that the improve -
mems situated thereon are within the property lines and do i o;
'.� overlap or encroach on the property lying adjacent thereto, that
no improvements on property Iy' gad)'acete! thereto encroach
{ on the prem ses In question and #hat there are no roadways,
transmisson lines or other visile easements on said property
except as indicated hereon. -
_ - ` `��'t• Dated at Eagle River, Alaska - -
r this—day o£ .JIt
ROBERT C, OHNSOId -' G"„.� . .
SCALE: Registered Land 5uiveyar No, it
I'" _ !b d Box 77-K%, Eagle River; Alaska 99577
Phone (907) 694-2543
Municipality of Anchorage
(s Development Services Department
4 Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Bax 196650
Anchorage, AK 99507
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-521-32
1. GENERAL INFORMATION
5
COSA # DSC 121037
Expiration Date: 6�27Z/Z
Complete legal description Groll S/D, Block 2, Lot 1
Location (site address) 25310 Eagle River Road, Eagle River, Alaska 99577
Current Property owner(s) Jim and Jennifer Fielder Day phone 694-1145 hm, 229-7710 cell
Mailing address -- --1908 Hillcrest. Road Apt #36, Anchomlie,.Alaska.9951z_._..
Lending agency Day phone
Mailing address
Real Estate Agent ReMax of Eagle River, Audrey Mason Agent Day phone 622-3344
Mailing Address 11525 Old Glenn Hwy, Eagle River, Alaska 99577
Unless otherwise requested, cOSA will be held by DSD for pickup.
1 NUMBER OF BEDROOMS:
3, TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
— - - - — -1rizilvidualMe -- - -- --- - --individual un=sl e Individual Water Storage ❑ Individual Holding Tank ❑
Community Class Well ❑ Community On-site ❑
Public Water System ❑ Public Sewer 0
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the 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 onsite 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
Address 9806 E. Northstar Circle, Palmer, AK 99645
Engineer's Printed Name Douglas T. Kersey
Douglas T. Kenley, P.E.
Phone (907) 746-1073
j - - 3 2-6 I
Dater -
Ck %'
5. DSD SIGNATURE�,,
Approved for 3 bedrooms. A
Disapproved:
Conditional approval for bedrooms, with the following
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
4
am �',,;'.D�U,•Y, ej
ON-SITE
X Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: lfi . u. 4. Original Certificate Date: til Z
(Rev. t1M)
Municipality of Anchorage
Development Services Department t
Building Safety Division
On -Site Water & Wastewater Program `
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Groh S/D, Block 2, Lot 1 Parcel ID: 050-521-32
A. WELL DATA
Well type Private
Date completed 7'21195
Total depth 600 ft.
Date of test
If A, B, or C provide PWSID # _
Sanitary seal (Y/N) Y
Cased to 137 ft.
FROM WELL LOG
7/1995
Static water level 330 ft,
Well production 0.6 9 -
P.M -WATER SAMPLE RESULTS:
Coliform Negative colonies/100 mL Nitrate 0.732 mg/L
Arsenic: No ug/L date of sample: 217/12
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel
Tank size 1000 gal. Number of Compartments 2
Foundation cleanout (Y/N) Y
Date of pumping 2/20/12
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 36 in.
AT INSPECTION
2117/12
254.2 ft
3.3 9 -
p.m -Collected by; F. Kenley
3a
Date installed 7/X/84
Cleanouts (YIN) Y
Depression over tank (YIN) N High water alarm (Y/N) NA
Pumper J.R.S Pumping
C. ABSORPTION FIELD DATA
Date installed 7/30/84 Soil rating (g.p.d./ft2 or fe/bdmt) 200 System type, Trench
Length 34 ft. Width 2.5 ft. Gravel below pipe 9 ft.
Total depth 13 ft. Eff. absorption area 12wftz Monitoring tube Y Depression over field N
Date of adequacy test 2/11112 Results (Pass/Fail) Pass For 3 bedrooms
�P
Fluid depth in absorption field before testK� in. Water added 595 gal. New depth32_1/2 in.
Elapsed Time: 1440 min. Final fluid depth 21-3'4 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
"Pump on" level at _ in.
E. SEPARATION DISTANCES
Size in gallons
"Pump oft'
Cycles tested
Manhole/Access (Y/N)
water alarm leve!
Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100+ ft. On adjacent lots
Absorption field on lot 100+ ft. On adjacent lots
Public sewer main NA
Sewer /septic service line 25+ ft.
Animal containment areas 50+ ft.
100+ ft.
100+ ft.
in.
Public sewer manhole/cleanout NA
Holding tank NA
Manure/animal excrete storage areas 100+ ft.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ft. Property line 5' Absorption field 5r
Water main NA Water service line 10'+ft. Surface water too'+ft.
Wells on adjacent lots 100' +ft.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line -' W+ ft. Building foundation 10+ft. Water main NA
Water Service line 10+ft- Surface water 100+ ft. Driveway, parkingivehicle storage
Curtain drain None Known Wells on adjacent lots 100+ ft.
F. COMMENTS
r i-�� rrr L -sl Se✓o�f.n� SN ?.fi�E,vlcy r S N4Yi N R7Et«Cw4Y o
G. ENGINEER'S CERTIFICATION 9,y<et o,
I certify that l have determined through field inspections and
review of Munic/pal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Douglas T. Kenley P.E.
Date - Eirl, 21, U f2
COSA Fee $ 0 -P4 Q VII Rush Waiver Fee $ _
Date of _ Pa ment�%Ial laZbOC,�d.
Y Date of Payment
Receipt Number Receipt Number,
(Rev. 4110)
N
oF.pe �
9 1Hn.
•�•� • nr 4 U,i. .•j
1
s3
e
f j pE x o'
0.
C
J is
jJIV
14
„g /ems j } Pre✓-uac,�/ i
toe Lag Jl
rra e{ k G
fl(I
AS -BUILT
hereby rectify that- I have surveyed thefollowing- describedroperty.t (i
5 re 23,
7-14- A;, R tt- sMi
Anchorage Recording- Precinct, - Alaska, and that the improve-
ments situated thereon are within the property lines and do not
overlap or encroach on the property lying adjacent thereto, that
no improvements on property I, ad'acent-thereto encroach
on the premises in question and that tem are no roadways,
transmission lines or other visible easements on said property
except as indicated hereon.
Dated at Eagle River, Alaska - - --
this :"L—day o -Le ^- ,-a 17.E
ROBERTPC. OHNSONc cs'�-� z
SCALE: Registered Land Surveyor No. b8
I- = !Ila Box 77-04%, Eagle River; Alaska 99577
Phone (907) 694-2543
Municipality of Anchorage
®
Department of Health and Human Services 1
Division of Environmental Services
On -Site Services Section 825 "L" Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci. anchorage. alk. us
(907)343-4744
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FORA SINGLE FAMILY DWELLING
Parcel I.D.OSY _ S'a I —3_)-
1. GENERAL INFORMATION
Complete legal description Lot 1, Block 2
Location (site address or directions)
Current Property owner(s)
Mailing address
Lending agency _
Mailing address
Real Estate Agent_
Mailing Address
HAA#_/Ya7LC�sSC' -
Expiration Date:
Groll Subdivision
25310 Eagle River Road
Joni Purcell
Dayphone 696-1986
PO Box 771795, Eagle River, AK 99577
Coldwell/Connie Hettinga
Day phone
Dayphone 696-7653
Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by:
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
TYPE OF WASTEWATER DISPOSAL:
M
Individual On-site
El
❑
Individual Holding Tank
❑
Well ❑
Community On-site
❑
❑
Public Sewer
❑
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of
Health Authority Approval (HAA) based only upon the representations given in paragraph 5 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) on properties served by a single family on-site
wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners.
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 sample results less than 30 days old. Certificates
are valid for one year for properties served by Class A or B wells or a public water system. The Municipality
of Anchoraae is not responsible for errors or omissions in the professional engineer's work.
i2-0251Re, _ 01 00C
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 Health Authority Approval Guidelines for the Health Authority Approval
application show 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation.
S & S ENGINEERING
Name of Firm 17034 Eagle River Loop Road No. 204 Phone cf `I — D,. 1I 7
Address Eagle River, Alaska 99577
Engineer's Printed Name Robert Cowan
6. DHHS SIGNATURE
Approved for 3 bedrooms.
Date yp �6 /o0
. O I .q e
RCHM C. COWAN ++.`
% CE - 8801 ;
Disapproved. ij�'Ae
Conditional approval for bedrooms, with the following stipulations.
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By:�% /%/Li i [,tJ�� Original Certificate Date: /d - Z ( - 0 0
Expiration Date
72-0251Rev 01'001"
-aL-col
Reissue Date:
Municipality of Anchorage R EC E I VEJk
• '� Department of Health and Human Services
Division of Environmental Services OCT o k 2000
On -Site Services Section 825 "L" Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650 MUNICIPALITY OF
www.ci.anchorage.ak.us ENVIRONMENTAL SERVCESD ANCHORAGE
(907)343-4744
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Z,,97- (oou- ��� Parcel I.D.:
dZ/-3Z
A. WELL DATA
Well type fKAW& If A, B, or C provide PWSID # — Well Log Y Cs 2
Date completedJ Sanitary seal C`3 Wires properly protected
�}
r /
Total depth rip'Cl f
_ ft Cased to — ft Casing height (above ground) / t in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level �5�;y ft 33 ft
Well production 0, & / g.p.m ° cP g.p.m
WATER SAMPLE RESULTS:
Coliform colonies/100 ml Nitrate 0 • S mg/I Other bacteria 9 colonies/100 ml
Date of sample: IQ h 2 h loo Collected by: S& S ENGINEERING
B. SEPTIC/HOLDING TANK DATA 17034 Eagle River Loop Road No. 204
C Eagle River, Alaska 99577
Tank Type/Material'' /�
Date installed Tank size IP" gal Number of Compartments Z
Cleanouts YIr_ Foundation cleanout VC/5 Depression over tank NQ High water alarm —
Date of pumping /D e Pumper �� S
C. ABSORPTION FIELD DATA
Date installed I Soil rating (g.p.d./ft2 or ft2/bdrm) 000 System type
i
Length54 ft Width 5 ft Gravel below pipe ft
Total depth /3 rft Effective absorption areaft2 Monitoring tube L Depression over field /V y
Date of adequacy test /OSlR� Results (Pass/Fail) � For 3 bedrooms
Fluid depth in absorption field before test 3 �1 in Water added 570 gal. New depth 4 S in.
Elapsed Time: 3'5 min Final fluid depth3'9?" in Absorption rate >= _7VO? g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type )111t_W&4l/// Al If yes, give date
72-026 (Rev. 01/00)'
D. LIFT STATION
Date installed —NJ Siz ' gallons Manhole/Access
"Pump on" level at in "Pump off" level at in High water alarm level at in
Datum Cycles tested Meets alarm & circuit requirements.
E. SEPARA11ON DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 11)(91-1-- On adjacent lots
Absorption field on lot /077 �/- On adjacent lots
/" 7r
/071 /fi-
Public sewer main /,//,4 Public sewer manhole/cleanout �
Sewer /septic service line Z S Holding tank _ /V 1A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation _ 5 �L Property line /�-> ./- Absorption field _
Water main A Water service line /0 Surface water
Drainage �—Z7 �> Wells on adjacent lots _ le-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
7 �
Property line /D Building foundation /O Water main A
0
Water Service line /O --- Surface water /PV a Driveway, parking/vehicle storage
Curtain drain /1/an%�-Ayawr/ Wells on adjacent lots � .f
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAAguidelines in effect on this date. /
Engineer's Printed Name 11 0Q1 oT C_ COwq,-,
Date I 0 16, /00
HAA Fee $ ?3 0-0 1 FV
Date of Payment
Receipt Number
72-026 (Rev. 01/00)'
Waiver Fee $
Date of Payment
Receipt Number
gem
. m.. . , ,-,. ,
ROBERT C. COWAN i•^-
�11`�C�f•.�
C[ - 8801
`fit+``\.k.
;���
- ,•.O
carol l Lot L , 131k L
i
Locatlon (site addressor directions)
s NhINrEagle River Road„ Eagle River
Property owner JohrL & Debbie ` Day Fhllenwider Da phone 694-3213
AJ 3Gf dY5fa _i,iv '
µ
Mailing address HC ;83' Fix 1628, Eagle Rivera AK 99577 —
>f-
�� Lending agency City Mortgage/Jim DiMaggio Day phone _ 277-0700
1
Y
k Malling address 0; Anchorage, AK 995092810
P 0- Box 9281
a a
Agent FtLne Prox�erf ,eG/r,Ga Hai *ung on Day phone 562-7653
>^
:WV, 1 -P, f yr FRz.. 4a?• ,t✓
Yn rte" Address =f 2'525 ,0 Street, -Anchorage, 'AK :`99503
r —
vs-Z'r'�frFFs[`S" tf Tzrf�7F'6 ,�
L4Yl
�� 4£,.h
Unless�otherwise requested, AA will be held for pickup}• {, <
gt j
�7�hE(7�
�Y ,�-
rF'
BEDROOMS �fs 3, z ;� j„ �x.
}�'r�}�v't•�,g" rMi{f 4?{•r�yi,a,�4•t"+.L.L-f+l{}J
�3 TXPEIOF WATER SUPPLY 5s f ' _ 1 -rt
fix$>�fi�sfrr_s*•x U iv�a.t}-c- _ >��, ,t �• .t ,
T1 50
i%tif-ys„ * i fndlviduai welCs n X , — ,..1 1 i �itJ�lSNitllt rn}•nC `Sri' t' j T !'. r ;
3 ../.J �r .r, 2 d z <-.> F r ,. U�t,.� ,l I' an ,_77�V ifs r
..� 4 r 1, ! r! ,. r ft thx a t 1 x
24 , , l'-
Commun►ty well ---
.. �t !
M.
tl GJ'(•X N * - i f
Publita water s r»3 - - -4tj o,i
s. I
(_j ... -, Seat .: A (,i '•i t.,.
r ♦,� , VCy
-
NOTE If community wel! system, provide written confirmation from state ALEttest
`� ing to the legality and status of system
tel
' J
l�
4 TYPE OF WASTEWATER. DISPOSAL
}t„ y 'Individual on site x
Holding tank v h
, f t k { t ' -e}
4�
.. Communityion -site /FFj it
t,}
rias 3 Y s lJ[, til `:i �,'Mtr ,i 1i uil f rtf
a
Public sewer r
NOTEffcommunity,wastewatersystem,`provide'written confirmation from stateA6E
attesting to the legality and status of system.
X 72-025 (Rev. 1/91) Front MOA A21
5. STATEMENT OF INSPECTION BY ENGINEE13
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm Eagle River Engineering Services Phone 694-5195
Address P.O. Box 773294, Eagle River AK 99577
Engineer's signature — _ Date-7--It-9,5-
C;
7--It-95CF a 'h
AVV
- s ., 7�
iiia ... r# uG S.•
L Hvflit
CE!6736 G�a�
0 AW
6. DHHS SIGNATURE
Approved" for 3 bedrooms.
Disapproved.
,
w Conditional approval fore' bedrooms, with the following 'stipulations:
� Addit gnail ments _ --
` 4ti 7 27 �i
By: Date
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 (R". 1/91) Beck MOA #21
® Municipality of Anchorage AiL
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: (,',Lot- t-. IA9-r / Z— Parcel I.D. (a - SZ Z -
A. Well Data Sce� Z�
Well type /Z1114 c If A, B, or C, attach ADEC letter. ADEC w ter system number H14
Log present (Y/N) YCS Date completed _��_Driller
Total depth (P01� Cased to Casing height
Sanitary seal (Y/N) _LLS Wires properly protected (Y/N)_ \/r,-5
FROM WELL LOG
Date of test 291
i
Static water level .� U
Well flow �w g.p.m.
Pump levell IJNK Uwe_
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
�ICIPALITY OF ANCHORAGE
)NMENTAL SERVICES DIVISION
'..'I. 2 ; 1995
RECEIVED
Septic/hekhng tank on lot /00 ; On adjacent lots
Absorption field on lot /00 ; On adjacent lots /00
Public sewer main Public sewer manhole/cleanout NIA
Sewer service line Petroleum tank LC d1VPIVEN %-
WATER SAMPLE RESULTS:
Coliform Nitrate /60(7 - Other bacteria _
Date of sample: U ��/ MY5 Collected by: z�- e, ES
B. SEPTIC/H960M TANK DATA
Date installed 0,)ln Tank size /000 Compartments l-
Cleanouts (Y/N) Y15 S _.Foundation cleanout (Y/N) N/GS Depression (Y/N) I* _
High water alarm (Y/N) /414 Alarm tested (Y/N)
Date of pumping 0?Z/ L1/95 Pumper
SEPARATION DISTANCES FROM SEPTIC/HQf=DtNG TANK TO:
Well(s) on lot 1007 _On adjacent lots
J-(001
i
Foundation ly _
To property line 11N01/V , L bsorption field S Water main/service line
i
Surface water/drainage
72.026 (3W)• Front CONTINUED ON BACK PAGE
C. LIFT STATION NIA
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y
SEPARATION DISTANCE FROM LIFT STATION TO:
lot
D. ABSORPTION FIELD DATA
On adjacent lots
Manufacturer
"Pump off" Level at
Cycles tested
Surface water
Date installed d� ��� Soil rating (GPD/Ft') 1-00 ��� %3/2 System type /l2rlynly
Length 3/� Width ��� Gravel thickness % Total depth
12
Total absorption area G-00 Cleanout present (Y/N) y�5 Depression over field (Y/N) JSL
Date of adequacy test 16619 Results (pass/fail) P4 -()LS for v Bedrooms
Water level in absorption field before test //� >; S After test "V�
Peroxide treatment (past 12 months) (Y/N) /V/,l If yes, give date /VIA
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /00 On adjacent lots L in() ' Property line^(!/i9 wrp�
To building foundation I To existing or abandoned system on lot N�/1
On adjacent lots Cutbank Nle+ Water-maWservice line
Surface water J IL20 Driveway, parking/vehicle storage area 2 Ll�� J
Curtain drain 1V01VZ-
E. ENGINEER'S CERTIFICATION
I certify that 1 have checked, verified, or conformed to all MOA and HAA
guidelines in efigad brl;t'd:fQpf,,this inspection.
1fi 1"t Jn °s- a m :Y
yZ n
4
Signature
C
0 `d �iSQJQY%4Y ax k�d`AER a
Engineer's Name -06/l S /130ZL 2' . PC
Date--z� �iS-
`( r9F °a•.,:,,>°°•,°°°" .;
��'
y+�, {�Pc, t^;Yip•=.;+"=,
HAA Fee $ 300 .00 Waiver Fee $ _
Date of Payment Date of Payment
Receipt Number �t1 �� Receipt Number.
1n nn. ,nu»,• 0....6
C�rxfiffteb �rilltng i[og
n,
DOC Co. 4ba
SULLMN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 • TELEPHONE 688.2759
OWNER OF LAND _1L �-L� 1"Q L[ / ,., 4QI;j.Z7,�_ DEPTH OF WELL ( 00
ADDRESS�v {f 4� T `(_)y
DATE • Started Ended GALS. PER HR
PERMIT NUMBER KIND OF CASING
KIND OF FORMATION
/
From Ft. to 1fr �FL-6` L` rr r L CLl_ From
Ft.
3-30
STATIC LLVEL OF 1V:\iER F'i.
LEGAL DESCRIPTION ��L?L<
/IU
From Ft. to'``t�`r''SL�Ft. t'[i� �<<. l�Li^ /�
From
5=�'`;'�'DRAW DOWN FT.
DATE • Started Ended GALS. PER HR
PERMIT NUMBER KIND OF CASING
KIND OF FORMATION
/
From Ft. to 1fr �FL-6` L` rr r L CLl_ From
Ft.
to
Ft._
/IU
From Ft. to'``t�`r''SL�Ft. t'[i� �<<. l�Li^ /�
From
Ft.
to
--Ft.
99t /
From4t�� Ft. ta��Ft. fir_' ��JC(G 1'�� `7
From
Ft.
(o__
Ft.
6—
Ft. to Ft Vii{ S ��i�l .� From
From/,
Ft.
to
Ftp_
p
From rc, [� Ft. to_s� l Ft. l r ✓1 �C- CIS/,4q
From Ft.
to--
Ft
Frc Ft. toS�_f FA's2CTQd
Ft. �3 �jCe t)
From
Ft.
to
Ft.
FromfJ Ft. to 7Q Ft. _ ? Jl,) 0 S 4.
From
Ft.
to__
Ft.
s tiv
From Ft. to Ft.4 _) s E �j Jd.14r z /
From'�4
Ft.
to
--Ft.
Fromz `� Ft. to ap Ft. 1y��9 u ': C /`?t r"
From
Ft.
to
--Ft.
From_ Ft. to— Ft.
From
Ft.
to
Ft._
From Ft. to Ft.
From
Ft.
to^—.Ft.
From Ft. to Ft.
From
Ft.
to--
Ft.
From Ft. to Ft.
From
Ft.
to--Ft.—
From Ft. to Ft.
From
Ft.
to
--Ft. _
From Ft. to Ft._
From
Ft.
to
Ft.
From Ft. to Ft.
From
Ft.
to
Ft.
From Ft. to Ft.
From
Ft.
to
Ft
7MIJRFM7AYrT UF ANCHORAGE
MISCL. INFORMATION:
ENVIRONMENTAL SERVICES DIVISION
"Y ?_ 1 1995
RECEIVED
DRILLER'S NAME
EAGLE RIVER ENGINEERING SERVICES
P.O. BOX 773294
EAGLE RIVER, AK 99577
TEST REPORT
TEST DATE: July 5, 1995
LEGAL: Groll Lot 1, Blk 2
LOCATION: NHN Eagle River Road
RESIDENCE: Single Family, 3 Bedrooms
WATER SYSTEM: Private Well
WELL FLOW: 0.61 gpm as per 07/95 well log only
SEPTIC SYSTEM: From Municipal Records
Tank: 1,000 Gallons
Absorption System: Trench Type
INSTALLATION DATE: 07/84
INSTALLED ABSORPTION AREA: +600 Square Feet
ORIGINAL SOIL, RATING: 200 SF From Original Soil Log
SEPTIC ADEQUACY TEST PROCEDURE
SEPTIC: The leachfield was charged with water from the on-site well at an average rate of 5.2 GPM for a
total of 192 gallons, depleting the water supply. This limited water supply was from the existing well, prior
to deepening 195'.
The septic tank and leachfield liquid levels were monitored referencing a measurement below the top of the
standpipe. During the test, water was added through the start of leachfield cleanout tube and the leachfield
water level was monitored as water was added and then absorbed into the surrounding soil.
The water level in the septic tank did not rise after the addition of 192 gallons of water showing that the
leachfield had accepted the entire amount. A total rise in liquid level in the leachfield was recorded as 2.5".
Measurements were taken of the leachfield level, at time intervals to record the recovery with a satisfactory
return reduction in liquid level. The monitoring of recovery time of the 192 gallons of water introduced
during the test, projected over 24 hours, indicates the septic system will accept the required 150 gallons per
day of effluent, per bedroom, which is the required absorption rate for Municipal approval.
WATER SUPPLY
The well was not flow tested, rather, the well log supplied by the well driller shows a flow rate of 0.61 gpm
which is acceptable in lieu of a flow test for a newly completed well. This flow rate meets the Municipal
requirement for a 3 bedroom home. Water samples for coliform & nitrates were satisfactory.
G: MTD O C S\ 1995\95-058B. RPC
TEST RESULTS
The septic system soil absorption rate meets the requirements of the Municipality of Anchorage for a 3
bedroom single family residence as of the day the system was tested.
Assessment of existing subsurface conditions by the inspecting engineer is limited to information obtained from
the available monitoring tubes and Municipal record search. We do not guarantee the validity or quality of
well tests and inspections performed by the well drilling contractor. This report is limited to absorption rate
testing and surface separation measurements as currently required by the Municipality of Anchorage and does
not verify the integrity of the piping for the water supply or water quality other than the bacterial and nitrate
content.
The operational life and the matter of compliance with State and Municipal codes, for all water and septic
systems depends on the local soil conditions, groundwater levels that may not be observed from the surface
without additional testing, water usage of the homes being served by the system, and the detail of required
testing procedure. Septic systems expire with use and future environmental concerns may require more
extensive testing, which could render the leachfield unusable. This is true of all septic systems.
There is no guarantee that the well and septic system tested will meet the requirements for approval in the
future. The test data and investigation of existing conditions is provided to our client for submittal to the
Municipality Health Department for their review and approval. Any concerns with this test report should be
discussed with the testing engineer.
c:\WPDocs\1995\95-058B. RPT
j
a
.fC !�I (' (
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE f/
1. General Information Application Date p,/Z) _ !�
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicants Name,/„`/",] �,� (�G,i�_s� Telephone — Home Business
Applicants Address jc` 11P/, �� r4/&'
(c) Applicant is (check one) Lending Institution ; Owner/builder
l°:
Buyer � ; Other [:::I (explain);
(d) Lending Institution�ti rjx /1/v 7r �7�i Telephone
Address
(e) Real Estate Co. & Agent A.2a-A% Cr.
Address
O
Telephone
(f) Mail theHAA to the�fo lowing address:
2. Type of Residence
Siugle--Family ^ Multi 4amily
Number of (Bedrooms
3. Water S2pp7.y
Individual Well
Community M Public M
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
G. Sewage Disposal
Onsite � Public Community Holding 'rank
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]
S. 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 onsite
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein. I further verify that,
based on the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firmr% i . " Telephone-
Address -
Date
ele honeAddress-Date% / sw,�m>;_ p.. nCga` i
F+ �
(ENGINEER SEAL) mossy}}; 49r_'
6. DHEP Approval -
J'. i i / >
Approved for bedrooms
Approved _�7/_ Disapproved Condition�
Tennis of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF 11 ALTH AND ENVIRONMENTAL PROTECTI0:3
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER`S WORK.
(DHEP SEAL)
RR4/ej/DI8
[Page 2 of 2] 7-19--84
MUNICIPALITY OF ANCHORAGE (MOA) V861, �j ZION
HEALTH AUTHORITY APPROVAL (HAA) N0110110 d 1V1NIV,1NOWN3
d HIIA11 JO UA
CHECKLIST - FEBRUARY 1984 2DVdOHDNV JO AII'IVdIDINnw
Legal Description: Z-7L
A. WELL DATA -roll 7-1 y At l pe j s -e c_ z�_) 3
Well Classification Pr- IVC,%t If A, B, or C, D.E.C. Approved(YM) A'Ad�-
Well Log Present (Y/N) y Date Completed Act Yieldda _4T 64"r"
Total Depth Cased to / 7 Depth of Grouting /V�r""-�� _
Static Water Level % a Pump Set
Casing Height Above Ground ccs e Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)_ Depression Around Wallhead (Y/N) N
Separation Distances from Wb11:
To Septic/Holding Tank on Lot /6d / _�; On Adjoining Lots A00
To Nearest Edge of Absorption Field on Lot� ; On Adjoining Lots
To Nearest Public Sewer Line 6" To Nearest Public Sewer
Cleanout/Manhole /vow To Nearest Sewer Service Line on Lot ;2 5
Water Sample Collected By Fri U, e Q Date le/i4l =
Water Sample Test Results �_
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed _ 71& / Size / el 00 6-edMo. of Compartments 0,
Standpipes (Y/N)Y Air -tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/N-) iy' Date Last Pumped &Af Lz1•
Pumping/Maintenance Contract on File (Y/N) V//i; for
Holding Tank High -Water Alarm (Y/N)� ) Temporary Holding.Tank Permit (Y/N) N/
Separation Distances from Septic/Holding Tank:
To Water -Supply 411 /Co 1- To Building Foundation_
To Property Line i s W over, F ;4zd }To Disposal Field
To Water Main/Service Line /cJ-r To Stream, Pond, Lake, or Major Drainage
Course IZ20 --
Comments v
[Page 1 of 21
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata o&O 4' Type of System Design Tri h C -A
Date Installed 7/4- y Length of Field '_ 4/
Width of Field ��?'' Depth of Field /3 '
Gravel Bed Thickness ! '
Square Feet of Absorption Area 600 Standpipes Present (YM)
Depression over Field (Y/N) /U Date of Last Adequacy Test /U / Z4J
Results of Last Adequacy Tbst /VL= L-�
Separation Distance from Absorption Field:
To Water -Supply Db11 lOo t To Property Line
To Building Foundation f�29/ To Existing or Abandoned System on
Lot On Adjoining Lots v
To Water Main/Service Line a 0 4 To Cutbank (if present) i1/o >i -e-
To Stream/Pond/Lake/or Major Drainage Course (o o
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION /?/J/4
Date Installed Divensions
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Convents
Manhole/Access (YM)
"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 HAA Guidelines in effect
on the date of this inspectio
Signed ,-0 Date // ,;� vc
Compa31, 'i'141ticf-d e/, MOA No.
KB1/d5/s
[Page 2 of 21
s
�, � F ®-
rn...'\�DD.BDO�
NEEAS
22' 5-E: a
�UNE. 2J tWl
2-1.5-84
