HomeMy WebLinkAboutMEADOW BROOK BLK 2 LT 23AMeadowbrook
Block 2
Lot 23A
#050-191-82
Municipality of Anchorage
Development Services Department `• "
��•
Building Safety Division
�- On-Site Water and Wastewater Program, 4700 S. Bragaw St.
P.O. Boz 196650 Anchorage, AK 99519-6650 Page I of Z
www.d.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number:ln) 12 PID Number: 0S - 2
Noma ye;lvGFY tI�IKC,e661/ystem:
Wastewater S []New OKUpgrade
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ABSORPTION FIELD
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LEGAL DESCRIPTION
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Inspections performed by: CN21 S WnnDh Dates: 1"
2n 5177/05
FLWODD
Development Services Department Approval
Reviewed and approved by: !4/. Date: G' %' O_6�
17No1
%. CEIMJ.
(Rev
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Y'Mw1•^^Ct`�
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Permit No. SW050127
Page 2 of 2
Municipality of Anchorage
DEVELOPMENT SERVICES DEPARTMENT
ON—SITE WATER & WASTEWATER PROGRAM
4700 SOUTH BRAGAW STREET P.O. BOX 196650, ANCHORAGE, AK 99519-6650
On—Site Wastewater Disposal System and/or Well Inspection Report
Legol Description: MEADOW BROOK, LOT23A, BLOCK2 050-191-82
S aew•m• c
Idao
�o
11
1s
Lot 23A
b�
z Gia' E
� Mc
I? ' 3' « Lot 22A
R.•�c
i�3J A B
0
o D sE
s07 �U. 1000 GAL TANK HW
CfG T°.y, c SWING TIES
%O S.M. �II
4
O - SEPTIC PIPE F
• - MONITOR TUBE
ELEVATI❑NS SCALE 1"=50'
(NOT TO SCALE)
IA A EE 06-03-05
ASSUMED ELEVATION - 100' LEVEL A GROUND ENGINEER'S SEAL
LEVEL ATS 95.2
\ 00004p�
0.5' ILL MT -I MT -2 1 TH-1 c� OF •A ���h
ao�P��C. ,.... -gsU�O
fOII 3.5 YPA O . a
-91.7
TANK . o , o o ..................
1,000 GAL o 6' GRAVEL CHRISTOPHER R. WOOD:' O
:3
101.4 0 • ..o ? o Na G.W.T. OQO�+f�% CE -10387 �O
96.9 96.9 91.7 / �Q� .............'• ooh
85.6 85.6 79.2/ �� �DFE$S� o
0004`J000
MUNICIPALITY OFANCHORAGE L�T
Development Services Department Il
On -Site Water 8 Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: May 18, 2005
Expiration Date: May 18, 2006
Permit Number: SWO50127 Parcel ID: 050-191-82
Legal Description: MEADOW BROOK BLK 2 LT 23A
Design Engineer: 0848 Eagle River Engineering Services Site Address: 018017 SANCTUARY DR
Owner Name: BRADLEY HARCROW Lot Size: 18859 SO. FT.
Owner Address: 6303 WALLACE ROAD Total Bedrooms: 3 Permit Bedrooms: 3
PANAMA CITY , FL 32404 -
This permit Is for the construction of.
E Disposal Field [✓ Septic Tank ❑ Holding Tank ❑ Privy E] Private Well 0 Water Storage
All construction must be In accordance with:
1. The attached approved design.
2. All requirements specked 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 DSD at least 2 hours prior to each inspection. Provide notification by catling
(907) 343-7904 ( 24 hours). ( Not required for a Water Supply Permit only).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, seated, and heated to prevent freezing.
5. The following special provisions.
-THE UPPER SIX INCHES OF THE SYSTEM MUST CONSIST OF TOP SOIL AND MUST BE VEGETATED
SUFFICIENTLY TO PREVENT EROSION.
Received By:
Date: Ll S /
Le I
Issued Date: J g eS
Municipality of Anchorage
-� Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us.
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. OSO /17/ 82 Permit Number SW
Property owners - %Yai
Mailing address (1) lo303 (iU�Qa c
irtaiting address (2 !:: 4WLV
v;
Legal description (Lot, Block & Sub'd.)
Legal description (Section, Township & Range)
Lot Size /,C AcrestgaV .
THIS APPLICATION IS FOR:
Day phone fSo -,2,f3- 5-75-7
Code _9
Number of Bedrooms 3
Sewer Only ❑ Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
I certify that the above Information Is correct. I further certify that this application Is being made for a
Single Family Dwelljng,*d is 19 accordgnce with applicable Municipal Codes.
(Signature of property owner or authorizbd agent)
Permit Fees: 1460 • ro Waiver Fees:
Date of Payment: 571?JIOA-S Date of Payment:
Receipt Number: G��G 1 I t Receipt Number:
(Rev. 12!00) _r
Eagle River Engineering Services
Christopher IL Wood, P.E.
10421 VFW RD. Suite 201 (907) 694-5195 tel
Eagle River, AK 99577 (907) 694-3297 fax
May 13, 2005
Dan Roth
Manager, On -Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Meadow Brook Sub. Lot 23A Block 2
Narrative & Permit Application
Dear Mr. Roth:
Eagle River Engineering Services (EKES) was contracted to obtain a septic upgrade permit for a
3 bedroom single family home at the above referenced property. The proposed septic system
will have very limited impact on adjacent properties for the following reasons:
1. The surrounding lots on 3 sides are all connected to city water.
2. Immediate neighboring septic systems arc all +20' distance, and no private (or
community) wells within 200' of the proposed septic system.
3. This permit is for a septic system upgrade only.
4. Drainage will not be affected and is not a major consideration in our design.
Installation of this leachfield will not adversely affect the wells or septic systems or reserve areas
on adjacent developed lots.
If you have any questions please call our office at 694-5195.
Sincer y, 2W
Christopher R. Wood, .E.
Principal
\2003\05-03 S S E PTI CN A RRAT I V E
No •IVIS +200
APPRO-X OpP1INSTALL08' `
WATER VALVE NEW 1000 gal.
LOCATION do R �3 �B SEPTIC TANK 0 12'
6,34. 1411 fo C 00
trO N OC
LN
i5G X30. ABANDON
Q^ TANK k FIELD
0 - TEST HOLE
w - MONITOR TUBE
a - SEWER CLEAN OUT
+ - WELL
— — - EASEMENT
PROPOSED LEACH FIELD
EXISTING LEACH FIELD
E - DRIVEWAY
NO SURFACE WATER
NO KNOWN CURTAIN DRAINS
S 25'0421' E
Lot 23A
H
L NEW ry
r•
Trench /41
NOOSE
0
Septic Are*
dor 0
VO
Septi 30•
Lot 22A
NOTES
1. NO SURFACE WATER.
A 2. NO KNOWN CURTAIN DRAINS.
Sectk Are* 3. ALL ADJACENT PROPERTIES ARE CONNECTED
TO PUBLIC WATER.
n0 DO
C2 No wells +200,
OF q�4
EAGLE RIVER
ENGINEERING SERVICES
P.O. Box 773294
10421 VFW Drive
Eagle River, Alaska 9957
(907) 694-3193 FAX. (907) 694-3297
ERES Project Number: 05-038
CADD File Name: 05-038
WELL/SEPTIC SITE PLAN
_EGAL: LOT 23A BLK. 2, Meadow Brook
)WNER: Brod Horcrow
,ONTRACTOR: GURANTEED SERVICES
SCALE:DATE: Br: SHEET:
1'=40' 05/12/05 CCB 1 1 1
.-. .-. .-. .. t .
.a1RISTOPHER R. WOOD.' or
CE -10387 .' �.AN
Eagle River Engineering Services
Christopher R. Wood, P.E.
10421 VFW Rd. Suite 201 (907) 694-5195 tel
Eagle River, AK 99577 (907) 694-3297 fax
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL: Meadow Brook Sub L 23A B 2
May 11, 2005
A. GENERAL
1. The well and septic plan is for a 3 bedroom single family residence only.
2. The drawing and or site plan shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of Health and State Department
of Environmental Conservation requirements.
4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet
Municipality of Anchorage, Department of Environmental Conservation requirements.
6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any
adjacent multi -family wells.
7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer
approval.
8. Any remaining open test hole excavations shall be filled and monitor tube removed.
9. It is the responsibility of the contractor to obtain any lot line staking or well radius staking, etc... by a
licensed surveyor prior to installation of any component of the septic system. Although not required,
it is highly recommended, and is purely the responsibility of the contractor if any component of the
wastewater system is installed too close to any lot line, house foundation, well radius, surface water, or
any other object which the MOA requires specific setback requirements.
B. SEPTIC TANK
1. The sewer piping from the house shall be 4" PVC 3034 laid at 2% grade minimum, and insulated with
2" of burial foam if shallower than 3 ft., with 2 ft. minimum. A foundation cleanout shall be installed
within 4' of the house foundation.
2. The septic tank shall be an Anchorage Tank 1,000 gallon 2 chambered septic tank. Contractor may
submit alternate tank and for approval, as long as it meets MOA requirements. Two opposing after -
tank cleanouts shall be installed.
C. TRENCH
1. The trench is to be located as shown on the site plan.
2. The total depth of the initial trench excavation is to be 10' max. relative to existing ground elevation at
ground water monitor tube. The bottom of the trench shall be level, plus or minus 1.5".
3. A 6 foot layer of sewer rock is to be placed over the native sand and gravel. The 4" effluent piping is
to be laid on top of the gravel layer with, with 6" additional gravel added as follows: 4" along sides of
effluent pipe, and 2" of gravel cover over the piping.
4. The completed trench gravel and piping is to be covered with typar fabric material.
5. Soil or combination of soil and extruded board insulation to a depth of +3' or equivalent is to be
placed over the leachfield. Soil shall be contoured over the trench to prevent runoff' from ponding.
Continued on next page
\\Era\docs\WPDOCS\2005\05-038trench- spcc.doc
Eagle River Engineering Services
Christopher R. Wood, P.E.
10421 VFW Rd. Suite 201
Eagle River, AK 99577
Continued:
RECOMMENDED LEACHFIELD DIMENSIONS:
(907) 694-5195 tel
(907) 694-3297 fax
TOTAL DEPTH = 9.5' GRAVEL DEPTH = 6' under effluent pipe, 2" over pipe
TRENCII LENGTII = 31' TRENCH WIDTII = 3'
SOIL RATING = 1.2 GPD/fe BEDROOM CAPACITY= 3
SEPTIC TANK= 1,000 gallons
EFFLUENT PIPE= 4" diameter of Muni and Engineer approved materials and construction
Twenty-four (24) hours notice required for all Inspections.
\\Errs\docs\W PDOCS\2005\05-038trench- spcc.dac
EAGLE RIVER
ENGINEERING SERVICES
P.O. Box 773294
Eagle River, Alaska 99577
(907)694.5195
ERES Project No.: 05.038
Calculated By. CW
Date: 5/11/2005
Legal: Meadow Brook Lot 23A Block 2 TEST HOLE 1
Single Family 3 Bedroom Dwelling
Deep Trench Subsurface Wastewater Disposal Field
Water use at 150 gallons per bedroom - 450 gallons
Percolation rate = 1 minutes per Inch
Wastewater application rale = 1.2 gallons per day per square fool
Required absorption area = 375 square feet
Trench width (W) = 3 feet
Gravel depth (D) - 6 feet
Required length = Required absorption area / 2 / D
Required length = 375 / 2 / 8
Required length = 31 feet
Total Excavation Depth = 9.5 feet
05-038 IeachfieldCalc 2:57 PM5/11/2005
Municipality of Anchorage
Development Services Department
Guiding Safety Division
y d on -Site Water and Wastewater Program
4700 South Gragaw SL
P.O. Sox 196850 Anchorage, AK 99519-8850
www d anchorage ak.ua
Y (907)343-7 904
Soils •L tog - Percolation Test.
Performed For, 13QAb AiA k t&k Date Performed:
i
Legal Description: /NrM,)r.,) (,Pf:-'r 7 -AF LZMUTownshlp,Range, Section: ^
Depth
wIM�(:)l'Z_APP'e"4-TiAJ
orL
VN 6)M -Tj j
—a117k0Aj
a w/�Rat1EL
8-
-0
-
7"L- ; -
13- .0 _
14-
'4
15-
16-
I
5-16
1
WAS GROUND WATER
NO
ENCOUNTERED?
a
IF YES, ATMMAT DEPTH?
L
O
Depth b WatarARsr
NonRMrgT DQE
.
e
Dater.
�!■11tit�It-7.2 IMAM= Mi�>f'.m1rm��sr
����tta�Iif�I�e
TEST RUN BETWEEN 6 FT AND —Fl
.? C.4AIK hr".40 .40 *rKAA) �
�'rRTIFY THAT
PERFORMED N ACCORDANCE WITH ALLSTATE
TALLSTATEAND MUNICIPAL��NE� EIC �N THIS DATE. OAT
TEgr A v
r�
GREA , r'R ANCHORAGE AREA BORA. ,GH
F Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME MAILING ADDRESS�'t t%'""i�� _PHONE
LOC. .P r7 , .
J—_
— ATIe qt,✓i '_��'- GAL DESCRIPTION_
SEPTIC TANK:
DISTANCE ���sr✓1 •' }�},�� y 1 NUMBER OF
FROM WELLMANUFACTURE RZ_�� rL�---MATERIAL _COMPARTMENTS .
6$�
INSIDE LENGTH �'� —INSIDE WIDTH ___ LIQUID DEPTH LIQUID CAPACITY /ALl_ONS.
TILE DRAIN FIELD:
,,,,7) TOTAL LENGTH
DISTANCE FROM WELL ( FOUNDATION _NEAREST LOT LINE—)—OF LINES
NUMBER OF LINES—_/ DISTANCE BETWEEN LINES TRENCH WIDTH IN. TOTAL EFFECTIVE
ABSORPTION AREA _.- SQ. FT. LENGTH OF EACH LINE -
DEPTH OF FILTER I �_ / l/
DEPTH: TOP OF TILE TO FINISH GRADE MATERIAL BENEATH TILE_ nAIN. ABOVE TILE IN.
WELL:
TYPE ._ Cf`�u� CONSTRUCTION
_—
BUILDING NEAREST NEAREST
FOUNDATION___, LOT LINE SEWER LINE
CESSPOOL OTHER SOURCES
APPROVED- _-.--DISAPPROVED ---REMARKS
DISTANCES:
INSTALLED BY:-,�
SEWER LINE DEPTH:
PIPE MATERIAL
LOT SLOPE:
REMARKS: �p
Form EQ -032
L� J
���.�P�.
.�f� DATE ('
.:1i;F' t
SEPTIC
TANK_
DEPTH —_ DISTANCE FROM:
SEEPAGE
SYSTEM -
DIAGRAM OF SYSTEM
APPROVE
C'"')
`� �' .• I.Y. l,l.(!
G.A.A.B.
�K_�V "j) F- ��
DEPHRTMENT OF HEHLTH HND ENVIRONMENTRL PROTECT1�N
10 E. TUDOI HNCHORHGE/ RK99507
276��221
��PIP, 9 .1 K~T,
PERMIT NO ( 76287 )
RPPLICHNT ^11.1'..E.00Rp'
LOCRTION CRESTVIEW LHNE
LEGHL L22 BMEADO WED, �OOK SUE -I's
TYPE OF SOIL HBSORBTION SYSTEM lS
4�6] MlNNESOTH DR
Lt.') T SIZE
18987 SQUHRE FEET
SOIL RATING (SQ FT/BR)� 150
THE REQUQRED SIZE OF THE SOIL HBS8RPTION SYSTEM IS�
E����lF��� �� ��������� �� �������� ����. �
THE LENGTH DI�ENSION IS TH� LENGTH IN FEU. -co:,- THE TRENCH OR DRHlNFIELD
THE DEPlH O� 8 TRENCH OR PIT IS THE DISTANCE THE SURFHCE OF THE
GROUND
(IND THE 8OTTOM OF THE EXCHVATION (lN FEET)
THER[ IS NO SET WIDTH FOR TRENCHES�
THE GRHVEL DEPTH JS THE MINIM�M DEPTH OF'GRHVEL BETWEEN THE OUTFHLL PIPE
ON0 THE BOTTOM OF THE EXC�VRTION (IN FEET)
1, Z.
j- P,_."
BHCKFILLING OF HNY SYSTEM WITHOUT FlNHL lNSPECTION AND APPROVAL BY THIS
���HRTMENT WlLL BE SUBJECT TO PROSECUTI8N
MlNIMUM DI�THNCE �ET�EEN R WELL AND HNY ON~�ITE SEWHGE DISPOSHL S,-., IS
100 FEET FOR H PRIVHTE WELL OR 200 FEET FOR R PUBLIC WELL
SPECIFICRTIONS HND CONSTRUCTION DIHGRANI
S ARE HYHLHBLE TO INSURE PRUPEk
INSTHLLHTIIll.
T CA IF;-- CA IF? IC VA EEK ���� V` It A I K��
I CCRTIFY THHT
1� I HM FHM�LIHR WITH TAE REQUIR�MENTS F�R ON�SITE SEWERS HND WELLS RS SET
FORTH BY THE MUNlClPHLITY OF ANCHORAGE.
2 l WILL INSTRLL THE SY5TEM IN HCCORDHNCE WITH THE CODES
3' I UNDERSTHND TH8T THE ON~SITE SE�6R SYSTEM MHY REQUIRE ENLHRGEMEN{ IF THE
RESlDENCE IS REMODELED TO INCLUDE MURE THHN ] BEDROOMS -
.1
ICRNT M K E. CORP
GREATER ANC1101ML ARLA L'OROUGH
r, fl i�;�`, Department of Environmental Quality
3330 "C" Street
J ! I Anchorage, Alaska 99;,03
SOILS LOG - PGROLATION 'PEST
Performed for
Date Performed
Legal Description: _�o� 2. c•- -oi•.r �, - • �i;, i�:�f This form reports: Soils1 g I Percolation test --
Dep th
Feet_.._ ._ __.._ .._........._..._
1 - /�;1-G, !,Ui`^C� �'U 6Gt/ytc�✓� Gj!•{' (.�'M�....-
2 - r: .J n ow v, ZG hG<U G1r2A'Lje't5
3 (6P)
5 - 17,{5d Go»d'a�n;, 6vm� r�t�lc�dc:c�
���Id-- ids, vc� lenses
b -
7 ----
9 4b
10
11 -
12 -
14
S/Ope
Was ground water encountered? if yes, at what depth?
Reading Date
Gross Time
Net Time
Depth to Water
Net Dropr-
Percolation rate - mInuIt.
-- - Drain Field
Proposed installation: Seepage Pit
Depth of Inlet __.._. _� Depth to bottom of�pit or trenIx
COMMENTS:���r-•!-
o
Date: �y ilc
-,. r .,.,, a n„ • �.. ,�,� ., � ,- i �..�� � Certified
0
I
NM
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 050-191-82-000
Leqal description MEADOW BROOK BLK 2 LT 23A
Expiration Date:
Site address 18017 SANCTUARY DR Eagle River AK 99577
Current property owner(s) SLETTEN JOLENE & HAAKON
10/15/2025
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
Original Certificate Date: 10/18/2024
Tlis Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory X Arsenic Advisory
Other
COSA Approval_June 2022
MUNICIPALITY OF ANCHORAGE
Development Services DepartmentPhone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 05019182000
Complete legal description MEADOW BROOK BLK 2 LT 23A
Location (site address) 18017 SANCTUARY DR
Current property owner(s) SLETTEN
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
Day phone 390-9484
3. TYPE OF WATER SUPPLY: ❑ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑■ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑■ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑t Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 24.5 _ See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑■ Deep Trench X Wide Trench ❑ Seepage Pit
Waiver request for: Distance:
Expedited review requested: ❑
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ .5.50 Waiver Fee $
Date of Payment
COSA# 05C2'11y25
Date of Payment
Waiver #
COSA Application—June 2022
COSA Checklist
Legal Description: MEADOW BROOK BLK 2 LT 23A Parcel ID: 05019182000
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Comments
B. TANK DATA
Measured operating fluid level in septic tank 50
Date of pumping 10/15/24
❑ Required maintenance completed, if AWWTS
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 5/27/05
❑■ ALL standpipes present per record drawing
Total measured depth from grade 11 ft (max)
Measured depth to pipe invert from grade 5 ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
❑■ Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Comments/Deficienci
COSA Checklist June 2022
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑■ No
❑ Coliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by
Date
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 10/9/24
Results g Pass
Fluid depth prior to test 27 in
Water added 450 gal
New fluid depth 35 in
Elapsed time 30 min
Final fluid depth 29 in
Absorption rate 450 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 73
Effective depth used 29 in
Effective depth remaining 44 in
in
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100'
L] Yes if No ft ❑ Yes if No ft
Neighboring Tank > 100' ❑ Yes if No ft Private Sewer/Septic Line > 25' ❑ Yes if No ft
Absorption Field on Lot > 100' ❑ Yes if No ft Holding Tank > 100' ❑ Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment > 50' [:]Yes if No ft
❑ Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑ Yes if No ft ['1 Yes if No
❑■ N/A— Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
ft
Building Foundations > 10'
F-15'+
Yes
*
if No
ft
Surface Water > 100'
■❑ Yes if No ft
Tank to Property Line > 5'■❑
Yes
if No
ft
Wells on Adjacent Lots:
Field to Property Line > 10'
❑■ Yes
if No
ft
Private Wells > 100'■❑
Yes if No ft
Water Main > 10'
■❑ Yes
if No
ft
Community Wells > 200'
❑■ Yes if No ft
Water Service Line > 10'■❑
Yes
if No
ft
If tank or field is under driveway
comment below
F. ENGINEER'S COMMENTS
Tank @ 5'+, field > 10'
G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm NorthRim Engineering
Engineer's Printed Namc Steve Eng
COSA Checklist June 2022
Phone
Datc
694-7028
10/15/24
AM
s* '49TH I
0 `cn Steve En
GE-6256s2i
ty—
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT o
On -Site Water and Wastewater Section 4
www.muni.org/onsite
Septic Tank Advisory
Certificate of On -Site Systems Approval # OSC241425
Subdivision: Meadow Brook Block:2, Lot: 23A
907-343-7904
Fax: 343-7997
The septic tank for this property is 25.5 years old. The average life of an asphalt
coated steel septic tank is 20 years. Typical replacement costs are $15,000 or more,
not including engineering, surveying, MOA permitting fees or site restoration.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
This is an example of what the metal of a 30 year old steel tank MAY look like.
Parcel I. D. 050-191-82
Municipality of AnchorarrN,
6 7 8 9 70
On -Site Water and Wastewater Program`'!(907) 343-7904 ® �J,v
//
Certificate of On -Site Systems Apftval
1. GENERAL INFORMATION:
�
Expiration D s t g n �0 JQ
Complete legal description MEADOW BROOK; BLOCK 2 LOT,* 23F1
Location (site address) 18017 Sanctuary Dr. *Eagle River 99577
Current Property owner(s) Bryan Kalseth Day phone 773-991-0991
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ® Public Sewer ❑
WaiverNariance request for: 1 Distance:
I
Received by: Date: jl
COSA to be released t e engineer; unless otherwise requested by the engineer.
COSA Fee $ Waiver Fee $
Date of Payment h, Date of Payment
Receipt Number 61--H � Receipt Number
COSA # Qt�(, al 5z� Waiver #
I-
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm: Garness Engineering Group Ltd (GEG) Phone
907-337-6179
Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date: �I !
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system
in accordance with the guidelines and regulations established by the Municipality of Anchorage and
industry practices. The reported results describe the condition of the system/s on the date/s of the
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or
encroachments may exist that were not identified during the evaluation. The operational life of all wells
and septic systems depend upon a variety of variables, including but not limited to, soil conditions,
groundwater levels (that may fluctuate during the year), quality of construction (materials and
workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the
system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of
the well or septic system. GEG makes no representation whether an alternative well or septic system
can be installed on the property in the event either of the current systems fail to perform adequately in
the future. The content of this report is for the sole benefit of the person/party that retained GEG to
perform the evaluation. Reliance upon the information provided in this report by any other person or
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
V�
6. DSD SIGNATURE J� ON-SITE m
An
System #1 Approved for �_ bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms,
WATER
WASTEWATER G
PROGRAM
�..l\�� �.
with the following stiipulatlons:
By:LA Original Certificate Date:
The Municipality of An orage 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 Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10-10-12.doc
4
.. ..........
QJ ey A.
QOM
G ness:
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rofesslo�oao
#AECC884
6. DSD SIGNATURE J� ON-SITE m
An
System #1 Approved for �_ bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms,
WATER
WASTEWATER G
PROGRAM
�..l\�� �.
with the following stiipulatlons:
By:LA Original Certificate Date:
The Municipality of An orage 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 Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10-10-12.doc
If more than 1 septic system is on the lot:
COSA Checklist # _of_
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description:
A. WELL DATA
Well type
Date completed _
Total depth
MEADOW BROOK; BLOCK 2, LOT 3A
If A, B, or C provide PWSID#
Sanitary seal (Y/N)
ft. Cased to ft.
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RES
Parcel ID: 050-191-82
PUBLIC WATER
Well Log (Y/N)
Wires properly protected (Y/N
Casing height (ab o ground)
AT I CTION
ft.
g.p.m.
in.
Coliform colonies/100 ml. Nitrate mg./L. Collected by:
enic: ug./L. Date of sample:
B. SEPTIC/HOLDING TANK DATA 49" OF LIQUID IN TANK ON 10/17/18
Tank Type/Material SEPTIC/STEEL Date installed 5/27/05
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A
Date of pumping ,�� `�� Pumper ��� S
C. ABSORPTION FIELD DATA -BELOW EXISTING GRADE AT MONITORING TUBE
Date installed 5/27/05 Soil rating .p.d./ft r ftz/bdrm) 1.2 System type DEEP TRENCH
Length 32 ft. Width 3 ft. Gravel below pipe 6.1 ft.
Total depth `11.3+ ft. Eff. absorption area 375 ftz Monitoring tube YES Depression over field NO
Date of adequacy test 10/17/1$ Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 26 in. Water added 1018 gal. New depth 50 in.
Elapsed Time: 1220 min. Final fluid depth 26 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date -
i.LA
D. LIFT STATION
Date installed
"Pump on" level at in.
Size in gallons Manhole/Access (Y/N)
"Pump off"level at wa er alarmlevel in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
ER
SEPARATION DISTANCES FROM WELL ON LOT TO: PUBLIC WAT
Septic tank/lift station on lot On adjacent lots
Absorption field on lot
Public sewer main -
On adjacent lots
ewer manhole/cleanout
Sewer /septic service line Holding tank
containment areas Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation *51+ Property line 51+ Absorption field
Water main 10'+ Water service line Surface water.
Wells on adjacent lots
100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Water service line
10'+
Building foundation 10'+ Water main
5'+
100'+
10'+
10'+ Surface water 100'+ Driveway, parking/vehicle storage
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
*MET CODE AT TIME OF INSTALLATION **SEE AWWU CONNECT CARD I -kmik 6.e oco
G. ENGINEER'S CERTIFICATION
1 certify that / have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printedame JEFFREY A. GARNESS
Date I 1
(Rev. 10/12/12)
10'+
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• Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS AP
Parcel I.D. 050-191-82 Expiration I
1. GENERAL INFORMATION
Complete legal description MEADOW BROOK BLOCK 2, LOT 23A
Location (site address) 18017 SANCTUARY DRIVE, EAGLE RIVER AK 99577
Current Property owner(s) KATHERIN M. MATOLCSY Day phone
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
18017 SANCTUARY DRIVE EAGLE RIVER AK 99577
® 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 _ Well
❑
Public Water System
❑
WaiverNariance request for:,
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual
Holding Tank
❑
Community
❑
Public Sewer
❑
Received by: Date:
COSA to be release ogineer, unless otherwise requested by the engineer.
COSA Fee $ 62& 9�
Date of Payment aV A5 1 *
Receipt Number 61146 b
COSA# 6)nC1&105_6
Waiver Fee $
Date of Payment
Receipt Number
Waiver *
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD. EAGLE RIVER AK 99577
Engineer's Printed Name KENNETH M. DUFFUS 2/6/2016
Engineers Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition
of the well and septic applies only to the conditions as of the day tested. The flow
and absorption rates may change due to subsurface
conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system. The
operational
subject to these various and dynamic characteristics and are outside the control of the
life of all well and septic systems are
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
�'
f �F AL\
<i 4
/YA0
.. iI C] TI{
37
6. DSD SIGNATURE
System #1 Approved for -3 bedrooms.
System #2 Approved for bedrooms.
Disapproved.
a+ MNNETIT a1. OUT 'U ,4
r� sn 7116 $�®
deo a G J �°mss
Conditional approval for bedrooms, with the following stipulations:
;m WASTEWATER ?=
By: Original Certificate Date: Z�
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 engineers work.
ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA bluesheei 10-10.12.dm
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: MEADOW BROOK BLOCK 2, LOT 23A Parcel ID: 050.191-62
A. WELL DATA --1?WRLl C,
Well type -rk- If A, B, or C provide PWSID # -# +NO+ Well Log (YIN)
Date completed Sanitary seal (Y/N) Y Wires properly protected (Y/N)
Total depth _ft. Cased to _ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g:p.m. 9 -
p.m -
WATER SAMPLE RESULTS:
Coliform colonies/100 mL
Arsenic: _ ug/L
Nitrate _mg/L
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC 1 STEEL
Tank size 1000 gal. Number of Compartments 2
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
Date of pumping 21412016 Pumper ALASKA SEWER & DRAIN
C. ABSORPTION FIELD DATA
Date installed 512712005 Soil rating (g.p.d./ft3 or ft lbdrm) 1.2
Collected by:
Date installed 5/27/2005
Cleanouts (Y/N) Y
High water alarm (Y/N) N
System type DEEP TRENCH
Length 32 ft. Width 3 ft. Gravel below pipe 6 ft.
3
Total depth 9,6 ft. (Measuredv5/16) Eff. absorption area a�i€T5fSSftZ Monitoring tubeY Depression over field N
Date of adequacy test 21512016 Results (Pass/Fail) PASS
Fluid depth in absorption field before test 0 in.
Elapsed Time-4� 40 mina` Final fluid depth 0 in.
Any rejuvenation treatment (past 12 mo.) (YIN & type)
Water added 770 gal.
For 3 bedrooms
New depth 20 in.
Absorption rate >=450+ g.p.d.
If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at_ in.
Datum
Size in gallons
"Pump off" level at _ in.
Cycles tested
E. SEPARATION DISTANCES - PUBLIC WATER
WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
Animal containment areas
SEPTIC/HOLDING TANK ON LOT TO:
Manhole/Access (Y/N)
High water alarm level at in.
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
Building foundation 54 Property line 5'+ Absorption field 5'+
Water main 101+ Water service line 101+ Surface water 100'+
Wells on adjacent lots 2004
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water. 1004 Driveway, parking/vehicle storage 104
Curtain drain 50'+ (NONE KNOWN) Wells on adjacent lots 2001+
F. COMMENTS
Zoog—Cd2
Vacant (3 months) -- system piesoaked prior to testing.
G. ENGINEER'S CERTIFICATION
1 certify that i have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on -this date.
Engineer's Printed Name KENNETH WDUFFUS ;
Date 2N616
COSA canary sheet-6-15.doc
'r
fV03! i /
11
A2unicipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
1 " '- ii www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. P50 /'!/ Za-
HAA # 051230
-• >: ; Expiration Date:
GENERAL INFORMATION,
Complete legal description `-n2Csc ozy L "r -A_ L 23A Z
Location (site address or directions) /fl0/-7
Current Property owners) (OraoGCaH_ 56 K 'GrD j Day phone (R 5'0) 974 -79417
Mailing address (303 A) &are
Lending agencyFi_ t�f jz2jtrzia,7 -7/-117, lB- Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
_
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
❑
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
[✓jam
Public Sewer
Q'
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water 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 Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage 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 Eagle River Engineering Services Phone &9N/ -S/95"
—10421 VFW Rd., Suite 201
Address
Engineer's Printed Name ('hriS�dv/cer /.t%Doti Date iofo6/os'
5. DSD SIGNATURE
✓ Approved for
Disapproved.
Conditional approval for
Additional Comments
bedrooms.
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
bedrooms, with the fo
Maintenance Agreements
Supplemental Engineer's Report
Other
By. lit'✓, Original Certificate Date: G os --
(Rev 01N2)
Municipality of Anchorage .._
• Development Services Department
Building Safety Division "
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST'
Legal Description: L�z��.oak L 23.4- J5Z Parcel ID: /75'Q /9/ 8.I -
A. WELL DATA
Well type PWL.17-(--
Date completed _
Total depth ft.
Date of test
Static water level
Well production
WATER SAMPLE
Coliform /
mg./I.
If A. B, or C provide PWSID # _
Sanitary seal (YIN) _
Cased to ft.
FROM WELL LOG
00 ml.
B. SEPTIC/HOLDING TANK DATA
g.p.m.
Nitrate mg./l.
Date of sample: _
Well Log (YIN)
Wires properly protected
Casing height(a ve ground) in.
ft.
9 -13 -m -
Other bacteria colonies/100 ml.
Collected by:
Tank Type/Material U6. l S%t� L Date installed S I2I ZQ 57
Tank size I. r9oJ gal. Number of Compartments Z Cleanouts 6N) yt 5
Foundation cleanout &N) jj j Depression over lank (Y4D -LO High water alarm (Y(N Ai tD
Date of pumping AJy7- &4&beh. Pumper N 14
C. ABSORPTION FIELD DATA
Date installed _W2 71P Soil rating (g.p.d./ft2 or-fF/bdrm) L• 2 System type 7R e4kH
Length 37- ft. Width 3 ft. Gravel below pipe 6 ft.
Total depth _ _L. ft. Eff. absorption area12&' Monitoring tube Depression over field NO
Date of adequacy test AWF NEb'bc h Results (Pass/Fail) PkSS For 3 bedrooms
Fluid depth in absorption field before test in. Water added gal. New depth in.
Elapsed Time: .A44 min. Final fluid depth'1/&in. Absorption rate >= O g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) NDr A OJ SIIQ If yes, give date /U//;L
D. LIFT STATION
Date installed Size in gallons
'Pump on' level at _ in. "psm off" F /
Datum Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift stelien on lot
Absorption field on lot
Public sewer main
Sewer
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/NQWD+ 6 TANK ON LOT TO:
Building foundation t 5� r Property line +/U Absorption field 4 5—
Water main 1' -Io Water service line f-10 Surface water t rU0
Wells on adjacent lots 4-100
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line t /O Building foundation •f' /O Water main t /O
Water Service line •t -10f Surface water -x-100 Driveway, parkingtvehicle storage f' A) /
r �
Curtain drain t SO Wells on adjacent lots f /00
F. COMMENTS
Att1,J 5KtFm . Pyr 6LiL 1n/a
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 NAA guidelines in effect on this date. , R
ti
Engineer's Printed Name G iJ STaPtiC� �• Infrh)� ,' CE'M
Date OWL) 5 --
HAA
HAA Fee $ 4-�5p0.1 ( Ps 6D �LJQ
Date of Payment l r JID15
Receipt Number bV r56
(Rev. 12101)
Waiver Fee $
Date of Payment
Receipt Number
Ns�
zz%
�•M
ASBUILT
-slet" / .
I HEREBY CERTIFY .THAT 1 HAVE SURVEYED THE SCALE' ---
FOLLOWING DESCRIBED PROPERTY' •� OF A�°°°
��rcvk. s wile' sum «rz�q�:'r '• •. q
DATE'
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS �/��s ,,~`Q•.•' .
INDICATED. IT IS THE RESPONSIBILITY OF THE ,�'� t_H
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID'
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI- 1 ou.-. Zk S. •.d . j
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB' io7 zp 1��'•. 15-6918 .*.f- Ar
ANY DATA HEREON BE USED FOR CONSTRUCTION It y�
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES. DRAWN'
o�yf 0. A q t►w.r.�
Municipality of Anchorage
Department of Health and Human Services ll�
Division of Environmental Services yf
On -Site Services Section 825 "V Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-4744
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. 050-191-82 HAA#�
Expiration Date:
1. GENERAL INFORMATION
Complete legal description Meadowbrook L 23A B 2
Location (site address or directions) 18107 Sanctuary
Current Property owner(s) Craig
Johnson
Day phone
Mailing address �C QC
X /3C"l)
n
/,f CC ��
U
17011,15,
Lending agency
Lending
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
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:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
Individual Water Storage
❑
Individual Holding lank
❑
Community Class Well
❑
Community On-site
13Public
Water System
®
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 Anchorage is not responsible for errors or omissions In the
professional engineer's work.
(Rev. IIM)
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 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 applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
Name of Firm -SND -Engineering Phone -696-R111
Address 204412tanniganFagte_31vE_r A 577
Engineer's Printed Name . Kenneth n11ff11s
6. DHHS SIGNATURE
—1eff_5 Approved for _ 3 bedrooms.
Disapproved.
Date—flawon
OF AI -4\''
Q Sr
�iKx4En"NzTD
S
CE -711 a
1 tri/
1 \ PROFESSIOI' '
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: / v �t Original Certificate Date: 5 - 3
Expiration Date: S" 3 i- 0 i Reissue Date:
(R*v 11Mx)
Municipality of Anchorage R fsC E I V E D
• ;` Department of Health and Human Servl �i
Division of Environmental Services
On -Site Services Section 825'L' Street Room 502 AUG 3 12000
P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchorage.ek.us
907) 3434
( 744 MUNICIPALITY OF ANCHORAGE
(907) 343ENIARONMENTAL SERVICES DIVISION
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Meadowbrook L23A B2 Parcel I.D.: 050-191-82
A. WELL DATA
Well type Public
Date completed
Total depth ft
Date of test
Static water level
Well production
If A, B, or C provide PWSID #
FROM WELL
Sanitary seal
Cased to ft
ft
9 -p.m
Well Log _
Wires property protected
Casing height (above ground) in.
AT INSPECTION
ft
9 -p.m
WATER SAMPLE RESULTS:
Coliform colonies/100 ml Nitrate mgn Other batter colonies/100 ml
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Steel
Date installed 6/17/1976 Tank size 1000 gal Number of Compartments 2
Cleanouts y Foundation cleanout y Depression over tank n High water alarm nla
Date of pumping 8/17/2000 Pumper JR's Pumping
C. ABSORPTION FIELD DATA
Date Installed t111110 Soil rating (g.p.dJft2 or ft"/bdrm)150 System type Deep Trench
Length 35 ft Width 3 ft Gravel below pipe 8 ft
Total depth 10 ft Effective absorption area 560 ft2 Monitoring tube y Depression over field p_
Date of adequacy test $ 1 Od Results (Pass/Fail) pass* For 3 bedrooms
Fluid depth in absorption field before test 65 in Water added635 gal. New depth77 in.
Elapsed Time: 15 min Final fluid depth 65 In Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YM & type) n If yes, give date
(Rev. 11199)
D. LIFT STATION
Date installed Size in gallons
'Pump on" level at in'Pump off' level at :in
Datum 1 .1
, . :".1
:Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO
Septic tank/lift station on lot
On adjacent
Absorption field on lot
On adjacent I
Public sewer main
Public sewer
Sewer /septic service line
Holding tank
Manhole/Access
High water alarm
Meets alarm &
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
in
Building foundation Win•+ Property tine +n•+ Absorption field In•+
Water main 25•+ Water service line 25•+ Surface water 10n•+
Drainage 100•+ Wells on adjacent lots Snn,+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 1n'+ Building foundation +0'+ Water main 2r'+
Water Service line 2S•+ Surface water 100 + Driveway, parkingtvehide storage 75_+
Curtain drain 10n'+ Wells on adjacent lots -2on•+
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 HAA guidelines in effect on this date.
Engineer's Printed Name Kennath hdfua
Date
HAA Fee $ dLz' Waiver Fee $ _
Date of Payment �/ s*Y7
Date of Payment
Receipt Number ���� �� 8% Receipt Number.
(Rev. 11/99)
A. WELL DATA
MUNICIPAI.IIY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTIOM
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST •- FEBRUARY 1984
1 Description:
01C 13 1110
RECEIVED
Z. c?._3 A l3 2,
F//C_wUvliv /L'l6iuyc a�
Well Classification 62 If A, B, or C. D.E.C. Approved(Y/N)
Well Log Present (Y/N) Date Completed Yield
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
Pump Set At
Depth of Grouting
Sanitary Seal on Casing (Y/N)
Depression Around 4\bllhead (Y/N)
To Sept ic/Ew1#kg. Tank on Lot `OL51D -f-- On Adjoining Lots
To Nearest Edge of Absorption Field on Lot?-(" ; On Adjoining Lots
To Nearest Public Sewer Line To Nearest Public Sewer
Cleanout/Manhole
Water Sample Collected By
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
0
y 'c.Ar
To Nearest Sewer Service Line on Lot
Date Instal?'l L� Size �/ t/,
Standpipes(I/fit) Air -tight Cap
Depression over Tank (s aDate I.,as
Pumping/Maintenance Contract on Fi.e A
Holding Tank High -Water Alarm (Y/Q a
Date
of Compartments CSG G<
711
Foundation Cleanout/(YJM
Temporary Holding Tank Permit
Separation Distances from Septic/Hel4i#iE2 Tank: /
To Water -Supply Db1]. _ -c51� `_ To Building Foundation 4
To Property Line _ /{� (� —To Disposal Field l¢ ---
To Water 44ai-n/Service Line TO T- To Stream, Pond, Lake, or Major Drainage
Course L.j 'O �J /�•
Comments
Receipt #
Date Paid: ,Z
Amount: yS:OU
[Page 1 of 21
2-15-84
C.
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata /�61�?'Type of System Design -,_&06i4
Date Installed Length of Field
Width of Field _/ Depth of Field
i
jj O Gravel Bed Thickness _
Square Feet of Absorption Area PJ . Standpipes Present (Y )
Depression over Field (VA Date of Last Adequacy Test ;Wo 6
Results of Last Adequacy Test jam( S G 7cJo2 �,
Separation Distance from Absorption Field:
To Water -Supply Gell 2 0 D -7L_ To Property Lire
To Building Foundation -:3c) /� To Existing or Abandoned System on
Lot A,) 0 )J E ; On Adjoining Lots 3—D ',,z
To Water Main/Service Line /0 -/-- To Cutbank(if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Stara ge AyeaL2/N ✓) ��/1�E
Comments
D. LIFT STATION
Date Installed Dimensions
Size in Gallons Manhole/Access (YM)
"Pump On" Level at "P p Off" Level at
High Water Alarm Level at Vent (YM)
Tested for Pumping cies during Adequacy Test. Meets MOA
Electrical Codes
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conforlred to all"MOA HAA Guidelines in effect
on the date of this inspection.—=
IV4 T✓
Signed
Date 12
rylLLf i�CEt./4l
Company
MOA No. a... _ C
KB1/d5/s - _ Rabart A.
Na. 7457.E
F'�asp � (G! ✓'if
[Page 2 of 21
' 2-15-84
MUNICIPALITY. OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date /Z. — 12,
(a) Legal Description (include lot, plock, subdivision, secti
L 2-s�q L 2 !M ea 01.j 6� 0
Lo tion (,address or direr ons)
(b) Applicants Name A pro Telephone - Home
Applicants Address ^�� .S `4-
, township, range)
;5ePc-)
(c) Applicant is (check one) Lending Institution ; Owner/builder ;
Buyer E:] ; Other �� (explain); _
(d) Lending Institution Telephone
Address
(e) Real Estate Co. & Agent Z--- _
Address
Telephone
Lam✓
(f) the HAA to the following address:
Gi1
8111.3`9166, KA I
N111Pr! AS
2. Type of Residence
Single -Family Multi -Family Other (describe)
Number of Bedrooms
3. Water Supply
Individual Well Community Public
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage
Disposal
Onsite
Public
Community
Holding Tank
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 21
5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein. I further verify that,
based on the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm I Telephone
Address
Date
6. DHEP Approval
Approved forT,� bedrooms
Approved A
Disapproved
Terms of Conditional Approval
CAUTION
Conditional
to
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPIi S 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/D18
[Page 2 of 2] 7-19-84
('46-0)
Time
APPLIC NT FILLS OUT UPPER HAI ONLY(
ProperlyOwner
Time
Time
Date
Mailing Address
Zip Code
Buyer
Date
Address
Zip Code
Lending Institution
Inspector
Phone
Address
Zip Code
Realty Co. & Agent
Phone
Address
Zip Code
Legal Description
Street Location
Type of Residence
Single Family
El Multiple Family
No. of Bedrooms
El Other
Water Supply
RECEIV D
(3) APPROVED BEDROOMS
F1 Individual
*CONDITIONS OF APPROVAL
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
P Community
For wells drilled prior to that date, give well depth (attach log if available).
Public Utility
I I q 16>
Sewer Disposal
Individual
Year Individual Installed:
'E1 Public Utility
When Connected to Public Utility:
El Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REOUEST BEFORE PROCESSING CAN BE INITIATED.
('46-0)
Time
Time
Time
Time
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes:
MUNICIPALITY OF ANC110RAGE
QViK).\"A'NiAL FRJiE'1ION
RECEIV D
(3) APPROVED BEDROOMS
*CONDITIONS OF APPROVAL
DISAPPROVED
CONDITIONAL APPROVAL'
I I q 16>
DATE —
BY:
a See Insta
Soils r t
0 Well To Absorption
Area Well Log Rec/o(ved
Well to Tank
Septic Tank Size I
]2-02313x621
ADEQUACY TEST
WATER AND SEWER INSPECTION
WELL INSPECTIONS AND
FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
ON SITE WASTE WATER
DISPOSAL SYSTEM DESIGN
EXCAVATION WORK
Bob FederOff
BOX 772808
Eagle River,
ROBERT A. SHAFER
CIVIL ENGINEER
694.2979
November 61 1983
O` P�C110KF''��
10
Alaska 99577
Dear Mr. Federoff,
Reference: bot 23AI Block 2; Meadowbrook subdivision
A sewer system adequacy test was performed on the system located
on the referenced property, as you requested. The septic tank
was pumped and verified to have a capacity of 1000 gallons.
The absorption trench was tested by a continuous flow of water
over a period of 24 hours without any adverse affect on the system.
it can be concluded from this test that the waste water.disposal
system serving the three bedroom residence located on this property
is currently functioning adequately. However, the system cannot
be guaranteed against subsequent failure.
If we may be of further service, please do not hesitate to contact
cc: Municipality of Anchorage
Department of Health and Environmental Protection
SRB 196X EAGLE RIVER, ALASKA 99577
SANITARY PumptRS
p•G• 6®X 71!2226
EAGLE RIVER, AK 99577
694-2408
70
Address
city
Dnte 49'o�S'19/'
i