HomeMy WebLinkAboutCAR-LYNN #1 BLK 2 LT 2Cel
ar�L y nn 2
Block 2
Lot 2
#015�111�21
Municipality of Anchorage Page —of
R
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 0 Anchorage, Alaska 99519-6650 0 Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Nurri 93022() PIDNumber: qi5 111 91 noc)
Name.
Sycks, Cary and Carol
Wastewater System: 0 New 0 Upgrade
Address:
I
-P.O. Box 110158, Anchorage, AK 99511
ABSORPTION FIELD
Phone:
No. of Bedrooms
346-8228
4
ODeepTrench OShallowTrench OBed MMound C10ther
LEGAL DESCRIPTION
sof Rahnq:Sand filter
Total Dep ir!� g
vade:
A " CPC/Sq Ff
�om
Lot. Block. Subdivision:
Dep�lh , til� pipe bottom from original grade:
Gravel depth beneath pipe
Par—T4mn .
0.0 Ff
0 - c; Ff
Township:
1 Range: Sect.on:-
1
Fill added above original grade:
Gravel length:
3.5 Ff
58' Ff
WELL: 11 New IR Upgrade
1� at width:
Numbjr of lines: Distance belaHvi leet:
Classification (Private. A.B.C): Total Depth: Cased To:
—(;R
Total absorption area: Ff
Pipe material: 5 Ff
Private 2 Ft, 7i Ff.
1160 SO Ff
ql-hpA Arl
Driller:
Alpine
Date Drilled
Static Water Level:
Installer:
Date installed:
Drilling
7/24 493
225 Ft.
c; P, A Pnll-pi
ifoll
Yield. �ump Set at:
Casing Height Above Ground
10 GPM 1 76 1
7 Ft.
TANK N /A
SEPARATION
DISTANCES
0 Septic 0 Holding El S.T.E.P.
To
Septic
At�,Pho.
Ld I
Holdin
I
bl.c/Nnale
�=er
Manufacturer:
Capacity in gallons:
From
Taft
Field
Slat,..
Tankg
Lines
I
Well
N/A
104'
100,
1 N/A
N/A
Material:
Number of Compartments:
Surface
Water
N/A
113'
112'
N/A
N/A
LIFT STATION
Lot
Line
N/A
21'
55'
N/A
N/A
Size in gallons:
1,500
Manufacturer:
Orpn�
Foundation
IN/A 1
191
81
N/A
N/A
'Pump on" level p olf*'Ievel at:
fit
High water alarm at:
I
42" 42'
46"
Curtain
Drain IN/A
I
N/A
N/A
N/A
N/A
Pump Make& Model I Electrical Inspections performed by:
20 OSI 05 W Public Works
Remarks:
BENCH MARK
Location and Description:
BM 100.nO at bottcm nf siding htlow kjtrh�n
window center.
Assumed Elevation:
ion-nov Ff
ENGINEER'S SEAL
h,
71
Inspections performed by: 50'V Dates: 1-st 24-
2nd 7--X7-
Department of Health and Human Services approval
Theod jolu=n :4
4a; 00 E 5191 4�
so,
XN , sw#*
Reviewed and approved by: Date: 15`44_3
01, looev
�00
IrAor o"'.. %�.
Aso
72-01
Ff S S00
3 ( ". 91 MOA 25
0
M
r=_j
th#2
existing failed si
and seepage pit
AREA
REQUIREU
4 bdrm *150 60—gi
600 gpd 857sf
0.7 g�pd/sf
Scale: 1"=50'
OUR RD.
radius th#I
ionitor tube
1500 gallon As—built adsorption
Bed w/ 2' sand filter.
Orenco lift stati�n\V.
Location distaf)ces in feet:
A 8
col 17.7 40.2
co2 :21.5 41.2
co3 17.1 33.9
co4 33.8 42.4
Note: field moved 15' to the N after well was drilled to close to
original site. Robby Robinson on 7-23-93 gave permission
to move the site based upon the digging of th#2 to confirm
consistent soil characteristics with th#l. No'perk test or
monitor tube was required for th#2.
JOB NUMBER
JOB DATE
Sol -
AA
5191
CRI TOR IE6WEER
P.D. BOX oilm
F" 9.7 N 3
Be� to consist of 3 lines
5 long. The lines are on
100' radius
gazebo
5 c enters with 2 1/2' to
the ed es- The lines will
be inte
,rco nnected at the
pit"
ends and in the middle to
insure prop;er distribution.
U
Bed Area
15' * 58' = 860 sf
Location distaf)ces in feet:
A 8
col 17.7 40.2
co2 :21.5 41.2
co3 17.1 33.9
co4 33.8 42.4
Note: field moved 15' to the N after well was drilled to close to
original site. Robby Robinson on 7-23-93 gave permission
to move the site based upon the digging of th#2 to confirm
consistent soil characteristics with th#l. No'perk test or
monitor tube was required for th#2.
JOB NUMBER
JOB DATE
Sol -
AA
5191
CRI TOR IE6WEER
P.D. BOX oilm
F" 9.7 N 3
PERFORMED
LEGAL
(FEET)
2
3-
4-
5-
6-7-
7-
8-
9.
12-
13-
14-
15-
16-
17-
8
19
'201
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SEAVICES
825 *V Street Anchorage. Alaska 99502-0650
SOILS LOG - PERCOLATION TEST
DATE
Range, Section:
SLOPE
PERFORMED BY.*
ACCORDANCE WITH ALL STATE AND MUNICIP L 1
72-008 (Aev. 4/es) /V!��
WASGROUNDWAI
rPjttf)t1mTFRFn7
PERCOLATION RATE � (minUteStinCh) PERC HOLE DIAMETER
TES�7N BETWEEN - FT AND ---- F1,
7
1 --7— CERTIFY THAT THIS TEST WAS PEA;1ORMED IN
P IN EFFECT ON TH!S DATE. DATE:
7V:a 7.
0
mom
NEON
Depth to
Water
PERCOLATION RATE � (minUteStinCh) PERC HOLE DIAMETER
TES�7N BETWEEN - FT AND ---- F1,
7
1 --7— CERTIFY THAT THIS TEST WAS PEA;1ORMED IN
P IN EFFECT ON TH!S DATE. DATE:
7V:a 7.
0
JL -26-1993 02:56PM FROti NWMed Anchorage TO 3449936 P.02
STATE OF Al ASKA -
DEPARTMENT OF WAyUM RESDURM
DIVISION OFWATM
OCATION Of WELL
WATER WELL RSCORD
BOWON LOT &L*m
7
"=ON CTRS sw
ICTION T*WWE3N
2.
ris ow
LOCATIONISKETCH: 0 ftftz(o
WELL OWNER:
DIMS MEASURED FROMMeajiling top 09round surface
WELL TH:
601111HIM DATA:
Depth of holc:,2-!r, T It DATE OF COMPLETION
Depth
Material Type and color From TO
Depth of casing: 7 IXVi9l
DEPTH TO STATIC WATER LIEVELt
Ib"
f 0'
JAA%9__f t below Is top of eating 0 Crowd surface
Data:
MIT"O OF I j)RILL1
METHOD OF DRILLING, t9 sk rotary 13 Cable too[
2�
E3 other
U= OF �jn
WELL.
UW OF WELLOM domestic E3 Irriostion E3 monitor
0 C
13 PUNIC supply 13 othe
CA
CASINO STICK-UP, ft. Diem: In. to It
Casing typ
L INTJ
WELL INTAKE OPENING Typj: AS Open end 0 screened
3 ra
Porto
13 Perforated 0 open hole
ZZ_/
Depths of openings: . to
SCREEN TYPE: Dism- in.
SlotJM"h
Size: L# noth: It
GRAVEL PACK TYPE-.
Volvmv
used: Pth to top:
GROUT TYPE- Volume:
Depth�
tro1mv, ft
DEVELOPMENT MrTmoo..
OONTRACTOR INFORMATION:
Istere 4 us ness amo
0
ut Jorze espr
,gnature 0 Ut % a sontat vc
AND
-2CJLA It after
PUMP INTAKE DEPTH: I t Horsepower
WEILL DISINFECTED UPON CoMpLgTION?
mb� D -WF �DNO
REMARKS:
PLEASE
OF LOG TO:
TER
& ( a division of Alaska Basic Industries
AS Q� . 0 a
ANOMM"r; UND gM GRAM Ca
IND 01W1QY Road ' AfkhWale. AlmkmW.. fS 9 pl,.,,# (907) 34g.3333 0 M (907) W2814
July 28, 1993
S & A Enterpases
P-0. BOX 110454
Anchorage, AK 99511
Attn: Steven Arduser
RE: Concrete Sand
Dear Mr. ArOuser
The Concrete Sand supplied by Anchorage Sand and Gravel Co. (AS&G) from
our Klatt Road TOrmInal meet$ ASTM C,33, The aggregate for Concrete Sand consists
of natural sand washed and Processed to as -sure suitable particle shape and gradation.
.. If you . have any questions, or if I can be of any service, please call me.
Sincerely,
ANCHORAGE SAND AND GRAVEL CO.
&61-- -
C. Ead Pofen
Aggregate SPle3 Manager
CEP:1rn
PAGE 1 OF 2
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 -L- STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW930229 DATE ISSUED: 7/19/93
DESIGN ENGINEER:TED JOHNSON, P.E., L.S. EXPIRATION DATE: 7/19/94
OWNER NAME:SYCKS CARY & CAROL
OWNER ADDRESS:P.O. BOX 110158
ANCHORAGE, AK 99511
PARCEL ID:01511121
LEGAL DESCRIPTION: CAR -LYNN #1 BLK 2 LT 2
LOT SIZE: 37729 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT:
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
THE SAND.USED'IN"THE FILTER LAYER MUST CONFORM TO ASTM -C-33
dbNCRETE SAND. A-SIEVE.ANALYSIS MUST BE TAKEN,ON THE SAND
USEDIN THE FILTER LAYER WITH THE RESULTS OF THE ANALYSIS
PROVIDED TO THIS DEPARTMENT.
IMMEDIATELY UPON
W#L., MUST BE Dy
RECEIVED
ISSUED BY:
PAGE 2 OF 2
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 -L- STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
?LETU%l OF THIS WELL, THE NEIGHBORING
DATE: ;q I I/ 5'-�
DATE: T, de�
OUR RD.
rkdius th#1
ionitor tube
-air vent
1500 gallon Proposed Mounded Absorpt
Bed w/ 2' sand filter.
existing failed septic Orenco lift stati n
and . seepage pit Bed to consist of 3 lines
proposed
private 58' long. The lines a or
100' radius well gazebo � . centers with 2 ;rFvto
the edges. The lines will
be interconnected at the
existin5l y ends and in the middle to
class C" LU insure proper distribution.
well W
Q� Bed Area -
L) 15' 6.0 sf
AREA
REQUIRED ote: 'existing class "c" we
4 bdr�n *150 60 gpd to become private well for
600 gpd the home on the west lot
857sf when the proposed new we
Q.7 gpd/sf is drilled for the east lot.
Scale: 1"=50' New well to be located 5'
from lot line.'
JOB NUMBER : —, Z /3 Z,
CRITLE JJSWEER
P.C. Sax I I 1"a
8-17"
JOB DATE 7- di:- f
I ?AX *0? " 003 A I
-Cleanouts (7)
\\Y11i,ft station manhole entrance
t m ito
air vent monitor tube
g g -
.40 eo—fabric
earth
fill
gA!:;*- A
7
,.low
JOB NUMBER
CRITLER 1AZWEER
P.O. Box IIITH
JOB DATE MCHOM L AX "SIR -IM
7M *07 C349 -IM
up -INS
Fa 07 A I
12"
2
J
3/4+
graded
1 2.5'l-- 5'---4— 5`4
2.5' 1
gravel
1
8, --1
—1500 gallon
clean, course, uniforml
cgded—sond
Orenco lift station
-Note:
field system designed in 'aCcordance
with EPA Design manual
figure 7-28.
Piping size 1 1/4"
hole size . 1/4"
hole spacing 3'
gA!:;*- A
7
,.low
JOB NUMBER
CRITLER 1AZWEER
P.O. Box IIITH
JOB DATE MCHOM L AX "SIR -IM
7M *07 C349 -IM
up -INS
Fa 07 A I
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street. Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: DATE
LEGAL�DESCRET
.)ON: -ZZ &v-- 4 !1 ,Township, Range. Section:
3- Tr
4 e 0-tt, ow
5 W�
-6
7
9 1 4.
1: '
10 ��n
11 -
12-
13-
14-
15-
16-
17-
18-
19
2 1
COMMENTS _:��
Usler -fa-6te '7
t
�K' I
SITE
WASGROUNDWATER
ENCOUNTERED?
a 1 471� IT
IF YES, AT WHAT L
DEPTH? 0
P
Depth to Water Mr
mon1wing? t. 6-ous,
Reading
Date
Gross
Time
Not
Time
Depth to
Water
Not
Drop
//5
r/0
I 'FIIA
:> 123,
PERCOLATION FIAT A (minutestinCh) PERO HOLE DIAMETER
TESTRUNBE....
EA,-3-�FTANQ FT
jc"' . I / . 101. '/ .
PERFORMED BY: - - — I CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Aft. 4/85)
7:9� 3:05 PM ;ANCHORAGE TANK & WELDING INC
r
1clo of arr
907 277 3716;9 2/ 6
-vz
F
t
z
1clo of arr
907 277 3716;9 2/ 6
I
F
t
z
7- 7-b3 3:05 PM ;ANCHORAGE TANK & WELDING INC
AS
I
F
907 277 3715;8 3/
HEAD im rur
E
r
�l
fly
71
I
F
907 277 3715;8 3/
HEAD im rur
E
r
�l
'OHENCO SYSTMIS, INC. �-
JLL-06-1993
21
24
28
17:16 FROM Al< PIPE ANCH-PLIJ11BING
TO
X
Access
Adep ter
rTuba
3449936
IN
The Bull Runt Valve Is designed to soft
effluent flow to distribution boxes. In addiftn
to the advantages of longer life and easier
frIsUflation the valve Is the most public
health sale aft9mating device available for
wast*waler disposal applications. The user
has absolutely no contact with wastewater
due to the valve's leak -proof and external
Operating Characteristics. The changeover
from one drainage field to another can be
accomplished In less than a minute by slrn�
ply turning a valve without digging or Contact
with wastewater.
P.01/01
The Bull Run Valve is available In 4' and is
suitable wherever septic tank disposal sys�.
tems are used -4n commercial, industrial,
and residential application.
OPERATING THE VALVE
The Direction Control Handle should be
rotated periodically to direct effluent to one or
-the other. of two septic fields. After removing
ft WeWcap at the top of Riser Tube, the
Valve handle Can be turned with the Yalve
Key fumished.
BULL RUN VALVE
Part NO. Size'
SM KIT 4*HXMXH
ORMEY28 28,
SDFIP4
4: CAP ADAPTER
PVC PWG 4 4 ACCIMS CAP
CorriPliite Valve Kit Contains:
1. Bull Sun Valve Body
2. Valvo Key
OL Riser Cap Adapter
4. Water-TigN Access Cap
CALL TOLL FREE 1-800--345-3132 3
.'7- 7-9,� 3:05 PM ;ANCHORAGE TANK & WELDING INC
ORENCO SYSTEMS."m ALARM -CONTROL
CIRENCO SYSTEMS" Alarm -Control Panel
offers fine quality components for reliable automatic
Pump operation. Standard functions include circuit
breaker, manual, off and automatic motor control
operation. plus an audio/visual high-water alarm circuit
with audio silence and automatic reset upon correction of
the high-water condition.
A selection of optional features offers flexibility for a
variety of pumping aPPlications.
ORENCO SYSTEMSIN alarm -control panels are
specifically engineered for pressure sewer (STEP)
Systems, for controlling Pumping Into conventional
gravity collection systemsand foron-site Systemssuchas
intermittent sand filters, recirculating gravel filters, low
pressure dralnfields, as well as forsimple uphill pumping
to standard drainfields.
ORENCO SYSTEMSTO alarm -control panels -are
especially designed for use with mercury float switches
capable of directly switching on & Off Pumps with high
starting currents. The alarm -control panel Is also
compatible with other standard dry -contact switching
methods.
907 277 371S;X 6/ 6
PANEL
STANDARD FEATURES:
Listing:
Underwriters Laboratories.
Rating:
Model A-1 rated at 1/2 HP/1 15 VAC, Single Phase, 60 Hz.
Model A-2 rated at 1 1/2 Hp/230 VAC, Single Phase. 60 Hz.
Current Limiting Circuit Breaken
20 amp. OFF/ON switch, DIN rail mounting with thermal magnetic
tri I
, ng characteristics. (Single POle/1115 VAC; Double Pole/230 VAC)
Toggle Switch:
A SPDT HOA switch with a 16 amp motor rating.
Fuse Disconnect:
2 amp SLO-BLO fuse with DIN rail mount. Ue L
Audible Alarm:
Panel mount with a minimum of 80 db sound pressure at 24 Inches, continuous sound.
Visual Alarm:
NEMA 4 -rated, 7/8 -inch diameter, red lens, oil -tight with Push -to -silence feature.
Audio -Alarm Silence Relay:
115 VAC. automatic reset. with DIN rail mount socket base.
Alarm Circuit:
Wired separately from the PUMP Circuit. so that If the Pump's Internal overload switch orcurrent-limiting circuit
breaker Is tripped the alarm system remains functional.
Enclosure:
NEMA 4X -rated, fiberglass with hinged cover. NoncorrodIng.
or 8" High x 6" Wide X 4-5/8" Deep. External mounting ears.
Podlockable Latch:
Constructed of noncorroding stainless steel.
OPTIONAL FEATURES:
Elapsed Tim* Motor
115 VAC. 7 -digit. nonresettable.
Counter.
115 VAC, "Igit, nonresettable. horizontal base mount,
Redundant Off Relay:
115VAC 25amps aut- I
Dimensions: 10" High X 8" Wide X 6-1/8" Deep,
I I -- C reset, provides low level alarm capability.
Other custom features can be Provided.
. .7—,7-2'93 3:06 PM ;ANCHOPLAGE TANK & WELDING INC
Terffiral
Strip
Aluff
Temural
Strip
Alarm
P=p
115 VAC 11/2 Po.
I Phase /so Hr.
pump
230 VAC I I U2 Hp.
I phoss IGO HL
907 277 3716;# e/ 8
M®r OvN4,1=9 ont.
Wiring Diagram
NZIM M
o7smoo evM(guns ont.
Wiring Diagram
uzdpo 4%-S?
al�
L, La
230 VAG. I Ph&". 60 Pa.
A L PA
E E R IS
CRII�L
July 15, 1993
Mr. Robbie Robinson
Municipality of Anchorage
Department of Health and Human Services
Environmental Services Division, On-Sitc Services
P.O. Box 196650
Anchorage, AK 99519-6650
P.O. BOX 111790
ANCHORAGE AK 99511-1790
TEL 907 349-1003
IN AK 800 478-ID03
FAX 907 344-9936
RECEIVED
JUL 161993
Municipality of Anchorage
Dept. Health & Human Services
Reference: Class C Well Serving Lots I and 2, Block 2, Car -Lynn Subdivision, Anchorage, AK
Job No.: 93381
Dear Mr. Robinson:
As indicated on our pcmiit application for the septic system for Lot 2, Block 2, Car -Lynn Subdivision, the
existing Class C water source will be abandoned by our clients and a new well drilled. The service to the
residence on Lot 2, Block 2, Car -Lynn Subdivision, will be s%vitched over to the new well as soon as it is
drilled and the source dcterrained suitable. We anticipate this will oom in conjunction with the
installation of the new on-site waste disposal system.
If you have any further questions please do not hesitate to contact us.
Sincoerel,
Theodore, . Johnson, P.E., US.
Principal
TAJ/jbj
REGISTERED
PROFESSIONAL
ENGINEERS
13UILDING INSPECTIONS
INVESTIGATIVE ENGINEERING
LITIGATION SUPPORT
CONSTRUCTION MANAGEMENT
6�
FROA : Criterium-Aiaska Engineers ALIG. 5.1993 9:39 Am P 2/2
FjJG-W-1.993 e4l IOPM FROM R&Ied Anchorage TO . 3449936 P.02
.L�Aljl INSPECTION REPORT
'?4t BUILDING SAFETY
KUNICIPAL2TY OF ANCHORAGEv R ROAD
3500 EAST. TUDO INFORMATION (907)786-8211
NSPECTIONS'(907)563-3464
PERMIT 0: 93-7876
AKE: ALCAN ELECT G nious t: 563-0073
pDRESs:'4920 R 1047H DATE. 8/-3/1993
OT: 2 BLOCK: 2 SUBD: CAVLIHt
OpMENT: .34G-8228
REIN--------------------------
---------------------- ----- 7
,ypE or INSPECTION: ELE;TRICAL 1:11IJ
0 0 -----
0 0 -------- --------------------
-------- ------ ---------- -------- C 3 rORRECTIONS ESS.ENTIAL AS
NO NONCOMPLIANCE OBSERVED EXPLAINED BELOW
3 DO NOT CONCEAL UNTIL REINSPECTED
AT NEXT INSPECTION -----
WILL REEXAMINE ----------- ---------- -------
----------- -------------
COMMENTS:
N
GRE1^7ER ANCHORAGE AREA BOrUGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL.SYSTEM
NAME MAILING ADDRESS 1434 A�S7714 PHONE V719 -177Z
LOCATIONIQU/C LEGAL DESCR IPTION ZIP, 145./k-0 1!a9e_Z1, 'I"" S1111
SEPTIC TANK:
DISTANCE NUMBER OF
FROM WELL/: -52 MANUFACTURER S�'/Oyt -MATERIAL COMPARTMENTS—;<
Ze/ e/ 1�-71 7cY
INSIDE LENGTH —INSIDE WIDTH —LIQUID DEPTH I IQUID CAPACITY 27-70 GALLONS.
SEEPAGE PIT:
NUMBER OF PITS DIAMETER —OR WIDTH/—S, LENGTHZve-', DEPTH
LINING MATERIAL lCytt'j"rtIr CRIB SIZE: DIAMETER --DEPTH— DISTANCE FROM: WELL/S-2-//
-2L, 7' TOTAL EFFECTIVE
BUILDING FOUNDATIONk-4. NEAREST LOT LINE- ABSORPTION AREA (WALL AREA) —SC. FT.
ADDITIONAL ABSORPTION
WELL:
TYPE —CONSTRUCTION DEPTH DISTANCE FROM:
BUILDING NEAREST NEAREST SEPTIC SEEPAGE
FOUNDATION LOT LINE—, SEWER LINE—, TANK SYSTEM
CESSPOOL OTHER SOURCES
APPROVED— DISAPPROVED —REMARKS
DISTANCES: DIAGRAM OF SYSTEM
INSTALLED BY-Oloo0b
PIPE MATERIAL:
LOT SLOPE:
REMARKS: tll) I T---_'�-
-�o'A br.,ck-,-b
Ak\tN\'�3 (_7 t
Form No. EQ -031
)�;L'
V--\
I
S r e -"
'��711jle —
APPROVED
G.A.A.B.
G
?.4 �19
GREATEF�ANCHORAGE AREA "ROUGH
IIEALTII DEPARTMENT
Anchorage, Alaska 99501 279-2511
�Vf �1'1 I' SEWAdE DISPOSAL SYSTEM - APPLICATION & PERMIT
CaseNo. ///�_
I Vi �77—.23,111
NAME OF APPLICANT MAILING ADDRESS 6Y10.7a PHONE NO-.��-
RESIDENCE ADDRESS LOCATION OF INSTALLATION dee"d
LEGAL DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK X SEEPAGE PIT tr DRAIN FIELD—, OTHER
TO SERVE THE FOLLOWING FAC ILITY
FINANCED THROUGH 140 BE INSTALLED B
PERCOLATION TEST RESULTS hl� *11'*4 ANTICIPATED DATE N -
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS 61) PERMIT TO INSTALL A
AS DESCRIBED BELOW. SIZE OF'UNIT TO BE SERVED
-76-
SEPTIC TANK SIZE TYPE 01 SEEPAGE AREA.—TYPE
DIAGRAM OF SYSTEM
DISTANCES:
f'H� CLe-d, .
L
HEALTH AUTHORITV
OR
UCINSED DESIGNER
fy that I am familiar with the requirements of Greater Anchorage Area BQrough Ordinance No 28-68 and that the
above described system is in accordance with said code. t r- 0 - !�� j
HQ) jmtl!'6�4 ZZV
qlcf
711
DATE APPLICANTS SIGNATURE,
r�) (00)
GRk...rER ANCHORAGE AREA BO.,OUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TU
DOR ROAD POUCH 6.650
ANCHORAGE. ALASKA 99502
Tr,CP.0.r 279.8686
SEWAGE DISPOSAL SYSTEM — APPLICATION AND PERMIT
PERMIT NO. �
NAME OF APPLICANT --400 Y-41-11tc) MAILING ADDRESS PHONEc,2,79-
INSTALLATION LOCATION e%,e ler,4 b -/ 0)/
LEGAL. DESCRIPTION CD
INSTALLATION OF: SEPTIC TANK SEEPAGE PIT
— DRAIN FIELD OTHER
TYPE AND SIZE OF FACILITY TO BE SERVED
, I
FINANCED THROUGH TO BE INSTALLED BY 0/1 lzlrtl�-_r en��rl—lk ez-
SOIL TEST RESULTS r
NOTE, THIS PERMIT 19 NOT VALID WITHOUT SOIL TEST
COMPLETION DATE ANTICIPATED I
FINAL INSPRCTION, 24 HOUR NOTICE REQUIRED. BACKPILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION my THE
HEALTH DEPARTMENT AUTHORITY WILL UK $UOJKCT TO PROSECUTION.
SEPTIC TANK SIZE TYPE
MINIMUM DISTANCES. REOUIRIEMENTS
FOUNDATION TO SEPTIC TANK — 5 -
FOUNDATION TO SEEPAGE PIT 4.:;b /
DRAIN FIELD
SEPTIC TANK TO SEEPAGE PIT V;ALL
— ol
SEPTIC TANK ---=L— SEEPAGE PIT (=5Z 0 DRAIN FIELD
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK SEEPAGE PIT
DRAIN FIELD e)
ALSO CONSIDER AREA WELLS.
WATER MAIN TO SEPTIC TANK SEEPAGE PIT
DRAIN FIELD
SEPTIC TANK. SEEPAGE PIT DRAIN FIELD
TO RIVER. LAKE. STREAM.
-CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
AICAVAILON 5 FEET INTO UNDISTURBED SOIL.
44ftCH-CLAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
� �EIXH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKPILL
CONFORM TO BOROUGH REGULATIONS REGARO'ING INSTALLATION.
HEA T' AUTI MITY
OR
L,C IEISI 0 DESIGNER
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATE
DESCRIBED SYSTEM 19 IN ACCORDANCE WITH SAID CODE.
VA.,-2ZffLz,)-,A,P,,CA.T., SIGNATURE
be;AREA SIZE — ;;k I I., I m - TYPE
DIAGRAM OF ISYSTEM
ORDINANCE NO. 28-08 AND THAT THE ABOVE
•
GC Bo,
•, tom Municipality of Anchorage °
On-Site Water and Wastewater Program
(907) 343-7904 till ti
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 015-111-21 Expiration Date: _UM-1Z ' 157- 1 13
1. GENERAL INFORMATION
Complete legal description CAR-LYNN#1 BLOCK 2, LOT 2
Location (site address) 4920 E 104TH AVENUE,ANCHORAGE,AK 99507
Current Property owner(s) SRINADH RAO& LESLIE HARDIES Day phone
Mailing address PMB 226,266 ELMWOOD AVENUE, BUFFALO, NY 14222
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (wlwo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Individual
Individual Well ® Holding Tank ❑
Individual Water Storage ❑ Community ❑
Community Class Well ❑ Public Sewer ❑
Public Water System ❑
WaiverNariance request for: Distance:
Received by: // ��-/� / 1t/ _ Date: / /
COSA to be released to the engineer,unless othe, -4e -:uested by the engineer.
I
COSA Fee $ 5-247 Waiver Fee $
Date of Payment /1 l %([9- Date of Payment
Receipt Number Oq I(Q(p Receipt Number
COSA# 3C('3"/5— -i 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 Date 10/25/2017
THIS COSA DOCUMENT CANNOT BE USED TO TRANSFER TITLE UNLESS ALL VENDORS(ENGINEERING,SURVEYING,CONTRACTORS,ETC...ASSOCIATED
WITH THIS COSA ARE PAID IN FULL AT OR BEFORE CLOSING. 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 life of all well and septic systems are subject to these various and dynamic characteristics and are outside the
control of the 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. OF AI
l * 4• TIl •
6. DSD SIGNATURE / 'r- —wirMihail
X System #1 Approved for ( bedrooms.
Y PP � KENNE111 Ni. ne.V;r/
7>>e
System #2 Approved for bedrooms. 4 ‹sT
-
Disapproved. ,
\
Conditional approval for bedrooms, with the following stipulations:
ON-SITE
= WATER AND
WASTEWATER o
PROGRAM
.0�jial Original Certificate Date: I I`1 S -I—7
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory •
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet10-10-12.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: CAR-LYNN#1 BLOCK 2, LOT 2 _ Parcel ID 015.111.21
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed 7/2411993 Sanitary seal (YIN)Y Wires properly protected (Y/N) Y
Total depth _ 268 ft. Cased to 268 ft. Casing height (above ground) 18 in.
FROM WELL LOG AT INSPECTION
Date of test 7/24/1993 6-24-2016
Static water level 225 _ ft. 233 ft.
Well production 10 g.p.m. 4.8 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate 0.832 mg/L
Arsenic: ND ug/L Date of sample: 10/16/2017 Collected by. ARCTERRA
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEP/STEEL Date installed 712411993
Tank size 1500 gal. Number of Compartments 2 Cleanouts (YIN) Y_
Foundation cleanout (YIIN) Y Depression over tank (YIN) N High water alarm (Y/N) Y
Date of pumping 11 ' 4 - I 1 Pumper I; `c'
C. ABSORPTION FIELD DATA
Date installed 712411993 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.7 System type MOUND
Length 58 ft. Width 15 _ ft. Gravel below pipe 0.5 ft.
Total depth 3.7 ft. (Measured 6/24/16) Eff. absorption area 860 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 6.24-16 Results(Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 0 in Water added 600 gal. New depth 0 in.
Elapsed Time: 1 min. Final fluid depth 0 in. Absorption rate >= 600 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed 712412008 Size in gallons 1500 Manhole/Access (Y/N) Y
"Pump on" level at 43 in. "Pump off" level at 44 in. High water alarm level at 44.5 in.
Datum BOTTOM OF TANK Cycles tested _2 Meets alarm &circuit requirements?Y
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots 100'+_
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 100'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 1001+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line_10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in conformance
with MOA COSA guidelines in effect on this date. �! QF A f -`14,
Engineer's Printed Name KENNETH M. DUFFUS A,Q`
Date 10125/17 * 9TH `9* f
COSA canary sheet_2-6-15.doc ` �r KEN T H M. nl,
4 °T 7116
k Ar
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 015-111-21 Expiration Date:. I
1. GENERAL INFORMATION
Complete legal description CAR -LYNN #1 BLOCK 2, LOT 2
Location (site address) 4920 E 104TH, ANCHORAGE, AK 99516
Current Property owner(s) MICHAEL& SHARON BAKER — Day phone
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
4920 E 104TH, ANCHORAGE, AK 99516
[0 Single Family (wiwo ADU)
El Duplex
[j Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY:
Individual Well
N
Individual Water Storage
E71
Community Class — Well
El
Public Water System
F
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual
N
Holding Tank
E71
Community
1-1
Public Sewer
El
Waiver/Variance request for: Distance:
COSA to be released to the engineer, unless othe5v q19110uested by the engineer.
COSA Fee r)2&
Date of Payment 71 -a 0 le-tv
Receipt Number..
COSA#_
Waiver Fee $
Date of Payment
Receipt Number
Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my sea] 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 ARCrERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 717/2016
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 so!] characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will fundon satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
OF AZ X
encroachments, deficiencies or discrepancies eAst. Ar o�
041 ` r4—qZH:*
,�K
6. DSD SIGNATURE
I f k1KM110E 1*36VV
System #1 Approved for bedrooms.
4L
Af
System #2 Approved for bedrooms.
v
Disapproved. V%,
Conditional approval for bedrooms, with the following stipulations:
'11VQ�0,
ON.SITE
7
Original Certificate Date:
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.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA b1w sh�LIG-113-12.dm
If more than I septic system Is on the lot:
COSA Checklist # —of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: CAR -LYNN #1 BLOCK 2, LOT 2 Parcel ID: 015-111-21
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID #
Date completed 712411993 Sanitary seal (Y/N) y
Total depth 268 ft. Cased to 268 ft.
FROM WELL LOG
Date of test 7t2411993
Static water level 225 ft.
Well production 10 9 -P -M.
WATER SAMPLE RESULTS:
Coliform colonies/100mL Nitrate 2,99-mg/L
Arsenic: AIV ug/L Date of sample: 612412016
B. SEPTICIHOLDING TANK DATA
Tank Type/Material STEPI STEEL
Tanksize 1500 gal. Number of Compartments 2
Foundation cleanout (Y/N) I Depression over tank (Y/N)
Dateofpumping Pumper A+
C. ABSORPTION FIELD DATA
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 18 in.
AT INSPECTION
61242016
ft.
9 -P.M.
Collected by: ARCTERRA
Date installed 712411993
Cleanouts; (Y/N)
High water alarm (YIN) Y
Date installed 712411993 Soil rating "(. d.e or felbdrm) 0.7 System type MOUND
Length 58 ft. Width 15 ft. Gravel below pipe 0.5 ft.
Total depth 3. 7 ft. (Measured 6/24/16) Eff. absorption area 860 If Monitoring tube Y Depression over field N
Date of adequacy test 612412016 Results (PasstFail) PASS For 4 bedroorris
Fluid depth in absorption field before test 0 in. Water added 600 gal. New depth 0 in.
Elapsed Tirne:' i rnin. Final fluid depth 0 in. Absorption rate >= 600+ g.p.d.
Any rejuvena ;i6n treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed 7/2412008 Size in gallons 1500 -Manhole/Access (Y/N) Y
"Pump on" level at 43 in. Purnp off' level at 44 in. High water alarm level at 44.5 in.
Datum BOTTOM OF TANK -Cycles tested 2 Meets alarm& circuit requirements? Y
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100'+
Absorption field on lot 1001+
Public sewer main 75'+
Sewer /septic service line 251+
Animal containment areas 501+
SEPTIC/HOLDING TANK ON LOT TO:
On adjacent lots 1001+
On adjacent lots 1001+
Public sewer manhole/cleanout 100'+
Holding tank 100'+
Manure/animal excrete storage areas 1001+
Building foundation 54 Property line T+ Absorption field 54
Water main 104 Water service line 101+ Surface water 1001+
Wells on adjacent lots 1001+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water. 1001+ Driveway, parking/vehicle storage 1104
Curtain drain 504 (NONE KNOWN) Wells on adjacent lots 1001+
F. COMMENTS
G. ENGINEER'S.CERTIFICATION
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 M. DUFFUS
Date 71712016
COSA canarysheet_2-6_16.doc
Aw OF AZ, 'k
Q TH *
% k KENNM
M"M
7
9 =*01P.W
LSF
Municipality of Anchorage 4�-! , -�
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. COSA M00*1�
Expiration Date: 10
1. GENERAL INFORMATIO14
Complete legal description &13nm 11L i gi.,V z Ut I
Location (site address) 41ZO L. 1041"
Current Property owner(s) /W�*�&k Aorlq^v___A_4,,"r Day phone
401D CD vv-,k"W tda— kA 0 Loo -M
Mailing address 44bi) U--,VAt- WO -4
Lending agency 0 t's' . Day phone
Mailing address
Real Estate Agent Dayphone_
Mailing Address
Unless otherwise requested, COSA willbe heldby DSD forpickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Individual On-site 10
Individual Water Storage D Individual Holding Tank El
Community Class Well 1:1 Community On-site El
Public Water System 0 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 8 wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below. I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm S �&& 10
ip�!M3^A 61-t m, Phone Z71-31i(p
V
Address to� w. 101, A�. Sfc,2,71 A., L.e4l. Als itin_
Engineer's Printed Name L4t� Date 7118/08
S. DSD SIG ATURE
Loo� Approved for bedrooms.
Disapproved.
T ..M
.. .... ......
S E. SPURK
1500
J. is
Conditional approval for — bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: �; Original Certificate Date:_7— -9— ci - o 3�
(Re, 11/05)
Municipality of Anchorage
Development Services Department
Building Safety Division
on-site water & wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 995IM650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Pc� L, nn ParcelID:
A. WELL DATA
Well type _PjjE!Akr, If A. B, or C provide PWSID # Well Log (YIN) y
Date completed .7144 3 Sanitary seal (YIN) Y Wires properly protected (YIN) 'y
Total depth Casedto V00 ft. Casing height (above ground) + IS n.
FROM WELL LOG AT INSPECTION
Date of test ------- 7 )08
Static water level ft. &0 ft .
:Well production to 9 P.M. 1/. 8 g.p.m.
WATER SAMPLE RESULTS:
Coliform __,(�_colonies/100 mL Nitrate 0.313mg/L Other bacteria colonies/100 mL
Arsenic: AJQ ug/L date of sample: _� W14 oe Collected by� tA25 S --A
B. SEPTICIHOLDING TANK DATA
Tank Type/Materiai A.,clioLa% _I�E SN -1 Dateinstalled 712.1113
.1 y
Tank size I S-00 __' 6�1- Number of Compartments I Cleanouts (YIN)
Foundation clea I nout (YIN) Y Depression over tank (YIN) A/ High water alarm (YIN)
*2009
Date of pumping _T _- - Pumper A+ -' ety;mo.
C. ABiORPTION FIELD DATA pe 110"AA
Dateinstalled '71�411-3 Soilrating (g.p.d.M2 or ft2ibdrm) 0.-+ System ty
Length ft. Width Is -ft. Gravel below pipe 0.5 ft.
Total depth 3ASf I I. Eff. absorption area �_Wfe Monitoring tube 2L Depression over field A/
Da r te of adequacy test _+ III ob Results (Pass/Fail) PAS!, For i bedrooms
Fluid depth in absorption field before test _0 in. Water acldecli�2 gal. New depth -.L- in.
Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= GOO g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN &type) None J�mow ^_ If yes, give date
D. LIFT STATION
Date installed 1124 lob Sizeingallons 1500 Manhole/Access (Y/N) Y
OPump on" level at 113 in. "Pumpofrievelat qq in. High water alarm level at q 4 '11 in.
Datum B.H." T. -k Cycles tested — 6 Meets alarm & circuit requirements? Y
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot '* 100
Absorption field on lot + Ict!
Public sewer main A
Sewer /septic service fine +16
Animal containment areas +50 1
On adjacent lots
On adjacent lots
+loot
+100 1
Public sewer manholelcleanout A.' /A
Holding tank LVIA
Manure/animal excrete storage areas 4 1001
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
Building foundation +101 Property line +10' Absorption field 5
Water main Ae . JA Water service line +10 —Surfacewater H00
Wells on adjacent lots * 100
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line * 10 1 Building foundation 4 101 Water main vLA
Water Service line + Surface water + 1co, Driveway, parkingtvehicle storage 5
Curtain drain kV, 0. Wells on adjacent lots +1100 *
F. COMMENTS
G. ENGINEER'S CERTIFICATION OF At
.qo
I certity that I have determined through field inspections and A, -
review of Municipal records that the above systems are in
TH
conformance with MOA COSA guidelines in effect on this date.
Engineers Printed Name LAQ.� S �URK
0
Date -4110106
46
COSA Fee 01
Date of Payment '4-1k 1 0 g
71
Receipt Number 6 �Igql
(Rev. 11105)
Waiver Fee $
Date of Payment
Receipt Number
;=T--71- -- - 1
------------
0
X
0 0
31. >
Is, K
4 a'.
SURVEY CERMMAIM
6**�wwMaII
PLDT PLAN
............
.... .. .....
FOUNDATION AS-46UILT
0
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4121—S
FINAL SrRUCnft AS�IKIILT
e
............
El Lvr 9uway SURVEY TYPE
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0 � sTsMR,%E �T
E3 PWT � ... �1 ... ... TO"a""
Prepared by
Robert E. Johns, Jr. & Assoc.
Professional Land Surveyors
1700 DRINK DR.
AN�HORArE ALAWA 09504
Scale: Rea. Lot 3.F. Ra� plat "a Na,
Chemed by:
oats SuIveye& Dramon ck*d b
OB
6_19-
_�EE
6-19-08
Date Ora": COIL 2536 W.O. PiLn
Wt 2 Block 2
SYMB=
SET REBAR DRAINAGE
0 FOUND RVIAR WOOD FENCE
A"ALT
CONCRETE
r -OT FLAJN� 0 LUI WXt—IQ
BUILDER OR OWNER. PRIORTTO ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL ISE
IT IS THE RESPONSIBILITY OF THE � L SOW,. ENCM WELLS SEPTIC CL"WOU"4 SIDEW�S. DRIVEWAYS.
CONSTRUCTION. To VERIFY PROPOSED BUILDING GRADE RELATIVE
I I
'S AN
To FINISHED GRADE AMD UTILITY CONNECTIONS AND TO OETERM14E ETC.. ARE SHOWN IN THOR APPROXIMATE LOCATION. ONLY- SNOW
I F NE
T14E EMSTENCE Of ANY EASEMENTS, COVENAtNTS OR RESTRICTIONS MAY PREVO47 SOME 1MI"ROVE�EN11i FROM B61NO SEEN AND LOCAnO-
11'�ER E V IVI I PLAT. n1STANCF_S_'-' -1-1.
�Cm 00 NOT APPEAR ON -THE R GARY OR FENCE LINES.
UNDER NO CIRCUUSTANCES SHOULD AN AS -BUILT BE USED FOR CONSTRICTON OR FOR E5TAVU��-
CW�M�RRIYV FOR THE INITAL TRANSACMON ONLY AND ASSUMES-F'NANC'AL UA81UTY ONLY FOR THE COST OF THE SURVEY.
FTMIN
L �.A
SGS Rcf.#
1082963001
Client Name
Tobbcn Spurkland P.E.
Project Name/H
Car -Lynn #I B2L2
('lic"t Sample ID
Car -Lynn #1 B2L2
Matrix
Drinking Water
P%%Sll)
0
Sample Remarks
All Datts/Times are Ala%ka Standard Time
Printed Datefl hne
07/0312008 9:02
Collected Dalt/Time
06124,2008 13:25
Received Dateffime
06124/2008 14:25
Technical Dircctor
Stephen C. Ede
Allimabic
Prep Analysis
Results
PQL Units
Method Container ID
Limits
Date Date
Init
Parmcicr
metals by IcP/MS
ug/L
EP200.8
c
(<10)
M/27108 07/02/08
NRB
Arsenic
ND
5.00
Waters Department
06127/08
JDZ
0.323
0.100 ml;JL
S%120450ONO3-F
11
<10)
Total NitratetNitrite-N
microbiology �ratO
-La
col/lOOmL
S%1209222B
A
(<200)
06r-)4,'08
DIX
Colon% Count
0
col/100MI,
S%1209222B
A
(<I)
OOr24,'Og
DLC
fatal coliform
0
colIlOOmL
S.%1209222B
A
(<[)
0(,124,108
DIX
Fecal Coliform
0
municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 9951 M650
www.cl.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FmLy DWELLING
Parcel I.D. '015-11111-21 HAA
Expiration Date:
1. GENERAL INFORMATION
Complete legal description - Lot 2 Block 2 Carr Lynn SfD
Location (site address or directions) 4920 East 10e, Anchorage. AK 99516
Current Property owner(s) Gary Schmitt Day phone 425-422-9233
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
629 Avenue J., Snohomish, WA 98290
Day phone
Mary Dee Fox/ReMax Properties Day phone 257-0120
2600 Cordova St., Ste. 100, Anchorage, AK 99503
Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by:
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
individual Well
individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL'
individual On-site
Individual Holding tank
Community On-site
Public Sewer El
The Municipality of Anchorage Development Services Department (DSD) 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. DSD 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.
(Rw. 11W)
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 an 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 Pannone Eng. Svc. Phone 272-8218
Address P.O. Box 102954, Anch, AK 99510
Engineer's Printed Name Steven R. Pannone, P.E. Date /e5b-ZE2
Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious
'6�& n'
engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The U� 4 44
'k . . ................ .
reported results describe the performance of the system under the conditions encountered at the time of
the test, and separation distances measured to readily identifiable features. The operational life of all �* AP
wells; arid septic systems depend on the local soil condition, ground water levels that may fluctuate
during the year, and the water usage of the family being served by die System 71esc conditions arc
.. ....... ...................
outside the control of the evaluator of this system_ All systems eventually fail and satisfactory test 0
results do not guarantee future performance of the system, nor do they guarantee that there are no .... ... .. .
hidden defects or encroachments. PES can therefore not provide any %mranty for future performance 00 —(�k I S t e v e r. P . c . n . n . c . n . e
nor give any estimate of how long the system will continue to meet the operational rcqw, # C) . Steier.
rements of the # ;:'� %. Nc. CE E 149
ADEC or MOA DSD. Ile content of this report is for the sole beriefit of the owner listed above. Any # U,- -
##
IL
reliancc upon or use of this report by any other person or party is not authorized nor will it confer any #� ..
legal right whatsoever. 5",
6. DSD SIGNATURE 4 it It
Approved for bedrooms.
Disapproved.
Conditional approval for _ bedrooms, with the following stipulations:
UN -W I t
WATER AND M
Addifional Comments WASTEWATER
Aftachments:
HAA Checidist x
Septic System Advisory
Well Flow Advisory
By:
ExpliraJDate�: 1 /(4 lar -7
(Rw. 11M) "(
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: --ZO I �Vz
Reissue Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ek.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 2 Block 2 Carr Lynn S/D Parcel I.D.7 015411-21
A. WELL DATA
Well type P If A, B. or C provide PWSID # —
Date completed 7/24/1993 Sanitary seal Y
Total depth _16_8ft Cased to 268 ft
FROM WELL LOG
Date of test 7/2411993
Static water level 225 ft
Well production 10 9 -p -m
WATER SAMPLE RESULTS:
Well Log Y
Wires property protected Y
Casing height (above ground) 18 In.
AT INSPECTION
912412002
230 It
4.7 — 9 -p -m
Coliform _A_colonies/1 00 ml Nitrate 1.43 mg/I Otherbacteria 0 colonies/100ml
Date of sample: 912412002 Collected by: Laura Pannone
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Orenco STEP
Date installed 7/2411993 - Tank size 1500 gal Number of Compartments _2
Cleanouts Y Foundation cleanout Y Depression over tank N_ High water alarm X_
Date of pumping 912412002 Pumper Northland Pumping
C. ABSORPTION FIELD DATA
Date installed 7/2411993 Soil rating��`r ft2lbdrm) 0.7 System type Bed
Length _L8 -_ft Width 15 fit Gravel below pipe 0.5 ft
Total depth 3.6 ft Effective absorption area 870 ft2 Monitoring tube _Y Depression over field _N
Date of adequacy test 9/2412002 Results (Pass/Fail) P For 4 bedrooms
Fluid depth in absorption field before test Dry/.25 in Water added600 gal. New depthDry/2.5 in.
Elapsed Time: 1440 min . Final fluid depth Dry/.26 in Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date
(Rev. I IM)
0. LIFT STATION
Date installed - 7/2411993 Size In gallons 1500 Manhole/Access Y
oPump on" level at 45.5 in'Pump off" level at
44.25 in 'High water alarm level at 48 In
Datum BonomofVault — Cyclestested 11 Meets alarm & circuit requ'irements? Y
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100,
On adjacent lots ' 100+
Absorption field on lot JOG+
Public sewer main i oo+
Sewer /septic service line 25+
Onadjacentlots 100+
Public sewer manhOle/cleanout 100+
Holding tank' 1100+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 8' Property line _.Lo: Absorption field 5'
Watermain 10+ Water service line 10+ Surfacewater Ili'
Drainage 100+ Wells on adjacent lots � 1100+ 1
SEPARATION DISTANCE FROM ABSORPTION FIELD6N LOT TO:
Property line 10+ — Building foundation 20, Watermain 10+
Water Service line 10+ Surfacewater 100+ Driveway, parkingfvehicle stora I ge 40+
Curtain drain 1100+ — Wells on adjacent lots 100+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
11
I cellifY that I have detennined 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 —Steven R. Pannone, P.E.
Date
C�v
HAA Fee $
Date of Payment 1 EL07
Receipt Numnfber G COD 0
(Rev. I V99)
Waiver Fee $
Date of Payment
Receipt Number,
/* 49TH
Steve; 0Pcnne
`%_ No CE 8149
r
.23
EAST j0jTH Al�ENUE - — - — ---
t4 eg Aff 34- E. M05 35'
I
3!
0�
=a-
m E19 w 19' E. 2?20 *
Tw gFOWTEN WREM 15 FGR DE USE OF EN
www%j
STRLCTLPES.
............ ...........
PC
SCALE. I' 4Er
AS - f3UILT SURVEY
;NC) CCR�ERS SET THIS DATE
IF1 WZEUY CERTIFY THAT I HA E P= A
MORMACZE-S MPECTION OF TW FOLLOW
DESCpff3M PROPERTY
LOT 2 BLOCK 2 CAR-LYW SLAO ADON ta I
rE
ANOHCFZAGE RECOROM DISTRICT. ALASKA AND
THAT TFf pipROVE�osiTS SITUATED TFEREUN
ARE hjT�#N T) -e PROPERTY LVES " NO
Et4CROAo4iENTS EXIST OTHR TKAN WTM
DATED AT AU>MAGE. ALASKA THS Ea --
DAY OF _ZLA�_-- 19-M—
H)L T LAAD SLPVEYM JOB 6"
TEL. 345-5513 F& 74-56
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section EX-ris
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # 01-C- III -?I HAA # Vk Q 'V�
1. GENERAL INFORMATION
Complete legal description �O � ?� 016-cle ? 6q r -I Y'7A S /.6 0 1
Location (site address or directions) IY9 20 C- 10V r" Avc
Property owner
Defle e
fle6ece. weae
Day phone
-3YL< - 9 Z33_
Mailing address
'Y9 20
15. 1 & 'V '" h,e
4ACAOrE7t�V� Ak
99S-14lr
Lending agency
Day phone
Mailing address
Agent ma;x Pee Fcy.- Re /lew Pfvgee tie, —Dayphone
Address ?LfOO eorc-yo�" Sl. .4A cAc r!;g. 4tt 99so_7
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
L_�
NOTE: If community well system, provide written confirmation from State ADEC attest -
Ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(R*..1/91) F� MOA821
S.
1-4
0
STATEMENT bF 'INSPECTION BY ENG INEER
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 numberof 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 Flakj�,_,4 T_-eekn;eck1 Serv;ee.�, Phone :?
Address 'r— CA SY.0 A�e,4 cwerg, 9_5'6'
V
Engineers signature Da t e 17 / 9 7
DHHS SIGNATURE
A., Approved for bedrooms.
Disapproved.
Conditional approval for
Additional (':-.�.,nments
(A,
0 -jv
-�j
T
CE - czz 2
Ir
bedrooms, with the
IXA�A 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 intheStateof Alaska. The DH HS does this as a courtesy to purchasers of homes
and their lending Institutions In order to satisfy certain federal and state requirements. Employees of DHHSdonot
conduct Inspections or analyze data before a certificate Is issued. The Municipality of Anchorage is not
responT'ble for errors or omissions in the professional engineer's work.
72-WSM-.1191) B� MOAR21
OF ANLhokAGI
Municipality of Anchonige I"YWA
DEPARTMENT OF HEALTH & HUMAN SERVICE90 18
Environmental Services Division
825"V Street, Room 502 0 Andiorage, Alaska 995010 (907) 3R
f
Health Authority Approval Checklist
Legal Description: L o 6 t k P G r Yn 40 Parcel I.D.: of$ -
A. WELL DATA
Well type P,/ If A, B, or C, attach ADEC letter. ADEC water rystem number
Log present (Y" Y - Date completed 7/ay /P.?
Total depth 26,01 Cased to ?d'40 Casing beight (above pound) (a
Sanitary seal (Y" Y Wires property protecw (Y" Ir
Daft of test
Static water level
Well production
FROM WELL LOG
7/ 2,Y/P-7
WATER SAMPLE RESULTS:
ATINSPECTION
197
23x,
g -p -m- Y. 4f * g-p-m-
Coumni 0 cat
hr-'ar"t
Nitrate < o, I &-
,�1-41!
Otherbacteria Afeo4e- rrjoo--Aft(
Date of sample:
o:�/ V / 7 7
Colleow by: f=10
/.:p 7ecA S�e
IL SEPTIC/HOLDING TANK DATA
Daft installed 7 3 Tank size q,*( Number of Compartments 2 Cteanouts (Y/N)__)L__
srep-
Foundation cleanout (Y/N) Y Depraision (Y" N High water alarm (Y/N)
Date of Pumping C 6- / 9 7 Pumper -Tsagc-r
C. ABSORMON FU3,D DATA
Date install 7 Y / 9 3 SOB rating (gp.dW or ff?A)dm) 0. 7 =!�. Systm rype 8e c,(
Length 5'49'--�Width IS" Gravel thickness below pipe 0-,�- Touddepth 3,s-' Lef�ey
Effwtr*v absorption area 6470 0' Monitoring Tube pres=t(Y/N)
_X_ Depressum am field (Y/N) IV
Date of adequacy test 9 7 Results (PasslFafl) rox r For bedroom
o" A/ Pi.r. 0 A/ ti. r
Fluid depth in absorption field before test (in.); 7 " -S ImmediM4 dtcr_2,d gd. water added (in.): 3 s
� N. M. r
Fluid depth 3 ins.) Minutes later: 2ev Absorption rate - > $'00 p.d.
Peroxidefteatment (Pao 12 months) (Y/N) Y*Ae kt,w. IfMgmedate y .4.
D. LIFT STATION
Due ingailed 712YI93 Sizeingallons ts-00
ManhalclAccess (Y/N) Ir -pump on- level w yr. s-" -pump air level at*
Mgh water alarm level at* ql� " I -*Datum i7o)41�f v)fewuff
Cycles tested �w
E. SEPARATION DISTANCES
SEPARA77ON DISTANCES FROM WELL ON LA)T TO:
Septic/holding tank an lot ; On adjacent lots > 100
Absorption field on lot (01 -,On adjacent lots '> too'
Public sewer main M. A. Public sewer manholdcleanout Al. A.
Sewer /septic service line '> 2 S" Lift station too,
SEPARATION DISTANCES FROM SEPT[CMOLDING TANK ON LOT TO:
Building foundation 9' Property line 30' Absorption field 5 -
Water mainhiervice lim _>�Surfacc watuldminage I 13 ' Wells on adjacent lots > 10, --
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation �, ? 0' Property Line _!Q�L_Watcr =Wservice line
Surficewater �> too' Driveway, parkinghrehicle storage area 5,0
drain JVcAe 5eel Wells on adjacent lots >too
F. ENGINEERS CERTIFICATION 'wv!MVW%� *%I
I cerafy that I have determined thrufleld Inspections and review ofUmnicipai
in conformance with MOA HAA guidelines in effect on this date.
or
......... ..
Signature 2; .,:.0
it
0.
Engincer's Name A du 00�,,d C,0 f n4
Date �T,4-g /7
19'97 ........
HAA Fee S ?0.9 "
Date of Paymeot ie 4 11 1--U—
ReceiptNumber.
Rev. 9/95 OSS: haa.wk.doc
Waiver Fee S
Date of Payment
Receipt Number
JUN -09-1997 08:16 ME ESI PJCHORAGE 9075615301 P.02/03
I
CT&E Rcf.#
Client Name
Project Name/#
Client Sample M
qatrix
:)cdered By
FWSED
CT&E Environmental Services Inc.
972840001
Flattop, Technical Srv.
L2,B2. Car -Lynn SID
L2,62, Car -Lynn SID
Drinking Water
client PO#
Printed DatelTime 06/06197 16:14
Collected Date/Time 06/04/97 13:25
Received Daleninm 06104197 13:40
Technical Dirtdvr-. Stephen C. Ede
Released By
Attowabte Prep AnalySis
)srwwt*r Resutts POL Units Method Limits Date Date Init
litrate-M 0.100 u 0.100 mg/L SMla 4500-MOU 10 wx 06/05/97 JSL
rotat cotiform 0 to[/100mt. SM18 92228 06/04/97 um
MUNICIPALITY OF ANCHORAGE "Rk
DEPARTMENT OF HEALTH & HUMAN SERVICES ALE;L
Division of Environmental Services 32M
On -Site Services Section Luu�
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # Q3 1, 111 71 000
1. GENERAL INFORMATION
_T_
HAA# IIAOSS LIAtn
Complete legal description 1,ot 2 Block 2 Car -Lynn subdivision
Location (site.address or directions) 104th and Our Road
-ty and Carol Sycks
Prop�rtykovvner -'CA I - Day phone 563-0073
0-. box 110158, Anchorage, AK 99511
Mliling qddress
L;nding'ag"ency.. Day phone
Mailing address
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual well X
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site X
Holding tank
Community on-site
PubliCsewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-M(R".1/91) FWt L40A#21
5. STATEMENT OF INSPECTION BY ENGINEER
Ascertified byrnysealaffixed heretoanclasof the validation date shown below, Iverifythatmy -
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 I urtherverify that based on the information obtained from
the Municipality of Anchorage files and from my invest�qation 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 Criterium -Alaska Engineers Phone
Address
Engineer's signature
7heodore X. Johnson, P.E.
6. DHHS SIGNATURE
__y2L Approved for bedroom s.
Disapproved.
Conditional approval for
Additional Comments
M
349-1003
leFlaw. .1c
bedrooms, with the following stipulations:
12 0010 me - W -A "I
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 doesthis as a courtesyto purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHSdo 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 (Rw. 1/91) BWk MOA 021
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L2 B2 Car -Lynn Parcel I.D. 015 111 21 000
A. Well Data
Well type Private If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) y —Date completed 7-24-93 -Driller Alpine Drilling
Total depth 268' Casedto 76111 Casing height
Sanitary seal (Y/N) y Wires properly protected (Y/N) V
Date of test
Static water level
'. I Well flow
Pump levell
FROM WELL LOG
7-24-93
92c; 1
AT INSPECTION
new well
10, —9 -P.M. 9 -P.M.
265'
SEPARATION DISTANCES FROM WELL TO:
la""nk on lot 100, ; On adjacent lots 100+
Absorption field on lot — 1041
On adjacent lots
100+
Public sewer main NIA Public sewer manhole/cleanout N/A
Sewer service line N4A Petroleum tank N/A
WATER SAMPLE RESULTS:
Coliform 0- —Nitrate 0.98 mg -L Other bacteria 0
Date of sample: 7/29/91 Collected by: F74T
B. SEPTICIHOLDING TANK DATA
Date Installed
Cleanouts(Y/N),
High water alarm (Y/N)
N/A
-Tank size Compartments.
cleanout (Y/N) —Depression (Y/N)
tested (Y/N)
Date of puTping.. V -pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
On adjacent lots Foundation
Well(s) on lot
To property line Absorption field
Surface water/drainage
Water main/service line
72-026 (3M3)' Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date Installed 7/26/93 Manufacturer Orenco
Size In gallons I - C;nn Manhole/Access (Y/N) v
Vent (Y/N) N "Pump on" level at 4211 —.Pump off" Level at 42,9
High water alarm level 461, - Cycles tested
Meets MOA electrical codes (Y/N) Y
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot 100, —On adjacent lots 126., —Surface water 1121
D. ABSORPTION FIELD DATA
Date Installed 7/26/93 Soil rating (GPD/Ft?) 0.7 -System type Mound
Length sp Width I C; I -Gravel thickness I Total depth --2_51_
Total absorption area 860 ft- 2 Cleanout present (Y/N) Y Depression over field (Y/N) m
Date of adequacy test New a),stem —Results (pass/fail) DbIA for 4 Bedrooms
Water level In absorption field before test N/A After test N/A
Peroxide treatment (past 12 months) (Y/N) N/A If yes, give date N/A
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot InAl —On adjacent lots 3.30, Property line 2V
To building foundation 19, To existing or abandoned system on lot in,
On adjacent lots 100+ -Cutbank NZA —Water maintservice line 71,
Surface water 1111, Driveway, parking/vehicle storage area 3:91
Curtain drain N/A
E. ENGINEER'S CERTIFICATION
/ cerfify that / have checked� verffiec� or conformed to all MOA and HAA guidelines in effect on the date of Ws inspection.
Signature
Date 8/3/93
HAA Fee$ / 7D e VD
Date of Payment 7 1 ';- - !��p 3
Receipt Number _a-zl�'7,Y�Cf �,30
72-026 (T93)* Back
I ;� "
k��Eo�hnson
00
CE 5191 -A�
Waiver Fee $
Date of Payment
Receipt Number