HomeMy WebLinkAboutELMORE #1 BLK 3 LT 2EIrnore I
Block 3
Lot 2
#018�171�28
_QUBMITTAI
Municipality of Anchorage V
On -Site Water and Wastewater Program - (907) 343-7904 MARPa# 21116of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: (Arp t ($I C) -:� ? PID Number: 42( 5e -f ?I - z_V�
Dwelling: [I -Single Family (SF) El Duplex (D) El Multiple (SF and/or D) Project:E] New fZ Upgrade
Name:
I'D Vk to we r
ABSORPTION FIELD
El Deep Trench aShallow Trench E]Bed El Mound
Address
1000 '5kU';Avn'
El Other
Phone
Number of Bedrooms
Soil Rating
depth from ori nal grade
d -f
ITotal
1, -2—, GPDISF
6to Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
'�f 0 Ft.
Gravel depth beneath pipe
I -L I C) Ft.
Subdivision Block Lot
Ph -0,4 Al( 31 -t--
Fill added above original grade
"Ll
3, Ft.1
Gravel length
7 L Ft.
Township Range Section
Gravel width
Ft.
I Beds: Number of Lines
rL_
Distance between lines
� `WA� Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist, between trenches
I
From
Tank
Field
Tank
Line
57 Q 0 Ft`�
I
— Ft.
Well
I
Vol
P44
d1A
I
SO P
TANK ASeptic El S.T.E.P. [:]Holding El Other
Manufacturer Capacity
*vl e if 7- r�O Gal.
SuraceWater
(F)d t
Material
4�,L t L.
Number of compartments
Lot Line
-IL-
NA
Foundation
LIFT STATION
Manufacturer
Capacity
Curtain Drain
ttvt
Gal,
Remarks
Pump on level at in. Pump off le in.1
High water alarm at in.
Pump
"m' nd model
jEI,,tnmI Inspections performed by
Installer
Tankto
PIPE MATERIAL House to tank drainfield
*,A, �c, 7 4 1'W 4 vat
Drainfield .)VILf COIMT -#099,/
Inspector M_Ar1Lr,(1#&4 P(P
BENCH MARK (Assumed elevation) 1U 0 It
Inspection
dates:
Location and description
3 fd
I qrqcc,
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
It
Conditional Approval: Da te
101
1W ......... .............
�0
.................
ri .0 MICHAEL N. ANDERSON
CE 69
�9
r7!
Appr d Date
W14-
nspection port_9-1-12.doc
Permit No OSP161037 page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744
On—Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: ELMORE #1, BLK 3, LOT 2 PID No.: 018-171-28
=a:
Imm
Imm
SHOSHINI AVE.
X
T I 1\� —
TH#2
Ct3
Co CO2
\T 01 5
NEW TANK IS LOCATED MORE THAN
F 5' FROM STAIR/DECK SUPPORT
�E�STING WELL
BEN CH, GARAGE SLAB
DECK OVERHANG
20' RO AD EASEMENT
SHED
VACANT LOT
_Z_ —Z
10 T&E EASEMENT
EXISTING WELL
SCALE: 1"--50'
CO2 CO3 T
9J(j5d TC 2
.5
OF 44"141,
0 4
................
49 TH
I .....................
0 77;;:
JAEL N. ANDLR
No. g�� 9469
55 Lj q �(�4) -.0 ? W,
,N4,9�ty,E� �_4
1 % INA a % u �L***
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99507
www.ci.anchgLggg.ak.us
(907) 343-7904
Soils Log - Percolation Test
Performed For: '30V\ W'r1LVCV-. Date Performed:
Legal Description: a ( W111 I t 14- 1 6 V C 1__� Township, Range, Section:
11-
12-
13-
14-
15-
16-
17-
18-
19-
(1��D
19 V, 01 1
Al
'Ovat"
WASGROUNDWATER
ENCOUNTERED9
S
IF YES, AT WHAT DEPTH9 L
0
Depth to Water After P
Monitoring? E
Date
. . . . . . . . . . . . . . . . .
MICHAEL N. ANDERSON
CE 9 9
Reading
Date
Gross Time
Net Time
Depth to Water
Net Drop
ef
5"
Oft
it
PERCOLATION RATE (m,nutesinch) PERC HOLE DIAMETER 110
TEST RUN BETWEEN FT AND 4V FT
COMMENTS 40 f a V (%- 't -7, X. r ( I 10;��
PERFORMED BY: NfAlA I CERTIFY THAT THIS TEST1W)S
PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: V f/ /to
On -Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water& Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number:
OSP161037
Tax Code Number:
01817128000
Work Type:
Septic Upgrade
Permit Effective Dates: March 04, 2016 to March 04, 2017
Design Engineer:
ANDERSON CONSTRUCTION & ENGIN
Subdivision:
ELMORE #1
Site Legal Address: ELMORE #1 BLK 3 LT 2 G:3036
Owner/Address: WEAVER JONATHAN S & AMBER D
4300 SHOSHONI AVE ANCHORAGE AK 995163683
Site Mailing Address: 4300 SHOSHONI AVE, Anchorage Lot Size in Sq Ft: 37299
Total Bedrooms: 4
This permit is forthe construction of:
Y Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage
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 (1 8AAC72) and Drinking Water Regulations (1 8AAC80).
3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Special Provisions: PRIOR TO CONSTRUCTION: Percolation tests shall be completed to verify the
entire proposed absorption field design. If design revisions are required, an approved change order
shall be available onsite prior to construction. Percolation test results shall be submitted with the
final inspection report.
Receiv(
Issued
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. Of V - 17 / - 2, �
Property owner(s) 'Jov% �4,6.ev Wauut"/' Day phone
Mailing address H -"Poo 4k04-AL5".'
Site address C7 to rek '=�-
Legal description (Sub'd., Block & Lot) P—
Legal description (Township, Range & Section)
Lot Size 372 It I - Ft.
APPLICATION IS FOR:
(N all that apply)
Absorption Field
9
Septic Tank
IN
Holding Tank
F-1
Privy
F-1
Private Well
D
Water Storage
F-1
Number of Bedrooms 1�
APPLICATION IS AN: TYPE OF DWELLING:
Initial F� Single Family (SF)
Upgrade (w/wo ADU)
Renewal Duplex (D)
Multiple Dwellin
) - 1*1
(SF and/ol
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 1)040waiver Fees:
Date of Payment: Co Date of Payment:
Receipt Number: 4 Receipt Number:
Permit No. b1c) IP16 10-31 Waiver No.
Perm1tApp__'-:
March 3, 2016
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: New Septic system
Legal: Elmore #1, Blk 3, Lot 2
To Whom it may concern:
This is a request for a septic permit on the above referenced lot, the old system has failed and needs
replacing. A new test hole was excavated in the backyard and found various types of sands and gravels,
GM/SM. Damp soils were observed during the excavation at 14 feet but after the 7 day monitoring period
the monitoring tube was dry. The old MOA file shows water at 8 feet but we could not determine were the
test hole was located therefore the new test hole data will be used. The bottom of the old system is currently
at 6.2 feet per the last COSA by others, The perc rate was 2 minutes per inch at 4 feet below grade. A
5 -wide trench has been designed as a replacement trench. The tank will also be replaced due its age.
The lot slopes to the southwest at about I percent, see the drawing. This replacement system will not
impact any of the neighboring properties due to the lot layout.
Please call me if you have any questions.
Sincerely 04--t
Mike Anderson, P.E.
4661 Natrona Ave.
Anch, Ak 99516
DESIGN CRITERIA-.
4 BDRM X 150 = 600 GPD
SOILS = 600/1.2 500 GPD
500 GA/5X(O.70) 70'
(TH#11) -
,-oETORG
OVER
(1)
TRENCH
GM/SM
�—SEWER ROCK
15.0'
DEEP
2.0'
5.0'
EFFECTIVE
WIDE
—6.0
".0
70'
LONG
15
0
- - - - - - - - - -- - - - - -
ELMORE S/D ELMORE S/—D
ELK 1, LOT 10 BLK 1, LOT 9
I ELMORE S/D
"'Z BLK 1. LOT 3A
EXISTING WELL
SEPTIC\) 1 100' RADIUS
WELL
\_1 I /t -WELL
I AVE— PROPOSED
DRAINAGE FIELD
ELMORE #1 S/C�'
BLK 3, LOT I I
ALL
t
PR6PERTY LINE
SEPTIC
I L — — — --- — — — — — \ 7
TE—' --�'
— — — i7o '�MFR I
EASEMENT WELL
Septic Design Prepared for
JON & AMBER WEAVER
ELMORE #1, BLK 3, LOT 2
Anchorage, Alaska
Michael N. Anderson, P.E. DATE:
4601 NATRONA AVE DRAWN:
ANCHORAGE, ALASKA 99516
(907) 727-8864 / FAX: (907) 345-1391 SCALE:
FA
,,,,,�—OLD SYSTEM TO BE
REBUILT PER DESIGN
ELMORE #1 S/D
BILK 3, LOT 3
r 10' UTILITY EASEMEI
I
I/ ���20' ACCESS EASEMENT
3/1/2016
DJR
1"=100'
VACANT LOT
r CREEK
OFF SET
PROPOSED
AGE FIELD
DECOMMISSIONED
-----PER UPC-�\
EXISTING CO FROM OLD
SYSTEM TO BE REMOVED
\TH#1
NEW TEST HOLE PRIOR
TO, EXCAVATION TO VERIFY
WELL
13
HO SE
NEW 1,250 GAI I ON
SEPTIC TANK
EXISTING WELL
/1�1�100' RADIUS
071%
Z_ - - <X
/Z
PROPERTY LINE
— — — — — — — — — — — — — -------- — — -
Septic Design Prepared for
JON &AMBER WEAVER
ELMORE #11, BLK 3, LOT 2
Anchorage, Alaska
Michael N. Anderson, RE DATE:
4601 NATRONA AVE DRAWN:
ANCHORAGE, ALASKA 99516
(907) 727-8864 /FAX: (907) 345-1391 SCALE:
- - - - - - - - - -
3/1/2016
DJR
1 "=30'
'7
kA rwr
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99507
www.ci.,qnchoraqe.ak.0
(907) 343-7904
Soils Log - Percolation Test
OF.4
*7
. . . . . . . . . . . .
. . . . . . . . . . . .
pc MICHAEL N. ANDL CNI
C E-9 9
rb
V
kik-'aftrizu '. I—
Performed For: "�� yx W--stv I%r - Date Performed:
Legal Description: 1z ("14), C� 4 ( B 3 11 Z__ Township, Range, Section:
C't %) 9.
C-� m //7/"
16 0 #/&W�
16-
17-
18-
19 -
WAS GROUND WATER
ENCOUNTERED�
IF YES, AT WHAT DEPTH?
Depth to Water After
Monitoring?
Date:
Piry ( to it, t
Reading
Date
Gross Time
Net Time
Depth to Water
Net Drop
I-Al/Ito
( 41
'0
541
to (I
5� /I
ff
'15 )1
ft
PERCOLATION RATE (mir.t./mir) PERC HOLE DIAMETER
TEST RYWE N FT AND C; FT
COMMENTS
PERFORMED BY: NAIA' I CERTIFY THAT THIS TES VVIS,.
PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: W 5
MUNICIPALITY OF ANCHORAGEm
fleoo��h and Environmental Prot7 �)ion
Fourth Floor West -
825 L Street
Anchorage, Alaska 99501
264-4720
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME -4z?A��O'w&a MAILING ADDRESS PHONE
LOCATION LEGAL DESCRIPTION -124��A -4&-?
SEPTIC TANK:
DISIANCE NUMBER OF
FROM VJLLL//Or-tA— MANUFACTURER -'�;�MATERIALJ-&P— COM PA RTM CUTS
INSIDE LENGTH— INSIDE WIDTH— LIQUID DEPTH — LIQUID CAPACITYZ;b-� GALLONS.
TILE DRAIN FIELD:
DISTANCE TOTAL LENGTH '75 10
rROM, WELL FOUNDATION NCAREST LOT LINE-./-P—OF LINE
0
# of Lines DISTANCE 6CTWECN LINES-N//9—TRENCH WIDTHJ;�: 14! TOTAL EFFECTIVE
ABSOIWT ION A14EA SQ. FT. LENGTH OF EACH LINE
DEPTH OF FILTER
DXPIII: TOP OF TILL 10 1 INISH GRADE MATERIAL BENEATH TILE -W"'—[N. ABOVE TILE —�9—IN.
SEEPAGIL PIT:
DIAMETER —OR WIDTH—, LENGTH- DEPTH
Log Crib —Rings_ Crib SiZe: DIAMETER —DEPTH— DISTANCE FROM: WELL
TOTAL EFFECTIVE
UUILDiriG FOLINDAI ION—. NEAREST LOT LINE APSORPTION AREA (WALL AREA) —SQ. FT.
loll
.lass: Depth:
loll Distance To: Lot Line
Ildg: Sewer Line:
lipc Materials:
of Bedrooms: q
.nstaller:
temarks:
h
--LI-1
TIFF
L
h
T. -E OF SOIL ADSORDTION SYSTEN IS: DRAINFIELD
i�.::JNUH NUI-IDER OF DEDRIXIMS 4 SOIL RATING (SO FT/BR)= 85
_F -F -TEII S
i. REQUIRED SIZE li THE SOIL A r' Slj,,PTIOIJ ST'S - I :
-cZI�*-Tl-J= I t- rE r -i c� -F i -i = a- fi- -4- 17-i f-ef=l L_ C- F=-. F_- _r F-1 !ff-
THE LENGTH DIMENSION IS THE LENGTH (III FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TREN1711 OF: PIT IS THE DISTAIK-;E BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
TIlE ZEF DRAINFIEL�)s La - EET.
,tif-IL — 3- r -
THE GRAVEL DEPTH 15 THE MINIMUM DErTli OF GRAVEL BETWEEN THE OUTFALL PIPE
f-jrjr� THE F;OTTOI-I OF THE EXCAVATION (IN FEET).
. -.-- — — — — — F-- 1--i §::: I f=l 1:3 E=- r�- L_ f--1 r-4 -r ID F-� -y- I ID r -j — — — — — — — — —
f'rij-'K.AGE PLANT HAY BE INSTALLED AT THE PERmITTEE'S OPTION SUBJECT TO THE
6.1-011ING CONDITIONS:
-1. EITHER A CLASS I OR II NSF APPROVED PLANT MAY BE INSTALLED.
A CONTINUOUS MAINTENANCE AGREEMENT IS REQUIRED. IF A MAINTENANCE
AGREEMENT IS NOT I . EPT CURRENT YOU MAY DE REQUIRED TO ENLARGE THE SOIL
ADSCIRPTION SYSTEM AND/OR, YOU MAY DE SUBJECT TO PROSECUTION.
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
ii,i.FILLING Or ANY SYSTEm WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
�:A.'.-MIDIT WILL P.17. SUBJECT TO PROSECUTION.
N]HUH DIS-TANCE DCTWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
,I' FEET FiN.: A F-'I:.IVFlTE WELL OR 200 FEET FOR A PUBLIC I -JELL.
i- I_CiGS. ARE RE(-,!l_'IRED AND NUST BE RETURNED TO THE DEPARTMENT WITHIN 20 DAYS
111F WELL COVIPLETION.
F'-' RE ' G�UIRENFNI"_- HFIY APFLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAM� ARE
li--1 PROPER INS.TALLATION.
rE: 1:� I-- I - I I I -E r" —1 :I_ :lL:D
i.F. I IFY T071T
i -ill IAl-lJLlfiV' WITH THE REOUIREMENIS FOR Orl-SITE SEWERS AND WELLS AS SET
L:,,' 1,11.1.14IFIFALI'llyl OF ANCHOR'AFiE.
011A. INS.TCiLt. THE SYSTFN IN ACCORDANCE WITH THE CODES.
I'Ark -iT Tfi� 014 -SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
T11i
-F -:EIT-lDELCD Ti -i INCLUDE Ni -,RE THAN 4 BEDROONS
�A I
(IPPLICA
1_-, _ V3
L_ 3: -r '-e r-_
F -i r -J f-- 1-11 I=i Gi I
DEPARTHENT 01
'L
HEALTH AND ENVIRONVIENTAL
PrOTECTI...
::25
STREET, ANCHORAGE,
N. . 99501 h
264-4720
wno
1-11-ZA-11- 171 r -j 1:
ID IN —,H. 3: -F r.E
IE I - I [:-: F-: f E: 1 -1 1 -F
PER.11IT
NO. < 771-D-7-0
LL6.
'il-IGANT
Jf_lHFq P111-11-1FIRDNER
B"' 474E
SRA ANCHORAGE
34,1-1-3- kA,6,
ji-:f-iT I ON
SHOSHFINE
L-, U-3 ELHORE SUBD
LOT SIZE 37024
SQUARE FEET
T. -E OF SOIL ADSORDTION SYSTEN IS: DRAINFIELD
i�.::JNUH NUI-IDER OF DEDRIXIMS 4 SOIL RATING (SO FT/BR)= 85
_F -F -TEII S
i. REQUIRED SIZE li THE SOIL A r' Slj,,PTIOIJ ST'S - I :
-cZI�*-Tl-J= I t- rE r -i c� -F i -i = a- fi- -4- 17-i f-ef=l L_ C- F=-. F_- _r F-1 !ff-
THE LENGTH DIMENSION IS THE LENGTH (III FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TREN1711 OF: PIT IS THE DISTAIK-;E BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
TIlE ZEF DRAINFIEL�)s La - EET.
,tif-IL — 3- r -
THE GRAVEL DEPTH 15 THE MINIMUM DErTli OF GRAVEL BETWEEN THE OUTFALL PIPE
f-jrjr� THE F;OTTOI-I OF THE EXCAVATION (IN FEET).
. -.-- — — — — — F-- 1--i §::: I f=l 1:3 E=- r�- L_ f--1 r-4 -r ID F-� -y- I ID r -j — — — — — — — — —
f'rij-'K.AGE PLANT HAY BE INSTALLED AT THE PERmITTEE'S OPTION SUBJECT TO THE
6.1-011ING CONDITIONS:
-1. EITHER A CLASS I OR II NSF APPROVED PLANT MAY BE INSTALLED.
A CONTINUOUS MAINTENANCE AGREEMENT IS REQUIRED. IF A MAINTENANCE
AGREEMENT IS NOT I . EPT CURRENT YOU MAY DE REQUIRED TO ENLARGE THE SOIL
ADSCIRPTION SYSTEM AND/OR, YOU MAY DE SUBJECT TO PROSECUTION.
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
ii,i.FILLING Or ANY SYSTEm WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
�:A.'.-MIDIT WILL P.17. SUBJECT TO PROSECUTION.
N]HUH DIS-TANCE DCTWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
,I' FEET FiN.: A F-'I:.IVFlTE WELL OR 200 FEET FOR A PUBLIC I -JELL.
i- I_CiGS. ARE RE(-,!l_'IRED AND NUST BE RETURNED TO THE DEPARTMENT WITHIN 20 DAYS
111F WELL COVIPLETION.
F'-' RE ' G�UIRENFNI"_- HFIY APFLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAM� ARE
li--1 PROPER INS.TALLATION.
rE: 1:� I-- I - I I I -E r" —1 :I_ :lL:D
i.F. I IFY T071T
i -ill IAl-lJLlfiV' WITH THE REOUIREMENIS FOR Orl-SITE SEWERS AND WELLS AS SET
L:,,' 1,11.1.14IFIFALI'llyl OF ANCHOR'AFiE.
011A. INS.TCiLt. THE SYSTFN IN ACCORDANCE WITH THE CODES.
I'Ark -iT Tfi� 014 -SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
T11i
-F -:EIT-lDELCD Ti -i INCLUDE Ni -,RE THAN 4 BEDROONS
�A I
(IPPLICA
1_-, _ V3
IS SO;LS LOG
MUNICIPALITY OF ANCHORAGE 'D PERCOLATION
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST
Pouch 6.650, Anchorage. Alaske 99602 276-2221
SOILS LOG — PERCOLATION TEST
PERFORMEDFOR: Tpxc-;5 D, DATE PERFORMED:-- e7e r /- 1 77
LEGAL DESCRIPTION: 1-07- 2- f7lmocry
SLOPE SITE PLAN
olyarr;� /nA44 4 6,"flt 0" Ally
11YI(Til t-015,wit&I
2
Date
Gross
Time
3-
Depth to
Water
Net
Drop
TEST SUN BETWEEN
FT AND - FT
4-
5 -
6-1
PERFORMEDBY:
Aeyvnre(
-CERTIFIEDBY;
DATE: rA-r- 4
7-
......
..
0
9
rlofrOA4 or- rrxcQv,
10
11 WASGROUNDWATER S
ENCOUNTERED? Yr-- L
0
P
12 IF YES, AT WHAT E
DEPTH? t43 Ff.
13
14
15
16
17
18
19
20
j
Reading
Date
Gross
Time
Not
Time
Depth to
Water
Net
Drop
TEST SUN BETWEEN
FT AND - FT
COMMENTS
PERFORMEDBY:
Aeyvnre(
-CERTIFIEDBY;
DATE: rA-r- 4
72-008 (7/76)
PERCOLATION RATE
Iminuieslinch)
TEST SUN BETWEEN
FT AND - FT
COMMENTS
PERFORMEDBY:
Aeyvnre(
-CERTIFIEDBY;
DATE: rA-r- 4
72-008 (7/76)
na WR
...........
'/ 1, " L ��,
Ac) F��I-)NofL P,,� � U -A :,-I-IL �\�Ij cr � b6c
:-h�L-�) b-,-nc, CAU0 IcAs Cc� O-Y\tAL"- LR-�t-
-71
Cr( 101 2711 951 1 e 35AM
/dUHMFIAUTY 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. 018-171-28
1. GENERAL INFORMATION
Expiration Date: 13 02 a,2
Complete legal description Lot 2, Bk 3, Elmore Subdivision, Addn #1
Location (site address) 4300 Shoshoni Ave Anchorage, Alaska 99516
Current property owner(s) Kevin Boyles Day phone ( 907) 444-7365
Mailing address
8933
Lakehurst #3,
Anchorage, Alaska
99502
Real estate agent
Margie
Hudok/RE/MAX
Dyn Day phone ( 907)
748-3656
2. TYPE OF DWELLING:
[�} Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
[
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by;(95�� Date: —(—;!z
COSA to be released to the engineer, unless otherwise requested by the engineer. /
COSA Fee $ 5--5-01 Vo Waiver Fee $
Date of Payment (7-/ "T/`zl Date of Payment
Receipt Number 2r7 119 ( Receipt Number
COSA # 05C2_1 1 1 CS 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. 1 acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Pinard Engineering Phone(907) 232-1347
Address PO Box 871347, Wasilla, Alaska 99687
Engineer's Printed Name Paul E. Pinard, PE Date 12/6/21
6. DSD SIGNATURE
-/ System #1 Approved for H bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for
bedrooms, with the following
'"j)))))))111i,.
By: j2iOriginal 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 engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Legal Description: Lot 2, Bk 3, Elmore Subdivision, Add 1 Parcel ID: 018-171-28
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled Unknown
Total depth 109+ ft
Cased to 40+ ft
Sanitary seal is functioning correctly
( Wires are properly protected
Casing height (above ground) 12 in.
Date of flow test for COSA 11/8/21
Static water level at beginning of test 108 - 8 ft.
Comments
B. TANK DATA
Age of tank(s) 5 years
Tank type/material Septic/Steel
Measured operating fluid level in septic tank 491'
Standpipes/foundation cleanout per record drawing
Date of pumping 11 /24/21 _
Structure served by this system _
Well production at time of test 5.3 gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes No
[� Coliform bacteria is Negative
Nitrate 2 -.53 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L 0 Arsenic less than MRL (ND)
Collected by Pinard Engineering
Date of Sample 11/3/21
C. LIFT STATION NA
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 3/5/1 6
Adequacy test date 11/8/21
® ALL standpipes present per record drawing
Results 13pass For 4 bedrooms
Total measured depth from grade 10 ft (max) ,(�
Fluid depth prior to test 11 in
Measured depth to pipe invert from grade- 7 (min),�?'' Water added 640 gal
ElN/A — pressurized field
® Monitor tubes go to bottom of effective. If not, state
New depth 15 in
depth into effective
Elapsed time 120
p min
® Code -required soil cover over field
Final fluid depth 11 in
❑ System presoaked
Absorption rate 600+ gpd
(Required if vacant for greater than 30 days prior to
date of test)
Any rejuvenation treatment (past 12 months) None Known
Gallons introduced gallons
If yes, enter date
Comments/Deficiencies:
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100'
ti� Yes if No ft LX_ -1 Yes if No ft
Neighboring Tank > 100' ?wX 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' X Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment > 50' x Yes if No ft
Yes if No ft
Community Sewer Main > 75'
' X Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Vii' Yes if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' Yews if No �ft 11'04urface Water > 100' P Yes if No ft
Property Line > 5'
` Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
FX Yes
if No
ft
Private Wells > 100' ]Yes if No ft
Water Main > 10'
Yes
if No
ft
Community Wells? 200' XJ Yes if No ft
Water Service Line > 10'
i X Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
', Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
;X Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
Yes
if No
ft
Private Wells > 100' f_ x Yes if No ft
Water Service Line > 10" -
X Yes
if No
ft
Community Wells > 200' X Yes if No ft
Surface Water > 100'
Yes
if No
ft
F. ENGINEER'S COMMENTS
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.
COSA Checklist yellow sheet
lzjzi
PINARD ENGINEERING
P.O. Box 871347
Wasilla, AK 99687
(907) 357-ENGR (3647)
WELL FLOW TEST
LOCATION: Lot 2, Block 3, Elmore Subdivision, Addition #1
DRILLER: Unknown
DATE WELL COMPLETED: Unknown
WELL DEPTH: Unknown (109'+, by probing)
STATIC WATER LEVEL (top of casing): 108.8'
JOB NUMBER: 21-293
DATE OF TEST: 11/8/21
FIELD STAFF: PJ Pinard
i�r
Time
Elapsed
Time
(Minutes)
Static
Water
Level
Flow
Rate
m
Cumulative
Gallons
Pumped
Remarks
11:30 AM
-
108.8'
5.3
- Start Test - Meter
23600
11:45
15
5.3
80
23680
1.2:00 PM
30
5.3
160
23760
12:15
45
5.3
240
23840
12:30
60
5.3
320
23920
12:45
75
109.2'
5.3
400
24000
1:00
90
5.3
480
24080
1:15
105
5.3
560
24160
1:30
120
5.3
640
24240
1:45
135
109.1'
5.3
720
24320
2:00
150
5.3
800
24400
2:15
165
5.3
880
24480
2:30
180
109.0'
-
960 Stop Test -
24560
RECOVERY
2:35 PM ( 5 ( 108.9' 1 All well protection features are adequate.
Average Flow Rate: 5.3 gpm
Comments: DURING THIS TEST, THIS WATER SUPPLY WELL WAS CAPABLE OF
PRODUCING 5.3 GPM.. THIS TEST DOES NOT CONSTITUTE A
WARRANTY OR GUARANTEE THAT THE WATER SUPPLY SYSTEM
WILL CONTINUE TO FUNCTION AND PRODUCE AT THIS RATE.
Reviewed by: Paul Pinard `I ,74>
Date: 11/15/21
�-� PINARD ENGINEERING
P.O. Box 871347
a� Wasilla, AK 99687
(907) 357-ENGR (3647)
ADEQUACY TEST
LOCATION: Lot 2, Block 3, Elmore Subdivision, Addition #1
APPLICANT: Jonathan & Amber Weaver
4300 Shoshoni Avenue
Anchorage, Alaska 99516
SEPTIC TANK TYPESIZE: Steel/1250 Gallons, per MOA Records
ABSORPTION SYSTEM: Shallow Trench, per MOA Records
DAILY FLOW:
4 BEDROOMS x 150 GAL/BR = 600 Gallons
TEST DATA
JOB NUMBER: 21-293
DATE OF TEST: 11/8/21
FIELD STAFF: PJ Pinard
NUMBER OF BEDROOMS: 4
SCUM: 0.0' SLUDGE: 0.0'
NEEDS TO BE PUMPED: Yes No XX
CURRENTLY IN USE: Yes XX No
Time
Flow
Rate
Volume
Cumulative
Volume
Septic Tank
Septic
Tank
Soil Absorption System
Comments
PM
(GPM)
(GALs)
(GALs)
Liquid Level
`
o Level
Monitor
Tube 1'
A, SAS
Level
Monitor
Tube 2`
A SAS
Level
12:00
5.3
-
-
4.0'
-
0.9'
-
Start Flow - Meter 23760
12:15
5.3
80
80
4.1'
0.1'
0.9'
0.0'
23840
12:30
5.3
80
160
4.1'
0.0'
0.9'
0.0'
23920
12:45
5.3
80
240
4.1'
0.0'
1.0'
0.1'
24000
1:00
5.3
80
320
4.1'
0.0'
1.0'
0.0'
24080
1:15
5.3
80
400
4.1'
0.0'
1.1'
0.1'
24160
1:30
5.3
80
480
4.1'
0.0'
1.1'
0.0'
24240
1:45
5.3
80
560
4.1'
0.0'
1.1'
0.0'
24320
80
640
4.1'
0.0'
1.2'
0.1
Stop Test - 24400
RFCOVFRY
Date
Time
ST MT
SAS MT
1118
2:45
PM
4.07-0.1'
0.91/-0.3'
`ALL MEASUREMENTS IN FT.
TEST: PASSED XXX FAILED
COMMENTS: This system was found to be operating satisfactorily. There was 0.9' of measurable liquid in the
SAS MT prior to beginning the test. With the addition of 640 gallons to the system (slightly more
than the design daily flow), the level slowly rase 0.3' to 1.2'. A recovery measurement, taken
shortly after stopping the test flow, showed a return to the starting level in only 45 minutes.
Reviewed by: Paul Pinard 1/-p
Date: 11/15/21
at -Su Test Lab,
L
Water Quality Testing
9131 E Frontage Rd, Ste 15
Palmer, AK 99645
(907) 745-3005
motsutestiob.office@amaii.com
Name:
Pinard Engineering
Lab ID#:
M211153
Mailing Address:
P.O. Box 871347
Date Sampled.•
11/03/2021
Colilert
Wasilla, AK 99687
Time Sampled:
1400
Legal Description:
Lot 2, Block 3, Elmore #1
Sampled By.
PJ Pinard
Date Received:
11/03/2021
Sample Site Location:
Kitchen Sink
Time Received:
1525
Health Guard I
Parameter
Method
Result
Unit
MRL
MCL
Date
Total Coliforms
Colilert
A---
---
_--
11/04/2021
SM 9223B
E. coli
Colilert
(SM 9223B)
A
---
"'
---
11!04/2021
Total Nitrate - N
TNTplus 835/836
2,53
mg/L
0.200
10.0
11/08/2021
Hach 10206
Arsenic
Arsenic by ASV
<MRL
µg/L
1.000
10
11/04/2021
Metrohm AB 416/3
Method Reporting Lindt (MRL): the lowest concentration that can be reported reliably
Maximum Contaminant Levet (MCL): highest acceptable level in public water systems as set by EPA
nq-L: milligrams per liter, 1/1000sofagram
trg/L: micrograms per liter, 1/1,000,000`" ora gram
Absent (A): none of this type of bacteria was detected
Present (P): one or more bacterial cells of this type were detected
Results Reported By:
Patience Lynch fl!
Laboratory Analyst
Reviewed By:
LX,ne Hill (Nov 8,2021 16:45AKST�
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PROFESSIONAL SEAL
Date:Frontier Surveys, LLC Project No:
650 W. 58th Ave. Suite E Anchorage, Alaska 99518
As-Built Survey of:
www.frontiersurveys.com
Frontier Surveys, LLC
I, Pierre Stragier, hereby certify that this Mortgage Inspection Survey was performed by me, or
under my direct supervision on
Plat:Grid:Ordered By:
907.460.1686 - info@frontiersurveys.com
This survey complies with the ASPLS Mortgage Location Standards. The survey represents visible improvements and
conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any
inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the
existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances
should this document be used for construction or for establishing a boundary or fence line.
November 8th, 2021.
Legend:
Scale 1" = 30'
Gas Meter
Electric Meter/Outside Power
Deck
Septic
Telephone Pole
Sign
Overhead Utility
Lot 2, Block 3 Elmore Subdivision Addn. No. 1
General Notes:
1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright Laws.
2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey.
3. All measurements/setbacks are to the visual/apparent building footprint.
4. All dimensions to property lines are plus/minus 0.1ft.
Margie Hudok
21-808 11/9/2021
P-635A 3036
Water Well
Tel. Pedestal
STA T E O F ALA
S
K
A49 TH
ROYEVRUSDNALLANOISSEFORP
DERE
T
S
IGER Pierre M. Stragier
NO. LS-9812
11/9/2021
G
E
S
T
W E Elec. Pedestal
%3W
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMs APPROVAL
Parcel LD. 018-171-28 Expiration Date:
1. GENERAL INFORMATION
Complete legal description ELrv10RE#1S/DBLOCK3,LOT2
Location (site address) 4300 SHOSHONI AVE, ANCHORAGE, AK99516
Current Property owner(s) JON&AMBERWEAVER — Day phone
Mailing address 4300 SHOSHONI AVE, ANCHORAGE, AK 99516
Real Estate Agent Day pho
'y P'0
2. TYPE OF DWELLING:
Z Single Family (w/wo ADU)
F-1 Duplex
Multiple Dwellings (Single Family and/or Duplex) 16AM A, 1,
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
z
Individual
Individual Water Storage
E]
Holding Tank
Community Class Well
El
Community
Public Water System
El
Public Sewer
El
Waiver/Variance request for:
Received by: !�Ma Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ q2-9jac)
Date of Payment y
, )jq 1114
Receipt Number M130
COSA# 35 Q (10 16-N
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 MIKE N ANDERSON, P.E. Phone 727-8864
Address 4661 NATRONA AVE.
Engineer's Printed Name MIKE N ANDERSON, PE Date 03/9/15
6. DSD SIGNATURE
System #1 Approved for bedrooms.
System #2 Approved for
Disapproved.
� I
9W�
. ,ditional approval for
bedrooms,
je�
4 9
MICHAEL N, AN[rRSC.%
CE 9 6
bedrooms, with the following
1,16 Lia=( 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 engineer's work.
ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet -10-10-1 2Aoc
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: ELMORE #1 S/D BLOCK 3. LOT 2 Parcel ID: 018-171-28
A. WELL DATA
Well type Private
Date completed UNKNOWN
Total depth _�109 ft.
Date of test
Static water level
Well production
If A, B, or C provide PWSID # _
Sanitary seal (Y/N) y
Cased to >40' ft.
FROM WELL LOG
UNKNOWN
UNKNOWN ft.
UNKNOWN g.p.rn
WATER SAMPLE RESULTS:
Well Log (YIN)
Wires properly protected (YIN) Y
Casing height (above ground) 18
AT INSPECTION
112612016
ft.
g.p.m.
Coliform NEG olonies/100 mL Nitrate ND mg1L
Arsenic: NO ug/L Date of sample: 112612016 Collected by: Mike Anderson
B. SEPTICIHOLDING TANK DATA
T.bnkType/Material SEPTICISTEEL
Tanksize 1250 gal. Number of Compartments 2
Date installed 315/2016
Cleanouts (YIN)
Foundation cleanout (Y/N) Depression over tank (YIN) High water alarm (Y(N) N
Date of pumping NEW Pumper NEW
C. ABSORPTION FIELD DATA – 1986 SYSTEM TESTED
Date installed 31512016 Soil rating (g.p.d ./ft2 or fe/bdrm) 1.2 System type 5 WIDE
Length _L0 ft. Width 5 ft.
Gravel below pipe 2.0 ft.
Total depth 7 ft, Eff. , absorption area 500+ ft? Monitoring tube Y Depression over field N
Date of ?dequacy-test NEW Results (Pass/Fail) NEW For 4 bedrooms
Fluid depth in absorption field before test NEW – in. Water added NEW gal. New depth NEW in.
Elapsed Time' NEW min. Final fluid depth NEW in. Absorption rate >= NEW g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) UNKNOWN — If yes, give date
D. LIFT STATION
Date installed Size in gallons _Manhole/Access (YIN)
"Pump on" level at_ in. "Pump off" level at — in.High water alarm level at — in.
Datum Cycles tested _ Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 11001+
Absorption field on lot 100'+
Public sewer main 75'+
Sewer /septic service line 50'+
Animal containment areas 100'+
SEPTIC/HOLDING TANK ON LOT TO:
On adjacent lots 1004
On adjacent lots 1004
Public sewer manhole/cleanout 1001+
Holding tank NA
Manure/animal excrete storage areas 1001+
Building foundation 51+ Property line 51+ Absorption field 54
Water main 100'+ Water service line - 1104 Surface water 100'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Propertyline 10'+ Building foundation 10'+ Watermain 1104
Water Service line 10'+ Surfacewater 100'+ Driveway. parking/vehicle storage 10'+
Curtain drain 504 (None Knowl Wells on adjacent lots 11001+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
/ certify that I havb 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.MIKE N. ANDERSON, PE
Date 031912016
COSA canary sheet-2-6-16.doc
OF At-'%%
4 9TH
MICHAEL N. ANDERSON -Rh, 00
CE
9769
0 4
v
��L
SHOSHONI AVENUE
N 89 46' 3e" E 2e8.71
" � �o �u r Z06.11
0.�L
TH 14
SHANEA.4&T. iN
�S-6914
THE INFORMATION HEREON 15 FOR THE USE OF LENDING INSTITUITONS SPECIFICALLY TO SHOW ANY
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES ANDIOR EASEMENTS; AND is
NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES.
EASEMENTS OF RECORD OTHER THAN THOSE APPEARING ON THE RECORD PLAT, ARE NOT SHOWN
HEREON ( UNLESS INDICATED)
NOTE: FENCEUNES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE
PROPERTY LINES OR POSITION A DDITIONAL IMPROVEMENTS.
ANY PAYING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW ANO/OR I�.
AS-BUILTSURVEY 1" =30'
NO CORNERS SET THIS DATE
(�'Ll HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY
LOT 2, BLOCK 3, ELMORE ADD'N. NO. I
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
VISIBLE IMPROVE14ENTS SITUATED THEREON ARE WITHIN
THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
EXIST OTHER THAN NOTED.
DATED AT ANCHORAGE, ALASKA THIS —8TH DAY OF
—MARCH —, 2016.
HOLT LAND SURVEYING
600 HlGHVUEVV DRIVE
ANCHORAGCAK 99515
345�5513
.. ........
SINGLI FAMILY
FfU 4E HOUSE
--------------
/
zz
------------------------------
---------------------------------------------------------------------------------------------------------------------
---------------------
-----------------------------------
lOr UT=TY EASEMENT
" � �o �u r Z06.11
0.�L
TH 14
SHANEA.4&T. iN
�S-6914
THE INFORMATION HEREON 15 FOR THE USE OF LENDING INSTITUITONS SPECIFICALLY TO SHOW ANY
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES ANDIOR EASEMENTS; AND is
NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES.
EASEMENTS OF RECORD OTHER THAN THOSE APPEARING ON THE RECORD PLAT, ARE NOT SHOWN
HEREON ( UNLESS INDICATED)
NOTE: FENCEUNES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE
PROPERTY LINES OR POSITION A DDITIONAL IMPROVEMENTS.
ANY PAYING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW ANO/OR I�.
AS-BUILTSURVEY 1" =30'
NO CORNERS SET THIS DATE
(�'Ll HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY
LOT 2, BLOCK 3, ELMORE ADD'N. NO. I
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
VISIBLE IMPROVE14ENTS SITUATED THEREON ARE WITHIN
THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
EXIST OTHER THAN NOTED.
DATED AT ANCHORAGE, ALASKA THIS —8TH DAY OF
—MARCH —, 2016.
HOLT LAND SURVEYING
600 HlGHVUEVV DRIVE
ANCHORAGCAK 99515
345�5513
Li S I
Municipality of Anchorage cle 8. &,
'lot
0 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. 019- 111- 23 COSA # 6i��C 116
- / '13
Expiration Date:
1. GEN ERAL, iNFORMATION.,
Comol6telega'i-desqriti LA2_
On
7
Location (site address) 4300 56shon;
Cu'rrent, Propert�.owner(s):_,-A I' ke— A4 ry Day phone Iq8 - 9 -500... -
Mail ing adclress�, PQ &A 2-3317 5 - An A pm4�z A k 775Z3
Lending agency
Mailing address
Day phone
Real Estate Agent Rona Florio Day phone
Mailing Address
Unless othetwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
individual Well
Individual Water Storage
Community Class Well
Public Water System
7; y L151
TYPE OF WASTEWATER DISPOSAL:
9
Individual On-site
El
Individual Holding Tank
EJ
C omm unity. On-site
F]
FJ
Public Sewer
El
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the -professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my. investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal. system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the 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 SwakkVJ Enoilltv-ri-04
Address 1013 W. 6" Ave. -ID2- �Anehange,AK
Engineer's Printed Name Lars So;.ilklimd
.6. DSD SIGNATURE
-L,-Z Approved for bedrooms.
Disapproved.
Phone 27-1-37IG
Date .4hol 'Zow
. ft��NN\vqx
_Z1 eOF.,14 X
44P It
r
,0
100
LA113*S E. PURKLAI�[)
20) low
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
V VI -1 1 1-1 X ntll Li
WASTEWATER
7- VKUUKX9
Arsenic Advisory
Maintenance Agreements
Supplemental Engineers Report
Other
By: Original Certificate Date: ,1- 0
(Rev. 11/05)
Municipality of Anchorage
Development Services Department
Building Safety Division
VA ET.V
On -Site Water & 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 CHECKLIST
Legal Description: More 863?_ 3 L.A I Parcel ID: 01%
A. WELL DATA
Well type Pr-.V.�G If A. B, or C provide PWSID Well Log (Y/N) IV
Date completed UslYnoWn Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth )109 ft. Cased to .7 qO ft. q0 t Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level
UA 60wr%
VA Y% 6% 0 W r,
Well production UV%6%0W^ — g.p.m.
WATER SAMPLE RESULTS:
Coliform A*--2colonies/100 mL Nitrate I - �08 mg/L
Arsenic: YQ ug/L date of sample: *bzolo
B. SEPTICIHOLDING TANK DATA
Tank Type/Material - G,., 1 5 lei -A
Tank size 1250 gal. Number ofCompartments Z
61612010
lio
5,7- 9 -p -m.
Other bacteria Ni -colonies/100 mL
1J_
Collected by: LARS Sour kICAV%A-
Date installed 7T
Cleanouts (YIN) Y
Foundation cleanout (Y/N) J Depression over tank (Y/N) )V High water alarm (Y/N) A/
Date of pumping Pumper 1:5q0'es pumpiAll Se r 0 1 ce,
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./fe orOSN 931 System type 5 Jel
Length 15 ft. Width ft. Gravel below pipe ft.
Total depth G -�, ft, Eff. absorption area 3_+5 ft2 Monitoring tube 'Y Depression over field A/
Date of adequacy test ild 101D Results (Pass/Fail) P05 For q bedrooms
I a
Fluid depth in absorption field before test 0 in. Water added GqO gal. New depth 5 in.
Elapsed Time: A21min. Final fluid depth -L in. Absorption rate >= 00 —g.p-d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) AID If yes, give date
D. LIFTSTATION
Date installed Size in gallons Z Manhole/Access (Y/N) 11
"Pump on" level at in, "Pump off" level at in. High water alarm level at in.
Datum led Meets alarm & circuit requ
Cycles tes . �irZents?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot +- 100 1
Absorption field on lot + ICD -
Public sewer main A4 A
Sewer /septic service line
Animal containment areas 50 +
On adjacent lots + 10D
On adjacent lots 4 1 CC)
Public sewer manhole/cleanout A
Holding tank IV. A -
Manure/animal excrete storage areas ICO'4
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
I I I
Building foundation 5 Property line 5 +. Absorption field 54
Water main
10'4
Wells on adjacent lots 100 1 +
Water service line 10 14- Surface water 1C0 8+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 101+
Water Service line 10 +
Curtain drain Nooe 01%e
F. COMMENTS
Building foundation (C; +
Surface water
Wells on adjacent lots MID t4
Water main
I C) 'I -
Driveway, parking/vehicle storage 5
A, %, -
OF A
G. ENGINEER'S CERTIFICATION
i certify that / have determined through field inspections and Co.
;� : 9TH*
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name L-A 13PUAM W� RKLAND.-,*i�C �e
J
-*- or
.01
.Z010 A -W .
Date 41?
COSA Fee $ Waiver Fee $
Date of Payment. Date of Payment
Receipt Number 6 qf Receipt Number
(Rev. 11/05)
I
SGS ReE#
1103777001
Client Name
Spurkla d Engineering
g
Project Nameffl
Elmore 3,L2
Client Sample ID
ElmoU3,L2
Matrix
Drinking Water
Sample Remarks:
Parameter Results
Printed Date/Time
08/09/2010 16:37
Collected Date/Time
07/30/2010 14:45
Received Date/Time
07/30/2010 16:00
Technical Director
Stephen C. Ede
Allowable Prep Analysis
LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic ND 5.00
Waters Department
Total Nitrate/Nitrite-N 1.68 0.100
Microbiology Laboratory
E. Coli Negative I
Total Coliform Negative I
ug/L
EP200.8
C
(<10)
08/02/10 08/05/10
KDC
mg/L
SM20 450ONO3-F
B
(<10)
08/02/10
AYC
I OOmL SM20 9223B A
lOOmL SM20 9223B A
07/30/10 DLC
07/30/10 DLC
to -
Yr
5 cy'9 " 30 " N 2a.6. 7/
4 M.;
I
mods#
1*7PA VC- e-
Dt I ve
SCA L. C
Meg RP/T 40'
7
30" W 206.7 f
ZUSE OF
THE INFORMATION HEREON IS FOR
7 LENDING INSTITUTIONS SPECIFICAl I Y TA QLie-,�A,
EASEMENTS OF RECORD, OTHER THAN ANY CONFLICTS BETWEEN EXISTING STRUCTURES
THOSE SHOWN ON THE RECORDED AND PLATTED LOT LINES OR EASEMENTS AND iS
PLAT, ARE NOT SHOWN HEREON. NOT TO SE USED FOR POSITIONING ADDITIONAL
STRUCTURES OR FENCELINES.
"ASSUILT"
No corners set
I hereby CeroifY that I have surveyed the following described Prooerty, Lot 2 slock
IFLHOAL SUN). -- Anchorage recording district Alaska, and that the
mPfOvemonts - Situated thereon are within the property lines and do not overlap or encroach on
he Property lyin ' C adjacent thereto, that no Improvements On property lying adjacent thereto
)ncroach on the Pr*mi"$ in question and that "t* are no roadways, transmission lines or other
hsible easements on sald Pf0P01`tY 9)(C001 as Inchcatod hemon.
NWWOP. Alaaa 7 Jq,0`,1f' 200,6
Book P9 rlir
OF A
dw"N 0
491w—*
-i . . . . . . . . . . . . . . . . .
N� 130a -S
;ve
L.
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.orglonsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEms APPROVAL
FOR A SINGLE FAmiLy DWELLING
Parcel I.D. (M _tq1_9% COSA # ()(pt),�;Lq
Expiration Date:
1. GENERAL INFORMATION 4,
Complete legal description LJ 2 Block 3 F I en re- 9b_
Location (site address) 43co sho.4onj* AvenLie,
Current Property owner(s) Rom
G"jrc3ki.A
— - Dayphone
Mailing address po
r-&):, Ito"
A /A tlCkt5ll
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, COSA
will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
19
Individual On-site
9
Individual Water Storage
0
Individual Holding Tank
11
Community Class Well 1:1
Community On-site
13
Public Water System
13
Public Sewer
11
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. Certficates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineers 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
Address
Engineer's Printed Name Io66tn =Spurh.1txnA
5. DSDSIGNATURE
V� Approved for Ll bedrooms.
Disapproved.
Conditional approval for
Phone 7-19-311(p __
Date JWVW 610 7 -cm.,
bedrooms, with the following stipulationq.:.
�UdW 1111CI IL�.
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory '
Maintenance Agreements
Supplemental Engineer's Report
Other
By: 4 — /.�?
__A , /,2/, -' &/, Original Certificate Date:
41�lr 1�017_ 4��r
JR" 11105)
Municipafity of Anchorage
Development Services Department
Building Safety Division
OrAfte Water & Wastewater Program
4700 Bragaw Street
P.O. BOX 198M
Anchorage, AK 99519 -MM
www.muni.org/onsft
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
A. WELL DATA
wen type lrivdNe- If A, B, or C provide PWSID, #
Date completed _Y& San" seat (YIN) -y-
Total depth _��ft cased to 4 40 ft.
FROM WELL LOG
Date of test Qk
Static water level WK it
Well production QK 9 -p -m -
WATER SAMPLE RESULTS:
Coldorm --0—polonies/100 ml- Nitrate 1, 6L mgtL
Arsenic: AID mgn Date of sample. *40
B. SEPTIGfHOLDING TANK DATA
Well Log (YIN) /%/
V'Ares property protected (YIN)
Casing height (above ground) + IS n.
AT INSPECTION
W150(o
loci It.
915 - g -p -m -
Other bacteria --SL colonies/1 00 mL
Collected by: L.4r5 S
Tank Type/Matenall bropci 51", 1 Datainstalled 1qjje-0 I -1-n
Tanksize (260 gal. Number of Compartments Cleanouts (Y/N) Y
FoundaUon cleano tit (YIN) Depression over tank (YIN) -6L High water alarm (Y/N)
Date -of pumping Pumper 15ftCzS
C. ABSORPTION FiE'LD DATA
Date Installed Son rating (g.p.d./fe orqi��;)-M
Length -15 It V*M 5 - ft.
system type 5- w1pre
Gravel below pipe 0 .5 ft.
Total depth -fai-7--ft Eff. absorption area 3-15 fe Monitoring tube _L_ Depression over field
Date of adequacy test AhSE— Results (Passffiall) For _1__ bedroom
Fluid depth in absorptli ast 0 n. Water addeo-!LC-0- gal. Newdepth_5_1n.
Elapsed Time: '210 min. Finalfluiddepth i n. Absorption rats >= (PW g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N & type) A(*4e- I<Aowe% If yes, give date
0. LIFT STATION
mn
.Pump on'Wiyrat_in.
E. SEPARATION DISTANCES
Size in gallons '11�
opump or in.
Cycles!�Z—
SEPARATION DISTANCES FROM WELL ON LOT TOr.
Septic tonMift station on lot IN000
Absorption field an lot _ + /00
Public sewer main dA
Sewer heptic service kne_ +'15'
Animal containment areas + 50,
YIN
Manhole(Acoess ( : )
High water alarm km in.
"Wm ?
Meets slarm MM1611101
On adjacent lols + /00 f
On aMacent lots +/00'
Public sewer manhole/cleanout
Holding tank
Manurstanimal excrete storage areas 4 100
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
Building foundation +5 Property line +/0 Absorption field + 5
Water main N /A Water service line -t 2 5 surface water 0
Wells an adjacent lots + fOO '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TOr.
Property line 410' Building foundation + 10' Water main 646A
Water Service line Surface water A4 0, Driveway. pgridngivenicig gtorlge 4.5
Curtain drain IV. 0 Wells on ad*M lots +100 1
F. COMMENTS'
G. ENGINEER'S CERTIFICATION
I cerMy that I have determined thnxigh field irMections and
review of Municipal records that ft above Systems are in
conformance with MOA COSA guidelines in effect an Uus date.
Engineer's Printed Name To6e--% Spur6hy%l
Date (jojroc> (o
, f
COSA Fee S
4/go. Ifo Walver Fee $
Date of Payment
(40191,04 - Date of Payment
Receipt Number
iia -is Receipt Number,
(Rev. 11M
CE 2ZM J�
Ilk
:5p -i -I r,.k L A Ai I
R.
Via,
e:�� C7 Y
4c, 30 IV 20,6.71
in
Z
r:
0
Oust or
40 "oust IL
4
ve
'SCA L. C
AD 40'
O:V" I
4'/
%
70 �p 1.
LZ -
THE INFORMATION HERELN IS FORZUSE OF
LENDING INSTITUTIONS SPEC:FICALLY TO SHOW
A CONFLICTS BETWEEN EXISTING STRUCTURES
EASEMENTS OF RECORD. OTHER THAN AND PLATTED LOT L114ES OR EASEMENTS AND IS
THOSE SHOWN ON THE RECORDED 'NOT TO BE USED FOR POSITIONING ADDITIONAL
PLAT. ARE NOT SHOWN HEREON. STRUCTURES OF; FENCELINES.
"ASSUILT"
No corners set
I bar by Conti that I have surveyed the following described Property. Lot —.L— Block 3
E-1 PORE 5UBD. Anchorage recording district Alaska. and that the
Improvements situated thereon &f& Wthin the property lines and do not overlap or encroach on
the property lying adjacent thereto, tt-at no Improvements on property lying adjacent thereto
encroach On the promises in question and that thiffe are no roadways. transmission lines or o
visible 4111116111141ontil On Sold property except as Indicated hereon.
r &Ahorop, A;"ka 7 Jd1Jf* 2ai:1,6
Book Pg rar
(4 9 1
not H.1dionen
40A *V)
SGS Rtf.N
1062512001
Client Name
Tobben Spurkland P.E.
Project Nameffl
Ut 2 Block 3 Elmore
Client Sample ID
Lot 2 Block 3 Elmore
Matrix
Drinking Water
Sample Remarks:
All Dates/Timei are Alaska Standard Time
Printed DalcMme
06/01/2006 14:59
Collected DateMme
05/18/2006 15:50
Received DateMme
05/19/2006 8:50
Technical Director
Stephen C- Ede
Allowable Prep Analysis
Parameter Results PQL Units Method CDntaimr ID Limits Date Date Init
Metals by
XCP/HS
Arsenic
Waters Department
Nitratc-N
Microbioloov
Laboratory
Total Colirorm
ND
1.66
M
5.00 ug/L EP200.8
0.100 mgIL EPA 353.2
C (<-10) 05/19/06 05/23/06 Mil
B (�10)
col/100ml, SM209222D A (<=I)
05119/06 ALR
05/19/06 TLF
0
40 P
to,
to'
5. LEGAL DESCRIPTION
OF ANL�Ti�
MUNICIPALITY OF A��N DEPT. OF HEALTI-I &
DEPARTMENT OF HEALTH AAMVMON. �NT� �ROTE ENTINI. r'OTECTION
M�E
'95��
95
825 L Street - Anchorage. Ala 95
NUMBER OF BEDROOMS
11�w� juw 9 1981
C3 One 0 Four 0 Other
ENVIRONMENTAL ENGINEERING,Q�VIS40N j/!
Telephone 264-4720
k -
0 Two 0 Five
RECEIVED
REQUEST FOR
APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requestswill not be processed. Please allow ten (10) days for proca'�P.,-',
1. PROPERTYOWNER
ATTACH WELL LOG. A well log is required for all wells drilled
P"'es-ti- S -o 1j.
since June 1975. For wells drilled prior to that date, give well
0 PUBLIC UTILITY
depth (attach log if available.)
MAILING ADDRESS
S-.02.4
&�—t 30 A" cj, '�7T-570 7
PROPERTY RESIDENT III different from
PHONE
E�—INDIVIDUAL/ON-SITE**
give
2. BUYER
r
PHTNE
MAILINGADURESS
3. LENDING INSTITUTION
PHONE
MAILING ADDRESS P. o -
c7r/, <4 2- 0 5z o
4. REALTORIAGENT
FHUNL
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
M--�S'INGLE FAMILY
C3 One 0 Four 0 Other
0 Two 0 Five
0 MULTIPLE FAMILY
LX—TEree 0 Six
7. WATER SUPPLY
G2-�TNDIVIDLIAL*
ATTACH WELL LOG. A well log is required for all wells drilled
[--] COMMUNITY
since June 1975. For wells drilled prior to that date, give well
0 PUBLIC UTILITY
depth (attach log if available.)
S. SEWAGE DISPOSAL SYSTEM
*11 individual/on-site, installation c1ate—jS-2-2---?9"
E�—INDIVIDUAL/ON-SITE**
give
If system is over two (2) years old an adequacy test is required
0 PUBLIC UTILITY
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REOUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/73)
'(Zt
r
E
0
THIS SIDE FOR OFFICIAL USE ONL"'I
INSPECTION APPOINTMENTS
DATE RECEIVED
TIME
TIME
.11 M �E
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE
13 SINGLE FAMILY
13 MULTIPLE FAMILY
NUMBER OF BEDROOMS
0 ONE THREE 0 FIVE 13 OTHER
El TWO --0 FOUR D six
2. WATER SUPPLY
0 INDIVIDUAL
0 COMMUNITY
0 PUBLIC UTILITY
Connection Verified_
PERMITNUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
0INDIVIDUAL/ON -SITE
OPUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATEINSTALLED
.
INSTALLER
SOILS RATING
OSept r OHolding Tank
Size:, i'c�)T�v If Tank. is homemade
give dimensions: � I
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
I
4. DISTANCES
WELLTO:
beptic/Holding Tank
Absorption A,ea
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
6. COMMENTS
[P/APPROVED FOR BEDROOMS
0 CONDITIONAL APPROVAL (letter must accompany certificate)
C3 DISAPPROVED
DATE
(-e , N 1
BY (Title)
LEGAL DESCRIPTION
L�
t2 -G; 0 i;;." 517
rAw
k
n-ef -dz�
/-ec� po-,e
It
5z�,tz _,lr�
Z�� X4-"�7
o0z's— 7
W04
3� ",-f ryll
;La /
N
72-014 (3t781
m
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720.
CERTIFICATE OF INSPECTION
SEWER AND WATER FACILITIES
1. PROPERTY OWNER
-6u 13-7 �7
MAILING ADDRESS I
-<-A '�? e!�20 x �' '7 'y
2. LEGAL DESCRIPTION
4,, 7�
C,
3. TYPE DWELLING
&
SINGLE FAMILY RESIDENCE 0 OTHER (Describe)
0
MULTIPLE FAMILY RESIDENCE
4. WATER SUPPLY
�r INDIVIDUAL
*0
COMMUNITY/PUBLIC
5. SEWAGE DISPOSAL
KINDIVIDUALJON-SITE
0
PUBLIC UTILITY
0
HOLDING TANK (Maintenance Required)
APPROVED FOR BEDROOMS
0
CONDITIONAL APPROVAL (See Attached)
0
DISAPPROVED
DATE
2
BY (TITLE)
72-014 (3t781
m
