HomeMy WebLinkAboutROCKHILL BLK 2 LT 2P. o c k hi'* I I
Block 2
Lot 2
#015�362�07
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON-SITE
WASTEWATER INSPECTION REPORT
Permit Number: OSP211116
PID Number: 015-362-07
Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New X Upgrade
Name
JENNiER HAYWOOD
ABSORPTION FIELD
Site Address
9321 MAIN TREE DR
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
❑other
Phone Number of Bedrooms
Soil Rating Total depth from original grade
4
GPD/SF Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot
ROCKHILL BLK 2, LOT 2
Ft' Ft.
Fill added above original grade
Gravel length
Township Range
Section
Ft.
Ft.
Gravel width Beds: Number of Lines Distance between lines
SEPARATION DISTANCES
To Septic Absorption
Lift Station
Holding Sewer
Ft. Ft.
Total absorption area Number of trenches Dist. between trenches
From Tank Field
Tank Line
Ft2
Well 100'+1
501+
Ft.
TANK ® septic S. T. E. P. ❑ Holding ❑ other
Manufacturer
G REER TANK
Capacity
1250 Gal.
Surface Water
'
100 +
I
Material
Number of compartments
Lot Line
(10'+
I
NA
PLASTIC
2
Foundation 110'+
LIFT STATION
Manufacturer
Capacity
Remarks TANK DEMO PER UPC,
Gal.
Alarm location Electrical installed by
Installer
PIPE MATERIAL House to tank 3034 Tank to 3034
drainfield
MIKE N ANDERSON, P.E.
Drainfield CO/MT3034
Inspector MIKE N ANDERSON, P.E.
BENCH MARK (Assumed 100
elevation) ft
Inspection 1a 5/12/21
dates: 2�c—
Location and description
3ld 4th
TOP OF MANHOLE
ON-SITE WATER AND WASTEWATER SECTION APPROVAL+t�t�9
Stamp
eta- G C:. c.•1
Conditional Approval:
Date
• • .... • . . .
�� • MICHAEL N. AI�GEkSGV•;'`'::"'
��`< ;;•. CE - 94 9
f7 2�.•�,.,
Septic System
Approve —
Date 5-1
Note: this approval does not include well permit requirements.
(Rev 05/02/18)
Permit No. OSP211116
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: ROCKHILL BLK 2 LT 2 PID No.: 015-362-07
SEPTIC SECTION
N.T.S.
OF
1141,
® �,.�
AF
•:
® 49 TN •: �0
`. y...y�...�/.... .s..y.. �...�....9.....0
;MICHAEL N. ANDERSON;' Cum
10. CE 9469 Ar
0 5-17-21 AW
MARK A
B
\
C01 33
% 55
CO2 34
' 56
TC01 37 /
60
TCO2 43',
63
CO3 46
65
C04 ,47
1 66
V
i
DWELL
1
I
N W 1250 GALLON ,PLASTIC NK
SO MOUNDED OVER TANK TO
C04d
PR ENT PARKING OVER THE TANK
CO3
02
TC01
i
e CO C01
BENCH, RAGE SLAB
DRIVEWAY
B
J
WELL
X I� x
-----'
ASBUILT
®
SCALE: 1 "=50' I
SEPTIC SECTION
N.T.S.
OF
1141,
® �,.�
AF
•:
® 49 TN •: �0
`. y...y�...�/.... .s..y.. �...�....9.....0
;MICHAEL N. ANDERSON;' Cum
10. CE 9469 Ar
0 5-17-21 AW
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP211116
Work Type: SepticTank Upgrade
Tax Code Number: 01536207000
Site Legal Address: ROCKHILL BLK 2 LT 2 G:2438
Site Mailing Address: 9231 MAIN TREE DR, Anchorage
Owner: HAYWOOD MARK A & JENNIFER PHAN
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date
Lot Size in Sq Ft
Total Bedrooms:
5/6/2021
5/6/2022
50052
❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: Date:
Issued By: Date: Jr i, a 0 2 1
El
MUNICIPALITY
L),5
Development Services Department ' { 7 Phone. 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 015-362-07
Property owner(s) JENNIFER HAYWOOD
Mailing address 9231 MAIN TREE DR, ANCH AK
Site address SAME
Legal description (Sub'd., Block & Lot) ROCKH ILL BLK 2 LT 2
Day phone
Legal description (Township, Range & Section)
Lot Size 50,052 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) El
(w/wo ADU)
Septic Tank
0
Upgrade 0
Duplex (D) ElHolding
Tank
❑
Renewal ❑
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES
A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 225 f 135
Date of Payment: Y- 7xq z
Receipt Number: Ll -2K -Z(
Permit No. C6p Z l 1116
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
April 26, 2021
Municipalities of Anchorage
On-Site Water and Waste Water Section
4700 Elmore Rd
Anchorage, Alaska
Phone 343-7904
Re: New septic tank permit
Legal: ROCKHILL BLK 2 LT 2
To Whom it may concern:
This is a request for a septic tank permit on the above referenced lot. This tank
replacement will not impact any of the neighbors or encroach on any wells, septic or
open water issues. The tank will be decommissioned per the Uniform Plumbing
Code (UPC).
Sincerely
Michael N. Anderson, P.E.
4661 Natrona
Anch, Ak 99516
Ph 727-8864
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211116, Rebecca Carroll, 05/06/21
1"=50'
SHED
PROPERTY LINE
EXISTING
HOUSE
REMOVE AND REPLACE 1,250
GALLON PLASTIC SEPTIC
TANK AND 20" RISER, DECOM.
PER UPC, 5' BETWEEN TANK
AND FIELD, NEW TANK NOT IN
PARKING AREA
EXISTING
DRAINAGE FIELD
-ABBOTT ROAD-
WELL
EXISTING WELL
100' RADIUSDRIVEWAY
ROCKHILL
BLOCK 2, LOT 1
SCALE:
DJRDRAWN:
DATE:
ROCKHILL, BLOCK 2, LOT 2
Anchorage, Alaska
JENNIFER HAYWOOD
4/24/2021
SHED
ROCKHILL
BLOCK 2, LOT 2
ROCKHILL
BLOCK 2, LOT 4
ROCKHILL
BLOCK 2, LOT 3
WELL
WELL
DCO
DCO
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211116, Rebecca Carroll, 05/06/21
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
0*
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITESEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME —�RKNEW
ED UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
L- ;)- 6 1.—) 04 ac
LOCATION
NO. OF BE30OMS
Absorption a Dwelling I
U r)
PERMIT NO.
9 / o (1-2 0
Manufacturer Material
No. of co rus
Liq. cape in gallons IF HOMEMADE: I nside length Width
Liquid depth
6
DISTANCE TO. well Dwelling
PERMIT NO.
1
024
7:
0
DISI FANCE T07
Well
r Aj
Foundation
a. t17-
FTa.trn.:h
PERMIT NO.
C/
to
�U-z
No.offines Length of each lin_,
o
Top of tile to finish
Total length of lines mtdih'a
inches
Material beneath
Distance betw 1 res
Total bsorption
grade
tile
effectiv area
Length
Width
Depth
PERMIT NO.
to
(D
<
Type
I otor
t o
to
DI
Well
Building foundation
Neanest-mTtIrre—
Class
Depth
Driller
Distance to lot line
PERMIT NO.
W
STANCE TO:
Building foundation
Sower line
Septic took
Absorption area((((
OTHER
PIPE MATERIALS
J
SOIL TEST RATING
INSTALLER
REMARKS
V,
le,
Y-1
APPROVED DATE
LEGAL
72-013 (RqY3/78) P
Well Log
Date completed ~ ~./~/
Depth of well .......... ~.~ ................. .................................... ' ....................................
Size of casin~: ~ ~/
Distance to water ..................................................................................................
Dist~ce to water while pumping ............ ~,~.,( ............................... a~ rate
..... Fo~...o {
n from to
I _ : , I l
I l
I l
I l
I l
I I
DILTA DRILLINg COMPANY
· RA I~OX ~ ~
ANCHORAGR AkA~KA ~07
�-X� b-� I D
o),O- W,�� ,
F if I
9_1�����1=4����5,A C-0 9-- ��������E-E. o;�)
DEPARTMENT O' iEHLTH AND ENVIRONMENTAL [ 7ECTION �&� —� /
»/u
825 'L STREET, ANCHORAGE, � HK 995y/
264-4720
114 EE L.- L__ F1 01 E> CA 04 --- �I -F r=-"E.E. 9 1�� ����
PERMIT NO. ( 810480 ) 0
APPLICANT GERALD H. PARK SRR 1621-11 I45-7448
LOCATION MAIN TREE
LEGHL LOT 2 BLK 2 ROCK HILL SUB LOT SIZE 13560 SQUARE
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = ] SOIL RATING (SQ FT/BR)= 125
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
1 -Ch R&l%lk_!'1_1-9=::*-
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRlNFIELD.
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET),
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
KREECaLj37F?EEE> A>EEF"l-lC? I`FIPA8< 15127E0-- .1. ED ED ED Cl FA L. L. CA r4�
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
F-gFZEE
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM R PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND
TO H COMMUNITY SEWER LINE IS 75 FEET,
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
EE:-fVo'J:FRlEEn3 "D A_
I CERTIFY THAT
1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF RNCHORHGE�
2: I WILL INSTALL THE SYSTEM IN 8CCDRD8NCE WITH THE CODES.
]: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS�
IT
SIGNED� .Q�~-_______.~.-_-^__-APPL ERALD H. PARK
|
4I5SUED BYx-�.,2_-` -------------���
V4. 0
lij/ SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTIVIENTOF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: —DATE PERFORMED: Ja4e- I-,
LEGAL DESCRIPTION:— ZZ /3z— IZ061<111zl.
DEPTH SLOPE /�jVT)E 'Mrr&�
6�
A--
(FEFT)
2 -
3 -
4- T/ - DO
Z-
6-
7 -- __z fa� PIT
8 - Ke, Ve dy
9- C e_ a V),
10-
14-
15
16-
Z� OF A�
at
17 -
'A.
Qlf. �r a
JA
'0*
NOr. 1732-E
,p. June 22, 1968
Reading
Date
Gross
Time
WASGROUNDWATER 411�? S
11
Net
Drop
ENCOUNTERED? L
0
12 -
E
IF YES, AT WHAT
DEPTH?
13-1
14-
15
16-
Z� OF A�
at
17 -
'A.
Qlf. �r a
JA
'0*
NOr. 1732-E
,p. June 22, 1968
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
20 -
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN --- FT AND — FT
I
74 ", Ub DATE:
PERFORMED BY: CERTIFIED BY:
72-009 (6/79)
v
MUNICIPALITY OF ANCHORAGE
Development Services Department 4 j Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 015-362-07
1. GENERAL INFORMATION
Expiration Date:
Complete legal description ROCKHILL BLK 2 LT 2
Location (site address) 9231 MAIN TREE DR, ANCH AK
Current property owner(s) JENNIFER HAYWOOD Day phone
Mailing address SAME
Real estate agent Day phone
2. TYPE OF DWELLING:
0 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 FX_1
Water Storage ❑ Holding Tank ❑
Community Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
Waiver request for: Distance.-
Received
istance:Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5-6-0
Date of Payment s-':- i- Zl
Receipt Number d l.97 S:�2
COSA #_ I /ZLi0
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864
Address 4661 NATRONA AVE ANCH AK
Engineer's Printed Name MIKE N ANDERSON, P.E. Date 5-15-21
6. DSD SIGNATURE
System #1 Approved for 4
System #2 Approved for
Disapproved
Conditional approval for
010
� pgor S-':+�`ti`''� 4
bedrooms, with the following stipulatlo�15_1:_..
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o
A7'ER AND )
J
PRO-- TER z
J-i.%iC:
tom\
°: • 49TH
bedrooms
r .......
... .... ° .... ° ,
f•• MICHACL N. ANDERSC-N
bedrooms
CE - 9469 .'•
010
� pgor S-':+�`ti`''� 4
bedrooms, with the following stipulatlo�15_1:_..
tttrrr
�) ' f S'ERVIC�` ,,'
yVVX Original Certificate Date: —E
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
o
A7'ER AND )
J
PRO-- TER z
J-i.%iC:
tom\
�) ' f S'ERVIC�` ,,'
yVVX Original Certificate Date: —E
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: ROCKHILL BLK 2 LT 2
If more than 1 septic system on lot: COSA Checklist #
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled ""/81
Total depth 86 ft
Cased to 86 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 12 in.
Date of flow test for COSA 4115/21
Static water level at beginning of test 50 ft.
Comments
B. TANK DATA
Age of tank(S) NEW years
Tank type/material ' P° PnW
Measured operating fluid level in septic tank NEW
❑ Standpipes/foundation cleanout per record drawing
Date of pumping NEW
D. ABSORPTION FIELD DATA
Which system tested (date installed) 8/19/81
❑ ALL standpipes present per record drawing
Total measured depth from grade 10 ft (max)
Measured depth to pipe invert from grade 5 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced 0 gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
of
Parcel ID: 015-362-07
Structure served by this system
Well production at time of test 5+ qpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate 8.44 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by MNA
Date of Sample 4115/21
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 4/15121
Results F, -/]Pass For 4 bedrooms
Fluid depth prior to test 36 in
Water added 600+ gal
New depth 54 in
Elapsed time 1440 min
Final fluid depth 35 in
Absorption rate 600+ gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
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'
F,/�
Yes
Community Sewer Manhole/Cleanout > 100'
r7✓ Yes
if No
ft
❑✓ Yes
if No
Neighboring Tank > 100' P11 Yes
if No
ft
Private Sewer/Septic Line > 25' [Z] Yes
if No
Absorption Field on Lot > 100' E✓ Yes
if No
ft
Holding Tank > 100' Yes
if No
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' Yes
if No
F/� Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' 7 Yes
if No
ft
2 Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' 0 Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
[✓ Yes if No ft
Property Line > 5'
F,/�
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
Q
Yes
if No
ft
Private Wells > 100' Yes if No.
Water Main > 10'✓❑
0
Yes
if No
ft
Community Wells > 200' Q Yes if No.
Water Service Line > 10'
✓Q
Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' Q Yes if No ft If absorption field is under driveway comment below
Property Line > 10'
0
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
171
Yes
if No
ft
Private Wells > 100'
Water Service Line > 10'
0
Yes
if No
ft
Community Wells > 200'
Surface Water > 100'
✓Q
Yes
if No
ft
F. ENGINEER'S 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.
COSA Checklist yellow sheet
ft
ft
Q Yes if No ft
M Yes if No ft
pl
MICHAEL N. ANDERSCN, I"
CE
('76.2 I,;,.�
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC211240
Subdivision: Rockhill Block 2 Lot 2
A water sample revealed a nitrate concentration of 8.44 milligrams per liter (mg/Q.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Please see the attached "Nitrate Fact Sheet" for important
information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
� r �z i �-�z� sza .:��` ,� •���',�s r;��. .s �,��.����`l� a..'�'':� �`� Jay,. ''r � •,,:�
� � � �� Ma�l�ng Address P� O Box 1r96650�* Arichorage, Alaska 99519 6650 * uvwuv muni org ��
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin.and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening, or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
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Municipality of Anchorage :�Q,GE 8
•
(4:-T.'4.
On-Site Water and Wastewater Program = 1
� (907) 343-7904 2"Lai
S A r r.T Y
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 015-362-07 Expiration Date: 3 22 -) 2
1. GENERAL INFORMATION
Complete legal description ROCK HILLS S/D BLOCK 2, LOT 2
Location (site address) 9231 MAIN TREE ANCHORAGE, AK 99516
Current Property owner(s) KIRK TOWNER Day phone
Mailing address 9231 MAIN TREE ANCHORAGE, AK 99516
Real Estate Agent Day phone
3 G�-
2. TYPE OF DWELLING:
® Single Family (w/wo ADU) • ^, . `, \
❑ Duplex `.
❑ Multiple Dwellings (Single Family and/or Duplex) !,0 `�� lea
/
3. NUMBER OF BEDROOMS: ` �9 S 7 £ /'
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual El
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
Waiver/Variance request for: Distance:
Received by: a Date: t 2 z / 2.
COSA to be released to the engineer,unless /
g otherwise requested by the engineer.
COSA Fee $ 5a(e, Waiver Fee $
Date of Payment 19-4g9-0-/ Date of Payment
Receipt Number 1U'K3q Receipt Number
COSA# (5C17 1575 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 12/4/17
P
•
r, MICHAEL N. AIDE;:5:
6. DSD SIGNATURE ,'��° CE 94 9
7( System #1 Approved for ' bedrooms. •
Wc-1)�?°•••af` ,` ;'
41 pif1,t>,
System #2 Approved for bedrooms. ���;=;a•r
Disapproved.
Conditional approval for v cZ� bedrooms, with the following stipulations:
q-A4 PevkAit wak
d &- f� rP /f
t'—tAAN , •
tS S
ON-SITE
WATER AND `T'
F., WASTEWATER -
co PROGRAM
A
L (1 Original Certificate Date: " 12 - 17
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10-10-12.doc
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system _
Certificate of On-Site Systems Approval Checklist
Legal Description: ROCK HILLS SID BLOCK 2, LOT 2 Parcel ID: 015-362-07
A. WELL DATA
Well type Private If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed 6/30/1981 Sanitary seal (Y/N)Y Wires properly protected (Y/N) Y
Total depth 86 ft. Cased to 86 ft. Casing height(above ground) 12 *
FROM WELL LOG AT INSPECTION
Date of test 6/30/1981 12/6/2017
Static water level 32 ft. 48 ft.
Well production 100 g.p.m. 5+ g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate 8.54 mg/L
Arsenic: ND ug/L Date of sample: 12115/201f Collected by: MNA
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC I STEEL Date installed 6/19/81
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 11/ 5/,/ 7- Pumper ,`%i Ad, t(c,ek,
C. ABSORPTION FIELD DATA—1985 SYSTEM TESTED
Date installed 6/19/81 Soil rating (g.p.d./ft2 ) 1.2 System type DEEP TRENCH
Length 50 ft. Width 2 ft. Gravel below pipe 5.0 ft.
Total depth 10 ft. Eff. absorption area 500+ ft2 Monitoring tube Y Depression over field N
Date of adequacy test 12/15/2017 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 12 in. Water added 600+ gal. New depth 20 in.
Elapsed Time: 24 hrs min. Final fluid depth 11 in. Absorption rate >= 600+ 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 (Y/N)
"Pump on" level at in. "Pump off level at in.High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 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 50'+ Holding tank 100'+
Animal containment areas 1001+ Manure/animal excrete storage areas 100'+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 100'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 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
SEPTIC TANK IS 36 YEARS OLD TYPICAL LIFE IS 25 YEARS, BUT IT APPEARS TO BE WORKING WELL AT THIS TIME.
G. ENGINEER'S CERTIFICATION
7c G
I certify that I have determined through field inspections and P kc :•'• ': t?
review of Municipal records that the above systems are in "P ••• ✓
conformance with MOA COSA guidelines in effect on this date. 0 *. 49T *.Irt
0
Engineer's Printed Name MIKE N. ANDERSON, PE �•s,: MICHAEL N. AN •,_
�+. DERSCN
��f•. C 9/69
Date 12!15!2017 t�fF,�•.1 2jL .•��
11N```E`Ss 1��
COSA canary sheet_2-6-15.doc
Municipality of Anchorage •
Development Services Department-
Building Safety Division t if;a_14 4 °
SAFETY
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage,AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Nitrate Advisory
Certificate of On-Site Systems Approval # OSC 171575
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 2, Lot 2 of
Rock Hills subdivision. This inspection revealed a nitrate concentration of
8.54 milligrams per liter (mg/L) was reported for the property's well water
sample. The Environmental Protection Agency (EPA) has established a
maximum contaminant level (MCL) of 10.0 mg/L for public drinking water
systems. While private wells are not subject to this regulation, EPA
standards are based on existing health information and can therefore be used
to gauge the relative quality of water from private wells. Please see the
attached "Nitrate Fact Sheet" for important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
\'Z
0
... AtCYD q���
49 T Y
s SHANE A. HOLT m c
LS -6914
OfessioW vs
LEGEND
o YARD LIGHT
O SEWER PIPE
THEINFORMATIONHEREONISFOR THE USEOFLENDINGINSTITUTIONSSPECIFICALLYTO SHOWANY
CONFLICTSBEYWEENEXISTINGSTRUCTURESAND PLATTED I OTLWESAND/OR EASEMENTS,
'AND IS
NOTTO BE USED FORPOSITIONINGADDITIONAL STRUCTURES, IMPROVEMENTS, ORFENCELINES.
EASEMEN750FRECORD, OTHER THAN THOSEAPPEARING ON THERECORDPLAT, ARENOTSHOWN
HEREON (UNLESS INDICA TED)
NOTEFENCELINES THATMAYAPPE41? ON THISDR4 WINGARENOTTO BE USED TO DETERMNE
PROPERTYLINES OR POSITIONADD?IONAL IMPROVEMENTS.
ANYPA VINGSHOWNHEREONMA YBEAPPROXIMATEDUE TO EXCESSI✓ESNOWAND/OR ICE
AS-3UILTSURVEY I" =40'
NO CORNERS SET THIS DATE
I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY
LOT2, BLOCK -2, ROCKHILL SUB
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
EXIST OTHER THAN NOTED.
DATED AT ANCHORAGE,ALASKA THIS 20TH DAY OF
APRIL , 2021
15010, FB 212-48
HOLT LAND SURVEYING
9309 GROVER DRIVE
ANCHORAGE,AK 99507
345-5513
man' --h ki,
Municipality of Anchorage
4,
On -Site Water and Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEms APPROVAL
Parcel I.D. 015-362-07 Expiration Date: 3 -17-
1. GENERAL INFORMATION
Complete legal description _
BLOCK 2, LOT 2
Location (site address) 9231 MAIN TREE ANCHORAGE, AK99516
Current Property owner(s) KrRKTOW'NER Day phone
Mailing address 9231 MAIN TREE ANCHORAGE, AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING:
Single Family (w/wo ADU)
El Duplex
El Multiple Dwellings ($ingle Family and/or Duplex)
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual
z
Individual Water Storage
El
Holding Tank
Community Class Well
Community
Public Water System
Public Sewer
Waiver/Variance request for:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer,
COSA Fee $ 5'9— (P Waiver Fee $
Date of Payment Date of Payment
Receipt Number Receipt Number
COSA# cSCAG1Woo Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seat 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 MHCE N ANDERSON, P.E. Phone 727-8864
Address 4661 NATRONA AVE.
Engineer's.Printed Name MIKE N ANDFRSON, PE Date 12/4/15
6. DSD SIGNATURE
1// System #1 Approved for bedrooms.
System #2 Approved for
Disapproved.
Conditional approval for
bedrooms.
49TH
........ . . .........
MICHAWWAN RS N
"C'q .......
bedrooms, with the following stipulations:
By:
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 St ate 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 blue sheet 1 D-1 0.1 2.doc
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: ROCK HIELLS S/D BLOCK 2, LOT 2 Parcel ID: 015-362-07
A. WELL DATA
Well type Private If A, B, or C provide PWSID #
Date completed 613011981 Sanitary seal (Y/N)
Total depth 86 ft. Cased to 86 ft.
FROM WELL LOG
Date of test 613011981
Static water level 32 ft.
Well production 9 -P.M.
WATER SAMPLE RESULTS'
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground) __L2
AT INSPECTION
111612015
ft.
5+ - 9 P.M.
Coliform NEG colonies/100 mL Nitrate 9.17 mg/L
Arsenic: ND ug/L Date of sample: 111612015 Collected by: Mike Anderson
B. SEPTICIHOLDING TANK DATA
Tank Type/Material SEPTIC I STEEL Date installed 6119181
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Depression over tank (Y/N) High water alarm (Y/N) N
Date of pumping 11-5-15 Pumper Around the Clock
C. ABSORPTION FIELD DATA – 1985 SYSTEM TESTED
Date installed 6119181 Soil rating (g.p.d./ft? or ft2 /bdrm) 1.2 System type DEEPTRENCH
Length 50 ft. Width 2 ft. Gravel below pipe 5.0 ft.
Totaldepth 10 ft. Eff. absorption area 500+ fe MonitoringtubeY Depression over field N
Date of adequacy test 111612015 Results (Pass/Fail) Pass Fortledrooms
Fluid depth in absorption field before test 6 in. Water added 600+ gal. New depth 13 in.
Elapsed Time: 6 hrs min. Finalfluiddepth 8 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N &type) UNKNOWN lf yes, give date
D. LIFT STATION
Date installed . Size in gallons —Manhole/Access (Y/N)
"Pump on" level at in. "Pump off" level at
Datum
Cycles tested
E. SEPARATION DISTANCES -
WELL ON LOT TO:
Septic tank/lift station on lot - 1001+
Absorption field on lot 100'+
Publicsewermain 75'+
Sewer /septic service line 501+
Animal containment areas —1001+
SEPTIC/HOL,DING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+
in.High water alarm level at
Meets alarm & circuit requirements?
in.
On adjacent lots 1001+
On adjacent lots 100'+
Public sewer manhole/cleanout 100'+
Holding tank 1001+
Manurelanimal excrete storage areas 1004
Absorption field 51+
Water main 100'+ Water service line 10'+ Surfacewater 100'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Property line
Building foundation 10'+ Water main
Water Service line 101+ .. Surface water 1001+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+ (None Known) Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that / have determined through field inspections and
review of Municipal records. that the above systems are in
conformance. with MOA COSA guidelines in effect on this date,
Engineer's Printed Name.MTKE N. ANDERSON, PE
Date 0612412015
COSA canary sheet 2-6-15.dOG
fW
4 gg
................
M1,HALL ANDEkICN
CE 9 9
0if S
Municipality of Anchorage
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
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC151660
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 2, Lot 2 of
Rockhill subdivision. This inspection revealed a nitrate concentration of 9.17
milligrams per liter (mg/L) was reported for the property's well water
sample. The Environmental Protection Agency (EPA) has established a
maximum contaminant level (MCL) of 10.0 mg/L for public drinking water
systems. While private wells are not subject to this regulation, EPA
standards are based on existing health information and can therefore be used
to gauge the relative quality of water from private wells. Please see the
attached "Nitrate Fact Sheet" for important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
Dee 16, 2015
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: Septic system testing
Legal: ROCK HILLS S/D BLOCK 2, LOT 2
To Whom it may concern:
This is a letter to explaining that the above system is large enough for a 4 bedroom. Previous
COSA's have be f 3 and 4 bedroom approval. The tank is 1250 gallons and the leach field is
,Ln or
500 square foot-(725sf/bedroom) therefore it meets the criteria for a 4 bedroom system. During
my adequacy test over 800 gallon was pumped into the system without any effects. Please
consider this system a 4 bedroom system and approve the current COSA.
Please call me if you have any questions.
Sincerely,,,
) j
Michael N. Anderson, P.E.
4661 Natrona Ave.
Anch, Ak 99516
Ph 727-8864
A� 12, S -s; �(00 iA k-rv�
olk4f
(-tdv.� LvC1 -
75. �� y/0 7-
Municipalit of Anchorage 0
y 25
Development Services Department
14
z Building Safety Division
oe* On -Site Water and Wastewater Program
9 T
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. HAA 9 9A t) i�ol3b
Expiration Date: -7 - P_
1. GENERAL INFORMATION
Complete legal description �-e T Q
f t; V,
q,2 31 tqa;
Location (site address or directions) �,vt k A2-Z—
Current Property owner(s) 1�0*r-U4&A Day phone
Mailing address
Lending agency
Mailing address
q P_-�b A g 6".7tn ��
Day phone
Real Estate Agent vw v" f 1,\!J Day phone '71- 2 =;g9j Sif 4 L -
Mailing Address 5go I C.
Unless otherwise requested, HAA 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 El
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properfies 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 we!ls or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system ls(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 ls(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm I n
Address
Engineer's Pdnted Name
5. DSD SIGNATURE
Approved for
Disapproved.
Conditional approval for
Additional Comments
U, H 7, 0 -7.
bedrooms.
Phone L�
Date 2—
WATER AND
PROGRA M
Note' Thp wP11 fnr thily property mpptq exigting Stote and Nfunicipill Codes. There are nitrates
present It Is suggested that periodic testing be performed to insure the wells continued suitability.
CUrMIL L11LIaLC CU11MILIU11011 is 5.20 111gA. EPA 111influlaill culmentlatioll is 10.0 sne. N10re
information on nitrates is available from the On -Site Services Program, at 343-7904.
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: _42:4ze_�� 1,1/, Original Certificate Date:_�L_ 2- 3 - 0 2,
-� // 2�/
:R". 01=1
MunicipaRty of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program S *A. 11
4700 South Bragaw St.
P.O. Box 1 9W50 Anchorage, AK 99519-6650
www.cl.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: La T' 12. ?o V< "L ?- e, e- L 1,,Z U 5V 0 Parcel ID: 0/!;- S4 2 - 6 7
A. WELL DATA
Well type R If A. B, or C provide PWSID # "/A Well Log (Y/N)
Date completed . �&/19 Sanitary seal (Y/N) Wires property protected (Y/N)
Total depth _J&__fL Cased to -9Lz-fL Casing height (above ground) n.
FROM WELL LOG AT INSPECTION
Date of test 4,40101 q-0 1 -0 2,
Static water level
Well production
*3, 2�
ft.
10-0 9 -p -m -
q & ft.
7y2, — 9 -p -m-
WATER SAMPLE RESULTS:
Cohfbrm colonies/100 mi. Nitrate &—:20rng.n. Other bacteria colonies/100 m
-0—, 4--;:=?
Arsenic: V--%ig.A. Date of sample:
-�Zf 4 7- Collected by'
B. SEPTICIHOLDING TANK DATA
Tank Type/Material Date installed
Tank size klw gal. Number of Compartments Cleanouts (Y/N)
Foundation cleanout (Y/N Depression over tank (YIN) _b4 High water alarm (Y/N)
A 4,4 e- L Ole 69-015
Data of pumping Pumper 1 19 -
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.r.*-W-or fetbdrm) _[i&- System type -TA4,tja4
Length SO ft Width -ft. Gravel below pipe ft.
Totaidepth /;L ft Eff. absorption area 2-17—oft' Monitoring tube 4— Depression over field
Date of adequacy test V-01-6'9- Results (Pass/Fail) �P For M bedrooms
Fluid depth in absorption fleld before test gy in. Water added"gal. New depthJJ in.
Elapsed Time: Final fluid depth 2_q in. Absorption rate >= k-5 V g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) 6 If yes, give date V/
D. UFT STATION
Date installed
"Pump on' level at
Datum
E. SEPARATION DISTANCES
in gallons
4Pump ofr Level at _ in.
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot / ?i.;;
Absorption field on lot
Public sewer main
Sewer /septic service line,
(Y/N)
High water alarm level at in.
Meets alarm & circuit requirements?
On adjacent lots 1&0
On adjacent lots lae
Public sewer manhole/cleanout
Holding tank t,44/44r
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation '30 Property line too - Absorption field S
Water main N/16, Water service line. >ar Surface wa I ter t-11 0
Wells on adjacent lots > 1060
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
-NI
Property line Iv + Building foundation Water main �4,
Water Service line > 2 15 Surface water H Driveway, parkingArshide storage
Curtain drain t�A 10 Wells on adjacent Ift 0.0
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I car* that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date
Engineer's Printed Name 717,oiabe,, 9pvrV-L^,,,X
Date 1/, 0
HAA Fee $ rb IT OJ- Waiver Fee $
Date of Payment /tip IV Date of Payment
Receipt Number Receipt Number
(Rev. 12101)
T "
L4
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.# 0/5 22�2- 0-7 HAA#
1. GENERAL INFORMATION
Complete legal description o —I I L L -
Location (site address or directions) C? _t:A
Property owner — �)-ro po y- LL -4 Day phone
Mailing address
Lending agency — Day phone
Mailing address
Agent Day phone
�60 0
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 2) -
3. TYPE OF WATER SUP13LY:
Individual well L/
Community well
Public wetter
N OTE: 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(flu.1/91) Front MOA#21
5. STATEMENT OF INSPECTION BY ENGINEER
Ascertified byrnyseal affixed heretoand as of the validation date shown below, lverifythatmy
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type -of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm be D U Y'k i a 0-W Phone -s
1
I t5 kf 20 3 A v- 9 qso t
Address
Engineer's signature —Date -
6
4
6. DHH6 SIGNATURE
22
_L� Approved for T_W��E_E bedrooms.
Disapproved.
Conditional approval for
Additional Comments
bedrooms, with the following stipulations:
AZ Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesyto purchasers of homes
and their lending institutions in orderto satisfy certain federal and state requirements. Employeesof DHHSdonot
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(RM1191) SUk MOA#21
& E C. E I \1 E b
Municipality of Anchorage AUG 27
DEPARTMENT OF HEALTH & HUMAN SERV10YWIPAUTY 011 ANCHOIA'
Environmental Services Division ENVIROMMENTALS'*RVICES DIVI
825 L Street, Room 502 - Anchorage, Alaska 99501 - (907) 343-474.4
Health Authority Approval Checklist
Legal Description:- L07 2 'BV,9- -F-r _kAILJ -)15- 3 62
— t t' :�CV - -Parcel (
A. WELL DATA
Well type — 7 — If A, B, or C, attach ADEC letter. ADEC water system number 1qA_
Log present (Y/N) Date completed
Total depth
Casedto Casing height (above ground)
Sanitary seal (Y/N) Wires properly protected (Y/N)
I -ROM WELL LOG AT INSPECTION
Date of test 013 A/1
Static water level 7
Well production ___g'p'm- ___ 1� g.p.m.
WATE R SAMPLE RESULTS: 't I
Coliform - 19- —_ Nitrate Other bacteria
Date of sample: SL_ 117 1 Collected by: _T' 151
B. SEPTIC/HOLDING TANK DATA
Dateinstalled &IJ-d9l Tank size
Number of Compartments Cleanouts (Y/N)--*-
Foundation cleanout (Y/N) -4- Depression (Y/N) High water alarm (Y/N)._�i—
Date of Pumping 1&1q el __ Pumper AVIC ) I I C) K 0- '739 P da (
C. ABSOR13TION FIELD DATA
Date installed b System type
_LLL—_ Soil rating (g4LdJJt-1 or ftl/bdrm) ___ - ) "T- Z' -
Length 0 _____�Wldth Gravel thickness below pipe.
�? - Total depth
Effective absorption area Monitoring Tube present (Y/N)4- Depression over field (Y/N)
Date of adequacy test Results (Pass/Fall) >__ I -or '��___Ibedrooms
Fluid depth in absorption field before test (in.); 2 immediately after. 6&40qal. water added 0n.):
Fluid depth - aZ )� (ins) Minutes later:. A9�i r
Peroxide treatment (past 12 months) (Y/N) - t -k
72-026 (Rev. 3/96)*
Absorption rate =. _2 V�5 0 p.d.
If yes, give date
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot —1 1> 6 -
Absorption field on lot I Lit)
Public sewer main NIA
"Pump off" level at*
On adjacent lots >
On adjacent lots ;� / Z-0
Public sewer manhole/cleanout _t�
Sewer /septic service line 1 &0 ± Lift station N�X�-
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation W — Property line bD Absorption field S
Water main/service line >A5 Surface water/drainage I'J/V Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 110 Building foundation Water main/service line > �;-V
Surface water Driveway, parking/vehicle storage area
Curtain drain Wells on adjacent lots > I
F. ENGINEER'S CERTIFICATION
certify that / have determined thru field inspections and review of Municipal records'that the above system's are
in conformance with MOA HAA guidelines in eh�act on this date.
Signature
Engineer's Name qL Vt lwk
Date
HAA Fee A 3 0-0 1- t)�o
Date of Payment
Receipt Number 17
I
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
ME Environmental Services Inc.
AL Laboratory Division
200 W. Potter Drive
Drinking Water Analysis Report for Total Colifomi Bacteria Anchorage, AK 99518-1605
Tel' (907) 562-2343
READ INSTRUCTIONS ON PEVERSESIDE BEFORE COLLECTING SAMPLE Fax: (907) 561-5301 —
-7—TO =FCOMPLFTED BY LABORATORY
-------FT—EDBy—N7ATER SUPPLIER
N,j, I -T FtF COMPL
o PUBLIC WATER SYSTEM I.D. #
PRIVATE WATER SYSTEM
0 SendReshrits 0 Send Invoice
Phone N.mber
0 Send Results C1 Send Invoice
F—Ity
SAMPLE DATE: 0� MDay qY e?r
SAMPLE TYPE:
0 Routine
Repeat Sample (for routine sample
with lab ref. no.
C] Special Purpose
SAMP E LOCATION
0 , "L
ITOLO� - L, IL—
Comments:
0 Treated Water
0 Untreated Water
Time Collected
Collected By
Plow Prwt
ysis shows this Water SAMPLE to be:
Satisfactory
• Unsatisfactory
• Sample Over 30 hours old, results may
be unreliable
• Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample v;a sPeci-1 delivery mail
Date Received
" Ived
, me ece
Analysis Began
Analytical Method; Membrane Filter
9- MMO-MUG
11---k�r of colrnies/100mi.
Result*
� "a
Analyst
BACTERIOLOGICAL WATER ANALYSIS RECORD
MMO-MUG Result: Total Coliform E. Coli
Membrane Filter: Direct Count Coloniesilo" all
Verification: I,TB g-", ___ COLIFIRM--
Fecal Coliform Conflrmatle�i _
Final Membrane
Reported By
N Coflforra/100 Pat
Date -'Z';4� Time lirs
Member of the SGS Group (Socidu§ Gdn6rale do Surveillance)
r,VTC- n,,N.Molou, T� 0t,rl
OB - Other Bacteria
ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA. FLORIDA, ILLINOIS. MARYLAND. MICHIGAN, mr3SOlim. NEW JERSEY, OM, WEST VIRGINIA
El
nch Fbks Jun
Faxed
Date:
Time:
Client notified of unsatisfactory results:
C]
11
—
Phoned
Spoke with
Faxed
Date: .
Time:
BACTERIOLOGICAL WATER ANALYSIS RECORD
MMO-MUG Result: Total Coliform E. Coli
Membrane Filter: Direct Count Coloniesilo" all
Verification: I,TB g-", ___ COLIFIRM--
Fecal Coliform Conflrmatle�i _
Final Membrane
Reported By
N Coflforra/100 Pat
Date -'Z';4� Time lirs
Member of the SGS Group (Socidu§ Gdn6rale do Surveillance)
r,VTC- n,,N.Molou, T� 0t,rl
OB - Other Bacteria
ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA. FLORIDA, ILLINOIS. MARYLAND. MICHIGAN, mr3SOlim. NEW JERSEY, OM, WEST VIRGINIA
CT&E Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
Parameter
Total Cotiform
Nitrate -N
CT&E Environmental Services Inc.
993918001
Tobben Spurkland P.F.
N/A
Lot 2 Bk 2 Roch Hill
Drinking Water
I
Results PQL Units
21 OB/100 ML, NO COLI
4.74 0.500 mg/L
Client PO#
Printed Date/Time 08/06/99 16:02
Collected Date/Time 08103199 17:00
Received Date/Time 08/04/99 08:10
Technical Director: Stephen C. Ede
Released
Allowable Prep Analysis
Method Limits Date Date Init
SM18 9222B 08/04/99 KAI)
EPA 300.0 10 max 08/04/99 08/04/99 SCL
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA #
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner (~,'?,\~,~.~ /~ Cr~ ~¢
Mailing address
Day phone
Lending agency
Mailing address
Day phone
Agent £ ~,~ G~R VAN
Address 2~o~ c. s'r~-: AN c. I-le,~ A & g AK
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: z{.
TYPE OF WATER SUPPLY:
Individual well X
Community well
Public water
NOTE:
Day phone 2_2 9- ~o~
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
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.
72q325 (Rev, 1/91) Front MOA #21
STATEMENT OF INSPECTION BY ENGINEER.
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I 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 -/~V--K H¥~r~m ~Av~. /,~,
Address c) I I V,/~- ~",~.~-r~ AvZ.
Engineer's signature ~
Phone
A*4c~4~,~A~ A~' 9c~ 5'~ I
Date
DHHS SIGNATURE
Approved for ¢
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificatee based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) BaCk
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description: / 0 -r'
A. WELL DATA
Well type
Health Authority Approval Checklist
If A, B, or C, attach ADEC letter. ADEC water system number
Log present ~l/N) ¥£5
Total depth 8~'
Date completed o~, /,.30/ 8l
Cased to ~;-~ - '"! //'0 Casing height (above ground)
I,O '
Sanitary seal (~/N) '
Wires properly~protected (~N)
FROM WELL LOG
AT INSPECTION
Date of test ~, / 3 {3 ? ~ I
Static water level ;52, '
37.9'
Well production
WATER SAMPLE RESULTS:
Coliform (~ Nitrate
Date of Sample: 7 / 03 /
g.p.m. IO p~o~
b~,-~-"'~'"~ Other bacteria
Collected by: ",P-~3~a~ /4~
g.p.m.
B. SEPTIC/HOLDING TANK DATA
Date installed (o//9/~ Tanksize iZ5o G44. Number of Compartments [ Cleanouts(~O'N)
Foundation cleanout (~N) Y~ Depression (Y~.~ /'/o High water alarm (Y/~
Date of Pumping 7/o~ / ~, Pumper /,/o~
C. ABSORPTION FIELD DATA
Date installed ~, / / 9 /
Length ,5o ' Width
Soil rating (g.p.d./fF or fF/bdrm) ~zs ~;~t/3~ystem type
;Sr~" Gravel thickness below pipe ~ Total depth
Effective absorption area 5 oO Monitoring Tube present (~N). Yg,~ Depression over field (Y~ ~o
Date of adequacy test 7/oz / ~ Results (~Fail) ~^,~ For
bedrooms
Fluid depth in absorption field before test (in.);
Fluid depth ~.1. Z4" (ins) Minutes later:
Eo. 8~" Immediately after~,3o gal. water added (in.):
; c, ¢, ,;3 Absorption rate = (~,30 ,p,~,~ g.p.d.
E7,0"
Peroxide treatment (past 12 months) (Y~J~ /'/o
If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
"Pump on" level at*
"Pump off" level at*
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot 1 3,5. ,5
Absorption field on lot - 14tO
Op adjacent lots
On adjacent lots
Public sewer main hi A
Public sewer manhole/cleanout
Sewer/septic service line I Z ~ ' Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation 3) I ° Property line ~O ' ~ Absorption field
/,50' +
N^
Water main/service line ~,O' Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line I O '. Building foundation 4.(,,,
Surface water hi A
Curtain drain I'~ /~
ENGINEER,S CERTIFICATION .
I certify that I have determined thru field inspections and re. view.
in conformance with~.M~A HAA guidelines in effect on this date.
Signature ~~'
Engineer'S Name .5 ~,~,/~ ~. '5 ~,.5 A
Date ~ :~//2-
Wells on adjacent lots
Water main/service line
Driveway, parking/vehicle storage area
Wells o~ adjace, nt lots . ?,5'0 ' -~-
HAA Fee $. C~ D-~ ~ ~
Date of Payment 7--,/~-.--~'~"
Receipt Number ~. ~Z/
72~026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
07×12×96
89:38 CT&E ESI ANCHORAGE ~ 90?2767679
N0.091 U03
CT&E Environmental Services Inc.
Laboratory Division m~-~J-~,~j,~~.~.~~~~
Laboratory Analysis Report
CT&E ReL#
Client Sample ID
~'Iatrlx
962709, 962709001
Lot 2 Blk 2 Rock Hi[[ $/D HB
Driaklng Water
Sample Remarks:
Collected Date 07103196
Technical Director: Stephen C. Ede
N~trato-N
Nitr{te-N
~uol
6,42
0.$00 n~j/l EPA 353,2
0,100 mg/L EPA ~5].Z
0 col/10amL SM18 92228
ALlowable Prep Analysis Init
Limit8 Date Oat~
07/09/96 EMB
07/09/96 EMB
07/05/96 YEP
U · Undetected
LT - Loss than
GT · Greater than
0 - Secondary O~Lutfon
J - aeto~ the calibration rahs
200 W. Potter Drive, Anchorage, AK 99518-1605 -- Tel: (907) 562.2343 Fax: (907) 561-5301
3180 Pager Road, Fairbanks, AK $$709-5471 -- Tel: (907) 474-8656 Fax: (907) 474-9685
ENVIRONMENTAL FACILITlf~$ IN ALASKA. CALIFORNIA. FLORIDA. iLLINOIS, MARYLRNO, MICHIGAN, MISSOURI. NEW JERSEY, OHI0, WEST VIRGINIA
MUNICIPALITY OF ANCHORAGE.
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL. HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date F" ('
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name Telephone: Home Business
Applicant Address
(c) Applicant is (check one): Lending Institution El ; Owner/builder Buyer[]; OtherO (explain);—
(d) Lending InstitutionTLA5A-Ei�ti—LiA-L�-t-�---7elephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
e-
2. TYPE OF RESIDENCE
Single-Family,ET' Multi -Family 11 Other
Number of Bedrooms 4
3. WATER SUPPLY
Individual Wel.10--l'CommunityD PublicD
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
OnsitQZ� Public 0 Community 0 Holding Tank 0
Note: If community well systern, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Pagel of2 72-025 (11/84)
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
6.
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm Telephone �tiv-7 /J.
Address
Date
WATER WELL NOTE: This Health Authority Approval inspection merely
certifies that the subject water well produced 150 gallons per
bedroom per day and that certified laboratory tests showed no
presence of coliform bacteria in a sample of that water. No warantee
or certification is expressed or implied concerning the long term
adequacy or safety of the water supply.
ON-SITE SEWAGE DISPOSAL SYSTEM NOTE: This Health Authority Approval
inspection merely certifies that the subject on-site sewage disposal
system accepted at least 150 gallons of water per bedroom per day
as determined by methods approved by the Municipality of Anchorage
DepartmLnt of Health and Human Services. No warantee or
certification is expressed or implied concerning the long term
adequacy of the on-site sewage disposal system. Construction data
reported on buried system components is from MOA files and was
not verified during this inspection.
DHEP APPROVA(�:i-a/�')
Approved for bedrooms
Approved Disappr
Terms of Conditional Approval
Conditional
CAUTION
E41 J6.
NEI 1:11111.-.!
%
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of hornes and their lending
institutions in orderto satisfycertain federal and state requirements. Employees of DIAEPdo not conduct inspectionsor
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 J 11/84)
MUNICIPALITY OF ANCHORAG�
DEPT. OF HEAUH &
MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTEC]ION
HEALTH AUTHORITY A13PROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720 RECEIVED
Legal Des ' ti n: 4" -
,Z
72 91-`0
A. WELL DATA 1514 1— 1 2- '\J R3
Well Classification A&rd" If A, B, Q D.E.C. Approved (Y/N) _Z0
Well Log Present (Y/N) __Y_dF5 - Date Completed t�_Jr - & / — Yield
Total Depth --g Cased to Depth of Grouting - (//IV
Static Water Level S ?_ --- Pump Set At
Casing Haight Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) y
ef's — Depression Around Wellhead (Y/N)
Separation Distances from Well
To Septic/Holding Tank on Lot On Adjoining Lots
To Nearest Edge of Absorption Field on Lot On Adjoining Lots znn
To Nearest Public Sewer Line �5 Ay To Nearest Public Sewer
Cleanout/Manhole - IV�All — To Nearest Sewer Service Line on Lot
Water Sample Collected by '�� ; Date-, 7-- ZZ --
Water Sample Test Results - -'>—
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed e6 -19 Size ZZ�0��d_ No. of Compartments __Zw
Standpipes (Y/N) - V&S Air -tight Caps (Y/N) _Z:nS Foundation Cleanout (Y/N) ye's
Depression over Tank (Y/N) Date Last Pumped
Purnping/Maintenance Contract on File (Y/N) --- ; for ?5e�
Holding Tank High -Water Alarm (Y/N) --"/- Temporary Holding Tank Permit (Y/N) Iel�
Separation Distances from Septic/Holding Tank:
To Water -Supply Well To Building Foundation
To Property Line - '�'?el To Disposal Field
To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course Wl��
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata �RIV Type of System Design M"C/
Date Installed 4�_19_lyl Length of Field
Width of Field Y4 // Depth of Field A9
Gravel Bed Thickness
Square Feet of Absorption Area 15-06 Standpipes Present (Y/N) Y1__S
Depression over Field (Y/N) X/O , Date of Last Adequacy Test g: —,3 6
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well Ae4 / To Property Line 157
To Building Foundation 7/ To Existing or Abandoned System on
Lot MM�Jo ot � " -e- ") I ; On Adjoining Lot - /-
To Water Main/Servire Line 15?�/ J� To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course A V_4�0
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
N
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test, Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify thaZe e ' t_orcon formed to all MOAand HAA guidelines in effect on the date of this inspection.
Signed 1A Date
Company c— MOA No. ol� At
Receipt No. q00 I cnoa%
Date of Payment
Amount: $ (,0,5
Page 2 of 2
72-026 (11184)
v
i
I NEIL TIAINTHORNE
CE 4369
&I zo,
10
1-0A-_ 1'a) eYI4
L luv L� )I v U1,
> aL-e_ --t3 � )t2,
NTM
PATE RECEIVED
-e
TIME TIME
_ Q! 1� 001 M OU
TIME
DATE
DATE
I\—\ __)__ 1� _� Q t
DATE
INSPECTOR
INSPECTOR R
INSPECTD�R
—MUNICIPAL �TY_Or
ANCHZ5=-
MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH &
DEPARTIVIENTOF HEALTH& ENVIRONMENI'ALPIIOTE(Lt4tg)NMENrAL P,,OTECTION
825 L Street - Anchorage, Alaska 99501
JUL 19 81
ENV] RONMENTAL SANITATION DI VISION
Telephone 264-4720 RECEIVED
REQUESTFOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DI RECTIONS: Complete all parts on page 1. 1 ncomplote requests will not be processed. Please allow ten (110) days for prTessing.
1. PROPERTYOWNER
011JONE'
MAILING ADDRESS
PROPERTY RESIDENT (if different from above)
TRION
:5 n
2, BUYER
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION P"ONE
I /_ - --e
JE12" k,:6(1L
MAILING ADDRESS
'o A-1 LIS
4. REALTOR/AGENT 'HONE
MAILING ADDRESS
5. LEGAL DESCRiprioN
1,e) V 2— 2___
STREET LOCATION
-e
6. TYPE OF RESIDENCE
NUMBER OF,SEDROOMS
SINGLE FAMILY
0 One ED Four 0 Other
0 Two ED Five
ED MULTIPLE FAMILY
ED Three ED six
7. WATER SUPPLY
DA INDIVIDUAL*
*ATTACH WELL LOG. Awell log is required forall wellsdrilled
0 COMMUNITY
since June 1975. For wells drilled prior to that date, give well
0 PUBLICUTILITY
depth (attach log if available.)
B, SEWAG E DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE**
YEAR ON-SITE SYSTEM WAS INSTALLED.
0 PUBLIC UTILITY
L - -04)
\01
NOTE: THE INSPECTION FEE MUSTACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
//— / � -Z/J
72-010 (Ray. 6/79) 44"&4Q
N// Al".
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
F—I SINGLE FAMILY
0 MULTIPLEFAMILY
NUMBER OF BEDROOMS
0 ONE
El TWO
El THREE 0 FIVE El OTHER
El FOUR EI six
2. WATER SUPPLY
ED INDIVIDUAL
El COMMUNITY
PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
DINDIVIDUAL/ON -SITE
EIPUBLIC UTILITY
Connection Verified —
PERMIT NUMBER
DATEINSTALLED
INSTALLER
ElSeptic Tank or El Holding Tank
Size: )__)_S—U If Tank is homemade
give dimensions:
SOILS RATING
)IDS—
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES WELLTO:
Septic/Holding Tank
Absorption Area
Absorption Area to nearest Lot Line
5. COMMENTS
15W-'�PPROVED FOR BEDROOMS
Cl CONDITIONAL APPROVAL (letter must accompany certificate)
Ell DISAPPROVED
DATE
BY
72-010 (Rev. 6/79)