HomeMy WebLinkAboutTROLL KNOLL BLK 1 LT 3Troll
Knoll
Block 1
Lot 3
#051-521-15
Municipality of Anchorage
Development Services Department
~�
Bidding Safety Ow,sion -Y I'll•
On Sde Water and Wavowater Program. 4700 B•agaw Sl
P O. Box 1{550 Auhorage• AK 9954.9-6550 Page of
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Ci anchorage ak us (9071 343-7394
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number. _�_l�_� ad ZC3-- — - - PID Number. 057 _5P_ f _-1 5
a,•rc
(311vei Rood
Wastewater System: []New Upgrade
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DEVELOPMENT SERVICES DEPARTMENT - BUILDING SAFETY DIVISION
ON-SITE WATER AND WASTEWATER PROGRAM, 4700 BRAGAW STREET
DISPOSAL ON—SITE WASTEWATER IN ,..: R L SYSTEM AND/OR WELL INSPECTION REPORT
[If; %:. LOT 3. BLOCK 1. TROLL KNOLL S/D H 1 D %o051 —521 —1 5
LOT 4
K eu H5
r; et'c T1 a"ct:
EXIST NO iCCO GALLON
CONCRETE � ?TC TANK
W.TH NEW A CON,;--T[-
UC TO REPLACE JET LNT
NEW PLM= BASF
1;:" PVC PRESS:IR ZED
'H♦
LOT 2
Pr:r:Y1Ct H 10
I'LHJ:, l%ATLX
--- ———————————————————
1-0—U'I—IS,Y—EASE—S
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CONTROL O%
c
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MT� •TH#2
EXIST NO iCCO GALLON
CONCRETE � ?TC TANK
W.TH NEW A CON,;--T[-
UC TO REPLACE JET LNT
NEW PLM= BASF
1;:" PVC PRESS:IR ZED
'H♦
LOT 2
Pr:r:Y1Ct H 10
I'LHJ:, l%ATLX
--- ———————————————————
1-0—U'I—IS,Y—EASE—S
V. a^'
A. Shaft,
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1,1 No SW0-8021.3
I I % G I .- 3 (A _. -3
DEVELOPMENT SERVICES DEPARTMENT BUILDING SAFETY DIVISION
.ON-SITE WATER AND WASTEWATER PROGRAM, 4700 BRAGAW STREET
ON-SITE WASTEWATER DISPOSAL 'SYSTEM "AND/O.R. WELL INSPECTION REPORT
L013._ -BLOCK 1, TROLL KNOLL S 051-521-15
NEW CONCRETE LID
- -
ST 2 C 1 --100.14
FINAL GRAD'=9 99.7'1
EXISTING_
EXISTING GALLON
1000
CONCRETE LID SEPTIC TANK
91.4'
44SOL kil, I =10 1. o'
IT 2 = I I
-7 2"
FINAL GPADE
DIST. LINE 99.5'
11'1'1 -90.5'
11T2-90.6'
A
F
NO lVA'IER FOUND w4r
A 4-4
0 35.5 2.5'fi pr V
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Munic117aIll tAncIiori go
Development Services Department
Dubfr'g Safely DlYixbn
On Sit- Vlaln and Waslewalar Program
4700 Smith Rragaw SI
P.O. Bo* WOW And'mage, AK 97519 GG50
W Ww nn PM m¢•mK40
(91) 7) 343 M4
oiislp(i - Percolation Test
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PERCCLATICNRATE ooew .al PEnC 1rOlF DIAMC:IER
TEST RLMAI,OCCMEENF�TT All) It
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C^.IEIITS Sct(-s c,:-kv iTTR40T Com// f rT rr'1.
PEnrormirD RY'. I CCN1IFY THAI THIS TEST WAS
PLRr OPMED IN ACCORDANCE PATI I ALL STATE ANU MUNICIPAL GUIDLLINCS I11 Err rcT ON 11 US VATE VATE.
10/10/2008 12:14 9076941211 SNSENGINEERING
Oct 10 2008 11:50RM HP LASERJET FAX
October10, 2008
Tweed Excavating Const.
Richard Tweed
15861 S. Birchwood Loop
Chuglak, AK 99567
Rising Son Qectric, Inc.
14916 Y oodlana rive
90g'e River, AK 99577
X907) 62-2-6777
Re: Lot 3 Block 1 Troll Knoll - 20473 Leprechaun
Dear Richard:
PAGE 02/02
The Wit station at the above referenced property has been wired In accordance with NEC
and State/Local codes.
Thank you.
Sincerely,
I(evint. Hornbuckle, owner
Administrator License Number 1284
Specialty Contractor License Number 27285
cc: rile
P.I
MUNICIPALITY OF ANCHORAGE \�U
Development Services Department O$
On -Site Water d Wastewater Program ��
\
4700 South Bragaw Street \�
P.O. Box 196650, Anchorage, AK 99519.6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Sep 30, 2008
Expiration Date: Sep 30, 2009
Permit Number: SWO80213 Parcel ID: 051-521-15
Legal Description: TROLL KNOLL BLK 1 LT 3
Design Engineer: 0003 S & S ENGINEERING Site Address: 020473 LEPRECHAN DR
Owner Name: SONYA ROOD Lot Size: 41233 SO. Fr.
Owner Address: 20473 LEPRECHAN DRIVE Total Bedrooms: 3 Permit Bedrooms: 3
CHUGIAK , AK 99567 -
This permit is for the construction of:
❑✓ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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 ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Date: '�/L08
Municipality of Anchorage
Development Services Department
l Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, Alaska 99507
www.muni.org/onsite
(907)343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. �ri I- ���' /5
Property owner(s) SONYA ROOD Day phone 630.4564
Mailing address 20473 LEPRECHAUN DRIVE Zip Code 99567
Legal description (Sub'd., Block & Lot) LOT 3, BLOCK 1 TROLL KNOLL
Legal description (Township, Range & Section)
Lot Size 41 ,, A3 �3 Sq. Ft.
THIS APPLICATION IS FOR (® all that apply):
Absorption Field
El
Septic Tank
❑
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
[�
Number of Bedrooms 3
THIS APPLICATION IS AN:
Initial
❑
Upgrade
Renewal
❑
I certify that the above informatior0s correct. I fu her certify that this application is being made for a
Single Family Dwelling and is i ac ordance wit applicable Municipal Codes.
(Signature of property
Permit/Rush Fees:
Date of Payment:
Date of Payment:
Receipt Number. 015 79b Receipt Number:
(Rev. 11/05)
S&
TEALTNNTTHGRTTY
APPROVALS
SEWERSWATER
TA VI EXTENWNS
SEWERS WATER
WSPECTION
040NEERNGSTUpES
ANOREPORTS
WELLMPECTION
l Ht7W TEST
SITE PLAAa
mar
SOILTEST
PERCOLATION
TEST
STRJCTUML A
MECKM CAL
MPECTI"
ONSRE
WASTEWATER
OGPOS&SYSTEM
OESIGN
ROBERT C. COWAN .
CIVIL ENGINEERING
PH: 907.694.2979
FAX: 907.694-1211
September 25, 2008
MUNICIPALITY OF ANCHORAGE
Development Services Department
P.O. Box 196650
Anchorage, AK 99519
REFERENCE: Lot 3; Block 1; Troll Knoll SID
It is requested that you issue a permit to install a new deep trench to serve the
existing three bedroom house on the referenced property.
A test hole was excavated and a percolation test performed. The approximate location of
the test hole is located on the attached site plan. At the time of excavation (9/16/08) water
was not found. After seven days of monitoring, no ground water was found.
The existing concrete septic tank was originally installed with a jet aeration system in the
tank. With this project, the tank integrity will be verified and replaced if necessary. If the
tank does not require replacement the aeration system components will be removed along
with the manhole that currently extends to the surface. After the manhole is removed the
access hole will be repaired with a 3 inch reinforced concrete lid set on an asphalt mastic.
The old absorption trench will be abandoned in place.
A lift station will be installed after the tank to allow the effluent to be lifted to the new
trench as shown on the plot plan.
The adjacent lots 2 R. 4 including this lot are served by a community water system which is
200' plus away from the proposed septic site. We do not anticipate any adverse effects on
other neighboring wells, septic systems, reserve areas or drainage patterns by the
installation of the proposed septic system. The construction of this system will not prevent
any future development on any of the adjacent properties.
If you require
Shafer, P.E.
information, please contact us.
15861 S. Birchwood Loop Road - Chugiak, Alaska 99567
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• _ter
Municipality of Anchorage
Development Services Department
Bulldnlg Safely Division
+.[
Oil -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage. AK 995196650
www.mvnl aglonsile
(907) 043-7904
Sol Percolation Test
Performed For:tor
W Dale
Legal Description: s I Rj(.L'k I fr-10—LL'Yr((� township. Range. Seawn
COMMENTS
.pP-ETyt1l(,S
-PAL(VeAt+tw)
r•
Readiingg�
Dat
vASGROUNO WATER
G
J ENCOUNTERED?
IF YES.ATWRAT DEPTH?
Depth to Water After
Montloring?Dal,
-- a
L
O
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E
Dale'
Not pop
r•
Readiingg�
Dat
Gloss Ylme
Not Time
Depth to Wale,
Not pop
1
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�l
'720
G
30
20
q,5/T1
„
o1 w Ilwlvc a T swat.~) PERCHOLE DIAMETER
TESTRUNBETWEEN N.5 Ft AND FT
PERrOnMED BY: 1 • CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES 114 EFFECT ON THIS DATE. DATE:
/-" — S & S\
ROBERTC.COWAN .
J EnGIneeRrnG
CIVIL ENGINEERING
PH: 907.694-2979
FAX: 907.694-1211
ON-SITE WASTENVATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
"EILTMNJhUMTY
AvmwAu
REFERENCE: Lot 3; Block 1 Troll Knoll S/D
September 25, 2008
SEINER& WATER
MwUNcmfaKm GENERAL:
1.
The scope of this project includes the installation of a new 30" DIA pump
basin with S.T.E.P. system to be connected to existing 1000 gallon concrete
SEWER& WATER
RSPECTION
tank. Also a new pressurized deep trench to serve the proposed three
bedroom residence located on the referenced property.
2•
Construction shall be in accordance with the approved site plan and design
ENOINEERIMGSTUaES
MOREPORTS
drawings, Municipal permit with any special provisions or conditions, and
all applicable State and Municipal Wastewater Disposal Regulations.
WELLWSPECTION 3.
The contractor shall be responsible for obtaining any necessary
AFLONTEST
underground utility locates.
4.
Unless specifically agreed otherwise, the property owner shall be
SITE BANS
responsible for final grading areas subsequently depressed from soil
settling.
5.
Contractors installing wastewater disposal systems must be certified by the
P0AD0ES4N
Municipal Development Services Department or ADEC if required, for
system installations. Owners installing their own systems must also receive
prior approval from the respective agency.
SOATEST
SEPTIC TANK INSTALLATION:
1.
A septic tank is to be constructed by a certified septic tank manufacturer.
PERCounoN
TEST
Construction shall include two 4" cleanouts for pumping access. All HDPE
septic tanks are required to have a 4" monitoring pipe installed next to the
tank extending to the bottom of the tank.
STRUCTLV IA
M CKVOCAL
94PEcnoRs
ON SITE
WASTEWATER
WKSALSISTEM
O'SIGN
15861 S. Birchwood Loop Road - Chuglak, Alaska 99567
Page 2
Lot 7, BW 7 Tml Wal Subdiv's
9!!5(1008
2. The septic tank shall be sufficiently bedded to prevent settling of shifting of the tank.
3. All standpipes on the septic tank shall extend a minimum of 12 inches above final
grade.
4. Septic tanks installed with less than 4 ft. of cover shall be insulated. All IIDPE septic
tanks are required to be covered with a minimum of 2" direct burial insulation, and a
maximum of 4 feet of cover.
5. A foundation cleanout shall be installed one to four feet from the building foundation.
6. Final grading over the septic tank shall be such that a positive slope exists away from
the septic tank.
ABSORPTION TRENCIIIDRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the design. The bottom of
the excavation shall be within 2 inches of level. If the sidewalls of the excavation
become smeared, they must be raked or scratched (ruffed -up) before gravel (sewer
rock) placement.
2. Once the gravel is installed, the distribution pipe is to be installed level with the holes
faced downward. The distribution piping is to be of PVC (ASTM D3034 or equal).
All joints are to be solvent cemented. Gravel is then to be placed over the distribution
pipe to provide a minimum of 2 inches of cover over the pipe.
3. A silt barrier must be installed between the final gravel layer and the native soil
backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill.
4. Monitor tubes shall be of four (4) inch diameter, installed approximately in the
locations shown on the design, and extend a minimum of 12 inches above final grade.
The portion of the monitoring tube extending through the gravel shall be perforated
from the bottom of the trench to the invert of the distribution pipe. This is equivalent
to the effective depth of the gravel as noted on the design.
5. Backfill over the final gravel layer must not be less than twenty-four (24) inches.
Insulation must be installed when the backfill depth is less than thirty-six (36) inches.
The finish grade over the trench must be mounded to prevent the formation of a
depression after settling.
Page 3
Lot 3; Bbck 1 Trot Knol SID
Septemoer 25.2008
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be constructed by a Municipally
approved septic tank manufacturer.
2. The following pipe materials are approved for use in septic system installations in the
Municipality of Anchorage:
Type of Pipe Perforated Solid
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F810 (IIDPE) Yes No
ASTM D2662 (ABS) Yes Yes
Use of a type of pipe other than listed above must be approved by the inspecting
engineer.
3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Styrofoam III or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco,
or equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed
between the final leachfield gravel layer and the native soil backfill.
6. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3%
passing the 4200 sieve.
7. When sand is being used as a filter material, its gradation specifications must conform to
current M.O.A. or D.E.C. requirements, which ever specifications applies.
Page 4
Lot J; Block 1 Tml Krd 9D
September25.2008
INSPECTIONS:
Typically there will be a minimum of three (3) inspections required during the installation of
the wastewater disposal system. These inspections will occur as follows:
1. The first inspection must be conducted after the excavation of ditches, pits,
trenches, or beds and before the installation of any gravel. A septic tank may be
set in place, but may not be backfilled before this inspection.
2. The second inspection must be conducted after the placement of the silt barrier,
gravel, distribution lines, standpipes, cleanouts, and insulation, but before the
placement of any other backfill.
3. The final inspection is to occur upon final grading of the property.
Often there will be more than these 3 inspections required. Especially with the installation of
multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting
engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a
pre -construction meeting will take place on-site. The inspecting engineer will not coordinate,
direct or control in any way the contractors activities.
The owner shall contract with the contractor to perform the work outlined in these
specifications and plans and in accordance with the attached M.O.A. permit. There will be no
contractual arrangement existing between the contractor and S & S Engineering. S & S
Engineering shall be the owner's representative and will inspect the work as stated above to
document the contractors activities. Final acceptance of the contractors work rests with the
owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or omissions of the
contractor or any other persons performing work on this project or the failure of the contractor
to carry out the work in accordance with these construction documents. S & S Engineering's
inspecting engineer will not be responsible for the construction means, methods, techniques,
sequence, procedures or the safety precautions incident to this project.
CONTRACTOR/INSTALLER
GREh ER ANCHORAGE AREA BOh,,UGH
✓,! Department of Environmental Ouatity
3330 C Street
Anchorage, Alaska 09503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME_ .�-^'!-`�c.�MAILING ADDRESS �:,$__c1(•, K,�y.a.� PHONE (09S1—asj
LOCATION l.C�1e • �v., �iU .�. LEGAL OCSCRIPTION
SEPTIC TANK:
DISTANCE/I NUMBER OF
FROM WELL MANUFACTU ER� /MPTERIAL COMPARTMENTS
INSIDE LENGTH INSIDE WI TH . L(Ot1ID DEPTH LIQUID CAPACITY GALLON
TILE DRAIN FIELD:
TOTAL LENGTH
DISTANCE FROM WELL FOUNDATION NEAREST LOT LINE OF LINES
NUMBER OF LINES �� DISTANCE BETWEEN LINES TRENCH WIOTH�L IN. TOTAL EFFECTII
ABSORPTION AREA SO. FT. LENGTH OF EACH LINE
1 .DEPTH Of FILTER i•
DEPTH: TOP OF TILE TO FINISH GRADE _MATERIAL BENEATH TILE I/ r¢. ABOVE TILE < I
WELL:
TYPE CONSTRUCTION
DEPTH OISTANCE FRO
BUILDING NEAREST NEAREST SEPTIC SEEPAGE
FOUNDATION , LOT LINE_. SEWER LINE . TANK . SYSTEM
CESSPOOL , OTHER SOURCES
APPROVED DISAPPROVED
DISTANCES:
INSTALLED BY.
SEWER LINE DEPTH:
PIPE MATERIAL% V.73O3Y
LOT SLOPE: S- w-
ft"Aa ewe.
REMARKS
w
DIAGRAM OF SYSTEM
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5
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7
t•1 t-1 rJ I 17: Tomo'� • F=1 L- I T Y r F F 1 rJ C'- Pill F: F1 C3 E
DEPARTMENT ,F HEALTH AND ENVIRONMENTAL 'ROTECTION
825 'L' STREET. ANCHORAGE, AY. 99501
279-2511
CA r4 I TE=•EIJEF' F•E=F:N1 I T
PERMIT NO. C 77438 )
APPLICANT JIMMY GATO'S BOX 265 E.R. 694-2835
LOCATION LENKtGHHN DR
LEGAL L3 Bi TROLL KNOLL S!BD LOT SIZE 41000 SQUARE FEET
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL EATING <50 FT/BR)= 280
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
E> Em F'TH= oto LE-rJC3TH= vimR & FQ FA %A EL C•EF•TH= 15
THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENrH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS• THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION CIN 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 CIN FEET).
F'EC_ IU1 I F:EC� :=+EF•IF I 3Y IF"rJF< '5 I E= 1C,C=1C-1 UHLLr�r-4
F•I=i 0KFir-iE PL -HINT C}F••T I CA r4
A PACKAGE PLANT MAY BE IN'=TALLED AT THE PERMITTEE'S OPTION SUBJECT TO THE
FOLLOWING CONDITIONS:
1. EITHER A CLASS I OR II NSF APPROVED PLANT MAY BE INSTALLED,
2. A CONTINUOUS MAINTENANCE AGREEMENT IS REQUIRED. IF A MAINTENANCE
AGREEMENT IS NOT KEPT CURRENT YOU MAY BE REQUIRED TO ENLARGE THE SOIL
ABSORPTION SYSTEM AND/OR YOU MAY BE SUBJECT TO PROSECUTION.
----------------------------------------
--- IFL4CA T� 7 I rJ.•F'ECT I HF'E F.*E:oD J I F:EGti ---
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F•EF'rl I T UXF• I F:E� CrE�3Er•IE:EF = Z: 1`_+
I CERTIFY THAT
1: I AM FAMILIAR, WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
_: I UNDERSTAND THAT THE ON-SITE SEWER, SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS.
S IGN A;& 0I� ,�e__
rdtt ✓--------------
AF'F'LI11
ISSUED BY-- �--- `l�="_--------DATE-Ju _1 -7---- V3. 0
V
r..
C.
M
A
eai
a.
MUNICIPALITY OF ANCHORAGE
Department of Health and Environmental',.otection
SOILS LOG
PERCOLATION TEST
Ti)7-11
.,,J
Performed for w^ 64c A -O S • Date Performed G / I � -7 7
Legal Description L,0+ " IS l a r_t e 1 '/ rn I 1 kho 1) Su b
2
6-D
10-.
12 = • �;,
14--
16-
20-
E P, "
4=:16
20 -ER" r
re -1 PtrL rd+tr 2�Sfial6��"'
10rowN gr,.ve,l/y SC V4 uw) pert, r -,-ice n4-4F'Mrn
Ver-)
rBrc Yti�c Z.'1Sf}i�S1fN,
Te, +-, 1 43ePtk C — 1(,1
de,wsc w /CL
110 Wa.•�Or '�"!�blc GtnGOGn}�rc •l '
P6 RI}Te- FRS SotLs 4 oc = 2 L15 Mho,,
Date Net Time Depth Net Drop
0 M h II 2,!N" 0.0 %M
30 . 10 NI B'tf 7.625 rh
0 5.sv ylasiH
130 w,., G,SD
8.25
j Percolation Rate / LJO minute$/1" :r
Performed IIY�. / �� J/t �.� �� u ¢{,_ A. 3&,..s q �
CO 1061
c1 t0 6
ihc1�GS pefc-'?-L
Ver-)
rBrc Yti�c Z.'1Sf}i�S1fN,
Te, +-, 1 43ePtk C — 1(,1
de,wsc w /CL
110 Wa.•�Or '�"!�blc GtnGOGn}�rc •l '
P6 RI}Te- FRS SotLs 4 oc = 2 L15 Mho,,
Date Net Time Depth Net Drop
0 M h II 2,!N" 0.0 %M
30 . 10 NI B'tf 7.625 rh
0 5.sv ylasiH
130 w,., G,SD
8.25
j Percolation Rate / LJO minute$/1" :r
Performed IIY�. / �� J/t �.� �� u ¢{,_ A. 3&,..s q �
MUMUPA UTY OF ', HC OR ,t ME -
Development Services Department ' : '1 Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 05152115000 Expiration Date: J" 3 0 3
1. GENERAL INFORMATION
Complete legal description TROLL KNOLL BLK 1 LT 3
Location (site address) 20473 LEPRECHAN DRIVE CHUGIAK, AK 99567
Current property owner(s) CHARLES CLARK Day phone
Mailing address 20473 LEPRECHAN DRIVE CHUGIAK, AK 99567
Real estate agent
2. TYPE OF DWELLING:
El Single Family ( w ADU
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
E
Water Storage
❑
Holding Tank
❑
Community Well
Q
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5 5 c)
Date of Payment J 3 1)0'�
Receipt Number 5 ��
COSA# 0s5 aac�
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 Eklutna Engineering, LLC Phone 907.406.1058
Address 19162 Mountain Rd Chugiak AK 99567 {
Engineer's Printed Name Curtis Townsend, PE Date J "-0,?z-2- Z
6. DSD SIGNATURE
_ System #1 Approved for 3
System #2 Approved for —
Disapproved
Conditional approval for
0 ."49 h!
bedrooms / •.� •ci,rui'r v�; na.....
bedrooms �� �F . °a1eZ.
CE 11
bedrooms, with the following stipulations:
By: kAu,� a 00 11)-raer
Original Certificate Date: 13 �Oa a
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineers work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
COSA Ghecklist
TROLL KNOLL BLK 1 LT 3Legal Description:
lf more than 1 septic system on lot: COSA Checklist #
A. WELL DATA
n Wett log is filed with Onsite (or attached)
Date drilled
Total depth _ ft
Cased to fl
! Sanitary seal is functioning correctly
! Wires are properly protected
Casing height (above ground)
Date of flow test for
Static water 'at beginning of test
community water
parcelD: 051-521-15
Structure served by this system _
Well production at time of
-gpm
Water storage gallons
Well for coliform test? n Yes fl tto
Coliform bacteria is Negative
Nitrate
-
mg/L n ruitrate less than MRL (ND)
Arsenic
-
ug/L n Arsenic less than MRL (ND)
Collected by
Date of Sample
of
ft
B. TANKDATA
Age of tank(s) 45 years
Tank type/material sePtic
Measured operating fluid level in septic tank I
E Standpipes/foundation cleanout per record drawing
Date of PumPing 512012022
D. ABSORPTION FIELD DATA
Which system tested (date ihstalleol 2009
E nll standpipes present per record drawing
Total measured depth from grade 11'3 1 16sx;
Measured depth to pipe invert from grade ft (min)
E run - pressurized field
E Monitor tubes go to bottom of effective. lf not, state
depth into effective
E Code-required soil cover over field
n System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced
-gallons
Comments/Deficiencies:
C. LIFT STATION
fl Required maintenance completed
Age of lift station 14 years
Lift station material Plastic
Comments:
Adequacy test date 5,tat2o22
Results I eass For 3 bedrooms
Fluid depth prior to test 64 in
Water added 451 gal
New depth 70 in
Elapsed time jS mrn
Finalfluid depth 64 in
Absorption r"," >450 gpd
Any rejuvenation treatment (past 12 months)
lf yes, enter date
no
COSA Checklist yellow sheet
E. SEPARATIONDISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot : 100'
E Yes
Neighboring Tank > 100'n Yes
Absorption Field on Lot > 100' ! Yes
Neighboring Absorption Fields : 100'
ifNo-ft
ifNo-ft
ifNo_ft
ifNo_ft
ifNo_ft
E Yes if No
@ Yes if No
EYes ifNo-ft
EYes ifNo-ft
EYes ifNo-ft
Tank > 100'
Private Wells > 100'
Community Wells > 200'
Community Sewer
Yes
Line>25'EYes
E yes
E ves
ifNo-ft
ifNo-ft
ifNo-ft
ifNo-ft
Building Foundations > 10'
Property Line > 5'
Absorption Field 2 5'
Water Main > '10'
Water Service Line > 10'
Community {zs' n ves
Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Animal Containment > 50'
Manure/Animal Excreta Storage > 100'
flYes if No
Surface Water > 100'
Wells on Adjacent Lots:
Private Wells > 100'
EYes if No
-
ft
flVes if No-
Community Wells > 200' fl Yes if No
-lf septic tank is under driveway comment below
lf absorption field is under driveway comment below
Wells on Adjacent Lots:
EYes ifNo-ft
EYes ifNo-ft
ft
ft
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' E Yes if No
-
ft
Property Line > 10' fl Yes if No
-
ft
Water Main > 10' El Yes if No
-
ft
Water Service Line 2 10' E Yes if No
-
ft
Surface Water > 100' El Yes if No
-
ft
F. ENGINEER'S COMMENTS
G.
COSA Checklist yellow sheet
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water &Wastewater Section ` Phone: 907-343-7904
Fax: 907-343-7997
Lift Station/Pump Vault
Maintenance Log
Owner l �� `� Street Address
Septic Tank:
-Sludge level � inches
Pumping: required es -Pumping completed yes no
Lift station:
*Pump basket cleaned e no *Effluent filter cleaned 441e3r no
*Control floats cleaned e no -Proper float settings confirmed no
*Operation satisfactory es no
Alarm System:
*Dedicated electrical alarmcircuit e es no -Audible and visual alarm inside dwelling no
*Alarm system operation atisfacto not—fig-
Manhole Riser
-Ground water intrusion at riser to tank connection es o
-Ground water intrusion around pipe penetrations es
-Manhole lid: Functional 9 no Insulated yes o
Other
OeWeep hole functionalno
Properly Secured es no
*All manufacturer required inspections and maintenance completed Q no
Comments:
Qualified Maintgjnance � iTechnicia[n) Date of maintenance_�_ 2-6--Z
'ompany �5 e,Signature
. r .'
• '� Municipality of Anchor a e A` ' 91 9 2016
On -Site Water and Wastewater Progra 6-
(907) 343-7904 ? ,
Certificate of -On -Site Systems Approval
Parcel I.D. 051-521-15
1. GENERAL INFORMATION
Complete legal description
Expiration Date:
Troll Knoll. Block 1, Lot 3.
Location (site address) 20473 Leprechan Drive
Current Property owner(s) James M & Laura B Macnell Day phone
Mailing address
Real Estate Agent
20473 Leprechan Drive. Chugiak, AK. 99567.
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual
FX I
Individual Water Storage
❑
Holding Tank
❑
CommunityClass'A Well
ll
Community
❑
Public Water System
❑
Public Sewer
❑
WaiverNariance request for:.
Received by: 7 G/. i` Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5a't
Date of Payment
Receipt Number OJ71 C'7
COSA#_ 66C/61-312
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal rand 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.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations. The reported results describe the performanceof the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil
condition; ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone
6. DSD SIGNATURE
Phone (907) 272-8218
Date 8/29/2016
—P– System #1 Approved for bedrooms � • S3even W. anrio�
r CE -8149
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
Original Certificate Date: R'_
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
COSADIuesheOS :., c
- If more than 7 septic system -I&on the lot:
COSA Checklist # + of 1
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: -Troll Knoll. Block 1, Lot 3.parcel ID. .051-521-45
A. WELL DATA
Well type Class A If A, B, or C provide PWSID # 210778 Well Log (Y/N) .
Date completed Sanitary seal (Y/N)_ Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of"test
Static water level ft. ft.
Well, production g.p.m... 9.p:m.
i
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate': mg/L
Arsenic ug/L Date of sampler Collected by:
B. SEPTIC/HOLDING TANK pArA
Tank Type/Material Septic/COnCrete Date installed 6/27/1977
Tank size 1000 gal. Number of Compartments 2 Cleanouts (YIN) Y
Foundation cleanout (Y/ly). Y Depression over tank (Y/N). N High water alarm (Y/N)
Date of pumping a6 d 'ac t (' Pumper n , +
C. ABSORPTION FIELD'DATA
10/2/2008 z z Oa g.p.d,/SF � Deep Trench
Date installed - Soil rating (g.p.d./ft or ft 7bdrm) System type
Length 47 ft. Width 3 ft. Gravel below pipe 18 #:
iE
Total depth 11.3 ft. Eff. absorption area 752 ftz Monitoring tube Y_. Depression over field N
Date of adequacy test 8%25/2016 Results (Pass/Fail) . Pass For 3bedrooms
Fluid depth in absorption field before test 42 " in. Water added 4'50 58
p p gal. New depth in.
Elapsed
Time: 465 min. Final fluid depth 42 in. Absorption rate >= 450+ g,p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date
D. LIFT STATION
Date installed 10/2/2908
Size in gallons 280
Manhole/Access (Y/N)
"Pump on" level at i�Q in.
"Pump off' level at % in. High water alarm level at' T �/
1> ' in.
Datum T
Cycles tested 5
Meets alarm & circuit requirements? Y
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot
On adjacent Igts
Absorption field on.lot
On adjacent lots
Public sewer main
Public sewer manhole/cleanout
Sewer /septic, service line
Holding tank
Animal containment areas
Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+
Property line 5+
Absorption field 5+
Water main�+
Water service line
10+ Surface water 100+
41
Wells on adjacent lots 200+
ABSORPTION FIELD ON LOT
TO:
Property line 10+
Building foundation 10+ Water main 10+
Water Service me'3 0+
Surface water 100+
Driveway, parking/vehicle storage '10+
Curtain drain 50+
Wells on adjacent lots
200+
F: COMMENTS
f.
Survey on File.
�� o� ��Y;d
;.•c f(04f"o
alel -Pe !d pPi r-ec.e"l rjlr
G. ENGINEER'S CERTIFICATION
I certify that t have determine.4 through field inspe�Qrtq and
review of Municipal records that. the .above ` systems are in
conformance with MOA COSH guidelines in effect on this date.
Engineer's Printed Name Steven Pannone
` 8129/2016
Date
(;OSA canary sheet_2-6-15.doc
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.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. S COSA #
Expiration Date:
1. GENERAL INFORMATION
Complete legal description
Location (site address) 'L ClCurrent Property owner(s) �O/Q 05Z PG19 C' Day phone 46?0, 4ZS-
L
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day
Day phone
unless otherwise requested, COSA will be held by DSD for pickup.
3
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
❑
Individual Water Storage
❑
Individual Holding Tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
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
Engineer's Printed Name
5. DSD SIGNATURE
�G Approved for S bedrooms.
Disapproved.
Phone 6%—Z4%%�!
hk 994-6
Date 4z97/_09_ g O9f
r A
•..
'
`t
••• a it Sdol� '
• 1437-E
; •A�i
Conditional approval forbedrooms, with the following stipulations:
Attachments:
COSA Checklist X Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory S I
upp ememal Engineer's Report
Nitr Advisory Other
By:AWA� —
(R•r IIM)
Original Certificate Date:4dV
Municipality of Anchorage
-r-'� Development Services Department -
�1�__Building Safety Division
s. ...
On -Site Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.orglonsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: L 3$�cxy I %—iP�Lt h/7 �-` Parcel ID: �� I — So? I—%S
A. WELL DATA C� Nr r"14/✓1 T 00%%0
Well type A If A, B, or C pfbvide PWSID # _ Well Log (Y/N) —
Sam a a Y!N irps properly protected (Y/N)
Date completed _ ry tJ �--
Total depth ft. ased to ft. Casing height (above aroun 1'�in
FROM WELL LOG AT INSPECTION
7Date
Static water level tom_ ft.
W ion g.p.m. m.
1'OATER-SAMRLEB SULTS:
Coliform colonies/iD0 mL Nitra elm Other bacteria colonies/100 mL
e.ennir• date of sample: _. Collec aby'�—
B. SEPTICIHOLDING'TANK DATA
Tank Type/Material t_e ''�Z Date installed G
Tank size 000 gal. Number of Compartments 2 Cleanouts(YI) � S
Foundation cleanout oY N) �S Depression over tank (Y/9 NV High water alarm
Date of pumping + Pumper ,'2 O y1t� G v
C. ABSORPTION FIELD DATA/ ,
Date installed �0 1-- 0 9 Soil ratin (g.p.d./ s or fe/bdrm) �� 6
Ln th 4- 7 ft. Width 3. D ft.
System type P c
Gravel below pipe a ft.
e g GtJ�
Total depth _fl.I�'/S✓• �% Eff. absorption area%6 Zft� Monitoring tube �?
Date of adequacy test e 1 C) Results (Pass/Fail)
Fluid depth in absorption field before test, =in.
Elapsed Time: --min.
Water added� gal.
Final fluid depth — In.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Depression over field ALO
For ,3_ bedrooms
New depth= in.
Absorption rate >= g p•d•
�^ If yes, give date --�
D. LIFT STATION
Date installed
"Pump on" level atl-6—in.
Datum
E. SEPARATIO DISTANCES
Size in gallons 2.g D Manhole/Access�(Y N) _e -CS
'Pump off" level' at 6 High water alarm level at in.
Cycles tested 3 Meets alarm & circuit requirements? i/ e c
SEPARATION DISTANCES FROM WELL ON LOT TO:
on lot
Absorption field on lot
Public sewer main
Sewer /septic service
/V//1 60 In KI
On adjacent lots
On adjacent
sewer manhole/cleanout
Holding tank
Animal c event areas Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/F16 TANK ON LOT TO:
Building foundation _L_ property line �/ � Absorption field_ 6 f
Water main L7 Water service line �� />`' Surface water /00 r7�
I
Wells on adjacent lots X00 >< 20fl �
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
/0 /
Property line c� f- /
P rtY ..y- Building foundation � Water main �O �
��% r /O
Water Service line 3L Surface water ��� � Driveway, parking/vehicle storage l %f'
Curtain drainA)OMF— K Jt7Gt) #d ' r
IIs on adjacent lots �" ZD � �-
COMMENTS
U►JIT /c EOOv� d FA?a f F X/ST//✓� LOrvC✓c
G. ENGINEER'S CERTIFICATION 0/0 EF/U/ �J it /N 7//IF %!ZGO.V f)
I certify that I have determh
review of Municipal records
conformance with MOA COS/
Engineer's Printed Name
Date A)AV
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
field inspections and
2
C
nw
Waiver Fee $ ' -.1 ` ' ,.
Date of Payment
Receipt Number
fl'
I
ASBUILT—NO CORNERS SET THIS
DATE. SEWARD & ASSOCIATES LAND SURVEYING 6RR-4561,
i HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
'roll Knoll Subd.,Lot 3,Blk. 1
f,ND THAT NO ENCROACHMENTS EXIST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
TUNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
VHICH DO NOT APPEAR ON THE RECORDED SUBDI-
IISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
%NY DATA HEREON BE USED FOR CONSTRUCTION
FENCE LINES, OR FOR ESTABLISHING BOUND -
MY LINES.
SCALEr
1"-40'
����`
' •
'•..�� •. s�f-Cf
r�Q
'9T—Es
7-25-90
,
't• J n•..
i.
GRID:
NW 1360
0. . a-
�• DYM* MMS' S,M�rA
1 �'. LS -s9
yf
FB
13-42
4 /0 /
DRAWNr
�w�
11
MunicipaUty of Anchorage o
• Development Services 'Department �'��
_ Budding Safety Division • . , ,,;
: ;• On Silo Water and Wastewater Program
:: t • . 4700 South Bragaw SL' : • • • "•
....P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchorage.okus '
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY -APPROVAL
FOR A SINGLE FAMi&DIIVELLINi3
Parcel I. .).051=521^15 HAAV--- 14A 6%009191
r. •. -.�: Expiration Date:
1..GENERAV INFORMATION `.'•'
'a ` Lot 3, block' -I, Troll Knoll Subdivision
Complete legl descpption
Location (site address ordirections) • 20473 Leprechan Drive
Current Property.owner(s)Jeff Duhrsen
"•``�� .20473.Leprechan
Mailing address
Lending agency
Mailing address
Dayphone•• 688-3036
Dr1ve0.Chugiak;.AK•99567 '••.i
Day phone
Real Estate Agent Remax/Sharon ttinsch Dayphone 1;cgL-49nn
Mailing Address 16630 Centerfield Dr., Ste 201, Eagle River; AK 99577
Unless otherwkerequested, HAA wJ7lbeheld byDSDforplckup.� Ltr..... '540/e/
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class A Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
❑
Individual On-site
❑
Individual Holding tank
❑
Community Onsite
❑
❑
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 5 by an Independent professional civil
engineer registered In the State of Alaska. Cert ficates 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 endfor water
supply system. DSD also Issues HAAs upon request to homeowners. CerGricates of Health Authority Approval are
valid for 90 days from the date of Issue for propertes served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates ere valid for one year for properties served by Class A or B wells or a public
water system. The lluniciparity of Anchorage is not responsible for errors or omissions In the professional
engineer's work
r
4. STATEMENT OF INSPECTION I3Y 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 disposaf system Is(are) safe, functional end adequate for the number of
bedrooms end 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 instattation.
S 6 S ENGINEERING
Name of Firm 17034 Eagle River Loop Road No. 204 phone &I r/ "3—' 7 y
Cagle xlver, AlAska 49377
Address
Engineer's Printed Name-` Robert C. Cowan, P.E.
S. DSO SIGNATURE
_/f Approved for �✓ bedroom:
Disapproved.
Conditional approval for neeroorns, min tine following stipulations:
Date
Additional Comments
Attachments:
HAA Checkfist X
Septic System Advisory
Well Flow Advisory
By: /tl.
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
BWWV Safety Division
on -eft Water a wastewater Program
47W Soca, Braoaw SL
P.O. Box 196850 Anchorage. AK 69519.6850
www.dAnctlorage.ak.us
(907) 543.7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L4Or'3 ;73crx rL I ; TV—n l -L 1640-11--L. mat w:105 -i —Sz 1
A. WELL DATA
Wen type
Date completed
Total depth ft.
Date of test
Static water level
Well production
WATER SAMPLE
WPM
if A. B, or C proves PWSID a Z4 oj-?$ wee fog (rlN)
son" Seel (YIN) _
Cased to fL
FROM WELL LOG j
6.p.m.
00 ml. Nitrate ffW.
prem (YM) . .
Casing height (above ground)
AT INSPECTION
ft.
Other bacteria cdon;Wig,
B. SEPTICIHOLDINO TAA/N-KTA /_
Tank Type/Materfiad &r/5!,077C,14,/yM.*W Data installed �i�//7�
'rank size �gal Number of Compatrnmlb Cleanoub�4T1) / C�3
Foundation deanout�Y t)J�K Depression over tank (YVA6D High water alarm (YM) )V/jn
Date of purnping S�Do Pumper ir;;bq� I T nw Y
C. ABSORPTION FIELD DATA ''� feA� tJ N Ir
Date installed Soil rating (g.p.d.1W or l 9 1. eg System type I� 96WCH
Length 43 >t Was, 4160
.ft- Gra ei glow pipe
Total depth l.__ ft. Eft.. absorption area 9 N6 fP Monbring lube Ysl Depression over fleld 4
Date of adequacy test 3 ! q �o ! Resultst�ss aa) 9 r For 3 bean
Fluid depth In absorption field before test] r� ~ln. Watx addadYJ-JLgar. New depthia
Elapsed Time: 30 min. Final find deptin o In. Absorption rate >- 115-0 I
Anv rwkrvwnatinn Iro4*tnu t rnn%t 19 rrv.1 NM It tv I IVOP't AC4aQWN If v rj.,-,t.#- —
D. LIFT STATION
Date instatled
'Pump On, level at
Datum /
Size in gallons ManhoblAccess (YIN)
'Puunp ff levet at _ b. High water alarm levet at in.
Cycles tested Lew *farm 6 dpwlt requirement?
E. SEPARATIOR DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: C�-7ML/ N 17Y
Sep@c tanIm etetkA Wn lot ?VO +- On adjacent bb
Absorption field on W ZBO - On adjacent lob
Public sewer main "IA Public sewer manfwle/dno
eaut
Sewerrseptfc service Ilm 'L5 �'f'" Hatdinp tank
SEPARATION DISTANCES FROM SEPTIC44OHMO TANK ON LOT TO:
Building Wx1adon 67 '1 Property Nns 57 Absorption field
Water main / O 'f-- water service tine / a7 Surtaee water
Wefts on adjacent lots 2dd f *-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Properly line /O Vii- Budding foundation /0 'f Water main
water Service Ilrro /O r-4- Surface water /X - Wnway parklrol hWa serape /Q /i -
Curtain drain.4/4W-4VOA'/A/ Web on adjacent lob �za'4-
F. COMMENTS
O. ENGINEER'S CERTIFICATION
h ww.y.� t •y. -0 AL
/ eerrHy that 1 have detemthted auotpr, Recd ktspecRans an1%
e ,a �
review of Municipal records fief The above systems ars In A
conformance wrth M04 HAA QuA*bws lir egad on this dare. T•" rte'" `''
R1
Engineers Prkrted Name RO AtAT G. C6#04.J '0'-.
COWAN •,f`
�i CE •8801
Dat.
HAA Fee E 3 00, = Waiver Fee S
Date of Payment 34- & /C / Date of payment
Receipt Number 0 o r 9/ p Receipt Number
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services low
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. f! C' tl HAAJI 1�tiY1L-( Il�� 1
1. GENERAL INFORMATION
Complete legal description Lot 3; BPock 1; TkoY.t'KnoP,Z SuLd%v.E6•i.on
Location (site address or directions) 20473 Lepae.chan Drive.
Ciuig.iah, AK
Property owner L.J. Evans Day phone 688-5619
Mailing address CIO Rema- o6 Eagfe. R.iveA 16600 Ce.nteAAietd Viti.ve. Eaafe. R.fveA, AK
Lending agency
Mailing address
Agent Shakon Min6eh/ Remax o6 EaaPe. R.ivvt
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3 k4
3. TYPE OF WATER SUPPLY:
Individual well
Community well XXX
Public water
Day phone
Day phone 694-4200
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
XXX
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.
72-023(R".1/21( F,.l MOAR21
S. 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 furtherverify 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.
5 3 5 ENGINEERING
Name of Firm —17W4 E0111s 116W -Le "02d No-.204Phone %
Address Eagle River, as a 99S77
Engineers signature 70V I�?r-- Date 3 -7 / C (
6
11
r+ �'� ROBERT C. COWAN
+
CE -8801
6. ,,DHHS SIGNATURE
(t,+1ZCj P11��
wr:H'h Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
By: �Gl j}��I l"v (l �L(��I Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an Independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending Institutions In order to satisy 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 engineers work.
nan Rw. wq Bain MOA D21
1
—� Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
8250L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 3434744
i
Health Authority Approval Checklist
Legal Description: La -r' 31 19 t-oc.v. t %ReL t Parcel I.D.:
KACLL. e10
A. WELL DATA
Well type Q If A. B. or C. attach ADEC letter. ADEC water system number -Z)0.7-78
Log present (Y/N) — Date completed
Total depth Cased to r Casing height (above ground)
Sanitary seal (Y/N) Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION 9
Date of test - z
i Static water level ^ ;:0
wa. oNo O
i Well production g.p.m. g.►aN z
WATER SAMPLE RESULTS: r n
Coliform `— Nitrate Other bacteria `— v ` £
u 6
Date of sample: Collected by: "— R
B. SEPTIC/11OLDING TANK DATA
Date installed L - Z 7 --17 Talc sire 1000 Number of Compartments _ Clamouts &N) Y
I
Foundation cleanout (TIPM Y Depression (Y,® IJ High water alarm (Y/A) a /A
� Date of Pumping l o - IM -4S Pumper
J. R fjIm Ito (:v
C. ABSORPTION FWLD DATA
Dateitutailed (,--L-7-77 Soil rating (g.p.d./ft'orft'/bdrm)2-90 ystemt)'pe 'TleaOC14
Length N m Width u Gravel thickness below pipe /1 1 Total depth I (� t . r
E17'ective absorption area q4 L Monitoring Tube present(g7N) Y Depression over field (Y® N
i
Date of adequacy test 9 -7L -'V(- Results ail) PP -SS For 3 bedrooms
Fluid depth in absorption field before test (in.): 611 Immediately afteryw gal. water added (in.):
i
Fluid depth (ins.) Minutes later: 100 a,A Absorption rate = Zf R47 X.p.d.
Peroxide treatmen (post 12 months) (Y/N) cls Kra If yes give date
i/L-7/77
FRIM A IM I/iGrrON Rt.'/4T, nGNITIA,. C T✓6t Mf.45/440 40,41LO A 1n*r4Ly
11 OfN r T*P c -I SI-vaFC _ FL -a DiPrM n4-4Ja4t'+OF- rS IN 9.P G OP: 6/41"'L,
D. LIFT STATION
Date installed Size in gal
Manhole/Access (YM) �ttn on" level at"
..Pump off' level at*
High water alarm level 'Datum
ted
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON IAT TO:
Septic/holding tank on lot 7-001 f , On adjacent lots /
Absorption field on lot Z 001 f JFLA7-oQo
Jalt`(
Public sewer main Ve Public sewer manhole/cleanout
Sc service line 7S 1 Lift station
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
1
Building foundation i Property line l o t-+ Absorption field lot
Water main/service line I D t{ Surface wateddtainage /oo t f Wells on adjacent lots Z oo t t
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation 7-V r Water maidurvice line lo, I+
Surface water too' P Drivewav, parking/vehicle storage area 150'+
Curtain drain to ' + Wells on adjacent lots loot 4 Property line 1 o It
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of.Wai icipal recce
in conformance with
MOA HAA guidelines in effect on this date.
Signature '7/"' L• '_n�.�
Engineer's Name Ii�OB ER r (f _ Ce M/d.J
Date 3 d 7 4
.o
HAA Fee s, 3 ted s- Waiver Fee S
Date of Payment 3 Date of Payment
Receipt Number a /7 3 41 �. Sid) Receipt Number
Rev. 8195 OSS: haa.wk.doc
MUNICIPALITY OF ANCHORAGE
!/Department of Health & Human Services e
• V DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcell.D.# HAA#
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 3: Block 1: Troll Knoll Subdivision
Location (address or directions)
2041 r.Pprpchaun Drive. PPtPrs r`rPPk. Alaska
(b) Property owner HIM 4111—O10177 Telephone: (home) Business
Mailing Address
(c) Lending Institution Telephone
Mailing Address
(d) Real Estate Company and Agent ASSOCIATED BROKERS/Sandy
Address 640 West 36th Avenue, Anchoraqe, Alaska 99503
Telephone 563-3333
(e) Mail the HAA to the following address: (or check here ®, if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING/694-2979
17034 Eagle River Loop Road, Suite 204
Eagle River, Alaska '99577
2. TYPE OF RESIDENCE
Single -Family IO Number of bedrooms
11
3. WATER SUPPLY
Individual Well ❑ Community IR Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site 91 Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Aft. 7/W) Page 1 of 2
it. �7.i:.:rw"lr'in>C__.. FLA�i'S:aka ::: uiCblx.Fx4: •....,..J: ..'er... b..r... .. ....-.�...-.... ....-.. ....--..-...........-r w.«. feta..... ....�.wr�: v.:.L :...R.x.
S. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the 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
Address 5 3 5 ENGINEERING
17034 Eagle Niver Loop Road No. 204
Date Eagle River, Alaska 99577
6: DHHS APPRO?AL
Approv=d for bedrooms by
Approved Disapproved
Terms of Conditional Approval
1
Telephone e12 fY-' Zf,�? �
//11 / o
0-s"I A :Nwkr
Ko. 1177.9
7,,!,, < /I-Ile-4-eeDate 7
Conditional
The Municipalityof Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above byan 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 orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
oranalyzedata beforea certificate is issued.The Municipality of Anchorage is not responsible forerrors oromissions
In the professional engineer's work.
72-025 (R". 7i88) Back Page 2 of 2
UNICIALITY OF
• �\ `Heath Authority Approval( AA) OA)
CHECKLIST- FEBRUARY 1984
c�QN,�►OSE 343-4744
Legal Description*
A. WELL DATA QQ C
Well Classificatio;R. A
Well Log Present (Y/N). Date Completed
Total Depth Cased to Depth of Grouting
Static Water Level
If A, B, C, D.E.C. Approved (Y/N)—
Yield
Pump Set At
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring In Conduit (Y/N) Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL: '
i
To Septic/Holding Tank on Lot .2-00 f ; On Adjoining Lots
i
To Nearest Edge of Absorption Field on Lot .2 t ; On Adjoining Lots
To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results y
Comments � II r� NA W A lir
B. SEPTIC/HOLDING TANK DATA
; Date
41y4L'M
Date Installed --23-73 Size 1000 No. of Compartments z
Standpipes (Y/N) 4 Air -tight Caps (Y/N) i Foundation Cleanout (Y/N) y
Depression over Tank (Y/N) 0 Date Last Pumped 1— q D
,Pump ing/Maintenance Contact on File (Y/N) SIA ; for d1A
Holding Tank High -Water Alarm (Y/N) IIIA Temporary Holding Tank Permit (Y/N) /v/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
� 7
To Water -Supply Well 7 t To Building Foundation
i
To Property Line V) t To Disposal Field /0
To Water Main/Service Line /0 f
To Stream, Pond, Lakee or Major Drainage Course
Comments �'ei I/G PJMPCd 11 tZ �PS�S'QOO/ PJM`DfNS
72-M (A r. 7M) Front Page 1 of 2
C. ABSORPTION FIELD DATA
7
Soils Rating in Absorption Strata Z 80 /�(1 Type of System Design (PEtiL^ �1
Date Installed Ip - 2 - '�-7 Length of Field
Width of Field 4b Depth of Field / 7
Gravel Bed Thickness ►
i
Square Feet of Absortion Area 94 6 Statndptpes Present (Y/N) h
Depression over Field (Y/N) Al.� [ Date of Last Adequacy Test
Results of Last Adequacy Test SQA I r ,, {A� ,I -o - 3 Ae-d POOM
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well 7,00 t To Property Line /0 t
i
To Building Foundation O To Existing or Abandoned System on
i
LotN ✓� ; On Adjoining Lots O t
r
To Water Main/Service Line / n t To•Cutback (if present) Adfl
To Stream, Pond, Lake, or Major Drainage Course A/✓a
To Driveway, Parking Area,/or Vehicle Storage Area
Comments t�: / _ ,P,,,,. �Cn��.,+,,, ili< �i✓�no.�
D. LIFT STATION
Date Installed \
Size in Gallons
"Pump On" Level at
High Water Alarm Level at 1
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N) `
• "Pump Off' Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test.
"Check Permitted Bedroom Rating Against HAA Request"
I certify that I have checked, verified, or conformed to all MOA and HAA guidelh
inspection.
Signed S 6 S ENGINEERING 4!i
Company 17024 Eagle River Loop Road No. 204 � -A
Eaala River, Alaska 49577 p D 00
Date
MOA No.
Receipt No.
Date of Payment
Amount: $
724M (R". 7/W) exk
t
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
date of this
tial
N.. 1A574 f. ;
Seat
r - SQ E OF
R COWPER, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
S & S Engineering
17034 Eagle River Loop, Suite 204
Eagle River, Alaska 99577
ATTN: ROGER SHAFER
April 17, 1990
PWSID: #210778
563-6775
According to the records on file in this office, the Troll Knoll
Subdivision Water System is in compliance with the State of Alaska
Drinking Water Regulations.
Sincerely,
E)
ERA E. A E. C�,
VCRAIG
Environmental = fficer
VEC:bas
� n
" 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 l�/-��/ Z f'
1. GENERAL INFORMATION
(a) L>e��g,aalpl De�scription (include lot, block, subdivision, section, township, range))
Location (address or directions) XT Q
(b) Applicant Name/��_ Telephone: Home6rr- 9W 7 Business
Applicant Address,4� S`3S 7
(c) Applicant is (check one): Lending Institution O ; Owner/builder E1; Buyer ❑ ;Other ❑ (explain);
(d) Lending Institution, ee* • jtv e%7cO%Tfryc-Telephone
Address C�?d �• �i a 5� �/ c �/ lG+� -
(e) Real Estate Company and Agent o /-/
Address
Zqep one
(1) a HAA to the following address:
S E i EENGIH EWN" ,
pH. s9�-?97rJ
2. TYPE OF RESIDENCE
Single -Family Multi -Family ❑ Other
Number o1 Bedrooms —3
3. WATER SUPPLY
Individual Well 13 Communit * PublicV_
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite Public 13 Community O Holding Tank 13
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2
t
72-025 411,84)
a
It
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm E 1 L`:G'%Lg€,1:IR
Address E_R133 /133GGK
L I�N.r ji'V Ii nY`�'1 Y�d11
Date PH._6'J4-2y7J
6. DHEP APPRO rL/ r ��
i
Approved for Me�/ bedrooms y
Approved Disap tied
Terms of Conditional Approval
Telephone
^40 6, RP/fOFE
Date
Condional
CAUTION
J
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 homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (1 V54)
MUNICIPALITY OF ANCHORAGE
^ DEPT. OF HEALTH d
f } ENVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
1"P Q G U),
CHECKLIST - FEBRUARY 1984
264-4720 R E E 1 V E D
Legal Descri tion: L-= 3 1&4— 1
A. WELL DATA
Well Classification A If A. B, C. D.E.C. Approved ®N)
Well Log Present (YIN) Date Completed Yield
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (YIN)
Separation Distances from Well:
To Septic/JA"ng Tank on Lot
To Nearest Edge of Absorption Field on Lo
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments iSDrr-✓ �.a1^+�+�
De h of Grouting
A , Pump Set At
1" nSanitary Seal on Casing (YIN)
Depression Around Wellhead (YIN)
it
On Adjoining Lots
t ?1011D ur `�; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
/ ; Date
Wa iv r s e-- ; is IF
B. SEPTIC/MOLDING TANK DATA
Date Installed Size Dexo c,A_ No. of Compartments
Standpipes (ON) Air -tight Caps CPN) Foundation Cleanout ON)
Depression over Tank (Ya
Pumping/Maintenance Contract on File (YIN)
Holding Tank High -Water Alarm (YIN) A
Separation Distances from Septic," leldingTank:
To Water -Supply Well _21-� Ii, �
To Property Line VC, 4 -
To Water Main/Service Line Il O IA -
Course
A -
Course N
Yate Last Pumped q-3 nc5 1_-
"1 /A ; for
N
Temporary Holding Tank Permit (YIN)
To Building Foundation ,7
1
To Disposal Field %/C>
To Stream, Pond, Lake, or Major Drainage
Comments TH,S lS P' -J%:r -, c.. (sem
\OJ L -n t.. -ti L P'.% CJ'_ 1 1
Page 1 of 2
72-026(11/64)
C. ABSORPTION FIELD DATA y e
Soils Rating in Absorption Strata 2�f3oPirt� Type of System Design Tn'" "-N
Date Installed 1, -27 -r7 -7 Length of Field 4-6,
Width of Field Depth of Field V6
Gravel Bed Thickness % 1
Square Feet of Absorption Area ��� Standpipes Present (DN)
Depression over Field (Y/19 Date of Last Adequacy Test g -14 -86' �
Results of Last Adequacy Test l✓� r't s>z�-c�t v*r 9 L --
Separation Distance from Absorption Field:
To Water -Supply Well
To Building Foundation
?�>
Lot a rn
To Water Main/Service Line tom.
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION _
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
.', To Property Line I, 4=—> t 4--
To
"
To Existing or Abandoned System on
On Adjoining Lots �'�%4-
TA Cutbank (if present)
�A
Dimensions
Manhole/Access (Y/N)
\ "Pump Off' Level at
N R Vent(Y/N)
f Pumping Cycles during Adequacy Test. Meets MOA
'• Check Permitted Bedroom Rating Against HAA Request ••
1 certify that I have checked, verified, orconformed to all M A an,0 HAA guidelines in effect on the date of this inspection.
Signed Date j%8 S
tBRe yscx
Compitookr i�NFR � MASA 'fir MOA No. e — o+ ?
ReceiptNo. = Q
Date of Payment �
`/K� i n •,
Amount: $ '
Page 2 of 2
72-026 n 1184)
.............
to A. Sha y
PW. 1457E _ ••: N
• \\ U W� � � � LJ ` � I (J l \\ W I (} 1 BILL SHEFFIELD, GOVERNOR
DEPT. OF E�JNVIRON"ENTALL CONSSEV�RVATIOON reiepnon.: 1s07)
Addmu:
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303 274-2533
ANCHORAGE, ALASKA 99501
DATE: R- U4 --SSSS.
PWS I.D.A Z 10770
To Whom it May Concern: jf _ /,�
According to records on file in this office the TvOl) I! S/P
Water System is in compliance with the State Drinking
Water Regulations
Sincerely,
-00^ i
September 9, 1985
Robert N. Jesser
SR 2 Box 4246
Chugiak, AK 99567 /
Lot 3, Blk. 1 Troll v/
Knoll Subdivision
TO WHOM IT MAY CONCERN:
m"zN0PXzUTi6' cm, ,k1VZ
mbPT. *ft- y GORAC,ac
� 7EIYiti PROTECTION
RECEIVED
This letter is to confirm that once a year as a preventative
measure the septic was pumped on the following dates:
September 1984
September 1983
November 1982
November 1981
In addition, the pump and motor were cleaned on those dates
and sprayed with an anti -corrosive material. The pump and
motor are approximately four years old and were observed
functioning by the i4 & S Engineer when the system was pumped
and tested in September 1985. (Sanitary Pumpers were used
for service.)
APPLI(-`NT FILLS OUT UPPER HA" � ONLY
Fr�operty�wner - Phone
Q0 `► LI>nc(cA- ,lesser
Mailing Address r�ZIP Code �y / 7/_% �Y//7
Buyer ' //�//�� V/
Address / ( / /i/i 0% AA Zip Code
Lending Institu Ion / _ r �"�'�� /. Phone
Address 77' Zip Code
Realty Co. d Agent X � /f / Phona
Address1,7,1). S(y Zip Code 6y y
/ Z
Legal Description 7-1611 /G // i--
K Sr,,� • �G K
Street Location
C—
T pe of Residence
Biagle Family
O Multiple Family
No. of Bedrooms_
❑ Other
Water Supply
❑ Individual
ATTACH WELL LOG. A well lop Is required for all wells drilled since June 1975.
Community
For wells trilled prior to that date. give well depth (attach log if available).
❑ Public Utility
Sewer Disposal
'JRUndlvidual
Year Individual Installed: O
O Public Utility
When Connected to Public Utill y:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Date
Inspector
Field Notes: 1
1
( PROVED BEDROOMS
( I DISAPPROVED
( I
CONDITIONAL APPQOIVAL•
DATE % k Y+/^ EiSi
BY:
Soils Rating
non Cann
Time Tim Time \Y,
Clt�t ��c rn a
Date Date Date UU
Inspector Inspector Inspector
MUNICIPALITY OF ANCHORAGE
COPT. C° Yc'U" A
ENVIR'�IL.:ct:CA- 1.t0•ECTION
0 1932
RECEIVED
*CONDITIONS OF APPROVAL
Date Sewer Installed
Well To Absorption Area
Well to Tank
Well Lop Received
Septic Tank Size —y T -el-