HomeMy WebLinkAboutLAKE O THE HILLS BLK 1 LT 1Lake O' The
Hills
Block
Lot 1
0�
#015-331-20
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program. 4700 Bragaw, St.
P.O. Box 196650 Anchorage. AK 9951"650 Page of
www,ci.anchorage.ak.us (907) 343.7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number-SW0503--+ PIDNumber: 015--331-2-0
Name CO f34ScH Wastewater System: ❑ New [IUpgrade
"°°rasa
tlZ.Ot MpL.n �Z�evL l4kG I�r�JG
ABSORPTION FIELD Sxs jig
i
Pn Neosar Of Beaoanf
o 0"P Trench 0 shallow Tr O Bea O Maatd O o1w
Sal Ratvq
Tolr D"M trap arpm,l crab
LEGAL DESCRIPTION
GPDIF?
Ft.
$WdMspn
BbaL La �1
Dn to pipit Dan ortrap mgv trade
pt
Greap
val d" DaneaM pip.
1
1 �A�E D' �K I�II'S SID
FI.
FI
Tonrup Rate S«dan
F° added eoova apnr trade
C wet Length
Ft.
FI.
Well: g.j i5
LL ❑ New ❑ Upgrade
Gray) aapl",
FI,
NurnDar r erws
Distance Da wean Ins,
FL
fin
CNsvliw2 (Pour*. A, C)
Tar DWM cased to
Taala Pt, ince
Pipe wlanel
FI. FI
F�
Driller
Do* Dab° Stam Water Lavr
1,5181W
A t- #pwe ✓ifM
Dre iislrt el
to lit as-
FI
/tea
YMd
Pump "M a
c.sag IbgM ADo.. GrpIM
o p5.OI D y TANK
GPM
FI.
FL
SEPARATION DISTANCES
m septic 0 Holding ❑ S.TZ P. O Other.
To
Septic
Absorption
Lift
Holding
ubltUPnvate1nit`
-•r
%�nr:�
+Peaty
Gr (7'50
From
Tank
Field
Station
Tank
Sewer Line
r!1 Ic„nk
ML'N
Nunoer r Compenmems
WNI
f 100'
St-cc1
2-
LIFT STATION
Sulacewr«
41001
La Loa
4 lo'
Gr
'Poop ai level et
'Pune oM bvNr
Wtn.'at«ramr
Fandstwt
t 5 f
In
M
in
Pump Make a ModN .l
Etlarrcet nspeawa pMpnmarl by
Dulrn Drrn
iv. An
,t
�7, Irsr�!;J
t
Ram s
BENCH MARK
Locamn arC Daaa�ptwn.
'
Bok4on; 5�e1; D•
anie0 bvrwn
foo FL
t -
Engineers Stamp
o
-Acs Dates: 1M Io 18 D5
t1r ditn�
Inspections performed by: J aR\
^-
•
2n°
F
Development Services Department Approval
Reviewed and approved by: Date:
'11d,k2Co
LOT 2
MOUNTAIN L RiVf�
to• urattr EasRwr —
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swrrc LIES
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AC=J85 BC=9.5�
AD=45'BD=17.5'
Ac=47.5' 8C=20.5'
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BENCH MARX
L0CAMD 0 A
I
1
♦ E,
♦
Well l 1
A
I
ANDONE X/ST/NG TANKS
I I
I
INSTALLED 1 $(1 GALLON STEEL TANK
♦
I 1
I 1
I
I♦ LOT i I
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LOT 2
n 00 25 50 75125
SCALEr 1' = 50 FT. 00
LOT 1
49th
No. CC -2225
I:
ITOBBEN SPURKLAND P.E. LT 1 BLK 1 LAKE 0 THE HILLS SEPTIC SYSTEM ASBUILT I
103 W 157H. AVENUE £D BUSCH DATE: OCT. 19, 2005
AN�cN. 71 AK. 9 9501 1tr 111201 MOUNTAIN LAKE DRIVE SHEET. 213 GRID 2639
I PERMIT k SVO50377 PIB ✓r 015-331-20 LUnwwcDrU I
0 0
0 1250 gal Septic tank
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Connect to Existing Drainfield
203 W15th Ave
Anchorage Ak 99501
iu;hinun)
1250 gal. septic tank
NO SCALE
O''y'•AS
ec
97H
��;70Et�Etd £FUn:LAIID
r'`� . CE 2225 '
LOT 1 BLOCK 1 ME 0' THE HILLS SIP
ED BUSCH
1I20r YDWTA/N WE MAT
'O11 �uom or Srowc
ASSWID EIEYAWN 100 FLET
SEPTIC SYSTEM ASBUILT
DATE, OCT. 19, 2005
SHEET, P/2 GRID 2717
I PERMIT / SWO50377 PARCEL ID f 015-331-20 L0H01013.DWC
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water B Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Permit Number: SWO50377
Legal Description: LAKE O THE HILLS BLK 1 LT 1
Design Engineer: 0007 Tobben Spurkland, PE
Owner Name: ED BUSCH
Owner Address: 2411 LAHONDA DRIVE
ANCHORAGE. AK 99517 -
Date Issued: Oct 03, 2005
Expiration Date: Oct 03, 2006
Parcel ID: 015-331-20
Site Address: 011201 MOUNTAIN LAKE DR
Lot Size: 54542 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit Is for the construction of.
❑ Disposal Field Z 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.
5. The following special provisions.
- (EMERGENCY TANK REPLACEMENT) - SEPTIC TANK INSTALLATION MAYBE LOCATED NO LESS THAN
FIVE FEET FROM ANY PROPERTY LINE OR BUILDING FOUNDATION; TEN FEET FROM ANY WATER
SERVICE LINE; ONE HUNDRED FEET FROM ANY SURFACE WATER; AND ONE HUNDRED FEET FROM ANY
PRIVATE WELL; AND THE SEPARATION DISTANCES REQUIRED BY 18AAC72 FROM WATER SUPPLY
WELLS.
Received By:
Date: *_0
Issued By: I / ( Date:
UI/
Municipality of Anchorage
Development Services Department
Building Safety Division
\_.. On -Site Water and Wastewater Program
4700 Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D.015-331-�)U Permit Number SW
Property owner(s) FD f3VSr_" Dayphone 2SB-0I(ol
Mailing address 2411
Drava,Anc��
1
AK Zip Code 91S11
Site address 11201 Mo-e-Azi;.,
LakO
Des.) 9-
Zip Code
Legal description (Lot, Block & Sub'd.)
Loi
1 Qlock 1
L4ke O' ll,t ";IIs s)D
Legal description (Section, Township & Range)
Lot Size 04LIon Acre q.Ft.
THIS APPLICATION IS FOR:
Number of Bedrooms 4
Sewer Only ❑ Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade IR
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: .0'0 Waiver Fees:
Date of Payment: i0 D Date of Payment:
Receipt Number: qq lkrgReceipt Number.
(Rev. 09104) ,�
` -• Environmental Consulting and Design
Municipality of Anchorage September 30, 2005
Development Services Department
Building Services Division
On-site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
Subject: SEPTIC TANK PERMIT
LOT 1 BLOCK 1 LAKE O' THE HILLS S/D
The septic tank serving Lot 1 block I Lake O' the Hills S/D has collapsed and needs to be
replaced. Two one thousand gallon septic tanks were permitted and approved for installation by
the Municipality of Anchorage in August of 1980 to serve a 4 -bedroom residence. Installation
of a 1250 -gallon septic tank will not prevent wells and septic systems from being installed on the
adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or
the adjacent lots. The proposed septic system will not change the general slope of the area.
Ponding and/or concentration of surface runoff will not result from this installation.
If you have any questions or are in need of additional information please contact me at 279-3916.
Sincerely,
Lars Spurkland
203 Nest 151" Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (907) 276-6013, SpurklandEngCaa�gci.net
Municipality of Anchorage
G Development Services Department
Building Safety Division
I\� On -Site Water and Wastewater Program
4700 Brogaw Street
P.O. Box 196650 Anchorage, AK 99519.6650
www.ci.anchorage.ek.us
(907)343.7904
Typical Deep Trench Requirements and Specifications
AMC 15.65
PERMITTING
0
A permit must be obtained from the Municipality of Anchorage, Development Services Department to modify,
upgrade or install an on-site wastewater disposal system.
TWO INSPECTIONS ARE REQUIRED BY A REGISTERED CIVIL ENGINEER
1- When all excavating is completed
2- When the septic tank is installed and the system is ready to be backfilled
SEPTIC TANK REQUIREMENTS
1- Municipality of Anchorage approved, two compartments— installed level, with a minimum volume of 1000
gallons plus 250 gallons for each bedroom over 3.
2- Watertight couplings on inlet and outlet.
3- Manholes must be equipped with watertight gaskets.
4- Five feet minimum undisturbed soil between the tank and trench, and the tank and foundation.
5- Tank must be insulated if buried four feet or less.
o- Tank and solid pipe must be set on well -compacted, stable soil.
7- Four inch diameter cleanouts with airtight caps are required:
a. One to four feet from foundation wall
b. Prior to any pre -tank ninety degree bends in 4 inch line
c. In each tank compartment
d. Two adjacent opposing cleanouts between the tank and the absorption field not more than 10 feet
from the tank positioned to provide cleanout access towards the tank and towards the absorption
field.
8- All cleanouts must extend to at least ground level.
9- In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron.
10- Tank must be cleaned and pumped at least once every two years or inspected to determine the need for
cleaning and pumping at least once each year.
11- Tank must be installed at a site accessible year-round to a pumping truck. The access site for the pump
truck must not be further than 100 feet from the tank at an elevation not more than 11 feet higher than the
bottom of the tank.
LOT 2
NOUNTAIN L
" '� 10' UT211Y £ASiYCNT
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♦ -¢- Well
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A DON f INC TANKS
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STALL 1250 GlLLON STEEL TANK I
I
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♦ I I♦ LOT 1 I
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Welly
` 141
BL\CK I I`
LOT 2
25 50 75
SCALE, P = 50 FT.
125 150
` 49th
LOT 1
No. CC -2225
0
/I
WOVEN W-UKALAlNU Y.L.
203 W 15TH. AVENUE LT 1 ELK 1 LAKE 0 THE HILLS SEPTIC SYSTEM DESIGN
ANCH. AK. 99501 ED BUSCH DATE.• SEPT. 27, 1005
(907) 279-3916 11 11201 MOUNTAIN LAK£ DRIVE SHUT • 2/3 GRID: 2639
P£RHIT LI SV020XXX PID # 016 -141 -XX LOH01012DVG
IF I
0
1250 gal Septic tank
c
t
m
$
83
m
c
a
$
c
4 Feet Cover (Minimum)
Connect to ExJstJng Dra/nfleld
A:
1250 gal. septic tank
•P f Y aW�Pp K' i` ?ln
NO SCALE R
{YJ'• YOP•IY•CJ•••P•M '
Y
CU
` Fi yJ
TOBBEN SPURKLAND P.E.
LOT I BLOCK I IAM 00 THE MIS SIB
SEPTIC SYSTEM DESIGN
203 W15th Ave
Anchorage Ak 99501
ED BUSCH
DATE SEPT. 27, 2a75
11201 MOLWAW LAKf DRM
SHEETS 2/2 GRID- 2737
PERMIT sW0500XX
PARCEL ID /
L0N010I3.DWG
\ MUNICIPALITY OF ANCHORAGE i
e�A 1 DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
q ENVIRONMENTAL ENGINEERING DIVISION
825 L Street • Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAMEt1 n
Alv i
`
OE
N
EW
O UPGRADE
MAILING ADDRESS
LEGAL DESCRIQTION
/
LOCATION
NO. OF BEDROOMS
G he
DISTANCE TO:
Well
Absorption area
Dwelling T
PERMIT
a Q
W F.
Manufacturer
Material jt ry
1J2.11Xs
No. of com rtments
Liq. pa it ]n adons
IF HOMEMADE:
Inside length
Width
Liquid depth
6OZ
DISTANCE TO:
Wet]
Dwelling
PERMIT NO.
_ F
Manufacturer
Material
Liquid capacity in gallons
WWell
=
DISTANCE TO:Ion
Foundation
Nearest lot line/,,
PERMIT NO. /
72
j.
No. of lines
Len A}�t ach a
aJ
Total lenyin of lines
Trench t
inches
Distance betwSP
/
Q f
0
Top of tile to finish grade
Material beneath til 5�f -
/a" inches
Total effective or tion area
W
Length
Width
Depth
PERMIT NO.
a F
W 1
Type of crib
Crib diameter
Crib depth
Total elective absorption area
a
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE TERI LS,Z t
41
Q�
SOIL TEST RATING s
INSTALLER
RENZRFKS
IZZ
O
PPH D
DATE LEGy�
((hJx 8
71-U131Hev. 3/713) C/
- MUN I G -I fiAL I TY Of ANGHARAGE I�e
DEPARTMENT 'HEALTH AND ENVIRONMENTAL' 'OTECTION M"_
825 'L' STREET, ANCHORAGE, AK. 99501
�.� 264-4720 (L ch �.
_�-
WELL A"E? OtJ—S I TE EWER PERM I T
PERMIT N0. ( 800166 ) ���y�
9-6 v
APPLICANT WENDY NIST 1027 BENCH CT. 333-2590-j
LOCATION
LEGAL L1 B1`LWE-'CO THE'HILLS" LOT SIZE 54000 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING CSQ FT/BR)= 275
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
E]EPTH= 10 LENGTH= 110 GRnVa:L- E>EPTH= 5
THE LENGTH DIMENSION IS THE LENGTH CIN FEET> OF THE TRENCH 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).
R E Q U I R EE] S E P T I C T A N K S I Z E— 1 2 5 0 G A L L O N S
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.
— — — TWO <2> INSPECTIONS ARE R E Q U I R EE? — — —
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION A14D 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 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER, LINE IS 25 FEET AND
TO A 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.
F='MMM I T EXP I RES I]ECEMBER 21s 1 01860
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.
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
SIGNED
NIST
ISSUED V4. 0
/ja P, 5e fcf No-Tg, "DKA wl ti G- P-TT-6(Nf� D
- ❑ SOILS LOG
I' MUNICIPALITY OF ANCHORAGE P---pERCOLATION
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION �'
TEST
Pouch 650
6. Anchorape. Alaska 99602 276-2221
SOILS LOG — PERCOLATION TEST
PERFORMED
LEGAL
1
DEPTH SM
(FEET)
2-
3-
4-
6-
47 34 6i a
a, .
8-
9-
10-
11 s10 11 ''•
12-
13-
14
2 13 14
15
20
PERFORMED
72008 (7/78)
O. Tolbot
4069•E
DATE PERFORMED: 0Z ,,'9&24",
WAS GROUND WATERY /D S
A
ENCOUNTERED? L
O:
P
IF YES. AT WHAT E
DEPTH? Z -t[ 4- —F TJ m
PERCOLATION RATE 312 (minutes/inch) VS,
i
TEST RUN BETWEEN FT AND FT
CERTIFIED
DATE: 2 //� I190
m K;A r2m� 1111111WPALl0m0a7/lilm
PERCOLATION RATE 312 (minutes/inch) VS,
i
TEST RUN BETWEEN FT AND FT
CERTIFIED
DATE: 2 //� I190
Gti'et!
3, _7i s,r
� VV Y
rQ�
�5
M♦♦.�.
•�.�r
r
M all \m Le maTtlia c?'ar w(Dan-fig
330S 1369, STAR UouwF. A Al\CIIOITAGI:, AlLASIiA .499502:
3414-7714
SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF 930 Tett-
DRILLED AT THE RATE OF 919_00 PER FOOT.
PROPERTY OWNER Pit. R.tchztd. ?. ll,!At
LOCATION OF WELL SITE Li. 7 BtA, 7 Sub. .Cake of, the ItO 4.
DRILLER Benue Ctmt4 of RamnaAt Dei Urm Vo2k4.
WELL LOG:
0-----78' Cou&4e gAavet. U"j, iZtt tz 4iLbp ma tc is t.
78----651 SarL&,t clary. 15% clay.
65----98' C.tay. wtth 30:5 q tauct rw te/t is t.
98---145' Sandy gAauet w•t.th. 35% clay.
145--186' Wet 4ttbl. stay. w.l th 10; gAauei.-in fav:w,tton.
186--204' Uet clay.
204--205' WateA beating mmte4iat. S-t�tonq ptoduetton, lioweve�t veAu/. -J ltj.
205--2301 Sandy q ta.vei. with good eowt4e Va tett beatln.g jAoa 225 .to 230 .feet.
P,.oduc, ton 4howtiuy
25
SPR w.i,th
120 acct oA Ca -tet 4tan ting .in ea4 n.g. One llc44e
Sutnca ibt: - 4hould
be
trwtnAted
five feet of -f botton.
Cort of DAZU ing.: 819 X 230 tett: 84370.00
Coot of Veit Seat: 522.50
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF 34392.50
THANK YOU VERY MUCH.
BERNIE CLAYS OF RAMPART DRILLING WORKS
Ruqun t 5th.. 9 U
DATE 180
SERVICE C�IARGE OF IY.% PER MONTH WILL' E ASSESSED ON PAST DUE ACCOUNTS.
n
r-)
5. LEGAL DESCRI ION
2v T
DATE RECEIVED
INSPECTION APPOINTMENTS
7
TIME
TIME
TIME
DATE
DATE
DATE
1
INSPECTOR
INSPECTOR
INSPECTOR
MUNICIPALITY OF ANCHORAGE MUNICIPALITY CF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT- Ci , _,
1 825 LStreet- Anchorage, Alaska 99501 w/I'R�'f "'"�"'- .-CTION
•
ENVIRONMENTAL SANITATION DIVISION FEE 12 1981
\� Telephone 2644720
RR ((" ``// CC ELnn
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEAkfAELW
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTYO
JST
depth (attach log if available.)
C Z
—
MAILING ADDRESS
/ .6';.' OTi✓
PROPERTY RESIDENT (If different from above)
PHONE
z'j1Z0C2r /l7 tVd1,L�'. A „t/ G A e��
-M-7-052 le
2. BUYER c r
PHONE
MAILING ADDRESS
3. LENDING INS/IiUTIQN I�
PHONE
S//ii//JJ
MAILING ADS
DRE
L, SAI—/
u>-'40�r'w'
4. REALTOR/AGENT
PHONE
MAILING ADDRESS
5. LEGAL DESCRI ION
2v T
ar- 7i1'C5-
STREET LOCATION
-57b,ver/ 49:iecCwz-
!-I 7-
6. TYPE OF RESIDENCE
6.
NUMBER OF,BEDROOMS
-I❑
❑ One our ❑ Other
R SINGLE FAMILY
Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATER SU
INDIVIDUAL'
' ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOS LSYSTEM
—
INDIVIDUAL/ON-SITE"
/ 986) YEAR ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72 010 (Rev. 6/79) �„/
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLEFAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLICUTILITY
Connection Verified
PERMITNUMBER
DEPTH OF WELL
GATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLICUTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
Q Q
INSTALLER
❑Septic Tank or ❑ Holding Tank—�
Size: ODd If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
Sew
Ne arest Lot Line
Absorption Area to nearest Lot Line -
5. COMMENTS
[,}APPROVED FOR _ BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
BY �(
72-010 (Rev. 6/79)
n
�1(
11,riicJL e1,1�ir zdS(ii
-ao-81
825 "L" STREET
ANCHORAGE, ALASKA 90503�_�'
(907) 264-4111
GEORGE M.'ULLIVAN.
MAYOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
February 18, 1981
Richard T. Nist
4115 Lake Otis Parkway
Anchorage, Alaska 99507
Subject: Lot 1 Block. 1 Lake O' the Hills Subdivision
Approval for your individual sewer and water facilities
cannot be granted until the following items have been
completed:
(1) The water analysis report heeds to be delivered to
this office from the Chem Lab, 5633 B Street, for
our review.
(2) A well log submitted to this department for our
review.
If there are any further questions, please call this
office at 264-4720.
Sincerely,
Robert C. Pratt, R.S.
Associate Specialist
RCP/ljw
cc: National Bank of Alaska
% Earl Carson
Pouch 7-025 99510
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE 1907)-279.4014 ANCHORAGE INDUSTRIAL CENTER
274.3364 6633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY
WATER SYSTEM: ,� A�nalysis shows this Water SAMPLE to be:
a
1.0 NO. ,&/;atisfactory
n ,e
[I Unsatisfactory
Water System Name Phone No.
❑ Sample too long in transit: sample should
not be over 48 hours old at examination
Mailing Address - o to indicate reliable results. Please send
new sample.
City
State - 21p code.-
SAMPLE
ode.-
SAMPLE DATE: = = =
Mo. Day Yea
SAMPLE TYPE
❑ Routine
❑ Check Sample (for routine sample
with lab ret. no. 10 Treated Water
[I Untreated Water
❑ Special Purpose
SAMPLE
NO. LOCATION
ger i
3
4 I
5
06-1220(b)
11". 1976
,, Data collected
READ INSTRUCTIONS "
BEFORE
Time Collected
Collected By
Date Received _
Time Received _
Analytical Method:
❑ Fermentation Tube
11
❑ Membrane Filter
Lab Ref. No. Result' Analyst
l I m
I m
j m
. No of colo.../ 100 ml. a No of p..0.e porvo e
BACTERIOLOGICAL WATER ANALYSIS RECORD
Source
a.m.
EMB Brom 24 hours) Broth 46 hours:
COLLECTING SAMPLE Multiple Tube Report) loml Tub" Poeltherruul loml P00110014
Membrane Felefl Direct count colltorin/100m1
Verltkalloln LTD BGB
Final Membrane Fater ReeuNs / collto"floorhl
Reported BY —oat*
y Time
(y P.M.
Directions for Collecting Samples of Water for
Total Coliform Bacteria Examination
This water analysis deals with materials present in very minute quantities. Carelessness in collecting
and handling may lead to misleading results.
Water samples will have to reach the laboratory as quickly as possible within 48 hours after collection.
After 48 hours, the significance of the bacteriological analysis is impaired and resampling will be nec-
essary. Send to Laboratory fastest way: (i.e. special delivery mail.)
In collecting samples from TAPS or PUMPS proceed as follows:
a) Remove any aerators or screens attached to the outlet.
b) Thoroughly flush tap or pump by allowing water to run freely with a fully opened outlet for three
or four minutes.
c) Reduce flow so that small stream flows.
d) Remove bottle from mailing tube. Hold bottle in one hand while removing cap with the other.
Avoid touching the neck of the bottle and the inside of the cap.
e) Fill the bottle to its shoulder while attempting to avoid splashing. Immediately replace cap, being
sure that it is tight, but not so tight as to split the cap.
f)- Complete the portion of the lab form which is indicated "TO BE COMPLETED BY SUPPLIER."
Fill in all appropriate blanks carefully, including your public water system identification number
(ID No.). Contact the Alaska Department of Environmental Conservation if you do not know your
ID. number. (Public water suppliers only)
g) -Pack bottle carefully in mailing tube with lab form.
The requirements for analysis of public water systems for total coliform bacteria are defined in the
Drinking Water regulations administered by the Department of Environmental Conservation.
c c'®
Gs e�
® Municipality of Anchorage }`
On-Site Water and Wastewater Program
(907)343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 015-331-20 Expiration Date:
1. GENERAL INFORMATION
Complete legal description Lake O' the Hills, Block 1, Lot 1
Location (site address) 11201 Mountain Lake Dr.
Current Property owner(s) Edward & Diana Busch Trust Day phone
Mailing address
Real Estate Agent
11201 Mountain Lake Dr. Anchorage, AK 99516
2. TYPE OF DWELLING:
Fx� Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: Q
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
0
Individual
0
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
WaiverNariance request for:,
Received by: ,�� C -7, -gr ( / Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $
Date of Payment
Receipt Number
COSA#
Waiver Fee $
Date of Payment
Receipt Number
ln�f3
5. STATEMENT OF INSPECTION BY ENQIN,EE�
As certified by my seal affixed hereto and as of the validation date sho'tfvm elow I vey.fitt� 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 performance of the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all 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 fisted
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone
6. DSD SIGNATURE
i< System #1 Approved for I bedrooms
r
System #2 Approved for bedrooms
Disapproved
Date 2/17/2016
Stever R. ESannone,
CE-8149.,�
Conditional approval for bedrooms, with the following stipulations:
VVATFR 4tii) ii
VVA STEWATER
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.
ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSAblueshee[ r ..,
If more than 1 septic system is on the lot:
COSA Checklist # + of i
Structure served by this system t
Certificate of On -Site ,Systems Approval Checklist
Legal Description: Lake U the Hills, Block 1, Lot 1 parcel iD:015-331-20
A. WELL DATA
Well type Private If A, B, or C provide PWSID # _
Date completed 8/5/1980 Sanitary seal (Y/N) Y
Total depth 230 ft. Cased to 230 ft
FROM WELL LOG
Date of test 8/5/1980
Static water level 120 ft
Well production 25 g.p.m.
WATER SAMPLE RESULTS:
Coliform Neg colonies/100 mL Nitrate 0.223 mg/L
Arsenic N/D ug/L Dateofsample:2/9/2016
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel
Tank size 1,250 gal. Number of Compartments 2
Foundation cleanout (YIN) Y
Date of pumping 6/8/2015
Well LogjY/N) Y
Wires properly protected (YIN) Y
Casing height (above ground) 12+ in.
AT INSPECTION
7/16/2015
118 ft.
5.3 9 -
p.m -
Collected by: PES
Date installed 10/18/2005
Cleanouts (Y/N) Y
Depression over tank (YIN) N High water alarm (YIN) N
Pumper. Northland Pumping.
C. ABSORPT40N FIELD DATA
Date installed 8f711980 Soil rating (g.p.d./ft2 orfethdrm) 275 SF/BR . System type Deep,Trench
Length 110 ft. Width 3 ft. Gravel below pipe 6 ft.
Total depth 12.3 ft. Eff. absorption area 1,320 fe Monitoring tube Y Depression over field N
Date of adequacy test 7/16/2015 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth In absorption field before test 5 in. Water added 634 gal. Newdepth 64 in.
Elapsed Time: 140 min. Final fluid depth 5 in. Absorption rate >= 600+ g.p.d.
Any rejuvepation treatment (past 12 mo.) (YIN & type) No 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.r 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 25+ Holding tank 100+
Animal containment areas 50+ Manure/animal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line 5+ Abscilption field 5+
Water main 10+ Water service line .10± Surface water 100+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOTTO.'
Property line 10+ Building foundation 10+ Water main 10+
Water Service line .10+ Surface water 10Q} Driveway, parking/vehicle -i.Korage "10+
Curtain drain 50+ Wells on adjacent.lots 100+
F. COMMENTS
G. ENGINEER'S CERTIFICATION .
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA dOSA guidelines in effect on this date.
Engineer's Printed Name Steven R. Pannone
Date 2/17/2016
COSA canary'sheet 2-6-15.doe
--npanrinne
CE -8149
AsStit
EO
Parcel I.D. 015-331-20
Municipality of Anchorage
On -Site Water and Wastewater Program
(907)343-7904 saF€ry
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Expiration Date: ! / - / .`J
Complete legal description Lake O the Hills, Block 1, Lot 1
Location (site address)
11201 Mountain Lake Dr.
Current Property owner(s) Edward & Duna Busch Trust Day phone
Mailing address
Real Estate Agent
11201 Mountain Lake Dr. Anchorage, AK 99516
2. TYPE OF DWELLING:
fx-1 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
WaiverNariance request
Received by:
COSA to be released to the
unless otherwise requested by the engineer.
COSA Fee $ J 2_Y -
Date of Payment l ) Pj►if5y
Receipt Number bb 1O
COSA# pSG51gb c
.. - ;i041M
Waiver Fee $ _
Date of Payment
Receipt Number,
Waiver #
4
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
7
Individual
0
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
WaiverNariance request
Received by:
COSA to be released to the
unless otherwise requested by the engineer.
COSA Fee $ J 2_Y -
Date of Payment l ) Pj►if5y
Receipt Number bb 1O
COSA# pSG51gb c
.. - ;i041M
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.
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 performance of the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all 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 Phone (907) 272"8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone
6. DSD SIG
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Date 7/21/2015
Conditional approval for bedrooms, with the following stipulations:
sy: /', *Original Certificate Date:
Th " nici A rage 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
Septic System Advisory
Well Flow Advisory
COSA blue sheet f .., ..
X Nitrate Advisory
Arsenic Advisory.
Other
If more than 1 septic system is on the lot:
COSA Checklist # I of
Structure served by this system 1
Certificate of On -Site Systems Approval Checklist
Legal Description: Lake O` the Hills, Block 1, Lot 1 Parcel ID: 0 15-331-20
A. WELL DATA
Well type Private If A, B, or C provide PWSID #
Date completed 8/5/1980 Sanitary seal (Y/N) Y
Total depth 230 ft. Cased to 230 ft.
FROM WELL LOG
Date of test 8/5/1980
Static water level 120 ft.
Well production 25 g.p.m.
WATER SAMPLE RESULTS:
Coliform Neg colonies/100 mL Nitrate N/D mg/L
Arsenic N/D ug/L Date of sample: 7/16/2015..
B. SEPTICIHOLDING TANK DATA
Tank Type/Material Septic/Steel
Well Log (YIN) Y
Wires properly protected (YIN) Y
Casing height (above ground) 12+ in.
AT INSPECTION
7/16/2015
118 ft
5.3
9 -13 -m -
Collected by: PES
Date installed 10/18/2005
Tank size 1,250 gal. Number of Compartments 2— Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank 1(Y/N) N High water alarm (YIN) N
Date of pumping )!5- Pumper PO:4
C. ABSORPTION FIELD DATA
Date installed 8/7/1980 Soil rating (9•p• d.lft2 or ft%drm ) S 275 SF/BR type e Deep Trench
System YP
Length 110 ft. Width 3 ft. Gravel below pipe 6 ft.
Total depth 12.3 ft. Eff. albsorption area 11320 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 7/16/2015 Pass Results (Pass/Fail) For 4� bedrooms
Fluid depth in absorption field before test 5 in. Water added 634 gal. - New depth 64 in.
Elapsed Time: 140 min. Final fluid depth 5 in. - Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date
D. LIFT STATION
Date installed Size in gallons
"Pump on" levet at in. "Pump off' level at
Datum Cycles tested _
Manhole/Access (Y/N)
in. High water alarm level -at in.
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 25+" Holding tank .100+
Animal containment areas 50+ Manure/animal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line 5+ Absorption field 5+
Water main 10+ Water service line 10+ Surface water 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+ Wells on adjacent lots 100+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that; the above -systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven R. Pannone
Date 7121/2015
COSA canary sheet 2-6-15.doc
zoo
MOUNTAIN LAKE DRIVE
M
N89°56'25"E 95.01
/R 30.00 10' UTILITY EASEMENT '..
00 EPSE As
LOT 1
1Vt/ Chain / LOT 1
Li
Fence--�� LAAKE O'THE
D HILLS
Septic 0/ -Concrete Block
Ven etaining Wali r -Well
O O rb
0 50.0 O
Wood 4 .'Deck ASPhalt; N
Fen
LOT DO
1 2 S me 10.0toLO
COHomme 7.3 9. O
��, —Board Z
48] Welk
r: m
w
peck ( W
2.30 oea� F u�i
6'2
7 �
peck I o
i�
"oQoo� N�2°�Soo�
o�
LAKE O' THE HILLS \
—�11
, �F AL 'FSI
�* 49th�I/
0000
.. ..i �
'','.Fred Walatka.•fi
3255 - S ••"
SCALE: 1"= 40' 11
EASEMENTS OF RECORD, OTHER THAN FB 15 10, 2024
THOSE SHOWN ON THE RECORDED HOLT
PLAT ARE NOT SHOWN HEREON:
AS -BUILT NO CORNERS SET THIS DATE
I hereby certify that I have performed a Modglegaes inspection
of the following described pproperty: LOT 1. BL CK 1,
LAKE O' THE HILLS SUBD,
Anchorage Recording District, Alaska, and that the
improvements situated thereon are within the property lines
and do not overlap or encroach on the property tying
adjacent thereto, that no improvements on the property lying
adjacent thereto encroach on the premises in question and
that there are no roadways, transmission lines or other
visible easements on said property except as indicated
hereon.
Dated at Anchorage, Alaska
this 24th day of JULY 2015.
FRED WALATKA 8 ASSOCIATES
CB Engineers and Surveyors
(907-248-1666) 2639
Municipalify of Anchorage
C,� `p' • Development Services Department '
1� Building Safety Division .. ...
OnSfte Water 3 Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage. AK 99119.6650
www.ci.anchorage.sk.uS
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. 015-331-20 HAA#
1. GENERAL INFORMATION Expiration Date: CO — 3 " 03"
Complete legal description LAKE 0' THE HILLS S/D LOT 1. BLOCK 1
Location (site address or directions) 11201 MOUNTAIN LAKE DRIVE
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
DR. RICHARD NIST Day phone 346-3556
4120 LAUREL STREET • ANCHORAGE. AK 99508
Day phone
GARY KUTiL w/ PRUDENTIAL VISTA Day phone 727-2717
3801 CENTERPOINT DRNE. #200 • ANCHORAGE. AK. 99503
Unless otherwise requested, HAA will be held by DSD forpickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
j1♦
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
i ne muniapaury or Ancnorage ueveiopment Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given In paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of Issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid
water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water
system. The Municipality of Anchorage is not responsible for errors or omissions In the professional engineer's
work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
Investigation, based on procedures outlined In the Health AuthorityApproval 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 ofAnchorage 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 Finn GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineers Printed Name JEFFREY A. GARNESS, P.E.
Engineers Comments:
In conducting this evaluation, GEG, Ltd. attempted to provide a thorough,
conscientious engineering analysis of the system In accordance with ADEC and MOA
DSD Guidelines 6 Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test and separation
distances measured to readily Identifiable features. The operational fife of alt wells and
septic systems depend on the local softs condition, groundwater levels that may
fluctuate during the year, and the water usage of the ramify being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide
any warranty ortuture estimate of how long the system will continue to meet the
operelional requirements of the ADEC or MOA DSD. The content of this report Is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party Is not authorized, nor will It confer any legal right whatsoever.
5. DSD SIGNATURE
t� Approved for q— bedrooms.
Disapproved.
Phone 337-6179
Date Zg o S
Conditional approval for bedrooms, with the following stipulations:
Attachments:
Septic System Advisory
Well Flow Advisory
ON-SITEAK
ci
;; WASTEWATER
Supplemental Engineers Report -virlll"h
Other
By Original Certificate Date: 3
(Rr.lu+)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Ste Water & Wastewater Program
4700 South 8ragaw St.
P.O. Box 195650 Anchorage, AK 99519-66W
www.d.androrage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LAKE 0 THE HILLS LOT 1. BLOCK 1 Parcel ID: 015-331-20
A. WELL DATA
*WELL TESTED LESS THAN 2 YEARS AGO.
WOO type Pf"VAh If A. B, or C provide PWSIDN N/A
Date completed 8/1980 Sanitary seal (Y/N) YES
Total depth 230 ft. Cased to 230 ft.
FROM WELL LOO
Date of test 8/5/80
Static water level 110 ft.
Well production 25 G.P.M.
Well Log (YM) YES
Wires properly protected (YIN) YES
Casing height (above ground) 24 In.
AT INSPECTION
09/29/2003
121 ft.
7+ g.p.m.
WATER SAMPLE RESULTS:
Collfbrm coloniea/100 ml. Nitrate p'1 Omg1L. Other bacteria coloniesJ100 ml.
Arsenic: N/A mgA. Date of sample: 2/4/2005 Collected by: G.E.G. Ltd.
S. SEPTICIHOLDING TANK DATA
Tank Typei'Matedal STEEL
Tank size 2%1000Qat. Number of Compartments &EACH
Foundation deanout (Y/N) YES Depression over tank (Y/N) NO
Date of pumping -2-J4,-04; Pumper
C. ABSORPTION FIELD DATA
Date installed 8/7/80
Cleanouts (YIN) YES
High water alarm (YIN) N/A
Date installed 4/7/80 Soll rating (g.p.dAbr drtn 275 system type DEEP TRENCH
Length 75 + 35 ft. Width 3 ft. ` Gravel below pipe 6 ft.
Total depth 114.4 fL Eft. absorption area 1320 ft' Monitoring tube YES Depression over field NO
Date of adequacy test "10/3/03 Results (Pass/FOR) PAM For 4 bedrooms
Fluid depth in absorption field before test 117 in. Water added655 gal. New depth 24 In.
Elapsed Time: 35 min. Final fluid depth 23 in. Absorption rate v. 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN &type) NONE KNOWN If yes, give date —
ORAINFIELD WAS DRY ON 2/4/2005.
**SYSTEM TESTED LESS THAN 2 YEARS AGO.
D. LIFT STATION
Date installed
'Pump one level at in.
E. SEPARATION DISTANCES
Size in gallons
High water alarm level at
Cycles tested Meets alar b circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tenkAiR station on lot 1001+
Absorption field on lot 1000+
Public sewer main N/A
Sewer /septic service line 25'+
On adjacent lots 100'+
On adjacent lots 1001+
Public sewer manhole/cleanout N/A
Holding tank N/A
SEPARATION DISTANCES FROM SEP71CIHOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 101+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 101+ Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 1001+ Driveway, parkingtvehide storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
0. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and *
review of Munidpal records that the above systems are in
conformance wilh MOA NAA guidelines in effect on this date. -,T1
��
Engineer's Printed N JEFFREY A. GARNESS
Date Z/ -2,f,6.—
HAA Fee $ f �r
Date of Payment ISIOS
Receipt Number 0(44 dr 5
(Rev. MCI)
Waiver Fee $
Date of Payment
Receipt Number
02-15-05 03:55PM FROM-CTIE ESI, SCS ENV SERVICES
SGS ReCN
1050622001
Client Name
Garnets Engineering Group, Ltd.
Project Name/q
Lake a the (tills Lt, 91
Client Sample ID
Lake O the Hills Ll, 91
Matrix
Drinking Water
Sample Remarks:
9075615301 T-663 P.02/06 F-477
All Dateslrimes are Alaska Standard Time
Printed Datefrlme 02/15/2005 12:06
Collected Daterrime 02/042005 12:00
Received Daterrlme 02/04 05 13:43
Technical Director / SStepl C. Ede
Released Rr�✓�s+�^/
Allowable Nep Analysis
Paramcrer Results PQL Units Method container W Limits Date Date (nit
Waters Department
Nitratc.N 0.100 U 0.100
Microbiology Laboratory
Total Coliform 0
mg/L E_PA300.0 H (<-10) 02/05/05 CAM
wV100mL SM209222D A (<-1) 02104105 DKC
02-15-05 03:55PM FROM -CUE ESI, SGS ENV SERVICES
9075615301
. SGSIME ENVIRONMENTAL SERVICES
Drinking Water AnaiYsis Report for Total Coliform. Baderia ..
READ WaTrAIM M W R.VWW EDL MiPDa! =U=7M
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T-683 P.03/06 F-477
200 W. POTTER DRIVE.
ANCHORAGE, ALASKA 99518
Tet 907.582-2343
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Fam t F* 0053 12JITO
ANCHORAGE CESSPOOL PUMPING
ALASKA PUMPING
12240 LILLIAN LANE
ANCHORAGE, AK 99515-2918
344.2632 or 344.2453
CL
(I rj
Z
PUMPED SEPTIC SYSTEM
PUMPED HOLDING TANK
APPROXIMATE GALLONS
,
FT EXTRA NOSE CHARGE O 300
Eft
CwswC NS E
TOTAL"
.7 F
0
• 0MONTHLY SEFMCE CHARGE ON ACCOUNTS PAST DUE.
.4.3-1-79 7bankcYou
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0662-LSZ-109 UIWPV d13 OUSHVAV 04Y 99:01 900z/21/10
Municipality of Anchorage 1,�,.' •.,
Development Services Department
V
Building Safety Division ,.
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
2 (^
Parcel I.D. 015-331-20 HAA#
1. GENERAL INFORMATION Expiration Date: 3
Complete legal description LAKE 0' THE HILLS S/D LOT 1, BLOCK 1
Location (site address or directions) 11201 MOUNTAIN LAKE DRIVE
Current Property owner(s) RICHARD NIST Day phone 346-3556
Mailing address 4120 LAUREL STREEr 0 ANCHORAGE, AK 99508 Ca{1 , 1106
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3: TYPE OF WATER SUPPLY:
Individual Well
N
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
N
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 properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid
water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water
system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's
work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
Investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the
information obtained from the Municipality of Anchorage files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) In compliance with all applicable Municipal
and State codes, ordinances, and regulations In effect at the time of installation.
Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE,
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough,
conscientious engineering analysis of the system In accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time ofthe test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater 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 the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. AKWWC, Inc. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report Is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party Is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
Approved for ____LL bedrooms.
Disapproved.
Conditional approval for
Attachments:
HAA Checklist !�
Septic System Advisory
Well Flow Advisory
bedrooms, with the fllowing stipulations:
Manitenance Agreements
Supplemental Engineer's Reort
Other
ON-SITE ••• ��m
WATER AND
WASTEWATER
12POrRAM
By:- J � / & . �� Original Certificate Date: 12 - A � - D3
(R". 11/01)
Municipality of Anchorage
Development Services Department
Building Safety Division `4-011
On-Site Water b Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519.6650
www.ci.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LAKE 0 THE HILLS LOT 1 BLOCK 1 Parcel ID: 015-331-20
A. WELL DATA
Wag type PRIVATE If A. B, or C provide PWSID# N/A
Date completed 8/1980 Sanitary seal (YIN) YES
Total depth 230 ft. Cased to 230 ft.
FROM WELL LOG
Data of test 8/5/80
Static water level 110 ft.
Well production 25 9 -
p.m -WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate 0.1 mgJL.
Well Log (YIN) YES
Wires properly protected (YIN) YES
Casing height (above ground) 24 in.
AT INSPECTION
9/29/2003
121 ft.
7+ 9 -
p.m -
Other bacteria 0 colonies/100 mi.
Arsenic: N/A mg./L. Date of sample: 9/29/03 Collected by: AKWWC, INC.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEEL Date installed 8/7/80
Tank size 2x1000 gal. Number of Compartments LEACH C4eanouts (YIN) YES
Foundation cieanout (YIN) YES Depression over tank (YIN) NO High water alarm (YIN) N/A
Date of pumping 4/29/2003 Pumper NORTHLAND PUMPING
C. ABSORPTION FIELD DATA FAR nw
Date installed 8/7/80 Soil rating (g.p.d./ft'or bdrrrt 275 System type DEEP TRENCH
Length 75 + 35 ft. Width 3 ft. Gravel below pipe 6 ft.
Total depth 12.9 ft. Eff. absorption area1320 ft' Monitoring tube YES Depression over field NO
Date of adequacy test 10/3/03 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test17 in. Water added 655 gal.. New depth 24 in.
Elapsed Time: 35 min. Final fluid depth 23 in, Absorption rate >- 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN 8 type) NONE KNOWN If yes, give date
UNE JETTING 9/30/2003 - NO CHEMICALS ADDED
0. LIFT STATION
Date installed
"Pump on" level at _in.
Size in gallons
High water alarm level at
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/ltft station on lot 100'+
Absorption field on lot 100'+
Public sewer main N/A
Sewer /septic service line 25'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/deanout N/A
Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 certNy that 1 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.
fmess.:
Engineers Printed Name JEFFREY A GARNESS A, E-7953 '
/1
�p,.�
Date load o3 ''_p,..,__.�d E
HAA Fee $ 97,50 t50
Date of Payment !/12' )9 -03 -
Receipt
9-O3Receipt Number T g 0 (0 %1.s�
(Rev. 12ro1)
Waiver Fee $
Date of Payment
Receipt Number
�P��.OF �Cqs���
...............................
..........................
SHANE A. HOLT
LS -6914
�s o
4n�°F•e ele ns\_ems'
NK
DRIVE
-99?56'25"W 95.01'
EASEMENT
DECK
NOTE, r
PLAT NO. 72-236 REFERS TO A PRIVATE
ACCESS DRIVEWAY ACROSS LOT I I AND D�
IS SHOWN CROSSING THE NORTHWEST S
PORTION OF SAID LOT 1. THIS DRIVEWAY
IS NOT VISIBLE AS OF THE DATE OF THIS SURVEY.
\ FPHT`V
i�K� NOJS
ID
A
I
\ P�-�' AS -BUILT SURVEY
V SCALE I -e 40'
O
O
Il -
cu
K
r
I HEREBY CERTIFY THAT I HAVE PERFORMEI
MORTGAGEE'S INSPECTION OF THE FOLLOWIN
DESCRIBED PROPERTY.
LOT 1, BLOCK 1, LAKE 0' THE HILLS SUB.
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY CONFUCTS BETWEEN
EXISTING STRUCTURES AND PLATTED ED TTED LOT LINES OR EASEMENTS AND IS NOT TO BE USE: FOR POSITIONING AD IVq_"A.RAGE RECORDING DISTRICT, ALASKA At
STRUCTURES OR FENCEUNES. THE VISIBLE IMPROVEMENTS SITUATED THT
EASEMENTS OF RECORD. OTHER THAN THOSE SHOWN ON THE RECORDED PUT, ARE NOT SHOWN HEREON. WITHIN THE PROPERTY LINES AND THAT NO
kENCR�O(NACHMENTS EXIST OTHER THAN NOTED.
NOTE: ANY FENCELINES SHOWN ARE LOCATED APPROXIMATELY AND ARE NOT TO BE USED TO DETERMINE PRO l7a•TCYEAST ANCHORAGE, ALASKA THIS __71H_
OR LOCATE STRUCTURES. DAY OF -OCTOBER ------------ 2703---_
ANY PAVING SHOWN MAY BE APPROXIMATE DUE TO SNOW CONDITIONS. HOLT LAND SURVEYING 9146, FBIDS-IB
10- 6-03: 5:06PM:
CS Ref.#
1036286001
Tient Name
AK Water & Wastewater Consultants Inc.
'roject Name/#
Lot 1 Bk I Lake'O the Hills
Ilent Sample ID
11201 Mtn Lake Dr.
lam:
Drinking Water
ample Remarks:
:907 6615301 0 2/ 3
All Dates/rimes are Alaska Standard Time
Printed Date/Time 10/06/2003 14:23
Collected Date/Time 09/29/2003 8:43
Received Date/Time 09/29/2003 11:30
Technical Director lrvC' Step Ede
Release
Allowable Prep Analysis
"meter Qualifies Results PQL Units Method Container ID limits Date pate Init
eters Department
Nitrate -N 0.100 U 0.100
mg/L EPA 300.0 B (<=10)
09/29/03 IIB
icrobiology Laboratory
Total Coliform 0 coV100mL SM189222B A (<=1) 0929/03 DKC
i
10— 6-03: S:OBPM: :907 5615301 w 3/ 3 _
.200 W. Potter Drive
Irinking Water: Analysis Report for Total Coliform Bacteria Anchorage. 62 2343618-,aoEi
READ INSTRUCTIONS ON REYEIZSE SIDE BEFORE�cOLLECTING S TO BE COMPLETED MFLE Far. 90 66
1-5301
BY LABORATORY
o PUBLIC WATER SYSTEM I.D. 0
PRIVATE WATER SYSTEM '
p SendResofts U Srndlarofu
w
SAMPLE DATE: M®
SAMPLE TYPE:
Routine O Treated Water
-
O Repeat Sample (tor routine sample, Untreated Water
withlabref.no. �.
tl Special Purpose Time Collected
SAMPLE LOCA Or Collected By
Comments:
Analysis shows this Water SAMPLE to be:
firl Satisfactory
13 Una3tisf2ctory.
O Sample over 30 hours old imults may
be unreliable
O Sample too long in transit; sample should
not be over3 flours old at exammatioo
toindicate bleresd
a a
new same special delivery mail -
Date Received
Time Received c
Analysis Began
Analytical Method: M�rnbran'e
110 MI.
1036286 -L
Result* Analyst
W1,11111111 � � Jf�FzzdD.
I. Date: 7 ime: '
:Client notified of unsatisfactory resulis:
Pboonned Spoke with Fazed
Date: t
BACTERIOLOGICAL NATER ANALYSIS RECORD
.E Coll
mm() -MUG Result: Total Collform
�— ' Colonies/too ml
Membrane Filter. DirectCount 7NTC-T" &-s w rs C a f
Veriftea(ion: LTB
BGB
COLIM,RM
Fecal Coliform Confirmation
Final Membrane Filter �ites6l^q A�
®� Coliformlloo ml
Reported BY
�t.-�J Date b �Z O Time L-� bra
_..__—�- 4/x'1 1 _
CT&E Emironmental Services Ine.
OB -OlMnawwrl.
562-2343 110011561.5301. awa.s9serW1r0=enm1.mm
N�MwdM�so& G•W Iswao GMNW Nfwvilued
i