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HomeMy WebLinkAboutSAND LAKE #2 BLK 7 LT 14andlake #2 Block 7 Lot 14 #011-132-23 Municipality of Anchorage On-Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201063 PID Number: 01,1-132-23 Dwelling: X Single Family (SF) [I with ADU El Duplex (D) R Two Single Family Project: 0 New RM Upgrade Name JOHN MORIARTY ABSORPTION FIELD El Deep Trench El Wide Trench [] B2ed!!ound Site Address 8340 ENDICOTT STREET 'ANCHORAGE, AK El Other* Phone Number of Bedrooms Soil Rating depth Uen original grade 748-4894 2 GPDfSF ITotal Ft. LEGAL DESCRIPTION Depth to pipe invert from original grad :Ii!P1 Ft. Gravel depth beneath pipe Ft, Subdivision Block Lot SAND LAKE #2; BLOCK 7, LOT 14 Fill added above original FL Gravel lenoth Ft Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES Tol Septic Absorption Holding Sewer Total area Number of trenches Dist, between trenches From Lift Station Tank i Field Tank Line Fl? Ft. Well 871+t TANK E] Septic [3 S.T.E.P. ❑ Holding E] Other Manufacturer GREER TANK Capacity 1000 Gal. Surface Water 100 Material HDPE Number of compartments 2 Lot Line 5'+4 NA LIFT STATION Foundation1+ 10I Manufacturer Capacity Gal Remarks OLD TANK DECOMMISSIONED PER UPC PER CONTRACTOR Alarm location Electrical installed by PIPE MATERIAL House to tank D3034 dTankto ri,fl,ldD3034 Installer A+ HOME SERVICES Drainfield o3o34iExtsrtt:c CO/MTD3034 inspector DAVID GARNESS, PE AND TIM ECKLUND BENCH MARK (Assumed elevation) 100.00 P, InspectionIse4/23/20 Location and description dates: TOP OF MH 41" - ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineers Stamp Conditional Approval: Date _7 -,. . .. ....... .......... f 'y 14. Gorjiess, CE Septic System Approved Date x, Note: this approval does not include well permit requirements, %,\,'fr-, -ioo =7 PAE Rev 05102/18) PERMIT i 7Ut2BER ,' u6l OSP201063 1 w ------------c---------------------z - , 1 A B ` , LOT $,B FCO 6.3 18.8 N 23.7 32.2 ST -I 25.3 30.1 DBL1 25.6 29.2 DBL2 26.0 28.8 SAND LAKE ------- - -- �� ,I ,' u6l LOT 10, BLK 7; 1 w SAND LAKE #2, 1 � )'WELL RADIUS (APPROX. LCJ LOT 9, BLK 7'. ----------------------- 1p� i RfiiJJ(lS, SAND LAKE #2 LOT 11, BLK r; ,'I IDPRO'k t / OCA SAND LAKE #2' 1 '100' VV LL RADIUS (APPROX. L CI ),X\ `. i U) LOT 12, BLK 7; EXISTING SAND LAKE #2 DRAINFIELI wU Is LOT 17, BLK 7; SAND LAKE #2 16, BLK 7; LAKE #2 GREER SEPTIC TANK LOT 15, B LOT 13, BLK 7; SAND LAKE #2 1OUP, Ltd L1.1511 1 1 `U ki ENGINEERING SALES CONSULTING 37G1 TUOOR ROA3.SU-TE 101'xA4e!pRh��, :@4i3T'Tr.9t.2j@:71 i97b179•fA%f037P:��32t6'VJEQ"uiE'Y.vs „prxiamnv<mge:m PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JOHN MORIARTY 907-748-4894 2 OF 3 LEGAL DESCRIPTION: DRAWN BY: SAND LAKE #2; BLOCK 7, LOT 14 D.J.G. TYP= OF VtORK: DATE: ,l SEPTIC TANK RECORD DRAWINGS 4/24/2020 PARCEL ID NUMBER: 011-132-23 W ui U) O W ® C-9-- ,'' .... o ........... ...... ...ffi r A. Garness � m 'ob Gl, CE 7953 �* LICENSE$ A �40t�`0�� PAECC884 / ,' u6l LOT 10, BLK 7; SAND LAKE #2, 't 10 )'WELL RADIUS (APPROX. LCJ ----------------------- 1p� i RfiiJJ(lS, I�( LOT 11, BLK r; ,'I IDPRO'k t / OCA SAND LAKE #2' 1 LOT 12, BLK 7; EXISTING SAND LAKE #2 DRAINFIELI wU Is LOT 17, BLK 7; SAND LAKE #2 16, BLK 7; LAKE #2 GREER SEPTIC TANK LOT 15, B LOT 13, BLK 7; SAND LAKE #2 1OUP, Ltd L1.1511 1 1 `U ki ENGINEERING SALES CONSULTING 37G1 TUOOR ROA3.SU-TE 101'xA4e!pRh��, :@4i3T'Tr.9t.2j@:71 i97b179•fA%f037P:��32t6'VJEQ"uiE'Y.vs „prxiamnv<mge:m PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JOHN MORIARTY 907-748-4894 2 OF 3 LEGAL DESCRIPTION: DRAWN BY: SAND LAKE #2; BLOCK 7, LOT 14 D.J.G. TYP= OF VtORK: DATE: ,l SEPTIC TANK RECORD DRAWINGS 4/24/2020 PARCEL ID NUMBER: 011-132-23 W ui U) O W ® C-9-- ,'' .... o ........... ...... ...ffi r A. Garness � m 'ob Gl, CE 7953 �* LICENSE$ A �40t�`0�� PAECC884 / CRm i iIUMBER: j'+ PARCEL ID NUMBER: OSP201063 RECORD DRAWING � 011-132-23 TOP OF MANHOLE = 100.00 FINAL GRADE= 99,97.99,76 MH �ST2 `j 2" INSULATION PER CONTRACTOR T OF OF TANK AT INTLET = 95.87 TOP OF TANK AT OUTLET = 95.86 NEW 1000 !NVERT OF SUNG AT INLET = 95.18 GALLON H, D.P.E. INVERT OF SUNG AT OUTLET = 95.07 SEPTIC TANK n OF �_ o 14 A NESS INS 4 �...........� �........ ENGINEERING =, SALES- CONSULTING - 0j / 0 101 INCH -RACE. %.1:545x7' PHONE (907)337-4170- FAX (907051-32'd 't:E551 iE; wxR Oomet,a qne<.r, um 7� • i Y..<L"•. •+<.t . ...<.. •. •... <•.. ... .....ffi PREPARED FOR: PHONE NUMBER: PAGE ilUtABER: ¢# 0 . I Ja tey�arne 5 JOHN MORIARTY Ar �' 907-748-4894 3 OF 3 0 C7953 : LEGAL DESCRIPTION:Di SAND LAKE #2; BLOCK 7, LOT 14 p BY: ��1? PROF TYPE OFVYORK: DATE: LICENSEP4 4 ROq� �4 SEPTIC TANK PROFILE 4/24/2020 #AECC884 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP201063 Work Type: SepticTank Upgrade Tax Code Number: 01113223000 Site Legal Address: SAND LAKE #2 BLK 7 LT 14 G:2224 Site Mailing Address: 8340 ENDICOTT ST, Anchorage Owner: DOERR GEORGIA 50% & Design Engineer: GARNESS ENGINEERING GROUP LTD This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: C� v llepartin ent 4/16/2020 4/16/2021 6750 ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing `o c�t� n e - ��� o �o l , I �Ti tb r v� 4b Received By: Date: Issued By: -c QJ Date: 2 _,Hent Municipality ®f Anchorage s�r^ Ucpartment P.O. Box 196650 ® 4700 Elmore Road Anchorage, Alaska 99519-6650 ® (907) 343-7904 ® Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Department On -Site Water and Wastewater Section * * * * VARIANCE/WAIVER REVIEW * * * * Waiver#: OSV201017 COSA#: Permit#:OSP201063 PID#: 011-132-23 Legal Description: Sand Lake #2 Block 7 Lot 14 Engineer: Garness Engineering Group Applicant: John Moriarty Your request for a waiver of the required100.0 feet horizontal separation from the septic tank to the private well on Sand Lake #2 Block 7 Lot 15 has been approved. The approved separation distance is 85.0 feet. This is a re -issuance of ADEC waiver #9921 -WW -223-330, issued November 12, 1998. See engineer's waiver request for justifications to re -issue this waiver. This waiver approval applies to the proposed septic tank only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. ............................................... ■ ............................. ■ t Waiver is Granted: X Waiver is not Granted: Date: a 3 a01/� Q Approved by: Name of Reviewer **** VARIAN C E/WAIVER REVIEW **** MUNICIPALITY F ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT -�'-� 3" On Site Water and t.Ptirastetfvacer Section �.>��rar.r�uni.orgfansice '� _�% PERMIT # OSP201063 PID 011-132-23 SUBD SAND LAKE #2 907-343-7904 Fax: 343-7997 TRACT BLOCK 7 LOT 14 CONTACT PERSON Jody Maus PHONE 337-6179 PLEASE GAVE A DESCRIPTION THE CHANGE Request change of location of new septic tank. Well radii were staked by surveyor and per the contractor, 'ON the tank cannot be installed as originally designed due to utilities (electric/phone) conflict. New tank is to be installed near the existing tank location and old tank is to removed and disposed offsite (see attached drawing). Per phone conversation with Becca Carroll, the existing 87 foot waiver from well on Lot 15, Block 7 (see ADEC Waiver #9921 WW2330 issued on 11/12/98) would be grandfathered with justification for issuance of waiver and no waiver fee is required. Justification for this reissuance is nIr-- 11 that the new tank will be made of plastic and recent water sample for Lot 14 showed ND for nitrate and negative for coliform. In short due the tank material and no indication of contamination of the well that serves this property should be adequate justification for the reissuance of this waiver. It is unclear if the 5 foot separation distance between the new tank to the existing drainfield can be achieved. Waiver may be required. It is our intention to to maximize the separation between tank and drainfield and keep the new tank outside the 100 foot well radii for Lot 13 & 14 and the 87 foot well radius of Lot 15. CUSTOMER SIGNATU Date: fr e On -Site Reviewer: Comments Issued (date) Review Time (hours) APPROVED (date) 7d d _TOTAL HOURS C �5 HOURLY RATE `X145 TOTAL TO BE PAID DATE PAID RECEIPT # SGS Refit 12Cs11.SSf;fl1 ^ Client Name Garttm Engirt vreject tame/9 Sand;LakQ '112:' Client Sample lD Sand Lake 42; Matrix Drinking Mate 14Amnin IZ6= ks: OnfIg croup, Ltd �'GmG} �. Fraxttcd� ietcCiune 37, L14 Collected Date/lime 37, L14 RccleWed DaIdIrime T,eelanie�tL illrL's,ttlr Results Lou0s . fit thsx# Unf atals by ICP /MS 3fa.:atf ttia �* ;.t? ug , �EP1200A EAhAIS Mti ANCHORAGE Development Services Department N Prone: 907-33-79174 On -Site. Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 011432-23 Property owner(s) JOHN MORIARTY Day phone 784-4894 Mailing address 8340 ENDICOTT STREET, ANCHORAGE, AK 99502 Site address 8340 ENDICC)TT STREET, ANCHORAGE, AK. 99502 Legal description (Sub'd:, Block & Lot) SAND LAKE #2; BLOCK 7, LOT 14 Legal description (Township. Range & Section) Lot Size Sq. Ft. Number of Bedrooms 2 APPLICATION IS FOR: (IS all that apply) Absorption Field ❑ Septic Tank iX Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ APPLICATION IS AN: Initial ❑ Upgradex❑ Renewal ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: LOT LINE WAIVER TO NEW SEPTIC TANK TYPE OF DWELLING: Single Family (SF) El (w/wo ADU) Duplex (D) ❑ Multiple Dwellings ❑ (SF and/or D) Distance:. 11 I certify that the above information is correct. I further certify that this is in ,accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: zs / / to g . 7-6 Date of Payment'. g' Z&1;20 20 Receipt Number: C) X5-q5L) Permit No. 6 S P I� b 1O (a3 Waiver Fees: Date of Payment: Receipt- Number: !oyLq L Waiver No. GADevelopment Seivices\Euilding SafetyQn Site water and WasibwaterTormskCilentForm Permit Appftation:rloc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201063, Rebecca Carroll, 04/16/20 I LOT 7, BLK 7; SAND LAKE #2 I LOT 18, BU< 7; I I I l \ I / SAND LAKE #2 I I -----� __-----�--- --- I 4 n , n I I (-----i---- \ \ , y WELL ID'US LOT 8, BLK 7; SAND LAI<E #2 100" YELL RADIUS (APF OX. LO )�— f �� I � � LOT 17, BLK 7: � ( 1 I / ( I SAND LAKE 02 I /LOT 6; ALDER PARK LOT 16, BLK 7; LOT 9, BLK 7; \ \ / ' U ( / SAN LAKE -2 SAND LAKE #222100-W 2 �,h` ` I / `\ _ — I ---------------- 100' W LL RADIUS (APPROX. L C.1� ----- L\I _ 1y�-------- / LOT 1 BLK 7;I-�s--------------- (ti / LOT 10, BL)7;,/ % x ice SANG LAKE OUBLL ICLEANO TS v �10 ' VdELPPROX �dC.) N I ( XIS I IIJG 87 FQU'i WAIVER` I I\ EXISTING SEPTIC TANK TO BE I \\ CFO DECOMMISSIONED PER UPCpPOC 0M"T'100''rIELL RADIUS I � LOT 5; M '/!` co I \ I ( ALDER PARE( �Cvl'rCE SEPARATION DISTANCE FOR iJ{:4's V \ \ ANK TO DRAINFIELD. WAIVER MAY BE RUjRED 1 00'WELL RADIUS LLI LOT 12, BLK 7; EXISTING I ,\ SAND LAKE A2 DRAINFIELD—f < ` LOT 13, BLK 7; u C SAND LAKE 02 / \ ----------- I W. 84TH AVE. PROPOSED •1000 GALLON \' GREERPLASTIC SEPTIC TANI< NOTE: THE EXISTING SEPTIC TAN- 'I<1 IS TO BE COMPLETELY REMOVED AND THE NEW TANK BE INSTALLED IN /NEAR U - THE SAME AREA AS THIS TANK. — LANCASTER; TRACT A NOTE: THE CONTRACTOR SHALL HAVE THE 100 (ANCHORAGE SAND & I N FOOT WELL RADII FOR LOTS '13, 1Y, AND 15; AND GRAVEL CO. - GRAVEL PIT) j ALSO THE SOUTH AND WEST LOT LINES FLAGGED/STAKED BY A REGISTERED LAND r SCALE: SURVEYOR. PRIOR TO ANY CONSTRUCTION. ( � GARNESS ENGINEMRING ENGINEERING SALES CONSULTING 3701 E. TUDOR ROAD, SUITE 101 "ANCHORAGE, AK 99507PHONE (S07) 337-6179 • FAX (907) 3303240 °'NEBSITE �Nnv.gamsssen0lnserin0.com PREPARED FOR: PNONE NURgBER: PAGE NUMBER: JOHN MORIARTY 784-4894 1 OF 1 PROJECT/LEGAL DESCRIPTION: _ DRAWN BY: SAND LAKE SID#2; BLOCK 7, LOT 14 J.L.M. TYPE OF WORK: DATE: REVISED SITE PLAN FOR SEPTIC TANK UPGRADE 4/22/2020 00 o �% .......... ... ... .....% ;M .......z , fi ey A. Garn ss W LICENSE �Mwaii m�wo�,� #AECC884 / r, • MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION d ENVIRONMENTAL ENGINEERING DIVISION \ 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME • /1 PHONE �NEW MAILING ADDRESS ii OUPGRADE O LEGAL DESCRIPTION LOCATION A G�/O �C,:31 Z4- �/Jpl6O7"T ST/ NO.OFBEDROOMS n •C• D sG DISTANCE TO: Well /OZ r Absorption area Dwelling n 7 PEH IT NO. �y s-Z awi Manulacturer a�� �i Material 00 Z No. of compartments Liq, capacity in gallons Inside len th O IF HOMEMADE: g Witlth Liquid depth dp Y Z DISTANCE TO: Well Dwelling PERMIT NO. _ Manulacturer Material Liquid capacity in gallons w2 DISTANCE TO: Well Foundation Nearest lot Itne / 1� / PEHMIT NO. F Z W O No. of lines / Length of each line Total length of lines Trench width 1 Distance between lines f 0 4,09 Top of lila to linish gr�de/ Material beneath lila inches inches Total effective absorption area �j w W.dthIle Depth U PERMIT NO. Wd Crib diameter Crib depth Total ellective absorption area w a : Well Building foundation Nearest lot line Depth nG0 Drill rDistance M,b to lot1 a PERM17yOLu.G : BuildingZUcl tion Sewerline . Septic tank /Absoption Q Ll areas)OTHERPIPE MA % SOIL TEST RATING — 7 INSTALLER 1 .� G REMARKS = Z��Jo Ot !; .. .. NI ti F, r ... ...�t a7> t '/ � Earl R. Barnard : Y_ t •. Sd-E v \I 2 APPHO ED DATEV LEGAL 72-013 (Rev. 3/781 [ r' MUNICIPALITY OF A�&`WfF1L DEPT. OF H=ALIr j pig e & T ? ENVIRONMENTAL PF.OT:CTION WATER WELLS ✓ OCT 3 1 1980 687th Avenue RECEIVED Anchh oraa ge, Alaska 99502 WELL CONSTRUCTION LOG Drilling Co. c / c2 USGS no. Driller rte' Vnti`' Type of rig ' Date Well completed /t��!' /Zry (s Well owner I Nearest community Well location:(address g legal description) Location sketch or remarks Depth of well2-1- ft. Casing: depth 241 ft, diam. �./* In. Static water *Vol —gr --ft. (above, below) land surface.Date cc.�a� �y /?to Finish of well: (Open-end, screen, perforated, open -hole, other) Describe intervals and site: Well yield tested by (pumping. balling, air) at .'S gal/min. for Ae hours wit inc_ft. of drawdown from static level. DRILLER'S MATERIAL LOG Depth below land surface in lest Give description of strata penetrated (site of material, color, hardness of drilling, and water content) el to A6 tot?,? 4k T�—I a 'mss to t 1,O&Zfl -le to to to —to- o to -to to a r " r /40( oltaid, to / to to to to to to I IL _ _. �. ,... �\ _.. '; .. \ � ,.. ' -� !' ... .. � .. _ _ �• _ T� / ` � ,J �� _ �� _ �. a' I C��v 4' � ��- I ?� � � � �� tel- �� _ _ J � sem° � .. ,f. �� .� �. 1 I, _� .:.1i'i+--`-'ter •--"i_..,---•_-.��- .. -- \���� �� � ���R �v 1� \ � �. \ I \ t•11 1 t•J I I=: I P M L I T •r- . 0 F= F=i N C H 17-6 F.' F=l a E DEPARTMENT gr -.,HEALTH AND ENVIRONMENTAL POTECTION F �w 225 'L STREET, ANCHORAGE, AY,. 93: • 264-4"'0 'J L•JEL_L- Fit4C' C�r4—= ITE *_=;EL4EF? PEFZP1 I T FERMI NO. C o, qO APPLICANT?aul no"' Q.tg0)e 1(- 13tY LOCATION Yf�] E�nc�cco7� LEGAL„-- -- 1 qj TYPE OF SOIL ABSORPTION SYSTEM IS: trlr°1 LOT SIZE 6750SQUARE FEET MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SQ FT/BR)= SS THE REQUIRED SIZE OF THE SOIL FBSOFPTION SYSTEM IS: C.EFsTH= IO ft, L-EFJGTH= o? (o {• 0E- FiVE:L_ GtiEF}TH= THE LENGTH DIMENSION IS THE LENGTH <IN FEET) OF THE TRENCH OR DP.AINFIELD. 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 A14D THE BOTTOM OF THE EXCAVATION <IN FEET). F?EQIJ I F2ELti SEF•T I C TFFFJK S I .=E_ 1000 GRLL_Ot•J_ PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTION_ OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF P.ESIDENCES THAT THE WELL WILL SERVE. --- TL40 < 2 ? I Y4EPECT I Qt4=. F=l F=-* E: FREQU I FREC> 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 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO R PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS PRE 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. PERt'I I T EXPIRE. C'ECEt�1BER =;�. yog�� I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR. Ott -SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL -THE SYSTEM Itt ACCOP..DANCE WITH THE CODES. 3: 1 UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS R�EMODDEL�EED TO INCLUDE MORE THAN 3 BEDROOMS. SIrttEG: ,” `-`4 _-�> -� �) ----------- App ISSUED BY__ -.---DATE_- _I � `� V4.0 r, SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Poi" 8880, AnrAorye, Auks 89802 271L2221 SOILS LOG — PERCOLATION TEST O PERCOLATION TEST PERFORMED FOR: �Li//,L DATE PERFORMED: CIVAILe- 2B.I �1�Q LEGAL 2V:4 3 4 , Gros ; o., _ 5 ,.0 l 6 Time Water „ b r , r 8 16 �. 9 j it 2 12- t•t �, t •� 13 13 4 14- 15- 15 ip 16 . 17 18 19 20 S%L.TV- Loa// 14µ0 � J RA V H . E.S CL�.g-,vim w D Y V'rf'rQYEL rr •..•4e Earl R Bamard 754.E WAS GROUND WATER S ENCOUNTERED? 0V0 L O P IF YES, AT WHAT E DEPTH? SITE EJYl7/Go7-7- ST, Reeding Dote Gros - Net I�I r Net l � Time Water Drop F a� EJYl7/Go7-7- ST, Reeding Dote Gros - Net Depth to Net Time Time Water Drop a� W r r PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT COMMENTS %?/ia/N ",gAM,= PERFORMED BY: BARNARD ENGINEERING CERTIFIED BY: DATE: 203 West 15th Avenue 72 009 (7/76) Anchorage, AJL*A 99501 . ti Parcel I.D. 011132-23 MuniciIP alit of Anchorage y On -Site Water and Wastewater Program (907) 343-7904 Rah Certificate of On -Site Systems Approval I 1. GENERAL INFORMATION: Complete legal description SAND LAKE #2: BLOCK 7. LOT 14 Location (site address) 8340 Endicott Street *Anchorage 9950 Expiration Date: _7--Z:Z-2020 Current Property Owner(s) John Moriarty Day phone 907-748A894 Mailing address Real Estate Agent Dayphone !I 2. TYPE OF, DWELLING: Z Single Family (w/wo ADU) 171 Duplex El Multiple Dwellings (Single FaIrnilyand/or Duplex) 3. NUMBER OF BEDROOMS: COVID-19 257o DISCOUNT APPLIED 4, TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual Individual Water Storage ❑ Holding Tank Community Class Well El Community ❑ Public Water System ❑ Public Sewer. WaiverNariance request for: -Distance. Received by: Date: COSA to be released to the engineer, unless otherwise recitiested by the.engineer. (In 1/1 o COSA Fee 202..50 Waiver Fee $ Date of Payment L/1971 Date of Payment Receipt Number 0 16- Receipt Number COSA# difir 961d,#2 Waiver # /'V/ Y/Z7/zo 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm: Gayness Engineering Group, Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness Date: — In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation, Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend upon a variety of variables, including but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s: therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fail to perform adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG to perform the evaluation. Reliance upon the information provided in this report by any other person or party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. 6. DSD SIGNATURE System #1 Approved for 2 bedrooms System #2 Approved for Disapproved Conditional approval for bedrooms bedrooms, with the following "k�kkk((MW 884 01 ON-SITE ip- WATER A ti Iat r T V`!ATER � FOGRPM By: _ "` 1� Original Certificate Date4-2,Y-2_00_0 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 Nitrate Advisory Septic System Advisory Arsenic Advisory >— Well Flow Advisory Other Legal Description: SAND LAKE #2; BLOCK 7, LOT 14 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA 0 Well log is filed with Onsite (or attached) Date drilled 10!22160 Total depth 263 ft Cased to 262 ft ❑ Sanitary seal is functioning correctly OR Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 3121120 Static water level at beginning of test 117.1 ft. Comments B. TANK DATA Age of tank(s) NEW years Tank type/material=E.`r"_'E Measured operating fluid level in septic tank NEW ON Standpipes/foundation cleanout per record drawing Date of pumping NEW D. ABSORPTION FIELD DATA Which system tested (date installed) 9120180 0_1 ALL standpipes present per record drawing Total measured depth from grade 9.16 ft (max) Measured depth to pipe invert from grade 4.4 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ' Parcel ID: 011-132-23 Structure served by this system 1 Well production at time of test 0.6 gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic 108 ug/L ❑ Arsenic less than MRL (ND) Collected by GEG LTD. Date of Sample' 311120 G. LIFT STATION ❑ Required maintenance c Age of lift station Lift station materif Adequacy test date 311120 Results ❑✓ Pass For 2 bedrooms Fluid depth prior to test 0 in Water added 308 gal New depth 0 in Elapsed time 0 min IN Code -required soil cover over field Final fluid depth 0 in ❑ System presoaked Absorption rate 300+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) NONE date of test) N/A Gallons introduced N/A gallons If yes, enter date Comments/Deficiencies: 'DRIVEN METAL MT EXTENDS APROXIMATLEY 9" PAST BOTTOM OF DRAINROCK COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Yes if No Community Sewer Manhole/Cleanout > 100' 0✓ Yes if No ft Q Yes if No Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No Absorption Field on Lot > 100' E] Yes if No ft Holding Tank > 100' 0 Yes if No Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' F/� Yes if No F71 Yes if No ft It Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' F/� Yes if No ft 0 Yes if No ft ft ft ft ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' M Yes if No ft Surface Water> 100' ❑✓ Yes if No ft Property Line > 5' Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Q Yes if No ft Private Wells > 100' ❑ Yes if No **87 ft Water Main > 10' P/1 Yes if No ft Community Wells > 200' 0 Yes if No ft Water Service Line > 10' Q Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑ Yes if No ft If absorption field is under driveway comment below Property Line > 10' M Yes if No ft Wells on Adjacent Lots: Water Main > 10' (,, Yes if No ft Private Wells > 100' Q Yes if No ft Water Service Line > 10' Yes if No ft Community Wells > 200' Q Yes if No ft Surface Water > 100' Q Yes if No It F. ENGINEER'S COMMENTS "TANK IS 5'+ TO SHED- NOT REQUIRED TO BE 10'+ PER CONVERSATIONS WITH MOA **WR#9921 ***CAVEAT - APROXIMATLEY 3 FEET TO SHED - COULD BE UNDER SHED BECAUSE CLEAN OUT MAY NOT BE AT END OF TRENCH. G. ENGINEER'S CERTIFICATION OF ' I certify that I have determined through field inspections and review T .� of Municipal records that the above systems are in conformance with �0 (r) y i MOA COSA guidelines in effect on this date. ,,�, , , , : , , j', , , r , �. , , ..... . /f/rey�A. Gar��ess,' 00CI GE —7 �r UV c� COSA Checklist yellow sheet -gAECC884 Well Water Advisory Certificate of On -Site Systems Approval # OSC2011162 Subdivision: Sand Lake #2 Block 7 Lot 14 This well's productivity was determined to be. 6 gallons per minute. The minimum well productivity required under (AMC 15.55) for a 2 -bedroom residence is.2 . gallons per minute or 150 gallons per day per bedroom. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. ,�' C .>.�f Y 5ws e' Nia�lmg Address P O� Box 196650* AnchorageAaska99519w6650 *uvwinrriuni org Arsenic Advisory Certificate of On -Site Systems Approval # OSC201062 Subdivision: Sand lake #2, Block 7, Lot 14 A water sample revealed an arsenic concentration of 108 micrograms per liter (ug/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. information on arsenic is available from the On -Site Water and Wastewater Program website (www.muni.org/onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. ¥ § § alias LLo eN3 A*e E1.100.90 OOS 2 2 / 7 m'3 M.,00,90 OON \ LO \ \ % z t: E ) / _\t( )/°: ) z q /§i < j - \\) ` \[}� , b §)}[ o§�) ) z » Z. [\®i in / \\} : \ § j \\\ \)\\g z e \ j\» - ( < (��t:0 ? )</§ a / m Q §9:o zz"( 4 3 , \/!) \)}/) § / \ / ��(� i i / / < \!>[ §/§)\ � < §S� Er li \\/\2/ �\ Z 2 § m / / ? § \ /� §}\) �Z Z a RLu % / _j\ Way/ ƒ (+� \ {)�8 u F \ \'\ \ Z u _ ./\Z �< \ / \�� \ / \\� 6 \ :©\ ... e2,141 E�. x o Li 6. � \ ul @ O � a a \ ° 0 +U m'3 M.,00,90 OON \ LO \ \ % z t: E ) / _\t( )/°: ) z q /§i < j - \\) ` \[}� , b §)}[ o§�) ) z » Z. [\®i in / \\} : \ § j \\\ \)\\g z e \ j\» - ( < (��t:0 ? )</§ a / m Q §9:o zz"( 4 3 , \/!) \)}/) § / \ / ��(� i i / / < \!>[ §/§)\ � < §S� Er li \\/\2/ �\ Z 2 § m / / ? § \ /� §}\) �Z Z a RLu % / _j\ Way/ ƒ (+� \ {)�8 �y� u \ }, � ? op \ Z [@2!u \ / \�� /< 702oU �y� u 5r+e# ? [ /, \ \�� z a> e2,141 { x o ul \ Oj aV£ 8L'( • Municipality of Anchorage On -Site Water and Wastewater Program y (907) 343-7904 s fi + Y Y Certificate of On -Site Systems Approval Parcell.D. (O<1 (3a a5 Expiration Date: GENERAL INFORMATION C Complete legal description �(ECK �� l Location (site address) EN JTCo /'1" 5 % pC-0 Current Property owners) IZA�fft Mailingaddres's 'Reai Estate Agent-'. 2. TYPE'.OF DWELLING:,' ( 8l[Aglp Family`(w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or.Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System WaiverNariance request for: Received COSA to be 4" L"65 Day phone qL7� -aS5 ( Day phone TYPE OF WASTEWATER DISPOSAL: ® Individual Q ❑ Holding Tank ❑ ❑ Community ❑ ❑ Public Sewer ❑ unless otherwise requested by the engineer. COSA Fee $ Date of Payment Receipt Number 81Ll g (40 COSA # 66C[& 13q? Date: ' 711 7 /JG Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm C -EM EN (< (, Address 3�� �t�J�F(r9F y Avg Engineer's Printed Name CNc�Rccs (3y(�dilzin�l 6. DSD SIGNATURE VA Phone 65; el- s sSg/ Date 5/S_12016 .q System #1 Approved for bedrooms System #2 Approved for bedrooms I m'. Charles G. Balzarini # • �e Disapproved s�•.••CE. 13,��{jj; Conditional approval for bedrooms, with the following W;b:"�� �_Vt4 Original Certificate Date: Co 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 COSAbluesheelf - S. c If more than 1 septic system is on the lot: COSA Checklist # Of _ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: SANi�LAKt#a- r3�ir % LA% t� Parcel ID: O(/ /32, z2 -3i A. WELL DATA Well type PRIVA?6 If AA,, B, orrCC provide PWSID # Well Log (9 4) 5 Date completed 4"1 Sani ary seal ®/N) -'14s Wires properly protected (ON) ES Total depth a&_ft. Cased to 2kal ft. Casing height (above ground) ay in. FROM WELL LOG Date of testes Static water level 95 ft. 5 Well production g.p.m. WATER SAMPLE RESULTS: A/EGA'T> vE Coliform colonies/100 mL Nitrate sl t> mg/L Arsenic 01Q, O ug/L Date of sample: B. SEPTIC/HOLDING TANK DATA AT INSPECTION 71dcold c7 <Iof ft. O. qq g.p.m. Collected by: F'V 6.r Ar'A'--7 ArN& Tank Type/Material S Elr=G/57-4eG. Date installed ( %P Tank size (600 gal. Number of Compartments CleanoutsdqN) YGS Foundation cleanout (VN) Depression over tank (Y/10 NO High water alarm (Y/& A/o Date of pumping & tjz4y Pumper tAC- povyiimis C. ABSORPTION FIELD DATA Q fi Date installed t RchQ Soil rating (gAAV#' or ft2/bdrm) " " System type T R "'454( Length 3d ft. Width 3 ft. vel below pipe ft. �� : Total depth ft. lEff. absorption area �fe Monitoring tube Depression over field .NO Date of adequacy test l b Results (in� Fail) w For bedrooms Fluid depth in absorption field before test ® in. Water added gal. New depth in. Elapsed Time: 10 min.'��� Final fluid depth ® in. Absorption rate >= g.p.d. Any rejuvenaiidndreatmertt-(past 12 mo.) (Y/N & type) A -WO jW&NI-f If yes, give date 111/A D. LIFT STATION ND 4T�7 Date installed r "Pump on" level at Iin. Datum Size in gallons "Pump off"level at Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot Absorption Feld on lot' Public sewer main r Sewer /septic service line f a� -4 (00 in. Manhole/Access (Y/N) _ High water alarm level at Meets alarm & circuit requirements? On adjacent lots On adjacent lots f «� ftoo' Public sewer manhole/cleanout 4 / oo � i Holding tank 4 5 Animal containment areas Manure/animal excrete storage areas ' SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5 Property line 4 $ Absorption field 1` S Water main l� Water service line fD Surface water 8 r Wells on adjacent lots �"' 7 ABSORPTION FIELD ON LOT TO: r � � Property line'f 7� Building foundation Water main �© Water Service line "EIC Surface water voo Driveway, parking/vehicle storage :f10 r Curtain drain 4 r7� Wells on adjacent lots 4 F. COMMENTS + WflTt/F(z #441 wt.✓ 334 S�dci�j I /(�/9fS G. ENGINEER'S CERTIFICATION I certify that 1 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 CHAPLGS -rvr Date e6151 COSA canary sheet_2-6-15.doc Charles G. Bairartni e, '.. E-13 . ay'} ...rt.SS,OtOP 44, in. Municipality of Anchorage v Development Services Department °x Building Safety Division .S.F ; On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Arsenic Advisory Certificate of On -Site Systems Approval # OSC161347 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 7, Lot 14 of Sand Lake#2 Subdivision. This inspection revealed an arsenic concentration of 29.0 micrograms per liter (ug/L) for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Information on arsenic is available from the On -Site Water and Wastewater Program website (www.muni.org/onsit ) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. Municipality of Anchorage _- ray Development Services Department Building Safety Division 5 5 F E T Y On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Advisory Certificate of On -Site Systems Approval (COSA) # OSC161347 During a recent COSA on-site inspection and test of the potable water supply well on Block 7, Lot 14 of Sand Lake #2 subdivision, the well's productivity was determined to be 0.49 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 2 -bedroom residence is 0.2 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. Municipality of Anchorage 'e Development Ser�vices Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anGhorage.ak.us (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 011-132-23 COSA# nsC 10a 1. GENERAL INFORMATION Expiration Date: S- 2 J Complete legal description SAND LAKE #2• BLOCK 7, LOT 14 Location (site address) 8340 ENDICOTT STREET *ANCHORAGE AK 99502 Current Property owner(s) FILOMENO BRAVO Day phone C/O AGENT Mailing address Lending agency Mailing address Real Estate Agent Mailing address 8340 ENDICOTT STREET *ANCHORAGE. AK 99502 Day phone DANIEL BENTON W/ PRUDENTIAL Day phone 242-3633 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 2 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site N 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 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 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. 1 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 GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's 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 & 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 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. GEG, LTD. 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 LZ Approved for 2� bedrooms. Disapproved. Conditional approval for bedrooms, with the following Phone 337-6179 Date ��pF �O44o �....:.... .... ............ r7 J f ey A G ness.' CE -79 4�4pfeie `J�21 .t`,7,-'�c�oG ON-SITE WATER AND WASTEWATER PROGRAM Attachments: (� COSA Checklist Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory Other By: Original Certificate Date: 'jf�_ —2 '12 — �! Municipality of Anchorage ' Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: SAND LAKE #2; BLOCK 7, LOT 14 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 10/22/80 Sanitary seal (Y/N) YES Total depth 263 ft. Cased to 262 ft. FROM WELL LOG Date of test 10/22/80 Static water level 85 ft. Well production g g.p.m. WATER SAMPLE RESULTS: Coliform © colonies/100 ml. Nitrate A)0 mg./L. Arsenic:52-Sug./L Date of sample: 5/9/12 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1000 gal. Number of Compartments 2 Foundation cleanout (Y/N) YES Depression o t ParcellD: 011_1_ 3= Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 5/8/12— 1 23ft. 0.68+ g.p.m. Collected by: GEG, Ltd. Date installed 9/20/80_ Cleanouts(Y/N) YES ver ank (Y/N) NO High water alarm (Y/N) N/` Date of pumping 5 / Pumper a � 3? C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE Date installed 9/2_ /80 Soil rating (g.p.d./ft2or5drm 85 Length �ft System type TRENCH Width 3 ft. Gravel below pipe 4 Total depth *8_91 ft. Eff. absorption area 240 ft� Mft onitoring tube YES Depression over field NO Date of adequacy test 5/8/12 -- Results (Pass/Fail) PASS For 2 Fluid depth in absorption field before test 0 bedrooms in. Water added 300 gal Elapsed Time: 0 New depth 0 in. p min. Final fluid depth 0 in. Absorption rate >=300+ 9-p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date – D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN "Pump on" level at in. "Pump off level ' . High water alarm level at Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankilift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100' Public sewer main Sewer /septic service line 25'+ Public sewer manhole/cleanout Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ 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 *87'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation 10'+ Water Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS *ADEC WAIVER #9921 WW22330 ISSUED ON 11/12/98 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. Q e ey A. rness.•' Engineer's Printed Name JEFFREY A. GARNESSQO 9 CE -79 3 m� Date COSA Fee $ gq(3.N Date of Payment sl aaU a Receipt Number G'+14g6 (Rev. 11/05) Waiver Fee $ Date of Receipt Number SGS Ref.# 1121570001 Client Name Gayness Engineering Group, Ltd Project Name/9 Sand Lake 2 B7 L14 Client Sample ID Sand Lake 2 B71,14 Matrix Drinking Water Sample Remarks: Parameter Results LOQ Metals by ICP/MS Received Date/Time 05/09/2012 10:00 Arsenic 57.8 * 5.00 Waters Department 05/15/12 AYC Total Nitrate/Nitrite-N ND 0.100 Microbiology Laboratory E. Coli Negative 1 Total Coliform Negative I Printed Date/Time 05/17/2012 10:19 Collected Date/Time 05/09/2012 9:50 Received Date/Time 05/09/2012 10:00 Technical Director Stephen C. Ede Allowable Prep Analysis Units Method Container ID Limits Date Date tnit ag/L EP200.8 C (<10) 05/11/12 05/14/12 ACF mg/L SM214500NO3-F B (<10) 05/15/12 AYC 100mL SM219223B A 100mL SM219223B A 05/09/12 DSH 05/09/12 DSH Municipality of Anchorage s Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Advisory Certificate of On -Site Systems Approval (COSA) # 121171 During a recent COSA on-site inspection and test of the potable water supply well on Block 7, Lot 14 of Sand Lake #2 subdivision, the well's productivity was determined to be 0.68 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 2 -bedroom residence is 0.2 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. Municipality of Anchorage &<., Community Development Department Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Arsenic Advisory Certificate of On -Site Systems Approval # 21171 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 7, Lot 14 of Sand Lake #2 Subdivision. This inspection revealed an arsenic concentration of 57.8 micrograms per liter (ug/L) for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Information on arsenic is available from the On -Site Water and Wastewater Program website (www.muni.org/onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 011-132-23 HAA # +jA b2)r 5 1. GENERAL INFORMATION Expiration Date: ! / Complete legal description Sand Lake #2 Blk 7 Lot 14 Location (site address or directions) 8340 Endicott St Individual Well Current Property owner(s) Phillip & Anna Tafs Day phone Mailing address 8340 Endicott St, Anchorage, AK 99502 Lending agency Day phone Mailing address ❑ Real Estate Agent Day phone Mailing Address ❑ Unless otherwise requested, NAA will be held by DSD for pickup. ❑ 2. NUMBER OF BEDROOMS: 2 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual On-site ❑r 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 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 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, 1 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 Watkins Engineering, Inc. Phone 349-1851 Address P.O. Box 110443, Anchorage, AK 99511-0443 Engineer's Printed Name Cindy W. Ellis Date 10/7/05 j `T 5. DSD SIGNATURE Cinhy W. Ellis Approved for 4:2— bedrooms. Vnw CE.1osm ; F Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report _4 Other By: IL�\ \ l% Q,. Original Certificate Date:jij-7 � (Pe . ouox) Municipality of Anchorage ' Development Services Department Building Safety Division On -Site Water S Wastewater Program s . 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.munLorglonsite (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Sand Lake #2 Ok 7 Lot 14 Parcel ID: 011-132-23 A. WELL DATA Well type Pri it A, B. or C provide PWSID # _ Well Log (YAV) Yes Date completed _ Sanitary seal (YIN) Yes Wires properlY Protected (YAV) Yes Total depth 283 ft. Cased to Z ft. Casing height (above ground) 13.5 In. FROM WELL LOG AT INSPECTION Date of test Oct 22, 1980 9/29/2005 Static water level 85 ft. 123 ft. Well production 5 9,p -m. 0.55 0 overy kers g.p.m. WATER SAMPLE RESULTS: Coliform o colonies/100 ml. Nitrate <0-1 mg.A. Other bacteria 0 colonies/100 ml. Arsenic: PIA mg.A. Date of sample: a' TO Collectedby: Rocky Tralnor B. SEPTICIHOLDING TANK DATA Tank Type/Material Stsel Date Installed 9/20/1950 Tank size 1000 gal. Number of Compartments 2 Cleanouts (YIN) Yes Foundation deanout (YIN) Y" Depression over tank (YIN) No High water alarm (YIN) No Data of pumping April 27, 2005 Pumper A+ Home Services C. ABSORPTION FIELD DATA Date installed 9120/1980 Sop rating (g.p.d.At2 or fl'Abdrm) 85 System type Deep Trench Length 30 ft. Width 2,6 ft. Gravel below pipe 4.0 ft. Total depth 5.8 IL Eft. absorption area 260 ft MwWring tube YOs Depression over field No Date of adequacy test 9/29/2005 Results (Pass/Fall) Paas For 2 bedrooms Fluid depth In absorption field before teat u In. Water added 301 gal. New depth In. Elapsed Time: 0 min. Final fluid depth o in. Absorption rate >a 300 g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN 6 type) No h yea, give date D. LIFT STATION Date installed NA 'Pump on' level at Datum Stze In gallons in. 'Pump off" level at _ in. Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank= station on lott W+ Absorption field on lot 107+ Public sewer main 100* Sewer /septic service One 80' Manhole/Access (YM) High water alarm level at in. Meets alarm & circuit requirements? On adjacent lots 1W+ On adjacent lots Public sewer manhole/deanout 100+ Holding tank 10D+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 19 Water main 10D+ Wells on adjacent lots Sr (waiver) Property line 15 Absorption field 5+ Water service One 80+ Surface water 100+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property One 10' Building foundation 3' Water main 100+ Water Service One 75• Surface water 100+ Driveway. parkingIvehide storage 70+ Curtain drain None known Wells on adjacent kits 100.5 F. COMMENTS ADEC waiver amnted for 76' to well on lot 15. G. ENGINEER'S I car* that I have determined through held inspections and review of Munidpal records that the above systems are in CIO Y W Ellis ; conformance with MOA HAA guidelines In effect on this date. CE •roan Engineer's Printed Name Cindy W. Ellis Date /0 -% HAA Fee $ LA 1� JWaiver Fee $ Date of Payment 14-1 acp Date of Payment Receipt Number. -J_C:-� r\U•(-", _\�l(Yl Receipt Number (Rev. 17111) Municipality of Anchorage ' Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Well Advisor Health Authority Approval # HA050515 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Block 7, Lot 14 of Sand Lake #2 subdivision, the well's productivity was determined to be 0.68 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 2 -bedroom residence is 0.21 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. Municipality of Anchorage Development Services Department Building Safety Division On -Site Water 8 Wastewater Program I 4700 South Bragaw, St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 011-132-23 HAA#_ 1. GENERAL INFORMATION Expiration Date: _ % — 12 - O 3 Complete legal description SANDLAKE SUBDMSION #2• LOT 14 BLOCK 7 Location (site address or directions) 8340 ENDICOTT ROAD • ANCHORAGE AK 99502 Individual Water Storage ❑ Individual Holding tank Current Property owner(s) CHARLES BALE Day phone 243-7372 Mailing address Lending agency Mailing address Real Estate Agent Mailing address 8340 ENDICOTT ROAD * ANCHORAGE AK 99502 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 2 Day phone Day phone 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual On-site N 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 Health Authority Approval (NAA) 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 cne year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public waver system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid S at, or prior to closing for the engineering services provided. 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 riles 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. Address 6901 DEBARR ROAD, SUITE 28 ' ANCHORAGE, AK 99504 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 Q 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 life of all welts 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 othow 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. S. DSD SIGNATURE 1/ Approved for bedrooms. Disapproved. Phone 337-6179 Date - G' �:� i I e f A. Gc ness. In •. CE -79 ARG ............ «90 Conditional approval for bedrooms, with the flowing stipulations: rtRto Wtur;r r 10FA.a11; z \VC < .• Irl-JIIC Attachments: HAA Checklist (/ Septic System Advisory Well Flow Advisory t/ Manitenance Agreements Supplemental Engineer's Reort Other Original Certificate Date: (Rm 12.101) / YVrJ I cvvn: u � p=0C;:��r1 :yam' -•aT Municipality of Anchorage ' Development Services Department ; Building Safety Division e OnStte Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 995198850 www.cLanchorage akus (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: SANDLAKE S/D 112: LOT 14, BLOCK 7 Parcel ID: 011-132-23 AL WELL DATA NEST DATA LESS THAN 2 YEARS OLD Well type SATE If A. B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 10/22/1980 Sanitary seal (YM) YES Wires properly protected (YIN) YES Total depth 263 ft. Cased to 262 ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 10/22/1980 07/11/2002 Static water level 85 ft. 123 ft. Well production 5 9 -p.m. 0.64 — g -p.m -WATER SAMPLE RESULTS: 'WATER SAMPLES PULLED BYANCHORAGE WELL & PUMP SERVICE Coliform •00 colonies/100 mi. Nitrate •0.2 m9h •7/9 2002 Arsenic: N/A mg./L. Date of sample: "3/1/2003 B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Tank size 1000 gal. Number of Compartments 2 Other bacteria **0 colonies/100 ml. Collected by: AKWWC Data installed 9/20/1980 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (YM) NO High water alarm (YIN) N/A Date of pumping 3/25/2003 Pumper NORTHLAND PUMPING C. ABSORPTION FIELD DATA ***BELOW EXISTING GRADE Date installed 9/20/1930 Soll rating (g.p.d./ft2ord16;–AJ85 System type DEEP TRENCH Length 30 ft. Width 3 ft. Gravel below pipe 4.0 ft. Total depth —=S—Aft. Eff. absorption area 240 ft' Monitoring tube YES Depression over field NO Date of adequacy test '•"7/11 /2002 Results (Pass/Fail) PASS For 2 bedrooms Fluid depth in absorption field before test 0 in. Water added 475 gal. New depth 0in. Elapsed Time: 0 min. Final fluid depth 0 In. Absorption rate >= 300+ g,p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date ***M:.ST DATA LESS THAN 2 YEARS OLD D. LIFT STATION Date installed "Pump on" level at _in. E. SEPARATION DISTANCES Size in gallons High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tenklllft station on lot 100'+ Absorption field on lot 100'+ Public sewer main NLA On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout NLA Sewer /septic service line 25' Holding tank NLA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main NLA Water service line 10'+ Surface water 100'+ Wells on adjacent lots "87'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 100+ Water main NLA Water service line 10'+ Surface water 100'+ Driveway, parking/vehide storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Munidpal records that the above Systems are in conformance with MOA HAA guidepnes in effect on this date. • ... , • • , • , , , , , • • •, , •.J ey Mesa: Engineers Printed dame JEFFREY A. GARNESS p CE -7953 ` Date , . •^edProfasdood�c HAA Fee $ 375, / J• Date of Payment Receipt Number (Rev. 12101) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage ` Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Nater Well Advisory Health Authority Approval # 030124 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Block 7, Lot 14 of Sand Lake #2 subdivision, the well's productivity was determined to be 0.64 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 2 -bedroom residence is 0.20 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. LOT 10 X 0 x LOT 11 / / / / i I I I LOT .12 LAND & C0~S1RUC'I10fl 440 WF..ST BEHSC~I gt.~1:). ! ~03 ANCHORAG~. AI. ASXA 99503 552-$291 94-L-', ~2. 1~94 LOT 15 '-. Ls-~2G2 ...." / N 8 5' W 155' "-~ ' ? 30' -\'~t. ®/~ "' "'- :Z' I / ,~.o'/ ~ ,, LO, T 14,/ / ~lk AS.~BUILT OF': ~ \ DUD 2224 KEN I Municipality of Anchorage .. Development Services Department .: C\��y Building Safety Division — On -Site Water 8 Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 011-132-23 HAA# 141—) O ;Z a 3 S- 1. GENERAL INFORMATION Expiration Date: 10 - -�z (o - O,2 d Complete legal description SANDLAKE SUBDIVISION H2• LOT 14, BLOCK 7 Location (site address or directions) 8340 ENDICOTT ROAD - ANCHORAGE. AK 99502 Current Property owner(s) SCOTT WEBER Day phone 243-7372 Mailing address 8340 ENDICOTT ROAD ' ANCHORAGE. AK 99502 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing address Unless otherwise requested, HAA will be held by DSO for pickup. 2. NUMBER OF BEDROOMS: 2 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well l0 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 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. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid 3 at, orprior to closing forthe engineering services provided. 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 Finn ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone Address 6901 DEBARR ROAD, SUITE 28 • ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, AKW WC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines B 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 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. AKW WC, 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 -�2— bedrooms. Disapproved. 337-6179 Date Z 0 Z_ Conditional approval for bedrooms, with the flowing stipulations: yam. ON-SITE �@' .w IeTGD AAll1 • m� WASTEWATER Attachments: ����'•, .. • '����` HAA Checklist ✓ Manitenance Agreements ���i lO'c' 1� Septic System Advisory Supplemental Engineer's Reort l yyy/1111)11)11 Well Flow Advisory Other By: Original Certificate Date: (IR".1210n Municipality of Anchorage Development Services Department Building Safety DWisbn Onsite Water & Wastewater Program 4700 South Bragaw St. P.O. Box 19WW Anchorage, AK 99519-WSO www.c1.erK:horage.ak.us (907)343.7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: SANDLAKE S/D i2: LOT 14 BLOCK 7 Parcel ID: 011-132-23 A. WELL DATA Web type _PRIVATE If A, B. or C provide PWSID# N/A Date completed 10/22/1980 Sanitary seal (Y/N) YES Total depth 263 ft. Cased to 262 ft. FROM WELL LOG Date of test 10/22/1980 Static water level 85 ft, Well Log (Y/N) YES Wires properly protected (YM) YES Casing height (above ground) 12+ in. AT INSPECTION 7/11/2002 123 ft. Web production 5 g,p,m. 0.64 — g -p.m -WATER SAMPLE RESULTS: *ANCHORAGE WELL k PUMP SERVICE Coliform 0 colonies/100 ml. Arsenic: 0.049 mg./L. B. SEPTIC/HOLDING TANK DATA Nitrate 0.2 mgJL. Other bacteria 0 colonies/100 ml. Data of sample: 7/9/2002 Collected by: • Tank Type/Material STEEL Date Installed 9/20/1980 Tank size 1000 gal, Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (YM) NO High water alar (YIN) N/A Date of pumping 1/23/2002 Pumper A+ HOME HOME SERVICES C. ABSORPTION FIELD DATA Date installed 9/20/1980 Sob rating (g.p.dJR'or([E�) 85 System type DEEP TRENCH Length 30 ft. Width 3 ft. Gravel below pipe 4.0 ft. Total depth 18 ft. Eft. absorption area 240 ft' Monitoring tube YES Depression over field NO Date of adequacy test 7/11/2002 Results (Pass/Fail) PASS For 2 bedrooms Fluid depth in absorption fleid before test 0 In. Water added 475 gal. New depth 0 In. Elapsed Time: 0 min. Final fluid depth 0 in, Absorption rete >. 300+ g,p,d, Any rejuvenation treatment (past 12 mo.) (YIN 3 type) NONE KNOWN If yes, give date D. LIFT STATION Date installed "Pump on" Wei at _in. E. SEPARATION DISTANCES Stre in gallons High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankllift station on lot 1006+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25' on adjacent lots 100'+ On adjacent kala 100'+ Public sewer manhole/cleanout N/A Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 15'+ Property line 10'+ Absorption field 5'+ Water main N/A Water service line 101+ Surface water 100'+ Walls on adjacent kits 087'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property Ane 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parldngtvehide storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lataOt 0,+ F. COMMENTS G. ENGINEER'S CERTIFICATION I cer* that I have determined through field inspect/o= and review of Municipal records that the above systems are in coMormance with MOA HAA guidelines in effed on this date. Je A. ass. Engineer's Printed am JEFFREY A. GARNESS E-7953 .•' Date � ) OZ !•'+eprofsssW+d�'o HAA Fee $ -375--Waiver Fee S _ Date of Payment ___%` ��3�� - Date of Payment Receipt Number 4� Receipt Number (ft". 12!01) Municipality of Anchorage !� Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Water Well Advisory Health Authority Approval # 020355 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Block 7, Lot 14 of Sand Lake #2 subdivision, the well's productivity was determined to be 0.64 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 2 -bedroom residence is 0.2 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. a 0 M ...........••..a•:.-....a•:.a.[.a�t.a�.tii+ '� i'�`""i"i'_i' I'..TFIJI_ .., /� J . M !moi f.f f.'. .^.'a aae'.9�Ja :Ta[. i•.'.a [. ia[�: i.l .. tn M r ENDICOTT i 00'06' 22.0' Y .i N STREET 16.4' ed 24 4' It ,3 0 M M 3 �- tn 3 4.9 m J H 1 L \ z / 00 O C x c opo LA s. �/ J .. W g• .oil �IL.� _. —x—X—X—X—X—X— N 00'06' W 50' C) N r - O ~ 0 O O • J I I 0 .j It N N n U O w a Z. W Y Y tL U U of Q R n C13 J / 92 m % Z i n A `1 ` PIN PICA 0 .j It N ® MUNICIPALITY OF & H ' DEPARTMENT OF HEALTHTH &HUMANMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 011-132-23 1. GENERAL INFORMATION aim an /lam/R9 HAA # Q c 9gcrL2,e, Complete legal description Lot 14, Block 7, Sand Lal�e #2 Location (site address or directions) 8340 Endicott Street Property owner Clark & Niki Countryman 243-7372 Day phone Mailing address "8340 Endicott Street, Anchorage, AK 99502 Lending agency .City Mortgage/Jerry Kincaid Day phone'2 3-0700 ' Mailing address ' 121 W. Fireweed, Anchorage, AK 99503 Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 2 ', Day phone 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. 72027 M".1/91) Fm MOA,21 5. 6. M 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 furtherverifythat 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 8 5 ENGINEERING Name of Firm RIVAP G y y_ y 7 q �-Read-tile 204 Phone Address Eagle River, Alaska 99577 Engineer's signature DHHS SIGNATURE _v Approved for 2 bedrooms. Disapproved. Conditional approval for Additional Comments K1 Date //2-t /`? 9 bedrooms, with the following stipulations: Date 2 - / 2 's% `/ 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 satisfy certain federal and state requirements. Employees of DHHS do not conduct Inspections or analyze data before a certificate is issued. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work. 72-73 (IN.. tNt) 0. A10A M RECEIVED JAN 2 6 1999 • .. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVI IGP'v'ITM of Environmental Services Division 4L'I 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: j- o r r q 4 L K 7 54 ,�o L A K E 2 Parcel I.D.: 0 1 1 - 13 i- a 3 A. WELL DATA Well type P/Z I vn r E If A. B, or C, attach ADEC letter. ADEC water system number Log present &N) _ Y f. S Date completed /0 /2L i / 80 Total depth b 3 Sanitary seal &I) Date of test Static water level Well production Cased to a V Yf f FROM WELL LOG /OI a / QO qr WATER SAMPLE RESULTS: Coliform S Casing height (above ground) Wires properly protected (ON) AT INSPECTION l�,Y I99 g.p.m. O. •/ Nitrate 0'1 YE S Other bacteria O Date of sample: I q q Collected by: S & S ENGINEERING I M-34 •R'V!FU66p-Wa-a-d1Uo-.25T— B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99577 Date Installed 9 / 10 / 8 0 Tank size /'0 o o Number of Compartments Z Cleanouts&l)y s S Foundation cleanout (2'N) Y E s Depression (YQ N 0 High water alarm (YAO N d Date of Pumping / / x Pumper /t`) Y //d M E 5"t 't v, c.r J C. ABSORPTION FIELD DATA Date installed cir/ a 0/ s c Soil rating (g•P•d.Htr or /bdrm 9r System type T R 4� G N Length 3 0 Width 3 Gravel thickness below pipe 4 Total depth Cl Effective absorption area A6 o f r z Monitoring Tube present (s61N) y+ rr Depression over field (YAFQ) f! 0 Date of adequacy test I / ' "/ 9 7 Results as IFaiq 14 t S For a bedrooms Fluid depth in absorption field before test (in.); pay Immediately afters y/ gal, water added (in.): S Fluid depth a , (ins) Minutes later. I I Absorption rate = 300 t a.p.d. Pero2dde treatment (past 12 months) (Y/N) "'-f a,.+c.. i✓ If yes, give date — 72-026 (Rev. 3/98)' D. LIFT STATION Date installed Manhoia/Access (Y/N) _ High water alarm level at' Cycles to E. SEPARATION DISTANCES 'Datum Size In gallons SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 10 r r o % On adjacent lots Absorption field on lot / 0 0 -/— On adjacent lots "Pump off" level at" Public sewer main N /-+ Public sewer manhole/cleanout Sewer /septic service line a S � 4— Litt station ^/ / .-J /q SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: 15' r PfOPertY line /a Absorption field '4 Foundation Water mainlservice line /a Surface water/drainage X00 r -t- Wells on adjacent lots 87 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / 0 Building foundation 3 3 Water main/service line O , Surface water 0 0 Driveway, parkingvehide storage area G Curtain drain NON i K N C w ,✓ Wells on adjacent lots /00 f F. ENGINEER'S CERTIFICATION OF q p 1 certtly that 1 have determined thru Held inspecdons and review of Municipal are in conformance with MOA HAA guidelines in effect on This date. AV +�9 Signature Engineer's Name /, 'O•ji RO6ERrNG. COWAN Date `I /ffcy;�y14CE-8801 HAA Fee $ 0� Waiver Fee $ Date of PaymentD //Z 6 %G, Date of Payment Receipt Number {S7 / Receipt Number 72-026 (Rev. 3/g6)' MUNICIPALITY OF ANCHORAGE M E M O R A N D U M WATER WELL ADVISORY HEALTH AUTHORITY APPROVAL NO. NA990035 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Lot to Block -7 of Soi� LnKe_2 Subdivision, the well's productivity was determined to be O JA gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for bedroom residence is gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies bf the subject Health Authority Approval. '. MUNICIPALITY. OF ANCHORAGE • DEPARTMENT.OF HEALTHr&`HUMAN SERVICES Division ofEngironmental'Sernces w Y'�' y'f !'' k ! ° 1 ✓.1 i_: a p On-$ite $eNICBS SBCtIOn -. P.O., Box 196650 ` Ah*cheorage Alaska 99519-6650 { 1 ,' f '� r v .n , , t �• ,M 4744 r , ) a ; 7 CERTIFICATE OF HEALTH AUTHORITY + 1 APPROVAL FOR A SINGLE FAMIL'Y,DWELLING' M1i k' i R Parcel 1: D# HAA 1 GENERAL'INFORMATION� Complete legal description r y 13u Location (site address or, direcUonsj r X Property.. owner 0.DaY,Phone1'2Y8-�l56 r, r'J 'Mailing address - • ` ` f , Lending agenck, `} Dai, hone Marling address Agent o�so 1= p Dayphone Address ;F U herwise requested,"HAA w1!! be held for pickup , , r • . nless of , L' � 2 NUMBER OF BEDROOMS t 3 -.TYPE OFIWATER'SUPPLY: Indivrdualweil -� i Community well Public watery NOTE:If communitywell system,' provide written confirmation from State ADEC attest Ing to the legahry,and status of system 4 TYPE OF WASTEWATER DISPOSAL-".' +, Individual on-site x f Holding tank_; �i Community on site ~� I , Public sewer1f NOTE if community wastewatersystem, provide written confirmahon from Sfate,ADEQ attesting to the legality and status of system: ti k 1L rear p+r 1A1) Front 'MOA m ' ' , ♦ ,. 5 STATEMENT°OF INSPECTION BY ENGINEER' v:B certified by my seal affixed hereto and as of the validation date shown As certbelow, I venfy that my, s investigation of th1�;Heatth Authority' Approval Bp�llcation shows that the on site water supply v 1 alt z{ n + ,r [ , ✓ .}. a v ry ti° . '� !' ^y and/or wastewater disposal system is safe,°#unctottal•anadequate for the number of be8rooms ti and type of structureInd icatecfherein Ifurthell rvenfythatbasedontheinformationobtainedfrom the Munic(pahty of Anchorage files and from my investigation and inspection, the on sde waw supply and/or wastewategdisposal system is incompliance wRh all Municipal and State codes ° ordinances, and r tions in effect on the date of this inspection., vur¢74 Name of Firm i a bh.u� �D v . Phone 3 y,•� 1 OyIt Address u � - - •-- _ - i ^- Date' Engineers signature y, • n -,n C I r c�or Af! Ck' 14 0 A �) % t% ob en SpvrVond cr 2 fO�N & DHHS SIGNATURE irFp " "« ••,P��.v L FROFESolO�,y+ ,Approved for ` bedrooms `[- Disapproved Condd}onaI approval forL rooms, wdh' the following stipulations - ' r 7777777, r •i Additional Commentsj. Date =1CAUTION ';-:The Municipality.ofAnchorage Department of Health and Human Services (DHHS) issues Health Authority 'ppP g reg y upon the representations gi3en in paragraph `S:above by an independent rofessionalen neer isteredintheStateofAlaska.TheDHHSdoe's this asacourtesy topurchasers ofhomes A royal Certificates based only 1. and their lending institutions in order to satisfy certain federal grid state requirements. Employees of DHHS do not coriduct'inspectfons or''anaI I data before'a certificate Is, as The°Municipality of Anchoragefisynci responsible for errors oro I misisi6ns in the professional engineer's work ' . •; ' , ' t rQ.= (pr. b9q B&ck MOA m . ® Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST am Legal Description:_(_ 14 g1�71 SO Hcvp1;7 Parcel I.D. %'1_I I — 1�3 A. Well Data Well type 7� If A, B, or C, attach ADEC letter. ADEC water system number N/ Log present (Y/N) Date completed 1012-240 Driller I F7_ Total depth 4/,3 Cased to 94- ' Casing height I I t1 Sanitary seal (Y/N) _ y Wires properly protected (YM) FROM WELL LOG Date of test I 0/2 Static water level eq 5 Well flow g,p,m, Pump Ievell �c+ rY? SEPARATION DISTANCES FROM WELL TO: AT INSPECTION byll319u , �;= 12 I M g U.� c g,p y A/ m In C Septic/holding tank on lot IDD ; On adjacent lots I OZ7 o R Absorption field on lot 112 ; On adjacent lots ) 1 Oro Public sewer main tJ /A Public sewer manhole/cleanout TJ lf-, Sewer service line 1 5 D Petroleum tank Ni 0-w WATER SAMPLE RESULTS: Coliform 6� Nitrate Other bacteria _ Date of sample: q/13 / a t/ Collected by: �+ _. S B. SEPTICIHOLDING TANK DATA Date Installed QI10 /J3' t7 Tank size 1000 Compartments .2 Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) N High water alarm (Y/N) Alarm tested (Y/N) Date of pumping ND f 1 tTPumper _ 4Q A,e IS SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: (i��lk q TIS Z Well(s) on lot 100 On adjacent lots q10 ( b Foundation 1 Q To property line 10 Absorption field S Water main/service line 5 5 D Surface water/drainage N b u P 72-026(3.93)• From CONTINUED ON BACK PAGE C. LIFT STATION Nl Date Installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) 'Pump on' level at 'Pump off" Level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots Surface water Date Installed �IZ[7 zgo_Soil rating (GPD/Ft) —System type re Length 3 Width 3 D _Gravel thickness q6_Total depth Total absorption area —It4n Cleanout present (Y/N) Depression over field (Y/N)_ Date of adequacy test —Results (pass/fail) for Bedrooms Water level In absorption field before test < I S n After test L 15 t t Peroxide treatment (past 12 months) (YM) �y If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot r I r On adjacent lots 10 Z Property line 10 To building foundation 'S1 To existing or abandoned system on lot NIA On adjacent lots 310 Cutbank N./A —Water main/service line 1 S D Surface water ^l o me Driveway, parking/vehicle storage area i So Curtain drain 1J ti" E. ENGINEER'S CERTIFICATION t certify that i have checked, verified, or conformed to all MOA and HAA guidelines is eHecfon the date Of. th ......... d. C� Ire .`............ 6; Signature 'C. r /1 � {�ifw 1 fCd (Ir q4 fr P] Engineers Name (o� eH �pu.-�°�weu ��^• �i �•� , c Date A 1 t{ 4 4 t-/ `���,<_,`•.:. �t HAA Fee $ 0a l Waiver Fee $ Date of Payment —g Date of Payment Receipt Number o2 S�' a Receipt Number 72-026 (399)' Back inspection. 5. LEGAk DESCRIPTION INSPECTION APPOINTMENTS DATE RECEIVED 'TIME TIME � TIME DATE DATE DATE NUMBER OF,BEDROOMS '--® SINGLE FAMILY❑ One ❑ Four ❑ Other INSPECTOR INSPECTOR INSPECTOR ❑ Three ❑ Six 7. WATER SUPPLY --ff7 INDIVIDUAL- MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANDEPT. OF I'...:LT?I 3 ❑ COMMUNITY DEPARTMENT OF HEALTH ENVIRONMENTAL PROTECTI )RONMENTAL ,.0KCTION • 1 825 LStreet - Anchorage, Alaska 99501 B. SEWAGE DISPOSAL SYSTEM ENVIRONMENTAL SANITATION DIVISION DEC 2 WO --Z] INDIVIDUAL/ON-SITE" Telephone 2644720 ❑ PUBLICUTILITY D. REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER � C E I V E DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PR9PEiRTYOWNERS PHONEh n 'hY%/a MAILING ADDRE S " v I PROPER TV hLbIULN F fit different from above) PHONE 2. BUYER PH NE N 8 -OS ,1 MAILIN DDR ESS 1 :; 4 C so 3. LENDING INSTITUTION PHONE MAILING ADDRESS \\ �L 4. REAL PHONE MAILING ADDRESS 5. LEGAk DESCRIPTION L STREET LOCATION � 6. TYPE OF RESIDEN E NUMBER OF,BEDROOMS '--® SINGLE FAMILY❑ One ❑ Four ❑ Other ❑ MULTIPLE FAMILY , EM Two ❑ Five ❑ Three ❑ Six 7. WATER SUPPLY --ff7 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.) B. SEWAGE DISPOSAL SYSTEM --Z] INDIVIDUAL/ON-SITE" 9Z1 YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLICUTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY - 1. TYPE OF RESIDENCE p SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOGRECEIVED r Q -f -,i 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON-SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED INSTALLER (, b ❑Septic Tank or C3 Holding Tank Size: I Or- 01 If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES W ELL TO: Septic/Holding Tank Absorption Area Sewer Line ` Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS 0 APPROVED FOR y�_ BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE P -G? o BY I PC. 72010 (Rev. 6/79)