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HomeMy WebLinkAboutSOUTHFORK NORTH BLK 2 LT 6outhfork North Block 2 Lot 6 #078 — 021 ma 10 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. Municipality of Anchorage e Development Services Department Building Safety Division On -Site Water and Wastewater Program, 4700 Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 Page of www.ci.anchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: PID Number: 07K-0111 -IC) Name: / AA `` I l�J�,.v /Kee.�A.rl,t,� Wastewater System: New Y � El Upgrade Address: i R 41 5 • �r 17c- ABSORPTION FIELD Phone: Number of Bedrooms: ❑ Deep Trench Shallow Trench ❑ Bad ❑ Mound ❑ Other: LEGAL DESCRIPTION Soil Rating: 1� � Total Depth from original grade: '1� GPD/Ft' Ft. Block: LIN: Subdivision: so � Depth to pipe bottom from original grade: Gravel depth beneath pipe: Ft. G Ft. Township: i Range: j Section: W Fill adbled above original grade: Gravel Length: l M I t.1 , S Ft. l V Ft. Well: µfpr El New ❑ Upgrade Gravel width: / In Number of lines: Distance between lines: FL L I V F[. Classification (Private, A, B, C): Total Depth: Cased to: Total absorption area: Pipe Material: Ft. Ft _ J'7D Fl= VC Driller. Dale Drilled: Static Water Level: Installer: (' Date Installed: Ft. �� �� Sit'I o M rq' cvksk, Yield: Pump Set at: Casing Height Above Ground: TANK GPM Ft. Ft. SEPARATION DISTANCES L7 septic ❑ Holding ❑ S.T.E.P. ❑ Other: To From Septic Tank Absorption Field Lift Station HoldingubliciPrivate Tank Sewer Line Manufacturer. (V- Capacity: J 1j;_0 Gal. Well I l f / 2 � P ' / rA /v �JA ^ 2 l.� Material: i JiTGI Number of Compartments: 4 Surface Water NA NA rJA �JA LIFT STATION CNA. Lot Line I � t, f,'I `TV9 . �A Q,A Size: Manufaqurec t Gel. Foundation I I I ,� r `Z 5 n N ✓•i N A "Pump on" level at: 'Pump off" levet at: High water atom at 11 in. in. in. Curtain Drain NA n IV'l tir'S n , N`A Pump Make &Model Electrical Inspections performed by: Remarks: jos" rowd BENCH MARK if i 0,1( C.0 Location and Description: r TT, cEm -'S -,-o o+ sir o Assumed Elevation: /I�yO Ft. C� t c a3 21 eto - E��Ceii� m\ AW. p1E.�F b 6i' easy Inspections performedby:z�a,�? L;.,.w9.4fjr,3��, Dates: is' 32i Oto /�*•• •k P, its T .P �N/ 2 n 4Z vM /•f•�j1P f4 PP �• • • P s . • Ijr/P)II 1 P f Development Services Department Approval 3`5 3 7- °e S� Edney P. Kinney, J, C Reviewed and approved by: I Date: (Rev _ 1J001 J ZN0 7 p Prp� P ' �► ni(�I'tIJNfl (C'JUPrL : k a CV�tE F3 vclAtey R lc,0ulc7 t_j6:7- Vq P''t•re r"AacFir 28 , 2oos(p) April 21, 2006 Municipality of Anchorage Development Service Department Onsite Water & Wastewater Program 4700 South Bragaw Street Anchorage, Alaska 99519-6650 (907)343-7904 Attention: Mr. Joe Goodall Subject: Onsite Wastewater System Lot 6, Block 2, Southfork North Subdivision Mr. Goodall, The subject septic system has been approved on a conditional onsite systems approval permit. The system was approved conditionally because the service line from the house to the new septic tank could not yet be installed due to the frost depth and utility conflicts at the project site. Southfork Construction has completed the service line and connected the new system to the house. The service line was sloped at 2%. The service line maintains a burial depth of approximately 3.5 feet from the house to the new septic tank. A total of 6 inches of 60 psi insulation was installed over the schedule 40 pipe. The work was completed as of April 17, 2006. The completion of this work should satisfy all requirements needed for final approval to operate the subject system. An escrow money account was opened to insure the completion of this system, we request notification to Andrea Fullbright of Wells Fargo Bank, fax number 689-4255, regarding the final approval of the system being complete. For more information regarding the escrow account, please contact Colin Meehan at 694- 2332. If you have any questions, please contact me at 694-2332. Sin ely od ey P. nney, JJrr.,,/^Pl`^E. Attachments March 28, 2006 Municipality of Anchorage Development Service Department Onsite Water & Wastewater Program 4700 South Bragaw Street Anchorage, Alaska 99519-6650 (907) 343-7904 Attention: Mr. Joe Goodall Subject: Onsite Wastewater System Lot 6, Block 2, Southfork North Subdivision Mr. Goodall, The subject septic system has been installed per design for the issued permit, see as -built package attached. During construction it was decided to replace the sewer service line from the existing house to the new septic tank entirely, due to poor installation of the existing line. This work cannot immediately be completed due to frost under the driveway and nearby gas and electric utilities. The service line is to be replaced at the earliest possible time and no later than May 15`, 2006. Until the new service line can be installed a temporary service will be provided by using a sump pump in the crawl space directing septic flows into an above ground insulated, heated pipe and into the new septic system. We will need conditional approval from your department to operate under this condition. A copy of the proposal from Southfork Construction has been attached and an escrow account has been opened through Wells Fargo Bank to insure the work is done by the scheduled time. A copy of the escrow account balance has been included as well. A water quality sample has been taken for nitrates, fecal coliforms, bacteria and other bacteria and has been submitted to a certified laboratory to be analyzed. I will forward the results to you as soon as I have received them. If you have any questions, please contact me at 694-2332. Sincerely, i Rodney P. ney, Jr., P.E. Attachments SPLITT 45' BEND WEST TRENCH 22.5 L.F. 4" SOLID PVC PIPE DOUBLE C EANOUTS 12 0 GALLON SE TIC TANK EL VATION MARK TH ESHO OF FRONT E TRY DOOR. ASSUMED EL.=100.0' �a• e a•a.a• r P. Kin . Jr. 1 1 l 1 1 1 1 GRAPHIC SCALE (In ter) I Iver — as AST CLEANO T 7' I TRENCH FLOW SPLITTER D ACH 4Ag9 . ARAGAGE � BE WEST TRENCH o, SECTION DETAIL 35 L.F • TEMPORARY FORCE MAIN TEMPORARY SUMP PUMP LOCATED IN CRAWL SPACE EXISTING 4 BEDROOM HOUSE 1 1 1 —� ALTERNATE SEPTIC DRAINFIELD SITE AND PROPOSED TEST HOLE LOCATION. rrcv. wre .[saamo• pr SOUTHFORK NORTH SUBD. LOT 6. BLOCK 2 BUILT PLAN OF 2 -� ^Om^AS a �m nor wic- vera ' GROUND SURFACE5.0 L.F. 4" SOLID EL.=96.50' 20.0 L.F. 4" SOLID PVC PIPE, VC PIPE SLOPE=2.00% SERVICE FROM HOUSE w J p Z 0 O 00 p O O p W M o Y O vip O O OI- p¢0) OQ O r� N� O X1-0) O i- II F- II � o d II o0w coww OOZ oZ ow oc(j 07 ¢dj Qd�j ¢w dw d. doj H w I- W H J 1- J I- H J V) V) Z m V) 0 Z N U (n 0 (n It V) w Z 14.0 L.F. 4" PERFORATED A() L.F. 4" SOLID 21.5 L.F. 4" PERFORATED PVC PIPE, VC PIPE, PVC PIPE, SLOPE=0.00% LOPE=8.00% SLOPE=0.00% GROUND SURFACE EL.=96.5' 41 -� Fa- w MONTORINGIc io Of CN oz� TUBE, INV.a iv p? N Owro p N EL=91.07'?�MODSM OfV) +��� Na11 +wrn BOTTOM OF��o LL o J + V I J p d' J L L o J ozw O w I-- Li TRENCH -ozw I Q o I- Z J I-- QJZ H W Z 1- Z.J V)wUZ V1L-Z V)hZ V)ui0z EAST TRENCH PROFILE 12.0 L.F. 4" PERFORATED 18.0 L.F. 4" SOLID 23.5 L.F. 4" PERFORATED PVC PIPE, PVC PIPE, PVC PIPE, SLOPE=0.00% �SLOPE=15.61% SLOPE=0.00% GROUND SURFACE EL.=95.0' .r•��OF A l� a ui - MONTORING a pt�.••••°•t;9s�� a TUBE, INV. a M,yt� . .•,�9�f . *• 9 '• '•• ..••*•'••le`� oN op owz EL.=88.26' a Np w N n zLn p=Oa N�r� O •' + + 0 D II N a pBOTTOM F +o 0) o of+oow 11 O O(nJC14 ci� -j TRENCH Z W W W N O Z W •.�+^ % Ro ney P. Kinney° .h'. ; h9ri Q 3;: 1 Q EE 7953 .°��� �ZJz ~�Z ~wZ LLJ ~zJZ (n w v _ (n L� _ cn � _ (n w o _ WEST TRENCH PROFILE x[v. w¢ cevlwncx or SOUTHFORK NORTH SUBD. LOT 6, BLOCK 2 AS BUILT PLAN rc•a®m GN SHEET N0. 2 1 0c 2 ° • m car. '�'�°� ,• � so' MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Date Issued: Jan 31. 2006 Expiration Date: Jan 31, 2007 Permit Number: SW060013 Parcel ID: 078-021-10 Legal Description: SCUT HF OORK NORTH BLK 2 LT 6 !V i P Design Engineer: &6"" " Site Address: 001941 SOUTH RIVER DR Owner Name: COLIN MEEHAN Lot Size: 61997 SQ. FT. Owner Address: 12100 BUTTERMILK WAY Total Bedrooms: 4 Permit Bedrooms: 4 EAGLE RIVER, AK 99577 - This permit is for the construction of: ❑✓ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3_ The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: Date: f 16-tr Date: 1 &0 hol. 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 1. D. D 7 $' 02-1 – 10 Number SW Property owner(s) mcorg.,LS Day phone (�– 2332 Mailing address /2110 FUTrEeMtt.k VJAy , 64GL6- Ow6ejr— Zip Code Site address I�LiI EIVEe ; A- Zip Code gSti27 Legal description (Lot, Block & Sub'd.) L.0 (o l _CL0 Legal description (/Section, Township & Range) —It -so I EIo S. M, Lot Size r "I 4rres$ Cq Number of Bedrooms L4 THIS APPLICATION IS FOR: Sewer Only ❑ Well Only ❑ Sewer and Well ❑ Water Storage ❑ Sewer Upgrade [� 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 accprqlance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees Date of Payment: Receipt Number: (Rev. 09104) Waiver Fees: Date of Payment: Receipt Number: January 31, 2006 Municipality of Anchorage Development Service Department Onsite Water & Wastewater Program 4700 South Bragaw Street Anchorage, Alaska 99519-6650 (907)343-7904 Attention: Mr. Joe Goodall Subject: Onsite Wastewater System Lot 6, Block 2, Southfork North Subdivision Mr. Goodall, Please reference our telephone conversation on January 30, 2006. Attached are the following: 1. Revised drainfield calculations 2. Revised Site Plan 3. Revised Details The calculations reflect a revision in the application rate used for determining the length of the drainfield from 125 s.f./bedroom to 150 s.f./bedroom. The trench length has increased from 60 feet total length to 70 feet of total length. The separation distance from property line has remained at 10 feet and the beginning of the trenches was moved toward the new septic tank 5 feet with each trench, while maintaining the required separation distance from the new septic tank. If you have any questions, please contact me at 694-2332. Since%P.' dnZey, r. P.1V Attachments January 11, 2006 Municipality of Anchorage Development Service Department Onsite Water & Wastewater Program 4700 South Bragaw Street Anchorage, Alaska 99519-6650 (907) 343-7904 Subject: Onsite Wastewater System Lot 6, Block 2, Southfork North Subdivision Gentlemen, The existing 4 bedroom house is served by a private well and septic system. The existing septic system is undersized and in a state of failure and needs to be upgraded. We are proposing to install a new 1250 gallon septic tank and dual 5' -wide trench type drainfields. One test hole was excavated on the property. The drainfields will be designed within a 30 foot radius of this test hole. Comments regarding the design are summarized as follows: 1. Soils: See the attached logs which show the soil classifications, groundwater monitoring and the percolation test results. 2. Drainfield Design: See attached design drawing for drainfield specifications. 3. Surface Waters: There are no surface waters within 100 feet of the proposed septic system. 4. Topography: The average topography around the drainfield is a 5-10 percent slope running approximately east to west, there are no slope concerns. We do not anticipate any adverse impacts to adjacent properties that this installation would have surrounding on adjacent wells or septic systems. We have indicated the location of the alternative drainfield location; however, a test hole and percolation test has not yet been completed. We request conditional approval to construct the new system until this work is completed in the spring. If you have any questions, please contact me at 694-2332 SAd.eyl' 6 Rnney,Jr., P.E. Attachments INSTALL SILT BARRIER, TYP. 6" GRAVEL; TYP. 2' GRAVEL,- TYP. NATIVE ON-SITE SOIL BACKFILL GRADE SWALE FOR POSITIVE RUNOFF DRAINAGE AROUND SEPTIC DRAINFIELD. REMOVE ORGANICS AND REPLACE WITH NATIVE ON-SITE SOIL, TYP. 10' 4" PERFORATED PIPE (PERFS DOWN), TYP. SEASONAL HIGH GROUNDWATER LEVEL 1. NATIVE ON-SITE SOIL(INORGANIC MATERIAL, GM, SM) BACKFILL MUST BE 24" MINIMUM, MUST BE INSULATED WITH 2" MIN. THICKNESS POLYSTYRENE INSULATION, IF LESS THAN 36". INSULATION TO BE INSTALLED 4 FEET BEYOND OUTSIDE EDGE OF TRENCH. 2. CLEANOUTS SHALL BE INSTALLED AT BEGINNING AND END OF DRAINFIELD, 3. MOUND OVER DRAINFIELD SHALL BE SLOPED TO DRAIN RUNOFF AWAY FROM DRAINFIELD. 4. ALL SOLID PIPE SHALL BE ASTM D-3034 OR C.I. 5. MAXIMUM TRENCH DEPTH IS TO BE 2 FEET BELOW EXISTING GRADE. WIDE DRAINFIELD SECTION A -A SCALE: 1"=5' 7ROeyP. Kinney, Jr. .t CE 795 i i"• f baa°•.t/3p o§•'�@��� CLEANOUT - EXISTING nDAinirirn n lQQ' WE/ 1 n . )/us SLOPE TO TRENCH 0 2.0% (MIN.) INSTALL DOUBLE CLEANOUTS� NEW 1250 GALLON SEPTIC TANK EXISTING 4" PVC PIPE ABANDON/REMOVE EXISTING TANK PER MOA REQUIREMENTS EXISTING SEPTIC TANK SHALL BE PUMPED AND CLEANED PRIOR TO DISPOSAL. SEE MOA APPROVED PUMPER LIST. ENLARGEMENT DETAIL SCALE: 1"=20' 6M DAM texAMN BY �p/� �+/y y���py /�p�� SU SOLITHFORK NORTH SUBO• LOT 6, BLOCK 2 1/L ItA�W DETAILS Mwom CJM SHEET N0. 2 OF 2 puwm CJM "v.vm an RPK snci l• - 2W B�OcK 4 o N G 2 z! C0 NEW 5'—WIDE 1 TRENCH DRAINFIELD TRACT C r 5 SEE ENLARGEMENT DETAIL, SHEET 2 ALTERNATE SEPTIC 1 DRAINFIELD SITE AND l PROPOSED TEST 1 1 1 HOLE LOCATION. 1 XISTING SEPTIC AINFIELD 7j' ��� GARAGE NEW 1250 GALLON SEPTIC TANK EXISTING C.O. T _ � SOUTH `-EXISTING BEDROOM 1 DESIGN CRITERIA: NO. OF BEDROOMS: 4 I GALLONS PER DAY: 600 ormmm CJM PERCOLATION RATE/S: 2.2 MIN/INCH \ PROPOSED APPLICATION RATE: 1.2 u..m CJM MINIMUM DRAINFIELD SQ. FT.: 500 \ DRAINFIELD DESIGN: \ MAXIMUM DEPTH: 2 FEET / \ WIDTH: 5 FEET 1/9/w LENGTH: 70 FEET TOTAL 2 FOOT GRAVEL DEPTH BELOW PERF. PIPE REDUCTION FACTOR: 0.70 ACTUAL SQ. FT.: 350 FROM OCTOBER 15 TO APRIL 15, A SUBSURFACE SOIL ABSORPTION SYSTEM \ UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER OPENED AND CLOSED ON THE SAME DAY, OR COVERED, \ \ SEALED AND HEATED TO PREVENT FREEZING. 6 1 nN \ SITE PLAN �����• of atlkkl+� ..• .... ........ Rp ney P. Kinney. Jr. • AZ CE; GRAPHIC SCALE o m (ce�f i Ines . eo tt xEv, wrz cescarnox BY MU7HF0RK NHM\WSUBID. LOT 8. VVy2 SITE ormmm CJM SHEET N0. ' OF 2 u..m CJM RPK 1/9/w sxe 1• - 9p' 2UU6 12:56PM Garness Engineering Group Ltd GARNESS ENGINEERING CROUP, Ltd. :, .: �::..:.�..�:n:s...•.::•::aa: CONSULTANY3g6ENffRAL CONTRACTORS..: _�c: xsc:::::r....:.--:.: :..�::::; 531L LOG — PERCOLATION TEST LEGAL DESCRIPTION: SOUTH FORK NORTH SUBDMSION: LOT 6, BLOOK 2 PERFORMED FOR: WILLIAM EDGEMON DATE: 10/26/05 DEPTH (feet)TEST HOLE 1 1 [:��J�ORGANICS 5 6—AlItHGM TO SM 10 71 12 13 14 15 16 17 16 DEPTH TO GROUNDWATER DATE SEEPS ® 6'-7' 10/28/05 6 11/4/2005 � — 111111111 — 1611141 1:32 10 %//% c- 4 4 t r%/_� 1:32 NNE • ,:''. 4 IIIIIIIII I % � SITE PLAN `o � J ` ' I /l% 1:42 �4i�i�L`yl �G /%y y�/� • II:4I'.4� 10 DEPTH TO GROUNDWATER DATE SEEPS ® 6'-7' 10/28/05 6 11/4/2005 1:22 — 1 I — No 1414 P. 6 a •Je rFy A. Garness.- VCE -7953 �.,r \� 1, SOUTH FORK NORTH S/D: CLOCK TIME ` LOT 5, BLOCK 2, WATER LEVEL READING NET DROP (INCHES) 10/26/05 1 1:22 — 1 I — o,' T+l, 1:32 10 1" c- 4 4 t 3 1:32 — 6" — 4 1:42 I % � SITE PLAN `o � J ` ' I 1^=1DD• 1:42 �G 6 1:52 10 1 1/2^ DATE READING CLOCK TIME NET TIME (MINUTES) WATER LEVEL READING NET DROP (INCHES) 10/26/05 1 1:22 — 6" — 2 1:32 10 1" 5" 3 1:32 — 6" — 4 1:42 10 1 1/2" 4 1/2- 2"5 5 1:42 6 1:52 10 1 1/2^ 4 1/2" 7 1:52 - 6" - 8 2:02 10 1 1/2- 4 1/2- /2^8 9 2:02 — 6" — 10 2:12 10 1 1 /2" 4 1/2' 11 2:12 - 6" - 12 2:22 1 10 1 1/2- 4 1/2" 19� PERCOLATION RATE 2.2 (MIN.ANCH) FERC. HOLE DIA. 6 (INCHES) TEST RUN BETWEEN 2.5 FT. AND 3.5 F'(. 20 A FOUR HOUR PRESOAK WAS PERFORMED- 0 YES ❑ NO SOILS LOGGED BY: JODY MAUS PERCOLATION TEST PERFORMED BY- CALEB GALL COMMENTS: PERFORMED BY GEG, Ltd, I, JEFFREY A. GARNESS, CERTIFY THAT THIS WAS PERrFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: if0/bti - (&RPKA Projeet• S�rC �ItJFIELt) l�klL�l.�k7lorSs Page• ,4pafQ i fob No.— .sit,- �--k kyle 4IA Sv6. 3 l-�-r `! R!Date, Rodney P. Rinnevisseciate% inc. CIRSI N,INeiNEns.nevEnn Title: Bv._.GJM �BPKA Project, Lor �F,irOC� 2 Page• � of �' Job No.•S."- NloKT" Date- Rodney ate- nndC.M.MinneYAsssci.116.1nc. Title: :SMLL-� TAO—TkCL-r) By. GJM • MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION - - 825 L Street- Anchorage, Alaska 99501 Telephone 264.4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE —L'] ❑ UPGRADE t.MAILIN ES� All- LEGAL DESCRIPTION L—c:3T ca T3 L -K. Z— 3VTl-t L `r: LOCATI0 Ir. r `f- 13 t -A 2 W NO. OF BEDROOMS O Well 0 / Ab orption area DISTANCE TO: 3— Dwelling > Z PERMIJ.T10, Y Z,7_ f Z pZ Manufacturer C• - M �L� � . No. of compartments L1q. a aci in allons IF HOMEMADE: Inside length -Width Li uid de pth az DISTANCE TO: Well D Iling PERMIT NO. Izta- Manufacturer Material Liquid capacity; -gallons 0 = LU DISTANCE TO: Well oundation Nearest lot line PERMIT NO. J LL Z No. of lines Length of each ling'Total length lines Z W of Trench width Distance 6etweenlines F Inches G OTotal Top of tile to finish grade Material beneath the effective absorption area inches Length I WidtF f De th PER T O. ,O /-' &/ s e. 04 !'//� 0!0/3 k. F wP� Type of crib Crib diameter Crib depth Total effective absorpti, qMa / rn DISTANCE TO: Well O� l Building f dati�'n1 Nearest lot line aJ j f� J J W ClassDepth Driller Distance to lot line PERMIT NO. [Building DISTANCE TO: fou-aon Seline Sewer ne Septic tank Absorption area (s) OTHER PIPE MATERIALS/�• SOIL TEST RATING INSTALLER oc_2E' t`i 5T 2vc r f s REMARKS :C'2 . 2 DEPT. OF HEAL '' ••..�• r"jIRr)NhAF IT -«••i•.•P�ils [AUG 3 198-4 APPROV It L L IR 1 & GGGIMEERIMUDATE SRO 196X I.k1 .3sa R{VER. ALASKA 'fa m 72-013 (Rev. 3/78) L- DE.S.C.RIP-- SECTIONa 3/4- TOWNSHIP: 13N, RANGE: 1W SF. Es. 61497 (SQ.FT. OR: ACRES).. BEDROOMS: 3 pd -'below. are the- options awaidable- to you .in. deep yi a: em. =Choose the option that beet fits your site. -- - -- -- - - -__ HtEI� ' *I TO. PIPE BOTTOM (FT.) 2.5 *ar =1. 'DEPTH FT.) 0.5 , )EPTH (FT.) t 3.0 sL WIDTH (FT:) 17.0. ;L, LENGTH (FT.) 34.0 ILVQLUM: (C -YDS.) 21.4 PPIZI (tl LS)' 1,000.0 +� RATING (SQ. FT. /BR) 125 AEPTH TO PIPE •BOTTOM C 3.5 FT. REQUIRES INSULATION, • )EPTT14 TO PIPE BOTTOM, '4. 4._0 FT. • MAY REQUIRE. _X LIFT STATIOU- TANK MUST HAVE:AT LEAST TWO COMPARTMENTS '1 - - ----- - --- -- - -r�� to f y thataFl an fam-iItar w4th the; requirements-- for firth by the Municipality of. Anchorage IMOA) and the State k vAl l install the systemL in ascordan a w=stty all HAAs adel" to In compliance -with the design .criteria of th-ir pvr*tt_ wki=l:1 adhere to .ail MOA- and, State-'4fr Alaska stances from any existing ,well, .-westewater dliposal systvn pi- siyatem, Gn this-or=afiyadjas °er ge y'P ur sttstarel that this permit is valid far a maxima y-attra^ar.ga*aftt= "A l Pawipe 4n: a"itaoneat �efra�tti Ise SOILS LOG MUNICIPALITY MUNICIPALITY OF ANCHORAGE 'q�IO C /-3 DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION 825 L. Street, Anchorage, Alaska 99501 264-4720 TEST SOILS LOG - PERCOLATION TEST PERFORMED FOR: V P—M N r OALO- 1 DATE PERFORMED:_// LEGAL DESCRIPTION: 1-67- LD �LOC� o) Al)JourF-oEIC J/ p C) (z G1=4AI IC, SLOPE SITE PLAN 2 3 4 5 6 7 8 9 10 11 12 13 14 15- 16- 17- 18- 19- 20 - %k10-r0rR Nr 7' (7-IS`svN $bvve' . of H01-rz \? WAS GROUND WATER 1 ENCOUNTERED? IF YES, AT WHAT DEPTH? f(vrfi U Reading Date Gross Time Net Time Depth to Water Net Drop 7 PERCOLATION RATE/J1/ 4 (minutes/inch) rz-wa lo�r7) LOCATION OF WELL Utz-& r -V2,<_ (Please complete either to, Ib or Ic.) ..WATER WELL RECORD -. STATE OF ALASKA DEPARTMENT OF. NATURAL RESO.URES Division of Geological a Geophysical Surveys Drilling Permit me. - A.D.L. No.. la. Borough Subdivision Lot Block Ib. I/4 qt re. Section No. Township N0 Range E� Mortdian Ch 2 - ;. _of_o}_ot_ S❑ W0 H11 DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELLMr.:Carl Di$otell° Well # �/2 kC Address: Eagle River, Ak 99517 3 Street Address and Area of Well Location 2. WELL LOG Feet Below Sur fele 4. WELOEPTH: (flnaO ! VV 5• [i_ATE OF Cf5PLETIr4 C$ 7 Ll Malerlat Type Top Botta. ft' - S. Cable fool XCD§ofary QOrivern E] Dug Q Auger Q Jelted -0 Bored " 0 Other: 7. USE: Ka vaamestic 0 Public Supply 0 Industry 0 Irrigation Q Recharge 0_commerical _ - Test Well 0 other: B. CA$ING: 0 Th r�adedXX Welded •I �x _ - Oleos._In, to `r ft. Depth W*Id1tl Ibs./fr clam. In. to_ ft. Depth Stickup it. 9. FINISH OF WELL: Typo: - Qlametert _ Slot�MUA Sia: `' Length. Set between it. and ft. Backfilling Gravel pacts ,. 10. STATIC WATER LEVEL.- Artesisg_ - 6/15/ ,t 4 0 Above or 0 Below land surface Dote Equipment used: I I. PUMPING LEVEL below land surface and YIELD - ft. after _hra.. pumpin9__.g.p,m. _ft. after _ Irca. pumping—O.P.M. 12.GROUTING Well Grouted: C] Yes 0 No Material; 0 Neot Cement.. 0 Other: fOd 13. PUMP: (if available) HP w 6 dy Length of Drop Pipe ft. capacity a. P•m. w 4 `°O 0 Subm. 0 Jet 0. Centrificat 0 Other r ij6L 14. REMARKS: Artesian - flows at 5 G1 K o J 2� Production of 15 GPM 16. WATER WELL CONTRACTOR'S CERTIFICATION: 15. Wafer Temperature 06. 0C This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Magnuson Drilling AA 5385 Registered Business Name Contract License Number P.O.: Box 770504 Eagle River, Ak. Address: Signed: -silData: June 15, f984. '... A fhorlxed Representative Form 02-WWR (11/8I) Copy Distribution: WHITE -State DGGS, PINK -Driller, CANARY -Customer - µ�G •B `/ ®� Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval Parcel I.D. 078-021-10 1. GENERAL INFORMATION: Expiration Date: I '-Z0 2 -o2 -Z Complete legal description SOUTHFORK NORTH; BLOCK 2, LOT 6 Location (site address) 1941 South River Drive *Eagle River Current Property owner(s) Ashley Shaffer Day phone 808-779-9265 Mailing address Real Estate Agent 2. TYPE OF DWELLING: X Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Fl Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 5.50 Waiver Fee $ Date of Payment 10L,27/)Z021 qDate of Payment Receipt Number 0 �0 $ 1 G Receipt Number COSA# 0.SG2 1 1 6 (1 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: _Garness 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 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, andl 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 luture-performanceof 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. DSQ –t`'— SIGNATURE System #1 Approved for _�_ bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, Date: tc%ZC,1 Zi , 17/1 TL At I f, V CE -179.53 0 12- ��,1d pro f e s slo #AECC884 `��\��Q p �y0 with the fl�✓in OtN Slt n : m By. w Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA e k 1 Legal Description: SOUTHFORK NORTH; BLOCK 2, LOT 6 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA I Well log is filed with Onsite (or attached) Date drilled 6/15/84 Total depth 40 ft Cased to 40 ft IJ Sanitary seal is functioning correctly IN VVires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 10/9/21 Static water level at beginning of test 19.8 ft. Comments B. TANK DATA Age of tar k(s) 15 years Tank type/material S.aTt STEE Measured operating fluid level in septic tank 49" W Standpipes/foundation cleanout per record drawing Date Of pumping / } Z s � '� 4-� %� `.�"v D. ABSORPTION FIELD DATA DUAL TRENCH Parcel ID: '078-021-10 Structure served by this system Well production at time of test 4.4+ gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes W No A Coliform bacteria is Negative Nitrate 0.283 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L 0 Arsenic less than IVIRL (ND) Collected by GEG, LTD Date of Sample 10/4/21 C. LIFT STATION f ❑ Required maintenance ompleted Age of lift station years Lift station ter a Comm�rifs: IN/A Which system tested (date installed) 3/23/06 Adequacy test date 10/10/21 1111111 ALL standpipes present per record drawing Results [DPass For 4 bedrooms Total measured depth from grade 5.0 ft (max) Fluid depth prior to test 0 in Measured depth to pipe invert from grade 2.5 ft (min) Water added 1007 gal ❑ N/A - pressurized field 0 New depth in j� Monitor tabes go to bottom of effective. If not, state 0 depth into effective "EAS T MT Elapsed time min ❑ Code -required soil cover over field Final fluid depth 0 in (1] System presoaked Absorption rate 600+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) NONE date of test} Gallons introduced "1139 gallons if yes, enter date N/A Comments/Deficiencies. PRESOAKED EAST TENCH ON IM/21- TESTED EAST TRENCH ONLY "MT IN WEST TRENCH NOT PRESENT DURING TESTING. MY LOCATED AFTER. BUT NOT EVALUATED COSA Checklist yeilo%v sheet 51 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' F✓ Yes if No ft ❑7 Yes if No Neighboring Tank > 100' P/ Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No Absorption Field on Lot > 100' P/ Yes if No ft Holding Tank > 100' F/I Yes if No Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' El Yes if No ✓� Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ✓0 Yes if No ft [✓ Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No *5'+ ft Surface Water > 100' ft ft ft ft ft D Yes if No ft Property Line > 5' ❑✓ Yes if No ft Wells on Adjacent Lots.- ots:Absorption AbsorptionField > 5' Yes if No ft Private Wells > 100' 0✓ Yes if No _ Nater Main > 10' Yes if No It Community Wells > 200'✓0 Yes if No _ !Nater Service Line > 10' 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' R1 Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No ft Wells on Adjacent Lots: Water Main > 10' P-1 Yes if No ft Private Wells > 100' Q Yes if No Water Service Line > 10' Yes if No ft Community Wells > 200' Yes if No Surface Water > 100' Yes if No ft F. ENGINEER'S COMMENTS 'MET CODE AT TIME OF INSTALL. "DRY CHANNEL NORTH OF DRAIN FIELDS (SEE ATTACHED PHOTOS). WATER WAS INTRODUCED THROUGH THE SOUTH CLEANOUT IN THE EAST TRENCH. IT WAS VISUALLY CONFIRMED THAT NO WATER PASSED THROUGH THE FLOW SPLITTER DURING THE DURATION OF THE TEST. SEE EMAIL FROM OWNER REGRDING FREEZING. DETACHED GARAGE IS NOT SERVED BY WELL OR SEPTIC (PER OWNER). G. ENGINEER'S CERTIFICATION 1 certify that I have determined through field inspections and review of Municipal records that the above systems are in confonnance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet #AECC884 ft ft ft M II/I/)-ot(e • Municipality of Anchor On -Site Water and Wastewater Program rid`) (907)343-7904 a s,Fc.* 6 A, Certificate of On -Site Systems Apprc� ' 14 c a 95 Parcel I.D. 978-921-19 Expiration Date: 1. GENERAL INFORMATION Complete legal description Southfork North, Block 2, Lot 6 Location (site address) 1941 South River Dr. Current Property owner(s) Christopher Lawrence Day phone Mailing address 1941 South River Dr. Eagle River, AK 99577 Real Estate Agent Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual I1 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Received by: _ Date: 111T6-01 w COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 521D•19D Waiver Fee $ Date of Payment �� 0 (� L0 Date of Payment Receipt Number 0 30 Receipt Number COSA# S('"l(Q(5l I 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 -Sit#, Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safQ;f functibnal'3and 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 areoutsidethe control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone 6. DSDSIGNATURE XL/ System #1 Approved for q bedrooms System #2 Approved for bedrooms Disapproved Phone (907)272-8218 Date 10/31/2016 IF A�CjAs�,t) / - *SI; R.•06nnone• 149` � Conditional approval for bedrooms, with the following stipulations: Original Certificate Date:_/�' The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet r ., 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: Southfork North, Block 2,-Lot6 A. WELL DATA Well type Private If A, B, or C provide PWSIID # Date completed 6/15/1984 Sanitary seal (Y/N) Total depth 40 ft. Cased to 40 ft. Date of test Static water level Well production FROM WELL LOG 6/15/1984 Artesian ft 15 WATER SAMPLE RESULTS g. p. m. Coliform Neg colonies/100mL Nitrate 1,02 mg/L Arsenic ND ug/L Date of sample: 10/12/2016 B. SEPTICIHOLDING TANK DATA Tank Type/Material Septic/Steel Tank size 1,250 gal. Number of Compartments 2 Foundation cleanout (Y/N) Y Date of pumping 9/22/2016 C. ABSORPTION FIELD DATA Depression over tank (Y/N) N 'Pumper JR's Pumping Parcel ID:078-021-10 Well Log-(Y/N). Y Wires properly protected (Y/N) Casing height (above ground) 12+ in. AT INSPECTION 10/12/2016 24 ft. 5.0+ g.p.m. Collected by: PES Date installed 3/2.112006 Cleanouts (Y/N) Y High water alarm (Y/N) N Date installed 3/23/2006 Soil rating (g.p.d./ft2 or ft2/bdrm) 1.2 GPD/SF System type Shallow Trench Length 70 ft. Width 5 ft. Gravel below pipe 2 ft. Soo Total depth 5.3-6.4 ft. Eff. absorption area �ftz Monitoring tube Y Depression over field N Date of adequacy test 10/12/2016 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption Feld before test 0-0 in. Water added 600 gal. New depth 0-2 in. Elapsed Time: 121 min. Final fluid depth 0-0 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" level 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 1 0+ Surface water- 100+ Driveway, parking/vehicle storage 1 0+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS M NX G. ENGINEER'S CERTIFICATION �oln �+ °� A4q�il� - I certify that I have determined through field inspections and �9 ,I 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 Pannone -- 9 • . Steven R. annone • 10/31 /2016 *4: CE-er_ag Date it .r� r ��l�A?rtirccn'NP�-�s . COSA canary sheet_2-6-15.doc ASBUILT SEWARD & ASSOCIATES LAND SURVEYING 694-08 1 HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE:��ya FOLLOWING DESCRIBED PROPERTY: _ ���� o� OF A%kuy �aO�H�liBGoTG �?CB Z AND THAT NO ENCROACHMENTS EXIST EPT AS DATL' INDICATED. IT IS THE RcSPOOBILITY OF THE n r GRID: OWNER TO DETERMINE THF E;CISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS SCv9si o r"y WHICH DO NOT APPEAR ON THE RECORDED SU$pl- d.. '•.:'"I Dv.n. FB: VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR ® C ark S.wodVaQ •• LS -. 1a �a CONSTRUCTION OFFENCE LINES, OR FOR ESTABLISHING BOUND- , ARY LINES. Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel 1. D. 0"ig-OZl- 10 1. GENERAL INFORMATION COSA #��U'i� Expiration Date:CA Complete legal description !J0v-rW-V-0M IJocz1y :> �9(K 2 Location (site address) )(ql q l �s� C t,)E2 >Z. Current Property owner(s) cu a d ��rrn �' I�C644Q Day phone 3 I-7 - LjTD(o Mailing address Lending agency Mailing address IR41 S&A_ Z ar-�-� e, Day phone Real Estate Agent W4& 51rb,_ - Trvu".j Day phone 3h I - y'SGTS Mailing Address 1424 t s� I �tG� (srR�e I 995©3 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Er Individual On-site [� Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm 1��NE r t� �tnsrJl Y Irx• Phone ( -,z3-,r 2 Address Engineer's Printed Name 5. DSD SIGNATURE _� Approved for _ bedrooms. Disapproved. Date I Conditional approval for bedrooms, with the following t✓ _ .�f au s3X, deyP, Khnney,Jr. CE Attachments COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: (Rev. 11M5) Municipality of Anchorage • �" Development Services Department = Building Safety Division On -Site Water & Wastewater Program s 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: bc�t�..i�rk t3or�1� j Kt� 2 3 Lor (9 Parcel ID: 0Z*6 67-I 1(% A. WELL DATA v Well type �� If A, B, or C provide PWSID # NA Well Log (Y/N) ! Date completed (�Lff/g4 Sanitary seal (Y/N) Wires properly protected (Y/N) y Total depth AJC ft. Cased to �D ft. Casing height (above ground) in. FROM WELL LOG AT INSPECTION Date of test 1/1f,/st1 // 29 0T � Static water level , ft. /O 6Gs ft. Well production K 9-p M- i yi 3 g.p.m. WATER SAMPLE RESULTS: F� Coliformy colonies/100 mL Nitrate d.'t89 mg/L Other bacteriay colonies/100 mL Arsenic: L?Tt ppb date of sample: Collected by: L0l'�J /4EE144r3 B. SEPTIC/HOLDING TANK DATA J / Tank Type/Material S Date installed Tank size l2SD gal. Number of Compartments 2 Cleanouts (Y/N) y Foundation cleanout (Y/N) y Depression over tank (Y/N) High water alarm (Y/N) Date of pumping 5 A9 OS Pumper SA,yr• Qy f i0aa};f 5 C. ABSORPTION FIELD DATA Date installed �zz 2s o Soil rating (g.p.d.lftZ ftZ/bd System type 01�e- Length -70 ft. Width ft. Gravel below pipe 2 ft. Total depth h t' ft. Eff, absorption area g5o ftZ Monitoring tube y Depression over field N Date of adequacy test 112a O$ Results (Pass/Fail)f a.55 For 'L_ bedrooms Fluid depth in absorption field before test ?) in. Water added 64D gal. New depth 1 in. Elapsed Time: / min. Final fluid depth D in. Absorption rate >= (POO g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) MD If yes, give date D. LIFT STATION I`JA Date installed "Pump on" level at _ in. Datum E. SEPARATION DISTANCES Size in gallons "Pump off" level at _ in. Cycles tested Manhole/Access(Y/N) High water alarm level at Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot On adjacent lots Absorption field on lot Public sewer main Sewer /septic service line M Animal containment areas N)Q On adjacent lots (Ott + IOC) + Public sewer manhole/cleanout Holding tank MA Manure/animal excrete storage areas )SJA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 1) Property line 1 Absorption field 1-1 Water main N34 Water service line 4� I Surface water "kx Ic r Wells on adjacent lots ICO + SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation 31 Water main NA Water Service line 7b Surface water Driveway, parking/vehicle storage Curtain drain IN3 4 Wells on adjacent lots IU) F. COMMENTSy�.�1 G. ENGINEER'S CERTIFICATION�s 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. va?`n RodAg to li nay fr> ,fa`;° Engineer's Printed Name —Ad, i %C rhr �� v , r= y ,� fq 9 �1�.a Date / /°//Q9 Q.i.cdtF�` COSA Fee $ —r '�w, Date of Payment fa(&9 Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number in. Municipality of Anchorage Development Services Department Building Safety Division _ On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.078"'Dz1-10 COSA# 010olrlc�- Expiration Date: 7��//l7/,� 1. GENERAL INFORMATION Complete legal description t3t r.t L i Sit- 2 L44' Location (site address) 19141 -5, ever. r)r Current Property owner(s) �,U^ � J"i2' Meekrx,. Day phone Mailing address _l$1` Lending agency �115 CLz I Z) e 44, Day phone (v91q- Oft Mailing address Real Estate Agent �v*,Oti `i �oIkAl Day phone Mailing Address Li2� ( S �v c l rc ce r 1 t y *)3 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: `I 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well [! Individual On-site ; [� Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Address Engineer 5. DSD SI( XX Conditional approval for y bedrooms, with the following stipulations: Money int the amount o 82.00, shallle—es-crowed to construct a new wastewoter service line from foundation to septic tank. Money in escrow shall not be released until this office has given final approval. Construction shall be completed no later than June 15, 2006. ON -SIT •. cn= �� � AS.I�wpiER Attachments: P �? COSA Checklist X Arsenic Advisory IIJ�i�o v��O?l\l\, Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Sal' Nitrate Advisory . Other 7� By: 4 Original Certificate Date: 4 (Rev. 11105) Municipality of Anchorage • ' ° Development Services Department Building Safety Division < On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: —D'-okA. t -c,+ Parcel ID: A. WELL DATA Well type` rw<' / If A, B, or C provide PWSID # Date completed ���I Sanitary seal (YIN) Total depth 4b ft. Cased to '40 ft. FROM WELL LOG Date of test (/l 17/-,-4 Static water level Acyc'a^ ft. Well production t5 g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL NitrateZ,,Z mg/L Arsenic: +±ZpZ, ppb date of sample: .31 zo�plp B. SEPTIC/HOLDING TANK DATA Tank Type/Material Siee-1 Tank size 120 gal. Number of Compartments Well Log (YIN) Wires properly protected (Y/N) Casing height (above ground) 2! in. AT INSPECTION � ft. > 72,, 7 g.p.m. Other bacteria r colonies/100 mL Collected by: C,, /�M« Aar Date installed S/23/0(0 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) High water alarm (Y/N) Date of pumping �bll NPW Pumper �J C. ABSORPTION FIELD DATA Date installed ' l2 _ VL Soil rating (g.p.d./ft2 ftZ/bdr ) /ti D System type JC �ra,; AeId Length 70 ft. Width ft. Gravel below pipe 2 ft. f� Total depth' ft. Eff. absorption area? 'O ft2 Monitoring tube Depression over field Y Date of adequacy test IJA Results (Pass/Fail) For — bedrooms Fluid depth in absorption field before test –4 in. Water added ° gal. New depthiq in. Elapsed Time: min. Final fluid depth dFl in. Absorption rate >= -- q g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) Nig If yes, give date N A D. LIFT STATION OA / Date installed "Pump on" level at _ in. Datum E. SEPARATION DISTANCES Size in gallons "Pump off' level at —in Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Pot -r' Public sewer main tjl R Sewer /septic service line 1 Animal containment areas Pr Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots /00 + On adjacent lots Public sewer manhole/cleanout MIA Holding tank rjm Manure/animal excrete storage areas tJLOI SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: I i r Building foundation tt Property line 4 ti Absorption field /7 Water main N1 i} Water service line Surface water Nf R Wells on adjacent lots ''t" SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Q. CC> r Building foundation ��' Water main Nlt� r r Water Service line _7D Surface water Driveway, parking/vehicle storage Curtain drain Wells on adjacent lots (DD °f F. COMMENTS aw G. ENGINEER'S CERTIFICATION or bj~.°• _` P 00 I certify that t have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSguidelines in effect on this date. t •° R dney-0 Kinney Jr.e Engineer's Printed Name s+ f f Sri.`• i 745 w�, J � I`'•1 804••'`x. Date 3/Z8�Ii6 �,li®��n 'eita�S��'• COSA Fee $ `f3y G`' Date of Payment Receipt Number��or� (Rev. 11105) RAI Waiver Fee $ Date of Payment Receipt Number Ra 28/03 2006 12:47 FAX 907 694 1122 SOUTH FORK CONSiTRUCTION P,O. Box 567 [a 001 Phone 6944351 �rII�1L1SMl I page ND. DL Pages STREET � � � � � � 739 NAME SOUTH FORK CONSTRUCTION P,O. Box 567 EAGLE RIVER, ALASKA 99577 Phone 6944351 PROPOSAL suaMItt *o/ NE STREET � � � � � � 739 NAME CITY, STATE AND ZIP CODE yl A, //t 577 Joe LOCA7A ARCHITECT DATE OF PLANSn 4Oe 1YJX PHONE we herebysubmit speciticatlorts and estimates for: y y r A I ✓'^i L �/ �y ,, �p -77 36e Frappe hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: dollars ($ ) Payment to be made as follows; _^ All material is guaranteed to be as speolfiad. All work to be cbMPletdd In a wOramenllke r Manner aceording to standard practices. Any Oita Been ar dwladon IMM above specfrtce Aulhorlged Vons Involving extra costs will be truce tad only upon written Orden, and will bacame an Signature antra charge over and above the e*I mote. All agreements contingent upon strikes, accidents ar delays beyond our control, owner m carry lira, tornado and ether c rosary insurance Note: This p opbsal may bar Out werben art fully enaered by Wer%Men'e COlnpansatlon InaufMee, withdrawn by us it no aaeptetl Whh�n days. .0 rreptmurk nf f ropusal —Tho above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will br made as outlined above. Date of Acceptance: signature Mal I1Sa MI'V IGH1 1911e-avallabl@1101®Ina„Orobm. Was, 01tW i<` : , _ 0 YA- ,ERII-ICAIIcOF r.l,":..C,ihJi!I0=,3 ?-i ',L. 4AL-IWRrfY,,"(`h01//-U_ OF Uh! ITL- S'aNM ANIO I'VA l EN I AG!D I Y 201 020 (c'j L(�Gui �CISOYIOiIJI {IhC- I,7„ IJ'C, KSi�J iUrJCI-I H7 D1 -;Cli Gil, i��A1+f LSi11J 'l1 C,4^,� Scuo ork. Noi' ,17 i 7 jP: H1 v ,- E_t , j c io;l (ad o- ; or c, ..— J l__�P1 .,w 7,11 P,; r obe / .._.—_ t� �- -._. A , ft 3�S _) J i 4, olkau%Ac s Wit; `'Z 1 ;qd Road, I use 1 i _Er, R K 925T_� (c) A "AM is (w ..,, ole) cl dir;; I,i,Arutio:i i -I !ti (d' Lending nG rion P. -as —1535A. Aiii_ &AUinJA,�� (e) Flcal Ty ~ddress --- Sing --'0" 11 !-,1 ,Nuim ;L` Q7 fiedroc"als Jj_ - 1'C n-jW-i'% VIAA A t null NYC WAMCr. PAncinon burnMe MeDaJarh na lofc.I w on, nanto Gunreivabo,1 tv nc Othe CSai: Onsde W Public I-! Moran u(n, L -I I;- rll lg Tank ID I\Ve: if coi rin-n lniivowl pyssr nun! have r .,,mco1K Abn h on We Solo Depufm.Aof1nvroUlentalConse?vaboil Page 1 of 2 1 XOn„0n% Ls stat Ctl, ,�.F l ., a h Jt uEn.,.a 2 � _!1. o -% Fit .i.' 3 E��.§F( f ,rI,14 €rigs As cel shod by my . cal MY hereto and as of We validation dai o b ;low, I venny that my invesAgnboi of .his l ieaRh Authority fil provalshows that the orpskumatorsuplWyand/ot a.sowaterdi<po:.aMOMiss6o,functionalandadequate for the number of bedmotm a td type of sAmAuro IncmMed h lean. I f urd -r von[y tl lot based on the information obtained from ,he lvumcipalhy of AnNorago its and `ro•n my invo,iigatlon aro inspection, the on-site water supply and/or wastm icr s ispocal syvton is in cornplinnc.c with 211 Municip 11 End Mate coda; ordinances, and roguia'tions in effect on we date of this iris char:. 1 -dare of Firm Ccu r, f. t;t )� Itl:a Val inifa� l}iCJ_ -— I etephonc { I_ 14LIl AX MY,` .ilo! Isar'-, Scal Mo ; AJiui pF.!iiy or / richorepc D -pad ment of Ho ita anrd Ern onmomm No'wymn (DFLsP) r5suos 1 !3elth .Authority P.pini oval (of ti'Ioales leasee 301 -�\: UOOn the r0p efIC 1i„iio S given in �; 1�'P . ab by by an Irl opendent professional engineer jog erad in the Stara of NaAa Ahe DFIEP Jo._> the a. cool "�in purchasers of homes and their lending ileo-itu'tion., m ct;c-ar o SQW y cumin federal and Wo r,quirerm ri.nmp'oy ec_ ci fA �P do no. conauet InSiDeeiions or _, c � Ir_ before a coiir set:� i:, rs.,u�:c The lt4um ,pakf, of , v . ao-age !, no: r,,. r)ors bye °or errors or emissions in the ).rc`cssinr nl cnr ,ncot's kvork. Page 2 of `? J2-025 (11;34) M1_JNfrAA!Ty%yNICIPALITY OF ANCHORAGE (mot DEPT, 009 TA ORITY APPROVAL (HAA) ENVIRONMENTAL P"ECXMST - FEBRUARY 1984 264-4720 EAUG 12 S% Legal Description: �+ Q�� S w7%fark RECEIVED �0 7� 7/3 ✓ 2rw Sec .3$� A. WELL DATA Well Classification �� /✓L 7-6 If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) y Date Completed c _ /S-S`t Yield 4!�- &P° Tis r k Total Depth '"+� r Cased to Z/4 Depth of Grouting Static Water Level 1,5-1 lk16, )<)ig' Pump Set At " '^ Casing Height Above Ground S If Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) y Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot me / On Adjoining Lots To Nearest Edge of Absorption Field on Lot eco ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by z�2 /2, !&, fN;Date 7- :r.) -86 Water Sample Test Results Ste, fca .4; ->an7 Comments B. SEPTIC/HOLDING TANK DATA Date Installed Size /moo -i�� No. of Compartments a Standpipes (Y/N) /V Air -tight Caps (Y/N) Foundation Cleanout (Y/N) Y Depression over Tank (Y/N) J✓ Date Last Pumped ��y6 Pumping/Maintenance Contract on File (Y/N) I A ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) "�,A Separation Distances from Septic/Holding Tank: To Water -Supply Well %L S To Building Foundation _e 3 To Disposal Field /5 - To Property Line r/c ' To Water Main/Service Line Course /�A Comments Page 1 of 2 72-026(11/84) To Stream, Pond, Lake, or Major Drainage 0 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed �� y Width of Field I Square Feet of Absorption Area S 7k 4 Type of System Design Length of Fmtdtd 5 i Depth of Field 3 Gravel Bed Thickness 6 Standpipes Present (Y/N) Depression over Field (Y/N) /✓ Date of Last Adequacy Test Results of Last Adequacy Test 5c f, -4 S ,6 ✓'e Separation Distance from Absorption Field: i To Water -Supply Well 16u To Property Line To Building Foundation Lot /'fX '-73 , To Water Main/Service Line _/�/� To Stream/Pond/Lake/or Major Drainage Course To Existing or Abandoned System on On Adjoining Lots - 3,.� To Cutbank (if present) To Driveway, Parking Area, or Vehicle Storage Area S_ / Comments #Ga rcaz /� c� a ✓e a e ��L &e ,l D. LIFT STATION //4 Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) — Comments Dimensions Manhole/Access (Y/N) — "Pump Off' Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection o?'`` Signed —� Date S` /-2 —'E�C Company /^IC fF s MOA No. AX Receipt No Date of Payment Amount: $ Eagle River Engineering Services Page 2 of 2 P. 04,9y 773294 Eagle River, AK 99577 694-5195 72-026 (11184) EAGLE RIV ENGINEERING SER 'ES INC. P. 0. Box 773294 EAGLE RIVER, ALASKA 99577 Phone 694.5195 JOB l--Ol -� 0/�.-� T•Z SHEET NO OF CALCULATED BY '�" '�t DATE e'//' Art CHECKED BY IoTl PAOpICf Y041 (..= s Iw.. W.. M. 01471. MUNICIPALITY OF ANC?V�AGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Descri tion (include lot, block, subdivision, section, townshi range) y Location (address or directions) (b) Applicants Name Applicants Address (c) Applicant is (check �oner) Lending Institution Buyer � E- ; Other f (explain); (d) Lending Institution Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. Type of Residence ne - Home ' Business ; Owner/builder ; Single -Family Multi -Family Other (describe) Number of Bedrooms ._3 3. Water Supply Individual Well Community Public hone Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite Public Community Holding Tank Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] d 5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that, based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firm Telephone Address Date Y� (ENGINEER SEAL) J 6. DHEP Approval A, Approved for rj bedrooms By / X -,t,— Approved �" Disapproved JConditional _ Terms of Cond�i.tional Approval CAUTTON THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THF, STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF IiOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D13 [Page 2 of 2] 7-19-34 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 NICIPg11�' O,, DEPT. OF fic<,_i:, SkP 17 1984 RECEIVED Legal Description . Z 6 f7 �- Well Classificati �i U& k If A, B, or C, D.E.C. Approved(YAJ4 WellLo9 Present (Y TY. 1 /`> ) Date Colleted � � Yield Total Depth c� Cased to U P � Depth of Grouting Static Water LevelPump Set At Casing Height Above Groundo Sanitary Seal on Casing (Y1 ) Electrical Wiring in Conduit Y ) Depression Around Wellhead (Y ) Separation Distances from Well To Septic/Holding Tank on Lot /U 7 On Adjoining Lots �f To Nearest Edge of Absorption Field 'on t 14- 5 On Adjoining Lots 16014 To Nearest Public Sewer Line _ N !% _ To Nearest Public Sewer Cleancut/Manhole d� `� To Nearest Sewer Servi e Line on Loth Water Sample Collected By Ldp...... /�� Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date :Installp.,4 Size /GSC' No. of Compartments Standpipes/(Y ) Air, tight Cap ( /N) Foundation Cleanout (Y ) Depression over Tank (Y ) Date Las �/Tenporary Pmmped /l1� �c/Pumping/Maintenance Contract on File (for AHolding Tank High -Water Alarm (Y/N) Holding Tank Permit (Y/N)`1-7iT Separation Distances from Septic/Holding Tank: To Water -Supply 6b ll _16j`J To Building Foundation _5 To Property Line /6 ;,(-- To Disposal Field %� r To Water Main/Service Line 3c To Stream, Pond, Lake, or Major Drainage Course j - Receipt # 9.T �4i"y Date Paid: Amount: q � � d n [Page 1 of 21 2-15-84 0 C. ABSORPTION FIELD DATA 0 Soils Rating in Absorpti n Strata ��! Type of System Design Date Installed �Length of Field 3 Width of Field /Z_ Depth of Field j Gravel Bed Thickness Square Feet of Absorption Area.S� Standpipes Present{ /N) Depression over Field (Y .) _ Date of Last. Adequacy Test IJ eC-J results of Last Adequacy Tast /J -L. kj Separation Distance from Absorption Field: To Water -Supply Wall %Z� � To Property Lire To Building Fcranda ion Z/ �� To Existing or Abandoned System cr7 Lot /j ; To Water Maims/Service Line On Adjoining Lots " /0C) 4 3n To C To Stream/Pond/Lake/or Major Drainage k (_i_f present) To Driveway, Parking Area, or Vehicle Storage Area 2 (�') D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (YM') "Pump On." Level at /" Off" Level at High Water Alarm Level at /U 2_ Vent (YM) Tested for Pumping Cycles during Adequacy lest. Meets MOA Electrical Codes(Y/N) Comments ** Check Permitted Bedrocm Rating Against HAA Request * I certify that I have checked, verified, or conforried to all MOA HAA Guidelines in effect on the date of this inspection. Signed & C, Ir-94dEcialhCa Date-vY ` �Qq�,.•••• °•�,4,4 Compam,r �Ql R1 ER, AUiSKA me577 MO_ � yr t�k RB1/d5/s l.... ,..... �? Rebeit A. Shafer' " 1457-E (Page 2 of 21 2-15-85