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HAMPTON HILLS BLK 2 LT 4
Onsite File Hampton Hills Block 2 Lot 4 #015-134-37 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201404 PID Number: 015-134-37 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Farnily Project: ❑ New n Upgrade Name TONY BARTER ABSORPTION FIELD E] Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 1te AHAMPTON DR d A ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 LEGAL DESCRIPTION GPD/SF Ft. Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot HAMPTON HILLS 2 4Fill Ft Ft. added above original grade Gravel length Township Range Section Ft. Ft. Gravel width Beds: Number of Lines Distance between lines SEPARATION DISTANCES =ToSepticAbsorption I Holding Sewer Lift Station Ft. Tolal absorption area Number of trenches Ft. Dist. between trenches From Field i Tank Line Fiz Ft. Well I 100'+ f TANK 0 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity Surface Water 100'+ j INFILTRATOR 1060 Gal. I Material Number of compartments Lot Line 5.0'+ NA POLY 2 Foundation10.04 LIFT STATION i Manufacturer Capacity Remarks Gal. Alarm location Electrical installed by Installer PIPE MATERIAL House to tank Tank to 3034 drainfield 3034 HOMEOWNER INSTALL Drainfield CO/MT3034 Inspector Pannone Engineering BENCH MARK (Assumed elevation) 812 ft Inspectiones: 1,' 20201020 2-1d20201021 Location and description 3 4111 Bottom House Trim ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date OF A,_,q `}�• Septic System qG T/��/q�/J Approved r,' t'an,:3, 4' 1-9 Date Note: this approval does not include well permit requirements. (Rev 05/02/1 M DESIGN PARAMETERS PRIMARY SEPTIC SYSTEM NO. BEDROOM: 3(450 gpd) TANK SIZE: IM -1060 TANK WATER LINE / WELL RADIUS NEW SEPTIC TH TEST HOLE (P) PROPOSED (E) EXISTING CO CLEAN OUT NO. FC FOUNDATION CLEANOUT FS .. FLOW SPLITTER MT MONITOR TUBE NO. TYP TYPICAL �I _4 � � LnE A B MH 13.7 35.9 T2 19.1 37.6 DC 22.0 38.7 CiE: REM VED EXIST&6 SEPTIC TANK , 47.9 / r 1 tNS'1'A r'� \ _LLED I —1 60 SEPTIC 1�NK N —T—^ j—�in I W DCOA TER/ TA K / / T MH 1.3 SFD / WELL E ` Al'\ �\N�W Y \\✓----_-- \ r, �,, \fes -T -_________=-=Ji PROFILE SCALE: 1:10 IM -1060 TANK N O rl M i O 0 0 0 O r .0 O � N ��C) N 6> mOf a) .: O� J n 0 O 11 i � z> -=Q z Wmo a v =o X0O w �N x Lo z 0 Ln j 00 co 0 0 � r .0 O � Ln ��C) N 6> mOf a) .: O� J n J<�Q Q 0), o = m Q �o� � z> -=Q z Wmo O < �0c00 zom :E O v Qn-w Q — Z Z o = Q Z a W 0. z � � Q w J n 0 Z � W � o g Cl) O S 00004'00" E 90.00' Z o m �l m Z ¢ WW, w W N W � , ._ _� fig! 44,60OG �- a N =mom Q ��f!) �" — — -- CARPORT -- oZ` s W _Q ZO 39.0' ¢ w 0 O - N w D- oo GARAGE o o _ o N • - �� 1R/3/y�sb.,,� 3 (L17��11,!! Fes- z I¢- w N 39.0' - _J w nW. -' ~ U' ¢ W O J m T(L � z Z W U / z O O z_W -'cn LL m 0 c / = m F EL O O Z wI-X ¢ U / r� Q O O ww < o �U)0 C) = wa0Z �� W u) CL w Y O. wo Q' td� O / wU > u)2 �_ �� r � J t Oz U 0 C7wW� UW �'_=O Q m U x ¢ C7 0 0 c 0c M ui0 m F- O�z0 p0 W 0 ty tLLI -j - c N 4 ��S cVj : n•_ 3_ O O z = z ¢ z �w o¢ LL ~O > - O �9� �1 \�� Z Q m o v C� 9.= / ` � * �0�����5 �ttt w w ? OW C) = Cj O,Gtt 6/ H� �m W0 00 i Q z W S = �< Qz ¢ v W W I W CD W t ll)Z m� OW ¢ /t�6•• tt/fit __ � 0 ¢ ¢ } a o w S �5N Z ¢ _ _ ¢ CO vi UJ 2 F- N Z W wz i F- to Z Q co W Owo CO WQQ CALLS oZ 0( tom o P352•p4 (kp �P� w0 0)¢W z- 055 WZU) F¢-Uw w? o}-i:Ew0 O z N LL z ¢ co V U) tL 0w0� �_zU cop ~ ¢ U O o �// 0 w m Z W U U P = zWO� cn o ww O -W,> m00 ODS OwF¢- ¢ W S D Z U) (4 -- W 0� F- 0 D5 W MUNICIPALITY OF ANCHORAGE On -Site Water& Wastewater Program POBox i9065D 47OQElmore Road Anchorage, Alaska 9S519 -665O Phone: 904 Fax: (9V7)343'7S87 http://www.muni,org/onsite Work Type: SepticTank Upgrade Tax Code Number: 01513437000 Site Legal Address: HAMPTON HILLS BLK 2 LT 4 G:2540 Site Mailing Address: 10461 HAMPTON DR, Anchora Owner: BARTER TOVY D A S/28/2020 8/28/2O21 0 Disposal Field Z Septic Tank F-1 Holding Tank 0 Privy 11 Private Well 171 Water Storage All construction shall beimaccordance with: 1. The attached approved design. U 2. ArequinamentSspenhQmdinAOchoMunicipal code Chapters 15 .55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) _. The wastewater code requires "inspections during the installation. The engineer shall notify� the Development t Services Department per AMC 15.65.Provide notification bvcalling (SO7)343-7904( 4'.4. From October 15toApril 15` �aubau�aoeani!@baurpUVnsystem under during freezing weather shall beeither: a. Opened and Closed onthe same day, 0r b. Covered, sealed, and heated tnprevent freezing Special Provisions: Existing septic tank appearstobeless than 1ODfthoexisting well. Contractor shall ensure Received By: 7-2 Issued By: Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201404, Rebecca Carroll, 09/28/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201404, Rebecca Carroll, 09/28/20 NAME 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 T PHONE F'-'~ EGAL DESCRIPTION OCAT,O . , I Well DISTANCE TO: J~ (~) O Manufacture~ DISTANCE TO: Well Manufacturer NO. OF BEDROOMS PERMIT NO, No. of c~:~partments Liquid-~.optL Well DISTANCE TO: NO. of liees Length of eacLJirL~ , Top of tile to finish grade ~ , Length Widtl~ Type of crib /"grSb~diarneter Deoth Buildin~nd~ ~'on SOIk T~ST ~ATI~G INSTALLER PERMIT NO. Liquid capacity in gallons Distance~] i TO 'al e ~ ,,,Tec t i'/e/.~b s °'~ ~area I'PERMIT NO. ' Crib depth Total effedtive absorption area [~uilding foandation Nearest lot line 3riller Sewer line Oistance to Jot line AbsorPERl~]a~r a~)[e I'rl''l[':i: t....l!ii;NG'!''l I I::' ][ I''!li!:i'"l:;i; '/ 01''1 ;i: :il; THE I...!:l''ll:!iTl'l ':; ]Z I''f F:'iEET ) EtF:' 'TILE 'l'[;;:[:;l'''llZ:::I'''l 01:'i: C'I;;:FI :i: i''11:::' ;i; [i:;l..I--';:'. !''t'lli: t;)E;I::''I'H 01::' I::1 TI:;i:Ei'''IC:H Ol:;i: tX'zi;I:' Z[::i!; 'TI''II:. !;:';[::ii;"FFli''lE:[i!; !'ii"l!i:'f'!''h~!:l:!;i''l 't''1'!I!!!: :!;!;I. II:;i:t:':l::;IrZ]:[:; I:11:: GI';;'.OI..f?,!I:::, FIN[;:' THI:il; I';i',EKi'I'CIM r3F: "!'t. IE; i-ii;XC:Fl',,,'l::l'f':!;CIh! ,:; ;[i'.,I I't. It:;F;:I:.: i;:!!i; 1'.,i0 ::;E;f' I,.1~t.[;:,'f'1-1 I:Ol:;i: '}'!-.1I:!; GI;i:F:I',/~!;I.. !::,tiiX::'"f'll ;[ :.:i; i'H[: I"1 :!: I'.,I ;1: PII..IM I::,~;F:"I'I.I CE::' Gl:;i:l:::l',,,'l:l. E',l:iZ"l'r,.ll::li:l'.,! 'l'llh!; of. ri'!::: i:::11, i I:::' ;!; !'::'~!' t::11',1!.) "f'l'll: li~O'l'T(:ll,'t OF: '!'11[~; lii;;:.:;E:i:'I',,,'FiT];I:)I'.,! ,:;]!;F.,I :[ I",i :[ i'"il..IM I::, :1: :E; 'i'l::liqC:[": E',i::'I !.,.t[i::li~:H I::1 I.,.l[!:l.I. F:ff.,l[) [::ll',I'-r' O!',1'" :!:!; ]: 1"ti: ::i;I::f.,.tF:fC!iF: [::' :[ :W:'O:!);I':!I.. :i:i;"r':::; I'E:P't :[ El~:i I:::'[i:[:i' t:::CI[;':: ¢::! F:'[;:: :[ VF:I '!'!E P.[I::I.I....; [!:iP'.l Th.') ;:::E~EI I::'ti::[::'T I:'I:~tC$i I:::! F:'Uh:',I .):l:: I.'.i[i:l..I.. [)l:::l:::'[i:i"4l')]:hlG UPI:d",! TI't!:: 'F"r'l::'l~: O[:' 1:::'11131. :!:C: t.'.!IEt.! [:!k I.OG:!ii; I:::11::;:[! I:'i:lXt;)l..l:[l:iiffi!:[::' !:::ll",l!:::' I"ll.l'_'-i;'t' E',!::: I:,i:[i!:r'l..IF;:!'.,lt:!!X)'1'O TI.II:: I::d!I:::'F:tf;itTI"iE:I.,I-! I,.t];TIt:[N :!:.:(!:l 1::' ]'1..11:i:: I.,.11!~1...I.. C:OMI:':'LE:'I"]:Cd'.,I. 'I'I.{EI:.i: I:;;:[i!1:¢..i :[ I:;i:¢:MILI'.I-I"?!: I"11::~',.' F:ll:::'f:'l.."r'. :! i; l::' l : ( : Z [:: :!: I::1'::1'i' :[ (:IF,l:::; I:::Ii",tD C:l:ll",!:il; [T,U...ICT :!: O1",1 [:' :[ i:::lGI;;'.r::!i"i!:; ~,,,~1::i :1: l..l:::l[~i',[..[i: "i'O :[ t'-,1'_'-2;I.1[;;:[:!: I:::'l:;;:i:d:::'l:::l;;'. :1: I',l:!i;"['l':ll ..[ .FIT ): E$,I. M.D.G. I;:NGINF_ERING SOILS LOG - PERO. TEST J~ so~ls log j~ percolation test per formed for :____(. ,~ date. I 9 lO 11 i5 depth_ ~jk Jl~J~L MUIqlCIPAI t~Y r]~'!: J~,ixl(]} IORAGi~ l;'l~P'l, OF i if AL[It & fiixtVi~;()NiCr:i,;[?,( i~,G'FLCII(?,b'. Well Owner. M-~/ DRILLING, P.O. Box 4-1224 · 1310C International Airport Road (907) 274-461 ] ANCHORAGE, ALASKA 99509 DRILLING LOG Use of Well Location (address of: Township, Range, Section, if known; or distance main road Size of casing_ ;; .Depth of Hole Static water level 'xJ ft. Screen ( ); Perforated ( c.% feet Cased to ~)"';, ~ feet (below) land surface. Finish of well (check one) open end ( ), : Describe screen or perforation Well pumping test at 2 '; gallons per (ltOlii~)': of drawdown from static level. : ); (minute) for r'~' hours with ft. Date of completion. WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness _TO _TO _TO _TO _TO TO TO TO TO TO_ TO TO __TO_ .TO_ .TO. 2 -- STATE MUNICIPALITY OF ANCHORAGE Development Services Department }° Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel 1. D. 015-134-37 Expiration Date --T / 6 - z.o ZZ 1. GENERAL INFORMATION Complete legal description Hampton Hills Block 2 Lot 4 Location (Site address) 10461 Hampton Dr, Anchorage, AK 99507 Current property owner(s) Sean Mcdonald & Michelle Greene Day phone (817)905-3804 Mailing address 3446 Oakheath Manor Way, Houston, TX 77365 Real estate agent 2. TYPE OF DWELLING: ❑■ Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑i■ Private Septic Q Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 14 5 2e-neu)CA Date of Payment Receipt Number COSA# OSC_,�91�213 Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On-Site staff may visit the site to verify the information submitted. Name of Firm Forge Engineering (M.J.) Phone (907) 522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Benjamin Schiller, P.E. Date 5/10/2022 A o 6. DSD SIGNATURE System #1 Approved for bedrooms % �. Ben)amVchiller •.:� System.#2 Approved for bedrooms �+�� CE 12592 . _... _ . _ . _ _ i �sr ' 5/10/22 . • � � Aow Disapproved �l`��pROFESSIONP���� Conditional approval for bedrooms, with the following stipulations: op llll(((((f `�J ON-S17 jz vo ERA rD Wq AND rn -m J o PRO OAM o 6 By: A-ILI y Original Certificate Date: _�__ /b _Z©ZZ The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist Legal Description: Hampton Hills Block 2 Lot 4 Parcel ID: 015-134-37 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 2/26/1976 Total depth 95 ft Cased to 93.5 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA 3/30/2021 Static water level at beginning of test 38 Comments ft. B. TANK DATA Age of tank(s) `2 years Tank type/material Septic/Poly Measured operating fluid level in septic tank 44 Standpipes/foundation cleanout per record drawing Date of pumping 5/10/22 A+ Home Services 111� D. ABSORPTION FIELD DATA Deep Trench Which system tested (date installed) 6/15/1979 ❑E ALL standpipes present per record drawing Total measured depth from grade 9.5 ft (max) Measured depth to pipe invert from grade *n/a ft (min) ❑ N/A — pressurized field ❑■ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field 0 System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced 2000 gallons Well production at time of test 3.9 gpm Water storage tank volume n/a gallons Well disinfected for coliform test? ❑ Yes 0 No Q Coliform bacteria is Negative Nitrate 1.41 mg/L E]Nitrate less than MRL (ND) Arsenic ug/L ■❑ Arsenic less than MRL (ND) Collected by Forge Engineering Date of Sample 5/4/22 C. T STATION El Require intenance completed Age of lift station ears Lift station material Comments: Adequacy test date 3/31/2021 Results © Pass For 3 bedrooms Fluid depth prior to test 17.5 in Water added 516 gal New depth 27 in Elapsed time 1440 min Final fluid depth 17 in Absorption rate '450 gpd Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: *Original absorption field installed with no cleanout. Total depth matches historical records indicating the monitor tube extends to bottom of trench. COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) ✓v Septic Tank/Lift Station on Lot > 100' if No ft Community Sewer Manhole/Cleanout > 100' Q✓ Yes if No ft M Yes if No Neighboring Tank > 100' 0✓ Yes if No ft Private Sewer/Septic Line > 25' 0✓ Yes if No Absorption Field on Lot > 100' 0✓ Yes if No ft Holding Tank > 100' 0✓ Yes if No Neighboring Absorption Fields > 100' ft If septic tank is under driveway comment below Animal Containment > 50' 0 Yes if No 0✓ Yes if No ft F. ENGINEER'S COMMENTS Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' �✓ 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' 0✓ Yes if No I ft Surface Water > 100' Q Yes if No ft Property Line > 5' ✓v Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 0✓ Yes if No ft Private Wells > 100' 0✓ Yes if No ft Water. Main.>.10' ___ ✓D Yes if No ft Community Wells > 200' 0✓ Yes if No ft Water Service Line > 10' M 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' 0✓ Yes if No ft If absorption field is under driveway comment below Property Line > 10' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' Yes if No Water Service Line > 10' M Yes if No ft Community Wells > 200' Q Yes if No Surface Water > 100' Q Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION 1"° �F 4o l certify that l have determined through field inspections and review••� of Municipal records that the above systems are in conformance with • , , TM MOA COSA guidelines in effect on this date. '.' Benjarrb„ Schiller CE 12592 5/10/22 PROFESS10N COSA Checklist yellow sheet ft ft MUNICIPALITY CH Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 015-134-37 1. GENERAL INFORMATION Expiration Date: JLdm Complete legal description Hampton Hills Sub, Block 2, Lot 4 Location (site address) 10461 Hampton Drive Current property owner(s) Tony Barter Day phone (907) 632-2652 Mailing address Real estate agent 10461 Hampton Drive, Anchorage, AK 99507 2. TYPE OF DWELLING: ■❑ Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Q Private Septic Fol Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ -6 50 Date of Payment / g .2 ev Receipt Number. 06 5 291b Waiver Fee $ Date of Payment Receipt Number COSA # 05621 115 L-` Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm Forge Engineering Phone (907) 522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Benjamin Schiller Date 4/5/21 -� 1A o . TH 9 1 DS E /D SIGNATURE �( System #1 Approved for 3 bedrooms �� PBeniarrrchiuer �� �Fc •. CE 12592 System #2 Approved for bedrooms l%V*-ROFESSIONA��,a�� Disapproved k�, PROFS ®� Conditional approval for bedrooms, with the following stipulations: r DATER ANa �3 WAST%=v:!ATER o By: W112L OWA Original Certificate Date: 1 a D 1 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Legal Description Hampton Hills Sub, Block 2, Lot 4 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 2/26/76 Total depth 95 ft Cased to 93.5 ft ❑ Sanitary seal is functioning correctly © Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA 3/30/21 Static water level at beginning of test 38 ft. Comments B. TANK DATA Age of tank(s) f1 years Tank type/material Septic/Poly Measured operating fluid level in septic tank New ❑ Standpipes/foundation cleanout per record drawing Date of pumping New Installation 10/20/2020 D. ABSORPTION FIELD DATA Trench Which system tested (date installed) 6/15/1979 limil ALL standpipes present per record drawing Total measured depth from grade 9.5 ft (max) Measured depth to pipe invert from grade *NSA ft (min) ❑ N/A — pressurized field © Monitor tubes go to bottom of effective. If not, state depth into effective Parcel ID: 015-134-37 Structure served by this system Well production at time of test 3.9 gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate 6.50 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by Forge Engineering Date of Sample 3/25/21 C. LIFT STATION 7oflift maintenance 7:completed tion years aterial Adequacy test date 3/31/21 Results Q Pass For 3 bedrooms Fluid depth prior to test 17.5 in Water added 516 gal New depth 27 in Elapsed time 1440 min ® Code -required soil cover over field Final fluid depth 17 in Absorption rate '500d FE-1Systempresoaked p gp (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) Gallons introduced 2000 gallons If yes, enter date Comments/Deficiencies: Original trench was installed without a clean out. Total depth matches historical records indicating that monitor tube extensions to bottom of trench. 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 Community Sewer Manhole/Cleanout > 100' Q✓ Yes if No ft ✓, Yes if No ft Neighboring Tank > 100' Fv Yes if No ft Private Sewer/Septic Line > 25'✓� Yes if No ft Absorption Field on Lot > 100' �✓ Yes if No ft Holding Tank > 100' 0✓ Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' Q✓ Yes if No ft F✓ Yes if No ft if No ft F. ENGINEER'S COMMENTS Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' [✓ Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water > 100' F Yes if No ft Property Line > 5'✓� Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' F/ Yes if No ft Private Wells > 100' F✓ Yes if No ft Water Main > 10'✓Q Yes if No ft Community Wells > 200' Fv Yes if No ft Water Service Line > 10' F✓ 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' ❑✓ Yes if No ft Wells on Adjacent Lots: Water Main > 10' Yes if No ft Private Wells > 100' Yes if No Water Service Line > 10' P Yes if No ft Community Wells > 200' 0✓ Yes if No Surface Water > 100'✓� Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION ,a.v�� ' ' • �tS���� 1 co certify that 1 have determined through field inspections and review,•TH �P of Municipal records that the above systems are in conformance with •- • • • • • •• • • I MOA COSA guidelines in effect on this date., p Benjar bfS' chiller ��j�FG' •. CE 12592 • i4`�� `� /s�F� • 4/5/21• • `ca�.� PROFESS1dNP-� COSA Checklist yellow sheet ft ft MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904 On‐Site Water and Wastewater Section Fax: 343‐7997 www.muni.org/onsite Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org Nitrate Advisory Certificate of On‐Site Systems Approval # OSC211154 Subdivision: Hampton Hills, Block: 2, Lot: 4 A water sample revealed a nitrate concentration of 6.5 milligrams per liter (mg/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Since nitrates are known to slowly increase, we recommend you monitor the water quality. Please see the attached “Nitrate Fact Sheet” for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On‐Site Systems Approval. Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org Nitrate Fact Sheet From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as “blue baby” disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a medi a with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several “wet chemical” methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive “screening test”, and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # _~,]/~----/zJL//~ ~7 1. GENERAL INFORMATION Complete legal description Location (site address or directions) .. JO,C&/' Property owner Mailing address _ Lending agency Mailing address Day phone Day phone ~ I 5 ~'z.... Agent_ Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ,~ ~ TYPE OF WATER SUPPLY: individual well ~L' Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/9t) Front MOA #21 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 of this Health Authority Approval application shows that the on-site water supply and/orwastewaterdisposalsystem is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address ,_/~) ~,/~. / Engineer s signature Phone DHHS SIGNATURE Approved for '-~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: 4ot-~,q ~.~',,~4 Date ~//~f/~f3 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 th is 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. 72~25 (Rev. 1/91) Back MOA t~21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAl- CHECKlIST Lega, Descript,on /-*/ ,'arce,,.D. A. WELL DATA Well type_ hI', ~¢~' Log present (Y/N) Total depth Sanitary seal (Y/N) if A, B, or C, attach ADEC letter. FROM WELL LOG Date of test ~ ~g'(¢ -'~ ~ Static water level ~ Well flow /'"~ Pump level (.AA,L ~LC~Z,"-~ · N SEPARATIO DISTANCES FROM WELL TO: Septic/holding tank on lot /&"~"C- Absorption field on lot /~<2'¢- g.p,m. ADEC water system number Public sewer main Sewer service line ___JC,CP WATER SAMPLE RESULTS: Coliform ',~/I'_"~--~_~¢_~ Nitrate Date of sample: Date completed ~-~-'¢- '~ Driller Cased to <:~'~'~ Casing height _ Wires properly protected (Y/N) ~/ AT INSPECTION ; On adjacent lots /~ ; On adjacent lots _ /~W Public sewer manhole/cleanout ~ Petroleum tank_ ~ ¢ ,~ Other bacteria Collected by:~ SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) ' Tank size / d-CO Compartments Foundation cleanout (Y/N) 'Y' Depression (Y/N) ' Alarm tested (Y/N) /h Date of pumping __ Pumper SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK TO: Well(s) on lot / d-'~"¢" .On adjacent lots_ To property line_ ~)"¢~ Absorption field Surface water/drainage /~/¢¢ ! 6-'~ -/L Foundation- ~_~ Water main/service line_ CONTINUED ON BACK PAGE 72-026 (Rev. 7/91) Front C. LIFT STATION Date installed ~ M an u factu ~.,.,,,," Size in gallons , ~ Manho/e/..~s (y/N) Vent (Y/N) "Pump on" lev'~..~ j~/ "Pump'off" level at High water alarm level ~ Cycles tested Meets MOA electrical codes (Y/N) _ _,~../... ~ SEPARATION DISTANC~TATION TO: Well on lot J On adjacent lots '~"~face water D. ABSORPTION FIELD DATA Date installed ~ ' Length '/¢'¢ Width Total absorPtion area _ Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating _ Gravel thickness _ Cleanouts present (Y/N) _ ~ Date of adequacy test. z~_ z/'_ ~,~ for ~ If yes, give date__ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot_ On adjacent lots System type t.,IDId~_ 7"~.¢_-¢(~ Total depth_. /08 To building foundation On adjacent lots /~ Surface water Curtain drain .~,,~ Property line To existing or abandoned system on lot Cutbank /./-~4- Water main/service line Driveway, parking/vehicle storage area bedrooms E. ENGINEER'S CERTIFICATION Signature~ Engineer's Na me ~r~~ I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effe~.?on.th¢.da~e of this inspection, ., ;, ~, .,, ,- ,: · : '., ~ ;, ,.~ ' · ...: . ' .~: ~ ...,.., HAA Fees /7~)! Date of Payment Receipt Number 72-026 (Rev. 3191) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number NORTHERN 'TESTING LABORATORIES, INC, 3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 · FAX 456-3125 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 277-8378 · FAX 274-9645 PRELIMINARY RESULTS REPORT Aprit 8, 1993 Customer Name Lab// Customer ID Method Parameter Units Resutt Tony Barter A122925 - EPA 353.3 Nitrate-N mg/[ ~ 4.3 / MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL FIgALTH~ DEPARTMENT OF HEALTH AND ENVIRO~R~ENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE Legal Descrip. tton (include lot,~lock, subdivision,, sect'ion, township, range) (a) Zo.~ i, ,,~l~ z ~~o,~ ,,'/,'t/ Location (address, or dir. ecttons~) ~o'~g~ . /z' o ~,~ ,o (b) Applicants Name (c) Applicant is (check one) Lending Institution ~ ; ~er/butlder ~ ; (e) Real Estate Coo & Agent Address (f) Telephone Flail the HAA to the following address: 2. T_~vpe of Residence Single-Family ~ Multi-Family ~ Other ~j?scri!e) Number of Bedrooms 3. Water Su~_~ Individual Well ~<~ Community Note: If community wall system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4.~ Onsite ~ Public 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] 5. Enginee?ing Fi~ Providing Ins~ctions_z__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 ~USH ENGINEERING Telephone ANOHOP, A(~E, ALASKA 99509 .~? £~' ~[~ '~, ~ ,. Rober~ D. Bush ~ ~ ~ ~ 333 Approved ~__ Disapproved ~ Condition~ Te~s of Conditional Approval CAUTION Tltg MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTtl AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPEbIDENT PROFESSIONAl, ENGINEER REGISTERED IN THE STATE OF AI~SKA. THE DHEP DOES Tills AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. ~MPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. 'IqtE MUNICIPALITY OF ANCHORAGE IS NOT Pd~SPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Well Classification ./-IUC~/'J;~/d~ / Well Log P~esent (Y/N) Total Dept~. ?~' f'~¢ ~ Cased tO statie-wate~ ~vel ~ 5~). ,£¢~ Casing Height Above Grcund Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/~olding Tank on Lot To Nearest Edge of Absorption Field on Lot TO Nearest Public Sewe~: Line If A, B, o~ C, D.E.C. Approved(Y/N) Date Completed 2/~ ~/~.~ Yield./~ _ ?~,.~-' / Depth of Grouting A;O Pump Set At ~),~ ~'~, Sanitary Seal on Casing (Y~_~7) ~_ Depression ~ound Wellhead (Y/N) ~/ ; On A~joining Lots /~O '~ /Q ~ ,~ .; On Adjoining Lots /~-~ '~ TO Nearest Public Sewer Cleancut/Manhole /L//'/~ To Nearest Sewe~ Service Line on LOt Wate~ Sample Collected By ~ ~3~ ; Date /~//~/~ Wate~ Sample Test P~sulLts ~ //,.~'~Oe /~} ~_ Cc~nts Standpipes (.Y/N) / .Air-tight Caps (Y/N)/ Depression ove~ Tahk _(Y/N) ~q Date Last Pureed No. of Cc~pa~tments ~ . Foundation Cleanout (Y/N) y Pumping/Maintenanos, Contract on File .(Y/N)~,/~ ; for Holding Tank High-Wate]~ Alarm (Y/N) ~///~- Temporary Holding Tank Permit (Y/N) /~./~ ! Separation Distanc~s f~om Septic/~{olding Tank: To Water-Supply Well_ /~/ ~"~. To Building Foundation_ ,~ / To Disposal Field ~(~ ~ To Stream, Pond, Lake, c~ Major D~aina~ To Line_ To Water ~ai~/~rvi~ Sine /~//~ cour Comments [Page 1 of 2] 2-15~84 C. ABSORPTION FIELD DATA Soils Rating in Abso£ption Strata Date Installed ~//~/~ ~ Width of Field ~d) u~zC~e~ Square Feet of Absorption A~ea Depression over Field (Y/N) ~/ Results of Last Adequacy Test ~'97) Type of System Design Length of Field ~ ~ ? Grail ~d ~ick~ss ~' ~ Stan~i~s ~esent (Y~) ~te of ~st A~a~ ~st Separation Distance f~om Absorption Field: To Water-Supply W~ll /O~- / To Building Foundation //~ / Lot ~///~ ; On Adjoining To Water Main/Service Line ~/,//~ To Stream/Pond/Lake/c~ Major D~ainage Course To D~iveway, Parkin~ A~ea, o~ Vehicle Storage Area To P~operty Line ~ / To Existing or Abandoned System cn ~ots /.~52) ~ To ~t~(if pre~nt) ~/~ Con~ents D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested fo~ Electrical Codes(Y/N) Dinmnsions Manhole/Access (Y/N) "Pump Off" Level at Vent ,(.Y/N ) Pumping Cycles du~ing Adequacy Test. Meets MOA Co~nents ** Check Permitted Bedroom Rating A~ainst HAA Request ** certify that I have checked, verified, or conform-=d to all MOA HAA G~d,e,,,lines in effect on the date of th~s inspection, C~any .................... MOA No. ~7~-P~. ~ 'r ,~9-~dfDEE~$.L~L~, . 2-15-84 ENVIRONMENTAL ENGINEERING DIVISION Te,epI, o.e 26.-4.20 R E C El V E D REOUEST FOR APPROVAL OF INDIVIDUAL WATER AND $EWER FACILITIES MUNICIPALli¥ ~1~ AMC~: ..... z' MUNICIPALITY OF ANCHORAGE DEPT. Cji ~ il) & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT|~N'hR©h.'MENI'AL 825 L Street - Anchorage, Alaska 99501 r)IRECTIONS: Comolete ali parrs on page 1, Incomplete requests will not be processed, Please allow ten (10) oays for processing. 1. PROPERTY OWNER ~ PHONE ~ROPERTY RESIDEN,T ( ~ different from above) PHONE 2, BUYER PHONE -MAI LING ADDRESS ~IAI LING ADDRESS '~. REALTOR/AGENT PHONE IPHONE MAILING ADDRESS LEGAL D ESCRIPTION~./ -STREET LOCATION TYPE OF RESIDENCE ~ SINGLE FAMILY [] MULTIPLE FAMILY '~', WATER SUPPLY INDIVIDUAL~ [] COMMUNITY [] PUBLIC UTIL TY NUMBER OF BEDROOMS [] One ~ Four [~] Two [] Five ~ Three [] Six Other * ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well deptl~ (attach Icg if available.) '*1 f individual/on'site, give installati°n ~actee' L¢/; --~u~i'<?/ If system is over two (2) vears old an qu'ac¥ ' re ' 8, SEWAGE DISPOSAL SYSTEM z~ INDIVIDUAL. ION-SITE** [] PUBLIC UTI LITY by this Department, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY BI ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY Fq TWO [] FOUR [] SIX 2, WATER SUPPLY PERMIT NUMBER [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3, SEWAGE DISPOSAl_ SYSTEM PERMIT NUMBER E] INDIVIDUAL/ON -SITE DATE INSTALLED E]PUBLIC UTILITY Connection Verified INSTALLER [~]Septic Tank or []Holding Tank Size: [~'~ o If Tank is homemade SOILS RATING give dimensions: ~ ~,.~ TYPE OF TANK MANUFACTURER /~ ¢~ .~ TOTAL ABSORPTION AREA MATERIAL 4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line [ Nearest Lot Line 1 WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS ~APPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION 72-010 (Rev, 3/78)