HomeMy WebLinkAboutMOUNTAIN PARK ESTATES BLK 12 LT 7PIPE MATERIAL House to tank D3034 Tank to D3034
Installer drainfield
WILCO EXCAVATION Drainfield D30341EXISTING CO/MTD3034
Inspector GEG AND MOA BENCH MARK (Assumed elevation) 99.89 ft
Inspection ection 151 10/28/2022 2�a ' Location and description
3� - 4t' - TOP OF MH
ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's St p
_Q46oO4 �
Conditional Approval: Date OF
Septic System
Approved Date �- -ZL
Note: this approval does not include well permit requirements.
(Rev 05/02/18)
O�G, '( .D.�dl .........-....... ........
t
V=.J P rors -_E-7
47.
4wedProfesslor' -=1
#AECC884
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP221294 PID Number: 017-441-21
v
Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ D Duplex p (D) ❑Two Single Family Project: ❑New ❑Upgrade
}�
Name
ROBERT & TANYA O'CONNER
ABSORPTION FIELD
0
—`
Site Address
12741 ALPINE DRIVE *ANCHORAGE, AK
El Deep Trench ❑Wide Trench E] 8ed ound
El Other
Phone
1-907-602-3990
Number of Bedrooms
3
Soil Rating
GPD/SF1
Total depth original grade
Ft.
:a
^
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
MOUNTAIN PARK ESTATES; BLOCK 12, LOT 7
Fill added above original gr
Ft,
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft
SEPARATION
DISTANCES
To
From
Septic
Tank
Absorption
Field
Lift Station
Holding
Tank
Sewer
I Line
Total orption area
Ftz
Number of trenches
Dist. between trenches
Ft.
Well
100'+
TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Capacity
Surface Water
100'+
GREER TANK 11000.
Gal.
Material
Number of compartments
Lot Line
5'+
NA
PLASTIC
2
Foundation
*10'+
LIFT STATION
Manufacturer
Capacity
Remarks OLD TANK DECOMMISSIONED PER UPC
Gal.
PER CONTRACTOR *5'+ TO DECK PILES
Alarm location
Electrical installed by
PIPE MATERIAL House to tank D3034 Tank to D3034
Installer drainfield
WILCO EXCAVATION Drainfield D30341EXISTING CO/MTD3034
Inspector GEG AND MOA BENCH MARK (Assumed elevation) 99.89 ft
Inspection ection 151 10/28/2022 2�a ' Location and description
3� - 4t' - TOP OF MH
ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's St p
_Q46oO4 �
Conditional Approval: Date OF
Septic System
Approved Date �- -ZL
Note: this approval does not include well permit requirements.
(Rev 05/02/18)
O�G, '( .D.�dl .........-....... ........
t
V=.J P rors -_E-7
47.
4wedProfesslor' -=1
#AECC884
PERMIT NUMBER:
OSP221294
A I B
14.4 25.7
15.4
25.6j26.4
V
4
26.38
�O
29.04
2 cV
z Y
30.0
Hi
o
30.6
NOTE: PIPE LOCATIONS ARE
SHOWN PER GEG SHOTS
TAKEN WITH LEICA DISTO
S910 LASER DISTANCE
METER. SWING -TIES TO
HOUSE CORNERS WERE
GENERATED IN AUTOCAD.
I
I
I ..
� I
®i
W 1
CL
�"J I
\ I
i
I \
I \
I \
N I
SCALE: I
1"=40'
RECORD DRAWING PARCEL ID NUMBER:
017-441-21
MOUNTAIN PARK ESTATES;
m
BLOCK 12, LOT 6
uH
�O
VACANT
2 cV
z Y
Hi
o
�m
D
rn
o I
I
r �
N
ti EXISTING 3 I m
M r BEDROOM #
HOUSE �-..J .__'i
I
F VIM0]
C
I� I DBL182
I t
MOUNTAIN PARK ESNEW 1000 GALLON GREER TANK
TATES;
BLOCK 12, LOT 8 ' ` A .
J
9a yaF'
1p -d Ed
I
ENGINEERING o SALES -CONSULTING
3701 E. TUDOR ROAD. SUITE 101 -ANCHORAGE. AK 99507 • PHONE (907) 3376179' FAX (907) 3383246-%'EBSITE: _.gemetsengm.,mg �m
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
ROBERT AND TANYA O'CONNOR 907-602-3990 2 OF 3
LEGAL DESCRIPTION: DRAWN BY:
MOUNTAIN PARK ESTATES; BLOCK 12, LOT 7 D.J.G.
TYPE OF WORK: DATE:
�, SEPTIC TANK RECORD DRAWINGS 12/5/2022
O tn_vCE-19
A. G ess w e
tl Ar
0®%1' CE- 953 Z®
lZi S. 17-...��®
LICENSE®%� ®S"®®®�
#AECC884
PERMIT NUMBER:
.OSP221294 RECORD pRAWING
DRAINFIELD IS SHY ON COVER - IT IS NOT TOP SOILED AND SEEDED.
4 IT IS PLAUSIBLE AFTER THE YARD IS TOPSOILED AND SEEDED IN
SPRING OF 2022 THERE WILL BE 4' OF SOIL COVER
TOP OF TANK AT INTLET = 95.82
INVERT OF BUNG AT INLET = 95.21
TOP OF MANHOLE = 99.89
FINAL GRADE = 99.45-99.64
NEW 1000 GALLON
GREER TANK
TOP OF TANK AT OUTLET = 95.81
PARCEL ID NUMBER:
017-441-21
INVERT OF BUNG AT OUTLET = 94.98
A—I kx Ir Tp
�u ENGINEERING o SALES z CONSULTING
3701 E. TUDOR ROAD, SUITE 101 'ANCHORAGE. AK 99507-PHONE(907) 337 -6179 -FAX M71119.1>u• u caaTc..,, .-_.________________
PREPARED FOR: PHONE NUMBER:
ROBERT & TANYA O'CONNOR 1 907-602-3990
LEGAL DESCRIPTION:
MOUNTAIN PARK ESTATES; BLOCK 12, LOT 7
TYPE OF WORK:
� SEPTIC TANK PROFILE
PAGE NUMBER:
3OF3
DRAWN BY:
D.J.G.
DATE:
11/3/2022
OF
�a0
®®� . ®0
•gyp: ', ®®AV o
% ®®'
p............ :. fit.... ............... p
l• .......................�..
0 J feyA. arness c Q iv
00
V AV
AV
®o.. �2�,�-��®®
LICENSE ��4e'�ti ESSO't :a
#AECC884
G'ARNESS ENGINEERING GROUP,Int
. u ENGINEERING -.SALES -CONSULTING AA�na��
December 5, 2022
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Ref: Mountain Park Estates; Block 12, Lot 7 — Well to tank waiver request
To whom it may concern:
A new septic tank was installed at the subject property on 10/28/2022. The contractor did not have the 100' well radii
flagged by a PLS prior to construction. Per the field measurements at that time (rag tape), it was believed that the
tank was installed 100'+ from the well on Lot 8; however, a measurement taken at a later date (with a Leica Disto)
indicated the distance from the edge of the well on Lot 8 and the edge of the new sewer manhole riser to be 99.6
feet. Based upon this measurement, we are requesting that your department issue a variance from the new tank to
the well on Lot 8 down to 98 feet. Justification for granting this wavier is as follows:
• The well on Log 8 is upgradient from the tank. If effluent were to overflow, it would not travel towards the
well head.
• Per MOA records, water samples were pulled in October 2022 on Lot 8 and the nitrates were 1.3 mg/L.
• The new septic tank is plastic, which is a significant improvement when compared to the previous tank
(steel) in terms of corrosion potential and/or leaching into the ground.
• We are only requesting a 2 -foot variance.
We feel there is minimal risk in granting this wavier. We are unaware of any adverse impacts this waiver would have
on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your
assistance.
:=�mcerely,
.E., M.S. OF
R 4. '* /
® r ..
Wetfr .•�
CE- �I`q,
0�.w
F� pROFESSION�4..:"
3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259
Phone: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com
I
Municipality of Anchorage
P.O. Box 196650 ® 4700 Elmore Road
Anchorage, Alaska 99519-6650 0 (907) 343-7904 0 Fax (907) 343-7997
http://www.muni.org/Onsite
evclop cntt Services Division
On -Site Water and Wastewater Program
Waiver#: OSV 221079
PID#: 017-441-21
COSA OSC 221561 Permit#: OSP 221294
Legal Description: Mountain Park Estates Block 12 Lot 7
Engineer: GEG
Applicant: O'Conner
Your request for a waiver of the required 100 feet horizontal separation from the Septic Tank to
the Well on lot 8 has been approved. The approved separation distance is 98.
This waiver approval applies to the Septic Tank only. Any future upgrade to the on-site
wastewater disposal system will require all separation distances be met or another approval from
this department
❑The affected adjacent property owner(s) have been given a 7 day notice regarding this
waiver.
❑ Notarized letter(s) of nonobjection have been received from the owner(s) of the affected
adjacent property.
9Adjacent properties are not affected by this waiver.
a avmmammaaaaamaemaamvamaaavamaa9aaaaoammaaaaaaavavaavaaaaaaaaaavaaaa0aaammvvav1
Waiver is Granted: X Waiver is not Granted:
Date: C 7, / Z Z— Approved' y� -> G
Name of Reviewer
amaavmvaasavamvvmamamammmamaaaavemammmmaammmvvvammmvmaavaeammmammmamvaaamamama�
AWN m (�/)M'Xil'I
C —N
0-v
O
O i T
m f� -{
Oa
_
cNi� m•L'rm
O C/)
z Z• p (n•
•O
•1.
do
•�1
D �•.N�
D9G`cyOR
•
' :
`�
AWN m (�/)M'Xil'I
C —N
0-v
Q to
m f� -{
Oa
O p
A
c
rt
j-y-fn
n= - o --w
n
�
N _
3 0 3 m
�r
O P to (D
3 N00 11%—
K (n"*
go
lb
14 0 5.' y `G
O.a d
tD Owl c
n M
O n
E� Tm 3
c m �
-
n
mnmim3�•
3 (D
� N
i �Vf
M
N
3v,H m
m
N -Ow f
1
o
O '
iv c
c . a
. o r
Op m tr
F+K
O
rr
ny N
33 y f)
o n
3
�'�O0
=' O
3 m
O {n
m �m v,
N
E m
2
VQ
`D
0
0
w n
3
CD
3
o N
ID
"t7
m
N p�
O o 3 .3., O
kDoCrQ
U'7
Nw
m3�o.
N
Si =r< 0
��
Do
oOn
m
(D 7
Cr n o
N�m�
X
m O
N 3
Vf
r}'?
cufo
d ' 7
O
fnD
rD
7N O ma, 00'
O
m
O G
N
cr m C
O
3
(!I
c ID
ymCD
(f:L ro
(n
0
aW
m p Q m
Q
m o
m
N
v -n
m m
o
G
C'
o m I&
— m
G
S
fn
n,
LnID
0
o
o
Om
.0 m
M
m Om y
d
O
Cm ay
�
3
0 v c
C
m O fn fp
a
CC}
O
c z
0-
0
<
V1 yo<
m
3m=
CD3
M�
*
N a
AWN m (�/)M'Xil'I
DD�n�O ",r�•-
cn
O
a3fD'yDim m
3m mID
t�'o 'n
m
N O 0O
3 C Cc C� n
n
�
N _
3 0 3 m
�r
(D
N W c0
rDD
O N N N =or
m
o m 7 fD
O
• a
.e
O
Q
N
y m m
m O m
(D
p
o
m a
v c =ma
(D
(D
C m=
N
` <• C
N
O O c
m 0m
0
0
•.'U m N m
3
CD
•0
C `0Z< 'O0
am m
00 N
X M
M
S
O
3
N
O O N
O
X
m O
Q =
�a c
O
m
O G
n
0 `m" rF
(f:L ro
not
0
(D �n
Q
m o
m
C
v -n
m m
CL
G
fn
0
o
�
?
d
y
�
m
°rnrn
O o
No
�m n
2
2 I v
N89* 59'00'E 196.13
'M'O'd
0'06
N
1
N) 2 34.0
o N {
16.3 o / n
I I of
z
o ( O 7.2 34.0 0
oc� I 0 68
C
rl
►ti I o '' N '� r �, Ri
to I I p v �C V
o I m Q 0 co c
In
/-
Z� +cnN a `D
pO I � moo. Z .•��/�' .'- .
v
:GRAVEL
ZY
i
S89° 59'00"W 196.18
I
I O ( SMB
C I
y
r
I�) o
( I �
I I
g
"I
p •n
G. O
(D
.s �•r
CL -(Ds
N
c
H
C r'
A
(D O
z
O
N
N
W
00
N
ffT Ln ;70
cn
O
o
co
CD
c
�r
(D
°rnrn
O o
No
�m n
2
2 I v
N89* 59'00'E 196.13
'M'O'd
0'06
N
1
N) 2 34.0
o N {
16.3 o / n
I I of
z
o ( O 7.2 34.0 0
oc� I 0 68
C
rl
►ti I o '' N '� r �, Ri
to I I p v �C V
o I m Q 0 co c
In
/-
Z� +cnN a `D
pO I � moo. Z .•��/�' .'- .
v
:GRAVEL
ZY
i
S89° 59'00"W 196.18
I
I O ( SMB
C I
y
r
I�) o
( I �
I I
g
"I
p •n
G. O
(D
.s �•r
CL -(Ds
N
c
H
C r'
A
(D O
z
O
N
N
W
00
N
MUNICIPALITY OFANCHORAGE
On-Site Water & Wastewater Program
clnt
PoBox 1yoosn 47ouElmore Road
Anchorage, Alaska ays19-6p oow pox:(e07)3*3-7997
On -Site Wastewater Disposal System Permit
Permit Number: 0SP221204 Effective Date:
8A9/2022
Work Type: SepUoTankUpQrado Expiration Date:
09/2023
Tax Code Number: 01744121000
Site Legal Address: MOUNTAIN PARK ESTATES 8LK 12LT7 G:2838
Site Mailing Address: 12741 ALPINE DR, Anchorage
Dxvnec O'CONNOR ROBERT E & TANYA L Lot Size |n Sq Ft:
22561
Design Engineer: GARMESSENGINEERING GROUP LTD Total Bedrooms:
3
This permit imfor the construction of:
ODisposal Field 10 Septic Tank OHoldhng Tank OPrivy El Private Well OWater Storage
All construction shall beinaccordance with:
1. The attached approved design.
2. All requirements specifiedi Anchorage Municipal codChapters 1555 and15G5 anddh State ofAlaska
Wastewater Disposal Regulations (1 8AAC72) and Drinking Water Regulations (1 8AAC80)
— The wastewater code requires 'inspections during the installation. The engineer shall notify—the Development
Services Department per AMC 15.85.Provide nubfioahonby calling (907) 343-7904
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall bneither:
a. Opened and Closed unthe same day, or
b. Covered, sealed, and heated to prevent freezing
Received Bi
Issued By:
MUMUIPALITY OF ANCHORAGE
Development Services Department�_�
Phone: 907-343-7904
On -Site Water & Wastewater Section Far.: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 017-441-21
Property owner(s) ROBERT & TANYA O'CONNER
Mailing address 12741 ALPINE DRIVE `ANCHORAGE, AK
Day phone 907-602-3990
Site address 12741 ALPINE DRIVE *ANCHORAGE, AK
Legal description (Sub'd., Block & Lot) MOUNTAIN PARK ESTATES; BLOCK 12, LOT 7
Legal description (Township, Range & Section)
Lot Size
Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial 0
Single Family (SF) El
Septic Tank
El
Upgrade
Upgrade ❑
AD U)
Holding Tank
El
Renewal❑
(D) EJRenewal
Privy
❑
Multiple Dwellings ❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 15 Waiver Fees:
Date of Payment: 2 5 ?o L Z Date of Payment:
Receipt Number: 5G Receipt Number:
Permit No. 0S N 2.12 9 `/ Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221294, Deb Wockenfuss, 08/09/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221294, Deb Wockenfuss, 08/09/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221294, Deb Wockenfuss, 08/09/22
LM
I
CL
so
4-0
m
�-i
0
co
0
C:
to
VOW
Qj
t
-C 4) CL
>
>
:3
0 uj
<F <LU
a(U
c 4)
0 4-1 x
.0 0
4) c
0
r
ate. -me (U
U 4-J
4-J
(U
Qj
U
4-1 iz
CL
m
wi
CL
0
0
CD
LL
CL
0 (1)
4.0 L-
CL
H.-
0
qqm
0
c 41D
C
2
CL c
0 0
cm
0-0
0
CL
0.= 0
40- 0
m
o
CL
0
C
4)
c E
0 0 0
E ' 1- 0 -w—
:3 m =1 r
0
z 0= w IV
-0 cL w E
X
c UJ Z
0
0 (-�
'0
c
m
E
0
>
o
C2 4 0
c
r
•>
OW
CL 0
Z
=4
0 6 8
(D c
c 0
C 0
0.00 0
m 0
0
c U) c 0
CD
o
CO vZ
C
>
0
=
0 ('1) SD
m v >, c
0 4-a M 0
0 c E — wo-
> 0
E
o
M 0
0
c r
C m
>�= r 8
0 0 "
;�..o >
<�t5�
(D
3r. 0 Q E
E M(D
co
s., -4� 0 E
E 0 m
cc 0
> M
c
.0
m HE m
a U
C:0.0 0
.0 8
cc
_r -
Qj
E
tUE
0
CL
tin
m
C:
0
CL
4A
C:
00
r -i
Ln
cn
m
m
E
0
L
L-
0
=
U
c
c E
uj 00
u
4-1 kD
00
00 T-4 C
Ln 0
4-J
c �:
0 0
L- Ln C)
Li- to m
MUNIQIPALi/Y Oi ANCHORAGE
DC . q MFNT O/ ItEAL'rli AND HUMAN SER
E.vironmenial Health Division
~2b 'L ~:~('~'; Anchoragt:. Ah~bka 5~9502, l elepnone 26,1 4720
SEWAGE DISPOSAL SYS i'EM A~D/OH WELL INSPECTION REPOI~T
DISTANCES
SEPTIC
'F' '~'" WILl.
TAI'.dt(S
"~ $i~P I lC; tiOLDtNG
..... ] ,::: ~ 7, ::
AS I]UlIT [)IAGR~,I --,.-, - -
!' ABSORPTION
i FIELD WEll.
so,s &-.
E]:=d"l ]: T Nil ~,
'-YT'E: ]: SSUIiE'D ::
VE]:;:NC)N LYNN
:!.~:Y74 :i. AI.,I:::' :1: Nlii: ]::)1::! :1: VE
ANCI'[OI:~AE)Iii!:, AK 99','3
345'- ~:.'J 679
] T S I Z I:i!::
:~X :EHii:)}RE)OMS:
BI.,..OE;K: :1, 2
i. E?~'..(.x)d ]](::! ]. t::H,,.~ ~::~u"c,) thc:,
/s/'.em,~ Chc)c)~:,:~, the c)pt:i, on tha'L best Eits youP s:i.'Le.
· ~i..l~- (:.)l;:~f'~Vlii:l_.. !,,..Ei]xI(3]'H > 7'~:; l:::"1~,, I'ZdiY:(:;!UZl::;:l:ii:S I~IUl,...]']:F:'l,,.l!i!: F;.'UIxlS (NC)T ti!!:X[;E:E:D:[NG 7',5 l:::'"f,, I!EACH)
· ~i..I.~- "lhNl::: MIJS]" I'IAVEi A'I I..EAS'f 'T'W[) CC)MI::'AR'I"MI~i]q]"S
f'or"l:.t'~ by 'Ll'ie Mur~:i.c:i.l::lal:i.-Ly of' An(::;hl;inage (MOA) and the State of' A].aska,,
;:':t,, ]' w:i. ]. ]. :i.r"~s'La]. :1. t.hi2 system :i,n accciPcla~lc:e;:~ ~J:i.'E.l"l al. ] M(]A cc)des ,a~'~d r'~.,:,gu].at :i.(::~rls~,
and in COml::)].:i. anc:e ~.~J.'LI'~ the cles:i, Eir'~ c:l, itel~:i.a (if th:i,s pel'm:i.'L,,
::~?; ,, Tl: I ) :i. ]. ]. ~'~ (::t h (:'>? J" (?? t', (:}) <'.::, 'l. ]. I'd [) A ~ ~ i d S L a-L e (:3 t' A 1 a s k a r' e q u :i. r' e m e n 'L s t' (::t I" t h e s (>:.~ t I:;) a (:: k
f~(?bJe}H'" ~E~(.~:JC.::' f~'~f~'E.e.:,l[~ CHI '~'.h :i. s ()r' any a(:lj a(:::(.)rd'. (::m 13(.Da~w' []y ]. c)t ,,
Zl.. :[ LUi CI C:* I" ~ ~', alii cl t h a'L 'L Il J. ~ ]::) e) 1" ~]~ :i. 'k :i. ~ va ]. J. (:J [' c3 I" a i¥1~:~.~ :i. fiit.~fli C) [' :::J: ~:) ~)(::1P (::)l::)fil~. a':~.FI d
: A I...]:!=T S"IAI"IC)N ]:S INE~'I"AI....I...Iiii:D IN AN AF~EA E;OVEI:~ED BY MOA BUII...DIF.II3
'fEN ( :I ) AN 17J:I..J2E:(::;] R ]:CAI_ I:'I~:RM I"l' hlxlD ]:NSI:::'I~:C]':I:ON MUST BIE: OBTA:I:NED; (:2) AS'-"BU:I:LI"S
:1.1_. NOT ):]E: AI::'F:'ROVE:D I,'.J:I:THOL!]' AN EL, E~:C] R].CAL, INE~PE:C'T']:ON RI:EF:'OR'F]I hlqD (3) THE:
,,E(::Tf'R:[E;AL WOI::~I'::: HUS'F BE DCINE BY A I..]:CEENSED
:1:::'t.. :1: E;AI'4T: ~ ........ ~ ~ ........ ~'~N'~
POL:_ .t 6-650
ANCHORAGE, ALASKA 99502-0650
(907) 264-4111
TONY KNOWLES.
MA YOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Permit II: 840682
January 31, 1985
TO: Permit Applicant
SUBJECT: Lot 7 Block 12 Mountain Park Estates Subdivision
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1984.
Permits are issued on a calendar year basis by authority
of Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system not
installed by the expiration date.
If you have drilled the well, a well log needs to be sent
to this Department for documentation of the installation
and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, the original as-built inspection report
and the yellow copy must be sent to this office for review
and approval, and for doct~entation.
If there are any further questions, please call this office
at 264-4720.
Sincerely,
Keith E. Bandt, Supervisor
Environmental Engineering Program
KEB/ljw
enc: Copy of Permit
SWP/057
F'ERM I 'T' I',10:
DATIE iSSUED:
Ii'dj L J; Ii'"'41% C} % iF::" ~'-'!'-~ Il._ % '"lF' %"" ~._]1 If=:' iCz~l, 1l",41 lei: IHI IE.) IF;;;: ¢.::'4~ ~[!F~ IEEE
DtEI:::'ARTM[ENT OF HE~I_TH ~I',ID EN~II'~ONMEI',IT(:tI~
8L-)5 I... STRI!(E:;]~, ANC;I'tCIR('tGE~ AK' 9950 1
26/I..-,.4.72 z)
84.()682
C ~:l/L" 9/84
AF F L. ,[ CAI',I'I":
ADDF'~ESS:
IZONTACT I:;:'l"tOl',lli:T.:
HARLEY/ARLEIqE':-' STEWARD
1274 1 ALF:'II',IE DR.
ANCHORAGE, ~1'.:: 99,5 ;L&
J!;Zl. 5- :L 530
LJ::b~L DI...,~:~CI-~ J,I .
LOT SIZE:
MAX BEDF::OOIq?',
SUBDIV):SION: MI". F"'ARK ESTATES
SEC'r'ION: 26 TC]NN,C::;HIP: 121',1
. ',SA (SC;). F~T., OR AJ]RES)
3
L.(]T:
RANGE::
L. isted b(.~.:low are {he optic)ns avail, able '(:.o yotJ ill desigrl:i, ng your' sep'L:i.c
system. Cl'~r,~ose the al::rL:i, orl that be~'t'. ¢'.i. ts yoLtr' '~!~.i. te,
DIEF:"/"H TC) I:::'.I]:::'E BOml"'I"C)H (I:':T..)
['~RAVE. L DEI:::'TH (F'T.)
]"C)]"AL DEI::'TH (I::'T.)
GRAVE],.. WIDTH (Fr'I'.)
6. () 6.5
5 .,'0 0.5
11.0 7.0
2.5* 26 ,, 0
(:{-)I'RAVI:'.B.... I.JZNE')TI.I (F'T ,, ) :1 ." 5, ()' .-x..~. 5 ] ,, ()
'T'AI~II< S I ZE'. (GAL.,:~) 1,0()0 ~ 0 .~!..x- 1 ~, ¢:u.. (' . 0 .~..~
SC]II.. RA]"ING (SQ,F:'T, /BR) 349 284
· ~:~., 0
147,0
1,000 ,, () .~!.,x.
.349
-~,x- GI"(AVEL I,,.IEtxlG'f'H > 75 I:::'l". RE(;!U]:RES MIJLTIPLE RLINS (NCJ'I" EX(]IEI:SDIIqG 75 F'T. EACH)
· .~.x. TAIqI< MUST HAVE A'I" I_EAST "FB/[] COMF:'AR]"MIEI',I]'S
I c e r' 'f.. i f' y '1:. h a t:
1. :[ am ~'ami],:i. ap ~J.'l:.h the r'eqt..tirements f'or' on-site sewrzH-s and ~f~e],:l,s as se,iL
for'th by the Hurlic:i. pality o¢ Ancl'~opage (MOA) arid the Sta'Le of' Alaska.
2.. :I: ~,¢:~.i]. install the system in a(:::cordanc~ w:i. th all IdOA codes arid
,~['lc] ii1 (::omp].iance ~,gitl"i 'N"te design crJ, t~:~ria of' tt'l:Ls
3,, I will adlner'e to all IdOA and State o{ A].a~ka r'eqLt:i.i*einer'YtLs {'(::H- the s(.;~'t:, back
disi'..arlces ¢r'om any ex is/:.ing w(,]:Ll~, ~astewater' d:i. spc~sa], sys't:.em or' pLtblic
s(m, xm-age systmur~ on th,is or' any acljac:ent o~' near'by lot.
Zl.. I L.u"H:Jer's'[.al](::l that '~.l]i~i~ per'mit :i.~; v¢:~].J.d [o~ a max:[mLtm of 3 bedr'ooms arid
any (m-~lal*g(.z)men.~.. ~J.].l r'equiPe an add:i, tional per'mit..
]:1::' A L,,IF]' STATIOIq :I:S II'4STAIJ,..ED Ihl AN AF~IEA []OVERED BY MOA BLJIL. DIIqG C, ODE,Cj!,
THEN (1) (41',! ELEC]'RICAL PI:'.']*~MIT AND Ii',ISPIEC':TICIN MUS]' BE OBTA;t:NED; (2) AS-BU:[LTS
WILL. NOT BE AF'F:'ROVED W):THOLJT AN IEI.,,.ECTF?ICAL. INSPECTIOIq RIEI='OR]"; AND (3) THIE
EL,.ECTR.T. CAI,. WORK MUS]' BIE DC)Nf:T. BY A L:I:CENSIED ELEC]"F~:I:CIAN.
........................ .............. : ..............................
APF:'I... I C, AN]" ~', I"'IAFd...E~.~,~ARI-IENF£ S"FEWAI:'~D
...................................................................... ........................ ......
PERFORMED FOR: ,
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
1325 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
DATE PERFORMED: 7/3 ~ /~
2
3
4
6
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
P£RFORMEDBY;
CE .. 4362
SLOPE
SITE PLAN
q
7
E
IF YES, AT WHAT
DEPTH7
Gross Net Deplh '~o Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BET~,/EEN
~ /_..~ Ii FT AND
{minutes/inch}
7c2
Parcel I. D. 017-441-21
Certificate of On -Site Systems Approval
Expiration Date: 3-9-2023
Legal description Mountain Park Estates, Block 12 lot 7
Site address 12741 Alpine Dr, Anchorage, Ak
Current property owner(s) O'Conner
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
BY Original Certificate Date: 2 " �-Z-
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approval_June 2022
MUMCIPAUT " OF
Development Services Department -n
On -Site Water & Wastewater Section
ANCHORAGE
Phone: 907-343-7904
Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 017-441-21
Complete legal description Mountain Park Estates; Block 12, Lot 7
Location (site address) 12741 Alpine Drive Anchorage, AK
Current property owner(s) Robert & Tanya O'Connor
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
Day phone 907-602-3990
3. TYPE OF WATER SUPPLY: ❑■ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: 0 Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑■ Plastic ❑ Concrete ❑ Fiberglass
Age NEW - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑■ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:Distance:
Expedited review requested: ❑
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ 65-7D / Waiver Fee $ �)
Date of Payment I P-/ P a ()5151 G) Date of Payment
COSA # OSe 2Z 1.5 (a I Waiver # ""1
COSA Application—June 2022
Legal Description: Mountain Park Estates; Block 12, Lot 7
Parcel ID: 017-441-21
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _
A. WELL DATA
❑ Well log is filed with Onsite (or attached) Well production at time of test 2+ gpm
Date drilled 1969(?) Total depth `230 ft Water storage tank volume "*300 gallons
Cased to *40+ ft Well disinfected for coliform test? ❑ Yes ❑ Nc
❑ Sanitary seal is functioning correctly OR Coliform bacteria is Negative
❑ Wires are properly protected Nitrate 0.69 mg/L ❑ Nitrate less than MRL (ND)
Casing height (above ground) 12+ in. Arsenic ug/L ❑ Arsenic less than MRL (ND)
Date of flow test for COSA 6/2/22 Collected by GEG
Static water level at beginning of test 216 ft. Date 5/19/2022
Comments *Per Alpine Drilling document dated 11/5/1985 in MOA records. Bypassed storage tank for well test. **Per agent Lew Ulmer
B. TANK DATA
Measured operating fluid level in septic tank NEW
Date of pumping N/A
❑ Required maintenance completed, if AWWTS
Comments: NEW INSTALL - RECORD DRAWINGS ATTACHED
C. LIFT STATION
❑ Required mierial
ntenance c
Age of lift statiyears
Lift statin
D. ABSORPTION FIELD DATA IWEST/EAST
Which system tested (date installed) 1985 West
Adequacy test date 5/19/2022
❑ ALL standpipes present per record drawing
Results ❑ Pass
Total measured depth from grade 11 ft (max)
Fluid depth prior to test 8 in
Measured depth to pipe invert from grade 6.4 ft (min)
Water added 532 gal
❑ N/A — pressurized field.
New fluid depth 24 in
❑ Per record drawings, field is insulated.
Elapsed time 120 min
❑ Monitor tubes go to bottom of effective.
Final fluid depth 15 in
If not, state depth into effective 39753"
Absorption rate 450+ gpd
❑ Presoaked required if
FIELD STATUS — POST RECOVERY
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Effective depth (per record-dMw'ngs) 60 in
f
Gallons introduced n/agallons - date
s
Effective depth used 36 in
An rejuvenation treatment a No
Any ) (past 12 months)
Effective depth remaining '4 -Zint
� 0&
If yes, enter date -
' - ,._ �_• iI%J
Comments/Deficiencies: Tested west trench only - East trench had 55" of liquid in it (surcharged)
*Assumed based upon the assumption the monitoring tube is 21 inches short. *Based upon the maximum reading (24 inches in the monitoring tube)
COSA Checklist June 2022
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100'
FmiI Yes if No ft ❑■ Yes if No ft
Neighboring Tank > 100' Di Yes if No ft Private Sewer/Septic Line > 25' 0 Yes if No ft
Absorption Field on Lot > 100' [j Yes if No ft Holding Tank > 100' 9 Yes if No ft
Neighboring Absorption Fields > 100' * Animal Containment > 50' 0 Yes if No ft
Qi Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' Q Yes if No ft Q Yes if No ft
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑■ Yes if No ** ft Surface Water > 100' ❑■ Yes if No ft
Tank to Property Line > 5'
Field to Property Line > 10'
Water Main > 10'
Water Service Line > 10'
0 Yes if No ft
Yes if No ft
Yes if No ft
Q Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100'
Community Wells > 200'
❑`**98Yes if No ft
❑■ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
*100' APPROX TO TRENCH ON ROBIN HILL #1; BLOCK 2, LOT 4
**5'+ FROM DECK PILES
***SEE ATTACHED WAIVER REQUEST TO WELL ON LOT 8
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Gamess Engineering Group LTD. (GEG) Phone 907-337-6179
Engineer's Printed Name Jeffrey A. Garness Date Z! b 1ZZ
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in
accordance with the guidelines and regulations established by the Municipality of Anchorage and industry
practices. The reported results describe the condition of the system/s on the date/s of the evaluation.
Separation distances were measured to readily identifiable features. Hidden defects or encroachments may
exist that were not identified during the evaluation. The operational life of all wells and septic systems depend
upon a variety of variables, including (but not limited to) soil conditions, groundwater levels (that may fluctuate
during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing
the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not
guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding
the future performance of the well or septic system. GEG makes no representation whether an alternative well
or septic system can be installed on the property in the event either of the current systems fail to perform
adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG
to perform the evaluation. Reliance upon the information provided in this report by any other person or party
(including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever,
COSA Checklist—June 2022
OF
�i
VO 9, !_- / J.JJ
LICENSE 4QQC/Pr o f e s sio�'oc
#AECC884 �DO�oOo�
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE ~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
/~UNICIPALITY OF ANCHORA(~
P.O. Box lg6650 Anchorage, Alaska g951g-6650 I~N~I~ONMENT^LSERViCE$ DIVISION
343-4744
JUN 2 6 1997
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
O/ 7-qq/ -'~ /
1. GENERAL INFORMATION
_,.2, Mountain Park Estates
Complete legal description Lob 7; Elock * ·
Location (site address or directions)
12741 Alpine Drive
Anchorage, AK
Property owner
Mailing address ":
Lending agency
Mailing address
Vernon Lynn Day phone
1274]. AJLpine Drive Anchoraqe/ AK 995].6
Day phone
345-5679
Agent
Address
Jack Blair/ Remax Properties
Day phone 257-0159
Uniess otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: '~
TYPE OF WATER SUPPLY:
Individual well xxx
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:
xxx
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) From MOA #21
STATEMENT OF INSPECTION BY ENGINEER.
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I 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
$ & $ ENGINEERING
Eagle River, Alaska 99577
/ L~
Phone
DH ,H~,~IGNATURE
I/ Approved for
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of ALaska. The DHHS does this as a courtesyto 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.
72-025 (Rev. 1/91 ) Back MOA ¢t21
Municipality of Anchorage
DEPAR'rMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
Legal Description:
A. WELL DATA
ParcelI.D.: 01,7 - z/ ~¢ / ~ ~1/
Well type f/I/v/-~ 7 &
Log present (Y/~_~ ,~ o
'fbtal depth ~ 3 o
Sanitary seal ~/N) ¥ ~ -~
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to ~o '-~-
Casing height (above ground)
Wires properly protected (~/N)
y~ j-
FROM WELL LOG AT INSPECTION
g.p.m.
Coliform ~ Nitrate
Date of sample: r~ /// ~, / ¢1 '7
B. SEPTIC/HOLDING TANK DATA
Date installed ~o/¢.,tj ~,¢- Tanksize /co o
Collected by:
Other bacteria 0
$ & S ENGINEERING
1/034 Eagle I~iver Loop Road No. 204
Eagle River, Alaska 9957~
Number of Compartments ~ Cleanouts (Y/N)~
Foundation c,,l_eanout ~/N) ~d-~ 7-4,,/~ Depression (Y/~-') ~O . High water alarm (Y/C) ,~ O
DateofPa~ping'~:/l~/'~ Pumper ~ ~ //o~,L Y~v/~
C. ABSORPTION RELD DATA ~' '
D t inst , : Soi ti,
Length 1 / ¢[ _Width ~ Gravel thickness below pipe
Effective absorption area t~ ~ 7 _/ Monitoring Tube uresent ~N) Y/; 5 Depression over field (Y~
Date of adequacy test ~ / '~/gn Results (Pass/Fail) ~4~ J For -~¢
Fluid depth in absorption field before test (in.); O Immediately after~O gal. water added (in.):
Fluid depth ~ ¢ (ins) Minutes later: ~ ~ ~ Absorption rate =
g.p.d.
Peroxide treatment (past 12 months) (Y/N) ..~0~ ¢~ ~,~ If yes, give date
72-026 (Rev. 3/96)*
System type
Total depth )) '
bedrooms
Manhole/Access (Y/N) ~evel at* "Pump off" level at*
High water a~ *Datum
Cycles d
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots ! ~ o -~'-
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation ~ + Property line J" J- Absorption field
Water main/service line
/
)o +-
Surface water/drainage
Wells on adjacent lots
!
/o ¥
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Surface water
Curtain drain
Building foundation ) O '/- Water main/service line
Driveway, parking/vehicle storage area
~,,,,' Wells on adjacent lots ! oO
I certify that I have determined thru field inspections and review of Municipal are
in conformanc~h~}H~A~ gui~ines in effect on this date.
Signature ' .f""~'"/ {-; (~
-
Engineer's Name
Date
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $.
Date of Payment
Receipt Number
ROBERT C. COWAN, RE,
ROBERT A. SHAFER, P.E.
CLIENT:
ADEQUACY TEST FORM
CIVIL ENGINEERS
(907) 694-2979
FAX(9OT) 69 - 2 t
DATE: C
:-ALTN AUTHORIiY
~PROVAL8
!wErl & WATER
AIN EXIENSIONS
!WER& WALES
SPECTION
IGINEERINGSTUDIES
IDREPOR18
]I.L INSPECTION
:LOWTEST
E PLANS
~AD DESIGN
ILTEST
RCOLATION
)UCTURAL&
CftANICAL
iPECTIONS
SIGN
LEGAL DESCRIPTION: L~7' 7 /~L¢6 /'Z //~. ~, r~._,
# OF BEDROOMS: ~L ('"ft/v,'~,,~-a l~"e-STk-~TIC TANK/FIELD SEPERATION TO WELL:
TYPEoFABsoRPTIONSYSTEM: ~1~,-., (.,/4 SEPTICTANKSIZE: /coo
ABSORPTION FIELD DATA: Depression over field (Y/._~): SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Driveway, parking/vehicle storage area: I0
Curtain drain: /,, o .-- ~_
Foundation: /d
;-
SEPTIC DATA: Date of pumpir, g: 4//'3.,/0? Pun, per:
Four. clarion cleanoui ~N): z,~,4,4- Depression (Y/~J:
'F4 ~-
LIFT STATION: t'PUMP ON" level at: ~-"
eve: -
METER GALLONS LIQUID LEVEL
TIME READING ADDED jl/O~/~ COMMENTS
(TOTAL) S.T. ~,~-M.T. ~,~,~M.T.
//- s"G ;c/)~'~,~f'9' -- ~'3" ~Y ~7
~. o~-'-.o/-~-7 3~3 3'1" J
RESULTS:
PASS/FAIL:
EXPLANATION:
TESTED BY: ~4 (--- -
THIS SYSTEM IS NOT GUARANTEED AGAINST SUBSEQUENT FAILURE
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
___L~_~ 7 Block 12 Mountain Park Estates Subdivision
Location (address or directions)
A] pine_ Road
(b) Applicant Name _.H~r]&~St:ewaTd Telephone: Home 345-1530 Business
12102 Lilac Circle, Anchorage, Alaska 99516
Applicant Address
(c) Applicant is (check one): Lending Institution []; Owner/builde~":~; Buyer []; Other [] (explain);
(d) Lending Institution Alaska Pacific Bank Telephone
Address 101 W. Benson Blvd. Anchorage, Alaska 99510
(e) Real Estate Company and Agent
Address
562-6100
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family ~x Multi-Family []
Number of Bedrooms three (3) __
Other
WATER SUPPLY
Individual Well ~ Community [] Public []
Note: If community well system, must have written confirmation from tile State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ~xx Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to tile legality and status.
Page 1 of 2 72-025 (11~84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Rrm Telephone
Address
Date
This Department has received and reviewed the as-builts of the installation
of the new on-site sewer system and this property now meets MOA standards.
Engineer's Seal
DHEP APPROVAL *:,-~ ~ /~ ~ -~
Approved _ ~:××× Disapproved Conditional
November 14~ 1985
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
PaRe 2 of 2
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AIJTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
li4UNICIPALI~Y OF ANCHo~.AG;:.
DEPT. OF HEALTH &
I='NVIRONIvtENTAL PROTECTtoN
NOV 0 5
Well Classification
Well Log Present (Y('I~,~
Total Depth _ ,=,.~.?~v, Cased to
Static Water Level ~/~
Casing Height Above Ground /~
Electrical Wiring in Conduit~'~/~q)
Separation Distances from Well:
To Septic/Holding Tank on Lot __
If A, B, C, D.E.C. Approved (Y/N) ,'~?~ :
Date Cofmpleted __ f;f.~,t~d--¢,.-~ Yield
Depth of Grouting
Pump Set At __. ~7//4 ~¢-';}
Sanitary Seal on Casing/~)
Depression Around Wellhead (Y/~)
/¢~' /¢ £7¢,~. ~- ; On Adjoining Lots ~-%'~- /-~'
To Nearest ledge of Absorption Field on Lot __ //"~ ~ ; On Adjoining Lots _ ~ ~.., /¢'~E¢ (
To Nearest Public Sewer Line __ ''.z(//j' To Nearest
Public
Sewer
Cleanout/Manhole /"//'~ To Nearest Sewer Service Line on Lot
Water Samp. I.,e Collected by ~, ~u~ ~- ; Date /~- ~- ~'%' .....
Water Sample Test Res,Its ¢~%¢[ ~ ~;~; ¢~
/ /
B. SFPTIC/HOLDING TANK DATA
Date Installed I(~-t"(-'~o~' Size ,~l'""(-- No. of Compartments ~-
Standpipes~) ,~.__q,-~('~¢~? ~,Air-tightCaps~__~N) FoundationCleanout(Y~
Depression over Tank (Y~) Date Last Pumped
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well I~'~
To Property Line _~'~'
To Water Main/Service Line _
Course ~ [(DO
Comments ]k/'~ /~')~/'¢~'~'~"¢'"~F'
; for
Temporary Holding Tank Permit (Y/N) ,"~/~- __
To Building Foundation
To Disposal Field _
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11184)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Abs~)rption Area
Depression over Field (Y,(~)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well I(
Type of System Design
Length of Field /(?'
Depth of Field
Gravel Bed Thickness
Standpipes Presen~'~N)
Date of Last-Adequacy Test
To Property Line
To Existing or Abandoned System on
/
To Building Foundation /~ ~("~"/
Lot
; On Adjoining Lots
To Water Main/Service Line ~ ~ ~¢ To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area [~ .
Comments ~6~ ~e~o~ ~) ~0~,~
LIFT STATION
Date Installed Dimensions
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for / Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permi edtt~BBedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date
MOA No. 1~'---~'~,-Z~ ~
Company .4~-~_~-~
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (~ 1/84)
I~JNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL IIEALTH
DEPAII%~ENT OF I~kLTH AND ENVIRONb~ENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAl, CERTIFICATE
1o General Information Application Date ~.~[~-~i~
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address.or directions)
(b) Applicants Name_~z__Ji~-f~uzg?':<( Telephone - Home'-- Business
Applicants ~re.8.~~ ...... ~:-'' ~--:'-- .
(c) Applicant is (check one) Lending Institution ~--[ ; 0~er/builder ~ ;
(d) Lending Institution ~ff~f~U/~~d~/j~/c /~/~z~'~( Telephone ~ ~/~
(e) Real Estate Co, & Agent
Address ~ ~
(f) Mai]. the HAA to the following, address:
2. T~y~p_e._of Residence
Single-Family ~
Number of Bedrooms
Multi~Family~
Other (describe)
3o Water Sup lpg-
Note: If community well system, must have written confirmation from the State
Department of Enviromnental Conservation attesting to the legality and status°
4. ~Sewage D~ispos~__a_~l
Onsite ~ Public [.~.~: Community ~-~_[ Holding Tank ~
Note: If community well system, must have written confirmation from the State
.Department of Environmental Conse~.wation attesting to the lega].ity and status.
[Page 1 of 2]
En~_g~Firm Providing I~?_ctions Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validatiom date shown below,
verifY that my tmvestigation of this Health Authority Approval shows that the on-site
water supply and/or wasgewater disposal system is safe, functional and adequate for
the number of bedrooms and gype of structure indicated herein~ ~ further verify tha~
based on ~he info~ation obgaine& from the ~ntcipalitY of ~chorage files and from my
imvesgigation and inspection, th~ on~slte water supply and/or wastewater disposal
system is in compliance ~th ~1 Municipal and State codes, ordinances, and regula~
tions in effect on the date of this inspection,
Telephone
Conditionmt ~
Approved . Disapproved ~
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTbIENT OF ~!EALTE AND E~WIRONMENTAL .PROTECTION
(DEEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON TIiE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFES'SIO---~--~ ENGINEER REGISTERED
,', IS AS A COURTESY TO pURCHASERS O~ HOMES AND
....... o~.~ mn ALAStG~. TIlE DEEP DOLS ~, - ........ ~=~Lt~ AND STATm REQUIRE-
£t~ ~m~ o~ ..... , ......... ~ ~n~p TO SATISFY C~t<'~z- ~r~..~, ........ nEFORE A
THEIR LENDING INSTITU~zo~o ~ '-'~,'-;,~," cm~mUCT INSPECTIONS OR ANAL~z~ ~._~
~mR, E~iPLOYEES OF DIIEP ~o moz ~%'% ........ ~P. PAGE IS NOT RESPONSIBLE
" ...... - -~ ~-ee~mn THE MUNICIPAL/T~ u~:
OK O14ISSLO~ z~
RR4/ej/D18
[Page 2 of 2]
(DHEP SF~L)
7 -,19-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAl. (HAA)
CHECKLIST - FEBRUARY 1984
264-4720 MUNICIPALITY OF ANCHORAGE
Legal Description: [,,.,l'~q ~pEPT..OF,I-~ALTH^&
0(;t 2 ~3 1985
WellClassification ~.¢-1,,~,~,'~ IfA, B,C,D.E.C. Approved(Y/N)RECEIVED
~~resent (Y/N) Date Completed Yiel~''''~
Total Depth'">~ Cased to Depth of Grouting .
Static Water Leve-'~"~..
- Pump Set ~
Casing Height Above G~ San~n Ca~ing (Y/N)
Electrical Wiring in Conduit (Y/N) ._ '"'~_ Pe'~ession Around Wellhead (Y/N)
Separation Distances from Well: ~ .........
To Septic/Holding Tank on Lot // '"""~..,...~' On Adjoining Lots
To Nearest Edge of Absorption F~Lot _ ; On A~.~Lots
To Nearest Public Sewer L~ To Nearest Public Sewe--'"dr~
Cleanout/Manh~,-."' 'Fo Nearest Sewer Service Line o~
Water Sample~J. ted'ted by ; Date
Water Semi, Test Results
..~n ts
B. SEPTIC/HOLDING TANK DATA
Date Installed ' O/, +/~)~"~ Size ~.~~No. of Compartments "~.
Standpipes~) Air-tight Caps Y[.~I)4) Foundation Cleanout (Y/N) ~D
Depression over Tank (~ Date Last Pumped ~) ~&~
Pumping/Maintenance Contract on File (Y/N) ; for ~
Holding Tank High-Water Alarm (Y/N) . P~ Temporary Holding Tank Permit (Y/N) d~
Separation Distances from Septic/Holding Tank:
To Water-Supply Well _ ~O(o ,~R,_ To Building Foundation S~ ~,
To Property Line ~ ~ To Disposal Field 5~
To Water Main/Service Line ~
oou,s _
Comments ~~ ~ ~,~,~ ~&~ ~]~
To Stream. Pond, Lake. or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Square Feet of Absorption Area
Depression over Field ('~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well I \'"'~
Type of System Design
Length o~T~ ~.-'¢-~ \\~ '''~ ''~ ('-
Depth o~""'F'~ I/ ,.~ "T'"'~"'~¢~(
G ravel~.~t;Cek~ D~ _
Standpipes Present(~
Date of Last Adequacy Test
To Property Line /'~' '~ -~
To Building Foundation "~O ,'~ "("~J~". To Existing or Abandoned System on
K , djo ,ng Lots
~ '
To Water Main/Service Line ~ ~ To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
LIFT STATION ~.~
Manhole/Access (Y/N) .
"Pump On" Level at ~
High Water Alarm Level at ~ ~ Vent (Y/N)
Tested for ....--~'~----..~ Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)~~ ~~
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I bave checked, ~e.r, ified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
SiNned
Receipt No.
Date of Payment
Amount: $ ~%,(~ -)' ~ '"¢"" .... ~""""~~'
Page 2 of 2
72-026 {11/84)