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MOUNTAIN PARK ESTATES #2 BLK 3 LT 5
Mountain Park Estates ' #017-022-17 Weal VLA -17— Q)-3 MUNICIPALITY OF ANCHORAGE w 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 l.l) O(0'j1 NNEW ❑UPGRADE MAILING ADDRESS LEGAL DESCRIPTION b LOCATION - S or UtJ NO. OF BEDROOMS U Y DISTANCE TO: Well \©O Absorptions area Dwelling 34 PERMIT NO. _190161 dF Q wF Manufacturer G - Material � � No. of compartments Liq, capacity in gallons � IF HOMEMADE: Inside length Width Liquid depth d� Z DISTANCE TO: Well Dwelling PERMIT NO. Oz F Manufacturer Material Liquid capacity in gallons W= DISTANCE TO: Well `05 Foundation 49 Nearest lot line PERMIT NO. 8O Zb2 u Z F ul No. of lines Length of each line 2- Total length of lines Jr �..3(6-72, Trench width inches Distance between lines N G F Top of tile to finish gradeI d I( 4 Material beneath the N o inches Total effective absorption area (p W l7 Length Width Depth PERMIT NO. a F wa Type of crib i dif m r Crib depth Total effective absorption area DISTANCE TO: well V I I Building foundation Nearest lot line j lass Depth Driller Distance to lot line PERMIT NO. -1 8e 26 W � DISTANCE TO: Building foundation Sewer line Septic tank Absorption � OTHER PIPE MATERIALS 1 SOILTESTRATING 130 INSTALLER KiH Wo2.�c T .L REMARKS Lu t 11 s S Q ROVED ATE LEGAL t 72 (R v. 3/78) TYPE. OF =OIL ABSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER: OF BEDROOMS = 4 SOIL RATING (SQ FT•BR)= 130 THE REQUIRED SIZE OF THE SOIL ABSORPTIONd SYSTEM IS: �_. K F=• -I- 1-1 = n (7) i— E hi = at of A3 Fes: FA ••s E= L E> E F=• I- to = �. THE LENGTH DIMENSION IS THE LENGTH (INd FEET) OF THE TRENCH OR DRAINdFIELD. THE DEPTH OF H TRENCH OR: PIT L_ THE DI';TANCE BETWER THE SURFACE OF THE GROUND AND THE BOTTOM OF THE E;CAVATION 0N FEET?. THERE IS, NO SET WIC>TH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINdIMUM DEPTH OF GRAVEL. BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION IN FEET?. F-'[=-: A_, a LJ I Fa!E= E> On Eo F" -Y- I A T 1=1 r,j p- -- _. I = E=== A 21 to ED Aa FA R_ L CA t003 PERMIT APPLICANT HAS THE R:ESPONSIBILITY TO INFORM THIN, DEPARTMENT DUR:INdG THE INdSTALLATIONd INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF R:ES•IDENC:ES THAT THE WELL WILL SERVE. . ; ' a 1144 _. F=• F=7 1= -i I A_A r4 n FR' E Ft- Ew CA l_A I Ft_ E E>— BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY ON --ITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL: OR 150 TO 200 FEET FROM A PUBLIC: WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. WELL LOGS ARE. REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTSMAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER: INSTALLATION. F= E=F='10 I T E1 F=° I F~"FE= CsEEE_:E41E_EIt A I I" co 753 I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR: ON-SITE SEWERS AND WELLS AS. SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 'c: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES I UNDERSTAND THAT THE ONd-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. �J SIGNED: --------------------------- y` L� ----- APPLICANT NORM BRI STOW --- ISSUED BY d�� --------- ------ ---DATE--`� — �— � - V `. in P1 A_A r -A z A_ - s F' 1St L. 17 a e CA F- FFA rA CT FA CA FQ FA A3 E —7 1 U DEPARTMENT HEALTH 825 AND ENVIFOdMEdTH TE=TICN w1w 1! ((AAYYtI tt - o STREET: ANCHOAA0Er AK. n ._ 264-4720 5. �-� tr= � t— A=A r-� a= a A—+ r-� — _: � -,- � �, � � �-M E _ ��� �• � �� s•• -s � -T- ;3U�+ PERMIT NO. A 780262 a' APPLICANT 2RM BRISTOId SRA BOX __-+E:1'{' :44 0071NiLi6LJ LOCATION SHL INDERS Nt LEGAL L5 BS MT PARK EST LOT SIZE 21000 SQUARE FEET TYPE. OF =OIL ABSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER: OF BEDROOMS = 4 SOIL RATING (SQ FT•BR)= 130 THE REQUIRED SIZE OF THE SOIL ABSORPTIONd SYSTEM IS: �_. K F=• -I- 1-1 = n (7) i— E hi = at of A3 Fes: FA ••s E= L E> E F=• I- to = �. THE LENGTH DIMENSION IS THE LENGTH (INd FEET) OF THE TRENCH OR DRAINdFIELD. THE DEPTH OF H TRENCH OR: PIT L_ THE DI';TANCE BETWER THE SURFACE OF THE GROUND AND THE BOTTOM OF THE E;CAVATION 0N FEET?. THERE IS, NO SET WIC>TH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINdIMUM DEPTH OF GRAVEL. BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION IN FEET?. F-'[=-: A_, a LJ I Fa!E= E> On Eo F" -Y- I A T 1=1 r,j p- -- _. I = E=== A 21 to ED Aa FA R_ L CA t003 PERMIT APPLICANT HAS THE R:ESPONSIBILITY TO INFORM THIN, DEPARTMENT DUR:INdG THE INdSTALLATIONd INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF R:ES•IDENC:ES THAT THE WELL WILL SERVE. . ; ' a 1144 _. F=• F=7 1= -i I A_A r4 n FR' E Ft- Ew CA l_A I Ft_ E E>— BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY ON --ITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL: OR 150 TO 200 FEET FROM A PUBLIC: WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. WELL LOGS ARE. REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTSMAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER: INSTALLATION. F= E=F='10 I T E1 F=° I F~"FE= CsEEE_:E41E_EIt A I I" co 753 I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR: ON-SITE SEWERS AND WELLS AS. SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 'c: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES I UNDERSTAND THAT THE ONd-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. �J SIGNED: --------------------------- y` L� ----- APPLICANT NORM BRI STOW --- ISSUED BY d�� --------- ------ ---DATE--`� — �— � - V `. in PERFORM€D FC LEGAL DESCRIF DEPTH (FEET) 1 2 3 4 5 75 6 7- 8- 9 10- 11 1,2- 13- 14- 15 2131415 16- 17- 18- 1, 6171819 20 A ,tea • ( SOILS LOG MUNICIPALIT%? OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION lfPERCOLATION TEST Pouch 6850, Anchorage, Alaska 99502 276-2221 SOILS LOG — PERCOLATION TEST / DATE PERFORMED: �— ` / 7 L S 63 M r N 5 T. SLOPE SITE PLAN G& s54 5 � S( `J/11 H±fl (�l2 Sc_!GtlT�Y ed A/0 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Reading Date Gross Time - Net Time Depth to Water Net Drop 1 C- iy �/: 2 a y 2 z j7 ; 3 a 6,-? 1A, :r PERCOLATION RATE ^I A/ (minutes/inch) TEST RUN BETWEENy FT AND FT PERFORMED BY: 64 L/ J Ata4?7. CERTIFIEDBY: /N '�/" DATE: 6-/9-2 72-008 (7/76) MtJN I C It9L_ I TVF At,1iGI-j� RAGE DEP" IC:Tt HERLTH RND ENVIRONMENTAL AOTECTION \a 825 L STREET, ANCHORAGE, AK. 99. 'v 264-4720 14E=1+t_ PERM I T PERMIT NO. C 780461 ) APPLICANT THOMAS DRILLERS PO BOX 10-516 ANC 99511 344-3133 LOCATION SAUNDERS ROAD LEGAL L5 B3 MOUNTAIN PARK ESTATES S/ LOT SIZE 20130 SQUARE'FEET MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL; OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. PERM I T EXP I ic''E E>ECEMEER :91� 1C-;l?E: I CERTIFY THAT 1: I RM AMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY NE MUNICIPALITY OF ANCHORAGE. 2: 1 WI L I STA�L THE SYSTEM IN ACCORDANCE WITH THE CODES. A cl. Sr 1 SIGNED ISSUED AWLICANT THOMAS DRILLERS V3. 2 40" Locatien: Ll -.t 1; WELL LOG Llock 3 Mt. Park Estates Description: 6" well cased to 135' approx.al feet east of house Materials: toosoil - 20' ;ravel - 21' - 30' boulders, surface water - 316 - 63' clay - 64' - 70' silt, sand - 71' - 85' gravel, small a:rount of water - 86' - 120' sand - 12I' - 130' gravel, small amount of wat,r - 131' - 305' rock Yield: 1 GPI -I. Static water level: 130' Drilled by: T_.o_as Drillin Company P.O. Bo, 10-516 Anchorage, Alaska 99511 municipal License //WD 78020 Completed: August 7, 1978 Municipality of Anchorage On -Site Water & Wastewater Program r (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 017-022-17 Expiration Date: �� — !( _1 1. GENERAL INFORMATION Complete legal description MOUNTAIN PARK ESTATES S/D #2; BLOCK 3 LOT 5 Location (site address) Current Property owner(s) Mailing address Real Estate Agent 12920 SAUNDERS ROAD, ANCHORAGE, AK, 99516 SONJA JAHRSDOERFER Day phone 12920 SAUNDERS ROAD, ANCHORAGE, AK, 99516 786-3323 SARAH HALTNESS W/ REMAX Day phone 227-0599 2. TYPE OF DWELLING: Single Family (w/wo ADU)'"� ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) DEC a 7 2013 3. NUMBER OF BEDROOMS: 4 4. 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 9 ❑ Public Sewer ❑ COSAFee $��— Date of Payment Receipt Number COSA# 0 S SC) 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, 1 verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 1 further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK, 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineefs Comments: In conducting this evaluation, GEG, UD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the lime of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local suis condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These candifions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this reportis for the sale benefit of the ownerfisted above. Any reliance upon or use of this report by any other person or party is not authorized, nor wilt it confer anylegal right whatsoever. 6. DSD SIGNATURE V System #1 Approved for bedrooms. Date U l61 i3 0060 0 4 ...... 9s 4p0 4. T �....:..... ... ...... .. .......i 1 yP e f Go ness,: 9, CE—%l795b.cop Q4pfe, ��s''��aoo System #2 Approved for bedrooms. Qw\-\N( OF CyO Disapproved. ON-SITE Conditional approval for bedrooms, with the following stipulations: g NATER AND By: Ze • D 'oma/ Original Certificate Date: /2 -a 0 - 1i3 Theicl ity r orage Develop, emt 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 worts. 7. ATTCHMENTS: COSA Checklist Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other ree� nmet If more than 1 septic system is on the lot: COSA Checklist # _of_ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: MOUNTAIN PARK ESTATES S/D #2; BLOCK 3, LOT 5 Parcel ID: 017-022-17 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (YIN) Date completed 8/7/1978 Sanitary seal (YIN) YES Total depth 305 ft. Cased to 135 ft. FROM WELL LOG Date of test 8/7/1978 Static water level 130 ft. Well production 1 g.p.m. Wires properly protected (YIN) Casing height (above ground) AT INSPECTION 12/6/2013 110 0.78 g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 ml. Nitrate LI/ •Cly mg./L. Collected by: GEG, Ltd. 11/27/2013 & Arsenic: ug./L. Date of sample: 12/6/2013 (BACTERIA RE—SAMPLE) B. SEPTIC/HOLDING TANK DATA YES YES 12+ in. Tank Type/Material SEPTIC/STEEL Date installed 8/17/1978 Tank size 1250 gal. Number of Compartments E Cleanouts (YIN) YES (ONE) Foundation cleanout (YIN) YES Depression over tank (YIN) NO High water alarm (YIN) N/A Date of pumping 3 1 Pumper oh I v'v C. ABSORPTION FIELD DATA (BELOW EXISTING GRADE Date installed 8/17/1978 Soil rating (g.p.d./ft or /bdrm 1130 System type TRENCH Length 52 ft. Width 3-6 ft. Gravel below pipe 6 ft. Total depth *10.6 ft. Eff. absorption area 624 ft2 Monitoring tube YES Depression over field NO Date of adequacy test 12/6/2013 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 24 in. Water added 845 gal. New depth 34 in. Elapsed Time: 12D min. Final fluid depth 25 in. Absorption rate >= 600+ g,p,d, Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed Size in gallons Manhole/Access "Pump on" level at in. "Pump off" level at we er alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO Septic tank/lift station on lot *91 On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots *90' Public sewer main N/A Public sewer manhole/cleanout N/A Sewer /septic service line 25'+ Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots *91' F. COMMENTS *WAIVERS EXISTING. MOA #WR040640 & ADEC #9921—DW/WW/-251-355. ��OF o0 G. ENGINEER'S CERTIFICATION Q P� 4p0o 00/x.' T y0 1 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. 0 P ..J Gar ess:' Engineer's Printed Name JEFFREY A. GARNESS Q 09, ' . CE -7 l Date 95 �0 � z�f cu %r p�fP ep.,tz1� 4��_ Pr,a_...%nn6 o (Rev. 11105) Municipality of Anchorage Development Services Department u s Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Advisory Certificate of On -Site Systems Approval (COSA) # 131650 During a recent COSA on-site inspection and test of the potable water supply well on Block 3, Lot 5 of Mountain Park Estates #2 subdivision, the well's productivity was determined to be 0.78 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 4 -bedroom residence is 0.41 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. .J Municipality of Anchorage K�Ociivt I.ibs Development Services Department -_ Building Safety Division , r, 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 FOR A SINGLE FAMILY DWELLING Parcel I.D. COSA# V�O(JlJ h iS 1. GENERAL INFORMATION Expiration Date: Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address MOUNTAIN PARK EST. #2; LOT 5 BLOCK 3, 12920 SAUNDERS ROAD * ANCHORAGE, AK 99516 CHUCK ROBERTS Day phone 440-8096 12920 SAUNDERS ROAD * ANCHORAGE. AK 99516 Day phone MIKE LOVE w/ ROY BRILEY REAL ESTATE Day phone 297-2908 2960 C STREET SUITE 202 * ANCHORAGE, AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 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 samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, t 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. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for 1l— bedrooms. Disapproved. Phone 337-6179 Date oo�o p�0 - '0 g40 o�. s0 �>� 4 T v* �....:.. ...................... :. . ....... ............ QO P ,J ey orness.- P CE -7 53 m� Of�4fe' ''.3116 o6.'cAoo 4 professlo�oo Conditional approval for bedrooms, with the fllowing stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Reort Other By: (/�ia� % Original Certificate Date: In.. IIIA11 �(YtOF 41�Jr�`/ter .�y01 ON-SITE WASTEWATER PROGRAM 11 _tea -0, , Municipality of Anchorage a 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: MOUNTAIN PARK ESTATES #2; LOT 5, BLOCK 3 Parcel ID: 0 f 7- O zmZ (% A. WELL DATA *TEST DATA LESS THAN 2 YEARS OLD Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (YIN) YES Date completed 8/7/1978 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 305 ft. Cased to 135 ft. Casing height (above ground) 12"+ in. Date of test Static water level Well production FROM WELL LOG 8/7/1978 130 ft. 1 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate 4.13 mg./L. AT INSPECTION *4/24/2004 127 0.43 Other bacteria 0 colonies/100 ml. Arsenic: <5.0 ug./L. Date of sample: 3/6/2006 Collected by: GEG, Ltd. B. SEPTIC/HOLDING TANK DATA Tank TypelMaterial STEEL Date installed 8/18/1978 Tank size 1250 gal. Number of Compartments 3 Cleanouts (YIN) YES (ONE) Foundation cleanout (YIN) YES Depression over tank (YIN) NO High water alarm (YIN) N/A Date of pumping 12/28/2005 Pumper NORTHLAND PUMPING C. ABSORPTION FIELD DATA Date installed 8/18/1978 Soil rating (g.p.d.lft`or /bdrm 130 System type TRENCH Length 52 ft. Width 36"-72" ft. Gravel below pipe 6 ft. Total depth *10 ft. Eff. absorption area 634 112 Monitoring tube YES Depression over field NO Date of adequacy test **4/27/2004 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 39 in. Water added 735 gal. New depth 39 in. Elapsed Time: 0 min. Final fluid depth 39 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date **TEST DATA LESS THAN 2 YEARS OLD. 36" OF WATER IN DRAINFIELD ON 3/6/2006 D. LIFT STATION Date installed "Pump on" level at in. E. SEPARATION DISTANCES Size in gallons High water alarm level at Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot **91 Absorption field on lot 100'+ Public sewer main 100'+ Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lots *90 Public sewer manhole/cleanout 100'+ Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots **91 COMMENTS *SEPTIC ON LOT 5, BLOCK 2 (A.D.E.C. #9921—DW/WW/-251-355) **WAIVER #WR040640 G. ENGINEER'S CERTIFICATION 1 certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS �0 m Date 3%t6& COSA Fee 6D Date of Payment 3 4 'b (e Receipt Number �lD_7c/4,� (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number L..........-ySVoo 4 - .* . .................. ey . arness. CE -7753 ,•',�O 3?�!6 J '1; Ad Municipality of Anchorage PPG T Vi Development Services Department Building Safety Division On -Site Water and Wastewater Program "Y 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. ci. an chorage. ak. us (907)343-7904 Water Well Advisory Health Authority Approval # 060088 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Block 3, Lot 5 of Mountain Park Estates #2 subdivision, the well's productivity was determined to be 0.43 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 4 -bedroom residence is 0.41 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. 0 a a°� A°d ado s�J3aNndsa as a 8 � Ursa . p ,o 0 �9 �'go 0 ) ,00'0 L L M„Sb,20.00 N 3 ti <Z w U°] m I �z . ~ s x ao LLJ w w o Q ZOww Ozz -Z to z g o w oz< 0 ¢ w¢ z J w H U W a -) U) Q w Z I V U ¢ moaz �Z=� x j _y 0 LJ U- Q Q w (n (n 2 W LL i. -,� zz - L, O V)(n Z w U O Z p z O x w O w w O O c0 ryry-�1 Vi «� d) d�i - �”' i-.. ii I —> O O w U H U Z z w (n W O x c`s v_) _'� •: F m z U_ O' %, a W �� rn ;; ', 5'z w �ox°o�v~w~n0w mo z m w ___.._ az.a ___— — .._ __— .�.T� — LTJ w z x w� � (-) L�Li }U�OwU�O O yam_ w �=� n d� a wm o F M�'ool a -� � �wZ V)IOf- w w w w w H U U' U' U Q O w� _- ? u) U �� �z wz ¢ }�UwzZoom= m o z W W m = — n O 0j LL] Lj 00mm z CYo-� nwwwwLLJ o _0,Z W �d zz W V ¢ Z Q � w -az V) ' wsc W W J w Q�1 Z w > > LO Z— Y N o. Ln m a CnLL] w w Q� Q O J d' - T 'x J < / /l � N 0 V M C¢9 Z z '1WS3 '�iin ,0l ¢ ,00'0 L L M„Sb,�'0.00 N Municipality of Anchorage 01 Development Services Department ' Building Safety Division a s. On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING:_; Parcell.D. 017-022-17 HAA# 0i:(n(octO 1. GENERAL INFORMATION Expiration Date: ?I05-- Complete legal description MOUNTAIN PARK ESTATES #2; LOT 5, BLOCK 3, Location (site address or directions) 12920 SAUNDERS ROAD * ANCHORAGE, AK 99516 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address KATHY BOUSCHOR Dayphone 346-2999 12920 SAUNDERS ROAD * ANCHORAGE, AK 99516 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 Day phone Day phone 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site 0 Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 " ANCHORAGE, AK 99507 Engineer's Printed Name Engineer's Comments: JEFFREY A. GARNESS, P.E. In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE r� Approved for bedrooms. Disapproved. Conditional approval for Attachments: HAA Checklist Septic System Advisory Well Flow Advisory bedrooms, with the filowing 337-6179 Date l/ Z.6 c OF AN& WATER AND •: PROGRAM Manitenance Agreements Supplemental Engineer's Reort Other V-44-1—Original Certificate Date: f Z x m (Re .11f Municipality of Anchorage R y` Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anch6rabe.ak.us (907).343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: MOUNTAIN PARK ESTATES #2; LOT 5, BLOCK 3 Parcel ID: 017-022-17 A. WELL DATA *TEST DATA LESS THAN 2 YEARS OLD Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 8/7/1978 Sanitary seal (Y/N) YES Total depth 305 ft. Cased to 135 ft. FROM WELL LOG Date of test 8/7/1978 Static water level 130 ft, Well production 1 — 9 -p.m - WATER SAMPLE RESULTS Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 18 in. AT INSPECTION *4/24/2004 1 0.43 g.p.m. Coliform 0 colonies/100 ml. Nitrate 3.55 mg./L. Other bacteria 0 colonies/100 ml. 4/22004 Arsenic: N/A mg./L. Date of sample: 11/10/2004 Collected by: GEG, Ltd. B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Date installed 8/18/1978 Tank size 1250 gal. Number of Compartments E Cleanouts (Y/N) YES (ONE) Foundation cleanout (YIN) YES Depression over tank (YIN) NO High water alarm (YIN) N/A Date of pumping Q 19I0y Pumper A f ikxne �2kVKPC C. ABSORPTION FIELD DATA BELOW EXISTING GRADE Date installed 8/18/1978 Soil rating .p.d./ r ftlbdrm) 130 System type TRENCH Length 52 ft. Width 36"-72" ft. Gravel below pipe 6 ft. Total depth *10 ft. Eff. absorption area 624 ft2 Monitoring tube YES Depression over field NO Date of adequacy test **4/27/2004 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 39 in. Water added 735 gal. New depth 39 in. Elapsed Time: 0 min. Final fluid depth 39 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date – **TEST DATA LESS THAN 2 YEARS OLD. D. LIFT STATION Date installed "Pump on" level at _in. E. SEPARATION DISTANCES Size in gallons High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot **91 Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lots *90, Public sewer manhole/cleanout Holding SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5' Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 50'+ Curtain drain NONE KNOWN Wells on adjacent lots **91'+ F. COMMENTS *SEPTIC ON LOT 5, BLOCK 2 (A.D.E.C. #9921—DW/WW/-251-355) **SEE ATTACHED WAIVER REQUEST PACKAGE G. ENGINEER'S CERTIFICATION !� 'JAI i certify that t have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA NAA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS QQ�o E 7953 . 4 r Date Lt /2.!1 Z04 04 nsProfe Rion°��� HAA Fee $ ��d�\ — '� Waiver Fee $ Date of Payment Date of Payment Receipt NumbeK/ Receipt Number 0(o\,�� (Rev. 12/01) I MOUNTAIN PARK EST S/D #2:1 LOT 21, BLOCK 3, i I ^` I i MOUNTAIN PARK EST S/D #2; LOT 20, BLOCK 3, '" Jg EXISTING WELL DRILLED IN 1994 I MOUNTAIN PARK EST S/D #2; I LOT 19, BLOCK 3, I t 100' WELL RADIUS 3700' WELL RADIUS I 1 i MOUNTAIN PARK EST S/D #2; A LOT 4, BLOCK 3, EXISTING 1250 GALLON SEP' TANK INSTALLED IN 1978 ZCSEPTIC AREA \ l / — — J EXISTING DRAINFIELD /INSTALLED IN 1976 (EXACT LOCATION i IS UNKNOWN) z� q w � S 6' ~\ RE STED )l l 0 EXISTING ) 3 BEDROOM OUSE EXISTIN WELL LL 91' WAIVER REQUESTED R I s 10' UTILITY EASEMENT 1p0 WELL RADIUS \ MOUNTAIN PARK EST S/D #2; y LOT 6, BLOCK 3, i \ DATE: op6pC 11/29/2004 §rrlf DRAWN BY: dC�" C J. G. GARNESS rN INEERIoNtj Gtv"ur, Ltd. - :.-. .. CONSULTANTS & GENERAL CONTRACTORS _...: am r TIJDnV RnAD cuTF I - Anlr DAD F nu ODaA7 - punk ,o x, c Im r cn v.¢ve xo, c PREPARED FOR: - PHONE NUMBER: PAGE NUMBER: KATHY BOUSCHOR 729-2632 1 OF 1 LEGAL DESCRIPTION: MOUNTAIN PARK ESTATES SUBDIVISION #2; LOT 5, BLOCK 3, TYPE OF WORK: SITE PLAN FOR WAIVER PACKAGE A. l�am�ss! r i i.vcu inc i�uuiocy icani av rcv �-�v.�a r,�, W co �O Ul 0 0 rn m w O a N 00003145"W 110. 00' 10° UTIL ESM -F, I ro 0 � e aAir s . o s• e s .+ W co �O Ul 0 0 rn m w O a N 00°03'45"W 110_847° z W 0 O 5AUNDERS ROAD N 00003145"W 110. 00' 10° UTIL ESM -F, I � 0 I �I o �I C o z co ,9YZ I 28° A2• 3S.W O V I w Rf CX ox X 4 T cX) U PF I ?] I N _ u ;K I p yk � i3® � _ 4 N 00°03'45"W 110_847° z W 0 O 5AUNDERS ROAD Municipality of Anchorage 04. P.O. Bos 196650 • Anchorage, Alaska 99519-6650 • Telephone (907) 3438301 • Fati (907) 343-8200 4 \\� 4700 Bragaw Street • Anchorage, Alaska 99507 milv.mcmi.org Mayor Mark Begich Building Safety Division December 7, 2004 Jeff Garness Garness Engineemig Group 3701 E Tudor Rd, Ste 101 Anchorage, Alaska 99507 Subject: Waiver Request for Mountain Park Estates #2 Block 3 LotX r Waiver Request #WR040640 Parcel ID #017-022-17 HAO40640 Dear Jeff Garness: Your request for a waiver of the required 100 feet horizontal separation from the on -lot septic tank to on -lot private well has been approved. And your request for a waiver of the required 100 feet horizontal separation from Lot 20 private well to on -lot septic field has been approved. The approved separation distance is for both cases is 91.0 feet. This waiver approval applies to the existing on -lot septic system to both private well separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-7904. Sincerely, roeGoodall Civil Engineer On -Site Water & Wastewater Program Community, Security, Prosperity Municipality of Anchorage Development Services Department • +c Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Waiver Review Worksheet WR#: 040091 PID#: 017-022-17 HAM 040640 Permit#: Date Received: 12/07/04 Legal Description: MOUNTAIN PARK ESTATES #2 BLOCK 3 LOT 5 Engineer: JEFF GARNESS GARNESS ENGINEERING GROUP 3701 E TUDOR RD, STE 101 ANCHORAGE, ALASKA 99507 Applicant: Waiver Requested: 91' SEPARATION OF ON -LOT WELL TO ON -LOT SEPTIC TANK. AND 91' SEPARATION OF LOT 20 WELL TO ON -LOT SEPTIC FIELD. Criteria: Geology A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: Points: ............................................................................... Waiver is Granted: ✓ List Conditions or Reasons for above: Waiver is not Granted: Date: t z 17 k By: ,J "C �OPP' -', Name of Reviewer ............................................................................... Rec#: 61322 Amount: $1150.00 Date Paid: 12/7/2004 WAIVER, AEQUEyT Foil fovoo-MW PjAk EsT4rE5.4-Z 6LOC_k Lor • wAIvEo{ 8rgVE5T NUw"g£Iq 6-%1R 010011 WRlUgf, 4EQVEST FoZ ON-LoT tJEGc Tp pV-Lor Sc-PTfc Taf(k of 9t FEET 4 W,41VFt� REQVEST J-o/p, fn/ELL LOCA-TEO Dn/ LOT 20 7-0 AN y Porl7-/Q J OF l�RA (rJ F f tr L.p Dni RE FE RfNCt f�R f)P6R T y n, �F 9/ FEET t11 41 Ui tU C h 4 6 • • I 'r SEPTIC- Tf�^fk Q (?/ZA(NF(6Lp DgrA-. — ToM SEPT fc, TgNkt /1jo [644-1 Ff Ef-O WEKE CuruSTRucTEb (N' /17& ANO THc WE" 714E 5vdSj6cT 1-07- wAi (o,-STRvcT£A, A -T TNc' SAME Ti -"E• TyE t -/ELL oA) Go7- 2r7 k/AS COe/ST/lVfTeb ON 199y, j/fE ON -407- OR4lVA1E4Z IS /D FEET v6=O . THE Soft I'" -m' 6 FOA, TWE ON-LoT OR4wr-IELo /$ /3p jP,�Jle&a. W F_LL P,4rf4 - THE w�L.L taf TI-tE sUBjEcT Lor rs jZEcArfvcc y o=Er /fr 303 rEET L?E£P (.JfTp/ STRrIc LJATE� /lEGp2/�p RT' /Z3 -FEET Ottp DUl?INfj IVS�EcTroq/, TyE "TEi2 S'AMpLE5 Fo/t 7 -,AX �_SUB,JfC T— LDT Sf-(DrJ � GO L(f=O�LM ( T•S S �'%LL� NfT�A iEs� it Alp 0 07'r(f,2 /31fc7i6aM. TrfE CN -f -or WELL- HAS "4o A g1 1`001' ENCN✓LOAcH+'hENT To SEPTIC T/•�Nlc Sr•vcrr /9�ge Tf(E 0�1"LoT $FpTIC I f S Pow(J Q?/RAW F1Vr FfjoM Tf-(E 0,V -Lor WELL. LF EFFL(jr NT W�,RE Tp 5J2FA4 Ir WOULD NDr TtiAVr< TpH/ARD iAj�E av-LoT '71Ei-t-. Ti{F tif_'-rte ' pN LoT Zo, 15 5#7 FEFT TaEEP iv'7-i4 s rA r f c bva rEi2 R -'r /L/ ?- FEf T, TI{E .WJ+Tcf2 &AMne.F5 7e02 7//fS WELL, ON L -Or 20 70 OR 0 Cocor-o b, S�(f MI/L A-�!p 0 O -J HE/Z f3Ac7Ff?1,q, 7-1.4E WELL pN 407- 20 ? WAS (nISTAV4E0 OAJ /9qy fj(Tfa A i5NC Acr MENT QF 9( FEFT, 9',10 I I Alos7 GfkEfy L?OCUruCA/760 WITo4 CRROt{ F04- 7o 7'IwC St/3/EG F)(4pet?7- SEPTfc- F(€L0. 7-AlEr4A fS F(c""RVY Ve6ET/iT((wv BET"VEGfJ sv©�E % SEPTIC. FIFO AN).0 toT 20 WEf-•L fF EFFLVFtn/T-hlErlE TO Sv"Ac£ • L J STRTE of /+"SkA f.Dc"oT *P E'yVI9O VAftnJTAc-- CDN$fR✓Arlo^.1 5EPARF►r(cnv PISTAA)GE AJAWcap, Q7Vr4.Et-IvEs 4a- S_ C.iR.O. Pafti7,> Foy AI -r-. 1:1ARl- ZsrArC5 Ti- 3 I -or s WATEK T*10i f POI vT5 SEwTIL FlE�O to FE£r D Ep• W RrEK TAOt e 127-7-- tt '- o 9 Ila ` i7/ X= Soles 5D09-371o/nJ tl 3z (,vgTEQ r. Ire r � PER61EA9j4L,r ry 30 3z tl 3z (,vgTEQ TfFB(,E,fj/tRDI£q/T ��9VN 4 [-o0;€S fwl/'k-y Fitprh h/K« 7 j� � /-/OA( ZO-j7-A• — SEPA2a'no.1 yr' rEET -L (0, (a z y f. / [CTRL • I�•�° pNLC.vS/u� gRFh1T WArvE2 CTRTE oi= s(-' EAJVIROIVMEgT&- CON5FZV4TIOnl •5£IPA/iF1TION DISTA^!cE hJAIV&12-, 4�'VIOEr_/4/95 Foa S. C.2.O. Po(IVTS FOS f4 T. ?,+A k- E.STi4TF5 6 L. y 4. r- 20 �/ItTF_2 TR/JI.E / �l TS WA -TCA, 7Ae/,E FA5ET, 2 ox ie tT:V 710 I Y: 3 Z: S9 tV 5 l ?�� �/3 2.f 7• S Z - 7- j PF_ R\\w E A,3 t T- 'WATE2 TAg�E EjR�t71c'�!T 6apunlb 5L-oPE5 Tvv^ao wf"c- Y/OXt -ao-J7/t (_ 56e4 RT/on/ pTn L-: Ib��J ';( LONGLOsro�: �jzakT wRI�E2 Municipality of Anchorage • '� Development Services Department Building Safety Division a 5 ^ e On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING //�ff II Parcel I.D. 017-022-17 HAA# D 1. GENERAL INFORMATION Expiration Date: ! { 7 Complete legal description MOUNTAIN PARK ESTATES #2 LOT 5, BLOCK 3 Location (site address or directions) 12920 SAUNDERS ROAD, ANCHORAGE Current Property owner(s) KATHY BOUSCHOR Day phone 346-2999 Mailing address 12920 SAUNDERS RD. *ANCHORAGE AK, 99516 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site E Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates maybe 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, t verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE 1n Approved for bedrooms. Disapproved. Phone 337-6179 Date ,- 4 Conditional approval for bedrooms, with the filowing stipulations: `76": ••ON-SITE `-; INATPR 4 N : m WASTEWATER Attachments: ����� •. Sp`v ` HAA Checklist _� Manitenance Agreements iiJv 11` Septic System Advisory Supplemental Engineer's Reort �IJJ)Illl)���1 Well Flow Advisory Other By: �=:Z J i — Original Certificate Date: 107 (Rev. 12101) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: MOUNTAIN PARK ESTATES #2 LOT 5, BLOCK 3 Parcel ID: 017-022-17 A. WELL DATA Well type PRNATE If A, B, or C provide PWSID# NIA Date completed 8/7/1978 Sanitary seal (YIN) YES Total depth 305 ft. Cased to 135 ft. FROM WELL LOG Date of test 8/7/1978 Static water level 130 Well production 1 WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Arsenic: N/A mg./L. B. SEPTIC/HOLDING TANK DATA Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 18 in. AT INSPECTION 4/24/2004 127 0.43 Nitrate 3.55 mg./L. Other bacteria 8 colonies/100 ml. Date of sample: 4/27/2004 Collected by: GEG, Ltd. Tank Type/Material STEEL Date installed 8/18/78 Tank size 1250 gal. Number of Compartments E Cleanouts (Y/N) YES (ONE) Foundation cleanout (YIN) YES Depression over tank (Y/N) NO High water alarm (YIN) N/A Date of pumping 10/16/2003 Pumper NORTHLAND PUMPING C. ABSORPTION FIELD DATA Date installed 8/18/1978 Soil rating OE>ft2/bdrm) 130 System type TRENCH Length 52 ft. Width 36"-72" ft. Gravel below pipe 6 ft. Total depth 10 ft. Eff. absorption area 624 ft2 Monitoring tube YES Depression over field NO Date of adequacy test 4/27/2004 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 39 in. Water added 735 gal. New depth 39 in. Elapsed Time: 0 min. Final fluid depth 39 in. Absorption rate >= 600+ g.p.d, Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed "Pump on" level atin. E. SEPARATION DISTANCES Size in gallons High water alarm level at Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main N/A On adjacent lots 100'+ On adjacent lots *90' Public sewer manhole/cleanout N/A Sewer /septic service line 25'+ Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5' Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 50'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS —251 G. ENGINEER'S CERTIFICATION I certify that I have determined through Feld inspections and q0ef review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date.ess.' Engineers Printed 74 - me JEFFREY A. GARNESS `�Date 40,.........'&_ S �4 d'orofessiooG, ���ovo�oa HAA Fee $(0-/,57-04 3 2 ' Date of Payment l0 " / S— 0 T Receipt Number ✓ 3 (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage 1�1! tP ksD` l • Development Services Department Building Safety Division y. On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Water Well Advisory Health Authority Approval # 040259 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Block 3, Lot 5 of Mountain Park Estates #2 subdivision, the well's productivity was determined to be 0.43 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 4 -bedroom residence is 0.42 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. GARNESS ENGINEERING GROUP, Ltd. CONSULTANTS & GENERAL CONTRACTORS November 22, 2004 Municipality of Anchorage Department of Health & Human Services Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref: Waiver Request and HAA for Mountain Park Estates Subdivision #2; Lot 5, Block 3. The existing 4 bedroom house is served by a private well and septic system which were both installed in 1978. We have obtained two health certificates in recent years, one on 1/13/1999 and the other on 6/17/2004. The owner requested a re -issuance of the most current HAA because it had expired. The bacteria water samples had expired and we went to the property to take a new sample. The field technician at the this time measured separation distances with our Topcon total station and found two encroachments. The first encroachment was from the well serving this property to the septic tank also serving this property. For our previous HAA's the separation distances was scaled off from a Jeffery A Gastaldi, L.S. as -built survey. According to his survey, the separation distance between the well and septic tank was 103+ feet from pipe to pipe. With our total station, we found the separation distance to be 95.3 feet from pipe to pipe. The second encroachment that we found was from the well located on lot 20, block 3; of the same subdivision to the drainfield located on the referenced property. On the previous HAA, this separation distance was checked with a rag tape. With a rag tape the separation distance measures more than 100 feet from well to standpipes. However, according to the total station, the separation distance is actually 99.8 from edge of well to the edge of the closest standpipe. The standpipes were installed in order to perform a septic adaquacy test for the 1999 HAA. The exact location of the drainfield is unknown. The well on lot 20 was drilled in 1994, so it is our understanding that any fees related to separation distance encroachment be charged to the owners of lot 20. We request the following separation distance waivers: • A 91 feet waiver from the well for the referenced property to the septic tank on the referenced property. • A 91 feet waiver from the well located on lot 20 to any portion of the drainfield on the referenced property. 3701 E. Tudor Road, Suite 101 * Anchorage, Ak 99507 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: gamessengineering.com The following items are justification for the waivers: • The referenced septic system is downhill from the well on the referenced property with the house between the well and septic system. If the septic system was to overflow, the effluent would not travel toward the well head. • The well on Lot 20, Block 3, is slightly down hill from the septic system on the referenced property. The area from the well and the septic system is heavily vegetated and if the septic system was to overflow, it appears that the effluent would not travel directally towards the well head. • The location of the septic system is in a very visible area so that if any effluent was to surface, it would be noticed and the problem corrected. The other path of contamination is subsurface migration of wastewater. As can be seen on the attached well logs, the aquifer is relatively deep, with approximately 31-70 feet of clay and silty gravel that have served to inhibit the migration of untreated wastewater into the aquifer. Recent water samples have been pulled on Lot 5, Block 3, and indicated nitrate levels of 3.55 mg/L and coliform bacteria to be undetected. Water samples were also pulled on Lot 20, Block 3, and indicated nitrate levels of 5.41 mg/L and coliform bacteria to be undetected. Nitrate levels also known to be elevated in this subdivision, so it is reasonable to assume that the moderately elevated levels in the well serving Lot 20, Block 3, is not a direct result of the encroachment. Based upon the aforementioned facts, it appears that there is minimal risk in granting the requested separation distance waivers. If you have questions, please contact us at 337-6179. Thank you for your assistance. .E., M.S. 3701 E. Tudor Road, Suite 101 *Anchorage, Ak 99507 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: gamessengineering.com 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. # 017-022 17 HAA# 1. GENERAL INFORMATION Complete legal description Lot 5; Block 3; Mountain Park Estates #2 Location (site address or directions) 12920 Saunders Rd. Anchorage, AK Property owner Cendant Mobility Services Day phone _ Mailing address C/O Jack White Real Est. 3201 "C" Street Lending agency Mailing address Agent Clair '?n Address _ /Jacl: r:i',itn 7.7. Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual well Community well Public water Ancho Day phone Day phone 762-3117 NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site xx 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.1/91) Front MOAs21 AK 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, l 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 ALASKA WATER & WASTEWATER CONSULTANTS, INC IS TO BE PAID #6);q-O—aAT CLOSING FOR ENGINEERING SERVICES PERFORMED. 6. DHHS SIGNATURE �1 X Approved for `T bedrooms. 0 Disapproved. Conditional approval for Phone?! 7— 617 2 Date A. bedrooms, with the following stipulations: Additional Comments 5 EE AjF ,(-pEp WATEe w,<t L AOU15CR v NUTIC Date / — /3 _ / The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (RW 1/91) Beck MOA k21 RECEIVE A= SE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES ,IAN 07 19 Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907JANC ANC DIVISION Health Authority Approval Checklist Legal Description: /0 LL S a1c ..3 M"n Ar/L F5 L # 2 Parcel 1. D.: 0/2 622-/7 A. WELL DATA/� Well type Pf 1 U O�� If A, B, or C, attach ADEC letter. ADEC water system number — Log present &N) Date completed r7 - 76 r1 Total depth 30 J(- Cased to I ,3,ri ( Casing height (above ground) a + Sanitary seal (Y N) s Wires properly protected (Y N) FROM WELL LOG AT INSPECTION Date of test ?z %B 1 i 2 O / g8 Static water level Well production g.p.m. ' yS On -7 g,p,m, f{ %yGrO.ir -P b.y Rlprne z9-;11nq 1l-18-r7t' WATER SAMPLE RESULTS: 1R Ott flow tip _ pei-46ry ped b.y 9rp�e�nll I _ ($4amatAalt Coliform 67-' Nitrate /, 0,8 rn L Other bacteria -�}- d a� Date of sample: .19, 49 '7 /9 6 Collected by: S maddc.L - A w W C_ B. SEPTIC/HOLDING TANK DATA Date installed 8/78 Tank size 1 a 5 0 Number of Compartments a Cleanouts (Y61 �k7e) Foundation cleanout(Y N) eS Depression (Y()f 90 High water alarm (Y6V N�A Date of Pumping q-2-8 -'F8 Pumper A-1- YOnle 7erulces C. ABSORPTION FIELD DATA Date installed !8 Soil rating (g.p.d./ftp or, ftz/bdrm) 130 System type1 ' ren Ch n " ' r nsp rPPor�I i Length Width 3& - 7a Gravel thickness below pipe &Total depth I O Effective absorption area &aq SF Monitoring Tube present©N)—y Depression over field (Yo N Date of adequacy test 10/2 C1 O!8 Resultsas /Fail) rG 65 For 1-50 f l r' bedrooms .� Fluid depth in absorption field before test (in.); c20 r r Immediately after 246 gal. water added (in.): 50 • S ,r Fluid depth a(o. 5 (ins) Minutes later: 102-0 Absorption rate = 1000 -1- g.p.d. Peroxide treatment (past 12 months) (YO �1d If yes, give date /V /A 72-026(Rev.3/96)' se�ttG �cu5ewl f )a-5 presocJ�ad on loft(,198 W c Ch 2000 5Q llon5 0-r wafer D. LIFT STATION Date installed Manhole/Access(Y/N) High water alarm level at* Cycles E. SEPARATION DISTANCES Size level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot / 00 On adjacent lots "Pump off" level at* Absorption field on lot 00 ' _ On adjacent lots 90 f f Lof 5 BK Z #;] n Pk Esi' I # 2 Public sewer main ��i�i Public sewer manhole/cleanout r Sewer /septic service line a S t Lift station _/1114 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: I r Foundation Property line Absorption 15 - Water Water main/service line ! D t- Surface water/drainage f 00 + Wells on adjacent lots Ion f SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: 04-SuProperty line Building foundation i F Water main/service line 104- Surface rface water X00 f Driveway, parking/vehicle storage area 5� r Curtaindrain 1 t; Kn O W ✓1% Wells on adjacent lots /00+ F. ENGINEER'S CERTIFICATIONCt1CcC 1 certify that ! h to a rJ5eld Inspections and review of Municipal r flj dl stems are in cohforman a wi H A gi ' Jelin sin effect on this date. .? +,I , Signature .. ...« _ Engineer's Name Date e-7953 e.•d® HAA Fee $ (,�0O Date of Payment 0/ % q Receipt Number 0114 ! /9�1 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number • C-1 5. LEGAL DESCRIPTIO �— DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE ED One Four ❑ Other ❑ Two ❑ Five INSPECTOR INSPECTOR / — INSPECTOR K INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECJ( MCI PALI TY OF ANCHORAGE 825 L Street - Anchorage, Alaska 99501 DEPT. OF HEALTH & ENVIRONMENTAL PRC%TECTION ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 (yljAY 2 7 1'71`1 _11 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEV1I IVrb DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten 1100) days for processing. 1. PROPERTYOWNER PHONE MAILING 5DRESS PROPERTY RESIDENT If different from above) PHONE NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 24c -2g0 2. BUYER PHONE MAILING ADDRES 3. LENDING INSTITUTION _ JaNt ��- � � l� �T 1S PHONE MAILING ADDRESS (,J 4. REALTOR/AGENTQ \ //'��� �1 PHONE � '\—`fa \tri IJv �C` CC ZFS.—LOC^C- MAILING ADDRESS _ 2�sC�L 5. LEGAL DESCRIPTIO �— STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF+BEDROOMS SINGLE FAMILY ED One Four ❑ Other ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY K INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM , v� INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLICUTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) ww-) �4 1 THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ six 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED V� 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: (asti If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER q TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS Zl—�APPROVED FOR J_ BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED j DATE g ((/ BY �6�� 72-010 ( Rev. 6/79) 0 t��IW0 - MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & STREET LOCATION F��t�V�� DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTRONMENTAL PROTECTION ION 825 L Street - Anchorage, Alaska 99501 ' SEP 2 6 1978 6. TYPE OF RESIDENCE ENVIRONMENTAL ENGINEERING DIVISION SINGLE FAMILY Telephone 264-4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all pares on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTYOWNER PHONE MAILING ADDRESS �S %4 .L< ee' i i f/ ,-ge k a' 9C S' A,Vc' 14 A Sa�;OSd 'ATTACH WELL LOG. A well log is required for all wells drilled cam. - PROPERTY RESIDENT (If different from above) PHONE 2. BUYER B. SEWAGE DISPOSAL SYSTEM PHONE MAILING ADDRESS �1 "`If individual/on-site, give installation date 3. LENDING INSTITUTION If system is over two (2) years old an adequacy test is required PHONE by this Department. ,4Z --45K-4 MAILING ADDRESS 4. REALTOR/AGENT 7� 145w PHONE Q7 -2-o6- 71 MAILING ADDRESS 5. LEGAL DESCRIPTION /-o 7- 5- L MDUA-)7-�4/�V IfACe STREET LOCATION ,4 ,I -aAf /-)F7 CS •�/� r L'L— — 1-.1 - S (LUi..n.es� \ at „...,..�s S 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS SINGLE FAMILY ❑ One --72�-' Four ❑ Other ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY INDIVIDUAL* 'ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to thatdate, give well ❑ PUBLIC UTILITY depth (attach log if available.) B. SEWAGE DISPOSAL SYSTEM D?K, INDIVIDUAL/ON-SITE'* �1 "`If individual/on-site, give installation date ❑ PUBLIC UTILITY If system is over two (2) years old an adequacy test is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. cvivwriw u"t� THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS DATE RECEIVED -- TIME TIME TIME DATE DATE DATE INSPECTOR, INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON-SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED INSTALLER S ❑Septic Tank or ❑ Holding Tank Sizer If Tank is homemade give dimensions: SOILS RATING + Q TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL T0: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY ITitlel LEGAL DESCRIPTION .i 72-010 (Rev. 3/78)