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Home My WebLink AboutMOUNTAIN PARK ESTATES #2 BLK 6 LT 1Onsite File t Municipality of Anchorage On-Site Water and Wastewater Section - (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201201 PID Number: 017-432-05 Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade Name DARIN APPLEBURY ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 12600 LUPINE DR ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot MOUNTAIN PARK ESTATES #2, BLK 6, LOT 1 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding I Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft' Ft. Well 100'+ 50,+ TANK [9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity ANCH TANK 1000 Gal. Surface Water 100,+ Material PLASTIC Number of compartments 2 { Lot Line 10,+ NA Foundation 10,+ ! LIFT STATION Manufacturer Capacity Remarks NEW TANK ONLY Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 drainfield Tank to 3034 Installer MIKE N ANDERSON, P.E. Drainfield CO/MT 3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 100 ft Inspect6/27/20 Location and description 2nd a GARAGE SLAB 3rd 4' ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp OY A �'� Conditional Approval: Date e e e e e o e o 0 0 o e e o e e Jj�e •�• • e e e e o e e ........... °• 1AICHAEL N. ANDERSON ; C' ° CE-94 Septic System r' Approved Date Note: this approval does not include well permit requirements.®®R FESSIQ�� (Nev uoiuz/i t9) Permit No. OSP201201 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744 On—Site Wastewater Disposal System and/or Well Inspection Report Legal Description: MOUNTAIN PARK ESTATES #2 BLK 6 LT 1 PID No.: 017-432-05 MARK A B C01 TC01 30 13 TCO2 33 17 CO2 36 21 CO3 40 26 CO3 C 0 2%'� II TC01 II GARAGE SLAB NEW 1000 GALLON PLASTIC TANK i B� ASBUILT SCALE: 1"=50' SEPTIC SECTION N.T.S. AV .; 49TH ;MICHAEL N. ANDERSON; tZA No. CE 9469 j ••'•.7-18-20 -•i --d •b m CT ym(I m EcK�= W� � RK m O c5 ID N m R. W �eC�rm+W �y ^W 0 D SS ^ " V�! o rt 67 R( rh iD C] M �*m m d a m �mW 5" m m o 0 9 Oy'7�n W.X y ri I- CD W000a �ID o `t m a O]y *Cl) CU N) ID. cc� cw o CQ CD 3 f CDD w C) � o z UD Ul o 00 O N��'{ ------------------ 96 '-bO L 3«S-VC20o00s —1 i3VUSd3 kinil�l—m Old3S n D ZEn Z z z O h � m0 Z m Q0 m � p Z'OC W—W O 5 LZ o z \' 00 m 1 , Q z 0 N O Z'LZ *Z. 4ti to i MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP201201 Work Type: SepticTank Upgrade Effective Date: Expiration Date Tax Code Number: 01743205000 Site Legal Address: MOUNTAIN PARK ESTATES #2 BLK 6 LT 1 G:2839 Site Mailing Address: 12600 LUPINE RD, Anchorage Owner: APPLEBURY RYAN 50% & Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy �ll�cni- O •� f Departinent 6/26/2020 6/26/2021 Lot Size in Sq Ft: 19032 Total Bedrooms: 3 ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Issued By: 77 Date: Date: 6 6 ZO MUNICIPALITY F ANCHORAGE RUSH Development Services Department �l('4 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 017-432-05 Property owner(s) RYAN APPLEBURY Day phone Mailing address 12600 LUPINE RD, ANCH AK Site address SAME Legal description (Sub'd., Block & Lot) MOUNTAIN PARK ESTATES #2 BLK 6 LT 1 Legal description (Township, Range & Section) Lot Size 19,032 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) El (w/wo ADU) Septic Tank 0 Upgrade 0 Duplex (D) ElHolding Tank F-1Renewal ❑ Multiple Dwellings ❑ Privy ❑ (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 270 COVIO Waiver Fees: Date of Payment: Date of Payment: Receipt Number: 006�7Z Receipt Number: Permit No. (?5P2012 -01 Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc June 26, 2020 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: New septic tank permit Legal: MOUNTAIN PARK ESTATES #2 BLK 6 LT 1 To Whom it may concern: This is a request for a septic tank permit on the above referenced lot. This tank replacement will not impact any of the neighbors or encroach on any wells, septic or open water issues. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201201, Deb Wockenfuss, 06/26/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201201, Deb Wockenfuss, 06/26/20 k.'ilJ;\qCiPALITY OF /'d¢CHORAGE DEPARTR'IENTOF HEALTH &ENVIRON.MENTAL PROTECTION ENVIRONMENTAL EI'4GINEERING DIVISION {::25 L Street - Anchorage, Alaska 99501 Te(ephone 26~-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WF.I_L INSP[-~CT~ON R~PORT F °u nda~,)~ I Total len§th of lip, es Material beneath tile -~r~nchw;~II inches OTHER PH~E !,AAT ER!A LS go_c_r.___ SOIl_ TES] RATING INSTALLER LEG&L .......... ~ 4~-~ ~__j~j~~'r__~,~' ~;~./L_../-~ .... >~-~ o~ ~oo,,~ - '- ............... ', i -- ~'[-~-- I ~ Absorption ~:'ea J D,',, ',ling Il I ~Y~'_~Z2~__.__I :I. LO J _ ~'_ .................. ~Tz_~_ ~~ ..... k;lar u acturer ~ ~ Mater~a] _, No, of c~j:m'tments Li~{~ Ions ~ ~de e ~gth j Width Liquid depth ' ~ HOM~: / / JWell J D,,~el ng PERMIT NO. DISTANCE TO: I / . WATER WELL RECORD STATE OF ALASKA ~UNICIPALITY OF ANCHOI~AQE DFPT 0~: HE.,~LTH AOEPARTMENT OF NATURAL RESOURES ENVIP.' ;NM~t;;'A. PRO. ECTIZiv~sion =of Geological ~ Geophysical Surveys JUL 1. 2, 1982 ling Permit No. LOCATION OF WELL {Please complete either Ia. lb or lc.) RECE j~ / I'" t~' V~.. ~ - A.D.L. No' la.llBorough Subdivision Lo, ,,ac, 'b.II I/4qtr'' Sect,o. No. Tgw.~h,;N0 Re.ge E~ Meridian ,. u~ ~.~:,,-~ ~ :D --of--of--of-- S~ W~ II ~'"m'~ lc. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS $. OWNER OF WELL: ~}~['J[O >-~ Address: Street Address and Area of Well Locution Feet Below 4. WELL DEPTH: (final) 5. DATE OF COMPLETION ~. WELL LOO Surfoce !.5'7 ft. 6 -- M oterlol Type Top Bottom b~-~''' ~:olm~ me4~ ~,a.,d ~'" l~0 e. ~:c.~[.too, O.o~a~ Oo~iv,. - ' - ""] F,'t" ' .... ~detted ~eored OOther: ;'~'J~ ~ [.::T'f~y ,"~]~ ?~: '?(;] /],2 ?0 7. USE: ~[Domestic ~ Public Supply ~ Industry Threaded ~(Welded diem. in. fo~ft. Depth Stickup 9. FINISH OF WELL: 'J;~:;::~ ,~.~ , u].',}:....,/ .,*: .,,. Type: ~i'~:~- ~ Q Diameter: Slot/Mesh Size: Length: I0, STATIC WATER LEVEL: ~)~' ft, Date ~ Above or ~ Below land surface Equipment used: ~'~:)]~ ~{~ ft. after J1- hrs. pumping [:- IL.GROUTING Well Grouted: ~Yes ~ No Material: ~ Neet Cement ~ Other: 2:'~"~L~["~ I~, PUMP: (if available) HP 15. Water Temperature ~o ~ F ~ C F'EF.:H Z T NO. L 0 C Fi T i' 0 N _.F DEPRRTJ'4Ei'.,FF HEF!LTH RN[:, ENV;~REINMEi",iTF!L ,:OTECTION :325 "L 264-4720 SRR E:r3M 1546E '3 :E =h;:r7 TYPE 0F :50iL RE':":~E~F,.'P"FION :5%.':5TEi'"! .IF:i;' TRENS:H i',t..F.::-~..,'[j',lJhi .'-.IU.h'IE:ER OF DEDF,.'~O(]M'.E; :':, 2: :BOIL. RFIT ! N6~ THE FdL:"..]L'Zi::-:'FZD '::.~;!2:E 3F -FHE :iS::Zl_ FiE::BORP'T!E~N '.5'¢:STEM T'.:~: THE LENGTH DZF'tENS:(ON Z:~; THE: LENGTH (ZN FrEE:T) OF THE TRENCH OR DRFIZNF'IEL.D. THE DEF'TH OF F! TRENCH OFt F'IT IS THE DISTRNCE BETHEEN 'THE SE;t. JRFRCE OF THE GF'.OLiND RP,i[::, THE BOTTOM OF THE ENCRVF!TZON 4IN FEE]'>. THERE Z~; NO :SET F.!I[:'TH FOR TRENCHERS. THE GRRVEL, DEP]"H IS THE HZi'.,!:EHUH DEF'TH OF GRR',,,'EL E:ETHEEN THE OU'I"F'RLL PIF'E RfqD THE BOTTOM OF THE EXC:R'¢RTZON (::!:N FEET). PFPr,ITT F:~F'PL..iCFIh,F.r' HR:.~; THE c~"-'-'"~ /,--.?~.:..f TT.. TO T~.,II::FtPM 'THI'~; f',FPR~'THENT C,L.!RING 'ri-IF ZN?FF!LLFCI-IEU'.~ I.'.4'F;PEZTIOH:L: OF FIN'¢ HELLS FIE' 'J'¢!CEi'.,!T Ti TF!ZE; F'F:OF'EF;'I"'.¢ RND THE NLU'"!E',ER OF F%~:E;I[)ENCE'..}:; TF!RT THE HEI_L P~!:[LL. '.~;ER-VE. E:FH'.'!.:'F:'.'L!.IF,~3 ':P' F'l!'.,i'¢ '.~i;¥'STEM kiI'!-.FiOUT F!HRL ZNSF'EE:TZEd'.~ FINF:, FtF'PREm'-'/F~L ECT' "FHI:::] C, EPF!R]"MENT !,.I I L.L. BE :E _.E Z.:F..": '.' TO F'RO:E;ECUTI ON. !"!ZN!MIJH,..r" ~',:~"¢,.-., _.,, , ,, ..-'c'~-: EFT!.,.![:'E'['.,! ....................... R I.,.!ELL F!N[) RN'.r' -iNI---'giTE ::,c.l.,.![ff.=b. r' ]:': PI-I'::;¢!! ,2'.¢,g]"Fh!, _}"2_ .'iF~¢~ FEET F':~, Fi PR.i: ,'RTE .,IELL OR :15Z TO ;2E~E~ FEE]' FROM F! F'UE:LIC HELL. DE'P~"N[,!Nr3 tl~,-,.,l THE T'¢F'E h'iZi'. 'r "i '4 D?:?f'FINCE F'ROH R F'RT'-'FFFF' ~"P .... l"f? ,::, .................. c--.L ..,, F'RZ',,,'R]"E ..,,.:',:.._..F'r~' ......... I 'r~.,~E ]'5 ;25 FEET FINE:, TO R -'r'q','tvt!lt,.,~'i",.¢ ,::[:' F'~;' ~ fhiE ~"q 75 ~:-~:.~-T ................ H .......... i illql-i~' .......................... fq'F:':~ !'~'EHF~',IT':: MF!"r' ,~ f !...~. ':;F'p:! .... , ..... T-F~T,..~,_ ~_, FIN[} ...... "i-FJ':4T~'ItF':T~t:It'-4 F'tRGRFIH:E; FiRE I CEF']T I FY TH, FFr' ::L: i RH FF:fMIL. IF,'r..:.~ HiTH THE RE(;!U:[REHEN]".::: FOR ON-SITE SEI.,.!ERL-q RND !.,.!ELL:5 Ri'..-':, :E;ET FOR'i'H E:'¢ THE I"ILiNZ[CZF:'FiLZT'¢ OF' RNCHORRGE. ;2: Z !4ZLL. ZN'=]TFIL.L. THE .S'¢STEP'i IN I::!E:CORDFINCE k!Z'T'H THE ~ii:: :[ UN[::,ERS'!'F~ND TF!RT THE: ON-.S:I:TE !~;EHEF: :E;'-,,'::STEM !"!Fi'¢ RE(.:.!U:rRE ENL. FiRGEHEN'T IF' THE RESIB, ENCE IS REHOE:,Ei_ED "FO t.NCLUDE f"iORE 'FHRN 2: BEE:,ROOH:E;. F)F'F'LZCRNT BEETER CON'JF.;T SOILS LOG I', '~IClPALITY OF ANCHORAGE DEPARTMENT;OF HEALTH AND ENVIRONMENTAL PRO'I'ECTION [] PERCOLATION TEST Pouch ~-S50, Anchor&ge, Alaska 99502 276-222~ SOILS LOG-- PERCOLATION TEST COMMENTS 2248-E WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT ' DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE TEST RUN iBETV~EF~J FT AND . {minutes/inch} FT DATE: 'R ANCHORAGE AREA BOF '-"GH ~_),~ Department of Environmental Quality '~ 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME .,..~_~.,//'.~--~-//~/z,~Y ,¢',~.?.~'/-./.1' MAILING ADDRESS .~z'.:'/~b.2,- ../~>/L'.~-':l~'- ~_ . PHONE DISTANCE /~' ~//]~/~/~.~ ~-~/-A~' ~/'~ .s '~:~/J~;2 .... NUMBER OF PROM WEL[,~'~/~¢/~-~ANUFACTURER ,/~//~///2,~- MATERIAL/~~;~'~ COMPARTMENTS INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY-%~:~-¢-?'~ GALLONS. SEEPAGE Pit: # NUMBER OF PITS / DIAMETER OR WIDTHX~,/ LENGTH~, ! DEPTH LINING MATERIALA~/~//2-~: CRIB SIZE: DIAMETER ~/' 'DEPTH DISTANCE FROM: :.~ /~27,F, ,~--~ TOTAL EFFECTIVE BUILDING FOUNDATIO~;~t~;~'? NEAREST LOT LINE ~-~ -~/ABSORPTION AREA (WALL AREA) ~,t/>~2 SQ. FT. ADDITIONAL ABSORPTION BUILDING NEAREST NEAREST FOUNDATION LOT LINE SEWER LINE CESSPOOL OTHER SOURCES APPROVED DISAPPROVED REMARKS, DEPTH DISTANCE FROM: SEPTIC SEEPAGE TANK__ SYSTEM DISTANCES: INSTALLED BY: ~'-.?~//4~,,¢.~.c/~ .... LOT SLOPE: REMARKS: Form No. EQ-O31 DIAGRAM OF SYSTEM DATE fr'' G.A.A.B. GReATEr ANCHOrAGe AREA BOROUGH - NAME OF APPLICANT PERMIT NO. DEPARTMENT OF ENVIRONMENTAL QUALITY 3350 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 ~¢-(/.~ / · ..~ ~ ,~,~.~'~, SEWAGE DISPOSAL SYSTEM -- APPLICATION'AND PERMIT J./<,' INSTALLATION LOCATION 'EgAL DEBCR,PTIG'N lk- INSTALLATION OF: SEPTIC TANK /~ SEEPAGE PIT ~ , DRAIN FIELD TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH TO BE INSTALLED BY SOIL TeST RESULTS , OTHER NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED / ~ FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. ' '-- "' ' SEPT,C TANK S, E TYPE SEEPAGE DIAGRAM OF SYSTEM MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK fOUNDatioN TO seepage Pit ~/~ . DRAIN FIELD · seePage PIT SEPTIC TANK ~' / TO NeaREST LOT LINE. WELL TO SEPTIC TANK DRAIN FIELD ID' DRAIN FIELD i//~) / · SEEPAGE PIT ///~¢ ' , ALSO CONSIDER AREA WELLS. SEEPAGE Pit ~:~ / WATER MAIN TO SEPTIC TANK~/3 DRAIN FIELD SEPTIC TANK, /~' ~ ' )- SEEPAGE PiT /(~/~ · , DRAIN FIELD TO RIVER LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE Pit PITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. I CERTIFY THat I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE Area BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE With SAID CODE. i i.R Ai'4CttOi~AGI, /\Ri:A ~OROU(-: DEPARFIqENT OF ENVIRONMFNTAL QLIAt,~TY 3330 "C" Street ANCHORAGE, ALASKA 99503 Case # Performed For_ Leo Sawy¢~.J~?~view !.ets) Legal Description: Lot t Block ~ This Form Reports Soils 'Log Soil Test Must Be Logged To 4' Below Proposed Depth Feet Soil Characteristics 2 -- 3 ~ 5 ~ 8 -- Peat and organics Medium -to- fine gravel with clay and silt; trace of fine sand, light brown color Gray, well-graded sand with trace of silt SW SW-SM Dated Performed May3, 1974 S u b d i v i s i o n .]~ount~LLn Pa~:k_~_~~ Percolation Test X Seepage System - Was Ground Water Encountered? No ~4n.. If Yes, At What Depth? Reading Date Gross Time Net Time Depth to H20 Net Drop Percolation Rate Minute. Proposed Installation: Seepage Pit X 'Drain Field Depth of Inlet Depth to Bottom o~--Pit Or Trench 16' COMMENTS: We recommend 180 sq, ft.,. per bedroom based on Bolzough regulations and soils conditions. Test Performed BY J.JEmeson Date Certified BY: ALASKA MINERAL & MATERIALS LAB Date:,,, MUNICIPALITY OF /ANCHORAGE X Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 017-432-05 Certificate of On -Site Systems Approval Expiration Date: Legal description Mountain Park Estates #2 Block 6 lot 1 Site address 12600 Lupine Rd , Anchorage, Alaska Current property owner(s) Mapes 1-14-22 X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 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 X Tank Age Advisory Arsenic Advisory _ Other COSA Approval_June 2022 MUHMP L UTY OF AHCHORAGE O '11 Development Services Department= Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 017-432-05 Complete legal description MOUNTAIN PARK ESTSATES #2 B6, L1 Location (site address) 12600 LUPINE ROAD, ANCHORAGE, AK 99516 Current property owner(s) JONATHAN & LORRAINE MAPES Day phone 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 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: ® Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ® Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age 2+ - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ® Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: 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 $ 6 `5_0 Waiver Fee $ Date of Payment / () too �2 �2 Date of Payment COSA # Q5C a. al yg a Waiver # -f51301q COSA Application 2022.doc Legal Description: MOUNTAIN PARK ESTATES #2 B6 L1 Parcel ID: 017-432-05 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) Water storage tank volume NA gallons Date drilled 6/7/1982 Total depth 137 ft Well disinfected for coliform test? ❑ Yes ® No Cased to 86 ft ® Coliform bacteria is Negative ® Sanitary seal is functioning correctly Nitrate 11.8 mg/L ❑ Nitrate less than MRL (ND) ® Wires are properly protected Arsenic ug/L ® Arsenic less than MRL (ND) Casing height (above ground) 12+ in. FWN Date of flow test for COSA 9/30/22 Collected by Static water level at beginning of test 12 ft. Date 9/29/22 Well production at time of test 5+ qpm Comments SEE ATTACHED SULLIVAN SCOPING LETTER. OLD WELD BUT WELL APPEARS TO BE SATISFACTORY PER THIS LETTER. POU SYSTEM BEING INSTALLED AT KITCHEN SINK FOR NITRATES. B. TANK DATA C. LIFT STATION Measured operating fluid level in septic tank 50" ❑ Required maintenance completed Date of pumping 9/30/22 Age of lift station years ❑ Required maintenance completed, if AWWTS Lift station material Comments: _ Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 9/28/1982 ® ALL standpipes present per record drawing Total measured depth from grade 10.2 ft (max) Measured depth to pipe invert from grade 4_5 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ® Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) N If yes, enter date Adequacy test date 9/30/22 Results E Pass Fluid depth prior to test 32 in Water added 690 gal New fluid depth 48 in Elapsed time 1440 min Final fluid depth 27 in Absorption rate 450 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 60 in Effective depth used 27 in (Final) Effective depth remaining 33 in Comments/Deficiencies: HOUSE WAS VACANT LESS THAN 30 DAYS, BUT PRESOAKED WITH 500 GALLONS OF WATER PRIOR TO ADEQUCY TEST. MT FOUND WITH 12" FLUID 48 HOURS AFTER TEST. SHOTS SHOW 5.9' EFFECTIVE DEPTH VS 5' MOA INSPECTION REPORT SHOWS. COSA Checklist 2022.docx 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' ® Yes if No ft ® Yes if No ft Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No ft Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' ® Yes if No ft ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ®Yes if No ft — ®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 Tank to Property Line > 5' ® Yes if No ft Field to Property Line > 10' ❑ Yes if No *9 ft Water Main > 10' ® Yes if No ft Water Service Line > 10' ® Yes if No ft F. ENGINEER'S COMMENTS *MOA WAIVER. Wells on Adjacent Lots: Private Wells > 100' ® Yes if No Community Wells > 200' ® Yes if No If tank or field is under driveway comment below ft ft i6 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 Finn FIRST WATER CONSULTING Phone 907-350-9566 Engineer's Printed Name CURTIS HUFFMAN, PE Date 10/03/22 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & Fkg COSA Checklist 2022.docx g•�P'-�� 49 H . �.. • Curtis Huffman �c�c CE 128991 �.�� l�C�•. 10/3/22. •�� lll,F�pROFESStONA -+ Municipality o Anchorage Development Services Department Building Safety Division ;.A F n On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # OSC221492 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 6, Lot 1 of Mountain Park Estates #2 subdivision. This inspection revealed a nitrate concentration of 11.8 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health inforination and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. P.O. Box 670269 Chugiak, AK 99567 P: (907) 688-2759 F: (907) 688-2259 TO: Brent Western 12600 Lupine Road Anchorage, AK 99516 Camera Inspection Report Date:10-7-22 Weld on pitless at 12' Old pitless hole at 12' next to weld on pitless. Looks like hole was sealed with most likely a welded on plate. Did not see any leaks from either the well on pitless or the welded on plate. Inspected casing down to 24' where the PVC liner started. No issues found. Well depth: 137' MUNICIPALITY OF ANCHORAGE a. Q Development Services Department " Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 017-432-05 1. GENERAL INFORMATION Complete legal description MOUNTAIN PARK ESTATES Expiration Date: J ) r z O z2, Location (site address) 12600 LUPINE ROAD, ANCHORAGE, AK 99516 Current property owner(s) DANIEL GETTMANN & MAYA RADONICH Day phone Mailing address Real estate agent 12600 LUPINE ROAD, ANCHORAGE, AK 99516 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3.. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 114 Date of Payment Receipt Number 1 '7a COSA # 0-5(—'Z2)()40 Date: Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY, ANCHORAGE, AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 02/09/2022 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & FWCS 6. DSD SIGNATURE System #1 Approved for Is___ bedrooms System #2 Approved for Disapproved Conditional approval for bedrooms lit . 4.. TM ......... . ......::: r� Curtis Huffman CE 128991 ll,FOpROFEWQ*, bedrooms, with the following stipul kiRkkgI(((((/(( Y OF,gii�� WATER AND r^ '-')))1I II I\\lei " Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other . L. Legal Description: MOUNTAIN PARK ESTATES #2 136 L1 Parcel ID: 017-432-05 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA ® Well log is filed with Onsite (or attached) Well production at time of test 5+ gpm Date drilled 6/7/1982 Water storage tank volume NA gallons Total depth 137 ft Well disinfected for coliform test? ❑ Yes ® No Cased to 86 ft ® Coliform bacteria is Negative ® Sanitary seal is functioning correctly Nitrate 9.41 mg/L ❑ Nitrate less than MRL (ND) ® Wires are properly protected Arsenic ug/L ® Arsenic less than MRL (ND) Casing height (above ground) 15+ in. F US Date of flow test for COSA *6/22/2020 Collected b Y Static water level at beginning of test 38 ft. Date of Sample 2/4/2022 Comments *TESTING PER 2020 MIKE N. ANDERSON, PE COSA OSC201320. WELL HEAD STATE REVERIFIED B. TANK DATA Age of tank(s) 1.5 years Tank type/material SEPTIC/HDPE Measured operating fluid level in septic tank 50" ® Standpipes/foundation cleanout per record drawing Date of pumping 2/4/2022 D. ABSORPTION FIELD DATA Which system tested (date installed) 9/28/1982 ® ALL standpipes present per record drawing Total measured depth from grade **10.2 ft (max) C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: Adequacy test date *6/22/2020 Results M Pass For 3 bedrooms Fluid depth prior to test 20 in (9" ON 2/4/22) Measured depth to pipe invert from grade **4.5 ft (min) Water added 500+ gal ❑ N/A — pressurized field New depth 26 in ® Monitor tubes go to bottom of effective. If not, state depth into effective ***5.9' OF THE 5'ED Elapsed time 1440 min ®Code -required soil cover over field Final fluid depth 20 in F-1 System presoaked Absorption rate 500+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) If yes, enter date Gallons introduced gallons Comments/Deficiencies: *TESTING PER 2020 MIKE N. ANDERSON, PE COSA OSC201320. MT LEVEL REVERIFIED **MEASURED AT GRADE & ***PER MT / CO ELEVATION SHOTS ON 2/4/2022 EWES E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ® Yes if No Community Sewer Manhole/Cleanout > 100' ® Yes if No ft ® Yes if No ft Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No ft Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ® Yes if No ft ® Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft ® Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: ® Yes Absorption Field > 5' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Main > 10' Yes if No ft Community Wells > 200' ® Yes if No ft Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No *9 ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No _ ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS *MOA WAIVER. G. ENGINEER'S CERTIFICATION l certify that / 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. �.—Ilk Aw AW WX .• . TM ....... Curtis Huffman CE 128991 •.�� kF�0 ROFliWQW�� Nitrate Advisory Certificate of On -Site Systems Approval # OSC 221040 Subdivision: Mountain Park Estates #2 B6 L1 A water -sample revealed a nitrate concentration of 9.41 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. Madmg Address P O Box 196650 * Anchorage, Alaska99519 6650 *www muni org From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening, or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. y Ma�hng Address P O Box x.96650 *Anchorage, Alaska 99519 6650 *www muni org �; MUNICIPALITY -OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 017-432-05 Certificate of On -Site Systems Approva 1. GENERAL INFORMATION Expiration Date: Oct 0� D Complete legal description MOUNTAIN PARK ESTATES #2 BLK 6 L -T 1 Location (site address) 12600 LUPINE RD, ANCH AK Current property owner(s) Mailing address Real estate agent 2. TYPE OF DWELLING: RYAN APPLEBURY SAME Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: Private Well El Water Storage ❑ Community Well ❑ Public Water System ❑ Waiver request for: bro n Day phone Day phone Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. Date of Payment Receipt Number 01319 G5 COSA4 050201320 Receipt Number 0��71 Waiver #- 0 SV 0010 Z TYPE OF WASTEWATER 'DISPOSAL: Private Septic El Holding Tank ❑ ; Community ❑ ; Public Sewer ❑ ' ,:' � • I C� Distance:` Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. Date of Payment Receipt Number 01319 G5 COSA4 050201320 Receipt Number 0��71 Waiver #- 0 SV 0010 Z STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 1 further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 7-5-20 49:-TH 6. DSD SIGNATURE d°...• •,• �••••••°•••°°�� System #1 Approved for 3 bedrooms �• • • ° • """"' ° ° ° ° y� MICHAEL N. ANDERSON System #2 Approved for bedrooms ¢¢ `�,.••° CE 94 9 ° Q,, -o Disapproved �'�fQ �� pROEESS4�: Conditional approval for bedrooms, with the following stipulatio�t�\®d�.� a,�Q`N QTY OF v -0 .zr "iF ER ANDst m ST 'V?,'AT A. i By:t"\ Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory I� Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist Legal Description: MOUNTAIN PARK ESTATES #2 BLK 6 LT 1 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA Al Well log is filed with Onsite (or attached) Date drilled 617182 Total depth 137 ft Cased to 86 ft ❑E Sanitary seal is functioning correctly * Wires are properly protected Casing height (above ground) 16"+ in. Date of flow test for COSA 6/22/20 Static water level at beginning of test 38 ft. Comments B. TANK DATA Age of tank(s) NEW years Tank type/material s.pl,VplasLc Measured operating fluid level in septic tank NEW ❑■ Standpipes/foundation cleanout per record drawing Date of pumping NEW D. ABSORPTION FIELD DATA Which system tested (date installed) 9/28/82 ❑■ ALL standpipes present per record drawing Total measured depth from grade 10.1 ft (max) Measured depth to pipe invert from grade 5.0 ft (min) ❑ N/A — pressurized field ❑■ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced 0 gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 017-432-05 Structure served by this system Well production at time of test 5+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes 0 No Al Coliform bacteria is Negative Nitrate 7.25 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑■ Arsenic less than MRL (ND) Collected by MNA Date of Sample 6/22/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 6/22/20 Results ✓❑Pass For 3 bedrooms Fluid depth prior to test 20 in Water added 500+ gal New depth 26 in Elapsed time 1440 min Final fluid depth 20 in Absorption rate 500+ gpd Any rejuvenation treatment (past 12 months) uk If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' 0✓ Yes Community Sewer Manhole/Cleanout > 100' ❑✓ Yes if No ft ❑✓ Yes if No ft Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No ft Absorption Field on Lot > 100' ❑✓ Yes if No ft Holding Tank > 100' ✓❑ Yes if No ft Neighboring Absorption Fields > 100' ✓0 Yes if No ft Water Main > 10' Animal Containment > 50' ❑✓ Yes if No ft ❑✓ Yes if No ft ❑✓ Yes if No ft Water Service Line > 10' ❑✓ Yes if No Manure/Animal Excreta Storage > 100' —❑✓ If septic tank is under driveway Community Sewer Main > 75' 0 Yes if No ft Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0✓ Yes if No ft Surface Water > 100' ❑✓ Yes if No ft Property Line > 5' ❑✓ Yes if No ft Wells on Adjacent Lots: ✓❑ Absorption Field > 5' ❑✓ Yes if No ft Private Wells > 100' ✓0 Yes if No ft Water Main > 10' ✓Q Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Water Service Line > 10' ❑✓ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑✓ Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No 9* ft Wells on Adjacent Lots: Water Main > 10' ✓❑ Yes if No ft Private Wells > 100' ❑✓ Yes if No ft Water Service Line > 10' ❑✓ Yes if No ft Community Wells > 200' Yes if No ft Surface Water > 100'✓❑ Yes if No ft F. ENGINEER'S COMMENTS * waiver requested G. ENGINEER'S CERTIFICATION / certify that / 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. COSA Checklist yellow sheet .e. . MICHAEL N. ANDERSON; � �•• CE 94 9 •°:°� �` 10pRQFESS10ta�'�'� MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904 On‐Site Water and Wastewater Section Fax: 343‐7997 www.muni.org/onsite Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org Nitrate Advisory Certificate of On‐Site Systems Approval # OSC201320 Subdivision: Mountain Park Estates #2, Block: 6, Lot: 1 A water sample revealed a nitrate concentration of 7.25 milligrams per liter (mg/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Since nitrates are known to slowly increase, we recommend you monitor the water quality. Please see the attached “Nitrate Fact Sheet” for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On‐Site Systems Approval. Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org Nitrate Fact Sheet From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as “blue baby” disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a medi a with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several “wet chemical” methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive “screening test”, and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Municipality of Anchorage P.O. Box 196650 ® 4700 Elmore Road Anchorage, Alaska 99519-6650 ® (907) 343-7904 ® Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Department On -Site Water and Wastewater Section Ao�rnt ,r; 1)cpartment * * * * VARIANCE/WAIVER REVIEW x * * x Waiver#: OSV201042 COSA#:OSC201320. Permit#: PID#: 017-432-05 Legal Description: Mountain Park Estates #2 Block 6 Lot 1 Engineer: Mike N. Anderson Applicant: Ryan Applebury Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the property line has been approved. The approved separation distance is 9.0 feet. See engineer's waiver request for justifications. This waiver approval applies to the existing absorption field only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. ...........................................i..................................1 Waiver is Granted: X Waiver is not Granted: as aQ�6M4 DD Date: Approved b �1UZ.y`� pp Y Name of Reviewer ■ t t f f ■ ■ 11 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 11 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 1 **** VARIANCE/WAIVER .REVIEW **** July 22, 2020 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: One Foot Lot Line Waiver Request Legal: MOUNTAIN PARK ESTATES #2 BLK 6 LT 1 To Whom it may concern: This is a request for a one foot lot waiver request on the above referenced lot. This waiver is for the leach field which is existing and will not impact any of the neighbors or encroach on any wells, septic or open water issues. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 MUNICIPALITY OF ANCHORAGE ' DEPARTMENT OF HEALTH & HUMAN SERVICES_ Division of Environmental Services On-Site Services Section P.O. Box lg6650 Anchorage, Alaska 99519-6650 343-4744 ;' Parcel I.D. # ~/'7 ~/--/- ~>'Z '~).~ 1. GENERAL INFORMATION 'Complete legal description CERTIFICATE Of HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING . :.- ~, :~.::~; ., ..::; ~.;, :i:~ -;,:- Lot 1.;' Bloe~'~'~"?~ou~n:'P~[Est~es Location (site address or directions) Property owner "Kay Landino Mailing address 12600 Lupine 12600 Lupine Road Anchorage, AK Road Anchorage, Day phone 694-9035 (w) 345-3059 AK 99516 Lending agency Mailing address Agent Brenda Geisler/ DON MCKENZIE REAL ESTATE Address-"'-' 13135 Old Glenn Hwy. Ea~le Riv~r~ Day phone Day phone 694-9035 AK 99577 .... Unless otherwise requested, HAA will be hel~for pickup. 2. NUMBER OF BEDROOMS: 3 3. .TYPE OF WATER SUPPLY: -', . Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. ' . ~"~,; '_-' ,~ I:)/2 ~ - ~ ' NOTE: If communi~ wastewate~system, provide wri~en confirmation from State ADEC .... 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 Shat 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 ~ & ~ ENGINEERING Phone 17034 Eagle River Loop Road No. 204 Address ~__,_,.: .... A,..u...~7~ .- Engineer's signature ~~/'~ .~.,~,-'" Oate . ~/~z'/q'~/ DHHS SIGNATURE Approved for 3 Disapproved. Conditional approval for bedrooms. Note: The well for bedrooms, with the following stipulations: this property meets existing State and Municipal Codes. There suggested that a periodic testinq continued suitability. Nitrate concentration is 6,3 mg/1. maximum ~n~n~r~i~n /--% Additional Comments are nitrates present. It is be performed to insure the wells EPA Date %.,T, he Mtbnicij~ality o,f'A~'~l'i0rage Department of Health and Human Services (DHHS) issues Health Authority Approval, .-" Cbrtific~,..,~' based, only upon the representabons' g~ven' in paragraph 5 above by an independent 'pro~es~onal engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes ,~, },.,~! . . ,, . ..... and their, lending [nst[tuttons 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.. 72-02~(Rev. 1/91} Back MOA#21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~.6T ./ /~/_oCK ~2 ~77~¢E-5 5/z, ¢¢~- Parcel I.D. A. Well Data Well type '~ lU~r f-~ Log present(~) ~'~ Total depth {.?~ r Sanitary sea Y~q) YE-~ If A, B, or C, attach ADEC letter. ADEC water system number fU/'~ Date completed ~/Q /~._ Driller F6~-~ ~(r..~/AJ L Cased to ~Kot "Casing height / ~ Wires properly protected(~N) ~_~ Date of test Static water level Well flow Pump level1 FROM WELL LOG g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/~ tank on lot Absorption field on lot Public sewer main 7-~'-'~ Sewer service line AT ,.SPECT O. im ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Z WATER SAMPLE RESULTS: Coliform gate of sample: ~/~/ Nitrate Collected by: Other bacteria B. SEPTIC/I-E)EBiNG TANK DATA Date installed Cleanouts ~1) High water alarm (Y(~ ~0 Date of pumping Tanksize /000 (~C_ *"~' Compartments Foundation cleanout~N) ?~'~ Depression (Y~_)~ Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/H~L-[85...,'G TANK TO: Well(s) on lot /OO/'-/~ On adjacent lots (/ To property line /cO f-'~ Absorption field -~- Surface water/drainage (~ 03 rJ~ Foundation Water main/service line /© 72-026 (a/e3)* Front /~T~'~/~E Oi~ f~-E-.J'¢-//.-)G. DI?'(Cf /~5 /~"-,u /"EE/"~.._~Td~ CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N~ SEPARATION DIS~-A~E FROM LIFT STATION TO: WeJJ.enl~ot On adjacent lets D, ABSORPTION FIELD DATA Date installed 7/2. r f ~ ~-- Length '~- 8' /'~ Width ~'~ '- Total absorption area ~6 Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Manufacturer ~ Manhole~ "Pump on" level at ~ "Pump off" Level at ~Cycles tested Surface water Soil rating (GPD/Ft2) (~- ~"'/~4 System type Gravel thickness .~" ~'~- Total depth ~' / ~" Cleanout present Y~) c//~T.~ Depression over field (/~ After test / (_,¢ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /~ To building foundation /(~ ~'~'~ On adjacent lots ~ © ~'~ Surface water / Curtain drain On adjacent lots /' d-~O/'¢- Property line 'To existing or abandoned system on lot Cutbank ~-~-) ~'¢~ Water main/service line Driveway, parking/vehicle storage area ~"~/7~ E. ENGINEER'S CERTIFICATION -/.~/.~.¢~.(~ Z~,~/~'-~E,~ ~/2-C~ .z.~d..o/.J G ,k..~,"L"J-P/ /'¢"'C'v. cG'~F'( I certify that I have checked, verified, or conformed to afl MOA and HAA guidelines in effect on the date of this inspection. Signature ~;~/~-~"'"~ Engineer's Name Date HAAFee$ v~¢(~ ' ~ Date of Payment Receipt Number 72~026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number Rick Mystrom, Mayor Municipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 January 17, 1995 Theodore R. and Joanne M. Gschwind Revocable Family Trust 5800 Holden Dr. Anchorage, AK 99516-3112 Dear Mr. and Mrs. Gschwind: During the fail of 1994, the On-Site Services Section of the Department of Health and Human Services conducted a review of on-site septic systems involved in the legal proceedings concerning Chuck Landers. Your property, Lot 1, Block 6, Mountain Park Estates Subdivision was involved in this review process. . Following site visits and submittal of additional required information by the engineer on this project, Mr. Henry Wilson, P.E., your system was determined to be in compliance with applicable municipal codes. One of the additional submittals required for your system was a Certificate of Health Authority Approval for a Single Family Dwelling. I have included the original of this certificate and an additional copy for your files. The original blue copy of the certificate should be delivered to the lending institution which processes the mortgage on this property, for the existing original in their possession includes an invalid signature. All remaining paperwork (permit designs and/or as-built inspection reports) concerning your on-site septic system has been updated and is on file at the Department of Health and Human Services. Should you desire, you may obtain a copy of this paperwork for your files. If you have any further questions regarding this matter, please contact me at 343-4744. .S..~erely, James Cross, P.E. Program Manager On-Site Water Quality HENRY WILSON 9601 BUDDY WERNER DR.: ANCHORAGE, AK 99516 (907) 346-2000 Constructing Engineers Engineers, Surveyors CHARLES A. lANDERS HC83 BOX 192-A, MYRTLE DR. EAGLE RIVER, AK 99577 (907) 694-9098 July ~, 1994 Muncipality of Anchorage DHHS, On-Site Services Po Box 196650 Anchorage, AK, 99519 re: Lot 1 Block 6 Mountain Park Estates Sub Health authority approval checklist & certificate Gentlemen: Please substitute the attached original signed reports for the reports originally submitted and processed, and remove the file copies and send to me at the above address. Henry H. Wilson, P.E. MUNICIPALITY Of ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska g9519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) 17-(ooo L,~,h~ Property owner Mailing address Lending agency Mailing address Agent Address Day phone Day phone Day phone Unless otherWise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well 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 NOTE: Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1191 ) Front MOA ~21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/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 ~-_~,~-~ F_.~,~ ~ Phone Address EngineeFs signature '~/~ ~'-' DHHS SIGNATURE ?, ~,?Z ~"'/Approved for _~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date 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 p?ofessional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data 0 1 q a-'-'5"z, e5 Well type ~¢, ivR~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) O~ ~t.P. ~> Date completed 6-``-0% Driller Total depth Sanitary seal (Y/N) ¥ Wires properly protected (Y/N) "/ FROM WELL LOG AT INSPECTION Date of test Static water level Well flow 4. <~ g.p.m, g.p.m. Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank -+-, oo' WATER SAMPLE RESULTS: Coliform (~ Date of sample: Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed 9- z~8~ 8'z- Cleanouts (Y/N) "/ High water alarm (Y/N) Date of pumping Tank size ~ooo ~- Compartments Foundation cleanout (Y/N) "/ Depression (Y/N) hJ ~ Alarm tested (Y/N) ~ I w 7_<;-~ Pumper N~o-~-o -~o~-~--~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot +, ~o' On adjacent lots To property line + ~ ~' Absorption field do:)' Water main/service line Sudace water/drainage -+~oo' 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) /~ ~ SEPARATION DISTANCE F~: Well on lot J On adjacer~ lots D. ABSORPTION FIELD DATA Date installed Length 7_~' Total absorption area Date of adequacy test Width Manufacturer Manhole/Access (Y/N) "Pu~l at Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/Ft2) $' Gravel thickness Cleanout present (Y/N) Results (pass/fail) Sudace water System type .~ karl o~ Total depth Depression over field (Y/N) for -% Bedrooms After test If yes, give date ~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots ~-~o' Sudace water Curtain drain On adjacent lots -+ icc' Properly line q-~ 5" To existing or abandoned system on lot rd ~ Cutbank -~, co' Water main/service line .. ~c~.y Driveway, parking/vehicle storage area ~ o<3' E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA Signature Engineer's Name Date HAA Fee $ I"~-o ~ Date of Payment 7_~z.~:-3-L Receipt Number ~-'5~-~ ~;~.)~ Waiver Fee $. Date of Payment Receipt Number 72-026 (3/93)' Back 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. # O I ~" ,¢:~ ~'_~ O~" 1. GENERAL INFORMATION Complete legal description Location (site address or directions) 17-,GOO Property owner. Mailing address Lending 'agency Mailing address Day phone ~- ~Z~ Day phone Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well ~( Community well NOTE: Public water 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 NOTE: Public sewer If,community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~25 (Rev. 1/91) Front 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 Anch. orage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in complian'ce with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~__~r~.~-~Yuc-~-~ ~ i~,,~5z.¢ Phone Address ..D~oOl ¢~,J~_~ ~J'U&~.~.v'~'~i ~'~x¢~ /,~L 9g51¢ Engineer's signature Date DHHS SIGNATURE X Approved for '7-/'~" ~ ) bed roe ms. 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 th is as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for erroi:s or omissions in the professional engineer's work. 72~25 (Rev. 1191) Back MOA/Y21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~o~ / ~/o¢~: (~ /~u~-/~;~Z;~,-I(~:~-~ Parcel I.D. A. WELL DATA ~='/?/~')~/-~' If A, B, or C, attach ADEC letter. ,~z/ ft~ ~,~/p,~ Date completed / :~ ~' Cased to Y Well type Log present (Y/N) Total depth Sanitary seal (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump level ADEC water system number ~ (('^~ Z Driller Casing height Wires properly protected (Y/N) AT INSPECTION ~-0 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot -I- ~O0' 4 I00' Absorption field on lot g.p.m. Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform f5/ Nitrate Date of sample: ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank ..,L ~o01 &tOO' -'~- ~ Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Tank size I OeO; Compartments Foundation cleanout (Y/N) "/ Depression (Y/N) l,J/~ Alarm tested (Y/N) I I-7--~"-~1 Pumper SEPARATION DISTANCES FROM SEPTIC/H~K TO: Well(s) on lot .L ~ OO,/ On adjacent lots To property line _LI~ / Surface water/drainage ~o',' r.~.~ 5o~/j 72-026 (Rev. 7,91)Fron, .,~ ~L|i~,.~ Foundation r-/' Absorption field ~)(f Water main/service line .t ~0' CONTINUED ON BACK PAGE C. LIFT STATION ~ Date installed Manufacturer Size in gallons Manhole~ Vent (Y/N) "Pump on" lev.el ~t k' '~""'"- "Pump off" level at High water alarm level _ /.,,7 v Cycles tested Meets M©A~___ _ SEPA.BA-T1ON DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length "~ Total absorption area Depression over field (Y/N) Width Results (pass/fail) 12A$ $ Peroxide treatment (past 12 months) (Y/N) Soil rating 25 Gravel thickness System type ~' ' Total dept'h Cleanouts present (Y/N) ')/ Date of adequacy test ~' t~''~z for ~ If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain .~ ~oO' On adjacent lots 4- IoO' Property line To existing or abandoned system on lot Cutbank 4-t oO' .Water main/service line -/-I O0 ' Driveway, parMng/vehicle storage area E, ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on. the:¢ate,,of.,this inspection. Engineer's Name Date · ~..,. ,. ,./., HAA Fee $ /~ Date of Payment Receipt Number 72-026 (Rev, 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number 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 .-~UELV'~ [~) tot~ GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lof [ Block H$. P d< Location (aooress or directions) . (b) (c) Applicant Name ~--~f-C_( b. ~'~E~v~C--t/~¢C'Telephone: Home ~d¢~'- ~'~'~._~ Business Applicant Address J Z. CO~) in~tit~Jti~)n' []; Owner/builder (~; ;uyer' []; Other [] (explain); Applicant is (check one): Lending (d) Lending Institution L~\'"f'V ["[Oyl-~' ; Telephone (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA,to the following address: TYPE OF RESIDENCE Single-Family d Multi-Family [] Number of Bedrooms '~ Other WATER SUPPLY Individual Well I~/~Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th.e legality and status. ./ 4. SEWAGE DISPOSAL Onsite [~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (11/84) Page 1 of 2 :h-ess Date 5, . ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health 3royal sh0w~ that the on-site water supply and/or wastewater disposal system is safe, functional and adequate Of bedrooms and type of structure indicated herein. I further verify that based on the information obtained pality of Anchorage files and from my investigation and inspection, the on-site water supply and/or )osal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on Of this inspection. / Firm ~'~t~--.. ~ 1~'$506/,q'1~¢,5 Telephone Engineer's Seal ~:;rm~V:;co n ditio ~n~il.'~A p prova~iSappr°vecr C°nditi°n I(aL) 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. Page 2 of 2 WELL DATA MUNICIPALITY OF ANCHORAGE (MO~i HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: . MUNJCIPALI'fY OF ANCHOP. AGI! DEPT. OF HEALTH & ENVIRONMENTAL. PROTECflON , xu 201 6 Well Classification Well Log Present (Y/N) Y Total Depth J=~'~ Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Y Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line - Cleanout/Manhole Water Sample Collected by If A, B, C, D.E.C. Approved (Y/N) - Date Completed 6,-/t-~- Yield Depth of Grouting - " Pump Set At ~4I~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Y ; On Adjoining Lots ;On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot .... ; Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) y Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line Size _/¢(~ No. of Compartments Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) Date Last Pumped · .--'--- ; for - ' Temporary Holding Tank Permit (Y/N) Y To Water Main/Service Line Course Comments Page 1 of 2 O To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage 72-026(1i/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test ~' ,~:,//~../Yt. Type of System Design Length of Field ,~,~ J"~', Depth of Field ~ ~ Gravel Bed Thickness '~T~~L ~ '~/¢: Standpipes Present (Y/N) ,/~ Date of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation ~- Lot To Water Main/Service Line ---' To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~ ¢~¢y~4/)n~. _./,~_ ~ ,~, To Property Line /,~ ~ To Existing or Abandoned System on ; On Adjoining Lots /~0 '/- To Cutbank (if present) D. LIFT STATION ~i:~~ M a n hD io Irr~ ~ ~ic°ensSs (Y/N) __~'~'"'~ ' "Pump On" Level at ~ "Pump Off" Level at .~ High Water Alarm Level at ~ .... Tested for ~.~...~.~"- Pu~dng Adequacy Test. Meets MOA Electrical Codes (Y/N) ~ ~ Comments .-~~' ~ ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I h. ave checked, verified, or conformed to all MOA and Signed ~4JJ ~ Date Company ,~ ! "~5~¢J¢~/'~ ~ MOANo Receipt No. ~."~ L~. Date of Payment I~ ~.~0 Amount: $ Page 2 of 2 72-026 (11/84) HAA guidelines in effect on the date of this inspection. Engineer's Seal APPLIC - ' IT FILLS OUT UPPER HA[ ' ONLY Propert, y oW>qel;~ ~-~ ~- - Phone Address r/"O C"~'~ ~ ~V'W {X, ZipCodo Lending Institution Phone x./ Phone Realty Co. & A~nt ( ~-. ~-~C~ Address ~ Type of Residence [] Single Family [] Multiple Family No, of Bedrooms [] Other Water Supply {~-dividual (J~,L~Jr /,7~ ~ ~ A3-rACH WELL LOG. A we{I log is required for all wells drilled since June 1975. [] Community For wells drilled prior to that date, give well depth (attach log if available). [] Public Utility Sewer Disposal - ' '~ ~ar Individual Installed: [] Public Utility When Connected to Public Utility: [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Dale Date Dale Inspector Inspector Inspector Inspector Field Notes:.- ~d~ ' ENVI~, .,Jt. gECE! [ ( ~PPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL* DATE y~5~-~ Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received Well to Tank Septic T~k Size 72-023