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Home My WebLink AboutPOLLOCK HOMESTEAD BLK B LT 3Onsite File Pollock Homestead Block B Lot 3 #017-112-45 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP221146 PID Number: 017-112-45 Page 1 of 2 Dwelling: ON Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New X Upgrade Name LUPKES ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench Q Bed ❑ Mound Site Address 15220 POLLOCK DR, ANCH ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 0.5 GPDISF 1.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 0.5 Ft Gravel depth beneath pipe 0.5 Subdivision Block Lot POLLOCK HOMESTEAD BLK B, LT 3 Ft. Fill added above original grade 2 5+, Gravel length Township Range Section Ft. 45 Ft. Gravel width 18'& 21' Ft. Beds: Number of Lines 3.0 Distance between lines 5.0 SEPARATION DISTANCES To Septic Absorption Holding Sewer Lift Station Total absorption area Number of trenches Ft. Dist. between trenches From Tank Field Tank Line 903 Ft2 Ft Well 100'+ 50'+ TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity Surface Water 100'+ Gal. Material Number of compartments Lot Line 10'+ NA Foundation 10'.+ LIFT STATION Manufacturer Capacity Remarks ANCH TANK 250 Gal. Alarm location NE CORNER HOUSE Electrical installed by RISING SON Installer PIPE MATERIAL House to tank Tank to drainfield 3034 MIKE N ANDERSON, P.E. Drainfield 3034 COIMT3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 101.0 ft Inspection n 1,t 8/21/22 2 � 8/22/22 datearo Location and description 41° TOP OF MANHOLE ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp 4 Conditional Approval: Date 49TH ; t' 4t........... . Septic System Approved Date �, MICHAEL N. ANDLRSCN : �� C �r -9 9 s.� • Note: this approval does not include well permit requirements. �� 'P_ r ��' �► 'R 05/42/18 Permit No. OSP221146 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: POLLOCK HOMESTEAD BLK B, LOT 3 PID No.: 017-112-45 MARK / PU\P\BASI 19 127 ( I I\ \ \ I 1 \ / I - MT17 \ 27 23 SEPTIC L MT2 67 160 MT3 69 66 I MT4 129 I40 \ I \I I 11 � \\ PUMP ASIN, BE CH P 0 H / DRIVEWAY \ EXITING TANI,\\ \\ I � \ /I WELL 1 I WELL I I ,il I/ / \\ \\\ ASBUILT I I! \ \\ SC> E: 1" 0' SEPTIC SECTION WATER ® 89 JULY 2022 N.T.S. t OF AV •• 49 LH- MICHAEL H MICHAEL N. ANDERSON: t ®®®®®®•ESS1®®®® MUNICIPALITY OF ANCHORAGE „Cnt On -Site Water & Wastewater Program"'' S�� PO Box 196650 4700 Elmore Road i Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite v 1)01)artIII ent On -Site Wastewater Disposal System Permit Permit Number: OSP221146 Effective Date: 6/1/2022 Work Type: Septic Upgrade Expiration Date: 6/1/2023 Tax Code Number: 01711245000 Site Legal Address: POLLOCK HOMESTEAD BLK B LT 3 G:3137 Site Mailing Address: 15220 POLLOCK DR, Anchorage Owner: LUPKES LINETTE D Lot Size in Sq Ft: 19228 Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 3 This permit is for the construction of: 2 Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ 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 Special Provisions: A portion of the proposed drainfield is outside the 30 ft radius of the percolation test. An additional percolation test shall be provided at time of construction to verify application rate on the east end of the field. If results require a design change, construction shall stop pending approval of a change order. Please submit results with inspection report (or change order, if required). Received By: Date: Issued By: Date: '�� U UW� UH CC 'D\ L0 7Y 0F % HCHOPR �� G E Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 017-112-45 Property owner(s) LINETTE LUPKES Mailing address 14120 SPECKING AVE ANCH AK Site address 15220 POLLOCK DR ANCH AK Day phone Legal description (Sub'd., Block & Lot) POLLOCK HOMESTEAD BLK B LT 3 Legal description (Township, Range & Section) Lot Size 19,228 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (M all that apply) Absorption Field 0 Initial ❑ Single Family (SF) ❑ (w/wo ADU) Septic Tank ❑ Upgrade El Duplex (D) El Holding Tank ❑ Renewal ❑ 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:Sc/.f -t35 7 ��USriWaiver Fees: Date of Payment: /?_2 -i 6 �1 Date of Payment: Receipt Number: Cil 8 31 C5 d 061 y �2(p Receipt Number: Permit No. 0_5P -'?-Z_ I I X16 Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc May 25, 2022 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: New septic field permit, CONDITIONAL & WAIVER Legal: POLLOCK HOMESTEAD BLK B LT 3 To whom it may concern: This is a request for a new septic field permit on the above referenced lot. The tank replacement in 2019 and now the field needs to be replaced. The existing bed is 18 43 and will be replaced in the same location but elevated two feet. The old system lasted a long time but after installing the system on the neighboring lot 4 which had water at 7.5 this new system needs to be raised from the original depth of 5 feet to 3.0 feet for a better design. We are also requesting a waiver for the 18 foot width which exceeds the max 15 foot bed width. With our Cat 312 excavator it has enough reach to not have to track onto the new bed system. The existing slope on the old bed system is less than the max 10 percent allowed. This new system will not impact any of the neighboring lots and has no water within 100 feet or slopes greater than 25percent with 50 feet. 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 OSP221146, Rebecca Carroll, 06/01/22 DESIGN CRITERIA: 3 BDRM X 150 = 450 GPD SOILS = 450/0.5 = 900 SQ FT REQ'D 900/18 = 50' (1) BED 3' DEEP 0.5' EFFECTIVE 18' WIDE )(50' LONG On-site Water and Wastewater REVIEWED FOR CODE CONIPLI b — GRADE OS 21146, Rebecca Carroll, OLIO FFABRIC & ;ILTER NSULATION -3.0' "0 PIPE WER ROCK -5.0' � MOA FILTER MATERIAL 18.0' SEPTIC FIELD SECTION I II II I — — — — — — — — — — — — — \ PROPERTY LINE I I I ��—�� 11 -. ♦ �i I n;.... EXISTING HOUSE t\ I w ij I EXISTING WELL I I t\ I� ► 100' RADIUS U) „ II '° II I I I I� I I M — -RAB ILCRE-EE-K-R13- — I Septic Tank Replacement LINETTE LUPKES �:�' °•`y POLLOCK HOMESTEAD, BLOCK B, LOT 3 ® 49TH Anchorage, Alaska ®.....=. ... ...... ...� 0 0 m................... .... ........ • s o 0�°,MICHAEL N. ANDERSON; Michael / DATE: 5/26/2022 0CE Gni 4601 NATRONA AVE DRAWN: DJR ®®®® NS/25/22g•°® ANCHORAGE, ALASKA 99516 o (907) 727-8864 / FAX: (907) 345-1391 SCALE: 1 "=200' 1"=50' EXISTING HOUSE DRIVEWAY WELL PROPERTY LINE ACCESS DRIVEWAYNEW PUMP BASIN MT 2' CONTOURS TYP SCALE: DJRDRAWN: DATE: POLLOCK HOMESTEAD, BLOCK B, LOT 3 Anchorage, Alaska LINETTE LUPKES 5/26/2022 MT MT MT EXISTING 1000 STEEL TANK NEW 18X50 BED SYSTEM TO REPLACE EXISTING SYSTEM.5-6%SEPTIC WELL WELL WELL WELL10' UTILITY EASEMENTORIGINAL 1983 DAMES & MOORE TH WATER AT 11.5' SEE MOA FILE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221146, Rebecca Carroll, 06/01/22 Municipality of Anchorage__ On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP191152 PID Number.- 017-112-45 Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade Name LUPKES ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 15220 POLLOCK, ANCH AK ❑ 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 POLLOCK HOMESTEAD BLK B, LOT 3 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 Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft2 Ft. Well 100'+1550'+ (44( TANK ® Septic [:1S.T.E.P. [IHolding [IOther I(I Manufacturer Capacity ANCH TANK 1000 Gal. Surface Water 100'+i Material Number of compartments Lot Line 10'+ NA STEEL 2 Foundation LIFT STATION Manufacturer Capacity Remarks NO CONFLICT W1 FOUNDAITON Gal. OUTSIDE SOIL BEARING PRISIM Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 drainfield Tank to 3034 Installer MIKE N ANDERSON, P.E. Drainfield COtMT3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 100 ft Inspection s' 9/25119 Location and description dates:2nd GARAGE SLAB Td 411 ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp ��''";� ,_� Conditional Approval: Date ,d .�: • _J 74 • A f T 1 ^: •, MICHAEL r:, ANLDI Septic System '! j j Approved Date 5 �2� CAI �� P', c> 4 9 y Note: this approval does not include well permit requirements. (Rev 05102118) Permit No. OSP191152 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: LOT 3, BLK B POLLOCK HOMESTEAD S/D PID No.: 017-112-45 i 8' �SBED, (3) CO OP OF 7RAGE S B / Tj 100' V ELL RADI IS \ \\ \ I \ I ® I \\ I II � II I / {I / ABUIT/// SCALE: 1"==/50' AMP C�,.4,• i �� 49 T" SECTION 281 ;.MICHAEL N. ANDERSON. iZ A No. CE 9469 AV •�•••.•5-22-22 �*- ► �,♦,,1 sa =; :•� M4< A B / / 5 2501 t01 25 T 02 1 26 7 r,92 15 C 16 7 / ) \ I \ I \ \ \\ I septic / I \ I \ I CO2 TCO2 i / 02 / \ 01 i / PI II OU E I /I II / I i 8' �SBED, (3) CO OP OF 7RAGE S B / Tj 100' V ELL RADI IS \ \\ \ I \ I ® I \\ I II � II I / {I / ABUIT/// SCALE: 1"==/50' AMP C�,.4,• i �� 49 T" SECTION 281 ;.MICHAEL N. ANDERSON. iZ A No. CE 9469 AV •�•••.•5-22-22 �*- ► �,♦,,1 sa =; :•� N7-7°1 (N77.014 34"W 25 1) W a C� LIJ L0 n 00 0*0 Z CD z LOT 2 BLK B ANCHORAGE RECORDING DISTRICT, ALASKA AS -BUILT OF: POLLOCK HOMESTEAD SUBDIVISION FND 5/8" REBAR LOT 3 BLOCK B MAT 69-76 C\V Ln 01) 25' 4%401 AM WAWW SURVEY CERTIFICATE: 1, John L. Schuller, Have conducted a AM" O.F.Az L A NSQk A - o AOW Z 00, physical survey of this property as shown on this drawing and that the . s : • 1 ",0 improvements situated hereon are within the property lines and no * enchroachments exist other than noted. Under no circumstance should TH ' -' 49 1H- A any information on this drawing be used for construction of fences, .................. ....... C.; Z� _Z structures, improvements, or for establishing boundary lines. ?A Cn 2. % C Fj PA EXCLUSION NOTES: It is the owners responsibility to determine "�'O' RA �N L. SCHULL ?A 0 j ER o the existence of any easements, covenants, or restrictions which _71111 LS -10408 qj do not appear on the recorded subdivision plat. _4 J1. 1831 Talkeetna Street WORK ORDER NUMBER:--- --DATE- SCALE: -AIL I CY Anchorage, Alaska 99508 APR 15, 2022 1 =30' schuller0ok.net %�Ao . . * AW DRAWN BY. CHECKED BY: GRID NUMBER: BOOK AGE: I 1. ,\ AW (907) 227-1455 office 22-025 JLS SW3137 220148 lk�l essiono\ 1 (907) 274-4992 fax MUNICIPALITY OF ANCHORAGE =0n -Site Water &Wastewater Program PO Box 196650 4700 Elmore RoadAnchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite AA, On -Site Wastewater Disposal System Permit Permit Number: OSP191152 Work Type: SepticTank Upgrade Tax Code Number: 01711245000 Site Legal Address: POLLOCK HOMESTEAD BLK B LT 3 G:3137 Site Mailing Address: 15220 POLLOCK DR, Anchorage Owner: LUPKES LINETTE D Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy epartine nt Effective Date: 5/24/2022 Expiration Date: 5/24/2023 Lot Size in Sq Ft: 19228 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: QQ Issued By: Date: r Date: �i D'� t -- --MUNICIPALITY OF ANCHORGE-- - - - --- - Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section �- Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 017-112-45 Property owner(s) LINETTE LUPKES Mailing address 15220 POLLOCK DR ANCH AK Site address SAME Day phone Legal description (Sub'd., Block & Lot) POLLOCK HOMESTEAD BLK B LT 3 Legal description (Township, Range & Section) Lot Size 19,228 Sq. Ft. Number of Bedrooms 3 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. (Sign of property owner or authorized agent) Permit/Rush Fees: 5- Waiver Fees: Date of Payment: 4130119 Date of Payment: Receipt Number: if trim Receipt Number: Permit No. 0SP O S-9 Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc 123 S APPLICATION IS FOR: APPLICATION IS AN: PE`_' ...( DWE ING: (N all that apply)114 Absorption Field p ❑ Initial ❑ Stn le F 1 SF 9 yy� ) X ❑ Septic Tank ❑ Upgrade ❑ (acv/wo? V ti DupleD) �( ❑ �a Holding Tank ❑ Renewal El o0<0wings <9 ulti I �y ElPrivy ElS 7 F /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. (Sign of property owner or authorized agent) Permit/Rush Fees: 5- Waiver Fees: Date of Payment: 4130119 Date of Payment: Receipt Number: if trim Receipt Number: Permit No. 0SP O S-9 Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc April 25, 2019 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: POLLOCK HOMESTEAD BLK B LT 3 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 WV4- Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Septic lank Keplacement LINETTE LUPKES POLLOCK HOMESTEAD, BLOCK B, LO - Anchorage, Alaska is ae' Anderson, RE DATE: 4601 NATRONA AVE DRAWN: ANCHORAGE, ALASKA 99516 (907) 727-8864 / FAX: (907) 345-1391 SCALE: OF ®'t' 49TH `-®®® ■ .. .... .......::.....o s......................................... 0 ♦'• MICHAEL N. ANDERSON: 4/26/2019 No. E 469 �s ®®? m DJR �C hj t�• ®o 0 1"=50' ®®®!®®ESS®®®®o 1 \ \ I POLLOCK HOMESTEAD 1 1 BLOCK B, LOT 4 I � PROPERTY LINE — TIMBERLUX #4 Bcoz , LOT,11A I �% R&R EXISTING 1000 GALLON vv� TANK PER vv� `CO� /' UPC. - ---I---- vli ( TCd CO < ` POLLOCK HOMESTEAD BLOCK A, LOT 3 \ \ EXITING WELL RADIUS HOUSE TO BE STAKED \ 1 \ BY SURVEYOR 11 I P,OLLOCK'HOMESTEAD �`•-. ' I BLOCKB, LOT,3 I y \ `LINE PROPERTY TIMBERLUX#4 BLOCK 1, LOT 10.E i \ i /POLLOCK HOMESTEAD / W BLOCK A, LOT 2 >GpN 1. r\ Y U A \ \ / \\POLLOCKHOMESTEAD \\BLOCK B— I'. \ ,LOT2—� \- I , Septic lank Keplacement LINETTE LUPKES POLLOCK HOMESTEAD, BLOCK B, LO - Anchorage, Alaska is ae' Anderson, RE DATE: 4601 NATRONA AVE DRAWN: ANCHORAGE, ALASKA 99516 (907) 727-8864 / FAX: (907) 345-1391 SCALE: OF ®'t' 49TH `-®®® ■ .. .... .......::.....o s......................................... 0 ♦'• MICHAEL N. ANDERSON: 4/26/2019 No. E 469 �s ®®? m DJR �C hj t�• ®o 0 1"=50' ®®®!®®ESS®®®®o MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OFf WELL INSPECTION REPORT NA~D_aqiel Warnock - Applicant PHONE I KNEW MAILING ADDRESS LEGAL DESCRIPTION LOC~TI'ON . Manufacturer Lit ~cbin gallons IF HOMEMADE: Inside leng,~ /~ Ma~lu~ct~:~ TO: IWell ~ /~ Dwel ng Dwelling Width NO, OF BEDROOMS .~./uM I T NO, No, of c~_.~artments Liquid depth PERMIT NO. DISTANCE TO: No. of lines.~.~;, ,' Well -IZO -- ' ILength:3fe ¥na F°unda~.nO / ~,~, Material ~eares~ I.~ ne Top of tile to finish grade Length Type of crib DISTANCE TO: Class DISTANCE TO: Width Crib diam?~J Well Depth ~ Building fo~rMa~(~n MateriaJ,beneat~ tiJe , Depth Liquid capacity in gallons PERMIT NO. Distance be, tv~een lines Total effectb/e abs~:~6tion ar6a PERMIT NO. Crib depth Total effective absorption area Building foundation Nearest lot line Driller Sewerline Distance to lot line PERMIT NO. Absorption area(s) Septic tank OTHER PIPE MATERIALS SOIL TEST RATING t5 Z INSTALLER REMARKS [APPROVED "(~'%3':.' '% ' ...... ' ,?, : DATE 72-013 (Rev. 3/78) LEGAL MUNICIPALITY OF ANCHORAGE ,~-fc/ /'7-~,mo Department f Health and Environmenta Protection 825 ~ Street, Anchorage, AK. ~39501 264-4720 * * * HANDWRITTEN PERMIT * * * Permi~ ~ ~'~/J-~,T, ~ WELL AND/~ ON-SITE SEWER PERMIT App[Licant: ,[~;/~j,~m Q¥'/%~W~IC ~< Mailing Address: ~O~C ~,~ ~/v/~/~ Location: ~r-3 Y/,.S /~//~ /~m.~ 2~Phone Number: _~'7~- -~9'/~7 Type of Soil Absorption System Is: · Trench: Drainfield: Seepage Bed: V/ Holding Tank: Maximum Number of Bedrooms: _~ Soil Rating (sq. ft/br) /~ z~', . .... DEPTH The Required Size of the Soil Absorption System Is: LENGTH ~ ,. GRAVEL DEPTH __~ WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfa!l pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~00 GALLONS * * Permi~ applicant has the responsibility ~o inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this departmen~ will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fee~ for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 * * I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if t~e~ residence is remodeled to include more th~3 bedro~s. Applicant Date: //~,~ ~ SWP/024 (1/81) ~.m.m~/~C. ZD./~ = .~ ~4~°/~z~ ~' D~*/: ~' Dames & Moore -i 'i-:' :~- :' ': 800 Co~'dova, Suite !01_ Anchoral~e, ^]aska 99501_ (907) :2?9-05?3 Telex: 090-2522? Cable address: DAMEMORE Mr. Robert W. Robinson Municipality of Anchorage 825 L Street Mail Stop 6-650 Anchorage, AK 99502 Dear Mr. Robinson: cc: Ms.Linette Lupkes 3605 Arctic Blvd.,#1810 Anchorage, AK 99503 cc: Ted Hammer/AN cc: 13642-001-1650 December 15, 1983:]_ - _ - :7;--~- - / (--': i "-.,. .../ _.~ '?~ . _,~ t / .-'1 I /l[ I On November 26-27, 1983 we performed a soils investigation and percolation test For Lot 3, Block B, of Pollook Subdivision, off -~-~a~ ...................... Rabbit Creek Road in Anchorage, A s a. Two soils borings were drilled using a 6-inch diameter solid Flight auger on the lot and subsurface conditions were logged at the locations indicated on the attached record sheets. A copy of the Field boring logs are also attached. The First hole was only drilled to 7 Feet since shallow water (at 4.5 Feet) confirmed that this location was unacceptable. The second hole was drilled on the west side of the lot to a depth of 15.5 Feet. The soil profile consisted of approximately 1 foot of organic peat over relatively uniform silty Fine to medium sands to sandy silts with some gravel which extended to the bottom of the borzng. The wa~m~_~Q!e waqoo%~d at ll.5_fee% below the ground surFace.~?~ v - The soil was only m~]s~ above-about 7.5 Feet and wet Lo saturated below that point. Frost penetration was minimal at the time of boring and all soils were Frost Free below about 6 inches. A percolation test was performed at a depth of 36 inches below the qround &, surface near the second test hole. The hole was FillDd with water on November~' ~" 25 and left to pre-soak over night, fhe~h~i~ wa~r~te~[ed From Freezing during the pre-soak period by covering the hole.with boardstock insulation. The next day, a percolation test was performed after a second pre-soak was performed. The results of the test showed a percolation rate of. 7.7 minutes per inch, which indicates relatively Free-draining soils. SubsurFace-.so~ls at the location have an adjusted soil rating of ZB~.~ .-sq~re Feel per bedr~/n. . Based on the Findings of the ~oils log and percola.t-iOn test, an adequate :,'..- septic tank drain Field can be designed on the above ~tioned lot. The drain Field must be located near the percolatio6 test location (within 10 FeeL) as a high water table exists on the east side of the lot near the first Lest hole. Mr. RoberL W. Robinson Municipality of Anchorage December 15, 1983 Page Two Dames & Moore poLable water will be obtained from an onsite well, the well must be at least 100 feet From Lhe drain Field. Other specifications can be obtained From the Municipality of Anehorage, Department of Health and Environmental ProLection. IF you have any questions regarding Lhe contents of this letLer or if we can be of assistance to you in the Future, please conLaet us. Sincerely, DAMES & MOORE lhomas G. Krze~insk~ ~heodore g. Hammer Staff Engineer TGK/TAH/cbm Enclosures xc: Ms. Linette Lupkes Dames & Moore LOCATIC~J OF BORING JO~ NO. I CLIE LOCATION ' ~ BORING NO, ~ ~ START FINISH ~7~ WAT~. L~L ~ / ~d / ' ~ SURFACE COND[TION~ J/ Dames & Moore LO~ATION OF BORING DATUM ELEVATION ILOCATION NO. D RI L LI N~ M ETH OD: '~'~(.'~'*~./~'~ h ;/ ~ '/~/~hI -'~ BORING NO. WATER LEVEL TIME DATE CASING DEPTH SURFACE CONDITIONS= CD 0~) SOILS LOG ,4,~/~ ~-'I MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION [] PERCOLATION TEST 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SLOPE "' SITE PLA"N ' 2 t 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17, 18- 19- 20 - ,/ WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND -- FT COMMENTS ~,~ PERFORMED BY: - ¥-,,¢~¢ /.'.. ,.,:~¢ ~,,.~..~/.' ~r' so~Ls LOG -for MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ~ PERCOLATION TEST 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SLOPE / SITE'PLAN g 10 11 12 13 14 15 16 .17 18 19 2O J WAS GROUND WATER ~y S ENCOUNTERED? r'~ ~ L o P / E IF YES, AT WHAT ~ DEPTH7 // '~ PERFORMED BY: ' -' /'J' 72-oo ~_~l.~) Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE '~ ° '7 (minutes/inch) ~ TESTiRUN BETWEEN FT AND __ FT ...?~,~,~,,-:~,.~z -- ~.~ /~,-~_ 4~./-/-.~,.,,f-~;.-,,.~,.I ~ · :" ,:',,--,,..'~'":" ~ ~/-7.-F7 ;~:~ J~';" [] SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERCOLATION /. TEST ~"C .ERFORMEO FOR: /~ = /~. Z~/~,~_~¢ DATE FERFORMED: LEGAL DESCRIPTION: /~/ S/~/oc~ ' ' ' ' "' / / / SLOP6 SITE PLAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16- 17- 18- 19- 20- COMMENTS PERFORMED BY: 72-008 (6/79) t , / ~, / ~¢'~ WAS WATER ~(~ [~t~ GROUND /- ENCOUNTERED? DEPTH? S Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE (minutes/inch) RUN BETWEEN FT AND ---- FT t. o 0o LLJ MUNICIPALITY OF ANCHORAGE Development Services Department `, 1' Phone: 907-343-7904 On -Site Water & Wastewater Section - Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel 1. D. 017-112-45 1. GENERAL INFORMATION Expiration Date: G - 2 -)-- Complete legal description POLLOCK HOMESTEAD BLK B, LOT 3 Location (site address) 15220 POLLOCK DR, ANCH. AK Current property owner(s) LUPKES Dav phone Mailing address 14120 SPECKING AVE. ANCH. AK Real estate agent 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septic E Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $25- Q -t- Z q O Waiver Fee $ Date of Payment (3/1'g/ 2 Z Date of Payment Receipt Number 0 0�3Receipt Number COSA # (1) SC_ ZZ (q 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. t 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 9-15-22 6. DSD SIGNATURE System #1 Approved for 3 System #2 Approved for Disapproved Conditional approval for r- A Li F.. bedrooms �. '°' ""°a•••°^r -i:.HAEI. N. ..-:JtR bedrooms - �E bedrooms, with the following stipulationn°�"4�� r BY Original Certificate Date: 121 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Legal Description: POLLOCK HOMESTEAD BLK B, LOT 3 If more than 1 septic system on lot: COSA Checklist # A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 8110/85 Total depth 125 ft Cased to 58 ft No Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 12 in. Date of flow test for COSA 5/15/22 Static water level at beginning of test 48 ft. Comments B. TAN Age of tank(s) 3 years Tank type/material SEMUSTEE Measured operating fluid level in septic tank 48 On Standpipes/foundation cleanout per record drawing Date of pumping ( ` I q ` Z D. ABSORPTION FIELD DATA new system Which system tested (date installed) 7/22/22 ❑ ALL standpipes present per record drawing Total measured depth from grade 3.5 ft (max) Measured depth to pipe invert from grade ft (min) ❑ NIA — 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: 017-112-45 of Structure served by this system Well production at time of test 3.3+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 5/25/22 LIFT -STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date NEW Results [D Pass For 3 bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) 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' Q✓ Yes Community Sewer Manhole/Cleanout > 100' [j✓ Yes if No ft M Yes if No ft Neighboring Tank > 100' Q✓ Yes if No ft Private Sewer/Septic Line > 25'[Zl Yes if No ft Absorption Field on Lot > 100' FV -1 Yes if No ft Holding Tank > 100' ✓M. Yes if No ft Neighboring Absorption Fields > 100' 0✓ Yes if No ft Water Main > 10' Animal Containment > 50' M Yes if No ft El Yes if No ft M✓ Yes if No ft Water Service Line > 10' Q Yes if No Manure/Animal Excreta Storage > 100' If septic tank is under driveway comment below Community Sewer Main > 75' Q Yes if No ft M Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Q✓ Yes if No ft Surface Water > 100' n✓ Yes if No ft Property Line > 5' El Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 0 Yes if No ft Private Wells > 100' 0✓ Yes if No ft Water Main > 10' ® Yes if No ft Community Wells > 200' M✓ Yes if No ft Water Service Line > 10' Q 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' Q Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No ft Wells on Adjacent Lots.- ots:Water WaterMain > 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 G. ENGINEER'S CERTIFICATION l certify that t 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 At�d�� _ .bpi+' • '' • •t. �� s'� >fr , 49TH f s �� MICHAEL N. ANDERSCNs; j P' I LOT 4 ' BLK B / r 03 34 25 "W 144.88) 44.88' / R) ® SEPTIC O VENT (typ)01 N W r O > O r— y N tCi Ln I ® N 11 MH N to GRAVEL a/W to - Z8' 2� � O ' z ( �' > f LOT 3 G`J'� ° °� BLK B N v O S� 2'x7.5' BW CANT d .— 0' IO 0 a z0 z o; WELL S89"58'25"W 137.91' (138.00' R) 25' 25' BASIS OF BEARING i LOT 2 BLK B r ANCHORAGE RECORDING DISTRICT, ALASKA AS -BUILT OF: POLLOCK HOMESTEAD SUBDIVISION LOT 3 BLOCK B PLAT 69-76 SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance shoul< any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. WORK ORDER NUMBER: DA7E: SCALE E—MAIL AUG 11, 2022 1"=30' schullerOoknet 22-025-2 DRANK BY: CHECKED BY GRID NUMBEi� 800lC Atrc: JLS SW3137 220307 fi�'•.OF AL'k%-� 49TH * 6 .................. .... . ... .... ..... ...... i. .30IIN L. SCHULLER,- o s %� LS -10408 �1� fessionot 1-0 t,. 10 LSUR v AN4 ^C L. �n 1831 Talkeetna Street Anchorage, Alaska 99508 (907) 227-1455 office (907) 274-4992 fax (' am a( out , en a4G/ MUNICIPALITY OF ANCHORAGE Development Services Department \ Phone: 907-343-7904 On -Site Water & Wastewater Section Fax.- 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 017-112-45 1. GENERAL INFORMATION Complete legal description Location (site address) Expiration Date: 9 — 1 2--2 POLLOCK HOMESTEAD BLK B LT 3 15220 POLLOCK DR, ANCH. AK Current property owner(s) LUPKES Mailing address Real estate agent Day phone 14120 SPECKING AVE, ANCH. AK 2. TYPE OF DWELLING: Fx] Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well FxJ Private Septic F-1 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ �550 4 $2 O Gond Date of Payment fz9A? Z Receipt Number DI 13,315 COSA # n5C ZZ I Z l9 Date: Waiver Fee $ _ Date of Payment Receipt Number Waiver # Distance: 5. STA EMENT OF INSPECTION BY ENGINEER As ce ified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on pr cedures 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 instaliation. 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 5-18-22 6. DSD SIGNATURE System #1 Approved for bedrooms . •' • ° • • •• Y pP . MICHAEL N. ANL— iSystem #2 Approved for bedrooms �+ •• C - 9 � g9 < Disapproved 1 �u : • • :�• • • �'�;• :w y Conditional approval for 3 bedrooms, with the following stipulations"`�'ti�`" B� By: Original Certificate Date:(,,, `7 — 2 ? 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 Weli Flow Advisory Other COSA Checklist blue sheet Legal Description: POLLOCK HOMESTEAD BLK B LT 3 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 8/1ors5 Total depth 125 ft Cased to 58 ft On Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 12 in. Date of flow test for COSA 5115122 Static water level at beginning of test 48 ft. Comments B. TANK DATA Age of tank(s) 3 years Tank type/material "f"' Measured operating fluid level in septic tank 48" ❑ Standpipes/foundation cleanout per record drawing Date of pumping NEW TANK IN 2019 D. ABSORPTION FIELD DATA CONDITIONAL Which system tested (date installed) ❑ ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade 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: 017-112-45 Structure served by this system Well production at time of test 3.3+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 5125/22 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date Results ❑ Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) 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' ❑✓ Yes Community Sewer Manhole/Cleanout > 100' Q Yes if No ft CE 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' Q Yes if No ft Water Main > 10'✓Q Animal Containment > 50' Yes if No ft M Yes if No ft Yes if No ft Water Service Line > 10' ✓M Yes if No Manure/Animal Excreta Storage > 100' If septic tank is under driveway comment below Community Sewer Main > 75' (�✓ Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑✓ Yes if No ft Surface Water? 100' Yes if No ft Property Line > 5' Yes Yes if No ft Wells on Adjacent Lots: Q Absorption Field > 5' if No Yes if No ft Private Wells > 100' Q Yes if No ft Water Main > 10'✓Q ft Yes if No ft Community Wells > 200'[]✓ Yes if No ft Water Service Line > 10' ✓M Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' 21 Yes if No ft If absorption field is under driveway comment below Property Line > 10' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10' Q Yes if No ft Private Wells > 100' El Yes if No ft Water Service Line > 10' Q Yes if No ft Community Wells > 200' IZI Yes if No ft Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS CONDITIONAL APPROVAL FOR NEW FIELD. WAIVER FOR 18' BED WIDTH G. ENGINEER'S CERTIFICATION 1 certify that t 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. MI.a lege A\DLRSC,N �= t CE-94 9`.�.� r � tib. }. '�►, COSA Checklist yellow sheet Parcel I.D~. 1, GENERALINF.ORMATION Complete legal description MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERV CES '~ :: Division of Environmental Services :~'~. P.O. Box 196650 Anct~orage, Alaska 99519;6650 CERT F CATE OF HEALTH AUTHORITY ' APPROVAL FOR A SINGLE FAMILY DWELLING Location (site addreS~ior_directions) %.. Property owner L¥/,~ ~'TT'E ~A--~.~ocK_ Day phone. Mailing address/~'~ d:;) Lending agency. (;~::/~,,~'~ /'~¢~7~¢~--~ ~/~ Day phone Mailing address Agent . Ad dress. 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: ing to the legality and status of system.. TYPE OF WASTEWATER DISPOSAL:- , Indi~iau~l o~site Holding tank .... ....v Community on-site If community well system, provide written confirmation from State ADEC attest- NOTE: Public sewer If community wastewater system, provide written confirmation from State AD£C attesting to the legality and status of system. 72-025 (Rev. 1/91} Front MOA ~21 :suolTelndp, s I~UIMOIIOJ eqT q3!M 'suJooJpeq JoJ le^o]dde leUO!~!puoo 'suJooJpeq Z' · pe^o~ddes!Q .;, JoJ pe^oJddV ~]I-li'IJ.¥NOlS SHHO~ '9 . ~,:. '4~;' ~,,*, .. :.:, 'uolloedsu! siql ¢o elep eq), uo ~,oejje u! suo!lelnSeJ pue 'seoueu!pJo-: 'sepoo reels pue led!o!unl/~ lie ql!~ eoue!ldLUOO u! s! Lue~sXs lesods!p je),eMelSe~ Jo/pue/~lddns ~m, eM m,!s-uo eql 'uop, oedsu! pue uo!le6Rse^u! ~uJ LUOJ~ pue sel!J e6eJoqou¥ ~o/~l!ledp!unlAI LUO~J peu!m, qo UOp, eLUJO~tU! eq~, uo peseq leq),/~jpe^ JeqlJnJ I 'u!eJeq pe~eo!pu! eJn~onJls jo ed,9, pue scuooJpeq jo Jeqcunu eq~, Joe m, enbepe pue leuop, oun¢ 'e~es s! Lue~s/~S lesods!p JeleMe3SeM Jo/pue ~lddns Jm, eM e),!s-uo eq~, ~,eql s~oqs uo!~eo!ldde le^oJdd¥ ~Tpoqlnv q~,leeH s!q~ jo uo!le6p, se^u! /~LU ~,eq), Xjpe^ I '~oleq u~oqs elep uol3eP!le^ eq~ ,to se pue oleJeq pex!jJe lees ~cu/~q peu!peo sv ~::I:INIgNg Ag NOIIOgdSNI dO .LNgl61'qlV.L$ 'g Legal Description: Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST ENVGNIAI. SLI,WR.,L,~ 01VISION L - 1991 Parcel I.D. I\I_L L I V LIJ A. WELL DATA Well type ~¢_.~NIA.'T'~ If A, B, or C, attach ADEC letter. ADEC waterf~stem number Log present (Y/N) ~,¢c¢ (~ Date completed 8-10~B~ ~ Driller Totaldepth \~-% ~'T (~) Casedto ~ F'T (~) Casing height 'Z PT CD Sanitary seal (Y/N) %~'~ (~) Wires properly protected (Y/N) ~¢_c¢ (~) FROM WELL LOG Date of test Static water level Well flow ~' (~) Pump level AT INSPECTION g.p.m, g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot _ [O,~ ~' (~) Absorption field on lot Public .sewer main Public sewer s'ervice line ; On adjacent lots ;Onadjacentlots JlO"b ~ h4, J/~ CD Public sewer manhole/cleanout Petroleum tank ,/V~ WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed c~-/'~'- ~t. ~) tC:)C)L~ ~,,~ (~ Tank size Compartments ~-- Cleanouts (Y/N) ~'c~ ~ Foundation cleanout (Y/N) ~% dj) Depression (Y/N) High water alarm (Y/N) hi//~ Alarm tested (Y/N) Date of pumping .~.../~?/~/ //,¢.¢/ /~jt/¢3/-/. u~,<'j/~¢¢// /2!,f/~,/'~///¢ No'CO SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I1:)~¢ :P- (~ Onadjacentlots IILcl ~ (~) Topropertyline ,,~dl~ I ~ CD ~ ~(~i~) ~ Absorption field ~ Surface water/drainage /~/',~ Foundation 72-026 (Rev. 3/91) Front MOA 21 Watermain/serviceline /'4 //& 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) "--- Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot - On adjacent lots Surface water D. ABSORPTION FIELD DATA Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating l~'~. System type Gravel thickness ~ Total depth Cleanouts present (Y/N) ~ S ~ Date of adequacy test for bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: I?"'0'+ ~D' ~'~'rl'l~Q~Propertyline ~ -1- (Z) Wellonlot ~.0~ 1' (~ Onadjacentlots lc, c~~+ T'¢ /,4 I,~ I ~ To building foundation t % ~ ¢r (~) To existing or abandoned system on lot h,t//~ On adjacent lots )(~Q>' + ¢J~ Surface water Curtain drain hA /,/~ Cutbank ¢4/,A. Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in affect on the date of this inspection. Signature ~z..,.~ NAA Fee $ /2(~ Waiver Fee: $ Date of Payment ? - J~ ''~ /' Date of Payment R ecei pt Number ~cL- ~ ~ ? ./_~f-,,~-----'~ R ecei p tNum her 72-026 (Rev. 3/91) Back MOA 21 MUNICIPAUTY OF ANCHORAGE '/'Y~7- DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEAL'rH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property Owner P¢.~1 ~t4e('f~ (.~r,c,c(~ Telephone: Home ~_7) ~'1'~ 7 Business Mailing Address 1~ 8~ ¢of(oct~ ¢ ~o~ ~t~ ~¢~t~ (c) Lending Institution ~ ~S~ F~ ~¢tdi~ ~ocb~ Telephone ~-~¢~ Mailing Address. ~OOO ~'~ Mn~o~ p¢~¢~ / ~o~ ~/ ~ (d) Real Estate Company and Agent ~ ~. Address Telephone (e) Mail the HAA to the followina address: or: Check here {~, if hold for pick up. List contact person and day phone number below. 'Ted ~oore_ 3 %v- /Z~ff' TYPE OF RESIDENCE Single-Family [] Number of Bedrooms WATER SUPPLY Individual Well [] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite [] Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 fRev 8/861 Front ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on ~the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. NameofFirm i~[~'l~ ~'~c/ln~'c~[ ~C~r~¢~Z Telephone ~Y3--/~ Address _ IV~30 ~c~ ~/~ ~C~ ~/~ ¢¢~/~ Date ~g /~ leaf DHHS APPROVAL Approved for 4/4/'~'~"~_/bedrooms by Approved Disapproved Conditional Terms of Conditional Approval CAUTION 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. Page 2 of 2 72 025 fRev 8J86) Back MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) MuNICiPALd'f (Ji~ ANCHOiRAGF- CHECKLIST - FEBRUARY 1984 · · ~tV~SION 264-4744 ~.N,./i ~,O Nl¢,.c N.f AL J U N 1 8 i987 Well Classification i Well Log Present (Y/N) Total Depth [~ Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot Legal Description: Pc~[(ocl~ /-/~/~e.cf-~ ~/~ If A, B, C, D.E.C. Approved (Y/N) N, A-. Date Completed '~/~{g_.5" Yield ,-¢,¢ ' Depth of Grouting (~.~ Pump Set At ~ ( e(,, ' ~ ¥" Sanitary Seal on Casing (Y/N) Y )' Depression Around Wellhead (Y/N) ; On Adjoining Lots _.--~ ,,o¢,, To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments No n,~ ~c.X I1:~ ; On Adjoining Lots p. To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date 6"/~'8/,¢ 7 B. SEPTIC/HOLDING TANK DATA _Size No. of Compartments ~-, '/' Foundation Cleanout (Y/N) N Date Last Pumped /4,.4., ~ A, ; for Temporary Holding Tank Permit (Y/N) N, ,~.. Date Installed Standpipes (Y/N) ~' Depression over Tank (Y/N) N Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) t,h ,~. Separation Distances from Septic/Holding Tank: To Water-Supply Well /~ .~ ' To Property Line Z-O ' .~ To Water Main/Service Line /4,/). Course .~ leo ' Air-tight Caps (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-O26 IRev 8/86~ Fronl C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~/t8 ~/¢ y Width of Field I,ff' Square Feet of Absorption Area Depression over Field (Y/N) R Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot N, ,4. To Water Main/Service Line /4, ,4. To Stream/Pond/Lake/or Major Drainage Course~ To Driveway, Parking Area, or Vehicle Storage Area Comments -T~ ere ~¢'~' 5'omc LIFT STATION t2 '/B' ~{r~ Type of System Design Length of Field fi3 ¢ Depth of Field ~c7~- Gravel Bed Thickness I~" Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line ;~O t _~ To Existing or Abandoned System on ; On Adjoining Lots '> .7o ' To Cutbank (if present) )V, A-. Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test, Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~J-~ ~ ~ Date Company /=(c~,z¢¢'~' T~c~ ~'c*r~r' MOA No. Receipt No. / O O / ~o O~ Date of Payment ~//~ Amount: $ /.~'~ Page 2 of 2 72 026 tReY 8/86~ Back Engineer's Seal