HomeMy WebLinkAboutPROSPECT HEIGHTS BLK 1 LT 15A%YasPic°i Wetvh�S
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DocuSign Envelope ID: 60966ACA-AFE8-41B1-9BF1-6DOAA8ADFC19
April 21, 2020
Dear Municipality of Anchorage
Following a phone conversation with Deb Wockenfuss, I am writing to request an exemption from the
requirement for a Certificate of On -Site Approval (COSA) for my home septic system & well.
My wife and I currently own the home at 9501 Prospect Drive in Anchorage. We purchased the home in
late 2018, and I understand that a COSA was most recently completed in 2017. Based on the previous
COSA a new tank was installed.
Unfortunately, due to the downturn in the oil industry, and a resulting layoff, we will be forced to
relocate later this year, however we would like to retain our property in Anchorage. We intend to rent
the property when we leave, and I recently established an LLC, called 49th State Investments, LLC, to
protect us, from a liability perspective, when we rent the home. I am the sole Member/ Owner of the
LLC, so the home is not technically "changing hands;" however the title will be transferred from our
names to the name of the LLC, and based on the rules around title transfer, a COSA would be required
for this transaction.
I have attached the Articles of Organization for 491h State Investments, so you can see that it is a
legitimate LLC and that there are no additional Members / Owners.
I really appreciate your consideration of this exemption request. Please reach out with any questions
you might have.
Sincerely,
EsDocuSlgned by:gaaAN D GALLA69q C� GCc.Y`Tr_vv� Vnowtc v���� ( S
1
87157AOD16F54C3...
Sheehan Gallagher L�,., G ,� �_ Cd S
9501 Prospect Drive 41:�— \s SpeC✓7t�C (G �-a lb-��—I C
Anchorage, Alaska 99507
719-838-0962 QO 55 No7� s► h���—
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41 '21-��
Municipality of Anchorage
On-Site Water and Wastewater Program • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: 0SP181408 PID Number: 015-091-06
Dwelling: ❑ Single Family (SF) ❑ Duplex(D) ❑ Multiple (SF and/or D) Project: ❑ New ❑■ Upgrade
Name:
Craig & Cheryl Hodges ABSORPTION FIELD
Address ❑ Deep Trench ❑ Shallow Trench [' Bed ❑ Mound
2124 N Nadina St. Palmer, AK 99645 ❑ Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
Mary Cox (Realtor) 440-9820 3 GPD/SF Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot Ft. Ft.
Fill added above original grade Gravel length
Township Range Section Ft. Ft.
Gravel width Beds: Number of Lines Distance between lines
SEPARATION DISTANCES Ft. Ft.
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' >100' ' N/A N/A >25' TANK L1 Septic ❑ S.T.E.P. ❑ Holding ❑Other
Manufacturer Capacity
Surface Water >100' >100' N/A N/A Anchorage Tank 1250 Gal.
Material Number of compartments
Lot Line >10' >10' N/A N/A Steel 2
NA
Foundation >10' >10' N/A N/A I LIFT STATION
Manufacturer Capacity
Curtain Drain 1None Noted Gal.
Pump on level at Pump off level at High water alarm at
Remarks *Permit was approved for a drain field
upgrade but only the septic tank was installed. in. in. in.
Current drain field is sized for 3 bedrooms. Pump make and model Electrical Inspections performed by
PIPE MATERIAL House to tank D3034Tank to D3034
Installer drainfield
A+ Home Services Drainfield D3034 CO/MT D3034
Inspector J. Williams BENCH MARK (Assumed elevation) 100 ft
Inspection 151 3/19/19Location and description
dates: 2"
3'd 4th Bottom of siding @ point A
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp
Conditional Approval: Date
41,,,,, .........'- F••447 4*
(91AV -k--GLvtiL. t vaL lir 1h44. : 49th /\ = 10
IIJ • 'fi .... _ .... .�
P-Q VIM tf C I OS epi � 1--L-c e. i
0 cn: MICHAEL E. ANDERSON =
0 CI,
LiT No. CE-4381 �•'���'=
a ��f;p•'•. 5124119 < a
Approve. —1 19 F ..... ir
Date !�1 4��a��S�+�44
Inspection Report_9-1-12.doc
PROSPECT HEIGHTS B1 L15A
PERMIT # OSP181408 PID # 015-091-06
0
O N(n cn N
— — f— 82.8 — — —
2" INSULATION
79.6 J
___fir
'''''— 78.4
79.0 2 1250 GAL 78.8
SEPTIC TANK
J
74.8
.issiasari k,
ri 1
a r 49th i\ =*$
cr••MICHAEL•E•'ANDERSON l�:
saw PROFILE AS-BUILT .''•TF% N . CE-98: ` '•_�=
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GE •,.Fa �... .,.N.. �..
.Ma , ...,Ma (NO SCALE) ♦ ,\.,4•
,�iIlliiswas 44
PROSPECT HEIGHTS, BLOCK 1 , LOT 15A
PERMIT # OSP181408 PID # 015-091-06
TH-a•
`` PROPOSED 30'LONG X 5'WIDE x 0.5'
lZ�v TH3 EFFECTIVE DEPTH ABSORPTION TRENCH.
O (PERMITTED BUT NOT INSTALLED)
NEW 1250-GAL SEPTIC TANK•
1.5.7's
•i"'7 .. eco
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TH#4 jr..1. • sU2�
4/.. •' .••.•.• .••• • •
Q
TH : LOT 16A
I
/ •
•
TH#2
•
•
0 /.
Q \FOG ALTERNATE SITE-CAT' ORY III SYSTEM
w/20'LONG x 5'WIDE x .5 ECTIVE DEPTH
/ 04 ABSORPTION TRENCH.0APFF ATE 6 GPD SF. //
/ ' <R....4\ /
/ EXISTING WELL ..9) /
/
/
100'WELL RADII LOT 15A /� /
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/// . .1.1-i/
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/ /
ADJACENT WELL
erg // / 44.
/
// // OCt
LOT 14 / / Q
// / CO
/ /
/ /
/ LOT11 /
/
// //
1111ORGE NGINWING
.•••t•OF q/%ill A B LEGEND
-.P '•"""'•"• �`�.• CO-CLEANOUT
c-3, ���� SV1 89.4 81.1
�1 ••;• �� PLAN AS-BUILT SV2 93.6 85.9 200-DOUBLECLEANOUT
49th " • 200 96.7 89.2 FCO-FOUNDATION CLEANOUT
71/it i�c2.,Z"'_ •-�i FS-FLOW SPLITTER VALVE
MICHAELE. ANDERSON + MH-MANHOLE
••-, No. CE-43a I._: 0 50 100 MT-MONITORING TUBE
•i'F-..• 5/2419 i MI — = = FEET SV-SEPTIC VENT
�•4181,, `..\Se4� 1"=50' TH-TEST HOLE
MUNICIPALITY OF ANCHORAGE
On-Site Water&Wastewater Program 'S
a�r'y PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 r,
" /` http:/lwww.muni.org/onsite
/ I r'i l
_ 1)cpai tmcnt
4NCMOp"o-
On-Site Wastewater Disposal System Permit
Permit Number: OSP181408 Effective Date: 11/13/2018
Work Type: SepticTank Upgrade Expiration Date: 11/13/2019
Tax Code Number: 01509106000
Site Legal Address: PROSPECT HEIGHTS BLK 1 LT 15A G:2441
Site Mailing Address: 9501 PROSPECT DR, Anchorage
Owner: HODGES CRAIG M & CHERYL L Lot Size in Sq Ft: 60225
Design Engineer: FORGE ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
0 Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 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
b
e. p� bedlavm y Th t✓
Co T,Ac-rea5e 5•te•C �v r y.h r.
fi
rertc�►� wit be. n1Ade, larrr �e- fylw
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Received By: ��h�i__�l) ' 1' ' l Date: 4/1&//9'L,1U l
Issued By: / )(f �� ,rc�-- Date: 1/9,9
kor toIP-
t VIA it
MUNICIPALITY OF ANCHORAGE
Community Development Department _`F Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On-Site Water& Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 015-091-06
Property owner(s) Craig & Cheryl Hodges Day phone
Mailing address 2124 N Nadina St, Palmer, AK 99645
Site address 9501 Prospect Drive
Legal description (Sub'd., Block & Lot) Prospect Heights, Block 1 Lot 15A
Legal description (Township, Range & Section)
Lot Size 60,225 Sq. Ft. Number of Bedrooms �l
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field 07 Initial ❑ Single Family (SF) 0
(w/wo ADU)
Septic Tank [ Upgrade 0
Duplex (D) ❑
Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE I 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: 63j�yD D Waiver Fees:
Date of Payment: /2b? Date of Payment:
Receipt Number: O� 3O D Receipt Number:
Permit No. OS P t 10 p Waiver No.
Permit App_.:-:•:L.,:c:
PO BOX 240773
ANCHORAGE, AK 99524
522-7773
,) ,, • 'V L
677-7766 (FAX;
E N G I N E E R I N G FORGECIVIL.COM
February 8, 2019 OP'Lkil
MOA Development Services, On-Site Water& Wastewater Program j*:•�m� � • *��/
4700 Elmore Rd /
Anchorage,AK 99507 •
' •. Be*•' • hiller '
t�9F6, 4 CE 12592 #W
'.''' 2/8/19
Subject: Prospect Heights Block 1 Lot 15A 1k ,r
1 ``DpRofEssb
Septic System Upgrade \‘\�\�`�
Dear On-Site Services Engineer:
The owner of the subject lot has requested the septic system be upgraded to serve a four-
bedroom home. We are submitting this permit application for the placement of a new septic tank
and sufficient absorption area for a four-bedroom home. The attached site plan identifies the
location of the existing home, well and septic system. The location of the proposed septic tank,
absorption system site and alternate site for a four-bedroom home are also shown. The drainage
pattern in general will not be changed by the construction. No conflicts exist between this
proposed system and any other well or septic system, whether on this lot or adjacent lots.
The ground surface on the lot slopes moderately to the northwest. Drainage arrows are shown on
the site plan showing the grade and direction of flow. Storm water drainage will not impact this
septic system. The new trench will be constructed parallel to the slope as much as possible. Two
flow splitter valves will be placed to insure 1/4 effluent flow to the new trench with the remainder
of the flow directed to the existing absorption bed which has been tested and found to be in good
condition for continued use.
Please refer to the attached test hole logs, and plan and profile sheets for the septic design. If this
design is followed, there will be no adverse impacts to adjacent properties.
Sincerely.
Benjamin Schiller, PE
PROSPECT HEIGHTS, BLOCK 1 , LOT 15A
il5) l'/FECTIVEDEPTH
G X 5'WIDE x.5' / TH-A `\
``(/ \\
2\/ ABSORPTION TRENCH. Svin.,
NQ ,QTH#3DECOMMISSION EXISTING SEPTIC TAMS PER
MOA CODE. INSTALL NEW 1250-GALLONr,N EXISTING 47'x 12' �'`, SEPTIC TANK.INSTALL DOUBLE CLEANOUT\ABSORPTION BED 'TQ BEFORE TANK IF FOUNDATION CLEANOUT
o / CANNOT BE LOCATED.� / — — — _ 0 TH'� �/j/=S�� LOT 16A
57 / S.,
/ N
TI-1#1 Zy�
/ \ eTH#2 \
\
ALTERNATE E-CATEGORY III SYSTEM
4iir
w/20'LONG 5' DE x.5'EFFECTIVE DEPTH
ABSORPTION.IR CH. APP.RATE 6 GPD/SF. /
/ ♦ /
�o /
/ l EXISTING WELL \ / t. . \ /
\' /4
>'S
/\ 100'WELL RADII / \ LOT 15A
N / \ NOTE: /�\- P
�
i / \ PLACE TWO FLOW SPLITTER VALVES TO INSURE J/� /
— — _ -- \ 1/4 FLOW TO NEW ABSORPTION TRENCH. 3/4 /^o 4
\`LOW TO EXISTING ABSORPTION BED. / / Z�
/ Q
/ / / -/
ADJACENT WELL I // O /
/ /
I / / / cy
LOT14 / / / Q
/
/ / / / C
/ / /
/ / /' cP
//
LOT 11 /
\ GE // // //
/
ill /
[HG I1...1 MG -
..����`Y.F A.q••• NOTE: LEGEND
�� `p f.••• ••••.,.4•• NO SURFACE WATER WITHIN 100'OF THE TANK LOCATION CO-CLEANOUT
6?••''� �1—\':• •• ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS 2C0-DOUBLE CLEANOUT
a • «�9th . % PROPERTY ARE SHOWN.NO CONFLICTS WITH WELLS OR SEPTIC FCO-FOUNDATION CLEANOUT
re• f.... i
PROSPECT HEIGHTS, BLOCK 1 , LOT 15A
DESIGN FACTORS: SYSTEM REQUIREMENTS:
150 GPD PEAK FLOW 5' WIDE TRENCH SYSTEM
PERK RATE: <1 1,250-GAL SEPTIC TANK
APPLICATION RATE: 1.0 GPD/SF (FILTER SAND)
150 GPD / 1.0 GPD/SF /5' WIDE/1.0 RED. FACTOR = 30 LF REQUIRED (30 LF SPECIFIED)
BOTTOM OF TRENCH: .5' ABOVE GRADE
FLOW LINE ELEVATION: 1.0'ABOVE GRADE
TOP OF TRENCH: 3.5' ABOVE GRADE
4"TOPSOIL &
REVEGETATE MOUND
2" INSULATION
&GEOTEXTILE FABRIC
2 rp 2C
er_ = =1� 4 PERFORATED PVC
• ,� (HOLES DOWN)
6" .__...::;._._. :_. . . .:. . ,
1-1
.. Ili
— �.11A1�� 6"
1 ��'i 11 11 ■.urs■.�
1' 6"
DRAINFIELD ROCK
REMOVE ORGANIC MATERIAL
5 AND REPLACE WITH MOA
APPROVED SAND.
TYPICAL TRENCH SECTION
(NO SCALE)
� ) GE
ENGINEERING
NOTES: :. 49th %` N'N
, %L'
1. GRADE AREA OVER BED TO DRAIN AWAY
2. PROVIDE 3' OF COVER OVER BED AND 4' OVER SEPTIC TANK, OR 2' WITH 2" ;MICHAEL E. ANDERSON !La/
I�c�•'• NO. CE-4381 ••_�
OF INSULATION �`r�F`•.y 4-12-19 or` '+
3. THAN PREVIOUSLYSOBSERVED, COALL ENGINEEROIMMEDIATELY Y IS HIGHER '•1,, :r,5,\:::.•�
J_
GE
• ENGINEERING
PO BOX 240773
ANCHORAGE,AK 99524
522-7773 677-7766(FAX)
April 9,2019
MOA Development Services Dept, On-Site Water& Wastewater Program
4700 Elmore Rd
Anchorage,AK 99507
Subject: Prospect Heights,Block 1,Lot 15A
Fill Slope Waiver Request
Dear On-Site Services Engineer:
Absorption system sites on Lot 15A, Block 1, Prospect Heights are limited by the presence of
groundwater and bedrock with few areas acceptable for the placement of a system upgrade. The
most suitable area to place the new trench is in close proximity to easements and lot lines. The
total height of the fill for the absorption bed will be approximately 3.5' above existing ground.
The 3:1 side slope will encroach past the lot line. We therefore request a waiver allowing the slope
to be 2:1 on the north and east fill slopes. The slopes will be covered with topsoil and seeded with
grass. Maintenance will be provided until a flourishing stand of grass is achieved. The 2:1 slope
is standard for fill slope requirements in the Municipality. No erosion of the slope is anticipated
once revegetation is complete.
Sincerely, 0 F A �k
1�r
Michael E. Anderson. PE *; 49 TH i' .*r r�
� Michael E.Anderson .
°'E%•r' 4381-E • �
� .
• assns ..•'av�,r
it 4: PROFESS10N0�0.�
130' --- 3
2 1
125' I -
33%
120' ___ . .d I21% Proposed
EXistin• ` Absorption Trench
115'
I
C
110' J
t
a�
a
105' °
a
0 5' 10' 15' 20' 25' 30' 35' 40' 45' 50' 55' 60' 65' 70' 75'
SSSSSSSSS._
PROSPECT HEIGHTS SUBDIVISION � � •• ••' q-,cP " .
LOT 15A, BLOCK 1 49th ' : •
SLOPE ASSESSMENT .d..':
. • MICHAEL E. ANDERSON JkJ:
•. o•.,4-9.19,,.. c7
.op�E ••ACI N..
_, s.4 49th •�' /O
SOILS LOG AND PERCOLATION TEST
GE .
�. r •i
ENGINEERING ... MICHAEL E. ANDERSON ll`fa:
4-9-19
I • No. CE-4381
l'•==
PROSPECT HEIGHTS BI LI5A ��fF'''••• §
LEGAL DESCRIPTION: ���Fa •••.......»»•�'•��'��
PERFORMED FOR: SHEEHAN D & ANGELA M GALLAGHER % ;S;;U':*•
DATE: 3/19/19 PROJECT No.:
T J. WILLIAMS Professional Engineers Stamp:
PARCEL ID#: 015-091-06 TECHNICIAN:
DEPTH TEST HOLE A
(feet)
1' OB SLOPE SITE PLAN
2
3 ••• , GP (SANDY GRAVEL)
4 ..
5 •
• SEE SITE PLAN
• BEDROCK
6
7
8
9
WAS GROUND WATER ENCOUNTERED? NO
10 IF YES C WHAT DEPTH? - S
DEPTH OF WATER AFTER MONITORING: NONE b
11 DATE OF MONITORING: 3/26/19
E
12 DEPTH TO
DATE READING GROSS TIME NET TIME WATER NET DROP
13 (MINUTES) (MINUTES) (INCHES) (INCHES)
14 3/19 TEST HOLE PRESOAKED PRIOR TO TESTING:
15 1 1:30/ 1:31 <30 sec 6" /0" 6"
2 1:35/ 1:36 <30 sec 6"/0" 6"
16
3 1:40/ 1:41 <30 sec 6"/0" 6"
17 4 1:43/ 1:44 <30 sec 6"/0" 6"
18 5 1:44/ 1:45 <30 sec 6"/0" 6"
19 6 1:47/ 1:48 <30 sec 6"/0" 6"
20
PERCOLATION RATE: <1 (MIN/INCH) PERC. HOLE DIA. 6 (INCHES)
TEST RUN BETWEEN: 2 FT. and 3 FT.
COMMENTS:
Municipality of Anchorage Page of 2
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
Permit Number: SW 9/d/!o0 PID Number: .015 -09/- 0(0
Name: C, y�CMEIE/Z
J�ONN
Wastewater System: 0 New ❑ Upgrade
Address:
ZXO/f V/, ///C//, 9 951;1
ABSORPTION FIELD
Phone:
No. of Bedrooms:
3
❑Deep Trench El Shallow Trench Bed ❑ Mound ❑ Other
LEGAL DESCRIPTION
Soil Rating: c,
D'
Total Depth from original grade:
d GPD/Sq. Ft.
Lot: Block: Subdivision:
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
/1514 T HTS
t1a,.5- Ft.
Ft.
Township:
///
Range:
I SW 1
Section:
/3
Fill added above original grade:
Gravel length:
fi.;1 o Ft.
.41 Ft.
WELL: kNew ❑ Upgrade
Gravel depttl:WID-rH
Number of lines:
I
Distance between lines:
/ 1z, Ft.
Z
1^- x'f 6 Ft.
Classification (Private, A,B,C):
Total Depth:
Cased To:
Total absorption area:
Pipe material:
v,2/ i//4 �
Z 9 0 F.
Z 0 Ft
ty 7 SG. Ft.
14,('1'^ 30 3'(
Driller: -
<COiN L/NE7
Date Drilled:
9l
Static Water Level:
9
Installer:
(7MCIC
Date Installed:
09 05' 9I
07 22
Ft.
H
Yield: /v5pump
Setat:
Casing Height Above Ground:
f2
TANK
1 GPM
uNittFt.
- Ft.
SEPARATION DISTANCES
gSeptic El Holding ❑S.T.E.P.
To
Septic
Absorption
Lift
Holding
PubiWPrivate
Manufacturer:
Capacity in gallons:
From
Tank
Field
Station
Tank
Sewer Lines
�.v �.(„�
/ �0
Well/A
/t4
/Z�
N/
IV14
/ %O
Material:
,57 -EE L
Number of Compartments:
Watere
f/00
t/00
11,//4
�/��
t 0C)
LIFT STATION
LotSize
Line
Z y
/0
//�A
in gallons:
Manufacturer: '
Foundation
"Pump on" level at:
off" level at:
High water alarm at:
CurtainPump
^/�4
NIA
A11A
%1JA
1\11A
Mak" Model
Electrical Inspections performed by:
Drain
Remarks:
BENCH MARK
Location and Description:
F L L te-r /
Assumed Elevation:
0010
EN%NEER..'S,S9AL
7.
Inspections performed by: 15M7/i1EEX� Dates: 1st 0
9 D
2nd 0
44,
`
Department of Health and Human Services approval
°<
Reviewed and approved by: Date:
72-013 (1/91) MOA 25
Permlt No. Sw 91 o JGo Page of Z
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: L* ILI s3i�/ ��rr�aeof /��s��`� PID No.: ois- 09i- oG
�`�/ TH3 ,12'x 47' LEACH DED
`1000 GAL. STEEL .
---- `\1� ® /6//P1 \ \ASEPTIC TANK
/ TH4
A`` �Fyc•Y � ``\ tip `\
T 2
\ �a
�e too• ®_ `off _} � � _, .._ . _ . — 3 .-
\In
1 60
I ,
WELL
72-013 A (2/91) MOA 25
\
/
/
/
J
/
I0' UTILITY
® TEST HOLE
b -
• — MONITOR TUBE
o — SEWER CLEANOUT
— WELL
LEACHFIELD
— — — — EASEMENT
1
ENGINEER'S SEAL
OF
i*'49TH *�0
�..���..........�
100.
v--_
., LOUIS A. BUTERA i
CE -6736?=
FO ..... F'�
� � � •OROfESSIONP ���
OCT— 4—SI F 2 I 8 4 S A P 0 1
- 0
sxl!
or AI,ASz►
DEPARTMENT'OF %;ATt1VAL RESOURCES
DIVISION OF GEOLOGICAL AND GEOPHYSICAL SORVEYS
WATER WELL RECORD
LOCATION OF WELL
BOROUGH SUODIVISION LOT I BLOCK SECTION MRS TOWNSHIP RANG& MERIDIAN
PABod i1-1 N rlE
DZRECTION5:
WELL OWNER:
�.
Regis red Business N m
Signature oe Auth6ri,zedrfiepresentative
S .
Date
PLEASE x AxL .WHITE COPY OF LOG WITHIN 45
DAYS TO:
DGGS
'Pp BOX 77-2116
EAGLE RIVER; AK. .99577
WELL DEPTH:
Depth of hole: P-2f
Depth aP casing: � ft
DATE OP COMPLETION;
MEASURING POINT: Cop of casing round surface other:_
dg
BOREHOLE DATA: Depth
STATIC WATER LEVEL: "6-;j ft. Date -2 -1 -al -4/
Material type and color
from
To
METHOD OF DRILLING: air rotary
[]Cable tool Bother.,.---
^
.r -^
0
2,
USEOF WELL: "4omestic irrigation ❑ monitor
public supply Ejother :�
R
CASING: Stick-up i ft. Dzam:--i _in
1A
IAp
WELL INTAKE: open end Q screened
0 perforated ❑open hole
Depths of openings: to £t ji
SCREEN TYPE: Diam; in
Slot/Mesh Size: Length �- _ft
Set Between and ft
RECEIVED
GRAVEL PACK TYPE:_-
Volume used; Depth to top:
rC 1 J 19 J1
Municipalky of AnchoraCa
GROUT TYPE; Volume :__ _•
Depth: from ft to ft
DEVELOPMENT METHOD:,_
REMWS:
CONTRACTOR IN£'MTZON:
Illi lr
PUMPING LEVEL AND YIELD:
low after hrs puMping gpm
PUMP INTAKE DEPTH: ft H*Xrsepowor:
Date Pump Installed -
WATER CHEMISTRY IAMPLE TAKEN?, { yen no
w .. �'-••-
Wall. disi_,nfected:upon completion? uvea no
�.
Regis red Business N m
Signature oe Auth6ri,zedrfiepresentative
S .
Date
PLEASE x AxL .WHITE COPY OF LOG WITHIN 45
DAYS TO:
DGGS
'Pp BOX 77-2116
EAGLE RIVER; AK. .99577
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE i® L)b
DEPARTMENT OF HEALTH AND HUMAN SERVICES 9-1sn-ci 1
P.O. BOX 196650, 825 "L" STREET, ROOM 502 2. LS.
ANCHORAGE, ALASKA 99519-6650 T�
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW910160 DATE ISSUED: 6/18/91
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES EXPIRATION DATE: 6/18/9-2-
OWNER NAME:HAGMEIER JOHN C &
OWNER ADDRESS:2204 CLEVELAND #201
ANCHORAGE, AK 99517
PARCEL ID:01509106
LEGAL DESCRIPTION: PROSPECT HEIGHTS BLK 1 LT 15A?
SEC 13, T12N, R3W, SM
LOT SIZE: 60225 (SQ. FT.)
NUMBER OF BEDROOMS: 4,��THIS PERMIT:
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD / WELL SYSTEM
ALL CONSTRUCTION MUST 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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED
ISSUED BY:
BY • DATE:
DATE:
Louis Butera, P.E.
Registered Civil Engineer
June 12, 1991
John Smith, P.E.
Manager, On -Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Lot 15A, Block 1, Prospect Heights
Dear Mr. Smith,
The proposed septic upgrade will have very limited impact on adjacent properties for the
following reasons:
1. The area has large lots allowing sufficient room for septic sites.
2. Immediate neighboring lots have septic systems or wells in place with no
conflict.
3. Reserve space is adequate, due to pre -planning of lot layout.
4. Drainage will not be effected by septic system installation.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
PO Rnv 7729QA . R,, I. P;—, AL, 1. 00077 - --- MA" cne ", I 1�1., 11
o
�d
OS �/
TH3
1 T
gF \\
100, T H 20
1000 G. TANK
22
QC
`S
0
Z'
WEST END OF
EXISTING SEPTIC
SYSTEM
1
I �
WELL
PROSED 1'
—_---F,— — PROPOSED AC j h
\ i --IIRIVEWAY �J
I\ i S
�9 \\ < l\�
Al
oh
Icy EXISTING I '� p,L
WELL I ''
i
i
NO KNOWN CURTAIN DRAINS
SEPTIC SITE
LEGAL: LOT 15A, BLK 1
OWNER: JOHN HAGMEIER
CONTRACTOR: HAGMEIER
i
,
,
,
,
,
,
,
PLAN
PROSPECT HEIGHTS
JOB # 91-066 DATE: 06/12/911 SCALE 1" = 60'
EAGLE RIVER ENGINEERING SERVICES
P.O. Box 773294
EAGLE RIVER, AK 99577
(907) 694-5195 FAX.- (907) 694-3297
10' UTILITY
EASEMENT
TEST HOLE
MONITOR TUBE
SEWER CLEANOUT
WELL
PROPOSED LEACHFIELD
EASEMENT
i
i
JOB # 91-066 DATE: 06/12/911 SCALE 1" = 60'
EAGLE RIVER ENGINEERING SERVICES
P.O. Box 773294
EAGLE RIVER, AK 99577
(907) 694-5195 FAX.- (907) 694-3297
10' UTILITY
EASEMENT
TEST HOLE
MONITOR TUBE
SEWER CLEANOUT
WELL
PROPOSED LEACHFIELD
EASEMENT
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL: LOT 15A BLOCK 1, PROSPECT HEIGHTS
A. GENERAL
1. The well and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of Health
and State Department of Environmental Conservation requirements.
4. All soil tests are advisory to the design and are to be verified or modified in the
field by the engineer.
5. All excavations and depths are advisory and are to be verified or modified in the
field by the contractor to meet Municipality of Anchorage, Department of
Environmental Conservation requirements.
6. It is the responsibility of the owner to obtain all necessary permits or easements.
7. The excavation is to be exactly in the area shown on the site plan, any deviation
requires engineer approval.
8. It is always recommended that a surveyor locate the nearest lot line position and
the location of any easements.
1. The bed is to follow the natural land contour to maintain uniform total depth of
the bed bottom.
2. The bottom of the bed shall be level, plus or minus 1.5".
3. The total depth of the bed excavation is not to exceed 0' at any point.
4. Cleanouts are to placed as shown on site plan. Effluent line to be insulated 2".
5. The bed gravel is to be covered with typar fabric material.
6. Soil or combination of soil and extruded board insulation to a depth of 4' or
equivalent is to be placed over the leachfeld.
7. The area over the bed is to be finish graded to prevent ponding of surface water
runoff.
8. The septic tank and leachfield must not be closer than 100' to any existing private
well, 150' to any Class "C" well, or 200 feet to any community well.
RECOMMENDED LEACHFIELD DIMENSIONS•
TOTAL DEPTH = 0' GRAVEL DEPTH = 6" under pipe BED LENGTH = 47'
BED WIDTH = 12' SOIL RATING = 0.8 GPD/ft2 BEDROOM CAPACITY = 3
SEPTIC TANK SIZE = 1,000 gallons
Twenty-four (24) hours notice required for all inspections.
NOTE: Inspection required prior to sand fill placement. Existing top soil to be removed down
to sandy material and scarified. Place imported sand material to surface grade at uphill side of
bed. Place 6" septic gravel under leachpipe. Excavated top soil to be placed at downhill side.
EAGLE RIVER
ENGINEERING SERVICES
P. 0. Box 773294
EAGLE RIVER, ALASKA 99577
Phone 694-5195
J013 dlr- -,-- � - "-
"/7`r
SHEET NO.
OF
CALCULATED BY—
DATE
CHECKED BY
DATE
SCALE
.2
rlv—'tt7lrc. c'e.. M. 01471.
10 SOILS LOG
MUNICIPALITY OF ANCHORAGE
♦ .., DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-0720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: DATE PERFORMED: dAl—l/
LEGAL DESCRIPTION:
SLOPE SITE PLAN
1 -1
2-
3-
4-
5-
1.51 34 5O
6-
7-
8-
9-
10-
11 78 9 1011 6
12 v
13
14
15
16
�rJ4 6�.✓✓
(d' )
Date
port- s.'��, s,✓-��
Net
Time
lj rove-(
WAS GROUND WATER
ENCOUNTERED?
S
Y6r L
O
Sore-
6.5-� E
IF YES, AT WHAT
DEPTH?
19
Reading
Date
Gross
Time
Net
Time
17
Net
Drop
Sore-
; v
18
\ _
f
19
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
Sore-
�/y
a6
20
III PERCOLATION RATE 2, y (minutes/inch)
TEST RUN BETWEEN � FT AND �' f FT
COMMENTS
PERFORMED BY:
72.008 (6/79)
IF/eFf CERTIFIED BY: � DATE: 9/
10 SOILS LOG
— MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
825 L. Street, Anchorage, Alaska 99501 264-4720 TEST
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: DATE PERFORMED:__
LEGAL DESCRIPTION: t �S �ILY / �ruJ�GL c f /y7`t T/7l
SLOPE SITE PLAN
1 T d
2-
3 3
4 d '
0
5-
6-
6 r
7
6
9-
10-
11
10
I
G�
6-. )
11
Date
WAS GROUND WATER S
Net
Depth to
ENCOUNTERED? YEr L
O
12
Water
3.�/ P
Svrr,
6/r
IF YES, AT WHATE
13
- DEPTH?
14
15
16
i
a=
17
i6 j t ` .Jg15 i.. vUic`r3 p :'J rfi
00 NO
n CE-6736
19`yFv®°en,b
20
d
Reading
Date
Gross
Net
Depth to
Net
Time
Time
Water
Drop
Svrr,
6/r
�2
3
N/y
PERCOLATION RATE -2,6 (minutes/inch)
TEST RUN BETWEEN /r S FT AND _-'il'_ FT
PERFORMED BY: `/PFJ CERTIFIED BY: �`� DATE:
72.008 (6/79)
Pa SOILS LOG
i MUNICIPALITY OF ANCHORAGE
• �.r DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Or PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 2644720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: DATE PERFORMED:
LEGAL DESCRIPTION:_ �t /S A ��k / �iu�/crc7 ry7`f T1-/ 3
77/3 �
1
d
2-
3-
4-
5
3 45
6 _
�a
7
8
9
SLOPE
10-
11 WAS GROUND WATER S
ENCOUNTERED? Yes L
0
12 6, 3 P
IF YES, AT WHAT E
/1�ir ,raa c n
13 DEPTH? r7g y s
14-
415
Date
Gross
Time
15-
Depth to
Water
Net
Drop
16
16
6 /o
17
'
G/B
�.2��,.,�
/O
�
18
'-
'2 �6 G
�C
20
SITE PLAN
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
SO�f r
6 /o
G/B
�.2��,.,�
/O
'2 �6 G
�C
PERCOLATION RATE
TEST RUN BETWEEN
el' / (minutes/inch)
LE FT AND a FT
PERFORMED BY: CERTIFIED BY: DATE:
72-008 (6/79)
00 SOILS LOG
�- MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION V PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99507 264-4720
`J SOILS LOG — PERCOLATION TEST
PERFORMED FOR: //45 DATE PERFORMED:
LEGAL DESCRIPTION:
7-
1
7/
TGrs,,'1
Depth to
Water
0
G D f
0'
E
2
/
DEPTH?
»gyr
3-
4-
4
r 6,
5
G6
L
6
�Q� fIfJ AL
7
9
10-
11
12
3
13-
14-
14
15
15-
'a
16-
ti
17
18
19
20
COMM
7` 177''1' 7'H K
SLOPE SITE PLAN
WAS GROUND WATER
S
ENCOUNTERED?
Y6s L
Depth to
Water
0
G D f
E
IF YES, AT WHAT
J7 it /rac c /
DEPTH?
»gyr
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE �/y (minutes/inch)
TEST RUN BETWEEN FT AND 2 "r FT
PERFORMED BY: CERTIFIED BY: / DATE:
72.008 (6/79)
•�1 SOILS LOG
MUNICIPALITY OF ANCHORAGE
• +.e DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
825 L. Street, Anchorage, Alaska 99501 264-4720 TEST
—� SOILS LOG — PERCOLATION TEST
PERFORMED FOR: /�l 4 L y-- f f)
_! ,, � DATE PERFORMED:./Q " �� '�
LEGAL DESCRIPTION: /o I.� /Q r �j,�� `%r„� �P c �7/ Ale r j /v /f
DEPTH - 7 SLOPE SITE PLAN
(FEET) Urgr„,e ,(07... ,u/dCL. jT(—Tt7
1
S
/VO
ENCOUNTERED?
2
W
r�
3
P
IF YES, AT WHAT
E
DEPTH?
n
5
6
8
9
11
12
13
14-
15
16
17
18-
19
20
COMMENTS
G']
WAS GROUND WATERS
S
/VO
ENCOUNTERED?
L
Depth to
Water
O
P
IF YES, AT WHAT
E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE
TEST RUN BETWEEN
PERFORMED BY:. lc.�„�t x CERTIFIED BY::
72-008 (6/79)
(minutes/inch) inutes/inch)
FT AND
".'DATE:
d '}
F covsrir,T:�vrs; r�i�.
249 EAST SIST AVENUE P -O. BOX 8087
December 1, 1975
ANCHORAGE
F IR BANKS
' ANCHORAGE. ALASKA 99503 TELEPHONE 907-279.0483 TELEX 090.35419
R & M No. 562154
Mery Wetherley
SRA Box 1461 E
Anchorage, Alaska 99502
Re: Test Hole and Soil Long Report for Sanitary System
Lot 15A, Block 1, Prospect Heights Subdivision
Dear Mr. Wetherley:
We are submitting herewith the test boring results and our comments regarding
soil conditions encountered at the subject site. This investigation was
performed in accordance with your request of November 15, 1975, and those
procedures outlined in a.letter dated July 15, 1975, by Mr. Rolf Strickland
of the Greater Anchorage Area Borough Department of Environmental Quality.
A single test hole was put down within the Lot 15A area for the purpose of
defining general subsurface soil conditions for the proposed sanitary system.
Excavation was accomplished with an auger type drilling rig and the test
hole was extended to a total depth of 11.5 feet below ground surface where
auger refusal was encountered. The final log prepared for the test hole has
been included in Drawing A-01.
Ground water was not encountered in the test hole.
We appreciate being given this opportunity to be of service to you. Should
you have any questions with regard to the above, please do not hesitate to
contact us.
Very truly yours,
R & M CONSULTANTS, INC.
James W. Rooney
Vice President
JWR/jrt
xc: GAAB
273
T. H.
l
11-30-75
0.0'
ORGANICS
�-.
0.5 .
y.
D.-
0
GRAVELLY SAND
Trace Silt, Many Cobbles (SP)
•/o
.o
°.:Q
Auger Refusal
T.H.1
NO ;•7ATER TABLE 11.5' T.D.
PROSPECT DRIVE
NO.SCALE
Log Represents
Location of Test Hole
Lot 15A Block 1
Prospect Heights Subdivision
Mery Wetherley Property
Log of Test Hole
Anchorage, Alaska
Consultants Inc.
ANCNOR AGE fAIRBA NKS %�L�nj'y((� JUNEAU
DATE
11-30-75
SCALE 1rr_3r DWNBY VRZ
CNKD 9Y _
PROJ. NO. 562154
0 3 NO. A-01
273
DePartmont Of "ealth and
C Street
Anchoraqe, Alaska 99so3
274-4561
Decomber 4. 1975
Mr. Mary uatheriay
Star Route A Box 1461-E
Anchorage, Alaska 9951-07
Dlear Pit. Wettierlay-
The sail tost for L JsF' HIOCk I PraspeAot "alobts Subdivision
subt,-q1tt6d tO this POWtv'Ont Shows a usable ahsorption Strata
from .51 to 61.5" In dopth.
State law requires all sewer absgrptjoh.systems to be V above
bedrock or imporanpable strata wch in your case is 11.51.
If you have any furtbar Qnest ionst PU460 do not besi tate to call
this Office, at �74-4561,o extension 135.
Sincer-fly,
Les 4. Buchholz
SanitarlAo
Las/lib
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. 015-091-06
1. GENERAL INFORMATION
Expiration Date: r 2 J r 2— C/
Complete legal description Prospect Heights, Block 1, Lot 15A
Location (site address) 9501 Prospect Drive Anchorage, AK
Current property owner(s) 49th State Investments, LLC Day phone 719-838-0962
Mailing address 125 N Willow Street Suite B, Kenai, AK 99611
Real estate agent Day phone
2. TYPE OF DWELLING:
❑■ Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
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 Seweri.; ❑
Waiver request for: Distance:
1
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ J��J� �l a -S -b
Date of Payment l / ����
Receipt Number 6Jft 62-b
COSA # Q 6C 96/ a 5Z9
Waiver Fee $
Date of Payment
Receipt.Number
Waiver #
COV I D-19
2520 DISCOUNT APOLIED
5
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Civil Engineering Phone 522-7773
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
Date 6/11/2020
e 49th
6. DSD SIGNATURE 51111111"T 1 ' '
v .. . � ,..... N........... I... ............ . .
System #1 Approved for 3 bedrooms a �, ; N4ICHALL E. ANDERSON . t4
00.
'n No. CE -4381 .�•.��e�
System #2 Approved for bedrooms tp4T�ir'% 6/11/20
Disapproved �� 4®�� ............
a50,'����
Conditional approval for bedrooms, with the following stipulations:
A' -g & OL
a N L6L
_ to
S
TY (rrl
OF 61
WATER ANn
VVASTL- wt'ATER
1
1
Original CertificatJ Date: & _2 r�
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
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
X Nitrate Advisory
Arsenic Advisory
Other
•
Legal Description: Prospect Heights, Block 1, Lot 15A
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 7/27/91
Total depth 298 ft
Cased to 20 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) '18 in.
Date of flow test for COSA 6/2/20
Parcel ID: 015-091-06
Structure served by this system
Well production at time of test 1.7 gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate 3.52 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date of Sample 6/8/20
Static water level at beginning of test 46 ft.
Comments ***Arsenic results are pending and will be submitted as soon as they are available. Past COSA
results indicate no arsenic in the well water on 2/17/2017 and 11/12/2018.
B. TANK DATA
Age of tank(s) 1 years
Tank type/material Septic/Steel
Measured operating fluid level in septic tank 50
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 6/15/20 - Alaska Quality Pumping
D. ABSORPTION FIELD DATA Absorption Bed
Which system tested (date installed) 9/4/91
❑ ALL standpipes present per record drawing
Total measured depth from grade 3 ft (max)
Measured depth to pipe invert from grade 2.5 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 N/A gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test dat6/2/20
e
Results GDPass For _
Fluid depth prior to test _
Water added 600 gal
New depth 4 in
Elapsed time 1440 min
Final fluid depth 3 in
Absorption rate >450 gpC
3 bedrooms
3 in
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'
✓0
Yes
Community Sewer Manhole/Cleanout > 100'
✓v7 Yes
if No
ft
Q Yes
if No ft
Neighboring Tank > 100' F,71 Yes
if No
ft
Private Sewer/Septic Line > 25' 0 Yes
if No ft
Absorption Field on Lot > 100' 0 Yes
if No
ft
Holding Tank > 100' El Yes
if No ft
Neighboring Absorption Fields > 100'
❑✓ Yes if No ft
Water Main > 10'
Animal Containment > 50' 0 Yes
if No ft
F/� Yes
if No
ft
0✓ 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' F/� 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'
✓0
Yes
if No
ft
Surface Water > 100'
❑✓ Yes if No ft
Property Line > 5'✓❑
Yes
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
❑✓
Yes
if No
ft
Private Wells > 100'
❑✓ Yes if No ft
Water Main > 10'
ft
Yes
if No
ft
Community Wells > 200'
0✓ 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'
Q✓
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
Yes
if No
ft
Private Wells > 100' U✓ Yes if No ft
Water Service Line > 10'
0
Yes
if No
ft
Community Wells > 200' Q✓ Yes if No ft
Surface Water > 100'
0
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
l certify that l 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
a4 ,�
49th
MICHAEL E. ANDERSON m
No. CE -4381 �
6/12/20
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MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On-Site Systems Approv _62_ 19 U P4e
Parcel I.D. 015-091 -06 Expiration Date: / / / 3 Cc/IG(k+to(o
afiprovo,A
1. GENERAL INFORMATION
Complete legal description Prospect Heights Block 1 Lot 15A
Location (site address) 9501 Prospect Drive
Current property owner(s) Craig & Cheryl Hodges Day phone
Mailing address 2124 N Nadina St, Palmer, AK 99645
Real estate agent Mary Cox Day phone 440-9820
2. TYPE OF DWELLING:
Single Family (w/wo ADU)
❑ Duplex
Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Private Well x Private Septic x
Water Storage Holding Tank n
Community Well Community ❑
Public Water System U Public Sewer n
Waiver request for: Distance:
c
•
Received by: Date: it I I I t
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ I a.V? off/ Waiver Fee $
Date of Payment I I // 5/2,01 Date of Payment
Receipt Number OO5(0(( Receipt Number
COSA# OS C l8 f 51 I 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.
Name of Firm Forge Engineering Phone 907-522-7773
Address PO Box 240773, Anchorage, AK 99524
Engineer's Printed Name Benjamin Schiller, PE Date 11/11/18
OF 441:•4.01:"k
/�*.49TH• j� •*�?
6. DSD SIGNATURE % .` ' •' •. �6
System #1 Approved for bedrooms / Benjamin Schiller • /
71— System #2 Approved for bedrooms �r+�Fc�f• ., 11/110E 598,.•
.•���/
,ikF9F�\\��` �
Disapproved ��
// Conditional approval for 3 bedrooms, with the following stipulations:
/�
1 &t at"(v 5u,iii ple i e t to . `��bwl t' ed b/ 11/ 3/i )
__--- 2) -otr►k +o be. i4 6-1-±11eb7 /9,/`I /
4-ewtc C--t ( — I (-1q
---..q--,..,
By: /L 4) Original Certificate Date: i(/6//5The Municipality of Anch ge 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
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: Prospect Heights Block 1 Lot 15 Parcel ID: 015-091 -06
A. WELL DATA
Well type Private If A, B, or C provide PWSID# Well Log (YIN) Y
Date completed 7/22/91 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 298 ft. Cased to 20 ft. Casing height (above ground) >24 in.
FROM WELL LOG AT INSPECTION
Date of test 7/23/91 2/28/17
Static water level 39.0 ft 48.6 ft.
Well production 3.0 g.p.m. 2.0 g.p.m.
WATER SAMPLE RESULTS: ,Z L ll'i2'1 g
Coliform 0 colonies/100 mL Nitrate 2.57 mg/L
Arsenic 0 ug/L Date of sample: 2/17/17 Collected by: Anderson Engineering
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 9/4/91 *
Tank size 1 000 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 5/31/16 Pumper A+ Home Services
C. ABSORPTION FIELD DATA
Date installed 9/4/91 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.8 System type Bed
Length 47 ft. Width 12 ft. Gravel below pipe 0.5 ft.
Total depth ft. Eff. absorption area 564 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 2/28/1 7 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 483 gal. New depth 0.75 in.
Elapsed Time: 1440 min. Final fluid depth 0 in. Absorption rate >= 450 g p d
Any rejuvenation treatment(past 12 mo.) (Y/N &type) None If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot >100On adjacent lots >100'
Absorption field on lot >100' On adjacent lots >100
Public sewer main '75' Public sewer manhole/cleanout >100'
Sewer/septic service line >25' Holding tank >100'
Animal containment areas >50' Manure/animal excrete storage areas >100'
SEPTIC/HOLDING TANK ON LOT TO:
>10'Building foundation Property line >5 Absorption field >5
Water main >10 Water service line > Surface water
Wells on adjacent lots >100
ABSORPTION FIELD ON LOT TO:
Property line >10 Building foundation >10 Water main > 0
Water Service line >10Surface water >1 00 Driveway, parking/vehicle storage >
Curtain drain None Noted Wells on adjacent lots >100'
F. COMMENTS
*Tank to be replaced as part of a conditional COSA
**Bed, lines, and tank all insulated per inspection report
G. ENGINEER'S CERTIFICATION .....1c���\\k
Agill/ certify that / have determined through field inspections and ' .04-1 treview of Municipal records that the above systems are in g' .. `�` .9++r
conformance with MOA COSA guidelines in effect on this date. *.•49 TH /\ •.* ,/
Benjamin Schiller, PE VP-
Engineer's Printed Name , . .-„ •. i�. . . .
Date 11/11/18 /,# 1 .• Benja• chiller ...,4".*
',4" j
�+0 4,..•...11/11/18...;t:F CEAl/
,ll °PROFESSIO\ '.�
COSA brown sheet 10-10-12.doc
SGS Ref.# 1186447001
Client Name Forge Engineering Inc. Printed Date/Time 11/15/2018 16:55
Project Name/# Prospect Heights B1 LISA Collected Date/Time 11/12/2018 13:37
Client Sample ID Prospect Heights B1 LISA Received Date/Time 11/12/2018 14:07
Matrix Drinking Water Technical Director Stephen C.Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic ND 5.00 ug/L EP200.8 C (<10) 11/14/18 11/14/18 DSH
Waters Department
Total Nitrate/Nitritc-\ 2.28 0.100 mg/L SM21 4500NO3-F B (<10) 11/14/18 DMM
Microbiology Laboratory
E.Coli Negative 1 100mL SM2I 9223B A 11/12/18 A.L
Total Coliform Negative 1 100mL SM21 9223B A 11/12/18 A.L
2 of 5
MIME\
PO BOX 240773
J ANCHORAGE, AK 99524
111.1110
522-7773
,1 / • GE 677-7766 (FAX)
ENG i N E E R N G FORGECIVIL.COM
November 13, 2018 'W.OP
MOA Development Services, On-Site Water& Wastewater Program j*:49 TM •*7
4700 Elmore Rd '''' '•
Anchorage, AK 99507 •••; • •• •••;• 0
Benja ' • chiller j
CE 12592 •���/
Subject: Lake 0 The Hills, Block 3 Lot 6 t,,sl •.1 1 1/13/ .
Conditional COSA request14"DPRoFESS�O��'�+
Dear On-Site Services Engineer:
The owners of this property are selling their home. They had a closing date and a loan lock set up
before they found out that their septic tank has failed. We are requesting that a conditional COSA be
issued so that the sale of the home can proceed on time, with the provision that the septic tank be
replaced soon after.
We have applied for a permit to replace the tank, and have three quotes from contractors. 150%of the
highest quote has been placed in escrow ($10,275). This will be sufficient to guarantee that the tank
can be replaced. At that time, we will submit an updated survey for the property.
Sincerely,
Benjamin Schiller,PE
• Municipality of Anc
On -Site Water and Wastewater
(907)343-7904
Certificate of On -Site Systems A
Parcel I.D. 015-091-06
-
5 7J GE 9�
r -
MAR
Expiration Date: CO^ ( !
1. GENERAL INFORMATION
Complete legal description Prospect Heights Sub, Block 1 Lot 15A
Location (site address) 9501 Prospect Drive
Current Property owner(s) Robert & Constance Weel Day phone
Mailing address 200 W 34th Ave, Ste 86, Anchorage, AK 99503
Reil Estate Agent. Jaime Harvey Day phone 227-1059
.. i
2. TYPE OF DWELLING:
7 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
0
Individual El
Individual Water Storage
❑
Holding Tank ❑
Community Class Well
❑
Community ❑
Public Water System
❑
Public Sewer ❑
WaiverNariance request for:
Distance:
Received by:
Date: 31 I-7
COSA to be released o the engi a r, unless otherwise requested by the engineer.
COSA Fee $ 52_1G —
Waiver Fee $
Date of Payment 31z%;, I n
Date of Payment
Receipt Number 05a 3t�
Receipt Number
COSA#- ac 1_1 1011
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.
Name of Firm Anderson Engineering
Address PO Box 240773, Anchorage, AK 99524
Engineer's Printed Name Benjamin Schiller, PE
6. DSD SIGNATURE
System #1 Approved for 3 bedrooms
System #2 Approved for bedrooms
Disapproved
Phone 522-7773
Date 3/9/2017
Conditional approval for bedrooms, with the following
®�OF At
is3QQ L
.6wtla►et 3t�&�S
' CF • 12592 '
40s_jk�•.3�1't'l2.'.e a
By L Original Certificate Date: 3 —17—/ 7
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.
ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet f - c
If more than 1 septic system is on the lot:
COSA Checklist # _of _
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: Prospect Heights, Block 1 Lot 15A ParcellD:015-091-06
A. WELL DATA
Well type Private If A, B, or C provide PWS ID #
Date completed 7/22/91 Sanitary seal (Y/N) Y
Total depth 298 ft. Cased to 20 ft.
Date of test
Static water level
Well production
FROM WELL LOG
7/23/91
39.0 ft.
3.0
WATER SAMPLE RESULTS
g. p. m.
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) >24 in.
AT INSPECTION
2/28/17
48.6 ft.
2.0
Coliform 0 colonies/100 mL Nitrate 2'57 mg/L
Arsenic 0 ug/L Date of sample: 2/17/17 Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel
Tank size 1000 gal. Number of Compartments 2
Foundation cleanout (Y/N) Y
Date of pumping 5/31 /1 6
C. ABSORPTION FIELD DATA
Anderson Engineering
Date installed 9/4/91'`
Cleanouts (Y/N)
Y
Depression over tank (Y/N) N High water alarm (Y/N)
Pumper A+ Home Services
N
Date installed 9/4/91 Soil rating p.d./ftz r ftZ/bdrm) 0.8 System type Bed
Length 47 ft t� Width ft. Gravel below pipe O' S ft.
* * �l
Total depth 3 ft. Eff.absorption area 564 ftz Monitoring tube Y Depression over field N
Date of adequacy test 2/28_1 7 Results (Pass/Fail) PASS For 3 bedrooms
Fluid dep� kabsorptiiogp,�ie( fore test 0 in. Water added 483 gal. New depth 0.75 in.
Elapsed Timex 446',x" Final fluid depth 0 n. Absorption rate >= 450 g p d
Any rejuvenation treatmen, (past 12 mo.) (Y/N & type) N If yes, give date
`SEPTIC TANK IS GREATER THAN 25 YRS OLD, NEARING THE END OF ITS USEFUL LIFE
"BED, LINES, AND TANK ALL ARE ALL INSULATED PER INSPECTION REPORT
D. LIFT STATION
Date installed
"Pump on" level at
Datum
Size in gallons
in. "Pump off' level at
Cycles tested
E. SEPARATION DISTANCES
WELL ON LOT TO:
in
Manhole/Access(Y/N)
High water alarm level at
Meets alarm & circuit requirements?
Septic tank/lift station on lot > 100' On adjacent lots > 100'
Absorption field on lot > 100' On adjacent lots > 100'
Public sewer main >75 Public sewer manhole/cleanout >100'
Sewer /septic service line >25 Holding tank >75'
Animal containment areas >50 Manure/animal excrete storage areas >100'
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5' Property line >5
Water main > 10 Water service line >10'
Wells on adjacent lots >100'
ABSORPTION FIELD ON LOT TO:
Property line >10, Building foundation >10'
Water Service line >10 Surface water >100'
Curtain drain None Noted Wells on adjacent lots >100'
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I 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.
Engineer's Printed Name Benjamin Schiller, PE
Date 3/9/2017
COSA brown sheet 10-10-12.doc
Absorption field >5
Surface water >100'
Water main >10'
Driveway, parking/vehicle storage > 10'
in.
G� O 0�
5Q�
s�
Snow dumped
onto Lot 16A
from Lot 14
7J
awee
Wood ret.
8451U
Note: Asphalt location is approximate due \
to snow and ice.
Record data per Plat No. 72-285
for Lot 15A is incomplete and does not
achieve mathematical closure. Computed data
shown hereon reflect the intent of the survey.
AW i'.. 49th *,i
. V.
go
[.4! /
%% .Fred Walatka: i
�� �siF • 3255 - S �=
SCALE: 1 "= 50' 1 1 \`sloty&
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED
PLAT ARE NOT SHOWN HEREON. FB 17-2, pg 1 BE
411
j C� Sl
Revised 3-17-17, Added septic ventlW
AS -BUILT NO CORNERS SET THIS DATE
I hereby certify that 1 have performed a Mortgagee's inspection
of the following described property: LOT 15A. BLOCK 1.
PROSPECT HEIGHTS SUBDIVISION
Anchorage Recording Precinct, Alaska, and that the
improvements situated thereon are within the property lines
and do not overlap or encroach on the property lying
adjacent thereto, that no improvements on the property lying
adjacent thereto encroach on the premises in question and
that there are no roadways, transmission lines or other
visible easements on said property except as indicated
hereon.
Dated at Anchorage, Alaska
this 28th day of February , 2017.
FRED WALATKA & ASSOCIATES
Engineers and Surveyors
(907-248-1666)
s@pf
%
O'N
0~�' y \
e' vtS
2n
ti�
nyF •r 2.0 OH
A
O
/
/
Note: Asphalt location is approximate due \
to snow and ice.
Record data per Plat No. 72-285
for Lot 15A is incomplete and does not
achieve mathematical closure. Computed data
shown hereon reflect the intent of the survey.
AW i'.. 49th *,i
. V.
go
[.4! /
%% .Fred Walatka: i
�� �siF • 3255 - S �=
SCALE: 1 "= 50' 1 1 \`sloty&
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED
PLAT ARE NOT SHOWN HEREON. FB 17-2, pg 1 BE
411
j C� Sl
Revised 3-17-17, Added septic ventlW
AS -BUILT NO CORNERS SET THIS DATE
I hereby certify that 1 have performed a Mortgagee's inspection
of the following described property: LOT 15A. BLOCK 1.
PROSPECT HEIGHTS SUBDIVISION
Anchorage Recording Precinct, Alaska, and that the
improvements situated thereon are within the property lines
and do not overlap or encroach on the property lying
adjacent thereto, that no improvements on the property lying
adjacent thereto encroach on the premises in question and
that there are no roadways, transmission lines or other
visible easements on said property except as indicated
hereon.
Dated at Anchorage, Alaska
this 28th day of February , 2017.
FRED WALATKA & ASSOCIATES
Engineers and Surveyors
(907-248-1666)
a
E
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
Parcell.D.# 015-091-06 HAA# 44-'/10 -)- 0'3
1. GENERAL INFORMATION
Complete legal description Prospect Heights, Lot 15A, Block 1
T12N R3W Section 13
Location (site address or directions)
9501 Prospect Drive, Anchoraqe
Property owner John c Haameier Day phone 248-678
Mailinq address 2204 Cleveland, Suite 201, Anchorage, AK 99517
Lending agency N/A Day phone
Mailing address
Agent
Address
N/A
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3
Day phone
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site X
Holding tank
Community on-site _
Public sewer _
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front 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 Eagle River Engineering Services Phone
Address
P.O. Box 773294, Eagle River, AK 99577
694-5195
Engineer's signature //`- Date
9
6. DHHS SIGNATURE
Approved for �y�'�`' bedrooms.
Disapproved.
Conditional approval for
Additional Comments
M
,I -
bedrooms, with the following stipulations:
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 professional engineer's work.
72-025(Rev.1/91) Back MOA#21
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES M�
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 DWELL G
015-091-06 HAA C nl
1. GENERAL INFORMATION
Complete legal description Prospect Height
Location (site address or directions)
9501
Property owner
Mailing address
Lending agency
Mailing address_
Agent
Address
Unless other
2. NUMBER OF
3. TYPE OF WA
2204 Cleve3
Ci
Lot 15A, Block 1
Drive, Anchorage
Day phone 248-6789
1, Anchorage, AK 99517
ted, H A will be held for pickup.
M • 4
SUPPLY:
I ividual well
om unity well
Pu 'c ater
Y
Day phone
Day phone
/NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. F WASTEWATER DISPOSAL:
Individual on-site X
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front 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 furtherverify 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 Eagle River Engineering Services Phone 694-5195
Address P.O. Box 773294, Eagle River, AK 99577
Engineer's signature —� �'` Date
6. DHHS SIGNATURE
Approved for ��? (`� bed
- - Disapproved.
Conditional approval Ifo
Additional Comments
By:
rooms, with the following stipulations:
Date / D — 3e' 1'7
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Ray. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: P/Z05PECT &a.. QE / /{, && / Parcel I.D. D/ 5 - 6 9J- 06
T/ ?_/V R.3 /v sEcT/a?✓ /,3
A. WELL DATA
Well type Z?t-'/k'47_,5 If A, B, or C, attach ADEC letter. ADEC water system number A/1A
Log present (Y/N) y Date completed/x/22/9 / Driller_ ALP/AX
Total depth Cased to _ZQ J ReIO OCJ� Casing height Z
Sanitary seal (Y/N) T Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
39�
SEPARATION DISTANCES FROM WELL TO:
9.p -m.
aM
Septic/holding tank on lot i% i ; On adjacent lots t/00
Absorption field on lot 11,41 ; On adjacent lots /-/00
Public sewer main NIA
Public sewer manhole/cleanout /VIA
Sewer service line / 20 Petroleum tank
WATER SAMPLE RESULTS:
Coliform Nitrate / M6.11. Other bacteria
Date of sample: Z/9/ Collected by: 61y
B. SEPTIC/HOLDING TANK DATA
Date installed 6 3U 9/ Tank size 1000 Compartments z
Cleanouts (Y/N) .Foundation cleanout (Y/N) y Depression (Y/N) N
High water alarm (Y/N) N Alarm tested (Y/N) /11A
Date of pumping tVVl/f - N "ly Pumper A11,4
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
i
Well(s)onlot _�O� On adjacent lots /-/L)0 Foundation
To property line /I Absorption field_ 13' Water main/service line f�UO
Surface water/drainage AlZA
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent(Y/N)
High water alarm level
Meets MOA electric _IA
"Pump on
es (Y/N)
Manufacturer
(Y/N)
Man
SEPARyTd'ON DISTANCE FROM LIFT STATION TO`.
I on lot
D. ABSORPTION FIELD DATA
On adjacent lots
"Pump off" level at
Cycles tested
Surface water .
C
Date installed o?ZgyJ 9/ Soil rating0• r &P,0 / y' System type BED
/�'
Length %
!f' Width Gravel thickness _ 0-5/ -Total
/depth j:57.1
Total absorption area — Cleanouts present (Y/N) /
Depression over field (Y/N) /V Date of adequacy test NIA — wcw
Results (pass/fail) 1455 for 13 bedrooms
Peroxide treatment (past 12 months) (Y/N) W If yes, give date IV14
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot �Zli '
On adjacent lots f' /DO Property line
To building foundation To existing or abandoned system on lot
On adjacent lots Cutbank N,A Water main/service line
Surface water N�s1 Driveway, parking/vehicle storage area Zt7
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
t g
r
Signature
En ineersName
g �
Date /D�' �Z 0 :u�¢oaoea
�� ,� a ! �•. Bofera o
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E�v
e1C��G�
�e • .�. ate.
HAA Fee $ Waiver Fee: $
Date of Payment Date of Payment
Receipt Number Receipt Number