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HomeMy WebLinkAboutHYLEN CREST #3 BLK 2 LT 16
Municipality of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP181445 PID Number: 05047441000
Dwelling: • Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Projectiiiiii htevy , Upgrade
Name
Palmer ABSORPTION FIELD
Site Address ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
10346 Stewart Drive ❑ Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
980-6232 4 GPD/SF Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot / Ft. Ft.
Z fro Fill added above original grade Gravel length
Township, /146 .N! ( eej,6tpage,..+S\ Section Ft. Ft.
C / # 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 na na na na na TANK i Septic l=1S.T.E.P. l=1Holding ❑ Other
Manufacturer Capacity
Greer 1250 Gal
Surface Water I 1 001+ 100'+ na na Material Number of compartments
Lot Line 10'+ 5'+ na na NA Steel 2
LIFT STATION
Foundation 101+ 10'+ na na Manufacturer Capacity
Remarks `T/�A ,!Z u 1 c(Z,Q.6 Gal
0-ML-k/
! /� 'k ` ! Ir Alarm location Electrical installed by
1/ PIPE MATERIAL House to tank D3034Tank to D3034
Installer drainfield
Stuart Gilbert Drainfield D3034 co/MT D3034
Inspector BENCH MARK (Assumed elevation) 100 ft
Inspection 151 4/10/194/11/19 Location and description
dates: 2" Back Deck
3`° 4/12/19 4.'h
ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp
Conditional Approval: Date
Septic ,--- ��-. C Col
w'z.�/�9Approve �— [.� Date b y r
Note: this approval does not include well permit requirements.
(Rev 05/02/18)
•
AS—BUILT MEASUREMENTS
A B
STI 14 23
ST2 21 28
DCO 25 31
SteWQ\ Drive
55j it I
15'\ifity
Ease
Q
15% Sio
15x Slope Pe
1 1 Line
er I 1
L15 Septic
4 Bdrn I
L17 Septic
, fco
ST1. New 1250 Gallon
ST • Septic Tank w/DC❑'s
.---- DCO Decommissioned Old
Septic Tank
-___,. PER UPC
15x Slope
I I
Existing
1Sj slope Trench
I 1 B2 L8 Septic 15j Slope
I 1 1
•".i* .lt." HYLERN CREST #3 1' 50
NORTHRIM 4,'•‘1-..
RECORD
ENGINEERING * '4''' ' ' , BLOCK 2 LOT 16
PO Box 770724 <i�'' „.r.o,, t LAYOUT
' WASTEWATER UPGRADE .
Eagle River, Alaska 99577 -ateyt, Aob:
907.694. 7028 V 'rIREPLACEZSEPTIC TANK 4/27/19 1424EETOC 3
DESIGN NOTES:
Foundation Cleanout Elevation @ 97.5'
/ Tank Cleanouts Elevation @ 93.5'
Fin ^ade Opposing Cleanouts Between Septic Tank & Trench
4 Foot Cover
or Equal
�' Elevation @ 93' "J r—�
To Trench
I\_
levation @ 93.x' 1250 Gallon E e tion @ 92.8'
MOA-Approved
Septic Tank
lid Pipe
Match Elevations To
Existing FCD & Line
NOR THRIM i~ ... . , t SEPTIC TANK PROFILE HYLEN CREST #3
ENGINEERING ,
Po Box 770724 !..:`.,, .11r. --1.05':‘'2:...;
t • �, 1 BLOCK 2 LOT 16
Eagle River, Alaska 99577 11
907.694.7028 '4, 1l9 TANK REPLACEMENT °ot'5/15/19 fO1M" BY: SE $Cale` i• = 5 ' SHEET.3 of, 3
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Nc,°"L_r. MUNICIPALITY OF ANCHORAGE ,,, »1
�\ On-Site Water&Wastewater Program N, , •, ,..
t ., PO Box 196650 4700 Elmore Road w .--
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 ,.,
/- http://www.muni.orglonsite '- a.1's N '`"
i Department
4,vc.OR 4
On-Site Wastewater Disposal System Permit
Permit Number: OSP181445 Effective Date: 12/31/2018
Work Type: SepticTank Upgrade Expiration Date: 12/31/2019
Tax Code Number: 05047441000
Site Legal Address: HYLEN CREST#3 BLK 2 LT 16 G:0057
Site Mailing Address: 10346 STEWART DR, Eagle River
Owner: PALMER JAMES &ARKELL SHEILA Lot Size in Sq Ft: 21059
Design Engineer: NORTH RIM ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
❑ Disposal Field El 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: Septic tank shall not be located under a retaining wall.
Received By: < Date: !/ / ,
Issued By: 0 if!..A & O.. Date: (' i 8
MUNICIPALITY OF ANCHORAGE
•
Community Development Department " " t 4 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. O50- '/7t,/-- L/f
Property owner(s) RI/4/R3 ' 7,4,44Day phone ?(Po -(2 3 2
Mailing address /Q34l( 4 e
Site address mac,
Legal description (Sub'd., Block & Lot) /7/y4e/4 e Re-Sr ? z_ .z.(‘
Legal description (Township, Range & Section)
Lot Size Z// as-9 Sq. Ft. Number of Bedrooms y
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field ❑ Initial Single Family(SF) J�
Q (w/wo ADU)
Septic Tank [ Upgr i'""
?1 Duplex(D) ❑
Holding Tank • CIR �Ai4
Multiple Dwellings ❑
Privy ❑ u,-..•� 7 ,0,-) (SF and/or D)
w
Private Well ❑ ti
4. w
Water Storage ❑ c //
01681.
THIS APPLICATION INCLUDES A VARIANCE/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 uthorized agent)
Permit/Rush Fees: tag. co Waiver Fees:
Date of Payment: aii]ia Date of Payment:
Receipt Number. Receipt Number:
Permit No. OSQI81 " S Waiver No.
Permit App_9-1-12.doc
NET FR IM
ENGINEERING MEMO
Steve Eng, PE, PH
(907) 694-7028
SteveEngPE@gmail.com
Date: 12/20/18 Number of Pages:
To: MOA On-Site Services
Subject: Hylen Crest#3 Block 2 Lot 16
Septic Tank Failure
The subject property requires a new septic tank.The tank baffles are broken,but the trench appears
to be working OK. Please expedite a permit so the tank can be replaced. The existing trench will
remain. Please review as soon as possible.
If there is need for additional information or clarification please give me a call.
Thanks-Steve
1\bTF- IM
ENGINEERING Hylen Crest#3, Block 2 Lot 16
SPECIFICATIONS & DESIGN GUIDELINES
Wastewater System Sizing: This is an existing 4-bedroom home. Most of the neighboring
lots are developed. The current septic tank has failed-the trench still functions. These lots
are near an acre and are served by a public water system .No adverse impacts are expected
from tank replacement. The easements are depicted on the lot. The slope is indicated in the
area of the septic system. Retaining walls are present on property.
Specification Requirements: All components and work must comply with the
Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water
Regulations and Wastewater Regulations.
• New 2- compartment, 1250 gallon septic tank. Watertight couplings on inlet& outlet.
• 5' minimum between the tank and bed. 10' to property lines &house.
• 4' of cover or insulation is required for tank; an equivalent of 1" insulation for 1' foot
soil cover. Tank& solid pipe must be set on well compacted, stable soil.
• 4" diameter cleanouts with airtight caps are required 1' to 4' from foundation wall,
prior to any 90 degree bend in 4 inch line, in each tank compartment, and two adjacent
opposing cleanouts between the tank and the absorption field,not more than 10' from
the tank positioned to provide cleanout access towards the tank and towards the
absorption field.
• All cleanouts must extend to at least ground level.
• In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron.
• Insulation must be placed over any pipe installed under driveways or parking areas.
• Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789,
ABS ASTM D2661,
• Sewer Service Line is minimum 2% slope.
• Septic Tank to be pumped every two years or when required.
• Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal)
�_ . .• a•f�
•
/0/2071r.,"<;',..;,,..
,'�0 X3.'3.'©► ' ''3
•
DESIGN NOTES:
1. Existing Trench Remains In Place.
2. Sewer Service Line minimum 2% slope.
3. Replace Septic Tank/Decommission Old Tank Per UPC.
Connect New Tank To Existing Trench.
4. Lots Served by Public Water System.
5. No Conflicts Within 200'.
6. Check Condition Of Sewer Service Line— Replace If Necessary.
7. Retaining Walls Are Present— Avoid Or Relocate Wall.
\ SteWQ\ Du,
t7
f
it i
15'.......1U
5'�I U ty cos__t en t
Q
K 15% Slope
IS% Slope Water '
) Llne 1
L15 Septic
4 Bdrm I
L17 Septic
fco
New 1250 Gallon
M Se•tic Tank w/DCO's
Decommission Old
�J' Septic Tank
I" 104, .. PER UPC
2 S ddl' m Slope
i Zizci/B I I Existing
Trench
15% Slope
' B2 L8 Septic 15% Slope
! i I
%%%%% 1' = 50'
r•C- �.%%% % HYLERN CREST #3
NORTHRIM *.49m *. BLOCK 2 LOT 16 DESIGN
ENGINEERING LAYOUT
° Box "0724 ' Zl WASTEWATER UPGRADE
Eagle RiverAlaska 99577 ' g . b .: - -_
907.694. 7028
REPLACE SEPTIC TANK ; 12/20/16 2of 3
Foundation Cleanout
Tank Cleanouts
Fin ^amide Opposing Cleanouts Between Septic Tank & Trench
4 Foot Cover
or Equal
1250 Gallon
To Trench
MOA-Approved
Septic Tank
•lid Pipe
Match Elevations To
DESIGN NOTES: Existing FCD & Line
1. Use Existing Trench.
2. Septic Tank & Solid Pipe to be Placed on Compacted,
Stable Soil, Free from Boulders.
3. Sewer Service Line is Minimum 2% Slope & 3' Cover.
4. Water-Tight Couplings.
S. See Specification Sheet.
6. All Work To Conform to Municipality of Anchorage (AMC)
Requirements & Specifications.
7. Decommission Old Septic Tank Per UPC.
8. Check Condition Of Sewer Service Line. Replace And/Or Insulate If Necessary.
9. Avoid Retaining Walls Or Reconstruct Wall.
lllllllllllllll
NORTHRIM *'�49m SEPTIC TANK PROFILE HYLEN CREST #3
ENGINEERING .* •
Po Box 770724 • st,,,,o,, f BLOCK 2 LOT 16
Eagb Rivrr, Alosko 99577f/ p1
907.694.7028 f Dots: *� By real.: SHEET•3 of 3
TANK REPLACEMENT 12/20/18a sE i• = 5 I
I SE
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephoto; 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHONE
~IEW
[~UPGRADE
NAME
MAILING A D(~R/SS
LEGAL DESCRIPTION
LOCATION
DISTANCE TO: Well A ~ D/elling
Manufacturer / ~//~ Material
DISTANCE TO: Well (~ Nearest lot line
Top of tile to finish grade ~}= /,~ Material beneath tile ~(~ inches
Length Width I~pth
Type of crib Crib diameter depth
No, of compartments
Liquid depth
PERMIT NO.
Liquid capacit9 in gallons
PERMIT NO, ~.~ ~ /i
Distance between lines
Total effective absorption area
PERMIT NO,
Total effective absorption area
Well foundation Nearest lot line
DISTANCE TO:
Driller
DISTANCE TO: Building foundation Sewer line
lot line PERMIT NO.
Septic tank
Absorption area(s)
OTHER
PiPE MATERIALS
SOIL TES1 RATING
IZ.
INSTALLER
5~ if tn //x-£ /.'3 ¢Zc; x,
REMARKS
DATE
MUNICIPALITY OF ANCHORAGE
Department ' ~ Health and Environmental ~rotection ~
825 ~ Street, Anchorage, AK. ~ 501
264-4720 ~
* * * HANDWRIITEN PERMIT * * *
Permit
~ ~' WELL AND/OR ON-SITE SEWER PERMIT ·
Applicant: ~Q93~ ~-~ Mailing Address: -~ t300
Location: Phone Number: G~~
Legal Description: ~ [~ ~ ~~ C~- Lot Size: ~O
Type of Soil ~sorption System Is:
Trench: ~ Drainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br)
The Required Size of the Soil ~sorption System Is:
DEPTH ]'0 LENGTH ~0 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 excavatio~(i~ feet). There is no set width for trenches.
The gravel depth is the minim~ depth of gravel between the outf~ll pipe ~nd
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(,HQbB~G) TANK SIZE.= [~-~' GALLONS *
~er~it ~pplicant has the responsibility to inform this department during the
ins%all~ion inspections of ~ny wells adj~cen% to this proper%y snd the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of ~ny system without final inspection and approval b~ this department
will be subjest to proseoution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. 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 8 3 * * *
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 under~s~tand that the on-site sewer system may require enlargement if
th~Tt ~i~ence is remodeled to include more ~_~ ~edroom~. ~ '
Signe~: ~~~ Issued by:~.~/~-~Z ~^~/ ~
~ppl'ica~t /7 Date: 4~/ ~-- ~
SWP/024 (1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
826 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
LEGAL DESCRIPTION:
i-t ',,, l ,~_ m
//'SLO-~' ' - SITE PLAN
10
11
12
13
14
15
16
17
18
19
2O
WAS GROUND WATER~ J__ S
ENCOUNTERED? . ~"V~) L
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND FT
COMMENTS soil
PERFORMED BY: ~/,~1.._~
72-008 (6/79)
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. 05047441000 Expiration Date: ( Z-2020
1. GENERAL INFORMATION
Complete legal description Hylen Crest #3 Block 2 Lot 16
Location (site address) 10346 Stewart Drive
Current property owner(s) Palmer Day phone 980-6232
Mailing address
Real estate agent na Day phone
2. TYPE OF DWELLING:
x Single Family (w/wo ADU)
Duplex
IJ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Private Well Private Septic x
Water Storage n Holding Tank ❑
Community Well I I Community n
Public Water System n Public Sewer
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 557) Waiver Fee $
Date of Payment L82_60/6) Date of Payment
Receipt Number 0917Co0 Receipt Number
COSA# 0.5619113? Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On-Site staff may visit the site to verify the information submitted.
Name of Firm NorthRim Eng. Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng Date 4/27/19
•
6. DSD SIGNATURE —� „`
System #1 Approved for bedrooms
System #2 Approved for bedrooms • %'•n Of
Disapproved
Conditional approval for bedrooms, with the following stipulations:
`���YtOF e/�q ///
ON-SITE
WATER AND
4VvASTEWATER
PROGRAM
)iii
)ll)))8ER},)`��
�� 73 1 �H
gy; �Y( Original Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
COSA Checklist
Legal Description: Hylen Crest#3 B2 L16 Parcel ID: 05047441
If more than 1 septic system on lot: COSA Checklist# of Structure served by this system
A. WELL DATA — � 4 t
❑Well log is filed with Onsite (or attached) Well production at time of test gpm
Date drilled Water storage tank volume gallons
Total depth ft Well disinfected for coliform test? ❑ Yes IIINo
Cased to ft ❑ Coliform bacteria is Negative
❑ Sanitary seal is functioning correctly Nitrate mg/L ❑ Nitrate less than MRL (ND)
❑ Wires are properly protected Arsenic ug/L ❑Arsenic less than MRL (ND)
Casing height(above ground) in. Collected by
Date of flow test for COSA Date of Sample
Static water level at beginning of test ft.
Comments
B. TANK DATA C. LIFT STATION
Age of tank(s) new years ❑ Required maintenance completed
Tank type/material Steel Age of lift station years
_. Measured operating fluid level in septic tank new Lift station material
Standpipes/foundation cleanout per record drawing Comments:
ate of pumping new
D. AB:ORPTION FIELD DATA "41118WP. 6 LS-het f, e/36/8
Which . stem tested (date installe• .AGI • • Adequacy test date 4/12/19
❑■ ALL standpipes • - --- •-r record drawing Results p✓ Pass For 'T ,bedrooms
Total measured depth from grade 8 ft(max) Fluid depth prior to test 30 in
Measured depth to pipe invert from grade 3.5 ft(min) Water added 600 gal
❑ N/A—pressurized field • New depth 35 in
❑■ Monitor tubes go to bottom of effective. If not, state Elapsed time 60 min
depth into effective
• Code-required soil cover over field Final fluid depth 30 in
1= System presoaked Absorption rate 600 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) n
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies:
COSA Checklist yellow sheet
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' Community Sewer Manhole/Cleanout > 100'
❑ Yes if No ft ❑ Yes if No ft
Neighboring Tank > 100' ❑Yes if No ft Private Sewer/Septic Line > 25' ❑Yes if No ft
Absorption Field on Lot > 100' ❑Yes if No ft Holding Tank > 100' ❑ Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment > 50' ❑ Yes if No ft
❑Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑ Yes if No ft ❑ Yes if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑✓ Yes if No ft Surface Water> 100' ❑✓ Yes if No ft
Property Line > 5' ✓❑ Yes if No ft Wells on Adjacent Lots:
Absorption Field > 5' ❑✓ Yes if No ft Private Wells > 100' p Yes if No ft
Water Main > 10' ✓❑ Yes if No ft Community Wells > 200' p 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' Q✓ Yes if No ft If absorption field is under driveway comment below
Property Line > 10' ✓❑ Yes if No ft Wells on Adjacent Lots:
Water Main > 10' p Yes if No ft Private Wells > 100' ❑✓ Yes if No ft
Water Service Line > 10' 0 Yes if No ft Community Wells > 200' E Yes if No ft
Surface Water > 100' ✓❑ Yes if No ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION �AA"N)- O Atk�(„nl
QJ -f}s, 0,,,,, 'Y ,, V.,
ispo:I certify that I have determined through field inspections and review ,,,1-;: ,O ,C. ,z
of Municipal records that the above systems are in conformance with �'" •. C'v. ! 0
MOA COSA guidelines in effect on this date. .. -'e N ER'S "• �` ��
o
-
Steven W. cng e' 101
<:L
t',.,J /9-:\c--„,00-• Pf 65 �/
ti 1 /\.,,r
•:s
COSA Checklist yellow sheet v� � '
Parcel i.D. #
(~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES_
Division of Environmental Services
On-S te Services Section .~95i9_6650
P O'. Box 196650 Anchorage,'A aska
,,, .. 343-4744
' CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATI ,ON -':
Complete legal description ,
Property owner ... ~)A-,,,J ~
Lending agency
Mailing address
~'Agent C~/~ l'Z.O ~,
Address
Day phone.,
Unless otherwise requested, HAA will be held for pickup.
2. ·NUMBER OF BEDROOMS: ~ r" .
3. TYPE OFWATER SUPPLY:
Individual well
::" ..... commu~iity'welI' ×X Y,~ - '
Public water
NOTE: /f community well sYStem, provide written confirmation from State ~D Ec attest-
ing to the legality and status of system.
4. TYPE OFWASTEWATER DISPOSAL:
ndividual on-site
-:'.Holding tank
Community on-site
72425 (Rev, I/91) Front MOA ~1
· Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system. ~.;-.,. - ,,.?:'.~c! ',i :': ~ ,,.?::_,: ,~:--
Se
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 ~hat the On-site water supply i".".
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms' :':-*i/
and type of structure indicated herein. I further vedfy 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. - "...
DHHS SIGNATURE
' Approved for bedroc ms.
Disapproved.
Conditional approval for
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
conduc{~inspections or analyze data before a certificate is issued, The Municipality of Anchorage is not
responsible for errors c r omissions in the professional engineer's work., ~- '"
72.025 (Rev. 1/~l) Back MOA~I
Municipality of Anchorage ,~
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /--u'r" /~,, /~/.,o Ur.._ Z-.,~ ,./~)/c~t~j Parcel I.D.
A. Well Data _T:::U1~LIC L,~
Well type /"-/'/~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) /'g//~ Date completed Driller
Total depth
Sanitary seal (Y/N)
5',/
Cased to Casing Ileight
Wires properly protected (Y/N)
~FROM WELL LOG AT INSPECTION
Date of test ~
Static water level
Well flow
Pump level1 ~
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ; On adjacent lots
Absorption field on lot
; On adjacent lots
Public sewer main
Public sewer manhole/cleanout
Sewer service line
WATER SAMPLE RESULTS:
Petroleum tank
Coliform
Date of sample:
Nitrate Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Cleanouts (Y/N) "~ Foundation cleanout (Y/N) 'Y~
High water alarm (Y/N) /'~/A Alarm tested (Y/N)
Date of pumping ~/.~ 0 / ~ 5L Pumper ~", ~ .'
SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK TO:
Compartments
Depression (Y/N)
Well(s) on lot ,~/~ On adjacent lots /',/'/A: Foundation
To property line ~ g Z_. t Absorption field ~ i Water main/service line
Surface water/drainage ,/~ o ~ ~
72-026 (3/93)* Front CONTINUED ON BACK PAGE
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots Sudace water
D. ABSORPTION FIELD DATA
Date installed c~ 0 ~ ~ Soil rating (GPD/Ft2) /'Z-~' ~ D/~.~.System type
Length
Width
Total absorption area ~'00 ~ z... Cleanout present (Y/N) 'Y Depression over field (Y/N) ,/~
Date of adequacy test ,:~>/Z~'"/~
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Results (pass/fail)
for
After test
If yes, give date
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
/.
Well on lot
To building foundation
On adjacent lots Z.
Surface water
Curtain drain /',Jo
on adjacent lots /~//~ Property line
To existing or abandoned system on lot
Cutbank ~ O ~J (=' Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I ce¢'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the.date of this inspection.
Signature
Engineer's Name /1~ C.~-/AL.o'/,.. E' ,/~,¢J~ L-'~0~
Date ~/.~ O/q'¢
HAA Fee $
Date of Payment
Receipt Number ~ ?r~ ~j~,.~.~
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3~93)* Back
SEPTIC SYSTEM ADVISORY
Prior to a recent adequacy test on the septic system for this lot, ~"~ inches of
standiung water was observed in the absorption field. This indicates that
approximately _~ ~ % of the absorption area is inundated. However, this system
did meet the minimum absorption requirements for a ~ bedroom residence.
This advisory must be attached to all copies of the subject Health Authority
Approval.
SHEET NO.
CALCULATED BY
CHECKED BY
OF
DATE
SCALE
%1
~.~1
~./
SENT BY:FORTUNE
; 8-28-04 ;12:18P~ ;
FORTUNE PROPERTIES~
~07 044 2130;# 2/ 8
09/09/94 15:1~ ~ 90? 344 21~0 ROCKFORD CORP 02
ADEQUACY
I NSPI-'~TOR ~ ~' .
TYPE OF DWELLING: '~/'~',
NO. OF BEDROOMS1 ~
PEAK LOAD CALCULATION=, ~,
TEST REPORT
PROJECT #
SEPTIC TANK S
TYPE OF $,A,$
TEST RESULTS:
REVIEWED BY;__
DATE:
MUNICIP'ALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # ~-~(~-Ct~'Lt- L~\\ NAA#
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 16; Block 2; Hylen Crest Subdivision ~r~
Location (address or directions)
Mile 3.5 Eagle River Road
(b) Property owner Larry Thomas
~' Mailing Address P.O.Bn~
(c) .Lehding Institution
Mail'ing Address
Telephone: (home) ~ct4-~870
Rdu¢,,~: Ab. 99~77
Telephone
Business ·
'(d)' Rea'l Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here [~,xif hold for pick up.)
List contact person and day phone number below:
$ & 5 ENGINEERING
17034 Eagle Ri,vet Loop Road
Eagle River, Alaska 9~577
2. TYPE OF RESIDENCE
Single-Family ~x Number of bedrooms __
3. WATER SUPPLY
Individual Well []
Community ~ Public ~'~
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-siteY~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page 1 of 2
5. 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, Iverifythat 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 inspect[on.
Name of Firm
S & S ENGINEERING
Address ,-__~ m~_r Lool~ Road No. 2u~
Eagle River, Alaska 99577
Date
Telephone
6. DHHS APPROVAL
Approved for ~1~ bedrooms by
Approved ~ Disapproved
Terms of Conditional Approval
~'IA,'~ ( T/-~ Date
Conditional
The Municipality of Anchorage Department of Health and Human Services(DHHS) issuesHealthAuthorityApproval
cerificated 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 DHHSdonotconductinspections
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. 7/88) Back Page 2 of 2
A, WELL DATA
Well Classification
Well Log Present (Y/N) Date Completed
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 ~ ~O
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments ~ ~kJ _<-, .%_ ~
MUNICIPALITY OF ANCHORAGE (MOA)
Healt.hj~.uthorily Approval (HAA)
O~ A~4~_.,,,~'~T - FEBRUARY 1984
s~v~~" 343-4744
Legal Description: ~o~ / ~ ',
Depth of Grouting
If A, B, C, D.E.C. Approved (Y/N) 4-
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
Z¢~:2 'f- ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ¢-5o-'S~ Size_;
Standpipes (Y/N) t./ Air-tight Caps (YIN)
Depression over Tank (Y/N) _ tO
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
No. of Compartments
U Foundation Cleanout (Y/N)
Date Last Pumped
/.)/¢1 ;for
Temporary Holding Tank Permit (Y/N)
To Water-Supply Well
To Property Line ! O ~ f-
To Water Main/Service Line / O
To Stream, Pond, Lake or Major Drainage Course
Comments ~ ~_~O '¢-'l'C~ ~0~¢¢_~
SFPARATION DISTANCES FROM SEPTIC/HOLDING 'I"ANK:
2¢oo fi- To Building Foundation
To Disposal Field
( O /-/-
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ - 30-~ ~
Width of Field ~0" *'
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well Z
/
~--oo ~
/d
! Z1 ~ '¢,/&:~ Type of System Design
Length of Field ~--O
IO
Depth of Field
Gravel Bed Thickness 6¢ o
Statndpipes Present (Y/N)
Date of Last Adequacy Test
- H
To Property Line
To Building Foundation
To Water Main/Service Line / O '~
To Stream, Pond, Lake, or Major Drainage Course ,~-)/~
To Driveway, Parking Area, or Vehicle Storage Area
To Existing or Abandoned System on
; On Adjoining Lots ~ o "/-
To Cutback (if present) ~J/db
GLo i
Comments
D. LIFT STATION
Date Installed ~
Size in Gallons ~
"Pump On" Level at ~
High Water Alarm Level at /k,/~% A
Tested for
Meets MOA Electrical Codes (Y/N) ~
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidel,ines in effe
inspection.
Signed
Company
Date
MOA No.
S & S ENGINEERING
17034 ~=g!e RJ',-'~' Loop Road No, 204
Eagle River, Alaska 99577
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
/90
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
AUgUSt 13,"1990
STEVE COWPER, GOVERNOR
563-6775
FOR: S & S Engineering
Attn: Rodney
PWSID: #2.13289
According to the records on file in this office, the Hylen Crest
subdivision Water System is in compliance with the State of Alaska
Drinking'Water Regulations.
Sincerely,
v~.~ ~.. c~i~ ( 1
Environmental S~e~ialist
VEC:pf
MUNICIPALITY OF ANCHORAGE
DIIr[SION OF ~VIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRC~NMENTAL PROTECTION
APPL:~CATIfIN FOR HEALTH AUTHORITY AI°PROVAL CERTIFICATE
1. C~neral Information Application Date ~.?~~_~
(a) Legal ~e. sc~.iptiop(include lot, block, ,subOivisipn, section, tq~4nship, range)
LocatiQn (addL~ess or directions)
(b) Applicants Nam~
Applicants AOdress~q
(e) Applicant is (che~ o~) ~nding Institution
(d) Lending Institution
2% le phone
Ad~:ess
(e) Ileal E~tate Co. & Agent
Add~ess
Telepho[~
2. ~t[~ qf~ l~sidenoe
Numbe~ of Bed~co~s
3. ~ate~ _Suppl_ji
Individual ~11 ~ Community ~ Publi~_~
Note: If conmunity well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status~
Is the ~11 adequate fo~ the nu.~mber of bedrccras specified in this [{~A (Y/N)
4. ~seWaJge Disp%%_a~l_~
Onsite~'- Public ~. Community t'-~ -~-' Holding TapJ~
Is the wastewater disposal system adequate fc~ the number of b~drooms ~.N)
[Page 1 of 2]
2-15-84
5. En~qineer_in_~. Firm Providing Inspections, Tests, D~ta and Information
Si~f~~ Date
Address
(ENGINEER SEAL)
6. DHEP ~Ap_p_r ova 1
Approved for z/~
Approved ~ Disapproved ~ Conditional
Terms of Conditional Approval
.The Municipality of Anchorage Department of Health and Envirorm~ntalProtection d~s
not ~arantee the contim~ed satisfactory perfom~ance of the wate~ supply and/or the
wastewater disposal system. This approval indicates that~ as of the validation date
shown above~ ~sed on the data and information furnished by an engineer registered ir~
the State of Alaska, the water supply and wastewater disposal si;stem is safe and func-
tional fo~ the nombe~ of bedrcoms and type of structure indicated.
( D~EP SEAL)
7. Mail the H~% to the following address:
KB2/dS/s
[Page 2 of 2]
2~15-84
A®
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Well Classification A
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level Pump Set At
Casing He ight Above Ground ~~
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cle ancut/Manho le
Water Sample Collected By ; Date
Water Sample Test Results
MUNICIPALII¥ OF ANCI-IO~AO5
DEFI'. OF HEALTH &
ENVIRONMENTAL PROTECTIOIX[
L
Date Completed Yield
Depth of Grouting
Sanitary Seal on Casing (Y/N)
_ Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
C~i~nts
B. SEPTIC/H~&~=NG TANK DATA
Date Installed ~.-.-fl~) --- 83 Size / ~.~--Oe~/{~, No. of Compartments, 7_-.
Standpipes ~.f~N) Air-tight Caps ~) Foundation Cleanout ~)
~pression o~ Ta~ (Y~ ~te ~st ~d ~ k/
P~ing~intenan~ Con~a~ ~ File (Y~)/~ ; for -~
Holding Ta~ High-Water ~a~ (Y~) ~/~ ~ra~y Holdi~ Tank Petit (Y/N).
~pt l~..~u~g Tank:
Separation Distan~s ~ ' "'--~=:-
To Water-Supply ~11 ~a~/C To ~ilding Foundation
To omrt To Dis sa
To Water Main/~rvi~ Li~ .~' To S~e~, Pond, ~e, ~ Major ~aina~
Course
[Page 1 of 2]
2.~:L5-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Stmata
Date Installed ~" ~- ~3
Width of Field ~O ~r _~
Square Feet of Absorption Area
Depression over Field (Y_~
Results of Last Adequacy Test
1 ~ ~- ~.~Type of System Design
Length of Field ~--O /
Depth of Field /~? /
Gravel Bed Thickness ' ~(~3
5--~ Standpipes P~esent ~/N)
Date of Last Adequacy Test ~/~
Separation Distance f~om Absorption Field:
To Water-Supply Well (~iQL;~/.-.~iC TO P~operty Line
TO Building Foundation ~ /4- To Existing or Abandoned System cn
Lot /%///4 ; On Adjoining Lots
To Wate~ Main/Service Line .'~ To Cutbank( if present) /~/~.
To Strew/Pond/Lake/or Sajo~ Drainage Ccurse
To Driveway, Parking Area, or Vehicle Storage Area ~ /
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
C~nts
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
/ Vent (Y/N)
du~ing Adequacy Test.
Meets MOA
**
** Check Permitted Bedroom Rating Against HAA Request
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection.
Date
[Page 2 of 2]
2-15-84
DEPT. O~ E~VIRONMENT/~L
SOUTHCENTRAL REGIONAL OFFICE
437 "E" STREET, SUITE 200
ANCHORAGE, ALASKA 99501
BILL SHEFFIELD, GOVERNOR
Telephone: (.,o07)
Address:
274-2533
To Whom It May Concern:
According to ¢ecords on fi, le in this office the J~.(~t~kl
~),UcJ~'l\Jl~;i~] _ Water system is in compliance with the State Drinking
Water Regulations.
Sincerely,