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HYLEN CREST #1 BLK 3 LT 3
Hylen Crest Block 3 Lot 3 #050-472-69 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP241029 PID Number: 050-472-69 Dwelling: FillSingle Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New X Upgrade Name VERLEY ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 10143 STEWART DR, Eagle River ❑ Other Phone Number of Bedrooms Soil Rating Total depth from :original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot HYLEN CREST # 1 BLK 3 LT 3 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft2 Ft. Well *NA 50'+ TANK © Septic ❑ S.T.E.P. El Holding ❑ Other Manufacturer Capacity GREET/ANCH TANK, 1000 Gal. Surface Water 100'+ Material Number of compartments Lot Line 10'+ NA PLASTIC 2 Foundation 10'-x- ILIFT STATION Manufacturer Capacity Remarks *AWWU WATER SERVICE Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034Tank to 3034 drainfield Installer MIKE N ANDERSON PE Drainfield CO/MT3034 Inspector MIKE N ANDERSON PE BENCH MARK (Assumed elevation) 100 ft Inspection 15' 3122124 3122124 da:3rd Location and description 2ntl t TOP OF MH L I D 4 ON-SITE WATER AND WASTEWATER SECTION APPROVAL�glez��,Stamp • Conditional Approval: Date 7,��:•' • • ��� c ' ' •, . w 1 4 ` Fr/ • •• MICHAEL N. ANDEB'_G7J �; .. CE-qr, Septic Syste Approved Date Z� Z •; >}�f��� .,���• ?�� ;,;` Note: this approv)a oes not include well permit requirements. (rcev u5iuz/11J) Permit No. OSP241029 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744 On—Site Wastewater Disposal System and/or Well Inspection Report Legal Description: HYLEN CREST # 1 BLK 3 LT 3 PID No.: 050-472-69 MARK A B TC01 21 50 TCO2 25 55 C01 26 57 CO2 26 58 BENCH, TOP OF MH O ISTING FCO CO2 NEW 1000 GALL P ST1C TANK OLD TANK REMO TO DUMP M M I ASBUILT SCALE: 1"=50' EXISTING FCO TC01 CO1 CO2 ..""■,1 OF FINISH GRADE / �,.• �� .. i� 49TH ..1� AW .... GALLON • TANK 91 °MICHAEL N. ANDERSON:AV No. CE 9469 AW ,3-22-24 ,.�'•i S� N SC71ON 441�I �SS�♦��.♦♦ :�x § !§§§|§ \ |§ �§ : \ ,km2 \§) .■`m;® §§; � 2�■ ; \) : � MUNICIPALITY OF ANCHORAGE cnr On -Site Water & Wastewater Program �o�s PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 n http://www.muni.org/onsite l�epartmeitr On -Site Wastewater Disposal System Permit Permit Number: OSP241029 Effective Date: 3/12/2024 Work Type: SepticTank Upgrade Expiration Date: 3/12/2025 Tax Code Number: 05047269000 Site Legal Address: HYLEN CREST #1 BLK 3 LT 3 G:0057 Site Mailing Address: 10143 STEWART DR, Eagle River Owner: VERLEY ANDREW Lot Size in Sq Ft: 21616 Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field Q 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: 1. Locate the south end of the trench prior to construction to ensure that the required tank -to -field separation is met. 2. The MOA has confirmed with AWWU that the wells on Lot 4 are not connected to the public water system. If they have not been decommissioned, they would have a 100' protective radius. 1,141/4 Issued By: Date: Date: 31 Z/z:'`/ MUNICIPALITY OF ANCHORAGE Development Services Department .7 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 050-472-69 Property owner(s) VERLEY Mailing address 10143 STEWART DR EAGLE RIVER AK Site address SAME Legal description (Sub'd., Block & Lot) HYLEN CREST #1 Legal description (Township, Range & Section) Lot Size 21,616 Sq. Ft. Number of Bedrooms 3 Day phone BLK3LT3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank X ❑ Upgrade X (D) El Holding Tank ❑ Renewal ElDuplex Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 360 Date of Payment: 3���Zq Receipt Number: 72 l 7 Permit No. 0 SP 2-611 Q Z g Waiver Fees: Date of Payment: Receipt Number: Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc MARCH 6, 2024 Municipalities of Anchorage On-Site Water and Waste Water Section 4700 Elmore Rd Anchorage, Alaska Phone 343-7904 Re: New septic tank permit Legal: HYLEN CREST #1 BLK 3 LT 3 To whom it may concern: This is a request for a septic tank permit on the above referenced lot. This tank replacement will not impact any of the neighbors or encroach on any wells, septic or open water issues. The tank will be decommissioned per the Uniform Plumbing Code (UPC). Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241029, Deb Wockenfuss, 03/12/24 1"=50' WATER SERVICE PER MOA FILE EXISTING HOUSE INSTALL NEW 1,250 GALLON PLASTIC SEPTIC TANK W/ 20" RISER, DOUBLE CO AFTER THE TANK. DECOM. OLD TANK PER UPC, MAINTAIN 5' FROM FIELD AND 10' FROM BLDG. SCALE: DJRDRAWN: DATE: HYLEN CREST #1 BLK 3 LT 3 Anchorage, Alaska ANDREW VERLEY 3/5/2024 LOW DECK WELL AWWU WELLS WHICH SERVICE SURROUNDING LOTS SEPTIC SURVEYOR REQ. TO STAKE 200' WELL RADIUS PRIOR TO INSTALLATION OF THE NEW SEPTIC TANK. ALL LEACH FIELD PIPES TO BE REPAIRED FOR FINAL COSA ALL LOTS SERVICED BY AWWU WATER SERVICE TYP. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241029, Deb Wockenfuss, 03/12/24 9F A�q�;�p �. 49 TH* �� fiat a SHANE A. HOLT LS -6914 44a a o \\"fessioW Loo NOTE NO CORNERS SET THIS DATE 2 (TWO) DIFFERENT 200' WELL RADII THA TAFFECT THIS PROPERTY 1 HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY ARE NOT SHOWN HEREON I OF THE FOLLOWING DESCRIBED PROPERTY THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES. EASEMENTS OF RECORD OR OTHER RIGHTS OF WAY, OR ANY ENTITY NOT ON THE RECORD PLAT ARE NOT SHOWN HEREON, UNLESS NOTED. NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS. ANY PAVING SHOWN HEREON MAYBE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE. ONLY VISIBLE IMPROVEMETNS ARE SHOWN HEREON LOT 3 BLOCK 3 HYL FN CREST SUB UNIT NO. 7 ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST OTHER THAN NOTED. DATED AT ANCHORAGE,ALASKA THIS 26 TH DAY OF FEBRUARY 2024 76006 235-132 HOLT LAND SURVEYING 9309 GROVER DRIVE ANCHORAGE,AK 99507 223-8615 MUNICIPALITY OF ANCHORAGE s DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 I_ Street - Anchorage, Alaska 99501 Telephone 264.4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME w"(� PHONE cs,7 ;�1-,,;Z�., ANEW ❑ UPGRADE MAILING ADDRESS LEGAL DESCRIPTION L3'. LLk, C(-ag (�C LOCATION 0 NO. OF BEDROOMS U Y DISTANCE T0: Well Absorption area Dwelling PERMIT NO. L zQ Nh Manufacturer n,( �J1J +ln� Material No. of compartments _L_ Lie. capacity in gallons JOCOO IF HOMEMADE: Inside length Width Liquid depth u�Z DISTANCE T0: Well Dwelling PERMIT NO. = Z F Manufacturer Material Liquid capacity in gallons 0 w S DISTANCE TO: Well Foundation Nearest lot line PERMIT NO. J U- z F= z ¢ No. of lines Length of each line Total length of lines Trench width inches Distance between lines CC H a Top of tile to finish grade, :_ Material beneath tile inches IC Total effective absorption area Lu 0 Length Width Depth PERMIT NO.� Q F Lu Type of crib Crib diameter Crib depth Total effective absorption area Uj W DISTANCE TO: Well Building foundation Nearest lot line a J Class Depth Driller Distance to lot line PERMIT N0. W DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOI L TEST RATING INSTALLER REMARKS i is APPROVED DATE LEGAL n -v i o muv. of f o/ 11 ILJ 1 C! 1 F:fi 0.-,- 1: -,r 'C: It lf`= W --A rr-d F.Fi II::: 9. DE PF1 R T P I E PIT FIE19LA-11 AtIC, 1--'RCITEC.:T 1'. Ohl I R E ET., GE.. AI---:', 9C, 51.1-,1 IEH P. .�il E:-" F;_', -11:. -T* PERI -11"I" NO. L *3 Qti"Le _11`1 ARCT' C: W'20,2 S--I.SI5 1_71 APPL ICF1I'-,I"F SH ITH t'l L 0 C AT I CI 1"4 L E G 1"'i L 1_7: B_::: 1-1111t EP -j CIREST L. ("I T ;IEE SQUARE f"EL-7 TYPF7 ._.C)lL ABSORPTION IS: TREhICH 0 1 F--FT..--'r,':P,', :150 I,-JUHBEJ.'. (Jf-' B R CI 0 IT --n _11 TFIE SIZE Cif -7 THE SOIL SY'_1JEH PERMIT F_9PPI_ICi9l,-.IT FULLS -1-FIE '1'0 THH.". DEPAP,TPlEt--IT DUP.Ilk-IG "I"HE I.-R.L.L.1-3 AD.J17-11:-.:ENT TO [='ROPERTY Alk -ID THE (JF ID['-.** 1,4C THAT riIE IdEL.L. kill -L. SERVE. c: . .1 .1.1 _ ..... ...... _r, 0 A.H fc,u -JR .- Y 11=� IG:, HJ ]] lf:�: EE 1-111 I F7, I ID A (.'.J:'1' FJ I Lft-,IG 01" F=INAL. ANC, AI`-`PRO%.lAL BIT' C,EPARTHE'1,17' kl).'l L BE SUB.,YEIDT TC) f-'ROSE:C-UTIClI'-4. BIETWEEhl A IdELL At. -ID AP -41r' EjhJ :f.'7E 'ElkIFICIE DISPOSAL I.S J.Eii.:'.) FEET f"i PV-.:I%,.1ATE WELL OF"' 1551E., TO 200 F:J_`E"F FIPOH A F-1.1BLIC I.kIELI L'. EPEhIC, J., kIC: Uf"'Oki TI -JF*-.* TYK.' CIF-' PUE'd IC kIELL I. II NI 1 - I I [I-! f'1,JSTI"1I`,ICE F:'RCjPI A kif-El. L TO A PRJAMTE SEI.kIER LIPIE ;-2ri F:T'.'ET Flhff) TO A k1[7JdEF-` LIJ-JE S 7- 171"..'E.T. I. F,,, E- P I E N T.15 I - I FIIr' f -I [--, F' L F1%Jf.'iILABLE TO lt-61JRE: PI-;TIPER fhI_;Tf`IL1 A, FI 0 kl. F":" E:.. KE'." 111 IF-- F�;" a: CERTIP-r' THFIT J., I AM F-AMIL.If:IR WITH THE R'ECAUTREPIENTS FOF--, ON .... '-IITF.,' SE.I.kKERS F::'Of;::T11 THE NUP-11C1PALITY CJ F' AP-401-IMPAGE. 1 1,111 L INSMI.A... THE S'i'l-ITEI-1 :I PI I.-JITI-I THU. CODF.-'S, Trij:iT THFIE Ot-.1--S)'"FE MAY REQUIRE REI-101,11"'LET) TC, INC11111"'fE MORE 'I"l-4411'•1 . ..... . . ..... ..... . ..... P P I- I A lk-IT `;MITI -I C:OI'-,I`'1'_I_RUI'. - . . A TI 0 ILI I'SSIJED E..* AND WELL.S AS SET IF THE I L IE-'A'A C.Y.. ll A=.:_. 1_5m 0 IF`1 %in E--- L.- CA K F= I THE LENG,ri-j DIlcIEhI1`;lO1'-4 Is THE L.Et-41311-i :'Itl F"EE"I") OF' THE" TF?EI',JC:II IR DF_,'AIP-4FIEt C.I. THE C-EPTI-I C"If" F',i'r is T[ -1E I'll BET14EP-4 lE OF' '-f-HE IJRO1 lk-IF..'- Ai%u THE F-':C.ITTCIJeI j'.Jf." THE f...:x:CAVATIOI',I r"11%) F'EET'..I. YIIE3,*,E NO SI :T WIDTH Ff_IR TREN(.HE'_----,. TFIE_ P�. 19 V E. -L C'lEPTI I is THE I-111%.Illell 11 I DEPTH CiF:' G,RA%-lEL. BETI.-IIEF.R-4 THE CIUTI PUT:" AhID THE [-':('YrTOl-1 OF- THE Ek11'CA%.l(-iTION -"P-I FUET). 7 C: LJ 1. 11-_,! If 1 C. 'Y F: -Io P-4 H_ T 1-1,E, J., 0 PERMIT F_9PPI_ICi9l,-.IT FULLS -1-FIE '1'0 THH.". DEPAP,TPlEt--IT DUP.Ilk-IG "I"HE I.-R.L.L.1-3 AD.J17-11:-.:ENT TO [='ROPERTY Alk -ID THE (JF ID['-.** 1,4C THAT riIE IdEL.L. kill -L. SERVE. c: . .1 .1.1 _ ..... ...... _r, 0 A.H fc,u -JR .- Y 11=� IG:, HJ ]] lf:�: EE 1-111 I F7, I ID A (.'.J:'1' FJ I Lft-,IG 01" F=INAL. ANC, AI`-`PRO%.lAL BIT' C,EPARTHE'1,17' kl).'l L BE SUB.,YEIDT TC) f-'ROSE:C-UTIClI'-4. BIETWEEhl A IdELL At. -ID AP -41r' EjhJ :f.'7E 'ElkIFICIE DISPOSAL I.S J.Eii.:'.) FEET f"i PV-.:I%,.1ATE WELL OF"' 1551E., TO 200 F:J_`E"F FIPOH A F-1.1BLIC I.kIELI L'. EPEhIC, J., kIC: Uf"'Oki TI -JF*-.* TYK.' CIF-' PUE'd IC kIELL I. II NI 1 - I I [I-! f'1,JSTI"1I`,ICE F:'RCjPI A kif-El. L TO A PRJAMTE SEI.kIER LIPIE ;-2ri F:T'.'ET Flhff) TO A k1[7JdEF-` LIJ-JE S 7- 171"..'E.T. I. F,,, E- P I E N T.15 I - I FIIr' f -I [--, F' L F1%Jf.'iILABLE TO lt-61JRE: PI-;TIPER fhI_;Tf`IL1 A, FI 0 kl. F":" E:.. KE'." 111 IF-- F�;" a: CERTIP-r' THFIT J., I AM F-AMIL.If:IR WITH THE R'ECAUTREPIENTS FOF--, ON .... '-IITF.,' SE.I.kKERS F::'Of;::T11 THE NUP-11C1PALITY CJ F' AP-401-IMPAGE. 1 1,111 L INSMI.A... THE S'i'l-ITEI-1 :I PI I.-JITI-I THU. CODF.-'S, Trij:iT THFIE Ot-.1--S)'"FE MAY REQUIRE REI-101,11"'LET) TC, INC11111"'fE MORE 'I"l-4411'•1 . ..... . . ..... ..... . ..... P P I- I A lk-IT `;MITI -I C:OI'-,I`'1'_I_RUI'. - . . A TI 0 ILI I'SSIJED E..* AND WELL.S AS SET IF THE XSOILS LOG MUNICIPALITY OF ANCHORAGE \� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION M PERCOLATION JTEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: girl IT /-) ( ' fq/ S7. DATE PERFORMED: CCS "— / 14 x--03 LEGAL DESCRIPTI 1 �bD 3 `Y�-j•� 4 6 G - ' 8 Y cc 9- 10 10 , 11- 12 1 12 a 13 14 17 18 ., t €iobart ft. 3ha9er t" 19- 20 9 Up + COMMENTS SAKIDY (P-AVCL. Tp-RCe CL -6y LCE0-v5E5 4 ! 6 Fd-" v 14- r yv 011se OF A q, SLOPE 3 -11 WAS GROUND WATER /� (, S ENCOUNTERED? / �1 D L 0 P IF YES, AT WHAT E DEPTH? SITE ,l Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE�_(minutes/inch) TEST RUN BETWEEN F AND -- FT PERFORMED BY: CERTIFIED 72-008 (6/79) _- DA MUNICIPALITY OF ANCHORAGE Development Services Department p p `--� Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 050-472-69 Legal description HYLEN CREST #1 BLK 3 LT 3 Site address 10143 STEWART DR Current property owner(s) VERLEY ANDREW Expiration Date: 3/26/2025 X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: By: _EZ4& �, Original Certificate Date: 3/26/2024 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 R05n- O'A }:t Lia. Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 050-472-69 Complete legal description HYLEN CREST #1 BLK 3 LT 3 Location (site address) 10143 STEWART DR EAGLE RIVER AK Current property owner(s) VERLEY 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 3. TYPE OF WATER SUPPLY: ❑ Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units 0 Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: Wo Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ❑® Plastic ❑ Concrete ❑ Fiberglass Age NEW - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed 0 Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ®❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ 'S60 Waiver Fee $ Date of Payment Date of Payment COSA # 05 G 2'-I 107 7 Waiver # COSA Applicationjune 2022 COSA Checklist Legal Description: HYLEN CREST # 1 BLK 3 LT 3 Parcel ID: 050-472-69 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled Casedto ft Total depth ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Comments AWWU WATER SERVICE B. TANK DATA Measured operating fluid level in septic tank NEW Date of pumping NEW ❑ Required maintenance completed, if AWWTS Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 7/25/83 0 ALL standpipes present per record drawing Total measured depth from grade 12.3 ft (max) Measured depth to pipe invert from grade 7.3 ft (min) ❑ N/A —pressurized field. ❑ Per record drawings, field is insulated. A Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: COSA Checklist June 2022 Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by Date C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: Adequacy test date 2/15/24 Results Q Pass Fluid depth prior to test 0 in Water added 450 gal New fluid depth 2 in Elapsed time 1440 min Final fluid depth 0 in Absorption rate 450 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 60 in Effective depth used 0 in Effective depth remaining 60 in E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' ❑o Yes if No _ ft Community Sewer Manhole/Cleanout > 100' Yes if No _ ft ❑ Yes if No _ ft Neighboring Tank > 100' ❑ Yes if No _ ft Private Sewer/Septic Line > 25' [-]Yes if No _ ft Absorption Field on Lot > 100' ❑ Yes if No _ ft Holding Tank > 100' ❑Yes if No _ ft Neighboring Absorption Fields > 100' Animal Containment > 50' ❑ Yes if No _ ft ❑ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑ Yes if No _ ft [�] Yes if No _ ft ❑ N/A - Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' Q Yes if No _ ft Surface Water > 100' Z Yes if No _ ft Tank to Property Line > 5' ❑o Yes if No _ ft Field to Property Line > 10' ❑o Yes if No _ ft Water Main > 10' ❑Q Yes if No _ ft Water Service Line > 10' Yes if No _ ft F. ENGINEER'S COMMENTS Wells on Adjacent Lots: Private Wells > 100' Community Wells > 200' ❑' Yes if No _ ft ❑E Yes if No _ It If tank or field is under driveway comment below G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm 0-0[k�Gl[ 14n d-r.V'6 Ur, A t�-. Phone 7 ZZ -Y iri! L+ Engineer's Printed Name Date ♦ • F OW �a r F� rte• MICHAEL N. ANDLRSCN e _ CE 9469 COSA Checklist June 2022 Municipality of Anchorage On -Site Water & Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 050-472-69 Expiration Date: I I Q 0 - / 60 1. GENERAL INFORMATION Complete legal description HYLEN CREST S/D #1; BLOCK 3, LOT 3 Location (site address) 10143 STEWART DRIVE, EAGLE RIVER, AK, 99577 Current Property owner(s) RONALD & CARRIE PIERI Day phone Mailing address 10143 STEWART DRIVE, EAGLE RIVER, AK, 99577 Real Estate Agent JAMEY WOOD W/ JACK WHITE 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: 230-7653 273-7245 TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System 0 Public Sewer ❑ WaiverNanance request for: N/A Distance: Received by: � Date: COSA to be released to the engineer, unless oche requested by the engineer. COSA Fee $ 'J 2- (o Waiver Fee $ Date of Payment 12-1511,4 c i" P, Date of Payment Receipt Number t,- tis � Receipt Number COSA # Cy�>C N )i I.,Z� 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. l further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, RE. Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD, can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 6. DSD SIGNATURE M t,% System #1 Approved for Y pp bedrooms. System #2 Approved for Disapproved. Conditional approval for bedrooms, bedrooms, with the following Phone 337-6179 Date IL(o ON-SITE WATER AND WASTEWATER YROvRAM. Original Certificate Date: The MurficiparRy brAgodnage Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTCHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory IR- 1109 Nitrate Advisory Arsenic Advisory Other If more than I septic system is on the lot: COSA Checklist # _of_ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: A. WELL DATA Well type Date completed Total depth ft. Date of test Static water level Well production WATER SAMPLE HYLEN CREST S/D #1; BLOCK 3, LOT 3 AWWU If A, B, or C provide PWSID# _ Sanitary seal (Y/N)— Cased to ft. FROM WELL LOG Coliform �_,-� colonies/100 ml. Nitrate mg./L. Vinic: ug./L. Date of sample: B. SEPTIC/HOLDING TANK DATA Parcel ID: 050-472-69 Well Log (Y/N)- Wires properly protected Casing height (abye-§`r( AT Collected by: in. Tank Type/Material SEPTIC/STEEL Date installed 7/25/1983 Tank size 1000 gal. Number of Compartments E Cleanouts (YIN) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (YIN) N/A Date of pumping _ ' P Pumper JR'S PUMPING C. ABSORPTION FIELD DATA VIBELOW EXISTING GRADE Date installed 7/25/1983 Soil rating (g.p.d./WorJ12bdrm 150 System type TRENCH Length 45 ft. Width UNSPECIFIED ft. Gravel below pipe 5 ft. Total depth *12.3 ft. Eff. absorption area 480 ft2 Monitoring tube YES Depression over field NO Date of adequacy test **11/20/2014 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 5 in. Water added 680 gal. New depth 5 in. Elapsed Time: 0 min. Final fluid depth 5 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date - **NOTE: HOUSE WAS VACANT AT TIME OF TEST. DRAINFIELD WAS PRE-SOAKED WITH 2050 GALLONS OF WATER IMMEDIATELY PRIOR TO ADEQUACY TEST. - D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N)_ "Pump on" level at in. "Pump off' level at wa er alarm level at Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES AWWU SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on Public sewer main Sewer /septic service On adjacent On adjacent lots manhole/cleanout Holding tank Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 51+ Property line 5'+ Absorption field 5'+ r Water main 101+Water service line- 10 � Surface water 1001+ Wells on adjacent lots 2004 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation IV+ Water 10'+ Water service line "IV+ Surface water 1001+ Driveway, parking/vehicle storage *0'+ Curtain drain NONE KNOWN Wells on adjacent lots 200'+ F. COMMENTS *SUMP IS 1 FOOT FROM EDGE OF GRAVEL PARKING PAD. WIDTH OF TRENCH IS NOT LISTED ON INSPECTION REPORT. '*WATER LINE LOCATED BY ONE STOP SERVICES; SUMP IS 26+' FROM WATER LINE AT CLOSEST POINT G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date t 1 1'2.(a f t W (Rev. 10/12/12) "qS to + C� 0 4 cLaz-h ASBUtLT-NO CORNERS SET THIS D TE_ SEHARD I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE: FOLLOWING DESCRIBED PROPERTY: 1"=30' Hylen Crest Subd.,Dnit Na- 1,Lot 3,Blk. 3 DATE= AND THAT NO ENCROACHMENTS EXIST EXCEPT AS 2-19-91 INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY GRID- EASE..MENTS, COVENANTS, OR RESTRICTIONS Nw 57 WHICH DO NOT APPEAR ON THE RECORDED SU8D1- VISION PLAT. UNDER NO CIRCUMSTANCES SHOULDrnRAwm. B: 18-70 ANY DATA HEREON BE USED FOR CONSTRUCTION OF FENCE LINES, OR FOR ESTABLISHING ECUND- 4s: 45TH 0#'' ,aeui Ali LS -691a &J �ty_"R7TiL �.i 2•d 1,120-T9S 3de1S e2E:60 1,O 91 unC I ��30 C° F,.c=s --;o \ Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program s r 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. COSA # Z, Expiration Date: 1. GENERAL INFORMATION Complete legal description IVI P Location (site address) /o 14 _2� STE wa1 vLT �Y2 wu Current Propertyowner(s) Ata A LY.�,, 4rr714-rFi,,,r Dayphone Mailing address /otu-2, -r�,A27' T)e i g.ACZeM 1zwe>4- AV_ q4 7-7 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class -�, Well Public Water System TYPE OF WASTEWATER DISPOSAL: ❑ Individual On-site ❑ Individual Holding Tank ID Community On-site 7/1" Public Sewer IVI P The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also Issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the 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 Pannone Engineering Services, LLC Phone 272-8218 Address P.O. Box 102954 Anchorage AK 99510 Engineer's Printed Name Steven It Pannone, P.E. Date S�3o/oYi Engineers Comments: In conducting an adequacy test, l attempt to provide a thorough, conscientious engineering analysis of the system in accordance with h10A DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water aaaa levels that may fluctuate during the year, and the water usage of the family being served by the system. Thesc conditions arc outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that a e o ,# there arc no hidden defects or encroachments. PFS can therefore not provide any warranty for future 00— performance nor give any estimate of how long the system will continue to meet the operational requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed Steven R. Ponnonei. above. Any reliance upon or use of this report by any other person or party is not authorized nor will it �.' No. CE 8149 confer any legal right whatsoever. 5. DSD SIGNATURE ���••aaaa ;'_�.•.� Approved for "2:)_ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory X Well Flow Advisory Nitrate Advisory Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: (�Y lrrc c ag.Em t +a- cv- ParcelID: A. WELL DATA 2f3 moo Well type ALVLVU If A. B, or C provide PWSID # Well Log (Y/N) Date completed _ Sanitary seal (Y/N) _ Wires proper�Zboo /N) Total depth ft. Cased to ft. Casing hei ground) in. FROM WELL LOG INSPECTION Date of test Static water level ft Well production g.p.m. g.p.m. WATER SAMPLE RES S: mL Coliform colonies/100 mL Nitrate mg/L Other bacteria colonies/100 y rsenic: ugA Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material ,�SerpTic /sYmr2t- Date installed Tank size o > gal. Number of Compartments _ Cleanouts (Y/N) Y Foundation cleanout (Y/N) i Depression over tank (Y/N) -e% High water alarm (Y/N) Date of pumping. elliq 108 Pumper rt'2 SAY r 1�t.v C. ABSORPTION FIELD DATA Date Installed�h5%>?y Soil rating (g.p.d.M or ft2/bdrm) /so System type-Ti2"cg Length tie ft. Width 3 ft. Gravel below pipe S ft. Total depth F2 S ft. Eff. absorption area kUCJ ftp Monitoring tube 1 Depression over field t xV Date of adequacy test S5 X141 Results (Pass/Fail) N71� cc For 3 bedrooms Fluid depth in absorption field before test'Dr- in. Water added tiogat New depth Z' in. Elapsed Timer min. Final fluid depth in. Absorption rate >= 1L51> fl g.p,d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N p If yes, give date - D. LIFT STATION Date installed Size in gallons "Pump on" level at _ In. "Pump off' Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer /septic Manhole/Access (Y/N) water alarm level at Meets alarm & circuit requirements? On adjacent lots lots Public sewer manhole/cleanout Holding tank Ani containment areas Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: i a line Absorption field Pro Sf Building foundation �S Property S' 1 Water main /o f Water service line /O i Surface water Wells on adjacent lots ZCL-1 • CrV f" SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /C7 -P Building foundation lVt Water main !c7 Water Service line 167 Surface water / OZ> Driveway, parking/vehicle storage •—O Curtain drain fit• Wells on adjacent lots 7eD F. COMMENTS G. ENGINEER'S CERTIFICATION •'fit, "' O I certify that I have determined through field inspections and 0 a91„ review of Municipal records that the above systems are in ;.»a n conformance with MDA COSA guidelines in effect on this date. 0 — I.." »...;. �.fA-�}Stever. R. PennonM Engineer's Printed Name Steven R. Pannone, P.E. �� ♦ No. CE 8149 Date 5-l•/�E ,, COSA Fee $ y3n /7_5�u Waiver Fee $ Date of Payment �� S Date of Payment Receipt Number Receipt Number (Rev. 11/05) In. Municipality of Anchorage • Development Services Department r - a Building Safety Division -� On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-472-69 HAA# 0g0Z`_ Expiration Date: O 1. GENERAL INFORMATION Complete legal description Lot 3; Block 3; Hylen Crest Subdivision til Location (site address or directions) 10143 Stewart Dr. Eagle River, AK 99577 Current Property ownei�(s) Ron Fisher Day phone. 694-7666 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Day phone Day phone Unless otherwise requested, HAA will be held by DSD for pickup. -�We� 4,, l � /° y 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-siteX] Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A -or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm S & S Engineering Phone 694-2979 Address 17034 N. Eagle River Loop Ste. 204 Eagle River, >AK 99577 Engineer's Printed Name _Robert C. Cowan Date �0 VA �tirryy ,...lr �`wur w rrrr•rsrr • rri:.•pr�.......... 5. DSD SIGNATURE `P� �„ ROBERT C. COWAN V-,*' Approved for bedrooms. +1=% C� - ssot f� Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory . /�Il)1)J)1111i� Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date:�i, (Rev. 01/02) r Municipality of Anchorage Development Services Department =YEA; I 'e Building Safety Division y On -Site WaterWastewater Program - S A F &! T Y 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 ` www.c1.ancnorage.aK.us 1 .(907) 343-7904 - HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: lo; 3 t3 La G� 3 HY.L-I-NC R�rr '-A Pa�rcel ID: o C O t'1 A. WELL DATA YP vide PWSID # a l 3� �r / . Well, Log .(Y/N) Well t e A If A, B, or C,pro Date colmpleted Sanitary seal �(Y/N) Wires properly,pr ed (Y/N) ! Total depth ft. Cased to ft. Casin fight (above ground) FROMWELL LOG '' AT INSPECTION; Date of .test ; ' Static! 1 ater level 9 Well production g.p.m. g.p.m. I I i - WATER SAMPL SULTS: a Coliform I colonies/100 ml. Nitrate Mg./I. Other bacteria colonies/100 mi. A , nic Mg./l. Date of sample: Collected' by k B. SEPTIC/HOLDING TANK DATA " I ' Tank Type /Material _YE-P,`.� s TE L ; 5 Date installetl t 77 � a- S'�8,3 Tank size 160o ,gal. '= Number of Compartments a- Cleanouts(�1) : Y< -S Foundation cleanout/N) `/gl Depression over tank (YAD P o High water alarm (Y/ ley w Date 01`!pum' in b //7 %o `/ P 9 Pumper T C. ABSORPTION FIELD DATA f t,, Date instilled'7I "Ig3 ' ; I Son'rating (g p.d.lft? or t2/b / r0 System t l e TR f, H ;I . nyp Length'! Zi �' ft. E, Width 3 ft. Gravel;below pipe ft. i I Total diep�h I ft. Eff.', absorption area li8o ft2. Monitoring tube 7I -S Regression over field N 0 6 t Date of adIequacy test l' �,7 ° y Results ass Fail) ('ASS i For 3 bedrooms :i Fluid depth in;absorption field before test DRY in. Water added '�Sogal. {j New depth �� in. d t Elapsed me: 60 min. Final fluid depth 1 in. Absorption) rate �>_ ys'y g.p.d. I - I P Any rejuvenation treatment (past 12 mo.) (Y/N & type) � �''''f' Atd'^�,� If yes,' give date � i , I> • r �I D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at High-water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELLON LOT TO: G c✓•�+y y w�2 Septic tank/lift station on lot On adjacent lots Absorption field on lot On adjacent to Public sewer main ublic seanhole/cleanout Sewer /septic se - Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ` S 47 Property line S" 4- Absorption field S 4" Water main 1 O �-t- Water service line l o r+ Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ID 1+ Building foundation 10 1� Water main I o �f Water Service line Surface water 1 ° r� Driveway, parking/vehicle storage O Curtain drain 110pJ1_ K^'owr Wells on adjacent lots MoD rt F. COMMENTS „ ........... G. ENGINEER'S CERTIFICATION r,,:'cj r' r•'•,; ; t��, 1 certify that l have determined through field inspections and * %`' v review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. '"" ROBERT IC.-COWAN J6,66,ti C. CCE=8801 Engineers Printed Name rte,'dy:Olt N /f Date . (o % ny ��`� `rr:---�;• HAA Fee $ 1430. o J Date of Payment Z;L �° y Receipt Number 0 6- u 0 s (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number d"_ ASBUILT-NO h- ASBUILT-NO CORNERS SETITHIS DATE. SEWARD & ASSOCIATES LAUD SURVEYING 688-4 SC 1 HEREBY CERTIFY THAT I HAVE SURVEYED THE"` ' FOLLOWING DESCRIBED PROPERTY= OF Al � Hylen Crest Subd. ,Unit No. 1,Lot 3,Blk. 3 - DATE: AND THAT NO ENCROACHMENTS EXIST EXCEPT AS 2-19-91 "� : '• . -•rte '•.!,,. INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY GRID: EASEMENTS, COVENANTS, OR RESTRICTIONS NW 57 WHICH DO NOT APPEAR ON THE RECORDED SUBDI- VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB: 18-70 ANY DATA HEREON BE USED FOR CONSTRUCTION OF FENCE LINES, OR FOR ESTABLISHING FOUND-D� _ 45TH ^ 01,cro�c� •.�G * ' Qvn� lNuk 5.•+•rd � per' 1 LS -6918 L s 2'd .1?I2D-I9G ddeIS e2C=60 -b0 9I unr I MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # D SO 7 — cl HAA # 1. GENERAL INFORMATION Complete legal description Lot 3; Btock 3; Hy.E'en Dcest ;41 _ Location (site address or directions) 10143 S,tewak t Dkiv e Riven.. AK Property owner Nancy 9 Tim Kan,now.5k Day phone 694-4359 Mailing address 10143 S.tewakt Dkive Eagle Riven, AK 99577 Lending agency Day phone Mailing address Agent Kathi 02mstead/ Remax a6 Eagte Riven. Day phone 694-4200 Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well Public water XXX 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 XXX 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 021 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. S & S ENGINEERING Name of Firm 17034 Eagla River Loop Road No 204 Phone L� y — 7 Address Eagle River, Alaska 99577 Engineer's signature Date 6. DHHS SIGNATURE Approved for 7 14��� Nbedrooms. By: Disapproved. Conditional approval for Additional Comments 1 OF q .►` ... ? ROBERT C. COWAN f `p'J . CE - 8801 bedrooms, with the following stipulations: Date G$f, 817 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 courtesyto 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-M(Rev.1N1) Back MOA1121 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 1325"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) IPWITY OF ANCHORA ENVIRONMENTAL SERVICES DIVI AUG 161996 Health Authority Approval Checklist Legal Description: t✓o-C d 13tom- -,3 N�-I 6.�,3 �F t Parcel I.D.: RECEIVED . -y7D _6cj A. WELL DATA Well type Log present (YIN) _ Total depth Sanitary seal (YIN) Date of test Static water level Well production If A, B. or C. attach ADEC letter. ADEC water system number WATER SAMPLE RE -SULTS: Date completed Cased to FROM WELL LOG Coliform / Nitrate g•p.un. Casing height (<iye<eground) Wires pjererly protected (YIN) of sample: Collected bv: B. SEPTIC/HOLDING TANK DATA AT INSPECTION Other bacteria g.p.nn. Date installed % ' fin' (Tank size 4-oc>" Number of Compartments � _ Clcan(�outs N)� Foundation clettnoul) Depression (Y High water alarm (Y__ Date of Pumping FSS tr�`�� Pumper C, ABSORPTION FIELD'DATA J, Date installed % a Soil rating (g.p.d./ft` or ft`/bdrm) /S l Systcm type Tr-1Eg/C lV Length V4( _Width a"7' o— Gravel thickness below pipe 6 -Total depth Effective absorption area gAPO Monitoring Tube present�N)_V _Depression over field (YQ iJ Date of adequacy test _S� t 5�' % L Result a ail) r41F, For _ 3 bedrooms Fluid depth in absorption field before test (in.); D Immediately after7W gal. water added (in.): 6-9 Fluid depth ;-r (ins.) Minutes later: /y "� Absorption rate = _ ' :Q) r g.p.d. Peroxide treatment (past 12 uiontlis) (YQ) If yes, give date F V�kfid 1/i=��C., l2dSh 1b 0y µ /J I Sr Sev `�fhC D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* E. SEPARATION DISTANCES Size in gallons .'Pump on•, *Datmm SEPARATION DISTANCES FROM WELL ON LOT TO: "Pump off' level at* Septic/holding tank on lot On adjacent lots Absorption field on lot ots Public sewer main Public sewer manhole/cleanout tc service line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: .t Building foundation 5- 1 Property line /) t Absorption field 5-4. Water main/service line /0 iL Surface water/drainage /ow Jt- Wells on adjacent lots 1�141 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation /v t Water main/service line 1Z) t Surface water 100 t Driveway, parking/vehicle storage area / t Curtain drain z' /.a- Wells on adjacent lots Nf/,A Property line /0 t / F. ENGINEER'S CERTIFICATION 1 certif that 1 have determined thru field inspections and review ofAlfunicipal records thaw in cw7farmance with A10 t1AAdeliness effect on this date. �P Signature (J n� Engineer's Name /l ooyt-e i C_ Co'.41V Date HAA Fee $ 05D . d -V Waiver Fee $ Date of Payment /,1144�c, Date of Payment Receipt Number ll) / % a ) Receipt Number Rev. 8/95 OSS: liaa.wk.doc r� • s are ROBERT C. COWAN + i• CE - 8801 n� MUNICIPALITY OF ANCHORAGE � • DEPARTMENT OF HEALTH & HUMAN SERVICES t Division of Environmental Services �}� On -Site Services Section r P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D.#HAA# 1. GENERAL INFORMATION Complete legal description Lot 3; Btock 3; Hyten C)ces.t SubcGivi.6ion; Location (site address or directions) 10143 S,tewa)tt D)Live Property owner Venni s Roper. Day phone Mailing address 10143c.Ii �. rig ! .� •• Lending agency— Seat -.Pp- Mnntgage Conpnnat on Day phone Mailing address Agent Audn.ey Mason RE/MAX OF EAGLE RIVER Day phone 644-4200 Address 11 Ce.pteAAJPjrJ /r I ■aq0 r e ! rr Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well Xx Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA 421 5. M 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 Phone S S S EiNGINE-ERS NG Address 17034 Ea, Ia River Loon Po r Eagle River, Alaska 99577 Engineer's signature STANDPIPE ON THE SEPTIC TANK HAS BEEN REPAIRED. DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for Additional Comments Date 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 421 MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services M DIVISION OF ENVIRONMENTAL SERVICES wh i 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # Cf n - LI —)- ( n01 HAA # 1-� ��� t IC_\14.1 1. GENERAL INF<,41MATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 3; Block 3; Eivlen Crest Subdivision Location (address or directions) 10143 Stewart Drive, Eagle River, Alaska (b) Property owrn r Dennis Roper Telephone : (home) Business Mailing Address (c) Lending Institution SEATTLE MORTGAGE CORPORATIONrelephone Mailing Address (d) Real Estate Company and Agent RE/MAX OF EAGLE RIVER -- Audrey Mason Address — 16600 Centerfield Drive Suite 201 Eagle River, Alaska 99577 Telephone (e) Mail the HAA to the following address: (or check here N, if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING/694-2979 1703-'_ Eagle River Loop Road, Suite 204, Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single -Family ❑ Number of bedrooms 3N 3. WATER SUPPLY Individual Well ❑ Communityft 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-site [,� 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 Z jo Z aged A068 (99/1'AGH) 9ZO-ZL •>laoM s,jeaulbua leuolssajoid agl ul suolsslwo ao saoaaa aoj alglsuodsaa jou si a6eaogouy jo Al!ledloiunW agl'panssl sl ajeoljljaao a aaojaq elep azAleue ao suoljoadsul Ion puoo lou op SHHO jo sea (oIdw3 •sluewaalnbei 91e18 pug Ieaapaj uleliao Alsilgs of aapao ui suollnl!lsui bulpual alagj pug sawog jo saasegojnd of Asalinoo a se slgl saop SHHO OU 'e�sely jo GIMS agj ul paaajsl6aa aaauibue leuolsseloid luepuedepul uv Aq anoge 9 4doil5wed ul uanl6 suoljejuasaidej agj uodn Aluo paseq paleolipao lenoaddV Al!jogjny g11eaH sanss! (SHHa) saolnaaS uewnH pug gllgaH jo juawlaedaa a6eaogouy jo /QlledlolunW agl leuoljlpuoO 97 �-� lenoaddy leuo1jlpuo0 jo swaal panoaddeslp panoaddy / G ' at- _ ajea -n-v'" -rn /v'� (q swooapaq�T,� J j panoaddy VVI/ (l ''1V'A�O(1>idd`d SHHa '9 � :' ldaS ,aaaui6u „� v -T66T 16uiads - pa.zigdaa aq oq si �,[u2q ozgdas uo adidpuags aled 1 — 2 LLS66 a)iSe1y'aan1N allies NW. ssaaPPV 1e Z ouogdelal wall 10 aweN •uo1loodsu! slgj jo alep agj uo joega ui suoljelnbei pue 'saougulpao 'sapoo ajejS pug lgdlolunW lle gj!rn aouelldwoo ul si we.1s�(s lgsodslp aajgMajseM jo/pug �(lddns aaleM ajls-uo agj 'uoljoodsul pue uoljgbljsanul AW woaj pus sell} a6eaogouy jo AjlledlolunW ag1 woaj paulelgo uoljewaojul agj uo paseq jegj (jlaan aagjanj ! 'ulaaag pajgolpul ainjonajs jo ads l pug swooapaq jo aagwnu agj aoj ajenbape pug 1euo1lounj 'ajgs sl wajs (s lesodslp aajeMalseM ao/pue (lddns aaleM aj!s-uo aqj 1eg1 sMogs lgnoaddy (jlaogjny gjleaH slgj jo uo1je6ljsanu1 AW jegj (jlaan ! 'Molaq uMogs ajep uoljep!len agj jo se pue ojaaag paxljje leas Aw Aq paljlpao sy NOIlVYYHOdNl ONV V1VO `HOHV3S 3'1Id `S1S31 `SNOI.LO3dSNl ONIOIAOad Wdid ONIH33NION3 'S MUNICIPALITY OF ANCHORAGE (MOA) • Health Authority Approval (HAA) CHECKLIST - FEBRUARY 19841 343-4744 Legal Description:)00 a X99 A. WELL DATA �C^\`V/� Well Classificati \ / If A, B, C, D.E.C. Approved (5)/N) Well Log Present (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Date Completed Electrical Wiring in Conduit (Y/N) Depth of Grouting Pump Set At Yield Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot k Zoo\ Y ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot 20 ` ` ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by To Nearest Public Sewer Cleanout/Manhole ; Date Water Sample Test Results CoI"mments R.JS IDS B. SEPTIC/HOLDING TANK DATA Date Installed % � 6-S Size 10,oc) No. of Compartments Standpipes N) — —_Air -tight CapsLDN) _Foundation Cleanout ON) N Depression over Tank (Y/O ►J Date Last Pumped - 2..- 1 L. - °t Pumping/Maintenance Contact on File (Y/N) r-114, ; for Holding Tank High -Water Alarm (Y/N) t-� Ilk Temporary Holding Tank Permit (Y/N) 1A, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well o To Building Foundation SIA - To Property Line to'r To Disposal Field S tk To Water Main/Service Line 1 O'A- To Stream, Pond Lake or Major Drainage Course (D Comments 1J IP( -Pz_ 13 V_ 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absgtytition Strata 15D4/5 —• Type of System Design Date Installed ' g3 Length of Field 9g Width of Fiefd �3D r Depth of Field /2 S� Gravel Bed Thickness V are Fjpo�f An Area gU� Statndpipes Present &N) v��r JS-�l Depression �C " %Id (Y&� Date of Last Adequacy Test ?-- Results of JAdequacy Test .SA-fISr-Srr-01e- 3 a42S SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well ZvC7`'� To Property Line Io, To Building FoundatioC=> To Existing or Abandoned System on Lot tj ; On Adjoining Lots 3a %+ To Water Main/Service Line lb` To Cutback (if present) ' /'r To Stream, Pond, Lake, or Major Drainage Course \o a , } To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed e in Gallons "Pump On" Lev . High Water Alarm Level at Tested for Meets MOA Electrical CDe Comments Dimensions Manhole/Access (Y/N) '"Check Permitted Bedroom Rating Against HAA Request" "Pump Oif=Ee9-e] at Vent(Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed 1%n ` ,_.,jlc_ River loop Road No. 204 ti r �.at�, `'' fVE; r '. Company Date 2� ^ % ? - e7l MOA No. C'c Qo - OFA 3 Receipt No. Date of Payment Amount: $ 1:70 Receipt No. Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 i I I 'i.� i cl r ! WALTER J. HICKEL, GOVERNOR r DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE T,113STERN DISTRICT OFFICE!, 3601 (1 � STREET, SUITE 322 ANCHORTV,31], A1,ASZA 99503 FOR: S & S Engineering Attn: Rodney P'qSIJ): .1213289 January 563-6775 ..y review -O view of the records on file in this OffiCa reveals that the Hylen Crest Subdivision C1,1s. A Public Plater System is in n compliance With the provisions of 10 80.0601 State of Alaska Drnifing '-later "le-gulations. I,- If a ii Sincerely, Narnowski EnvironmQnllcal Engineer �r�L�, -� � �� fi gteq Hereon,; kas ;, ,w.-,�-c--:-,� 19 tJ ,. t ! ' .. �� �r�L�, -� � �� fi gteq Hereon,; kas ;, ,w.-,�-c--:-,� 19 tJ MUNICIPALITY OF ANCHORAGE DIVISION OFENWRONMEN'TAL, HEALTI DEPARTMENT OF HEALTH AND ENVIRONMENTAL, PROTECTION APPLICATION FOR HEAL'T'H AUEHORITY APPROVAL CERTIFICATE 1. General. Information (a) Legal Dascri.pti.or. ( include Location (address or directions) Application Date block�e subdj,vis.i_on, cj�,cticn, tr--,-A.ship, range) (b) Applicants Name CG<�Jl /-/,/ 'ib lephone --S- 6 /m .5 y/ / Appl. icants Address, >> (� �) Ar<.(' T tG f�/• l.`/)• �,! / "I c rt -1 c ;7 �%� , --- (c) Applicant is (check orr-) TPrding InstitutionOwrer/bui.l(br ; Buyer [� ; Other [�j (explain); (d) Iordirg Tnsti.tuti.on - Telephone Address (e) Real Estate Co. & Agent'G_I�l�l Addr.!ess Telephone 2. 'T Re of Res:i.dence S i rgle--Family Number of Pp-drocros 3. water_ Supply Individual Nbll .__<TIT - Multi -Family F� Community Other (cbscrith Public C,- /7 s: S' A. Note: If comffunity mll system, must have written confirmation from the State Department of L.'nvirommntal Conservation attesting to tYe� legality and status. Is the well adequate for the number of bedroans specified in this HAA(Y . L--.- 4. Sebe Disposal Onsite Public Fel Cormnunity Holding Tark, I• Is the 4nstewater disposal system adequate for the rmiber of bodroms (YA [Page 1 of 21 2-15-84 5. Engineering Firm Providing Ins actions, Tests, Data and Information I certify that 7 have;clocked, verified, or conformed to all MOA HAA Guidelinas in effect on the &ate o� thn:L ins.tion. 5igimd LZZ Date A'll' Name of Film AddresEe_. :i igr A by( tt ra�lR(�$IIVF rI, /v.11,d�1 Date (ENGINEER SENT) 6. DHEP Apmoval Approved for_ bedrooms Approved PQ Disapproved Q�j Perm, of CoApproval To r9 Conditional I--10 .9fP rti,'�i1IIt'�( ad'; q� Date / <I Y The Municipality of Anchorage Department of Health and Environmy-.ntal Protection does not guarantee the continued satisfactory performance of tl�e water supply and/or the wastewater_ disposal system. This approval indicates that, as of the validation date shown above, based on the data and information furnished by an engineer registered in the :hate of Alaska, the water supply and wastewater_ disposal system is sate and fun(--, tional for the number of bedrazns and type of structure indicated. (OHEP SEAL) 7, Mail the HAA to the following address: KB2/d5/s (.Page 2 of 21 ?.-15-84 MUNICIPALITY OF ANCHORAGE (MOA) `•'I `"I I HEALTH AUTHORITY APPROVAL (HAA) vffi T � �V W CHECKLIST - FEBRUARY 1984 N0I1J3214 1V1N3WNOMN3 A. WELL DATA i Legal De cr' ptio — Cr Well Classification If A, B, or C, 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 Lott To Nearest Edge of Absorption Fie To Nearest Public Sewer Line Cleanout/Manhole Pump Set At A D.E.C. Approved(Y/N) Yield Depth of Grouting Sanitary Seal on Casing (Y/N) Depression Around VJkllhead (Y/N) On Adjoining Lots _; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot Water Sample Collected By ; Date Water Sample Test Results Comments �'L-/� 5'S' /� G�G�(i� �7 '✓ B. SEPTIC/H6B83WA,TANK DATA Date Installed 'Z5 -f; SizeNo. of Compartments 2 - Standpipes O Air -tight Caps 619) Foundation Cleanout (8� Depression over Tank ( Date Last Pumped )r/ _ Pumping/Maintenance Contract on File (Y/N) /y•(1 ; for _ Holding Tank High -Water Alarm (Y/N) f l Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: �To Water -Supply Wbll lv_ To Building Foundation Z";)/=- To Property Line //?/� To Disposal Field To Water Mair1/,Service Line PC/13L-% C To Stream, Pond, Lake, or Major Drainage Course Commnts G6, (Page 1 of 21 6LCI'l stir Siy€ OF [�cc�sc — 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata `e ' i _ Type of System Design Date Installed Length of Field Width of Field �D 1' Depth of Field d Gravel Bed Thickness "' Square Feet of Absorption Area Standpipes Present (Y/N) Depression over Field (*/W Date of Last Adequacy Test � Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well 1poaz_/G To Property Line To Building F undation 'Zo lt, To Existing or Abandoned System on Lot_ �/j ; O,n7Adjoining Lots 30 To Water Main/Service Line f vBL/,L-, To Cutbank(if resent) A To Stream/Pond/Lake/or Major Drainage Course IYZA To Driveway, Parl ing Area, or Vehicle Storage Area 2-0 '� Com ents D. LIFT STATION Date Installed Size in Gallons i "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(YM) Continents Dimensions Manhole/Access (Y/N) "Pump Off" Level at / Z k Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify tha I ave checked, verified, or, conformed to all MOA HAA Guidelines in effect on theA11.111�1 of ion. Sianed / Date(_�_X7,*1- CoTrpaoiv/ b { MOA No. UAD I9PJ)C KB1/d5/s (Page 2 of 21 .7.r.:,.,.- 2-15-84 DEPT. OF ENVIRONMENTAL CONSERVATION SOUTHCENTRAL REGIONAL OFFICE 437 "E" STREET, SUITE 200 ANCHORAGE, ALASKA 99501 DATE: s- — 12 F — PWS I. D. # 2 /-2 o� q/' / To Whom It May Concern: BILL SHEFFIELD, GOVERNOR Telephone: (907) Address: 274-2533 According to records on file in this office the Water System is in compliance ith the State Drinking Water Regulations. Sincerely, v