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Home My WebLink AboutHYLEN CREST #3 BLK 4 LT 2Hyl n Crest lock 4 Lot 2: 050-474 -16 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: '~(A) ~Z-O I~.~ PID Number: O~ Name: E==~ ~ ~1~ ~ Wastewater System': ~ New ~ Upgrade Address: Fo~ ~t~ ~~ ~ ~5~4 ABSORPTION FIELD Phone: ~¢~ No. of BeSoms: ~ Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other LEGAL DESCRIPTION so, Rating: Total Depth from original grade: I. ~ GPD/Sq. Ft. ~ / Lot; ~ Block:~ ~Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe Townsh~p~ Range: )~ Sectio~:~[~ ~8 Fill added above~original grade: Ft. Gravel length:~of Ft.- WELL: ~ New ~ Upgrad~ Gravel~ ~ Numberoflines: Oistancebetweenlines: Classification (Private, A,B,C): Total Dept~ ~ased To: Total absorption area: Pipe material: Driller: ~~% - StsticWater Level: Installer: Date installed: ~~..v,~,.. GPM ~at: Casing Height Above Ground: TANK Fi, Ft. SEPARATION DISTANCES ~Septic ~ Holding ~ S.T,E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacily in gallons: From Tank Field Station Tank Sewer Lines ~ ~ ~ I ~ O ~ ~,% Material: Number of Co~artments: Well ~v ~~ Surface ~' Water ~' ~' / ~ LIFT STATION Lot Line ~%~ ~ ¢~ +t~ Size in gallons:~ Manufacturer: ~ ~ ~ound~tio. ~ [ ~ ~. -- "~.~, o." ~ve~ ~:~,~v~ ~: ,i~, w~r ~.~ ~: Pump Mak~l Electrical Inspections performed by: CurtainDrain ~ ~ ~D~ ~ Remarks:~~ ~ F~a~ ~Ns~o4 ~¢~ ~ BENCH MARK Location and Description: n,,e tion , rfor ed : ate :lst Department of Health and Human Services approval '~*~':%~,%,, ..,, Reviewed and approved by: ~ ~~ Date: ~ ~(~ , ' 72-013 (1/91) MOA 25 Permit No. Page of 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: PID No.: (~0 4'~' 72-013 A (2/91)MOA 25 ~ PAGE 1 OF 1 ~- /~,~z- 3'~,~;~ //u~ MUNICIPALITY OF ANCHORAGE ~ ,~,,,~ ,~ . , .o. , , "-- ' - ANCHORAGE, ALASKA 99519-6650 L2"~ ~'~$~¢~- J'~r /.~ ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT~"~LO~ PERMIT NUMBER:SW920173 DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC. OWNER NAME:EAGLE RIVER VALLEY DEV OWNER ADDRESS: PO BOX 141907 ANCHORAGE, AK 99514 DATE ISSUED: 7/09/92 EXPIRATION DATE: 7/09/93 PARCEL ID:05047416 LEGAL DESCRIPTION: HYLEN CREST UNIT #3 BLK 2 4 LT LOT SIZE: 20014 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: THIS SYSTEM MUST BE INSTALLED IN ACCORDANCE WITH THE APPROVED ENGINEER'S DESIGN DATED 7/2/92. RECEIVED BY: ~ ~%~/~'--' ISSUED BY:~ DATE ABSORPTION SYSTEM DESIGN DETAILS ABSORPTION AREA CALCULATIONS: Minimum Required: 4 Bedrooms x 150gpd/bedroom = 600 gpd capac±ty Soils rating, proposed addition, 1.2 gpd/sf Minimum sizing: 600 gpd + 1.2 gpd/sf = 500 sf absorption area Use 3'W x 50'L x 6' effective* D = 500 sf minimum for trench * 8' trench depth - 2 ea 1' thick silty sand layers = 6' effective depth IMPACT ON ADJACENT LOTS: There are no public wells within 200' of this absorption system. There are no private wells within 100' of this lot. The proposed absorption system has no impact upon any adjacent lots as shown on attached site diagram. ENGINEER' S SEAL DESIGN DETAILS PROPOSED WASTEWATERABSORPTION SYSTEM LOT 2, BLOCK 4 HYLENCREST SUBDIVISION, #3 PREPARED FOR: MICHAEL QUINN ~x 7-7-4~-4~ig'~Z4 ~'~ EAGLE RIVER, AK, 99577 NOT TO SCALE CONSTRUCTING ENGINEERS346-2000 9601 BUDDY WEANER DR 694-9098 ANCHORAGE, AK, 99516 DRAWN BY CAL 7 - /'-9L DI~AWING # 92-S2-06-2 ABSORPTION SYSTEM DESIGN ' t :1// / / ? t'-A DESIGN DETAILS PROPOSED WASTEWATERABSORPTION SYSTEM LOT 2 BLOCK 4 HYLENCREST SUBDIVISION, #3 PREPARED FOR: MICHAEL QUINN PO-BOX 7~195~1C~ke,~'nk EAGLE RIVER, AK, 99577 SCALE: 1" : 30' CONSTRUCTING ENGINEERS3~6-2000 9601 BUDDY WERNER DR 694-9098 ANCHORAGE, AK, 99516 DRAWN BY CAL DRAWING # 92-S3-06-2 SITE PLAN-WASTEWATERABSORPTION SYSTEM SITE PLAN DETAILS PROPOSED WASTEWATER ABSORPTION SYSTEM LOT 2 BLOCK 4 HYLEN CREST SUBDIVISION, #3 PREPARED FOR: MICHAEL QUINN EAGLE RIVER, AK, 99577 SCALE: 1" = I00' DRAWN BY CAL CONSTRUCTING ENGINEERS 346-2000 9601 BUDDY WERNER DR 694-9098 ANCHORAGE, AK, 99516 '7 DRAWING # 92-SI-06-2 Municipality o! Anchorage DEPARTMENT OF HEALTH & HUM"' / ¢~{'-'-- _ 825 "L" Street, Anchorage Alaska LC SOILS LOG-- PERCOLATIC ' . LE6ALDESCRmTON ~ ~l~~ Township Ran, SLOPE 8 9 I0 11 12 13 14 15 16 17 18, 19- 20- WAS GROUND WATER Al O ENCOUNTERED? /V S IF YES, AT WHAT L DEPTH? /'k//D~ pO E Doplh to Waler After Monitoring? Dale: _ ~° Reading Date Gross Net Depth to Net Time Time Water Drop % ¢o~k )o~,;,. 0~/~'/~'' I,~. ~ t~ ,'.1 A' :)),: PERCOLATION RATE 4' (minutes/inch) PERC HOLE DIAMETER ~" TEST RUN BETWEEN ~ FTAND C _~FT PERFORMED BY; ~5~O~X~ ~"~ ~~ CERTIFY THAT ~HIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~- ~O~ 72-008 (Rev. 4/85) Parcel I.D. 050-474-16 Certificate of On -Site Systems Approval Expiration Date: 1S —C �, ^2.020 1. GENERAL INFORMATION Complete legal description HYLEN CREST #3 BLK 4 LT 2 Location (site address) 10219 Stewart Dr Current` property owners) PLOOF NATHAN Day phone 907-500-2724 Mailing address Real estate agent owner Day phone �1b ro 7p �r 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) Q AUG 0 a 219 ❑ Duplex ❑ Multiple Dwellings.(Single Family and/or Duplex) �Aj << 3. NUMBER OF BEDROOMS: 5 �� 6 8 L 9 4. TYPE OF WATER.SUPPLY; TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic El Water`Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System F Public Sewer ❑ Waiver request for: Received by: Date: COSA to be released to the engineer, unless othenmise requested by the engineer. COSA Fee $ �� / Date of Payment �! /a ll q Receipt Number Q l 71-15-b COSA# 6�5CLg1371 Waiver Fee $ Date of Payment Receipt Number Waiver # Distance: 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 8/7/19 ''/J))t a ►��ll�t' Original Certificate Date: e-1 5---1 ? — 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 Septic System Advisory Well Flow Advisory COSA Checklist blue sheet Nitrate Advisory Arsenic Advisory OtherOta-��i/' 6. DSD SIGNATURE 9 � a ; 4 System #1 Approved for bedrooms ss V — System #2 Approved for bedrooms _ q Steven ,V. Eng e w Disapproved �� ,4� ano �� FESS Conditional approval for bedrooms, with the following stipulations` ,=,; . , ''/J))t a ►��ll�t' Original Certificate Date: e-1 5---1 ? — 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 Septic System Advisory Well Flow Advisory COSA Checklist blue sheet Nitrate Advisory Arsenic Advisory OtherOta-��i/' Legal Description: HYLEN CREST #3 BLK 4 LT 2 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to 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 B. TANK DATA Age of tank(s) 7711 92 years Tank type/material Steel Measured operating fluid level in septic tank 49 ❑ Standpipes/foundation cleanout per record drawing Date of pumping $/6/19 _ D. ABSORPTION FIELD DATA 7/12/92 Which system tested (date installed) 7/12192 ❑ ALL standpipes present per record drawing Total measured depth from grade 12 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective 9' ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 050-474-16 Structure served by this system Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑ N ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by _ Date of Sample C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 7/26/19 Results ❑✓ Pass For 5 bedrooms Fluid depth prior to test 65 in Water added 750 gal New depth 77 in Elapsed time 60 min Final fluid depth 66 in Absorption rate 750 gp.d Any rejuvenation treatment (past 12 months) no If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Yes Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft ❑ Yes if No Neighboring Tank > 100' ❑ Yes if No ft Private Sewer/Septic Line > 25' ❑ Yes if No Absorption Field on Lot > 100' ❑ Yes if No ft Holding Tank > 100' ❑ Yes if No Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' ❑ Yes if No ❑ Yes if No ft if No ft F. ENGINEER'S COMMENTS Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑ Yes if No ft ❑ Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ✓❑ Yes if No ft Surface Water > 100' ft ft ft ft ft U 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' ❑✓ Yes if No _ Water Main > 10'✓❑ Yes if No ft Community Wells > 200' ❑✓ Yes if No _ Water Service Line > 10'✓❑ M Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10'✓❑ 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'✓❑ Yes if No ft Private Wells > 100' Yes if No Water Service Line > 10' M Yes if No ft Community Wells > 200'✓❑ Yes if No Surface Water > 100' ✓❑ Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION l certify that l have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet ft ft M ft Septic Tank Advisory Certificate of On -Site Systems Approval #OSC191371 Subdivision: Hylen Crest #3 blk 4 Lot 2 Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this property is 27 years old. Typical replacement costs range from $6,000 to $9,000. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 20 year old steel tank MAY look like. x�� i �� I re Pr �� 966 tagW110#_ 665 r vu ri� org �� 189 /0 • • h >4> 1- a6, • r Municipality of Anchor. ° A� _° = On Site Water and Wastewater Progr-m ��'. (907) 343-7904 MAY 16 Z017 i li E,Y ti tea. w Certificate of On-Site Systems Ap. b Ot 6 8 L9�� Parcel I.D. 050-474-16 Expiration Date: 1. GENERAL INFORMATION Complete legal description Hylen Crest #3, Block 4 Lot 2 Location (site address) 10219 Stewart Drive Current Property owner(s) Rodney & Angela George Day phone Mailing address 10219 Stewart Dr, Eagle River, AK 99577 Real Estate Agent Day phone 2. TYPE OF DWELLING: E Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 5 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual L] Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community Cl Public Water System Public Sewer ❑ WaiverNariance request for: Distance: Received by: (;.G041,{.60i *1-1 Date: 5//q//7 COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ E'7--Ce Waiver Fee $ Date of Payment S 111 1 11 Date of Payment Receipt Number oL 32-SC- Receipt Number COSA# �7CI-1 l t g6 Waiver# 5. STATEMENT OFtelfa_fitTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Engineering Phone 5. 22-7773 Address PO Box 240773, Anchorage, AK 99524 Engineer's Printed Name Benjamin SchillerDate 5/9f2017 •1! •i 4, • 6r Li 6. DSD SIGNATURE ....., System #1 Approved for -"�� 1�_12592 ` s"j bedrooms $� System #2 Approved for bedrooms �; '� ••L11I.0•••�c� �" Disapproved �� PhlOn gEsS101, ' Conditional approval for bedrooms, with the following stipulations: --55- Fie td l he 25- ear ON-SITE 5G% WATER AND 2 WA STCWATEk z cr PROGRAM =y: A Original Certificate Date: 57-1 —J7 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 blue sheet .c - c If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Certificate of On-Site Systems Approval Checklist Legal Description: Hylen Crest #3, Block 4 Lot 2 Parcel ID: 050-474-16 A. WELL DATA Well type Public If A, B, or C provide PWSID# 213289 Well Log (Y/N) Date completed Sanitary seal (Y/N) Wires properly protected (Y/N) Total depth ft. Cased to ft. Casing height(above ground) in. FROM WELL LOG AT INSPECTION Date of test Static water level ft. _ ft. Well production g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate mg/L Arsenic ug/L Date of sample. Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 7/11/92 Tank size 1 500 gal. Number of Compartments 2 Cleanouts (YIN) Y Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping S / , 1 7 Pumper ((%ISP S . C. ABSORPTION FIELD DATA Date installed 7/12/92 Soil rating (g.p.d./ftl or ft2/bdrm) 1 .2 GPD System type Deep Trench Length 50 ft. Width 3.5 ft Gravel below pipe 8.0 ft. Total depth 12.2 ft. Eff. absorption area 800 ft2 Monitoring tube Depression over field N Date of adequacy test 5/3/17 Results (Pass/Fail) Pass For 5 bedrooms Fluid depth in absorption field before test 58 in. Water added 750 gal. New depth 78 in. Elapsed Time. 1 320 min. Final fluid depth 58 in. Absorption rate >= 750 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm& circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot >100On adjacent lots >100' Absorption field on lot 100' On adjacent lots 100' Public sewer main >75' Public sewer manhole/cleanout >100' Sewer/septic service line >25' Holding tank >75' Animal containment areas >50' Manure/animal excrete storage areas 100' SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Absorption field >5 Water main Water service line Surface water 100 Wells on adjacent lots 100' ABSORPTION FIELD ON LOT TO: Property line Building foundation_>10 Water main X10 Water Service line Surface water >10>10' Driveway, parking/vehicle storage >10' Curtain drain None Noted Wells on adjacent lots >100' F. COMMENTS G. ENGINEER'S CERTIFICATIONg: '•' �' ••4'C4 i I certify that / have determined through field inspections and • -=- ''•'f,.,' review of Municipal records that the above systems are in * A •.,'g¢tiLd conformance with MOA COSA guidelines in effect on this date. - , -s' Benjamin Schiller . ' ••-•M• Engineer's Printed Namei ile d Date 5-9-2017 ‘.10. -7 �` C�• ,.• COSA brown sheet 10-10-12.doc Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and 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 FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-474-16 GENERAL INFORMATION Complete legal description Location (site address) COSA# O~)~-I\ \\ Expiration Date: ,~- Hylen Crest Subdivision No. 3, Block 4, Lot 2 10219 Stewart Drive 'Eagle River, AK 99577 Current Property owner(s) Curtis and Roxane Stoner Mailing address 1018 North 7th Street Tacoma, WA 98403 Lending agency Day phone Day phone Mailing address .,~ ~1 Estate Agent Mailing Address -Urtless Ot,.;~etwi~O~ roquested, COSA will be held by DSD for pickup. Day phone 2:,' ~Ui~I'B~Ei~Ol~ BEDROOMS: ' :3:~ TYPE OF'WATER SUPPLY: I'ndiVidUal Well [] Individual Water Storage [] Community Class Well [] Public Water System [] Five (5) TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding Tank [] Community On-site [] Public Sewer [] 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 orB wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professiona! engineer's work. 4. STATEMENT OF INSPECTION By ENGINEER o As certified by my seal affixed hereto and as of the validation date shown below, I vedfy that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Engineering Phone 522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, .P.E. DSD SIGNATURE ~v/'/' Approved for ~ bedrooms. Disapproved. Date 45/17/2011 ~, ~_'N~,o° '.. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other (Rev. 11/05) riginal Certificate Date: ~.~':'- / ? "' / ./ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.orglonsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: A. WELL DATA Well type Public* Date completed Total depth ~ Date of test Static water level Lot 2, Block 4, Hylen Crest Subdivision, Addition'No. 3 Parcel ID: 050.474-16 ft, IfA, B, or C provide PWSID #213289 Sanitary seal (Y/N) Cased to ft. FROM WELL LOG Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION Well production WATER SAMPLE RESULTS: Coliform colonies/100 mL Arsenic: ug/I SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Tank size 1,500 gal. Foundation clean0ut (Y/N) Y Date of pumping 8/25/09 ABSORPTION FIELD DATA Date inStalled 7/11-12/92 Length 50 f. Total depth 12.2 ft. g.p.m. Nitrate rng/L Other bacteria Date of sample: ~ Collected by: g.p.m. Number of Compartments Two Depression over tank (Y/N) N Pumper JR's Pumping - (No Sludge Noted in Tank on ~,/28/11 ) Soil rating (g.p.d./ft2 or ft2/bdrm} 1.2 GPD/SF Width 3.5 ft. Eft. absorption area 800 ft2 Monitoring tube Date installed 7/11/92 Cleanouts (Y/N) High water alarm (Y/N) in. colonies/100 mL Date of adequacy test 4/28/11 Results (Pass/Fail) Pass Fluid depth in absorption field before test 58 Elapsed Time: 1,245 min. Final fluid depth 58 Any rejuvenation treatment (past 12 mo.) (Y/N & type) . y . System type Deep Trench Gravelbelow pipe 8 Y Depression over field 69.5 For 5. bedrooms in. Water added 812 gal. New depth in. Absorption rate >= 750 N If yes, give date in. g.p.d. LIFT STATION Date installed "Pump on" level at Datum in. E. SEPARATION DISTANCES Size in gallons "Pump off' level at . Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/IR station ion lot N/A Absorption field on lot N/A Public sewer main N/A Sewer/septic service iline N/A Animal containment areas None in. Manhole/Access (Y/N) · High water alarm level at Meets alarm & circuit requirements? On adjacent lots N/A On adjacent lots N/A Public sewer manhole/cleanout Holding tank N/A Manure/animal excrete storage areas in. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' Property line >5' Water main >1o' ' Water service line >1o' Wells on adjacent lOts >200' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: N/A None Property line >1o' Water Service line >1o, Curtain drain None Noted Absorption field >s' Surface water >100' Building foundation >10' Water main >10' Surface water >100' Driveway, parking/vehicle storage >25' Wells on adjacent lots >200' F. COMMENTS: Property is Served by AWWU Water System. G. icertifythatlhavedeterminedthroughfieldinspectionsand review of Municipal irecorcls that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name U~haa E. Anderson, P.E. COSA Fee $ ~ -- Waiver Fee $ Date of Payment '~' I X Z / \1 Date of Payment R~ce~pt Numar C'"~"'/~"1 R~ipt .umber (Rev. 11/05) Municipality of Anchorage Development Services Department Building Safety Division On. Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www. muni.orglonsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-474-1s t. GENERAL INFORMATION Complete legal description Lot 2, ekx:~ 4, H~en Crest Subdivision No. 3 Location (site address) 10219 Stewart Drive Eagle PJver, AK 99577 COSA# / D Expiration Date: Current Property owner(s) c~na~ RoxanneSmeer Mailing address 10219 stewart Drive Eagle R~ver, AK 99577 Day phone 6~-~9o Lending agency Mailing address Day phone Real Estate Agent Mailing Address Unless otherwise requested, COSA wtTI be held by DSD for pickup. 2. NUMBER OF BEDROOMS: F~ (5) Day phone 'rOPE OF WATER SUPPLY: Individual Well [] Individual Water Storage [] Community Class Well [] Public Water System [] I'~PE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding Tank [] Community On-site [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval'(~QSA) based only upon the representations given In paragraph 4 by an Independent professional civil englneer registered in the State of Alaska. Certificates of On-Site Systems Approval ara requirad 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 ApprovaI ara 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 pedod of up to one year with valid water samples.) Certificates ara 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 afl'Geed hereto and as of the validation date shown below, I vedfy 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 sb"ucture indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Engineering Address P.o. Box 240773 A~chor:age, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. 6. DSD SIGNATURE / Approved for Disapproved. Conditional approval for Phone 522-7773 Date 12/24/2009 bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other ' Odgtnal Certificate Date: Municipality of Anchorage Development Services Depa 'u.ent Building Safety Division On. Site Water & Westewater Program . 4700 Elmore Road P.O. Sox 196650 Anchorage, AK 99507 www.munLorg/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lot 2. Block 4. Hylen Cre~ Sulx~Mslon. Addt~on No. 3 A. WELL DATA Well type Date completed Total depth Date of test IfA, B, or C provide PWSID # Sanitary ~eal (Y/N) Cased to., fL FROM WELL LOG Parcel ID: o5o.474-16 Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION in. Static water level Well production WATER SAMPLE RESULTS: Cotiform . colonies/100 mL Arsenic:, .. ug~ B. SEPTIC/HOLDING TANK DATA Tank Type/Material se~uc/st~ Tank $~ze .1.50o gal. . Foundafion'cleanout (Y/N). ,Y Date of pumping 8/2.5~o9 C. AI~ORPT1ON FIELD DATA Date installed .7/11-12/92 Length ' 5o fL Total depth .12.2 fL fL g.p.m. fL g.p.m. Nitrate , mg/L Date of sample: Other bacteria, Collected by: colonies/100 mL Number of Compartments .Two Depression over tank (y/N), N Pumper, JR'I Puma, lng Date installed 7/11/92 Cleanouts (y/N) Y High ~vater alarm (y/N) N Soit rating (g.p.d./ft2 or ft=/bdrm) !:20PD/SF W~lth 3.S ft. Eft. absorption area ~00 ft= Monitoring tube, System type De. Trench Gravel below pipe. 8 Y Depression Over field N Date of adequacy test. 12/21/09 Results (Pass/Fail),Paa~ For 5 bedrooms Fluid depth in absorption field before test 59.5 in. Water added .820 gal. New depth Elapsed Time: .540 min. Final fluid depth s9.$ In. Absorption rate >=. 750 -Any rejuvenation treatment (past 12 mo.) (Y/N & type). N If yes, give date 75.5 in. g.p.d. D. LIFT STATION DMe installed 'Pump on' level at in. Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOTTO: Septic tan~ift station on lot. N/^ Absorption field on lot Public sewer main N/A Sewer/septic sen/ice line N/A Animal containment areas 'None Manhole/Access (Y/N). High water alarm level at Meets alarm & circuit requirements? Size in gallons 'Pump of~ level at in. Cycles tested N/A On adjacent lots On adjacent lots N/A PubIic sewer manhole/cleanout, Holding tank N/A Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' Property line >5' Water main >1o' Water service line >10' Wells on adjacent lots >200' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Absorption field Surface water Water main >10' Building foundation. >10' Surface water >1oo' Wells on adjacent lots Property line Water Service line >1o' Curtain drain None Noted N/A >200' Driveway, parldng/vehicle storage >25' F. COMMENTS: P~e~/is Sewed by AWW~ Water System. In. G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections end review of Municipal recon~s that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Micflael E. Anderson, P.E. Date 1 ?J'24/2009 COSA Fee S Date of Payment Receipt Number ~ev. 11~ Waiver Fee $ Date of Payment Receipt Number December 24, 2009 Curt and Roxanne Stoner P.O. Box 773415 Eagle River, AK 99577 Su~e~: Lot 2, Block 4, Hylen Crest Subdivision, Addition No. 3 Septic System Inspection, Testing and Certification Certificate of On Site System Approval (COSA) Dear Mr. and Mrs. Stoner: The septic system on your lot was originally constructed in July of 1992 and is composed of a 1,500 gallon septic tank and a single absorption trench 50' in length, approximately 3.5' wide with 8' of septic gravel beneath the distribution pipe. The soil strata surrounding the absorption trench was tested at the time of construction and found to have an absorption rate of 1.2 gallons per day per square foot. The total absorption area is 800 square feet. The volume of the septic tank and the size of the absorption trench satisfy the Municipality of Anchorage requirements for a five bedroom home. The last adequacy test on the septic system was completed in 1995. At that time the absorption trench was found to have a standing water level of 35". Records indicate the trench was capable of absorbing more than 750 gallons of water per day and was certified acceptable for a five bedroom home. The septic system was recently inspected on December 21, 2009 to vedfy it was still functioning in accordance with the original design and capable of supporting a five bedroom home. Initial probing of the absorption trench indicated water at 59.5" above the bottom of the trench. A total of 820 gallons was then introduced into the absorption trench through the cleanout at the beginning of the trench. The liquid level in the monitor tube rose to 75.5" for a total rise of 16". The water level was then checked 9 hours later and found to be 59.5" above the bottom of the trench or at the initial reading. The system is therefore capable of absorbing a minimum of 750 gallons of water over a 24 hour period and meets Municipal cdteria for certification for a five bedroom home. The septic tank was last pumped on August 25, 2009 by JR's Pumping of Eagle River. No additional work or pumping is required to meet the Municipal requirement for certification. The lot is served by a community water system and all separation distance requirements are easily met. Lot 2, Block 4, Hylen Crest No. 3 December 24, 2009 Page 2 of 2 In summary, the septic system appears to be in good condition and meets all Municipal requirements for certification as of this date. No guarantees or warrantees of the future life of the system are either made or implied based on our inspection or testing as the life of a septic system is dependant upon many variables. Sincerely, Michael E. Anderson, P.E. Attachments ITY OFANCHORAGE.. ............ · ...... ' .... CIpAL .... ·~ '-- ' , .r' ::,..,,/._=__~,?--,, .~.,~:..M_NI , ".' ~'.k .:. ':.'-'- :, ":_ ?~- :. ', r {~',~iC'~)~' r/ DEPARIMENT.'. OF HEAFTH':S:. HUMANSERVICES'';~ "" '"~ ' ' ' '"; '} .' .'",, ~'~,'' :'.,:~ .',~:~:~ ~ r 'Division o~ EpVironmental So,ices ~?. ~ .... .' --.-' '"" ~ ~. ,.'. '~}'dl;~,~:',i)~5~'.~.:~:~:::'.;' hh"P.O. Box. 196650?~n'Ch0rage;Alaska "99519;~650 ' '~' ::':";~ ~.CER~ F CATE OF HEAl. TH AUTHORITY., ...... '?'~.~':':'" :~'~:~'"~'~ '~' '~ ""-'":~'~?:::';~" ~PROVA~'FOR ~:S~G~E~AM'ILY DWELLING .~: '" "~'.~" ~':~ ..... '~" . ... · "" ' " ' ' ~ · ~ ~,'~'~ ~ ,~ ;5' ~ ~ ~' '~ ;' ........ Parce D ~ · 't:z '" ,::..¢.;. ' ': ¢ t~ L'.,, .'- "'-~ ". ".~z.~ .. ',~.-.'- ,-' .' , · ,.:.:,-.?' :',* ';%7]'-~ ~' ",', 1' ; , ,-,- , t ~;f)~ , ,'.' ' ", L,.;;' ......; .. ....,. ~ :.' :';; :. ~:.~ Location~s te address ordirections) ..... ' ' · ':"- cbmmonityi-we!! system ..... to the le ahty and status o~system ~ ',,'~ ' ' :::';,' ~'?: ,. ' ' ~;~' Individual on,site 5. STATEMENT OF INSPECTION. BY ENGINEER: 'i:?,~'~'''-;. .:.' ,~.. ~.. ..: ' As certified by my seal affixed hereto and ~s of the vafidation date shown belo~,'l verify that my. investigation of this Health Authority Approva! 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 ins pection, the on-site water supply and/or wastewater disposal system is n corn pliance with all Municipal and State codes, :... ordinances and regu at ons n effect on the date of this inspectiom? 4' ',.~ ,'-,.?,";'~ ., Name~of~'irm. /~,Jb~'-II.$o~ ~'-,,Jt,,~'~J~"-~'---------------~t,,J& '. Phone..~_~l~' . ..... . - ~nginee'~ssigfiature~~-,' ~ ~ ' ' 'Date ""q/bBJq~ "::. · ::.'.._,~ ,..~ '..%'. . .......... ... , . .. .. . . ........ ,;,.-.:~'..,_~ ~.~ ~ -~-'~..~. . ~ . _,.. . .. . .-.- .r . ~ ,., .,'~'' ...'._-'...'~' '. : -... ::,.,'~'. ;~:~;.; -?~,....,-- _ ,~ , ~ , . ~ . · ... ., , .' , -.: -- ,, -.- ~ . ' , ._~,,,' :,. -.,.;~ ~' ~ '?~ ~.'-,~ . :,,.~:;:. ~::~ ~.n,amona~ approval for. ' :~bedrooms,~';.with~th~:-following ~stipbi~ti0nS:'. :-. ~., u s ~he Mudi~' li~ of Anchora e De a~ment of ~'~" ' ...... · ' ..~ ~.~_.~ ~(/'. ~<,,,, . ~',~ ~ . g p Health and Human Se~lces (DHHS) I~ues Health Author ~ . . . · · r,,~,~ppro~ ~e~'Cams oaseo only upon the representations gWen m paragraph 5 above by'an indepondent"': p'r0fe~onal engin~r r~istered in the State 0f Alaska2 The DHHS does thi~ as a c~u~esy to purchasem of homes an~. ~he~r,l~ndi~g ~n~itutions in order to satis~ ce~ain f~eral and state [equirements Emp oy~s of DHHS do not conduct inspections or analyze data before a ce~ificate is issued.-:~he Mun ciPali~of Anchorage is not responsible for errom or omissions in the professional ~n~i'n~ w~r~~ ....... '.: ...... · ..... '- - . : ' 72~{~.1~1) ~. MOA~ . ~:.. . . . · : .~- ':..'. : : '~....,.... ,:-. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: [~O'r-,~ r~coc,~. ~ A. Well Data Well type ~D¢I.~i~ Log present (Y/N) Total depth Sanitary seal (Y/N) Parcel I.D. 0 ~"'O ~ 7 ~'- ~/~¢¢'~'~f A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to Casing height Wires properly protected Date of test Static water level Well flow Pump level1 FROM WELL LOG g.p.r AT INSPEC'I'I(; g.p.m. SEPARATION DISTANCES Septic/holding tank on lot __ Absorption field on lot Public sewer mai~ Sewer sar SAMPLE RESULTS: Coliform Date of sample: Nitrate ' On adjacent lots · On adjacent lots Public sewer manhole/cleanout Petroleum tank Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) Y High water alarm (Y/N) Date of pumping Tank size l, ~"g)O Foundation cleanout (Y/N) 7//~ / ~/'5' Pumper ~ IIL/4;~ M Compartments Depression (Y/N) Alarm tested (Y/N) t Well(s) on lot /,,/¢ A/ To property line .~./~ Surface water/drainage SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: / On adjacent lots Absorption field Foundation Water main/service line 72-028 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons High water alarm level .~~es tested Meets MOA electrical codes (Y/N)~~ SEPARATION D~M LIFT STATION TO: On adjacent lots Manufacturer ~ Vent (Y/N) "Pump on" level at ...~.~Pump off" Level at I-ri 0 Z Surface water D, ABSORPTION FIELD DATA Date installed 7/q'~. Soil rating (GPD/Ft2) /. ~ ~ P ~)/F)7 System type Length _,~.~ r Width ~ /~ Gravel thickness Total depth Total absorption area ~-~t~) '/~=T;'. '~ Cleanout present (Y/N) Date of adequacy test '~/'~-J~-/~ ~ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Depression over field (Y/N) ~ Results (pass/fail) J;::>~ $-~ for '~t~ ~b.-' ,, ,, After test ,"~' If yes, give date /~/~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: AO ,"u c? /,8 ! On adjacent lots '~/00 Property line To existing or abandoned system on lot Cutbank ~/00 Water main/service line Driveway, parking/vehicle storage area Well on lot To building foundation On adjacent lots Surface water Curtain drain Bedrooms E. ENGINEER'S CERTIFICATION I certify that I have chocked, verified, or conformed to all MOA and HAA guidelines in e~eotOn:~he: d~Ce,~[ this inspection. Engineer's Name ~.,r4..//4,~-6-."-~ ~ ~,,~VOd?ZS0,J HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back July 28, 1995 ANDERSON ENGINEERING P,O. BOX 240773 ANCHORAGE, AK 99524 563-7155 563-5389 (FAX) Municipality of Anchorage Department of Health and Human Services Onsite Services Section P.O. Box 196650 Anchorage, AK 99519-6650 Attention: Jim Cross Subject: Lot 2, Block 4, Hylen Crest Subdivision No. 3 Dear Jim: The certified as-built for the septic system placed on Lot 2, Block 4, Hylen Crest Subdivision No. 3 indicates it was constructed for a 4 bedroom home. The components of the system, however, are suitable for 5 bedrooms. A 1,500 gallon septic tank was installed and a total absorption area of over 800 square feet was placed. The as-built states under the remark section that during installation the absorption trench was found to contain 6' of soils with a rating of 1.2 gallons per day per square foot and 2' of what is classified as a silty sand layer with no classification. Assuming the silty sand layer percolated at a rate between 30 and 60 minutes per inch it would be rated at .45 gallons per day per square foot. The total design capacity of the absorption trench is then 810 gallons per day which is in excess of the 750 gallons per day required for a 5 bedroom home. Two adequacy tests have been performed on the system in the last two weeks and both indicate capacity to serve a five bedroom home. The first completed by Eagle River Engineering can be projected to show the necessary capacity. The second completed by Anderson Engineering, included an injection of 832 gallons of water into the absorption trench. The initial water level in the trench was measured at 35". After 24 hours the level had receded from a high of 53" back to 40". During this same period the homeowner had injected approximately 215 gallons of additional water into the system. By simple interpolation the system absorbed nearly 816 gallons of water in a 24 hour period. It therefore meets Municipal criteria to serve a 5 bedroom home. Lot 2, Block 4, Hylen Crest No. 3 July 28, 1995 Page Two We hereby request a Health Authority Approval be issued for the septic system on this property to serve a 5 bedroom home. Please let me know if you have any questions or comments. Sincerely, Michael E. Anderson, P.E. Attachment 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Add ress Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State AD£C attest- ing to 'the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site 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) Fronl MOA 421 Name of Firm (_~,,,..~"~-~o~ ~ Address .~60\ Engineer's signature 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. Phone ~/9~-S-o ~ DHHS SIGNATURE .~ Approved for ~:~c(/&~/0 Disapproved. Date ~-~.-.~-L- Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does 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~)25{Rev. 1/91) 8ack MOA Legal Description: Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Parcel I.D. A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to Casing heig FROM WELL LOG Date of test Statiowater level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line Wires properly protected (Y/N) g.p.m. AT INS ; On adjacent lots On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE Coliform __ Date of sa~: B. SEPTIC/HOLDING TANK DATA Date instal,ed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Nitrate Other bacteria Collected by: Tank size t ~ Compartments Foundation cleanout (Y/N) ~/ Depression (Y/N) tv Pr Alarm tested (Y/N) fV P~ ~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot td ~ On adjacent lots -~oo ' To property line 4~' -/~- Surface water/drainage Absorption field Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C, LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) ~ SEPARATION DISTiChS'ROM LIFT STATION TO: Well ~ On adjacent lots Manufacturer Manhole/Access (Y/N) ~'i ~-'"~P~u mp off" level at ~'~ -~es tested Surface water D. ABSORPTION FIELD DATA Date installed "'7,,~ .~ ~. Soil rating I-~ ~p~ /~-~" System type Length ~"o' Width ~lz. Gravel thickness ~, .I, Total depth Total absorption area ~oo ~ '~- Cleanouts present (Y/N) ~ Depression over field (Y/N) tJ Date of adequacy test ~ p~ Results (pass/fail) f',/i~ for ~ ~ If yes, give date Peroxide treatment (past 12 month, s) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot IJ'~ To building foundation On adjacent lots Surface water Curtain drain +-too' On adjacent lots -~--~oo' Property line To existing or abandoned system on lot Cutbank '~"L°° ~ Water main/service line __ Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. :ng~neer s Name ~'~ Date ~ ............ ,~. HAA Fees [ ~, O~ Waiver Fee:$ Date of Payment ~//~ ~ ~ Date of Payment Receipt Number ~~ ~~ Receipt Number 72-026 (Rev. 3/91) Back MOA 21