HomeMy WebLinkAboutEKLUND #1 BLK 4 LT 12Eklund Block 4 Lo1' 12 #050-541-06 Jan 27 20 11:17.1 ark B Mich (Major Anctlorage 4Veli & Pla;np Ser 9072430742 on--c;te vvGcz'i ' A .Procrulm A700 Elrnar= Pcod P.0. Sciy. i9l650 Al' 99�07 -,crv, n.jj ri arcions, te. - j�3.7npq — Pump Installation Log 22 62 lVell Drilling PermitGinher::�W-.._— Date of Issue. q --z 'N" Parcel Identification Number: 050 P.1 Lc&l Description. A Property C2wuer -Name & Address: `1 L 1 kcYyt-L epi. (� rc s S l c.i,rl � � � �� 5 ! � c��� r°�� � G 4 r v �� r- ie !='r • � f. r I 1, ymstallation Dat;: /--, ti - ! 0 Pump Intake Depth Below Top of Well Lasing: ;70 feet 1 1 Pump Manufacturer's Name: eL l Pump Model. 5 " .� � '' r tlG; i 7_ 1l PUII!in Siam 2 hg Pitiiss Adapter Burial Depth.- feet Pitless A.dagter IslareuCac:.c:rPr's Name: �fli Pitless Adapter linslaller: 14 / i Well Disinfected Upm Completion" � kl-(es L7 No Method of Disinfection: Comments: Pwnp Installer Ngme: r D6C Ur Attention: The purcp irsta[l r shall provide a pump installation lug to the DSD within 30 days of pump irstallatior. Development Services Department ;'": Building Safety Division On-Site INatet end Wastewater Program, 4700 $. Bragaw SL P.O, Box 196650 Anchorage, AK 99519-6650 Page of wv,,w.cLanchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: ~(/O~.OI t-{ O PID Number. "~": ~{.h.~'R; ~-ek,n "~'w~'O~0~, WastewaterSystem: I-INew ~Upgrade ~*"': UeE~i t~ L~l:,~,-~v- V_~o,,r~ ABSORPTION FIELD LEGAL DESCRIPTION r'~ ~,'p*¢ ~ ~,, Well: [] New [] Upgrade o,.,~,.~-~ ~.~: -- ~.~ s~,~ TAN K SEPARATION DISTANCES [] septic [] Holding ~S.T,E.P. n Other. From~.~,. Septic Absorption Lift H oldin g ,uUlr.,Prtvate u.*,~,..c.~, Tank Field Sta~on Tank Se*er ~e ,; ~ ¢ ~ ~ ~ c,~. s,,.~w.,,r'tlo H}o 'Hlo X~ ,,.~,,,~LIFT STATION "'"'~: 014 '7"o,~ L, c,m~_~ ~' j~vW.eSP ' BENCHMARK E. ngioeer's Stamp Inspections performed by: '~..~ Dates: 1" Devel°pmeltSeF~3epartmentAppr°val&/ 8/0 ''"" .... Reviewed and approved by: _1 .. J t Date: CRUSHED EXIST. 1000 GAL SEPTIC jjMA INSTALLED B/OCYCLE UNIT C m INSTALLED D 5 -WIDE TRENCH 60 FT LONG E 2 FT DEEP TH ® 61NCHES ® OF ROCK ♦ fig, f B BENCH MARK -(- Well SWING RES.- AC IES:AC 18 FT BC 46 AD 64 BD 75 AE 81 BE 62 ..... ... .,................. m o •,•TOB N SPURKLAND ®®� �'•. No. CE -2225 ® ..,,.�'®® 25 0 25 50 75 100 125 150 / SCALE, 1' = 50 FT. / BENCH MARX DOOR SILL, LOWER LEVEL ASSUMED ELEV. 100.00 FT 1 UHHEN SPUKKLANU F.E. LOT 12 BLOCK 4 EKL UND SID SEPTIC SYSTEM AS BUILT 203 W 15TH. AVENUE 4514 UPPER KOGRU DATE: JUNE 26, 2002 ANCH. AK. 99501 JOHN AND MYRA BRIDGES SHEET.• 213 GRID: SE -602 907 279-3916 PERMIT # SVO20140 PID # 050-541-06 EKL04121,DVG 6" MIN 4—INCH INSULATION AIRCOMPRESSOR 1-1/4 PVC WITH 1/8" HOLES AT 30- 5 X 60.0 DRAINFIELD 2 FT TOTAL DEPTH .5 FT EFFECTIVE ROCK LEVELING SAND \I" !')_i NU SCALE YLUEBOARD LEGEND: BIOCYCLE 6000 1. PRIMARY TREATMENT, SEPTIC TANK 2. AERATION TANK J. CLARIFICATION TANK EXISTING GROUND 4. DISCHARGE TANK 5. SOIL ABSORPTION 2 FT OF COVER i— INSULAT MTO I I g P..✓ ••.........,�e ��.................. °i ': # # # # # . . i i i i . . f f f # ♦ f . . i= 49th +++++++,4++++++ i### f# f#+++++++++ i i i ++++++++.+++++++++ f i f f �� :.� ®♦tn TOB EN SPURKLAN•• a! t 6' OF fig CK 1 No CE -2225 .;1�® LEVELING SAND t®i®i®® wSSO� '90 AS QUILT TOBBEN SPURKLAND P.E. EKLUND SID MbCK 4 LOT 12 WASTEWATER SYSTEM SCHEMATIC 203 ra?e Ave BIOCYCLE WASTE WATER SYSTEM DATE: JUNE 26, 2002 27.gAnchors a Ak 99501 4514 UPPER KOGRU SHEET.• 3/1 GRID: SE602 PERMIT # SW020140 PID # 050-541-06 EKL©41? „BIO Municipality of Anchorage Development Services Department Building Safety Division On-SJl¢ Water and Wastewater Program 4700 Bragaw Slxeet P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorag¢.ak.us (907) 343-7904 PROPERTY OWNER AGREEMENT FOR TIlE MAINTENANCE OF AN ON-SITE WASTEWATER DISPOSAL SYSTEM This agreement, dated ,,JU.Y~_~ ~,,~., 7_.X:~, is made between the Municipality of Anchorage Development Services Department (DSD) and the property owner(s) of: t~l~Lutqt) ~tl ko~ -t:~, "OIz q This agreement is made for the purpose of ma,nta,mng an on-s~te waste ater d,sposal system on the subject property. The property mvners agree to the following: Submit to the Municipality of Anchorage, on an annual basis, an inspection and operation statement from a registered professional engineer. This inspection and operation statement shall verify that the engineer has inspected all effluent and air pumps, timers, and alarms, and that any deficiencies have been repaired and that the system is functioning as designed. ~gh'aturej'v- (Signature) (Printed Name) (Printed Name) The Foreeoine Instrument was acknowle.dged before me by '~C~C~.,(C~- ~.\e_)'kO'~"~ on th,s 7_~ day of O tz.tw. , =o~ Witne~ my h=~and S~,ff ~ /Z,~ ~ ~ot~'s printed n~e) ~ t . I F'RCtl -' ~:~IO.3.JI~LL FRI'IlLY FP.X N~. : 345-2923 .Tun, l1425 Avion Street Ancl~oragg ~K 99516 State Contractor License #28624 MOA Contracfor Lic~nse #1976 ~2~02 To who it my concern: Brick's glectric has performed all wfi-/ng necessary for the Bio-Cycle sept/c system at the following locat/on: John & Myra Bridges 4514 Upper Kogru Dr. Eagle River, Ak Lot 12 Blk 4 Eklund Subdiv/sioa All work performed as per current National Electrical Code Sincerely, W'tll/am Brickwell- Owner P~one: 90Y-34~.292~ * Fax: 907-770-2955 · Cell: 440-9S51 MUNICIPALITY OF ANCHORAGE Development Services Department On-Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEtNATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Jun 03, 2002 Expiration Date: Jun 03, 2003 Permit Number: SW020140 Legal Description: EKLUND #1 BLK 4 LT 12 Design Engineer: 0007 Tobben Spurkland, PE Owner Name: John & Myra Bridges Owner Address: 4514 Upper Kogru Dr. EAGLE RIVER. AK 99577-9503 Parcel ID: 050-541-06 Site Address: 004514 UPPER KOGRU DR Lot Size: 38889 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. Ail 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 engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Date: Issued By: Date: / f Municipality of Anchorage Development Services Department 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 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 0 0- W/-0 Permit Number SW Propertyowner(s) "~tl; ~"~'~- '-~H(~¢c/ Dayphone Mailing address (1) ~ ~ [ q ~ Mailing address (2) ~ ~o&~ ~ ZipCode q~77 Legal description (Lot, Block&Sub'd.)- ~ ~l~, ~q ~t]Nl~ ~/ Legal description (Section, Township & Range) ~ Lot Size %~'~ Acre~ Number of Bedrooms_ Z.~ THIS APPLICATION IS FOR: Sewer Only Sewer and Well Sewer Upgrade THIS PROP~=RTY CONTAINS: Hot Tub Swimming Pool Therapy Pool [] Well Only [] [] Water Storage [] [] Jacuzzi [] [] Water Softening Unit [] I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. - (Signature of prier o~uthorized agent) Permit Fees; Date of Payment: Receipt Number: (Rev. 12/00) Waiver Fees: Date of Payment: Receipt Number: 203 W 15th. Avenue, Suite 203 ANCIIORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 12, BLOCK 4 EKLUND S/D 4514 KOGRU Municipality of Anchorage Development Services Department Building Safety Division On Site Water and waste Water Program 4700 South Bragaw Street Anchorage, Alaska 99519-650 May 22, 2002 We are submitting an application for the upgrade ofthe septic system for this lot. The submittal consists of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the septic system is subject to this permit application, (sheet 2/3), and a schematic ofthe septic system, (sheet 3/3). Soil logs and percolation tests ofapplicable test holes are also enclosed. The septic system design is based on the following: Groundwater During Break Up at 6 Ft. Use Standard 5-Wide with BioCycle Soil Rating. From Testhole 05/15/02. 20 rain/in = 2 gal per sq.ft/day No. of Bedrooms 4 Required Area per Bedroom: 150/2 =75 sq. fL Total area required: 50 x 4 = 300 ~qf~ Rock Depth 0.5 feet Total Trench Length 200 15 TM 40 USE 40 VF SYSTEM CONFIGURATION BIOCYCLE STANDARD 5-WIDE TRENCIt TOTAL LENGTH 40 FT TOTAL WIDTll 5 FT TOTAL DEPTII 2 FT ROCK DEPTH 0. 5 FT COVER 3 FT The installation of this septic system will not prevent wells from being installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface ruooffwill not result from this installation. N SCAL£~ 1' = lO0 Fl'. LOT 13 VACANT LOT\~ / LOT 3 VACANT LDT 3 ~LDCK 5 I I - LOT 11 / // / // / // LOT 4 VACANT TOBBEN SPURKblND P.E. 203 Pl ISTN. AVENUE :ANON. AK. 99§01 [ £OT 412 BLOCK 4 EK£UND $/D 451,t UPPER KOGRU JOHN AND MYRA BRIDGES SEPTIC SYSTEI~ DESIGN DATE: MAY 22, 2002 SHEET: I/$ GRID: SE602 $~RMIT Il SVOSOXX Plfl # 050-541-06 EKLO4121.D~/G ~'OBBEN SPURKI. AND P.E. 205 W 151't'1. AVENUE ANCN. AN. 99501 (~07) LOT 412 BLOCK 4 EK~UND $/D 4514 UPPER KOGRU JOHN AND MYRA BRIDGES SEPTIC SYSTEM DESIGN DATE: MAY 22, 2002 SHEET: 2/$ GRID: S£$02 PERMIT # SVOSOXX PIB # 050-$41-0~ EKLO41£1,BWG Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Pmgraro 4700 South Bragaw SL P.O. Box 196650 A~cflorage. AK 99519-6650 v,v,%v.~,an.;homne.ak.u$ (907) 343-7904 Soils Log - Percolation Test Perforroed For: Legal Description: SIo~ ,~- (E, NGINEER'S SEAL) T~ship. Range. Section: Site Plan 11- 12- 13- 14- 15- 16- 17- 18- 19- 20- COMMENTS WAS GROUNO WATER ENCOUNTERED? ~F YES. AT W~T =EPTH? ~.eTTOI~( 0 ~-' ~CLt'-'-- DepthloWatecA~ler Monttorlng? ~ ~ PE Reading Date Gross Tiroe Net Tiroe Depth to Water Net Drop / PERCOLATION RATE .~) (mm~) PERC HOLE DIAMETER TEST RUN BET~NEEN ~ FT AND ..~ FT PERFORMED BY: I% ~'~ I ~ ,.~ CERTIFYTHATTHIS TEST WAS PERFORMED IN ACCORDANCE WiTH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL DESCRIPTION LOCATION Manufacturer city in gallons DISTANCE TO: IF HOMEMADE: Material~_lL~ Inside length Width - PHONE NO. OF BEDROOMS PERMIT NO. No. of compartments Liquid depth PERMIT NO. Well Dwelling Manufacturer Liquid capacity in gallons Foundation Material Neare~_tat~ine Total I~.~of lines Tren'~.~<~h inches Materi~l beneath tile ~4 inches Depth Well DISTANCE TO: /~;~ No, of lines Length of each line TOp of tile to finish grade ~.~ ~ ~ ~C~- Length Width PERMIT NO, DiStance between lines Total effecti.~e ~ PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: Class · Depth Driller Distance to lot line PERMIT NO. DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) [] UPGRADE area OTHER .,~ ~T~.~MATERIALS SOIL TEST RATING REMARKS 72-013 (Rev. 3/78) DATE LEGAL F'ERMI T t40. DEF HF..TtlEN 1 Ur. FL. HEHL] H hIND Et',!,,, I F. UNtlEN THL ~3 .~EL.'[ I UN 6:~,,~-~ /~ LOT SIZE ,,:~3~5~]E~ S6!L.IFIRE FEET MRXIMUM NUMBER OF E:E[:,ROOMS = z, UIL RATING - '"'-.-. - ' "' ' "- "=' - I S: THE REE.¢.IIRED SIZE OF THE '-']OIL MBzUF..FTIUhl THE LENGTH DIMENSION IS THE LENGTFI (IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTFI OF A TRENCH OR PIT' IS THE DISTANCE BETWEEN THE SLIRFRCE OF THE GROUND ANt:, THE BOTTOM OF THE EXCAVATION ,::IN FEET;,. THERE IS NO SET WIDTH FOR TRENCHES. TFtE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRR',,,'EL BETWEEN THE OUTFRLL PIF'E RND THE BOTTOM OF THE EXCAVATION (IN FEET). F:'ERMIT APPLICANT HFIS THE RE=FuN..IBILIT-r TO INF~RM ]HI .... DEPARTMENT [:,URING THE ,-., f-. _ _ r'r,...r'~:.~*.~'r AND THE INSTALLR"rION IN.=,FE_.TInN¢* OF RN"r' WELLS ADJACENT TO THIS ~',',*r~ .... ~,"~" NUMBE'R OF F..E=,IDENL. E-., THAT THE WELL WILL _,EF,,E. T'I..,..I C~ ,:: ;.~: '.':, ~.. t'-,~2L;F"EC:"T ]: ,E~l'-,t~--:''; RF."E RE~;!LI :[ E~:E-2 [: BACKFILLING OF RN~r' =r_TEtt WITHOUT FINAL INSPECTION AND AF'PROVRL E,'k' THIS DEPARTMENT WILL BE ';ItBJECT TO F'F..'OSEC_T~CN MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL S"?STEM IS ±C4C~ FEET FOR FI PRI',,,'RTE WELL OR ±5C~ TO 20C~ FEET FROM A PUBLIC WELL DEPENDING L.IPON THE T'¢PE OF PUBLIC WELL MINIMUM DISTANCE FROM R PRIVATE WELL TO R PRIVATE SEWER LiNE IS 25 FEET AND TO A COMMUNIT9 SEWER LINE IS '75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ]:E~ DA~¢S OF' THE I.,.IEL. L. COMPLETION. OTHER REQUIREMENTS MA'¢ RPPL'¢. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAIL. ABLE TO INSURE PROPER INSTALLATION. F"EF4:f.1 I T E::<P I F.:ES [:.EE:Et. IBEF4: ]::t.- J, ..... ']- I CERTIF'.r' THRT ~: I 8M FRMILIBR WITH THE REQtJIREMENTS FOR ON-SITE SEWERS AND WELL.S RS SE]" FORTH B~¢ THE MUNICIPALIT~'r' OF ANCHORAGE. 2: I WILL INSTALL THE S'¢STEM IN ACCORDANCE WITH TFIE CODES. ]:: I UNDERSTAND THAT THE ON-SITE SEWER S'¢STEM MA'¢ REQUIRE ENL. RRGEMENT IF THE RESIDENC ,E I5 R.EMD[:'ELE[' TO INCLUDE MORE TNRN 2: BEDROOMS. S I GNE[,: ...... ~__~~ ......................... RPPLICFtNT RL LARSON [:,BR RLISTI HOMES I SS_ED B~?. .......... Russell Oyster 694-2774 Performed for: Legal Description: O & E ENC.NEERING & DEVELO, MENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Earl Ellis SOIL LOG 688-2280 Name: ~ ~- ~-- ~-~J Tel. No/~z.,/.- ~- ~ Depth (feet) Soil Characteristics 7__ 15__ i61 Ground Water Encountered: Yes-- hat depth PLOT PLAN PERC. TEST Proposed Installation: Seepage Pit Drain Field Comments: .~z~,,~_ ~-~F~I~,,~ z)~J ~c~ Po'ormed by: ~~ /~' ~-~ Date: (ger2ifiei rmmg by DO~ Co. SULLIVAN WATER WELLS P. O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759 OWNER OF LAND ADDRESS / e LEGAL DESCRI~ION DATE - Sta~ed ~:~ PE~IT NUMBER DEPTH OF WELL ~r"~ ga STATIC LEVEL OF WATER FT. DRAW DOWN FT. ~,, C' ' GALS. PER HR -.~ ~ KIND OF CASING ~ -be 0~'~ KIND OF FORMATION From ~ Ft. to -~ From ;~" Ft. to ~ From ~ '? ~ Ft. to ~' / From Ft. to From ~ Ft. to ~ From Ft. to From Ft. to Ft. From Ft. to. 'Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. F/om Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to. Ft. From Ft. to Ft From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft, From Ft. to Ft From__ F~. 'to' Ft._ From.__.Ftto Ft, From · Ft. to Ft. From Ft. to Ft. From Ft. to____Ft. From Ft. to Ft. From Ft. to Ft From Ft. to Ft From Ft. to.__Ft. From Ft. to Ft._ From Ft. to _ Ft. From Ft. to Ft. MISCL. INFORMATION: DRILLER'S NAME MUNICIPALITY OF ANCHORAGE Development Services Department' Phone: 907-343-7904 On -Site Water & Wastewater Section ��- -� Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 050 541 06 1. GENERAL INFORMATION Expiration Date: Q_--12_-( 7 Complete legal description EKLUND#1 BLOCK 4 LOT 12 Location (site address) 4514 UPPER KOGRU Current property owner(s) VALENOTE Mailing address Day phone Real estate agent Day phone 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: 55-6 TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic' 0 Water Storage ❑ Holding Tank i ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: N O N E Distance: NA Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 55-6 Date of Payment 9/tall q Receipt Number COSA Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm C&M ENGINEERING Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI Date 9/5/2019 �Z nl� kl Idw i kl 49 .*I 6. DSD SIGNATURE • ' • ' • ;' System #1 Approved for bedrooms � / CHARLES G BALZARKI � System #2 Approved for bedrooms ��F���.. CE-13854AW Disapproved �l0`FOPROFESSV P� Conditional approval for bedrooms, with the following stipulations: �nn�eal�iu�� Original Certificate Date:sui ��� The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Legal Description: EKLUND#1 BLOCK 4 LOT 12 Parcel ID: 050 541 06 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 6/3/81 Total depth 85 ft Cased to +40 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) +12 in. Date of flow test for COSA 8/30 Static water level at beginning of test ft. Comments *ARTISAN PLUG B. TANK DATA Age of tank(s) 17 years Tank type/material e'OCYCLE ❑ Standpipes/foundation cleanout per record drawing Date of pumping NA D. ABSORPTION FIELD DATA shallow trench Well production at time of test 1.31 gpm Water storage tank volume 300 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 C&M ENGINEERING Date of Sample 9/3/19 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: BIOCYCLE MAINTENENCE VERIFIED Which system tested (date installed) 6/19/02 Adequacy test date 8/30/19 Q ALL standpipes present per record drawing Results ❑ Pass For 4 bedrooms Total measured depth from grade 4 ft (max) Fluid depth prior to test 0 in Measured depth to pipe invert from grade ft (min) Water added 600 gal ❑ N/A — pressurized field New depth 4 in ❑ Monitor tubes go to bottom of drainfield. If not, state Elapsed time 60 min depth into effective d ❑ Code -required soil cover over field Final fluid depth 0 in ❑ System presoaked Absorption rate 600 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) NO date of test) Gallons introduced 600 gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Q Yes if No Community Sewer Manhole/Cleanout > 100' Q Yes if No ft Q Yes if No ft Neighboring Tank > 100' QYes if No ft Private Sewer/Septic Line > 25' 0✓ Yes if No ft Absorption Field on Lot > 100' QYes if No ft Holding Tank > 100' O✓ Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' Q✓ Yes if No ft 0✓ Yes if No ft ft Community Wells > 200' Q✓ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Q Yes if No ft F71 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Q Yes if No ft Surface Water > 100' 0✓ Yes if No ft Property Line > 5' QYes if No ft Driveway/Parking > 0' Q Yes if No, comment Absorption Field > 5' QYes if No ft Wells on Adjacent Lots: Q Yes if No ft Water Main > 10' Q✓ Yes if No ft Private Wells > 100' QYes if No ft Water Service Line > 10' Q,/ Yes if No ft Community Wells > 200' Q✓ Yes if No ft From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Q✓ Yes if No ft Driveway/Parking > 0' Q Yes if No, comment Property Line > 10' Q Yes if No ft Wells on Adjacent Lots: Water Main > 10' Q Yes if No ft Private Wells > 100' Q Yes if No ft Water Service Line > 10' Q✓ Yes if No ft Community Wells > 200' O✓ Yes if No ft Surface Water > 100' Q✓ Yes if No ft F. ENGINEER'S COMMENTS all cleanouts verified during cosy inspection G. ENGINEER'S CERTIFICATION l certify that / have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. 9/5/2019 COSA Checklist yellow sheet .�I1`®0® OF A/-, k t * TH r� r CHARLES G BALZARI14f % �s . CE -13854 ..`���� PR0FE, Ss N Scale 1" = SO' Frontier Surveys, LLC Project No: 19-335 Date: 08/30/2019 Ordered By: Daniela Valenote I Plat: 71-115 1 Grid: N/A \ 50'RADIUS TEMPORARY TURNAROUND EASEMENT "E 71 Electric Meter/Outside Power 10, Telephone Pole _T� Tel. Ped. iy Gas Meter ® Deck Fence e� Elec.Ped. Septic iW; Water Well INCMailbox Overhead Utility General Notes: 0 25 50 100 1. This document is created for the purpose ora single property transaction and is subject to Federal Copyright Laws. 2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey. Scale In Feet 3. All measurementslselbacks are to the visuattapparent building footprint. 4. All dimensions to property lines are plustminus OAR. X 11 t t This survey complies with the ASPLS Mortgage Location Standards. The survey represents visible improvements and 0 F A I 1 I1 conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any '� .9s 111 inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the 0vmer to determine the -: ,`Q' •' • , existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances Lj .' •' �-9 .1 /should this document be used for construction or for establishing a boundary or fence line. ' 49T" As -Built Survey of: ...:.. ....�...... ........� Lot 12, Block 4 Eklund Subdivision Addn. No. 1 y Frederic W. ner a; .. NO. LS. -9946 ��� 1, Frederic Wagner, hereby certify that this Mortgage Inspection Survey was performed by me, or 8/30/2019 -S under my direct supervision on August 29th, 2019. Ill F��•. •.' SJ= er 111, t11%x„"ONA; ` -,: y 650 W. 58th Ave. Suite E Anchorage, Alaska 99518 ys, LLC FRONTIER. 907.460.1686 - info@frcintiersurveys.com PROFESSIONAL SEAL www.frontiersurveys.com ��. ec'lvyarrc:.:.d �V ..ac«rid"yctio�n+ai'ne.rt 2nd Quarter Inspection Report 2011 3705 Arctic Blvd #313 Anchorage AK 99503 Email: crbioak@gmail.com (907)274-0314 Homeowner Info Customer Name: Victor Valenote Tank#: 136 Install Date: July 2002 Address: 4514 Upper Kogru Drive Area Eagle River Initial Inspection: Alarms Tested: Air 0 High Water Battery Tested: Yes ❑ No ❑ N/A (Please make sure alarm is on "normal", not "mute") Does system have a septic tank ? No �] Yes ❑ (Recommend pumping tank every 2 years) Is System Lid Locked? Lid hardware in working order? Is there any noticeable odor? Yes ❑ Repaired ElYes Repaired E]Strong ❑ Mild F -]None System Inspection Filter cleaned? Yes � N/A ❑ Comments: Inspected By: Chris Discharge line condition: Good ® Replaced ❑ 05/11/2019 Has emailing or mailing of form been requested? Date: (contact office to request...) Yes ❑ No MUNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATMENT SYSTEM MIATNTENANCE ANY) RFPAIR A(TR'FFVFNT THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and enter d into as of this eY L1 Day of 5p4 of 20 by and between � #' � herein the "OWNER," and the Municipality of Anchorage, herein the "MUNICIPALITY", in, accordance with Anchorage Municipal Code (AMC) 15.65365. In consideration of the mutual covenants contained herein, the parties to this Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Trea . tment System (AWWTS), described as BIOCYCLE located at (legal description) EKLUND#1 BLOCK 4 LOT 12 2. Maintenance- Renairg and Alterations (Owner is required to read, understand and initial each section) Throughout the term of this Agreement the Owner shall enter into a service nreemen., t with an AWWTS service and maintenance provider approved by the Municipality or the in R cahcfarYnry condition capable of performing as designed and producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality. It shall be the responsibility of the Owner during the term of this Agreement to pay for all repair(s), maintenance, a4justment(s), replacement costs, and inspection costs. This includes an annual maintenance fee (typically $400 to $600). 1("/Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, repairs or permitted alterations to the system. 0 -wrier acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield (rev 0,5/1 R/101 9) P.' -10'P I nf 3 Owner acknowledges that the Municipality may request records of maintenance and repairs from the manufacturer's representative or maintenance provider. Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60.030. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS_ The Municipality will give at least 24-hour notice. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems ,,knnroval, Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the poverning guidelines for the construction, maintenance and repair of the Owner's AWWTS. Owner agrees to maintain remote monitoring of the AWWTS as required by the AWWTS approval. 3. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system, or upon transfer of title, and shall continue while the AWWTS is operational or until title is transferred. 4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of ' the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shallgovern the rights and obli". tions of the parties under this Agreement. 7. CrQve"abilifv. Anv prnvig;nnc nftl�rc Agreeme t riempp 1 4 vali{j 1?y a ctlllrt of r{}pr»Atpnt _jurisdiction shall not invalidate the remaining,provisions of the Agreement. (rev, 05/1 PaRP 1 of'i O"ER: ��---�-`�---�-�..---- By:`_ (signature) Date: {print name) STATE OF ALASKA ) ) ss. THIRD JUDICIAL DISTRICT ) The foregoing instrument was acknowledged before me this day of zoo, by KcnnGk+,- 4. Oj)N ErY / NOTARY PUBLIC FOR ALASKA ..........�0'''. o° Na r . �o My Commission expires: 01- T - 2oZ2, _ .1", q9� : ' • i `.,! N, ��:•Oy GeLIG 0�i yF4 OF ALPS MUNICIPALITY: By: (signature) Date: 9' �2 1 • (print name) Title: Municipality of Anchorage Development Services Department Building Safety Division ~,,4 _ , ~=- On-Site Water and Wastewater Program [J 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. ~O- Expiration Date: GENERAL INFORMATION Completelegaldescription LoT I0-, '~Eq) ~EV-_t_I) Nt~ ~Jr~ ::~/ Location (site address or directions) /-Jl.~-"~ I M Co O~¢' ~3E,~'~) . I~., ~ Cu~ent Prope~ owner(s) ~{ '~ ~ )~ Day phone Mailing address ~-I q [)Fp~ ¢¢~ Lending agency Day phone = Mailing address Real Estate Agent Mailing Address \/~ ~-~. 1~-~ Day phone % Un/ess otherwise requested, HAA will be held by DSD for pickup. NUMBER OF BEDROOMS: ~ TYPE OF WATER SUPPLY: ' Individual Well Individual Water Storage Community Class ~ Public Water System Well [] D [] 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 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 pdvate er 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 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 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 flies 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. Address Engineers PHnted Name DSD SIGNATURE ~ Approved for Disapproved. Conditional approval for Phone Date -~../. 'j,. ,~ Cc..e..* 2 $ ,o .:': .. bedrooms. . ,3.'./;: -,... ,...:...,..- ; :/,:,'";7 ,"""~,-,o"~ :,'. ' . .' ' bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Odginal Certificate Date: 7 ' ~ - (:~)-~-- (Rev. 01,~Z) Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & W~ewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorege.ak, us (907) 343-79O4 HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescripfion: LoT A. WELL DATA We~l type Date completed Total depth ~ ~' fL If A, B, or C provide PWSID # Sanitary seal (Y/N) y Cased to.~..~fL Parcel ID: O ~ - put I - O ~ Well Log (Y/N) ~/ Wires p~perly protected (Y/N) ~,/ Casing height (above ground) 14~ in. Date of test Static water level Well production FROM WELL LOG AT INSPECTION fL I ~ ' fL g.p.m. /,~'~ g.p.m. WATER SAMPLE RESULTS: Coliform ~ colonies/100 mi. Arsenic: '// mg,/L Nitrate 0 ~3' mg./I. Other bacteria ~ I colonies/100 mi. Date of sample: /"lle ~ Collected by: ~ B. SEPTIC/HOLDING TANK DATA Tank Type/Material '~) ;~L~lu ~i~_ Date installed Tank size J/~a/) gal. Foundation deanout (Y/N) Date of pumping C. ABSORPTION FIELD DATA Number of Comparl~ents Depression over tank (Y/N) Pumper Length b/.~ ff. Width .~ ff. Total depth ~ fL Eft. absorption area ,~a-~ ft2 Monitoring tube . Date of adequacy test !~//,6.. Resu~ (Pass/Fail) Fluid depth in absorption field before test V~in. Water added Elapsed Time: L/'min. Final fluid depth I~in. Any rejuvenation treatment(past 12 mo.) (Y/N & type) Cleanoute (Y/N) High water alarm (Y/N) v~rption rate >= If yes, give date Gravel below pipe 0~ It. y Deprassion over flelc! t~ For ~ bedrooms New depth ~'/in. g.p.d. D. UFT STATION Dateinstalled /¢/~2~/0 '~ · Pump on" level at ~' in. Datum ~-4~; ,," E. SEPARATION DISTANCES Size in gallons · Pump off' level at _~...~n. Cycles tested Manhole/Access (Y/N) "/ High water alarm level at. ,~,~. ?t. Meets alarm & drcuit requirements? y in. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption ilL;id on lot ] b .,~ Public sewer main Sewer/septic service line On adjacent lots On adjacent lots '~ /O-cb Public sewer manhole/cleanout ~ Holding tank ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation '~ i~ Property line J O Absorption field 50 Water main I"V/,,~ Water sewice line ,~..G + Surface water t'-t I 0 Wells on adjacent lots Fe SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property mine ! 0 4- Building foundation Water Service line ~ t~ Surface water ~'///~ Curtain drain /,,//7'~'~ Wells on adjacent lots /~'~ COMMENTS Water main Ddv~my, paddng/v~hicle storage I O-~ G. ENGINEER'S CERTIRCATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance w~th MOA HAA guidelines in effect on this date. Engineer's Printed Name "~/¢/0~- 4.4. Waiver Fee $ Date of Payment Receipt Number 06/30/02 $~ 17:17 FAX 0896499 VISTA REAL ESTATE ER 1~002 ASBUILT FOLLOWING DE. SCRIBED PROPERTY= AND THAT NO ENCR~ACHM~NT~ E"XIST E~=£1~T AS I~ICA~. IT IS THE RE~NS~BILI~ OF THE ~ ~ D~RM~NE T~ ~ISTEN~ C,F ANY ~TS, ~NA~S~ OR RES~I~rI~S ~ ~ N~ ~E~ ~ THE RE~) ~l- VlSl~ ~T. U~ NO ClR~MSTANCES S~ ~ATA H~ ~ ~ ~ ~S~U~ON ~ LINES. Sample Remark~ Wa~e~s l~icrob J. olog~ Coliform PQL Di~ D~e 0.200 mg~L EPA 300.0 col~l OOmL $MI$ 9Z~2B JDT ~6/1~/02 }tAP MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date \(~::~ GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, r. ange) Location (address or directions) (b) Applicant Name [~¢/~,4L- ~ j~/~Ct,[ , Telephone: Home (_,,o~ - 4~'~ Business Applicant. Address -¢°~ _.Ij~¢:3,~. q rT~ J~'~'~'l .~ i~::;;~="~L.-~ ~-~./~CCL.--j ~ O'l..~t~d'"] - (c) Applicant is (check one): Lending Institution [] ;,Owner/,buHder~; Buyer []; Other [] (explain); (d) Lending Institution '~' ~"~'~.~' F~--~L~ Address Telephone (e) Real Estate Company and Agent Address Telephone (f) IVle~the HAA to the following address: _2, TYPE OF RESIDENCE Single-Family/~'~ Multi-Family [] Number of Bedrooms '~ Other WATER SUPPLY Individual Welll~ Community [] Public [] Note: If corn munity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DI, SPOSAL Onsite~ l'~ublic [] Community [] Holding Tank [] Note: If corn munity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (11/84) Page 1 of 2 Name of Firm Address - Date ENGINEERING FIRM PROVIDIk,..~ INSPECTIONS, TESTS, FILE SEARCH, DA. ~ AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of thi: Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adeq~ for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtain~ from the Municipality of Anchorage flies and from my investigation and inspection, the on-site water supply and/o~ wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Telephone Approved for~'~ ~ bedrooms by ~¢~ Date _/ Approved f Disappr~~ ~_ onditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) MI,I.NIClPALITY OF ANCHORAGE ~ DFPT. OF HEALTH PROTECTION MUNICIPALITY OF ANCHORAGE (M~'~IR°NMENTAL~ HEALTH AUTHORITY APPROVAL (HAA) OCT 'J. CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: . WELL DATA Well Classification Well Log Present Total Depth ~ ' Static Water Level Casing Height Above Ground Electrical Wiring in Conduit Separation Distances from Well: To Septic/l~ Tank on Lot To Nearest Edge of Absorption Field on ~_ot To Near~st Public Sewer Line '~,~, *"'~" If'A, B, C, D.E.C. Approved (Y/N) Date Completed ~_O-"~- ~:~ Yield Cased to ~"'/""' Depth of Grouting ~ Pump Set At Sanitary Seal on Casing~N) Depression Around Wellhead (Y~P ; On Adjoining Lots [, C:~' ~"-~ On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot j. te Water Sample Test Results ~ ~i ~ ~ Comments'~ k~~ ~ ~ ~~ ~ ~~ / B. SEPTIC/H;g~B~i~ TANK DATA Date Installed [,~ -~'{~"~) ~ize [,C~;~::~ No. of Compartments ~, Standpipes~N) Air-tight CapsCN) Foundation Cleanout~N) Depression over Tank (Y/~ j Date Last pumped tc~ - ~Jr'-~' ~'"'~' Pumping/Maintenance Contract on File (Y/N)/,&l~ t,~ j j~ ,' for '~ ~ /.~ Holding Tank High'Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Huldi~ Tank: To 'Water-Supply Well ~. l,~Lo ~ / To Building Foundation '~ ~ To Property Line ~. ~'~ t~ To Disposal Field ~ ~ To Water Main/Service Line J ~:,['Jr" To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026(11t84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/.~'. Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To BuildingLot F°undati~n~~1~ Type of System Design Length of Field Depth of Field ~; Gravel Bed Thickness Standpipes Present ~N) Date of Last Adequacy Test To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line ~ of To Existing or Abandoned System on ; On Adjoining Lots '"~t~ To C~utbank (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MpA an¢ HAA guidelines in effect on the date of this inspection. Signed~ ~'~ ~' Compa~'~fa:~ A~& ~· MOA No Date of Payment Page 2 of 2 72-026 (11/84) ' * MUNICIPALITY OF ANCHORAGE , ~ 825 L Street - Anchorage, Alaska 99501 E~ RON~p~OTE~ ~ ~ Telephone 264-4720 DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proceed. Please allow ten (10) days for processing. 1. PROP~RTYOWNER . / /, / / j PHONE~ MAI~ ADDRESS~ ~ /~ PROPERTY RESIDENT (If different fro ab ~ ~ PHONE ~. L~N~S~TUTmN ~ ~ ~ ~NE__ 4. RECTOR/AGENT ~ d ) n~ ~ : / ~1 PHONE STR E ET LOCAT),O~N / 6, T P Y E OF NUMBER OF BEDROOMS [] One [] Four ~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [~ Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL* COMMUNITY [] PUBL C UTILITY 8. SEWAGE DISPOSAL SYSTEM '~ INDIVIDUAL/ON-SITE** '-~ PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for al wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) **If individua/on-site, give installation date ~)/' If system ~s over two (2) years old an adequacy test is required by this Department, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN RE INITIATED. 72-010(3/78) 7'HIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR I NSP ECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY F_~ ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM -- PER"MIT NUMBER E~]INDIVIDUAL/ON -SITE ~ATE INSTALLED []PUBLIC UTILITY ~ "~O~- gl Connection Verified INSTALLER E~]Septic Tan~k or [] Holding Tank Size:_J~)f-~-J~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL ,--~.,,¢. ~) 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS [~APPROVED FOR .) BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED LEGAL DESCRIPTION 72~010 (Rev. 3/78)