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HomeMy WebLinkAboutELMORE #1 BLK 6 LT 2Elmore #1 Lot 2 Block 6 #018-172-08 Municipality of Anchorage On -Site Water and Wastewater Program • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP171172 PID Number: 018-172-08 Dwelling:* Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ❑■ Upgrade Name: Kim Barrett ABSORPTION FIELD ❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound Address 341 E. Benson #4 Anchorage, AK 99503 ❑ Other Phone Number of Bedrooms Soil Rating I Total depth from original grade 404-414-2631 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot Elmore No. 1 6 2 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 Ftp Ft. Well >100' NA NA NA >25' TANK 9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Anchorage Tank Capacity 11000 Gal.Material Surface Water >100' NA NA NA Steel Number of compartments 2 Lot Line >5' NALNA NA NA Foundation >5' NA NA LIFT STATION Manufacturer Capacity Gal. Curtain Drain None Noted Remarks Septic tank only replaced under this Pump on level at in. Pump off level at in. High water alarm at in. permit. Existing septic tank decommissioned in accordance With Municipal code. Pump make and model Electrical Inspections performed by PIPE MATERIAL House to tank D3034 Tank to drainfield D3034 Installer Denali Excavating Drainfield NA CO/MT D3034 Inspector MEA BENCH MARK (Assumed elevation) 100 ft Inspectiones: 15` 6/30/17 7/1/17 Location and description 2nd Garage slab 3rd 4,h COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp OF q��t� Conditional Approval: DateAW P��•."''••� '•• JW* ��e� 49TH .. .... , -G� /..........•.......•..•• •.... u...s �, %MICHAEL E. ANDERSON :1-- A CEi - 4381 �J�,�p, 7 Approved Date 31201p1?0FESS10�A�v~ Inspection Repo rt_9-1-12.doc F il) Z � Op ch 0) m a Qoa 0W® v o Ei IX S. QW c z g W i CL w vt �j 3e 00 Em EE m { \ ICN ® ( 1 I I � { I � ol�I rn C { { ( rr I / W I C, uj / I= I n / { � / W a 1 r, � I / � U / C r v 0- O N O — U Y C C � L Q '- O O p_ EM �- �� •rrasaHrv+a xosasanro N V 'C I r� � W© 3 { \ ICN ( I I I I I � { I � I j { { ( rr I / C, uj I= I n U to { � W a Permit Number: OSP171172 Municipality of Anchorage DEVEOPMENT SERVICES DEPARTMENT 4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904 On -Site Wastewater Disposal System or Well Inspection Report 99.5 NNM (0UU J 1,000 Gallon R _// Septic Tank \ i6.1 95.95 Page 3 of 3 PID No. 018-172-08 Septic Tank Only Replaced Under This Permit. 2" Insulation Placed Over Tank and All Absorption Trench Areas Exposed. Monitor Tubes and Cleanouts Placed to Facilitate Testing of System. Exact Location of Absorption Trenches Could Not be Determined. Length of Trenches Shown on Site Plan are Taken from Municipal Files. ELMORE NO. 1 BLOCK 6, LOT 2 PROFILE AS -BUILT No Scale P,��.QF•A4 4tAV� ® 49TH '•,�W ` e:...::.......se � MICHAEL E4381ERSON° � a� C N,"°""'r MUNICIPALITY OF ANCHORAGE silent On-Site Water &Wastewater Program �o ': PO Box 196650 4700 Elmore Road 4a Anchorage,Alaska 99519-6650 Phone: (907)343-7904 Fax:(907)343-7997 http:llwww.muni.orglonsite / cl}artmfnt INCH-C-1 p'Y On-Site Wastewater Disposal System Permit Permit Number: OSP171172 Effective Date: 6/30/2017 Work Type: SepticTank Upgrade Expiration Date: 6/30/2018 Tax Code Number: 01817208000 Site Legal Address: ELMORE#1 BLK 6 LT 2 G:3036 Site Mailing Address: 4640 NATRONA AVE, Anchorage Owner: BARRETT KIM E Lot Size in Sq Ft: 37299 Design Engineer: ANDERSON ENGINEERING Total Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field 0 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 Received By: (//J1 meet. rn ( Date: ("l3o// Issued By: � 4:142� Date: 6��0'7 MUNICIPALITY OF AN.0 AGE Community Development Department � O 70 I•ne: 907-343-7904 Development Services Division `_� �U� 3 N ax: 907-343-7997 On-Site Water& Wastewater Program PM ON-SITE SEWER/WELL PERMI Parcel I.D. 018-172-08 Property owner(s) Kim E. Barrett Day phone (404)414-2631 Mailing address 341 E. Benson #4 Anchorage, AK 99503 Site address 4640 Natrona Avenue Anchorage, AK 99516 Legal description (Sub'd_, Block & Lot) Elmore No. 1, Block 6, Lot 2 Legal description (Township, Range & Section) Lot Size 37,299 Sq. Ft. Number of Bedrooms Three APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank ❑Q Upgrade ❑x Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE 1 WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. 61 ---+ (Signature of property owner or authorized agent) Permit/Rush Fees: 1' 39 t(; t U Waiver Fees: Date of Payment: tO/ I/`7 Date of Payment: Receipt Number: OS 2 f L7 Receipt Number: Permit No. n601-711 Ta-- Waiver No. Permit App_ : ._..:c, ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 522-6779 (FAX) June 30, 2017 Municipality of Anchorage Development Services Department On-Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: Lot 2, Block 6, Elmore No. 1 Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer: The Septic Tank on the subject lot has failed and must be replaced on an emergency basis. The tank is leaking profusely and will not hold water. We are proposing to replace the tank with a new 1,000-gallon septic tank to serve the three-bedroom home on the lot. The existing tank will be decommissioned in accordance with Municipal Code. We are therefore requesting a permit be issued on an emergency basis for the construction of a new tank to serve the home. The new tank will be placed outside the 100' protective well radius. The attached Site Plan and backup documentation identify the location and configuration of the existing septic system and the location of the new septic tank. No conflicts exist between the well and septic system on this lot and those on adjacent lots. The drainage patterns on the property will be maintained after construction. The ground surface on the lot is basically flat in the area of the new tank. The tank will be placed near the same location as the existing tank at nearly the same elevation. It will then be tied in to the existing service line. The tank will be constructed in conformance with Municipal requirements. If the tank is constructed in accordance with our design the following statements apply: I . The tank, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. 2. The tank, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. Lot 2, Block 6, Elmore No. 1 Subdivision June 30, 2017 Page 2 of 2 3. The tank, if constructed as designed, will have no adverse impact on reserve space, either surface or subsurface, on any lots located in the area. 4. The tank, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, Michael E. Anderson, P.E. Attachments •!' IN* • 's : 1 a I • :• 411(..HAE. E. ANDERSQN �4i *E ••• No. CE-4381 ••* te) SECTt -LOT 38B ELM0l2C tJO . 1 i3LK (o LT- 2_ NATRONA AVENUE 208.71 // / LEGEND ? at doibk� c,(ta.n 41 SV - Septic Vent 1'IExisting CO — Clean Out 01,4 upsiTtani f ijv Well MT - Monitor Tube Cre / TH - Test Hole - J �Gizt n uh�tsS MH - Man Hole ciliect WA 'qQ° bend Driveway t: CAM be AC.in►,i•or,eI, Four Bedroom \ Home 1 \ 3 Place New Septic sy Tank Outside Well S� asV Radius. 2C0 SCOPE OF WORK: 1. Place Foundation Cleanout. 2. Decommission Existing Septic Tank in Accordance with Municipal Code. 3. Placed New 1,000 Gallon Septic r Tank and 2 Post Tank Cleanouts. Exact Location of Existing 4. Connect to Existing Absorption Absorption Trench to Well Trench. be Determined. 5. Place Cleanout and Monitor Tubes As Shown. _ cow:/ ..•'SOF 44411 o c� mal'(/): 1 .•/.. * 10 Utillity Easement i*: 49� :"0 • * _po No Conflict with Well or •i,,%MICHAEL E. ANDERSON•:Q.i Septic System This Lot. VACANT VACANT ,* s;•••• E_4381 - � � S TP LAS 14 1'�9i.� Boa•,�,�_: 13 12 SCALE 1" = 40' G"YD1 GR ANCHORAGE AREA BORO D RTMENT OF ENVIRONMENTAL (MALL110 3500 TUDOR ROAD ANCHORAGE, ALASKA 99607 279.8686 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM MAILING 3yy NAME �/M �/7R((NE�%US ADDRESS 7%.26 /NIJFjY L)i7 6�pHONE 7U LOCATION ��MdR� 1�R, LEGAL DESCRIPTION 11' .2 13146, .. ?'' '-` SEPTIC TANK: MBER OF DISTANCE FROM WELL D 7 MATERIAL 976KI COMPARTMENTS LIQUID LIQUID CAPACITY I nQCi GALLONS. INSIDE LENGTH INSIDE WIDTH DEPTH — SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS OU E DIAMETER OR WIDTH , LENGDEPTH LINING DISTANCE FROM WELL _-'� , BUILDING FOUNDATION , NEAREST LOT LINE TOTAL EFFECTIVE-A856R�16td'A-R A (WALL AREA) SQ. FT. TILE DRAIN FIELD: TOTAL LENGT i DISTANCE FROM WELL / n ,FOUNDATION o NEAREST LOT LINE d OF LINES, NUMBER OF LINES? 1 DISTANCE BETWEEN LINES J/ TRENCH WIDTH �) IN. TOTAL EFFECTIVE ABSORPTION AREA / / _ z SQ. FT. LENGTH OF EACH LINE . DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILES IN. ABOVE TILE WELL.DISTANCE FROM WATER TYPE 0,411E13 DEPTH 400 " , BUILDING FOUNDATION. SAMPLE NEAREST �a' NEAREST ,TANKC br%T SEEPAGE �8, OTHER LOT LINE - ,SYSTEM CESSPOOL SOURCES= DISTANCES: PPES rl"71f GOK'iPE,p DIAGRAM OF SYSTEM DATE APPROVED G. B�� ew GREOER ANCHORAGE AREA BOUGH 2T94 DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO. 35GO TUDOR ROAD POUCH 6-650 ANCHORAGE. ALASKA 99502 TELEPHONE 279.8688 SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT NAME OF APPLICANT MAILING ADDRESS/,Z& Z"Wzk Z� PHONE 3Vr ^7770 I INSTALLATION LOCATION LEGAL DESCRIPTION INSTALLATION OF: SEPTIC TANK TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH SOIL TEST RESULTS COMPLETION DATE ANTICIPATED OTHER TO BE INSTALLED BY NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE HEALTH DEPARTMENT AUTHORITY.WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE /V`�✓ TYPE t ___f7- SEEPAGE AREA SIZE MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT ^� DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL ' ✓ SEPTIC TANK �, SEEPAGE PIT 20 ! DRAIN FIELD TO NEAREST LOT LINE. ^!7� WELL TO SEPTIC TANK u©' SEEPAGE PIT �DO' DRAIN FIELD ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK •D SEEPAGE PIT �D , DRAIN FIELD SEPTIC TANK, �, SEEPAGE PITDRAIN FIELD TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK O:ND�SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. HEALTH AUTHORITY OR LICENSED DESIGNER DIAGRAM OF SYSTEM 1 CERTIFY THW I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28.68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE APPLICANT'S SIGNATURE C ✓ ✓Wwl T. H. -I 6-6-72 N ORGANICS 0.0 0.5 ORGANIC SILT a W/ SOME GRAVEL o.oa: a�0. SILTY SANDY GRAVEL Dgalj W / COBBLESy GM� Q .' Redish brown / 8.5 ®W.O. 4..:° 9.0, Note : Hole excavation with tractor mounted backhoe. t Tim Cornelius Property Engineering &Geological Consultants LOG OF TEST HOLE ANCHORAGE PAIRBANK9 ALASKA JUNEAU Anchorage Alaska DATE 6-6-72 SCALE 1n = 2' DWN BY GAW CHKD BY WED PROJ. NO. 26509 DWG NO. A -0i . 0 NWWA Certified Contractor TO— OWW"icate OTS —TO - 3 — CONTRACTO O 3—CONTRACTOR M -W DRILLING, Inc. 86-147 ° - - - P.O. Box 110378. 10330 Old Seward Highway (907) 349.8535 -. ANCHORAGE, ALASKA 99511 f DRILLING LOG Well Owner. LANGSTON, STEVE UseofWe» Domestic Location (address of: Township, Range, Section, if known; or distance main road 'Lot 2, Block 6 Elmore Subd. -Anchorage Size of caping ---L Depth of Hole „ 121 feet Cased to 120.1 feet Static water levet q3 ft. t low) land surface. Finish of well (check one) open end ( g ); Screen ( ) ; Perforated d Describe screen or perfoaatzon AILs Well pumping test at 25 gx (minute) for -1 --hours with 100"% ft, of drawdown from stat' - j ; 4 r Date of completio :. - gs' WELL LOG Depth in feet from ground surface a � of rmations penetrated, size of matQrj=sqa*ss O Tom 93 n%E7,hole JUL 10 n 93_TO 101 rd an ATO- ;. 1; RECEIVED 114 TO 121 n Rave l t7 NWWA Certified Contractor TO— OWW"icate OTS —TO - 3 — CONTRACTO O 3—CONTRACTOR MUNICIPALITY QF ANCHORAGE Development Services Department 1 - % Phone: 907-343-7994 On -Site Water & Wastewater Section - Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 018-172-08 1. GENERAL INFORMATION Expiration Date: --,, 13 Q D Q a Complete legal description ELMORE #1 BLK 6 LT 2 Location (site address) 4640 NATRONA AVE, ANCH AK Current property owner(s) HROMADA Mailing address SAME Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone Day phone 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Date of Payment `i 13 0,2,? Receipt Number 013 % �9 COSA # OSc. 2 - Waiver Fee $ Date of Payment Receipt Number Waiver # 6. 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 MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. 6. DSD SIGNATURE J System #1 Approved for 3 bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, Date 4/4/22 -P MICHAEL N. ANDERXN C 9469 r... ;d QNB � !>• ..� with the following stipulations: ON-SITE m% SA TLy;'ATER o PROGRAM O~� 1 By: Original Certificate Date:(3 2 0 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist Legal Description: ELMORE #1 BLK 6 LT 2 If more than 1 septic system on lot: COSA Checklist # _of A. WELL DATA 0 Well log is filed with Onsite (or attached) Date drilled 6n6/86 Total depth 121 ft Cased to 120 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 24 in. Date of flow test for COSA 3/8/22 Static water level at beginning of test 86 ft. Comments B. TANK DATA Age of tank(s) 5 years Tank type/material Measured operating fluid level in septic tank 48 N Standpipes/foundation cleanout per record drawing Date of pumping 4/13/22 D. ABSORPTION FIELD DATA 'TESTED MIDDLE TRENCH Which system tested (date installed) 7/72 X ALL standpipes present per record drawing Total measured depth from grade 3 ft (max) Measured depth to pipe invert from grade 2.5 ft (min) ❑ N/A — pressurized field ❑EI Monitor tubes go to bottom of effective. If not, state depth into effective X Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Parcel ID: 018-172-08 Structure served by this system _ Well production at time of test 4+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑� No X Coliform bacteria is Negative Nitrate 2.22 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L 2 Arsenic less than MRL (ND) Collected by MNA Date of Sample 3/8/22 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 3/8/22 Results Q✓ Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 450 gal New depth 3 in Elapsed time 1440 min Final fluid depth 0 in Absorption rate 450 god Any rejuvenation treatment (past 12 months) _ Gallons introduced 0 gallons If yes, enter date (:nmmP.ntR/nP.fiCiP.nCiP.R*TESTED THE MIDDLE TRENCH, water in al CO#6 and checked CO#5/MT 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' I] Yes Community Sewer Manhole/Cleanout > 100' v❑ Yes if No ft M Yes if No ft Neighboring Tank > 100' ❑v Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No _ ft Absorption Field on Lot > 100' ❑ Yes if No "98 ft Holding Tank > 100' I] Yes if No _ ft Neighboring Absorption Fields > 100' Yes if No _ ft Water Main > 10'✓❑ Animal Containment > 50' ❑✓ Yes if No ft i] Yes if No ft ❑ Yes if No _ It _ Yes _ Manure/Animal Excreta Storage > 100' If septic tank is under driveway Community Sewer Main > 75' ❑✓ Yes if No _ ft ❑✓ Yes if No _ ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10'❑ I] Yes if No _ ft Surface Water > 100' Yes if No _ ft Property Line > 5'✓❑ Yes Yes if No _ ft Wells on Adjacent Lots: Absorption Field > 5' i] Yes if No _ ft Private Wells > 100' Yes if No _ ft Water Main > 10'✓❑ _ ft Yes if No _ ft Community Wells > 200' ❑ Yes if No _ It Water Service Line > 10' Yes if No—ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' I] 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 _ ft Water Service Line > 10' 0 Yes if No _ ft Community Wells > 200' Yes if No _ ft Surface Water > 100' F71 Yes if No ft F. ENGINEER'S COMMENTS waiver of 98' granted in July of 1996 by MCA. Dem =1:[HI:1=1 =1:76Kd=1A111;1WIN d to] :l I certify that / have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet e P • f �z %fir -49TH r MICHAfC-�P -• AKOtRSCiJ t'f CE 94y 9 � � 9 10 17 • • h6 1 �c e •'2Z Municipality of Anchor auso A� On-Site Water and Wastewater Progr (907) 343-7904 n ���'.i n JUL 7 2017 SAi ETT Certificate of On-Site Systems Ap* al 0,4` " 0169 Parcel I.D. 018-172-08 Expiration Date: Off+ \ 3. 11 1. GENERAL INFORMATION Complete legal description Elmore No. 1 , Block 6, Lot 2 Location (site address) 4640 Natrona Avenue Anchorage, AK 99516 Current Property owner(s) Kim E. Barrett Day phone Mailing address 341 E. Benson No. 4 Anchorage, AK 99503 Real Estate Agent Day phone 2. TYPE OF DWELLING: [] Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: Three 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: Date: 3/13 J t i COSA to be released to the engi r,unless otherwise requested by the engineer. COSA Fee $ c$ / Waiver Fee $ Date of Payment 71 l b 1l 7 Date of Payment Receipt Number Do-340 aZ C Receipt Number COSA# 05C-1117--r2- Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Engineering Phone 522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Benjamin Schiller Date 7!712017 JP 67 t 6. DSD SIGNATURE ,o'* 4911:17k. 91Nj .*0 X System #1 Approved for 3 bedrooms „ .A— m System #2 Approved for bedrooms �e� ;� 1 : Disapproved g�` o 71 $2 °.. g Conditional approval for bedrooms, with the following stipt1.- Z'` ��`q b rye\ OF ANC -L' Oy-SVTE (c" . p \'!A�rVVP eR c WAS RAM 4? .,'f PROL, �� • n By: /LO to I .UL( Yn Original Certificate Date: 7/ 15/2 0 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 Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other CASA blue sheet [ - . 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: Elmore No. 1 , Block 6, Lot 2 Parcel ID:018-172-08 A. WELL DATA Well type Private If A, B, or C provide PWSID# Well Log (YIN) Y Date completed 3/18/86 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth 121 ftCased to 1 20 ft_ Casing height(above ground) X12 in. FROM WELL LOG AT INSPECTION Date of test 3/18/86 6/30/2017 Static water level 93 ft. 80 ft. Well production 25 g.p.m. 4.7 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate .938 mg/L Arsenic ND ug/L Date of sample: 6/28/17 Collected by: And. Engineering B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 6130117 Tank size 1,000 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping Pumper New Construction C. ABSORPTION FIELD DATA Date installed 7/72 Soil rating (g.p.d./ft2 or ft2/bdrm) 225 SFIsoRM' System type Trench Length 239* ft. Width 3* ft. Gravel below pipe •5* ft. Total depth 3 ft. Eff. absorption area 717 ft2 Monitoring tube Y Depression over field N Date of adequacy test 6/30/17 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 450 gal. New depth 0 in. Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 450 9.P-€1. Any rejuvenation treatment(past 12 mo.)(YIN &type) N If yes, give date * From Municipal Files. Monitor Tubes and Cleanouts Added and Insulation Placed over Much of the Trench Area. New Septic Tank Placed >100' From Well. D. LIFT STATION Date installed Size in gallons Manhole/Access(YIN) "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 100 On adjacent lots >100 Absorption field on lot 98 On adjacent lots >100 Public sewer main >75' Public sewer manhole/cleanout >100' Sewer/septic service line >25' Holding tank >75' Animal containment areas >5 Manure/animal excrete storage areas 100 SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line >5 Absorption field 5' Water main 10' Water service line 10' Surface water 100' Wells on adjacent lots >100' ABSORPTION FIELD ON LOT TO: >10' ' 10' Property line Building foundation X10 Water main >10'Water Service line Surface water >100 Driveway, parking/vehicle storage >10' Curtain drain None Noted Wells on adjacent lots >100' F. COMMENTS **See Waiver 86-092. G. ENGINEER'S CERTIFICATION .'+��t`%II1t I certify that I have determined through field inspections and 4'S,F;•�*' A•:QS,O/ review of Municipal records that the above systems are in „1?-.• ,� #t conformance with MOA COSA guidelines in effect on this date. s :• 4 g ry /. *1I Engineer's Printed Name Benjamin Schiller, P.E. �'•••'• �_� � 67.1;A:.4 • Date 7/7/2017 fI {,„•MICHAEL E. ANDERSON " ♦ �, CE-4381 :4'-o ,,I h t o pR0 ZSS10N�� ♦♦17 COSA brown sheet 10-10-12.doc NATRONAAVENUE S 89046' 30" W. 208.71 _ 4 �vE« I„ s,..,„„ ..6...... CPP N. 0 44,0 a t P 4$' - Rq'1./$• 4 AY Y Rus r CO N- e- N. Oti 11111 •AT91UAr 1\� b STI 25' W 0 b ° Q 0 0 0 1- °00 el.. Z CO SI' w 8 6 m.? b --- 10' UTILITY EASEMENT N 89°46' 30" E. 208.71 �4,000pp� o OF .... , Qfl,� . ........ ,gsp0 O= P TH i\ �-0u * . 49 — ..Oa n, . • 4VA a SHANE A.HOLT Oa AS-BUILT SURVEY l''V = 3D Q e LS-6914 a MO CORNERS SET THIS DATE 5� SURVEY ORDERED BY: O�dpe "" 0C, HOMES UNRONA LIMIIO TED ����OOOO���o OFHEREBY FOLLOWING ESCRIBEDHAVE PROPERTYPERFORMED ASURVEY LOT 2, BLOCK 6, ELMORE SUB. ADO'N. NO. 1 THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS:AND IS VISIBLE ISITUATED THEREON ARE WITHIN NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES,IMPROVEMENTS,OR FENCELINES. THE PROPERRTYTY LINES AND NO VISIBLE ENCROACHMENTS EASEMENTS OF RECORD,OTHER THAN THOSE APPEARING ON THE RECORD PLAT•ARE NOT SHOWN DATEDAIST OTHER THAN NOTED. AT ANCHORAGE,ALASKA THIS _7TH DAY OF HEREON(UNLESS INDICATED) NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO bETERMNE _ JULY 2017. PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS. HOLT LAND SURVEYING ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE. 9309 GROVER DRIVE ANCHORAGE Alf 99507 7E+2, FB 87-24, 182-75,183 48 345-5513 Municipality of Anchorage • Department of Health and Human Services Division of Environmental Services On -Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FORA SINGLE FAMILY DWELLING Parcel I.D. R (,72_ -06 HAA# `SI31 Expiration Date: GENERAL INFORMATION Complete legal description (0 e- 9r - Location (site address or directions) LF{oLFo 1d a � v0rct, Current Propertyowner(s) C?u.w�/44WT4 Qrcw Dayphone Mailing address Lending agency _ Mailing address Real Estate Agent_ Mailing Address Day phone Day phone Unless otherwise requested, HAA will be \ DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. 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 less than 30 days old. 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. 72-025 (Rev_ 01/00)' Individual On-site ❑ Individual Holding Tank ❑ ❑ Community On-site ❑ ❑ Public Sewer ❑ The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. 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 less than 30 days old. 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. 72-025 (Rev_ 01/00)' 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 Health Authority Approval Guidelines for the Health Authority Approval application show 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm M t �k ( /qs Asl cr,_,aPhone Address 4640 v e. Engineer's Printed Name ✓(c ac C Date 7 G ow 1...'. P ....� 6. DHHS SIGNATURE It Cc o q \ 1� Approved for 3 bedrooms. @�6 14 Disapproved. Elko' ,` r= Conditional approval for bedrooms, with the following stipulations. Additional Comments Attachments: HAA Checklist Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: Original Certificate Date: — / Ll— d 0 - Expiration Date: Reissue Date: 'S-025 (Rev. 01/00)• •Municipality of Anchorage • • '� Department of Health and Human Services C t it Division of Environmental Services On -Site Services Section 825 "L" Street Room 502 �' 200® P.O. Box 196650 Anchorage, AK 99519-6650 APR www.ci.anchorage.ak.us (907) 343-4744 MUNICir u(v ur SFRViOi eH�r �,�eo 'VJINLF' r, , HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: 14 Z N6 -,(o at",e_-: #E / Parcel I.D.: A. WELL DATA Well type _ w�a e� If A, B, or C provide PWSID # Date completed 02/ Y(17 Sanitary seal __ Total depth (21 ft Cased to /21 It FROM WELL LOG Date of test Static water level R ft Well production g.p.m Well Log XC S Wires properly protected VC Casing height (above ground) 3 (v in. AT INSPECTION y 60 %8 ft d g.p.m WATER SAMPLE RESULTS: Coliform colonies/100 ml Nitrateo(� mg/I Other bacteria_ colonies/100 ml Date of sample: -*LF11V Collected by: /''r1vA B. SEPTIC/HOLDING TANK DATA f Tank Type/Material Date installed 7 72, Tank size 10oO gal Number of Compartments Cleanduts C. Foundation cleanout t'" t+%e. Depression over tank _/� High water alarm µ� Gv.wl sw�cR Date of pumping 0 Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft2 or ft2/bdrm) System type S �g i/r/rh4j firrzz;, Length 2 -S2 -ft Width 3 ft Grav J beJowpipe �ft Total depth 3 ft Effective absorption area 2 Monitoring tube Depression over field Date of adequacy testo Results (Pass/Fail)For _� bedrooms Fluid depth in absorption field before test in Water added gal. New depth Q in. Elapsed Time: 1"4gO min Final fluid depth O in ��Absorption rate >= 500 � g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) t T`('O. If yes, give date 72-026 (Rev. 01100)' D. LIFT STATION Date installed "Pump on" level at E. SEPARATION DISTANCES 41 Size in off" level at _ in Cycles tested 0 Manhole/Access High water alarm level at in Meets alarm & circuit requirements_ SEPARATION DISTANCES FROM WELL ON LOT TO: i Septic tank/Ufi.station on lot On adjacent lots /00 y` Absorption field on lot TO On adjacent lots lo(.I- Public f Public sewer main Public sewer manhole/cleanout Sewer /septic service line 25 -G Holding tank f SEPARATION DISTANCES FROM SEPTIC/11OHNIZ TANK ON LOT TO: Building foundation [ �r f Property line /hoop +4- Absorption field [ S r Water main N �,� Water service line Z 5`+ Surface water +>< Drainage 1 b o+ 4 Wells on adjacent lots rOov f f - SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line AVt¢ 22+•f Building foundation 2a tf Water mainy/4 Water Service line 6 /, A /-00O`* Surface water /o +,�- Driveway, parking/vehicle storage Z - ACurtain drain N Wells on adjacent lots I o o r, - F. COMMENTS o GCtOA-ehe�y v}` N04%-6Vru +Qht 7-hefC-Ircr/1\1tW OrnrS. ac-li G. ENGINEER'S CERTIFICATIONF AO ��1't I certify that I have determined through field inspections and SNE • • •' • S� 1�+ review of l records hat the ove systems are in conformance nwi hatMOA HAAguidelines in effect on this date: Engineer's Printed Name 1v1«��,pl/��./.n ��+5•ii i • . vC e MICHAEL N. ANDERSON .yam Date ry cE 94 9 L y HAA Fee $ J Date of Payment[ Receipt Number I 72-026 (Rev. 011PO)' Waiver Fee $ Date of Payment Receipt Number 0 NATR❑NA AVENUE S 89'46' 30" W. 208.71 1I� N SHEp WELL Url PPRR �T pR� JET' VRP 68J I £'9Z SHEp 11R ST -1 FRAME HOUSE N z A � 1M� W W � Z63 pecx pp13a W NEW DOUBLE CLEANOUT INSTALLED O O SEWER VENT APPORXIMATE LOCATION OF LEACH FIELD FROM ASBUILT ON FILE O O DHHS O V1 NEW MONITOR TUBE INSTALLED AS—BUILT SURVEY NO CORNERS SET THIS DATE 1" = 30' LOT 2, BLOCK 6, ELMORE SUB, ADD'N. NO, 1 10' JTILITr EASEMENT N 89046' 30" E. 208.71 "`�„• MICHAEL N..SNC ;;gON•� =z / g�CEpip a C6 I` O O r Q O Ow 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. # C 1 1121 - [)Q�- L0 El HAA # QA')i]i0'A l] 1. GENERAL INFORMATION Complete legal description Lot 2, Block 6, Elmore subdivision #1 Location (site address or directions) 4640 Natrona Avenue Anchorage, Alaska Property owner Mailing address Mary Boyd Day phone 4640 Natrona Avenue, Anchorage, Alaska 99516 Lending agency Seattle Mo Mailing Agent Address Carol Douthit Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 2 3. TYPE OF WATER SUPPLY: Individual well Community well Public water Day phone Day phone 345-2095 276-2761 NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site X Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legalityand status of system. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm GiIfIIian Engineering, Inc. Phone Address Engineer's 255 E. Fireweed 6. DHHS SIGNATURE XApproved for Disapproved. 376-3005 or 277-2021 , Suite 102 Anchorage, AK 99503 Robert E/Gi Ifi I ian, P.E. Conditional approval for Additional Comments M_ bedrooms. 1IITIO a Date /V OF AL e 3ooen c. Ji!r' mn Ce 1034 ; PROFESSION-� bedrooms, with the following stipulations: /o - �1_6-93 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 (Av. 1191) Back MOAN 1 Municipality of Anchorage Department of Health and Human Services 44 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lot 2, Block 6, Elmore #1 Parcel I.D. d/S- - 1'7,:z — 09 A. Well Data Welltype Private Log present(Y/N) Total depth 121 Sanitary seal (Y/N) _ Date of test Static water level Well flow Pump levell _If A, B, or C, attach ADEC letter. ADEC water system number y Date completed 3/18/86 Driller Wayne E. West I ey Cased to 120' Casing height 36" 11 FROM WELL LOG March 18, 1986 93' 25 Unknown Wires properly protected (Y/N) y AT INSPECTION MUNICIPALITY OF ANCHORAGE 10/1/93 ENVIRONMENTAL SERVICES DIVISION 781 811 0('11 19 119/93 p.m. 6 9P (lnkn nun RECEIVED ED SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 871 �4 ? a ; On adjacent lots 100 + Absorption field on lot 90'+ 4- ; On adjacent lots 100 + Public sewer main NA Public sewer manhole/cleanout Sewer service line 251+ Petroleum tank 251+ " Waiver granted 7/10/86 WATER SAMPLE RESULTS: Coliform Absent Date of sample: 10/l/93 B. SEPTIC/HOLDING TANK DATA a _ I? M G/L Other bacteria Collected by: K. Sheets E Date installed 7/7/72 Tank size 1000 Compartments i n craw - Cleanouts (Y/N) y Foundation cleanout (Y/N) space Depression (Y/N) N High water alarm (Y/N) NA Alarm tested (Y/N) NA Date of pumping l 9 --3 Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 87' On adjacent lots 100' Foundation 12' To property line 251+ Absorption field 101+ Water main/service line 101+ Surface water/drainage 1 00 , + 72-026(3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA (Y/N) "Pump off" Level at tested On adjacent lots Surface water Date installed 7/7/72 Soil rating (GPD/F?) 225 sq. f t . /BR System type Dra i of i e I d Length 239' Width Unknown Gravel thickness 0.5' Total depth 2.5' + Total absorption area 717 sq . f t . Cleanout present (Y/N) N Date of adequacy test 10/1/93 Results (pass/fail) Pass Water level in absorption field before test Depression over field (Y/N) N _for 2 Bedrooms test Peroxide treatment (past 12 months) (Y/N) If yes, give date "'No monitor tube - Put in 600 gallons of water SEPARATION DISTANCE FROM ABSORPTION FIELD TO: (double normal rate) with no backup in septic tank. Well on lot 90, +_�On adjacent lots 100' + Property line 20' + To building foundation 121 + To existing or abandoned system on lot NA On adjacent lots 25' + Surface water 100' + Curtain drain 25' E. ENGINEER'S CERTIFICATION NA Water main/service line 10, + Driveway, parking/vehicle storage area 25' + S Waiver granted 7/10/86 1 certify that I have checked, verified, or conformed to all MOR and NAA guidelines in Signature !�/�i c✓""//`" — Engineer'sNa a Robert E. Gi If I ian P.E. Date &_ %3 inspection. HAA Fee $ JUO, U U Waiver Fee $ Date of Payment l6 - / g �9-3 Date of Payment Receipt Number 6706 Receipt Number. 72-026 (3/93)' Back MUNICIPALITY OF ANCHORAGE (MOA) • Health Authority Approval (HAA) y d,GtAL'i' CHECKLIST- FEBRUARY 1984 w 1 nCNMENTAL SE:RViCc6 ulvi�43 4744 7� 1� if Legal Description: `� /g� �Gej A. WELL DATA R C L 1 V C U rJ Well Classification YG If A, B, C. D.E.C. Approved (Y/N) Well Log Present (Y/N) _/ Date Completed Yield Yield �pG Total Depth O�/ / Cased to � Depth of Grouting N��r i Static Water Level Casing Height Above Ground 5/ Pump Set At Gli��e�uvr Sanitary Seal on Casing (Y/N) /! Electrical Wiring in Conduit (Y/N) Z Depression Around Wellhead (Y/N) ti SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot rF7 i ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ` / ; On Adjoining Lots To Nearest Public Sewer Line �� To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line/on Lot 50 "7L - Water Sample Collected by / �GY�u/,J ; Date Water Sample Test Results Comments ���—/c'r<2�c lj�( L X7'_ B. SEPTIC/HOLDING TANK DATA Date Installed 7.2- 72 Size No. of Compartments Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (Y/N) /v Date Last Pumped ' n Pumping/Maintenance Contact on File (Y/N) ��� ; for Holding Tank High -Water Alarm (Y/N) A_� Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: i I To Water -Supply Well To Building Foundation /i To Dis osal Field 7� To roper y ine p To Water Main/Service Line �U i To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Z J X/ j% Soils Rating in Absorption Strata Type of System Design SGL E Date Installed 7' 7' %L Length of Field Z3 Width of Field Depth of Field Z S y Gravel Bed Thickness D S Square Feet of Absortion Area 7Y 7 v Statndpipes Present (Y/N) Depression over Field (Y/N) /t% Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: � To Water -Supply Well To Property Line 22 To Building Foundation %Z To Existing or Abandoned System on Lot A/) ; On Adjoining Lots 25 To Water Main/Service Line ��� r To Cutback (if present) A2,4 To Stream, Pond, Lake, or Major Drainage Course lUG' 1.f To Driveway, Parking Area, or Vehicle Storage Area �sr'f Comments �?` L/ u Iy Ct D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Comments Dimensions hole/ Off' Level at Vent(Y/N) "Check Permitte Bedroom R ting Against HAA Request" I certify that I Checkederif' d, or conformed to all MOA and inspection. Signed � =" Compan Date —C� - �- C �/ MZg0 � y MOA No. GE w(S Receipt No. ,��.S�/6-5 Date of Payment 3 ! Z _w Amount:$ /_7e�• 67) Receipt No, Waiver Fee: $ Date of Payment 72-026 )Rev. ]/88) Back Page 2 of 2 Pumping Cycles during Adequacy Test. on the date of this Engineer's Seal 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 r�?_3 zU1X rr,/� 1. GENERAL INFORMATION 2. (a) Legal Description (include lot, block, subdivision, section, township, range) 13,we! e- 41'-/ Tiz.✓ e3ld Location Icddress or directions) (b) App!icant Name Sl `?✓6 Telephone: Home S5 BusinessSJG /-lOG "Applicant Address ��°�° i/rt e�✓r� �� /}x 9 F-.5 (c) Applicant is (dheck one); 4endfng Institution ❑ ;Owner/builder; Buyer ❑ Other ❑ (explain); (d) Lending Instittftiorl _,_;e Address (e) Real Estate Company and Agent Address __ Telephone — (f) Mail the HAA to y following address: TYPE OF RESIDENCE Single -Family Multi -Family ❑ Number of Bedrooms Other Telephone 3. WATER SUPPLY Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite 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. Page 1 of 2 72-025(11/84) 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, `FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. �/p Name of Firm a S Telephone �'� S' - Address3j/`ui'E �•�i� 9�s�3 Date X2"3 Jt i nD ao, 6. DHEP APPROVAL Approved for �"'� bedrooms by �'� Date Approved L� Disapproved Conditional Terms of Conditional Approval �1T CAUTION 7- T- 8& 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) •MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE (MO DEPT. of HE,%LT}T g HEALTH AUTHORITY APPROVAL (HAA) ENVIRONMENTAL PacrecnoN CHECKLIST - FEBRUARY 1984 U44 p 11986 264-4720 Legal Description: tory fi *1; � [ I €>ex� / %fy,✓ 1p33u1 A. WELL DATA Well Classification � Ri✓RTE If A, B, Q, D.E.C. Approved (Y/N) '�� Well Log Presen (Y N) Date Completed 3P/g- Yield y_T- Total Depth /L/ Cased to /�' / Depth of Grouting W t4 Static Water Level Casing Height Above Ground Electrical Wiring in Conduit CN) Pump Set At Sanitary Seal on Casing) Depression Around Wellhead (Y)N Separation Distances from Well: To Septic/Holding Tank on Lot �7 ; On Adjoining Lots /&-d f To Nearest Edge of Absorption Field on Lot w On Adjoining Lots /0V 7 - To Nearest Public Sewer Line ✓4 To Nearest Public Sewer Cleanout/Manhole d A'(114lTo Nearest Sewer Service Line on Lot SO Water Sample Collected by A)/ex/ Date Water Sample Test Results SSffi�/oe Comments B. SEPTIC/HOLDING TANK DATA ZO06 . Date Installed 7'-7-7v Size IoW 6"ft No. of Compartments Standpipe gN) Air -tight Caps.) Foundation Cleanout (Y0 Depression over Tank (YA Date Last Pumped (1-6-84 Pumping/Maintenance Contract on File (Y/N) W14 for All Holding Tank High -Water Alarm (Y/N) A�( Temporary Holding Tank Permit (Y/N) _ Separation Distances from Septic/Holding Tank: To Water -Supply Well Y7 To Property Line 7_5 j To Water Main/Service Line To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Course leu 7 Comments �` jIiTA�✓L� /�� l�%{Pa�?"/(+6 A7- 7//yE of �JS7ipu Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 7-7-77— Width of Field 3' �ZS 0 Type of System Design � 7w`lez Length of Field — Depth of Field �• S ' -t" t1 Gravel Bed Thickness Square Feet of Absorption Area '717 Standpipes Present (Y® Depression over Field (Ya Date �ooff.Last Adequacy Test 6-1-3-s4 Results of Last Adequacy Test /z✓ u/�f - f�� /n7A/J &�5uc7f Separation Distance from Absorption Field: To Water -Supply Well To Property Line y� s To Building Foundation !Z To Existing or Abandoned System on Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, F Comments 4 D. LIFT STATION Date Ins Size in Gallons On Adjoining Lots ys'fi To Cutbank (if present) �/14 king Area, or Vehicle Storage Area D/3TAx/P6 AW,eci/� !o -X&-78 "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 " Check Permitted Bedroom Rating Against HAA Request " Vent(Y/N) Cycles during Adequacy Test. Meets MOA I certify that h he ed, 1/e Pied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ` Date Company �S MOA No. g�S UZj,r Receipt No. 34qb-7N 6 Date of Payment 7`�-�i� Amount: $ in J O�— �1e�Ts Page 2 of 2 4✓ 3Ah ?uc73 72-026 (11/84) 0 Municipality of Anchorage July 10, 1986 0 P.O. BOX 6650 ANCHORAGE, ALASKA 99502-0650 (907)264-4111 TONY ANO WLES, MAYOR DEPARTMENT OF HEALTH & HUMAN SERVICES Alan Wien Alaska Environmental Control Services, Inc. 1200 West 33 Avenue, Suite B Anchorage, Alaska 99503 Subject: Lot 2 Block 6 Elmore Subdivision Waiver Request, WR86-092 Dear Mr. Wien: The waiver issued by Les Buchholz of this department approving a 98 foot separation between the drainfield and well on the subject lot has been re-evaluated using criteria established by Bruce Erickson of the State Department of Environmental Conservation. This evaluation indicated that a waiver was warranted in this case. Sincerely, Stephen S. Morris Civil Engineer On-site Services SSM/ljw ALASKA ENVIRONMENTAL CONTROL SERVIC& INC. 1200 West 33rd Aven Suite B ANCHORAGE, ALASKA 99503 (907) 561.5040 JO8 1r!" SHEET NO.-_.- OF - CALCULATED !- CHECKED BY DATE SCALE /')EI., Z' r* MUNICIPALITY OF ANCHORAGE LEGAL DESCRIPTION DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION - STREET 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION Natron a Street Telephone 264-4720 6. REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTYOWNER PHONE John Kiewik home -344 5460 wk 277 8143- MAILINGADDRESS -.. SRA Box 323—T ( Natrona St.) off DeArmon ❑ MULTIPLE FAMILY PROPERTY RESIDENT (If different from above) PHONE 2. BUYER PHONE Steve Langston 349 4011 MAILING ADDRESS P O Box 123 Palmer Alaska since June 1975. For wells drilled prior to that date, give well 3. LENDING INSTITUTION PHONE Alaska Pacific Bank 276 3110 MAILING ADDRESS P O Box 420 Anchorage, Alaska 99510 CR INDIVIDUAL/ON-SITE** 4. REALTOR/AGENT PHONE None If system is over two (2) years old an adequacy test is required MAILING ADDRESS ❑ PUBLIC UTILITY 5. LEGAL DESCRIPTION STREET LOCATION Natron a Street 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS ED SINGLE FAMILY ❑ One ❑ Four ❑ Other © Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY P INDIVIDUAL* *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM CR INDIVIDUAL/ON-SITE** **If individual/on-site, give installation date If system is over two (2) years old an adequacy test is required ❑ PUBLIC UTILITY by this Department. over 2 yrs NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. al ill THIS SIDE FOR OFFICIAL USE ON12 + INSPECTION APPOINTMENTS DATE RECEIVED TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE F RESIDENCE SINGLE FAMILY❑ ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS O E ❑ THREE EJFIVE ED OTHER 0 ❑ FOUR ❑ SIX 2. WATER SUPPLY INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEW GE DISPOSAL SYSTEM IDUAUON -SITE ED PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING Septic Tank or Ll Holding Tank Size: 000 If Tank is homemade give dimensions: TYPE OF TAN MANUFACTURER TOTAL ABSORPTION AR MATERIAL 4. DISTANCES WELL TO: Septic/Holding lank bsorption A a 1 Sewer Linc , J Nearest Lot�ine Absorption Area to nearest Lot Line h f T 5. COMMENTS R�APPROVEDFOR f�_ BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY (Title) LEGAL DE CRIPTI N 72-010 (Rev. 3/78) a 16 i GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received September 23, 1976 CO- Time of Inspection 11:00 a.m. Date of Inspection 9-28-76 Monday Pratt REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR Conv. 1. Approval requested by: Home Federal Savings & Loan Mailing Address: 835 D Street Phone: 2. Property Owner: John Kiewik Phone: Mailing Address: 3. Legal Description: Lot 2 Block 6 Elmore #1 4. Location: See map on back 5. Type of facility to be inspected Single Family No. of bedrooms 1 6. Well Data: Individual A. Type B. Depth C. Construction D. Bacterial Analysis 7. Sewage Disposal System: On --site system A. Installed 1972 B. Installer C. Septic Tank: 1. Size D. Seepage Pit: 1. Absorption Area E. Disposal Field: Total length of lines 8.. Distances: 2. Manufacturer 2. Material A. Well to: Septic tank , Absorption area Sewer Lines , Nearest lot line Other contamination B. Foundation to septic tank , Absorption area C. Absorption area to nearest lot line EQ -034 (1/74) Page 1 of two pages I ' Page 2 of two pages - Reit for Approval of Individual S r & Water Facilities `Legal Description Lot 2 Block 6 Elmore #1 Comments Approved Disapproved Date Approval;Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM 1 certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED EQ -034 (1/74) Date