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Home My WebLink AboutCLEARVIEW LT 12 Municipality of Anchorage Community Development Department Page 1 of 3 ' On-Site Water&Wastewater Program 4700 Elmore St. •P.O. Box 196650 Anchorage,AK 99519-6650 •http://www.muni.org/onsite•(907)343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: _ OSP191196 PID Number: 015-242-51 0 New M Upgrade Name: PHILIP ANDRESS ABSORPTION FIELD Address: 0 Deep Trench 0 Shallow Trench 0 Bed P ound 11621 SNOWLINE DRIVE *ANCHORAGE,AK 99507 0 Other Phone: No.of Bedrooms: Sail Rating. Total Depth from original. -de. (907) 223-0836 4 GaoIsa.Ft. Ft Depth to pipe invert from original grade: Grave •-pth beneath pipe: LEGAL DESCRIPTION G Ft. Subdivision: Block: Lot: Fill added above original grade: �41 Gravel length: CLEARVIEW - 12 a Ft I ownshlp: Range: Section: Gravel vidth: Beds Number of lines. Distance between lines: Ft. Ft. SEPARATIONDISTANCES Total absorpt. area Number of trenches Dist.between trenches: To Septic Absorption Lift Holding Public/Private From Tank Field Station Tank Sewer Lines e0.Ft. Ft Well 100'+ y - - 25'+ TANK ■ Septic 0 S.T.E.P. ❑Holding 0 Other Manufacturer. Capacity: Surface Water 100'+ - - ANCHORAGE TANK 1250Gal. Material Number of compartments.Lot Line 5'+ NIA EPDXY COATED STEEL 2 Foundation 10'+ - - LIFT STATION Curtain Drain Manufacturer C.•- - N/A Gal. Remarks: *EXISTING TANK DECOMISSIONED PER UPC 'Pump on"level at' "Pump off'level at (High water alarm at: TANK IS EPDXY COATED STEEL RATED FOR 10 FOOT BURIAL tSEPTIC TANK IS 4.5 FEET TO DRAINFIELD PER CONTRACTOR Pump Make&Model Electrical Inspections performed by: cee. A--T'-AAG LIED 1.044.4 6?-F-6?-. PIPE MATERIAL House to tank EXISTING/D3034 Tank to EXISTING/D3034 drainfield - Installer A+ HOME SERVICES Drainfield EXISTING CO/MT EXISTING/D3034 Inspector GEG, Ltd. BENCH MARK (Assumed elevation) 100.82 Ft. Inspection Dates: 1st 6/28/2019 2nd - Location and Description 3rd - 4th TOP OF MH LID ENGINEER'S SEAL Community Development Department Approval �o�o pO0 .5-' ... *i Conditional approval: Date: QO Q.. •.--00 11••" D e f rness.: 0 y C�' • '. 17-fi '... .'°.‘ i e F. Approved: Date: ` r LICENSE�p�0 fesstO. :. #AECC884 0�� IncroHinn Rnm.1 1.1.17 Anr PERMIT NUMBER: PARCEL ID NUMBER: 1 1 OSP191196 RECORD DRAWING 015-242-51 \ / \ / \ / • / SUNNY;BLOCK 2,LOT 6 � / l N. SEPTIC TANK TO DRAINFIELD IS 4.5 FEET PER A+HOME SERVICES. DUE TO THE BURIAL DEPTH OF THE SEPTIC TANK,THE DRAINFIELD / WAS NOT EXPOSED DURING THE TANK INSPECTION AND THE / ENGINEER COULD NOT PHYSICALLY VERIFY THE SEPARATION DISTANCE.SEE ATTACHED LETTER/WAIVER REQUEST A B \FCO 11.5 29.3 MH 23.7 26.0 /11/ EXISTING DRAINFIELD ST2 29.9 29.7 DBL1 31.1 33.0 DBL2 30.9 33.6 CO1 30.4 37.4 MT1 30.5 37.9 DOUBLE 1&2 STCo MT MH .... •• -- � 411P/10 • Ce NEW 1250 GALLON EPDXY COATED DEEP BURIAL STEEL SEPTIC TANK `!' �•• Z EXISTING 4 N. / BEDROOM HOUSE \ • :: .: •• DRIVEWAY,;;,,•'r;::•• • ., '�• • / \ N. 1 '2 • .• / 1 I / \ I .100.WELL RADIUS I I \ / / \ \ / / \ \ I / SCALE: 1 \ I / V.40. I 1••• ' i� •••• • •••• •♦•♦ • • GARNESS ENGINEERING GROUP, Ltd .�*° 4: ��. = :'��'. ENGINEERING O SALES a CONSULTING 0\ ' I i 3701 E.TUDOR ROAD.SUITE 101'ANCHORAGE.AK 99507•PHONE(907)337-6179'FAX(907)338-3246•WEBSITE www.(pn,a••n9n••my con, 10. 0 PREPARED FOR: PHONE NUMBER: PAGE NUMBER: I 0 73# •: �N y A.Game_s PHILIP ANDRESS 907-223-0836 2 OF 3 •jG1i��;• l W C •- LEGAL DESCRIPTION: DRAWN BY: �♦♦ • ••• „' Z I• .` CLEARVIEW; LOT 2 D.J.G. �, TYPE OF WORK: DATE: LICENSE111�ESS\�4•• SEPTIC TANK RECORD DRAWING SITE PLAN 7/2/2019 #AECC884 1l‘11‘�� J PERMIT NUMBER: RECORD DRAWING PARCEL ID NUMBER: OSP 191196 015-242-51 • FINAL GRADE=100.65-100.68 TOP OF TANK ST1 ST2 AT INLET=90.96 c c\.,........... TOP OF TANK AT OUTLET=90.91 til INVERT OF BUNG NEW 1250 GALLON EPDXY COATED AT INLET=90.40 STEEL SEPTIC TANK INVERT OF BUNG AT OUTLET=90.14 k ,/ . N. (voi\\\\4c• oF / 11 GARNESS ENGINEERING GROUP, Ltd : .� . • • ENGINEERING SALES CONSULTING r� 1. / 3701 E TUDOR ROAD,SLATE 101•ANCHORAGE.AK 99507'PHONE(907)337$179'FAX(907)338-3246.IAEBSI7E www 9amessenpneermp corn ; .N . . PREPARED FOR: PHONE NUMBER: PAGE NUMBER: ,0 ) • rey • Gamess : cir• •PHILIP ANDRESS 907-223-0470 3 OF 3 0•0 • CE-79 ' •'�� LEGAL DESCRIPTION: DRAWN BY: .� �'e I `�: CLEARVIEW; LOT 12 D.J.G. •j • •••'• .( / '•�,C'♦ TYPE OF WORK: DATE: LICENS�44 RO I II IA ;;;'.44♦ SEPTIC TANK PROFILE 7/2/2019 #AECC884 panics GARNESS ENGINEERING GROUP, Ltd « 0,3r,n .,,: ENGINEERING SALES CONSULTING p July 2, 2019 Municipality of Anchorage Development Service Department On-Site Water &Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Ref: Septic Tank to Drainfield Waiver Request for Clearview; Lot 12 To whom it may concern: The top of new septic tank for the subject lot is approximately 9.6+ feet below grade. In short, the hole for excavation/installation of the septic tank was significantly deep. Due to this fact. the drainfield was not exposed during the installation of the septic tank. As stated on the permit, the contactor was to install a new cleanout/monitoring tube on the south end of the trench to confirm its location. This was not completed until after the new septic tank was installed. Based upon this fact, the engineer doing inspections (David Garness, P.E.), could not confirm the separation distance from the new tank to the existing drainfield. Per conversations with the contractor (A+ Home Services), the proposed tank is 4.5 feet from the existing drainfield when it was exposed for the CO and MT installation. We are requesting that your department issue a variance from the required separation distance of 5 feet from tank to drainfield down to 4 feet. We are unaware of any adverse impacts this waiver would have on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your assistance. Sincerely, CJo:nf, � - 'r= • t -rness, P.. ., M.S. Presi• : t ,S EX Pos > (at CdO Mf Licj 3701 East Tudor Road, Suite 101 *Anchorage,Alaska 99507-1259 Phone: (907)337-6179*Fax: (907) 338-3246*Website: www.garnessengineering.com MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite Permit Number: OSP191196 Work Type: SepticTank Upgrade Tax Code Number: 01524251000 Site Legal Address: CLEARVIEW LT 12 G:2740 Site Mailing Address: 11621 SNOWLINE CIR, Anchorage Owner: ANDRESS PHILIP M III & Design Engineer: GARNESS ENGINEERING GROUP LTD This permit is for the construction of: Effective Date Expiration Date Lot Size in Sq Ft: III N 0 IML -1011 r It In CII t 6/10/2019 6/9/2020 56941 0 Disposal Field EJ Septic Tank 171 Holding Tank 0 Privy 171 Private Well 0 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 (1 8AAC72) and Drinking Water Regulations (1 8AAC80) 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, seated, and heated to prevent freezing Special Provisions: The design calls for a deep bury tank (>8 ft). Currently there are no deep bury tanks special for installation in the MOA. If the tank has to be replaced prior to approval of a deep bury tank, a approved change hange order will be required. Received BY—'- Issued By:tiit� 4 MUNICIPALITY OF ANCHORAGE Community Development Department Phone: 907-343-7904 Development Services Fax: 907- 343-7997 On -Site Water & Wastewater Program Mayor Dan Sullivan On -Site SewerNWell Permit Application For A Single Family Dwelling Parcel I.D. 015-242-51 Property owner(s) PHILIP ANDRESS Day phone 907-223-0470 Mailing address 11621 SNOWLINE CIRCLE *ANCHORAGE, AK 99507 Site address 11621 SNOWLINE CIRCLE *ANCHORAGE, AK 99507 Legal description (Sub'd, Block & Lot) CLEARVIEW: LOT 12 Legal description (Township, Section & Range) Lot Size APPLICATION IS FOR: (gall that apply) Absorption Field ❑ Septic Tank Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ Sq.Ft. Number of Bedrooms APPLICATION IS AN: Initial ❑ Upgrade Renewal ❑ 4 THIS APPLICATION INCLUDES A VARIANCE/ WAIVER REQUEST FOR: N/A TYPE OF DEWELLING: Single Family (SF) (w/wo ADU) Duplex (D) ❑ Multiple Dwellings ❑ (SF and/or D) Distance: - certify that the above information is correct. I further certify that this is in accordance with applicable Municipal codes. GARNESS ENGINEERING GROUP, Ltd. (Signature of property owner or authorized agent) Permit/Rush Fees: 9A5 / Waiver Fees: Date of Payment: 5I p.,3 1 /p Date of Payment: Receipt Number: U 0 til ��7 Receipt Number: Permit No. Q's�%��1 Waiver No. (Rev. 01/11) Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191196, Rebecca Carroll, 06/10/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191196, Rebecca Carroll, 06/10/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191196, Rebecca Carroll, 06/10/19 · ~ 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 IPHONE _J Z: NEW DISTANCE TO: Iwell ~ ~ I Absorption area"~l Dwellin~o~ ~ ~ ~anufacturer IF HOMEMADE: Inside lengt~ Width ~ Liquid depth Well Dwelling PERMIT NO, ~ DISTANCE TO: ~ _ ~ Manufacturer Material Liquid capacity in gallons Q Well Fou~ ~earest lot line ~ Top of tiie to inis grade fl'/ Materialbeneat tie ~ inches Total Length Width Depth 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, ~ Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER SOIL TEST RATING ~ INSTALLER REMA~K~ APPROVED DATE LE6AL 72-013 (Rev. 3/78) F'E R:'! ! T N O. E:,EF'FiRTMENT ¢~'.: HEF~LTH F~F,i[:, EN',,,'i F.:Oh?!ENTFI, L '"~:O'TECT ! :_:',25 :STREET. fiNE:HORRGE, 2: g ,:.!.- 47 2 0 ,:: 6:2E~565 LOCRT ! ON LEGRL FRR TRR[:,E C:ONST Li~, CLERRV I EN F'C EC,Y i0-i±]:5 995:2± LOT SIZE ]: 45 - :::2 ~: 3:'9 99999.9 SL.-.!UARE FEET TYPE OF 'Sn!L FfE:LZ, OF::F'T!Cd".~ .:T:]'E.i't iS' TRENCH H F~. ::':: ! I'd U I"! N U hl B E R 0 F E, E L. R U U M.:, = 4 SOIL RATING ,::SL.] FT,.-'E~F.:>= 284 THE REL:.!U ! F.'.E[:, S i -.--'E nF THE: S '.] ! L. F!.E~SARF'T I AN SYSTEM ilS::, E:_' F' -T' H =: :::L :1. b. E: t'-,l ~3 T' H =--: ':~_- ."E," ~:.~ F: R [:. E F' T H --"- THE LENGTH [.',!HENSION IS THE LENGTH <!N FEET) OF THE TF.:ENCH OR [:,RRINFIELD. ]"HE DEPTH OF .a, TRENCH OR PIT tS THE D!STFiNCE E:ETHEEN THE SURFRCE OF THE GROUN[:, RN[:, THE E:O'f'TOM OF THE EXCRYR]"ION ,.'.'IN FEET). THEF.:E IS NO SET I,.!I[:,TH FOR TREN. C:HES. ]"HE GRR',,,'EL [:,EF'TH IS THE M INIHUH DEF'TH OF GRFP,,'EL E:ETHEEN THE OUTFRLL P IF'E ,q.N[:, THE BOTTOM OF THE E::'::E:F!',,,'RTION < iN FEET::,. F'E'RH !'T RF'F'L.I '_-:RNT HR'::; 'f'HE RFZSF'}NSIE:! L ! TY ]"0 i NFORM THIS [:,EF'RF.:TMENT DURING THE iN'_:,TF~LLRT!ON, INSF'EE:TIONL:, OF RNY HELL'_:, RE:,J~.CENT 'TO THI'.S PF.:OF'ERTY RN[:, THE NU!"tBER ] ¢ RE::-, I [,E.N ] ES THRT THE !4ELL !,.! ILL :_:;EF.I',,,'E. T I-,-! C~ .:] ",::: ::, I !'-,I. :2_-] F' E C: 'T '! C" !'-,I S Ft F: E F:: E ~]:! lB I F: E [:, ERCKFILLING OF BNY %"r'STEH NiTHOUT FINRL INSPECTION RND FtPPF.:O:,,,'RL BY 'f'HIS [:,EF'RRTMENT I4!LL 8E SI...IELIECT TO F'F.:OSECUTION. M!NtHUH. DISTANCE BETWEEN F:I .WELL AND RNY ON-S!TE SEP]RGE DISPOSRL SYSTEM IS :200 FEET FOR R PR!',,,'R]"E iqEL. L OR ±SE~ TO 2Em3 FEE']' FROM R F'UBLIC 14ELL C, EPENDING UPON THE TYF'E OF PLIBLIC !,.IELL. MINIMUM [:,ISTP, NE:E FROM ~ PRIVATE NELL TO F! PRI',?RTE SEI.qER LINE i:5 25 FEET RND TO .FI COM!"!UNI T'.-r' SEWER LINE !S; 75 FEET. NELL_ LOGS RErE F.:EQUIRE[:, RN[) MUST BE RETURNED TO ]"HE: DEPRRTMENT 14ITHIN 30 OF THE .NELL C:Oh!F'LETIC~N. OTHER REC!UiREHENTS MRY RPF'L.Y. SPEC!FiC.qT!ONS RN[:, CONSTRUCTION [:,IRGF.~RMS F!;,,,',atLRBLE TO INSUF.:E F'ROPER !NS'TRL. LRT!ON. ! C:ERTIFY THRT ±' ! BM F'F~MILiRR HITH THE RE_.qJlREMEHTS FOR ON-SITE SE.WERS RN[:' .t,.!ELLS RS SET FORTH E',Y THE MUNICtPF~LIT',-' OF R.NC:HOF.:RGE - '-' '"--r"-i" TN F!CCOR[:,FtNCE [,ItTH THE '":I}[)ES .2 I I.,.tILL Z.N:_:;TRLL THE :,T.:,~r:...'~ .... 3- f UN£:'ERSTRN£:' THRT THE n~.J-SITE SENEF.: -'"':,"r'F', ............. .... :,r-._tl !"IFfY F.'EK.'~!IF.'E EI'.4~ FtF4."GEHEN]" ZF 'THE RES--.- I [:,ENCE I S F'EI'4C [':,E'L E[:, TO t NCLLtDE HOF.'E THFtN 4 E~EE:,RC,]MS. , 513.NED ' ..................................................................... "; ' FtF'PL I C:F-tNT FFtF.: 'T~,E CONS'f' /~. "7'-' ---. ,,.x'"' ,, ./ / .......................... Cx- .................. 71 ......................................... -. · ' ~ ~ ~ SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVl RONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] PERCOLATION TEST LEGALDESCR,PT,O.: 2..\~,~arVt¢.~O ~. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 SLOPE COMMENTS 9P~ ~' ~¢~ - PERFORMED BY: 72-0o8 (6/79) DATE PERFORMED: SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? S Gross Net Depth to Net Reading Date Time Time ~ ~l I~ Water Drop q: ~ l 0 I .Zb . oq ~o:1~ I0 I.IZ ,0~ ~ I O: ~ ~ ~ 1.0~ .0,~- ~ i 0:30 I0 I.~ , O~ PERCOLATION RATE TEST RUN BETWEEN CERTIFIED BY: q.k'~ FT PtND ~ FY WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological /~ Geophysical Surveys Drilling Permit No. LOCATION OF WELL (Please complete either la~ lb or lc.) A.D.L. No. ,a.llsorouoh Sub,,v,e,on Lot Block Ib"~.I '/4qfr,. Section No. TownehiPN0 Renge EI'-~ Meridian ~ ~ of-- of ~of ~ s ~ w~ Ic.I~DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS ~. OWNER OF WELL: fief ~elo~ ~, WELL DEPTH; (final) [. D~TE OF ~OMPLETION · . FINISH O~ WELL: Type: Diameter: Slot/Me~h Size: Length: Set between ft. and ft. Backfilling Gravel ~ack ~ Above or ~ Below land lurface Date Equipment used: II. PUMPING LEVEL below land surface and YIE.LD ft. after ,,~ hrs. pumping g.p.m. 12.GROUTING Well Grouted: ~ Yes ~ No Material: ~ Neat Cement ~ Other: 15. PUMP: (if available) HP Length of Drop Pipe ft. capacity g.p.m. 14. REMARKS: 16. WATER WELL CONTRACTOR'S CERTIFICATION: 15. Water Temperature ~o ~ F ~ C T~is well ~as drilled u~der ~y jurisdiction and this report is true tothe b~t ~f my knowledge and belief; Registered Business'Nam,e ~ Contract License Number ,' A u~ h~rf'zCd Representative ,' Form OE-WWR (11/8l) Copy Distribution; WHITE-State D~GS, FiNK-Driller, CANARY-Customer IIIIIIIIIIII!IIIIIIIII Afiff Development Services Department On -Site IA/ + 2 1A1 + + Section 0 C; 1 00 UVV0 Ul Certificate of On -Site Systems Approval Parcel I.D. 015-242-51 1. GENERAL INFORMATION Complete legal description Location (site address) CLEARVIEW LT 12 11621 Snowline Cir Expiration Date:. Phone: 907-343-7904 Fax: 907-343-7997 Current property owner(s) WALKER Day phone 703-293-1535 Mailing address Real estate agent 2. TYPE OF DWELLING: Fx_1 Single Family (w/wo ADU) ❑ Duplex F-1 Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well E Private Septic 0 Water Storage 0 Holding Tank El Community Well M Community 0 Public Water System 0 Public Sewer D Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm NorthRim Eng. Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name , Steve Eng Date 8/13/21 $teaOF 4 A, ` _ 44 Ar 1�., A� . - 1 1. '� # AF .49 M 6. DSD SIGNATURE System #1 Approved for bedrooms1�647, System #2 Approved for bedrooms V#\CE-62M44 Disapproved Conditional approval for bedrooms, with the following stipulations: �i,;,WM(Wirirq OF lu ON_Z)j INTr-R MAD \N SE9 By: Original Certificate Date:. The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional 6,41 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 Legal Description: CLEARVIEW LT 12 If more than 1 septic system on lot: COSA Checklist # A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 8/13/82 Total depth 54 ft Cased to 54 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA $/5/21 Static water level at beginning of test 39 Comments B. TANK DATA Age of tank(s) 2 years Tank type/material Sptcstl Measured operating fluid level in septic tank 50 ❑ Standpipes/foundation cleanout per record drawing Date of pumping 8/11/21 D. ABSORPTION FIELD DATA 7/23/82 Which system tested (date installed) same OR ALL standpipes present per record drawing Total measured depth from grade 15 ft (max) Measured depth to pipe invert from grade 11 ft (min) ❑ N/A - pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective 4' ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 015-242-51 of Structure served by this system Well production at time of test 5+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No [� Coliform bacteria is Negative Nitrate 3.71 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by NRimEng Date of Sample 8/10/21 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date $/5/21 Results Q Pass For 4 bedrooms Fluid depth prior to test 12 in Water added 600 gal New depth 20 in Elapsed time 30 min Final fluid depth 15 in Absorption rate 600 gpd Any rejuvenation treatment (past 12 months) no If yes, enter date E. SEPARATION DISTANCES From Private Well onLot to: (Please enter distances Kless than required miftcomnmnkywell) SepticTank/Lift Station onLot >10/ El Yes JN$1`1 Community Sewer Manhole/Cleanout >100' 2] Yes i[NoM FlYes [J,Yes if No Neighboring Tank >10O' P1 Yes ifNoft [D Yes Private Sewer/Septic Line >25'[-7lYes if No Absorption Field onLot >100' F-�, Ye8 i[NoM R-1 Yes Holding Tank >18O' 2Yes if No Neighboring Absorption Fields >180' Animal Containment �50' ��Yes |(N$ RlYon ifNoft Manure/Animal Excreta Storage�> 100' Community Sewer Main >75' [D Yen i[NuR ��Yes |[N$ ft ft ft ft, h From SepticlHolding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' M-1 Yes if No ft Surface Water> 100' Yes if No ft Property Line > 51 El Yes JN$1`1 Wells onAdjacent Lots: Absorption Field > 5' FlYes if No 4.5ft Private Wells >1OO' Yes JNoM Water Main >�10' [D Yes ifNoft Community Wells >2OO' Yes ifWoM Water Service Line >10' R-1 Yes |fNnM |fseptic tank isunder driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation >10' EJ Yes ifNoft |fabsorption field iuunder driveway comment below Property Line >10' F71 Yes i[NnK Wells 0nAdjacent Lots: Water Main >10` EJ Yes i[NoD Private Wells >1O0` P1Yes if No Water Service Line >1O' Fv�Yoo ifNuft Community Wells > 200' El Yes if No SurfaooYVoter>1O0' ��'Yem if ft _ ��. F.ENGINEER'S COMMENTS OFJerG. ENGINEER'S CERTIFICATION o .49 THI certify that / have determined through fleld inspections and reviewof Municipal records that the above systems are in conrormance with IVA- Steva Eng 0MOA COSA uidelines in effect on this date. -,,CE-!-6256 M ft • • 3, !, , Municipality of Anchorage On-Site Water and Wastewater Program �.Ll (907) 343-7904 s• E,. Certificate of On-Site Systems Approval Parcel I.D. 015-242-51 Expiration Date: ( —3 1. GENERAL INFORMATION: Complete legal description Clearview; Lot 12 Location (site address) 11621 Snowline Circle*Anchorage,AK 99507 Current Property owner(s) Phillip Andress Day phone 223-0470 Mailing address 11621 Snowline Circle*Anchorage.AK 99507 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: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: Date: COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ S '3 D•OD Waiver Fee $ 3 (-0-DV Date of Payment -1(3 I a of'J Date of Payment I 1 , (R 011 Receipt Number Du 3 - 1 Receipt Number 0 S 5 55"1 I COSA# 0S C 10l t Waiver# OSV 11 ID-5 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: Garness Engineering Group,Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road,Suite 101-Anchorage,Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness Date: 7/2/(q `�ooOp., In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system o in accordance with the guidelines and regulations established by the Municipality of Anchorage and ��•O�•••i•.._ industry practices. The reported results describe the condition of the system/s on the date/s of the i Q' •• ;1 A ••.. .._O evaluation. Separation distances were measured to readily identifiable features. Hidden defects or • H �; • • encroachments may exist that were not identified during the evaluation. The operational life of all wells �ir�' O and septic systems depend upon a variety of variables, including but not limited to, soil conditions, 4 G groundwater levels (that may fluctuate during the year), quality of construction (materials and r ( 0 workmanship),and the water usage of the family utilizing the system/s. These conditions can vary,and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the - f Carne- - o system/s; therefore, GEG makes no warranty(express or implied)regarding the future performance of vh - CE-7853 • `rove the well or septic system. GEG makes no representation whether an alternative well or septic system 09 • e• �� 1 •.. .Abp can be installed on the property in the event either of the current systems fail to perform adequately in C z•, ' �0 •• the future. The content of this report is for the sole benefit of the person/party that retained GEG to kl ajDrofessio^°moo perform the evaluation. Reliance upon the information provided in this report by any other person or ��00�oo party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. #AECC884 6. DSD SIGNATURE System #1 Approved for bedrooms ��\\`ZyttE IIQ��I�(//� System#2 Approved for bedrooms �\�Q�`'` " 1 CA/0 �� Disapproved ON-SITE R Conditional approval for bedrooms, with the folio g stippktrtsR AN Z= 2 WASTEWATER o i� PROGRAM /tl>i(491,14a. -�„ SER\1*;;`) '))))))))1111 _--------,---'--(r::ej,Czk By: ►l �—� Original Certificate Date: 7-3 -/ ? 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 /C.- Nitrate Advisory Septic System Advisory / Arsenic Advisory Well Flow Advisory Other COSA blue sheet 10-10-12.doc COSA Checklist Legal Description: Clearview; Lot 12A Parcel ID: 015-242-51 If more than 1 septic system on lot: COSA Checklist# of Structure served by this system A. WELL DATA 0 Well log is filed with Onsite (or attached) Well production at time of test 5.2+ gpm Date drilled 8113/52 Water storage tank volume n/a gallons Total depth 54 ft Well disinfected for coliform test? ❑ Yes ❑■ No Cased to 54 ft ❑■ Coliform bacteria is Negative s ■❑ Sanitary seal is functioning correctly Nitrate 3.7 mg/L ❑ Nitrate less than MRL (ND) EU Wires are properly protected Arsenic ug/L 0 Arsenic less than MRL (ND) Casing height(above ground) 12+ in. Collected by GEG, LTD. Date of flow test for COSA 5/14/19 Date of Sample 5/14/19 Static water level at beginning of test 40.1 ft. Comments B. TANK DATA C. LIFT STATION Age of tank(s) new years ❑ Required maintenance completed ___------ Tank type/material ''°` ''' epoxy coated Age of lift station years___---------- Measured -Measured operating fluid level in septic tank new Lift station material _------ ❑� Standpipes/foundation cleanout per record drawing Comments. Date of pumping new D. ABSORPTION FIELD DATA Which system tested (date installed) 7/23/82 Adequacy test date 5/1,V19 ❑■ ALL standpipes present per record drawing Results E Pass For 4 bedrooms Total measured depth from grade *20+ ft (max) Fluid depth prior to test 30 in Measured depth to pipe invert from grade *14+ ft(min) Water added 794 gal ❑ N/A—pressurized field New depth *'60 in ❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 120 min depth into effective 5 9* 0 Code-required soil cover over field Final fluid depth 52 in Absorption rate 600+ gpd ❑ System presoaked (Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) no date of test) Gallons introduced n/a gallons If yes, enter date - Comments/Deficiencies:'At sump(end of trench)"11"below invert COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot> 100' Community Sewer Manhole/Cleanout > 100' 0 Yes if No ft n Yes if No ft Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25' El Yes if No ft Absorption Field on Lot> 100' 0 Yes if No ft Holding Tank> 100' E Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' LI Yes if No ft 0 Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑l 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' CI Yes if No ft Surface Water> 100' Q Yes if No ft Property Line >5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑ Yes if No *4.5 ft Private Wells > 100' 0 Yes if No ft Water Main > 10' El Yes if No ft Community Wells > 200' 0 Yes if No ft Water Service Line > 10' El Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑ Yes if No ft If absorption field is under driveway comment below Property Line> 10' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' El Yes if No ft Water Service Line > 10' El Yes if No ft Community Wells > 200' El Yes if No ft Surface Water> 100' ,❑ Yes if No ft F. ENGINEER'S COMMENTS *See attached waiver request with inspection report. o�000 r G. ENGINEER'S CERTIFICATION o OF 4/X044 I certify that I have determined through field inspections and review O'P _ . of Municipal records that the above systems are in conformance with pO .•' A •• . , 0 MOA COSA guidelines in effect on this date. * : �` ,y, O VA / , I A. Corn; s.= G/ 0 � p 0 (1 P....'1 • .L J• 7.�c �o COSA Checklist yellow sheet 440 n o dp p\ o ofess�o a #Aeccsaa 04O000�� Municipality of Anchorage No IAA C 11 j \ : / P.O. Box 196650 I 4700 Elmore Road Anchorage, Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997 , e pa r anent http://www.muni.orq/Onsite Development Services Division On-Site Water and Wastewater Program **** VARIANCE/WAIVER REVIEW **** Waiver#: OSV191051 COSA#: OSC191282 Permit#: OSP191196 PID#: 015-242-51 Legal Description: Clearview Lot13A Engineer: GEG Applicant: Phillip Andress Your request for a waiver of the required 5 feet horizontal separation from the absorption field to the tank has been approved. The approved separation distance is 4.5 feet. This waiver approval applies to the Existing absorption field only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. ❑ The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. n Notarized letter(s) of non-objection have been received from the owner(s) of the affected adjacent property. Adjacent properties are not affected by this waiver. p ... ' Waiver is Granted: X Waiver is not Granted: Date: 7,-3--1 Approved � Name of Re ewer k. N S o 184 lr- c? S10 ,00•Ol►tea +i N / \ oye* ti �``LN / 02 y 4 o. 8. / O \ N� -r / ''N / N \ 01 MI r r. I r N �o •-p•6 /, G.\.5 co ,p 9t 91B /"' v 9'9£ yN3V13 yaOIS z '� 1 c (0. `6 30N301S3� � ` v' - \ + OGZ+ 06 /oX Qf S./ v U! \ O El n i. 2. 1 Of r, 0 o�/ `1 10. c. M / .`D/y v 7 / –– 89'tt L 3„,_5Z.170_.50 S -- — — —/---- 1— o .. o rr --I t m r rn m I fI- ` of / PLOT PLAN _ AS BUILT X SCALE 1" = 40' GRID SW 2740 Project No. 19-151/R2 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone (907) 522-4625 Fax . � Professional Land Surveyors kenolangsurvey.com •=/-TOT. 6i_N Y jonathanOlangsurvey.com '�`... . I hereby certify that I hove surveyed the following described property: q Q• LOT 12, CLEARVIEW SUBDIVISION (PLAT No. 80-178) a* 4913 :* Anchorage Recording District, Alaska, and that the improvements situated thereon ore 0 within the properly lines and do not encroach onto the property adjacent thereto, that no Improvements on the property lying adjacent thereto encroach on the surveyed �•AKENNETH Uitc..•1 promises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. OQ�S Z t3 (q D `• .jS-5202.••' G' Dated this the ter"'_ Day of �iL.,-( , L"\'l , at Anchorage, Alaska 'le:A'�A• 0 'COSI It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # O I .,c- ..- CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING H~- - ~ / HAA # ~'~,~l,nP'~-~L'~ "~ GENERAL INFORMATION Complete legal description Lot 12; Clearview Subdivision Location (site address or directions) Property owner Mailing address Jim Abel 11621Snowline Drive Anchoraqe, AK 11621Snowline Drive Anchorage, Day phone AK 99516 345-0039 Lending agency Mailing address Premier Mortgage Day phone 563-7736 Agent Address Shel Hensley/ Remax Properties Day phone Unless otherwise reqUested, HAA will be held for pickup. 4 NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site HOlding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1/91) Front MOA#21 T 5. STATEMENT OF INSPECTION BY ENGINEER. Se As certified by mY seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature S & S ENGINEERING iiU.~4 ~agie River Loop Read Ne. 204 Eagle Rive.r, Alasl~a 9._95~7 Phone Date /~- //(./ q~ DHHS SIGNATURE · /~ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments BY:' ~'/-"/ ~ Date/2- 2 7~ ~' 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 DHH$ 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(Flev. 1/91) Back MOAiffZ1 ENVIRONMENTAL SERVICES DIVISION DEC 1 7 199 Municipality of Anchorage ~ DEPARTMENT OF HEALTH & HUMAN SERVICE~ E C E IV E D Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: Health Authority Approval Checklist [~-- ~_.~-~L.~~lt ~-~.,~ Parcel I.D.: A. WELL DATA Well type ~?~-~..~-T~J Log presen Y~N)~--~ Total depth Sanitary seal (~) If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to ~'~i'A~i Casing height (above ground) Wires properly protected) FROM WELL LOG AT INSPECTION Date of test ~ f J~ -' ~'~ j~.~ - 1~ Static water level L~ [, ~ I,~?~.1 Well production \ ~ ,'~) g.p.m, q, g.p.m. WATER SAMPLE RESULTS: Coliform (~ Date of sample: Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~ ~ ~' ~5 - Y Z-Tank size Foundation cleanou~N) ~-~ Date of Pumping [ -Z..- (~5 --'"~ C. ABSORPTION FIELD DATA Date installed '~'~ ")- ~J" Length ' ~ (_~ i Width Effective absorption area Date of adequacy test t ~ ~ ~ .ti Fluid depth in absorption field before test (in.); Fluid depth (~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y~ Depression (Y~? Pumper Number of Compartments ~'"' Cleanouts~N)~(__ 0,~ High water alarm (Y/<~ ~-~ Soil rating (g.p.d./~ or fF/bdrm) /,~J--~//~/,~-~System type ~ Gravel thickness below pipe Total depth /~ /'~ Monitoring Tube present ~)~ Depression over field ~ ~ Result~Fail) ~ For ~ bedrooms Immediately affe~gal, water added (in.): ~ ~" · Absorption rate = ~~ .g.p.d. {~yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* E. SEPARATION DISTANCES Size in gallons "Pump on" level at* ~ _--------'-~- *Datum F. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~ I"~ ' Property line /cC) / '/' Absorption field · Water main/service line /0 / ~ Surface water/drainage /~z2C)/~Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ~, ~ ~ ~ Building foundation I O ~ Jr Water main/service line Surface water \1~1~~'['- Driveway, parking/vehicle storage area Curtain drain ~ O ~ ¢__ [~-'-~ C~ J Wells on adjacent lots ~ O ~ ENGINEER'S CE~IFICATION I ce~i~ that l have determined thru field inspections and rewew of Municipal rec~t the a~'~s in conformance with. MO~ H~ guideli~s in effect on this date. ~ ~ ~ ~,,~;~' ~gnature ~/ - ~? ~ ~ ~ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 AnchoKage, Alaska 99519~-6650 343-47~4 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Lot 12; Clearvle~"Subdivision Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Renkert .qnnul ine: An~hn~g~; Day phone qqK1 345-0744 (h) 274-7232 (w) Day phone Day phone m Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 '~ TYPE OF WATER SUPPLY: Indivi.dual well ~ Community well. Public water NOTE: lng to the legality and status of system. If community well system, provide written confirmation from State ADEC attest- x TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC . ; '- attesting to the legality and status of system. 72-025 (Rev. 1/91] Front MOA #21 ¸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 of this Health Authority Approval appliCation shows that the on-site water supply and/or wastewater dispoSal system is safe, functiOnal and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm = ~, o ........ 17034 Eagle River l.oop R~I~' 2~1'- / Address ., , - ,.,,,-','/ /' Engineer's signature . ///~ ~Date ~'"'-/_~ ~_? _/_~ DHHS SIGNATURE '"'~'~"~"~"'~'"'~"~"" ' ~ "' :' '~ Approved for ~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Th~:Municipality of Anchorage Department of Health and Human ServiCes (DHHS) issues Health Authority APpr0,Vb, l:~Cert, ificat?s:lsased only upon the representations given in paragraph 5 above by an independent profeSSional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not Conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.. 72..025(Rev. 1/91) Back MOA#21 MunicipalitY of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: / o?'- /2_ ~ CE/~.~//E4J ~//~ Parcel I.D. A. Well Data Well type j~/~ I ~/~7'~ If A, B, or C, attach ADEC letter. ADEC water system number /L///r~ Log present ~1) ~/~-,5' Date completed ~/[..~/~- Driller Total depth ,_~-/_~. t Sanitary seal,N) Cased to ..~"~r- ' Casing height Wires properly protected (~N) FROM WELL LOG AT INSPECTION Date of test ~_~//.~/ Stat~ water level Well flow G.p.m. Pump level1 SEPARATION DISTANCES FROM WELL TO: Se~i~~ tank on lot ~so~tion field on lot / Publ~ sewer main Sewer sewice line WATER SAMPLE RESULTS: Coliform (~)//00/~ Nitrate Date of sample: d~__/o~ / ~+ Collected by: Other bacteria (__~/~o ~.A~ ~ B. SEPTI~ TANK DATA Date installed r~/z'~ / &7_ Tanksize / ~-.~"(0 ~'~_ Compartments Cleanouts~N) ~'(5-.~ Foundation cleanout(~N) y~.,Y Depression (Y~__)~ High water alarm (Y~ ./'tJL~ Alarm tested (Y/N) Oate of pumping Z//..~'-//'~ Pumper A4 ~o/1//~, -..~~/C__~_~ SEPARATION DISTANCES FROM SEPTIC/I-I~t;t~Ne-TANK TO: Well(s) on lot //(~--~ ~'//~ On adjacent lots TO property line / 0 r'~'~ Absorption field ~' ~'~' Suflace water/drainage /~](Z) ~7~ Foundation Water main/service line 72026 (3/g3)' Front CONTINUED ON BACK PAGE C. UFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) ~ SEPARA~ STATION TO: We, J.en~t On adjacent lots D. ABSORPTION FIELD DATA Date inst~lled 7/7_. '3 / $ 7__ Length ~, -X-- W'~h Manufacturer Manhole/Access (..~ J ...--"l~ump off" Level at Soil rating (GPD/FF) Surface water. Total absorption area ~ qO ~'' .-X-- Date of adequacy test '~- ] I ~" [ q ~ Water level in absorption field before test Peroxide treatment (past 12 months) (Y N) Cleanout present ~1) Result~ail) Systemtype ~!L~E D~-/ /,J Gravelthickness r~o'"~ Total depth 15' /~r" ~' O) Depressbn over field (Y~_) p~ ~ ~.~ for ~F qO c] r,~') Bedrooms ~ertest /~(j/LJ ~- /x~ (3 ~/(~ If yes, give date 8EPA~TION DISTANCE FROU A~ORPTION FIELD TO: ELo~E A~D A~O~ F~ ~L fl~. On adjacent lots / OD r./_ Property line To existing or abandoned system on lot ,~.70/,./~ P~E$~-~ 7 Cutbank /Jo A)E ?,~"~'E'~,~"Watermain/service line Driveway, pa~ing/vehicle storage area -~' Well on lot /~>0 To building foundation On adjacent lots Surface water /(~0 Curtain drain f~ ~J ~ J~f,j a ~,*d E. ENGINEER'S CERTIFICATION I ce~fy ~at I have checked, verified, or conformed to all MOA and HAA guidelines in effect ~,the ~te of ~is inspection. signature ___~~- Engineer's N~l~4;a~::;~ ~ L~~P ,I~d Ne. 204 Date HAA Fee $ ~:> Date of Payment Waiver F~ $ Date of Payme~ Re~i~ Numar 72-o2e (3/g3)' Back APPLICANT FILLS OUT UPPER HA['-'"ONLY Phone F Address Zip Code Address Phone Realty Co. & A~nt Address Zip Code Street Locati~ // r Type of Resi~nce Single Family '~ Multiple Family ,o. of Bedroo~ ~ Other Water Supply Individual A~ACH WELL LOG. A wal log is required for all wells driaed since June 1975, Community For wells ~illed prior to that date, give well depth (attach log if available). ~ Public Utility Sewer Disposal Individ~l Year Indiv~ual Installed: ~ Public ~ility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED. Time Time Time Time Date Date Date D{te Inspector Inspector Inspector In s{~,~ect or Field Notes: MUNICIPALITY OF ANCHORAGE ////3- ~ DFPT C" i-%'LT ! ~'. ,~ ~, ENVIR',Ji,IM:i'.,. A.. ' .~. 5(.TION _RECE!_VED ( ~ APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL* Soils Rating Date Sewer Installed Well To Absorption Area ~ Well Log Received /"~.....~,,,' Well to Tank Septic Tank Size / ~-- .~) 72-023 (3182)