HomeMy WebLinkAboutT12N R3W SEC 15 LT 2T12N R3W
Section 15
Lot 2
#015-501-30
— Municipality of Anchorage Page I of a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: SWg5001td PID Number: 01550130
Name:
Wastewater System: 0 New ❑ Upgrade
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Address: 99$1A
rjYd Da E. 16`{ht"',QVts: ANC NOTtAb4/QL.ASKA
ABSORPTION FIELD
—
Phone:
No. of Bedrooms:
={
+9 Deep Trench El Shallow Trench ❑Bed 11 Mound ❑Other
LEGAL DESCRIPTION
Soil Rating:
Total Depth from original grade:
Q.`K GPD/Sq. .Ft.
10t —
_
Lot: Block: Subdivision:
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
a —
I ,1 qFt.
10 I @ ( Ft.
Township: RaSection: e–
f1aN nge: RSI % IIT
Fill added above original grade:
0. es To jj Ft,
Gravel length./)�. I� O
ioTAr_ t% Ft.
WELL: 9 New ❑ Upgrade
.
Gravel width:
Number of lines:
a
Distance between lines:
Ft.
Ia�—Ft.
Classification (Private, A,B,C):
_
Total Depth:
Cased To:
_a.s
Total absorption area:
Pipe material: AS?`AA
12AVAleE
I `1 FL
/ q / Ft.
39a SQ.Ft.
F'610 MO34
Driller:
RLPIM(;
Date Drilled:Sialic
Water Level:
Install r:
Date installed:
fo/a_)l9s
1 y Ft.915)
o
Yield:
GPM
Pump Set at: Casing Height Above Ground:
Il /C �Ft. .1 Ft.
TANK
--- —
SEPARATION
DISTANCES
ZSeptic ❑Holding ❑S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer:/Capacity
V (2. F_ -EV-
in gallons:
I a Gb
From
Tank
Field
Station
Tank
Sewer Lines
Well-
r
'1-
cis
Material
Number of Compartments:
/00
/G16 4-
--
--
Surface
-
—
LIFT STATION
Water
lo��-
ILS+
-
Lot
Size in gallons:
Manufacturer: --
Line
IU +
Iv +
Foundation
'59
�J(,
–
,__
"Pump on" level at:
Pump off" ley
High water alarm at:
Curtain--
--
h.IUN
Pump Make 8
Electrical Inspections performed by:
Drain
�
BENCH MARK
Remarks: AL Z_ LCA/arf S r7 Irs6%) I)v
—
YD CoN S'72eci Id /J A/:/3/Pr1 /37 7- M
Location and Description: /.I 1 1 /
rnY or C Ho �(jAOA(�
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—
Assumed Elevation:
ZL"F�c. Try L' JKaDTy CNAN4&U 7'e2 Trc'g,,, ct/@J
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—
ENGINEER'S SEAL
TO MAr.vTArN SrE /1.NnAT/orV r0 G'IN42-45
Or�ld,�
4.4
S ENGINEERING
17034 Eagle River Loop Road, No. 204
Inspections performedkglelalver,�057-x— Dates: ist
2ntl�a8-q5
.;f1. T. ...
,'I'- 'j aoaORT C. COWAI, r o;
Department of Health and Human Services approval
°a;`>` c` 81101 `
> Date: 1—`1 1lv
Reviewed and approved by:
72-013 (Rev. 9/91) MOA 25
Permit No. SW950276 Page- 2 of 2
Municipaiity of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 4 Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On. -Site Wastewater Disposal System and/or Well Inspection Report
LOT 2, SECTION 15, T12N, R3W, SM, AK.
Legal Description:
PID No.:
01550130
72-013 A (Rev. 9191) MOA 25
STI ST2
'
FINAL GRAD
00.2'
FINAL GRA
C C05 /,1(2.1'
C07
99.2'
B?N
INSULATION
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89.
88.3'
NEW TRENCHES
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79'
120'
--
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50 GAL
04
78'
12
' --
ST1
SEPTIC
TANK
05
85'
-
99'
7
06
99'
14
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ELL
T1 84' 99'
ADIUS
T2 104' - 119'
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
99519 6650
PAGE I OF 1
/ 5
1A, Sfy^c %
11-27-11-
ANCHORAGE, ALASKA 1n ('Yl
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW950276
DESIGN ENGINEEER:S & S ENGINEERING
OWNER NAME:NELSON M G
OWNER ADDRESS:5602 E 104TH AVE
ANCHORAGE, AK 99516
PARCEL ID:01550130
LEGAL DESCRIPTION:
T12N R3W SEC 15 LT 2
LOT SIZE: 206735 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WEILL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
DATE ISSUED: 9/13/95
EXPIRATION DATE: 9/13/96
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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY: .�9U L'G_?`C �✓ ��-.-aG�Zv'__—._-�.
DATE:�,�'� G=�_
c7
DATE:
HEALTHAUTHORITY
APPROVALS
SEWER& WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
ANDREPORTS
WELLINSPECRON
& FLOW TEST
EquaurcEy
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ONSITE
WASTEWATER
DISPOSALSYSTEM
DESIGN
s&s�
,inepunq
September 1, 1995
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, PE.
CIVIL ENGINEERS
(907)694-2979
FAX(907)694-1211
REFERENCE: BLM Lot 2, Section 15, T12N, R3W, S.M., Alaska
Request you issue a permit to drill a well and install a
septic system to serve the proposed four bedroom house on
the referenced property.
Two test holes were excavated and a percolation -tests
performed. The approximate location of the test holes are
located on the attached site plan.
At the time of excavation no water was encountered in test
hole #kl, water was encountered at 15' in test hole #k2 and
after seven day ground water monitoring, the monitoring
tube for test hole #1 was found to be dry and water was
found at 15' in the monitoring tube for test hole #k2.
This property has enough area for a future septic upgrade
which can be seen on the attached site plan.
We do not anticipate any adverse effects on neighboring
wells, septic systems or drainage patterns by the
installation of the proposed septic system.
There are no points of contamination within the proposed
well radius which can be seen on the attached site plan.
If you require additional information, please contact us.
Sincerely,
/
Robert C. Cowan, P.E.
RCC/gk
Enclosure
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
e f� Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG - PERCOLATION TEST
PERFORMED FORj ^I—L- 5-- DATE
LEGAL DESCRIPTION: LOT 2? f"C'' "Y--`/2N1Township, Range, Section:
P H SLOPE SITE PLAN
(FTrE� 6iZ CtF1-N ICj /
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
t_7
Slc-T}� SArvD "�a
'F-1tiF (�.rvlFraDan
SA,00 — MOItT•
t/t--N.S2 �2;` ,
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Depth to Water After
Monitoring? �r
k
5
ISS 0 _ -
E
Date: 7119A9S"
Reading Date
Gross Net Depth to
Time Time Water
Net
Drop
S-0,
14
J J cl v
3iQ,.
n
1�
PERCOLATION RATE �� (minutes/inch) PERC HOLE DIAMETER
-EST RON BETWEEN FT AND 8 FT
S & S ENGINEERING
PERFORMED BY: IZ,eu CERTIFY THAT THIS TEST WAS PERFORMED IN
M34 h§916 Rlver Loop Road No. 204
ACCORDANCE WIT*vkRh%vTgtktkd/#"grAL GUIDELINES IN EFFECT ON THIS DATE. DATE: /"1" �' / 9 S_
72-008 (Rev. 4/85)
t Municipality of Anchorage ,T
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 ••L• Street, Anchorage, Alaska 99502-0650 0 r
SOILS LOG •— PERCOLATION TEST
PERFORMED FOR: l—�• L�� _ DATE PERFORMED:
LEGAL DESCRIPTION: Src IS(�Io1N�3W Township, Range, Section:
uPr'r2 SLOPE SITE PLAN
SI�Ty 5 0 S"'
7crvsa � ��-Y
COMMENTS --1 11-i t= A
ti 5E 01 (. GPD
WAS GROUND WATER MC)ENCOUNTERED? a__
IF YES, AT WHAT "—
DEPTH?
Depth to Water Aller —, I
Monitoring? _ nate: -7j-n
hS
ROBERT C. COWAN
CE -8001
S $off
L
O
P
E
Reading
Date
Gross Net Depth to Net
Time Time Water Drop
r0(L-
:16 Iv ori 5..
Z2 It, ' v"
rr
PERCOLATION RATE _I6 (minutes/inch) PERC HOLE DIAMETER
RUN BETWEEN FT AND FT
nt-r4kttitdC,
PERFORMED BY: ' ` .,. _ ct 1211 - 'z.A�-- CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL SLATE ANd MUNId'!GUIOELINES IN EFFECT ON THIS DATE. DATE: �1 I /15-
72-008
1•S
72-008 (Rev. 4/85)
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[L,09 �N01S]4 r{��d 3115 ®®
HEALTHAUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
ROADOESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ONSITE
WASTEWATER
DISPOSALSYSTEM
DESIGN
s&
nG
GENERAL:
ROBERTO. COWAN, P.E.
ROBERTA. SHAFER, P.E.
ON --SITE WASTEWATER DISPOSAL SYSTEM CIVILENGINEERS
CONSTRUCTION PRACTICES FAX(994-29AX (907) 6944--
1211
and
MATERIAL SPECIFICATIONS
HLM Lot 2, Section 15, T12N, R3W, S.M., Alaska
September 1, 1995
1. The scope of this project includes the installation of
a 1250 gallon septic tank and leachfield trench to
serve the proposed four bedroom :residence located on
the referenced property.
2. Construction shall be in accordance with the approved
site plan and design drawings, Municipal permit with
any special provisions or conditions, and al:L
applicable State and Municipal Wastewater Disposal
Regulations.
3. The contractor_ shall be responsible for obtaining any
necessary underground utility locates.
4. Unless specifically agreed otherwise, the property
owner shall be responsible for final grading areas
subsequently depressed from soil settling.
5. Contractors installing wastewater disposal systems
must be certified by the Municipal Health Department
for system installations. Owners installing their own
systems must also receive prior approval from the
Municipal Health Department.
SEPTIC 'TANK INSTALLATION:
1. A septic tank .is to be constructed by a certified
septic tank manufacturer. Construction shall include
two 4" cleanouts for pumping access.
2. The septic tank shall. be sufficiently bedded to
prevent settling or shifting of the tank.
3. All standpipes on the septic tank shall extend a
minimum of 12 inches above final grade.
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
Page Two
BLM Lot 2, Section 15, T12N, R3W, S.M., Alaska
September 1, 1995
4. Septic tanks installed with :Less than 4 ft. of cover shall
be insulated.
A foundation cleanout shall be installed one to four feet:
from the building foundation. In the line between the tank
and the leachfield there shall be two adjacent cleanouts
(unless an effluent pumping system exists within the septic
tank). These cleanouts shall be located on undisturbed
soil not more than 10 ft. from the tank. The first:
cleanout, in line, shall be to clean toward the leachfield.
The second cleanout shall be to clean toward -the septic
tank.
6. Final grading over the septic tan], shall be such that a
positive slope exists away from the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
1. Excavate the proposed trench to the dimensions shown on the
design. The bottom of the excavation shall be within 2
inches of level. If the sidewal:Ls of the excavation become
smeared, they must be raked or scratched (ruffed -up) before
gravel (sewer rock) placement.
2. Once the gravel is installed, the distribution pipe is to
be installed level with the perforations faced downward.
Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
3. A silt barrier must be installed between the final grave]_
layer and the native soil backfill. Ensure the silt
barrier covers the entire gravel surface before placing
backfill.
4. Monitor tubes shall be of four (4) inch diameter,
installed approximately in the locations shown on the
design, and extend a minimum of 12 inches above final.
grade. The portion of the monitoring tube extending
through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is
equivalent to the effective depth of the gravel as noted on
the design.
Page Three
BLM Lot 2, Section 15, T12N, R3W, S.M., Alaska
September 1, 1995
5. Backfill over the final gravel layer must not be less than
twenty-four (24) inches. Insulation must be installed when
the backfill depth is less than thirty-six (36) inches.
The finish grade: over the trench must be mounded to prevent
the formation of a depression after. settling.
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Type of Pipe Perforated Solid
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F810 (HDPE) Yes No
ASTM D2662 (ABS) Yes Yes
Use of a type of pipe other than listed above must be
approved by the inspecting engineer.
3. Insulation shall be at least 2" thick extruded direct
burial polystyrene (Dow Chemical Company Styrofoam HI or.
equal).
4. Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulde.r, Fernco, or equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N,
or equal) must be installed between the final leachfield
gravel layer and the native soil backfill.
6. All. leachfield gravel (sewer rock) shall be 0.5"-2.5"
screened gravel with less than 3% passing the (6200 sieve.
7. When sand is being used as a filter material, its gradation
specifications must conform to current M.O.A. or D.E.C.
requirements.
Page Four
BLM Lot 2, Section 15, T12N, R3W, S.M., Alaska
September 1, 1995
INSPECTIONS:
Typically there will be a minimum of three (3) inspections
required during the installation o:E the wastewater disposal
system. These inspections will occur as follows:
1. The first inspection must be conducted after the
excavation of ditches, pits, trenches, or beds and
before the installation of any gravel. A septic tank
may be set in place, but may not be backfilled before
this inspection.
2. The second inspection must be conducted after the
placement of the silt barrier, gravel, distribution
lines, standpipes, cleanouts, and insulation, but
before the placement of any other backfill.
3. The final inspection is to occur upon final grading of
the property.
Often there will be more than these 3 inspections required.
Especially with the installation of multiple trenches, sand
filters, pressurized distribution systems, etc. Thus, the
inspecting engineer is to be contacted at :Least 24 hours prior
to the start of construction. If necessary, a pre -construction
meeting will take place on-site. The inspecting engineer will
not coordinate, direct or control in any way the contractors
activities.
The owner shall contract with the contractor to perform the work
outlined in these specifications and plans and in accordance
with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S
Engineering. S & S Engineering shall be the owner's
representative and will. inspect the work as stated above to
document the contractors activities. Final acceptance of the
contractors work rests with the owner and the M.O.A.
Iage Five
BLM Lot 2, Section 15, T12N, R3W, S.M., Alaska
September 1, 1995
S & S Engineering shall have no liability to the owner or to
others for acts or omissions of the contractor or any other
persons performing work on this project or the failure of the
contractor to carry out the work in accordance with these
construction documents. S & S Engineering's inspecting engineer
will not be responsible for the construction means, methods,
techniques, sequence, procedures or the safety precautions
incident to this project.
CONTRACTOR/INSTALLER
STATE OF ALASKA
- DEPARTMENT OF NATURAL RESOURCES
DIVISION OF MINING & WATER MGMT
WATER WELL RECORD
LOCATION OF WELL
BOROUOM
WBONIBION L9T
BLOCK
SECTION UTRS
SECTION
YOVJNSHIP
.RANGE
MERIDIAN
LOCATION/SKETCH:
WELL OWNER:
,�L_rn
DEPTHS MEASURED FRO11,11:0casing top ❑ground surface
WELL DEPTH DATE OF COMPLETION
Depth of hole: /411' ft
BOREHOLE DATA: Depth
Depth of casing: ft /L3 /_%
S&Sl
;ineekinq
96-04-04 11:44 RCVD
April 2, 1996
ROBERT C. COWAN, PE.
ROBERTA. SHAFER, P.E.
CIVILENGINEERS
(907)694-2979
FAX(907)694-1211
HEAITHAHORIn
LS
APPROVALS
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
SEWER & WATER
MAIN EXTENSIONS
REFERENCE: BLM Lot 2, Section 15, T12N, R3W, S.M., Ak.
Please note the well location for the above referenced
SEWER&WATER
property has been moved from the original proposed design.
INSPECTION
The relocation was done at the owners request. The new
location puts the well closer to the residence and reduces
the length of water and electrical lines to be run from the
ENGINEERING STUDIES
Wellhead to the house. There is also less impact to
ANDREPORTS
adjoining properties from the 100ft. well radius than the
original proposed location.
We do not anticipate any adverse effects on neighboring
WELL INSPECTION
&ELow TEST
wells, septic systems or drainage patterns by the
installation of the proposed septic system and well.
If you require additional information, please contact us.
SITE PLANS
Sincerely,
14- `
ROAD DESIGN
Robert C. Cowan, P.E.
RCC/g],
Enclosure
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ONSITE
WASTEWATER
DISPOSALSYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
EPL$?JS
Municipality of Anchorage =�*
On-Site Water and Wastewater Program ar
(907) 343-7904 s AM
Certificate of On-Site Systems Approval
Parcel I.D. 015-501-30 Expiration Date: C(-11
I_i
1. GENERAL INFORMATION:
Complete legal description T12N, R3W, Sec 15, Lot 2
Location (site address) 5602 E. 1041h Avenue*Anchorage,AK 99507
Current Property owner(s) Molly McCarthy Day phone 244-3467
Mailing address 5602 E. 104th Avenue*Anchorage,AK 99507
Real'Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
n Duplex
(l 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 n Holding Tank n
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 $ 55'6 Waiver Fee $
Date of Payment 5MS/Ag Date of Payment
Receipt Number 05426 Receipt Number
COSA# 0SCHU N 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: 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: C/2?A
��0000p•,, ,
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system �� 3 1 '�
in accordance with the guidelines and regulations established by the Municipality of Anchorage and o . c� 4Rl
industry practices. The reported results describe the condition of the system/s on the date/s of the Q' '� .V�l0
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or n h
encroachments may exist that were not identified during the evaluation. The operational life of all wells o°e ? .•.1*v
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, 0••. t%
groundwater levels (that may fluctuate during the year), quality of construction (materials and , U
workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and 0'..... •.
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the f • `Or: , Corn-._s: o
system/s: therefore, GEG makes no warranty (express or implied) regarding the future performance of In
o / ! /E-79 ► . �Q• �
the well or septic system. GEG makes no representation whether an alternative well or septic system h sr •• •: / 2.3 I• °�O
can be installed on the property in the event either of the current systems fail to perform adequately in �Q P, ' (.... • r��°d
the future. The content of this report is for the sole benefit of the person/party that retained GEG to ) ProfeS$%on° a
perform the evaluation. Reliance upon the information provided in this report by any other person or D�OOooaQ
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
Y System #1 Approved for it bedrooms ```k�llll(1(lif'f��,��
System #2 Approved for bedrooms ```��`G�QPI,ITY pF„ / �
Disapproved ` '5,f?
�N-SI TE
Conditional approval for bedrooms, with the foil) z.r' I s.
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�11/7)))1111�1���
By...------ j"----
1.•.� Original Certificate Date:l :,`/
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 Nitrate/Advisory
Septic System Advisory Arsenic Advisory r/
Well Flow Advisory Other J ' v S Act UiSi d�'V
COSA blue sheet 10.10-12.doc /
COSA Checklist
Legal Description: T12N, R3W, SECTION 15, LOT 02 Parcel ID: 015-501-30
If more than 1 septic system on lot: COSA Checklist# of Structure served by this system_
A. WELL DATA
❑■ Well log is filed with Onsite(or attached) Well production at time of test 5.7+ gpm
Date drilled 9/24/93 Water storage tank volume n/a gallons
Total depth 141 ft Well disinfected for coliform test? ❑Yes E No
Cased to 141 ft ❑■ Coliform bacteria is Negative
• Sanitary seal is functioning correctly Nitrate 13) mg/L ❑ Nitrate less than MRL (ND)
0 Wires are properly protected Arsenic ug/L at Arsenic less than MRL(ND)
Casing height(above ground) 12+ in. Collected by GEG, LTD.
Date of flow test for COSA 5110/19 Date of Sample 5/10/19
Static water level at beginning of test 80.4 ft.
Comments
B. TANK DATA C. LIFT STATION
Age of tank(s) 23 years ❑ Required maintenance completed
Tank type/material "else" Age of lift station years
❑ti Standpipes/foundation cleanout per record drawing Lift station material
Date of pumping 6/28/18 Comments: NO LIFT STATION
TANK LIQUID LEVEL WAS 48"ON 5/10/19
D. ABSORPTION FIELD DATA
Which system tested (date installed) Adequacy test date 5/10119
❑ALL standpipes present per record drawing Results Pass For 4 bedrooms
Total measured depth from grade 10.3+ft(max) Fluid depth prior to test 0 in
Measured depth to pipe invert from grade 3.75 ft(min) Water added 686 gal
0 N/A—pressurized field
New depth 5 in
❑ Monitor tubes go to bottom of drainfield. If not, state Elapsed time 105 min
depth into effective 6=SSO4fN TRENCH
■❑
Final fluid depth 0 in
Code-required soil cover over field
Absorption rate 600+ gpd
❑ System presoaked NO
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months)
date of test)
Gallons introduced N/A gallons If yes, enter date -
Comments/Deficiencies:LIQUID LEVEL NOT CHECKED FOR NORTH TRENCH
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'
2 Yes if No ft E Yes if No ft
Neighboring Tank> 100' Z Yes if No ft Private Sewer/Septic Line>25' ['Yes if No ft
Absorption Field on Lot> 100' EYes if No ft Holding Tank> 100' EYes if No ft
Neighboring Absorption Fields> 100' Animal Containment> 50' Q Yes if No ft
Q Yes if No ft
Manure/Animal Excreta Storage> 100'
Community Sewer Main >75' ❑✓ Yes if No ft 0✓ Yes if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations> 10' 0 Yes if No •5+ ft Surface Water> 100' OYes if No ft
Property Line> 5' 0 Yes if No ft Driveway/Parking > 0' 2 Yes if No,comment
Absorption Field > 5' EYes if No ft Wells on Adjacent Lots:
Water Main > 10' 0 Yes if No ft Private Wells> 100' EYes if No ft
Water Service Line> 10' ['Yes if No ft Community Wells >200' 0 Yes if No ft
From Absorption Field on Lot to:(Please enter distances if less than required)
Building Foundation > 10' Q✓ Yes if No ft Driveway/Parking> 0' 0 Yes if No,comment
Property Line> 10' 0 Yes if No ft Wells on Adjacent Lots:
Water Main > 10' 0 Yes if No ft Private Wells> 100' 0 Yes if No ft
Water Service Line> 10' 0 Yes if No ft Community Wells>200' E Yes if No ft
Surface Water> 100' 0 Yes if No ft
F. ENGINEER'S COMMENTS
*MET CODE AT TIME OF INSTALL.
Qo60000O
G. ENGINEER'S CERTIFICATION o, OFA �'N
rA
I certify that I have determined through field inspections and review 0�' QD
of Municipal records that the above systems are in conformance with o* 49 TH /'' .757*0o,
MOA COSA guidelines in effect on this date.
D
D D
0 0 13 %Jeffrey A. Garness: 1
0,1%. CE—7953 �4p
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COSA Checklist yellow sheet ��0 o f e s s o a�
#AECC884 000��
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT +• 1 cAge) 907-343-7904
On-Site Water and Wastewater Section / Fax: 343-7997
www.muni.org/onsite
Septic Tank Advisory
Certificate of On-Site Systems Approval #0SC191184
Subdivision: T12N R3W Sec 15 lot 2
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this property is 23 years old. Typical replacement costs range from $6,000 to $9,000.
This advisory must be attached to all copies of the subject Certificate of On-Site Systems
Approval.
This is an example of what the metal of a 20 year old steel tank MAY look like.
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Mailing Address: P. 0. Box 196650 * Anchorage,Alaska 99519-6650 *www.muni.org
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite (907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 015-501-30 COSA # 65C l a L 3(,l -:7-
Expiration Date:_J/
1. GENERAL INFORMATION
Complete legal description T12N R3W SECTION 15 LOT 2'
Location (site address) 5602 E 104"` Avenue ANCHORAGE AK 99507
Current Property owner(s) Mary Strawbridge Day phone
Mailing address
Lending agency
Mailing address
5602 E 104' Avenue ANCHORAGE AK 99507
Day phone
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
4
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual On-site
Individual Water Storage
❑
Individual Holding Tank
Community Class _ Well
❑
Community On-site
Public Water System
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Appfavdl (CogA) based ohly upoh the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD. EAGLE RIVER AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date — 7/31/2012
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow
and absorption rates may change due to subsurface conditions that may not be observed from the surface,
changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current orfuture'
occupants or can ArcTerra guarantee that no unseen ��rt
encroachments, deficiencies or discrepancies exist.` u?
5. DSD SIGNATURE
t✓ Approved for � bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
woHcnecKusc A Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory Other
By. 14 Original Certificate Date:
(Rev. 11105)),
Municipality of Anchorage Qpos
• '` Development Services Department
Building Safety Division
On -Site Water and Wastewater Program s a E
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite (907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: T12N R3W SECTION 15 LOT 2 Parcel ID: 015-501-30
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID # _ Well Log (Y/N) N
Date completed 10/95 Sanitary seal (YM) Y Wires properly protected (Y/N) Y
Total depth 141 ft. Cased to 141 ft.
FROM WELL LOG
Date of test 10/95
Static water level 74 ft.
Well production 12 9 -
p.m -WATER SAMPLE RESULTS:
Coliform colonies/100mL Nitrate All) mg/L
Casing height (above ground) 18 in.
AT INSPECTION
7/27112
ft.
5.76 g.p.m.
Arsenic:mg/I Date of sample: 7/30112 Collected by: ArtI erra
B. SEPTICIHOLDING TANK DATA
Tank Type/Material Se_P�tic/Steel Date installed 11/27/95 Tank size 1250 gal.
Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (YIN) Y Depression over tank (Y/N) N
High water alarm (YIN) N Date of pumping 71012 Pumper A+
C. ABSORPTION FIELD DATA
Date installed 11/28/1995 Soil rating (g.p.d./f:2 or ftp/bdrm) 0.45 System type Trench
Length 44 & 50 ft. Width 2.5 ft. Gravel below pipe 9 & 6 ft. Total depth 10 & 9 ft. (Measured 7/27/12)
Eff. absorption area 1392 ftZ Monitoring tube Y
Date of adequacy test7/27J /2
Depression over field N
Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test ' ` 43 in. Water added 605 gal. New depth *11.4148 in.
Elapsed Time: 1440 min. Final fluid depth *4ry/43 in. Absorption rate >= 600+ g.p.d.
Any rejuvenstlon treatment (past 12 ma.) (YIN & type) N If yes, give date -_
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at _in. "Pump off' level at _in. High water alarm level at in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 1001+
Absorption field on lot 1o0'+
Public sewer main
Sewer/septic service line 251+
Animal containment areas 50'+
On adjacent lots 100'+
On adjacent lots loo'+
Public sewer manhole/cleanout 100'+
Holding tank 100'+
Manure/animal excrete storage areas 1001+
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
Building foundation 51+ Property line 51+
Absorption field 5'+
Water main 101+ Water service line 10'+ Surface water *100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 101+ Building foundation 10'+ Water main
Water Service line 101+ Surface water 100'+ Driveway, parking/vehicle storage 101+
Curtain drain 50'+ (None Known) Wells on adjacent lots 100'+
F. COMMENTS
*Water added to cleanout in southern (upper) trench that was dry. Both trenches were monitored
rinrmn t.ct
G. ENGINEER'S CERTIFICATION
1 certify that l have determined through field inspections and
review of Municipal records that the above systems are, in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name KENNETH M. DUFFUS
Date 7/31/2012 i.
COSA Fee $490.00 Waiver Fee $
Date of Payment 8 /a Date of Payment
Receipt Number/nn,15-3 Receipt Number
(Rev. 11/05)
N90`00'00"E 330.48' (M) 329.67' (R)
BASIS OF BEARING E. 104TH
33' R.O.W. EASEMENT
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AS -BUILT OF: ANCHORAGE
BLM LOT2 RECORDING
T12N R3W SEC 15 S.M. AK. DISTRICT
SURVEY CERTIFICATION: I, John L. Schuller, have conducted a
physical survey of this property as shown on this drawing and that the
improvements situated thereon are within the property lines and no
enchroachments exist other that noted.
EXCLUSION NOTES: It is the owners responsibility to determine the
existence of any easements, covenants, or restrictions which do not
appear on the recorded subdivision plat. Under no circumstance should
any information on this drawing be used for construction of fences,
structures, improvements, or for establishing boundary lines.
AUG 18, 2012 1 1"=50'
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AS -BUILT OF: ANCHORAGE
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T12N R3W SEC 15 S.M. AK. DISTRICT
SURVEY CERTIFICATION: I, John L. Schuller, have conducted a
physical survey of this property as shown on this drawing and that the
improvements situated thereon are within the property lines and no
enchroachments exist other that noted.
EXCLUSION NOTES: It is the owners responsibility to determine the
existence of any easements, covenants, or restrictions which do not
appear on the recorded subdivision plat. Under no circumstance should
any information on this drawing be used for construction of fences,
structures, improvements, or for establishing boundary lines.
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Anchorage, Alaska 99508
(907) 227-1455 office
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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. # 01 5-501 -30
— HAA#
1. GENERAL INFORMATION
Complete legal description _BLM Lot 2; T1 2N; R3W; Sec 15 —
Location (site address or directions)
5602 E. 104th Avenue
AnchoracYe.
Property owner - Sandy Donahue _ Day phone
Mailing address _
Lending agency Day phone
Mailing address
Agent —David Windsor/Remax Properties Day phone 257-01 29
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4 _
3. TYPE OF: WATER SUPPLY:
Individual well XX
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XX _
Holding tank
Community on-site
Public sewer _
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1191) 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 ALASKA WATER & WASTEWATER phone 337-0-17
J
Address 6801 DEBARR ROAD, SUITE 28
Engineer's signature
Alaska Water &
Wastewater Consultants, Inc:
Shall be PAID $m_.• D00
or prior to, closing for the
Engineering Services Provided,
6. DHHS SIGNATURE
Approved for Cy bedrooms.
Disapproved.
Conditional approval for
Additional Comments —
By.
4L1TIC
— Date ' '1-7
e`•�FA o�
.A eq...p• fi.
.. � at( •A. carne.+- ;1,�
f =s
bedrooms, with the following stipulations:
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesyto purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025(RevAM) Back MOAk21
KtUIVW
0*)—Municipality of Anchorage MAR 2 6 1999DEPARTMENTOF HEALTH & HUMAN SERVICE&ICu>ALITYOFANCH0Environmental Services Division ENVIRONMENTAL. SERVICES DI
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: -�7 Tia �7 �3w1 � 15 _ Parcel I.D.: US -56( "30
A. WELL DATA
Well type 11� 0'476 — If A, B, or C, attach ADEC letter. ADEC water system number
Log present (ON) —�S —_ Date completed --LO
dy. n
Total depth _-- I /�� _ Cased to _—% L� r _ Casing height (above ground) — rZ +
Sanitary seal (Y/N) _-- Wires properly protected ON)
FROM WELL LOG AT INSPECTION
Date of test �� a( �S —_ j=q /%
Static water levelWell production --—_gm, _ I , V 9 -P.M.
WATER
WATER SAMPLE RESULTS:
Coliform _ _ --_Nitrate _ m
�� L _Other bacteria
Date of sample: Collected by/✓C_
B. SEPTIC/liOLDING TANI( DATA
Date installed /1Tank size � � �� Number of Compartments 'ZCleanouts�/N)
Foundation cleanout (YJN) _ 7� 5 _ Depression (YA No High water alarm (Y/&_ 7 —
Date of Pumping3_� % �Pumper _ �E�h�� -SL_/?-a1 c -E,3
C. ABSORPTION FIELD DATA �)C ( Mc�rol'7ogfz Tufsi i Do n'� ',7 FX7F_"O T'b rflC 8u77o�
UO TIT] T2G,xl1 r_ur-,V4-7»u T4s SHown, jj��ui�
Date installed —19 a, `js _— Soil rating ogp�d./Wr ft2/bdrm) _QHS _ System type I _C F S
CO 50 (� 6' � /0,5' F/FJ.o MIAs
Length y _W/,i,dth a ryo) . Gravel thickness below pipe Sad 9 A sa nTotal depth IO,�' O lvtTl�mrz
V 00 SF ,,f
Effective absorption area (A_`0;& `139f monitoring Tube present (�l N)_ oZ , Depression over field (Y(f�1j"t IVWNr 1q*MA"7
Date of adequacy test _ � _ Results (Pass/Fail) _ �_ For _& k,_ --bedrooms
53,5
Fluid depth in absorption field before test (in.); (� P�Y__ Immediately after_Iv1�b gal. water added (in.): ®DW_
T
Fluid depthQLft__ (ins) Minutes later:_ la3o hh',u Absorption rate =_— 2 � _g.p.d.
Peroxide treatment (past 12 months) (Y/0— NomLA V-� If yes, give date L4�4 --_
72-026 (Rev. 3/96)` NbaH Ta8l y-cl
�u7W �(ttcNcU TI'
D. LIFT STATION
Date installed /v�rI Size in gallons
Manhole/Access (Y/N) 'Pump on" level at* "Pump off" level at*
High water alarm level at* *Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot On adjacent lots
Absorption field on lot F On adjacent lots
1. 00
( W /-h
Public sewer main P//4 /{4 Public sewer manhole/cleanout WV14
Sewer /septic service line riLs 4 Lift station r ��
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation �0 Property line 0 Absorption field s
Water main/service line / Surface water/drainage /0( Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line 16 Building foundation / 0 f Water main/service line a
`1
Surface water 60 Driveway, parking/vehicle storage area S
Curtain drain MONY ��� Wells on adjacent lots / 00
F. ENGINEER'S CERTIFICATION
1 certify that ave d e in (Id
el inspections and review of Municipal rec Q
in conform nce w hi A lin s in effect on this date.
A f
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p C afhs� a e
Engineer'sName �`t
_ a m e Jo a A..6� t'd Ja="t �Q
Date
HAA Fee $ 3 D -b , &-T
Date of Payment '2 /�� / �1) —
Receipt Number G -j-7 Q Cz,
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
are
VAR -1 1-99 00:45 FROM -GTE VVIKUNVOIAL
CTM Environmental 3ervicea Inc.
.�vsrv�rev�orara'—�,r
'Shia is a Preliminary report
CTdk Ref.1t
990535001
Client Narno
AK W=T st Waslevvau.r COn5Ulla1LtS Inc
Pra.ject Name/1r
5602 E. 10411:
Client sample. lD
5602 E. 104th
Matrix
Drinking Water
Ordered By
PWSID
0
Client PO!
Printed Date/Time 03/11/99 09:33
Culleeted Acte/Time 03/05/99 10:30
Reeeived Date/Titrle 03/05/99 10:45
Technical Directat: Stephen C. Ede
Adeased By
Allowaole Prep AnalyO 5
PBrdmeLef Re®sutra �. F0L t,nitu HeLpod v-� Limits Parem! PCLe Inix
Tccnt Coliform a Cel/100% SH18 92224 03/C5/99 KAP
N1 xraLe-h 0.103 u 0.1CC m4/l EVA 300.0 10 man 03/05/99 03105/99 _CL
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE
E*-D
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
C, -S-v 1-3C 'v
HAA # =t Ec clLL ICA
1. GENERAL INFORMATION
Complete legal description Lot 2; Sec 15; T12A'; R3W; S.M.
Location (site address or directions) 5602 E. 104.t1i Ave.
Anchonage, AK
Property owner
BeE'2
Homes
_ Day phone 345-2355
Mailing address
18622
Gui. Uemo.t C,vActe.
Ancho/cage, AK 99516
Lending agency Day phone
Mailing address
Agent. _ Day phone
Address —
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual well XXX
Community well
Public water
NOTE: If community well system, provide written confirmation frorn State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XXX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
724)25 (Rev. 1/9p Front MOA x21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm S & S ENGINEERING Phone 6 C ?L cy -7 �l
17034 Eagle River Loop Road No. 204
Address
Engineer's signature
6. DHHS SIGNATURE
Approved for
Disapproved.
M
River
2 y bedrooms.
Conditional approval for
Additional Comments
Date -3b-7/9C
bedrooms, with the following stipulations:
UITIC
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 (R.V. v9p a .k MOA r l
Municipality of Anchorage n^d tlt'Rn"r
DEPARTMENT OF HEALTH & HUMAN SERVICE f't � ut 'tvlsl
Environmental Services Division tgieuttlmrN,rl§€
825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
�
Health Authority Approval Checklist � ��
Legal Description: Lp 7 a 5k -c_ ) r T 1I- lu , 83W Parcel I.D.: 01 5' – S10 I – 3 0
A. WELL, DATA
Well type PA rvn Y(- If A, B; or C, attach ADEC letter. ADEC water system number
Log present &)N) YF _> Date completed J o 3 -7 q S
Total depth
Sanitary seal &N)
Date of test
Static water level
Well production
11-1 / Cased to ) H /
Yk S
FROM WELL LOG
l0 /0-7
17
WATER SAMPLE: RESULTS:
Coliform 0 Nitrate
Casing height (above ground)
Wires properly protected O/N)
AT INSPECTION
— Yf s _
g.p.m. _—g.p.m.
6. 1 Other bacteria O
Date of sample: 36Y -k C '3 3 Collected by: — 5 P' S ENGINEERING
t7014-CrzW ver Loop Road Ne. 24
B. SEPTIC/HOLDING TANK DATA skiver, Alaska 99577
Date installed 1/6'6 �S_ Tank sizeY d_ Number of Compartments2 _ Cleanouts ")_r'_3
Foundation cleanout ( Y(�M _ Y 4 -( _ Depression (Y&
Date of Pumping _ti/A` Ne" Pumper
C. ABSORPTION FIELD DATA
,16 _ High water alarm (Y/& N 0 -
Date installed i r a $A J Soil rating (g.p.d./ft' or fe/bdrm) 0- S _ System type _ T /2 4
70
Length °I H Width - s" Gravel thickness below pipe 6 Total depth ) 3
Effective absorption arca ) 3 h -JL Monitoring Tube presentty/N Yt S Depression over field (Yo 1° 0
Date of adequacy test N ��" H Y c� Results (Pass/Fail) For _— _bedr oo
Fluid depth in absorption field before test (in.);
Fluid depth __(ms)
(past 12 months) (Y/N)
Absorption rate =
If yes, give date
added (in.):
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (YIN) "Pump Oil" "Pump off" level at*
High water alarm level at* *Datum
Cycles tq5ta
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Se tic tolling tank on lot 1001+ ; On adjacent lots /00 ".1 -
Absorption field on lot loo f 'f' On adjacent lots d 0
Public sewer main N 44 Public sewer manhole/cleanout N 14
i
Sewer /septic service line Lift station "V
SEPARATION DISTANCES FROk�OLDING TANK ON LOT TO:
Building foundation S 0 f Property line -7S- f Absorption field
Water main/service line S�d "/" Surface water/drainage 1 e 0 Wells on adjacent lots / o d
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation '7S- Water main/service line -7 S
Surface water / U e --J-
Curtain drain N d zt �-
F. ENGINEER'S CERTIFICATION
Driveway, parking/vehicle storage area
30 7'
Wells on adjacent lots / 00 - Property line
I certify that I have determined thtw field inspections and review of Municipal
in conformance with Af A HAA guideli s in effect on this date.
Signature � ny
Engineer's Name 01613647- Co u 4-0
Date 3 /d "] I % b
HAA Fec $ 066 (D Waiver Fee $ _
Date of Payment 27J z7�/, Date of Payment
Receipt Number _/ZZ 3 ��✓ ��) Receipt Number
Rev. 8/95 OSS: Itaa.wk.doc
� r- i
ROBERT C. COWAPt...,r,
CE - 8601
rule
IL
'I
f cea Inc. u
IP Laboratory pivlofe Nrwrtrr�trrr �iwitau.�...Natrpe�e.et �
CTU Ror,# 960958.7288
Cllent Sample ID 1-2 51S T121J
Matrix Drinking Watar
PW81D 8
Parameter
Nltrete•N ..r....�....�..,`.`�
Analysis Report
Collected Date 03/18/96
Technical Director
Releasacll8y`�^jam.-
Altowalote Prep AnolY9la
PU Units Method_ 41mtv i Date Ufte Inst
D,1 n/L MA353.2 ...M 03/19/96 emu
a
200 W. Potter Drive, Ano , . .. 18-11111015 — TO (907) 662.2343 Fax: (90'7) 661-6301
3180 Pager Road Fe di 709 5471 Tel' (907)474.8556 Fax:1907)474-9685
..,... .. ,...., may,`
ENVIRONMENTAL FACILITIES IN ALASKA, CAU1'ONf11A, fl. . ILUN018, MARYLAND MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WSeT VIRGINIA
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Analysis Report
Collected Date 03/18/96
Technical Director
Releasacll8y`�^jam.-
Altowalote Prep AnolY9la
PU Units Method_ 41mtv i Date Ufte Inst
D,1 n/L MA353.2 ...M 03/19/96 emu
a
200 W. Potter Drive, Ano , . .. 18-11111015 — TO (907) 662.2343 Fax: (90'7) 661-6301
3180 Pager Road Fe di 709 5471 Tel' (907)474.8556 Fax:1907)474-9685
..,... .. ,...., may,`
ENVIRONMENTAL FACILITIES IN ALASKA, CAU1'ONf11A, fl. . ILUN018, MARYLAND MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WSeT VIRGINIA
ee�.......-..'..... .. .r��_
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