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T12N R3W SEC 35 S2NE4NW4NW4 PTN
T12N R3W Sec. 35 52 NE4 NW4 NW4 PTN #017-092-15 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Pae 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT g Permit Number: OSP211433 PID Number: 017-092-15 Dwelling: Q Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New R Upgrade Name pg Glenn Ball ABSORPTION FIELD Site Address 6001 E 142nd Avenue ❑ Deep Trench ❑ Wide Trench ❑ Bed D Mound Phone El Other Number of Bedrooms Soil Rating Total depth from original grade 5 GPD/SF F LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot SRNE4NW4NW4 PFt- FI Township Fill added above original grade Gravel length Range Section 12N 3W 35 Ft. Ft SEPARATION DISTANCES Gravel width Beds: Number of Lines Distance between lines To Ft' Ft Septic Absorption Holding Sewer Total absorption area Number of trenches From Tank Field Lift Station Tank Line Ftp Dist. between trenches Ft. Well 100'+ W Septic 100 + 25'+ TANK p ' ❑ S.T.E.P. E] Holding Other Manufacturer Capacity Surface Water 1001+ 100'+ Anchorage Tank/ Greer 1500 Material GaL', Lot Line 5'+ Number of compartments NA HDPE 2 Foundation 10'+ 10'+ LIFT STATION Manufacturer Capacity Remarks -a Only 4 Gal. Insulated over entire install Alarm location Electrical installed by Installer PIPE MATERIAL House to tank 3034 Tank to 3034 -owner P(Dn ��(' P ��� drainfield Drainfield C0/MT3034 Inspector PES BENCH MARK (Assumed elevation) 100.0 ft Inspection, 151 10/18/21 Location and descri tion dates: 2nd P 3`d 01 Near Corner of Patio ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval:"'��-I- OF A' Date / 4 Septic System Approved Date / Q Note: this approval does not include well permit requirements. (Rev 05/02/18) TH� Steven r?, f'ar riore �'c_ CE 8149 ^_ - SEPTIC AREA (E) 1 I A B DC 1 57.8 78.3 T1 62.2 81.8 T2 66.1 84.9 DC2 67.4 85.8 GREENHOUSE ON BLOCKS(E) DECOMMISSIONED EXISTING SEPTIC TANK I PER CODE INSTALLED NEW 1500g SEPTIC TANK I�pppppp SLOPE WELL (E)� � FIELD VERIFIED SEPARATION TO PROPOSED TANK M nn M� CON 41CRETE � C 1� � T1 T2 �Vr A I �� a 5BR HOUSE INSTALLED NEW DOUBLE CLEAN OUT \ (E) {5� BEFORE AND AFTER I NOTES: RECORD DRAWING L DRAWN BY: DRM PLAN SLOPE Al VV ---_W I — IS WELL' WELL (E) 4 I 10' GAS EASEMENT: � Q' ROADWAY EASEMENT • _ . 142nd AVENUE SEPTIC AREA (E) PATIO CORNER: 100 97. W In D' PAMONE ENG SVC, LLC P:0. 90X-100217—ANCHORAGE—,AK-9951-0— PHONE (907) 272-8218 FAX (907) 272-8211 GLENN BALL T12N, RM, Sec 35, S2NE4NW4NW4 PTN 6001 E 142nd AVENUE ANCHORAGE, AK SEPTIC AREA (E) EG/FG: 100.3-101.3 F- r - O w O zm z ULETION OVER ENTIRRIGID o -j % INSTALLATION 9 Date Scale �� P.I,D NO 017-092-15 Steven R. Pannone pERMiT N0. CE 8149 ��®� OSP211433 �B03IF�Fo • • .... • • •����'�' Sheet ��>� MOFESSIONP�.� ®�®ems®ate 2 OF 2 (� p gLaaw Offices of C .1029'W. _j.Yd Avenue, S►ut(, 250 A=horga' Alav" 99501 '1'oleplicune: (907) 276-211]7 Donna P. Orr, Associate Jack White meal Estate 3241 C Street, Suite 200 Anchorage, Alaska 90503-3994 A apka Only: 800-478-5345 January 8, 1999 RE: Listing oMale & Susan Fasting at 6001 E. 142nd Ave. Dear Ms. Orr - 1 am in receipt of your correspondence of January 4, 1999 which inc of t13e Kasting's property, my neighbors to the immediate south with whot lot lige. 1 understand that the surveyors believe that part of the septic/leach fi Consists of the subterranean; gravel geld and possibly a portion of the pipe lot line onto my pmperN, according to the survey which was conducted 4n Kasting advised me of this fact as soon.as he heard of it last November. Pax: (907) 268.3504 tded an as -built survey we share a contiguous c1, at least the pati that self extends across the ovember 9, 1998. -Mr. It is true that I represented to Mr. Kasting that he may leave the leech eld where it is and that the permissive use extends to the purchaser of the property. However, I & not intend to give an casement, merely a license to use the existing leech field in its present locatic n until such time as the leech field fails and it is necessary to dig a new one. When the leech field fails I do expect it to be relocated entirely upon Parcel 27. I understand that tine life of a leech field is an uncertain thing and c•� vary from as little as a couple of years to as many as 30 or so, but the average leech .field life expe tancy is between 12-20 years. i also understand that in that respect both the Kasting's and my house is located in an area which is noted for the longevity of the leach fields. Having been in the legal business for awhile I suspect that the b yer and title insurance company may require more formal documentation at some future date. Yc u are certainly free to Donna Orr .1annary 8, 1999 Page -2- advise any potential buyer, who would of course ultimately become my new text door neighbor, that the existing system can stay where it is until it quits functioning of its own cczord. ,Sincerely, LAW OFRICES OF STVEVSH,1',C. Steven D. Smith SDSfdlw O N NK NK Encroachments Co S89`55'S0"E 330.00' Grenhouse_L---�—Septic— S j Ooperete 1 c6 Septic Tank Lid to 52.3 • Ice Rink ( ;:::::::.:::::::::::::::::: 14.0 Existing House co 14.0 1.002 Acres — — — — — _ _ _ 10' Gas Easement Bk823 Pg736 Per Grid SW3038— N89'55'50"W 330.00' 142nd Avenue Survey Certification: 124E 7th Avenue I hereby certify that a Mortgagee's Inspection was performed on the described property. Anchorage, Alaska 99501 Notes: (907) 306-8104 It is the owner's responsibility to determine the existence of mail@S4AK.com any easements, covenants, or restrictions that may pertain AEC# 173042 to this property. This asbuilt does not constitute a boundary survey and thereby shall not be used for construction or for im establishing property lines. Checked by. Crane Scale 1" = 30' Drawn by: CB Grid SW3038 Job 2021-107 Date: 9/29/2022 Gravel Road Legal Description: 39.2 I 00 o I � I i I I a I E I N 0 W I � N PedestallO % Asbuilt Deed Parcel Deed 2012-033719-0 Sec. 35, T12N, R3W. S.M. AK. ON OF A .. ....... .... cBenjamin Holmstrom � � LS „87 B G 3. �4'N'°fessiono� 00 Legend: Well @ Septic QS Pavement Overhang Nr;' Wood Deck Concrete Fence—o--o-- 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 On -Site Wastewater Disposal System Permit Permit Number: OSP211433 Work Type: SepticTank Upgrade Tax Code Number: 01709215000 Site Legal Address: T12N R3W SEC 35 S2NE4NW4NW4 PTN G:3038 Site Mailing Address: 6001 E 142ND AVE, Anchorage Owner: BALL GLENN E III Design Engineer: PANNONE ENGINEERING SERVICES This permit is for the construction of: Effective Date Expiration Date: Lot Size in Sq Ft ,t J Department Total Bedrooms: 10/14/2021 10/14/2022 43659 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Issued By: Date: Date: D Z 5 C ommunity Development Department s Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 017-092-15 Property owner(s) Glenn Ball Day phone Mailing address 6001 E. 142nd Avenue, Anchorage, AK 99516 Site address same Legal description (Sub'd., Block & Lot) Legal description (Township, Range & Section) T12N, R3W, Sec35, S2NE4NW4NW4 PTN Lot Size 43,659 Sq. Ft Number of Bedrooms 5 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) X❑ Septic Tank X❑ Upgrade X❑ (w/wo ADU) Holding Tank ❑ Renewal 1-1Duplex (D) ❑ Privy ❑ Multiple Dwellings ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 122 ci Waiver Fees: Date of Payment:/T7 1 ��Date of Payment: Receipt Number: 05 7.51 Gs Receipt Number: Permit No. d c,a 21 I �� 3 3 Waiver No. Permit App_:- : :_'.,:c Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211433, Deb Wockenfuss, 10/14/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211433, Deb Wockenfuss, 10/14/21 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 NAME MAILING ADDRESS LEGAL DESCRIPTION LOCATION iyL~~ ?;~.~ o'T~ ~- z Manufacturer Material ~ Liq. capacity in Inside length gallons IF HOMEMADE: Dwelling ~ DISTANCE TO: Well ~ Manufacturer -- Material~: Well Foundation Nearest lot llne DISTANCE TO: N q~o~lin es Total length'--'~ '~°f~ lines ~ I Trench ~,~,~ ~ width Top of Ute to E,nls~h grad~ ~ .~ irrc{'~ Length Width _ Crib diameter Well DISTANCE TO: Depth DISTANCE TO: Building four PERMIT NO. No. of compartments Liquid de,_pt h PERMIT NO, Liquid capacity i~_n gallons Depth Crib depth -- Total effective absorption area Building foundation Nearest ]et line Driller ~ Distance~to lot line PERMIT NO.~ Sewer line t/-r~ Septic tank //~2/ Absorption area(s) PERMIT NO. Distanc between lines Total e f ,e c~S~z~, !~/~n a r,. PERMIT NO. OTHER PIPE MATERIALS OIL ~FEST RATIN~ INSTAI~LER REMARKS ~ t o:~ :~ o~ ~ o~o o o~o oo O~ '~ ~ ~'~ oh- : : : ~g: :. ~ ~ ~ ! ~ : ! I: : : 0 0 0 0 0 0 0 0 0 0 0 EN / I ~ JI,,tMEI,.,ITFIL DEF'FII.:TMENT ElF HEFILTH FINE:' ' * ' "' F'I.P3TECTION _,,=._, L STREE:T., FtNEHZI.'FI.]iE, RI-,:: 9'950t 264-4720 PERMIT NO: DATE ISSUED; FI [:,DF;'.E SS: COI",ITRCT PHOI,~IE: !_..EGFIL r',F'::; ~' I.' I P: [J]T SIZE: l,,1R ::.:; - E: E [:; I.: 00 f,1S: E 3:..';:2 ;3,.-' E .-!.. FRRNK F:'. .]'R. ',,,'RSQUEZ P.O. BO',:.:', 12L22]:5 RNCHOI.:F:~GE., Al< 995±:L ]:4E;-~SEi4 SUBDiViSiON. -, o -.. -. SECTIOH; 3;5 TOHNSHIF' . 98FI (SCL FT. OR FIE;RES) LOT: BLOE:K: LISTED EEl F'II.,.I F!I.'.E ']'FIE -F'Ti]I,.I':: " .... T'~]~ %"- IN [:,ESIGNING 'T'l]ll..lfi'. :,EFTI_. ........ Tc.H. ]:PIr'30SE TFIE L')F'TIOI,.~ THFFF BEST I.-ITS 'Th]UR SITE. [:,E]:'TH TEl PiPE BOT"f'OH <F:'T. GRFI',,,'EL DEPTH ,::FT. ::, TOTFIL DEF'TH EFT. > GRR',/EL P.!![:'TH (FT.) GRI:IVEL LENGTH (FT. ::' GRFI',,,'EL. ',,,'OLUHE (CU. '¢[>S. TFII",IK SIZE <GFILS) SOIL RFITII'.,!G <SQ. FT'. ,.-'BI.:) 4.8 5.0 4.0 7. 0 0. 5 3:. 5 iI. 0 5.5 7.5 2.5 24.0 5.0 54. 0 47. 0 8t. 0 ** 2:7. 5 41. 7 60. 0 750. 0 :+::+, i.. 750. 0 *:+: 1, 750. 0 :+::+: 125 125 t25 :+::+: GRFI',,,'EL LENGTH 2::' /5 FT. I..~.=IJII~.E.:, I',IUI._TIF'LE ~.IJbl:, (NOT E,:.:,L. EEE. INb ,'-'?, FT. EFICH) :+::+: TFINK I1U.:T HFI',,,'E FIT L. EH_ T TI.,I.O L. UIII.I-]I..IIIENt_ I CERTiF"r' THFIT: !. I RH FRI,dlL. IFIR WITH THE REQUIREHEI,,ITS FOR ON-SITE SE!.qEI.'.S Fii"g} HELLS RS '--';ET FOl.:TH E,'"? ]"Hi"_- HUI,4ICIPFILIT"r' OF FINCHORFIGE <f"lOFi) Fil,'lB, THE STRTE OF FILRSKFI. 2. I I.,.III_L IN:S~i-FILL THE S'¢STEM IN RCCORDRNCE 14ITH FILL: MOFI CODES RN[:, REGULFITIOI,',IS., FIND IN COMPL. IRI,4CE I.,.IITH THE DESIGN CRITERIFI OF TI-lIS PERMIT. 3:. I I.,.IILL RDHERE TO FILL i'IOFi Rl,,tr.:, S'TFiTE 01:: RLFISKFI REC!UIREI'tEI,,tTS FOR THE SE]' BFICK DtSTFINCES FROI',i FIF,!'¢ EY',tSTIIqG WELL, 14FISTEI4FITER DISPOSFIL S"r'STEM OR' PUBLIC SEI.4ERRGE S:¢STEM 0/4 THIS OI.: FIN'-r' FIDJFICENT OR NEFIRB'¢ LOT. 4. I UI,qDE:RSTFII,qD THFIT THIS PERMIT IS VRLID FOR FI i':IFIY-,'IMUH OF G E:EDROOMS FIND RN"r' ENt_FIRGEI,'tENT HILL I.:EG!IJII.:E RN FIDDITIONFIL F'ERHIT. IF Fl LIFT STFITION IS INSTFILLED IN FIN RREFI COVEI.:E[:, B'T' MOFI E:UILDING CO[:,ES., '' .... ' - " H--, E,I.JILT-, THEN ':::L) FIN ELEC:TRICFIL F'ERMi-r FINE:, IHSF'EC:TION I.,1LIz, T E:E uETHINE[., (2.':, -'--' ':' ........... ' - , -.~ ,- , ,:: 3: ) !4ILL NOT E:E FIF'F'F~'"I',,'Fr" J.,.IITHEIUT FIN ELE-TI.'I-RI INSF'ECTIOI,',i F. EF..Rr, FIND THE ELECTRICFIL t.,I04~K Mt]ST 8E [:,ONE E:'-r' lq L);E:ENSED ELEE:TRIC:iFIN. - ....... ] .............. ........ =- -2--7, .......... RFFI.LIE;~I,.~T :,~::~ I.. JF' '.~!LIE~' ' ISSIJED F.':T' DFITE; ~/~_ . .......................... MUNICIPALITY OF ANCHORAGE D PERCOLATION DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 6 7 8 9 10 12 13 14 15 16 17 18 19 2O COMMENTS · 'Z/V,/b,,,,:~ .~vF, ~t,':.,, 33, P~,r~:~[ S L~/P E S I~"E PLAN WAS GR~)UND WATER IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) V; "'/~] ~-'~ TEST RUN 5ETWEEN ~ ,7AND PT CERTIFIED BY: /, I~ ,'J DATE: PERFORMED BY: 72-008 (6/79) f Development Services Department \ Phone. 907-343-7904 On -Site Water & Wastewater Section/Fa,.u - . 907-343 7997 Certificate of On -Site Systems Approval Parcel I. D. 017-092-15 1. GENERAL INFORMATION Expiration Date: _ _ _2c2Z2 Complete legal description T1 2N R3W Sec 35 S2NE4NW4NW4 PTCI Location (site address) 6001 E 142nd Ave Current property owner(s) Mailing address Real estate agent Glenn Ball 6001 E 142nd Ave .. 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 5 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic ED Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 55 0 Waiver Fee $ Date of Payment 7a a0 a Date of Payment Receipt Number ©S 5 3'-7 G Receipt Number COSA # 0 SC 2 )- 1 3 '/ 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. 6. DSD SIGNATURE N System #1 Approved for bedrooms Phone (907) 745-8200 DateZ®�Z� 9TH • • Steven �_ •f'cr System #2 Approved for bedrooms °<� CE 8149 FAL !Y'elp • . • �'� Disapproved � `��0,F_5S "1 Conditional approval for bedrooms, with the following stipulations: `,,filvn l ( A I( I r-, - fr By: t �^- /JJ i JJ Original Certificate Date: % 0 `S The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Legal Description: T12N R3W Sec 35 S2NE4NW4NW4 PTN If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA 0 Well log is filed with Onsite (or attached) Date drilled 8/84 Total depth 325 ft Cased to 180 ft 0 Sanitary seal is functioning correctly 0 Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 11/10/21 Static water level at beginning of test 86 ft. Comments B. TANK DATA Age of tank(s) "rz°Z" °" years Tank type/material1-16 qA1 0 Measured operating fluid level in septic tank , ' � ❑ Standpipes/foundation cleanout per record drawing Date of pumping new tank D. ABSORPTION FIELD DATA Deep Trench Which system tested (date installed) 8/30/84 ❑ ALL standpipes present per record drawing Total measured depth from grade6,• _' ft (max) Measured depth to pipe invert from grade 4:3ft (min) ❑ N/A — pressurized field Monitor tubes go torbottom of effective. If not, state depth into effective ode -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: 017-092-15 Structure served by this system 1 Well production at time of test 2.8 gpm Water storage tank volume na gallons Well disinfected for coliform test? ❑ Yes ❑✓ No Coliform bacteria is Negative Nitrate e UO mg/L E]Nitrate less than MRL (ND) Arsenic 3-1,1 ug/L ❑ Arsenic less than MRL (ND) Collected by _ Pf 7 Date of Sample C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 11/10/21 Results ❑✓ Pass For 5 bedrooms Fluid depth prior to test f in Water added 110 gal New depth in Elapsed time H-0 min Final fluid depth iin Absorption rate 750+ gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' C]✓ Yes Community Sewer Manhole/Cleanout > 100' Q✓ Yes if No ft ✓Q Yes if No ft Neighboring Tank > 100' Yes if No ft Private Sewer/Septic Line > 25' M Yes if No ft Absorption Field on Lot > 100' [✓ Yes if No ft Holding Tank > 100' 0✓ Yes if No ft Neighboring Absorption Fields > 100' - ft Private Wells > 100' Animal Containment > 50' ✓❑ Yes if No ft ❑✓ Yes if No ft if No ft Community Wells > 200' Q Yes if No ft Manure/Animal Excreta Storage > 100' Q 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' C]✓ Yes if No ft Surface Water > 100' M Yes if No ft Property Line > 5' Q Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 0 Yes if No ft Private Wells > 100' 0 Yes if No ft Water Main > 10' Yes if No ft Community Wells > 200' Q Yes if No ft Water Service Line > 10' Q Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Yes if No ft If absorption field is under driveway comment below Property Line > 10' [, Yes if No 0* ft Wells on Adjacent Lots: Water Main > 10'✓Q Yes if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' 0 Yes if No ft Community Wells > 200' Yes if No ft Surface Water > 100' Q Yes if No ft F. ENGINEER'S COMMENTS * waiver on file G. ENGINEER'S CERTIFICATION l certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with on this date. `22.•� �z� COSA Checklist yellow sheet Ry Stev Pannone, CF 8149 �. DEVELOPMENT SERVICES DEPARTMENT On -Site Water and Wastewater Section www.muni.org/onsite Arsenic Advisory Certificate of On -Site Systems Approval # OSC221379 Subdivision: T12N R2W Sec 35 S2NE4NW4NW4 PTN 907-343-7904 Fax: 343-7997 A water sample revealed an arsenic concentration of 27.9 micrograms per liter (ug/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Information on arsenic is available from the On -Site Water and Wastewater Program website (www.muni.org/onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. Mailing Address P O Box 196650 *Anchorage, glaska 99519 6650 *www muni org L, 5 Municipality of Anchorage Development Services Department �E Building Safety Division o- 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. 017-092-15 COSA # OSC I a I 1 LI5 Expiration Date: 53 r 4 ` /Z' 1. GENERAL INFORMATION Complete legal description T12N R3W SEC 35 S2NE4NW4NW4 PTtj Location (site address) 6001 E. 142ND AVE., ANCHORAGE, AK 99516 Current Property owner(s) TERRY SHUPE Mailing address Lending agency Mailing address Real Estate Agent Mailing Address KAREN CISMOSKI Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Q Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ Day phone Day phone Day phone 242-1761 TYPE OF WASTEWATER DISPOSAL: Individual On-site Q Individual Holding Tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A 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 Spurkland Enginneering Address 203 W. 15th Ave., Ste 202, Anchorage, AK 99501 Engineer's Printed Name Lars Spurkland 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Phone 279-3916 Date May 9, 2012 OF At Conditional approval for bedrooms, with the following stipulations: Attachments COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory _ XC Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: J '/q -rl (Rev.11/05) Municipality of Anchorage PP f • '� Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: T IZN f.33W Sec 35 SZNE4 NW 4 Nw4 Parcel ID: 017 - 09Z- 15 A. WELL DATA Well type RES. If A, B, or C provide PWSID # = Well Log (YIN) Y Date completed $=Z' 64 Sanitary seal (Y/N) Y Wires properly protected (Y/N) i Total depth 325 ft. Cased to (90 ft. Casing height (above ground) t f in. FROM WELL LOG AT INSPECTION Date of test Static water level 115 ft. 91 ft. Well production 310 g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform 14EG, colonies/100mL Nitrate ND mg/L Collected by: LAR-$ Sp14ak1A'AA Arsenic: 34-6 ug/L date of sample: 5 3 [2 B. SEPTIC/HOLDING TANK DATA Tank Type/MaterialCIZCVF4 S+ee\ Date installed �df 3DJ `d 4 Tank size 1'-4 50 gal. Number of Compartments Z Cleanouts (Y/N) y Foundation cleanout (YIN) iY Depression over tank (Y/N) A/ High water alarm (Y/N) N Date of pumping S io 1 Z Pumper A+ NomE .SE2ViLLS C. ABSORPTION FIELD DATA Date installed i34 Soil rating (g.p.d./ft2 or /bd 125 System type DEeq TRENG� Length __k14iLSft7 / Width 2 ft. Gravel below pipe 7 i (o ft. Total depth li ft. Eff. absorption area f3Qft2 Monitoring tube Depression over field JV Date of adequacy test SIS117- Results (Pass/Fail) P455 For (� bedrooms Fluid depth in absorption field before test 4- in. Water added—Wgal. New depth 4 in. Elapsed Time: �LO min. Final fluid depth _jP' in. Absorption rate >= 900 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) MOAC kAOW r, If yes, give date D. LIFT STATION Date installed "Pump on" level at in. Datum E. SEPARATION DISTANCES Size in gallons "Pump off' level at= in. Cycles tested Manhole/Access(Y/N) High water alarm level at Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100 t+ On adjacent lots Absorption field on lot IODt + On adjacent lots loo + .• in. Public sewer main rv1A Public sewer manhole/cle/anout Nr'A t ! Sewer /septic service line -2'5 i- Holding tank N A Animal containment areas rJD+ (M.O. Manure/animal excrete storage areas 100'+ WO.) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5 t t �y sorptonet t Water main /✓ A Water service line jD + Surface water 100't t Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Q Building foundation tOt + Water main IVA ` + t Water Service line 4 Surface water 1061 CN,o, Driveway, parking/vehicle storage tQ 1 t Curtain drain 5i)i r+ l9•0• Wells on adjacent lots too+ F. COMMENTS _ WAiJE ov) fi te. G. ENGINEER'S CERTIFICATION O 4sti l+t ! certify that !have determined through field inspections and .4.1 review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. j SPU Engineer's Printed Name / A •; R . 0 "1 ; , Pt t' i� t Date COSA Fee $ 001,10 Date of Payment �J ilo(I-.' Receipt Number (Rev. 4110) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Community Development Department Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Arsenic Advisory Certificate of On -Site Systems Approval # 121145 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply of T12N R3W Section 35 S2NE4NW4NW4 PTN Subdivision. This inspection revealed an arsenic concentration of 34.6 micrograms per liter (ug/L) for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Information on arsenic is available from the On -Site Water and Wastewater Program website (www.muni.org/onsit ) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. 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 ParcelhD.# 0!7 9P2 15 ~' 1. GENERAL INFORMATION Complete'legal description ~e! ~7~ Se~ 35; T19~ R3W Location (site address or directions) 6001 E. 142nd Str~t Anchorage, AK Property owner Mailing address Lending agency Mailin. g address Agent Address 6001 ~. 142n~ $~ree~ Day phone 345-6513 Anchorage~ AK 99516 Day phone Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well XX Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. "- 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site XX Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legafity and status of system. 72025 (Rev, 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I 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 thi,s NameofFirm ALASKAW_~ATER ~AST~/~lX' Address 690A/DEB/~/ )A~, 8¢JITE2~ , ~CHO~. c¢, L~SKCV 9(JS04 Engineers signature ( ///~/'/~4 '/~ ~ Alaska Water & Wastewater Consultants, ~ Shall be PAID $ 2.~ 5; ~ or prior to, closing for the Engineering Services Provided. DHHS SIGNATURE ~/ Approved for Disapproved. bedrooms. ~pection. Phone Date Conditional approval for bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesyto pumhasers 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. RECEIVED Municipality of Anchorage JUN 1 8 DEPARTMENT OF HEALTH & HUMAN SERVICE,~uN~¢~p^u~ or ^N¢~ Environmental Services Division ENVII{ONNENTALSEI{VIC[~) 825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907) 343-4744 Health Authority Approval Checklist Legal DescriptioP."~~t~'~XJ ~--~I/V~ ~' ,~ P~/'~'~:~ ~)-/7 Parcel I.D.: A. WELL DATA Well type F/~'I Log presenl~N) Y-~ ! Total depth .~;~ Sanitary seal (~)N) Date completed Cased to /~ / IfA, B, Or C, attach ^DEC letter. ^DEC water system number Casing height (above ground) Wires properly protected(~l) FROM WELL LOG AT INSPECTION Date of test o~/~?--~/~/7~ Static water level / ~ ~-~ Well production g.p.m. WATER SAMPLE RESULTS: Coliform 0 Date of sample: .~//4?/~' ? B. SEPTIC/HOLDING TANK DATA Date installed 8/30/~'~/' Tank size. Foundation cleanout ~) y Nitrate ¢ ~ /:~5//-' Otherbacteria / Collectedby: A~/~A~ /~'0 Number of Compartments ~ Cleanouts~iN) Y Depression (Y/~'~ J/~ High water alarm (Y~)- /'~/ Date of Pumping /0//~/~ Pumper C. ABSORPTION FIELD DATA Date installed {~/~/o~z'// Soil rating (g.p.d./fF /'~-, 5 SyStem type Length 5 ? / Width ~, 5 ~' ' ' Gravel thickness below pipe 7 /~'~ Total depth ~'/ ''/' Effective absorption area ~7~(~ -,~ ~'Monitoring Tube present ~i~l) y Depression over field (Y/~ /~ Date of adequacy test /d~/~//~,.~ Resultsj~l/Fail) F~"-~ For ~¢~ bedrooms Fluid depth in absorption field before test (in.); Fluid depth ~ (ins) Minutes later: '--- Peroxide treatment (past 12 monthsi (Yi~ /~ Immediately after/~gal, water added (in.): Absorption rate ~-~ = g.p.d. If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION ~ Date installed ~ Manhole/Access (Y/N) ./"~ump on" level at* "Pump off" level at* High water~ *Datum C~ed E, SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: / Septic/holding tank on lot //OO '~- Absorption field on lot t/t~ '~'- On adjacent lots On adjacent lots /~2E¢ ,/- Public sewer manhole/cleanout Public sewer main Sewer/septic service line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~,~ '¢- Property line ,.~ ~ Absorption field / Water main/service line /O '~ Surface water/drainage /~O '~ Wells on adjacent lots / SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: .,' / Properly line O '~ Building foundation /O '~' Water main/service line Surface water ~0~) '"~ Driveway, parking/vehicle storage area Curtain drain Wells on adjacent lots P. ¢- .¢¢¢ ¢'t 04 , ceRify that ,/~v~ d¢~mi~rutield inspections and review of Municipal record~'~'~vstems~:¢ ~f are ..... guiCellnes effect this date. ~. v-- HAAFee $ ~ ~ ' ~ Receipt Number ~.~7.D ~-~.~ Waiver Fee $ / Date of Payment ~ .//~/q~ Receipt Number--'~-~) ] ,~/ ¢ ~-~ :~)~ 72-026 (Rev. 3/96)* Rick Mystrom. Mayor Municipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 http://www.cJ.anchorage.ak.us AK Water & Wastewater Consultants, Inc. ATTN: Jeffrey Garness, PE 6901 De Ban- Road, Suite 2B Anchorage, AK 99504-0000 June 24, 1999 Subject: Waiver Request for T12N R3W SEC 35 PARCEL 27 Waiver # WR990037 Lot Line Request for Parcel ID 017-092-15 Dear Engineer: Your request for a waiver of the required 10 feet horizontal separation of the on-site wastewater disposal system to the lot line has been approved. The approved separation distance is 0 feet. This waiver approval applies to the current on-site wastewater disposal system and lot line separation only. Any future upgrade to the on-site wastewater disposal system and lot line will require all separation distances to be met or another waiver approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-4744. Sincerely, Engineering Technician III On-Site Water Quality Program MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR~ WR990037 PID~ 017-092-15 HA# HA990284 Permit ~. Date Received: June 18, 1999 Legal Description: T12N R3W Section 35 Parcel 27 Engineer: Jeff Garness, PE, Alaska Water & Wastewater Consultants, Inc. 6901 De Barr Road, Suite 204, Anchorage, Alaska 99504 Applicant: Dale Kasting Waiver Requested: line of 0 feet. Lot line,waiver from the leachfield to the north property Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: List Conditions or Reasons Waiver is NOT Granted: for above: Rec ~: 05018/5680 Alnount: N~m~/~f Reviewer $ 115.00 Date Paid: June 18. 1999 Alaska Water & Wastewater Consultants, Inc. 6901 Debarr Road, Suite 2-B ~ Anchorage N Alaska 99504 Phone (907) 337-6179 N Fax (907) 338-3246 Consulting Engineers June 18, 1999 Municipality of Anchorage Department of Health & Human Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 Subject: Lot Line Waiver for T12N; R3W; Sec 35; Lot 27 To whom it may concern: Request you issue a property line waiver on the subject property for the separation distance between the leachfield and the north property line at zero (0) feet. Enclosed is a copy of a recent asbuilt survey by Lantech Surveying. The clean-out at the end of the leachfield is located just over the north property line. Please see attached letter from the owner of the property, on wtfich the clean-out encroaches. Said property owner acknowledges the encroachment and grants permission to allow it to remain, in place until such time that the septic system is upgraded in the future. The separation distance between this clean-out and the neighboring well is over 100 feet. We do not anticipate any adverse effects by issuance of this waiver. If you have any questi JAG/gd ~ns, please contact us at 337-6179, or 244-9612. 0--98 TUE N 0000 ~0 ~. j~ ~00'00~10"W 132,30 Telephon.; (90?) 276-2197 1029 W. 3rd A,,.=~,., S,d&, 250 ~ckos~ge, Ahek~ 99501 only: 800-478-534b January 8, 1999 Donna P. Orr, Associate Jack White Real Estate 3201 C Street, Suite 200 Anchorage, Alaska 99503-3994 KE: Listing of Dale & Susan Kasting at 6001 E. 142nd Ave, Dear Ms. Orr: I am in receipt of your correspondence of January 4, 1999 which incl et'the Kasting's property, my neighbors to the immediate south with whore lot line. I understand that the surveyors believe that, part of the septic/leech fie consists of the subteganeam geavel field and possibly a portion of the pipe i lot line onto my property, according to the survey whleh was c~ndueted on ~' Kasting advised me of this fact as soon as he heard of it last November. it is true that ! represented to Mr. Kasting that he may leave the leech the permissive use extends to the purchaser or,he property. However, 1 easement, merely a license to use the existin~ leech field in its present loeatk leech field fails and it is necessary to dig a new one. When the leech field relocated entirely upon Pared 2?. I understmxd that the life ora lee, eh field is an uncertain thing and t;a couple of years to as many as 30 or so, but the average leech field life expe, years. I also understand that in that rospect both the Kastmg $ and my ho which is noted for the longevity of the leach fields, Having been in the legal business for awhile I respect that the b company may require more formal documentation at some future date. Y, Pe~x: (907) 268.3804 lded an as-built survey we share a oontig~OUS d, at least the part that :edt extends aero~s the ',,ember 9, 1998, Mt'. Id where it is and that not intend to give an until such time as the ils I do expect it to be vary from as little as a :tancy is between 12-20 lac is located in an area · yet and title insurance are certainly free to Donna Orl' .[anm~J~'g, 1999 advise any potential buyer, who would ofcour~o ultimately become my new ~ the existing sy,qtem can stay where it is until it quits functioning of its own: Sincerely, Steven D S~ SDS/dlw ~xt dom' neighbor, that :cord. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH OF ON'SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lo.t, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name /.~,,4~ //",,u-~,~.~*z- Telephone: Home ~ ¥~--~J to~ Business Applicant Address ,.~"~'~'/ ~' I'/~/-- ,,~N.,.(, /~-,1~4,:,r~.~?~.., ,'t.~ (c) Applicant is (check one): Lending Instit[~tion []; Owner/builder ~; Buyer []; Other [] (exPlain); (d) (e) Lending Institution /~(oj/~,~ ?,~2~f~' r',J,~,~ Telephone ,E'~'2-- ~/¢~ Address I ~1 Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family [] Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Individual Well [] Community [] Public [] '~ Note: If community well system, must have written confirmation from the State Depanmem of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite ~ Public [] Community [] Holding Tank [] Note: If corn munity well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) Z ~o ~ OD,d '~Jo~ s,Jeeu!eue leUO!SSo~bJd oql u! sue!ss]we JO sJoJJo Joj olq!suodsoJ tou s! ofieJOqOUV jo XHled!o!unR eql 'panes! s! eleo!,t!peo e eJo,teq elep ezXleue ' Jo suo!loodsu! pnpuo3 leu op dqHG ,to see~oldW3 's~uoweJ!nboJ elels pue leJOpo,t uleiJoo X,ts!ies o) JopJo u! suoilnlBsu! 6u!pual J!@ql pue sewoq ,to sJaseqoJnd el XsolJnoo e se s!ql s@op dOHG oql 'e~Sel¥ ,to clots eq~ u! pe]els!ae~ Joou!6ue leUO!SSO,toJd ~uopuodepu! ue Xq e^oqe S qdeJ§eied u! ua^!6 suoBeluesaJdoJ oql uodn ~lalOS poseq soleo!,t!peo le^oJddv Xlpoq~nv qlleOH s@nss! (dOHG) uoBoelOJd lelUOWUO~!^u3 pue qlleeH 1o luowuedoQ eaeJoqou¥ ,to ~l!led!oun~ oq/ NOIJ. n¥o leUOB!puoo leAoJdd¥ leUO!llpuoo ,to swJa± pe^oJddes!Q ~/~/ pe^oJddv ~q swooJp@q ~ Jo,t po^oJddv '9 leas s,Jeeu!fiu~ 'uoBoedsu! uo toe,Jo u! suoBelnfio~ puc 'sooueu!pJo 'sopoo o~e~$ pue ledp!un~ lib q~!~ eoUe!ldwOo u! Jo/pue /~lddns Jale~ ol!s-uo oq~ 'uoBoedsu! pue uoBefiBse^u! ~w woJ,t pue peu!e~qo uo!~ewJo,tu! eq~ uo peseq ~eqt/~,t!Ja^ Jeqpn,t I 'u!o~eq pe~eo!pu! e~n~enJ~s elenbepe pue leUOBOUn,t 'o,tes s! waists lesods!p ~e~e~e~se~ ~o/pue Aldd ns q~leeH s!ql,to uoBe§Bso^u! A~ leql A,tpo^ I '~oloq u~oqs e~ep uoReP!le^ oqi ,to se pue o~eJeq paxi,tje leas Aw ~q pa!,t!peo sv NOI.I. YINaO:INI aNY ¥.1.¥0 'HO~JY=IS :rll-I 'SAS:IA 'SNOI.LO:IdSNI DNIQIAOEId INal-I DNIM=I~NIDN:I WELL DA;C . MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: Well Classification Well Log Present (Y/N) Total Depth Static Water Level ~'<4'~('~ IfA, B, C, D.E.C. Approved (Y/N) ~' Date Completed ~/~./8 y Yield Cased to t,ff~ Depth of Grouting Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot l O~)t Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) To Nearest Edge of Absorption Field on Lot · To Nearest Public Sewer Line H, A, Cleanout/Manhole Water Sample Collected by '-r'Ftl Water Sample Test Results ~',¢~¢-~r-y -- Comments c~$~^..~ ~':/~-,:~.¢-~f- ~-¢ /~'~' ; On Adjoining Lots· t 28 ' ; On Adjoining Lots IO'7 To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date ¢ ['tf [&7 ~ B. SEPTIC/HOLDING TANK DATA Date Installed ~'/.~¢'/~ Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: Size I'"/,¢'Q No. of Compartments Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) Y' Date Last Pumped ,.~/8¢'/,~ ? t....- N,A. ; for N,fi. Temporary Holding Tank Permit (Y/N) To Water-Supply Well To Property Line To Water Main/Service Line Course ~ To Building Foundation ,-.¢! ~ To Disposal Field -¢ ' To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ¢' { $¢' ! ¢¥ Width of Field ~,5' '~ = Square Feet of Absorption Area "7 7~' Depression over Field (Y/N) ~ Results of Last Adequacy Test ~'¢4¢~2'¢z~/'~- Separation Distance from Absorption Field: To Water-Supply Well I ~ ?~ ~ TO Building Foundation ~*' Lot N,,4., r~'/¢¢(,.~,.~ Type of System Design Length of Field Depth of Field Gravel Bed Thickness ~'~ ~ Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line II~ To Existing or Abandoned System on ; On Adjoining Lots ..~ ~o ' To Cutbank (if present) Comments .~gr~ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area / D. LIFT STATION N¢,~. Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed .o'~-~.~._ ~. ,'~¢&,.~.~__ Date Company ~(~/"./'~¢ 7"~¢.4 ~.,c~- MOA No. Receipt No. //0 0 / Dale of Payment Amount: $ Page 2 of 2 72-026 (1 ~/84) Engineer's Seal MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SiTE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (includ/e. lot, block, subdivision, section, township, rang\e) Location (address or direotJons) (b) Applicant Name ~.~0,~- Cf'}~-~- ~relephone: Home ~-~/,z~: '~,l(~',/ Business App,,cantAddress gO, aC??' ( UC 'o (c) Applicant is (check one): Lending Institution []; Owner/builder.~; Buyer []; Other [] (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family[~ Multi-Family[] Number of Bedrooms ~' Other I1 / / WATER SUPPLY Individual Well [] Community [] Public I"'l Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL OnsiteJ~ Public [] Community[] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Enviro'nmental Conservation attesting to the legality and status. 72-025 ¢ u84) Page 1 of 2 ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is sate, 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 Fish'Cc-- 7-~C.~n~c~! .~r./~j Telephone Address I Date o~/~--5 DHEP, APpROV~. ~ Terms of'Conditio~nal Approval Conditional CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purohasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 MUNICIPALITy OF ANCHOP-AGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION JUN 5 1985 WELL DATA Well Classification Well Log Present (Y/N) Total Depth ;~ ~ Ca~ed to Static Water Level i Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D.E.C. Approved (Y/N) Date Completed 8/E/8 ¥ Yield Depth of Grouting ~'/~' Y III ' To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole N, Water Sample Collected by Water Sample Test Results ~'¢¢'~z'J'¢~-/'~ ¢'/y Comments Pump Set At ,7 2_42 Sanitary Seal on Casing (Y/N) ~ Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots IlO To Nearest Public Sewer To Nearest Sewer Service Line on Lot /~1,/;~ ; Date B. SEPTIC/HOLDING TANK DATA Date installed Size Standpipes (Y/N) Depression over Tank (Y/N) N Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) IxL A. Separation Distances from Septic/Holding Tank: To Water-Supply Well ~! I To Property Line '~' I ~ * To Water Main/Service Line /~/¢ ~, Air-tight Caps (Y/N) No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation ~'~ ¢ To Disposal Field To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~//~0 (~¢ Width of Field .'~0 I~ Square Feet of Absorption Area 7 7¢) Depression over Field (Y/N) ~1'. Results of Last Adequacy Test ~1_, ~. Separation Distance from Absorption Field: To Water-Supply Well I ~O ' To Building Foundation Lot N,.4'. To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course ~3*/~D/'~ I'~ Type of System Design Length of Field Depth of Field f f Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line _ ';2 ~'o To Existing or Abandoned System on ; On Adjoining Lots '~ toO' To Cutbank (if present) To Driveway, Parking Area, or Vehicle Storage Area LIFT STATION i~,¢, Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Amount: $ MUNICIPALIT~ OF ANCHORAGE DIVISION 0F ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIHONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b~ Applicants Name t:}~! ~ P, t]~X7.~7. Telephon~, - Home Eusiness 'Applicants Address ~. O, ~./~ i i (¢) Applicant is (check one) Lending Institution ~; Owner/bufldgr Buyer [--U; Other 1 I (e).Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single-Family~ Number of Bedrooms. 3. Water Supply~ Individual Well~ Multi-Family~ Other (describe) community[---~ ~ublt¢[--] Note: If community well system, must have written confirmation from the State · Department of Environmental Conservation attesting to the' legality and status. 4. Sewage Disposal .Onsite~ Public~-~ Community~ Holding Tank~-~ \~ ~ote: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status· [Page 1 of 2] 5. Engineerin$ Firm Providin$ Inspections, Tests~ File Search~ Data and InformatiOn As certified by my seal a~fixed hereto and as of the validation date shown below, verify .that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that, based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regula- tions in' effact on the date of this inspection.~ 6. DHEP Approval ~ · ~ · Approved for bedrooms B ~ (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS OIVE~ IN PZ~,AmUrH s A~ow EY AN INDEFENDE~ ~.~OFESSIOmL EN~Im~ER ~O~STE~ I~ THE STATE OF ALASr, A. ~ O~F OOES ~IS AS A COtmTES~ TO PU~¢m~S~S OF Hom~s A~O THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- ,~mm~s. mFs.Or, ES OF OHEP ~0 NOT com~ucT n~SFECTIONS OR A~AL~ZE DATA ~E~O~E A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEF SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) CHECKLIST - FEBRUARY 1984 Legal Description: A4UAIICI~;~LITY ~-;,.,,vri ' , ,., 0£C l i 9S4 Well Classification Well Lcg P~esent (Y/N) Total Depth 3~$- Ca~ed to Static Water Level /IA~ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) ¥ Separation Distances f~cm Well: To Septic/Holding Tank c~ Lot [II To Nearest Edge of Absoz~ption Field on Lot To Nearest Public Sewer Line Cleancut/Manhole ~". Water Sample Collected By Water Sample Test Results C~Lat~nts Date C~tgleted Pump Set At If A, B, c~ C, D.E.C. Approved(Y/N) 8/~/~ Yield Depth of G~outing. N./~. Sanitary Seal on Casing (Y/N) Depression A~ound Wellhead (Y/N) I%~ ; On Adjoining Lots ~ ~O ~ ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on LOt B. SEPTIC/HOLDING TANK DATA Date Installed ~/~///~ Size t7 .3~Z[ NO. of C~,vartm~nts Standpipes (Y/N) .~ / Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) Dap~ession over Tank (Y/N) Y + Date Last Pumped Pumping/~aintenance Contract on File (Y/N) N,~. ; for Holding Tank High-Water Alarm (Y/N) ~,/~. Tempo~az~ Holding Tank Permit (Y/N) Separation Distances fzom Septic/Holding Tank: To Water-Supply Well ~1( ' To Building Foundation To Property Line ~ tO' To Disposal Field 6-' TO Water Main/Service Lir~ N,/~. To St~ea~, Pond, Lake, c~r ~ajor D~ainage Course ~ ~od ' [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date .Installed ~f 3~ f~¥ Width of Field ~ e (/~ ~ Square Feet of Absorption A~sa Depression over Field (Y/N) Results of Last Adequacy Test ~U, Separation Distance frc~ A~sorption Field: To ~ater-Supply Well I~'' TO P~o~ert,y Line J2b- L~' Type of System Design Length of Field ~-7' ,o Depth of Field ~! ' Gravel Bed Thickness 7' ~.~( ~ ' Standpipes Present (Y/N) Date of Last Adequacy Test To Building Foundation Lot ~//-. ; On Adjoining Lots To Water Main/Service Line ~.6, To Cutbank(if present) To Stream/Pond/Lake/or Majo~ D~ainage Ccurse 7 To D~iveway, Parking Area, or Vehicle Storage A~ea ~-~ Coa'~t~nts t-'~n~( t~'"l:tCXt~/ '"lOIL C°"~,(;(et~. ~n~r TO Existing or Abandoned Syste~ cn /v D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electn~ical Codes(Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (_Y/N) Pumping Cycles during Adequacy Test° Meets MOA Counts ** Cheek Permitted Bedrocm Rating Against HAA Bequest I certify that I have checked, verified, o~ conformed to all MOA HAA Guidelines in effect on the date of this inspection. Si ed Ccmpany /~c~ 7~¢~ KB1/d5/s [Page 2 of 2] · .... .... 2-15-84