HomeMy WebLinkAboutT12N R3W SEC 33 LT 110AT12N R3W
Sec. 33
Lot i I OA
#018-252-35
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON
-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP 241082
PID Number: 018-252-35
Dwelling: X Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family
Project: ❑ New ❑■ Upgrade
Name
Jonathan E & Shanna S Springer
ABSORPTION FIELD
❑ Deep Trench ❑■ Wide Trench El Bed El Mound
Site Address
2800 Nugget Lane
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
4
1.0 GPD/SF
1.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
0.5
Ft.
Gravel depth beneath pipe
0.5 Ft.
Subdivision Block Lot
T12N R3W Sec 33
110A
Fill added above original grade
2.0
Ft.
Gravel length
2@60 Ft.
Township Range Section
12N 3W 33
Gravel width
5.0 Ft.
Beds: Number
n/a
of Lines
Distance between lines
n/a Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
600 Fe
2
6.0 Ft.
Well
NA
100'+
100'+
NA
25'+
TANK ❑ Septic ❑ S.T.E.P.
❑ Holding ❑ Other
Manufacturer
Capacity
Surface Water
NA
100'+
100'+
NA
Gal.
Material
Number of compartments
Lot Line
NA
10'+
51+
NA
NA
Foundation
NA
10'+
10'+
NA
LIFT STATION
Manufacturer
Capacity
Remarks
Anch. Tank
500 Gal.
Alarm location
House
Electrical installed by
Solid Ground
PIPE MATERIAL House to tank Tank to Pvc c900 DR19
drainfield
Installer
Whitters Excavating
Drainfield PVC C900 DR18 CO/MT 3034
Inspector PES
BENCH MARK (Assumed elevation) 100.0 ft
Inspdection 15` 05/13/24
05/13/24
Location and description
3'd 05/13/24
2nd
4th
See Site Plan, House Slab
ON -SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
OF A�qs����
Conditional Approval:
Date
®�P.��
...... -
Steven f2 Pannorie
cE 8149
��F�/I
Septic System
Approved j�/ �� a�. �o� fir- n_ Date Z
PRO7/2024
FESSIONP��®��
Note: this approval does not include well permit requirements.
(Rev 05/02118)
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J I I I Q Q �C-li
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
hftp://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP241082
Work Type: Septic Upgrade
Tax Code Number: 01825235000
Site Legal Address: T12N R3W SEC 33 LT 110A G:3034
Site Mailing Address: 2800 NUGGET LN, Anchorage
Owner: SPRINGER JONATHAN E & SHANNA S
Design Engineer: PANNONE ENGINEERING SERVICES
This permit is for the construction of:
Effective Date:
Expiration Date
1»cnt S
�°
n �
Department
Lot Size in Sq Ft:
Total Bedrooms:
5/7/2024
5/7/2025
48982
Q 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: 5 UCD
Issued By:
Date:
Date: Z
9
MUFMKPAUTY of AHCHORAGE
Community Development Department n=r1 Phone: 907-343-7904
Development Services Divisio
n on Fax: 907-343-7997
On -Site Water & Wastewater Program
ON -SITE SEWER/WELL PERMIT APPLICATIONv
Parcel I.D. 018-252-35
Property owner(s) Shanna S & Jonathan E Springer Day phone
Mailing address
Site address 2800 Nugget Lane
Legal description (Sub'd., Block & Lot)
Legal description (Township, Range & Section)
48 982
T12N R3W SEC33 Lot 110A
Lot Size
Sq. Ft.
Number of Bedrooms
APPLICATION IS FOR:
APPLICATION IS AN:
(® all that apply)
Absorption Field
❑X
Initial ❑
Septic Tank
x❑
Upgrade ❑X
Holding Tank
❑
Renewal ❑
Privy
❑
Private Well
❑
Water Storage
❑
M
TYPE OF DWELLING:
Single Family (SF) ❑X
(w/wo ADU)
Duplex (D) ❑
Multiple Dwellings ❑
(SF and/or D)
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
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: I � I /?_ Waiver Fees:
Date of Payment: J / � / 2 y Date of Payment:
Receipt Number:
Permit No. (D S P 2-- y 1 0� 7_
Receipt Number:
Waiver No.
Permit App_-'- : .'-..:c
Pannone Engineering Services LLC
Steven R. Pannone, Principal
Registered Professional Engineer
E‐mail: steve@panengak.com
Mailing: P.O.Box 1807, Palmer, AK 99645
Telephone: (907) 745‐8200 FAX: (907) 745‐8201
Municipality of Anchorage
Development Services Department
On‐Site Water & Wastewater Program
4700 Elmore Road
Anchorage, Alaska
Subject: T12N R3W Sec 33 Lot 110A
Septic System Upgrade Permit Request
This is a design narrative for a permit to install a septic system upgrade on the subject property. The proposed
upgrade will serve an existing four‐bedroom (4) house. This lot and surrounding lots are served by private wells.
Currently there are no wells within 100 feet of the proposed system.
1. Soils:
A test hole was performed on this lot by Pannone Engineering Services, LLC on 4/29/2024. Groundwater was
observed at a depth of five and a half (5.5’) feet during the excavation of the test hole, and bedrock was not
encountered. Groundwater was observed in the test hole monitor tube after 7‐days at a depth of five and a half feet
(5.5’). Based on the results of the percolation test and overall soils appearance an application rate of 1.0 gpd/SF was
used for the design of a conventional wastewater treatment system in the area of the test hole.
2. Soil Absorption System Design.
a. See Sheet 1 of the design package.
3. Surface Water:
There is no surface water within 100 feet of the proposed septic tank and drain field.
4. Topography:
See attached site plan for area topography. There are no slopes exceeding 25% less than 50ft from the proposed
drain field.
5. Drawing Markings: The Drawings are marked “For MOA Review Only”. When written notification that the
review is complete and no further comments are received from MoA On‐Site Department, the note will be removed
and “For Construction” drawings will be issued.
The proposed installation will not affect the future development of this or the surrounding lots.
If you have any questions or concerns, please contact me at (907) 745‐8200.
Sincerely,
Steven R. Pannone, PE, F. ASCE
Owner/Civil Engineer
7 May 2024
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241082, Curtis Townsend, 05/07/24
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241082, Curtis Townsend, 05/07/24
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241082, Curtis Townsend, 05/07/24
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241082, Curtis Townsend, 05/07/24
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 ///{/ PHONE []NEW
/ // vJ��OAl — _. PG RAbE
MAILING ADDRESS--
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
Well
Dwelling
PERMIT NO. /�
DISTANCE TO:
Uy—
h 2
Manufacturer
Material
No. of compartments
aQ
wh
rn
Liq. rapacity in gallons
IF HOMEMADE:
Inside length
-
Width
Liquid depth
_
Well
Dwelling
PERMIT NO.
O�z
DISTANCE TO:
Z H
Manufacturer
Material
Liquid capacity in gallons
I
Cl
Well i
Foundation l
Nearest lot line
PERMIT NO. p` A, 6
La�'i
J y
DISTANCE TO:
/2,�,�
T Ja Z
Z w
No. of lines /
Length of each line
Total length of Iue�
g '33 v
Trench w¢ [h.
i4l G inches
Distance between lines
/Oy
h Q CL
h
Top of tile to finish grade /
- _
Material beneath tile a
72.
Total effective absorption area
4- 1'
w
O
Length Width
inches
Depth
PERMIT NO. „ , ,�
/ �y
w
_
Qh
Type of crib
Crib diameter
Crib depth
Total effective absorption area
--
w
Lu
w
Well
Building foundation
Nearest Int line
as
DISTANCE TO:
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
J
u'
Building foundation
Sewer line
Septic tank
Absorption area(s)
DISTANCE TO:
OTHER
PIPE MATERIALS
�r�
—
SOIL TEST RATING
'J
INSTALLER
_
REMARKS
_y
i
LU�6
L1�.. "y�b3✓BISu,UE6G
_. IAD, l ft."-C s ti eD
—
In�'b, �+pAnoroaN¢E'''spd'
t
DATE LEGAL
APPROVED/)
v DEPARTMENT' O' HEALTH AND ENVIRONMENTAL f �TF_•C:T ION ///U
t
025 "L' STREET, 1 iNCHORAK. ��:.�5•.:
GE, A.
n
C31%1101 .Y: _1- ti - P�°p P<:.. Fk" F�, P �'^ A.ea IES-^. P_..q P_' °. ,_': N'=° F' : __° F'• i :L
ADPL I CANE GARY NIL SON SRA BOX 4020C 144-2264
LOCATION NUGGET LANE:
L.EGAL.. L1.iO 'SEC: 33 T12N R3W SM LOT SIZE 108900 SQUARE E-L,:E
'T'YP'E= OF SOIL ABSOREIT'ION SYSTEM IS: TRENCH
MA„IMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT/8R)= 85
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
Vv_uE_F-"..F_F_V`-. if V _V- V °VA..: TE F..q;W := & A.A@"t1=141KY_, P -°F .�_„"..� ,:::: a;
THE LENGTH DIMENSION I S THE: LENGTH CIN FEET) OF THE TRENCH OR DRA I NF I EI_ D.
THE DEPTH OF A TRENCH OR PIT 15 THE DISTANCE BETWEEN THE SURFACE OF lH[:
GROUND AND THE: BOTTOM OF THE. EXCAVATION CIN FEET).
THERE IS NO SCT WIDTH FOR TRENCHES.
THE GRAVEL DEPTH 15 THE MINIMUM DEPTH OF GRAVEL. BETWEEN THE OUTFALL PIP
AND THE BOTTOM OF THE: EXCAVATION ':IN FEET:,.
PERMIT APPLICANT HAS THE: RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING TETE:
INSTALLATION INSPECTIONS OF ANY WELLS ADJACEN1. TO THIS PROPERTY AND THE:
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
_..- __. ...F..119 ®^A
r._ er ••° 1 Fl� L--:= ®_.Y "t- :F: C3 V4 n5 Fl re EE=
le EO G1 I_..
P 1: FT FE E>
BACKFILLING OF
ANY
SYSTEM WITHOUT FINAE.. INSPECTION AND
APPROVAL,
BY THIS
DEPARTMENT WILL
BE
SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEE N1 A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM EM I S,
100 FEET FOR A PRIVATE WELL.; OR
150 TO 200 FEET FROM A PUBLIC: WELL DEPENDING UPON THE TYPE OF PUBLIC: WELL.
OTHER REQUIREMENTS MAY APPLY. SPEC'IFIC:ATIONS AND CONSTRUCTION DIAGRAMS ARE:.
AVAILABLE TO INSURE PROPER INSTALLATION.
F• F a U' '1 1 1 : F' E P F """ "AT FE F T '"s on no o” E3
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REQUIREMENT'S FOR ON-SITE SEWERS AND WELLS, AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE,CODES.
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE. ENLARGEMENT EENT I F THE.
RESIDENCE 15 REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
APPLICANT CiEIR4' NIL.SON
ISSUED C5''�t2:� �'-� /� - -BATE_.. � ,+:;
_... t s.^W_.._.,_
PERFORMED FOR:
LEGAL DESCRIPTION: rC
PERFORMED BY:
72008 (7/76)
C SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION
TEST
Pouch 6650, Anchorage, Alaska 99502 276-2224
SOILS LOG — PERCOLATION TEST
SLOI
1
DATE PERFORMED: \ ..Gl2 </ /�)F
E
i
WAS GROUND WATER S
ENCOUNTERED? 1c) L
O
P
IF YES, AT WHAT E
DEPTH?
Reading
DEPTH
Gross
Time
Net
Time
(FEET)
Net
Drop
1
2
11-
3
G l�
4^5
v_
5
12
6
7
0
8
14
PERFORMED BY:
72008 (7/76)
C SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION
TEST
Pouch 6650, Anchorage, Alaska 99502 276-2224
SOILS LOG — PERCOLATION TEST
SLOI
1
DATE PERFORMED: \ ..Gl2 </ /�)F
E
i
WAS GROUND WATER S
ENCOUNTERED? 1c) L
O
P
IF YES, AT WHAT E
DEPTH?
Reading
1
Gross
Time
Net
Time
5 M
Net
Drop
10
�Oo
11-
v_
12
13
0
�r
14
15-
16
17
18
19
20 --
PERFORMED BY:
72008 (7/76)
C SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION
TEST
Pouch 6650, Anchorage, Alaska 99502 276-2224
SOILS LOG — PERCOLATION TEST
SLOI
1
DATE PERFORMED: \ ..Gl2 </ /�)F
E
i
WAS GROUND WATER S
ENCOUNTERED? 1c) L
O
P
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE
TEST RUN BETW�E-/E-N FT AND
CERTIFIED B
(minutes/inch)
— FT
_ DATE: / �O
#- 101710
1 240
6K02 131 PG215
WATER WELL AGREEMENT
This Agreement dated this 29th, March 1991 between Gary Layne Nilson aka
Care W. NUaon and Edna Jean Nilson aka E. Jeans Nilson, Owners of Lot
110A; a subdiviaiorx oL Section Lot 11.0, Section 33, Twp. 12 North, Range 3
West, plat No. 78-251, Anchorage Recording District, State of Alaska and
David W. Souders and Many M. Soxiders, awnera of Lot 110B, a subdivision
of Section Lot 110, Section 33, Trap. 1.2 North, Range 3 Wert, Plat No. 78-
251, Anchorage Recording District, State of Alaska.
Owners of L.at 1108 agree to supply (via the exisit ing we -11) wat.ar to
€wmers/Gccupants of Lnt I10A. far tho life of the well. Owners of Lit
I10A agrees to pay a monthly fee to cover electrical charges to be
reviowed annually and act by tautual -agreement by owners of Lots 1.10A, and
11GB.
Owners of Lot 110A & Lot 1100 mutually agree to share equally the cost of
maiaaaer'nnee and repairs to the pump system.
Tho agrooment shall he binding on heirs, assignees and successors.
This agropment entered into this 29th day of March, 1991.
Gary W One Ntivon ka. Gar; W. Nllac+n Edn .learn Nilson aka E. Jean N11wn
David W. Souders Mary M. r radars t
State of A Yaa e
) Iss :
Third Judicial 31{3triet)
The foregoing iin3trument was acknowledge before me
by Gary Edna Je.
CF#1CL1 " ,,Si
STATE OF ALA.
NOTARY PUISUC
OW
STAT O' 9USASXi ®i�A L.. �''f
Third JudIci.al District i
this 29th day of' March, 1991
r PiA1: on aka E. Jean Nl.l:aon.
otary Public 1n and for t1le 6tete of Alaska
y Commission Expires: 3/24/94
"'he foregoing Instrument was ;acknewledge(i before- m -e thla 29th day of Marchi, :��gi
Y DaNrl d W. Souders and Lary M.
$711 OF ALA W- Notary Public
[qty Corruni:5.31 on
RA L. STOW
_! 6 z7
ANMRWE FEC.
DiSTR[CT " a�,A.
REQUESTED BY
`31 RPR 1 Fico 8 35
In aCd ror the State of Aalaska
Expire,: 3/24/94
AFTC11l HL`X tXI0INC'j RETURN TGd
u .Foust
Strent
SUA0 tG.r
Anchofav, Alaska 99503
Y
DAILY DRILLING LOG
SYREN BROS. DRILLING, INC
2701 Eagle Street
Anchorage, Alaska 99503 274-6437
367 feet (cased) 369 total
• .................... 128 ..... ft ..............................................
OWNER OF LAND....... Gary...6[..W.SdI,lL1a...Nz.l.Solt .............................. DEPTH OF WELL ..............
Nugget Lane off DeArmoun Access f.g.1.
ADDRESS....................................................................................."I........... STATIC LEVEL OF WATER FT ................................................................
WELL- SITE...............................................................................................
DRAW DOWN FT.......................................................................................
............................
4/28/83
GALS. PER HR/MN.................
0.. g:pm .......................................
silty clay/small gravel
DATE -STARTED .........................................................
. . .............................
.......
6" A53 Grd B
Steel
5/4/83
KIND OF CASING......................................................................................
43
clay/gravel (wet)
DATE -ENDED ..............................................................................
...........
KIND OF FORMATION:
43
84
clay/gravel (grey dry)
0
14
clay/gravel/large rocks 170
FROM........................FT.
198
TO.......................FT..............-...y
wet c�a ,sm r
......:...Qc s
FROM........................FT.
TO.......................FT...................................
91
brown clay/gravel
FT.
14
24
silty/clay/gravel/few ro�1� 198
200
TO................................
r:T sand/water mix
.
FROM........................FT.
TO.......................FT...................................
FROM .... I...................FT.
200
337
clay/gravel (wet)
24
32
FT silty sand ..... FROM........................FT.
TO.......................FT...................................
FT...................................
FROM........................—.1
.......................
............................
3238
silty clay/small gravel
FROM........................FT.
TO.......................FT...................................
38
43
clay/gravel (wet)
FROM........................FT.
TO.......................FT...................................
43
84
clay/gravel (grey dry)
FROM........................FT.
TO.......................FT...................................
84
91
brown clay/gravel
FT.
FROM........................FT.
TO .....
..................
................ .............. ....
91
98
brown clay/gravel/water
FROM........................FT.
TO .......................
FT...................................
98
104
grey clay (wet)
FROM........................FT.
TO.......................FT...................................
104
115
grey clay (dry)
FROM........................FT.
TO.......................FT...................................
115
117
brown clay/gravel (dry)
FROM........................FT.
TO.......................FT...................................
117
170
_grey clay (dry)
FROM........................FT.
TO.......................F1
...................................
MISCL. INFORMATION:
FROM..., 337............FT.TO....364.....,...,., FT.,claywater/gwouldn6t cle
FROM........................FT. TO.......................FT...................................
364 369 large tight gravel
FROM........................FT. TO.......................FT...................................
& water
FROM........................FT. TO ....................... FT...................................
(ffo tatic)
FROM........................FT. TO ....................... FT...................................
FROM........................FT. TO ....................... FT...................................
FROM........................FT. TO ....................... FT...................................
FROM........................FT. TO ....................... FT...................................
Stephen D. Syren
DRILLER'S NAME......................................................................................
MUNICIPALITY OF ANCHORAGE
Development Services Department 11 Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel 1. D. 018-252-35
Legal description T12N R3W SEC 33 LT 110A
Site address 2800 NUGGET LN Anchorage AK
Current property owner(s) SPRINGER
Expiration Date:
5/15/2025
X The On -site system(s) is/are approved for 4 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
a
F0�L_ 5611 C-9 G 6 C (I -
Original Certificate Date: 5/21 /2024
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist
Absorption Field Advisory
Tank Age Advisory
Other
X Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
COSA Approvdjune 2022
Development Services Department - .r Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 018-252-35
Complete legal description T12N R3W Sec 33 Lot 110A
Location (site address) 2800 Nugget Lane
Current property owner(s) Jonathan E & Shanna S Springer Day phone
2. ON -SITE SYSTEMS SIZED FOR 4 BEDROOMS
3. TYPE OF WATER SUPPLY: ❑ Private Well ®❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: 0 Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic R Concrete ❑ Fiberglass
Age 47+ - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench 0 Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: 0
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On -site staff
to verify the accuracy of the information provided.
COSA Fee $ �$�� '� f� I24s = CN r Waiver Fee $
Date of Payment �ll (o % Date of Payment
COSA # sc' a ` y3 Waiver #
�L O e 1010
COSA Application —June 2022
COSA Checklist_June 2022
COSA Checklist
Legal Description: Parcel ID:
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes go to bottom of effective.
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Adequacy test date
Results Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
Comments/Deficiencies:
COSA Checklist_June 2022
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F.ENGINEER’S COMMENTS
G.CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Phone
Engineer’s Printed Name Date
Municipality of Anchorage
On -Site Water & Wastewater Program - 40
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 018-252-35 Expiration Date: S 9 t3
1. GENERAL INFORMATION
Complete legal description T12N, R3W SEC33, LOT 110A
Location (site address) 2800 NUGGET LANE *ANCHORAGE, AK
Current Property owner(s) DAVID & KAYCE ARTHUN Day phone C/O AGENT
Mailing address 2800 NUGGET LANE *ANCHORAGE, AK
Real Estate Agent HEATHER DEMASSIOTIS W/ KELLER WILLIAMS Day phone 865-6433
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
0
Individual Water Storage
❑
Individual Holding tank
❑
Community Class C Well
Community On-site
❑
Public Water System
❑
Public Sewer
❑
Received by: i�f Date: Z
COSA to be released to the engineer, unless othemise requested by the engineer.
COSA Fee $_ L49 0 Waiver Fee $
Date of Payment c21 1a.11 3 Date of Payment
Receipt Numberb1223-6qg Receipt Number
COSA # 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. 1 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.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described 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 soils condition, groundwater 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 the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
6. DSD SIGNATURE
System #1 Approved for q bedrooms.
System #2 Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following
337-6179
...... .. .. ........ .......
Jf A. rn sr
' E-7953 c°O�
f 1A,
44�k\ px ofessiO_
X1
ON-SITE
WATER AND
WASTEWATER
PROGRAM
The Municipality or Anchorage Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenatations 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. ATTCHMENTS:
COSA Checklist
Septic System Advisory
Nitrate Advisory
Arsenic Advisory
We low Advi Other
B:
C, % 17dd' -def{l PQ tt.,
(Rev 11105)
Original Certificat@bate:'•o� (J
If more than 1 septic system is on the lot:
COSA Checklist # _of_
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: T1 2N, R3W, SEC33 LOT 11 OA Parcel ID: 018-252-35
A. WELL DATA
Well type C
Date completed
Total depth ft.
Date of test
Static water level
Well production
WATER SAMPLE RE:
COMMUNITY WATER (SEE ATTACHED)
If A, B, or C provide PWSID# 216960 Well Log (Y/N)
Sanitary seal (Y/N)—
Cased to ft.
FROM WELL LOG
Wires properly protected
Casing height
AT
M.
Coliform colonies/100 ml. Nitrate /J0 mg./L. Collected by: G.t 6
A Ic: I o I ug./L. Date of sample: / 3o / 3
B. SEPTIClHOLDING TANK DATA *PER LARS SPURKLAND, P.E. 2009 COSA.
**DOUBLE C/O'S PRIOR TO TANK,
Tank Type/Material SEPTIC/*CONCRETE Date installed PRE -1977
Tank size *1250 gal. Number of Compartments UNK Cleanouts (Y/N) YES
Foundation cleanout (Y/N) **YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A
Date of pumping 1/24/13 Pumper NORTHLAND PUMPING SERVICE
C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE
Date installed 6/6/77 Soil rating (g.p.d./ftlor /bdrm 85 System type TRENCH
in.
Length 32 ft. Width 3 ft. Gravel below pipe 6 ft.
Total depth *9.33 ft. Eff. absorption area 384 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test **1/30/12 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 29 in. Water added 860 gal. New depth 59 in.
Elapsed Time: 120 min. Final fluid depth 39 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE If yes, give date —
**PRE—SOAKED WITH 2000 GALLONS OF LIQUID ON 1/29/12.
D. LIFT STATION
Date installed Size in gallons Manhole/Access(YIN)
"Pump on" level at in. "Pump oft" level High water alarm level at in.
Cycles tested Meets alar &circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on
Public sewer main
Sewer /septic service line
On adjacent
On adjacent lots
Holding tank
manholetcleanout
Animal areas Manurelanimal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field **$'
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots *112'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
10'+
Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage
Curtain drain NONE KNOWN Wells on adjacent lots *142'
F. COMMENTS
*ADEC WAIVER ON FILE **PER INSPECTION REPORT OLD PRIVATE WELL ON PROPERTY
ABANDONED (DE—COMMISSIONED) BY APWS. SEE ATTACHED RECEIPT
G. ENGINEER'S CERTIFICATION
I certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSH guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date
(Rev. 11/05)
Municipality of Anchorage
or
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 # 131036
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
110A of T12N R3W Section 33 Subdivision. This inspection revealed an
arsenic concentration of 10.1 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/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
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No. 3255-S
SCALE: 1"= 30' r'I �l\'�AFSSIDoLL
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FREDWA TKA4ASSOCIATES
Eipl�wa2 en85urveyors
BE (gp).ga&1860)
I WA
Community Development Department
Ori -Si e WateF and Wastewater PrNrafn
4700 Eirttiore St. - P.O. Box 196650 Anchorage, AK 99519-6650 - hIp:/&vww.muni.orgiomft - (907)343-7904
Well Decommissioning Log
Subdivision Block Lot
___--
T1,2 AJ R Section Lot!/l3
on-site Water & Vhwwoter Ptograr, rertifi�d ocntracVtr PerforMirig the well
Name: Signature. �:
Company
"Noldocorartissien't-0 OMO AMC 15.55.06,00 b,
Lornliatf: Use ti.:: Spale Lelow ll ,td, v jwAjr,3 of inxnpvty bh)Wiftg !I -P foilcmll5, darns
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Municipality of Anchorage
Development Services Department = --
4 i
� Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. oi8 — a5a- 35 COSA # 020 3 s'%
Expiration Date: /— la — IAO
1. GENERAL INFORMATION
Complete legal description Ti z At R3 W SEC 33 Lt I tOA
Location (site address) ZWO 6/wrd Ave
Current Property owner(s) Fri}Z wokivienA 'Day phone 345— 3(o00
Mailing address
Lending agency Day phone
Mailing address
Real Estate Agent . 14A14AJ L qM � Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup
2. NUMBER OF BEDROOMS:
7
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
0
Individual Water Storage
❑
Individual Holding Tank
❑
Community Class "0--, Well
IR
Community On-site
❑
Public Water System
❑
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
hone 219-3911 Lo
Address 103 W. IS'" Hoz Xf 4LUZ-0 Mrienome4e, nn i1JN1
Engineer's Printed Name ARS .4' Orr a rAnA Date 1017bo9
5. DSD SIGNATURE
_Z Approved for bedrooms.
Disapproved.
oFAaL�s lyf
c�IG'.. ... : • . i
A . LA.9S E. S?UFF:LA\u; y
�Jt� �Fo . �y j�'oy..
I >, °no -ESSlC L
Conditional approval for bedrooms, with the following stipulations:
U
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
it—
By: Original Certificate Date:, 0 9
(Aw 11,0%
Municipality of Anchorage
Development Services Department
/ Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: '111M R3W SEC33 LOT IIoA ParcelID: O18 -25Z-35
A. WELL DATA
Well type ll_ If A. B, or C provide PWSID # 2L6jr 60 Well Log (WN)
Date completed _ Sanitary seal (Y/N) = Wires properly protected (Y/N)
Total depth "'- ft. Cased to ft. Casing height (above ground) — in.
FROM WELL LOG AT INSPECTION
Date of test _
Static water level
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform --!9—Colonies/100 mL Nitrate At D mg1L Other bacteria:pcolonies/100 mL
Arsenic: ,02 ug/L date of sample: 4 001 Collected by: APS S
B. SEPTIC/HOLDING TANK DATA
TankType/Material Ccncrje Dateinstalled 'Prior to 1IS-6
Tank size I. 25b gal. Number of Compartments ull6ovrl Cleanouts (Y/N) Y
Foundation cleanout (Y/N) _)f4 Depression over tank (Y/N) _JV High water alarm (Y/N) A/
Date of pumping i 2 20 Pumper A4 YoME Servle/>
C. ABSORPTION FIELD DATA 1
Date installed b 6 I �� Soil rating (g.p.d./ft2 o 2 bdr System type DEEP Tr" ch
Length 19_k ft.
Width
3 ft. Gravel below pipe (0 ft.
Total depth IID ft. Eff. absorption area 181.112 Monitoring tube Y Depression over field /✓
Date of adequacy test Results (Pass/Fail) V465 For bedrooms
Fluid depth In absorption field before test 4 in. Water added 1000gal. New depth4 (& In.
Elapsed Time: 230 min. Final fluid depth5_• in. Absorption rate >= 0450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) /VD If yes, give date
P POtimt ent&^ Cat's Iv%56,1 J rior 1" TA-liz.
D. LIFT STATION
Date Installed Size in gallons Manhole/Access (YIN)
'Pump on' level at Zin. 'Pump off" eZatin. High water alarm level in.
Datum Cycles testedMeets alar & cir requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot IC01+
1
Absorption field on lot 100 +-
Public sewer main /V/A
Sewer /septic service line 25'+
Animal containment areas 50 1+
On adjacent lots 1121
1
On adjacent lots 14? *
Public sewer manhole/cleanout
Holding tank N�A
I
Manure/animal excrete storage areas 100+-
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
I 1 1
Building foundation 5+- Property line 5 t Absorption field St
Water main N.1 A Water service line lot+- Surface water 1001+
Wells on adjacent lots 1171 #
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line to I+ Building foundation 10 1+ Water main N�A
r
Water Service line 01+ Surface water I00 + Driveway, parking/vehicle storage 51.1
Curtain drain 50 1 t Wells on adjacent lots 14a 1*
F. COMMENTS
-s AoEe Amn- on Re
�I%Xe
G. ENGINEER'S CERTIFICATION �E OF A4 * ,1
I certify that 1 have determined through held inspections and 49TH S '.
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date. f
Engineer's Printed Name LABS Sin,,Al J% �•, •�S-c.6FiM X1
Date fo�o9 ,111tjFpO�Ot���``y�
COSA Fee $_ Waiver Fee $
Date of Payment 10- 7 0 q Date of Payment
Receipt Number Q % Receipt Number
(Rev. 11/05)
M
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LOT 114 I N8905747"E 164.85
LOT 115
SCALE: 1"= 30'
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED FB 0". pg 53-54
PLAT ARE NOT SHOWN HEREON.
C� OF A4qS�)
* . 49 TIIH�/� 171
Fred Walatka
No. 3255-S .Vi:
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AS -BUILT NO CORNERS SET THIS DATE
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. # LSF- aL.)
1. GENERAL INFORMATION
HAA# i�\)C1` 0,2 'f
Complete legal description T ^t- 11nA Sect 13 112N.
Seward Merd.
Location (site address or directions) 2800 Nugget= Lane
Gary W. Nilson 345-0528
Property owner Day phone
Mailing address 2800 Nugget lane, Anchorage, Alaska 99516
Premier. Mortgage 563-7736
Lending agency _ Day phone
Mailing address 3000 A Street, AnchoraVQ, Alaska 99503
Agent ERA, Pete Peterson
Day phone
Address 3333 Denali Suite 110. Anchorage, Alaska 99503
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well —
Community well X
Public water
349-5840
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site X
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(Rev.1/91) Front MOA#21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
Phul= Consulting Engineers & Associates Phone
2702 Gambell Street, Suite 201,
Engineer's signature
6. DHHS SIGNATURE
X_ Approved for
Disapproved.
M
Conditional approval for
Additional Comments
272-7111
Alaska 99503
Date
�001SS3f0yd Ill
•••LZZ9"a
N
..... .. ... 'A
..................... ' J.J.'
bedrooms.
bedrooms, with the following stipulations:
1l
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 engineers work.
72-025(8ev1/91) Back MOA#21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 • Anchorage, Alaska 995010 (907) 343-4744 16
Health Authority Approval Checklist
Legal Description: Gary Nilson Subdivision, Lot 110AParcel I.D.:
A. WELL DATA Sect. 33, T12N, R3W Seward Heridian
Well type
Log present (Y/N)
Total depth
Sanitary seal (YIN)
Dale of test
Static water level
Well production
If A, B, or C, attach ADEC letter. ADEC water system number 216960
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Date completed
Cased to
FROM WELL LOG
g.p.m.
Nitrate
B. SEPTIC/IIOLDING TANK DATA
Date installed 4/5/83 Tank size 1250
Casing height (above ground)
Wires properly protected (Y/N) �
//
AT INSPECTIONCP
05,s
l
9-13 In. /Cl
19S
Collected by:
Other bacteria
Number of Cornparhncnts 2 Cleanouls (YIN) Y
Foundation cleanout (YIN) Y Depression (Y/N) N _ High water alarm (Y/N) N
Date of Pumping 12/2 95 Pumper Isaacs Pumping, Service
n
C. ABSORPTION FIELD DATAC� 0,�
Date installed 4/5/83 Soil rating (g.7.tttft2 or ft`/bdnn) 85 System type Trench
Length 32' Width 3611 Gravel thickness below pipe 6' Total depth 9'
Effective absorption arca 384 sf Monitoring Tube present(Y/N) Y Depression over field (Y" N
Date ofadequacy test 8/7/95 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test (fiij; 31 Immediately after550 gal. water added (in.): 3"
Fluid depth 240 Minutes later: 3 (in.) Absorption rate — 550 g.p,d.
Peroxide treatment (past 12 months) (Y/N) _ N If yes, give date
D. LIFT STATION
Date installed None
Manhole/Access (Y/N)
High water alam level at*
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
118'
Absorption field on lot
121'
Public sewer main
N/A
Sewer /septic service line N/A
"Pump oft' level at*
On adjacent lots 144'
On adjacent lots 151'
Public sewer manhole/cleanout N/A
Lift station N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 121511 Property line Z41+1 Absorption field 51
Water main service line N/A Surface water/drainage 150
Wells on adjacent lots 156'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation 20.5' Water main/service line
Surface water None
Curtain drain None
F. ENGINEER'S CERTIFICATION
N/A
Driveway, parking/vehicle storage area
Wells on adjacent lots 159'
35'
I certify that / have determined thru field inspections and review of1funicipal rgR;,4-4h2fL,Ffrq\above systems are
in conformance with NIOA HAA guidelines in effect on this date. 0 {
Signature � I , .`,,t;kyV
r y 4 ; /� 71J f
Engineer's Name ✓t �'Plyl' N...: _`
Date (71� I�j j� ��� An to iui<nN
HAA Fee
Date of Payment
Receipt Number
Rev. 8/95 OSS: haa.wk.doc
(C Y
Waiver Fee $
Date of Payment
Receipt Number
40
FLA; Geotechnical Surveying Environmental Civil
August 31, 1995
Municipality of Anchorage
Department of Health and Human Services
825 L Street, Room 502
Anchorage, Alaska 99501
Attn: Mr. Robbie Robinson
Re: Health Authority Approval Checklist
Dear Mr. Robinson:
W.O. #95922.1
chol
SerVices
Arun �a1th`y Human
wept. H
We apologize for the incompleteness of the prior submitted checklist. Please find the
revised submittal enclosed.
We have not included information regarding the well. The client has informed us that the
well is a Class C system and already is approved with the ADEC. The lender has
accepted this current approval and requests nothing else. Please review the information
regarding the septic system and approve as soon as possible.
Thank you. Please contact us if you have questions or comments regarding this matter.
Sincerely yours,
PFIUKAN CONSULTING ENGINEERS & ASSOCIATES, INC.
`4
wx 94oe--
Michael John n, Civil Engineer
projdoc/922nd I g.Aoc
2702 Gambell, Suite 201 • Anchorage, Alaska 99503 • (907) 272.7111 /FAX 277-3177
Municipality of Anchorage
® DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
RECEIVED
Health Authority Approval Checklist AUG 2 9 1995
Municipality of Anchorage
Legal Description: Cu�Ni 7 Gnn_Subd_T at=h,,Sect_,I3 parcel I.D.: Dept. Health & Human Services
A. WELL DATA T12N, POW, Seward Meridian
Well type _CIf A, B, or C, attach ADEC letter. ADEC water system number
Log present (YM) Y
Total depth 369 feet
Sanitary seal (Y/N)
Date
Y
Date completed 5/4/83
Cased to 367' Casing height (above ground) 2' 3"
FROM WELL LOG
Wires
(YIN) Y
Static w iter level 1 1
Well pro action g.p.m.
WATERS MPLE SULT�:
Coliform 0 N' at mgt Other bacteria 0
Date of sample: 8 4 95 Collected by: Pete Peterson
t
B. SEPTIC/HOLD TANK DAT
Date installed 4/5 Tank size _ 1200 galutnber of Compartments Cleanouts (Y/N) Y
Foundation cleanout(Y ) Y Depression (Y/N) N High water alarm (Y/N) N
Date of pumping 12/28/94 pumper Isaacs Pumping Service
C, ABSORPTION FIELD DATA
Date installed 4/5/83 _ Soil rating (g.p.d./ftz or f 2/bdrm) 85sf_/bisystem type
Length 32' Width 36" Gravel thickness below pipe 6' Total depth 91
Effective absorption area 384 sf Monitoring Tribe present(Y/l)_ Depression over field (Y/N) __
Date of adequacy test 8/10/95 Results (Pass/Fail) P For 3 bedrooms
Fluid depth in absorption field before test (in.); _ Immediately after__ gal. water added (in.):
Fluid depth (ins.) Minutes later: Absorption rate = g.p.d
Peroxide treatment (past 12 months) (Y/N) If yes, give date
D, LIFT STATION
Date installed
Manhole/Access(YIN)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot 118' On adjacent lots
Absorption field on lot 121' On adjacent lots
Public sewer main N/A
"Pump off' level at*
0
151'
Public sewer manhole/cleanout N/A
Sewer /septic service line N/A Lift station 1v/r
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 121511 Property line 44' Absorption field_
Water main/service line N/A Surface water/drainage good Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation 2016" Water maintservice line N/A
Surface water
Curtain drain
N
1
5'
151'
Driveway, parking/vehicle storage area 35'
Wells on adjacent lots 159' Property line 13'
F. ENGINEER'S CERTIFICATION
certify that I have determined thru field inspections and review of Municipal
in conformance with A-fOA HAA guidelines in effect on this date.
Signature_
Engineer's Name wl�-m Nort\-A
Date(_
HAA Fee $ C)C>•U,�) Waiver Fee $
Date of Payment t6— X - C\ S Date of Payment
Receipt Number CJI J 'Lj Receipt Number
Rev. 8/95 OSS: haa.wk.doc
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STATE Up ALASKA
DEPT OF ENVIRONMENTAL CONSERVATIUN
PUBLIC WATER SYSTEM SANITARY SURVEY AND
INVENTORY UPDATE FORM
*Indicates required response
*PWSID k *CLASS (A,g,c) *rtt,aurvr rurlj"iiun
*NUN-1%Mauni rwrWLA
;fid 94 G
-- - — __
*SYSTEM NAME
GAR. !Vl�SoN
(�`�7
JLi8l71t/ISlON
,
L07• 116A 1l0E
� FIR i k/l L -.S o tij
W MAILING ADDRESS
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SYSTEM PHONE 0
MAILING CITY
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OWNER NAME r
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w OWNER ADDRESS
OWNER PHONE #� _
OWNER CITY
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OWNS STATE
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OWNER ZIP CODE
OPERATOR NAM OR RESPONSIBLE AGENT f
OPERATOR PHONE M
Lo i // 0 8 SEC. 3 3
3 bo
TTILU Use;
tat us. q r
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ab Accessy
WaiverY
ile
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;arbon Copy
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N
SEASONAL OPERATIONS PRODUCTION t
Is system operational? YES/NO AVG DAILY:
Operation Dates—/. to —/, (MM/DD) MAX DAILY: m
Days Open per Year zbJ' STORAGE
Is system permanently closed? YES/NO
If YES, closure dates — /_ /_
FACILITY TYPE:(CIRCLE ALL THAT APPLY)
F -S Food Servico M Bar SC School
Campground•, JU Subdivision MResidential
M�f Municipal SF Seafood Processor AK State of Alaska
WH Water Hauler US Military, Govns't CU Logging Camp
MH Mobile Home Park -0 Daycare Preschool Resi7ental care
a Public Accomodations Hof—oil Motel, Showers, Toilets
JE Industrial Facilitys Drill Rigs, Pump Stn, Construction Camps, Mining Camps
Public Facility; Food Processors, Stores, Markets, Barber/Beauty Shops, Dairy
xg Other, specifY�_- ------_--
CONSTRUCTION AND OPERATION CERTIFICATE
ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION
PUBLIC WATER SYSTEM
APPROVAL TO CONSTRUCT
Plans for the construction of
�2 14 22 -public water system located
in AL A Alaska, submitted in accordance with 18 AAC 80.100
by N d 107— ff(is l�� — CWS=�R1 Ef' /U_ _have been reviewed and are
M approved.
❑ conditionally approved (see attached conditions).
TITLE lSAI`r—
If construction has not started within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED CHANGE ORDERS
Change (contract oraor no. _ Approved by Date
or aescriptive (olerenco)
J
The "APPROVAL TO OPERATE" section must be completed before any water is made available to
the public.
APPROVAL 1'0 OPERATE
r
The construction of the�l_ i I SL1 �cT i/c.�l t -//a 13 public
water system was completed on a` C /a s s C � 3,;t f - F4—.,7vC (date). The system is hereby
granted interim approval to operate for 90 days following the cprnpletion date.
DATE
As -built plans submitted during the interim approval period, or an inspection by the Department has
confirmed the system was constructed according to the approved plans. The system is hereby granted
,nal approval to Aerate.
BY TITLE DATE
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SURVEY TYPE
SYMBOLS
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ELEVATION
C� PLOT PLAN'
DRAINAGE
❑ LOT SURVEY
WOOD FENCE
❑ RECERTIFICATION AS-BUILT
A/F�- 134ALN LINK FENCE
-
_ NOTE, FENCES ARE SHOWN IN THEIR APPROXIMATE LOCATIONS
ONLY.
It n the responsibility of the builder at ovrner, prior to
LEGEND hub 8 IOGk' found 0
sal 4
conauuction, to verily proposed balding grade rclalivo
iron Tabor -found O
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to hnished grade and uhlny Connections and to determine
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set O
the existence of any easements, covenants or restrictions
do not appear on tl> recorded
brass Cpp -found
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PREPARED BYI RESIDENCE OF:
DeCamp—Brown, Land Surveying UAy
P•0.aDX 1120. WASILLA.ALASKA 99687
7-Y
REVISIONS IOY IDATE
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DRAWN SY: DATE: W.O. NO. DRAWING NO. FIELD BOOK NO.
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PREPARED BYI RESIDENCE OF:
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P•0.aDX 1120. WASILLA.ALASKA 99687
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3330 INDUST RIAL AVENUE FAIRBANKS, ALASKA 99701 1907145"--111 t'Pix 4E-31.';-
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 90503 19071 ?71 831:; • I "X Ila 9646
W Report Date: 08/22/95
Gary & Jean Nilson Date Arrived: 08/15/95
c/o ERA Realty Date Sampled: 08/14/95
3333 Denali St., Ste. 110 Time Sampled:
Anchorage, AK 99503 Collected By:
Attn: Pete Peterson
Our Lab #:
Location/Project:
Your Sample ID:
Sample Matrix:
Comments:
Lab
Number Method
--------------------
A139885 EPA 353.3
A139885
2800 Nugget Lane
Water
Parameter
--------------
Nitrate-N
Reported By: AnthonyJ. Lange
Chemistry Supervisor
* Definitions
ND = Non Detected
H = Above Regulatory Max.
E = Estimated Value
M = Matrix Interference
D = Lost to Dilution
MDL = Method Detection Limit
Date Date
Units Result * MDL Prepared Analyzed
--------------------------------------------------------
mg/L <MDL 0.10 08/15/95
I
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1�, �L��r�'IL
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN PUBLIC SERVICE AREA OFFICE
555 CORDOVA STREET
ANCHORAGE, ALASKA 99501
August 28, 1995
Mr. Gary Nilson
2800 Nugget Lane
Anchorage, AK 99516
TONYKNOWLES, UUVLHNUH
(907) 269-7505
SUBJECT: Lot 110A, Sec. 33, T1 2N, R3W, S.M. Gary Nilson Subdivision - 2800
Nugget Lane; Anchorage, Alaska. Class "C" Public Water System ID no.
216960, ADEC Project No. 9621 -DW -237-046.
Dear Mr. Nilson:
This letter is in response to the information received in this office August 25, 1995,
requesting a letter of compliance regarding the above Class "C" Public Water System.
The Department has completed its review of the submitted information which included a
previous health authority approval, well log, construction and operation certificate, and
recent water sample analyses for total coliform bacteria and inorganics for nitrate.
Since this drinking water system has been previously approved by the Department, and
because it serves less than 13 bedrooms or 25 residents, this water system is viewed
as a Class "C" Public Water System. Verification that the water supply has been
recently tested will be required to maintain compliance with State Drinking Water
Regulations. The submitted water analyses were satisfactory for both total coliform
bacteria and nitrate and satisfy this concern. Therefore, for the concerns of this
Department, this system is in compliance with State of Alaska Drinking Water
Regulations (18 AAC 80). Attached is an "Approval of On -Site Residential Water
and Sewer Systems" certificate verifying this system's status as an approved water
system that is in compliance with 18 AAC 80.
Thank you for your cooperation with this Department, if there are any questions
regarding the above please do not hesitate to call.
Sincerely,
Michael Lu, F.I.T.
Environmental Engineer
M L/cf
Attachments
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 / c
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
l07- //O A 5�zr 33 7-/ ?-.,\) ?=,3Lj SM
Location (address or directions)
(b) Applicant Name Telephone: Home Business
Applicant Address —_
(c) Applicant is (check one): Lending Institution CI ; Owner/builder Buyer O ; Other ❑ (explain);
(d) Lending Institution
Address —
(e) Real Estate Company and Agent
Address
Telephone
(f) I
Telephone
2. TYPE OF RESIDENCE
Single -Family t,, Multi -Family EI Other
Number of Bedrooms --I
3. WATER SUPPLY 64-465 ( C
y -465(G t
Individual Well E1 Communilyp Public ❑ - -
Note: If community well system, must have written confirmation Irom the State Department of Environmental Conservation
attesting to the legality and status.
d. SEWAGE DISPOSAL
Onsite Pl� Public Cl Community ❑ Holding Tank d
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72425 ill 64)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certdied by my seal alhxed hereto and as of the validation dale shown below. I verily that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is Safe. functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
r Telephone
Name of Firm 7:
Address
Date����
J� K
O "�ct9irjgatjs Seat-,
00 e. •up ua.. a...i•.•
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��t. Car S. Meyer 4wd
#635300
4Q ' ►�PROFESStg��®��
6. DHEP APPROVAL
Approved for �� bedrooms by Data
Approved __A. Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Municipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain lederal and slate 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
i2025111.b4)
MUNICIPALITY OF ANCHORAGE (MOH)
HEALTH AUTHORITY APPROVAL; (HAA)
CHECKLIST - FEBRUARY 1984
264-4720 Q
Legal Description: 4/'E A
A. WELL DATA
Well Classification (� ), D If A. B, C, D.E.C. Approved (Y/N)
Date Completed
Well Log Present (Y/N) _ `' Yield
Total Depth:: Glcicl to ` 5&f
Depth of Grouting—
Static Water Level 7 Pump Set At -
Casing Height Above Ground — % Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) 41 _{- Depression Around Wellhead (Y/N)
Separation Distances from Well:
0
To Septic/Holding Tank on Lot --��-P ', ;Om Adjoining Lots
To Nearest Edge of Absorption Field on Lot �/_OZ,) On Adjoining Lots )Z7-
To
LZTo Nearest Public Sewer Line -A To Nearest Public Sewer
Cleanout/Manhole —ek To Nearest Sewer Service Line on Lot /0'OF
t
!9_// eSS2o- Date
Water Sample Collected by%✓�F 1 -�-
Water Sample Test Results ��7ZSF/AG77�/�
Comments`47171r�4��1F7>Y - v JfF7m��tLG�r5t)CIJ
B. SEPTIC/HOLDING TANK DATA
-?1-71�✓
Date Installed� Size �2Sb �T No. of Compartments
Standpipes (Y/N)- Air -tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/N) — �`� ate Last Pumped
Pumping/Maintenance Contract on File (Y/N) for
1,4
Holding Tank High -Water Alarm (Y/N) Temporary,Holding Tank Permit (Y/N) 7
Separation Distances from Septic/Holding Tank:
To Water -Supply Well _-- // To Building Foundation �L
To Property Line 1' To Disposal Field �n
To Water Main/Service Line ?�r To Stream, Pond, Lake, or Major Drainage
Course 'J %fie
i
Comments
Pagel of 2
72-026(1 V841
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 0� Type of System Desigi /xewj
Date Installed (0 Length of Field �q�9
Width of Field a Depth of Field /
Gravel Bed Thickness to
Square Feet of Absorption Area / )3t/f}f�°_--
P � Standpipes Present (Y/N)
Depression over Field (Y/N) AJ Date of Last Adequacy Test
Results of Last Adequacy Test 6 Tls'PAC_1`DLs l�
�t
Separation Distance from Absorption Field:
To Water -Supply Well _i . =ZZ %/� i %) x/006 To Property Line
To Building Foundation To Existing or Abandoned System on
Lot 6%IA On Adjoining Lots /l.�7fF9
To Water Main/Service Line ��� To Cutbank (if present)/h
To Stream/Pond/Lake/or Major Drainage Course _�/� /
To Driveway, Parking Area, or Vehicle Storage Area __ tFT�
Comments
D. LIFT STATION
Date Installed -
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
'Pump Off' Level at
ng Cycles during Adequacy Test. Meets MOA
Check Permitted Bedroom Rating Against HAA Request **
I certify that I hav hec e , v ri i conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed,�� ate
Company MOA No. 6 ;ate w4a��
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
MUNICIPALITY OF ANCHORA(3E
DEPT, OF HEALTH &
ENVIRONMENTAL PROTECTION
�P
3 0 f�86
RECEIVED
pROFE
Location:
BESSE, EPPS S P07TS
2220 EAST 88 AVENUE
ANMORAGE, AK 99507
(907) 349-6451
WATER WELL TEST
Date: D I —
Subdivision:
Lot: to A r. -7" 1—:L 3w
Block:
Client's Name: La� ^ii (
Address:
Tester: /17 M�,-/t /J
'Two "5
Initial Reading on Neter: _) -A (, p 1 n (a C
r
_
TIME
GPM
GALLONS
A VOLUME
GALLONS
TOTAL VOLUME
yf 0
a W
-( i
-7
1 o
:00
I
-Z
1
a4
y R' 0
5
e
601
/t)4) z
NOTES:
No C �; n
I
2 L L L
DEPT. OF ENVI6iONNIENTAL CONS>FIg"TION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
September 9, 1986
Besse, Epps & Potts
ATTN: Dave Merrell
2220 East 88th Avenue
Anchorage, Alaska 99516
BILL SHEFFIELD, GOVERNOR
274-2533
SUBJECT: Lots 110A & 110B, T12N, R3W, Section 33, SM, Anchorage
8721—WA-014
Dear Mr. Merrell:
The Department has reviewed the information submitted by you
along with the updated plan view as—built which we requested.
The reported distance of 112 feet to the neighboring septic
tank appears to meet the intent of our May 23, 1983 waiver
approval which allowed a separation distance to 114 feet.
Therefore, the septic tank separation on Lot 110A to the Class
C well on Lot 110B is approved to 112 feet. This approval is
valid only for a 4 bedroom home on Lot 110A. The Class C well
meets State requirements at this time and the operation
certificate issued in September 6, 1983 is valid and current.
In future submittals, please submit your request on a state
application form or provide a cover letter explaining what it
is you are requesting.
Sincerely,
Steven W ng, PE
Distric Engineer
SWE:pkk
MUNICIPALITY OF ANCHORAGE
Pil-
S7t'a�°rt
G%[f.
DEPT. OF HEALTH &
oi��.l lis -"/=a, i=�: ✓,: fi, !',��C��'J'7 ENVIRONMENTAL PROTECTION
i
301996
RECEIVED
Time
� : o (
APPLK NT FILLS OUT UPPER HAL ONLY
Property Owner5
Cr c,��y
�- _ i_
�,._ , to �,c, 1,
Phone
Mailing Address
1 - Zip Code
1_ l,2_,.,_ t !?.�-(� C. !'IrT C'_%t /-� K
Date 2
Buyer
1
Address
/
\/ - Zip Code
Lending Institution
Date
Phone
Address
lq — Zip Code
Realty Co. & Agent
Inspector
Phone
Address
Zip Code
Legal Description/.-.ui"
1AC� jec-
0
Street Location
` �O(i . C ( _,:.-� �.. C', "l l ' �'f \C',� ❑�C.�.<> C a / ' 1
Type of Residence
-
Single Family
ii
❑ Multiple Family
No. of Bedrooms -
❑ Other
ENVIR.: 1'. 3...<. _ '—TION
Water Supply
_
Individual
5/ ��
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
❑ Community
For wells drilled prior to that date, give well depth (attach log if available).
❑ Public Utility��
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Sewer DisposalS-IP(-I1/
Individual
Year Individual Installed: .,✓_.__ 1 1 I ! C)
❑ Public Utility
When Connected to Public Utility:
CI Holding Tank
l 1 DISAPPROVED
�'(! //-: 3 -.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
� : o (
Time
-,I C Ps
Time
Time
CAr_`1C�e�I 0, C, _
Date 2
Date
�A calL_.l
Date
nn
Date
Inspect Inspector
Inspector
Inspector
Field Nots:
e
MUNICIPALITY OF ANCHORAGE.
!Le "i
do a
ENVIR.: 1'. 3...<. _ '—TION
5/ ��
♦
,.lL!/_'
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!94�
( j APPROVE BEDROO
__._
'CONDITIONS OF APPROVAL
l 1 DISAPPROVED
�'(! //-: 3 -.
i' .:£:°
NDITIOL APR
Soils Rat jnq
Date Sewer Installed
Well To Absorption Area
Well Log Received
4
Well to Tank
Septic Tank Size
72 023 INK)
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