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HomeMy WebLinkAboutT12N R3W SEC 33 LT 182 SE4 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211395 PID Number: 018-292-29 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name DOUGLAS ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ME Mound Site Address 3241 RABBIT CREEK RD, ANCH AK ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 3.0 GPD/SF 1 Ft_ LEGAL DESCRIPTION Depth to pipe invert from original grade 1 Ft. Gravel depth beneath pipe 1 Ft. Subdivision Block Lot T12N, R3W, SEC 33 LOT 182, SE4 Fill added above original grade 3'+ Ft. Gravel length 30 Ft. Township Range Section Gravel width 5 Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 150 Ftp 1 Ft. Well 50'+ 50'+ 50'+ TANK X Septic ❑ S.T.E.P. ❑ Holding X Other Manufacturer Capacity ADVANTEX-ANCH TANK 15500 Gal. Surface Water 50'x' 50'+i Material Number of compartments Lot Line 10'+ 10'+ NA FIBERGLASS 2 Foundation 1101+ 101+ I LIFT STATION Manufacturer Capacity Remarks AN C H TANK 250 Gal. Alarm location SE CORNER OF BLDG Electrical installed by RISING SUN ELECT Installer PIPE MATERIAL House to tank 3034Tank to 3034 drainfield MIKE N ANDERSON, P.E. Drainfield 3034 CO/MT3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 99.5 ft Inspection 1v 3/4/22 3/5/22 da:3'd Location and description 2'� TOP OF TANK MH 4'h ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Datetoo d °��•' • " ' • '- 49TH '. % -"r?• MICHAEL N. ARDLRSCN .*& d t.;,• Septic System Approved '�- (✓ Date 1( ^?' — CE -9469 �� '•.�,y�/,� y,''�� .� Note: this approval does not include well permit requirements. kKev voluzilo) Permit No. OSP211395 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744 On—Site Wastewater Disposal System and/or Well Inspection Report Legal Description: T12N, R3W, SEC 33, LOT 182 SE4 PID No.: 018-292-29 1 MARK AB C 1 I \ FCO 35 5 I C01 18 / CO2 18 Tc01 19 POD 22 / \ MT1 21 / \ MT2 1 42 / MT1 - — - MT2 \\ 1 B <�Y\ 1 I I I 1 I I 1 2 I 1 \ / 1 \ / 100' WELL RADIUS 100' WELL RADIUS L;v PUMP BASIN BENCH, TOP OF MH A / 1500 GALLON ADVANTEX TANK AND POD URIED ELECTRICAL MARKERS gSBUIL1 SCALE: 1"=50' ®®.®®®®®jj®® CO, CO2 TCO,/MN ® OF A/ ®o® MT1 MT2 ®®���� ..Loon": `� ^��®® i Ar ;• ®®® POD PUMP BASIN -1.0 ).R 49THwFALTER FABRE 004 11 PO 11115111111 111 NEW 1.500 GALLON somexaxid ADVANTEX TANK W/ PO ®MICHAEL N. ANDERSON.`® ®�AF No. CE 9469 •\9,®®®®® �.AW ..3-28-22 .•' SE TS WATER 095.5 NOV. 2021 ®t®® ssl® ® II I S89'56'18"E 164.77' — --x •xx—x `X—X—X—X ' -x_y S96 -00'00"E 164.80' R) ANCHORAGE RECORDING DISTRICT, ALASKA AS -BUILT OF: SEI/4 LOT 182 T12N R3W Sec33 Seward Meridian, AK SURVEY CERTIFICATE: I; John L. Schuller, Have conducted a physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance should any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. WORK ORDER NUMBER: DATE: SCAM* E-MAIL MAR 19, 2022 1"=30' schuft-ftk.net 22-014 DRAM D, CKCJSD BY WD NUWM 8"/PACE: IL 5W3134 220136 NOTE: Record information per plat 68-108 s* ; 49TH :............... yA it I .JOHN L. SCHULLER; ' LS -10408 ;® c ®fessionot a 1831 Talkeetna Street Anchorage, Alaska 99508 (907) 227-1455 office (907) 274-4992 fax ® ® SEPTIC VENT (typ) LY^ 2�0 57.2' o I SE1 /4 LOT 182 o N Vi `- ` U-) tri O ori WELL ® r- � tPrt W CV ro C) rn LTJ O to 0 O � O O O4OMH p 00 z O x ® MH 00 Z 11 GRAVEL d ®VAULT 37.4' 0 O 0/W 2h :r N N N90°00'00"W 164.86' (164.82' R) BASIS OF BEARING 0 LO to RABBIT CREEK ROAD ANCHORAGE RECORDING DISTRICT, ALASKA AS -BUILT OF: SEI/4 LOT 182 T12N R3W Sec33 Seward Meridian, AK SURVEY CERTIFICATE: I; John L. Schuller, Have conducted a physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance should any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. WORK ORDER NUMBER: DATE: SCAM* E-MAIL MAR 19, 2022 1"=30' schuft-ftk.net 22-014 DRAM D, CKCJSD BY WD NUWM 8"/PACE: IL 5W3134 220136 NOTE: Record information per plat 68-108 s* ; 49TH :............... yA it I .JOHN L. SCHULLER; ' LS -10408 ;® c ®fessionot a 1831 Talkeetna Street Anchorage, Alaska 99508 (907) 227-1455 office (907) 274-4992 fax 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: OSP211395 Work Type: Septic Upgrade Tax Code Number: 01829229000 Site Legal Address: T12N R3W SEC 33 LT 182 SE4 G:3134 Site Mailing Address: 3241 RABBIT CREEK RD, Anchorage Owner: VAUGHN MARK DOUGLAS Design Engineer: FIRST WATER CONSULTING This permit is for the construction of: Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: ent "V Uc:partment 9/20/2021 9/20/2022 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: Date: Issued By: Date: //1151 1 i 3 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 018-292-29 Property owner(s) MARK DOUGLAS VAUGHN Day phone Mailinq address 3241 RABBIT CREEK ROAD, ANCHORAGE, AK 99516 Site address 3241 RABBIT CREEK ROAD, ANCHORAGE, AK 99516 Legal description (Sub'd., Block & Lot) Legal description (Township, Range & Section) T12N R3W SEC 33 LOT 182 SE4 Lot Size 18,958 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: (® all that apply) Absorption Field EZ Septic Tank 0 Holding Tank El Privy ❑ Private Well ❑ Water Storage ❑ APPLICATION IS AN: Initial ❑ Upgrade El Renewal ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: TYPE OF DWELLING: Single Family (SF) 0 (w/wo ADU) Duplex (D) ❑ Multiple Dwellings ❑ (SF and/or D) 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: 25 70 Waiver Fees: Date of Payment: / ia1ai Date of Payment: Receipt Number: O l5 13 3 7121O� Receipt Number: Permit No. 05.eZ I Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc 0 F'FS[ Wder I$ CONSULTING 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / firstwaterAK@gmail.com November 10, 2021 Municipalities of Anchorage On -Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: CHANGE ORDER — HOLDING TANK TO ADVANTEX SYSTEM LEGAL: T12N R3W SEC 33 LOT 182 SE4 PHYSICAL: 3241 RABBIT CREEK ROAD, ANCHORAGE, AK 99516 The owner has requested that we obtain a septic permit to upgrade the existing aged steel holding tank to an advanced wastewater system on the above referenced lot. Per the recently conducted testhole, we propose to install a pressurized shallow trench with an Advantex system to serve the existing 3 -bedroom residence. The lot and area are served by private water. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. ® 1,, 9 �Ut (WiN..rv .. E,i JICCS ' C 1'+�� �fF hPSIEYr0.7EP . f=PN7id Pl0.NNINf DESIGN CALCS: 3 BDRM X 150 GPD = 450 GPD 450 GPD/3 GPD/SF. = 150 SF SAS 150 SF / 5 (.87RF) = 27 FT. TRENCH USE 1 TRENCH - 30' (L) X 5' (W) X 1'(ED) TOTAL DEPTH FROM EXISTING GRADE, -2.5' USED REDUCED APPLICATOIN RATE DAMSON S/D LOT 1 IAMSON S/D i S89 56'1 LOT 2 I TH21-1 DAMSONI WELL S/D RADIUS LOT 4 ( n DECOMMISSION DOSTING - HOLDING TANK & INSTALL NEW 1500 -GAL STEEL.. SEPTIC TANK I WITH PUMP BASIN & AnO POD. Ui O In SE1 /4 LOT 182 r W,� 3 M O M O iQ 00 00, Z O Z GRAVEL NO WELLS (THIN 50' OF PROP ED SEPTIC SYSTE NO SLOPES >25% WITHIN 50' OF PROPOSED FIELD. SEPTIC AREA 7164.87-R) . i -11 NO PRVT. 50' WELL ELL. W/IN RADIUS & PL 5o GP PRIOR TO CONST. PROPOSED MAINTAIN 5D' TO WELLS & 5+ TO PL LS MH 0. MH t� O Lri FCOWELL T00'� AX-- o RADIUS U) a OZ W -In W 0 TNi W� O r- 00 O 00 (n O Z� d 37.4' N �. :r i� N90 00'00"W 164.86' (164.82' BASIS OF BEARING RABBIT CREEK ROAD 0 In NOTES: STAKE PROPERTY LINE & 50' WELL RADII PRI❑R TO CONSTRUCTION T12N R3W SEC 33 LOT 182 SE4 SUPPORTSERVICES: PREPARED FOR: ��� OF �<Q� MARK DOUGLAS VAUGHN c� 3241 RABBIT CREEK ROAD C ° * -" 9TH ANCHORAGE, AK 99516 FIRST WATER CONSULTING DATE: 11/10/2021 is Huffman -4 A4 SURVEY: JLS CE 128991 13030 SUES WAY DRAWN: FWCS 11/10/2021e� ANCHORAGE, AK 99516 SCALE: 1" = 40' 907-350-9566 FirstWaterAK@gmail.com PAGE: 1 OF 2 ss1010 DESIGN DETAILS: INSTALL NEW 1500—GAL ADVANTEX 3BR STEEL TANK / SYSTEM. MAINTAIN 10'+ FROM FOUNDATION, 50' TO WELLS, 5' TO FIELD & DECK SUPPORTS WITH 4' OF COVER OR INSULATION. INSTALL 1 30'L x 5'W x 1'ED TRENCH —2.5' FROM GRADE w/ 3'+ OF COVER MAINTAINING 50' TO WELLS / SURFACE WATER, 5'+ TO LOT LINE,.... INSTALL PER AMC 15.65, 15.55, & MASS ... TANK BEDDING, SEPARATIONS, MATERIALS,... NO f S89056'1 8 164.77' STAKE 50' WELL WELLS , „ , RADIUS & PL 50' X X ooo 16 4. 80 R) PRIOR TO CONST. PROF SYS + EXTENT 50' TH21-1 `o MT OF COVER WELL MAINT, RADIUS TO WE MT Lo J ® 5'+ � J ISSION EXISTING II _o G ANK & INSTALL NEW J I LS 0A STEEL SEPTIC TANK MH JM I BASIN & AX20 POD. 24 c 0 ^ MH O O /4 LOT 182 —�o'' Lo 100'— WELL II W WELL O J O FCO RADIUS rn y �� o_ W W OZ 00 uo) o o1,- b 0 o 0 V) o GRAVEL U) D/W 37.4' T12N R3W SEC 33 LOT 182 SE4 SUPPORTgSERVICES: - OF ®®® �� PREPARED FOR: 1 MARK DOUGLAS VAUGHN 3241 RABBIT CREEK ROAD C * 9 TH ANCHORAGE, AK 99516 FIRST WATER CONSULTING DATE: 11/10/2021 tis Huffman / SURVEY: JLS�, CE 126991 13030 SUES WAY DRAWN: FWCS`'� 11/101/202 ,,x' ANCHORAGE, AK 99516 SCALE: 1" = 20' 1ossio�Ay PAGE: 2 OF 2 907-350-9566 FirstWaterAK@gmail.com 0 FJO Water CONSULTING INATEFf/"VAs I£Vl AiEF. SUPPORT E Pt.:14111NG 13030 Sues Way - Anchorage, Alaska 99516 Tel. 907-350-9566 firstwaterAK(cr,gmail.com SOILS LOG - PERCOLATION TEST LEGAL:— T12N R3W SEC 33 LOT 182 SE4 DEPTH FEET OG SOILS ORG/OL 1 2 3 4 SP/SM 6 7 8. 9 BOH 10 11 12 13 14 15 16 17 18 19 20 / • 'TH TH '• * / ' • ' _ Curtis Huffman CE 128991.••0 ���cislF�F. 11/10/21.-:0; - �, �pROFESSI�N�`Aw PERFORMED FOR: DOUG VAUGHN TESTHOLE # 21-1 DATE PERFORMED: 11 /3/2021 GROUNDWATER ENCOUNTERED: YES IF YES, AT WHAT DEPTH: 6' DEPTH TO WATER AT MONITORING: 5.5' DATE: 11/10/2021 SEE SITE PLAN FOR SLOPE & LOCATION COMMENTS: VERIFY GROUNDWATER MT AT TIME OF CONSTRUCTION Reading Date Gross Net Time Time Depth to Water Net Drop 11/3/21 10 min 6" 5 1/16" " 6" 5 0/16" " 6" 5 1/16" " 6" 5 2/16" " 6" 5 1/16" " 6" 5 1/16' PERCOLATION RATE 2 (MIN / INCH) TEST RUN BEWTWEEN 3 & 4 FT PERC HOLE DIAMETER 6" PRE-SOAKED PRIOR TO TEST & ALL READINGS TO THE 1/16TH PERFORMED BY: FWC - I CURTIS HUFFMAN CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE & MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 11/10/2021 MUNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATIVIE NT SYSTEM MAINTENANCE AND REPAIR AGREEMENT THIS MAINTENANCE AND REPAIR AGaVEMENT, herein the "AGREEMENT" made and entered into as of this lay of �,?Jt�EA?of 20,2�_, by and between herein the "OWNER," and the Municipality of Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code (AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this Agreement agree as follows: 1. Advance Wasteivater-Treatment Systerns. "I'lie Municipality grants pen-nission to the Owner to utilize and operate an Advanced Wastewater Treatment Systern (AWWTS), described as located at (legal description) AN ADVANTEX SYSTEM 2. Maintenance, Repairs and Alterations. (Owner is required to read, understand and initial each section) 4W Throughout the term of this Agreement, the Owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the Municipality or the manufacturer's representative. The AWWTS shall be maintained in a satisfactory condition capable of performing as designed and producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality.. 4LbV! It shall be the responsibility of the Owner during the term of this Agreement to pay for all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This includes an annual maintenance fee (typically $400 to $600). &V Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, repairs or permitted alterations to the system. Owner acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield replacement. (rev. 05/18/2018) Page I of 3 4)/ Owner acknowledges that the Municipality may request records of maintenance and repairs from the manufacturers representative or maintenance provider, Af)—V Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60.030. 100V Owner agrees to grant the Municipality reasonable access to test and inspect the �iR-- AWWTS. The Municipality will give at least 24-hour notice. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. AO/ Owner agrees that the AWWTS installation and maintenance requirement.-; as provided by the AWWTS vendor/installer and approved by the Municipality are the governing g guidelines for the construction, maintenance and repair of the Owner's AWWTS. Aji) Owner agrees to maintain remote monitoring of the AWWIS as required by the AWWTS approval. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system, or upon transfer of title, and -,-,hall continue while the AWWTS is operational or until title is transferred. 4. Nonwaiver. Tlie failure of the Municipality at any tirne to enlibree a provision of this Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. S. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and M tin icipal ity. Any attempt to arnend this agreement. by either an unauthorized representative or unauthorized means shall be void, 6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be brought inthe Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Agreement. 7. Severability. Any provisions of this Agreement decreed invalid by a court of competent .jurisdiction shall not invalidate the remaining provisions of the Agreement. (rev. 05/18/2018.) Page 2 of 3 OWNER: By: si nat re Date, c O UcrZA-- VA (print (print name) STATF OF ALASKA ) ss. THIRD JUDICIAL DISTRIC"•T } The foregoing instrument was ack owledged before me this l 1 day of �J pv gty:, 20 by NOTARY PUBL"M FOR ALASKA 1\11y Commission expires; MUNICIP'ALI_TY: By: � (signature) (print name) (rev. 05/18/2018) MARIA MCCRAW tk YPubFc•,Q4*dAftM MARICOPA COUNTY comwoUon # 812809 Ekp m August 26,2025_ Date: 1-tz;7 Title: Page 3 of 3 II X S89°56'18"E 164.77' X X::— X X X X X X TS96-0 0, 0 0 1) E 164.801 R) Wb AMM 9 SEP Ti C 0 VEN T (typ) ry 57.2" 0 SE1 /4 LOT 18 2 0 IN C� >•� WELL G LIJ 0 LJ N0") N') -ft, 0 CD 0 jL0 0 CD (0 0 0 0 00 00 71 0 U) 0 z GRAVEL C/) D/W 37.4' 4 CV 04 N90*00'00"W 164.86' (164.82' R) BASIS OF BEARING RABBIT CREEK ROAD ANCHORAGE RECORDING DISTRICT, ALASKA AS -BUILT OF: NOTE: SE1/4 LOT 182 Record information per plat 68-108 T12N R3W Sec33 Seward Meridian, AK !QXXXI SURVEY CERTIFICATE: I John L. Schuller Have conducted a OF %6,�kNL LAN1? AW 4Z physical survey of this property as shown on this drawing and that the 4 improvements situated hereon are within the property lines and no 00 enchroachments exist other than noted. Under no circumstance should C.� 49TH 0,0 any information on this drawing be used for construction of fences. OF .......... . ...... structures, improvements, or for establishing boundary lines. R • ?, ?A% PA �.,� r . EXCLUSION NOTES: It is the owners responsibility to determine ?j ............ t: OVA the existence of any easements, covenants, or restrictions which JOHN L. SCHULLER.- 0 LS -10408 do not appear on the recorded subdivision plat. #i 1831 Talkeetna Street WORK ORDER NUMBER: DATE: SCALE -E-MAIL AUG 1, 2021 1 11 =30' schullerftk.net • Anchorage, Alaska 99508 21-116 DRAWN BY: CHECKED BY. GRID NUMBER: BOOKPAM C) f e's S 10 n & (907) 227-1455 office L JLS SW3134 210255 N16 (907) 274-4992 fax MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ~)/ ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT N~me DISTANCES AddressC('"C' ~e4°~ o~ ~ ~ ~°c(°~~O ~ ABSORPTION WELL ~ ~o~TANK FIELD ~-~ ~00~ ~ LOT LiNE i0' N,~. LEGAL DESCRIPTION FOUNDATION Township, Range, Section TANKS N ~ SEPTIC ~ HOLDING I Manu(ac{urer Capacity in gallons TYPE OF SYSTEM ~TRENCH ~ BED ~ W. DRAIN ~OTHER originalDepth to pipe bottom from grade Total depth from original grade :ill added above original grade Gravel depth beneath pipe Gravel leng[h ~ravel width FT Date ,ns,a,,ed Total absorption area Distance between lines FT SQ Numberoflines Soilrating8, FT Pipe mateda, O,~ WELLS ~ PRIVATE ~ OTHER Ildentifv) Classihcation (A.B.C, Total Depth C~sed ,o lye FT /~ ,T Inslaller Date Installed: REMARKS: ~o{~tn~ ~n~ C¢[0C~ ~ [Io f tr:¢ ~eb ~ ach , ~ ~ ~ cmHythatthis,.s.e~ionwaspe.ormedaccordingloall Municipal and Slate guidelines in effecl on this date: Jl {~/~ ~9~',;. ''~ ~,% C~- - 35S9' ' ,," 72-013 (3/85) November 29, 1990 TO FILE: SUBS: SE4. Lt. 182, Sec. 33, T12N, The original inspection tank aboot 30 feet from from the holding tank is Rabbit CreekS. submitted bv Ted Moore shows the holding the ditch on Rabbit Creek. The slope to the ditch and to the west (toward Because it was known that during most parts of the vear the ditch in question runs water, field inspection was made on October 31, 1990. Although weather conditions had been below freezing for several days, an open water flow was found in the ditch. Photos of the water were taken that day. It appears that the stream flow begins at the eastern property line (a sprinq perhaps) and continues in the ditch to Rabbit Creek. On a subsequent day, ,John Smith and Dan P\o{~ ~ confirmed the presence of water. At this point the engineer was instructed to move the holdinq tank to a point outside the 100' required separation radios, The inspection report dated 11/26/90 represents that move. Ted Moore indicated that the tank is now 109' from the edge of the stream, / o ~x~- 9 o MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 O / ~' '-- '~ ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT 'dame Hub TANKS [] SEPTIC '[~ HOLDING ~TE~L TYPE OF SYSTEM [] TRENCH [] BED [] W. DRAIN [] OTHER FT FiC added above original grade Gravel depth benea!h pipe F1- Fr DISTANCES F RO M~"~.....~ -SEPTIC ABSORPTION WELL Wo~-~.TANK FIELD WELL LOT LINE FOUNDATION IOO/ I0° N,h. AS-BUILT DIAGRAM (Show Iocalion of well, septic system, property lines, foundation, driveway, water bodies, etc.) Total absorption area SO FT Number of lines Soll ratingS{~ FT ~ PRIVATE [] OTHER (Identify) Classgicatioh (A,B,C) Total Depth Cased to InstaCer ..~ULLIVfIN la/~TE~ W REMARKS: I ~j'.,,4.~I,~N~F~,,,~.~ ~ //?,~'-~'~- certily that Ihis inspeclion was pedormed according to all Health Department Approval: '~" 72-013 {3/85) Flattop Technical Services 14530 Echo Street ~irichorc~ge, Alaska 99516 Southeast Portion of BLM Lot 182, Section 33, T12N, R3W, S.M. 3241 Rabbit Creek Road . Water Supply and Wastewater Disposal Systems UPgrade Specifications GENERAL: 1. The scope of the project includes the abandonment of the existing well and drilling of a new well which is to be connected into the existing water distribution system serving the residence. In addition the existing wastewater disposal system is to be abandoned and a new 3000 gallon holding tank installed. The locations of the existing and proposed systems are as depicted on the attached site plan. All construction practices, and material specifications are to be in conformance with M.O.A. requirements. No construction is to take place until a permit has been issued. WELL SPECIFICATIONS: 2. The existing we!l is approximately 130 feet deep and has a static water level 110 feet below ground level with a measured yield of 0.78 gpm. Due to it's poor yield and location less than 100 feet from the septic system to the north, this well is to be properly abandoned by filling with concrete and cutting the casing off below grade with a steel plate welded across the top. 3. The new well is to be drilled in the location shown approximately 10 feet away from the existing well. The well shall produce water at a rate.of 3+ gpm from an aquifer located more than 40 feet below ground surfac~. If the combination of well yield plus water standing in the casing above the pump intake is insufficient to allow 160 gallons of water to be pumped from the well over a 20 minute period, a "Coyote" or equal pump protection device shall be installed. 4. A pitle~s adapter is to be installed and the water line from the new well connected into the water line leading from the old well into the residence. The new well is to be equipped with an appropriately sized submersible pump capable of pumping water at 7+ gpm into a pressure tank with the cutoff switch set at 50 psi. The pump in the existing well may be re-used if it is in good condition and it meets the pumping rate requirement. 5. The final product shall be a completely functional well connected up to the residence. The well casing shall extend 12+ inches above ground level and shall be fitted with an approved well seal and conduit protecting the aboveground portion of the wiring. The driller shall provide a standard well log, and shall take have samples from the well tested by a certified test lab demonstrating that the water quality is in compliance with requirements for coliform bacteria and nitrate-N. Copies of the well log and sample test results shall be provided to the engineer. ~'laffop Techn~ca! Services 14530 Echo Street A~/chorage, -~laska 9951~ WASTEWATER HOLDING TANK SPECIFICATIONS: 6. An on-site soil absorption system is not feasible due to the presence of seasonal high groundwater within 2 feet of ground surface which totally saturates the existing soil absorption trench. 7. The existing septic tank is to be thoroughly pumped and then crushed and buried in it's present location. The existing soil absorption trench is to be abandoned in place with the standpipes removed. 8. A new 3000 gallon holding tank is to be installed in the approximate location shown outside a 75 foot radius from the proposed well. The holding tank shall be fabricated from 3/16~ steel with bituminous coating inside and out, and shall be equipped with a watertight manhole cover and separate 4~ diameter access pipes for pumping and alarm float installation. 9. The holding tank shall be set level and buried such that the top of the tank is between 5 and 6 feet below ground surface, which may be raised by the addition of fill material. The finished surface shall be graded to ensure surface drainage flows away from the holding tank. The waste line leading into the holding tank shall be connected to a new cleanout pipe located between 2 and 5 feet from the building foundation. 10. An approved alarm float shall be installed in the holding tank and set to trigger an audible and visible alarm mounted inside the building when the remaining capacity inside the tank is 500 gallons or less. 11. Two inspections shall be required during constructions,,( 1 ) Initial stakeout, and (2) after the tank is set and the alarm box mounted with the float, properly adjusted for elevation, but prior to backfill over the tank. Flattop Technical Services 14530 Echo Street ~ffchorage, Alaska 99516 CL RABBIT ~CREEK RoAD PORTION OF BLN't LOT 15'2 WELL AND SEPTIC UP<SPADE SiTE PLAH DATE b~N 8Y NOTE: THIS IS Nc, T SURVEYED PLAT, ALL LOCATIONS ARE APPRoXiMATE by SULLIVAN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-275g OWNER OF LAND /'/,.) ~ DEPTH OF WELL ADDRESS ~L]O t/,J ~L~J ,~'-~'~ I ~4 ~ STATIC LEVEL OF WATER FT LEGALDESCRI~ION L. Iff~ ~< .~,~ Z}~} ~,Y~&) DRAW DOWN FT. ~/c/0 GALS. PER HR DATE Started Ended PE~IT NUMBER KIND OF CASING KIND OF FORMATION: From 0 Ft. to c~ Ft. ¢'~,D~0~5 ,(7~t~.Ctc, ,J}O From Ft. to--Ft From ¢~ Ft. to ~] Ft. O~ I~'~ From Ft. to Ft. From .~ Ft. to Ft.~ ~) ~ ~g~tzm From Fi. to_ Ft. From ~] Ft. to /1 Ft. ~'/~]~ 6(~0 ?~d~l~"< From__Ft. to Ft. From !l Ft. to ,~ Ft. 'F/d~'F' ~[~~ 7 r/ ~4d~Z&rrom rt. to Ft From~'~TM Ft. to ~0 .Ft,[/~;'Y ~0'~ ~/ ~t~ From__Ft. to Ft. From 7~3 Ft. to / 7.~ Ft. 'J~ 6 ~ ~'/c7"~ ,~O~) From Ft. to. Ft. From__Ft. to Ft. p' ~deL ~ I From Ft. tc. Ft. From [ ,5,-;' Ft. to [~'c~ Ft. -~'~ (~[d~d,~, ';' From Ft. t¢~ From Ft. to Ft. ~¢ ~ I ~-/~, From .Ft. to Ft., From Ft. to Ft._ From Ft to Ft Fromm. Ft. to' Ft. From ' ' Ft. t6 Ft. Fromm. Ft. to Ft. From Ft. t6 .... Ft From Ft. to Ft. From__Ft. to__ Ft. From Ft. to Ft. From Ft. to Ft From Ft. to _Ft. From__Ft. to Ft From Ft. to Ft._ From Ft. to Ft M1SCL. INFORMATION: ........ ,r~.lir gF AN(~JORAI~ DEFT, OF HEALTH;& ENVIRONMENTAL PROTECTION ? o RECEIVED DRILLER'S NAME . GREAiER ANCHORAGE AREA BORudGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTIC~ REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: DISTANCE FROM WELL ~/~2~D/~- 7~MANUFACTURER INSIDE LENGTH INSIDE WIDTH COMPARTMENTS 4~ LIQUID DEPTH LIQUID CAPACITY/1~ GALLONS. SEEPAGE P~: NUMBER OF PITS LINING MATERIAL ~'¢) CRIB SIZE: DIAMETER BUILDING FOUNDATION .r~)~,-'/'NEAREST LOT LINE.-~/~. ADDITIONAL ABSORPTION DEPTH DISTANCE FROM: WELL /L'~ ,~-,2'- '~, TOTAL EFFECTIVE ~ ABSORPTION AREA (WALL AREA) ~ SQ. FT. Well: ~.~.~ ,~,~_/~ ~-~./~ ~/~__.~ ,,..,]~:~-- /).,Z-~ g' ~ ~ ~ ~..7~.4 TYPE ~.~ ? CONSTRUCTI ~/ DEPTH __ DISTANCE"FR_R_R_R_~M: ~- BUILDING NEAREST NEAREST SEPTIC SEEPAGE,~' FOUNDATION LOT LINE SEWER LINE TANK SYSTEM CESSPOOL _ OTHER SOURCES APPROVED DISAPPROVED REMARKS INSTALLED BY: , LOT SLOPE: ,- NLINICIPRL'II-"w' OF' F~r~CNORR6E [:EPRRT~ENT OF HERLTH RND ENVIRONNENTRL' PROTECTION ~ ~ ~ ~.~ ' : , 274~456i . PERMIT NO.( ') ~ ~ .; SRB'BO,,, 4~C LOCRTION RBBBIT CREEK RD LEGRL SEt74 L182 SEC ~ TiZN L~r SIZE 18975 SQFT ,~¥PE OF SOIL BBSORPTION SYSTEM... TRENCH ,'NUMBER OF BEDROOMS~ ~ SOIL RRTING, SQFT?BR 120 ~-- ~ THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS:DEP~H='~ LENGTH=,--~C~, THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE EXCRVBTION BOTTOM IS'~ FT THERE IS NO SET WIDTH FOR TRENCHES. FOR DRRINFIELDS,THE WIDTH IS ~ FT. THE DEPTH OF TRENCH OR PIT IS THE DISTRNCE BETWEEN THE GROUND SURFBCE RND THE BOTTOM OF THE EXCRVRTION. THE LENGTH DIMENSION IS THE LENGTH OF ERCH SIDE FOR R SEEPBGE PIT OR THE LENGTH OF THE TRENCH, OR DRRINFIELD. THE REQUIRED SEPTIC TRNK SIZE IS IO00 GBLLONS B~CKFILLING OF ~NY SYSTEM WITHOUT FINAL INSPECTION BY THIS DEPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTBNCE FROM WELL TO RNY SEPTIC TRNK?PBCKRGE PLANT OR SOIL RBSORPTION SYSTEM IS iO0 FT FOR ~ PRIVRTE WELL RND 200 FT FOR ~ PUBLIC WELL. SPECIFICRTIONS RND CONSTRUCTION DIBGR~MS RRE RVRILRBLE TO INSURE PROPER INST~LLBTION. I CERTIFY THaT I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS ~ND WELLS RS SET FORTH BY THE MUNICIPBLITY OF RNCHORRGE BND WILL INSTRLL IN ~CCORDRNCE WITH THE CODE. CONSULTANTS. INC. JUNE'~U November 3, 1975 R & M No. 562150 Mrak Vaughn Star Rt. A Box 496C Anchorage, Alaska 99507 RE: Test Hole and Soil Log Report for Sanitary System Lot 18~, SE~, Section 33, T12N, R3W, S.~4. Dear Mr. Vaughn: We are submitting herewith the test boring results and our comments regarding soil conditions encountered at the subject site. This inves- tigation was performed in accordance with your request of October 27, 1975, and those procedures outlined in a letter dated July 15, 1975, by Mr. Rolf Strickland of the Greater Anchorage Area Borough Department of Environmental Quality. A single test hole was pus down within the Lot ~Z"area for the purpose of defining general subsurface soil conditions for the proposed sanitary system. Excavation was accomplished with a ~racsor-mounted backhoe and the test hole was extended to a total depth of 12.0 feet below ground surface. The final log prepared fQr the test hole has been included in Drawing A-O1. Ground water was encountered in the test hole at a depth of 12.0 feet. We appreciate being given this opportunity to be of service to you. Should you have any questions with regard to the above, please do not hesitate to contact us. Very truly yours, R & M CONSULTANTS, INC. J es Rooney/ 3 Vice President ~ JWR/WED/sc Encl. xc: GAAB T.H. 1 No Scale N W. D. T.H. 1 10-31-75 Silty Sand (Fill?) Organzcs Silt Trace Sand (~L) 0.0' 0.5' 1.5' Sand, Trace Silt (SP) Sandy Gravel Trace Silt (GW) Silty Sands w/Some Gravel (SM) Qravelly Sand Trace Silt, (SW) t2.0' Log Represents Location of Test Hole SE ¼, Lot 182, Section 33 T12N, R3Q, S.M. R ConsuJtants Inc. ANCHORAGE FAIRRAN~[G ALASKA JUNEAU Mark Vaughn Property Log of Test Hole Anchorage, Alaska I ..... I,".~rn mY ~PRO,J. NO. = ..... Iowa NO. A--Fi1 MUNICIPALITY OF ANCHORAGE Development Services Department `�' �� p p `--.�T Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 018-292-29 Legal description T12N R3W SEC 33 LT 182 SE4 Site address 3241 RABBIT CREEK RD Current property owner(s) JI YUNJEONG Expiration Date: 4/30/25 X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: By: Gt% Original Certificate Date: 5/24/2024 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 X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval June 2022 Development Services Department w F1 On -Site 'Nater & Wastewater Section Phone: 907-34.3-7904 Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 018-292-29 Complete legal description T1 2N, RM, SECTION 33; LOT 182 SE 1/4 Location (site address) 3241 RABBIT CREEK ROAD, ANCHORAGE, AK 99516 Current property owner(s) JI YUNJEONG Day phone 907-952-4596 2. ON-SITE SYSTEMS SIZED FOR 3 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 FW Plastic ❑ Concrete ❑ Fiberglass Age - See advisory if steel older than 20 years 6. ABSORPTION FIELD: FE� AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited reVi6W requested' ❑ 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. �2c C, COSH Application June 2022 COSA Checklist Legal Description: T12N, R3W, SECTION 33; LOT 182 SE 1/4 Parcel ID: 018-292-29 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system 1 A. WELL DATA ❑■ Well log is filed with Onsite (or attached) Date drilled 8/1990 Total depth 142 ft Cased to 142 ft 0 Sanitary seal is functioning correctly ■❑ Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 4/30/2024 Static water level at beginning of test 106 ft Comments R V4 2�f � Well production at time of est 7.9 gpm Water storage tank volume N/A 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 GEG, LTD. Date 4/30/2024 �- 512Y%2`v 61V B. TANK DATA C. LIFT STATION Measured operating fluid level in septic nk ❑■ Required maintenance completed Date of pumping ' S�2 3I 2� Age of lift station 2 years AN Required maintenance completed, if A Lift station material PLASTIC Comments: *SEE AWWTS MAINTENANCE LOG Comments: *SEE AWWTS MAINTENANCE LOG D. ABSORPTION FIELD DATA Which system tested (date installed) 3/4-5/2022 ❑■ ALL standpipes present per record drawing Total measured depth from grade *5.0 ft (max) Measured depth to pipe invert from grade ft (min) ❑Q 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 **597 gallons 4/30/2024 date Any rejuvenation treatment (past 12 months) N/A If yes, enter date Adequacy test date 4/30/2024 Results ❑■ Pass Fluid depth prior to test Water added 639 gal New fluid depth 0 in Elapsed time 0 min 0 in Final fluid depth 0 in Absorption rate 450+ gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 12 in Effective depth used 0 in Effective depth remaining 12 in Comments/Deficiencies: *FOR EAST MT, 3.9' T.D. FOR WEST MT. **CALCULATED POOR SPACE IN DRAINROCK IS 449 GALLONS (30 X 5 x1 = 150 cu.ft. X 7.48 gallons/cu.ft. = 1122 gallons x 0.4 = 448.8 gallons). COSA Checklist June 2022 E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distance/if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' if No ft Community Sewer Manhole/Cleanout > 100' ❑ Yes if No 0+ ft E Yes if No ft if No ft Neighboring Tank > 100' ❑w Yes if No \ft Private Sewer/Septic Line > 25' ❑■ Yes if No ft Absorption Field on Lot > 100' ❑ Yes if N 0+ Holding Tank > 100' ❑■ Yes if No ft Neighboring Absorption Fields > 100' I nimal Containment > 50' ❑■ Yes if No ft ❑■ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑■ Yes if No ❑■ 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 Surface Water > 100' [:]Yes if No *50+ ft Tank to Property Line > 5' Field to Property Line > 10' Water Main > 10' Water Service Line > 10' F. ENGINEER'S COMMENTS ❑ Yes if No ft ❑ Yes if No *5+ ft ■❑ Yes if No ft Yes if No ft Wells on Adjacent Lots: Private Wells > 100' Community Wells > 200' ❑ Yes if No *50+ ft ❑■ Yes if No ft If tank or field is under driveway comment below NOTE: FCO NOT FOUND, BUT DOUBLE CLEANOUTS PRIOR TO TANK WILL ACT AS FOUNDATION CLEANOUT. Q4Z-ePF THE.DRAINFIELD APPEARS TO BE JUST SHY ON COVER. NO FREEZING ISSUES PER OWNER. SEE ATTACHED EMAIL. L G. CERTIFICA NT 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 Garness Engineering Group, LTD. (GEG) Phone 907-337-6179 Engineer's Printed Name Jeffrey A. Garness Date In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend upon a variety of variables, including (but not limited to) soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fail to perform adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG to perform the evaluation. Reliance upon the information provided in this report by any other person or party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. COSA Checklist June 2022 W= ),SFS Sf 7y 12 -JI ®o>>' AT&T ^ 3:11 PM 100%. dug 10-12 inches down, on the swing tie location for the supposed FCU. I dug approximately a 3' diameter around the swing tie point and. Followed the path where I can see the f sewer line was excavated. There was no FCO to find. Jeff Garness From: Jody Maus Sent: Friday, May 17, 2024 3:01 PM To: Jeff Garness; Sonja Blewett Subject: FW: 3241 Rabbit Creek COSA From: YunJeong Ji <doog7011@gmail.com> Sent: Friday, May 17, 2024 2:59 PM To: Jody Maus <Jody@garnessengineering.com> Subject: 3241 Rabbit Creek COSA In the time that I have owned 3241 Rabbit Creek, I have never lived in the home. It has been a rental property the whole time. My tenants never complained of any freeze up issues with the septic. I have had the septic serviced every year and the technician never mentioned any problems with the system. Thank you. Yunjeong Ji MUNIC'IPALITV OF AN('110RAGE ADVANC'ED WA5'1't WA'1'1?It A'1'M1�,N'1' IMA1N FINAN('it, AND REPAIR AG'REPMENT THIS N4A1N'1'I:;NANCI: ANT) REPAIR AGREEMENT. herein the "AGREEIMENi'" made and entered into as ofthis,►'t( Day ai'A of 20�, by and between SZ , herein the "OWNER." and the Municipality of .Anchorage, herein the "MUNICIPALI'T'Y", in accordance with Anchorage Municipal Code (AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as tQ-/ Ig-�)uA-m T"c-( !S q S7`6 -IM located at (legal. description) 3 9"bi I-- i9e4c n 3 ki 9&a 3,3 car 2. Maintenance, Repairs and Alterations. (Owner is required to read, understand and initial each section) Throughout the term of this Agreement, the Owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the Municipality or the manufacturer's representative. The AWWTS shall be maintained in a satisfactory condition capable of performing as designed and producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality. It shall be the responsibility of the Owner during the term of this Agreement to pay for all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This includes an annual maintenance fee (typically $400 to $600). Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, repairs or permitted alterations to the system. Owner acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield replacement. (rev. 05/18/2018) Pagel of3 =6 th\-ner acknowledges that the Municipality may request records of maintenance and Irhairs from the ltlanut'hetureCs representative or maintenance provider. 0� t�rrnes acknowledges that the fine 1m• failing to maintain and repair an AWWTS may be assessed In accordance with AMC 14.60.030. ON\ -mer agrees to grant the Municipality reasonable access to test and inspect the AVl%\\ITS. The Mumclpallty will give at least 24-hour notice. Owner agrees that any sale or transfer of title of the property wi11 not occur without a new Certificate of On -Site Systems Approval. Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing guidelines for the construction, maintenance and repair of the Owner's AWWTS. Owner agrees to maintain remote monitoring of the AWWTS as required by the AWWTS approval. 3. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system, or upon transfer of title, and shall continue while the AWWTS is operational or until title is transferred. 4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Agreement. 7. Severability. Any provisions of this Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. (rev- 05/18/2018) Page 2 of 3 OWNER: (Sign, 5 z -- J h U IT STAIT OF ALASKA ) ) Ss. THIRD JUDICIAL DISTRICT ) d The foregoing instrument eras acknowledged before me this day of May 20rug FWCanw�rkft ofAlwAa N TARP PUBLIC FOR ALASKA ypmuc eaelani My Commission expires: 02 - o9 --A P � 0z _ 02-2- MUNICIPALITY: By: (signature) (print name) (rev. 0511812018) Date: �Z 2 -I Title: Page 3 of 3 489 673 tai on ■ on among Bonn ■ ■ no o an mann■ titer 3 on ■ on ■ ■ a ■ ■ on ■ a rr ■o■ ■ a m B on ■ on on ■■ rr s �"vanTexO Field Maintenance Report AnchorageTank Annual Inspection 907-272-3543 Property Ownerfrmcking X Inspect Operator RiserA id ..................... Yunjeong Ji Spline Box .................... Lary Betts Previous Site Address Previous Contact Ptwrre 3241 Rabbit Creek Road, Anchorage AK 99516 }` (907) 555-5555 Ax Site IDX County IDX Pod X RTU XNL N Date of Last Inspection AX -155077 OSP211395 ............ RTU146809 09/14/2023 Retrieve O&M Info Daily flow Recirc ratio Timer settings: This is a COSA Inspection Perform Field Sampling/Observations NTLI (15 t NTUs) pH (6-9) DO (2-6) Odor of Sample Typical 0 Musty ❑ Earthy ❑ Moldy Non -typical oSutfide ❑ Cabbage ❑ Decay Oily film in PVU ❑ Yes No Foam In tank ❑ Yes No Check Control Panel Recirc Amps Discharge Amps I t- 0 Audible and visual alarms � OK Dial tone (telemetry only) ❑ Yes /No Inspect/Clean Pump System Signature Measure Sludge/Scum Sludge Scum I st Compartment Inspect Clean RiserA id ..................... Previous Spline Box .................... Current Previous Float Cords ................... Previous Floats........................ }` Pump........................ Inspect/Clean Discharge Pump System , Blotubee Fitter ................. Inspect Biotube Pump Vardt ............ Clean RecirculatingSplitter Valve ....... Floats Comments _ `3 X)N t ->,C Signature Measure Sludge/Scum Sludge Scum I st Compartment Current Previous Current Previous 2nd Compartment Current Previous Current Previous Inspect/Ciean AdvanTex Filter InspectfService Other System Components Inspect Clean Inspect Clean Disinfection Equipment Dispersal Laterais/Orifices Observations ��1�izC0 Additional Services Rendered ❑ Cleaned textile sheets? ❑ Replaced UV items? ❑ Replaced/Used other items? Parts Used: W = Warranty, B = Billable {✓ appropriate selection) W B kern Number Description Final/Safety Inspection (P RSV reinstalled] Lids bolted on Manifold reconnected; flush valves closed )6Controi panel reactivated Summary/Recommendations Q System performing; no further action needed ❑ Tank needs pumping Q Cali for service © " ' t� 6 d 0 i l� 1 t t/ O other? � Date Fax completed form to 1-866-384-7404 Inspect Clean Odor. ] Normal ❑ Pungent Laterals/Orifices ID Biomat: Normal ❑ Excessive Pod Bottom Bridging/Ponding: None/Minor ❑ Excessive intake Vent r� Inspect/Clean Discharge Pump System Inspect Inspect Clean Riser/Lid Floats Splice Box Pump ,{ Float cords InspectfService Other System Components Inspect Clean Inspect Clean Disinfection Equipment Dispersal Laterais/Orifices Observations ��1�izC0 Additional Services Rendered ❑ Cleaned textile sheets? ❑ Replaced UV items? ❑ Replaced/Used other items? Parts Used: W = Warranty, B = Billable {✓ appropriate selection) W B kern Number Description Final/Safety Inspection (P RSV reinstalled] Lids bolted on Manifold reconnected; flush valves closed )6Controi panel reactivated Summary/Recommendations Q System performing; no further action needed ❑ Tank needs pumping Q Cali for service © " ' t� 6 d 0 i l� 1 t t/ O other? � Date Fax completed form to 1-866-384-7404 MUNICIPALITY OF ANCHORAGE Development Services Department -T Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 018-292- 1. GENERAL INFORMATION Complete legal description T12N R3W SEC 33 LOT 182 SE4 Expiration Date Location (site address) 3241 RABBIT CREEK ROAD, ANCHORAGE, AK 99516 S=I- zozZ Current property owner(s) MARK VAUGHN DOUGLAS Day phone Mailing address Real estate agent 3241 RABBIT CREEK ROAD, ANCHORAGE AK 99516 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: COSH to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Date of Payment Receipt Number COSA# Date: Waiver Fee $ Date of Payment Receipt Number 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY, ANCHORAGE, AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 03/31/2022 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the •�ii ` OF A well and septic system. Therefore, any estimate of how long a system will function satisfactory ��%Q: •' • • . for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting& FWC5 ' / *' •� 7H • •'* �� ...: ...... / 6. DSD SIGNATURE .. "'...." Curtis Huffman / System #1 Approved for bedrooms CE 128991 . �Aw'� lF� -.Q3/31122- System .Q3/31/22'System #2 Approved for bedrooms It F�1'°ROFESSIONP Disapproved Conditional approval for bedrooms, with the following stipulations: �P�vhP co 10 F�OPMOA\ By: t"~' ., Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional 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 Legal Description: T12N R3W SEC 33 LOT 182 SE4 Parcel ID: 018-292-29 If more than 1 septic system on lot: COSA Checklist # _of _ Structure served by this system A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled 8/1990 Total depth 142 ft Cased to 142 ft ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 8/9/2021 Static water level at beginning of test 108 ft. Comments B. TANK DATA Age of tank(s) *NEW TANK _ years Tank type/material ADVANTEX / FIBERGLASS Measured operating fluid level in septic tank NA* ® Standpipes/foundation cleanout per record drawing Date of pumping *NEW D. ABSORPTION FIELD DATA — NEW FIELD Which system tested (date installed) NA ® ALL standpipes present per record drawing Total measured depth from grade 6.2 ft (max) Measured depth to pipe invert from grade ft (min) ® N/A — pressurized field ® Monitor tubes go to bottom of effective. If not, state depth into effective Well production at time of test 6+ 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 NES Date of Sample 10/26/2021 C. LIFT STATION ® Required maintenance completed Age of lift station * years Lift station material PLASTIC Comments: *NEW Adequacy test date NEW FIELD Results 0 Pass For 3 bedrooms Fluid depth prior to test _in Water added gal New depth in Elapsed time min ®Code -required soil cover over field Final fluid depth in ❑ System presoaked Absorption rate gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) If yes, enter date Gallons introduced gallons NES Comments/Deficiencies: NEW ADVANTEX PER MNA AIR/ASB ,; 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' ® Yes if No Community Sewer Manhole/Cleanout > 100' ❑ Yes if No *50'+ ft ® Yes if No ft Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No *50'+ ft Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ® Yes if No ft ® Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ®Yes if No ft ® Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water >' 100 _ ❑Yes if No 50+ ft Property Line > 5' ❑ Yes if No *5+ ft Wells on Adjacent Lots: ® Yes Absorption Field > 5' ® Yes if No ft Private Wells >100' _ El Yes if No *50+ ft Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property tine > 10' ❑ Yes if No *5'+ ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ❑ Yes if No *50+ ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ❑ Yes if No *50+ ft F. ENGINEER'S COMMENTS *SYSTEM MEETS CAT III SEPARATION DISTANCE REQUIREMENTS. G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Aw 00 zi :.... i Curtis Huffman f �F'�•. CE 128991 i`� e o 03/31/2z-��c��i il�®twaE:``��- MUNICIPALITY OF ANCHORAGE tG\•a AUNT' Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax.: 907 343 799-7— Certificate of On -Site Systems Approval Parcel I.D. 018-292-29 Expiration Date: 1. GENERAL INFORMATION Complete legal description T12N R3W SEC 33 LOT 182 SE4 Location (site address) 3241 RABBIT CREEK ROAD ANCHORAGE, AK 99516 Current property owner(s) MARK VAUGHN DOUGLAS Day phone Mailing address 3241 RABBIT CREEK ROAD ANCHORAGE AK 99516 Real estate agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. ,-- Ire-Fuhd rec�uecltd Date: COSA Fee $ -i- A 2 9 0 co lQ7jopWaiver Fee $ Date of Payment 11 Lf5 / u Receipt Number 51 5 1 G H COSA # o s c a 11 (o (o l(o Date of Payment Receipt Number 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 dispo'al sy5temis (arerin compliance with al pa pflca a unlcipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY, ANCHORAGE AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 11/12/2021 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & N'H 6. DSD SIGNATURE System #1 Approved for System #2 Approved for / Disapproved Conditional approval for 3 bedrooms bedrooms 1 � OF,�s�l�� 67H •.* Curtis Huffman • • • • ' I��Fc•. CE 128991 .•oi i�,F, PROFESS100 bedrooms, with the following stipulations: By Original Certificate Date: 111231aO,471 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 Legal Description: T12N R3W SEC 33 LOT 182 SE4 Parcel ID: 018-292-29 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA Well log is filed with Onsite (or attached) Date drilled 8/1990 Total depth 142 ft Cased to 142 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 8/9/2021 Static water level at beginning of test 108 ft. Well production at time of test 6+ 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 of Sample 10/26/2021 Comments B. TANK DATA Age of tank(s) *NEW TANK PENDING years Tank type/material ADVANTEX / STEEL Measured operating fluid level in septic tank NA Standpipes/foundation cleanout per record drawing Date of pumping * C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA – NEW FIELD PENDING Which system tested (date installed) NA 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 Monitor tubes go to bottom of effective. If not, state depth into effective Code-required soil cover over field System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Adequacy test date NEW FIELD PENDING Results Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) N If yes, enter date Comments/Deficiencies: 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’ Yes if No *50’+ ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No *50’+ 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 From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Property Line > 5’ Yes if No ft Absorption Field > 5’ 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 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 Property Line > 10’ Yes if No *5’+ ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No F. ENGINEER’S COMMENTS *PROPOSED SYSTEM MEETS CAT III SEPARATION DISTANCE REQUIREMENTS. G. ENGINEER’S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. 11/12/21 A11D VAN CIED W"1P]e.1WA17IEIR TI &A17i`W EN7I' S YSMEM MAIN71ERiMC E AND R EIIAM A GIIBJEIEREENT THJS MAINTENANCE AND REPAJUR AGREENDENT, herein the "AGRJEEMENT" made and entered into a-- of this lam- Day of rV o ilL�:;'"I l' of 24 -,!V -L by and between W -t'' '6 herein the "OVftC-R," and the Municipality c Aurhorage, herein the "ll Jl-CIPALITY", in accordance with Anchorage Municipal Code (AMC) 15.65.365. In consideration of the mutual covenants contained 'herein, the partLes to :his Agmement agree as follows: Adlafnsecl WMIZIewaterr T ar�r mc��nt atter a The Municipality grants penjz'ss=on to the Owner to uta and operate an Advanced Wastewater T-eaiunen. System (AWWTS), described as AN AZ"V N l SYST1:---M located at (IegaF description) (3241 RABBIT GRE-:ZK ROAO) T1 2N R3W SEC 33 LOT 162 SE -4 2. _W[fi m- M:n@rj-^e� iF3 ;mrvs nand! AL-IeLrytli ancs. r,�ner is -equired z read, understand and irnitiaeach section) i Throughout she terra of this Agreernent, the Owner shall enter into a servt.ce agreement with. an Q WWTS service and maintenance provider approved by the Municipality or the manufacturer's :-epresentat'.ve. The AWWTS shat' be maintained in a satisfactery condition capable of performing as designed and producing vxeated septic effluent ir.. accordance with the equipment's approval_ for operation in the Municipality. :'t saa:l be the responsibi'ity of tike Owner during the :enn of this Agreement to pray for all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. TiLs includes an annual maintenance fee (typically $400 to $600). ~ Owner agrees that only main6.enance and repair personnel approved by the Municipality or the mmufacturen's representative will anspect and make. any necessary maiintr.aance, repairs or pemtitted alterations to the system. er acknowledges that -egular maimbe:vance of an .4+.WW7S reduces rhe potentia_ failure of the systema, which could Liclude sewage backup and costly reairs or, d.4aint;eld zep�acemaent. (rev. 05/18/2,028) Mage it of 3 Owner aclmowitedges that the Municipality may request records of nr„aintenance and repairs om'he manufacturer's representative or nminienance provider. ` Owner acknowledges that the fine nor Failing to maintain and repair xn AWWTS --my be assessed in accordance with ALIO 14.60.030. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS. The hllunicipahty will give at least 24-hour notice. Owner agrees that any sale or transfer of title of the properly will not occur without a new Certificate of On -Site Systems Approval. Owner agrees fiat 6e AWWTS nstailatron and maintenance regWrelments as provided by the AFITS vendor/installer and approved by the Municipality are the governing guidelines for the construction, maintenance and repair of the ®w net's A li S. eT agrees to maintain remote monitoring of the AC'S as required by the ATS approval. 3. 7c =,,. Tae term of finis Agreement shall begin on the date of approval by tine Muwcipality to operate the insta::led system, or upon transfer of title, and sinal:: cont::nue while the AWWTS is operational or until title is transferred. 4. 1Yggw@AveT. The failure of the Municipality at any t'Me to en.{'orce a provision of this A&recment shall qn no way constitute a waiver of the pTovisions, aor in any way a 7ect the validity of the Agreement or any part hereof, or the right of tiae Municipality thereafter to enforce every provision hereof. g. Amsmafl.mermt. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either as unautaor ized representative or unauthorized means shall be void. 6. Cbofic e of 1Lsiw. Any civil action a-ising from this Agreement shayl be brought in the Superior Coun for the Third Judicial District of the State of Alaska at Anchorage. The Laws of the grate of Alaska shall govern the rights and obligations of the parties sander this Agreement. `/. ? rffiLv_i . Any previsions of this Agreement decreed invalid by a court of competent jurisdicV.ora shall not invalidate the remaining provisions of the Agreement. (rev. 05/19/7C 18) )?age 2 of 3 ~, (signature; Date: By: j YLA M �O�N C/ ! lY {lrlt nwne j Ss. TI JRD s UDYCIAL DlSTPJC T ) po vel TLB fe:egeing astz=ent was ael-.nawledgedi befa:e ris tL s lZ, day �% h1a��..rr*.ber Lt , by a!;t MATTSAUVAGEAU NotaryPublic 1 OR ALi',S't;.f State of Alaska Y Commission e) pipes: � 07A M 1�y Commission Expires Jul 21, 2024 /� / rs na¢ure`� 13y: IC D,C l'1 g 61 Re e CC:A �ro /( (p:int name) ]Cate: �t Z3 X02 Ttle: Page 3 of 3 (rev. 05/18/2019) MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING ~:r,~'-- D.~t::Z - 3.? HAA# /L~. /~0,0xTL~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Location (address or directions) Telephone: (home) t'/o w'/"~'~v~'~-- Telephone (b) Property owner Mailing Address ~ (c) Lending Institution Address Business ~71 - ?'),~'~ / Telephone Id) Real Estate Company and Agent &.~.r~'~,-~ ~,"~ /~C" -- -~'"~Z /~'/'"""'~ (e) Mail the HAA to the following address: (or check here ~, if hold for pick up.) List contact person and day phone number.below: 2. TYPE OF RESIDENCE Single-Family I~1 Number of bedrooms 3. WATER SUPPLY Individual Well [] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental ConservatiOn attesting to th legality and status. 4. SEWAGE DISPOSAL · On-site [] Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 {Rev. 7/88) Page 1 of 2 '~JOM s,Jaeu!Bue leuo!$s@~oJd eH1 u! suoiss!uJo Jo sJOJJe Jo; elq!suodsa~ lou s! e§sJoqouv jo ~l!led!o!u n~l eH.L 'penss! s! eleoy!peo e a~oIeq el~p ezXl~ue Jo suo!~oedsu! ~onpuoo ~ou op SNHQ lo saeXoldLU~ 'slueLue~!nbe~ re, els pue le~ep@~ u!m~eo XIs!l~s ol ~ep~o u! suo!lnl!lsu! 8u!puel ~!eql pue seuJoq lo s~eseqoJnd o~ ~sepnoo ~ s~ s!ql seop SHHQ eW.L 'miseIV ~o el~lS eq~ u! peJe~s!BeJ ~eeuI6ue leUO!Sselo~d luepuadepu! ue Xq eAoqe ~ ttde~§e~ed u! U~A!8 suo!l~lueseJdeJ eq], uodn/~lUO peseq le^oJdd¥ Xlpoq~,n¥ qll~eH senss! (SHHQ) seO!A~eS UeLUnH pue qlleeH ~o ~ueuJ1J8dac] eBeJoqou¥ ~Lo Xl!led!o!unJAI eqL leuo!l!puoo leAo~dd¥ leuo!l!puoo to SLU~eI p@AoJddee!c] ~/ peAo~dd¥ 'l~AOl~dd~ SNHCl '9 le~S MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: -~ A. WELL DATA Well Classification Well Log Present (Y/N) Total Depth I~'/ ~ Cased to Static Water Level II ,~ ' Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To $cp"~s/Holding Tank on Lot ;~5- ' To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by ~'(¢.('~'.P If A, B, C, D.E.C. Approved (Y/N) Date Completed ~'/Pa Yield ~ ~, I"(E Depth of Grouting I~1,,~ Pump Set At ~' ~1 ~ ~ ~ Sanitary Seal on Casing (Y/N) Y' Depression Around Wellhead (Y/N) ; On 'Adjoining Lots '~. ICG ¢4,/t. ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole 5"v ¢£, ; Date Io/17 Water Sample Test Results Comments B. S~I~/HOLDiNG TANK DATA Date Installed II ('~-~/~ Size '~OO~,.¢,¢,¢ Standpipes (Y/N) ~ Air-tight Caps (Y/N) Depression over Tank (Y/N) /V Pumping/Maintenance Contact on File (Y/N) )' Holding Tank High-Water Alarm (Y/N) ~' No. of Compartments ! Foundation Cleanout (Y/N) Date Last Pumped N,/I.. ; for Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well ~,~'~ To Building Foundation To Property Line l ~' To Disposal Field To Water Main/Service Line 5'0 ' To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) F¢ont Page 1 of 2 C. ABSORPTION FIELD DATA h/, Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) D. LIFT STATION A{,~. Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **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 Company ...... ;v~;;;,~,','~,~' ~' '~ '7 -~-5 Engineer's Seal Date 0f Payment / o ~ ~--- ¢ o .,~L~¢Fee:$-- Amount:$ /",O e~ l~ of Payment 72-026 (Rev. 7/88)Back ~ Page 2 of 2 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELL 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, townshi Location (address or directions) 3' 2¥1 rf ~ &i,~ (b) Property owner ~,~'. Dcp¥ ~ Mailing Address ~ (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Address ~,4~' ¥d_.2 (,4M. Telephone (e) Mail the HAA to the followin List contact person and ~hone: (home) .h= ?qS-O ! Telephone Business (or check here ~', if hold for pick up.) number below: 2. TYPE OF RESIDE Single-Family Number of bedrooms 3. WATER SUI Individual Note: Community [] Public [] system, mus~ nave written confirmation from the State Department of Environmental to th legality and status. 4. S~/WAGE DISPOSAL /~n-site [] Public [] Community. E] Holding Tank [] //Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025(Rev. 7/88) Page ' of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION' As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of th is 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. Name of Firm ,~[~'~/¢ 7-¢c/~'~/ .~'e~'~';¢~' Telephone Address I~O ~o ~ ~o~ ~ ¢~'/~ Date /0 [ 8~ / ~d 6. DHHS APPROVAL Approved for Approved bedrooms by Disapproved Terms of Conditional Approval Conditional Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 Mu nicipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Bsck Page 2 of 2 · ' .~.C_~"~-'%. MUNICIPALITY OF ANCHORAGE (MOA)~ ~ ,.L~,O~_,~\a~[~.~ Health Authority Approval (HAA) ~[~ ~ O~ ~Ct59~// CHECKLIST- FEBRUARY 1984 ~ ~t~~ ~ ~ 343-4744 ~ ~F.~-- ~ LegalDescription: ~ Po~e~ ~ ~ ~t~ Well Clarification ~u~4 If A, B, C, D.E.C. Approved (Y/N) N,~. Date Completed ~/~ Yield~y~p~ ~ Io/Ip/?~ Well Log Present (Y/N) i~' Total Depth I~-' Cased to Static Water Level t Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Ccptlc/Holding Tank on Lot tOO* To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by f:' "r'_( Water Sample Test Results I¥'Z' Depth of Grouting Pump Set At · ~2 ,, ~ II'Z.~ Sanitary Seal on Casing (Y/N) T' Depression Around Wellhead (Y/N) ; On Adjoining Lots ? tc.,o ' N,/t-, ; On Adjoining Lots ~' too ' To Nearest Public Sewer Cleanout/Manhole ; Date ! Foundation Cleanout (Y/N) Date Last Pumped ; for ..~..~ ~ ~-c ../ Temporary Holding Tank Permit (Y/N) /~,,4,-, .~ ooo~,,,! No. of Compartments B. 9~c'P-T-'IC?HOLDING TANK DATA Date Installed lO/~"/Po Size Standpipes (Y/N) ~' Air-tight Caps (Y/N) Depression over Tank (Y/N) N Pumping/Maintenance Contact on File (Y/N) Y' Holding Tank High-Water Alarm (Y/N) I" SEPARATION DISTANCES FROM S'E'P-T'I'O~HOLDING TANK: To Building Foundation To Disposal Field To Water-Supply Well t To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course _-~ Comments 72-026 {Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Hr~'. Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) D. LIFT STATION N,~, Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA gg.'t~cl;[Ee~[r~ effect on the date of this inspection. Signed ~-"~ ~ .......................... ¢ Engineer's Seal Date Io MOA No. ReceiptNo. ~,~,Y(/"~ (,--~op',~- .) Date of Payment /~' ~ ¢ ~ ~ ~ Waiver Fee: $ Amo.nt:$ /~ ~O Date of Payment 72 026 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE DMSION OF E~JIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ~NVIRONMENTAL PROTECTION APPLICATICkN FOR HEALTH ~371/qORITY APPROVAL CERTIFICATE 1. C~r~al Inforraaticn Application Date (a) Lega_ Description (include lot, block, subdivision, section, tc~ns~fip, ran~) Location (address o~ di. rections) (b) ~plicants N~~F M. ~eM~ Applicants Ad~ess~ ~ ~~ (c) Applicant is (che~ o~) ~nding Institution Burr ~; ~e~ ~ (e~lain); (d) nding Institution r Ad,ess (e) ~al Estate Co. & Agent ~ Address Te le phone 2. ~ ./~e cf ~sidence Single-Family ~ Number of Bedrc<~ 3. Water Su o_pp~[ · Individual Well ~lti-Family ~-~ OtJ~er (describe) Note: If CC~T~nity well system, must have w~itten confirmation fr~n the State D~pa~,tn~nt of Enviro~tn~ntal Conservation attesting to t~ legality an.d status. Is the well adequate for the number of bedrc~n~ specified in this HAA (Y/N) ~.---~ Sewage Disposal Onsite ~--~ Public ~--] Co, unity r-q Holding Ta~k F-~-~ Is the wastewater dist~osal system adequate for the n~a~er of b~drooms (Y/N) [Page ! of 2] 2-15~84 5. Engineering Firm Providin9 Inspections, Tests, E~ta and Information I certify that I have c~.~cked, verified, or conformed to all MOA HAA Guidelines ir effect on t~. o..~_~_.!s i~ction. Signed ........ , ~<""~' Date '~/~--/fe~g- . DHEP Approval Approved for Appr ovid [~ ! (ENGINEER SEAL) Disapp-~oved ~-~ Conditionai~ Terms of Conditional Approval The Municipality of ~chorage Eepcmrt~r~.nt of ~ealth and Ep. viror~ntal P~-otection dc not ~uarantee the continued satisfactory perfc~mance cf the wate~ supply ar~/ct, th wastewater dis~nosal system. This approval indicates that, as of the. validation da shc~an above, based on tP~ data and information furnished by an engineer registered the State of Alaska, the water supply and wastewater disposal system is safe and f ticnal fo~ the number of bedrccms and tg~pe of structure indicated. ( DHEP SEAL) 7. Mail the HAA to the follo,;ing adctress: KB2/d5/S [Page 2 of 2] 2-15-84 A. W~.T.f. DATA Well Classification ANCHORAGE MUNICIPALITY OF A~2HORAGE (MOA) , MUNICIPALI~'Y DEPT. ~DF HEALTH & H~T~ AU~R.ITY AP~%OVAL (~)-'- ENVIRONMENI~L 'PROTECTION ~IST - FEBRUARY 1984 ' If A, B, C~ .C,, D.E%C;' 'Approved(Y/N) Well Log P~esent (Y/N) ~(~ Total Depth LA~..~ W~ Cased to Static Water Level IL% '7 ' C~sing Height Above Ground I.~" Elect=ical Wiring in Conduit (Y/N) Separation Distances f~c~ Well: To _ ~Sg_p_tic/Holding Tank on Lot I Q)~ / TO Nearest Edge of Absorption Field on. Lot To Nearest Public Se~ Line Clean_out/Manhole 'IQ/~F Wate~ Sample Collected By Wate~ Sample ~e. st '1~esults Stan~ims (Y~) ~ a~-ttght ~ (y~) ~ .P~i~inte~n~ ~n~a~ ~ File (Y~) ~ ; f~ ~ati0n Distan~s ~ ~ptic~olding Ta~: ; o~ ~30t. n3ng Lots I ac, .*- j O~' ; On. Adjoining. Lots l~a ~" TO Nearest Public Se~er To Nearest Sews= Service Line on Lot A~ NO. _of Cu,~a~tments :~-- : FCUndation CleanOUt (Y/N) ~¢~ To Stream, Pondi Lake,' cr Major D=ainage · [Page I Of 2.! C. AB_~DPPTION FIELD DATA Soils Rating in Absorption_ / ~Strata . I ~U) Ty.me Of System Design ~-~-IQC~ Date I~talled ~-~/ /~L/7A. ~ngth of Width of Field----~--0" ~p~ of Field Gravel ~d Thick,ss Squ~e Feet of ~so~tion ~'ea ~ ~ Stan~i~s ~esent (Y/~) ~p~ession over Field (Y~) ~ ~t~ of ~st A~'~acf ~s~ To ~ter-Supply ~!1 ~ To P~o~rty ~ne To Building Foun~tion ~.~ z To Ex!sting or ~andoned System Lot ~ ~,~ ,~ ; ~ Adjoining Lons '~'+ <~ . , . TO Wate~ Ma~n/~vl~ Line ~ ~ut~a~(~f present LIFT STATIC~~] TO Stream/Pcnd~make./or Major Drainage Course To Driveway, Parkipg A~ea, cc Vehicle Stcrac~ ~ca .~ / Cc~,~nts ~o ~.~ o~=. '~t _ ~ Date Installed Size in Gallons "~amp 0~." Level at High Water Alarm Level at Tested fcr Electrical Codes(Y~N) __ Manhole/AcCess (Yz%~) _ __ "Pump Off"~Leve! at__ Cements [ Check Permitted Bedroom Rating Against HAA Request I- certify t.hat I ha~_~_c~hecked, verified, or confo~r~d 5o all v~)A H~. Guide~i?:es in effect . ..,..~'l~.~'~','~' , (~n the date of thi~ i~gec~icn. I ~ 0~'./~'~'-' ' Siqned , Date KB1/d5/s , ''~ ,% CE-8816 .."~S 2-15-~4 TECTOPIICS INCORPORATED SEPTZC SYSTEM ADEQUACY TEST S- CLIENT: Address ~-4'I Telephone 34- 14zZ- LEGAL DESCRIPTION: ~. ~/Y~- , ~ 18~- / ....~_c_ ~'~. ! T )~! LEACH PIT: SEPTIC TANK: Material Type Size DRAIN FIELD: Number Bedrooms ~ Surcharge Test ~ Rate of percolation ~J~--O Sludge condition in tank: Required Tank Size lO00 ~ gal. water; .0.80 (150 x No. bedrooms) min. gal ./day (1-~-i ~F~F-~ ~,~em ~,~-~) Remarks: Engineering · Civil · Structural · Mechanical · Electrical · Surveying PO BOX 4-2265 ANCHORAGE ALASKA 99509 · 1207 EAST 74TH AVE. (907)-349-2526 P.O. BOX 3-4016 · ANCHORAGE, ALASKA · 99501 P.O. BOX 3-401 6 · ANCHORAGE, ALASKA · 99501 GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received February Time of Inspection Date of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR 17 , 1977 ~-77 Cony. l. Approval requested by: National Bank of Alaska % Ruth Mailing Address: Post Office Box 3-3859 Phone: 27~°-2506 2. Property 0wner::'~ Mark L. Vaughn Phone: 344-9634 x 23.~ (mrs) Mailing Address: Star Route A Box 596 99507 3. Legal Description: SE~ of Lot 182 Section 33 T12N R3W 4. Location: Rabbit Creek Road- 5. Type of facility to be inspected Single Family No. of b~drooms 3 6. Well Data: ~,,-~,~ A. Type Individual ' B. Depth C. Construction_ D. Bacterial Analysis 7. Sewage Disposal System: On-site system ~ '~ B. Installer A. Installed C. Septic Tank: 1. Size 2. Manufacturer D. Seepage Pit: 1. Absorption Area 2. Material E~ Disposal Field: Total length of lines 8~ Distances: A. Well to: Septic tank , Absorption area ., Sewer Lines Nearest lot line , Other contamination B. Foundation to septic tank , Absorption area C. Absorption area to nearest lot line EQ-034 (1/74) Page 1 of two pages P~ge 2 ~f two~ pages - Req ;t for Approval ~of Individual S'-~.~r & Water Facilities Le~gal Description SE¼ of Lot 182 Section 33 T12N R3W Comments ~_/~_ ~ Disapproved Date t~.7 Appro~aq' Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (1/74) MUNICIPALITY OF ANCHORAGE MUNICIPALIT'( OF ANCHORAGE DEPT. OF HEALTH & DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTIO~,,[VIRONMENTAL PROTECTION 2§10 Fast Tudor Road, Anchorage, Alaska 99504 276-2221 FEB 1 ? 1977 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES I. Type of Inspection: CMRO ~/)~ 2. Property Owner: Mailing Address: Name of Buyer: Mailing Address: Name of Lending Institution: Mailing Address: 5. Name of Realtor or Agent: ~//~ ./ FHA CONV. Day Phone: Day Phone: Phone: ~7'~' Mailing Address: Phone: Legal Description: ~ Location: 7. Type of Facility to be Inspected: 8. Water Supply Type of Supply: Public Utility No. Bdrms. '-~ ,Individual If Individual, number of dwellings presently served If Individual, depth of well Sewage Disposal System Type of System: Public Utility If Individual, date of installation Individual (on-site) 72-OO3(3/76)