The URL can be used to link to this page

Home My WebLink AboutMOUNTAINSIDE VILLAGE BLK 3 LT 6Onsite File Mountainside Village Block 3 Lot 6 #020-172-25 Aug 19 22 08:43p Anchorage Well & Pump Ser 9072430742 p.1 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section 4 Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: Parcel Identification Number: 020_17225 Date of Issue: Legal Description MOUNTAINSIDE VILLAGE Block 3 Lot 6 Property Owner Name & Address: RZESZUT RAYMOND A& JEANNE E TRUSTS 50% EA RZESZUT R TTE / RZESZUI J ITE 17710MOUNTAiNSiCEV1U_A3EOR ANCHORAGE, AL99516 Pump Installation Date: 08 - 18 - 202 75 Pump Intake Depth Below Top of Well Casing: feet XYLEM Pump Manufacturer's Name: 50C3118S 12 Pump Model: Pump size: '50 hp 9 Pitless Adapter Burial Depth: feet MARLIN Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Well Disinfected Upon Completion? X Yes I]No Method of Disinfection: PELLETS I Comments: Pump Installer Name: ANCHORAGE WELL &PUMP SERVICE Company: 7640 KING STREET ANCHORAGE, AK 99518 Mailing Address: 907-243-0740 City: State: Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump instal lation. tKev u5/uz/iu) Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201332 PID Number: 020-172-25 Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade Name Raymond &Jeanne Rzeszut ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 17710 Mountainside Village Dr ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 907-345-6596 4 1.2 GPD/SF 8.6 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 4.6 Ft. Gravel depth beneath pipe 4 Ft. Subdivision Block Lot Mountainside Village 3 6 Fill added above original grade -1.1 Ft. Gravel length 50 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 500 Ft2 1 Ft. Well >100' >100' N/A N/A >25' TANK ❑® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1,250 Gal. Surface Water >100' >1 00' N/A N/A Material Plastic Number of compartments Two Lot Line >5' >10' N/A N/A NA Foundation > 10' >10' N/A N/A LIFT STATION Manufacturer Capacity Gal. Remarks Alarm location Electrical installed by PIPE MATERIAL House to tank D3034Tank to D3034 drainfield Installer Denali Excavating Drainfield D3034 CO/MTD3034 Inspector L. TidWel / J. Mlllette BENCH MARK (Assumed elevation) 100 ft Inspection151 9/1/20 9/3/20 Location and description dates:2 nd Threshold of Back Door (NW) 3rd 4th ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp OF '.•l9�,�� Conditional Approval: Date ��P,,,••""""" ' 49th „s'f...... ......... .... ..i..... f ......................................... g MICHAEL E. ANDERSON Septic System 00. !n ' Na. ce-4381, ,: Approved p p Date 1 a a 8 ao ��; >, •.. • .c� � ,�/./� 12/4/20 � wc� ` "p\ FO "• ••........... .....•. �444FE Note: this approval does not include well permit requirements. tKev u5/uz/iu) EXISTING WELL FCO 1"=50' 50' LONG x 5' WIDE x 4' EFFECTIVE DEPTH ABSORPTION TRENCH 3-BDRM HOME 1,250 GALLON SEPTIC TANK w/20" MANWAY NOTE: CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT LEGEND CO1 PERMIT # OSP201332 PID # 020-172-25 MOUNTAINSIDE VILLAGE, BLOCK 3 LOT 6 A B MH 34.7 SV 35.6 2CO 35.8 A B C C MT1 46.9 CO1 50.9 MT2 47.1 CO2 54.4 47.9 46.2 44.4 55.5 60.1 36.7 38.6MOUNTAINSIDE12/4/20 FEET 0 50 100 VILLAGE DRIVE 10' UTILITY EASEMENT1260125512501245MT1 MH SV 2CO CO2 TH1 EXISTING WELL EXISTING WELL ALTERNATE SITE EXISTING SEPTIC TANK DECOMMISSIONED PER U.P.C. FCO 14.21.75PLAN AS-BUILT MT2 NOTE: PERMIT # OSP201332 PID # 020-172-25 12/28/20 50' PROFILE AS-BUILT (NO SCALE) 84.4 78.5 84.6 89.25FCOMH SVMOUNTAINSIDE VILLAGE, BLOCK 3 LOT 6 1250 GAL SEPTIC TANK 87.5 FINISH GRADE DRAINFIELD ROCKMT1 TH#1NO GROUNDWATER 11/30/20 84.0 CO1CO273.6 80.0 84.0 88.6 ORIGINAL GRADE MT22CO84.2 79.9 LEGAL DESCRIPTION: PERFORMED FOR: DATE: PARCEL ID#: SOILS LOG AND PERCOLATION TEST TECHNICIAN: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 DEPTH (feet) PROJECT No.: TEST HOLE 1 SLOPE SLOPE SITE PLAN DATE READING GROSS TIME(minutes)NET TIME(minutes) DEPTH toWATER NET DROP PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH) TEST RUN BETWEEN: FT. and FT. COMMENTS: (inches)(inches) Mountainside Village, Block 3, Lot 6 8/11/20 M. Jakubisin DATE OF MONITORING: WAS GROUND WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING: IF YES @ WHAT DEPTH?- 2.1 6 6 7 020-172-25 Ray Szeszut 4:00/4:11 --- 1 2 3 4 6/0 4:13/4:25 4:30/4:40 4:41/4:51 1' OB Professional Engineers Stamp: 12/28/20 11:44 NO none 11/30/20 SILTY GRAVEL GM 6/012:11 6/1 4 1610 6/1 3 1610 6 6 412 16 413 16 TEST HOLE DEEPENED TO 15' TO VERIFY LACK OF IMPERMEABLE LAYERS. BOTTOM OF HOLE PERCOLATION TEST VERIFIED AT 2.1 MIN./INCH. TEST COMPLETED AT SAME LOCATION. 8/27/20 MUNICIPALITY ANCHORAGE Community Development Department c Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 020-172-25 Property owner(s) Raymond & Jeanne Rzeszut Day phone 345-6596 Mailing address 17710 Mountainside Village Drive Anchorage, AK 99516 Site address Same Legal description (Sub'd., Block & Lot) Mountainside Village, Block 3, Lot 6 Legal description (Township, Range & Section) Lot Size 47,700 Sq. Ft. Number of Bedrooms Four (4) APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑X Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank [ZUpgrade ❑X Duplex ElHolding (D) Tank ElRenewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 4 u(.6, 2 S 60LJI Date of Payment: 6/2-1 /20 Receipt Number: Og G Lk D Permit No. Permit App__- :-.,:c Waiver Fees: Date of Payment: Receipt Number: Waiver No. PO BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) August 26, 2020 M.O.A. Development Services Department On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Subject: Mountainside Village, Block 3, Lot 6 – 17710 Mountainside Village Drive Septic System Design Dear On-Site Services Engineer: The existing septic system on the subject lot has failed and must be replaced to serve the three- bedroom home on the property. The new septic system is designed to serve a four-bedroom home at the request of the owner. We are submitting this permit application for the construction of a new septic system. The attached site plan identifies the location of the home and the existing well and the existing and proposed septic system. No conflicts exist between this proposed system and any other well or septic system on this lot or adjacent lots. The ground surface on the lot slopes to the west at grades approximating 30%. There are slopes greater than 25% within 50 feet downslope of the proposed site but the absorption trench has been designed to meet the steep slope provisions of the Municipal Code. Ground contours are shown on the site plan indicating the grade and direction of flow. Stormwater drainage will not impact this septic system. The new trench will be constructed parallel to the slope as much as possible. The test hole for the lot is only 12’ deep. We request a provision be added to the permit requiring the test hole to be extended to 15’ to verify the lack of impermeable soil layers. A second test hole will be placed to 18’ to verify the design parameters for the alternate site. Wells on this and adjacent lots are shown. The new system will be a minimum of 100’ from all wells and surface water and more than 5’ from the septic tank. Please refer to the attached test hole log and plan and profile sheets for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Michael E. Anderson, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201332, Rebecca Carroll, 08/27/20 EXISTING WELL 1"=50' 50' LONG x 5' WIDE x 4' EFFECTIVE DEPTH ABSORPTION TRENCH 3-BDRM HOME 1,250 GALLON SEPTIC TANK w/20" MANWAY NOTE: SLOPES >25% WITHIN 50' OF THE PROPOSED SEPTIC SYSTEM. SYSTEM DESIGNED TO MEET STEEP SLOPE CRITERIA OF MUNICIPAL CODE. NO SURFACE WATER WITHIN 100' OF PROPOSED SEPTIC SYSTEM. ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC SYSTEMS. CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FD - FLOW DIVERTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND CO MOUNTAINSIDE VILLAGE, BLOCK 3 LOT 6 MOUNTAINSIDE8/20/20 FEET 0 50 100 VILLAGE DRIVE10' UTILITY EASEMENT1260125512501245MT MH SV 2CO FD CO TH1 EXISTING WELL EXISTING WELL RESERVE AREA - EXTEND EXISTING TRENCH 6' x 8' EFFECTIVE DEPTH. DECOMMISSION EXISTING SEPTIC TANK PER U.B.C. FUTURE LIFT STATION TO SERVE ALTERNATE SITE (IF REQUIRED). PROPOSED TEST HOLE TO VERIFY DESIGN REQUIREMENTS FOR ALTERNATE SITE. MINIMUM DEPTH 18'. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201332, Rebecca Carroll, 08/27/20 MOUNTAINSIDE VILLAGE, BLOCK 3, LOT 6 DESIGN FACTORS: SYSTEM REQUIREMENTS: 600 GPD PEAK FLOW PERK RATE: 2.1 MIN/IN APPLICATION RATE: 1.2 GPD/SF 5' WIDE TRENCH SYSTEM 1,250-GALLON SEPTIC TANK TYPICAL TRENCH SECTION (NO SCALE) 4" PERFORATED PVC (HOLES DOWN) DRAINFIELD ROCK 5' 3' 4' NOTES: 1. GRADE AREA OVER TRENCH TO DRAIN AWAY 2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2' WITH 2" OF INSULATION 3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY BOTTOM OF TRENCH: 7.5' BELOW GRADE - MEASURED FROM LOW SIDE FLOW LINE ELEVATION: 3.5' BELOW GRADE - MEASURED FROM LOW SIDE TOP OF TRENCH: 0.5' ABOVE GRADE - MEASURED FROM LOW SIDE 600 GPD /1.2 GPD/SF /5' WIDE * .5 (RED. FACTOR) = 50 LF TRENCH REQUIRED (50 LF SPECIFIED) 8/26/20 4.5' 6" GEOTEXTILE FABRIC TEST HOLE MUST BE DEEPENED TO 15' TO VERIFY LACK OF GROUNDWATER AND IMPERMEABLE SOIL LAYERS. NOTE: Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201332, Rebecca Carroll, 08/27/20 LEGAL DESCRIPTION: PERFORMED FOR: DATE: PARCEL ID#: SOILS LOG AND PERCOLATION TEST TECHNICIAN: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 DEPTH (feet) PROJECT No.: TEST HOLE 1 SLOPE SLOPE SITE PLAN DATE READING GROSS TIME (minutes) NET TIME (minutes) DEPTH to WATER NET DROP PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH) TEST RUN BETWEEN: FT. and FT. COMMENTS: (inches)(inches) Mountainside Village, Block 3, Lot 6 8/11/20 M. Jakubisin DATE OF MONITORING: WAS GROUND WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING: IF YES @ WHAT DEPTH? - 2.1 6 6 7 020-172-25 Ray Szeszut 4:00/4:11 --- 1 2 3 4 6/0 4:13/4:25 4:30/4:40 4:41/4:51 1' OB Professional Engineers Stamp: 8/26/20 11:44 NO none 8/18/20 SILTY GRAVEL GM 6/012:11 6/1 4 1610 6/1 3 1610 6 6 412 16 413 16 PERCOLATION TEST TO BE RERUN PRIOR TO CONSTRUCTION. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201332, Rebecca Carroll, 08/27/20 \ Lot 3 �\ \ Lot 7 100' PROTECTIVE \ Lot 6 / WELL RADIUS Oil \ 47,700 S.F. rn �+ d - RETAINING c0 / SEPTIC PIPES - y6 WALLS O_ � 12 / I Lot 4 i SW —WELL 0 0 � .. 6.p '80'" / �� _z $rJ 6 CANT°F8 Y 8.2'x11.2' 6' GREENHOUSE RETAINING WALL �p O,� Q,ZP `L \ P� N Q i9 10' UTILITY EASEMENTS O Lot 5 PLOT PLAN ___ AS BUILT _X_ SCALE _ 1 50__ GRID _ SW 3439 Project No. ____ 20-381/L ____ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone 000Op��O Professional Land Surveyors (907) 592-46yOF A 5 Fax �/ ken®Ian surve com � jonathan®langsurvey.com I hereby certify that I have surveyed the following described property: LOT 6, BLOCK 3, MOUNTAINSIDE VILLAGE SUBDIVISION (PLAT No. 79-177) Anchorage Recording District, Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated this the _______ Day of ________________9 ______- at Anchorage, Alaska It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. '* 49T' ................................ ................................ KENNETH G. LANG o 0044�'F .LS -5202.•• SJ�pO �QOROFESSIONA� �a AECC963 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME MAILING ADDRESS LEGAL DESCRIPTION LOCATION Well ~ Absorption area D~STANCETO: ~ ~6 lO,&' hiq capacity in gallons IF HOMEMADE: Inside length DISTANCE ~O: Well Foundation DISTANCE TO: Total Length q~e~ line_ lend, fi. lines Top of tile to finish grade~l Material beneath tile Width Depth Type of crib Crib diameter Crib depth Well Building foundation DISTANCE TO: Depth Driller c~a~ ~ VA'T E - ~uilding'~qundation Sewer line DISTANCE TO: PHONE [ ,[~ NEW 27¥--~,~o~ [~] UPGRADE v,'c~^~' E 'TIIIkl R3 Dwelling Material Width.~ Material Nearest lot Ii. ne ITrench ? inches inches NO. OF B~DROOMS PERMIT NO. No. of coml~tments Liquid depth PERMIT NO. Liquid capacity in gallons PEP~MIT NO. D istanc e/~/tT,~n I i n e s Total e.~Tf~ ~s~rption ar ea PERMIT NO. Total effective absorption area Nearest lot line Distance to lot line PERMIT NO. Septic t 1 n~.~ ¢. Absorpii~r~l~a(s) OTHER PIPE MATERIALS SOIL TEST RATING' INSTALLER REMARKS APPROV) DATE btUN I C I F'd-~L I TY OF DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTE:CTION S25 L. STREE:T., ANCNORAGE., AK 99501 264-4720 ~t]~'4 S I T'E SEWEF~ ~ ~E:~ :~L. F"EF;~M'I T PERMIT NE): DATE ISSUED: 840621 07/25/84 APPL I CANT: ADDRESS: CONTACT PHONE: L. E6JAL DESCRIP: LOT S I ZE: MAX BEDROOMS: DONALD L DOTSON 1200 I STREET ANCHORAGE., Al< 99501 274-6104 SUBDIVISION: MOUNTAINSIDE 'VILLAGE LOT: 6 SECTION: 11 TOWNSNIP: 11N RANGE: 3W 4.7700 (SQ.FT. OR ACRES) BLGCI<: 3 Listed below are the options available to you in designing your septic system. Choose the option that best ~its your site. T R E I~1 II ~'-~ ~£~ ~2 D DEPTH TO PIPE BOTTOM (FT.) 4.0 ~4.0 GRAVEL DEPTH (Fl'.) $. 0 \ TOTAL DEPTN (FT.) 12.~? GRAVEL WIDTH (FT.) 2.5 1 GRAVEL LENGTH (Fl'.) 29.0 5~ GRAVEl.. VOLUME (CU. YDS. ) 22.8 T'ANI< SIZE (GALS) 1.~000.0 ** 1~00 SOIL RATING (SQ. FT./BR) 152 4.0 ~.5 7.5 5.0 50.0 37.0 000.0 ** 152 ** TANK MLIST HAVE AT I_EAST TWO COMPARTNENTS I cer'tif'y that: 1. I am tlamiliar wi'Lh the requirements for on-site sewers and wel~ls as set ~orth by the M~.~nicipality o£ Anchorage (MOA) and the State o~ Alaska. 2. I will install the systmm in accordance with all MOA cx~des and regulation~s, and in compliance with the design criteria of' this permit. 5. I will adhere to all MOA and State of' Alaska requirements ~o~ th~ se~ back distances ~r'om any existing well~ wastewater disposal system of public sewerage system on 'Lhi~ or any adjacent or nearby lot. 4. I understand that this permit is valid fop a maximum ~ 3 bedrooms and any enlargement will require an addi%.ional permi'L. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL. INSPECTION REPORT; AND (5) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. DATE: ~ I BNE D APPLICANT: ~DONALD L DOTSON MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] SOILS LOG PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: Don Dotson Lot 6 block 3 DATE PERFORMED: Mountainside Village Subd. 10-!2-83 5 6 7 8 9 10 11 12 13 ~ Pez Brown silty sandy qraVel Brown fiborous peat (PT) c zone Brown silty sandy gravel with occasional cobbles ubrounded particals to 6"+ (GM) SLOPE SITE PLAN 14- 15- WAS GROUND WATER S ENCOUNTERED? no L P ~F YES~ AT WHAT Reading Dante Gross Net Depth to Net Time Time Water Drop '/ :-'/-, '~ -I0-11-113- j,.,~ 24 hours saturatLon time .e ;!.-2-.¥ '~ q .10.12.113 . 0 hour.= 2.25" ~ 10 min. 3.75" 1.5" "~ 20 min. 5.0" !.25" ~ 30 min. 6.25" 1.25" ", Lewis E. Dickinson ,' ,:/' CE- 1183 . ~, ~' ((:>, ~', ...... ' ,-~ PERCOLATION RATE 8. 0 (minutes/inch) '~~ TEST RUN BETWEEN 5 FT AND 7 FT COMMENTS 150 PERFORMED BY: CERTIFIED BY: ~,.uL. IE~k3~IA~C~/~'~S ~ DATE: MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING (b) Property owner Mailing Address F.~. (c) Lending institution Mailing Address (d) Real Estate Company and Agent Telephone: (home) E33 o,¢87i] Business Telephone Address Telephone (e) Mail the HAA to the following address: (or check here Bi', if hold for pick up.) List contact person and day phone number below: ~f'e~ I~oor~ 3 ~S'- tX.c'-; TYPE OF RESIDENCE Single-Family [] Number of bedrooms 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. 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 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 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. Name of Firm FJ~t-/~i~ T~c/I/'I I'c~/' ~'~r'~,~- Telephone Address l~.5--~ ~C~ ..C'~.~ /Z~-~C/~"~'~/~z 4/'~ ~/_5-10 Date ~T~n 15-~ Fl? / Engineer's Seal 6. DHHS APPROVAL Approved for ,~ Approved ~ bedroomsby~/.~, ~~. ate /~ 2 Disapproved Conditional Terms of Conditional Approval If:Iii / [I] ~ I 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. Em ployees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not res pc nsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 ~ MUNICIPALITY OF ANCHORAGE (MOA) (,~__~,/ Health Authority Approval (HAA) ~ CHECKLIST - FEBRUARY 1984 .~,';;....;-~,~,,4'4;AL L~,:r.'¥ ~.,-50IV~SIO~ 343-4744 Legal Description: L JAH 1 6 1991 A. WEL'D^TA RECEIVED Well Glassification ~lTt ~'Xt Well Log Present (Y/N) ~ Date Completed 8[15 Total Depth J o5 ~Gased to __~' ~ Depth of Grouting /~ /~ Static Water Level ~l' ~/ ~/~ Pump Set At '~ ff 7 Casing Height Above Ground 2.(~" Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) x/~c-S Depression Around Wellhead (Y/N) If A, B, C, D.E.C. Approved (Y/N) ~1/,4 Yielc~5.7 ~?~I t'1£A~ ; On Adjoining Lots ; On Adjoining Lots SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ~ lDO To Nearest Sewer Service Line on Lot Water Sample Collected by ICt./~TTOP Water Sample Test Results ~'~ ~ Comments D~cm~ J To Nearest Public Sewer Cleanout/Manhole ;Date //$/"/I B. SEPTIC/HOLDING TANK DATA Date Installed ~[~Zl/~q Size Standpipes (Y/N) '~ Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) IOOO No. of Compartments ~ Foundation Cleanout (Y/N) Date Last Pumped l[/~' {9! ; for Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course '7/00 To Building Foundation To Disposal Field Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field 152 Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test a'// ~3~1 Type of System Design Length of Field ,~2 r Depth of Field 12 ' Gravel Bed Thickness 8' Statndpipes Present (Y/N) Date of Last Adequacy Test ~REN(N SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot ~ /,~ To Water Main/Service Line ~ ~)5 / To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line To Existing or Abandoned System on ; On Adjoining Lots -;~ To Cutback (if present) ?/oo ~ (~5/ D. LIFT STATION hi, ~. 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 Bequest** I certify that I have checked, verified, or conformed to all MOA and HAA guj.dc~,i~'~i'~t, on the date of this inspection. Signed ~~ Company ~(~ ~ Date ~. ~5~ I¢~/ ~~ ¢~E~gineer'sSeal MOA No. Receipt No. Date of Payment Amount: $ 72~026 (Rev 7~88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET · ANCHORAGE,ALASKA 99518 · TELEPHONE (907) 562-2343 FEDERAL TAX I.D. #92-0040440 [:'0 ii Or]' :.l,..,~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) .. Applicant Name , ~OR' ¢0 ~0~ Telephone: Home Applicant Address ~?F/O ~F~ ~J~ ~/¢A~, ~C~¢ (c) (d) Business Applicant is (check one): Lending Institution []; Owner/builder ~'; Buyer []; Other [] (explain); Lending Institution Telephone (e) (f) Address Real Estate Company and Agent Address ......... II//_//~ ' t . HAA to the following address: TYPE OF RESIDENCE Single-Family [~' Multi-Family [] Number of Bedrooms .~ Other WATER SUPPLY Individual Well~ Community[] Public[] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite 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. Page 1 of 2 72-025 (11/84) ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DA'! A AND INFORMATION ,, As certified by my seal affixed hereto and as of the validation date shown below, I verify that rny 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. Name of Firm ~ ~"~ [/~/'~r Telephone Address 12o Date 7~~_~~ Approved /.~% - Disapprov~ Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: ~3 LG 1'/I IV MUNICIPALITY OF ANCHORAGE DEPT, OF HEALTH & ENVIRONMENTAL PROTECTION! .sp¢,/! Well Classification IN.Of ~J! D~//~* If A, B, C, D.E.C. Approved (Y/N) Well Log Present ~/N) Date Completed Total Depth / 0-~J- / Cased Static Water Level ~ r ? Casing Height Above Ground Electrical Wiring in Conduit ((~'N) Separation Distances from Well: To Septic/Holding Tank on Lot Depth of Grouting Pump Set At Sanitary Seal on Casing CN) Depression Around Wellhead (Y,~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot IF// ; On Adjoining Lots 1O0 To Nearest Public Sewer Line ~//f{"_ To Nearest Public Sewer Cleanout/Manhole f~//~ TO Nearest Sewer Service Line on Lot , Water Sample Collected by '~' ~1~1¢( 7'(:::~'~('J~--'/¢~ ; Date . Water Sample Test Results ~._~t~-r 1,~> .~/~r(~. f(~/~ Y Comments B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes C/N) Depression over Tank (Y~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) (~// Separation Distances from Septic/Holding Tank: To Water-Supply Well ) [ ~ / To Property Line To Water Main/Service Line N'/j3r course Size 100~) No. of Compartments Air-tight Caps ¢N) Foundation CleanOut (~.N) Date Last Pumped '~//77~¢:'~ ,/~/~_ ;for ~//A' Temporary Holding Tank Permit (Y/N) To Building Foundation -~'7 / To Disposal Field [~),~ / To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Width of Field /,5-2_ Square Feet of Absorption Area Depression over Field (Y,~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well /i~/ To Building Foundation .~>~ Lot .~//it~- To Water Main/Service Line '1 To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field J~2- / Depth of Field /Z / Gravel Bed Thickness ~) ! Standpipes Present (~N) Date of Last Adequacy Test To Property Line 36 / To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) D. LIFT STATION Date Installed Dimensions jl Size in Gallons / Manhole/Access ~ . "Pump On" Level at - / ~ "Pump~"~vel at _ High Water Alarm Level at ~ / / ~ J Vent (Y/N) __ Tested for ' V/ / -J' J Pul~-;;~l"C~;~l~'s d~ring Adequacy ~l:CmtrirnCt~t~odes (Y/N) . / Test. Meets MOA ** Check Permitted ~nst HAA Request ** I certify that I h?~.J~2~, veriJied, or conformed to all ~OA a~nd HAA guidelines in effect on the date Signed 9/.¢~~ Date ~//¢/~ of this inspection. Receipt No.. Date of Payment Amount: $ Page 2 of 2 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date ! ! Legal Description (inci,ude lot, block, subdivision, section, township, range) ! f ~ ! Location (address or directions) . Applicants Name ,~/:~ ~/~'~/~-~ Telephone - Home Business Applicants Addres~ /~/J ~" ~/~g~z(/ ~/Z~y ./-~?~r,~j~ ~5~' Applicant is (check one) Lending Institution ~_~ ; Owner/builder~'; Buyer Other (=plain>; (a) (c) (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. T_zpe of Residence Single-Family I'll Number of Bedrooms 3o Water Supply Other (describe) Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. ~ewage Disposal Onsite~--~ Public [--~ Community~ Holding Tank~-~ Note: If community well system, must have written confirmation from ~he State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] 5. Engineering Firm Providin~ Inspections~ Tes.ts~ File Search~ Data and Infm As certified by my seal affixed hereto and as of the validation date shown verify that my investigation of this Health Authority Approval shows that the ~ ~.~ water supply and/or ~stewater disposal system is safe, f~ction~ and ~equa:e the number of bedrooms a~ type of structure indicat~ herein.- I further based on the infomation obtain~ from the ~nicipality of ~%chorage f~!e~ and investigation ~d inspection, the on-site ~ter supply and/or ~stewater disposal system is in compliance ~th ~1 ~nicipal and Sta~e codes~ ordinances, and reEula.~ tions in effec~ on the date of this inspection. Name of Fi~ ~/a~ ~ ~~4/ ~.o~[[~/.,.~W~tc~ Telephone Address ~ ~ o L y C. Rend, J'. ,: "':~ 6- D~P Approval / / ~ ~ o~,u.: Approved for, ,'-r"(L ~ ,, q bedrooms Bj ,. ' )" Approved '5~- Disapproved .... Co~ition~ ' Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONmeNTAL PROTECTION (DHEP) ISSUES ~ALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGI~JER 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 FEDERAL AND STATE REQUIRE- ~9~NTSo ~IPLOYEE$ OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA ~EFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS LN ~{E PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 MUNICIPALITY OF ANCHOR~/~E (MOA) HZ LT AU OR TY aPPROVAL CHECKLIST - FEBRUARY 1984 Well Classification b~[o~_ If A, B, c~ C, D.E.C. Approved(Y/N) Well Log P~esent ) ~ Date Cc~pleted ~ Yield Static Water Level ~7, ~ Casing Hsight Above Ground Electrical Wiring in Conduit ~Y~N) Separation Distances f~tcm Well: Pump Set At ... ~ ! Sanitary Seal on Casing Depression Around Wellhead (Y~ To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ~]~ To Nearest Public Sewer Cleanout/Manhole ~/~ To Nearest Sewe~ Service Line on Lot Water Sample Collected By ~ ~ ; Date Water Sample Test P~sults .~'~77~k-~ ,~ ~ ; On Adjoining Lots /[~' ~ ; On Adjoining Lots B. SEPTIC/HOLDING TANK DATA Date Installed ~-~/-~ Size /DO9 No. cf Compartments Foundation Cleanout Depression over Tank (Y~ Date Last Pumped '~ Pumping/Maintenance Contract on File (Y/N) ~/~ ; for Holding Tank High-Water Alarm (Y/N) ~ Temporary Holding Tank Permit (Y/N) ~/~. Separation Distances f=cm Septic/Holding Tank: / To Water-SupDly Well To Property Line To Water Main/Service Line Course ! (~ To Building Foundation ~ ~ To Disposal Field . /dP.g To St=earn, Pond, Lake, c= Major Drainage [Page 1 of 2] Receipt ~ Date Paid: mount: 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date .Installed ~- 2 (. g q Width of Field ~" Square Feet of Absorption Amea Depression over Field (Y~ Results of Last Adequacy Test Length of Field ~ / pth of Field Gravel Bed Thickness Standpipes P=esent _~/N) Date of Last Adequacy Test Separation Distance f=cm A~sc~ption Field: / To Water-Supply Well //~ ' ~) To P=operty Line To Buildi~ F~n~tion ~ ~ ~ To Existing or' ~ndo~d System Lot ~ . ' ; ~ ~joining ~ ~ ~ To ~te~ Mai~vi~ Line .... ~ To ~t~.( if pre~nt) To Stre~ond~ke/~ ~jo~ ~ai~ ~se To ~i~y, P~ki~ ~ea, ~ Vehicle St~a~ ~a /O ~ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Weter Alarm Lavel at Tested for Electrical Codes(Y/N) M~ets MOA ** ** Check Peznnitted Bedrccm Rating Against HAA ~quest I certify that I have checked, verified, c~. confc~red to all MOA HAA Guidelines in effect on the date of this inspection. KB1/d5/s [Page 2 of 2] 7529 E. 6th Avenue August 13, 1984 Anchorage, Alaska 99504 (907) 333-6435 Hark T. Johnson 1013 E. Dimond Box 104 Anchorage, Alaska Dear Mr. Johnson, The following information is your copy of the well lo.~ for the property locateS, at Lot 6, Block 3, Mt.Side Village Subdivision. This should be retained as your permanent record of improvements to y([ur prop~e~rtY. WELL LOG o To 12 Feet 12 35 Silty sand, ~ravel Altered shale, silica streaks 35 81 Limestone, silica streaks 81 ~ ~105 Altered shale, silica streaks WATER 5 GALLONS PER MINUTE you for specifying BIG DIPPE~_DR!LL~G_for your water well needs. cal~when you are read~f6k~your pu~p. This will entitle ycu to ~nce in the drawing for two round trip airline tickets t~H~a%;aii. ~~'aw~r~wili be held in December. Sincerely, C. R. Kron MUNICIPALITY OF ANCHORAQI~ DEPT. OF HEALTH & ENVIRONMENTAL PROTECTIOI~I J JUL 2 9 1986 RECEIVED Licensed · Bonded · Insured DEPT. OF HEALTH & E~IRON~ENTAL PROTE~IO~ FEB 2 ? 1985 RECEIVED ?529 E. 6th Avenue August 13, ]984 Anchorage, Alaska 99504 (907) 333-6435 Mark T. Johnson 1013 F. Dimond Box 104 A,,caor~, Alaska Dear Mr. Johnson, The following information is your copy of the well log for the property located at Lot 6, Block 3, Mt. Side Village Subdivision. This should be retained as your permanent record of improvements to your property. WELL LOG o To 12 Feet Silty sand, gravel 12 35 Altered shale, silica streaks 35 81 Limestone, silica streaks 105 Altered shale, silica streaks WATER 5 GALLONS PER MINUTE ~..e o.. :,.zing will Sincerely, ,~ _.? C. R. Kro.n vou for specifying BIG DIPPER DRILLING for your water well needs. call when you are ready for your pump. This will entitle ycu to nce ir] the drawing for two round trip airline tickets to Hawaii. be held in December. Licensed · Bonded · Insured BIG DIPPER DRU .IN 7529 E. 6th Avenue · Anchorage, Alaska 99504 -/ (907) 333-6435 February 18, 1985 Mark T. Johnson 1013 E. Dimond Box 104 Anchorage, Alaska Dear Mark, The casing in the well located at Lot 6, Block 3, Mt. Side Village Subdivision, is 45 feet deep. This information should be added to the well log provided August 13, 1984. If we can be of further assistance please let us know. Sincerely, C. R. Kron Owner Licensed · Bonded · Insured BIG DIPPER DRILLING 7529 E. 6th Avenue · Anchorage, Alaska 99504 (907) 333-6435 February 18, 1985 Mark T. Johnson 1013 E. Dimond Box 104 Anchorage, Alaska Dear Mark, The casing in the well located at Lot 6, Block 3, Mt. Side Village Subdivision, is 45 feet deep. This information should be added to the well log provided August 13, 1984. If we can be of further assistance please let us know. Sincerely, C. R. Kron Owner Licensed · Bonded · Insured /~L/Z,~I~F~ I::l~lVll~UflMl::fl I/~L CONTROL SERVIC"~, INC. 1200 West 33rd Aver,~ , Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 JOB ~ ~' rP IV]~ I/V, ~.,~ll. lt-- VIL6M[~ SHEET NO OF CHECKED BY DATE \