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PID:015-142-56 PERMIT:OSP221060
FIRST WATER CONSULTING
MOUNTAIN MANOR B3, L4
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
hftp://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP231403
Work Type: SepticTank Upgrade
Tax Code Number: 05067136000
Site Legal Address: MOUNTAIN MANOR BLK 3 LT 4 G:0254
Site Mailing Address: 18920 JAMIE DR, Eagle River
Owner: LYC TRUST
Design Engineer: FIRST WATER CONSULTING
This permit is for the construction of:
Effective Date:
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
n,cnt
f
De partinent
11 /30/2023
11 /29/2024
78280
❑ 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: l S 5 LA(...D
Issued By: L.
Date:
Date: I I (5 z° L 3
3
MUNICIPALITY OF ANCHORAGE
Development Services Department = Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON -SITE SEPTICIWELL PERMIT APPLICATION
Parcel I.D. 050-671-36
Property owner(s) LYC TRUST (LARRY CHING Y TRUSTEE) Day phone
Mailing address 18920 JAMIE DRIVE, EAGLE RIVER, AK 99577
Site address 18920 JAMIE DRIVE, EAGLE RIVER, AK 99577
Legal description (Sub'd., Block & Lot) MOUNTAIN MANOR BLOCK 3, LOT 4
Legal description (Township, Range & Section)
Lot Size 78,280 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(N all that apply)
Absorption Field
❑ Initial ❑
Single Family (SF) X❑
Septic Tank
X❑ Upgrade X❑
(w/wo ADU)
Holding Tank
❑ Renewal ❑
Duplex (D) ❑
Privy
❑
Multiple Dwellings ❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION
INCLUDES A 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: 2 2, S_ Waiver Fees:
Date of Payment: Date of Payment:
Receipt Number:
Permit No. ()SP Z 3 %y U S
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / FirstWaterAK@gmail.com
!
!!
November 27, 2023
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: MOUNTAIN MANOR BLOCK 3, LOT 4
The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic
tank on the above referenced lot. We propose to install a 1500-gallon HDPE tank for current
functionality and future flexibility per the attached design to serve the existing 3-bedroom
residence. No groundwater was noted in the MOA on-site file, but if groundwater is encountered
during installation an epoxy coated steel septic tank may be required. The lot and area are served
by private water and any encroaching wells, easements, … must be staked prior to construction.
The design will not impact any of the neighboring properties. Please contact us if you have any
questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231403, Curtis Townsend, 11/30/23
FIRST WATER CONSULTING
MOUNTAIN MANOR B3, L4
DESIGN DETAILS:
SERVED BY PRIVATE
WATER - NO WELLS
W/IN 100' OF PROPOSED
SEPTIC TANK.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231403, Curtis Townsend, 11/30/23
1 a n n n' ��
ANCHORAGE RECORDING DISTRICT, ALASKA
AS -BUILT OF:
MOUNTAIN MANOR SUBD
LOT 4 BLOCK 3 PLAT 77-23
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 shoulc
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: DAIS: SCALE: E-MAIL
NOV 18, 2023 1 "=50' schullerOak.net
23-121 DRAWN BY: CHECKED BY GRID NUMBER: BOOB rAGE:
JLS N W0254 230357
* = FND 5/8" REBAR"
.s.•OF 4 L A, N
AW
�
4 9TH
/� �� �'� •yam ..r`.
?A
:;.. ....
,JOHN L. SCHULLER.• o � = .
LS--10408
1f f^� � �i►jam .sx,�r'
•' �\ ,� 1831 Tal.keetna Street
kk ��'cy ' •�.�. ,,,, Ancharage, Alaska 99508
;47 Of
o� �. ,,,. (907)207-1455 office
SSIQi'` fir•
��®�•®�o'� (907) 274-4992 fax
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
87.5 L Street - Anrhorage, Alaska 99501 Telephone 264-477.0
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
nnr=
MAILING ADe
%SS
O
LEGAL DESCRIPTION
LOCATION
E MATERIALS
!' I/ C
L TEST RATING
/ t-71 0
INSTALLE
REMARKS
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absorption area/ Dwell
Q < Matr
nside length Wi
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;bines
'Crib depth
uil di�dation
Driller
Sewer line
APPROVED ", ., ^- a 4t D TE LES
.hr a "tiitila
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Mater
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PHONE FW
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DISTANCE TO:
Well /
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Manufacturer^
PERMIT NO.
y �
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Liquid depth
Liq. r�apa�Cn gallons
PERMIT NO.
31
Liquid capacity in gallons
IF HOMEMADE:
❑ YDISTANCE
0 2z
TO:
Well
= z F
Manufacturer
- --
❑
W=
W
DISTANCE TO:
Well /
Zu
No. of lines
Length of each line
~ a
Top of till finish grade �T
w
Length
Width
❑
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wa
Type of crib
Crib diameterUl
w
DISTANCE T0:
Well
J
Class
Dept
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DISTANCE T0:
Building foundation
OTHER
E MATERIALS
!' I/ C
L TEST RATING
/ t-71 0
INSTALLE
REMARKS
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absorption area/ Dwell
Q < Matr
nside length Wi
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uil di�dation
Driller
Sewer line
APPROVED ", ., ^- a 4t D TE LES
.hr a "tiitila
�' ✓ tY +� i � GJ V
Mater
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PHONE FW
_ ❑ UPGRADE
NO.OFBEDROOMS
In ,� /
PERMIT NO.
a
N` No. of compartments
Z
—�
Liquid depth
PERMIT NO.
31
Liquid capacity in gallons
jpdine/F
PERMIT N;30
widt�Distance
bellnesN
L'`inches
inches
Total effectsorptio area
PERMIT N
ffective absorption area
lot line
e to lot line
PERMIT NO.
Septic tank I Absorption area
owl U TVA S cis Z act Q 1: -T- ,y f 111 a!!:)j A I ."T 11 if !F::":: AEEEE�
DEPARTMENT UF HEALTH AND ENVIRONMENTAL /ROTECTION
825 L STREET, ANCHORAGE, AK 99501« JA --41
, 264~4720
M HIEZ JWE�E 151 lot Up 1H H... 1.. 104 111 IT! TO El: -1,
PERMIT NO: 850126 ^
DATE ISSUED: 04/26/85
APPLICANT: C/O S & S Ell IEERING NORMAN CONSTR
ADDRESS: SRB 1960
EAGLE RIVER, AK 99577
CONTACT PHONE: 694~2979
LEGAL DESCRIP: SUBDIVISION: MOUNTAIN MANOR LOT: A.I. BLOCK: 3
SECTION: 6 TOWNSHIP: 14N RANGE: 1W
LOT SIZE: 40O00 (SQ.FT, OR ACRES)
LOT, LOCATION: INSPIRATION CIRCLE
MAX BEDROOMS: 3
Listed below are the options available to you in designing your septic
system. Choose the option that best fits your site"
��..... ..... .... ��... ..... .... ~..... ..... .....
��������^���������_�
TEE), I!::::;:! ac��! J[ 11 P
DEPTH TO PIPE BOTTOM (FT.) 4"0 4 0
GRAVEL DEPTH (FT") 10"0 3^5
TOTAL DEPTH (FT )"
, 14,0 7
GRAVEL WIDTH (FT ) " 5
^
. 2"5 5 0
GRAVEL LENGTH (FT^) 23"0 49^0
GRAVEL VOLUME (CU^YDS.� 22.4 16.7T` SIZE (GALS) 1,000 0 ** 1 000"0
SOIL RATING (SQ"FT./BR) 1�0 , ^ **
. � 150
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
I certiI"y that:
J. I am [amiliar with the requirements [or on-site sewers and ll
forth by the Municipality o[Anchorage (MOA) and the St t we s as set
2. I will install the system in accordance with all MOAa e o� Alaska"
and in comPliance with the design criteria o{ thi co�es and 'egulations;
3" I will adhere to all MOA and State o[ Al k s pe'mit^
' distances from any existing well wa t as a 'equirements {o' the set back
sewerage system on this or an � s ewater disPosal system or Public
4" I understand that thi ` y a�jacentor nearby lot,
s permit is a maximum i..:) 3 b d
any enlargement will require an additional pprmit, e 'ooms and
IFEA LIFT'
STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES
/nLp nu`��/ BN �LECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS B�TS
�+E�T/ALcW*rr�UYt� WITHOUT AN ELECTRICAL INSPECTION REPORT; AND <3>�TuILE
M. l nI C V�K MUST BE DONE BY A LICENSED ELECTRICIAN. M
SIGNED
APPLICANT:S'ENIEERING NORM�� CONST��-~^
ISSUED BY
__ _,^__~__�_^__
;K-. SOILS LOG
MUNICIPALITY OF ANCHORAGE
• ��I DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION
825 L. Street, Anchorage, Alaska 99501 264-4720
TEST
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: --L � r)Lk&A-/1 � ( -f- DATE PERFORMED: 4-2-4 -
LEGAL DESCRIPTION:_ t..p'r f3L,K -3 M DUN 1
SLOPE — SITE PLAN
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COMMENTS
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Robert A. 3hahsr.
No. 1457•E a
®fit pROFE'a5�p� a.'a'
�cC--T'r cm Qfy
1-1-t L
WAS GROUNDWATER S k
ENCOUNTERED? L? L
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P
YES, AT WHAT E
EPTH?
2
Reading Date Gross Net Depth to Net
Time Time Water
Drop
n
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
PERFORMED wa 'g'rJIT CERTIFIED /„/
.. PH.604-4v DATE:
72-008 (6/79)
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
PERFORMED wa 'g'rJIT CERTIFIED /„/
.. PH.604-4v DATE:
72-008 (6/79)
DURbIN DR..fiNq CO
Mile 1.2, Lucas Road
P.O. Box 871348
Wasilla, Alaska 99687
(907) 376-2305
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CCOSA WS Checklist .docx
COSA Checklist
Legal Description: MOUNTAIN MANOR B3, L4 Parcel ID: 050-671-36
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled 4/1985 Total depth 50 ft
Cased to 50 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 11/22/2023
Static water level at beginning of test 21ft.
Well production at time of test 5.8 gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate 4.55 mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by Date 11/20/2023
Comments
B. TANK DATA
Measured operating fluid level in septic tank NA
Date of pumping NA – NEW TANK
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 4/1985
ALL standpipes present per record drawing
Total measured depth from grade 15.7 ft (max)
Measured depth to pipe invert from grade 5.1 ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes (MT) go to bottom of effective. (ED)
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 1300 gallons 11/21/23 date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Adequacy test date 11/22/23
Results Pass
Fluid depth prior to test 89 in
Water added 550 gal
New fluid depth 122 in (2” INTO LATERAL)
Elapsed time 1335 min
Final fluid depth 87 in
Absorption rate 450 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 120 in (MOA 10’ ED)
Effective depth used 87 in (Final Fluid Depth)
Effective depth (ED) remaining 33 in
Comments/Deficiencies: 1300 gallon presoak saturated total absorption field & began to back into septic tank with test 24
hours later. Approximate total measured depths from existing grade. ED per elevation measured shots & appears
approximately no ED is missing of this short, original system operating in the top ED.
CCOSA WS Checklist .docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 06/24/24
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 or NO 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 &
06/24/24
NRq*5_q':_)R" 1141 14n nn'
ANCHORAGE RECORDING DISTRICT, ALASKA
AS -BUILT OF:
MOUNTAIN MANOR SUBD 00 FND 5/8" REBAR
LOT 4 BLOCK I PLAT 77-23
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A10W 0 F 4Z P L A 0 01
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0 HN L. SCHULLER: o
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1831 Talkeetna Street
Anchorage, Alaska 99508
AW
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�l AMW
Llssionc low (907) 227-1455 office
(907) 274-4992 fax
SURVEY CERTIFICATE: 1, 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 shout(
I
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- SCALE; E-MAJL-
MAY 28, 2024 1 "-50' schu.1 lerok0gm oil. com
24-044 DRAWN BY, ICHECKED BY: GRID NUMBER: BOOK AGE:
JLS NW0254 240161
UNICIPALITY OF ANCHORAGE
Development Services Department ala
p p Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 050-671-36-000
Expiration Date: 6/30/2024
Legal description MOUNTAIN MANOR BLK 3 LT 4
Site address 18920 JAMIE DR Eagle River AK 99577
Current property owner(s) LYC TRUSTCHING LARRY Y / TRUSTEE
The On-site system(s) is/are approved for bedrooms
X Conditional approval for 3 bedrooms, with the following stipulations:
Comments or advisories: Upgrade to be completed by June 30, 2024
Original Certificate Date: 1/5/2024
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
MUNICIPALITY OF ANCHORAGE
0
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 050-671-36
Complete legal description MOUNTAIN MANOR BLOCK 3, LOT 4
Location (site address) 18920 JAMIE DRIVE, EAGLE RIVER, AK 99577
Current property owner(s) LYC TRUST (LARRY CHING TRUSTEE) Day phone
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: ® Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ® Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 38 - See advisory if steel older than 20 years. AGED S.T. TO BE REPLACED WITH THIS CCOSA
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ® Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distan
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ .550 -4- 2.9 0
Date of Payment/2,
COSA # 0 5 C 2314 G 9
Waiver Fee $
Date of Payment
Waiver #
CCOSA Application 2022.doc
CCOSA WS Checklist .docx
COSA Checklist
Legal Description: MOUNTAIN MANOR B3, L4 Parcel ID: 050-671-36
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled 4/1985 Total depth 50 ft
Cased to 50 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 11/22/2023
Static water level at beginning of test 21ft.
Well production at time of test 5.8 gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate 4.55 mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by Date 11/20/2023
Comments
B. TANK DATA
Measured operating fluid level in septic tank NA
Date of pumping NA – NEW TANK PENDING
Required maintenance completed, if AWWTS
Comments: Please see escrow letter & 3 bids.
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 4/1985
ALL standpipes present per record drawing
Total measured depth from grade 15.7 ft (max)
Measured depth to pipe invert from grade 5.1 ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes (MT) go to bottom of effective. (ED)
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 1300 gallons 11/21/23 date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Adequacy test date 11/22/23
Results Pass
Fluid depth prior to test 89 in
Water added 550 gal
New fluid depth 122 in (2” INTO LATERAL)
Elapsed time 1335 min
Final fluid depth 87 in
Absorption rate 450 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 120 in (MOA 10’ ED)
Effective depth used 87 in (Final Fluid Depth)
Effective depth (ED) remaining 33 in
Comments/Deficiencies: 1300 gallon presoak saturated total absorption field & began to back into septic tank with test 24
hours later. Approximate total measured depths from existing grade. ED per elevation measured shots & appears
approximately no ED is missing of this short, original system operating in the top ED. 1500-gallon septic tank to be installed
for current functionality and future flexibility.
CCOSA WS Checklist .docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 12/19/2023
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 or NO 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 &
12/19/23
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / FirstWaterAK@gmail.com
December 13, 2023
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: CONDITIONAL COSA - CCOSA
LEGAL: MOUNTAIN MANOR BLOCK 3, LOT 4
Due to unprecedented events, seasonal conditions and site accessibility, the septic tank
installation or upgrade cannot occur at this time. We are requesting a Conditional COSA for the
above referenced property. The permitted OSP231403 of this 3-bedroom septic tank upgrade has
been impeded due to these conditions with no specific known date on when the conditions and
other factors would allow the septic tank installation to occur safely. The septic tank will be
installed once prudent, and the conditions are favorable for installation.
The system has been working for the occupants, recently passed a septic adequacy test and
granting of this Conditional COSA (CCOSA) will not impact any of the neighboring properties
or pose a public health risk. Attached are three septic tank upgrade estimates and escrow letter
from title for the pending installation. Please contact us if you have any questions.
Sincerely,
Curtis Huffman, P.E.
Allstewart
TITLE
YUKON DIVISION
1174 N Leatherleaf Loop, Suite B,
Wasilla, AK 99654
Main: 907-376-2220 1 efax:907-308-6981
2197096
1/4/2024
Property: 18920 Jamie Dr, Eagle River, AK 99577
Loan Number: 2610994355
To whom it may concern:
This letter is to confirm that Stewart Title Company will be holding funds in the amount of $19,325 for
the septic replacement, with work to be completed by June 30, 2024. The money shall be held in
escrow until such time as a final unconditional Certificate of On -Site systems Approval is issued by the
On -Site Water & Wastewater Section.
Thank you,
1.
HEATHER BILLSBOROUGH
Branch Manager I Escrow Officer
Stewart Title of Alaska
1174 N Leatherleaf Loop, Ste B, Wasilla, AK 99654
Direct (907) 631-4853
stewart.com/wasilla I heather.billsborough@stewart.com
License #AK100140632 I Stewart License #AK73852
---TITLE---
File No.: 2197096
Escrow Holdback Agreement AK
Page 1 of 1
ESCROW HOLDBACK AGREEMENT
To: Stewart Title Company
File No.: 2197096
Agreement between: Earl B Market and Debra L Addessi, husband and wife Buyer(s) and The LYC
Trust Seller(s)
Amount withheld: $19,325
The undersigned parties authorized Stewart Title Company to escrow funds in the amount of $19,325
from the Seller.
For the purpose of: Septic replacement
It is the sole responsibility of the undersigned parties to provide invoices to Stewart Title Company for
payment. Upon receipt, Stewart Title Company shall pay invoices for the above-mentioned work. In the
event parties are requesting to be reimbursed for invoices they paid out of pocket, Stewart Title Company
will require evidence of paid invoices before any reimbursement is paid.
If work is not completed by June 30, 2024, Stewart Title Company shall disburse the balance of the
escrow hold to LYC Trust without further consideration. This escrow holdback agreement does not
contain a provision to extend the completion date.
The undersigned parties hereby jointly and severally indemnify and hold Stewart Title Company harmless
from and against all costs, damages, judgments, attorneys’ fees, expenses or obligations every kind and
descriptions which, in good faith, it may incur or suffer in connection with this escrow.
Dated: ________________________, 2024
Buyer(s):
______________________________________
Earl B Market
______________________________________
Debra L Addessi
Seller(s):
The LYC Trust
____________________________________
Kenneth R. A. Ching, Co-Trustee
READ AND APPROVED BY:
Stewart Title Company
_________________________________________
Heather Billsborough
Escrow Officer
Shanon Levandowski
Shanon Levandowski
EXCAVATION PROPOSAL
OWNER INFORMATION
LYC Trust- Larry Ching
18920 Jamie Dr
CONTRACTOR
Denali Excavating
Jacob Tramp
PO Bx 770965
Eagle River, Ak
(907)240-3919
denaliexcavatingak@gmail.com
Project Location: 18920 Jamie Dr
SCOPE OF WORK
We will pump, clean and decommission existing septic tank- Install new 1,500-
Gallon HDPE. Tank will be bedded and compacted. Grade and clean-up on
completion.
Unless specifically agreed otherwise, the property owner shall be responsible for
final grading areas subsequently depressed from soil settling. On all leach field
mound systems, property owner is responsible for ensuring a satisfactory
vegetation growth over the mounded area is in place.
Denali Excavating LLC proposes the above scope of work for $11,568. No additional
work will be done without a change order. This proposal is good for thirty days.
Jacob Tramp
12/06/23
Summited by Jacob Tramp
OWNER ACCEPTANCE
I, do accept the above scope of work for $11,568. A deposit of
one-half is due when work is started and payment in full is due upon completion of
project. We will accept cash, check, or credit card(additional 3.4% for credit card).
JR’S SEPTIC PUMPING AND EXCAVATION LLC
P.O.Box 773415
Eagle River,AK 99577
Office:(907)694-6454
Fax:(907)688-1506
Email:jrsseptic@gmail.com
PROPOSAL
Submitted To:Brent Western
Phone:907-440-4601
Email:FirstWaterAK@gmail.com
Project Location:18920 Jamie Dr.
Project Description:Install new septic tank.
PRICE INCLUDES:
1.Decommission existing tank per municipal code.
2.Install new HDPE tank per engineered design.
3.Install double cleanouts after the tank.
4.Survey for well radius.
Estimated price for the above work:$12,229.00
PRICE DOES NOT INCLUDE:
PROJECT LAY OUT
ENGINEERING FEES
ELECTRICAL (NONE EXPECTED)
TOPSOIL AND SEEDING
UTILITIES NOT LOCATED BY LOCATE CENTER (NONE EXPECTED)
REMOVAL OF ANY MATERIALS FROM SITE UNLESS OTHERWISE STATED IN BID
PURCHASE AND INSTALLATION OF INSULATION IF NEEDED.
PAYMENT:
50%DOWN PAYMENT PRIOR TO WORK COMMENCING UNLESS OTHER ARRANGEMENTS
ARE MADE.BALANCE DUE 30 DAY AFTER THE INVOICE DATE.
Limitations
Project layout will be the responsibility of the engineering firm or a licensed surveyor if needed.
A.Bid amount includes installation,materials,and labor and equipment to install the septic system as
designed.
Unless stated otherwise,the bid amount does not include engineering services.
B.Unless stated otherwise,the bid amount does not include export of overburden,trees,stumps,etc.They
will be disposed of on-site unless otherwise stated.
C.Final grading will consist of backfilling the construction area with onsite native soils to create a rough
construction grade that meets the minimum M.O.A.soil cover requirements and provides drainage away
from,or around,the septic system.Prior to landscaping,most excavation sites will require hand raking and
shoveling to remove larger rocks,sticks and debris.This work is not included in the bid and unless stated
otherwise landscaping is not included in the bid.
D.There are limitations regarding the quality of final grading.Typically,there is settlement that may occur.
JR’s Septic Pumping and Excavation LLC will not be responsible for any ground settlement.
E.Unless stated otherwise,the bid does not include reconstruction or restoration of decks,fences,driveways,
and asphalt,trees,grass that must be removed or disturbed as part of the construction.
F.If this is an engineered project,layout will be the responsibility of the engineer.
All work will be in accordance with M.O.A.and State Guidelines
All work will be performed as per Engineering Plans and Specifications
Any alterations or deviations from the above specifications involving extra costs will be executed only upon
written orders or verbal and will become an extra charge over and above the estimate.
All work will be done in a workmanlike manner in accordance with standard construction practices.
This is a legally binding contract between the client and JR’s Septic Pumping and Excavation.
All collection fees,attorney’s fees,and late fees plus a 15%rate of interest will be applied to all accounts 30 days
past due.
Both parties acknowledge the right to lien the work site if the balance of this contract is not paid within 30 days
of invoicing the work performed.
This proposal will be void if not accepted within 14 days of the proposal date.
By signing this construction proposal,you authorize JR’s Septic Pumping and Excavation to proceed in the work
listed above and are agreeing to all terms and conditions listed.
Accept of Proposal /Contract
_______________________________________Date:________________
Larry Ching
_______________________________________
JR’s Septic Pumping and Excavation LLC Date:________________
Michael R Wehr
2
Proposal
Michael N. Anderson, P.E.
Civil/Structural Engineering and Construction
4661 Natrona Ave.
Anchorage, Alaska 99516
Phone 727-8864
Fax 345-1391
December 8, 2023
LYC TRUST – Larry Ching
18920 Jamie Drive
Eagle River, AK 99577
Re: Septic Tank Upgrade - Install 1500 GAL HDPE Septic Tank
Physical: 18920 Jamie Drive, Eagle River
Legal: Mountain Manor Block 3, Lot 4
Description of Excavation Services Provided:
1. Excavation to upgrade tank per the MOA permitted design by First
Water Consulting.
Total Proposal $12,550.00
1 an nn, ��
ANCHORAGE RECORDING DISTRICT, ALASKA
AS -BUILT OF:
MOUNTAIN MANOR SUBD
LOT 4 BLOCK 3 PLAT 77-23
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 shoulc
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: DAIS: SCALE: E-MAIL
NOV 18, 2023 1 "=50' schullerOak.net
23-121 DRAWN BY: CHECKED BY GRID NUMBER: BOOB rAGE:
JLS N W0254 230357
* = FND 5/8" REBAR"
.s.•OF 4 L A, N
AW
� .• �,
49TH
/� �� �'� •yam ..r`.
?A
:;.. ....
,JOHN L. SCHULLER.• o � = .
LS --10408
1f f^� � �i►jam .sx,�r'
•' �\ ,� 1831. Tal.keetna Street
kk ��'cy ' •�.�. ,,,, Ancharage, Alaska 99508
;47 Of
o� �. ,,,. (9Q7) 2<7-1455 office
SSIQi'` fir•
��®�•®�o'� (907) 274--4992 fax
Parcel I.D.
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.d.anchora-e.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORi T Y APPROVAL
FOR A SINGLE FAMILY L)WELLING
050-671-36
1. GENERAL INFORMATION
HAA #
Expiration Date:
Complete legal description l,nt• 4 * R1 nrk 3 - Mmintain tianor Rjibd; l,; gi nn
Location (site address or directions) 18920 Jamie Dr. Eagle River
Current Property owner(s) Gary Palmer Day phone- 694-3672
Mailing address
Lending agency
Mailing address
same
Day phone
Real Estate Agent Kathy G.ra .i Dayphone 694-919.9
Mailing Address 11411 old Glenn irwjr_ Fag1PR�r-AIC 99577
Unless otherwise requested, HAA will be held by DSD for pickup. 7al Z 71 s to 3
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:'
Individual Well
®C
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
)s
Individual Holding tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
r
D. LIFT STATION
Date installed Al A
"Pump on" level at in.
Datum
E. SEPARATION DISTANCES
Size in gallons
"Pump off' level at ` in.
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Manhole/Access (Y/N)
High water alarm level at in.
Meets alarm & circuit requirements?
Septic tank/lift / �� '
.lOn adjacent lots _ /00 'r -
Absorption field on lot X00 rf- On adjacent lots X00 1*
Public sewer main IV14 Public sewer manhoWcleanout
Scw6flseptic service line 2� �+ Holding tank AJ i4
SEPARATION DISTANCES FROM SEPTIC/H9Ler9G TANK ON LOT TO.-
Building
O:Building foundation g f Property line ^r Absorption field S
Water main J I LA Water service line i + Surface water tod�) Ir—
Wells on adjacent lots l00 tr-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /0 -►- Building foundation �Water main
�149 •� 1A -
Water Service line --C_0 Surface water 079 /'O Driveway, parkingNehide storage
Curtain drain NPIY6E 1/vN&GW. Wells on adjacent lots lob
F. COMMENTS
G. ENGINEER'S CERTIFICATION C'
i' •'
I certify that I have determined through field inspections and • ••+-• ••^•~
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date. �, R Z or
A
Engineer's Printed Name �d'Q f"� C. CowAr' ,+��l•,%
i Fcj. ..,`'
Date Cv 3o Id 3 y��i:: 'a�,Ms+r'
HAA Fee $ Waiver Fee $
Date of Payment r �0� Date of Payment
Receipt Number 0-3-7 $ 6 �L Receipt Number
(Rev. 12/01)
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority 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.
Blame of firm S & S Engineering Phune 694-2979
Address 17034 N. Eagle River Loop Ste. 204 Eagle River, AK 99577
Engineer's Printed Name Robert C. Cowan Date 6134103
�-_- OF
�•.........
11, ��� ROBERT C. COWAN
5. DSD SIGNATURE 3 4# CE
4C •8801
Approved for bedrooms. +E .•
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
WASTEWATER
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: 00 �a Original Certificate Date: %- S -03
(Rev. 01102)
Municipality of Anchorage
' Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 995IM650
www.clanchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: 1VT4-,' 12,Mt?CK 1: r 0UNEA f N %' AI Jp2 Parcel ID: OSQ ^
A. WELL DATA S t t
Well type 'tF If A, B. or C provide PWSID # — Well Log (YIN) Y
Date completed Sanitary seal (YM) Wires properly protected (YM)1 7—
Total depth _V—ft. Cased to L2 ft. Casing height (above ground) _ 9 t in.
Date of test
Static water level
Well production
FROM WELL LOG
4
3S' ft.
WATER SAMPLE RESULTS:
/O
g.p.m.
AT INSPECTION
G2 C3
33' ft.
4-"6 g.p.m.
ColiformO
--2—co ml. Nitrate 3•s4 mg./l. Othel4t�Ionies/100 ml.
Arsenic: mg./l. Date of sample: L6±/0 3 Colle I'agle River Loop Resd ft 204
B. SEPTICIHOLDING TANK DATA
Tank Type/MaterialSt-Orle, rjhkG Date installed
Tank size 1!100 gal Number of Compartments Z Cleanouts (YIN)
Foundation cleanout (YIN) Depression over tank (YIN) _A11 High water alarm (Y/N) 14/
Date of pumping G / D 3 Pumper LT4 's
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft otg System type TA&Ve f
Length ZS ft. Width Z. 5- ft. Gravel below pipe /19 ft.
Total depth t4 ft. Eff. absorption area _IaLfl? Monitoring tube Y Depression over field
Date of adequacy test 0 Results (Pass/Fail) A4 ss For 3 bedrooms
Fluid depth In absorption field before test Oe in. Water added gal. New depth in.
Elapsed Time: [44min. Final fluid depth f_O in. Absorption rate >= 45-� g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date —
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by myseal affixed hereto and as of the validation date shown below, I verify that my investigation of this h,
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adeqL,.,
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtainer,
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
Addre
Date
A��'4
mo eo••a ■■
° °^ •o ••ee�d�i
W
• mmm "'b
"• e
aemm ••••mm •mr=r
16obert A. Shafer'
'o No. 1457•E
s �
DPMOF
AW
00 ••• � A
9 •••°e•.mmNim• ��".rV
6. DHEP APPROVA
Approved for L �bedrooms by -- �� v
--- Date
Approved Disapprove _ Conditional
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 engineers work.
Page 2 of 2
6-30-03;12:15PM; ;907 561530/ u 2/ 5
J
SGS Ref.#
1033653001
Client Name
S & S Engineering
Project Name/#
Various
Client Sample ID
L4, B3, Mountain Manor S/D
Matrix
Drinking Water
All Dates/Tlmes are Alaska Standard Time
Printed Date/fime 0627/2003 9:50
Collected Date/Time 06202003 13:10
Received Date/Time 06202003 17:13
Technical Director Step . Ede
Released
Sample Remarks:
Allowable pM Analysis
Parameter Qualifiers Results PQL Units Method Container ID omits Date Date Init
Metals by ICP/MS
Arsenic 5.00 U 5.00 ug/L EP200.8 C 06/23/03 06/26/03 WAW
Waters Department
Nitrate -N 358
Microbiology Laboratory
Total Coliform 0
0.100 mg/l, EPA 300.0 B (r--10)
col/100mL SMIS 9222B A (<_))
06/21/03 JJB
06/20/03 KAP
JAMIE DRIVE-..
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2.
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 Z Z&.0
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Na
Applicant Ad
Telephone: Home
F
Business3'6'L
(c) Applicant is (check one): Lending Institution ; Owner/builderA�,Buyer O ; Other CT (explain);
(d) Lending Institution A_Y�o /--) r Telephone
Address
(e) Real Estate Company and Agent ✓V LR-7.Irti _
Address
T I phone
(f) I the HAA to the following address:
TYPE OF RESIDENCE
Single -Family Multi -Family C7
Number of Bedrooms 3
3. WATER SUPPLY
Other
Individual Wel%< Community C] Public C)
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite Public ❑ Community ❑ Holding Tank 0
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)
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTION
HEALTH AUTHORITY APPROVAL (HAA) I,. AY 2 Q 05
CHECKLIST - FEBRUARY 1984
284.4720 E 1 V E D
Legal Description: Z- 0T `/ �K
A. WELL DATA
Well Classification �iCw#}T If A, B, C, .E.C. Approved (Y/N) �/�
Well Log Present (Y N) Date Completed Yield
Total Depth Cased to ?j"—D r Depth of Grouting
Static Water Level 3's--' Pump Set At 6
Casing Height Above Ground Sanitary Seal on Casing(Y/ )
Electrical Wiring in Conduit (Y/) Depression Around Wellhead (Y V�
Sepatation Distances from Well:
To Septic/Holding Tank on Lot /0
On Adjoining Lots /00
To Nearest Edge of Absorption Field on Lot ///
On Adjoining Lots — /011
To Nearest Public Sewer Line AJ f k$ To Nearest Public Sewer
Cleanout/Manhole � To Nearest Sewer Service Line on Lot 'z f
Water Sample Collected by S `It_!�__ ; Date 5
Water Sample Test Results ..
s
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed y �r Size /OO O No. of Compartments `L
Standpipes &�WAir-tight Caps 47/,PJ) Foundation Cleanout 4,D -Df)
Depression over Tank4*4 Date Last Pumped /vim/�/V
Pumping/Maintenance Contract on File (Y/N) ^///f� ; for '`//�
Holding Tank High -Water Alarm (Y/N) N�d Temporary Holding Tank Permit (Y/N)=
Separation Distances from Septic/Holding Tank:
To Water -Supply Well /0l "
To Property Line
To Water Main/Service Line
Course
Comments
Page 1 of 2
72-026(11/84)
ri
3 ✓
To Building Foundation
To Disposal Field �O
To Stream, Pond, Lake, or Major Drainage
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata j« I v2 Type of System Design I-T,:�sN� f r
Date Installed Length of Field
Width of Field Depth of Field Zr
Gravel Bed Thickness ,,pp,,
Square Feet of Absorption Area �`�" /moi
Standpipes Presentct-rw
Depression over Field Date of Last Adequacy Test
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well
To Building Foundation
Lot
To Water blot/Service Line Ir" t
To Stream/Pond/Lake/or Major Drainage Course _
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
�6
To Property Line
To Existing or Abandoned System on
7— 14-
On
tOn Adjoining Lots
To Cutbank (if esent)
eVul_" Nr:=
O /It -
AV ul_"
It-
A-114-
D.
1
Date Installed
Dimensions
Size in Gallons
Manhole/Access (Y/N)
"Pump On" Level at
'Pump Off' Level at
High Water Alarm Level at
Vent (Y/N)
Tested for
Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signes' IML3INProaikla DateSAN r
GQf7, $RB d9ax
+MPIVFf? nL ASK .. '29577 MOA No. X_
PH. 684.2979
Receipt No- ._...-_u _ 1-!a d
Date of Payment �-a9 -85
Amount: $ yst-ob
Page 2 of 2
72-026 (11/84
