HomeMy WebLinkAboutMOUNTAIN VALLEY ESTATES BLK 1 LT 12Mountain
Valley
stat s
lock I
Lot 12
050-64!
Municipality of Anchorage
Development Services Department~~,~";:"
Building Safety Division
On-Site Water and Wastewater Program, 4700 Elmore Road ~ ~'~
P.O. Box 196650 Anchorage, AK 99507 Page of
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: osp lilt 2_~ PID Number: 050 -G~/- ZB
Name:
~g~Ly L~4.~ Wastewater System: ~ New ~Upgrade
Address:
Phone: Number ¢ Bedrooms:
~ ~ Deep Tren~ ~ Shallow Trench ~ Bed ~ Mound D O~er:
LEGAL DESCRIPTION Sci, Rating: Total Depth from original grade:
GPD/F¢ Ft.
Block: Lot: Subdivision: Depth to pipe bottom from odginal grade: Gravel depth beneath pipe:
Township: Range: 'Se~ion: Fill added a~ve odginal grade: Gravel LenCh:
Ft. Ft.
Wall: ~¢5~;¢fl ~ New ~ Upgrade Gravelwid~: Ft. Number ~ lines: ]Distancebe~eenlines:Ft.
Classifi~tion (Pr[rate'A, B, C): Total Depth: Cased to: Total absorption area: Pipe Material:
Ft. Ft. Ft~
Driller: Date Drilled: Static Water Level: Installer:
Yield: Pump Set at: Casing Height ~ove Ground:
~.. .~. .~. TANK
SEPARATION DISTANCES ~Septic U Holding ~ S.T.E.P. ~ Other:
Tank Field Station Tank Sewer Line / ~0~ Gal.
Number of Compadments:
Su~a~ Water l00~ --'¢ ~ LIFT STATION
Size: Man~a~uren
Lot Line 5 [ ~ Gal.
Foundation ~ t~ "Pump on" level at: "Pump o~' level at: ~ High water ala~ at:
in. in.l in.
Pump Make &Medel Electd~l Insp~tions pedormed by:
Cudain Drain
Lo~tion and Description:
~ Assumed Elevation:
Inspections pefformed by: L.¢, ~/.~l Dates: 1st 7/~///
Development Semites Depa~ment ~pproval ~ ~.' ~ '.~
Conditional Approval Date:
Lot 11
NOTE: NO P/ELLS OR SEPTIC SYSTE~tS WITH IN 150 £Ecrr
PROPOSED SEPTIC TANK REPLACEMENT SITE.
I
SWING TIES
C 8.0' 19.0'
0 9.5' 19.5'
E 15.0' 21.5'
F 18.0' 22.5'
TA]~"~ L L E Y ES TA TES AeANDONED EXI~IN~
SEPTIC TANK PER MOA
~ .~~ CODE REOUIREI~ENTS
O EF
' : :-" IINSTaL~O NEW lO00 ~LLON STEEL SEP~C
kCONNECTEO TO DRAIN FIE~
NOTE: NO ~E~S OR SEPTIC SYSTEMS WITH IN 150 FE~ O~
~ 0 ~ ~ P~SED SEPTIC TANK REP~CE~ENT SITE.
I
25 0 25 ~0 75 100 125 1~0
SCALD' 1' = 50 FT,
N
INSTALLED DOUBLE ~
CLEANDUTS~~, E~.. =~
CllNNECTED TII ~ lOflO GALLON SEPTIC TANK
EXIST B£AINFIEL'T~' D ~
4 FEET C£VER
INSTALLED DOUBLE
CLEANDUTS
SPURKLAND ENGINEERING
205 W 15TH. AVENUE
ARCH. AK. 99501
(907) 279-$916
MOUNTMN VALLEY ESTATES BLK 1 LOT 12
BEV LEWANSKI
4717 BIRDSONG RD., EAGLE R/YEN, AK 99577
SEPTIC SYSTEM ASBUILT
DATE: JULY 19, 2011
SHEET: 1/1 GRID: SIC 658
PERMIT tl lISP 111125 Piti ti 050-641-23 MVEB1Li2.fll. flVG
Permit Number:
Tax Code Number:
Work Type:
Permit Effective Dates:
Design Engineer:
Subdivision:
Site Legal Address:
Owner/Address:
Site Mailing Address:
On-Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
OSPl11125
05064123000
Septic Upgrade
July 01,2011 to
SPURKLAND ENGINEERING
MOUNTAIN VALLEY ESTATES
June 30,2012
MOUNTAIN VALLEY ESTATES BLK 1 LT 12 G:0658
~°
l.)epartment
LEWANSKI BEVERLY ANN REVOCABLE
TRUST LEWANSKI BEVERLY ANN / TRUSTEE 4717 BIRDSONG DRIVE EAGLE RIVER AK 99.~
4717 BIRDSONG DR, Eagle River Lot Size in Sq Ft: 61427
Total Bedrooms: 2
This permit is for the construction of:
N Disposal Field Y Septic Tank
N Holding Tank N Privy N Private Well N Water Storage
All construction must 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 must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Date:
Date:
MUNICIPALITY OF ANCHORAGE
Community Development Department
Development Services Division
On-Site Water & Wastewater Program
Phone: 907-343-7904 Fax: 907-343-7997
Mayor Dan Sullivan
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O,~:X~)- 6 c/i- '~ 3
Property owner(s) /~e,¢
Mailing address 4.']rj."{ J~i,*'~7
Site address '- SA v~ 6 -
Legal description (Sub'd., Block & Lot)
/
Legal description (Township, Range & Section)
Lot Size Sq. Ft. Number of Bedrooms
Day phone '-
THIS APPLICATION IS FOR:
([~ all that apply)
Absorption Field
Septic Tank
Holding Tank
Privy
Private Well
Water Storage
THIS APPLICATION IS AN:
Initial []
Upgrade ~
Renewal []
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
I certify that the above information is correct. I further certify that this application is being made
for § Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Si-~ature o~ property owner or authorized agent)
~k,~Per~m~Rush Fees: ,'.-~OO "~ ~-6¢ ~ Waiver Fees:
Date of Payment: (,¢ ~ ~' ~ - ~, ~ Date of Payment:
Receipt Number: CDt ~,-~-O"'~ ~ Receipt Number:
Permit No. O%tOV~*\\ "c~-~ Waiver No.
G:\Building\On Site\Forms\Client Forms\Permit App_010411 ,doc (Rev. 1/11)
Environmental Consulting and Design
Municipality of Anchorage
Development Services Department
Building Services Division
On-site Water and Wastewater Program
4700 Elmore Road
Anchorage, AK 99519-6650
I
June 22,2011
Subject:
SEPTIC TANK PERMIT APPLICATION
Mountain Valley Estates Block 1 Lot 2
Ladies and Gentlemen:
We are submitting an application to upgrade the septic tank for this lot. The existing septic tank serving
the above referenced property is 32 years old and the owner would like to replace it. The submittal
consists of one (1) drawing showing the present improvements on the lot and the proposed improvements
of the lot, of which only the septic tank is subject to this permit application.
There are no wells within one hundred feet of the proposed replacement site. The installation of this
septic tank will not prevent wells and septic systems from being installed on the adjacent lots. There are
no developed or natural surface / sub surface drainage courses within 100 feet oft he proposed septic tank
location. The proposed septic tank will not change the general slope of the area. Ponding and/or
concentration of surface runoff will not result from this installation.
If you have any questions or are in need of additional information please contact me at 279-3916.
Sincerely,/,) , ,
Lars Spur'klind, P.E.
203 West 15th Avenue Suite 202, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (907) 276-6013, SpurklandEng~gci.net
Io-t: 11
NOTE: ND WELLS DR SEPTIC SYSTEI~S WITH IN I$0 FEET
PROPOSED SEPTIC TANK REPLACEI~ENT SITE.
NOTE: NO P~ELLS OR SEPTIC SYSTEI~S P~ITN IN I58 FEET
L o t 13 PROPOSED SEPTIC TANK REPLACEI~ENT SITE.
£5 0 £5 58 75
SCALE: 1' = 50 FT.
158
DOUBLE
CONNECTT~D
EXIST DRAINFIELD -~
4 FEET COVER
"~ INSTALL FOUNDATION
CLEANOUT
1888 GALLON SEPTIC TANK
SPURKLAND ENGINEERING
205 14/ ISTH. AVENUE
ANCH. AK. 9950!
('907) 279-$916
MOUNTAIN VALLEY ESTATES BIX 1 LOT 12
BEV LEWANSKI
47¥7 BIRO$ONG RD., EAGLE RIVER, AK
SEPTIC SYSTEkl DESIGN
DATE: JUNE 22, 2011
SHEET: 1/1 CRID: SI4/ 658
PERMIT # DSP 1110XXX PID # 050-641-23 MVEBIL12.D1.DWG
Subject Property:
Date:
Environmental Consulting and Design
I
Single Family On-site Wastewater Disposal System
Construction and Material Specifications
Mountain Valley Estates Block I Lot 12
3une 22, 2011
General:
1.
The owner shall contract with a contractor to perform the work outlined in these
specifications and plans in accordance with the attached MOA permit. There is not
contractual arrangement between the contractor and the Engineer. The Engineer shall
be the owner's representative and will inspect the work to document the contractors
activities. Final acceptance of the contractors work rests with the owner and the MOA.
The scope of the work includes the installation of a new 1000 gallon septic tank. The
location of the drain field is shown on the attached site plan drawings. All components of
the proposed septic system must be constructed a minimum of 100 feet from any surface
water or water wells in the area. A minimum of 4 feet of earthen cover is required over
the septic tank. If less than 4 feet of cover is available, 2-inch thick, 40 psi, direct bury
board foam shall be installed directly over the septic tank and all installed piping.
Construction shall be in accordance with the approved site plan and design drawings and
any special provisions noted on the Municipal well and/or septic permit. All materials,
components, workmanship and construction practices shall comply with the Municipality
of Anchorage's latest ordinances regarding wells and septic systems, as well as MOA,
Development Services Department, On-site Water and Wastewater Program (DSD)
policies.
The contractor is responsible for obtaining all underground utility locates, layout of the
proposed system, and verifying and maintaining all required separation distances to lot
lines, surface water, wells, steep slopes, etc.
The property owner shall be responsible for final grading any depressions formed from
settlement of backfill material. The property owner is also responsible for vegetation of
all areas disturbed by septic system installation activities.
Contractors installing wastewater disposal systems must be certified to do so by the MOA
DSD, On-site Water Wastewater Program. Property owners installing their own systems
must receive advanced approval from MOA DSD prior to system installation activities.
The contractor shall ensure that ALL materials being used are in compliance with the
most current guidelines established by the Municipality of Anchorage. Refer to
"Standards and Specifications for Component Parts and Materials Used in the
Construction of On-site Wastewater Disposal Systems", Dated December 2000, as
provided by MOA DSD, On-site Water and Wastewater Program.
203 West 15th Avenue Suite 202, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (866) 354-1597, Lspurkland~gci.net
Environmental Consulting and Design
Septic Tank Znstallation:
3.
4.
5.
6.
9.
10.
11.
12.
13.
14.
15.
16.
A new septic tank, of the size specified in the design drawings, shall be procured from a
qualified manufacture/supplier if the existing septic tank is found to be defective.
Construction shall include two 4" diameter cleanouts for pumping access.
The burial rating of the tank shall be adequate for the actual burial depth encountered.
The tank shall be level and sufficiently bedded to prevent settling of shifting of the tank.
All standpipes on the tank shall extend a minimum of 12inches above the final grade.
Tanks installed with less than 4 feet of cover shall be insulated.
The sewer service line from the house to the tank shall have a minimum slope of 2%
unless prior approval is obtained from the engineer.
The inlet and outlet lines from the tank shall be bedded in drain rock or the soil shall be
sufficiently compacted to prevent future settlement of the soil.
Septic tank inlets, outlets and cleanouts shall be fitted with water tight couplings.
A cleanout shall be installed 1 to 4 feet from the foundation.
Post tank cleanouts shall be installed per MOA requirements. Does not apply to
pressurized lines.
]:n areas with high ground water, the septic tank shall be sufficiently anchored to resist
buoyancy forces when there is not adequate soil cover to resist uplift force. The
contractor shall refer to the engineer for direction regarding this matter.
The tank backfill shall be graded sufficiently to ensure positive drainage away from the
tank.
All holding tank and lift stations shall have an audible and visible alarm inside the
residence being served.
All lift stations shall be wired in compliance with all MOA guidelines and the Uniform
Electrical Code. A municipal electrical permit and inspections must be obtained where
required by the IVlOA.
The contractor shall verify that the septic tank/lift station is a minimum of 100 feet from
any residential water well, 150' from any class 'C' well and 200 feet from any community
water wells. Additional separation distances must also be maintained.
The contractor shall remove or abandon the existing tank in compliance with the Unform
Plumbing Code.
Tnspections:
A minimum of one inspection is required by the Municipality of Anchorage. These
inspections must be conducted under the supervision of a Professional Engineer licensed
to practice in the State of Alaska.
The septic tank may be set in place, but may not be backfilled.
The contractor shall provide a legible copy of all field notes relating to system layout and
construction to the engineer for the use in preparing the record drawings.
203 West 15th Avenue Suite 202, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (866) 354-1597, Lspurkland~gci.net
Environmental Consulting and Design
I
The contractor shall coordinate all inspections with the Engineer. A minimum of 24 hours
notice is required prior to the start of construction. Tf necessary, a preconstructJon
meeting will be held on-site.
203 West 15th Avenue Suite 202, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (866) 354-1597, Lspurkland~gci.net
MUNICIPALITY OF ANCHORAGE
~., =, .~-.,,//_..~ 'z't-, '~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
(l~ ENVIRONMENTAL ENGINEERING DIVISION
~ 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAM E TPHON E
~ ~ Manufauturer
Materla~¢~ No. of comp~ts
T 'e"e Inside Ion,th Width Liquid depth
Liq. Ions I F HOMEMADE:
0 Well Foundati~ Nearest I~t I~ PERMIT NO,
~Z DISTANCE TO: 10 O d"
~ No. oflines [ Length ofeach:~s 'line Total length of lines Trenchwid~Oinche` Distance between,ines
~ ~ ~ Top of tile to finish grade - Material beneath tile -- Total effective absorption area
Length Width Depth PERMIT NO.
~u Well Building foundation Nearest lot line
¢ DISTANCE TO:
Clas~ / Depth Driller Distance to lot line PERMIT NO.
~ '~ Building foundation Sewer line Septic tank Absorption area(s)
DISTANCE
OTHER
PIPE MATERIALS
INSTALLER
REMARKS
k PL-
APPROVED ~ DATE LEGAL
2-013 (Rev. 3~78)
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~. SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Alaska 99502 276-222'~
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8--
9
DATE PERFORMED:
SLOPE
SITE PLAN
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND -- FT
72 008 (7/76)
C�,rrfi trb Draft il[vg
by
A & L, DRILLING COMPANY
BOX 97, EAGLE RIVER, ALASKA 99577 • TELEPHONE 694-2588
OWNER OF LAND DEPTH OF WELL
ADDRESS
STATIC LEVEL OF WATER FT
LEGAL DESCRIPTION ,4 U 7'7- �L DRAW DOWN FT.
DATE - Started EndAd �/ -- U 9 GALS. PER HR
PERMIT NUMBER 19'01 Y KIND OF CASING
KIND OF FORMATION:
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MISCL. INFORMATION:
DRILLER'S NAME
I ..l~[(i!il::ll. I... 11 .;:-:i
H i!i t:',1
:if. Iii!l ,(i!i F"t !1:i21"
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iii!;i::'l! [ C;
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Certificate of On -Site Systems Approval
Parcel I.D. 050-641-23
Expiration Date: Pohp/ z- -z y
Legal description MOUNTAIN VALLEY ESTATES BLK 1 LT 12
Site address 4717 BIRDSONG DR Eagle River AK
Current property owner(s)' LEWANSKI
X The On -site system(s) is/are approved for 2 bedrooms
Conditional approval for bedrooms, with the following stipulations:
a
Original Certificate Date: 11/2/2023
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.
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approvaijune 2022
MUNICIPALITY OF ANCHORAGE
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. 050-641-23
Complete legal description MOUNTAIN VALLEY ESTATES BLOCK 1, LOT 12
Location (site address) 4717 BIRDSONG DRIVE, EAGLE RIVER, AK 99577
Current property owner(s) BEVERLY ANN LEWANSKI REV. TRUST ... Day phone
2. ON -SITE SYSTEMS SIZED FOR 2 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 12 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ® Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review 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.
COSA Fee $ 5 -50
Date of Payment
COSA # 0,5C231q07
J2 vS 1- P C_ (_ 4330 1' � 3t � ?-J 7.3
Waiver Fee $
Date of Payment
Waiver #
COSA Application.doc
COSA Checklist.docx
COSA Checklist
Legal Description: MOUNTAIN VALLEY ESTATES BLOCK 1, LOT 12 Parcel ID: 050-641-23
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 1/10/1977 Total depth 111.5 ft
Cased to UNKNOWN ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 10/18/2023
Static water level at beginning of test 87 ft.
Well production at time of test 5,7 gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate 2.12 mg/L Nitrate less than MRL (ND)
Arsenic 7.23 ug/L Arsenic less than MRL (ND)
Collected by Date 10/18/23 & 10/24/23
Comments Sullivan installed new sanitary seal with conduit and chlorinated / shocked water system with new
coli sample on 10/24/23.
B. TANK DATA
Measured operating fluid level in septic tank 52”
Date of pumping 10/18/23
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) 11/02/1979
ALL standpipes present per record drawing
Total measured depth from grade 6.8 ft (max)
Measured depth to pipe invert from grade 4 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 2.8’
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Adequacy test date 10/18/23
Results Pass
Fluid depth prior to test 1 in
Water added 375 gal
New fluid depth 11 in
Elapsed time 20 min
Final fluid depth 1 in
Absorption rate 300 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 60 in (MOA 5’ ED)
Effective depth used 27 in (Missing ED + Final Fluid Depth)
Effective depth (ED) remaining 33 in
Comments/Deficiencies: Approximate total measured depths from existing grade. Existing depths & ED per visual
observations of sump invert measured & appears approximately 2.2’ or 26” of ED is missing.
COSA 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 11/01/2023
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 &
11/01/23
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343~4744
1. GENERAL INFORMATION
Complete legal description
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA#
Birdson9 Road
Location (site address or directions) Birdson9 Road
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Noal Presla~ Day phone 694-4368
SR Box 9357 Hiland Road Ea¢le River, AK 99577
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 2
3. TYPE OF WATER SUPPLY:
XXX
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site X×X
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Fronl MOA #21
STATEMENT OF INSPECTION BY ENGINEER '
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my inves_ti~gation 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 __5_&_S_EN~~~/Phone ~'-'~'/~//~--~'7//¢'
Address
Engineer's signature ~Eagle Ei~CL,~,ST/ / D a t e//~/;,~_~,///~,,~
o
DHHS SIGNATURE
~ Approved for '7'~/x'~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev, 1/91) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:~:,% ~?--- ~'z~F- \ P~I~. \l~,,'u~C~d.
A. Well Data
Well type ~'P(/,-'\ ti A,~,~
Log present(~N)
Total depth \\\ L., Cased to
Sanitary seal (~N) '~/
Parcel I.D.
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed / ¢/c, - '7 '7 Driller
Casing height
Wires properly protected ("~'N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
g.p.m. ~' ~ g.p.m.
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
~.C
o
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
Date of sample: ~.~
B. SEPTIC/HOLDING TANK DATA
Collected by:
Other bacteria
Date installed \ o~ .~ c~ Tank size \ ~:=,-~ c.~ Compartments
Cleanouts ~) ',,( Foundation cleanout (Y~) ~-~ ~De~ (Y,~)
High water alarm (Y/~). ¢ Alarm tested (Y/N)
Date of pumping o~ _ /7.-- ..~_c.~. ~ Pumper '~_¢-~. ~.~¢__~;¢~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~,~ ~ \ ~r- On adjacent lets
To property line L, ,.~ Absorption field
Surface water/drainage
Foundation Lc t
Water main/service line /'C:) \E
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Manufacturer
Vent (Y/N) "Pump on" level at
High water alarm level ~ ~ tested
Meets MOA electrical codes (Y/N)
SEPARATION DI~S.T-ANC~ FROM LIFT STATION TO:
Welr~on lot On adjacent lots
Manhole/Access (Y/N)
"Pu~l at
Surface water
D, ABSORPTION FIELD DATA
Date installed \ 5'"1 ~
Length '%~ \
Total absorption area
Date of adequacy test
/
Soil rating (GPD/FF) ~ ~ /(2~.. System type '~¢~ (-~
Width "2~~ Gravel thickness ~" ~ Total depth
'~ %-~ ~ Cleanout present (~i) k/ Depression over field
°~ ./?/'~ ----c1~ Result~ail) ,¢¢,~¢ % for
Water level in absorption field before test ~" After test 4~ '~
Peroxide treatment (past 12 months) (¥~ ~o~ E.- ,¢.--.~ o v~ ,3 If yes, give date ~'~l/~
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot \ ~ ~ On adjacent lots ~ ~o Property line
To building foundation / ~ ~
To existing or abandoned system on lot
On adjacent lots "~-'~ ~ ~ Cutbank ~ l J~ Water main/service line
Surface water \ ~ o Driveway, parking/vehicle storage area
Curtain drain ~,/~
E, ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on,(hetda~e~o./¢his inspect!on.
;:.,., : ,... ,~,¢ ;%,- ,
., . "%'%: 4~. .'
]7034 ~le RiCr Loop Rbaa
__ ' ..:. :..~,. ',~:,:: " '
HAA Fee $
Date of Payment ~,.~-~'~:'~.~
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
DATE RECEIVED
INSPECTION APPOINTMENTS ~"-,, ~"(i. (J~.'~.. '~L.~ ~
TIME" TIME !~ .I TIME
DATE DATE '~j ('~.~ DATE~[ _
INSPECTOR INSPECTOR I NSP ECT(~B
MUNICIPALITY OF ANCHORAGE '"' IPA
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE'~ L TY OF ANCHORAGE
EPT OF H ~ITH &B25
L
Street-
Anchorage, Alaska 99501 ENVIRONMENTAL P:,OTECTION
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720 APR 2 4 1!~81
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SF-~I~I:CF~,~I~/I~I~
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing,
1.
PROPERTY OWNER ~ ~
M~AILING A D~J~5
PROPERTY RESIDENT (if different from above) PHONE
2' BUYER gSS~)~'-~MAILINGAD ~~ -- ~ ~ ' PHONE
3. LENDINGINSTITUTIONMAiLINGADDRESS ~~ ' P~'~' ~~ ' I PHONE
4. REALTOR/AGENT I PHONE
I
MAILING ADDRESS
5, LEGAL DESCRIPTI~..~
STREET LOCATION
6, TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One [] Four
~' [] Two [] Five
SINGLE
FAMILY
[] MULTIPLE FAMILY ~ Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG, A well log is required for all wells drilled
since June 1975, For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVI DUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[~] PUBLIC UTILITY
Connection Verified INSTALLER
r--ISeptic Tank or [] Holding Tank
Size: /~¢:2OO If Tank is homemade SOILS RATING '
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot kine
WELL TO:
Absorption Area to nearest Lot kine
5. COMMENTS
[~//APPROV ED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL {letter must accompany certificate)
[] DISAPPROVED
DATE BY
72-010 (Rev. 6/79)
t9Z_/
~=~_t~(~ .S T A T E M E N T
OK 882
DATE RECEIVED
' NSPECT' ON APPO'NTM ENTS
TIME~ TIME TIM['.'
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR^
MUNICIPALITY OF ANCHORAGE DEPT. OF I::;,LT;I &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE~It~/(~I~)NMEN]/''L ;:;;?i :CTION
825 L Street-Anchorage, Alaska 99501 MAR 2,5 1980
ENVIRONMENTAL SANITATION DIVISION
Telephone264-4720 RECEI_YED~_ .
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER PHONE
MAI LING ADDRESS
PROPERTY RESIDENT Ill different from above) PHONE
,..UYER : PHONE
MAILING ADDRESS
3. LI:NDING I~STITUTION PHONE
4, REALTOR/AGENT ] PHONE
I
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
-
6. TYPE OF RESIDENCE
~SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One [] Four
] .~ Two [] Five
Three [] Six
[] Other
7. WATER SUPPLY
~INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG, A well log is required for all wells drilled
since June 1975, For wells drilled prior to that date, give well
depth (attach log if available.) //0 /:T,
8. SEWAGE DISPOSAL SYSTEM
I~I~DIVI DUAL/ON-SITE~
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] IN DIVI DUAL/ON -SITE DATE INSTALLED
[]PUBL,C UT, L,TY 1/
Connection Verified
[]Septic Tan,~.or [] Holding Tank INSTALLER
Size: I~?~_~)~) If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCESwELL TO: Septic/Holding/l~(~ Tank Absorption/~.)Area(/.~ Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
~A~PROVED FOR ..2~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED /,~
DATE BY ~~.~
72-010 (Rev. 6/79)