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Home My WebLink AboutNETTLETON LT 1A Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Q2 Permit Number: OSP2012iI PID Number: 015-081-25 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New X Upgrade Name OKSUN SPRINGER ABSORPTION FIELD X Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 7240 NEWBY AVENUE ❑ Other Phone Number of Bedrooms Soil Rating depth from original grade 5 0.8 GPD/SF JTotal 10 Fl. LEGAL DESCRIPTION Depth to pipe invert from original grade 2.0 Ft. Gravel depth beneath pipe 8 Ft. Subdivision Block Lot NETTLETON LT 1A Fill added above original grade 1 + Ft. Gravel length 60 Ft. Township Range Section Gravel width 2.0 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 750 Ft2 1 Ft. Well 100,+ 100'+ 50'+ TANK I] Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity GREER TANK 1500 Gal. Surface Water 100++ 100'+ Material Number of compartments Lot Line 10'+ 10'+ NA PLASTIC 2 Foundation 1 0'�- 10'+ LIFT STATION Manufacturer Capacity Remarks OLD TANK DECOM. PER UPC Gal. Alarm location Electrical installed by Tank to PIPE MATERIAL House to tank 3034 d3034 Installer MIKE N ANDERSON, P.E. rainfietd Drainfield 3034 CO/MT3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 102.1 ft f -t 8/15/20 8/15/20 Inspect Location and description es: 2^° SIDEWALK SLAB 3rd 4th ON-SITE WATER AND WASTEWATER SECTION APPROVAL E qiq 'p Conditional Approval: Date! gyp;••' ';srr�9 ....... ..s �• MICHAEL N. ANDLRSCN Septic System Approves �2l —26t ��;•,. CE 94 9 •,•\ �� Date �f�.c•��?�?;�� Note: this approval does not include well permit requirements.��,� R(+ff S:l� •r" kNev uoiuuiu/ Permit No. OSP201202 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744 On—Site Wastewater Disposal System and/or Well Inspection Report Legal Description: NETTLETON LT 1A PID No.: 015-081-25 ARK /AB— \ , CO 25 23 02� ( 7 24 N C0 33 26 \ CO � 36 29 I 03 40 31 041 32 M5" 65 117n / 06' 85 75' T I, 64 69, NEW '1500 GALLON PLASTIC TANK =NCH, SIDEWALK 'SLA .MT IH WELL U C06®®®®® TCO2 MT ®®®® 1 0C DF flNISN GRADE 6��/�. • 7 —FILTER FABRIC .0 ORG AW J ••� AN 49 TH �' ®®0 94.8 ,.500 scwc. xoa .0 GALLON 4. ••••�• PLAS C GM TANK s 7 e .,10 ® ;MICHAELU-1.0 , N. ANDERSON:, A# No. CE 9469 ®® 8-18-20 .�.� SEPTIC SECTION 84 ® tSS N.T.S. DRY, AUG 2020 Nil ®®® �V U C06®®®®® TCO2 MT ®®®® 1 0C DF flNISN GRADE 6��/�. • 7 —FILTER FABRIC .0 ORG AW J ••� AN 49 TH �' ®®0 94.8 ,.500 scwc. xoa .0 GALLON 4. ••••�• PLAS C GM TANK s 7 e .,10 ® ;MICHAELU-1.0 , N. ANDERSON:, A# No. CE 9469 ®® 8-18-20 .�.� SEPTIC SECTION 84 ® tSS N.T.S. DRY, AUG 2020 Nil ®®® MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http:itwww. muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP201292 Work Type: Septic Upgrade Tax Code Number: 01508125000 Site Legal Address: NETTLETON LT 1A G:2439 Site Mailing Address: 7240 NEWBY AVE, Anchorage Owner: SPRINGER OKSUN Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING This permit is for the construction of: Effective Date: Expiration Date: picnr v � Q �n Lep') �rment y Lot Size in Sq Ft: Total Bedrooms: 8/13/2020 8/13/2021 43379 Q Disposal Field CSI Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Date: Issued By: Date: MUNICIPALITY F ANCHORAGE Development Services Department -: Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 015-081-25 Property owner(s) OKSUN SPRINGER Mailing address 7240 NEWBY AVE, ANCH AK Site address SAME Day phone Legal description (Sub'd., Block & Lot) NETTLETON LT 1A Legal description (Township, Range & Section) Lot Size 43,379 Sq. Ft. Number of Bedrooms 5 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field Fx_1 Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank 0 Upgrade IT I (D) El Holding Tank ❑ RenewalDuplex ❑ Multiple Dwellings ❑ Privy ❑ (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: 1tLiL-1 L ZS 6V I D -1q) Waiver Fees: Date of Payment: " `! —2-02--o Date of Payment: Receipt Number: d3c/ SS Receipt Number: Permit No. Q cS P2- 6 12 l L Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc July 25, 2020 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: New septic permit Legal: NETTLETON LT 1A To Whom it may concern: This is a request for a septic permit on the above referenced lot. A test hole was completed and found silty gravel (GM) for the full 16 foot depth with no water observed. The perc rate was measured at 13 minutes per inch. A simple deep trench has been designed with 8 feet of effective depth. A new plastic tank will also be installed. This new replacement system will not impact any of the neighbors or encroach on any wells, septic or open water issues. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201292, Deb Wockenfuss, 08/21/20 SEPTIC FIELD SECTION DESIGN CRITERIA: 8.0' EFFECTIVE 5 BDRM X 150 = 750 GPD SOILS = 600/0.8 = 938 GPD 938 GA/16 = 60' 2.0' WIDE 60' LONG (1) TRENCH 10.0' DEEP 16 (TH#1) 1.0 GM ORG 1.5'2.0' -10.0 -2.0 MOUND OVER FILTER FABRIC SEWER ROCK  3,3( GRADE 1"=200' PROPERTY LINE EXISTING SEPTIC -GROVER DRIVE-EXISTING WELL 100' RADIUS -HILLSIDE DRIVE-EXISTING HOUSE SCALE: DJRDRAWN: DATE: NETTLETON, LOT 1A Anchorage, Alaska OKSUN SPRINGER 7/25/2020 -NEWBY AVE- -THAYER CIR- -STAMPS CIR- SEPTIC SEPTIC Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201292, Deb Wockenfuss, 08/21/20 1"=50' PROPERTY LINE EXISTING HOUSE EXISTING WELL 100' RADIUS WELL R&R EXISTING TANK W/ NEW 1500 GALLON PLASTIC TANK W/ 20 RISER, DEMO STEEL TANK PER UPC EXISTING ABSORPTION FIELD DRIV E W A Y -GROVER DRIVE--NEWBY AVE- NETTLETON LOT 1A SCALE: DJRDRAWN: DATE: NETTLETON, LOT 1A Anchorage, Alaska OKSUN SPRINGER 7/25/2020 DRIVE W A Y NETTLETON LOT 1B NETTLETON LOT 1C SILVER CREST BLOCK 2, LOT 22 SILVER CREST BLOCK 2, LOT 21 CO CO CO DCO CO CO DCO TH#1 2' CONTOURS TYP SHED SHED SEPTIC WOOD STAIRS TO BE RELOCATED SHED 15-20 SLOPE WELL 15-20 SLOPE 2' CONTOUR LINES, TYP SHED Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201292, Deb Wockenfuss, 08/21/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201292, Deb Wockenfuss, 08/21/20 MUNICIPALll'Y OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENI'AL PROTECTION ENVIRONMENI'AL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELl_ INSPECTION REPORT '~-~-E . -'-- [PHONE / ~U~RADE LEGAL DESCRIPTION Liq. cap/C~[~ga[Ions IF HOMEMADE: I Inside length Width ~e / Length No. of co¢,~[ments Liquid depth Dwelling PERMIT NO. Material Liquid capacity in gallons F o u n dat ion~/'<S~-~/ DISTANCE TO: Wep~"~'O~ ND. of lines / I_"angth Top of tile ~o finish 9rade Width Total I~t,.~l Ii nes Material beneath tile Depth N~a(est lot J+~e Trench3~,~ inches Distance between lines Total effer~e~ab~,~rp~on area PERMIT NO. inches Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: ;lass Depth Driller Distance to lot line Sewer line Septic tank Building foundation OTHER DISTANCE TO: PIPE MATERIALS SOIL TEST RATING INSTALLER R EMAR I/-~S~ L DATE LEGAL PERMI~ NO. IAbsorption area(s) 72-013 (Rev. 3/78) DEF'FItRTt"IEN'T L',, HEFIL. TH FIr.,l[:, EI'.,P,,,'IF.:E~NHENTFIL. r,..OTECTIO1`.,I :.::;;2! .... I... "' ~;I"F.:EET., FI1`..IE:HORFIGEE., F1F:::. :.~i,'.':.,~:.h;~EL FERrlI 1 NO. ,' ::::I. OJ.t:E: ", %, Fi. f" E'r '::' ..... F~F'PL Z CFII'.,IT ...TOHi'.,I !-,.I. EI2:';E:OI;.':N "' ' ......... " I FnqFIT '[ r"ll'.¢i % . _ .:, :,,.-E. ,~E ,::I-.3:5E;O ~~;.~..~/ LEGFIL L.."iT ! 1`..!E 1 '1 L.E FUI'4 'T"¢F'E OF fE;OI[.. FIE~2;OF::PT1.O1`..I tE;',':i~;'l'b.'i"l IE;: '-*' BEE:,F.:OOHS = q: SOIL F:FI'I"ING NUHE~EF.': I]IF' t ,-.. ' -., ' ~ ,,- - ', , ,"', ,,: ..... 1' THE FREL';!UIRED =,].,,:..E OF THE 2101'L. HE,:,_F-.'F-T1'O1`..I .=,z_,fE..i'l : THE L..E1`.,IGTH DIHENSION I:-~; THE LE1`.,tGTH ,::IN FEET) OF '1"HE TF.:ENCH OR E:,RFII1`.IFIELD. 'THE [::,EPTH OF FI TI:REI'.,tE:H O[R PIT 1.:~.; THE I:.',1. STFtNC':E BETHEE1`.,I THE ::~;IJF..'.Fi::ICE OF:' THE GROUND FI1`4B', THE BO.1"TOH OF THE E',:.:',CR',,,'R.1"ION ,::1.N FEE.1"). THERE IS 1`.40 ~i~E:]' !.4I[Y'f'H FOR TRENCHES. TFIE (.iF;i:FI',/EI._ B, EF"I"H :[:-~; THE H I1`.4 :[ HUH DEPTH OF' GF.:FIVEL. BE:T!-4EEN .1"HE OUTFFIL. L. PIPE FiND THE E:OTTOH OF TFIE E',:gCRVRTION (I'N FEE'r). F:'EI'4:H I T FIPPL I i":Fi1`-,IT FIFi:-.-', THE F..E::,F Jhl:, I E: I L. l T'T' TO '[ i",tFEIF.:f"I TH .1: :E; [::'EF'FtF.:TI'"IE1`',FF [:,t..IF~: :.( NG THE 1.1`',t:,TI'flI.J..H'1 1.ON :[1`'45F'E(::TZO1`',I'..E; OF FI1`',IY I.,-IEL. I...:5 FtD..]'FICENT TE.I THIS ~-~**F:~: ~' fiND THE 1`'.!JHFEF' OF' I;::ES1.DE1`',!CE5 TFIAT THE NELL. HILL SERVE. ............ '1"" ~....1~ ~n ,:: ;.~Z :", :E ~-.~ %~ F" E-K EZ: ~lr'" :][ ,,:z~ 11,,-41 :.:.£i;;, IF'~ F.~: E~: ~.". E ~::;::~ LI Z If:~:: E~i~ ItC: ................. BFICKFILL.1Li",IG OF' FI1`4Y :,~.:,IEII t.4ITHOUT F1.NFIL [1`.~:,FE..1]:O1`-,I FI1`.,I[:, HFFI, .,I.L DEF'RRTHE1`.,IT I.,.1 ~ L.L DE .:::,I. IE,..fE . F '1"O F'fq'.05ECI_IT ]: O1`.L HIIqlHUH [:,IS'I"R1`.4CE E:ETHEE1`',t FI 14ELL RND R1`-IY ON,-SI'f'E 2~EI.,.Ifl(3E DISF'O::SFIL :S'~.'2;"FEI','I I:..'5., tOO FEET F:'OF;: FI PF::I:',,,'FITE HE:I_I_ OR t50 TO 200 FEET FF:OH R PUE:LIC HELL [:,EPEI'.,t[.:,1.1`.,IE.i UF'CIN THE TYF'E OF F'L.IBLIC HEL_L HINIr,ILIH DISTFIi'-,IC':E FROH R F'F..'1.',,,'RTE .t,.!EL.L TO R F'F..:I',,,'flTE E;E!.,.!EF4: LINE I::5, 2.5 F:'EET FIND TO FI COHHLINITY SEI.,.IER I..;I:NE: IS 7'!21 FEET. !.,.IEL.L. LOGS FIRE RE[.;!UIRED fiN[:, r,'lus'r E:E F:':ETURNE[:, TO .1'HE DEPFIF;'.Tr,IENT 1.4ITHI1`.,I 3:E~ DRYS OF THE I.,.IEL. L COHPLE"FION. OTHER REQUIF.'.EHENT2; HRY FIPF'L.Y. SF'ECIFICFITIONS R1`.,I[:, CO1`.,ISTI:RUCTIO1`.,I B, IFIGF~'.flH:5 F:tRE F:F,,'RILFIE:L..E TO I1`..ISI.JRE PROPER INSTRLLFITION. 1. C:EF.':TIF'¢ THAT :1..: I AM FFIMiL. IRR !-,.!ITH THE REQUIF::EME1`.,ITS FOR ON-SITE :.2;EI.,.IEF..'~.; FI1`.,ID I.,.IELL.'.~::'; FIS :~;ET F'Oi';i:TH BY THE HI..IN.T. E: I F'FIL I TY OF' RNCHOR'.RGE. 2.: I I.,.IILL I1`.,ISTFILL THE S'.r"...~;TEH :[t''4 FICCOF'.DRNCE F.IITH THE CO[.':,E~;. .:~:: I U1'',!DEF.'.'L~;TFtND 'f'HRT THE ON-SITE :~E.[4ER SYSTEr,1 1`,,1RY REg!U 'I:. RE Et'.,ILRB:GEHENT IF THE F'.ESII)ENCE IS I:;':EHODELE[:, "FO INCLUI)E f,IOR'.E THRN ~: BEDROOH::5. :!i; I GNE[::,: HFFI.,,.ICRNT T:I.-IH H. U:.,E,~FN ~UNICIPALITY OF ANCHORAGE Department ~ Health and Environmental :otection 825 L Street, Anchorage, AK. 99501 264-4720 * * * HANDWRITTEN PERMIT * * * Applicant: Id, ~S'~Oe~ Mailing Address: ~'~ ~O~.ff~7 Location.:. Phone Number: "'~ .~-----. (~ ~ .... Legal Description, Lo.~ /~ /~:~X~ Lot Size, ~~O Type of Soil ~sorption System Is: Trench: ~'~rainfield: Seepage Bed: Holding Tank: Maximum N~ber of Bedrooms: ~ Soil Rating(sq.ft/br) /~~ The Required Size of the Soil ~sorption System Is: LENGTH ~ GRAVEL DEPTH WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minim~ depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * ReQUIRe: SSPTIC(HOZ:IN~) TANK SIZ~ = /~ SALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED ~ ~ * Backfilling of any system without final inspection and approval by this department will be subject to prosecution. ~inimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. ~inim~ distance from a private well to a private sewer line is 25 feet and to a co--unity sewer line is 75 feet. ~ell logs are required and must be returned to this department within 30 days of the well completion, Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 8 1 * * * I certify that: (1) I a failiar with the requirements for on-site sewers and wells as set forth by the ~unigipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more that~bedrooms. Signed: Issued by: ~' ~~_,~ ApplicantDate: ~//~~/ ~ ~ SWP/024(1/81) tbs ~ttot~ OE the excavationfin f~k). ~ ~ REOU{Rt~D S~PrlC(~LDi~) TANK mush b8 ~ot~ to this depa~at within 30 days O~ the we~k cOmp~_k',LOi~ ~ * * PERmr ~PIR~S O~:C~ th~ re~dence i~o.~a%ed to inoku~ d Z Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel 1. D. 015-081-25 1. GENERAL INFORMATION Expiration Date: l ('�? ( - Z dZ0 Complete legal description N ETTLETON LT 1 A Location (site address) 7240 NEWBY AVE, ANCH AK Current property owner(s) OKSUN SPRINGER Day phone Mailing address SAME Real estate agent Day phone 2. TYPE OF DWELLING: ❑ Single Family (w/wo ADU) ❑ Duplex(' �e ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 5 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee Date of Payment Waiver Fee $ Date of Payment Receipt Number 611 F& F 9 Receipt Number COSA# 05Ca01 H9 0 Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 8-18-26 OF. 4x��e�, 6. DSD SIGNATURE OW 49TH /............. System #1 Approved for 6 bedrooms �.. , ..• • , • . . System #2 Approved for bedrooms Disapproved efu`c.'�r•`......'s .'•�`, tom'=..�:> Conditional approval for bedrooms, with the following stipulati6 +-� — Original Certificate Date:.^ The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory COSA Checklist blue sheet X Nitrate Advisory Arsenic Advisory Other COSA Checklist Legal Description: NETTLETON LT 1A If more than 1 septic system on lot: COSA Checklist # A. WELL DATA ❑■ Well log is filed with Onsite (or attached) Date drilled 6/2'81 Total depth 160 ft Cased to 160 ft ■❑ Sanitary seal is functioning correctly 0 Wires are properly protected Casing height (above ground) 20"+ in. Date of flow test for COSA 7122120 Static water level at beginning of test 80 ft. Comments B. TANK DATA Age of tank(s) NEW years Tank type/material Measured operating fluid level in septic tank NEW ❑■ Standpipes/foundation cleanout per record drawing Date of pumping k plastic septic tank D. ABSORPTION FIELD DATA S- I �- Z 6 2 v Which system tested (date installed) new ❑E ALL standpipes present per record drawing Total measured depth from grade 12 ft (max) Measured depth to pipe invert from grade 4.0 ft (min) ❑ N/A - pressurized field FN Monitor tubes go to bottom of effective. If not, state depth into effective X Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced 0 gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 015-081-25 of Structure served by this system Well production at time of test 5+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes Nc 0 Coliform bacteria is Negative Nitrate mg/L FN Nitrate less than MRL (ND) Arsenic ug/L ❑0 Arsenic less than MRL (ND) Collected by MNA Date of Sample 7124120 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date new Results Q✓ Pass For 5 bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Fvl Yes Community Sewer Manhole/Cleanout > 100' ft Yes if No ft Q Yes if No ft Neighboring Tank > 100' M Yes if No ft Private Sewer/Septic Line > 25' M Yes if No ft Absorption Field on Lot > 100' 0 Yes if No ft Holding Tank > 100' ❑✓ Yes if No ft Neighboring Absorption Fields > 100' If septic tank is under driveway comment below Surface Water > 100' Animal Containment? 50' 0 Yes if No ft Q Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' 0 Yes if No ft M Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water > 100' Yes if No ft Property Line > 5' Fvl Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Q Yes if No ft Private Wells > 100' Fv� Yes if No ft Water Main > 10' Q Yes if No ft Community Wells > 200' [✓ Yes if No ft Water Service Line > 10' Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ✓V Yes if No ft If absorption field is under driveway comment below Property Line > 10' Q Yes if No ft Wells on Adjacent Lots: Water Main > 10' Q Yes if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' Yes if No ft Community Wells > 200' ❑✓ Yes if Na ft Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I certify that / have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet ./ JOT 11 /....i .............. ,I -% MICHAEL N. ANDERSON �" • CE -/9469 ` �r dpi 19�0F MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # _{-3/-~- ~:~: ) - ~.L~ HAA # .~-1 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property owner ~/~c~r ~/J~fr~,x Mailing Address . ¢0, ~ /~ (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Address ~70~ ~cU Telephone ~7~ -~T7¢ Telephone: (home) 3' ~'-/7~-0 Business (e) Mail the HAA to the following address: (or check here [], if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE[ Number of bedrooms Singie-Familyl~ 3. WATER SUPPLY Individual Well [] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site [] Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 ~ ~o ~ ~leed 'MJo~ s,J@@u!!Su@ leUO!SS@loJd @q~ u! SUO!SS!LUO JO sJoJJa Jo~ elq!suodsaJ ~ou s! @beJOqOU¥' ~O X~!led!o!un~ aqJ_ 'penss! s! a~eo!~BJao e aJoJaq e~,ep aZXleUe JO suop, o@dsu! ~,onpuoo ~ou op SHHQ jo saaXoldUJ3 's~uaLu~J!nbaJ a~e~s pue leJap@l u!e~Jao X~sBes o~ J~pJo u! suoj~n~Bsu! bu!pual J!@q~ pue Se~OLI JO sJ@seqoJnd ol Xs9~Jnoo e se s!q~ seep SHHC] @qz 'e~selV jo @le~S aq~, u! paJa~S!6aJ Ja@u!~ua leUO!SS@joJd ~uapuadapu! ue Xq a^oqe g qde~§eJed u! ua^!6 suo!te~u@seJd@J @q~, uodn ,~lUO p@seq p@~eo!j!Jeo le^oJddv X~!Joq~nv q~leaH sanss! (SHHQ) sao!^J~$ uegunH pue qlleaH ~o ~uagu~JedaQ d~eJoqou¥ ~o X~!ledp!unl/~ 9qJ_ le^oJdd¥ leuop4puoo ,to SLUJ8/ leUO!].!puoo peAoJddes!Q ,~ peAoJddV ~ ~¢~.~ AqsLuooJpeq ~ Jo,tpeAoJdd¥ l~'^Ol:id~lV SHH(] '9 MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: A, WELL DATA Well Classification Well Log Present (Y/N) ~ _Date Completed_~/ Total Depth l¢O Cased to_t~'O Depth of Grouting Static Water Level ~ ! Casing Height Above Ground i~0 ' Electrical Wiring in Conduit (Y/N) Y SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot ~ Z. To Nearest Public Sewer Line N, To Nearest Sewer Service Line on Lot Water Sample Collected by "r: ~ t-/ Water SamPle Test Results ¢-~,/t.r Comments Pc~ri ~.~ (~ ¢(! B. SEPTIC/HOLDING TANK DATA Date Installed ~/'q [81 _Size Standpipes (Y/N) ¥ Air-tight Caps (Y/N) _ Depression over Tank (Y/N) (1( Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) kl, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Li,ne , To Water Main/Service Line ~ ~' To Stream, Pond, Lake or Major Drainage Course If A, B, C, D.E.C. Approved (Y/N) ~" v,. .'> 7, o~p~ ~ ~ ~/l/&~-2 Y~eld ~ ~¢ ~ d' ' J ~.~, Pump Set At :~ ~ ~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Y ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ~ 85-~ ; Date 8/I/~ No. of Compartments ~ Foundation Cleanout (Y/N) Date Last Pumped ~/!/~¢ ~/v ~¢' ; for Temporary Holding Tank Permit (Y/N) N. To Building Foundation 'Fo Disposal Field Comments 7~-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~/'/' ~/ Width of Field Type of System Design Length of Field Depth of Field Gravel Bed Thickness Square Feet of Absortion Area ~ _,~ Stal'ndpipes Present (Y/N) Depression over Field (Y/N) /V Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-SupPly Well I To Building Foundation ~'~' Lot To Water Main/Service Line To Stream, Pond, Lake. or Major Drainage Course '~. too, To Driveway, Parking Area, or Vehicle Storage Area Comments ~'r~,,'~ C ~' To Property Line ~'O ' To Existing or Abandoned System on ; On Adjoining Lots :~ ,~,~ ' To Cutback (if present) ~,A. D. LIFT STATION N,A-, Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Company Date MOA No. Receipt No. Date of Payment amount: $ 72-026 (Rev. 7188) Back ,,," .... ,~-- . ,~: ~ Engineer's Seal '~ ,,THEODORE F. MOOREo,, ¢."¢~¢~,',o CE- 3589 Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 'D, ~ RECEIVED ' INSPECTION APPOINTMENTS ' INSPECTOR OR ~-) ' INSPECTOR · INSPECT ~]kJ MUNICIPALITY OF ANCHORAGE ~EPT. OF HEAL']'H & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECI~J~IRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION AU(3 2 b 1981 · Telephone 264-4720 RECEIVED 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 processin§, 15R~PE~R'TY-RES~DI~NT (if different fr~m above) ' PHONE PHONE 2, BUrR 3. LENDING INSTITU'r.J.ON ~ ' . ./) I PHONE ~AI LING 'ADDRESS ~/ - __ PHONE 4, REALTOR/AGENT MAI~JG ADDRESS 6. TYPE OF R~IDENCE ~""' OOMS [] One ~] Four _~ Other I~ SINGLE FAMILY [] Two [] Five [~] MULTIPLE FAMILY ~ Three E] Six 7. WATER SUPPLY INDIVIDUAL~ [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISPOSAL SYSTEM [~ NDIVIDUAL/ON-SITE~ [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled ' since June 1975. For wells drilled ~rio~ to that date, give well I depth (attach log if available,) //~:~/ YEAR ON-SITE SYSTEMWAS NSTALLED. 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 []INDIVIDUAL/ON -SITE DATE INSTALLED E~]PUBLIC UTILITY ~ _(~-~ Connection Verified INSTALLER [~Septic Tank or [] Holding Tank Size: /~'-~ If Tank [s 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 Line I WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS [~]'~'PPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED :z'~ DATE BY ~ 72-010 (Rev. 6/79)